Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. The nurse explains to the patient that together they will plan the patient’s care and set goals to
achieve by discharge. The patient asks how this differs from what the physician does. Which
statement best describes the difference between the roles of nursing and medicine in planning
the patient’s care and setting goals to achieve discharge?
a. Medicine cures; nursing cares.
b. Nurses assist physicians to diagnose and treat patients with health care problems.
c. Very little role difference exists between medicine and nursing; nurses perform
many of the procedures done by physicians.
d. Medicine focuses on diagnosis and treatment of the health problem; nursing
focuses on diagnosis and treatment of the patient’s response to the health problem.
ANS: D
This response is consistent with the Canadian Nurses Association’s (CNA’s) definition of
registered nursing, which states that registered nurses enable individuals, families, groups,
communities, and populations to achieve their optimal level of health. The other responses
describe some of the dependent and collaborative functions of the nursing role but do not
accurately describe the nurse’s role in the health care system.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 4
MSC: CRNE: PP-9
2. A woman with hypertension is concerned that if she sees the nurse practitioner (an advanced
practice nurse), only her hypertension will be assessed, and she is worried that another health
problem may not be diagnosed. What should the nurse tell the patient regarding nurse
practitioners’ scope of practice as it relates to diagnosis?
a. They diagnose and treat all major health problems.
b. They have the same role and scope of practice as physicians.
c. They write prescriptions for all classifications of medications.
d. They focus on primary care and health promotion, including diagnosis.
ANS: D
Advanced practice nurses (for example, nurse practitioners) focus on the management of
primary care and health promotion for a wide variety of health problems in various
specialties; roles include physical examination, diagnosis, treatment of health problems,
patient and family education, and counselling.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 9
MSC: CRNE: PP-9
3. When asking a clinical question using the PICO format, which of the following would
represent the “C”?
a. Controlled diabetes in a woman aged 50 to 65 years
b. Conditioning and exercise program for one hour, three times weekly
c. Weekly blood glucose levels within normal range
d. Standard care for women with diabetes
ANS: D
The “C” in PICO stands for comparison of interest, which would be standard care, in this
case, for women with diabetes. Controlled diabetes in a woman aged 50 to 65 years is the “P,”
the population. Conditioning and exercise program for one hour, three times weekly is the “I,”
or intervention. Weekly blood glucose levels within normal range is the “O,” or outcome of
interest.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 7
MSC: CRNE: CH-15
4. How does the nurse primarily use the nursing process in the care of patients?
a. As a science-based process of diagnosing the patient’s health care problems
b. To establish nursing theory that incorporates the bio-psycho-social nature of
humans
c. To promote the management of patient care in collaboration with other health care
providers
d. As a tool to organize the nurse’s thinking and clinical decision making about the
patient’s health care needs
ANS: D
The nursing process is a problem-solving approach to the identification and treatment of
patients’ problems. Diagnosis is only one phase of the nursing process. The primary use of the
nursing process is in patient care, not to establish nursing theory or explain nursing
interventions to other health care providers.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: All phases
REF: page 10
MSC: CRNE: CH-7
5. An emaciated older adult patient is admitted to the critical care unit. The nurse plans a
schedule of turning the patient every two hours to prevent skin breakdown. This is considered
to be what type of nursing action?
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D
When implementing collaborative nursing actions, the nurse is responsible primarily for
monitoring for complications or providing care to prevent or treat complications. Independent
nursing actions are focused on health promotion, illness prevention, and patient advocacy. A
dependent action would require a physician order to implement. Cooperative nursing
functions are not described as one of the formal nursing functions.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: pages 11-12
MSC: CRNE: CH-10
6. A woman who is a lone parent is about to undergo gallbladder surgery. She tells the nurse on
admission that she is uneasy about being in the hospital and leaving her two preschool
children with a neighbour. During the assessment phase, what is an appropriate nursing
action?
a. Reassure the patient that her children are fine.
b. Call the neighbour to determine whether she is an adequate care provider.
c. Have the patient call the children to reassure herself that they are doing well.
d. Gather more data about the patient’s feelings about the child care arrangements.
ANS: D
The assessment phase includes gathering multidimensional data about the patient. The other
nursing actions may be appropriate during the implementation phase (after the nurse
accomplishes further assessment of the patient’s concerns), but they are not part of the
assessment phase.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 10
MSC: CRNE: CH-3
7. A patient with a stroke is paralyzed on the left side of the body and is not responsive enough
to turn or move independently in bed. A pressure ulcer has developed on the patient’s left hip.
What is the most appropriate nursing diagnosis?
a. Impaired physical mobility related to paralysis
b. Impaired skin integrity related to altered circulation and pressure
c. Risk for impaired tissue integrity related to impaired physical mobility
d. Ineffective tissue perfusion related to inability to turn and move self in bed
ANS: B
The patient’s major problem is the impaired skin integrity as demonstrated by the presence of
a pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure by
frequently repositioning the patient. Although impaired physical mobility is a problem for the
patient, the nurse cannot treat the paralysis. The risk for diagnosis is not appropriate for this
patient, who already has impaired tissue integrity. The patient does have ineffective tissue
perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health
problem is.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
REF: page 15
MSC: CRNE: CH-20
8. A patient with an infection has a nursing diagnosis of fluid volume deficit related to excessive
diaphoresis. What is an appropriate patient outcome?
a. Balanced intake and output are achieved.
b. Patient verbalizes a need for increased fluid intake.
c. Bedding is changed when it becomes damp.
d. Skin remains cool and dry throughout hospitalization.
ANS: A
This statement gives measurable data showing resolution of the problem of fluid volume
deficit that was identified in the nursing diagnosis statement. The other statements would not
indicate that the problem of fluid volume deficit was resolved.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 13
MSC: CRNE: CH-25
9. Which characteristic is consistent with critical thinking?
a. Do not use abstract ideas.
b. Think within alternative systems of thought.
c. Encourage cooperative relationships from positions of power and authority.
d. Use the trial-and-error method for effective problem-solving options.
ANS: B
Critical thinking is the art of analyzing and evaluating thinking with a view to improving it.
Characteristics of critical thinking include thinking open-mindedly within alternative systems
of thought, and recognizing and assessing their assumptions, implications, and practical
consequences.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 6
MSC: CRNE: PP-11
10. The nurse reads on the care plan that a patient is at risk for developing an infection. What does
the nurse recognize about this patient’s problem?
a. It is always a nursing diagnosis.
b. It is always a collaborative problem.
c. It may be either a nursing diagnosis or a collaborative problem, depending on the
etiology.
d. It should not be addressed as a special problem because all nursing measures
should protect patients from infection.
ANS: C
If the source of the risk for infection is something that can be treated by nursing, then the
problem is a nursing diagnosis. If it is one that requires treatment by other health care
providers, the problem is collaborative. In either case, the risk for infection should be included
in the care plan.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: pages 10-11
MSC: CRNE: PP-9
11. Which of the following is an example of the “P” in a SOAP progress note?
a. The patient stating that her right arm is numb
b. Encouragement of alternating rest and activity periods
c. Activity intolerance related to fatigue
d. Blood pressure 140/85 mm Hg
ANS: B
“P” stands for plan in the SOAP method of documentation; encouraging alternating rest and
activity periods is an example of a specific intervention related to a diagnostic problem. The
patient stating that the right arm is numb is an example of subjective data. Activity intolerance
is a nursing diagnosis and is an example of assessment. A blood pressure reading is an
objective assessment.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: pages 1-16
MSC: CRNE: CH-15
12. Which of the following refers to the use of communication and information technologies in
order to support the delivery and integration of clinical care?
a. e-Health
b. Nursing informatics
c. Electronic health record
d. ICT (information and communication technology)
ANS: A
e-Health refers to the use of communication and information technologies in order to support
the delivery and integration of clinical care. Nursing informatics refers to the integration of
nursing science, computer science, and information technology to manage and communicate
data, information, and knowledge in nursing practice. Electronic health record is an electronic
version of the patient health record. ICT consists of tools and applications that support the
management of clinical data, information, and knowledge.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 10
MSC: CRNE: CH-16
13. Which phase of the nursing process is too often not addressed sufficiently?
a. Planning
b. Diagnosis
c. Implementation
d. Evaluation
ANS: D
Evaluation is an extremely important part of the nursing process that is too often not
addressed sufficiently. The planning, diagnosis, and implementation phases are often
addressed sufficiently.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Evaluation
REF: page 10
MSC: CRNE: CH-25
14. Which of the following refers to a situation that results in unintended harm to the patient and
is related to the care or services provided rather than the patient’s medical condition?
a. Negligence
b. Adverse event
c. Incident report
d. Nonmaleficence
ANS: B
An adverse event is an event that results in unintended harm to the patient and is related to the
care or services provided rather than the patient’s medical condition. Negligence is an ethical
principle, not a situation that results in unintended harm to the patient, although it is related to
the care or services provided rather than the patient’s medical condition. An incident report
may be completed; however, it is not the event itself. Nonmaleficence is an ethical principle,
not a situation that results in unintended harm to the patient, although it is related to the care
or services provided rather than the patient’s medical condition.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Implementation
REF: page 4
MSC: CRNE: PP-14
Chapter 02: Cultural Competence and Health Equity in Nursing Care
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. An Aboriginal patient tells the nurse that he thinks his abdominal pain is caused by eating too
much seal fat and that strong massage over the stomach will help it. What is this patient
describing?
a. Awareness and knowledge of his own culture
b. Encounters with cultures different from his own
c. Explanatory model of health and health practices
d. Knowledge about the differences in modern and folk health practices
ANS: C
Further assessment of the patient’s cultural beliefs is appropriate before implementing any
interventions. A massage may be helpful, but more information about the patient’s beliefs is
needed to determine which intervention(s) will be most helpful. This is eliciting the patient’s
explanatory model of health practices.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 26
MSC: CRNE: NCP-7
2. Which following term refers to characteristics of a group whose members share a common
social, cultural, linguistic, or religious heritage?
a. Diversity
b. Ethnicity
c. Ethnocentrism
d. Cultural imposition
ANS: B
Ethnicity refers to characteristics of a group whose members share a common social, cultural,
linguistic, or religious heritage. Diversity is differences or variations across individuals and
social groups. Ethnocentrism is a tendency for an individual to believe that their way of
viewing the world is the most correct. Cultural imposition is the situation in which one`s own
cultural beliefs are imposed on another, intentionally or unintentionally.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 25
MSC: CRNE: NCP-7
3. Having a commitment to the goal of inclusivity and equity is classified as which domain in
the ABCs of cultural competence?
a. Skills
b. Affective
c. Knowledge
d. Behavioural
ANS: B
Having a commitment to the goal of inclusivity and equity is classified as a component of the
affective domain. It is not an example of the skills domain, the knowledge domain, or the
behavioural domain.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 27, Table 2-3
MSC: CRNE: NCP-7
4. Which of the following is a system factor that influences help-seeking behaviour for health
care?
a. Lack of health insurance
b. Association by patients of hospitals with death
c. Lack of ethnic-specific health care programs
d. Possible patient distrust of the dominant population and institutions
ANS: C
An example of a system factor that influences help-seeking behaviour for health care is a lack
of ethnic-specific health care programs. Lack of health insurance is an economic factor.
Patients associating hospitals with death is a belief and practice factor, as is patients’ distrust
of the dominant population and institutions.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 30, Table 2-7
MSC: CRNE: HW-19
5. What is the most appropriate action when the patient constantly pauses before answering
questions about his or her health history on an admission assessment?
a. Stop the assessment and return later.
b. Wait for the patient to answer the questions.
c. Ask why the questions require so much time to answer.
d. Give the patient the assessment form listing the questions and a pen.
ANS: B
Although members of some groups may respond effectively to direct questions, members of
others will respond more comfortably in interactions that are less direct, in which information
is requested and presented in the third person, and more silence and reflection are allowed for;
therefore, the nurse should wait for the patient to answer the questions.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 28
MSC: CRNE: NCP-7
6. If an interpreter is not available when a patient speaks a language different from the nurse’s,
which action is most appropriate?
a. Use specific medical terms in the Latin form.
b. Talk loudly and slowly so that each word is clearly heard.
c. Repeat important words so that the patient recognizes their importance.
d. Use pantomime to demonstrate what is to be communicated to the patient.
ANS: D
The use of gestures will enable some information to be communicated to the patient. Using
specific medical terms in the Latin form is not appropriate, as one cannot assume that all
patients understand Latin. Talking loudly and slowly is not appropriate. Repeating important
words is not appropriate.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 29, Table 2-6
MSC: CRNE: NCP-2
7. A recent RN graduate is assessing a newly admitted non–English-speaking Chinese patient.
Which action would alert the preceptor to intervene and assist the nurse with culturally
appropriate care?
a. Sitting down at the bedside
b. Calling for a medical interpreter
c. Beginning the physical assessment with palpation
d. Avoiding eye contact with the patient
ANS: C
Given that touch is an important aspect of cultural practices, the nurse should always ask
permission to touch before touching a patient. This demonstrates respect for the patient’s
cultural values. The other actions are appropriate.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 30
MSC: CRNE: NCP-7
8. Which best describes culturally appropriate nursing care?
a. Asking permission to touch a patient
b. Avoiding questions about male-female relationships
c. Explaining how Western medical care differs from cultural folk remedies
d. Applying knowledge of a culture to patients of the same cultural group
ANS: A
Many cultures consider it disrespectful to touch a patient without asking permission, so asking
a patient for permission is culturally appropriate. The other actions may be appropriate for
some patients but are not appropriate across all cultural groups or for all patients.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 30
MSC: CRNE: NCP-7
9. What is a primary factor that shapes the health of Canadians?
a. Medical treatments
b. Living conditions
c. Lifestyle choices
d. Obesity
ANS: B
Living conditions (economic, social, and political) are the primary factor that shapes the
health of Canadians. Medical treatment, lifestyle choices, and obesity all play a role in health,
but they are not the primary factor that shapes the health of Canadians.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 22
MSC: CRNE: HW-19
10. Which statement accurately reflects a health inequity experienced in Canada today?
a. Aboriginal adults are less likely to smoke tobacco than other adults in Canada.
b. Overall suicide rate among First Nation communities is about twice the rate of the
general population.
c. Individuals from lower income neighborhoods undergo preventative health
screening more than their higher income counterparts.
d. Recent immigrants are more likely to have a primary care physician than
Canadian-born respondents.
ANS: B
The overall suicide rate among First Nation communities is about twice that of the total
Canadian population; the rate among Inuit is still higher—six to ten times that of the general
population. Aboriginal adults are more likely to smoke tobacco than other adults in Canada.
Individuals from lower income neighbourhoods undergo preventative health screening less
than their higher income counterparts. Recent immigrants are less likely to have a primary
care physician than Canadian-born respondents.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 23, Table 2-1
MSC: CRNE: PP-7
Chapter 03: Health History and Physical Examination
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A man is admitted to the hospital with difficulty breathing. What is the best approach to
obtain a health history?
a. Obtain subjective data about the patient from his family members.
b. Delay any subjective data collection, and focus only on his physical examination.
c. Schedule several short sessions with the patient to gather necessary subjective
data.
d. Use the physician’s medical history as the primary source of subjective data.
ANS: C
In an emergency situation, the nurse may need to ask only the most pertinent questions for a
specific problem and obtain more information later. A complete health history will include
subjective information that is not available in the health care provider’s medical history.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 40
MSC: CRNE: CH-1
2. When the nurse is gathering information of a personal nature, which best demonstrates an
acceptance of the patient’s behaviour?
a. “Tell me, do you drink alcohol like I do?”
b. “Many drugs used for hypertension cause sexual dysfunction. How is your sexual
functioning?”
c. “Most of my friends have been divorced. Would you like to tell me about the
problems with your divorce?”
d. “Many older people have limited financial resources for food and medications. Is
this a concern for you?”
ANS: D
When asking personal or potentially sensitive questions, prefacing the question with phrases
such as “many people” indicates that the patient’s situation is normal. Therefore, the best
response is the one in which the nurse asks whether the patient actually has the problem of
limited resources but does not imply any judgments about the patient in this regard.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 39
MSC: CRNE: NCP-1
3. A patient is admitted to the orthopedic unit with a fractured right elbow following a skiing
accident. During the initial nursing assessment, what information is related to the functional
health pattern regarding the patient’s fractured elbow and the treatment he has received?
a. Activity–exercise
b. Cognitive–perceptual
c. Self-perception–self-concept
d. Health perception–health management
ANS: D
In a hospitalized patient, the health perception–health management pattern includes
information about the patient’s understanding of the onset and treatment of the current health
problem.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 41, Table 3-3
MSC: CRNE: CH-9
4. Which of the following findings is a positive sign in relation to a patient with an enlarged
liver?
a. Blood pressure of 128/78 mm Hg
b. Pulse of 82 beats per minute
c. Yellow-tinged sclera
d. Painful and swollen great right toe
ANS: C
A positive finding is one that indicates that the patient has or had the particular problem or
sign under discussion. In this example, yellow-tinged sclera in a patient with an enlarged liver
would indicate jaundice and be a positive sign.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
REF: page 44
MSC: CRNE: CH-8
5. A patient reports that she has periodic fainting spells. In gathering more specific information,
the nurse asks where these episodes most commonly occur. In what area is the nurse pursuing
symptom investigation?
a. Setting
b. Frequency
c. Chronology
d. Associated manifestations
ANS: A
Information about the setting is obtained by asking where the patient was and what the patient
was doing when the symptom occurred.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 40
MSC: CRNE: CH-1
6. The nurse records the following general survey of a patient: “The patient is a 68-year-old male
Asian attended by his wife and two daughters. Alert and oriented. Does not make eye contact
with the nurse and responds slowly, but appropriately, to questions. No apparent disabilities or
distinguishing features.” What additional information should be added to this general survey?
a. Body movements
b. Intake and output
c. Reasons for contact with the health care system
d. Comments of family members about his condition
ANS: A
In addition to body movements, the general survey also describes the patient’s general
nutritional status. The other information will be obtained when doing the complete nursing
history and examination but is not obtained through the initial scanning of a patient.
PTS: 1
DIF: Cognitive Level: Application
REF: page 44
OBJ: 4
TOP: Nursing Process: Assessment
MSC: CRNE: CH-1
7. Following knee surgery, the patient has an elastic bandage applied to the surgical site. What
examination technique is used to assess the patient’s distal extremity pulses and temperature?
a. Palpation
b. Inspection
c. Percussion
d. Auscultation
ANS: A
Distal extremity pulses and temperature can be assessed only by palpation.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 44
MSC: CRNE: CH-4
8. What does a negative finding obtained from the patient during the initial nursing history
indicate?
a. The patient is healthy.
b. The symptom related to the specific health problem presented is delayed.
c. The patient uses health promotion practices.
d. A symptom normally associated with the patient’s health problem is absent.
ANS: D
A negative finding is the absence of a sign or symptom that is usually associated with a
problem, for example, if a patient with advanced liver disease has no peripheral edema.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 44
MSC: CRNE: CH-6
9. As the nurse assesses the patient’s neck, the patient tells the nurse that it is so stiff she can
hardly move it. The nurse should next perform a(n) _____ examination.
a. emergency
b. screening
c. focused
d. extensive
ANS: C
The focused examination is needed when a patient has clinical manifestations that indicate a
problem.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 48, Table 3-6
MSC: CRNE: CH-3
10. When assessing using mediated percussion, which finger of which hand will the nurse use on
the patient’s body?
a. Middle finger of dominant hand
b. Index finger of dominant hand
c. Middle finger of nondominant hand
d. Index finger of nondominant hand
ANS: C
When performing mediated (indirect) percussion, the examiner uses the middle finger of the
nondominant hand against the patient’s body for percussion.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 44
MSC: CRNE: CH-4
11. Which functional health pattern is the nurse assessing when asking a patient how his or her
family feels about the patient being hospitalized?
a. Cognitive–perceptual
b. Role–relationship
c. Coping–stress tolerance
d. Self-perception–self-concept
ANS: B
The nurse is assessing the functional health pattern of role–relationships when asking a patient
about how his or her family feels about the patient being hospitalized.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Assessment
TOP: Nursing Process: Implementation
REF: page 41, Table 3-3
MSC: CRNE: CH-3
12. Which part of the stethoscope is best to use when the nurse is listening to low-pitched sounds?
a. Bell
b. Tube
c. Diaphragm
d. The largest area for auscultation
ANS: A
The bell of the stethoscope is best to listen to low-pitched sounds. The diaphragm (or largest
part) is best used when assessing for high-pitched sounds.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 45
MSC: CRNE: CH-4
13. While the nurse is taking a health history, the patient indicates that his father and grandfather
both had heart attacks and were unable to be very active afterward. Which functional health
pattern is reflected in this statement?
a. Health perception–health management
b. Coping–stress tolerance
c. Cognitive–perceptual
d. Activity–exercise
ANS: A
The information in the patient statement relates to risk factors that may cause cardiovascular
problems in the future. Identification of risk factors falls into the health perception–health
management pattern.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 42
MSC: CRNE: CH-9
14. Which assessment technique would the nurse have used to document a finding of crepitus?
a. Inspection
b. Palpation
c. Auscultation
d. Percussion
ANS: B
The use of light, moderate, and deep palpation can yield information related to masses,
pulsations, organ enlargement, tenderness or pain, swelling, muscular spasm or rigidity,
elasticity, vibration of voice sounds, crepitus, moisture, and differences in texture.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 44
MSC: CRNE: CH-4
Chapter 04: Patient and Caregiver Teaching
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A patient is diagnosed with breast cancer following a needle biopsy of a breast lump.
Considering the teaching process, what is the priority goal?
a. Learning to live with the disease
b. Selecting and using treatment options
c. Preventing the recurrence of the tumour
d. Minimizing the untoward effects of treatment
ANS: B
Adults learn best when given information that can be used immediately. The first action the
patient will need to take after a cancer diagnosis is to choose a treatment option. The other
goals may be appropriate as treatment progresses.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 53, Table 4-1
MSC: CRNE: NCP-14
2. After the nurse implements diet instruction with a patient with heart disease, the patient can
explain the information but fails to make the recommended dietary changes. Which of the
following statements best describes the nurse’s evaluation observation?
a. The nursing responsibility has been fulfilled.
b. Learning did not occur because the patient’s behaviour did not change.
c. Choosing not to follow the diet is the learning behaviour that resulted.
d. The instructional methods were not effective in helping the patient learn.
ANS: C
Although the patient’s behaviour has not changed, the patient’s ability to explain the
information indicates that learning has occurred and the patient is choosing at this time to
continue with the previous diet. The patient may be in the contemplation or preparation state
of the transtheoretical model of health behaviour change. The nurse should reinforce the need
for change and continue to provide information and assistance with planning for change.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 54, Table 4-3
MSC: CRNE: NCP-14
3. Which of the following is a recent health literacy tool that health care providers can use to
identify patients who are at risk for low health literacy?
a. Rapid Estimate of Adult Literacy in Medicine
b. Newest Vital Sign
c. Test of Functional Health Literacy in Adults
d. Adult Literacy and Skills Survey
ANS: B
Newest Vital Sign is the most recent health literacy tool; this test provides information about
the patient that allows health care providers to adapt their communication practices in an
effort to achieve better health outcomes.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 58
MSC: CRNE: CH-7
4. A patient admitted to the hospital with hyperglycemia and diagnosed with diabetes mellitus is
scheduled for discharge the second day after admission. In view of the patient’s limited
hospitalization, what should the nurse’s teaching plan emphasize first for the patient’s
education about diabetes?
a. Prioritize realistic goals that are essential to the patient’s immediate learning
needs.
b. Reflect a complete plan that can be implemented by home health care nurses.
c. Use all available time to teach the patient as much as possible about the condition.
d. Involve teaching the family instead of the patient about management of diabetes.
ANS: A
When time is limited, the nurse should set realistic goals with the patient that can meet
immediate needs. The patient and the family will need further teaching about the role of diet,
exercise, medications, and so on, in controlling glucose, but these topics can be addressed
through planning for appropriate referrals.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 55, Table 4-4
MSC: CRNE: CH-2
5. When using the transtheoretical model of health behaviour change during patient teaching, the
nurse listens to the patient state, “I told my wife that I was going to start exercising, and I
think I will join a fitness club.” Which stage of change is this patient in?
a. Action
b. Preparation
c. Termination
d. Maintenance
ANS: B
The patient’s statement indicating that the plan for change is being shared with someone else
indicates that the preparation stage has been achieved.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Evaluation
REF: page 54, Table 4-3
MSC: CRNE: CH-19
6. Which of the following nursing care plan entries would be a correctly worded nursing
diagnosis?
a. Ineffective knowledge
b. Deficient knowledge
c. Inappropriate knowledge
d. Stereotypical knowledge
ANS: B
A correctly worded and common nursing diagnosis for learning needs is deficient knowledge.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
REF: page 60
MSC: CRNE: CH-15
7. A patient admits to the nurse that she does not read well. In developing a teaching plan for the
patient, what does this information guide the nurse in determining?
a.
b.
c.
d.
The degree of the patient’s motivation to learn
What information the patient will be able to understand
What instructional strategies should be used in teaching
That the family must be included in the teaching process
ANS: C
The information that the patient is illiterate indicates that the nurse should avoid the use of
written materials in teaching and consider other instructional strategies in planning care for
this patient.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 63
MSC: CRNE: NCP-14
8. A postoperative patient says it hurts too much to breathe deeply and cough every two hours;
the patient refuses to carry out the activity. Which is an appropriate intervention based on
adult learning principles?
a. Respect the patient’s wishes and turn the patient side to side instead but more
frequently.
b. Enlist the help of the physician in reinforcing the need to cough and breathe
deeply.
c. Explain what happens to the lungs postoperatively and why the exercise is
important.
d. Explain that it is the nurse’s responsibility to prevent complications and insist that
she comply.
ANS: C
Teaching the patient about the reason for the deep breathing and coughing will be likely to
improve compliance and decrease the risk for complications. Adult learning principles
indicate that adults learn best when they can use the information that they are learning
immediately.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 53, Table 4-1
MSC: CRNE: NCP-14
9. Which following teaching strategy is most efficient, versatile, and economical to implement?
a. Role play
b. Print materials
c. Lecture
d. Discussion
ANS: C
The lecture format is the most efficient, versatile, and economical teaching strategy that can
be used when the amount of time is limited or when a group can benefit from acquiring a core
of basic information.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 61
MSC: CRNE: NCP-14
10. What should the nurse ask the patient, in order to assess readiness to learn before planning
teaching activities?
a. What are the patient’s living conditions and employment?
b. What type of environment or activities help the patient to learn best?
c. What information has been provided about the patient’s health problem?
d. Does the patient have any beliefs that are inconsistent with the proposed
treatment?
ANS: C
Before implementing the teaching plan, the nurse should determine where the patient is in the
stages of the change process, as the nurse may have to provide support and increase the
patient’s awareness of the problem. The only way to do this is to assess what information has
been provided to the patient about the health problem.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 60
MSC: CRNE: NCP-14
11. Which of the following is a technique to enhance patient learning?
a. Keep patient expression of needs at a minimum.
b. Focus on “nice to know” information initially.
c. Emphasize relevancy of information to patient’s lifestyle.
d. Maintain a formal physical environment at all times.
ANS: C
Emphasizing the relevancy of the information to the patient’s lifestyle and suggesting how it
may provide an immediate solution to a problem is a technique to enhance patient learning.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 63, Table 4-7
MSC: CRNE: NCP-14
12. The nurse is teaching a patient with peripheral vascular disease about foot care. Which is a
correctly written specific learning objective for this patient?
a. “The nurse will instruct the patient on appropriate foot care.”
b. “Demonstrate the proper technique for trimming toenails to the patient.”
c. “By discharge, the patient will list three ways to protect the feet from injury.”
d. “The patient will understand the rationale for proper foot care after instruction.”
ANS: C
This objective contains all four elements of a specific learning objective, namely, who will
perform the activity, the actual behaviour, the conditions under which the behaviour is to be
demonstrated, and the specific criteria that will be used to measure the patient’s success.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 60
MSC: CRNE: NCP-14
13. Which of the following teaching strategies is most appropriate to promote use of coping skills
by an adult patient?
a. Lecture
b. Role play
c. Group teaching
d. Printed materials
ANS: B
Role play allows the patient to practise assertive behaviour and receive feedback about how
the behaviour is perceived.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 62
MSC: CRNE: NCP-14
14. When completing the educational component of a general nursing assessment to prepare a
teaching plan, which question is the best one to ask, initially?
a. What is the patient’s level of motivation?
b. What does the patient think is most important to learn first?
c. Is the patient ready to learn?
d. What does the patient already know?
ANS: D
The initial question should be to ascertain what the patient already knows about the topic for
which the teaching plan is being developed.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 56, Table 4-5
MSC: CRNE: NCP-14
15. How can the nurse most effectively evaluate a teaching objective of “the patient will select a
2000-mg sodium diet from the hospital menu daily for three days with 90% accuracy”?
a. Ask the patient to identify what foods on the daily menu are high in sodium.
b. Have the patient describe the foods that were consumed for the past three days, and
total their sodium content.
c. Note the food selected on three daily menus and determine whether the daily
sodium content is within 1800 to 2200 mg.
d. Use a record of the patient’s food intake for three days to determine whether the
total sodium content is 6000 mg.
ANS: C
The statement of the teaching objective is most clearly addressed with this answer, as the
other answers do not directly address the objective as written.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 60
MSC: CRNE: CH-25
Chapter 05: Chronic Illness
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. Chronic illness accounts for well over half (63%) of all deaths globally. Which chronic
illness accounts for the highest proportion of those deaths in Canada?
a. Cancer
b. Diabetes
c. Cardiovascular disease
d. Chronic respiratory disease
ANS: C
According to Statistics Canada, cardiovascular diseases continue to be the underlying cause
of death for one in three Canadians and are responsible for the largest economic impact of
all illnesses in Canada.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: pages 69-70
MSC: CRNE: CH-8
2. Which patient history indicates multimorbidity?
a. Chronic obstructive pulmonary disease and a urinary tract infection
b. Chronic kidney disease requiring an appendectomy
c. Lung cancer and pneumonia
d. Diabetes with exacerbation of rheumatoid arthritis
ANS: D
Multimorbidity is the simultaneous occurrence of several chronic medical conditions in the
same person; therefore, the correct choice is one that has two chronic illnesses, namely,
diabetes and rheumatoid arthritis.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: pages 71-72
MSC: CRNE: CH-8
3. Which factor has a major impact on the development of chronic illness?
a. Poverty
b. Social stability
c. Urban dwelling
d. High school diploma
ANS: A
Poverty and socioeconomic disadvantage are recognized to have a major impact on the
development of chronic illness, whereas social stability, education, and access to tertiary
care facilities do not impact on the development of chronic illness.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 72
MSC: CRNE: HW-19
4. Which characteristic reflects a nonmodifiable risk factor for chronic illness?
a.
b.
c.
d.
The risk factor cannot be changed.
The risk factor requires intervention in order to change.
The risk factor can be altered to benefit health outcomes.
The risk factor can be changed with patient perseverance.
ANS: A
Behavioural risk factors are considered modifiable, whereas nonmodifiable risk factors (e.g.,
age, gender, genetic makeup) cannot be changed.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 72
MSC: CRNE: HW-2
5. Life expectancy in Canada is estimated to be approximately how many years?
a. 60
b. 70
c. 80
d. 90
ANS: C
The life expectancy for Canadians in 2005 was 78.0 years for males and 82.7 years for
females, thus averaging approximately 80 years of age for the population.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 73
MSC: CRNE: CH-8
6. For which type of cancer does evidence exist to support a genetic predisposition to
occurrence?
a. Lung
b. Breast
c. Cervical
d. Testicular
ANS: B
Genetic testing has shown an inherited predisposition to several types of cancer, including
breast and ovarian cancer, melanoma, and colon cancer.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 73
MSC: CRNE: CH-8
7. Viewing disability as directly caused by disease or trauma reflects which model
perspective?
a. Social
b. Nursing
c. Medical
d. Collaborative
ANS: C
According to the World Health Organization, two main models have shaped the manner in
which we think about disability, namely, the medical model and the social model. The
medical model views disability as directly caused by trauma, disease, or another health
condition, whereas the social model views disability as a socially created problem and not
an inherent attribute of an individual.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 73
MSC: CRNE: CH-8
8. Which statement by the patient reflects an outcome expectancy?
a. I am not able to exercise.
b. Exercise helps people lose weight.
c. Exercise is too hard on my arthritis.
d. Dietary restrictions work better than exercise to lose weight.
ANS: B
An outcome expectancy is the individual’s belief that a specific behaviour will lead to
certain outcomes. For example, the patient who tells the nurse that exercising helps people
lose weight is voicing an outcome expectancy, whereas the patient who tells the nurse that
she is not able to exercise is voicing an efficacy expectancy.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: pages 75-76
MSC: CRNE: NCP-14
9. Which is the most influential source of self-efficacy?
a. Mastery
b. Affective states
c. Verbal persuasion
d. Vicarious experience
ANS: A
Although all of the choices are sources of self-efficacy, mastery relates to a belief about
whether we have what it takes to succeed and is considered the most influential source of
self-efficacy.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 76
MSC: CRNE: CH-8
10. Which of the following reflects a characteristic of health-related hardiness known as
“challenge”?
a. Confidence to appraise a health stressor
b. Ability to modify responses to health stressors
c. Viewing a health stressor as an opportunity for growth
d. Optimal psychosocial adaptation to a health stressor
ANS: C
The three general characteristics of hardy people are control, commitment, and challenge.
Challenge is described as the anticipation of change as an exciting challenge to further
development. Individuals who cognitively reappraise the health stressor so it is viewed as a
stimulating and beneficial opportunity for growth possess the characteristic of challenge.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 76
MSC: CRNE: CH-7
11. Which of the following is a characteristic of chronic illness?
a. Abrupt onset
b. Usually single cause
c. Cure usually likely
d. Uncertainty pervasive
ANS: D
A characteristic of chronic illness is that the uncertainty is pervasive, as opposed to acute
illness, in which the characteristic is minimal uncertainty.
PTS: 1
DIF: Cognitive Level: Knowledge
REF: page 72, Table 5-3
OBJ: 2
TOP: Nursing Process: Assessment
MSC: CRNE: CH-17
12. Which of the following is an example of an environment contextual factor according to the
World Health Organizations’ ICF Bio-Psycho-Social Model?
a. Social background
b. Behaviour pattern
c. Social attitudes
d. Coping style
ANS: C
Social attitudes are an example of an environment contextual factor according to the World
Health Organizations’ ICF Bio-Psycho-Social Model. All of the other options are examples
of internal personal factors.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 74
MSC: CRNE: CH-8
13. Which of the following is an example of effective communication in the domain of respect?
a. Politeness
b. Sincerity
c. Listening
d. Coaching
ANS: C
Listening is an example of an effective communication strategy in the domain of respect.
Politeness and sincerity are effective communication strategies in the domain of courtesy.
Coaching is an example in the engagement domain.
PTS: 1
DIF: Cognitive Level: Application
REF: page 75, Table 5-6
OBJ: 9
TOP: Nursing Process: Assessment
MSC: CRNE:
14. Which illness trajectory phase has, as its goal of management, “Set in motion and continue
the trajectory projection and scheme”?
a.
b.
c.
d.
Pretrajectory
Trajectory onset
Comeback
Downward
ANS: C
The illness trajectory phase of comeback has as its goal of management to “Set in motion
and continue the trajectory projection and scheme”.
PTS: 1
DIF: Cognitive Level: Analysis
REF: pages 78-79, Table 5-7
OBJ: 7
TOP: Nursing Process: Assessment
MSC: CRNE: CH-17
15. Which of the following has been identified by patients with chronic illness as something
they want from the health care system?
a. Less information
b. Less travel and wait times
c. Ways to adjust to disease consequences
d. Limited information on ways to cope with symptoms
ANS: C
Patients with chronic illness identified ways to adjust to disease consequences as one of the
things that they want from the health care system.
PTS: 1
DIF: Cognitive Level: Knowledge
REF: page 81, Table 5-8
OBJ: 8
TOP: Nursing Process: Assessment
MSC: CRNE: HW-26
Chapter 06: Community-Based Nursing and Home Care
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. Which of the following is a current trend in home health nursing?
a. Increased numbers of registered nurses (RNs) are being employed as home health
nurses.
b. Decreased numbers of licensed practical nurses (LPNs) are being employed as
home health nurses.
c. There are more employment opportunities for newly graduated nurses.
d. A minimum of two years of acute care experience is required before employment
as a home health nurse.
ANS: C
Partly because of the nursing shortage, enhancements to the scope of practice and educational
programs for LPNs, and the need to provide long-term intervention to a growing population
with complex and unpredictable health care needs, many home health employers now hire
RNs and LPNs right after graduation.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 93
MSC: CRNE: CH-7
2. Which of the following is considered a foundational concept of home health nursing?
a. Acute care management
b. Health promotion
c. Chronic disease management
d. Health restoration
ANS: B
The two foundations of home health nursing are health promotion and illness prevention.
Health restoration is an element of home health nursing rather than a foundational concept.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 92, Table 6-3
MSC: CRNE: CH-7
3. Home health care nurses deliver care to a variety of patients with acute and chronic illnesses
as part of their nursing practice. These nurses would explain to their patients that they are
practising which type of nursing?
a. Public health nursing
b. Long-term care nursing
c. Community-based nursing
d. Community health nursing
ANS: C
The shared history of visiting and public health nursing continues to unify the two groups of
community health nurses, who are now joined by nurses in many other community-based
roles. Although the community is the context of care for community-based nurses, they
possess an understanding of the entire health system continuum and are able to deliver care to
patients who are acutely or chronically ill.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 87
MSC: CRNE: CH-7
4. Health care services by a specific institution are often implemented through case management.
Which of the following is an activity related to case management?
a. Each member of the health care team performs specific tasks for patient care under
the supervision of a case manager.
b. One nurse manages all interventions required to meet the needs of the patient in
the hospital and the community.
c. The patient’s nurse collaborates with other health care disciplines to plan and
implement coordinated patient care.
d. A professional nurse assesses the patient’s needs and plans and coordinates patient
care with other nurses under the direction of a physician.
ANS: A
Case management is a collaborative patient-driven strategy undertaken by health care
providers and patients to maximize the patient’s ability and autonomy through advocacy,
communication, education, identification of and access to requisite resources, and service
coordination.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 90, Table 6-2
MSC: CRNE: CH-7
5. A 78-year-old woman hospitalized for surgical repair of a fractured hip has recovered from
the surgery but continues to have a nursing diagnosis of impaired physical mobility related to
decreased muscle strength. In planning continued care for the patient, in which setting would
the nurse consider that the patient’s needs would best be met?
a. A public health unit
b. A community health centre
c. The patient’s home
d. An occupational health facility
ANS: C
The patient no longer needs registered nursing care, nor does she need to be in an acute care
setting; therefore, she could be discharged to her home, as a home health care provider is able
to meet her needs. The home health care provider may see the patient in her home as often as
several times a week, depending on the patient’s needs.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 89
MSC: CRNE: CH-14
6. A patient hospitalized with diabetes mellitus is being referred to a certified home health care
agency on discharge from the hospital. Which of the following people will coordinate the
care?
a. A case manager
b. A community registered nurse
c. The patient’s family physician
d. A certified diabetic educator from the hospital
ANS: A
The case manager coordinates the comprehensive care plan and services for the patient,
including arranging for and funding services.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Implementation
REF: page 90, Table 6-2
MSC: CRNE: CH-77
7. How should the nurse describe home care services to a patient requiring extended care?
a. Home care services are limited to visits by nurses or home health aides.
b. For the expenses of home care to be covered, the patient must be confined to bed.
c. The patient’s family will need to be included in planning and teaching about the
patient’s care.
d. Technologically complex therapies, such as parenteral chemotherapy and
mechanical ventilators, cannot be managed at home.
ANS: C
The home health care nurse negotiates the care with the patient and the family. Families often
provide care for ill members and assist in decision making about all aspects of the care
provided.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 90
MSC: CRNE: CH-19
8. Which of the following is a key principle of primary health care?
a. Universal access to health care on an economic basis
b. Focus on acute illness and cure
c. Partnership with other professions and sectors for health
d. Individuals as passive recipients of health care
ANS: C
One of the six key principles of primary health care is to partner with other disciplines,
communities, and sectors for health (intersectoral approach).
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 88
MSC: CRNE: CH-28
9. On average, what is the approximate national percentage of provincial/territorial budgets in
Canada that are expended on health care costs?
a. 19%
b. 29%
c. 39%
d. 49%
ANS: C
Approximately 39% of provincial and territorial budgets are consumed with health care costs;
the range is between 30% in Quebec and 47% in Nova Scotia, giving an average of 38.5%.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 88
MSC: CRNE: CH-8
10. Primary health care is increasingly being embraced as a strategy to shift the health system’s
focus from treatment of disease to health promotion. This shift is known as which of the
following?
a.
b.
c.
d.
Economic shift
Reforming the system
Enhancing primary health care
Chronic disease management in home care settings
ANS: B
This shift is also known as reforming the system. Primary health care is increasingly being
embraced as a strategy to shift the health system’s focus from diagnosis and treatment of
illness and injury to health promotion and disease prevention.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 88
MSC: CRNE: CH-8
Chapter 07: Older Adults
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. While obtaining a health history, the nurse finds that the patient takes daily supplements of
the antioxidants beta carotene, selenium, and vitamin E. What biological aging theory is
related to the use of these substances?
a. Free radicals
b. Cross-linking
c. Somatic mutation
d. Telomere-telomerase depletion
ANS: A
The free radical theory was initially proposed in 1956, and since then, research has focused
on the use of antioxidants to slow the oxidative process caused by free radicals.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 101
MSC: CRNE: CH-8
2. Which of the following is an element of a stochastic theory of aging?
a. Programmed
b. Transcription
c. Neuroendocrine
d. Immunological-autoimmunological
ANS: B
Transcription is an element of a stochastic theory; all of the others are elements of
nonstochastic theories.
PTS: 1
DIF: Cognitive Level: Knowledge
REF: page 101, Table 7-1
OBJ: 2
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
3. Which of the following is an appropriate approach that the nurse should use to facilitate
learning in older adults?
a. Using peer educators
b. Avoiding issues of a personal nature
c. Presenting material quickly to avoid fatigue
d. Acknowledging the older adult’s dependence
ANS: A
A specific strategy to decrease anxiety and distractions when teaching older adults is to use
peer educators to enhance learning.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 114, Table 7-10
OBJ: 9
TOP: Nursing Process: Implementation MSC: CRNE: NCP-14
4. In planning care for older adult patients with chronic illnesses, what does the nurse
recognize that management of chronic illness requires?
a. Institutionalization in long-term care facilities
b. Adjusting to changes in the course of the disease
c. Restricting social interactions outside of the home
d. Frequent hospitalizations for treatment of acute episodes of the illness
ANS: B
Individualized care is the standard of practice with older adults; therefore, it is important
during the planning phase of managing chronic illness to adjust care to changes in the
course of the disease.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 108, Table 7-5
OBJ: 4
TOP: Nursing Process: Planning
MSC: CRNE: CH-17
5. What should be considered when developing the plan of care for an older adult who is
hospitalized for an acute illness?
a. Use a standardized geriatric nursing care plan.
b. Consider preadmission functional abilities when setting goals.
c. Minimize activity level during hospitalization.
d. Plan for likely long-term care transfer to allow additional time for recovery.
ANS: B
The plan of care for older adults should be individualized and based on the patient’s current
functional abilities, so it is important for the nurse to assess preadmission functional abilities
when setting goals.
PTS: 1
DIF: Cognitive Level: Application
REF: pages 113, 114, Table 7-11
OBJ: 5
TOP: Nursing Process: Planning
MSC: CRNE: CH-10
6. As the nurse is teaching a 72-year-old woman about her new medications, she replies that
she “just can’t remember all that information anymore.” What knowledge about aging does
the nurse use to understand why the woman may have difficulty learning about the
medications?
a. Intellectual ability declines with age.
b. All mental abilities slow as individual’s age.
c. Declining physical health can impair cognitive function.
d. Impaired vocabulary and verbal function decrease reasoning with age.
ANS: C
The process of learning new information is slower in older adults with declining physical
health as it can impair cognitive functioning, but the patient has given no indication that she
will be unable to learn about the new medications.
PTS: 1
DIF: Cognitive Level: Application
REF: page 114, Table 7-10
OBJ: 5
TOP: Nursing Process: Planning
MSC: CRNE: NCP-14
7. Which of the following is a normal physiological age-related change of the cardiovascular
system?
a. Elastin and smooth muscle increases.
b. Vessel rigidity decreases.
c. Heart muscle decreases.
d. Mitral valve constriction increases.
ANS: C
A normal physiological age-related change in the cardiovascular system is that the heart
muscle decreases.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 103, Table 7-2
OBJ: 9
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
8. What data collection method does the nurse recognize as eliciting the most complete
information during a geriatric assessment?
a. Having the patient recount his or her health history
b. Having the caregiver provide the information on the patient
c. Using a reliable geriatric assessment instrument to evaluate the patient
d. Having the patient provide a diary of medical conditions and treatments
ANS: C
The most complete information about the patient will be obtained through the use of an
assessment instrument specific to the geriatric population, which will include information
about medical diagnoses and treatments as well as about functional health patterns and
abilities.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 113
MSC: CRNE: CH-4
9. An older adult patient has experienced physiological changes of the cardiovascular system
that are related to aging. What is an appropriate nursing diagnosis for the nurse to document
for this patient?
a. Fatigue related to decreased hemoglobin
b. Activity intolerance related to bed rest deconditioning
c. Fatigue related to loss of muscle strength and increased work of breathing
d. Activity intolerance related to imbalance between oxygen supply and demand
ANS: D
Activity intolerance is a common nursing diagnosis for the older adult because of agerelated cardiovascular changes.
PTS: 1
DIF: Cognitive Level: Application
REF: page 113, Table 7-9
OBJ: 1
TOP: Nursing Process: Diagnosis
MSC: CRNE: CH-15
10. Which of the following functions declines during old age?
a. Fluid intelligence
b. Spatial perception
c. Mental performance speed
d. Short-term recall memory
ANS: D
Short-term memory recall is a manifestation of healthy aging that declines during old age.
Fluid intelligence and mental performance speed decline during middle age. Spatial
perception remains constant or improves with aging.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 107, Table 7-3
OBJ: 9
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
11. In planning care for an older adult, what does the nurse recognize as a major goal of health
promotion and prevention of health problems in the elderly?
a. Adequate planning for post-hospital care
b. Preventing the physiological degeneration of aging
c. Teaching the older adult about alternative care options
d. Increasing personal participation and responsibility in health
ANS: D
By increasing personal participation and responsibility in health, the nurse is assisting with
the priority goals for the older adult, which contribute to gaining a sense of control, feeling
safe, and reducing stress.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 114
MSC: CRNE: HW-1
12. When performing a nutrition assessment of an older adult using the SCALES acronym, what
would the nurse be assessing when documenting the findings from the “A” portion of this
assessment tool?
a. Anxiety
b. Albumin level
c. Appearance in general
d. AC glucose level
ANS: B
The A in the SCALES acronym for a nutritional assessment if an older adult represents
albumin levels; specifically, assessing if the albumin level is low.
PTS: 1
DIF: Cognitive Level: Application
REF: page 107, Table 7-4
OBJ: 9
TOP: Nursing Process: Assessment
MSC: CRNE: CH-1
13. What is an appropriate teaching topic to help prevent drug–drug interactions in an older
adult patient taking many medications?
a. “Do not take any over-the-counter drugs with your prescription drugs.”
b. “Be sure a family member knows the name and use of all of your medications.”
c. “Bring all the medications, supplements, and herbs that you use to every health
care appointment.”
d. “Use a medication reminder system so that you won’t forget to take your
medications as scheduled.”
ANS: C
The most information about drug use and possible interactions is obtained when the patient
brings all prescribed medications, over-the-counter medications, and supplements to every
health care appointment.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 115
MSC: CRNE: CH-3
14. The nurse assesses an older adult patient’s living arrangements and care needs with the
knowledge that abuse of older adults often occurs in which of the following situations?
a. Stress in the caregiver is overwhelming.
b. Programs for the elderly are not being utilized.
c. Several generations are providing the care.
d. The older adult is not appreciative of those who provide care.
ANS: A
The intensity and complexity of caregiving place the caregiver at risk for high levels of
stress. The caregiver may develop a sense of being overwhelmed and have feelings of
inadequacy, powerlessness, and depression, which may lead to abuse of the older adult.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 109
MSC: CRNE: HW-7
15. When admitting an older adult patient to the hospital, the nurse asks the patient about
advance directives. The patient notes that he has a proxy directive for health care. What does
the nurse recognize that the patient has done?
a. Left instructions that are not legally binding about actions to be taken regarding his
care in the event of a terminal or irreversible condition
b. Designated another person to make legally binding health care decisions for him if
he is unable to do so for himself
c. Documented directions that are legally binding about actions to be taken regarding
his care in the event of a terminal or irreversible condition
d. Designated another person to make health care decisions for him if he is unable to
do so for himself, but those decisions are not legally binding.
ANS: B
In a proxy directive, the older adult specifies who is to make health care decisions if the
person becomes unable to make his or her wishes known.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 112
MSC: CRNE: NCP-9
16. Why is ageism an important concept to understand when caring for the elderly?
a. May damage the self-esteem of older adults
b. Increases social awareness of the needs of older adults
c. Provides statistical information regarding the older adult population
d. Promotes consideration of the diversity of the older adult population
ANS: A
Negative attitudes about aging may lead to disparities in the way older patients are treated,
thus damaging their self-esteem.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 100
MSC: CRNE: CH-8
17. Among the older population, what classification would represent a 78-year-old woman who
has multiple health problems associated with her diabetes, including unplanned weight loss
(7 kg over the past year), poor endurance, and low activity?
a. Old-old
b. Ill older adult
c. Young-old
d. Frail older adult
ANS: D
Frail older adult is a term used to identify those older adults who, because of declining
physical health and resources, are most vulnerable. Risk factors include disability, multiple
chronic illnesses, and the presence of geriatric syndromes. Frailty has been defined as the
presence of three or more of the following: unplanned weight loss ( 4.5 kg in the last year),
weakness, poor endurance and energy, slowness, and low activity.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 107
MSC: CRNE: HW-22
18. The frail older adult is at particularly high risk for which one of the following health
interferences?
a. Hip fractures
b. Malnutrition
c. Overhydration
d. Obesity
ANS: B
The frail older adult is at particular risk for malnutrition and problems with dehydration.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 107
MSC: CRNE: CH-8
19. In establishing a therapeutic environment for an older adult patient, how can the nurse
provide special considerations?
a. Limiting the contact to 15-minute intervals
b. Allowing greater time to gather a medical history
c. Speaking slowly and loudly to ensure understanding
d. Ensuring that the patient is free of pain and is comfortable
ANS: D
When beginning the assessment process, the nurse should attend to primary needs first, for
example, ensuring that the patient is free of pain and does not need to urinate.
PTS:
1
DIF:
Cognitive Level: Application
REF: page 113
OBJ: 9
TOP: Nursing Process: Assessment
MSC: CRNE: CH-1
20. In planning discharge teaching for an older, homeless adult, what is a common reason that
older homeless adults often do not utilize shelter and meal-site services?
a. They are ashamed about being homeless.
b. They fear that they will be institutionalized.
c. They feel that they do not deserve community support.
d. They feel that use of such services means they cannot make it on their own.
ANS: B
Fear of institutionalization may explain the reason the older homeless adult does not use
shelter and meal-site services.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 107
MSC: CRNE: HW-6
Chapter 08: Stress and Stress Management
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A 40-year-old woman comes to the health clinic requesting sleeping medication and
treatment for headaches. She tells the nurse that her husband has moved out to live with
another woman. Her 16-year-old son, who has a drug problem, sold her jewellery and
electronic equipment. What stress theory is the nurse using in concluding that the woman’s
life events are contributing to her insomnia and headaches?
a. Stress as a stimulus
b. Stress as a response
c. Stress as a perception
d. Stress as a transaction
ANS: A
The major assumption of stress as a stimulus theory is that frequent life changes make
people more vulnerable to illness. Life changes can range from minor violations of the law
to the death of a loved one.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 123
MSC: CRNE: CH-7
2. A woman is brought to the emergency department after she was assaulted in a shopping
centre parking lot. Her purse was stolen, and she was thrown to the pavement, suffering
minor abrasions and contusions. What finding related to the general adaptation syndrome
would the nurse expect to find on assessment of the patient?
a. Uncontrolled sobbing
b. Repeatedly describing the attack
c. Hypoglycemia with tremors and hunger
d. Increased blood pressure, pulse, and respirations
ANS: D
The first stage of the stress response is the alarm reaction of the general adaptation
syndrome, in which the individual perceives a stressor physically or mentally and the fightor-flight response is initiated, as evidenced by an increase in blood pressure, pulse, and
respirations.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 123
MSC: CRNE: CH-7
3. A patient is scheduled for exploratory abdominal surgery to determine the cause of
intermittent abdominal pain that he has had for the past six months. He tells the nurse that it
will be a relief to finally have an answer as to the cause of the pain and that he feels relaxed
about having the surgery. The nurse concludes that the patient is depicting stress as which
type of transaction?
a. He is denying his anxiety about the planned surgery.
b. He will have no physiological response to the surgical procedure.
c. He has a sense of coherence that is able to mediate his stress.
d. He does not perceive that he is lacking adaptive resources for the planned surgery.
ANS: D
A third stress theory focuses on person–environment transactions and is referred to as the
transaction or interaction theory. It emphasizes the role of cognitive appraisal in assessing
stressful situations and selecting coping options.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 123
MSC: CRNE: CH-7
4. A middle-aged man is recovering from a heart attack. He tells the nurse he is not surprised
he had the attack because his work and home life are very stressful and he feels as if he is
going to explode most of the time. What coping behaviours should the nurse suggest that
would both increase the patient’s resistance to stress and reduce the amount of stress he
feels?
a. Changing his job and reorganizing his priorities at home
b. Learning all he can about heart disease and its effects on his body
c. Joining a community group of individuals with heart disease and their families
d. Performing healthy lifestyle behaviours related to diet, sleep, and exercise
ANS: D
Resistance to stress can be increased with a healthy lifestyle to maintain good health
regardless of sex, age, and economic status. Healthy behaviours are also cumulative, that is,
the greater the number of these factors habitually practised by the individual, the better the
health.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 133
MSC: CRNE: CH-7
5. A hospitalized patient is very anxious about missing work and is afraid he will be fired
because of his illness. What effect of stress on the nervous system does the nurse recognize
that the patient is experiencing?
a. Sleep disturbances
b. Orthostatic hypotension
c. Increased sensitivity to pain
d. Fluid and electrolyte imbalances
ANS: A
Symptomatic experiences of stress may include headache, musculoskeletal pain,
gastrointestinal upset, skin disorders, insomnia, and chronic fatigue.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 132
MSC: CRNE: CH-7
6. When developing a pathophysiological map for a cognitive appraisal process, what must
occur first?
a. A stimulus
b. A patient-identified need
c. Evidence of alteration in cognitive functioning
d. A primary appraisal of the patient and the situation
ANS: A
When developing a pathophysiological map for a cognitive appraisal process, a stimulus
must first be presented, followed by a primary appraisal.
PTS: 1
DIF: Cognitive Level: Application
REF: page 123, Figure 8-1
OBJ: 9
TOP: Nursing Process: Planning
MSC: CRNE: CH-10
7. According to the general adaptation theory, which of the following occurs when a patient is
in the alarm reaction phase?
a. Decreased cardiac output
b. Peripheral vasodilatation
c. Decreased stroke volume
d. Decreased gastrointestinal secretions
ANS: D
Decreased gastrointestinal secretions and peristalsis are responses that occur in the alarm
reaction phase of the general adaptation theory.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 124, Figure 8-2
OBJ: 2
TOP: Nursing Process: Assessment
MSC: CRNE: CH-7
8. Which of the following is an external factor that affects an individual’s response to stress?
a. Sleep status
b. Coping skills
c. Income and social status
d. Personality
ANS: C
Three external factors have been identified that affect an individual`s response to stress:
income and social status, social support, and culture.
PTS: 1
DIF: Cognitive Level: Application
REF: page 124, Determinants of Health Box
OBJ: 8
TOP: Nursing Process: Assessment
MSC: CRNE: CH-7
9. Which initial area is stimulated when an individual experiences stress?
a. Anterior pituitary gland
b. Hypothalamus
c. Adrenal cortex
d. Posterior pituitary gland
ANS: B
The initial area stimulated in response to stress is the hypothalamus.
PTS: 1
DIF: Cognitive Level: Knowledge
REF: page 126, Figure 8-5
OBJ: 6
TOP: Nursing Process: Assessment
MSC: CRNE: CH-7
10. Which complementary and alternative therapy is an ancient strategy that is used to relax and
promote mindfulness?
a. Imagery
b. Meditation
c. Acupuncture
d. Music for relaxation
ANS: B
Meditation is an ancient strategy that is used to relax and promote mindfulness.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 130
MSC: CRNE: NCP-10
Chapter 09: Sleep and Sleep Disorders
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. Which of the following is a common misconception about sleep in the older adult?
a. Older adults need less sleep than middle-aged adults.
b. Insomnia symptoms in the older adult frequently occur with depression.
c. Older female adults report more trouble falling asleep than their male counterparts.
d. Diabetes in the older adult can increase the prevalence of insomnia.
ANS: A
A common myth is that older people need less sleep than younger people; in fact, the
amount of sleep needed as a person ages remains relatively constant. All of the other
statements are true.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 148
MSC: CRNE: CH-7
2. What should the nurse do, initially, to assist in determining whether a patient seen in the
ambulatory care setting has chronic insomnia?
a. Schedule a polysomnography (PSG) study.
b. Arrange for the patient to have a sleep study.
c. Ask the patient to keep a two-week sleep diary.
d. Teach the patient about the use of an actigraph.
ANS: C
The diagnosis of insomnia is made on the basis of subjective complaints and an evaluation
of a one- to two-week sleep diary completed by the patient. Actigraphy and PSG studies or
sleep studies can be used for determining specific sleep disorders but are not necessary to
make an initial insomnia diagnosis.
PTS: 1
DIF: Cognitive Level: Application
REF: page 140-141, Table 9-3
OBJ: 4
TOP: Nursing Process: Assessment
MSC: CRNE: CH-4
3. Which instruction will the nurse include when teaching a patient with chronic insomnia
about ways to improve sleep quality?
a. Avoid aerobic exercise during the day.
b. Read in bed for a few minutes each night.
c. Keep the bedroom temperature slightly warm.
d. Try to go to bed at the same time every evening.
ANS: D
A regular evening schedule is recommended to improve sleep time and quality. Aerobic
exercise may improve sleep quality but should occur at least six hours before bedtime.
Reading in bed is discouraged for patients with insomnia. The bedroom temperature should
be slightly cool.
PTS: 1
DIF: Cognitive Level: Application
REF: page 141, Table 9-4
OBJ: 4
TOP: Nursing Process: Implementation MSC: CRNE: CH-10
4. After the nurse has taught a patient about the use of extended-release Zopiclone (Imovane)
for insomnia, which patient statement indicates a need for further teaching?
a. “I will take the medication an hour before bedtime.”
b. “I should take the medication on an empty stomach.”
c. “I should not take this medication unless I can sleep for at least six hours.”
d. “I will schedule activities that require mental alertness for later in the day.”
ANS: A
Benzodiazepine receptor-like agonists such as Zopiclone work quickly and should be taken
immediately before bedtime. The other patient statements are correct.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 144
MSC: CRNE: CH-44
5. Which action is best for the nurse to include in the plan of care in order to improve sleep
quality for a critically ill patient in the critical care unit (CCU)?
a. Ask all visitors to leave the CCU for the night.
b. Lower the level of light from 2000 hours until 0700 hours.
c. Avoid the use of opioids for pain relief during the evening hours.
d. Schedule assessments to allow at least four hours of uninterrupted sleep.
ANS: B
Lowering the level of light will help mimic normal day/night patterns and maximize the
opportunity for sleep. Although frequent assessments and opioid use can disturb sleep
patterns, these actions are necessary for the care of critically ill patients. For some patients,
having a family member or friend at the bedside may decrease anxiety and improve sleep.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 144
MSC: CRNE: CH-13
6. Which information will the nurse plan to include when teaching a patient with narcolepsy
about management of the disorder?
a. Stimulant drugs should be used for only a short time because of the risk for abuse.
b. Driving an automobile may be possible with appropriate treatment of narcolepsy.
c. Changes in sleep hygiene are ineffective in improving sleep quality in narcolepsy.
d. Antidepressant drugs are prescribed to treat the depression caused by the disorder.
ANS: B
The accident rate for patients with narcolepsy who are receiving appropriate treatment is
similar to the general population. Stimulant medications are used on an ongoing basis for
patients with narcolepsy. The purpose of antidepressant drugs in the treatment of narcolepsy
is the management of cataplexy, not to treat depression. Changes in sleep hygiene are
recommended for patients with narcolepsy to improve sleep quality.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 145
MSC: CRNE: HW-26
7. Healthy adults spend what percentage of sleep time in non–rapid eye movement (NREM)
sleep?
a. 20% to 25%
b. 45% to 50%
c. 75% to 80%
d. 85% to 90%
ANS: C
Healthy adults spend the largest percentage of sleep time in NREM sleep—75% to 80% of
total sleep time.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 138
MSC: CRNE: CH-7
8. Which of the following is a relatively noninvasive method of monitoring rest and activity
cycles?
a. Self-report
b. Actigraphy
c. Polysomnography
d. Pittsburgh Sleep Quality Index
ANS: B
Actigraphy is a relatively noninvasive method of monitoring rest and activity cycles; a
watch can be worn on the wrist to measure gross motor activity.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 142
MSC: CRNE: CH-4
9. Which of the following should the nurse teach a patient to assist him or her with a sleep
disturbance?
a. If you are not asleep within one hour of going to bed, get out of the bed.
b. Exercise an hour before going to bed.
c. Have a glass of wine or a beer just before bedtime.
d. Avoid caffeine and alcohol for at least four hours before bedtime.
ANS: D
The nurse should teach the patient to avoid caffeine, nicotine, and alcohol for at least four to
six hours before bedtime.
PTS: 1
DIF: Cognitive Level: Application
REF: page 141, Table 9-4
OBJ: 4
TOP: Nursing Process: Implementation MSC: CRNE: HW-2
10. Which of the following is an arousal parasomnia that occurs during NREM sleep?
a. Enuresis
b. Hallucinations
c. Sleepwalking
d. Nightmares
ANS: C
Sleepwalking and sleep terrors are arousal parasomnias that occur during NREM sleep.
Enuresis and hallucinations are parasomnias that occur during REM sleep. Nightmares are
parasomnias that normally occur during the final third of sleep and in association with REM
sleep.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 149
MSC: CRNE: CH-7
Chapter 10: Pain
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A 45-year-old woman has breast cancer that has spread to her liver and spine. She has been
taking oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home, but she now
has constant severe pain and is hospitalized for pain control and development of a pain
management program. During assessment of the patient, what information related to her pain
is most important for the nurse to obtain initially?
a. The pattern, area, intensity, and nature of her pain
b. Identification of trigger points of pain by palpation of painful areas
c. The schedule and total dosages of the drugs she is currently taking and when
breakthrough pain occurs
d. The presence of a sympathetic response, such as tachycardia, diaphoresis, and a
rise in blood pressure
ANS: A
Pain is a complex experience involving physiological, sensory (i.e., the perception of pain by
the individual that addresses the pain location, intensity, pattern, and quality), affective,
behavioural, and cognitive dimensions; therefore, the nurse needs to assess the pattern, area,
nature, and intensity of the pain immediately.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 158
MSC: CRNE: CH-1
2. The physician plans to titrate narcotic analgesic to provide pain relief for a patient with
surgical pain. What does the nurse’s role in include?
a. Monitoring the effects of continuous intravenous (IV) infusion of narcotic
analgesics
b. Teaching the patient to try to increase the time between doses of pain medication
c. Assisting the patient to plan the use of a specific total dose of analgesic over a 24hour period
d. Determining with the patient the optimal analgesic dosage required for pain relief
with attention to the side effects produced
ANS: D
The goal of titration is to use the smallest dosage of analgesic that provides effective pain
control with the fewest side effects.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 166
MSC: CRNE: CH-52
3. It is determined that a step 3 drug as proposed by the World Health Organization (WHO) is
necessary for a patient whose cancer pain is unrelieved by step 2 drugs. Which is an
appropriate drug and route for this patient?
a. Oral codeine
b. Oral morphine
c. Intramuscular meperidine (Demerol)
d. Intravenous oxymorphone (Numorphan)
ANS: B
A step 2 drug that would be appropriate is morphine, which is the standard of comparison for
all other opioid analgesics. Sustained-release preparations (e.g., MS Contin) are also
available.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: pages 168-169, Table 10-11
MSC: CRNE: CH-52
4. Which of the following is true of persistent pain?
a. It occurs within the normal healing time.
b. The course of pain decreases over time.
c. It is accompanied by an increased heart and pulse rate.
d. It is often accompanied by changes in affect and withdrawal from other people.
ANS: D
A behavioural manifestation of persistent pain is a change in affect and withdrawal from other
people and social interaction.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 161, Table 10-5
MSC: CRNE: CH-7
5. The physician tells a patient to use ibuprofen (Motrin, Advil) to relieve the pain after treating
a laceration on the patient’s forearm from a dog bite. The patient tells the nurse that he does
not think ibuprofen will control his pain. The nurse’s response is based on the knowledge that
ibuprofen interferes with the pain by decreasing what process?
a. Perception
b. Modulation
c. Transduction
d. Transmission
ANS: C
Therapies directed at altering either the primary afferent nociceptor (PAN) environment or the
sensitivity of the PAN are used to prevent the transduction and initiation of an action
potential. An example is ibuprofen.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: pages 166-167, Table 10-9
MSC: CRNE: CH-52
6. A postoperative patient who has undergone extensive bowel surgery moves as little as
possible and does not use his incentive spirometer unless specifically reminded. He rates his
pain severity as an 8 on a 10-point scale but tells the nurse that he can “tough it out.” To
encourage the patient to use pain medication, what should the nurse explain about the effects
of withholding or delaying analgesics?
a. Very few patients become addicted to opioids when using them for pain control.
b. He should not worry about side effects because these problems usually decrease
over time.
c. Multiple options of medications are available, and if one drug does not relieve his
pain, other drugs may be tried.
d. Unrelieved pain can be harmful because it impairs respiratory and gastrointestinal
function and can impair his recovery from surgery.
ANS: D
In the acutely ill patient, unrelieved pain can result in increased morbidity as a result of
respiratory dysfunction, increased heart rate and cardiac workload, increased muscular
contraction and spasm, decreased gastrointestinal motility and transit, and increased
catabolism.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 166
MSC: CRNE: CH-52
7. A patient with a kidney stone in her right ureter has pain in her right flank area and also
complains of pain in her right inner thigh. She asks the nurse whether something is wrong
with her leg. In responding to the question, on what knowledge does the nurse base the
patient’s understanding of pain?
a. Referred pain results when dorsal horn neurons receive input from both C fibres
and A-beta fibres.
b. Stimulation of the cerebral cortex by small C fibres causes muscle spasm, leading
to pain perception in large muscle groups.
c. Radiating type of pain results from activation of normally inactive receptors by
repetitive nociceptive signals to the dorsal horn.
d. Poor localization of pain occurs when PANs release neurotransmitters that inhibit
nerve cells in the dorsal column.
ANS: A
Inputs from both C fibres and A-beta fibres converge on the wide-dynamic-range neurons,
and when the message is transmitted to the brain, the originating area of the body is poorly
localized. The concept of referred pain must be considered when interpreting the location of
pain reported by the person with injury to or disease involving visceral organs.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 158
MSC: CRNE: CH-7
8. Which of the following is a possible musculoskeletal consequence of unrelieved pain?
a. Decreased peristalsis
b. Hypermobility
c. Muscle spasm
d. Muscle protein catabolism
ANS: C
Possible musculoskeletal consequences of unrelieved pain include muscle spasm, impaired
muscle function, fatigue, and immobility. Muscle protein catabolism is a consequence of
unrelieved pain, but it is a metabolic consequence, not a musculoskeletal one.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 155, Table 10-1
MSC: CRNE: CH-7
9. Amitriptyline, a tricyclic antidepressant, is being administered to a patient with chronic cancer
pain. What does the nurse recognize as the expected outcome of administration of this drug?
a. Increased pain threshold by stimulating the release of endogenous enkephalins
b. Decreased perception of pain by blocking opiate receptors in the brain and
descending inhibitory nerves
c. Decreased transmission of pain impulses by altering serotonin and norepinephrine
activity at nerve synapses
d. Increased pain tolerance through relief of depression by increasing the amounts of
norepinephrine in the brain
ANS: C
Tricyclic antidepressants have analgesic properties at doses lower than those effective for
depression. They enhance the descending inhibitory system by preventing synaptic reuptake
of serotonin and norepinephrine, thereby decreasing the transmission of pain impulses.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 170
MSC: CRNE: CH-48
10. A patient with chronic abdominal pain has learned to control the pain with the use of imagery
and hypnosis. What does the nurse recognize about how these cognitive strategies work?
a. They reduce the sensory and affective components of pain.
b. They prevent transmission of nociceptive stimuli to the cortex.
c. They decrease the intensity of the pain that the patient is willing to tolerate.
d. They decrease sensitization by increasing the production of glutamate in the spinal
cord.
ANS: A
Imagery is a structured technique that uses the patient’s own imagination to develop sensory
images that divert focus away from the pain sensation and emphasize other sensory
experiences and pleasant memories. Hypnotic therapy is a structured technique that enables a
patient to achieve a state of heightened awareness and focused concentration that can be used
to alter the patient’s pain perception.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 177
MSC: CRNE: CH-51
11. A patient in a publicly funded pain clinic asks the nurse how long he will have to wait to see a
health care provider who is an expert in pain. The nurse’s response is based on the fact that
the average wait time in Canada for expert pain-related care is approximately how long?
a. One month
b. Three months
c. Six months
d. One year
ANS: D
Average wait times in Canada for expert pain-related care are approximately one year at more
than one-third of the publicly funded pain clinics, and many regions have no access to
appropriate care.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Planning
REF: page 155
MSC: CRNE: CH-8
12. An 86-year-old man has severe degenerative arthritis in his hips. In planning care for the
patient, what does the nurse recognize about chronic pain in an older adult?
a. It is more readily tolerated than in younger patients.
b. It does not require the use of narcotic drugs for control.
c. It is poorly tolerated because of past experiences with pain.
d. It is often believed by the patient to be an inevitable part of aging.
ANS: D
Older patients often believe that pain is a normal, inevitable part of aging. They may also
believe that nothing can be done to relieve the pain.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 180
MSC: CRNE: HW-22
13. In developing a concept of pain to use in working with patients experiencing pain, what does
the nurse acknowledge about pain?
a. Pain always causes suffering.
b. All pain serves a physiological purpose.
c. Pain is a phenomenon.
d. Pain is present whenever nociception occurs.
ANS: C
Pain is a complex, multidimensional, and subjective experience, and its management is
influenced greatly by psychosocial, sociocultural, and legal and ethical factors.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 156
MSC: CRNE: CH-7
14. To obtain the most complete assessment data about a patient’s chronic pain pattern, what
should the nurse ask the patient?
a. “Can you describe where your pain is the worst?”
b. “What is the intensity of your pain on a scale of 0 to 10?”
c. “Would you describe your pain as aching, throbbing, or sharp?”
d. “Can you describe your daily activities in relation to your pain?”
ANS: D
At a bare minimum, the effects of the pain on the patient’s sleep and daily activities,
relationships with others, physical activity, and emotional well-being should be assessed.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 164
MSC: CRNE: CH-1
15. Morphine 10 mg IV every four to six hours as needed is ordered for a patient with a
pancreatic tumour who has a history of alcoholism. After three days of receiving the morphine
every six hours, the patient tells the nurse that the medication is needed more frequently to
control the pain. In responding to the patient’s request, what does the nurse recognize?
a. A tolerance to the morphine is developing, and the patient should receive the drug
more frequently.
b. Administering the morphine more frequently will increase the patient’s physical
dependence on the drug.
c. Physical dependence should be avoided at all costs, and the drug should continue
to be administered every six hours.
d. The patient is becoming addicted to the morphine, and it should be administered
less frequently than every six hours.
ANS: A
People with past or current substance abuse are at high risk for inadequate pain management.
Health care providers must understand that adequate pain relief is a basic human right, be
aware of their own biases, and ensure that all patients are treated respectfully.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 167
MSC: CRNE: CH-51
16. A patient with extensive second-degree burns on his legs and trunk is using patient-controlled
analgesia (PCA) with IV morphine to be delivered at 1 mg every 10 minutes to control his
pain. Several times during the night, he awakens in severe pain, and it takes more than an hour
to regain pain relief. What is the most appropriate nursing action at this time?
a. Administer a dose of morphine every hour from the PCA machine while the
patient sleeps.
b. Request that the physician order a bolus dose of morphine to be given when the
patient awakens with pain.
c. Consult with the patient’s physician about adding a continuous morphine infusion
to the PCA regimen at night.
d. Teach the patient to push the button every 10 minutes for an hour before he goes to
sleep, even if he has minimal pain at that time.
ANS: C
The addition of a continuous basal infusion to a PCA regimen improves nighttime pain relief
and promotes better sleep postoperatively (known as PCA plus basal).
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 173
MSC: CRNE: CH-51
17. When caring for a patient who is receiving epidural fentanyl, the nurse should monitor the
patient for which common side effect?
a. Headache
b. Agitation
c. Urinary retention
d. Abdominal cramping and diarrhea
ANS: C
Nausea, itching, and urinary retention are common side effects of intraspinal opioids. Drugs
that are delivered intraspinally include morphine, fentanyl, and hydromorphone.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 172
MSC: CRNE: CH-44
18. Which type of pain is caused by damage to somatic tissue?
a. Visceral
b. Nociceptive
c. Neuropathic
d. Sensory-discriminative
ANS: B
Nociceptive pain is caused by damage to somatic or visceral tissue.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 157, Figure 10-2
MSC: CRNE: CH-7
19. What is the mechanism of action of NSAIDs?
a. They block action potential initiation.
b. They block prostaglandin production.
c. They inhibit cyclo-oxygenase action.
d. They interfere with serotonin uptake.
ANS: B
The mechanism of action of NSAIDs is to block prostaglandin production.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Synthesis
TOP: Nursing Process: Assessment
REF: page 159, Table 10-3
MSC: CRNE: CH-44
Chapter 11: Substance Use
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. When explaining the effects of abused substances to a group of young adults, what should the
nurse tell them about changes in the brain that are caused by prolonged use of these
substances?
a. Causes increased sensitivity to environmental stimuli
b. Requires the continual use of the substances to feel normal
c. Promotes the hyperrelease and activity of neurotransmitters
d. Leads to destruction of brain cells in the cerebral cortex
ANS: B
Without the substance or behaviour, the individual experiences depression, anxiety, and
irritability. To feel normal, the individual must take the drug.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: pages 189-190
MSC: CRNE: HW-17
2. During physical assessment of a patient with chronic alcohol abuse, what does the nurse
identify as a pathophysiological change related to alcohol?
a. Hypotension
b. Hyperthermia
c. Hepatomegaly
d. Dependent edema
ANS: C
Hepatic system changes include steatosis (reversible), nausea, vomiting, hepatomegaly, and
alcoholic hepatitis.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: pages 202-204, Table 11-14
MSC: CRNE: CH-8
3. A young man is brought to the emergency department by the police, who found him running
through traffic and yelling that he could fly over the cars. He is very agitated and restless. On
questioning, he admits to the nurse that he took some drugs at a party a few hours before.
What is an appropriate nursing diagnosis for the nurse to document for this patient?
a. Anxiety related to effects of drugs
b. Risk for injury related to altered perception
c. Risk for violence: self-directed related to guilt
d. Powerlessness related to loss of control of behaviour
ANS: B
The patient is at high risk for injury because of a lack of coordination and impaired
judgement, and protective measures should be used. The priority nursing goal would be to
prevent the patient from hurting himself.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
REF: page 202
MSC: CRNE: CH-15
4. A patient hospitalized for elective surgery stopped smoking two days before admission as
advised by the nurse. When caring for the patient postoperatively, what does the nurse
recognize that nicotine withdrawal may cause?
a. Insomnia, craving, and hyperirritability
b. Headache, nervousness, and depression
c. Fatigue, somnolence, and shortness of breath
d. Loss of appetite, increased heart rate, and increased blood pressure
ANS: A
Nicotine withdrawal symptoms include craving, restlessness, depression, hyperirritability,
headache, insomnia, decreased blood pressure and heart rate, and increased appetite.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 190, Table 11-4
MSC: CRNE: CH-9
5. When working with individuals with any substance dependency, during cessation and
recovery, why does the nurse advise them to avoid activities and places associated with the
substance use?
a. To decrease cue-induced craving
b. To increase their motivation to continue abstinence
c. To prevent substance-abusing friends from influencing their behaviour
d. To avoid reminders of the negative behaviours they previously demonstrated
ANS: A
An important type of craving experienced by individuals with addictions, cue-induced
craving, occurs in the presence of people, places, or things that they have previously
associated with drug taking. Cue-induced craving may occur after long periods of abstinence
and is a common cause of relapse; therefore, patients are advised to avoid places and activities
associated with their substance abuse.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 190
MSC: CRNE: CH-8
6. During which stage of alcohol withdrawal would the nurse expect to see a patient experience
delirium tremens?
a. Early
b. Minor
c. Intermediate
d. Major
ANS: D
One would expect to see delirium tremens during the major stage of alcohol withdrawal, along
with severe agitation, confusion, disorientation, auditory, tactile, visual hallucinations,
psychomotor and autonomic hyperactivity.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 202, Table 11-12
MSC: CRNE: CH-8
7. A patient who is alcohol intoxicated must undergo emergency surgery for a ruptured spleen.
What does the nurse recognize about the postoperative period for this patient?
a. The patient will require lower than normal doses of analgesics.
b. The patient is likely to develop withdrawal symptoms within 24 hours.
c. The patient is at increased risk for bleeding and respiratory complications.
d. The patient should be stimulated every hour to prevent the prolonged effects of the
anaesthesia.
ANS: C
Substance-abusing patients undergoing surgery have an increased susceptibility to cardiac and
respiratory depression and have an increased risk for bleeding, postoperative complications,
and infection, to name a few.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 194
MSC: CRNE: CH-31
8. A patient with alcohol dependence is admitted to the hospital following an episode of
hematemesis. Twenty-four hours after admission, the patient becomes very tremulous and
anxious. What is an appropriate nursing intervention?
a. Promoting oral intake to 3000 mL/day
b. Administering narcotics to provide sedation
c. Providing a calm, quiet, well-lit environment
d. Restraining the patient with vest and arm restraints
ANS: C
Provide a quiet, nonstimulating, well-lit environment to reduce external stimuli and calm an
overactive central nervous system (CNS).
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 207
MSC: CRNE: CH-43
9. A 60-year-old man has been a heavy drinker for 30 years, drinking daily with his business
associates. When he is seen at the clinic for acute gastritis, which of the following responses
by the patient will help the nurse determine that the patient is in the contemplation stage of
change?
a. “Alcohol has never bothered my stomach. I may just have the flu.”
b. “I know that I have to stop drinking, but it is the only way I can relax.”
c. “I think my drinking is affecting my stomach, but maybe some drugs will help
calm it down.”
d. “My wife keeps telling me that I am killing myself with alcohol, but I really feel
pretty good, except for my stomach.”
ANS: B
A patient in the contemplation stage of change often experiences ambivalence. The patient
understands that the behaviour is a problem and that change is necessary.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 211
MSC: CRNE: CH-8
10. For which reason does the nurse administer thiamine and multivitamins to a patient in alcohol
withdrawal?
a. To prevent development of encephalopathy
b. To offset vitamin deficiencies caused by excessive drinking
c. To begin to reverse the symptoms of malnutrition
d. To aid in flushing the liver of alcohol-related metabolites
ANS: A
Thiamine and multivitamins are administered to a patient in alcohol withdrawal to prevent
development of Wernicke’s encephalopathy.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 202
MSC: CRNE: HW-9
11. A 36-year-old man is admitted to the hospital for treatment of large abscesses of both anterior
thighs. He has multiple needle puncture sites on both arms and is drowsy during the nursing
assessment. After 12 hours, which of the following signs would lead the nurse to suspect
opioid abuse by the patient?
a. Tachycardia, convulsions, and delirium
b. Diaphoresis, restlessness, and lacrimation
c. Depression, irritability, and disorientation
d. Gross tremor, hallucinations, and seizures
ANS: B
Opioid withdrawal symptoms include watery eyes, dilated pupils, a runny nose, yawning,
tremors, pain, chills, fever, diaphoresis, nausea, vomiting, diarrhea, and abdominal cramps.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: pages 190-191, Table 11-4
MSC: CRNE: CH-8
12. A patient hospitalized for a stab wound is found to be addicted to opioids. Which of the
following statements by the patient leads the nurse to believe that the patient is in the
contemplation stage of change?
a. “I need to reform my friends.”
b. “What kind of help is there for me?”
c. “I promise I will never use drugs again.”
d. “Would sniffing drugs be better for me than shooting up?”
ANS: B
A patient in the contemplation stage of change often experiences ambivalence. The patient
understands that the behaviour is a problem and that change is necessary.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 211
MSC: CRNE: HW-9
13. A patient has a history of drug abuse and is hospitalized following a fall down a flight of
stairs. After a visit by a friend, the nurse finds the patient unresponsive, with pinpoint pupils.
What drug should the nurse anticipate will be used to treat this patient?
a. Caffeine
b. Methadone
c. Naloxone (Narcan)
d. Diazepam (Valium)
ANS: C
The patient’s assessment indicates an opiate overdose, and naloxone should be given to
prevent respiratory arrest if CNS depression is present.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 193
MSC: CRNE: CH-49
14. While the night nurse is giving a morning report on a patient who has been admitted with an
opiate overdose, one nurse says, “I don’t know why we should waste our efforts on her. This
is her third admission, and she’ll be back on the needle as soon as we save her life.” What is
the most appropriate response by the night nurse to this remark?
a. “That’s a totally unprofessional attitude, and you should be ashamed of yourself.”
b. “You know the patient always comes first, even though we feel that way about
her.”
c. “You probably shouldn’t care for this patient since you have such negative feelings
about her.”
d. “It is important for us to recognize and deal with the feelings we have about caring
for difficult patients like this woman.”
ANS: D
To provide nonjudgemental care for substance-using patients, nurses must examine their own
values and feelings. This statement validates the nurse’s feelings but recognizes the need to
care for the patient in a nonjudgemental way.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 212
MSC: CRNE: NCP-5
15. A patient comes to the health clinic because of a chronic respiratory infection and sinus
headache. During physical assessment of the patient, the nurse finds nasal sores and necrosis
of the nasal septum. What drug use should the nurse ask the patient specifically about?
a. Heroin
b. Cocaine
c. Tobacco
d. Marijuana
ANS: B
Nasal sores, septal necrosis, and perforation are signs of cocaine use.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 189, Table 11-3
MSC: CRNE: CH-6
16. Which of the following is an objective measure that would indicate alcohol dependence?
a. The person drinks fewer than four drinks every day.
b. The person is usually considered socially stable.
c. The person has a mild tolerance to alcohol.
d. The person drinks more than 40 drinks in a week.
ANS: D
An objective measure that indicates alcohol dependence is drinking more than 40 to 60 drinks
a week.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: pages 199-200, Table 11-11
MSC: CRNE: CH-4
17. A young woman was brought to the hospital by friends when she developed visual and
auditory hallucinations and extreme agitation after she smoked a large dose of “speed”
(amphetamines). Her vital signs are blood pressure 162/98 mm Hg, heart rate is 142 beats per
minute and irregular, and respiration is 32 breaths per minute. What is the most important
nursing intervention at this time?
a. Monitor the patient’s electrocardiogram and vital signs.
b. Orient the patient with consistent verbal contact.
c. Obtain a health history that includes prior drug use.
d. Promote continuous ambulation and physical activity.
ANS: A
The priority is to ensure physiological stability given that amphetamine use can lead to
complications such as myocardial infarction.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 190, Table 11-4
MSC: CRNE: CH-24
18. A patient at the clinic tells the nurse that she is worried about her 17-year-old son, who has
been socializing with some teenagers she thinks are using drugs. What is the best motivational
response to address the patient’s concern?
a. “Most young people experiment with drugs, but very few really become addicted
to illegal substances.”
b. “You must stop his association with these friends to prevent him from being
exposed to drug use.”
c. “You should learn about the early signs and symptoms of drug abuse and share
your concerns with your son.”
d. “You need to make an appointment for your son with a drug counsellor so that he
can be taught about the harmful effects of drugs.”
ANS: C
Peer influence can contribute to alcohol abuse in young adults; therefore, it is important that
the woman is aware of the early signs and symptoms of drug abuse and shares her concerns
with her son.
PTS: 1
OBJ: 11
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 212
MSC: CRNE: NCP-1
19. Which statement is true in relation to Canada’s low-risk drinking guidelines?
a. Drink no more than 15 drinks per week if you are a female.
b. Have no more than six drinks on any one occasion if you are a male.
c. Limit alcohol intake to two drinks in any three-hour period, regardless of gender.
d. Eat before but not while drinking alcohol.
ANS: C
A tip in relation to Canada’s low-risk drinking guidelines is to limit alcohol intake to two
drinks in any three-hour period.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 199, Table 11-9
MSC: CRNE: HW-26
20. At what blood alcohol concentration (BAC), in mg%, do many people lose consciousness?
a. 0.06
b. 0.10
c. 0.15
d. 0.30
ANS: D
Many people lose consciousness with a BAC of 0.30 mg%.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 200, Table 11-10
MSC: CRNE: CH-8
Chapter 12: Complementary and Alternative Therapies
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. Which of the following patients does the nurse deduce is seeing an alternative medical
practitioner?
a. A patient who prevents and treats migraine headaches with acupuncture
b. A patient who uses progressive relaxation to control the nausea of cancer
chemotherapy
c. A patient who supplements chiropractic manipulation for low back pain with
muscle relaxants
d. A patient who takes vitamin and mineral supplements as treatment for
gastrointestinal malabsorption
ANS: A
Alternative therapies are those used instead of conventional Western medical practice. This
patient is using acupuncture instead of taking medications to prevent or treat migraine.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 220
MSC: CRNE: CH-11
2. A patient with high blood pressure asks the nurse about the use of fish oil supplements to help
lower blood pressure. Which is the nurse’s best response?
a. “Some evidence exists that fish oil supplements are helpful in treating
hypertension.”
b. “Fish oil supplements are helpful for treating rheumatoid arthritis.”
c. “No clear evidence exists that fish oil supplements are helpful.”
d. “Discuss the use of fish oil supplements with the hospital dietitian.”
ANS: A
Good evidence exists that fish oil is helpful in treating hypertension as well as preventing
cardiovascular disease.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 223, Table 12-9
MSC: CRNE: HW-26
3. Which therapy is appropriate for the nurse to suggest for a patient with fibromyalgia?
a. Acupuncture
b. Aromatherapy
c. Magnetic therapy
d. Therapeutic touch
ANS: A
Acupuncture may be useful in the treatment of fibromyalgia, whereas the research related to
therapeutic touch is inconclusive.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 220, Table 12-6
MSC: CRNE: CH-11
4. Which of the following should the nurse assess to evaluate the effect of aromatherapy on a
patient after surgery?
a. Incision for signs of infection
b. Intake and output
c. Blood pressure and pulse
d. Breath sounds
ANS: C
Aromatherapy is used for stress reduction, and a decrease in the patient’s blood pressure and
pulse would indicate that the aromatherapy was effective.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 218, Table 12-3
MSC: CRNE: CH-44
5. Which of the following is used to gently lift and knead the muscle?
a. Simple massage
b. Effleurage
c. Pétrissage
d. Circular massage
ANS: C
Pétrissage is a kneading stroke, used to gently knead and lift muscles, often used following
effleurage.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 223
MSC: CRNE: CH-11
6. The nurse is using imagery as a technique for pain management with a patient who has
rheumatoid arthritis. What should the nurse tell the patient to promote reinforcement of the
image of a pleasant scene by the patient?
a. “Tell me what you hear, smell, or feel at this place.”
b. “Place your pain in the image of a form you can destroy.”
c. “Bring what you hear and sense in your present environment into your image of
the scene.”
d. “If your scene is distressing to you, continue its visualization until you can
overcome the distress.”
ANS: A
Imagery uses one’s mind to create images that have a calming effect on the body. Outcomes
may include reduction of anxiety, relaxation, enhanced immunity, and changes in hormonal
responses.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 218, Table 12-2
MSC: CRNE: CH-11
7. Which one of the following patients is most likely to use complementary and alternative
therapies?
a. A patient who is a vegetarian
b. A patient who is of Asian heritage
c. A patient who is an older adults with a chronic condition
d. A patient who is pregnant
ANS: C
Older adults with non–life-threatening, chronic conditions are most likely to use
complementary and alternative therapies.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 228
MSC: CRNE: HW-26
8. A patient with chronic headaches seeks treatment from a nurse trained in therapeutic touch.
What does the nurse explain to the patient that therapeutic touch involves?
a. The use of the practitioner’s hands to assess and redirect energy
b. The forceful, passive movement of joints to restore structural and functional
imbalances
c. Application of pressure with the fingers at points on the body where energy is
obstructed
d. Manipulation of soft tissue and small joints that alters the length and tone of
myofascial tissue
ANS: A
Therapeutic touch is a method of detecting and balancing human energy. It involves the
conscious use of the practitioner’s hands to direct or modulate human energy.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 219, Table 12-4
MSC: CRNE: CH-11
9. A patient comes to an outpatient clinic and requests an acupuncturist for treatment of her
asthma. In responding to the patient’s request, what does the nurse recognize about the effect
of acupuncture on asthma?
a. Asthma is a disorder that should not be treated with acupuncture because of the
risk for respiratory complications.
b. Acupuncture needles stimulate or block specific superficial nerves that cause
alterations in physiological function.
c. Research has indicated that asthma patients may benefit from the effects of
acupuncture.
d. The patient must have a strong belief in the concepts of health and disease held by
traditional Chinese medicine for treatment to be effective.
ANS: C
Some research has indicated that acupuncture improves lung function, which would benefit
the patient with asthma.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 220, Table 12-6
MSC: CRNE: HW-26
10. A patient always seems to develop an upper respiratory tract infection in the spring, and he
asks if any herbal preparation is available that would help him. Which one of the following
recommended herbs should the nurse suggest?
a. Comfrey
b. Echinacea
c. Ginkgo biloba
d. St. John’s wort
ANS: B
Good scientific evidence exists to suggest that echinacea prevents upper respiratory tract
infections, and strong evidence suggests that it is also beneficial in the treatment of upper
respiratory tract infections.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 222, Table 12-8
MSC: CRNE: HW-26
11. A patient tells the nurse that she has been taking melatonin every day. The nurse would ask
questions about which of the following during assessment, to evaluate the effectiveness of this
herb for its intended use?
a. Glucose levels
b. Sleep habits
c. Bruising or bleeding tendencies
d. Bowel habits
ANS: B
Melatonin use as a sleep enhancement has been informed by scientific evidence; therefore, the
nurse would want to assess sleep habits.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
REF: page 223, Table 12-9
MSC: CRNE: CH-3
12. During a routine health examination, the patient tells the nurse that she uses a variety of herbal
therapies to maintain her health. In discussing her use of herbs, what should the nurse caution
the patient about?
a. Most herbs are toxic and carcinogenic and should be used only when proven
effective.
b. Herbs are not any better than conventional drugs in maintaining health and may be
more unsafe.
c. Herbs should be purchased only from manufacturers with a history of quality
control of their products.
d. Because herbal therapies may mask the symptoms of serious disease, frequent
medical evaluation is required during their use.
ANS: C
The quality of herb preparations can vary, so it is important that patients purchase herbal
remedies from reputable manufacturers. Health Canada (2011) advises Canadians to use only
herbal products that have been approved for sale under the Natural Health Products
regulations. If the product has been assessed, it will have a Drug Identification Number or
Natural Products Number on its label. This certifies that the product has passed a review of
formulation, labelling, and instructions for use.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 221
MSC: CRNE: HW-26
13. Which of the following is a commonly used herb for treating nausea and vomiting during
pregnancy?
a. Aloe
b. Ginger
c. Kava
d. Milk thistle
ANS: B
Ginger is commonly used for treating nausea and vomiting during pregnancy.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 222, Table 12-8
MSC: CRNE: HW-26
14. Which of the following is true regarding healing touch?
a. It has strong ties to religious beliefs.
b. It is a physician-based program.
c. It assists the patient to self-heal.
d. The nurse determines its effectiveness.
ANS: C
Healing touch is a nurse-based program that is an organized system designed to assist the
patient to self-heal.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: pages 224-225
MSC: CRNE: HW-26
Chapter 13: Palliative Care at the End of Life
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. One of the physical changes in the respiratory system that is commonly seen as death
approaches is alternating periods of apnea and deep, rapid breathing. How should the nurse
document this finding?
a. The death rattle
b. Agonal breathing
c. Apneustic breathing
d. Cheyne-Stokes respiration
ANS: D
An abnormal pattern of respiration characterized by alternating periods of apnea and deep,
rapid breathing is termed Cheyne-Stokes respiration.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 231
MSC: CRNE: CH-15
2. When caring for a patient close to death, when does the nurse recognize that death legally
occurs?
a. When the cerebral cortex function ceases
b. When respirations cease
c. When coma, absence of brainstem reflexes, and apnea occur
d. When cardiopulmonary resuscitative efforts are not effective
ANS: C
The diagnosis of death is based on brain death; therefore, death has occurred when the patient
has irreversible loss of all brain functions, including brainstem functions that control
respirations and brainstem reflexes.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 232
MSC: CRNE: CH-8
3. Which of the following refers to care that is provided in the last days or weeks of the patient’s
life?
a. Hospice care
b. Palliative care
c. Respite care
d. End-of-life care
ANS: D
End-of-life care is the care that is provided in the last days or weeks of life.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 230, Key Terms
MSC: CRNE: CH-71
4. A 48-year-old man has been diagnosed with metastatic malignant melanoma and has a poor
prognosis. He plans an extensive trip around the country to visit family he has not seen or
talked with in years. What psychosocial response does the nurse recognize that the patient is
manifesting?
a. Restlessness
b. Saying goodbye
c. Unfinished business
d. Altered decision making
ANS: C
One of the psychosocial manifestations of approaching death is anxiety about unfinished
business (including asking for forgiveness and forgiving others).
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 243
MSC: CRNE: CH-71
5. For two months after a patient was diagnosed with pancreatic cancer, she did not admit that
she was ill and in need of health care. What is the emotional response associated with this
stage of grief?
a. Yearning and protest
b. Acceptance and accommodation
c. Denial, disbelief, and avoidance
d. Anger, despair, and confrontation
ANS: C
Many different theories explaining grief and the grieving process have been articulated over
the years. Kübler-Ross (1969), Martocchio (1985), and Rando (1993) have all identified
stages of grief and indicate that the first stage includes denial, disbelief, and avoidance.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 233
MSC: CRNE: CH-71
6. The wife of a patient with terminal lung cancer visits daily and cheerfully talks with the
patient about vacation plans for the next year. When the nurse asks how she is feeling, the
patient’s wife says, “I’m busy at work, but otherwise things are fine.” What is an appropriate
nursing diagnosis for the wife?
a. Caregiver role strain related to feeling overwhelmed
b. Disabled family coping related to lack of grieving
c. Anxiety related to complicated grieving process
d. Hopelessness related to knowledge deficit about cancer
ANS: B
The wife’s behaviour and statements indicate the presence of avoidance, which may lead to
impaired adjustment as the patient progresses toward death.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
REF: page 233
MSC: CRNE: CH-71
7. As the nurse admits a patient with acquired immune deficiency syndrome (AIDS) who has
cryptococcal meningitis, the patient tells the nurse that she does not want to be resuscitated if
she stops breathing. What should the nurse do with this information?
a. Document the patient’s request in the patient’s record.
b. Ask the patient if she has discussed this decision with her physician.
c. Inform the patient that unless she has a written, notarized advance directive,
resuscitation must be performed.
d. Advise the patient to designate a person to make health care decisions on her
behalf in the event that she cannot make her own decisions.
ANS: B
As a physician’s order should be written to include the information concerning the patient’s or
the family’s wishes for the use of cardiopulmonary resuscitation, it is imperative that the nurse
assess whether the patient has discussed this with his or her physician.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 235
MSC: CRNE: PP-12
8. A patient who is very close to death is very restless and repeats, “I am not ready to die.” What
is the most appropriate nursing intervention at this time?
a. Call the hospital chaplain to visit the patient.
b. Sit with the patient, and ask him if he wants to talk.
c. Inform the patient that everything possible is being done for him.
d. Ask the patient what he needs to do to come to acceptance of his death.
ANS: B
A simple, caring presence provides support and comfort. Neither words nor actions are
necessary unless the patient wants to talk. Holding hands, touching, and listening are
considered to be high-quality nursing responses. Simply providing companionship allows the
dying person a sense of security.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: pages 238-239
MSC: CRNE: CH-71
9. The nurse consults with the physician to arrange a referral for hospice care for a patient with
end-stage kidney disease, based on what knowledge regarding when hospice care is indicated?
a. Family members can no longer care for dying patients at home.
b. Patients and families are having difficulty coping with grief reactions.
c. Preparation for death with palliative care and comfort are the goals of care.
d. Patients have unmanageable pain and suffering as a result of their condition.
ANS: C
Palliative care is defined as care aimed at relief of suffering and improving the quality of life
for persons who are living with or dying from advanced illness or are bereaved. The goal of
palliative care is comfort and dignity for the person living with the illness and the best quality
of life for both this person and his or her family.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 236
MSC: CRNE: CH-71
10. Which sense is usually the last one to disappear before death?
a. Touch
b. Sight
c. Smell
d. Hearing
ANS: D
Hearing is usually the last sense to disappear before death.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 232, Table 13-1
MSC: CRNE: CH-8
11. Which of the following is a lay term used to describe instructions about future medical care?
a. DNR orders
b. Living will
c. Advance directive
d. Power of attorney for personal care
ANS: B
A living will is a lay term used to describe any number of documents that give instructions
about future medical care and treatment.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 235
MSC: CRNE: CH-8
12. A patient near death has withdrawn from his family and the physical hospice environment.
The nurse’s response is based upon which of the following nursing management guidelines?
a. Encourage family to tell the dying person it is okay to die.
b. Inform the family that the patient is about to die, as he has withdrawn from this
world.
c. Reinforce that this is a normal part of the dying process, and support the family.
d. Encourage the dying person and the family to verbalize their feelings.
ANS: C
A patient nearing death may withdraw from others and from the physical environment, and
the nurse bases her interaction on the nursing management guideline to reinforce that this is a
normal part of the dying process and support the family. Conversely, s if the patient is alert,
using a soft voice and gentle touch.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 240, Table 13-8
MSC: CRNE: CH-71
13. Which of the following health care providers is legally qualified to complete a certification of
death?
a. Paramedic
b. Physician
c. Registered nurse
d. Licensed practical nurse
ANS: B
Certification of death can only be undertaken by a physician or coroner. In many jurisdictions
in Canada, registered nurses are legally able to provide a pronouncement of death, but not
certification of death.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 240
MSC: CRNE: PP-9
Chapter 14: Inflammation and Wound Healing
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. The physician has told a patient that her heart has hypertrophied because of damage to her
heart when she had her heart attack. How should the nurse explain the damage to the heart to
help the patient understand what has happened?
a. The cells in her heart have become larger in response to the loss of heart tissue.
b. The cells in her heart have changed from contractive muscle cells into scar tissue.
c. Some of her heart cells have decreased in size because of the loss of normal cells.
d. The number of heart cells has increased to compensate for the cells that died
during her heart attack.
ANS: A
Hypertrophy is an increase in the size of cells resulting in increased tissue mass without cell
division. Hypertrophy is usually due to the response of an organ or a select area of tissue to an
increased demand for work, for example, following a heart attack.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 249
MSC: CRNE: CH-8
2. The nurse assesses a surgical patient the morning of the first postoperative day. Which of the
following signs of a local inflammatory response would the nurse expect to find?
a. Redness and heat of the incision
b. Leukocytosis with elevated monocytes
c. Pain and purulent drainage of the incision
d. Fever and increased pulse and respiratory rate
ANS: A
The local response to inflammation includes the manifestations of redness, heat, pain,
swelling, and loss of function.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 252, Figure 14-2
MSC: CRNE: CH-8
3. In evaluating a patient’s inflammatory response, by what does the nurse understand that the
activation of the classical complement pathway to mediate an inflammatory response is
stimulated?
a. Lysis of bacterial cells
b. An antigen–antibody complex
c. Monocyte diapedesis to injured tissue
d. Release of histamine from injured cells
ANS: B
The primary pathway for activation of the complement system is through fixation of
component C1 to an antigen–antibody complex.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: pages 253-254
MSC: CRNE: CH-8
4. The nurse is preparing to perform a wet-to-dry dressing change for a patient with infected leg
burns. Which action is appropriate for this type of dressing change?
a. Administer the ordered as-needed oral opioid 30 minutes before the dressing
change.
b. Pour sterile saline onto the new dry dressings after the wound has been packed.
c. Soak the old dressings with sterile saline a few minutes before removing them.
d. Spread Silverderm ointment into the wound before repacking with moist dressings.
ANS: A
This method of mechanical debridement is painful, and the patient should receive appropriate
pain management before the removal of a wet-to-dry dressing.
PTS: 1
OBJ: 13
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 263
MSC: CRNE: CH-41
5. A patient is brought to the health care facility with abdominal pain and fever. A complete
blood count and white blood cell differential are completed and indicate a shift to the left.
What does the nurse understand this finding to indicate?
a. An infection caused by pyogenic pathogens
b. An infection that is in the vascular response phase of inflammation
c. A chronic infection that stimulates the increased release of monocytes into the
bloodstream
d. An acute inflammation with release of increased immature neutrophils into the
circulation
ANS: D
The finding of increased numbers of band neutrophils in circulation is called a shift to the left,
which is commonly found in patients with acute bacterial infections.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 253
MSC: CRNE: CH-8
6. A patient with a systemic bacterial infection has “goose pimples,” feels cold, and has a
shaking chill. At this stage of the febrile response, what would the nurse expect to find?
a. Flushing of the skin
b. Rising body temperature
c. Decreasing blood pressure
d. Relief of muscle aching and fatigue
ANS: B
As the set point is raised, the hypothalamus signals an increase in heat production and
conservation to raise the body temperature to the new level. At this point, the individual feels
chilled and shivers. The shivering response is the body’s method of raising the body’s
temperature until the new set point is attained.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 255, Table 14-7
MSC: CRNE: CH-6
7. Following bowel surgery, a patient develops a bacterial peritonitis. The patient is diaphoretic,
with a temperature of 38.4°C. What would the nurse plan to do after establishing the nursing
diagnosis of hyperthermia related to the response to infection?
a. Reduce the patient’s caloric intake to slow the body’s metabolic rate.
b. Change linens frequently to prevent rapid heat loss and subsequent chilling.
c. Administer antipyretic drugs immediately to prevent fever-induced cell damage.
d. Cover the patient with additional blankets to promote heat loss through sweating.
ANS: B
Change linens frequently if the patient is diaphoretic to prevent shivering and a subsequent
rise in body temperature from muscular activity.
PTS: 1
DIF: Cognitive Level: Application
REF: page 262, Nursing Care Plan 14-1 OBJ: 7
TOP: Nursing Process: Implementation
MSC: CRNE: CH-7
8. During administration of antipyretic drugs, what does the nurse understand about the
mechanism of action of these agents in decreasing body temperature?
a. They dilate small arterioles in the skin, promoting heat loss through radiation.
b. They stimulate the activity of sweat glands, leading to heat loss through
evaporation from the skin.
c. They block the release of interleukins to raise the core body temperature in the
midbrain.
d. They interfere with the production of prostaglandins and their effect on the
temperature-regulating centre in the hypothalamus.
ANS: D
Antipyretic drugs lower temperature by acting on the heat-regulating centre in the
hypothalamus, resulting in peripheral dilation and heat loss; interfere with formation and
release of prostaglandins; and selectively depress the central nervous system.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 261, Table 14-12
MSC: CRNE: CH-44
9. A 34-year-old patient with diabetes mellitus had an abdominal cholecystectomy two years ago
and has had intermittent abdominal pain and gastrointestinal distress since that time. An
exploratory laparotomy was performed, and multiple adhesions were released. Why should
the nurse expect that this patient’s wound healing may be delayed?
a. Because of damage to her intestinal organs caused by the adhesions
b. Because of her prior history of adhesion development with a surgical procedure
c. Because of her diabetes, which decreases collagen synthesis and early capillary
growth
d. Because of the lack of a gallbladder, which provides necessary mediators for
healing
ANS: C
Diabetes mellitus decreases collagen synthesis, retards early capillary growth, impairs
phagocytosis (a result of hyperglycemia), and reduces supply of oxygen and nutrients
secondary to vascular disease.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 259, Table 14-11
MSC: CRNE: CH-41
10. The charge nurse observes a new graduate performing a dressing change on a stage III sacral
pressure ulcer. Which action by the new graduate indicates a need for further education about
pressure ulcer care?
a. The new graduate uses a hydrocolloid dressing (DuoDerm) to cover the ulcer.
b. The new graduate inserts a sterile cotton-tipped applicator into the pressure ulcer.
c. The new graduate irrigates the pressure ulcer with a 30-mL syringe using sterile
saline.
d. The new graduate cleans the ulcer with a sterile dressing soaked in half-strength
peroxide.
ANS: D
Pressure ulcers should not be cleaned with solutions that are cytotoxic, such as hydrogen
peroxide. The other actions by the new graduate are appropriate.
PTS: 1
OBJ: 13
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 263
MSC: CRNE: CH-41
11. An older adult patient has a large, open, infected surgical wound on the abdomen that contains
a creamy exudate and small areas of red granulation tissue. How should the nurse classify this
wound?
a. Black wound
b. Yellow wound
c. Superficial red wound
d. Full-thickness red wound
ANS: B
A yellow wound has nonviable necrotic tissue and creamy exudate.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 263
MSC: CRNE: CH-41
12. A patient with massive trauma to the leg has extensive skeletal muscle damage and wide,
irregular wound edges. Which of the following responses to the patient’s questions best
describes healing of the injury?
a. “All of the damaged tissue will regenerate if infection does not occur.”
b. “Most of the skin and skeletal muscle will be replaced by connective tissue.”
c. “The skin will regenerate to cover the injury, but the muscle will not be replaced.”
d. “Regeneration of skin and skeletal muscle tissue is usually possible but may take
months or years to occur.”
ANS: B
Connective tissue replaces severely damaged muscle. Some regeneration in moderately
damaged muscle occurs.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 256, Table 14-8
MSC: CRNE: CH-8
13. Which one of the following types of macrophages would be found in bone tissue?
a. Type A cells
b. Microglial cells
c. Osteoclasts
d. Histiocytes
ANS: C
The macrophages that are found in bone tissue are osteoclasts.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 251, Table 14-3
MSC: CRNE: CH-41
14. A patient arrives at the emergency department with a swollen ankle after an injury occurred
while playing soccer. What is the cause of this patient’s swelling?
a. Hyperemia from vasodilation
b. Increased metabolism at the inflammatory site
c. Fluid shift to interstitial spaces
d. Change in local ionic concentration
ANS: C
A local manifestation of inflammation is swelling and is caused by a fluid shift to interstitial
spaces and fluid exudate accumulation.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 254, Table 14-6
MSC: CRNE: CH-8
15. Which of the following causes of lethal cell injury results in destruction of the cell membrane
or nucleus and the production of lethal toxins?
a. Hypoxia
b. Chemical
c. Microbial
d. Immunological
ANS: C
A microbial injury, specifically bacterial, causes destruction of the cell membrane or cell
nucleus and the production of lethal toxins.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 250, Table 14-1
MSC: CRNE: CH-8
16. Which local manifestation of inflammation causes a change in pH?
a. Heat
b. Pain
c. Redness
d. Swelling
ANS: B
Pain causes a change in pH, a change in local ionic concentration, nerve stimulation by
chemicals, and pressure from fluid exudate.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 254, Table 14-6
MSC: CRNE: CH-8
17. During which stage of the febrile response would the nurse expect to see the patient sweating?
a. Chill
b. Flush
c. Prodromal
d. Defervescence
ANS: D
In the febrile response stage of defervescence, the nurse would anticipate that the patient
would be sweating.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Planning
REF: page 255, Table 14-7
MSC: CRNE: CH-8
18. Which of the following activities occurs during the granulation phase of primary intention
healing?
a. Migration of epithelial cells and clot formation
b. Remodelling of collagen and initiation of capillary growth
c. Migration of fibroblasts and secretion of collagen
d. Approximation of incision edges and increased capillary buds
ANS: C
During the granulation phase of primary intention healing (five days to four weeks), activities
include migration of fibroblasts, secretion of collagen, abundance of capillary buds, and
fragility of the wound.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 257, Table 14-9
MSC: CRNE: CH-8
Chapter 15: Genetics
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A young woman’s mother has been diagnosed with BRCA gene–associated breast cancer, an
autosomal dominant genetic disorder. She asks the nurse about the inheritance patterns of this
disorder. On what knowledge will the nurse base the response to this young woman?
a. Most affected offspring of autosomal dominant disorders are males.
b. The young woman’s mother had unaffected parents who were heterozygous for the
gene.
c. The young woman has a 50% chance of having the mutated gene if her mother is
heterozygous.
d. Daughters of women who are heterozygotic with an autosomal dominant disorder
are usually carriers of the gene.
ANS: C
An autosomal dominant trait is one that manifests in the heterozygous state, that is, in a
person who has both an abnormal (mutated) and a normal gene. The mutated gene dominates
the other normal gene.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 277
MSC: CRNE: CH-8
2. The nurse is participating in a clinical trial involving in vitro gene therapy in the treatment of
a patient with adenosine deaminase (ADA) deficiency. What should the nurse explain to the
patient is involved in this method of gene therapy?
a. Direct instillation of modified viruses carrying the desired genes into the patient
b. Direct microinjection of DNA into cells that have been removed from the body and
reinfused
c. Removal of lung cells from the body, which are altered genetically and reinfused
into the patient’s blood
d. Removal of cells from the body, which are exposed to modified viruses containing
desired genes and reinfusion of the cells back into the body
ANS: A
The viral vector containing the therapeutic ADA gene is inserted into the patient’s
lymphocytes. These cells can then make the ADA enzyme.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: pages 282-283
MSC: CRNE: CH-8
3. What is the name given to a family tree that contains the genetic information and disorders of
the family?
a. Genome
b. Hereditary
c. Phenotype
d. Pedigree
ANS: D
Pedigree is the name given to a family tree that contains the genetic information and disorders
of the family.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 276, Table 15-1
MSC: CRNE: CH-4
4. On average, what percentage of children in a family will be affected with the mutated gene in
an autosomal recessive trait?
a. 0%
b. 25%
c. 50%
d. 100%
ANS: B
On average, one in four children in a family, or 25%, will be affected with an autosomal
recessive trait.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 278
MSC: CRNE: CH-8
5. When counselling parents about hemophilia A, an X-linked recessive trait, which of the
following would be the basis for the nurse’s response related to offspring?
a. Daughters will not be affected with the trait or be carriers.
b. Sons will not be affected with the trait or be carriers.
c. Fifty percent of sons will be normal, and 50% will be affected with the trait.
d. Fifty percent of daughters will be normal, and 50% will be affected with the trait.
ANS: C
An X-linked recessive trait indicates that 50% of sons will be normal and 50% will be
affected with the trait. Females will not be affected with the trait; however, 50% of them
would be a carrier of the trait.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
REF: page 279
MSC: CRNE: CH-8
6. A pregnant woman has asked the nurse when the best time is to undergo chorionic villus
sampling. The nurse’s best response is which of the following statements?
a. Any time before the tenth week of gestation
b. Between the eleventh and twelfth week of gestation
c. Between the twenty-fourth and twenty-sixth week of gestation
d. Any time during the second trimester of pregnancy
ANS: B
Chorionic villus sampling is done in the first trimester, usually between the eleventh and
twelfth week of gestation.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 281
MSC: CRNE: CH-30
7. When completing a pedigree, the nurse knows to use the symbol  (blue square) to denote
which of the following?
a. Unknown sex, normal
b. Normal male
c. Female heterozygote
d. Affected male
ANS: D
The blue square symbol is used to represent an affected male in a pedigree.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 280, Figure 15-11
MSC: CRNE: CH-8
Chapter 16: Altered Immune Response and Transplantation
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. The nurse encourages a new mother to breastfeed her infant, even for a short time, because
colostrum will provide the infant with which type of immunity?
a. Indefinite active immunity to childhood illnesses
b. Passive immunity to all childhood illnesses for several months
c. Passive immunity to diseases to which the mother has immunity
d. Active immunity for several years to diseases to which the mother has immunity
ANS: C
Infants may also get some passive immunity from immunoglobulin A in breast milk and
colostrum.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 287, Table 16-1
MSC: CRNE: CH-8
2. When monitoring older adult patients for signs of cancer, the nurse explains that the incidence
of cancer is increased in this age group primarily as a result of the decreased action of which
of the following cells?
a. D lymphocytes
b. T lymphocytes
c. Immunoglobulins
d. Granulocyte colony–stimulating factor
ANS: B
Age-related changes include a change in both T and B cells as they show deficiencies in
activation, transit time through the cell cycle, and subsequent differentiation, thereby causing
their action to decrease.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 293
MSC: CRNE: CH-8
3. What initial evidence would indicate to the nurse that a patient is experiencing a systemic
anaphylaxis to an injected allergen?
a. Dyspnea
b. Dilation of the pupils
c. Itching and edema at the injection site
d. A wheal-and-flare reaction at the injection site
ANS: C
Initial symptoms of a systemic anaphylaxis reaction are edema and itching at the site of the
exposure to the allergen.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 293
MSC: CRNE: CH-62
4. A patient develops a severe angioedema involving her face, hands, and feet, with burning and
stinging of the lesions. What significant risk factor for allergies should the nurse ask the
patient about?
a. A family history of allergies
b. The use of over-the-counter medications
c. Recurrent respiratory infections
d. A history of a recent fungal infection
ANS: A
Important health information to collect includes the patient’s past health history, a component
of which is to gather a family history of allergies.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 298, Table 16-10
MSC: CRNE: CH-3
5. A patient with a severe allergic reaction is treated with epinephrine. The nurse recognizes that
the rationale for the use of epinephrine is that epinephrine opposes the effects of which one of
the following?
a. Adrenergic receptors
b. Lymphokines
c. Interleukin-2
d. Lysosomal enzymes
ANS: A
Epinephrine is a hormone produced by the adrenal medulla that stimulates - and adrenergic receptors. Stimulation of the -adrenergic receptors causes vasoconstriction of
peripheral blood vessels. -receptor stimulation relaxes bronchial smooth muscles.
Epinephrine opposes the effects of adrenergic receptors.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 300
MSC: CRNE: CH-44
6. After being bitten by an unknown insect, a patient who is allergic to wasp stings is brought to
a clinic by a co-worker. On arrival, the patient is anxious and is having difficulty breathing.
What should the nurse’s first action be?
a. Administer oxygen.
b. Maintain the patient’s airway.
c. Remove the stinger from the site.
d. Place the patient in a recumbent position with his legs elevated.
ANS: B
An initial intervention in the management of anaphylactic shock is to ensure a patent airway.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 299, Table 16-11
MSC: CRNE: CH-62
7. The nurse discusses the prevention and management of allergic reactions with a beekeeper
who has developed a hypersensitivity to bee bites. The nurse identifies a need for additional
teaching when the patient makes which of the following statements?
a. “I need to think about a change in my occupation.”
b. “I should wear a MedicAlert bracelet indicating my allergy to insect stings.”
c. “I will learn to administer epinephrine so that I will be prepared if I am stung
again.”
d. “I will need to take doses of corticosteroids to prevent reactions to further stings.”
ANS: D
Corticosteroids are very effective in relieving the symptoms of some allergic reactions but do
not prevent reactions to further stings.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 308, Table 16-15
MSC: CRNE: CH-44
8. The nurse is administering skin testing with intracutaneous injections of allergens on a
patient’s forearm. Immediately after the nurse administers one of the injections, the patient
complains of itching at the site and of weakness and dizziness. What should the nurse do first?
a. Elevate the arm above the shoulder.
b. Administer subcutaneous epinephrine.
c. Apply a tourniquet above the injection site.
d. Apply a local anti-inflammatory cream to the site.
ANS: C
For intracutaneous testing, the arm is used so that a tourniquet can be applied during a severe
reaction.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 298
MSC: CRNE: CH-24
9. A patient is treated at a clinic with an injection of long-acting penicillin for a streptococcal
throat infection. Her history reveals that she has received penicillin before with no allergic
responses. When the penicillin injection is administered, what should the nurse inform the
patient about?
a. She must wait in the clinic area for 20 minutes before she is discharged.
b. Given that she has taken penicillin before without problems, she can safely take it
now.
c. She would have immediate symptoms if she had developed an allergy to penicillin.
d. She should monitor for fever and skin rash typical of type III immune-complex
reactions.
ANS: A
After the injection is given, the patient should be carefully observed for 20 minutes because,
typically, systemic reactions occur immediately. However, the patient should be warned that a
delayed reaction can occur as long as 24 hours later.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 301
MSC: CRNE: CH-10
10. A patient has been undergoing immunotherapy for 1 year. How does the nurse recognize that
the goals of immunotherapy are achieved?
a. When blood analysis reveals increased IgG levels
b. When blood analysis reveals decreased IgE levels
c. When blood analysis reveals increased natural killer cells
d. When blood analysis reveals decreased T helper (CD4) cells
ANS: A
Immunotherapy involves injecting allergen extracts that will stimulate increased IgG levels.
The binding of IgG to allergen-reactive sites interferes with allergen binding to mast cell–
bound IgE, preventing mast cell degranulation and thus reducing the number of reactions that
cause tissue damage.
PTS: 1
OBJ: 11
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 298
MSC: CRNE: CH-6
11. Which of the following is a side effect of corticosteroids?
a. Peptic ulcers
b. Nausea and vomiting
c. Pulmonary edema
d. Decreased appetite
ANS: A
Peptic ulcers are a side effect of corticosteroids. Appetite is also affected, but it is increased,
not decreased.
PTS: 1
OBJ: 11
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 308, Table 16-15
MSC: CRNE: CH-44
12. A patient who is employed as a laboratory technician is scheduled for knee surgery. While
obtaining a health history from the patient, the nurse learns that the patient has a history of
allergic rhinitis, asthma, and multiple food allergies. What is most important that the nurse do
with this information?
a. Document the allergic history, and be alert for the possibility of a type I latex
allergy.
b. Encourage the patient to carry an epinephrine kit in case a type IV allergic reaction
to latex develops.
c. Advise the patient to use oil-based hand creams to decrease contact with natural
proteins in latex gloves.
d. Recommend that the patient use vinyl gloves instead of latex gloves in preventing
bloodborne pathogen contact.
ANS: A
Based on the patient’s history, the nurse should be alerted to a possible latex allergy as people
with latex allergies may also have a history of hay fever, asthma, and allergies to certain
foods; therefore, the nurse needs to document the allergic history and be alert for the
possibility of a latex allergy.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
REF: page 301
MSC: CRNE: CH-8
13. A patient is diagnosed with systemic lupus erythematosus (SLE). What does the nurse
understand is included in the pathophysiology that occurs in this autoimmune disorder?
a. Systemic tissue destruction initiated by sensitized T cells attacking DNA antigens
and releasing lymphokines
b. A deficiency of T suppressor (CD8) cells, allowing unchecked destruction of all
organ tissue by T cytotoxic cells
c. Activation of the complement cascade as a result of IgM binding with viral
antigens, causing cytolysis of vascular tissue
d. DNA released into the circulation and reacting with an antibody
ANS: D
In SLE, tissue injury appears to be the result of the formation of antinuclear antibodies. For an
unknown reason (possibly a viral infection), the cell membrane is damaged and DNA is
released into the systemic circulation, where it is viewed as non-self. This DNA is normally
sequestered inside the nucleus of cells. On release into circulation, the DNA antigen reacts
with an antibody.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 302
MSC: CRNE: CH-8
14. The nurse should explain to a patient undergoing plasmapheresis for treatment of an
autoimmune disorder that this procedure involves which of the following?
a. Selective destruction of autoantibodies
b. Separation and removal of specific blood cells
c. Exchanging saline or albumin for blood plasma
d. Removal of white cells responsible for immune reactions
ANS: C
In addition to removing antibodies and antigen–antibody complexes, plasmapheresis may also
remove inflammatory mediators.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 303
MSC: CRNE: CH-8
15. While the nurse is obtaining a health history from a patient with a secondary
immunodeficiency disorder, awareness of the most common cause of this disorder prompts
the nurse to ask specifically about which of the following treatments?
a. Dietary intake
b. Medication use
c. Stress management
d. History of radiation therapy
ANS: B
Drug-induced immunosuppression is the most common cause of secondary immunodeficiency
disorder; therefore, the nurse should assess medication use.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 309
MSC: CRNE: CH-48
16. Which of the following is an example of a type IV delayed hypersensitivity reaction?
a. Transfusion reaction
b. Serum sickness
c. Contact dermatitis
d. Systemic lupus erythematosis
ANS: C
Contact dermatitis is an example of a type IV delayed hypersensitivity reaction. Transfusion
reaction is type II cytotoxic reaction. Serum sickness and systemic lupus erythematosis are
type III immune-complex reactions.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 298, Table 16-7
MSC: CRNE: CH-8
17. What is the role of serotonin that is released from platelets during an allergic response?
a. It increases vascular permeability.
b. It stimulates irritant receptors.
c. It dilates smooth muscle.
d. It stimulates vasodilation.
ANS: A
Serotonin that is released from platelets during an allergic response acts to increase vascular
permeability and stimulate smooth muscle contraction.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page
MSC: CRNE:
18. Which one of the following actions would the nurse take to treat a patient who is experiencing
anaphylactic shock?
a. Place the patient in Trendelenburg position.
b. Using cooling blankets to maintain cool body temperature.
c. Administer epinephrine 1:1000 as ordered.
d. Administer low-flow oxygen via nasal prongs.
ANS: C
The nurse would anticipate the administration of epinephrine 1:1000, as ordered. Usually 0.2
to 0.5 mL SC for mild symptoms, repeated at 20 minute intervals. Although oxygen would be
anticipated as part of treatment, it would be administered as high-flow oxygen via a
nonrebreather mask.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
REF: page 303, Table 16-11
MSC: CRNE: CH-62
19. Which of the following processes represents the replacement of a patient’s diseased organ
with an organ harvested from another species?
a. Cadaveric transplantation
b. Ex vivo transplantation
c. Xenotransplantation
d. Hybridoma transplantation
ANS: C
Xenotransplantation is the replacement of a patient’s diseased organ with an organ harvested
from another species.
PTS: 1
OBJ: 13
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 314
MSC: CRNE: CH-8
Chapter 17: Infection and Human Immunodeficiency Virus Infection
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A recently divorced woman seeks health care for vague symptoms of fatigue and headache.
During her examination, she agrees to human immunodeficiency virus (HIV) testing and is
found to have a positive enzyme immunoassay (EIA) for HIV antibodies. In discussing the
test results with the patient, what should the nurse inform the patient about?
a. The EIA test will have to be repeated to verify the results.
b. A viral culture will be done to determine the progress of her disease.
c. It will probably be 10 or more years before she develops acquired immune
deficiency syndrome (AIDS).
d. The EIA test is frequently false-positive, and a more specific Western blot test will
determine whether she has AIDS.
ANS: A
If the EIA of the blood shows positive findings, the test is repeated.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 330, Table 17-12
MSC: CRNE: CH-30
2. Four years after seroconversion, an HIV-infected patient has a CD4+ T-cell count of 800 per
microlitre and a low viral load. What does the nurse recognize at this time?
a. The patient is at risk for development of opportunistic infections because of CD4+
T-cell destruction.
b. The patient is in a clinical and biological latent period during which very few
viruses are being replicated.
c. The body currently is able to produce an adequate number of CD4+ T cells to
replace those destroyed by viral activity.
d. Anti-HIV antibodies produced by B cells enter CD4+ T cells infected with HIV to
stop replication of viruses in the cells.
ANS: C
The patient is in the early chronic stage of infection, when the body is able to produce enough
CD4+ cells to maintain the CD4+ count at a normal level.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 326
MSC: CRNE: CH-8
3. A patient who tested positive for HIV 3 years ago is admitted to the hospital with
Pneumocystis pneumonia. Based on diagnostic criteria established by the World Health
Organization, what is the patient diagnosed as having?
a. AIDS
b. HIV infection
c. Early chronic infection
d. Intermediate chronic infection
ANS: A
A diagnosis of AIDS is made when an individual with HIV demonstrates one of many
different diseases, one of them being Pneumocystis pneumonia.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Diagnosis
REF: page 327, Table 17-10
MSC: CRNE: CH-6
4. To evaluate the effect of HIV infection in a patient, the nurse assesses the patient with the
knowledge that in addition to lymphocytes, the virus also commonly infects which of the
following?
a. Osteocytes
b. Astrocytes
c. Hepatocytes
d. Erythrocytes
ANS: B
HIV infects human cells that have CD4 receptors on their surfaces. These include
lymphocytes, monocytes and macrophages, astrocytes, and oligodendrocytes.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 325
MSC: CRNE: CH-8
5. During post-test counselling for a patient who has tested positive for HIV, the patient is very
anxious and does not appear to hear what the nurse is saying. To promote the patient’s
adjustment to HIV infection, what is it important that the nurse do?
a. Inform the patient how to protect sexual and needle-sharing partners.
b. Teach the patient about the medications that are available for treatment.
c. Identify the need to test others who have had risky contact with the patient.
d. Discuss retesting to verify the results, which will ensure continuing contact with
the health care system.
ANS: D
After an initial positive antibody test, the next step is retesting to confirm the results. A patient
who is anxious is not likely to be able to take in new information or be willing to disclose
information about the HIV status of other individuals.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 330, Table 17-12
MSC: CRNE: CH-30
6. Which following condition is most commonly caused by Escherichia coli?
a. Diphtheria
b. Food poisoning
c. Urinary tract infection
d. Gastroenteritis
ANS: C
E. coli organisms commonly cause urinary tract infections and gastritis.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 316, Table 17-1
MSC: CRNE: CH-8
7. A young mother with a history of intravenous drug use and HIV infection delivered a baby
who has tested positive for HIV. The mother will not care for the baby because she believes
the baby will die soon. When counselling the mother about the care of her infant, what is an
appropriate approach for the nurse to take?
a. Confirm with the mother that the baby will develop AIDS and refer her to a local
AIDS support group.
b. Remind the mother that she has not yet developed AIDS and that it is possible the
baby will not develop AIDS for many years.
c. Inform the mother that if the infant is started on zidovudine (AZT) within the first
month after delivery, AIDS can be prevented.
d. Inform the mother that although infants of HIV-infected mothers always test
positive for HIV antibodies, most infants are not infected with the virus.
ANS: D
If HIV-infected pregnant women are appropriately treated during pregnancy, the rate of
perinatal transmission can be decreased from 25% to less than 2% with the use of
antiretroviral therapy (ART).
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 337
MSC: CRNE: HW-26
8. The nurse should promote interventions such as nutrition, exercise, and stress reduction in
patients who have HIV infection primarily because these interventions will do which of the
following?
a. Improve immune function.
b. Prevent transmission of the virus to others.
c. Promote a feeling of well-being in the patient.
d. Increase the patient’s strength and ability to care for himself or herself.
ANS: A
HIV disease progression may be delayed by promoting a healthy immune system. Useful
interventions for HIV-infected patients include (1) nutritional support to maintain lean body
mass and ensure appropriate levels of vitamins and micronutrients; (2) moderation or
elimination of alcohol intake, smoking, and drug use; (3) adequate rest and exercise; (4) stress
reduction; (5) avoidance of exposure to new infectious agents; (6) mental health counselling;
and (7) involvement in support groups and community activities.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: pages 339-340
MSC: CRNE: HW-2
9. In health care workers, which following activity poses the highest risk for acquiring HIV from
an HIV-infected patient?
a. A needle stick with a suture needle
b. Contamination of open skin lesions with vaginal secretions
c. A needle stick with a needle and syringe used to draw blood
d. A needle stick with a needle and syringe used to administer an intramuscular
injection
ANS: C
HIV can be transmitted only under specific conditions that allow contact with infected body
fluids, including blood, semen, vaginal secretions, and breast milk, with blood being the
highest risk. Precautions and safety devices decrease the risk of direct contact with blood and
body fluids. The risk is higher with a needle that has a hollow bore and visible blood.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: pages 321-322
MSC: CRNE: HW-24
10. A patient has recently tested positive for HIV and asks the nurse about drug therapy for HIV
infection. What should the nurse tell the patient about drug therapy?
a. Drug therapy for HIV is indicated only when CD4+ T-cell counts are abnormal.
b. Drug therapy is delayed as long as possible to prevent development of viral
resistance to the drugs.
c. When to start drug therapy is controversial, and treatment decisions are
individualized for each patient.
d. AZT is administered initially to all patients who test positive for HIV to slow viral
growth.
ANS: C
Treatment decisions should be individualized by indicated by higher viral loads and lower
CD4+ T-cell counts and by a patient’s desires for therapy.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: pages 330-331, Table 17-13
MSC: CRNE: CH-53
11. Drug therapy is being considered for an HIV-infected patient who has asymptomatic HIV
infection with a CD4+ T-cell count of 400 per microlitre. Which nursing assessment is most
important in determining whether therapy will be used?
a. The patient’s social support system offered by significant others and family
b. The patient’s socioeconomic status and availability of medical insurance
c. The patient’s understanding of the multiple side effects that the drugs may cause
d. The patient’s willingness and ability to comply with stringent schedules and
dietary prescriptions
ANS: D
A major problem with most drugs used in ART is that resistance develops rapidly, and some
patients will not be able to use combination therapies because of the expense, side effects, or
inability to adhere to required stringent schedules.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 330
MSC: CRNE: CH-44
12. Which of the following patients should be instructed to report to a health care provider
immediately?
a. A patient with blurry or black areas in the vision field
b. A patient with burning, itching, or discharge from the eyes
c. A patient with headache accompanied by fever and nasal congestion
d. A patient with painful urination with blood in the urine and urethral discharge
ANS: A
Blurry or black areas in the vision field are to be reported immediately, whereas the other
symptoms are to be repeated within 24 hours if they continue.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 339, Table 17-24
MSC: CRNE: HW-26
13. When teaching a patient with HIV infection about ART, what should the nurse explain that
these drugs do?
a. They work in various ways to decrease viral replication in the blood.
b. They alter the cellular surface of cells with CD4 receptors, preventing viral
attachment.
c. They destroy the viral envelope, enabling monocyte and macrophage phagocytosis
of the viral ribonucleic acid.
d. They stimulate the activity of B lymphocytes to produce antibodies that react with
the virus in the blood.
ANS: A
The goal of ART is to decrease the amount of virus in the blood. This is called viral load.
Viral load can be determined by tests such as the polymerase chain reaction or bDNA
(branched-chain deoxyribonucleic acid). The results are reported in absolute numbers. The
goal is to reduce the viral load to an undetectable level.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 339, Table 17-23
MSC: CRNE: CH-44
14. What early manifestations of HIV infection should the nurse assess for in both the nursing
history and the physical examination?
a. Ataxia and confusion
b. Rectal lesions and bleeding
c. Lesions of the mouth and tongue
d. Weight loss and wasting syndrome
ANS: C
Assessment should include mouth lesions, including blisters (herpes simplex virus), whitegrey patches (Candida), painless white lesions on the lateral aspect of the tongue (hairy
leukoplakia), and discolorations (Kaposi’s sarcoma, KS).
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 334, Table 17-16
MSC: CRNE: CH-1
15. While teaching community groups about AIDS, which of the following should the nurse tell
people is currently the most common method of transmission of the HIV virus?
a. Nonsexual exposure to saliva and tears
b. Sharing equipment to inject illegal drugs
c. Transfusions with HIV-contaminated blood
d. Sexual contact with an HIV-infected partner
ANS: D
Transmission of HIV occurs through sexual intercourse with an infected partner, exposure to
HIV-infected blood or blood products, and perinatal transmission during pregnancy, at the
time of delivery, or through breastfeeding; however, the most common method of
transmission is sexual contact with an HIV-infected partner.
PTS: 1
DIF: Cognitive Level: Application
REF: page 323
OBJ: 5
TOP: Nursing Process: Implementation
MSC: CRNE: HW-26
16. A 24-year-old woman who uses injectable, illegal drugs asks the nurse about preventing
AIDS. The nurse should inform the patient that which of the following activities can eliminate
the risk of HIV infection from drug use?
a. Participating in a needle exchange program
b. Cleaning drug injection equipment before use
c. Asking those she shares equipment with to be tested for HIV
d. Not having sexual intercourse when under the influence of the drugs
ANS: A
The risk for HIV can be eliminated if users do not share injecting equipment. Injecting
equipment (“works”) includes needles, syringes, cookers (spoons or bottle caps used to mix
the drug), cotton, and rinse water. None of this equipment should be shared.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 336
MSC: CRNE: HW-4
17. At the health promotion level of care for HIV infection, what should the nurse assess for?
a. Symptoms the patient may be experiencing
b. Drug side effects or interactions that may be present
c. The patient’s need for assistance from the community
d. Behaviours that place the patient at risk for HIV infection
ANS: D
The nurse should ask the patient the following: “What behaviours or social, physical,
emotional, pathological, and immune factors place you at risk?”
PTS: 1
OBJ: 13
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 333
MSC: CRNE: CH-2
18. A patient with HIV infection has developed Mycobacterium avium complex. What is an
appropriate outcome for the nurse to expect for the patient?
a. The patient will be free from injury.
b. The patient will maintain intact perineal skin.
c. The patient will maintain adequate oxygenation.
d. The patient will contact agencies that provide services for the visually impaired.
ANS: B
Clinical manifestations include gastroenteritis, watery diarrhea, and weight loss; therefore, an
appropriate nursing goal would be for the patient to maintain intact perineal skin.
PTS: 1
OBJ: 13
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
REF: page 328, Table 17-11
MSC: CRNE: CH-26
19. What is the median interval between untreated HIV infection and a diagnosis of AIDS?
a. 2 years
b. 5 years
c. 10 years
d. 20 years
ANS: C
The median interval between untreated HIV infection and a diagnosis of AIDS is 10 years.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 326
MSC: CRNE: CH-8
20. Which of the following involves malignant vascular lesions on the torso?
a. Leukoplakia
b. Toxoplasma gondii
c. Kaposi’s sarcoma
d. Coccidioides immitis
ANS: C
KS consists of malignant vascular lesions on the torso that can also appear on internal organs.
PTS: 1
OBJ: 12
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 326
MSC: CRNE: CH-8
21. The nurse should counsel a newly infected HIV patient to anticipate that symptoms of acute
retroviral syndrome will appear at which time?
a. Within 48 hours of diagnosis
b. During the initial 7 days after diagnosis
c. 1 to 3 weeks after diagnosis
d. Within the first 6 months after diagnosis
ANS: C
Symptoms of retroviral syndrome normally appear 1 to 3 weeks after diagnosis and include
fever, swollen lymph glands, sore throat, headache, malaise, nausea, muscle and joint pain,
diarrhea, and a diffuse rash.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 325
MSC: CRNE: CH-8
22. During which period of chronic HIV infection would the patient experience lymphadenopathy
and nervous system manifestations?
a. Early
b. Intermediate
c. Late
d. Terminal
ANS: B
During intermediate chronic HIV infection, the patient will experience worsening of
symptoms from early infection in addition to lymphadenopathy and nervous system
manifestations.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 326
MSC: CRNE: CH-8
Chapter 18: Cancer
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. While she is being prepared for a biopsy of a lump in her right breast, the patient asks the
nurse what the difference is between a benign tumour and a malignant tumour. Which of the
following explanations about benign tumours best describes the difference from malignant
tumours?
a. Benign tumours frequently recur in the same site.
b. Benign tumours do not cause damage to adjacent tissue.
c. Benign tumours do not spread to other tissues and organs.
d. Benign tumours are simply an overgrowth of normal cells.
ANS: C
The major difference between malignant and benign tumours is that benign tumours never
metastasize, whereas malignant tumours invade adjacent tissues and spread to distant
tissues.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 350, Table 18-4
OBJ: 5
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
2. A patient has been told by his physician that the tumour in his bowel is poorly
differentiated. He asks the nurse what is meant by “poorly differentiated.” On what
knowledge should the nurse base the response to the patient’s question?
a. Cancer cells develop a new gene, called an oncogene, which promotes continuous,
immature reproduction of cells.
b. Poorly differentiated cells are fetal cells that do not have time to mature as a result
of the rapid division of malignant cells.
c. Normal cells revert to a more fetal appearance and function, probably because of
mutation of cellular genes called proto-oncogenes.
d. Normal mature cells with specific functions become immature, nonfunctioning
cells when chemical agents, such as oncogenes, cause cell mutation.
ANS: C
An undifferentiated cell has an appearance more like that of a stem cell or a fetal cell and
less like that of a normal cell of the organ or tissue. The DNA in cancer cells is always
different from that of normal cells.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 349
MSC: CRNE: CH-8
3. A patient tells the nurse that he read that asbestos is a carcinogen and asks whether that
means it causes cancer. Which of the following explains what a carcinogen is?
a. Any agent or condition that can promote the proliferation of altered, mutated cells
b. Any chemical, physical, or genetic agent that can irreversibly alter cellular DNA,
causing abnormal cells to be produced
c. Any agent or condition that causes chronic irritation and stimulation of tissue,
resulting in uncontrolled overgrowth of tissue
d. A specific, known chemical or physical agent that can start uncontrolled cellular
proliferation by fracturing cellular DNA
ANS: B
Carcinogens are cancer-causing agents capable of producing cellular alterations and may be
chemical, radioactive, or viral in nature.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 350
MSC: CRNE: CH-8
4. When teaching a patient who smokes about the relationship of smoking to the development
of cancer, how should the nurse explain tobacco smoke as a “complete” carcinogen?
a. Exposure to the smoke always causes cellular changes.
b. Tobacco smoke is capable of both initiating and promoting cancer growth.
c. Cancer will always develop when people who smoke are exposed to other
carcinogens.
d. Tobacco smoke serves as a vehicle for the spread of cancer cells during the
progression stage of cancer.
ANS: B
Some carcinogens (called complete carcinogens) are capable of both initiating and
promoting the development of cancer. Tobacco is an example of a complete carcinogen,
capable of initiating and promoting cancer.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 351
MSC: CRNE: CH-8
5. In teaching about cancer prevention, why does the nurse stress promotion of exercise,
normal body weight, and a low-fat diet?
a. General aerobic health is an important defence against cellular mutation.
b. Obesity is a factor that promotes cancer growth; if it is reversed, the risk of cancer
can be decreased.
c. People who are overweight usually consume large amounts of fat, which is a
chemical carcinogen.
d. The development of fatty tumours, such as lipomas, is increased when fatty tissue
is abundant.
ANS: B
Promoting factors include dietary fat, obesity, cigarette smoking, and alcohol consumption.
The withdrawal of or reduction in these factors can reduce the risk of cancer development.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 351
MSC: CRNE: HW-2
6. During a routine health examination, the patient tells the nurse that she has a family history
of colon cancer. What should the nurse advise the patient to do?
a. Schedule a sigmoidoscopy every year after the age of 40.
b. Schedule a digital rectal examination every 6 months after the age of 45.
c. Have a sigmoidoscopy for baseline at the age of 50 and every 5 years afterward.
d. Discuss specific testing with her doctor because her risk for colon cancer is
increased.
ANS: D
If the patient has a higher known risk (a first-degree relative with colorectal cancer or a
history of inflammatory bowel disease or benign polyps), then screening should be
individualized and started before the age of 50.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 355
MSC: CRNE: HW-2
7. A 58-year-old woman has breast cancer that has metastasized to the liver. On which fact
about metastatic cells does the nurse understand that the treatment plan for the patient is
based?
a. They become more unlike the cells of the primary site as mutations occur in the
tumour cells at both sites.
b. They are identical to the cells in the breast, having passively been spread through
blood and lymph vessels.
c. They do not proliferate as rapidly as the malignant cells in the primary site and are
therefore less sensitive to treatment.
d. They retain the characteristics of the malignant cells in the breast and have the
same response to treatment as the primary tumour does.
ANS: A
As the primary and metastatic sites develop, the cells quickly become more heterogeneous
as they repeatedly undergo spontaneous genetic mutations.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 356
MSC: CRNE: CH-8
8. A patient undergoes a needle biopsy of the prostate. What type of tumour classification can
be provided from a needle biopsy?
a. Clinical status of the patient with cancer
b. Staging of the extent and spread of the tumour
c. Appearance of cells and degree of differentiation
d. TNM staging with size, node involvement, and presence of metastasis
ANS: C
This examination will determine whether the tissue is benign or malignant, the anatomic
tissue from which the tumour arises, and the degree of cellular differentiation (i.e., how
closely the specimen cells resemble the normal cells of the tissue).
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 356
MSC: CRNE: CH-8
9. The nurse is teaching a postmenopausal patient with breast cancer about the expected
outcomes of her cancer treatment. The nurse evaluates that the teaching has been effective
when the patient makes which of the following statements?
a. “If I have no recurrence in the tumour for 5 years after treatment, I will be cured of
my cancer.”
b. “Because my tumour is slow-growing, it will be many years before I can be
considered cured of cancer.”
c. “Cancer can be cured only with surgery, and other treatments are used to control
the symptoms cancer causes.”
d. “Cancer is never considered cured, and the goal of treatment is control of tumour
growth over a long period of time.”
ANS: B
The patient with a tumour that has a slower mitotic rate (e.g., postmenopausal breast cancer)
needs 20 or more disease-free years before she can be considered cured of cancer.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 357
MSC: CRNE: CH-8
10. A patient with a large stomach tumour that is attached to the liver is scheduled to have a
debulking procedure. What should the nurse explain that the expected outcome for this
surgery will be?
a. Relief of pain by cutting sensory nerves in the stomach
b. Reduction of the tumour burden to enhance adjuvant therapy
c. Control of the tumour growth by removal of malignant tissue
d. Promotion of better nutrition by relieving the pressure in his stomach
ANS: B
A debulking or cytoreductive procedure may be used if the tumour cannot be completely
removed (e.g., is attached to a vital organ). When this occurs, as much tumour as possible is
removed, and the patient may be given chemotherapy or radiation therapy.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 358
MSC: CRNE: CH-30
11. External beam radiation is planned for a patient with cancer of the colon. Because the
treatment area is in the lower abdomen and pelvic area, which of the following measures
should the nurse teach the patient is important to prevent complications from the effects of
the radiation?
a. Maintain a high-residue, high-fat diet.
b. Test all stools for the presence of blood.
c. Inspect the mouth and throat daily for the appearance of thrush.
d. Perform perianal care with sitz baths and meticulous cleaning.
ANS: D
Radiation to the lower abdomen will affect organs in the radiation path, such as the bowel.
Nausea, vomiting, and diarrhea are early responses to irradiation of the gastrointestinal
tissue and may occur immediately following the first treatment.
PTS: 1
DIF: Cognitive Level: Application
REF: page 367, Table 18-14
OBJ: 10
TOP: Nursing Process: Implementation MSC: CRNE: HW-4
12. Approximately what percentage of Canadians will develop cancer during their lifetimes?
a. 12%
b. 27%
c. 43%
d. 55%
ANS: C
Approximately 43% of Canadians will develop cancer during their lifetimes.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 347
MSC: CRNE: CH-8
13. A patient with Hodgkin’s disease is undergoing external radiation therapy on an outpatient
basis. After 2 weeks of treatment, he tells the nurse that he is so tired he can hardly get out
of bed in the morning. What is an appropriate goal for the nurse to plan with this patient?
a. Establish a daily walking program.
b. Exercise vigorously when fatigue is not as noticeable.
c. Consult with a psychiatrist for treatment of depression.
d. Maintain bed rest until the radiation treatment is completed.
ANS: A
Mild physical activity programs are usually within the abilities of patients undergoing
external radiation therapy and have been found to improve symptoms of fatigue, lessen
anxiety, and facilitate sleep in cancer patients.
PTS: 1
OBJ: 12
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 364
MSC: CRNE: HW-2
14. After 3 weeks of radiation therapy, a patient has lost 4.5 kg and does not eat well because
nothing tastes good. What is an appropriate nursing diagnosis for the patient?
a. Risk for infection related to poor nutrition
b. Ineffective therapeutic regimen management related to refusal to eat
c. Imbalanced nutrition: less than body requirements related to anorexia
d. Ineffective health maintenance related to lack of knowledge of nutritional
requirements during radiation therapy
ANS: B
The patient is not eating; therefore, the nurse needs to encourage small, frequent meals of
high-protein, high-calorie foods (e.g., Ensure or other supplements) to achieve an effective
therapeutic regimen management and avoid weight loss.
PTS: 1
DIF: Cognitive Level: Application
REF: page 367, Table 18-14
OBJ: 13
TOP: Nursing Process: Diagnosis
MSC: CRNE: CH-35
15. A patient undergoing external radiation has developed a dry desquamation of the skin in the
treatment area. Which of the following statements by the patient indicates to the nurse that
the teaching about management of the skin reaction has been effective?
a. “I can use ice packs to relieve itching and scaling in the treatment area.”
b. “I can lubricate the area with a nonmedicated, nonperfumed moisturizing lotion.”
c. “I will expose the treatment area to a sun lamp daily to increase blood supply to
the area.”
d. “I should scrub the area with warm water to remove the scales and apply alcohol to
toughen the skin.”
ANS: B
Dry skin should be lubricated with a nonirritating lotion or solution that contains no metal,
alcohol, perfume, or additives that irritate the skin.
PTS: 1
OBJ: 12
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 369
MSC: CRNE: CH-41
16. A patient with metastatic cancer of the colon experiences severe vomiting following each
administration of chemotherapy. What is an important nursing intervention for the patient?
a. Weigh the patient twice a week.
b. Have the patient eat full meals when nausea is not present.
c. Administer prescribed antiemetics 1 hour before the treatments.
d. Offer dry crackers and carbonated fluids immediately following the treatments.
ANS: C
The introduction into the oncology settings of antiemetic clinical practice guidelines and
effective implementation of the guidelines are essential methods for managing this treatment
side effect. Administration of antiemetics before treatment will alleviate the patient’s
experience of nausea and vomiting.
PTS: 1
DIF: Cognitive Level: Application
REF: page 371, Table 18-14
OBJ: 12
TOP: Nursing Process: Implementation MSC: CRNE: CH-35
17. When administering vesicant chemotherapeutic agents intravenously, what is an important
consideration?
a. Stop the infusion if swelling is observed at the site.
b. Administer the drug by intravenous (IV) push.
c. Administer the chemotherapy through a small-bore catheter.
d. Administer the drug only through a central vascular access device.
ANS: A
Protect the patient from extravasation through careful attention to chemotherapy delivery
and assessment of venous access. Swelling, redness, and the presence of vesicles on the skin
are other signs of extravasation that would require the nurse to stop the infusion.
PTS: 1
OBJ: 12
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 360
MSC: CRNE: CH-24
18. A chemotherapeutic agent known to cause alopecia is prescribed for a female patient. To
maintain the patient’s self-esteem, what should the nurse plan?
a. Suggest that the patient limit social contacts until her hair regrows.
b. Encourage the patient to purchase a wig or turban and wear it as her hair loss
begins.
c. Have the patient wash her hair daily with a mild shampoo to stimulate her scalp
and promote hair growth.
d. Inform the patient that her hair loss will not be permanent and that her hair will
grow back as it was before.
ANS: B
One intervention for alopecia is for the nurse to suggest ways to cope with hair loss (e.g.,
hair pieces, scarves, wigs).
PTS: 1
DIF: Cognitive Level: Application
REF: page 368, Table 18-14
OBJ: 15
TOP: Nursing Process: Implementation MSC: CRNE: CH-18
19. A patient hospitalized with ovarian cancer tells the nurse that she thinks her husband does
not care for her anymore since she has become ill because he rarely visits her. On one
occasion when the husband was present, he told the nurse he just could not stand to see his
wife so ill and never knew what to say to her. What is an appropriate nursing diagnosis in
this situation?
a. Impaired home maintenance related to perceived role changes
b. Risk for caregiver role strain related to burdens of caregiving responsibilities
c. Interrupted family processes related to effect of illness on family members
d. Compromised family coping related to disruption in lifestyle and necessary role
changes
ANS: C
A diagnosis of cancer may precipitate a crisis in the lives of the patient and his or her
family, with repercussions affecting all aspects of their lives; therefore, interrupted family
processes are evident in this situation.
PTS: 1
OBJ: 12
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
REF: pages 379-380
MSC: CRNE: CH-19
20. A patient receiving external radiation and chemotherapy for oropharyngeal carcinoma has a
denuded and swollen oral mucosa. He has ulcerations over his bucca and tongue, and his
saliva is thick and ropey. What is an appropriate intervention for the nurse to teach the
patient?
a. Maintain a liquid diet until the acute reaction subsides.
b. Use cotton-tipped applicators dipped in hydrogen peroxide to clean his teeth.
c. Gargle and rinse his mouth several times a day with a commercial antiseptic
mouthwash.
d. Rinse his mouth before and after each meal and at bedtime with a solution of salt
and sodium bicarbonate.
ANS: D
The patient should be taught how to perform oral care at least before and after each meal
and at bedtime. A saline solution of 1 teaspoon of salt in 1 litre of water is an effective
cleansing agent. One teaspoon of sodium bicarbonate may be added to the oral care solution
to decrease odour and alleviate pain.
PTS:
1
DIF:
Cognitive Level: Application
REF: page 371
OBJ: 12
TOP: Nursing Process: Implementation
MSC: CRNE: CH-10
21. A patient is receiving chemotherapy for a large tumour of the liver. For which of the
following reasons does the nurse recognize that the expected response to this therapy is
limited?
a. The fewer the cancer cells, the greater is the response to chemotherapy.
b. Large tumours become encapsulated, preventing exposure to chemotherapeutic
agents.
c. The patient’s natural defences are compromised by the presence of numerous
tumour cells.
d. Large tumours have a greater number of undifferentiated cells.
ANS: A
The lower the tumour burden is (i.e., the fewer the cancer cells), the greater the response to
chemotherapy.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 359
MSC: CRNE: CH-8
22. A 32-year-old male patient who recently married is to undergo radiation therapy for
Hodgkin’s disease. He expresses concern to the nurse about the effect of chemotherapy on
his sexual function. What is the best response to the patient’s concerns?
a. “The radiation will make you sterile, but sexual performance will not be
impaired.”
b. “You may have some temporary erectile dysfunction during the course of the
radiation, but normal sexual function will return.”
c. “Radiation does not cause the problems with sexual functioning that occur with
chemotherapy or surgical procedures used to treat cancer.”
d. “It is possible you may have some changes in your sexual function, and you may
want to consider pretreatment harvesting of sperm if you want children.”
ANS: D
Pretreatment status may be a significant factor because a low sperm count and loss of
motility are seen in individuals with testicular cancer and Hodgkin’s disease before any
therapy. Compromised reproductive function in men may also result from erectile
dysfunction following pelvic radiation and its related vascular and neurological effects.
Potential infertility can be a significant consequence for the individual, and counselling is
indicated. Pretreatment harvesting of sperm or ova may be considered.
PTS: 1
OBJ: 12
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 372
MSC: CRNE: HW-26
23. A 40-year-old divorced mother of four school-aged children is hospitalized with metastatic
cancer of the ovary. The nurse finds the patient crying, and the patient tells the nurse that
she does not know what will happen to her children when she dies. What is the most
appropriate response?
a. “Why don’t we talk about the options you have for the care of your children.”
b. “You are going to live for a long time yet, and your children will be just fine.”
c. “I wouldn’t worry about that right now. You need to concentrate on getting well.”
d. “Won’t your ex-husband take the children when you can’t care for them
anymore?”
ANS: A
Psychosocial care is an important aspect of cancer care. Supportive care includes services
and strategies to help cancer patients and their families cope with the cancer experience.
This response expresses the nurse’s willingness to listen and recognizes the patient’s
concern.
PTS: 1
OBJ: 15
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: pages 379-380
MSC: CRNE: CH-18
24. A 63-year-old man 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. Which of the following actions by the patient will the nurse recognize as evidence that
teaching regarding pain management has been effective?
a. The patient limits the use of opiate analgesics to prevent addiction.
b. The patient resigns himself to the fact that pain is an inevitable consequence of
cancer.
c. The patient uses pain medication only when the pain becomes more than he can
tolerate.
d. The patient takes analgesics around the clock on a regular schedule, using
additional doses for breakthrough pain.
ANS: D
Analgesic medications should be given on a regular schedule, around the clock, with
additional doses as needed for breakthrough pain.
PTS: 1
OBJ: 12
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 379
MSC: CRNE: CH-51
25. Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell
carcinoma. Which of the following does the nurse recognize as a goal of therapy with this
agent?
a. Selectively altering the DNA of malignant cells
b. Enhancing the patient’s immunological response to tumour cells
c. Stimulating malignant cells in the resting phase to enter mitosis
d. Preventing the bone marrow depression common with the use of chemotherapeutic
agents
ANS: B
IL-2 enhances the ability of the patient’s own immune response to suppress tumour cells.
PTS: 1
OBJ: 12
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 374
MSC: CRNE: CH-44
26. A patient has been receiving interferon therapy for treatment of cancer. For what common
side effects should the nurse assess the patient?
a. Nausea, vomiting, and diarrhea
b. Fever, chills, fatigue, and malaise
c. Opportunistic infections, such as candidiasis
d. Renal damage with increased serum blood urea nitrogen and creatinine
ANS: B
Side effects of interferon include flulike syndrome (fever, chills, myalgia, headache),
cognitive changes, fatigue, nausea, vomiting, anorexia, and weight loss.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 373, Table 18-16
OBJ: 12
TOP: Nursing Process: Assessment
MSC: CRNE: CH-44
27. Which stage would a patient with Hodgkin’s disease be experiencing when there is
extensive local and regional spread of the cancer cells?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANS: C
In stage III, there is extensive local and regional spread of the disease. This staging system
is commonly used for Hodgkin’s disease and cervical cancer.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 355
MSC: CRNE: CH-8
28. Which one of the flowing malignancies has been linked to radiation?
a. Cervical cancer
b. Breast cancer
c. Thyroid cancer
d. Lung cancer
ANS: C
Thyroid cancer has been linked to effects of radiation exposure, along with leukemia,
lymphoma, bone cancer, and childhood cancers.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 351
MSC: CRNE: CH-8
29. Which of the following is a characteristic of a malignant neoplasm?
a. Usually encapsulated
b. Normally differentiated
c. Moderate to marked vascularity
d. Cells similar to parent cells
ANS: C
A characteristic of a malignant neoplasm is moderate to marked vascularity. Malignant
neoplasms are rarely encapsulated, are poorly differentiated, and the cell characteristics are
abnormal, bearing little resemblance to parent cells.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 350, Table 18-4
OBJ: 2
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
30. Prevalence is the total number of people who are living with cancer. It is more often and
more usefully defined as those still alive how many years after the initial cancer diagnosis?
a. 1 year
b. 2 years
c. 5 years
d. 10 years
ANS: D
Prevalence is more often and more usefully defined as those that are still alive 10 years after
the initial diagnosis of cancer.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 347
MSC: CRNE: CH-8
Chapter 19: Fluid, Electrolyte, and Acid–Base Imbalances
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. Which of the following is a clinical manifestation of hypokalemia?
a. Irritability
b. Soft, flabby muscles
c. Abdominal cramping
d. Oliguria
ANS: B
A clinical manifestation of hypokalemia is soft, flabby muscles. Abdominal cramping and
irritability are manifestations of hyperkalemia. Patients with hypokalemia experience
polyuria, not oliguria.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 398, Table 19-6
MSC: CRNE: CH-8
2. A patient has a small-cell carcinoma of the lung, which is causing the syndrome of
inappropriate antidiuretic hormone (SIADH). Which of the following would the nurse expect
the patient to manifest?
a. Weight loss
b. Increased urinary output
c. Decreased serum sodium level
d. Peripheral and pulmonary edema
ANS: C
SIADH will result in dilutional hyponatremia caused by abnormal retention of water;
therefore, it is important to monitor for a decreased serum sodium level.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: pages 391, 394
MSC: CRNE: CH-8
3. Following bowel surgery, a patient has been receiving normal saline intravenous (IV) fluids at
100 mL per hour; has a nasogastric tube attached to low, intermittent suction; and is on
nothing by mouth (NPO) status. Which of the following assessment findings would alert the
nurse to a major fluid and electrolyte problem?
a. Weight gain
b. Flushed, moist skin
c. A decreasing level of consciousness (LOC)
d. A serum sodium level of 138 mmol/L
ANS: C
A decreasing LOC could be indicative of several fluid and electrolyte disturbances: K+ deficit,
fluid volume excess, Ca2+ excess, Mg2+ excess, and H2O excess. Further diagnostic
information will be ordered by the health care provider to determine the cause of the change in
LOC and the appropriate interventions.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 410, Table 19-19
MSC: CRNE: CH-24
4. For which of the following reasons would the nurse recognize that a patient’s serum sodium
level may not accurately reflect changes in total body sodium?
a. Total body sodium is not reflected in serum sodium levels.
b. Excess serum sodium is taken into the cells in exchange for potassium.
c. Increased serum sodium causes increased retention of water in the blood.
d. Serum sodium concentration is kept constant by the effect of ADH on the kidney.
ANS: C
An abnormal serum sodium level may reflect a sodium problem or, more likely, a water
problem because increased serum sodium causes increased retention of water in the blood.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 410
MSC: CRNE: CH-6
5. What is the most reliable index of volume status when caring for a patient with a fluid
imbalance?
a. Skin turgor
b. Presence of edema
c. Hourly urinary output
d. Daily weight patterns
ANS: D
Accurate daily weight measurements provide the easiest measurement of volume status.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 396
MSC: CRNE: CH-4
6. When monitoring the fluid and electrolyte status of the older adult, what does the nurse
recognize that impairment of the thirst mechanism may lead to?
a. Hyperosmolality
b. Cellular edema
c. Isotonic fluid deficit
d. Decreased production of ADH
ANS: A
An intact thirst mechanism is critical because it is the primary protection against the
development of hyperosmolality, and the sensitivity of the thirst mechanism decreases in older
adults. Symptoms of dehydration and hypernatremia develop if the water losses are not
adequately replaced.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 390
MSC: CRNE: CH-8
7. A patient is taking hydrochlorothiazide, a potassium-wasting diuretic, for treatment of
hypertension. What symptoms should the nurse teach the patient to report?
a. Fatigue and muscle weakness
b. Anxiety and muscle twitching
c. Abdominal cramping and diarrhea
d. Confusion and personality changes
ANS: A
Fatigue and muscle weakness are two of the common signs of hypokalemia.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
REF: page 398, Table 19-6
MSC: CRNE: CH-48
8. A patient who is receiving iso-osmolar continuous tube feedings develops restlessness,
agitation, and weakness. Which serum laboratory finding would the nurse expect to find?
a. K+ 3.2 mmol/L
b. Ca2+ 1.95 mmol/L
c. Na+ 154 mmol/L
d. PO43– 1.55 mmol/L
ANS: C
The elevated serum sodium level is consistent with the patient’s neurological symptoms and
indicates a need for immediate action to prevent further serious complications, such as
seizures.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 393, Table 19-3
MSC: CRNE: CH-6
9. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as a diuretic.
What dietary modifications should the nurse teach the patient to prevent electrolyte
imbalances?
a. Increasing foods high in sodium
b. Decreasing foods high in potassium
c. Restricting fluid intake to 1000 mL per day
d. Increasing intake of milk and milk products
ANS: B
Spironolactone is a potassium-sparing diuretic, and patients should be taught to choose lowpotassium foods.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 398
MSC: CRNE: CH-44
10. What is the best area to assess for skin turgor in the older adult?
a. Forearm
b. Upper arm
c. Sternum
d. Thigh
ANS: C
The preferred areas to assess for tissue turgor in the older person are areas where decreases in
skin elasticity are less significant, such as the sternum or forehead.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 396
MSC: CRNE: CH-4
11. A patient in acid–base imbalance has altered potassium levels. What knowledge does the
nurse use to recognize that the potassium levels are altered in acid–base imbalances?
a. Potassium is returned to extracellular fluid on correction of metabolic acidosis.
b. Hyperkalemia causes an alkalosis that results in potassium being shifted into the
cell.
c. In acidosis, hydrogen ions in the blood are exchanged for potassium from the cell.
d. In alkalosis, potassium is shifted into extracellular fluid to bind excessive
bicarbonate.
ANS: C
Hydrogen ions in the blood are exchanged for potassium from the cell when the patient is
experiencing acidosis.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 398
MSC: CRNE: CH-8
12. IV potassium chloride is ordered for treatment of a patient with hypokalemia. What should the
nurse be aware of when administering the potassium solution?
a. KCl should be administered as rapidly as necessary to correct hypokalemia.
b. To prevent hyperkalemia, the amount of KCl added to IV fluids should never
exceed 80 mmol/L.
c. KCl should be given only through central lines to prevent venospasm and
inflammation at the site of entry.
d. To prevent cardiac dysrhythmias and arrest, the maximum amount of KCl to be
administered in 1 hour is 20 mEq.
ANS: D
Recommendations for giving potassium vary, but, in general, no more than 10 to 20 mEq per
hour is considered safe for routine administration.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 400
MSC: CRNE: CH-58
13. To prevent laryngeal spasms and respiratory arrest in a patient who is at risk for
hypocalcemia, the nurse should assess the patient for which early sign of hypocalcemia?
a. Tetany
b. Confusion
c. Constipation
d. Numbness and tingling around the lips or in the fingers
ANS: D
Numbness and tingling in the extremities and the region around the mouth are an early sign of
hypocalcemia.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 401, Table 19-8
MSC: CRNE: CH-20
14. A patient who has been on NPO status with gastric suction and IV fluid replacement for 3
days following surgery develops nausea and vomiting, weakness, and confusion and has a
serum sodium level of 125 mmol/L. The nurse reviews the patient’s IV fluid orders for the
past several days. Which of the following fluid replacements would lead the nurse to suspect
they are the cause of the patient’s symptoms?
a. 3% saline
b. 0.9% NaCl
c. Dextrose 5% in water
d. Lactated Ringer’s solution
ANS: C
A cause of hyponatremia is excessive hypotonic IV fluids, which includes dextrose 5% in
water. It is often used to treat hypernatremia; therefore, the nurse suspects that this is what has
caused the patient’s decreased sodium level.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 395, Table 19-4
MSC: CRNE: CH-6
15. A patient with renal insufficiency develops lethargy and somnolence with a blood pressure of
100/60 mm Hg, a pulse of 62 beats/min, and respirations of 10 breaths/min. The nurse notes
that the patient has been taking an aluminum hydroxide–magnesium hydroxide suspension
(Maalox) for indigestion. Which of the following drugs would the nurse expect to be used by
IV administration in the management of this patient?
a. Calcium gluconate
b. Magnesium sulphate
c. Potassium chloride
d. 50% dextrose and regular insulin
ANS: A
The patient has a history of hypermagnesemia, and the treatment is IV administration of
calcium chloride or calcium gluconate to physiologically oppose the effects of the magnesium
on cardiac muscle.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: pages 403-404
MSC: CRNE: CH-44
16. A patient who has required prolonged mechanical ventilation has the following arterial blood
gas results: pH 7.48, PO2 85 mm Hg, PCO2 32 mm Hg, and HCO3– 25 mmol/L. How would
the nurse interpret these results?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
ANS: D
The pH indicates that the patient has alkalosis, and the low PCO2 indicates a respiratory cause.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 407, Table 19-13
MSC: CRNE: CH-8
17. A patient is in metabolic acidosis. Which of the following findings indicates to the nurse that
the patient’s body is attempting to compensate for the acidosis?
a. Rapid, deep respirations
b. An increase in urinary pH
c. Decreased plasma proteins
d. Increased urinary bicarbonate
ANS: A
Compensatory response of CO2 excretion by the lungs is evident when a patient is in
metabolic acidosis and is exhibited by rapid, deep respirations.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 407, Table 19-13
MSC: CRNE: CH-8
18. What is the normal approximate fluid balance in the adult?
a. 1000 mL
b. 1500 mL
c. 2000 mL
d. 2500 mL
ANS: D
The normal fluid balance in the adult is 2500 mL.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 392, Table 19-2
MSC: CRNE: CH-34
19. A postoperative patient with prolonged nasogastric suction is at risk for a specific acid–base
imbalance. Which of the following symptoms noted by the nurse indicates that the patient is
developing the acid–base imbalance?
a. Headache
b. Bradycardia
c. Hypotension
d. Hypoventilation
ANS: D
Hypoventilation is a sign of an acid–base imbalance.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 406
MSC: CRNE: CH-8
20. A patient is receiving 3% NaCl solution for correction of hyponatremia. What is important for
the nurse to monitor during administration of the solution?
a. Lung sounds
b. Peripheral pulses
c. Peripheral edema
d. Hourly urinary output
ANS: A
Hypertonic solutions (e.g., 3% NaCl) necessitate frequent monitoring of blood pressure, lung
sounds, and serum sodium levels, and should be used with caution because of the risk for
intravascular fluid volume excess, as well as intracellular dehydration.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 412
MSC: CRNE: CH-34
21. Water accounts for approximately which percentage of total adult body weight?
a. 30%
b. 40%
c. 50%
d. 60%
ANS: D
Water is the primary component of the body, accounting for approximately 60% of adult body
weight.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 385
MSC: CRNE: CH-8
22. Which one of the following terms describes something that is capable of dissolving a
substance that is a liquid or a gas?
a. Osmolarity
b. Osmolality
c. Solvent
d. Valence
ANS: C
A solvent is a substance that is capable of dissolving a solute (liquid or gas).
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 386, Table 19-1
MSC: CRNE: CH-8
23. A patient has the following arterial blood gas results: pH 7.32, PaO2 88 mm Hg, PaCO2 37
mm Hg, and HCO3¯ 16 mmol/L. The patient also has the following electrocardiogram (ECG)
pattern:
How should the nurse interpret these results?
a. Respiratory acidosis with hyperkalemia
b. Respiratory alkalosis with hyperkalemia
c. Metabolic acidosis with hypokalemia
d. Metabolic alkalosis with hypokalemia
ANS: C
The blood values and the resulting ECG pattern indicate metabolic acidosis with hypokalemia.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 399, Figure 19-14
MSC: CRNE: CH-8
Chapter 20: Nursing Management: Preoperative Care
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. During the preoperative interview, a patient scheduled for an elective hysterectomy to treat
benign tumours of the uterus tells the nurse that she does not know whether she can go
through with the surgery because she knows she will die in surgery, as her mother did. What
is the most appropriate response?
a. “Tell me more about what happened to your mother.”
b. “Have you discussed these feelings with anyone else?”
c. “I am sure surgical techniques have improved since your mother had surgery.”
d. “Think positively! Positive thoughts have been shown to influence a positive
surgical outcome.”
ANS: A
Anxiety can arise from lack of knowledge, which may range from not knowing what to expect
during the surgical experience to uncertainty about the outcome of surgery and the potential
findings; therefore, it is important that the nurse help explore the patient’s feelings. Also,
further assessment may uncover a history of malignant hyperthermia, which will require
precautions during the surgery.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 424
MSC: CRNE: CH-31
2. A 74-year-old man is to have a left inguinal hernia repair at the outpatient surgical clinic.
Preoperatively, what is it most important for the nurse to determine?
a. The patient has had outpatient surgery in the past.
b. The patient’s medical plan covers outpatient surgery.
c. The patient plans to stay overnight at the surgical centre.
d. A family member or friend is available for transportation and care at home.
ANS: D
Priority assessment is related to the need to have a responsible adult present for transportation
home after surgery. Other preoperative information can include the day-of-surgery events
such as patient registration, parking, what to wear, and what to bring, but these are not the
priority.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 429
MSC: CRNE: CH-31
3. A 36-year-old woman has been admitted to the hospital for knee surgery. Which of the
following information that was obtained by the nurse during the preoperative assessment
should be reported to the surgeon before surgery is performed?
a. Lack of knowledge about postoperative pain control
b. Knowledge of the possibility of an early, unplanned pregnancy
c. History of a postoperative infection following a prior cholecystectomy
d. Concern that she will be physically limited in caring for her children for a period
postoperatively
ANS: B
If the patient states that she might be pregnant, information should be immediately given to
the surgeon to avoid maternal and subsequent fetal exposure to anaesthetics during the first
trimester.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 429, Table 20-6
MSC: CRNE: CH-27
4. Why is it especially important for the nurse to determine the patient’s current use of
medications during the preoperative assessment?
a. These medications may alter the patient’s perceptions about surgery.
b. Anaesthetics alter renal and hepatic function, causing toxicity by other drugs.
c. Other medications may cause interactions with anaesthetics, altering the potency
and effect of the drugs.
d. Routine medications are usually withheld the day of surgery, requiring dosage and
schedule adjustments.
ANS: C
All findings of the medication history should be documented and communicated to the
intraoperative and postoperative personnel. Although the anaesthesiologist will determine the
appropriate schedule and dose of the patient’s routine medications before and after surgery
based on the medication history, the nurse must ensure that all of the patient’s medications are
identified, administer the medications as ordered, and monitor the patient for potential
interactions and complications.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 425
MSC: CRNE: CH-31
5. During a preoperative assessment, which of the following reported allergies does the nurse
recognize as a risk for latex allergy in the patient?
a. Iodine
b. Penicillin
c. Dairy products
d. Bananas
ANS: D
An allergy to bananas puts the patient at risk for a latex allergy. Additional risk factors include
food allergies to papain (meat tenderizer), avocados, kiwis, papayas, chestnuts, potatoes,
tomatoes, celery, peaches, and other fruit with stones.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 425
MSC: CRNE: CH-1
6. Sarah, 46 years old, is in the preoperative assessment area awaiting surgery. She is wringing
her hands and perspiring, and she has a worried affect. The nurse’s communication with Sarah
is based on the knowledge that the most prevalent fear of patients awaiting surgery is which of
the following?
a. Pain
b. Altered body image
c. Potential for death
d. Results of the procedure
ANS: C
Patients fear surgery for many reasons, but the most prevalent are death and permanent
disability.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 423
MSC: CRNE: CH-7
7. During the preoperative assessment of a patient scheduled for a cholecystectomy at an
outpatient centre, the patient tells the nurse that she uses St. John’s wort to keep her spirits up.
Why should the nurse notify the anaesthesiologist about this use of St. John’s wort?
a. It may increase the risk of bleeding.
b. It may prolong the effects of anaesthetics.
c. It may cause serious elevations in blood pressure.
d. It may depress the immune system response, delaying healing.
ANS: B
St. John’s wort may prolong the effects of anaesthetic agents.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 424, Complementary and Alternative Therapies box
OBJ: 5
TOP: Nursing Process: Assessment
MSC: CRNE: NCP-10
8. Which of the following is the meaning of the suffix -ostomy?
a. Excision or removal
b. Creation of opening into
c. Incision or cutting into
d. Repair and reconstruction
ANS: B
The meaning of the suffix -ostomy is creation of an opening into; an example is a colostomy.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 421, Table 20-1
MSC: CRNE: CH-8
9. According to the Canadian Anesthesiologists’ Society, what is the minimum preoperative
fasting time period for intake of clear fluids?
a. 30 minutes
b. 1 hour
c. 2 hours
d. 4 hours
ANS: C
According to the Canadian Anesthesiologists’ Society, the minimum preoperative fasting time
period for intake of clear fluids is 2 hours.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 431, Table 20-9
MSC: CRNE: CH-31
10. The nurse visits the patient to have him sign the operative permit as directed in the physician’s
preoperative orders. The patient tells the nurse that the physician has not really told him what
is involved in the surgical procedure. What should the nurse do?
a. Ask family members whether they have discussed the surgical procedure with the
physician.
b. Explain what the planned surgical procedure entails before having the patient sign
the consent form.
c. Have the patient sign the form, and tell him the physician will visit him before
surgery to explain the procedure.
d. Delay the patient’s signature on the consent form, and notify the physician that the
informed-consent process is not complete.
ANS: D
The nurse can be a patient advocate, verifying that the patient (or a family member)
understands the consent form and its implications and that consent for surgery is truly
voluntary. The nurse will contact the surgeon and explain the need for additional information
if the patient is unclear about operative plans.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 431
MSC: CRNE: PP-1
11. What does appropriate preoperative teaching for a patient scheduled for abdominal surgery
include?
a. How to care for the wound
b. How to breathe deeply and cough
c. What medications will be used during surgery
d. What drains and tubes will be present after surgery
ANS: B
All abdominal surgery patients are taught deep breathing and coughing exercises in the
preoperative period.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 430, Table 20-7
MSC: CRNE: CH-31
12. Which following class of preoperative medications is administered to increase the patients’
gastric pH and decrease gastric volume?
a. Narcotics
b. Benzodiazepines
c. Anticholinergics
d. Histamine H2-receptor antagonists
ANS: D
Histamine H2-receptor antagonists—for example, cimetidine (Tagamet), famotidine (Pepcid),
and ranitidine (Zantac)—are used preoperatively to increase gastric pH and decrease gastric
volume.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 434, Table 20-11
MSC: CRNE: CH-44
13. An 82-year-old man is admitted to the hospital the evening before a prostatectomy for cancer
of the prostate. He is alert and oriented but has difficulty seeing and hearing. His wife is at his
bedside and answers most questions directed to the patient. What should the nurse do to
accomplish preoperative teaching with the patient?
a. Use printed materials for instruction because the patient does not hear well.
b. Direct the teaching toward the wife because she is the obvious support and
caregiver for the patient.
c. Provide additional time for the patient to understand preoperative instructions and
carry out procedures.
d. Ask the patient’s wife to wait in the hall in order to focus on preoperative teaching
with the patient himself.
ANS: C
Sensory deficits may necessitate that more time be allowed for the older adult to complete
preoperative testing and understand preoperative instructions.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 435
MSC: CRNE: NCP-14
14. A patient with diabetes that is well controlled with insulin injections has been on nothing by
mouth (NPO) status since midnight before having a mastectomy. The nurse notes that there
are no preoperative orders regarding the patient’s daily insulin dose. What is the most
appropriate nursing action?
a. Withhold any insulin dose because none is ordered and the patient is on NPO
status.
b. Call the physician to clarify whether insulin should be given and at what dosage.
c. Give the patient half of her usual daily insulin dose because she will not be eating
in the morning.
d. Give the patient her usual daily insulin dose because the stress of surgery will
increase her blood glucose level.
ANS: B
In the case of insulin, it is important to clarify the time and amount of the last dose before
surgery.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 426
MSC: CRNE: CH-31
15. How would the nurse document the preoperative rating of physical status for a patient who
has a history of controlled asthma?
a. Healthy patient with no systemic disease
b. Mild systemic disease without functional limitations
c. Severe systemic disease associated with functional limitations
d. Severe systemic disease that is an ongoing threat to life
ANS: B
A patient that has a history of controlled asthma would be rated as a II—a mild systemic
disease without functional limitations.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 427, Table 20-4
MSC: CRNE: CH-31
16. As the nurse prepares a patient the morning of surgery, the patient refuses to remove her
wedding ring. What should the nurse do?
a. Tape the ring securely to the finger.
b. Note the presence of the ring on the preoperative checklist form.
c. Insist that the patient remove the ring, and take it to the facility’s safe.
d. Tell the patient that the health facility cannot be responsible if something happens
to her finger or the ring.
ANS: A
If the patient prefers not to remove a wedding ring, the ring can be taped securely to the finger
to prevent loss.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 432
MSC: CRNE: CH-31
17. Which of the following should be the nurse’s preoperative consideration when the patient
states that she takes a garlic pill every day?
a. Garlic may cause inflammation of the liver.
b. Garlic may inhibit platelet activity.
c. Garlic may increase bleeding.
d. Garlic may increase pulse rate.
ANS: C
Garlic may increase bleeding, especially in patients taking anticoagulants.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 424, Complementary and Alternative Therapies box
OBJ: 3
TOP: Nursing Process: Assessment
MSC: CRNE: NCP-10
Chapter 21: Nursing Management: Intraoperative Care
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. What is the primary reason the perioperative nurse encourages a family member or a friend
to remain with a patient in the preoperative holding area until the patient is taken into the
operating room (OR)?
a. To ensure the proper identification of the patient before surgery
b. To protect the patient from cross-contamination with other patients
c. To assist the perioperative nurse to perform a complete patient history
d. To help minimize patient anxiety
ANS: D
Some institutions permit the family or a friend to wait with the patient until it is time to be
transferred to the OR. It is believed that having a family member stay with the patient helps
relieve anxiety.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 440
MSC: CRNE: CH-31
2. What is the intraoperative activity that is performed by the perioperative nurse and is
specific to the circulating function?
a. Identifying and assessing the patient
b. Counting sponges, needles, and instruments
c. Passing instruments to the surgeon and assistants
d. Preparing the instrument table and organizing sterile equipment
ANS: A
The circulating nurse is responsible for identifying and assessing the physiological and
emotional status of the patient. Counting sponges, needles, and surgical instruments is
included in both the circulating and scrub roles. Management of sterile instruments and
handing instruments to the surgeon are included in the scrub role. Preparation of the
instrument table and sterile equipment is included in both the circulating and scrub roles.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 441, Table 21-1
OBJ: 1
TOP: Nursing Process: Implementation MSC: CRNE: CH-4
3. Which of the following is a principle of basic aseptic technique in the OR?
a. All supplies for the day are opened at the beginning of the shift in the sterile
surgical room.
b. Torn items can be used as long as they are opened in the sterile room.
c. Sterile items can be opened and flipped onto the sterile table.
d. Each wrapper should be checked for wrapper integrity and changed chemical
indicators.
ANS: D
Ensuring that each wrapper is checked for wrapper integrity and changed chemical
indicators before use is a principle of basic aseptic technique in the OR.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 445, Table 21-3
OBJ: 6
TOP: Nursing Process: Implementation MSC: CRNE: CH-31
4. What are the physical environment and traffic control measures of the OR primarily
designed to do?
a. Protect the patient’s privacy.
b. Prevent transmission of infection.
c. Ensure the proper function of electrical equipment.
d. Promote the development of teamwork among the OR staff.
ANS: B
The surgical suite is a controlled environment designed to minimize the spread of infectious
organisms and allow a smooth flow of patients, personnel, and the instruments and
equipment needed to provide safe patient care.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 439
MSC: CRNE: CH-8
5. Which one of the following intraoperative patient positions would the nurse anticipate for
the patient who is being prepared for abdominal surgery?
a. Prone
b. Supine
c. Trendelenburg
d. Lateral decubitus
ANS: B
The nurse would anticipate a patient that was being prepared for abdominal surgery to be in
a supine position for surgery.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 446, Figure 21-6
OBJ: 7
TOP: Nursing Process: Planning
MSC: CRNE: CH-20
6. The nurse would implement postoperative monitoring of a patient’s sedation score when the
patient had received which one of the following anaesthetics?
a. Lidocaine (local spinal)
b. Fentanyl (analgesic spinal)
c. Lidocaine (local epidural)
d. Sufentanil (analgesic epidural)
ANS: C
The nurse would implement postoperative monitoring of the patient’s sedation score when
the patient had received a local epidural anaesthetic, for example, lidocaine.
PTS: 1
DIF: Cognitive Level: Application
REF: page 452, Table 21-7
OBJ: 8
TOP: Nursing Process: Implementation
MSC: CRNE: CH-31
7. Which of the following data obtained during the perioperative nurse’s assessment of an
older patient in the preoperative holding area would indicate a need for special protection
techniques during surgery?
a. A history of spinal and hip arthritis
b. Verbalization of anxiety by the patient
c. The patient asking about the details of the surgical procedure
d. An 8-mm Hg increase in systolic blood pressure from the time of hospital
admission
ANS: A
Older adults often have osteoporosis and osteoarthritis. These factors reinforce the need for
careful transferring, lifting, and positioning techniques.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 453
MSC: CRNE: CH-20
8. The nurse notes that a preoperative patient is drowsy, but oriented, in the receiving area. In
addition to checking her hospital number and identification band, what should the nurse
check?
a. Ask family members to verify the patient’s identity.
b. Check that the operative procedure is noted on the chart.
c. Ask the surgeon to identify the patient and the planned surgical procedure.
d. Ask the patient to state her name, her doctor’s name, and the operative procedure
planned.
ANS: D
The identification process in the receiving area includes asking the patient to state her or his
name, the surgeon’s name, and the operative procedure and location.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 443
MSC: CRNE: CH-31
9. The nurse from the general surgical unit brings the patient’s hearing aid to the surgical suite
because the patient left the unit without it and it is needed to communicate with the patient.
At the surgical suite, what areas can the general surgical unit nurse enter?
a. Clean core
b. Scrub sink areas
c. Information or nursing station
d. Corridors of the ORs
ANS: C
In the OR area, the unrestricted area is where personnel in street clothes can interact with
those in scrub clothing. These areas typically include the points of entry for patients (e.g.,
holding area), staff (e.g., locker rooms), and information (e.g., nursing station).
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 439
MSC: CRNE: CH-31
10. A preoperative patient in the holding area asks the nurse whether he will be “put to sleep”
with a mask over his face. What is the most appropriate response?
a. “A drug will be injected through your intravenous line, which will cause you to go
to sleep almost immediately.”
b. “Only your surgeon can tell you for sure what method of anaesthesia will be used.
Should I ask your surgeon?”
c. “Masks are not used anymore for anaesthesia. A tube will be inserted into your
throat to deliver a gas that will put you to sleep.”
d. “You will be so sleepy from the preoperative medication you have received that
you will not be aware of the anaesthetic administration.”
ANS: A
Virtually all routine general anaesthetic protocols for use with adults begin with an
intravenous (IV) induction agent, such as midazolam (Versed) or propofol (Diprivan).
PTS: 1
OBJ: 9
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 443
MSC: CRNE: CH-31
11. A surgical patient received a volatile liquid as an inhalation anaesthetic during surgery.
What would the nurse expect the patient to experience postoperatively?
a. Early onset of pain
b. Nausea and vomiting
c. Respiratory depression
d. Significant cardiac depression
ANS: A
With an inhalation anaesthetic, the nurse needs to assess and treat pain during early
anaesthesia recovery.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 449, Table 21-4
OBJ: 8
TOP: Nursing Process: Assessment
MSC: CRNE: CH-44
12. Which assessment finding would the nurse expect to observe in a patient with malignant
hyperthermia?
a. Decreased heart rate
b. Low, irregular respirations
c. Decreased temperature
d. Ventricular dysrhythmias
ANS: D
A patient with malignant hyperthermia will exhibit tachycardia, tachypnea, hypercarbia, and
ventricular dysrhythmias.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 453
MSC: CRNE: CH-8
13. A patient with a dislocated shoulder is prepared for a closed, manual reduction of the
dislocation with conscious sedation. Which of the following would the nurse anticipate
would be administered preoperatively?
a.
b.
c.
d.
Inhaled nitrous oxide
IV midazolam
Intramuscular ketamine (Ketalar)
Intramuscular fentanyl–droperidol (Innovar)
ANS: B
Because of its excellent amnestic property, shorter duration of action, and absence of pain
on injection, midazolam is presently the most frequently used benzodiazepine for conscious
sedation.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 448
MSC: CRNE: CH-8
14. What is one of the most important goals of the registered nurse first assistant?
a. Safety of the patient
b. Monitoring of the activities of others
c. Documentation of the intraoperative care
d. Admission of the patient to the OR
ANS: A
The registered nurse first assistant’s primary role is to carry out preoperative, intraoperative,
and postoperative nursing responsibilities to ensure a safe, efficient patient experience.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: pages 441-442
MSC: CRNE: PP-9
15. Which of the following is part of the minimum requirements for the health record in
ambulatory surgery facilities?
a. Postoperative checklist
b. Consult request
c. Documentation of consent
d. Detailed surgical procedure report
ANS: C
Minimum requirements for the health record in ambulatory surgery facilities include
documentation of informed consent, preoperative checklist, and a history and physical
examination.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 443
MSC: CRNE: CH-31
16. A patient in surgery receives a neuromuscular blocking agent as an adjunct to general
anaesthesia. At the completion of the surgery, it is most important that the nurse monitor the
patient for which one of the following?
a. Nausea and vomiting
b. Agitation and seizures
c. Laryngospasm or bronchospasm
d. Adequacy of respiratory muscle movement
ANS: D
The patient should be carefully observed for airway patency and adequacy of respiratory
muscle movement.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 450
MSC: CRNE: CH-31
Chapter 22: Nursing Management: Postoperative Care
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. On admission of a patient to the postanaesthesia care unit (PACU) from surgery, the nurse
should place the highest priority on assessing which of the following?
a. The condition of the surgical site
b. The patient’s level of consciousness
c. The adequacy of respiratory function
d. The status of fluid and electrolyte balance
ANS: C
While the patient is in the PACU, priority care includes monitoring and management of
respiratory and circulatory function, pain, temperature, and surgical site, with the priority
being the adequacy of respiratory function.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 457
MSC: CRNE: CH-31
2. A 42-year-old patient is recovering from anaesthesia in the PACU following a
hysterectomy. Her preoperative blood pressure was 120/68 mm Hg, and on admission to the
PACU, her blood pressure was 124/70 mm Hg. Thirty minutes after admission, her blood
pressure is 112/60 mm Hg. Her pulse is 72 beats/min, and her skin is warm and dry. What is
the most appropriate nursing action at this time?
a. Administer oxygen therapy per mask.
b. Notify the anaesthesiologist immediately.
c. Increase the rate of the patient’s intravenous (IV) fluid replacement.
d. Continue to monitor the patient, taking vital signs every 15 minutes.
ANS: D
The assessment findings are within the normal range, which directs the nurse to continue to
monitor the patient’s status, taking vital signs every 15 minutes.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
REF: pages 473-474
MSC: CRNE: CH-31
3. A 70-year-old patient becomes restless and agitated as he begins to regain consciousness in
the PACU, and his SpO2 is 88%. What is the most common cause of hypoxemia during
anaesthesia recovery that the nurse bases her knowledge on to intervene?
a. Atelectasis
b. Bronchospasm
c. Pulmonary edema
d. Aspiration of gastric contents
ANS: A
The most common cause of postoperative hypoxemia is atelectasis. Atelectasis (alveolar
collapse) may be the result of bronchial obstruction caused by retained secretions or
decreased respiratory excursion.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 461
MSC: CRNE: CH-24
4. During recovery from anaesthesia in the PACU, a patient’s vital signs for the past hour have
been as follows: blood pressure 112/82, 110/82, 112/80, and 114/82 mm Hg; pulse 76, 78,
78, and 80 beats/min; and respirations 22, 24, 24, and 26 breaths/min; her SpO2 is 90%. She
is sleepy but awakens easily and is oriented when spoken to. Her surgical dressing is dry
and intact. What is the most appropriate nursing action?
a. Position the patient in a lateral position.
b. Encourage the patient to take deep breaths.
c. Check the patient’s temperature, and apply warm blankets.
d. Notify the anaesthesiologist that the patient is ready for discharge from the PACU.
ANS: B
Deep breathing and coughing techniques help the patient prevent alveolar collapse and
move respiratory secretions to larger airway passages for expectoration. As long as the vital
signs are within the normal range, the patient should be assisted to breathe deeply 10 times
every hour while awake.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 458
MSC: CRNE: CH-31
5. When a postoperative patient in the PACU complains of pain at the incision site, what
should the nurse do?
a. Administer analgesics as written in the patient’s postoperative orders.
b. Administer half of the postoperative dose of analgesic ordered for the patient.
c. Tell the patient that pain medication cannot be given until transfer to the
postoperative clinical unit.
d. Consult with the anaesthesiologist to determine an effective, reduced dose of an
analgesic for the patient.
ANS: D
Adequate and regular analgesic medication should be provided because incisional pain often
is the greatest deterrent to patient participation in effective ventilation and ambulation;
therefore, the nurse should consult with the anaesthesiologist to determine an effective dose
in light of the amount of medications that the patient had in the operating room.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 467
MSC: CRNE: CH-27
6. While assessing patients for complications during recovery from anaesthesia, the nurse
recognizes that which of the following patients is at the greatest risk for developing
postoperative hypothermia?
a. A 78-year-old female patient undergoing a vaginal hysterectomy under general
anaesthesia
b. A 58-year-old male patient undergoing repair of a knee cartilage under general
anaesthesia
c. A 68-year-old female patient with diabetes undergoing a great toe amputation
under local anaesthesia
d. A 72-year-old male patient undergoing bowel resection for colon cancer under
general anaesthesia
ANS: D
Long surgical procedures and prolonged anaesthetic administration lead to redistribution of
body heat from the core to the periphery. This places the patient at an increased risk for
hypothermia; therefore, the patient at greatest risk is one undergoing a bowel resection
because of the length of the surgery.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 467
MSC: CRNE: CH-31
7. To maintain the airway and promote respiratory function, in which preferred position should
the nurse place unconscious patients in the PACU?
a. Prone
b. Lateral
c. Dorsal recumbent
d. Supine with the head of the bed elevated
ANS: B
Unless contraindicated by the surgical procedure, the unconscious patient is positioned in a
lateral “recovery” position.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 469
MSC: CRNE: CH-31
8. A patient’s blood pressure in the PACU has dropped from an admission blood pressure of
138/84 to 110/78 mm Hg, with a pulse change of 68 to 84 beats/min. What is the first
nursing action to be performed?
a. Administer oxygen.
b. Assess for a full bladder.
c. Auscultate the patient’s lungs.
d. Check the patient’s temperature.
ANS: A
Treatment of hypotension should always begin with oxygen therapy to promote oxygenation
of hypoperfused organs.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 458
MSC: CRNE: CH-32
9. The nurse is documenting the daily amount that was collected in a patient’s T-tube. Which
one of the following daily totals would be considered normal?
a. 100 mL
b. 250 mL
c. 500 mL
d. 1000 mL
ANS: C
The normal daily total for T-tube daily volume is 500 mL.
PTS: 1
DIF: Cognitive Level: Application
REF: page 473, Table 22-8
OBJ: 4
TOP: Nursing Process: Assessment
MSC: CRNE: CH-31
10. When a patient is transferred from the PACU to the clinical surgical unit, what is the first
nursing action on the surgical unit?
a. Assess the patient’s pain.
b. Take the patient’s vital signs.
c. Check the rate of the IV infusion.
d. Check the physician’s postoperative orders.
ANS: B
Vital signs should be obtained, and patient status should be compared with the report
provided by the PACU.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 474, Table 22-10
OBJ: 4
TOP: Nursing Process: Implementation MSC: CRNE: CH-31
11. Which of the following is an ambulatory surgery discharge criterion?
a. Voided at least three times
b. No IV narcotics for last 30 minutes
c. Had at least one bowel movement
d. Oxygen saturation 88%
ANS: B
One of the discharge criteria for ambulatory surgery discharge is that the patient has not
received IV narcotics in the past 30 minutes. The patient is only required to have had one
void. No bowel movement is required before discharge. Oxygen saturations should be
>90%, according to the PACU discharge criteria, which must be met for ambulatory surgery
discharge.
PTS: 1
DIF: Cognitive Level: Application
REF: page 473, Table 22-9
OBJ: 6
TOP: Nursing Process: Assessment
MSC: CRNE: CH-14
12. A patient who had bowel surgery 2 days ago has orders for morphine sulphate 4 mg IV
every 2 hours and a clear liquid diet. The patient tells the nurse that she feels distended and
has gas pains. What is the most appropriate intervention in response to the patient’s
complaint?
a. Obtain an order for a laxative.
b. Withhold all oral fluid and food.
c. Assist the patient to ambulate in the hall.
d. Administer the prescribed morphine sulphate.
ANS: C
Fifty percent of patients who have bowel surgery experience postoperative ileus (POI), a
transient cessation of bowel motility that prevents effective passage of intestinal contents
and may affect the patient’s tolerance of oral intake. Recent studies suggest starting a clear
liquid diet for some types of POI and initiating early ambulation and pharmacological
interventions.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 469
MSC: CRNE: CH-38
13. Postoperatively, a patient is receiving low–molecular weight heparin. What should the nurse
do when administering this drug?
a. Explain that the drug will help prevent clot formation in the legs.
b. Administer the dose with meals to prevent gastrointestinal irritation and bleeding.
c. Check the results of the partial thromboplastin time before administration.
d. Inform the patient that blood will be drawn every 6 hours to monitor the
prothrombin time.
ANS: A
The use of unfractionated heparin or low–molecular weight heparin is a prophylactic
measure for venous thrombosis and pulmonary embolism.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 465
MSC: CRNE: CH-44
14. Following gallbladder surgery, a patient has a T-tube with thick, dark green drainage. When
the patient asks about the tube and the drainage, what is the nurse’s best response?
a. “The tube you see has been placed in the bile duct, and the drainage is normal
bile.”
b. “The drainage is from your gallbladder, but it should be bright yellow rather than
green.”
c. “The drainage is old blood and fluid that accumulates at the surgical site, and its
removal will promote healing.”
d. “The tube is draining secretions from the duodenum and small bowel, and this is
normal drainage from this area.”
ANS: A
The assessment indicates normal findings for a T-tube; therefore, the nurse needs to tell the
patient that this is normal and that the T-tube is in the bile duct.
PTS: 1
DIF: Cognitive Level: Application
REF: page 473, Table 22-8
OBJ: 4
TOP: Nursing Process: Implementation MSC: CRNE: CH-8
15. A postoperative patient has not voided for 7 hours after return to the postsurgical unit.
Initially, what should the nurse do?
a. Call the physician.
b. Palpate and percuss the bladder.
c. Ambulate the patient to the bathroom.
d. Check the postoperative orders for catheterization orders.
ANS: B
If no voiding occurs, the abdominal contour should be inspected, and the initial action is to
palpate and percuss the bladder for distension.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 470
MSC: CRNE: CH-37
16. Which of the following is a possible cause for a temperature of 36.1°C in a patient at 8
hours postoperative abdominal surgery?
a. Surgical stress response
b. Lung congestion, atelectasis
c. Effects of anaesthesia
d. Phlebitis
ANS: C
Hypothermia during the first 12 hours after surgery is probably caused by the effects of the
anaesthesia or body heat loss during surgical exposure. The other answer options all cause
an increase in body temperature, not a decrease.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 468, Table 22-6
OBJ: 2
TOP: Nursing Process: Assessment
MSC: CRNE: CH-31
17. During planning to promote ambulation, coughing, deep breathing, and turning in a
postoperative patient, which of the following does the nurse know will help ensure that the
desired outcomes will most readily be met?
a. The patient understands the rationale for these activities.
b. The patient receives praise when the activities are completed.
c. The patient receives enough analgesics to promote relative freedom from pain.
d. The patient is warned about complications that can occur without the activities.
ANS: C
Adequate and regular analgesic medication should be provided because incisional pain often
is the greatest deterrent to patient participation in effective ventilation and ambulation.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 467
MSC: CRNE: CH-31
18. Which of the following is an integumentary system clinical manifestation of inadequate
oxygenation?
a. Muscle twitching
b. Use of accessory muscles
c. Hypotension
d. Prolonged capillary refill
ANS: D
An integumentary system clinical manifestation of inadequate oxygen is prolonged capillary
refill.
PTS:
1
DIF:
Cognitive Level: Analysis
REF: page 474, Table 22-10
TOP: Nursing Process: Assessment
OBJ: 4
MSC: CRNE: CH-32
19. While caring for a postoperative patient, what should the nurse expect that a physiological
response to stress during the first 2 to 5 days postoperatively will result in?
a. Tachycardia
b. Hyperventilation
c. Fluid retention with decreased urinary output
d. An elevation of body temperature to 38.3°C
ANS: C
Fluid retention during the first 2 to 5 postoperative days can be the result of the stress
response.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 464
MSC: CRNE: CH-8
20. A patient is one day postoperative for abdominal surgery and has an indwelling catheter.
Which of the following amounts represents the normal daily range of urine volume?
a. 200 to 400 mL
b. 500 to 700 mL
c. 800 to 1000 mL
d. 1500 to 2000 mL
ANS: B
The normal daily range of urine volume expected from a patient with an indwelling catheter
1 to 2 days postoperatively is 500 to 700 mL. After this time period, 1500 to 2500 mL is
expected daily.
PTS: 1
DIF: Cognitive Level: Application
REF: page 473, Table 22-8
OBJ: 4
TOP: Nursing Process: Assessment
MSC: CRNE: CH-37
Chapter 23: Nursing Assessment: Visual and Auditory Systems
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A 56-year-old patient schedules annual testing for glaucoma with the ophthalmologist. What
is involved in the procedure that is used to test for glaucoma?
a. Reading a Snellen chart at 6 metres (20 feet)
b. Application of a Tono-Pen to the cornea of the eye
c. Shining a light into the pupil to determine its reaction
d. Ophthalmoscopic examination of the posterior chamber
ANS: B
Testing for glaucoma involves measuring the intraocular pressure, and this is done with a
Tono-Pen.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 488, Table 23-4
MSC: CRNE: CH-4
2. During assessment of a 68-year-old patient’s eyes, the nurse determines that the patient needs
more extensive examination of the eyes when which of the following data are found?
a. Persistent photophobia
b. Light-yellow colouring of the sclera
c. Slow recovery of the pupil after light stimulation
d. A whitish-grey ring encircling the periphery of the iris
ANS: A
Persistent photophobia can indicate inflammation or infection of the cornea or anterior uveal
tract (iris and ciliary body) or conjunctivitis; therefore, a more extensive examination is
warranted.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 488, Table 23-5
MSC: CRNE: CH-3
3. How should the nurse assess a patient’s pupillary response to accommodation?
a. Shine a light into the patient’s eye, and watch the pupil response in the opposite
eye.
b. Cover one eye for 1 minute, and note the pupil reaction when the cover is
removed.
c. Touch the cornea with a small piece of sterile cotton, and observe for a change in
pupil size.
d. Ask the patient to focus on an object at 60 to 90 cm and then to focus on the object
at 7 to 8 cm.
ANS: D
Accommodation is when the patient looks at a distant object 60 to 90 cm away and then is
asked to focus on an object 7 to 8 cm from the nose. The nurse should observe convergence of
the eyes and constriction of the pupils.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 490
MSC: CRNE: CH-4
4. A 44-year-old patient tells the nurse that she recently bought some reading glasses at the
drugstore because they help her see at close range much better. When she asks the nurse what
is happening to her eyes, the nurse explains that this often occurs in middle age and is a result
of which of the following aging processes?
a. Thinning of the retina
b. Loss of lens elasticity
c. Degeneration of the cornea
d. Unevenness of the cornea
ANS: B
Presbyopia is a common age-related change and involves an increased rigidity of the lens,
meaning that a loss of lens elasticity occurs.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 485
MSC: CRNE: CH-8
5. At the eye clinic, the nurse advises all patients to protect the eyes from ultraviolet (UV) light
with the use of good sunglasses because UV light exposure is associated with the
development of which of the following conditions?
a. Glaucoma
b. Exophthalmos
c. Floaters and anisocoria
d. Cataracts
ANS: D
Cataracts can result from blunt or penetrating trauma, congenital factors such as maternal
rubella, radiation or UV light exposure, certain drugs such as systemic corticosteroids or longterm topical corticosteroids, and ocular inflammation.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 494, Determinants of Health box
OBJ: 7
TOP: Nursing Process: Assessment
MSC: CRNE: HW-19
6. Women are at greater risk for which one of the following diseases?
a. Cataracts
b. Eye trauma
c. Colour blindness
d. Macular degeneration
ANS: D
Women are at greater risk for age-related macular degeneration and glaucoma.
PTS: 1
DIF: Cognitive Level: Knowledge
REF: page 494, Determinants of Health box
OBJ: 7
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
7. For which reason would a patient be having the diagnostic test keratometry?
a. To determine field of vision
b. To determine papillary response
c. To measure the corneal curvature
d. To provide a magnified view of the optic nerve head
ANS: C
Keratometry is done to measure the corneal curvature and is often performed before fitting of
contact lenses, before refractive surgery, or after corneal transplantation.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 488, Table 23-4
MSC: CRNE: CH-4
8. In performing the confrontation test, for what is the nurse assessing?
a. Visual acuity
b. Visual field perimetry
c. Extraocular muscle function
d. Consensual pupillary response
ANS: B
The nurse uses this test to determine if the patient has a full field of vision, without obvious
scotomas, and is therefore assessing visual field perimetry.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 488, Table 23-4
MSC: CRNE: CH-8
9. Which of the following is a possible cause of diplopia?
a. Superficial corneal erosion
b. Anterior uveitis
c. Abnormalities of extraocular muscle action
d. Liquefaction of the vitreous humor
ANS: C
A possible cause of diplopia is abnormalities of extraocular muscle action related to muscle or
cranial nerve abnormality.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 488, Table 23-5
MSC: CRNE: CH-8
10. During assessment of a patient’s eyes, the nurse notes that the pupil of the right eye is
irregular and appears to protrude into the iris. The nurse should question the patient about a
history of which of the following?
a. Pinguecula
b. Eye trauma
c. Corticosteroid use
d. Glaucoma surgery
ANS: D
Round or notched areas of missing iris tissue are often the result of cataract or glaucoma
surgery.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 490
MSC: CRNE: CH-4
11. A 42-year-old man complains of seeing small spots moving in front of his eyes. What should
the nurse do?
a. Refer the patient to an ophthalmologist for further evaluation.
b. Explain that these “floaters” are usually normal and caused by liquefaction of the
vitreous.
c. Examine the retina of the patient’s eye with an ophthalmoscope to visualize the
spots.
d. Inform the patient that these spots usually occur with aging and can be surgically
removed if they are bothersome.
ANS: C
The most common cause of spots is vitreous liquefaction (benign phenomenon); other
possible causes include hemorrhage into the vitreous humor, retinal holes, or tears. Therefore,
the retina of the patient’s eye should be examined more closely.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 488, Table 23-5
MSC: CRNE: CH-4
12. When examining a patient’s eyes, the nurse suspects a weakness or imbalance of the
extraocular nerves on finding which of the following data?
a. A limited field of vision
b. A sluggish papillary reflex
c. An irregular corneal light reflex
d. Conjugate movement of the eyes through the cardinal fields of gaze
ANS: C
The nurse observes the corneal light reflex to evaluate for weakness or imbalance of the
extraocular muscles.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 488, Table 23-4
MSC: CRNE: CH-6
13. During a nursing history, the patient comments that he cannot bend over and lift an object
without becoming dizzy and that he frequently has to stop physical activities because of
dizziness and nausea. Dysfunction of which of the following is most likely causing the
patient’s symptoms?
a. Cochlea
b. Middle ear
c. Organ of Corti
d. Semicircular canals
ANS: D
Dysfunction in the semicircular canals causes an alteration in balance and body orientation.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 494, Table 23-7
MSC: CRNE: CH-8
14. When assessing a patient, the nurse is alerted to the possibility of tinnitus when the patient
reports which of the following information?
a. Using a pillow over her upright ear
b. Playing the radio for background music
c. Putting her feet against the end of the bed frame
d. Elevating her head and shoulders on three pillows
ANS: B
The patient should be asked if any masking devices or techniques are used or have been tried
to drown out the tinnitus.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 496
MSC: CRNE: CH-5
15. An 87-year-old patient has marked bilateral presbycusis. In performing a Rinne’s test on the
patient, what would the nurse anticipate?
a. The patient can “feel” the noise longer than she can hear the noise.
b. The patient hears the tuning fork best when it is placed next to the ear canal.
c. The patient hears the tuning fork better when it is placed on the mastoid bone.
d. The sound is equally diminished in both ears when the fork is placed in the middle
of the forehead.
ANS: B
If the patient hears the tuning fork better by bone conduction, the Rinne’s test is negative and
indicates that a conductive hearing loss is present.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 497|page 499
MSC: CRNE: CH-8
16. When documenting the physical assessment findings of the pupils, the nurse writes PERRLA.
How does the nurse interpret the initial “R” in this chart entry?
a. Redness
b. Round
c. Reactive to light
d. Retinal vessels normal
ANS: B
In PERRLA, the initial R stands for round; the complete assessment is pupils equal, round and
reactive to light and accommodation.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 487, Table 23-3
MSC: CRNE: CH-15
17. While observing a patient undergoing a caloric test, the nurse recognizes that which of the
following is a normal finding?
a. Vertigo
b. Ear pain
c. Hearing loss
d. Little or no nystagmus
ANS: A
This test involves the instillation of cold or warm water and may cause vertigo.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 500, Table 23-12
MSC: CRNE: CH-8
18. The nurse examines a patient’s auditory canal and tympanic membrane with an otoscope.
Which of the following is an abnormal finding?
a. The presence of cerumen
b. A bluish-tinged tympanum
c. The presence of a cone of light
d. A translucent, shiny tympanum
ANS: B
The tympanic membrane normally is pearl-grey, white, or pink; shiny; and translucent;
therefore, a bluish-tinged tympanum is an abnormal finding.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 498
MSC: CRNE: CH-8
19. In the visual pathway, fibres from the nasal portion of each retina cross over to the opposite
side of which structure?
a. Optic nerve
b. Lateral geniculate body
c. Optic chiasma
d. Fovea centralis
ANS: C
In the visual pathway, fibres from the nasal portion of each retina cross over to the opposite
side of the optic chiasma.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 482, Figure 23-2
MSC: CRNE: CH-8
20. At a clinic visit, a patient’s wife tells the nurse that her husband is losing his hearing. The
patient protests, saying that his wife mumbles. During the visit, the nurse identifies a hearing
loss in the patient based on which of the following findings?
a. He speaks softly but slurs constantly during conversation.
b. He cannot repeat a word whispered at 25 cm from one ear.
c. He asks for frequent repetition and has a flat facial expression.
d. He leans forward to hear the nurse and complains of buzzing in the ears.
ANS: B
Normal hearing is the ability to hear a low whisper at 30 cm. As the patient cannot hear a
whisper at 25 cm, he probably has a hearing impairment.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 497, Table 23-10
MSC: CRNE: CH-4
Chapter 24: Nursing Management: Visual and Auditory Problems
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A 74-year-old woman has worn corrective lenses most of her life to correct myopia, and for
the last several years, she has had bifocals to correct presbyopia. What does the nurse
recognize that the patient’s lenses are used to achieve?
a. Improvement in near vision
b. Improvement in distance vision
c. Strengthening of the eye muscles
d. Improvement in both near and distance vision
ANS: D
The lenses are prescribed to correct the patient’s near and distance vision.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: pages 504-505
MSC: CRNE: CH-8
2. What type of strabismus does the patient have when he describes his symptom as his right
eye looking in toward his nose?
a. Esotropia
b. Exotropia
c. Hypotropia
d. Hypertropia
ANS: A
Strabismus is a condition in which the patient cannot consistently focus two eyes
simultaneously on the same object. One eye may deviate inward (esotropia), outward
(exotropia), upward (hypertropia), or downward (hypotropia).
PTS: 1
OBJ: 3
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 512
MSC: CRNE: CH-8
3. A young woman asks the nurse at a local health fair for information about LASIK as a
method of refractive correction. The young woman has very thick, concave lenses in her
glasses. What is the best response to the young woman?
a. “This procedure probably would not be appropriate for you since you appear to be
hyperopic rather than myopic.”
b. “The LASIK procedure is a highly successful surgery for treating refractive errors
of vision with virtually no risks or complications.”
c. “Various types of surgery effectively treat refractive errors, and you should consult
an ophthalmologist about what is best for you.”
d. “Surgical correction of refractive errors is a highly controversial procedure among
ophthalmic specialists, and it cannot be recommended at this time.”
ANS: C
Several types of LASIK surgeries are effective; therefore, the nurse should advise the
patient to consult an ophthalmologist to see what would be the most appropriate course of
treatment.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 505
MSC: CRNE: CH-28
4. The nurse answers the call light of a newly admitted patient. The patient tells the nurse she
is blind and asks the nurse to assist her to the bathroom. To assist the patient, how should
the nurse proceed?
a. Take the patient by the arm, and lead her slowly to the bathroom.
b. Walk slightly ahead of the patient, and allow the patient to hold your elbow.
c. Lead the patient to the bathroom by the hand, describing the location and
providing verbal cues.
d. Give the patient exact descriptive directions to the bathroom so that she can walk
there independently.
ANS: B
When using this technique, the nurse should stand slightly in front and to one side of the
patient and offer an elbow for the patient to hold. The nurse serves as the sighted guide,
walking slightly ahead of the patient with the patient holding the back of the nurse’s arm.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 507
MSC: CRNE: HW-12
5. A 72-year-old man is admitted to the hospital for elective surgery. As the nurse prepares to
perform an initial assessment of the patient, the patient’s wife tells the nurse that her
husband is functionally blind and that she has cared for him for years. During the initial
assessment of the patient, what is it important for the nurse to do?
a. Ask the patient’s wife about the cause of her husband’s loss of vision.
b. Make eye contact with the patient, and ask him what assistance he needs.
c. Obtain as much information as possible from the wife about the patient’s special
needs.
d. Perform an evaluation of the patient’s visual acuity, and schedule an ophthalmic
examination.
ANS: B
Making eye contact with the partially sighted patient accomplishes several objectives. It
ensures that the nurse speaks while facing the patient so the patient has no difficulty hearing
the nurse. The nurse’s head position confirms that the nurse is attentive to the patient. Also,
establishing eye contact ensures that the nurse can observe the patient’s facial expressions
and reactions. The nurse should always communicate in a normal conversational tone and
manner with the patient, and the nurse should address the patient, not a family member or
friend who may be with the patient.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 507
MSC: CRNE: NCP-2
6. A counsellor at a camp for children with diabetes was tending a campfire when a log
exploded, sending sparks into his eyes. Initially, as the camp nurse, what should the nurse
do?
a. Apply ice packs to the eyes.
b. Flush the eyes with cool, sterile, normal saline for 10 minutes.
c. Cover the eyes with dry, sterile patches and protective eye shields.
d. Apply an antiseptic ophthalmic ointment from the first aid kit to the eyes.
ANS: C
Cover the eye(s) with dry, sterile patches and a protective shield.
PTS: 1
DIF: Cognitive Level: Application
REF: page 509, Table 24-2
OBJ: 4
TOP: Nursing Process: Implementation MSC: CRNE: CH-24
7. A patient is seen at a clinic for repeated hordeolum of her eyes during the last 6 months. To
help prevent further infection, what should the nurse advise the patient to do?
a. Discard all open or used eye cosmetics.
b. Avoid wearing contact lenses as much as possible.
c. Use an antiseborrheic shampoo on the scalp and eyebrows.
d. Be evaluated for the presence of sexually transmitted infections.
ANS: A
The patient who develops infections should discard all opened or used lens care products
and cosmetics to decrease the risk of repeat infection from contaminated products (a
common problem and a probable source of infection for many patients).
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 508
MSC: CRNE: HW-26
8. A patient with herpes simplex type I keratitis of the left eye is very concerned about his
diagnosis and is afraid his right eye will become involved. What should the nurse advise the
patient to do, to prevent spread of the infection?
a. Apply an occlusive dressing to the affected eye.
b. Avoid touching the eye, and wash the hands frequently and thoroughly.
c. Use the eye drops prescribed for the left eye in the right eye as well for a
prophylactic measure.
d. Use disposable tissues to wash the drainage from the affected eye frequently,
discarding the tissues in a covered container.
ANS: B
The nurse’s most important role is to teach the patient and family members about good
hygiene practices to avoid spreading the disease; therefore, the nurse should teach the
patient to avoid touching the eye and to practise frequent handwashing.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 510
MSC: CRNE: HW-8
9. During a routine health examination at the clinic, the patient tells the nurse that he is legally
blind. In planning care for the patient, what does the nurse recognize?
a. The patient probably has some light perception but no usable vision.
b. No vision enhancement techniques would be appropriate for the patient because he
has a total lack of vision.
c. Further assessment is needed to determine how the patient’s visual impairment
affects his normal functioning.
d. The patient would be expected to have some usable vision, which enables him to
function at an acceptable level.
ANS: C
As part of the assessment process, the nurse should determine how the patient’s visual
impairment affects normal functioning.
PTS: 1
OBJ: 11
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 506
MSC: CRNE: CH-1
10. A patient is diagnosed with adult inclusion conjunctivitis (AIC) caused by the Chlamydia
trachomatis organism. In teaching the patient about his disorder, what should the nurse
explain?
a. This disorder may progress to trachoma, a blindness-producing
keratoconjunctivitis.
b. The infection is usually self-limiting, but antiviral eye drops help shorten the
course of the infection.
c. The conjunctivitis can be easily treated with antibiotics and should not recur if
good hand–eye hygiene is maintained.
d. The disorder is highly associated with genital chlamydia, and he should be
evaluated for sexually transmitted Chlamydia.
ANS: D
Although antibiotic treatment may be successful in the adult with AIC, these patients have a
high risk of concurrent chlamydial genital infection, as well as other sexually transmitted
infections. The nurse’s responsibility with the patient with AIC includes education about the
ocular condition, as well as the implications of the condition for sexual activity and
reproductive health.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 510
MSC: CRNE: HW-8
11. Which of the following would the nurse teach a patient who asks how to prevent the
development of cataracts?
a. Wear sunglasses when in the sun.
b. There are no proven preventative measures.
c. An appropriate intake of vitamins B and D is important.
d. Wear shaded glasses when using a computer.
ANS: B
There are no proven measures to prevent cataract development. Although it is wise to wear
sunglasses in the sun, this does not prevent the development of cataracts.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 513
MSC: CRNE: HW-26
12. A patient is prepared for discharge following outpatient cataract surgery. To evaluate
whether the patient understands the postoperative regimen and procedures, what should the
nurse ask the patient to do?
a. Rate his pain on a scale of 0 to 10.
b. Explain the purpose of the prescribed medication.
c. Describe how well he can see with the operative eye.
d. Indicate who will be caring for him at home for the first 24 hours.
ANS: B
It is essential that the nurse give patients written and verbal instructions before discharge.
These teachings should include information about postoperative eye medications, and to
assess the patient’s understanding, the nurse can ask the patient to explain the purpose of the
prescribed medication.
PTS: 1
DIF: Cognitive Level: Application
REF: page 516, Table 24-5
OBJ: 5
TOP: Nursing Process: Implementation MSC: CRNE: CH-14
13. During postoperative teaching for a patient with a cataract extraction and intraocular lens
implantation, what instructions should the nurse give the patient?
a. Normal activities can be resumed on return home.
b. In several weeks, aphakic glasses will be prescribed to enhance her vision.
c. The physician should be notified if increasing pain in the operative eye occurs.
d. Normal vision should be present when the eye patch is removed postoperatively.
ANS: C
The postoperative cataract patient usually experiences little or no pain. Some scratchiness
may occur in the operative eye. Mild analgesics are usually sufficient to relieve any pain. If
the pain is intense, the patient should notify the surgeon because this may indicate
hemorrhage, infection, or increased intraocular pressure (IOP).
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 516
MSC: CRNE: CH-31
14. In reviewing a 50-year-old man’s medical record, the nurse notes that his last eye
examination revealed an IOP of 28 mm Hg. Which of the following questions is it most
appropriate for the nurse to ask the patient?
a. “How long have you had to wear glasses?”
b. “Do you see light flashes or floaters in your vision?”
c. “Have you noticed blind spots in your field of vision?”
d. “Do you use eye drops prescribed by an ophthalmologist?”
ANS: D
The normal range for IOP is 10 to 21 mm Hg; therefore, this patient has an increased IOP
and should be on medications. So the nurse would assess whether the patient uses the
prescribed eye drops.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
REF: page 521
MSC: CRNE: CH-4
15. A 68-year-old man with an extensive left retinal detachment is scheduled for a scleral
buckling with cryopexy and pneumatic retinopexy. Preoperatively, the nurse prepares the
patient for postoperative expectations by explaining which of the following?
a. He will need to wear dark or tinted glasses to protect his eyes from ultraviolet
light.
b. He will have to wear bilateral eye patches to reduce movement of the operative
eye.
c. He will not have a return of lost vision, but the surgery will prevent further loss of
vision in his left eye.
d. He will have to maintain a prescribed head position to maintain contact of the
bubble with the retinal break.
ANS: D
The patient with an intravitreal bubble must position the head so that the bubble is in contact
with the retinal break. It may be necessary for the patient to maintain this position as much
as possible for up to several weeks.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 519
MSC: CRNE: CH-31
16. A patient who was struck in the right eye with a handball while playing without the use of
protective eyewear has pain and swelling around the orbit and loss of central vision. On
assessment of the patient, the nurse suspects the presence of a retinal detachment on the
patient’s report of which of the following data?
a. Severe eye pain
b. Abnormal colour perception
c. Glare and halos around lights
d. Light flashes in the affected eye
ANS: D
Patients with a detaching retina describe symptoms that include photopsia (light flashes),
floaters, and a “cobweb,” “hairnet,” or ring in the field of vision.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 518
MSC: CRNE: CH-8
17. A 78-year-old woman has age-related macular degeneration and has undergone laser
photocoagulation without significant improvement in her vision. The ophthalmologist has
told her that further treatment is not warranted. What is an appropriate outcome for the nurse
to plan with the patient?
a. The patient plans for institutional care when blindness becomes total.
b. The patient uses optical and nonoptical methods for vision enhancement.
c. The patient comes to accept the visual impairment and eventual blindness.
d. The patient verbalizes the need to seek a second opinion regarding her condition.
ANS: B
For most patients who have some remaining vision, vision enhancement techniques (optical
and nonoptical) can provide enough help for many patients to learn to ambulate, read
printed material, and accomplish activities of daily living.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 520
MSC: CRNE: CH-10
18. A 48-year-old woman is found to have early presbyopia on examination by her
ophthalmologist. The patient asks the nurse whether she is losing her sight like her mother,
who has age-related macular degeneration. What is the nurse’s best response to the patient?
a. “Both of these disorders are age related and may cause eventual loss of vision.”
b. “These two disorders are not related, and you have no risk factors for age-related
macular degeneration.”
c. “Presbyopia is an age-related loss of elasticity of the lens and is not the same as
age-related macular degeneration.”
d. “Presbyopia is the early stage of age-related macular degeneration, but you have
many years before your vision will be seriously impaired.”
ANS: C
Presbyopia is farsightedness resulting from a decrease in the accommodative ability of the
eye as a result of aging and is different from age-related macular degeneration.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 504
MSC: CRNE: CH-8
19. Primary open-angle glaucoma (POAG) is diagnosed in a middle-aged woman during a
routine examination by her ophthalmologist. During the initial assessment of the patient,
what would the nurse expect the patient history to include?
a. Blurred vision
b. No symptoms of pain or pressure
c. Seeing coloured halos around lights
d. Eye pain accompanied by nausea and vomiting
ANS: B
POAG develops slowly and without symptoms. The patient with POAG reports no
symptoms of pain or pressure.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 521
MSC: CRNE: CH-1
20. In teaching a patient with POAG about the disorder, what should the nurse explain?
a. The retinal nerve is damaged by an abnormal increase in the production of aqueous
humor.
b. Aqueous humor produced in the eye cannot drain from the eye, causing pressure
damage to the optic nerve.
c. Lens enlargement that occurs normally with aging pushes the iris forward,
covering the outflow channels of the eye.
d. The flow of aqueous humor into the anterior chamber is decreased by the lens of
the eye blocking the pupillary opening.
ANS: B
In POAG, the outflow of aqueous humor through the trabecular meshwork is decreased. In
essence, the drainage channels become clogged, like a clogged kitchen sink.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 521
MSC: CRNE: CH-8
21. Timolol (Timoptic) ophthalmic drops are prescribed for a patient with open-angle glaucoma.
After using the drops for several days, the patient tells the nurse that the eye drops cause her
vision to become blurry for a period of time. What is the best response to the patient’s
complaint?
a. “These are normal side effects of the medication, which should become less
noticeable with time.”
b. “If you occlude the puncta after you administer the drops, it will help relieve these
side effects.”
c. “These symptoms are related to the glaucoma and may indicate a need for
increased dosage of eye drops.”
d. “The drops are uncomfortable, but it is very important for you to continue using
them as prescribed to retain your vision.”
ANS: D
A common side effect is transient ocular discomfort and blurred vision, but it is important
that the patient continue to use the eye drops as prescribed.
PTS: 1
DIF: Cognitive Level: Application
REF: page 522, Table 24-9
OBJ: 6
TOP: Nursing Process: Implementation MSC: CRNE: CH-44
22. A patient is hospitalized with acute angle-closure glaucoma. What immediate collaborative
care would the nurse anticipate?
a. Administration of analgesics
b. Administration of cycloplegics
c. Administration of cholinergic agents
d. Preparation for a surgical iridectomy
ANS: C
Immediate treatment of acute open-angle glaucoma is a topical cholinergic agent to lower
the IOP.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 522, Table 24-8
OBJ: 3
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
23. A patient is admitted to the surgical unit in preparation for vein stripping and ligation for
varicose veins. During the admission history, the patient tells the nurse that she has narrowangle glaucoma and will need to continue her eye drops while hospitalized. For this patient,
what preoperative order should the nurse question?
a. Atropine (Isopto Atropine) 0.4 mg intramuscularly (IM) on call to the operating
room (OR)
b. Morphine sulphate 10 mg IM on call to the OR
c. Betaxolol (Betoptic) 1 drop in each eye on the morning of surgery
d. Diazepam (Valium) 5 mg orally on the morning of surgery with sips of water
ANS: A
Atropine (Isopto Atropine) is contraindicated for use in patients with narrow-angle
glaucoma because angle-closure glaucoma may be produced.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
REF: page 521
MSC: CRNE: CH-45
24. Which of the following is a manifestation of cerumen impaction?
a. Temporal headache
b. Difficulty breathing
c. Amplified low-pitch sounds
d. Cardiac depression
ANS: D
Manifestations of cerumen impaction are hearing loss, otalgia, tinnitus, vertigo, cough and
cardiac depression (vagal stimulation).
PTS: 1
DIF: Cognitive Level: Application
REF: page 527, Table 24-12
OBJ: 7
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
25. What is a major role of the nurse who works in a women’s health clinic in promoting the
preservation of hearing?
a. Monitoring the noise level at the clinic
b. Discouraging excessive television watching
c. Promoting rubella immunizations for women
d. Including otoscopic examinations for all patients who attend the clinic
ANS: C
Childhood and adult immunizations, including the measles, mumps, and rubella vaccine,
should be promoted because congenital rubella syndrome commonly involves sensorineural
deafness.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 534
MSC: CRNE: HW-21
26. A patient with refractory congestive heart failure has been receiving large doses of
intravenous furosemide (Lasix) and oral spironolactone (Aldactone) for 5 days. One
morning, the patient tells the nurse he has ringing in his ears and does not seem to hear very
well. What is the most appropriate nursing action?
a. Arrange for the patient to have his hearing tested with audiometry.
b. Withhold the morning dose of furosemide, and notify the physician.
c. Tell the patient that these symptoms are temporary and will subside when his
condition improves.
d. Add the nursing diagnosis of disturbed auditory sensory perception related to
ototoxicity to the patient’s care plan.
ANS: B
Medications commonly associated with ototoxicity include salicylates, diuretics,
antineoplastic drugs, and antibiotics. The most common symptoms of ototoxicity are
tinnitus; therefore, the nurse should be alerted to the use of furosemide (Lasix), withhold the
morning dose, and notify the physician.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 534
MSC: CRNE: CH-48
27. The physician places an ear wick in the external ear canal and prescribes antibiotic otic
drops for a patient with external otitis. Before the patient leaves the clinic, the nurse reviews
the management of the disorder and determines that the patient needs additional instruction
when the patient makes which of the following statements?
a. “I may use aspirin for the pain.”
b. “I should clean my ear canal daily with a cotton-tipped applicator.”
c. “I may use warm compresses to the outside of my ear for comfort.”
d. “I should apply the eardrops to the cotton wick placed in my ear canal.”
ANS: B
The patient should be instructed to keep objects out of the ear. Ears should be cleaned only
with a washcloth and finger. Hairpins and cotton-tipped applicators should especially be
avoided. Penetration of the middle ear by a cotton-tipped applicator can cause serious injury
to the tympanic membrane and ossicles and may result in facial paralysis as a result of nerve
damage. The use of cotton-tipped applicators can also pack cerumen against the tympanic
membrane and impair hearing.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 528
MSC: CRNE: HW-2
28. Otoscopic examination reveals a central perforation of the eardrum with purulent drainage
into the ear canal in a patient with chronic otitis media. A computed tomography scan
confirms the presence of a cholesteatoma in the middle ear, and the patient is scheduled for
a tympanoplasty. Preoperatively, the nurse teaches the patient that which of the following
postoperative orders should be expected?
a. Avoidance of nose blowing
b. The need for prolonged bed rest
c. Frequent turning, coughing, and deep breathing
d. Continuous irrigation of the ear canal with antibiotic solutions
ANS: A
The patient should not cough or blow the nose because this causes increased pressure in the
eustachian tube and middle ear cavity and disrupts healing.
PTS: 1
DIF: Cognitive Level: Application
REF: page 529, Table 24-14
OBJ: 5
TOP: Nursing Process: Implementation MSC: CRNE: CH-31
29. A patient with acute otitis media of the left ear, which has been unresponsive to antibiotics,
undergoes a myringotomy with placement of a ventilating tube, performed in an ambulatory
surgical centre. Before she leaves the centre after the procedure, what is it most important
for the nurse to instruct the patient to do?
a.
b.
c.
d.
Avoid coughing or sneezing.
Avoid getting water in her ear.
Use aspirin or acetaminophen for pain.
Restrict fluid intake for 24 hours to prevent nausea.
ANS: B
After ear surgery, it is important to avoid getting the head wet (including showering) until
directed by the surgeon so that no water gets into the ear.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 529, Table 24-14
OBJ: 5
TOP: Nursing Process: Implementation MSC: CRNE: CH-31
30. A 28-year-old woman with otosclerosis elects to have a stapedectomy for treatment of her
hearing loss. Two days after the surgery, she tells the nurse she does not hear as well as she
did immediately after the surgery. Which of the following is the best response to the patient?
a. “You may have a sensorineural hearing loss that is not related to the otosclerosis.”
b. “The cotton ball dressing in your ear canal most likely is impairing your hearing in
that ear.”
c. “Postoperative accumulation of fluid and blood in your middle ear will temporarily
decrease your hearing.”
d. “I will let the physician know about this because you could have a fistula or other
complication of the surgery.”
ANS: C
During surgery, the patient will often report an immediate improvement in hearing in the
operative ear. Because of the accumulation of blood and fluid in the middle ear, the hearing
level decreases postoperatively but will improve with healing.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 530
MSC: CRNE: CH-31
31. A patient with Ménière’s disease is totally incapacitated by vertigo and is lying rigidly in
bed, grasping the siderails, and staring at the television. What is an appropriate nursing
intervention to decrease the patient’s vertigo?
a. Encouraging fluids to 3000 mL/day
b. Changing the patient’s position every 2 hours
c. Keeping the head of the bed elevated 30 degrees
d. Turning off the television set and darkening the room
ANS: D
The nurse should encourage the patient to stay in a quiet, darkened room in a comfortable
position. The patient needs to be taught to avoid sudden head movements or position
changes. Fluorescent or flickering lights or watching television may exacerbate symptoms
and should be avoided.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 530
MSC: CRNE: CH-20
32. What would the nurse document as an appropriate nursing diagnosis for a patient with
Ménière’s disease who has an acute attack of vertigo, nausea and vomiting, and ringing in
the ears?
a. Risk for injury related to dizziness
b. Impaired verbal communication related to hearing loss
c. Risk for altered health maintenance related to inability to care for self
d. Disturbed auditory sensory perception related to increased middle-ear pressure
ANS: A
Nursing interventions are planned to minimize vertigo and provide for patient safety;
therefore, an appropriate nursing diagnosis is “Risk for injury related to dizziness.”
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
REF: page 530
MSC: CRNE: CH-15
33. Which following central vision acuity finding would indicate legal blindness?
a. 20/50
b. 20/100
c. 20/150
d. 20/200
ANS: D
Legal blindness is defined as central visual acuity for a distance of 20/200 or worse in the
better eye with correction and the visual field of no greater than 20 degrees in its widest
diameter or in the better eye.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 506, Table 24-1
OBJ: 3
TOP: Nursing Process: Assessment
MSC: CRNE: CH-6
34. Which of the following is an infection of the sebaceous glands in the eyelid margin?
a. Chalazion
b. Hordeolum
c. Blepharitis
d. Keratitis
ANS: B
Hordeolum is an infection of the sebaceous glands in the eyelid margin, commonly called a
sty.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 508
MSC: CRNE: CH-8
35. When teaching a patient about the administration of eye drops, the nurse instructs the patient
to close his eye and apply gentle pressure with his fingers to the inside corner of the eye for
which length of time?
a. 20 to 30 seconds
b. 1 to 2 minutes
c. 2 to 3 minutes
d. 4 to 5 minutes
ANS: C
When teaching about the administration of eye drops, the nurse instructs the patient to close
his eye and apply gentle pressure with their fingers to the inside corner of the eye for 2 to 3
minutes.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 516, Safety alert
OBJ: 6
TOP: Nursing Process: Implementation MSC: CRNE: CH-44
Chapter 25: Nursing Assessment: Integumentary System
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. When obtaining a self-care integument history, the nurse will ask the patient about which of
the following?
a. Pain associated with skin conditions
b. The brands of moisturizers and cosmetics used
c. Lifestyle changes associated with skin conditions
d. Changes in the condition of the skin, hair, and nails
ANS: B
Part of a self-care integument history includes asking patients to describe their daily hygiene
practices as well as what skin products they are currently using.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 545, Table 25-3
MSC: CRNE: CH-1
2. A patient has an injury to the end of the finger, which has caused the loss of the nail. The
nurse informs the patient that the nail can be expected to grow back if permanent damage has
not occurred to which of the following parts?
a. Cuticle
b. Nail bed
c. Nail root
d. Nail body
ANS: C
Nails grow from under the matrix. The matrix is commonly called the lunula, which is the
white crescent-shaped area visible through the nail root. With damage to the nail root, the
fingernail may not grow back.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 542
MSC: CRNE: CH-8
3. Which of the following is the best example of nursing documentation of a normal assessment
of the skin?
a. “Skin warm and dry; turgor good; nails flat and pink; old surgical scars noted on
abdomen.”
b. “History of allergic rashes; skin very fair with numerous freckles, warm and intact;
no lesions noted.”
c. “Skin brown, slightly moist, and warm; turgor immediate return; no lesions noted.
States no problems with skin.”
d. “No history of skin problems; skin intact, pink; temperature consistent over body;
no lesions except numerous brown moles.”
ANS: C
Normal integument assessment of the skin includes “evenly pigmented and warm; good
turgor; no petechiae, purpura, lesions, or excoriations”; therefore, the best example is “skin
brown, slightly moist, and warm; turgor immediate return; no lesions noted. States no
problems with skin.”
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 544, Table 25-2
MSC: CRNE: CH-15
4. A patient has a circular, flat, reddened lesion about 5 cm in diameter on his ankle. How does
the nurse know that the lesion is related to vessel dilation?
a. The lesion is painless.
b. The lesion is warmer than the surrounding skin.
c. The discoloration disappears when the leg is elevated.
d. The discoloration blanches temporarily with direct pressure.
ANS: D
If a lesion blanches on direct pressure and then refills, the redness is due to dilated blood
vessels.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 544
MSC: CRNE: CH-4
5. When examining a patient, the nurse notes a musky body odour and relates this finding to
activity of which of the following glands?
a. Melanocyte glands
b. Ductless glands
c. Apocrine glands
d. Sebaceous glands
ANS: C
The apocrine glands secrete a thick, milky substance whose precise composition is unknown;
this becomes odoriferous when altered by skin surface bacteria.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 542
MSC: CRNE: CH-8
6. A dark-skinned patient has been admitted to the hospital in severe respiratory distress. What
knowledge does the nurse use to assess for cyanosis in the patient?
a. Cyanosis in patients with dark skin can be seen only in the sclera.
b. Cyanosis is not possible to assess in patients with dark skin.
c. Cyanosis can be seen in the conjunctiva of the eye and mucous membranes of
patients with dark skin.
d. Cyanosis will blanch out with direct pressure to the soles of the feet in darkskinned patients.
ANS: C
Assessment in dark-skinned individuals of cyanosis is an ashen or greyish colour most easily
seen in the conjunctiva of the eye, mucous membranes, and nail beds.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 547, Table 25-6
MSC: CRNE: CH-4
7. A patient with pruritus has a large area of superficial excavation of the skin on the right
forearm. How should the nurse record this finding?
a. Erythema
b. Excoriation
c. Carotenosis
d. Lichenification
ANS: B
Excoriation is an area in which epidermis is missing, exposing the dermis. Examples include
scabies, an abrasion, or a scratch.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Implementation
REF: page 546, Table 25-5
MSC: CRNE: CH-15
8. A 73-year-old patient tells the nurse that she is concerned because she has been experiencing
large, reddened lumps on her legs for the last 6 to 8 months. The nurse recognizes the lesions
as angiomas. Which following response should the nurse give the patient?
a. “Don’t worry. These lesions are a normal part of aging.”
b. “Angiomas are serious tumours, and you should see your physician about them.”
c. “They are probably just related to varicose veins, which are common in older
adults.”
d. “Have your doctor evaluate them. Although they can be normal in aging, they are
also associated with some diseases.”
ANS: D
Although angiomas are a common age-related change in the integumentary system, it is
important to have them assessed by a physician as angiomas are also a sign of liver disease.
PTS: 1
DIF: Cognitive Level: Application
REF: page 544|page 549, Table 25-9
OBJ: 2
TOP: Nursing Process: Implementation
MSC: CRNE: CH-8
9. Which of the following is an age-related change in the integumentary system?
a. Increased proliferative capacity in the skin
b. Decreased keratin in the nails
c. Decreased melanin in the hair
d. Increased extracellular water in the skin
ANS: C
Age-related changes in the hair include decreased melanin and melanocytes, decreased oil,
decreased density of the hair, and a cumulative androgen effect, decreasing estrogen levels.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
10. Where would you find apocrine sweat glands?
a. Scalp
b. Eyelids
c. Back
d. Upper chest
ANS: B
REF: page 543, Table 25-1
MSC: CRNE: CH-8
Apocrine sweat glands are found mainly in the axillae, the breast areolae, the umbilical and
anogenital areas, external auditory canals, and the eyelids.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 542
MSC: CRNE: CH-8
11. What is the primary function of the skin?
a. Sensory perception
b. Mirroring of emotions
c. Protecting underlying tissues of the body
d. Displaying the individual identity of the person
ANS: C
The primary function of the skin is to protect the underlying tissues of the body by serving as
a surface barrier to the external environment.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 541
MSC: CRNE: CH-8
12. How would the nurse document a papule?
a. Firm, edematous, irregularly shaped area
b. Elevated, solid lesion smaller than 1 cm in diameter
c. Circumscribed, flat area with a change in skin colour, less than 1 cm in diameter
d. Circumscribed, elevated solid lesion, larger than 1 cm in diameter
ANS: B
A papule is an elevated, solid lesion that is smaller than 1 cm in diameter (e.g., a wart or an
elevated mole).
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 546, Table 25-4
MSC: CRNE: CH-15
13. How would the nurse describe vitiligo, a common assessment abnormality of the
integumentary system?
a. Tumour consisting of lymph vessels
b. Male-pattern distribution of hair in women
c. Complete absence of melanin resulting in chalky white patches
d. A sac containing fluid or semisolid material
ANS: C
Vitiligo is the complete absence of melanin resulting in chalky white patches.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 549, Table 25-9
MSC: CRNE: CH-8
Chapter 26: Nursing Management: Integumentary Problems
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A young woman who is planning a vacation to the beach asks the nurse about precautions she
should take to protect her skin while enjoying the sun and water. What is the best response?
a. “You should wear clothing that covers your arms and legs and use a wide-brimmed
hat to shade your face.”
b. “Apply a waterproof sunscreen with a sun protection factor of 15 to the exposed
areas of your skin, reapplying it as the directions indicate.”
c. “Gradually increase the time of sun exposure each day, starting with 30 minutes a
day and adding 30 minutes each following day.”
d. “Sunscreens with a sun protection factor of 40 to 50 are the best protection against
both ultraviolet A and ultraviolet B rays and should be applied during all sun
exposure.”
ANS: B
The general recommendation is that everyone should use a sunscreen with a minimum sun
protection factor (SPF) of 15 daily. Sunscreens with an SPF of 15 or more filter 92% of the
ultraviolet (UV)B rays responsible for erythema and make sunburn unlikely in most
individuals when applied appropriately.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 553, Table 26-1
MSC: CRNE: HW-16
2. A patient is taking azithromycin (Zithromax)–doxycycline prescribed by his physician for
acute bronchitis. He tells the nurse that the information provided by his pharmacy indicates
that this drug causes photosensitivity, and he asks about what will happen to him if he is
exposed to sunlight while taking the drug. What is the nurse’s best response?
a. The heat from the sun is more readily absorbed by the body, predisposing him to
heatstroke.
b. Sun exposure may cause an exaggerated sunburn with redness, swelling, and
blistering on exposed areas.
c. The most common effect of photosensitivity is corneal damage because the drug
causes corneal absorption of UV light.
d. The photosensitivity causes abnormal melanocyte activity on exposure to UV light,
resulting in splotchy, abnormally dark tanning.
ANS: B
Azithromycin and doxycycline potentiate the effect of the sun, even with brief exposure.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 555, Table 26-3
MSC: CRNE: CH-44
3. A patient is diagnosed with a squamous cell carcinoma of the face. What should the nurse
explain about this type of tumour?
a. It is the most common and least deadly of the skin cancers.
b. It commonly occurs on the mouths of individuals who smoke.
c. It is the only type of skin cancer that is not associated with sun exposure.
d. It arises from cells that produce melanin and can metastasize to any organ.
ANS: B
Pipe, cigar, and cigarette smoking contributes to the formation of squamous cell carcinoma on
the mouth and lips.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 556
MSC: CRNE: CH-8
4. A patient has a small, slow-growing papule with ulceration and depression of the centre of the
lesion on the right cheek. The nurse recognizes that this finding is characteristic of which of
the following skin conditions?
a. Actinic keratosis
b. Seborrheic keratosis
c. Basal cell carcinoma
d. Squamous cell carcinoma
ANS: C
Clinical manifestations of basal cell carcinoma include a small, slowly enlarging papule;
borders semitranslucent or “pearly,” with overlying telangiectasia; erosion, ulceration, and
depression of the centre; and lost normal skin markings.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 558, Table 26-4
MSC: CRNE: CH-8
5. A 32-year-old woman whose mother recently died from malignant melanoma asks the nurse
what she can do to prevent the development of malignant melanoma in herself and her
children. What is the best response regarding risk factors for malignant melanoma?
a. Only moles that develop during adulthood are the most likely to become
malignant.
b. She does not need to worry because there is no familial tendency to develop
malignant melanoma.
c. Excessive exposure to the sun should be avoided, and protection should be used
when exposure occurs.
d. Unless she and her children have an abnormal mole pattern known as dysplastic
nevi syndrome, the risk of melanoma is small.
ANS: C
Risk factors for malignant melanoma include chronic UV exposure without protection or
overexposure to artificial light such as from a tanning bed; therefore, excessive exposure to
the sun should be avoided.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 559
MSC: CRNE: HW-26
6. A patient with multiple commonly acquired nevi expresses concern about their presence and
the possibility of malignant changes. How should the nurse advise the patient?
a. To consult the physician if the moles develop irregular coloration or borders
b. To request removal of all nevi larger than 4 mm to prevent malignant changes
c. That only moles occurring on the back and chest are likely to become malignant
d. That malignant changes are characterized by scaling, ulceration, and an opaque
appearance of the moles
ANS: A
About one third of melanomas occur in existing nevi or moles; therefore, patients need to
know that they should consult their physician if the moles develop irregular borders or
coloration.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 560
MSC: CRNE: CH-8
7. A patient hospitalized with acute pyelonephritis develops small grouped vesicles on a
reddened base on the lips extending to the skin. What does the nurse recognize about the
patient?
a. Most likely will require administration of topical acyclovir to prevent scarring of
the lips and face
b. Most likely has a recurrence of an oral herpes simplex virus infection due to stress
and systemic infection
c. Most likely has a mixed streptococcal or staphylococcal infection that is causing
the kidney infection and the lesions on the lips
d. Most likely has an activation of the varicella-zoster virus, which is contagious to
those who have not had varicella
ANS: B
Clinical manifestations of a recurrent outbreak of the herpes simplex virus include a small
recurrence in a similar spot and are characteristic grouped vesicles on an erythematous base.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 562, Table 26-6
MSC: CRNE: CH-8
8. The physician diagnoses impetigo and prescribes penicillin for a 68-year-old patient who has
crusty vesiculopustular lesions over the lower face and skin creases in the neck. While
planning care instructions for the patient, what does the nurse recognize is the most common
risk factor for impetigo?
a. Obesity
b. Exposure to grease or oils
c. Inadequate personal hygiene
d. Deficiency of vitamin A in the diet
ANS: C
Impetigo is associated with poor hygiene and low socioeconomic status.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 561, Table 26-5
MSC: CRNE: CH-8
9. Which one of the following diseases has a dermatological manifestation of eczematous
patches of the nipple and areola area?
a. Primary syphilis
b. Paget’s disease
c. Hodgkin’s disease
d. Hyperpituitarism
ANS: B
Paget’s disease has the dermatological manifestation of eczematous patches of the nipple and
areola area.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 568, Table 26-11
MSC: CRNE: CH-8
10. An older adult patient is admitted to the hospital with a possible head injury following a fall at
home. While examining the patient’s scalp, the nurse suspects the presence of pediculosis on
finding which of the following?
a. Ringlike rashes with red, scaly borders over the entire scalp
b. Papular, wheal-like lesions with white deposits on the hair shaft
c. Patchy areas of alopecia with small vesicles and excoriated areas
d. Red, hivelike papules and plaques with sharply circumscribed borders
ANS: B
The clinical manifestations of pediculosis include minute, red, noninflammatory points flush
with skin; progression to papular wheal-like lesions; pruritus; secondary excoriation,
especially parallel linear excoriations in the intrascapular region; head and body lice firmly
attach themselves to the patient’s hair shaft.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 564, Table 26-8
MSC: CRNE: CH-8
11. After spending an afternoon picking strawberries, a woman developed a severe contact
dermatitis of her hands, arms, and lower legs. She states that the itching is severe, and she
cannot keep from scratching. To help the patient manage the pruritus, what should the nurse
advise her to do?
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
additional irritation.
ANS: A
Wet dressings are used to relieve itching, and a cool environment may cause vasoconstriction
and decrease itching.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 573
MSC: CRNE: CH-42
12. The physician prescribes topical fluorouracil (5-FU) for a patient with actinic keratosis. To
promote patient compliance with the use of this drug, what is it most important for the nurse
to inform the patient about?
a. She will experience transient symptoms of bone marrow depression because 5-FU
is a cytotoxic agent.
b. Dermatitis will develop, with painful, eroded areas that will take weeks to heal.
c. The drug will induce nausea and vomiting, which may be relieved by eating small
meals and drinking cool liquids.
d. Initially, the size and depth of the lesion will increase, but it will disappear in about
2 weeks.
ANS: B
This medication produces erythema and pruritus within 3 to 5 days and painful, eroded areas
over the damaged skin within 1 to 3 weeks. Treatment must continue with applications one to
two times a day for 2 to 6 weeks. Healing may take up to 4 weeks after the medication is
stopped.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 571
MSC: CRNE: CH-44
13. A topical corticosteroid ointment is prescribed for a patient who has atopic dermatitis in her
antecubital and popliteal spaces. During a follow-up visit by the patient, the nurse determines
that the patient’s administration of the drug should be assessed on observing which of the
following findings?
a. Atrophy of the skin
b. Alopecia of the affected areas
c. Red-brown coloration of the lesions
d. Lesions covered with small gauze dressings
ANS: A
High-potency corticosteroids may produce side effects when their use is prolonged, including
atrophy of the skin.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 570
MSC: CRNE: CH-44
14. A patient is undergoing psoralen plus UVA light (PUVA) therapy for treatment of psoriasis.
To prevent complications from this procedure, what should the nurse plan to do?
a. Shield unaffected areas with lead-lined drapes.
b. Monitor for accumulation of laser light in adjacent tissue.
c. Apply petroleum jelly to unaffected areas surrounding the lesions.
d. Have the patient use protective eyewear that blocks 100% of UV light.
ANS: D
The patient’s eyes must be protected during the phototherapy session using PUVA.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 569
MSC: CRNE: CH-30
15. A patient with an enlarging, irregular mole is scheduled for diagnosis and treatment. Which of
the following procedures should the nurse anticipate will be performed?
a. Curettage
b. Cryosurgery
c. Mohs’ micrographic surgery
d. Electrodesiccation and electrocoagulation
ANS: C
The description of the mole is consistent with malignancy; therefore, excision and biopsy are
indicated. Mohs’ surgery is used when the lesion involves the dermis. It sections the surgical
specimen horizontally so that 100% of the surgical margin can be examined. Tissue is
removed in thin layers, and all margins of the specimen are mapped to determine whether
tumour remains.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 572
OBJ: 4
TOP: Nursing Process: Planning
MSC: CRNE: CH-8
16. The nurse identifies a nursing diagnosis of “Risk for infection related to skin lesions and
presence of environmental pathogens” for a patient with an allergic dermatitis. The nurse
recognizes that the teaching regarding prevention of infection has been effective when the
patient states which of the following?
a. “I will use measures to keep me from scratching the inflamed areas.”
b. “I should use antibiotic solutions to moisten dressings applied to the rash.”
c. “I should take my temperature twice a day to detect the onset of any fever.”
d. “I should use sterile dressings and towels when applying wet compresses to the
rash.”
ANS: A
The risk for infection is increased if the patient causes breaks in the skin or transfer of bacteria
from the hands to the affected area. The patient should be warned about scratching lesions,
which can cause excoriations and create a portal of entry for pathogens. The patient’s nails
should be trimmed short to minimize trauma from scratching.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 574
MSC: CRNE: HW-2
17. A patient complains of severe itching, especially at night, and the nurse notes the presence of
burrows in the flexor surface of his wrists. What does the nurse suspect?
a. Scabies
b. Bedbugs
c. Pediculosis
d. Lyme disease
ANS: A
Scabies manifestations include severe itching, especially at night, usually not on the face; the
presence of burrows, especially in the interdigital webs, flexor surface of wrists, genitals, and
anterior axillary folds; erythematous papules (may be crusted); possible vesiculation; and
interdigital web crusting.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 564, Table 26-8
MSC: CRNE: CH-8
18. During application of a wet dressing to the skin of a patient with impetigo, what is it most
important for the nurse to do?
a. Use cool solutions to debride the lesions.
b. Use clean gloves to prevent the spread of the infection to others.
c. Use sterile gloves and dressings to prevent infection of the lesions.
d. Apply a prescribed topical antibiotic ointment before the application of the
dressings.
ANS: B
Although most skin problems are not contagious, impetigo is contagious; therefore, infection
precautions indicate the need for clean gloves with open or bleeding wounds. Careful
handwashing and safe disposal of soiled dressings are the best means of preventing the spread
of skin problems.
PTS: 1
DIF: Cognitive Level: Application
REF: page 573
OBJ: 7
TOP: Nursing Process: Implementation
MSC: CRNE: HW-8
19. Which of the following would the nurse recommend to the patient who has vitiligo?
a. Chemical peels
b. Use of warm compresses to decrease pain
c. Rehabilitative cosmetics to camouflage the lesion
d. Injection of botulinum toxins (Botox)
ANS: C
Rehabilitative cosmetics are available to help camouflage and de-emphasize such lesions as
vitiligo, melasma, and healed postoperative wound sites.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 574
MSC: CRNE: CH-8
20. What is the most common reason that people undergo a cosmetic procedure?
a. To increase longevity
b. To obtain different employment
c. To improve their body image
d. To improve function of the area that is involved
ANS: C
The most common reason that people suffer the discomfort and financial expense of cosmetic
surgery is to improve their body image.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 574
MSC: CRNE: CH-8
21. Why is it important to ensure that piercings in the mouth are done with plastic jewellery rather
than metal jewellery?
a. The piercing may get dislodged and be swallowed.
b. Plastic will not chip teeth.
c. This eliminates the risk of metal absorption into the bloodstream.
d. Plastic is easier to clean and disinfect than metal.
ANS: B
Plastic jewellery should be used in mouth piercings because metal jewellery can chip the
patients’ teeth.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 575
MSC: CRNE: HW-26
22. Which of the following would the nurse suspect when assessment data revealed six groups of
three wheals surrounded by vivid flare with firm urticaria and intense pruritus?
a. Wasp stings
b. Bedbugs
c. Scabies
d. Pediculosis
ANS: B
The clinical manifestations of bedbugs include a wheal surrounded by vivid flare: firm
urticaria transforming into persistent lesion; severe pruritus; wheals often grouped in threes
appearing on noncovered parts of the body.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 564, Table 26-8
MSC: CRNE: CH-8
Chapter 27: Nursing Management: Burns
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. An employee spilled industrial acids on his arms and legs at work. What is the appropriate
action by the occupational nurse at the facility?
a. Apply cool compresses to the area of exposure.
b. Apply an alkaline solution to the affected area.
c. Cover the affected area with dry, sterile dressings.
d. Flush the substance with large amounts of tap water.
ANS: D
If the acid is a dry chemical, it should be brushed from the skin, and then the affected area
should be flushed with copious amounts of water to irrigate the skin. This technique is
effective when used anywhere from 20 minutes to 2 hours post exposure.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 586, Table 27-5
MSC: CRNE: CH-68
2. A patient is admitted to the emergency department after suffering an electrical burn from
exposure to a high-voltage current. In addition to the burn injuries, the nurse should initially
assess for the presence of what?
a. Renal failure
b. Cerebral edema
c. Spinal fractures
d. Metabolic alkalosis
ANS: C
Contact with electric current can cause muscle contractions strong enough to fracture the long
bones and the vertebrae. Another reason to suspect long bone or spinal fractures is a fall. Most
electrical injuries occur when the victim is elevated above the ground and comes in contact
with a current source. For this reason, all patients with electrical burns should be considered at
risk for a potential cervical spine injury. Cervical spine immobilization should be used during
transport and subsequent spinal X-ray films made to rule out any injury.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 588, Table 27-7
MSC: CRNE: CH-3
3. A young woman spilled hot oil from a deep-fat fryer on her right lower leg and foot. Her leg
and foot are red and swollen and covered with large blisters. She states that they are very
painful. According to burn classification systems, how should the nurse document the burn?
a. Full-thickness skin destruction
b. Deep, partial-thickness skin destruction
c. Superficial, partial-thickness skin destruction
d. Third degree, with partial-thickness skin destruction
ANS: B
A deep, partial-thickness skin destruction gives the appearance of fluid-filled vesicles that are
red, shiny, and wet (if vesicles have ruptured). There is also severe pain caused by nerve
injury and mild to moderate edema, which is exhibited by this patient.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 584, Table 27-4
MSC: CRNE: CH-15
4. During the emergent phase of burn injury, the nurse assesses for the presence of hypovolemia.
What does the nurse understand is the primary cause of hypovolemia in burn victims?
a. Major blood loss from injured tissue
b. Evaporation of fluid from denuded body surfaces
c. Capillary permeability that causes fluid shift to the interstitium
d. Third spacing of fluid from the interstitial space into fluid-filled vesicles
ANS: C
Hypovolemia occurs in burn victims, although fluid is not actually lost from the body as much
as it is sequestered in the interstitial spaces and third spaces. As the capillary seal is lost, the
interstitial edema fluid is formed.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 590
MSC: CRNE: CH-8
5. To prevent hypothermia, what is the maximum amount of time a large burn should be cooled?
a. 2 to 3 minutes
b. 5 minutes
c. 10 minutes
d. 20 minutes
ANS: C
To prevent hypothermia, large burns should be cooled for no more than 10 minutes. Do not
immerse the burned body part in cool water because doing so might lead to extensive heat
loss.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 586
MSC: CRNE: CH-42
6. A patient is admitted to the burn unit with burns on his head and neck, chest and back, and left
arm and hand following an explosion and fire in his garage. On his admission to the unit, the
nurse auscultates wheezes in the patient’s lungs. One hour later, the wheezes cannot be heard,
and lung sounds are decreased. What is the most appropriate nursing action at this time?
a. Place the patient in the high-Fowler’s position.
b. Encourage the patient to cough, and auscultate the lungs again.
c. Document the results, and continue to monitor the patient’s progress.
d. Anticipate the need for endotracheal intubation, and notify the physician.
ANS: D
The nurse should anticipate the need for intubation with significant inhalation injury,
circumferential full-thickness burns to the neck and chest or a large total body surface area
(TBSA) burn, or both, and with decreasing lung sounds. The nurse should notify the
physician.
PTS: 1
DIF: Cognitive Level: Analysis
REF: page 586, Table 27-5
OBJ: 8
TOP: Nursing Process: Implementation
MSC: CRNE: CH-24
7. During the early emergent phase of burns, the nurse understands that analgesics should be
given intravenously for which of the following reasons?
a. Absorption of oral or intramuscular drugs is diminished because of impaired
circulation.
b. Analgesics do not need to be administered as frequently when they are given
intravenously.
c. Larger doses of narcotics can be given when administered intravenously than when
given intramuscularly.
d. Respiratory depression is easier to diagnose and treat when narcotics are
administered intravenously.
ANS: A
Early in the postburn period, pain medications should be given intravenously because (1)
onset of action is fastest with this route; (2) gastrointestinal function is slowed or impaired as
a result of shock or paralytic ileus; and (3) medications injected intramuscularly are not
absorbed adequately in burned or edematous areas, and so medications pool in the tissues.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 595
MSC: CRNE: CH-52
8. A patient with severe burns has fluid replacement ordered using the Parkland formula. The
initial rate of administration is 1050 mL/hour. What should the nurse expect the rate of fluid
administration to be 18 hours after the burn occurred?
a. 263 mL/hour
b. 350 mL/hour
c. 525 mL/hour
d. 1050 mL/hour
ANS: C
According to the Parkland formula, during the first 24 hours, half of the volume is to be given
during the first 8 hours, then a quarter is given during each of the next 8-hour periods.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 593, Table 27-11
MSC: CRNE: CH-58
9. The nurse determines that fluid replacement for a patient with major electrical burns is
adequate based on which of the following findings?
a. A stable weight
b. A blood pressure of 90/58 mm Hg
c. A urinary output of 80 mL/hour
d. An intake equal to urinary output
ANS: C
Urinary output is the most commonly used parameter for assessment of adequacy of fluid
replacement. The goal for urine output is 0.5 to 1 mL/kg/hour and 75 to 100 mL/hour in
patients with electrical burns.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 593
MSC: CRNE: CH-34
10. Which is an appropriate intervention during the emergent phase of a patient with extensive
burns to address the nursing diagnosis of imbalanced nutrition?
a. An oral intake of 5000 kcal/day
b. Intravenous administration of multivitamins and minerals
c. Administration of total parenteral nutrition via a central catheter
d. Continuous enteral feeding via a feeding tube positioned in the duodenum
ANS: D
During the emergent phase of a patient with extensive burns, the nurse should administer
enteral feedings to provide nutrition until oral intake can be resumed.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 596
MSC: CRNE: CH-35
11. A patient with deep partial-thickness and full-thickness burns of the face and chest has the
wounds treated with the open method. The nurse identifies a nursing diagnosis of risk for
infection and an expected patient outcome of absence of wound infections. What is an
appropriate nursing intervention to help the patient meet the expected outcome?
a. Restrict all visitors to prevent cross-contamination of wounds.
b. Wear gowns, caps, masks, and gloves during all care of the patient.
c. Use sterile water for cleansing and debridement in the hydrotherapy tank.
d. Administer prophylactic broad-spectrum antibiotics to prevent bacterial
colonization of wounds.
ANS: B
When the patient’s open burn wounds are exposed, staff must wear personal protective
equipment (e.g., disposable hats, masks, gowns, gloves).
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 594
MSC: CRNE: CH-59
12. To prevent contractures in a patient with burns of the head, neck, chest, and right arm and
hand, how should the nurse position the patient?
a. Supine with a pillow under the head and the right arm and hand elevated on a
pillow
b. In a Fowler’s position without a pillow with the right arm and hand extended and
elevated on a pillow
c. Laterally on the left side with a small pillow under the head and the right arm and
hand hyperextended
d. Supine without a pillow and with the right arm and hand flexed in a position of
comfort and elevated on pillows
ANS: B
The patient should be placed in a high-Fowler’s position unless contraindicated by a possible
spinal injury, in which case, a reverse Trendelenburg’s position may be the position of choice.
Hands and arms should be extended and elevated on pillows or in slings to minimize edema.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 592, Table 27-10
MSC: CRNE: CH-39
13. A patient with burns on the upper thorax and circumferential burns on both arms develops
decreased radial pulses and loss of sensation in the fingers. What is the most appropriate
nursing action?
a. Notify the physician because an escharotomy is indicated.
b. Increase the rate of fluid administration to prevent sludging.
c. Put the patient’s arms through passive range-of-motion exercises.
d. Elevate the extremities on pillows and re-evaluate the patient in 30 minutes.
ANS: A
Circulation to the extremities can be severely impaired by circumferential burns and
subsequent edema formation. These processes occlude the blood supply, causing ischemia,
paresthesias, necrosis, and, eventually, gangrene. An escharotomy (a scalpel incision through
the full-thickness eschar) is frequently performed following transfer to a burn unit to restore
circulation to compromised extremities.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 590
MSC: CRNE: CH-27
14. Ranitidine (Zantac) is prescribed for a patient with major burns. In teaching the patient about
the drug’s purpose, the nurse should explain that it is used to prevent which of the following?
a. Diarrhea
b. Constipation
c. Adynamic ileus
d. Curling’s ulcer
ANS: D
Ranitidine is given to decrease the incidence of Curling’s ulcer.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 596, Table 27-14
MSC: CRNE: CH-44
15. A patient is to undergo skin grafting with the use of cultured epithelial autografts (CEAs) as
skin replacement for full-thickness burns. The nurse explains to the patient that this treatment
involves which of the following?
a. Shaving a split-thickness layer of the patient’s skin from an unburned area to apply
over burn wounds
b. Growing small specimens of the patient’s skin in sheets, which are grafted as
permanent skin coverage
c. Cultivating skin from a cadaver with epidermal growth factor to temporarily cover
burn wounds for 1 to 2 weeks
d. Exposing animal skin to growth factors that stimulate its proliferation and decrease
antigenicity for permanent skin coverage of the wound
ANS: B
CEA is a method of obtaining permanent skin from a person with limited available skin for
harvesting. CEA is grown from biopsy specimens obtained from the patient’s own unburned
skin.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 599
MSC: CRNE: CH-8
16. A patient with burns has the nursing diagnosis of pain related to lack of knowledge of pain
control methods. What is an appropriate nursing intervention for this problem?
a. Request that the physician order a patient-controlled analgesia machine for the
patient.
b. Administer pain medications on a routine basis so that the pain does not become
out of control.
c. Teach the patient how to use ordered analgesics with adjunctive methods, such as
guided imagery and relaxation.
d. Use sedative or amnesic drugs in combination with narcotics to reduce the
perception of the pain experience.
ANS: C
The timing and use of analgesics are important for the nurse to teach patients to assist them in
pain control. Pharmacological and nonpharmacological pain management techniques are to be
used. These techniques are considered adjuncts to traditional pharmacological treatments of
pain (e.g., distraction, music therapy, virtual reality). They are not meant to be used
exclusively to control pain in the patient with burn injury.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 601
MSC: CRNE: CH-51, CH-52
17. A common nursing diagnosis for the patient with burns is situational low self-esteem. When
would the nurse evaluate that patient outcomes for this nursing diagnosis are met?
a. When the patient sets realistic goals regarding future lifestyle
b. When the patient accepts the need for psychiatric intervention
c. When the patient is interested in learning to care for wounds at home
d. When the patient expresses that the effects of the burn are not important
ANS: A
Burn survivors and their families remark on the powerful learning experience of the burn and
a renewed appreciation of life, despite the ongoing challenges of a prolonged and challenging
recovery. Acknowledgement that their many feelings are real and valid can be therapeutic for
patients and their families as burn survivors seek to incorporate this life event into their view
of themselves and the life they had imagined. Setting realistic goals regarding their future
lifestyle is a positive outcome goal.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 603-604
MSC: CRNE: CH-18
18. Which of the following burn victims should the nurse assess for carbon monoxide inhalation?
a. Was found unconscious in a burning building
b. Has facial burns, hoarseness, and sooty sputum
c. Inhaled a large amount of steam released by a radiator
d. Was burned in a charcoal grill fire ignited with gasoline
ANS: A
Often the victims of fires, especially those who have been trapped in a closed space, will have
elevated carboxyhemoglobin levels; therefore, a patient who was found unconscious in a
burning building should be assessed for carbon monoxide levels.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 587, Table 27-6
OBJ: 4
TOP: Nursing Process: Assessment
MSC: CRNE: CH-1
19. When does the nurse recognize that the patient with a burn injury moves from the emergent
phase to the acute phase?
a. When inflammatory symptoms subside
b. When the burn area is completely covered
c. When granulation tissue forms in the wounds
d. When diuresis occurs with low urine specific gravity
ANS: D
The emergent phase ends when fluid mobilization and diuresis begin.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 587|page 596
MSC: CRNE: CH-8
20. Which of the following laboratory results should the nurse monitor closely in the patient
during the acute phase of burn injury?
a. Hematocrit and serum sodium
b. Serum albumin and hematocrit
c. Serum potassium and hematocrit
d. Serum sodium and serum potassium
ANS: D
Sodium and potassium are involved in electrolyte shifts; therefore, sodium and potassium
must be monitored closely during the acute phase of the burn injury. Sodium rapidly shifts to
the interstitial spaces and remains there until edema formation ceases (see Figure 27-6). A
potassium shift develops initially because injured cells and hemolyzed red blood cells release
potassium into the extracellular spaces.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 597
MSC: CRNE: CH-8
21. Which of the following injuries is most often chemically produced?
a. Carbon monoxide poisoning
b. Inhalation injury below the glottis
c. Alkali burn
d. Circumferential chest burn
ANS: B
An inhalation injury below the glottis is usually chemically produced.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 582
MSC: CRNE: CH-8
22. Which of the following is considered the most accurate guide for determining the total body
surface area affected by a burn?
a. Rule-of-nines chart
b. Lund-Browder chart
c. Sage burn diagram
d. Burn injury depth classification
ANS: B
The Lund-Browder chart is considered more accurate because the patient’s age, in proportion
to relative body-area size, is taken into account.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 584
MSC: CRNE: CH-8
23. According to the rule-of-nines chart, what percentage of TBSA is affected when the patient
has burns to both of his legs and his right arm?
a. 18%
b. 22.5%
c. 27%
d. 31.5%
ANS: B
According to the rule-of-nines chart, this patient would have a TBSA of 22.5%: 9% for each
leg and 4.5% for one arm.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 585, Figure 27-4
MSC: CRNE: CH-4
24. With chemical burns, the nurse knows that tissue destruction can continue for up to how many
hours after the initial burn?
a. 12
b. 24
c. 48
d. 72
ANS: D
Chemical burns can continue to destroy tissue for up to 72 hours following the initial burn.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 586, Table 27-5
MSC: CRNE: Ch-8
Chapter 28: Nursing Assessment: Respiratory System
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A patient in severe respiratory distress is admitted to the medical unit at the hospital. During
the admission assessment of the patient, what should the nurse do?
a. Perform a comprehensive health history with the patient to determine the extent of
prior respiratory problems.
b. Complete a full physical examination to determine the effect of the respiratory
distress on other body functions.
c. Delay any physical assessment of the patient, and ask family members about the
patient’s history of respiratory problems.
d. Perform a physical assessment of the respiratory system, and ask specific questions
related to this episode of respiratory distress.
ANS: D
When a patient has severe respiratory distress, only information pertinent to the current
episode is obtained, and a more thorough assessment is deferred until later.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 617
MSC: CRNE: CH-1
2. A hypothermic patient is admitted to the emergency department, and pulse oximetry (SpO2)
indicates that the O2 saturation is 95%. Which action should the nurse take next?
a. Complete a head-to-toe assessment.
b. Place the patient on high-flow oxygen.
c. Start rewarming the patient.
d. Obtain arterial blood gases.
ANS: B
Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation
curve will decrease the amount of oxygen delivered to tissues, so high oxygen
concentrations should be given until the patient is normothermic.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 613
MSC: CRNE: CH-8
3. The physician performs a thoracentesis on a patient with a right pleural effusion. In
preparing the patient for the procedure, how should the nurse position the patient?
a. Supine with the head of the bed elevated 45 degrees
b. On his left side with his right arm extended above his head
c. Sitting upright with his arms supported on an overbed table
d. On his left side in the Trendelenburg’s position with both arms extended
ANS: C
The upright position with the arms supported increases lung expansion, allows fluid to
collect at the lung bases, and expands the intercostal space so that access to the pleural space
is easier.
PTS: 1
DIF: Cognitive Level: Application
REF: page 626, Table 28-11
OBJ: 11
TOP: Nursing Process: Implementation MSC: CRNE: CH-30
4. A patient is admitted with a metabolic acidosis of unknown origin. Based on this diagnosis,
the nurse would expect the patient to have which one of the following?
a. Kussmaul’s respirations
b. Slow, shallow respirations
c. A low oxygen saturation (SpO2)
d. A decrease in PVO2
ANS: A
Kussmaul’s (deep and rapid) respirations are a compensatory mechanism for metabolic
acidosis.
PTS: 1
DIF: Cognitive Level: Analysis
REF: page 623, Table 28-9
OBJ: 4
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
5. While caring for a patient who has a 30-pack-year history of smoking, the nurse recognizes
that the patient most likely has decreased respiratory defences due to which of the following
conditions?
a. Impaired cough reflex
b. Impaired mucociliary clearance
c. Impaired reflex bronchoconstriction
d. Impaired ability to filter particles from the air
ANS: B
Smoking decreases ciliary action and the ability of the mucociliary clearance system to trap
particles and move them out of the lung.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 616
MSC: CRNE: CH-8
6. An 80-year-old patient breathing room air has an arterial blood gas analysis. Which of the
following results does the nurse interpret as normal?
a. pH 7.32, PaO2 85 mm Hg, PaCO2 55 mm Hg, and O2 saturation 90%
b. pH 7.38, PaO2 75 mm Hg, PaCO2 40 mm Hg, and O2 saturation 92%
c. pH 7.42, PaO2 80 mm Hg, PaCO2 33 mm Hg, and O2 saturation 98%
d. pH 7.52, PaO2 90 mm Hg, PaCO2 30 mm Hg, and O2 saturation 94%
ANS: B
All of the values, pH 7.38, PaO2 75 mm Hg, PaCO2 40 mm Hg, and O2 saturation 92%, are
normal.
PTS: 1
DIF: Cognitive Level: Application
REF: page 613, Table 28-1
OBJ: 5
TOP: Nursing Process: Assessment
MSC: CRNE: CH-6
7. A patient with amyotrophic lateral sclerosis (ALS) is admitted to the hospital with dyspnea.
During palpation of the patient’s thorax, what would the nurse expect to find?
a. Diminished expansion
b. Asymmetrical expansion
c. Normal expansion of 2.5 cm
d. Unequal, diminished expansion
ANS: A
Expansion is symmetrical but diminished in conditions that produce a hyperinflated or
barrel-shaped chest or in neuromuscular diseases (e.g., amyotrophic lateral sclerosis, spinal
cord lesions).
PTS: 1
DIF: Cognitive Level: Application
REF: page 623, Table 28-9
OBJ: 10
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
8. On auscultation of a patient’s lungs, the nurse hears short, high-pitched sounds just before
the end of inspiration in the right and left lower lobes. How should the nurse document this
finding?
a. Inspiratory wheezes in both lungs
b. Crackles in the right and left lower lobes
c. Abnormal lung sounds in the bases of both lungs
d. Pleural friction rub in the right and left lower lobes
ANS: A
Wheezes are high-pitched sounds; in this case, they are heard during the inspiratory phase of
the respiratory cycle. Abnormal breath sounds are bronchial or bronchovesicular sounds
heard in the peripheral lung fields. Crackles are low-pitched, “bubbling” sounds. Pleural
friction rubs are grating sounds that are usually heard during both inspiration and expiration.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: pages 623-624, Table 28-9
OBJ: 9
TOP: Nursing Process: Implementation MSC: CRNE: CH-15
9. A patient with chronic obstructive pulmonary disease (COPD) has a barrel chest. What
would the nurse expect the results of a chest X-ray to reveal?
a. Fluid in the alveoli
b. Air in the pleural space
c. Overinflation of the alveoli with air
d. Consolidation of lung tissue with mucus and exudates
ANS: C
A barrel chest results from lung hyperinflation and is a common finding in patients with
COPD.
PTS: 1
DIF: Cognitive Level: Application
REF: page 623, Table 28-9
OBJ: 11
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
10. When admitting a patient who has a pleural effusion, which technique will the nurse use to
assess for tactile fremitus?
a. Percuss over the entire posterior chest.
b. Use the fingertips to assess for vibration.
c. Place the palms of the hands on the chest wall.
d. Auscultate while the patient says “ninety-nine.”
ANS: C
To assess for tactile fremitus, the nurse should use the palms of the hands to assess for
vibration when the patient repeats a word or phrase such as “ninety-nine.”
PTS: 1
OBJ: 9
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 620
MSC: CRNE: CH-4
11. On auscultation of a patient’s lungs, the nurse hears short, low-pitched, ‘bubbling’ sounds in
the right and left lower lung areas. How should the nurse document this finding?
a. Inspiratory wheezes in both lungs
b. Crackles in the right and left lower lobes
c. Abnormal lung sounds in the bases of both lungs
d. Pleural friction rub in the right and left lower lobes
ANS: B
Crackles are low-pitched, “bubbling” sounds. Wheezes are high-pitched sounds; in this case,
they are heard during the inspiratory phase of the respiratory cycle. Abnormal breath sounds
are bronchial or bronchovesicular sounds heard in the peripheral lung fields. Pleural friction
rubs are grating sounds that are usually heard during both inspiration and expiration.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: pages 623-624, Table 28-9
OBJ: 9
TOP: Nursing Process: Implementation MSC: CRNE: CH-15
12. A patient with a chronic cough with blood-tinged sputum undergoes a bronchoscopy.
Following the bronchoscopy, what should the nurse do?
a. Keep the patient on bed rest for 8 hours.
b. Keep the patient on nothing by mouth (NPO) status until the gag reflex returns.
c. Check vital signs every 15 minutes for 2 hours.
d. Encourage fluid intake to promote elimination of the contrast media.
ANS: B
Because a local anaesthetic is used to suppress the gag or cough reflex during
bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the
patient to take oral fluids or food.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 627, Table 28-11
OBJ: 11
TOP: Nursing Process: Implementation MSC: CRNE: CH-20
13. Which of the following is an age-related change in the respiratory system?
a. Increased elastic recoil of the lungs
b. Increase in chest wall compliance
c. Increase in anteroposterior diameter
d. Increase in functional alveoli
ANS: C
Many older adults have a barrel-shaped thorax as a result of an increased anteroposterior
diameter.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 616
MSC: CRNE: CH-8
14. While auscultating a patient’s chest as the patient takes a deep breath, the nurse hears loud,
high-pitched, “blowing” sounds at both lung bases. How will the nurse document these
sounds?
a. Adventitious sounds
b. Abnormal sounds
c. Vesicular sounds
d. Normal sounds
ANS: B
The description indicates that the nurse hears bronchial breath sounds that are abnormal
when heard at the lung base.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 624, Table 28-9
OBJ: 10
TOP: Nursing Process: Implementation MSC: CRNE: CH-15
15. In analyzing the results of a patient’s blood gas analysis, the nurse will be most concerned
about which of the following?
a. Arterial oxygen tension (PaO2) of 60 mm Hg
b. Arterial oxygen saturation (SaO2) of 91%
c. Arterial carbon dioxide (PaCO2) of 47 mm Hg
d. Arterial bicarbonate level (HCO3-) of 27 mmol/L
ANS: A
All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the
oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop
in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene
immediately to improve the patient’s oxygenation.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: pages 612-613
MSC: CRNE: CH-6
16. While assessing a patient with respiratory problems, what should the nurse specifically ask
about?
a. Smoking habits
b. Alterations in sexual activity
c. The course of the patient’s illness
d. Occupational exposure to heavy lifting
ANS: A
An important aspect of a patient respiratory history, especially one with respiratory
problems, is the history of smoking and smoking habits.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 619
MSC: CRNE: CH-1
17. While caring for a patient with respiratory disease, the nurse observes that the patient’s
SpO2 drops from 94% to 85% when the patient ambulates in the hall. What does the nurse
determine from this response?
a. Supplemental oxygen should be used when the patient exercises.
b. Arterial blood gas determinations should be done to verify the SpO2.
c. This finding is a normal response to activity, and the patient should continue to be
monitored.
d. The oximetry probe should be moved from the finger to the earlobe for an accurate
SpO2 during activity.
ANS: A
The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental
oxygen when exercising.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 615
MSC: CRNE: CH-32
18. Which of the following is a normal partial pressure of oxygen value at sea level?
a. 60 mm Hg
b. 75 mm Hg
c. 90 mm Hg
d. 105 mm Hg
ANS: C
The normal partial pressure of oxygen at sea level is 80 to 100 mm Hg.
PTS: 1
DIF: Cognitive Level: Knowledge
REF: page 613, Table 28-1
OBJ: 5
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
19. The nurse is observing a student who is auscultating a patient’s lungs. Which action by the
student indicates that the nurse should intervene?
a. The student compares breath sounds from side to side.
b. The student starts at the base of the posterior lung and moves to the apices.
c. The student places the stethoscope over the scapulae and then auscultates.
d. The student listens only over the posterior part of the chest.
ANS: C
The stethoscope should be placed over lung tissue, not over bony structures. Breath sounds
should be compared from side to side. The techniques of starting at the lung base and then
moving toward the apices and listening only over the posterior chest are acceptable.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 621
MSC: CRNE: CH-4
20. When assessing the respiratory system of a 78-year-old patient, which of these findings
indicates that the nurse should take immediate action?
a. Barrel-shaped chest
b. Weak cough effort
c. Audible crackles in the lower two thirds of the posterior chest
d. Hyperresonance across both sides of the chest
ANS: C
Crackles in the lower two thirds of the lungs indicate that the patient may have an acute
problem such as congestive heart failure. The nurse should immediately accomplish further
assessments, such as oxygen saturation, and notify the physician.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 623, Table 28-9
OBJ: 10
TOP: Nursing Process: Implementation MSC: CRNE: CH-27
21. When performing an assessment of the patient’s respiratory system, the nurse uses the
following illustrated technique to evaluate which of the following respiratory functions?
a.
b.
c.
d.
Chest expansion
Tactile fremitus
Accessory muscle use
Diaphragmatic excursion
ANS: A
When assessing chest expansion on the posterior chest, the nurse will place the hands at the
level of the tenth rib, position the thumbs until they meet over the spine, and have the
patient breathe deeply.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 620, Figure 28-8
OBJ: 9
TOP: Nursing Process: Assessment
MSC: CRNE: CH-4
22. What is the normal volume of total lung capacity?
a. 1.0 L
b. 2.0 L
c. 3.5 L
d. 6.0 L
ANS: D
The normal total lung capacity volume is 6 L.
PTS: 1
DIF: Cognitive Level: Knowledge
REF: page 630, Table 28-13
OBJ: 1
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
23. A patient is admitted to the emergency department complaining of sudden-onset shortness
of breath and is diagnosed with a possible pulmonary embolus. To confirm the diagnosis,
the nurse will anticipate preparing the patient for which of the following?
a. Chest X-ray
b. Ventilation–perfusion scan
c. Bronchoscopy
d. Positron emission tomography scan
ANS: B
A ventilation–perfusion scan is used primarily to check for the presence of a pulmonary
embolus. There is no specific preparation or aftercare.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 627, Table 28-11
OBJ: 11
TOP: Nursing Process: Planning
MSC: CRNE: CH-30
24. Which of the following is a measure of the elasticity of the lung?
a. Inspiration
b. Compliance
c. Elastic recoil
d. Oxygen–hemoglobin dissociation curve
ANS: B
Compliance (distensibility) is a measure of the elasticity of the lungs and the thorax.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 612
MSC: CRNE: CH-8
25. Which of the following is an early symptom of inadequate oxygenation?
a. Dyspnea at rest
b. Hypotension
c. Tachypnea
d. Cyanosis
ANS: C
Tachypnea is an early symptom of inadequate oxygenation. Dyspnea at rest, hypotension,
and cyanosis are all late signs.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 614, Table 28-2
OBJ: 6
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
Chapter 29: Nursing Management: Upper Respiratory Problems
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. Which is the most common infection causing acute pharyngitis?
a. Fungal
b. Viral
c. Acute follicular
d. Peritonsillar
ANS: B
Viral pharyngitis accounts for approximately 70% of all cases of acute pharyngitis.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 641
MSC: CRNE: CH-8
2. When the nurse removes a nasogastric tube that has been in place for 7 days postoperatively,
the patient develops a nosebleed. To control the bleeding, what should the nurse do?
a. Pinch the soft lower portion of the nose for 10 to 15 minutes.
b. Place the patient in a sitting position with the head hyperextended.
c. Apply ice compresses to the patient’s forehead and back of the neck.
d. Pack the nares with ribbon gauze to apply pressure to the source of the bleeding.
ANS: A
The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: pages 634-635
MSC: CRNE: CH-69
3. In teaching the patient with allergic rhinitis about management of the condition, what should
the nurse explain?
a. Identification and avoidance of triggers of the symptoms are important to avoid
reactions.
b. Allergic reactions can be prevented if oral antihistamines are taken before
exposure to allergens.
c. Corticosteroid nasal sprays are the only topical drugs recommended for treatment
of hay fever.
d. Prescription antihistamine drugs should be requested because over-the-counter
preparations are ineffective for allergic rhinitis.
ANS: A
The most important intervention is to assist the patient to identify and avoid potential
allergens.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 635
MSC: CRNE: HW-4
4. A woman calls the clinic and tells the nurse that her mother, an older adult, has had a cold for
the past week. The woman is worried that pneumonia will develop. After the nurse discusses
care of upper respiratory infections and prevention of secondary infections, which of the
following responses by the woman alerts the nurse that additional teaching is needed?
a. “I should encourage my mother to drink a lot of juices and other fluids.”
b. “I should watch for changes in nasal secretions or the sputum she coughs up.”
c. “I can give my mother aspirin or acetaminophen to make her more comfortable.”
d. “I can encourage my mother to continue to use nasal decongestant spray until the
congestion is gone.”
ANS: D
The nurse should clarify that nasal decongestant sprays should be used for no more than 5
days to prevent rebound vasodilation and congestion.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 637, Table 29-2
MSC: CRNE: CH-44
5. When doing nutrition-related teaching with a patient who has acute pharyngitis, what should
the nurse tell the patient to avoid ingesting?
a. Orange Jell-o
b. Vanilla ice cream
c. Grape popsicles
d. Orange juice
ANS: D
Cool, bland liquids and gelatin will not irritate the pharynx; citrus juices are to be avoided, as
they can be irritating to the throat.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 641
MSC: CRNE: CH-35
6. To which one of the following patients should the nurse strongly recommend an influenza
immunization in the autumn each year?
a. A 24-year-old woman who has an allergy to penicillin
b. A 42-year-old man who has a history of smoking for 20 years
c. A 36-year-old man who had pneumonia when he was in university
d. A 30-year-old woman who takes corticosteroids for rheumatoid arthritis
ANS: D
It is recommended that patients who are immunocompromised receive yearly influenza
vaccinations. The corticosteroid use by the 30-year-old patient increases that person’s risk for
infection.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 639, Table 29-3
MSC: CRNE: HW-25
7. The nurse determines that complications of influenza are developing in a patient who
experiences which of the following?
a. Myalgia and headache
b. Diffuse crackles in the lungs
c. Sore throat and productive cough
d. A fever of 38°C with chills
ANS: B
The crackles indicate that the patient may be developing pneumonia, a common complication
of influenza, which would require aggressive treatment.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 639
MSC: CRNE: CH-8
8. The nurse is caring for a hospitalized 82-year-old patient who has nasal packing in place to
treat a nosebleed. Which of these assessments will require the most immediate nursing action?
a. The patient’s temperature is 38.3°C.
b. The nose appears red and swollen.
c. The patient’s oxygen saturation is 89%.
d. The patient complains of pain rated as 7 on a 10-point scale.
ANS: C
Older patients with nasal packing are at risk for aspiration or airway obstruction. An O2
saturation of 89% should alert the nurse to assess further for these complications.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 635
MSC: CRNE: CH-32
9. Which of the following is the most commonly used voice prosthesis?
a. Electrolarynx
b. Blom-Singer
c. Cooper-Rand
d. Artificial larynx
ANS: B
The most commonly used voice prosthesis is the Blom-Singer.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 654
MSC: CRNE: CH-8
10. A registered nurse is observing a nursing student who is suctioning a hospitalized patient with
a tracheostomy in place. Which action by the student requires the registered nurse to
intervene?
a. The student preoxygenates the patient for 2 minutes before suctioning.
b. The student applies suction for 10 seconds while withdrawing the catheter.
c. The student puts on clean gloves and uses a sterile catheter to suction.
d. The student inserts the catheter about 12.7 cm into the tracheostomy tube.
ANS: C
Sterile gloves and a sterile catheter are used when suctioning a tracheostomy.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 646, Table 29-8
MSC: CRNE: PP-19
11. When the nurse is deflating the cuff of a tracheostomy tube to evaluate the patient’s ability to
swallow, what is it most important to do?
a. Deflate the cuff during the patient’s inhalation.
b. Clean the inner cannula of the tracheostomy tube.
c. Suction the mouth and trachea before deflation of the tube.
d. Measure the amount of air removed from the cuff during deflation.
ANS: C
The patient’s mouth and trachea should be suctioned before the cuff is deflated to prevent
aspiration of oral secretions.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 647, Nursing Care Plan 29-1 OBJ: 4
TOP: Nursing Process: Implementation
MSC: CRNE: CH-13
12. A home care nurse is completing a follow-up visit with a patient who has recently undergone
a radical neck dissection. The nurse will assess the patient for signs and symptoms of which of
the following emotional concerns?
a. Anxiety
b. Anorexia
c. Depression
d. Speech impediment
ANS: C
Depression is common in the patient who has had a radical neck dissection; therefore, the
nurse should assess for its presence when providing follow-up home care.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 655
MSC: CRNE: CH-17
13. A patient with an uncuffed tracheostomy tube coughs violently during suctioning and
dislodges the tracheostomy tube. Initially, what should the nurse do?
a. Call the physician.
b. Attempt to reinsert the tracheostomy tube.
c. Position the patient in a lateral position with the neck extended.
d. Cover the stoma with a sterile dressing, and ventilate the patient with a manual
bag-mask until the physician arrives.
ANS: B
The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient’s
airway.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 643
MSC: CRNE: CH-24
14. A patient with a tracheostomy is to use a fenestrated tracheostomy tube to provide for speech.
What is it important that the nurse do?
a. Place the decannulation cap in the tube before cuff deflation.
b. Assess the patient’s ability to swallow without risk of aspiration.
c. Remove the inner cannula of the tracheostomy tube after deflating the cuff.
d. Connect oxygen at 4 to 6 L/min to the second pigtail tubing of the tracheostomy
tube.
ANS: B
Because the cuff is deflated when using a fenestrated tube, the patient’s risk for aspiration
should be assessed before changing to a fenestrated tracheostomy tube.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 646
MSC: CRNE: CH-10
15. When inflating the cuff on a tracheostomy tube to the appropriate level, the best nursing
action will be which of the following?
a. Use a manometer to ensure cuff pressure is at an appropriate level.
b. Verify the health care provider’s order for the amount of cuff pressure required.
c. Fill the balloon until no leakage around the cuff is auscultated.
d. Check the pilot balloon after inflation to ensure that it is firm.
ANS: A
Cuff inflation pressure should not exceed 20 mm Hg or 25 cm H2O because higher pressures
may compress tracheal capillaries, limit blood flow, and predispose to tracheal necrosis.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 643
MSC: CRNE: CH-10
16. A patient is discharged from the hospital with a tracheostomy tube for long-term airway
management. Which of the following responses by the patient helps the nurse determine that
teaching related to care of the tracheostomy has been effective?
a. “I must use sterile gloves and catheters to suction my tracheostomy.”
b. “I should maintain a liquid diet as long as I have the tracheostomy tube in place.”
c. “I will be changing my tracheostomy tube at home about once a month.”
d. “If I have thick mucus, I can instill about a teaspoon of tap water into my
tracheostomy tube.”
ANS: C
It takes several months for the formation of a fully healed tract, so the patient is taught that
after the initial tube change the tracheostomy is to be changed once a month. Clean technique
is used to suction a tracheostomy in the home environment, not sterile technique. A liquid diet
is not required when a patient has a tracheostomy; many people live with a permanent
tracheostomy and consume a normal diet. Tap water should not be inserted into a
tracheostomy tube; if secretions are thick provide humidification and hydration.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 646
MSC: CRNE: NCP-14
17. A patient with laryngeal cancer has received teaching about radiation therapy. Which
statement by the patient indicates that the teaching has been effective?
a. “I will need to buy a water bottle to carry with me.”
b. “Until the radiation is complete, I may have diarrhea.”
c. “Alcohol-based mouthwashes will help clean oral ulcers.”
d. “I can use lotions to moisturize the skin on my throat.”
ANS: A
Xerostomia can be partially alleviated by drinking fluids at frequent intervals.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Evaluation
REF: page 654
MSC: CRNE: NCP-14
18. When obtaining a health history from a patient with hoarseness and tightness in his throat, the
nurse should specifically ask the patient about which of the following information?
a. Alcohol and tobacco use
b. The presence of dentures
c. A history of allergic rhinitis
d. A history of streptococcal pharyngitis
ANS: A
Prolonged alcohol use is associated with the development of laryngeal cancer, which the
patient’s symptoms and history suggest.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: pages 649, 652
MSC: CRNE: CH-1
19. A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the
larynx asks the nurse how the surgery will affect his throat. What is the best response?
a. “You will breathe through a permanent opening in your neck, and you will not be
able to speak.”
b. “You will have a permanent opening into your neck, and you will need to have
rehabilitation for some type of voice restoration.”
c. “You won’t be able to speak as you used to, but a lot of artificial voice devices are
available that will give you the ability to speak normally.”
d. “You will have a tube into your trachea through which you will breathe, but you
will be able to speak when the stoma heals and the tube is removed.”
ANS: B
Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices
are available to restore communication.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 654
MSC: CRNE: CH-8
20. A patient returns from surgery with a cuffed, single-cannula tracheostomy tube after a total
laryngectomy and radical neck dissection. In planning tracheostomy care for the patient
during the first 24 hours after surgery, what is the priority nursing intervention?
a. The tracheostomy ties should not be changed.
b. The tracheostomy dressings should not be changed.
c. The patient should be encouraged to assist in the procedure.
d. Assess the airway and breath sounds.
ANS: D
The most important goals post-tracheotomy are to maintain the airway and ensure adequate
oxygenation. Assessment of the airway and breath sounds is the priority action.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 647, Nursing Care Plan 29-1 OBJ: 7
TOP: Nursing Process: Implementation
MSC: CRNE: CH-31
21. On entering the room of the patient who has just returned from surgery for a total
laryngectomy and radical neck dissection, the nurse recognizes a need for intervention upon
making which one of the following observations?
a. The gastrostomy tube is clamped.
b. The patient is coughing blood-tinged secretions from the tracheostomy.
c. The patient is positioned in a lateral position with the head of the bed flat.
d. There are 200 mL of serosanguineous drainage in the patient’s portable drainage
device.
ANS: C
The nurse should elevate the head of the bed to maximize lung expansion and enable an
effective cough.
PTS: 1
DIF: Cognitive Level: Application
REF: page 647, Nursing Care Plan 29-1 OBJ: 7
TOP: Nursing Process: Implementation
MSC: CRNE: PP-19
22. In which position should the nurse position the patient before commencing tracheostomy
care?
a. Prone position
b. Supine position
c. Semi-Fowler’s position
d. High-Fowler’s position
ANS: C
Patients should be positioned in a semi-Fowler’s position before commencing tracheostomy
care.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 646, Table 29-8
MSC: CRNE: CH-10
23. After completing discharge instructions for a patient with a total laryngectomy, the nurse
determines that additional instruction is needed when the patient makes which of the
following responses?
a. “I must keep the stoma covered with a dressing at all times.”
b. “I can participate in most of my prior fitness activities except swimming.”
c. “I need to eat nutritious meals even though I can’t smell or taste very well.”
d. “I should wear a MedicAlert bracelet that identifies me as a neck breather.”
ANS: A
The stoma may be covered with clothing or a loose dressing, but this is not essential.
PTS: 1
DIF: Cognitive Level: Application
REF: page 652, Nursing Care Plan 29-2 OBJ: 7
MSC: CRNE: NCP-14
TOP: Nursing Process: Evaluation
Chapter 30: Nursing Management: Lower Respiratory Problems
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. Following assessment of a patient with pneumonia, the nurse documents a nursing diagnosis
of ineffective airway clearance. On which of the following data would the nurse base this
nursing diagnosis?
a. SpO2 of 85%
b. Respiratory rate of 28 breaths/min
c. Presence of greenish sputum
d. Weak, nonproductive cough
ANS: D
The weak, nonproductive cough indicates that the patient is unable to clear the airway
effectively.
PTS: 1
DIF: Cognitive Level: Application
REF: page 667, Nursing Care Plan 30-1 OBJ: 2
TOP: Nursing Process: Diagnosis
MSC: CRNE: CH-15
2. A 56-year-old normally healthy patient at the clinic is diagnosed with community-acquired
pneumonia. The nurse anticipates that empirical treatment of the patient could include the
administration of which of the following medications?
a. Ciprofloxacin (Cipro)
b. Azithromycin (Zithromax)
c. Trimethoprim–sulfamethoxazole (Bactrim)
d. A second- or third-generation cephalosporin
ANS: B
Early initiation of appropriate antibiotic therapy has been demonstrated to reduce mortality.
The treatment of choice is a macrolide (erythromycin, azithromycin, or clarithromycin).
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 665
MSC: CRNE: CH-44
3. During assessment of the chest in a patient with pneumococcal pneumonia, what would the
nurse expect to find?
a. Hyperresonance on percussion
b. Increased tactile fremitus on palpation
c. Fine crackles in all lobes on auscultation
d. Asymmetrical chest expansion on inspection
ANS: B
Pneumonias caused by Streptococcus pneumoniae are typically lobar or segmental. The
nurse would expect to find increased tactile fremitus over the affected area of the lungs. The
area would be dull to percussion.
PTS:
1
DIF:
Cognitive Level: Application
REF: page 666, Table 30-5
TOP: Nursing Process: Assessment
OBJ: 1
MSC: CRNE: CH-4
4. To promote airway clearance in a patient with pleurisy, what should the nurse instruct the
patient to do?
a. Splint the chest when coughing.
b. Maintain a semi-Fowler’s position.
c. Wear the nasal oxygen cannula at all times.
d. Use relaxation techniques to reduce anxiety.
ANS: A
Coughing is less painful and more likely to be effective when the patient splints the chest
during coughing.
PTS: 1
OBJ: 11
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 699
MSC: CRNE: CH-32
5. Four days after admission, a patient with chronic obstructive lung disease is diagnosed with
hospital-acquired pneumonia (HAP). Which of the following organisms does the nurse
recognize is a common cause of this type of pneumonia?
a. Pneumocystis carinii
b. Haemophilus influenzae
c. Pseudomonas aeruginosa
d. Mycoplasma pneumoniae
ANS: C
Bacteria are responsible for the majority of HAP infections, including Pseudomonas,
Enterobacter, Staphylococcus aureus, methicillin-resistant S. aureus, and S. pneumoniae.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: pages 660-662
MSC: CRNE: CH-8
6. The nurse is preparing a patient with a diagnosis of bronchiectasis for chest physiotherapy
with postural drainage. Which one of the following will the nurse implement?
a. Position the patient supine.
b. Elevate the head of the bed by 20 cm.
c. Elevate the foot of the bed by 10 to 15 cm.
d. Ensure the patient is in the left lateral position for the first part of the chest
physiotherapy.
ANS: C
Chest physiotherapy with postural drainage should be done on affected parts of the lung;
elevate the foot of the bed 10 to 15 cm, to facilitate drainage.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 677
MSC: CRNE: CH-32
7. During assessment of the patient with pneumonia, what does the nurse understand about the
disease?
a. All patients with pneumonia will have a productive cough.
b. Manifestations of pneumonia vary, depending on the causative organism.
c. The typical pneumonia symptoms are usually caused by M. pneumoniae.
d. The pathophysiology of the disease is the same, regardless of the causative
microorganism.
ANS: B
Manifestations of pneumonia vary according to their causative agent.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 660
MSC: CRNE: CH-8
8. Following discharge teaching, the nurse evaluates that the patient with pneumonia
understands measures to prevent a relapse of the pneumonia when the patient gives which of
the following responses?
a. “I will increase my food intake to 2400 calories a day.”
b. “I must use home oxygen therapy for 3 months.”
c. “I will seek medical treatment for any upper respiratory infections.”
d. “I should continue to do deep breathing and coughing exercises for at least 6
weeks.”
ANS: D
Patients at risk for recurrent pneumonia should use the incentive spirometer or do deep
breathing and coughing exercises or both for 6 to 8 weeks after discharge.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 668
MSC: CRNE: NCP-14
9. To protect susceptible patients in the hospital from aspiration pneumonia, what must the
nurse do?
a. Turn and reposition immobile patients every 2 hours.
b. Position patients with altered consciousness in a lateral position.
c. Monitor for respiratory symptoms in those patients who are immunosuppressed.
d. Plan room assignments to prevent infected patients from placement with surgical
patients.
ANS: B
The risk for aspiration is decreased when patients with a decreased level of consciousness
are placed in a side-lying or upright position.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 666
MSC: CRNE: CH-32
10. Which of the following is a general term used for lung diseases caused by the inhalation and
retention of dust particles?
a. Berylliosis
b. Byssinosis
c. Paraneoplastic syndrome
d. Pneumoconiosis
ANS: D
Pneumoconiosis is a general term for lung diseases caused by the inhalation and retention of
dust particles.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 678
MSC: CRNE: CH-8
11. What should the nurse teach patients at risk for pneumonia to obtain?
a. Staphylococcal vaccine
b. Measles, mumps, rubella (MMR) vaccine
c. Pneumococcal vaccine
d. Bacille Calmette-Guérin (BCG) vaccine
ANS: C
Individuals at risk for pneumonia (e.g., the chronically ill, older adults) should be
encouraged to obtain both influenza and pneumococcal vaccines. This is particularly
important because the rate of drug-resistant S. pneumoniae infections is increasing.
Pneumococcal vaccine can be given simultaneously with other vaccines, such as the flu
vaccine, but each should be administered in a separate site.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 665
MSC: CRNE: HW-25
12. A hospitalized patient who may have tuberculosis (TB) has an order for a sputum specimen.
When will be the best time for the nurse to collect the specimen?
a. After the patient rinses the mouth with mouthwash
b. As soon as the order is received from the physician
c. Right after the patient gets up in the morning
d. After the skin test is administered
ANS: C
If the patient has a productive cough, an early-morning sputum specimen will be required
for an acid-fast bacilli (AFB) smear, to detect the presence of mycobacteria.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 674
MSC: CRNE: CH-4
13. A patient has just been started on chemotherapy for TB. What should the nurse tell the
patient regarding how long the disease can be transmitted to others?
a. Until the night sweats have subsided
b. Until three AFB smears are negative
c. Until the medications have been taken for 6 months
d. Until sputum cultures on 3 consecutive days are negative
ANS: B
The patient is considered infectious until three sputum smears are negative for AFB.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 674
MSC: CRNE: HW-8
14. The nurse recognizes that the goals of teaching regarding the transmission of TB have been
met when the patient with TB carries out which of the following actions?
a. Wears a mask when in contact with others
b. Reports daily to the public health department
c. Boils dishes and personal items between uses
d. Covers the mouth and nose when coughing or sneezing
ANS: D
Covering the mouth and nose will help decrease airborne transmission of TB. The other
actions will not be effective in decreasing the spread of TB.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Evaluation
REF: page 674
MSC: CRNE: NCP-14
15. A patient is receiving isoniazid (INH) after having a positive tuberculin skin test. Which
information will the nurse include in the patient teaching plan?
a. “Take vitamin B6 daily to prevent peripheral nerve damage.”
b. “Read a newspaper daily to check for changes in vision.”
c. “Schedule an audiometric examination to monitor for hearing loss.”
d. “Avoid wearing soft contact lenses to avoid orange staining.”
ANS: A
Peripheral neurotoxicity associated with this drug can be prevented by taking vitamin B6
when being treated with INH.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 672, Table 30-8
OBJ: 3
TOP: Nursing Process: Evaluation
MSC: CRNE: CH-44
16. A patient diagnosed with TB is started on initial drug therapy. Which of the following
medications should the nurse plan to teach the patient about the uses and effects of?
a. INH, rifampin, and ethambutol
b. INH, pyrazinamide, and streptomycin
c. INH, rifampin, pyrazinamide, streptomycin, and ethambutol
d. Para-aminosalicylic acid, ethambutol, rifampin, and pyrazinamide
ANS: C
The five primary drugs used are INH, rifampin, pyrazinamide, streptomycin, and
ethambutol.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 672
MSC: CRNE: CH-44
17. A homeless patient with alcoholism is diagnosed with active TB. Which nursing
intervention will be most effective in ensuring adherence to the treatment regimen?
a. Giving the patient written instructions about how to take the medications
b. Teaching the patient about the high risk for infecting others unless treatment is
followed
c. Arranging for a daily noontime meal at a community centre and giving the
medication then
d. Educating the patient about the long-term impact of TB on health
ANS: C
Directly observed therapy (DOT) is the most effective means for ensuring compliance with
the treatment regimen, and arranging a daily meal will help ensure that the patient is
available to receive the medication.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 673
MSC: CRNE: HW-4
18. A patient being treated for TB comes to the clinic after 2 months for a follow-up visit.
Sputum smears for AFB are still positive. A sputum specimen is taken for culture and to
determine whether the microorganism is sensitive to the medications. What knowledge does
the nurse use to question the patient regarding the treatment regimen?
a. DOT will be necessary if the patient has been noncompliant.
b. A combination product of INH, rifampin, and pyrazinamide is indicated if the
patient skips doses.
c. Treatment protocols involving twice-weekly administration of the drugs are not as
effective as daily administration.
d. If the drugs are causing side effects, a regimen including the administration of only
INH can be substituted.
ANS: A
After 2 months of therapy, negative sputum smears would be expected if the TB bacillus is
susceptible to the medications and if the medications have been taken correctly. The nurse
will need to initiate DOT if the patient has not been consistently taking the medications.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 673
MSC: CRNE: CH-8
19. A staff nurse has a TB skin test of 16-mm induration. A chest radiograph is negative, and
the nurse has no symptoms of TB. The occupational health nurse will plan on teaching the
staff nurse about which of the following?
a. Use and side effects of INH
b. Standard four-medication therapy for TB
c. Need for annual repeat TB skin testing
d. Recommendation guidelines for BCG vaccine
ANS: A
The nurse is considered to have a latent TB infection and should be treated with INH daily
for 6 to 9 months.
PTS: 1
DIF: Cognitive Level: Application
REF: page 672, Table 30-8
OBJ: 3
TOP: Nursing Process: Implementation MSC: CRNE: CH-44
20. During intravenous (IV) administration of amphotericin B ordered for treatment of
coccidioidomycosis, how can the nurse increase the patient’s tolerance of the drug?
a. Cooling the solution to 26.7°C before administration
b. Keeping the patient flat in bed for 1 hour after the infusion is completed
c. Diluting the amphotericin B in 500 mL of distilled water before administering
d. Administering diphenhydramine (Benadryl) 1 hour before the infusion
ANS: D
Many of the side effects of an infusion can be avoided by premedicating with an antiinflammatory or diphenhydramine 1 hour before the infusion.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 675
MSC: CRNE: CH-47
21. The nurse is performing TB screening in a clinic that has many patients who have
immigrated to Canada. Before doing a TB skin test on a patient, which question is most
important for the nurse to ask?
a. “How long have you lived in Canada?”
b. “Do you have a family history of TB?”
c. “Have you received the BCG vaccine for TB?”
d. “Do you take any over-the-counter medications?”
ANS: C
Patients who have received the BCG vaccine will have a positive purified protein derivative
test. Another method for screening (such as a chest X-ray) will be used in determining
whether the patient has a TB infection.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 673
MSC: CRNE: CH-1
22. When caring for a patient who is hospitalized with active TB, the nurse observes a family
member who is visiting the patient. The nurse will need to intervene if the family member
does which of the following?
a. Washes the hands before entering the patient’s room
b. Puts on a surgical face mask before visiting the patient
c. Brings food from a “fast-food” restaurant to the patient
d. Hands the patient a tissue from the box at the bedside
ANS: B
A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask,
should be used when entering the patient’s room because the HEPA mask can filter out
100% of small airborne particles.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 674
MSC: CRNE: HW-8
23. The occupational nurse at a manufacturing plant where there is high worker exposure to
beryllium dust will monitor workers for which of the following?
a. Shortness of breath
b. Stabbing chest pain
c. Elevated temperature
d. Barrel chest
ANS: A
Occupational asthma refers to the development of symptoms of shortness of breath,
wheezing, cough, and chest tightness as a result of exposure to fumes or dust that trigger an
allergic response.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 679
MSC: CRNE: CH-1
24. When developing a teaching plan for a patient with a 42-pack-year history of cigarette
smoking, it will be most important for the nurse to include information about which of the
following?
a. Reasons for annual sputum cytology testing
b. Computed tomography screening for lung cancer
c. Erlotinib (Tarceva) therapy to prevent tumour risk
d. Options for smoking cessation
ANS: D
Because smoking is the major cause of lung cancer, the most important role for the nurse to
educate patients about the benefits of and means of smoking cessation.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 685
MSC: CRNE: HW-2
25. A lobectomy is scheduled for a patient with squamous cell carcinoma of the lung. The
patient tells the nurse, “I would rather have radiation than surgery.” What is the most
appropriate response?
a. “Are you afraid that the surgery will be very painful?”
b. “Tell me what you know about the various treatments available.”
c. “Surgery is the treatment of choice for stage I lung cancer.”
d. “Did you have bad experiences with previous surgeries?”
ANS: B
More assessment of the patient’s concerns about surgery is indicated. An open-ended
response will elicit the most information from the patient.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 695
MSC: CRNE: NCP-4
26. A 52-year-old patient has a 40-pack-year history of smoking and has been diagnosed with
cancer of the lung. He tells the nurse that he did not know that anything was wrong until he
had a routine chest X-ray. The nurse explains that symptoms of lung cancer occur late in the
disease. What is the first thing people usually notice?
a. Fatigue
b. Chest pain
c. A persistent cough
d. Shortness of breath
ANS: C
The first thing usually noticed with lung cancer is a persistent cough.
PTS:
1
DIF:
Cognitive Level: Comprehension
REF: page 682
OBJ: 7
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
27. In relation to lung cancer and gender, which of the following statements is true?
a. More women than men are diagnosed with lung cancer.
b. Men are more likely to develop small-cell carcinoma than women.
c. Women develop lung cancer after fewer years of smoking than men do.
d. Lung cancer incidence and deaths are increasing in men.
ANS: C
The accurate fact related to gender and lung cancer is that women develop lung cancer after
fewer years of smoking than men do.
PTS: 1
DIF: Cognitive Level: Knowledge
REF: page 681, Determinants of Health OBJ: 7
TOP: Nursing Process: Assessment
MSC: CRNE: HW-19
28. A young man is admitted to the emergency department with a stab wound to the right chest.
He has moderate bleeding from the site, and his vital signs show symptoms of shock. Air
can be heard entering his chest with each inspiration. To decrease the possibility of a tension
pneumothorax in the patient, what should the nurse do?
a. Position the patient on his injured side.
b. Administer high-flow oxygen using a nonrebreathing mask.
c. Cover the sucking chest wound with a petrolatum gauze dressing.
d. Apply a nonporous dressing taped on three sides to the chest wound.
ANS: D
The dressing taped on three sides will allow air to escape when intrapleural pressure
increases during expiration, but it will prevent air from moving into the pleural space during
inspiration.
PTS: 1
DIF: Cognitive Level: Application
REF: page 688, Table 30-21
OBJ: 8
TOP: Nursing Process: Implementation MSC: CRNE: CH-68
29. The physician inserts two chest tubes connected with a Y-connecter in a patient with a
hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse
will be concerned about which of the following?
a. A large air leak in the water-seal chamber
b. 400 mL of blood in the collection chamber
c. Severe pain with each deep patient inspiration
d. Subcutaneous emphysema at the insertion site
ANS: B
The large amount of blood may indicate that the patient is in danger of developing
hypovolemic shock.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 689, Table 30-22
OBJ: 9
TOP: Nursing Process: Assessment
MSC: CRNE: CH-56
30. A patient experiences a flail chest as a result of an automobile accident. During the
respiratory assessment, what would the nurse expect to find?
a. Bloody sputum
b. Laryngeal stridor
c. Deep, irregular respirations
d. Paradoxical chest movement
ANS: D
Paradoxical chest movement indicates that the patient may have flail chest, which will
severely compromise gas exchange and can rapidly lead to hypoxemia.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 690
MSC: CRNE: CH-8
31. The nurse establishes the presence of a tension pneumothorax when assessment findings
reveal which of the following results?
a. Decreased breath sounds on the affected side
b. Inability to auscultate tracheal breath sounds
c. A sucking sound with each patient breath
d. A shift of the point of maximal impulse to the left, with bounding pulses
ANS: A
Breath sounds are decreased on the affected side with tension pneumothorax because air
trapped in the pleural space compresses the lung on that side.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 689
MSC: CRNE: CH-8
32. The nurse identifies a nursing diagnosis of ineffective airway clearance for a patient who
has incisional pain, a poor cough effort, and expiratory wheezing after having a
pneumonectomy. To promote airway clearance, what is the nurse’s initial action?
a. Have the patient use the incentive spirometer.
b. Medicate the patient with the ordered morphine.
c. Splint the patient’s chest during coughing.
d. Assist the patient to sit up at the bedside.
ANS: B
A major reason for atelectasis and poor airway clearance in patients after chest surgery is
incisional pain (which increases with deep breathing and coughing), so it is important that
patients be appropriately medicated so that they are able to breathe deeply and cough.
PTS: 1
DIF: Cognitive Level: Application
REF: page 697, Nursing Care Plan 30-2 OBJ: 10
TOP: Nursing Process: Implementation MSC: CRNE: CH-52
33. A patient has a chest tube following a thoracotomy. Continuous bubbling in the suctioncontrol chamber of the collection device would alert the nurse to which of the following
facts?
a. An air leak may be present.
b. The lung has fully expanded.
c. The unit is functioning normally.
d. A tension pneumothorax is developing.
ANS: C
Continuous bubbling is expected in the suction-control chamber and indicates that the
suction-control chamber is connected to suction.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 693, Table 30-23
OBJ: 9
TOP: Nursing Process: Evaluation
MSC: CRNE: CH-56
34. When providing preoperative instruction for a patient scheduled for a left pneumonectomy
for cancer of the lung, the nurse informs the patient that postoperatively he can expect which
of the following interventions?
a. To be positioned on the unaffected side
b. Chest tubes to water-seal chest drainage
c. Endotracheal intubation with mechanical ventilation
d. Frequent use of an incentive spirometer
ANS: D
Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis.
PTS: 1
DIF: Cognitive Level: Application
REF: page 697, Nursing Care Plan 30-2 OBJ: 10
TOP: Nursing Process: Implementation MSC: CRNE: CH-32
35. A 68-year-old man has a long history of chronic obstructive pulmonary disease and is
admitted to the hospital with cor pulmonale. Which clinical manifestation noted by the nurse
is would indicate that the patient with a diagnosis of cor pulmonale also has heart failure?
a. Audible crackles at both lung bases
b. Peripheral edema
c. Loud murmur at the mitral area
d. High systemic blood pressure
ANS: B
Clinical manifestations of cor pulmonale include dyspnea, chronic productive cough,
wheezing respirations, retrosternal or substernal pain, and fatigue. If heart failure
accompanies cor pulmonale, additional manifestations will also be found, including
peripheral edema; weight gain; distended neck veins; full, bounding pulse; and enlarged
liver.
PTS: 1
OBJ: 12
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 704
MSC: CRNE: CH-8
36. Which of the following is an extrapulmonary cause of restrictive lung disease?
a. Kyphoscoliosis
b. Atelectasis
c. Interstitial lung disease
d. Tuberculosis
ANS: A
Kyphoscoliosis is an extrapulmonary cause of restrictive lung disease. The other answer
choices are all intrapulmonary causes of restrictive lung disease.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 698, Table 30-26
OBJ: 11
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
37. A patient with primary pulmonary hypertension (PPH) is on diuretic therapy. The nurse will
evaluate that the treatment is effective in which of the following situations?
a. The patient reports decreased exertional dyspnea.
b. The blood pressure is less than 140/90 mm Hg.
c. The heart rate is between 60 and 100 beats/min.
d. The patient’s chest X-ray indicates clear lung fields.
ANS: A
Given that a major symptom of PPH is exertional dyspnea, an improvement in this symptom
would indicate that the medication was effective.
PTS: 1
OBJ: 12
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Evaluation
REF: page 703
MSC: CRNE: CH-48
38. A patient is scheduled for a thoracentesis to obtain pleural fluid for diagnosis of a large
pleural effusion. Before the procedure, the nurse will anticipate which of the following?
a. Position the patient sitting upright on the edge of the bed and leaning forward.
b. Instruct the patient about the importance of incentive spirometer use after the
procedure.
c. Start a peripheral IV line to administer the necessary sedative drugs.
d. Remove the water pitcher and remind the patient not to eat or drink anything for 8
hours.
ANS: A
When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and
can be located and removed more easily. The lung will expand after the effusion is removed.
PTS: 1
OBJ: 11
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 698
MSC: CRNE: CH-30
39. After discharge teaching has been completed for a patient who has had a lung transplant, the
nurse will evaluate that the teaching has been effective if the patient states which of the
following?
a. “I will make an appointment to see the doctor every year.”
b. “I will not turn the home oxygen up higher than 2 L/min.”
c. “I will be careful to use sterile technique with my central line.”
d. “I will write down my medications and spirometry in a journal.”
ANS: D
After lung transplant, patients are taught to keep logs of medications, spirometry, and
laboratory results.
PTS:
1
DIF:
Cognitive Level: Application
REF: page 705
OBJ: 13
TOP: Nursing Process: Evaluation
MSC: CRNE: NCP-14
40. A patient who was admitted the previous day with pneumonia complains of a sharp pain
whenever he takes a deep breath. Which action will the nurse take next?
a. Listen to the patient’s lungs.
b. Check the patient’s O2 saturation.
c. Have the patient cough forcefully.
d. Notify the patient’s health care provider.
ANS: A
The patient’s statement indicates that pleurisy or a pleural effusion may have developed, so
the nurse will need to listen for a pleural friction rub, decreased breath sounds, or both.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 699
MSC: CRNE: CH-63
41. A patient with a chronic productive cough and weight loss is receiving a TB skin test and
asks the nurse the reason for the test. Which response should the nurse give?
a. “The skin test will determine if you have a TB infection.”
b. “The skin test will indicate whether you have active TB.”
c. “The skin test is used to decide which antibiotic therapy will work best.”
d. “The skin test is done before notification of the public health department.”
ANS: A
A positive skin test will indicate whether the patient has been infected with TB.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 671
MSC: CRNE: CH-30
42. The nurse obtains the following information when caring for a patient receiving
subcutaneous heparin injections to treat a pulmonary embolus. Which assessment
information is most important to communicate to the physician?
a. The patient has many abdominal bruises.
b. The patient’s blood pressure is 90/46 mm Hg.
c. The activated partial thromboplastin time is two times the patient baseline.
d. The patient’s stool is dark green and liquid.
ANS: B
The low blood pressure may indicate that the patient is experiencing bleeding, a possible
adverse effect of heparin therapy.
PTS: 1
OBJ: 11
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 702
MSC: CRNE: CH-27
43. The nurse is preparing a patient for discharge after treatment for a pulmonary embolism.
The patient asks the nurse how long he will have to be on anticoagulant therapy. The nurse’s
response is based on knowledge that the patient will be on this therapy for which period of
time?
a. 10 days post discharge
b. 2 to 4 weeks
c. 3 to 6 months
d. 6 to 8 months
ANS: C
Anticoagulant therapy continues for at least 3 to 6 months for patients after having a
pulmonary embolism.
PTS: 1
OBJ: 12
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 703
MSC: CRNE: CH-44
44. Which assessment information obtained by the nurse when caring for a patient who has just
had a thoracentesis is most important to communicate to the physician?
a. Blood pressure is 150/90 mm Hg.
b. Pain level is 5 on a 10-point scale with a deep breath.
c. Oxygen saturation is 89%.
d. Respiratory rate is 24 breaths/min when lying flat.
ANS: C
Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 89%
indicates that a complication such as pneumothorax may be occurring.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: pages 697-698
MSC: CRNE: CH-27
45. All of the following orders are received for a patient who has just been admitted with
probable bacterial pneumonia and sepsis. Which one will the nurse accomplish first?
a. Obtain blood cultures from two sites.
b. Give ciprofloxacin (Cipro) 400 mg IV.
c. Send patient to have a chest radiograph.
d. Administer an aspirin suppository.
ANS: A
Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be
obtained before antibiotic administration.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 664
MSC: CRNE: CH-22
46. The nurse has received a change-of-shift report about these four patients. Which one will the
nurse plan to assess first?
a. A 23-year-old patient with cystic fibrosis who has pulmonary function testing
scheduled in 30 minutes
b. A 35-year-old patient who was admitted the previous day with bacterial
pneumonia and has a temperature of 38.5°C
c. A 46-year-old patient who is complaining of dyspnea after having a thoracentesis
an hour previously
d. A 77-year-old patient with TB who has four antitubercular medications due in 15
minutes
ANS: C
Dyspnea after a thoracentesis may indicate a pneumothorax or hemothorax and requires
immediate evaluation by the nurse.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 698
MSC: CRNE: CH-22
47. A patient with a deep-vein thrombophlebitis complains of sudden chest pain and difficulty
breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg,
and respiration of 42 breaths/min. The nurse’s first action should be to do which of the
following?
a. Elevate the head of the bed.
b. Administer the ordered pain medication.
c. Notify the patient’s health care provider.
d. Offer emotional support and reassurance.
ANS: A
The patient has symptoms consistent with a pulmonary embolism, so elevating the head of
the bed will improve ventilation and gas exchange.
PTS: 1
OBJ: 11
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 701
MSC: CRNE: CH-22
Chapter 31: Nursing Management: Obstructive Pulmonary Diseases
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A patient with a history of asthma is admitted to the hospital in acute respiratory distress.
During assessment of the patient, the nurse would notify the physician immediately on
finding which of the following assessment data?
a. An SpO2 of 90%
b. A peak expiratory flow rate of 240 mL/min
c. Decreased breath sounds and decreased audible wheezing
d. Arterial blood gas (ABG) results of pH 7.4, PaCO2 50 mm Hg, and PaO2 74 mm
Hg
ANS: C
Decreased breath sounds and wheezing would indicate that the patient was experiencing an
asthma attack, and immediate bronchodilator treatment would be indicated.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 710
MSC: CRNE: CH-63
2. The nurse recognizes that intubation and mechanical ventilation are indicated for a patient
experiencing a severe asthma attach when which one of the following changes occurs?
a. Ventricular dysrhythmias occur.
b. The thorax becomes hyperinflated.
c. Pulsus paradoxus is greater than 40 mm Hg.
d. Fatigue leads to increased hypercapnia and hypoxemia.
ANS: D
Although all of the assessment data indicate the need for rapid intervention, the fatigue and
hypoxia indicate that the patient is no longer able to maintain an adequate respiratory effort
and needs mechanical ventilation.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 715
MSC: CRNE: CH-63
3. An Advair Diskus DPI (combined fluticasone and salmeterol) dry powder inhaler is
prescribed for a patient diagnosed with mild, persistent asthma. The patient asks the nurse
why she must use two different drugs. What should the nurse explain about this treatment?
a. Both drugs are bronchodilators, but the exact mechanism of action of fluticasone is
not known.
b. Both the salmeterol and the fluticasone are bronchodilators but act in different
ways to decrease bronchospasm.
c. The salmeterol is used to decrease the bronchospasm, and the fluticasone helps
control the inflammatory response.
d. The salmeterol stimulates the bronchodilator effect of 2 receptors, and the
fluticasone blocks the bronchoconstrictor effect of the parasympathetic nervous
system.
ANS: C
Salmeterol is a long-acting bronchodilator, and fluticasone is a corticosteroid. They work
together to prevent asthma attacks.
PTS: 1
DIF: Cognitive Level: Application
REF: page 720, Table 31-7
OBJ: 1
TOP: Nursing Process: Implementation MSC: CRNE: CH-44
4. The physician has prescribed a budesonide metered-dose inhaler (MDI) two puffs every 8
hours and ciclesonide MDI one puff twice daily (BID). In teaching the patient about the use
of the inhalers, what is the best instruction?
a. “Use the budesonide inhaler first, wait a few minutes, then use the ciclesonide
inhaler.”
b. “Using a spacer with the MDIs will improve the inhalation of the medications.”
c. “To avoid side effects, the inhalers should not be used within 1 hour of each
other.”
d. “To maximize the effectiveness of the medications, inhale quickly when using the
inhalers.”
ANS: B
More medication reaches the bronchioles when a spacer is used along with an MDI.
PTS: 1
DIF: Cognitive Level: Application
REF: page 722, Table 31-7
OBJ: 1
TOP: Nursing Process: Implementation MSC: CRNE: CH-44
5. Clinically significant airway obstruction develops in what percentage of smokers?
a. 5% to 10%
b. 15% to 20%
c. 25% to 30%
d. 40% to 50%
ANS: B
Clinically significant airway obstruction develops in 15% to 20% of smokers.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 732
MSC: CRNE: CH-8
6. The nurse identifies the nursing diagnosis of activity intolerance for a patient with asthma.
Which common etiological factor would the nurse document for this nursing diagnosis in
patients with asthma?
a. Work of breathing
b. Fear of suffocation
c. Anxiety and restlessness
d. Side effects of medications
ANS: A
The activity intolerance patients with asthma experience is related to the increased effort
needed to breathe when airways are inflamed and narrowed, and interventions are focused
on decreasing inflammation and bronchoconstriction.
PTS: 1
DIF: Cognitive Level: Application
REF: page 728, Table 31-11
OBJ: 2
TOP: Nursing Process: Diagnosis
MSC: CRNE: CH-15
7. The nurse evaluates the effectiveness of therapy for a patient with an acute asthma
exacerbation. Which of the following findings indicates to the nurse that the patient’s
respiratory function is beginning to improve?
a. Wheezing becomes louder.
b. The cough remains unproductive.
c. Vesicular breath sounds decrease.
d. Aerosol bronchodilators stimulate coughing.
ANS: A
Louder wheezes indicate that more air is moving through the airways and that the
bronchodilator therapy is working.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 719
MSC: CRNE: CH-48
8. A 25-year-old patient has had moderate asthma for 10 years. She uses an salbutamol (ApoSalvent) inhaler when she develops chest tightness and wheezing but does not use her
salmeterol (Serevent) as prescribed. To increase the patient’s management and control of her
asthma, what should the nurse teach the patient?
a. She should use the salmeterol when the albuterol does not relieve her symptoms.
b. Using the salmeterol helps prevent the early-phase response of bronchospasm and
thus further inflammatory changes.
c. Salmeterol should be used when she uses the -agonist inhaler to decrease the
late-phase inflammatory reaction of asthma.
d. Asthma attacks can be prevented if she uses both the albuterol and the salmeterol
as prescribed and not just when symptoms develop.
ANS: B
Salmeterol is prescribed to reduce airway inflammation. It takes several weeks for maximal
effect and is not used to treat acute asthma symptoms.
PTS: 1
DIF: Cognitive Level: Application
REF: page 720, Table 31-7
OBJ: 1
TOP: Nursing Process: Implementation MSC: CRNE: CH-44
9. During assessment of a patient with asthma, the nurse notes wheezing and dyspnea,
recognizing that these symptoms are related to which of the following pathophysiological
features?
a. Laryngospasm
b. Pulmonary edema
c. Airway narrowing
d. Overdistension of the alveoli
ANS: C
The symptoms of asthma are caused by inflammation and spasm of the bronchioles, leading
to airway narrowing.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 714
MSC: CRNE: CH-8
10. A patient with an acute attack of asthma comes to the emergency department, where blood
is drawn for ABGs. The nurse determines the patient is in the early phase of the attack,
based on which of the following ABG results?
a. pH 7.0, PaCO2 50 mm Hg, and PaO2 74 mm Hg
b. pH 7.4, PaCO2 32 mm Hg, and PaO2 70 mm Hg
c. pH 7.36, PaCO2 40 mm Hg, and PaO2 80 mm Hg
d. pH 7.32, PaCO2 58 mm Hg, and PaO2 60 mm Hg
ANS: B
The initial response to hypoxemia caused by airway narrowing in a patient having an acute
asthma attack is an increase in respiratory rate, which causes a drop in PaCO2.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 715
MSC: CRNE: CH-6
11. While teaching a patient with asthma the appropriate use of a peak flow meter, the nurse
instructs the patient to implement which of the following actions?
a. Take and record peak flow readings when having asthma symptoms or an attack.
b. Increase the doses of long-term control medications if the peak flow numbers
decrease.
c. Use the flow meter each morning after taking medications to evaluate the
effectiveness of the medications.
d. Empty the lungs, and then inhale as rapidly as possible through the mouthpiece to
measure how fast air can be inhaled.
ANS: A
It is recommended that patients check peak flows when asthma symptoms or attacks occur
to compare the peak flow with the baseline.
PTS: 1
DIF: Cognitive Level: Application
REF: page 732, Table 31-13
OBJ: 2
TOP: Nursing Process: Implementation MSC: CRNE: CH-12
12. A 32-year-old patient is seen in the clinic for dyspnea associated with the diagnosis of
emphysema. The patient denies any history of smoking. The nurse will anticipate teaching
the patient about which of the following?
a.
1-Antitrypsin testing
b. Use of the nicotine patch
c. Continuous pulse oximetry
d. Effects of leukotriene modifiers
ANS: A
When emphysema occurs in young patients, especially without a smoking history, a
congenital deficiency in 1-antitrypsin should be suspected.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 733
MSC: CRNE: CH-8
13. A patient with chronic obstructive pulmonary disease (COPD) asks the nurse how his
smoking caused his lung disease. The nurse explains that long-term exposure to tobacco
smoke leads to which of the following?
a. Weakening of the smooth muscle lining the airways
b. Decrease in the area available for oxygen absorption
c. A reduction in the number of red blood cells available for oxygen delivery
d. Decreased production of protective respiratory secretions
ANS: B
Carbon monoxide is a component of tobacco smoke. Carbon monoxide has a high affinity
for hemoglobin and combines with it more readily than does oxygen, thereby reducing the
smoker’s oxygen-carrying capacity. Smokers inhale a lower percentage of oxygen than
normal; as a result, less oxygen is available at the alveolar level.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 733
MSC: CRNE: CH-8
14. The nurse knows that the interventions carried out to promote airway clearance in the
patient with COPD are successful based on which of the following findings?
a. The patient has no dyspnea.
b. The patient’s mental status is improved.
c. The patient has effective and productive coughing.
d. The PaO2 is within the normal range for the patient.
ANS: C
The goal for the nursing diagnosis of ineffective airway clearance is to maintain a clear
airway by coughing effectively.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 748, Nursing Care Plan 31-2 OBJ: 3
TOP: Nursing Process: Evaluation
MSC: CRNE: CH-25
15. A patient with an acute exacerbation of COPD has the following ABG analysis: pH 7.32,
PaO2 58 mm Hg, PaCO2 55 mm Hg, and SaO2 86%. What does the nurse recognize these
values as evidence of?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Normal acid–base balance with hypoxemia
d. Normal acid–base balance with hypercapnia
ANS: A
The elevated PaCO2 and low pH indicate respiratory acidosis. The patient is hypoxemic and
hypercapnic, but the pH indicates acidosis, not a normal acid–base balance.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 715
MSC: CRNE: CH-6
16. The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body
requirements for a patient with COPD. What is an appropriate intervention for this problem?
a. Order fruits and fruit juices to be offered between meals.
b. Order a high-calorie, high-protein diet with six small meals a day.
c. Teach the patient to use frozen meals that can be microwaved at home.
d. Provide a high-calorie, high-carbohydrate, nonirritating, frequent-feeding diet.
ANS: B
Eating small amounts more frequently (as occurs with snacking) will increase caloric intake
by decreasing the fatigue and feelings of fullness associated with large meals.
PTS: 1
DIF: Cognitive Level: Application
REF: page 749, Nursing Care Plan 31-2 OBJ: 5
TOP: Nursing Process: Implementation MSC: CRNE: CH-35
17. A patient is seen in the clinic with COPD. Which information given by the patient would
help most in confirming a diagnosis of chronic bronchitis?
a. The patient tells the nurse about a family history of bronchitis.
b. The patient denies having any respiratory problems until the last 6 months.
c. The patient’s history indicates a 40-pack-year cigarette history.
d. The patient complains about having a productive cough all winter for the past 2
years.
ANS: D
A diagnosis of chronic bronchitis is based on a history of having a productive cough for at
least 3 months for at least 2 consecutive years.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 732
MSC: CRNE: CH-8
18. The nurse teaches a patient with COPD how to perform pursed-lip breathing, explaining that
this technique will assist respiration by which of the following methods?
a. Loosening secretions so that they may be coughed up more easily
b. Promoting maximal inhalation for better oxygenation of the lungs
c. Preventing bronchial collapse and air trapping in the lungs during expiration
d. Slowing the respiratory rate and giving the patient control of respiratory patterns
ANS: C
Pursed-lip breathing increases the airway pressure during the expiratory phase and prevents
collapse of the airways, allowing for more complete exhalation.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 747
MSC: CRNE: CH-32
19. The nurse makes a diagnosis of impaired gas exchange for a patient with COPD in acute
respiratory distress based on which of the following assessment findings?
a. An SpO2 of 86%
b. Dyspnea and a respiratory rate of 32 breaths/min
c. Use of the accessory muscles of respiration
d. The presence of crackles and coarse rales in the lungs
ANS: A
The best data to support the diagnosis of impaired gas exchange are abnormalities in the
ABGs or pulse oximetry.
PTS: 1
DIF: Cognitive Level: Application
REF: page 748, Table 31-21
OBJ: 5
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
20. When reading the chart for a patient with COPD, the nurse notes that the patient has cor
pulmonale. The nurse will monitor which of the following to assess for cor pulmonale?
a. Elevated temperature
b. Complaints of chest pain
c. Jugular vein distension
d. Clubbing of the fingers
ANS: C
Cor pulmonale causes clinical manifestations of right ventricular failure, such as jugular
vein distension.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 737
MSC: CRNE: CH-8
21. What is the best nursing action when a patient with COPD is receiving oxygen?
a. Avoid administration of oxygen at a rate of more than 2 L/min.
b. Minimize oxygen use to avoid oxygen dependency.
c. Administer oxygen according to the patient’s level of dyspnea.
d. Maintain the pulse oximetry level at 90% or greater.
ANS: D
The best way to determine the appropriate oxygen flow rate is by monitoring the patient’s
oxygenation either by ABGs or pulse oximetry. An oxygen saturation of 90% indicates an
adequate blood oxygen level without the danger of suppressing the respiratory drive.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 719
MSC: CRNE: CH-25
22. A patient has been receiving oxygen per nasal cannula during her hospitalization for
emphysema. She asks the nurse whether she will have to use oxygen at home. What should
the nurse tell the patient about long-term home oxygen therapy?
a. It can improve the patient’s prognosis and quality of life.
b. It is contraindicated in patients with COPD to prevent oxygen dependency.
c. It is used only for patients who have severe end-stage respiratory disease.
d. It should never be used at night because the patient cannot monitor its effect.
ANS: A
Research supports the use of home oxygen to improve quality of life and prognosis.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 744
MSC: CRNE: CH-12
23. A patient is receiving 35% oxygen via a Venturi mask. To ensure the correct amount of
oxygen delivery, what is it most important for the nurse to do?
a. Keep the air entrainment ports clean and unobstructed.
b. Apply an adaptor to increase humidification of the oxygen.
c. Drain moisture condensation from the oxygen tubing every hour.
d. Keep the flow rate high enough to keep the bag from collapsing during inspiration.
ANS: A
The air entrainment ports regulate the oxygen percentage delivered to the patient, so they
must be unobstructed.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 741, Table 31-17
OBJ: 6
TOP: Nursing Process: Implementation MSC: CRNE: CH-32
24. What grade of dyspnea would the nurse document when a patient with COPD walks slower
than his peers of the same age and needs to stop for breath when walking at his own pace on
a flat surface?
a. Grade 1
b. Grade 2
c. Grade 3
d. Grade 4
ANS: C
A patient with grade 3 dyspnea walks slower than people of the same age on the level or
stops for breath while walking at his or her own pace on the level.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 738, Figure 31-11
OBJ: 1
TOP: Nursing Process: Implementation MSC: CRNE: CH-15
25. A 70-year-old patient is recovering from an acute episode of COPD. In planning with the
patient to increase his activity tolerance at home, which of the following activities does the
nurse understand is an appropriate exercise goal for the patient?
a. Increase his activity any amount over his current level.
b. Walk for 20 minutes a day with his pulse rate less than 150 beats/min.
c. Limit his exercise to activities of daily living to conserve his energy.
d. Swim for 10 minutes a day, gradually increasing to 30 minutes a day.
ANS: B
The goal for exercise programs for patients with COPD is to increase exercise time
gradually to a total of 20 minutes daily, with the pulse rate not to exceed 150 beats/min.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 750-752
MSC: CRNE: CH-40
26. A patient with severe COPD tells the nurse he wishes he would die because he is so disabled
with his disease that he just cannot do anything for himself. Based on this information, the
nurse identifies which of the following nursing diagnoses?
a.
b.
c.
d.
Hopelessness related to long-term stress
Anticipatory grieving related to expectation of death
Ineffective coping related to unknown outcome of illness
Depression related to physical and psychological dependence
ANS: D
The patient’s statement about not being able to do anything for himself supports this
diagnosis. Although hopelessness, anticipatory grieving, and ineffective coping may also be
appropriate diagnoses for patients with COPD, the patient does not mention long-term
stress, death, or an unknown outcome as being concerns.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
REF: page 749
MSC: [n/a]
27. A patient with COPD is admitted to the hospital. How can the nurse best position the patient
to improve gas exchange?
a. Sitting up at the bedside in a chair and leaning slightly forward
b. Resting in bed with the head elevated to 45 to 60 degrees
c. In the Trendelenburg’s position, with several pillows behind the head
d. Resting in bed in a high-Fowler’s position with the knees flexed
ANS: A
Patients with COPD improve the mechanics of breathing by sitting up in the “tripod”
position. Resting in bed with the head elevated would be an alternative position if the patient
was confined to bed, but sitting in a chair allows better ventilation.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 752
MSC: CRNE: CH-39
28. When evaluating a patient’s oral intake, the nurse knows that which fluid intake would be
considered adequate for the patient with COPD?
a. 1200 mL
b. 2000 mL
c. 2500 mL
d. 3000 mL
ANS: D
Collaborative care for the patient with COPD includes hydration of 3 L/day.
PTS: 1
DIF: Cognitive Level: Application
REF: page 739, Table 31-16
OBJ: 2
TOP: Nursing Process: Assessment
MSC: CRNE: CH-34
29. The nurse has completed teaching a patient about MDI use. Which statement by the patient
indicates to the nurse that further patient teaching is needed?
a. “I will shake the MDI to check for fullness each time before using.”
b. “I will take a slow, deep breath in after pushing down on the MDI.”
c. “I will check the MDI counter.”
d. “I will attach a spacer to the MDI to make it easier for me to use.”
ANS: A
Shaking the container is no longer recommended as a means of determining whether the
medication needs replacement because the patient may be hearing only the propellant move
in the canister when the MDI is nearly empty.
PTS: 1
DIF: Cognitive Level: Application
REF: page 726, Table 31-9
OBJ: 2
TOP: Nursing Process: Implementation MSC: CRNE: NCP-14
30. To promote healthy coping in the patient with COPD, what should the nurse do?
a. Assist the patient to identify strengths and ignore limitations.
b. Teach the patient relaxation techniques and other alternative therapies.
c. Encourage family members to include the patient in family and social activities.
d. Refer the patient to a support group at the local chapter of the Lung Association.
ANS: B
Relaxation techniques may provide benefit in terms of relief of dyspnea for some patients,
but the evidence for this is unclear. Relaxation techniques include progressive muscular
relaxation; positive thinking and visualization; and use of music, yoga, massage, and
humour.
PTS: 1
DIF: Cognitive Level: Application
REF: page 739, Table 31-16
OBJ: 5
TOP: Nursing Process: Implementation MSC: CRNE: CH-42
31. In planning care for the patient with cystic fibrosis (CF), the nurse understands that which of
the following interventions is the most important therapeutic approach to promote
pulmonary function in the patient?
a. Regular administration of bronchodilators
b. Administration of continuous low-flow oxygen
c. Maintenance of prophylactic doses of antibiotics
d. Chest physiotherapy every 4 hours to mobilize secretions
ANS: D
Routine scheduling of airway clearance techniques is an essential intervention for patients
with CF.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 755
MSC: CRNE: CH-32
32. When teaching a patient about the various methods of oxygen administration, the nurse tells
the patient that, with high flow rates, pain may develop in the frontal sinuses as a result of
which of the following methods?
a. Simple face mask
b. Nasal cannula
c. Partial rebreathing mask
d. Transtracheal catheter
ANS: B
When using nasal prongs, high-flow rates often cause dry nasal membranes and pain in the
frontal sinuses.
PTS: 1
DIF: Cognitive Level: Application
REF: page 741, Table 31-17
OBJ: 6
TOP: Nursing Process: Implementation MSC: CRNE: CH-32
33. A 19-year-old male with CF and his wife are considering having a child. In counselling the
patient and his wife, the nurse determines their knowledge of the situation by asking them
for which following information?
a. Whether they have considered that the patient is probably sterile
b. Whether they have thought about the patient’s ability to care for a child
c. Whether they have considered adoption as a solution to their desire to have a
family
d. Whether they know that any children produced by them will have CF
ANS: A
Most men with CF are sterile.
PTS: 1
DIF: Cognitive Level: Application
REF: page 757, Table 31-23
OBJ: 7
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
34. When caring for a patient with CF, the nurse recognizes that the manifestations of the
disease are caused by which of the following pathophysiological processes?
a. Inflammation and fibrosis of lung tissue
b. Failure of the bronchial goblet cells to produce mucus
c. Altered function of exocrine glands, with abnormally thick, viscous secretions
d. Thickening and fibrosis of the pleural linings of the lungs, causing thoracic wall
changes
ANS: C
CF is characterized by abnormal secretions of exocrine glands, mainly of the lungs,
pancreas, and sweat glands.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 754
MSC: CRNE: CH-8
35. All of the following orders are received for a patient having an acute asthma attack. Which
one will the nurse administer first?
a. Intravenous methylprednisolone (Solu-Medrol) 60 mg
b. Triamcinolone (Azmacort) two puffs per MDI
c. Salmeterol 50 mcg per dry-powder inhaler (DPI)
d. Albuterol (Ventolin) 2.5 mg per nebulizer
ANS: D
Albuterol (Ventolin) is a rapidly acting bronchodilator and is the first-line medication to
reverse airway narrowing in acute asthma attacks. The other medications work more slowly.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 720, Table 31-7
OBJ: 7
TOP: Nursing Process: Implementation MSC: CRNE: CH-49
36. Which following statement by the patient with COPD indicates that the nurse’s teaching
about nutrition has been effective?
a. “I will drink a lot of fluids with my meals.”
b. “I will have ice cream as a snack every day.”
c. “I should exercise for 15 minutes before meals.”
d. “I should avoid too much meat or dairy products.”
ANS: B
High-calorie foods such as ice cream are an appropriate snack for patients with COPD.
Fluid intake of 3 L/day is recommended, but fluids should be taken between meals rather
than with meals to improve oral intake of solid foods.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Evaluation
REF: page 747
MSC: CRNE: CH-35
37. When teaching the patient with COPD about exercise, which information should the nurse
include?
a. “Stop exercising if you start to feel short of breath.”
b. “Use the bronchodilator before you start to exercise.”
c. “Breathe in and out through the mouth while you exercise.”
d. “Upper body exercise should be avoided to prevent dyspnea.”
ANS: B
Use of a bronchodilator before exercise improves airflow for some patients and is
recommended.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 752
MSC: CRNE: HW-13
38. When teaching a patient about continuous home oxygen use, the nurse tells the patient that
evaporation of the oxygen accelerates during which season, and they should take extra care
to ensure that they do not run out of oxygen?
a. Spring
b. Summer
c. Fall
d. Winter
ANS: B
During the summer, with liquid oxygen, evaporation is accelerated and may decrease
reservoir duration to less than 1 week.
PTS: 1
DIF: Cognitive Level: Application
REF: page 745, Table 31-18
OBJ: 6
TOP: Nursing Process: Implementation MSC: CRNE: HW-11
39. Which information given by an asthmatic patient during the admission assessment will be of
most concern to the nurse?
a. The patient says that the asthma symptoms are worse every spring.
b. The patient’s only asthma medications are albuterol (Ventolin) and salmeterol.
c. The patient uses hydrocortisone (Solu-Cortef) before any aerobic exercise.
d. The patient’s heart rate increases after using the albuterol (Ventolin) inhaler.
ANS: B
Long-acting 2-adrenergic agonists should be used only in patients who are also using
another medication for long-term control (typically an inhaled corticosteroid). Salmeterol
should not be used as the first-line therapy for long-term control.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 720
MSC: CRNE: CH-44
40. When taking an admission history of a patient with COPD who has new-onset wheezing and
shortness of breath, the nurse will be most concerned about which information?
a. The patient has a history of pneumonia 2 years ago.
b. The patient takes propranolol (Inderal) for hypertension.
c. The patient uses acetaminophen (Tylenol) for headaches.
d. The patient has chronic inflammatory bowel disease.
ANS: B
-Adrenergic blockers such as propranolol can cause bronchospasm in some patients.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 738
MSC: CRNE: CH-8
41. A patient who is experiencing an acute asthma attack is admitted to the emergency
department. What is the priority nursing action?
a. Determine when the dyspnea started.
b. Obtain the forced expiratory flow rate.
c. Listen to the patient’s breath sounds.
d. Ask about inhaled corticosteroid use.
ANS: C
Assessment of the patient’s breath sounds will help determine how effectively the patient is
ventilating and whether rapid intubation may be necessary.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 715
MSC: CRNE: CH-63
42. After teaching the patient with asthma about home care, the nurse will evaluate that the
teaching has been successful if the patient states which of the following?
a. “I will use my corticosteroid inhaler as soon as I start to get short of breath.”
b. “I will turn the home oxygen level up only after checking with the doctor first.”
c. “My medications are working if I wake up short of breath only once during the
night.”
d. “No changes in my medications are needed if my peak flow is at 80% of normal.”
ANS: D
Peak flows of 80% or greater indicate that the asthma is well controlled.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 730
MSC: CRNE: CH-48
Chapter 32: Nursing Assessment: Hematological System
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. Which of the following cells function to provide protection from parasitic infections?
a. Monocytes
b. Basophils
c. Eosinophils
d. Neutrophils
ANS: C
Eosinophils function in the allergic response, phagocytosis, and protection from parasitic
infections.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 767, Table 32-2
MSC: CRNE: CH-8
2. While obtaining a health history from a patient with numerous petechiae on the skin, the nurse
asks the patient specifically about the patient’s use of which of the following drugs?
a. Antiseizure medications
b. Oral contraceptives
c. Aspirin compounds
d. Antihypertensive agents
ANS: C
Salicylates interfere with platelet function and can lead to petechiae and ecchymoses.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 773, Table 32-6
MSC: CRNE: CH-44
3. Which one of the following hematological findings would the nurse question in a 78-year-old
patient?
a. White blood cell (WBC) count 3500 cells/microlitre
b. Hematocrit 37%
c. Platelets 450,000 cells/microlitre
d. Hemoglobin 7.3 mmol/L (11.8 g/dL)
ANS: A
The total WBC count is not usually affected by aging, and the low WBC count here would
indicate that the patient’s immune function may be compromised.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 771
MSC: CRNE: CH-6
4. The physician performs a bone marrow aspiration from the posterior iliac crest on a patient
with pancytopenia. Following the procedure, what should the nurse do?
a. Apply a topical antimicrobial agent to the site.
b. Administer an analgesic to control pain at the site.
c. Apply pressure over the site for 5 to 10 minutes.
d. Position the patient supine with a small pillow at the aspiration site.
ANS: C
Because the patient has pancytopenia and is at increased risk for bleeding, pressure should be
applied for at least 5 to 10 minutes at the site of the aspiration.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 783
MSC: CRNE: CH-8
5. During physical assessment of a patient, the nurse suspects a chronic, severe iron-deficiency
anemia on finding which of the following?
a. Yellowed sclera
b. Shiny, smooth tongue
c. Gum bleeding and tenderness
d. Loss of position and vibratory sensation in the extremities
ANS: B
Loss of the papillae of the tongue occurs with chronic iron deficiency.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 777, Table 32-7
MSC: CRNE: CH-6
6. A patient is found to have leukopenia, anemia, neutropenia, and thrombocytopenia. Which
drug classification is known to exhibit these hematological alterations?
a. Isoniazid
b. Aminoglycosides
c. H2-receptor blockers
d. Trimethoprim–sulfamethoxazole (Septra)
ANS: D
Hematological alterations with the use of trimethoprim–sulfamethoxazole include
leukopenia, anemia, neutropenia, and thrombocytopenia.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 773, Table 32-6
MSC: CRNE: CH-44
7. The nurse reviews the results of coagulation testing for a patient with a bleeding disorder.
Which of the following diagnostic tests is most valuable in evaluating the intrinsic coagulation
process?
a. Bleeding time
b. Prothrombin time
c. Fibrin split products
d. Activated partial thromboplastin time (aPTT)
ANS: D
aPTT testing is an assessment of intrinsic coagulation by measuring factors I, II, V, VIII, IX,
X, XI, and XII.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 779, Table 32-9
MSC: CRNE: CH-6
8. When evaluating the red blood cell (RBC) indices of a patient, what does the nurse know is
indicated by a low mean corpuscular volume (MCV)?
a.
b.
c.
d.
RBCs of small size
A decrease in RBCs
Decreased saturation of RBCs with hemoglobin
Decreased weight of the amount of hemoglobin or RBCs
ANS: A
The MCV is low when the RBCs are smaller than normal.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 779, Table 32-8
MSC: CRNE: CH-6
9. While examining the lymph nodes during physical assessment, about which of the following
findings would the nurse be most concerned?
a. Firm inguinal nodes in a patient with an infected foot
b. Inability to palpate any superficial lymph nodes
c. 1-cm mobile and nontender axillary node
d. 2-cm nonpainful supraclavicular node
ANS: D
Enlarged and nontender nodes are most suggestive of malignancy, such as lymphoma.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 775
MSC: CRNE: CH-8
10. Which of the following is a normal age-related change in hematological studies?
a. MCV slightly decreased
b. Hemoglobin slightly increased in men
c. Ferritin level increased
d. Erythrocyte sedimentation rate (ESR) decreased
ANS: C
Ferritin level is increased as a result of normal age-related changes. MCV is slightly
increased. Hemoglobin is slightly decreased in men. ESR is increased significantly.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 771, Table 32-4
MSC: CRNE: CH-8
11. How would the nurse document a physical assessment finding of a small group of conditions
characterized by ecchymosis on the skin and mucous membranes?
a. Excoriation
b. Angioma
c. Purpura
d. Spider nevus
ANS: C
A physical assessment finding of a small group of conditions characterized by ecchymosis or
other small hemorrhages in skin and mucous membranes is purpura.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 777, Table 32-7
MSC: CRNE: CH-15
12. The history and physical examination for a newly admitted patient states that the complete
blood count shows a “shift to the left.” What is the priority nursing assessment?
a. Elevated temperature
b. Low oxygen saturation
c. Pallor and weakness
d. Cool extremities
ANS: A
The term shift to the left indicates that the number of immature polymorphonuclear
neutrophils, or bands, is elevated and is a sign of severe infection, including an elevated
temperature.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 776
MSC: CRNE: CH-6
13. Approximately what percentage of the composition of blood is plasma?
a. 30%
b. 45%
c. 55%
d. 75%
ANS: C
Approximately 55% of blood is plasma. Blood cells compose about 45% of blood.
PTS: 1
DIF: Cognitive Level: Knowledge
REF: page 765|page 767, Figure 32-2
OBJ: 1
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
14. Which one of the following cells is a WBC?
a. Myeloblast
b. Band cell
c. Basophil
d. Megakaryocyte
ANS: C
WBCs include basophils, eosinophils, neutrophils, monocytes, and lymphocytes.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: pages 767-768, Figure 32-2
MSC: CRNE: CH-8
Chapter 33: Nursing Management: Hematological Problems
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A patient with a history of iron-deficiency anemia who has not taken iron supplements for
several years is experiencing increased fatigue and dizziness. What would the nurse expect the
patient’s laboratory findings to include?
a. Hematocrit 0.38 (38%)
b. Red blood cell (RBC) count 4,500,000/µL
c. Hemoglobin (Hb) 86 g/L
d. Normal RBC indices
ANS: C
The patient’s clinical manifestations indicate moderate anemia, which is consistent with an Hb
of 60 to 100 g/L.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 786
MSC: CRNE: CH-6
2. When the nurse discusses foods high in iron with a patient who has iron-deficiency anemia,
the patient tells the nurse that she prepares low-cholesterol foods for her family and probably
does not eat enough meat to meet her iron requirements. It is an appropriate goal for the
patient to increase dietary intake of which of the following?
a. Eggs and fish
b. Nuts and cornmeal
c. Milk and milk products
d. Legumes and dried fruit
ANS: D
Legumes and dried fruits are high in iron and low in fat and cholesterol.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 790, Table 33-5
MSC: CRNE: CH-35
3. Which one of the following groups of people is at an increased risk for developing iron-
deficiency anemia?
a. Postmenopausal women
b. Middle-class people
c. Pregnant women
d. School-aged males
ANS: C
Those at risk for the development of iron-deficiency anemia are premenopausal and pregnant
women, people from low socioeconomic backgrounds, older adults, and individuals
experiencing blood loss.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 790
MSC: CRNE: CH-8
4. A 52-year-old patient has pernicious anemia with long-standing weakness and paraesthesia of
the feet and hands. The nurse determines that expected outcomes related to knowledge of the
therapeutic regimen have been met when the patient states which of the following?
a. “I will need to have cobalamin (B12) injections regularly for the rest of my life.”
b. “I will increase sources of cobalamin (B12), such as muscle meats and liver, in my
diet.”
c. “The feeling in my hands and feet will return when my hemoglobin level returns to
normal.”
d. “I should plan for only part-time employment because of the chronic fatigue that
pernicious anemia causes.”
ANS: A
Pernicious anemia prevents the absorption of vitamin B12, and the patient requires injections
or intranasal administration of cobalamin.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 793
MSC: CRNE: CH-8
5. A patient with chronic lymphocytic leukemia is hospitalized for treatment of severe hemolytic
anemia. What is an appropriate nursing intervention for the patient?
a. Provide a diet high in vitamin K and folic acid.
b. Plan care to alternate periods of rest and activity.
c. Isolate the patient from visitors and other patients.
d. Encourage increased intake of fluid and fibre in the diet.
ANS: B
Nursing care for patients with anemia should alternate periods of rest and activity to maintain
patient mobility without causing undue fatigue.
PTS: 1
DIF: Cognitive Level: Application
REF: page 789, Nursing Care Plan 33-1 OBJ: 4
TOP: Nursing Process: Implementation
MSC: CRNE: CH-13
6. After teaching the patient about taking oral iron preparations for a moderate iron-deficiency
anemia, which of the following patient statements indicates to the nurse that additional
instruction is needed?
a. “I will contact my doctor if my stools start to turn black.”
b. “I will call the doctor if the tablets cause a lot of stomach upset.”
c. “I will increase my fluid intake if the iron tablets make me constipated.”
d. “I should take the iron tablets with orange juice about an hour before meals.”
ANS: A
It is normal for the stools to appear black when a patient is taking iron, and the patient should
not call the doctor about this.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 792
MSC: CRNE: NCP-14
7. A 42-year-old patient is admitted to the hospital with idiopathic aplastic anemia. What is an
appropriate collaborative problem for the nurse to identify for the patient?
a. Potential complication: seizures
b. Potential complication: hemorrhage
c. Potential complication: neurogenic shock
d. Potential complication: pulmonary edema
ANS: B
Because the patient with aplastic anemia has pancytopenia, the patient is at risk for bleeding
and infection.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 795
MSC: CRNE: CH-8
8. A patient with sickle cell anemia is admitted to the hospital in crisis with severe abdominal
pain. While caring for the patient, what is it most important for the nurse to do?
a. Limit the patient’s intake of oral fluids.
b. Evaluate the effectiveness of narcotic analgesics.
c. Encourage the patient to ambulate as much as tolerated.
d. Teach the patient about high-protein, high-calorie foods.
ANS: B
Pain is the most common clinical manifestation of a crisis and usually requires large doses of
continuous opioids for control.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 799
MSC: CRNE: CH-52
9. A 21-year-old patient is having a sickle cell crisis for the first time in many years. He asks the
nurse why the sickling causes such pain. The nurse should explain that the pain of sickling is
caused by which of the following?
a. Spasms of the blood cells as they change shape
b. Deposition of sickled red cells in the bone marrow
c. Tissue hypoxia caused by small blood vessel occlusion
d. Bacterial or viral infections of organs that caused the sickling
ANS: C
The pain associated with a sickle cell crisis is caused by ischemia, as the sickled cells occlude
small blood vessels and capillaries.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 798
MSC: CRNE: CH-8
10. During discharge teaching for the patient with neutropenia, which of the following issues
should the nurse include?
a. Caffeine and alcohol intake
b. Excessive dietary iron intake
c. Limiting fluids to 2 L per day
d. Exposure to crowds
ANS: D
Patients with neutropenia should be instructed to avoid crowds and people who have colds,
flu, or infections. If they are in a public area, they should be taught to wear a mask.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 818, Table 33-25
MSC: CRNE: HW-8
11. A patient who has experienced an acute blood loss exhibits a normal supine blood pressure
and pulse at rest but complains of postural hypotension and has a pulse of 110 beats/min when
exercising. The nurse knows that these signs and symptoms are manifestations of what
percentage of blood loss?
a. 10%
b. 20%
c. 30%
d. 40%
ANS: C
A patient who has experienced an acute blood loss and exhibits a normal supine blood
pressure and pulse at rest but complains of postural hypotension and has a pulse of 110
beats/min when exercising has lost approximately 30% of their total blood volume.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 796, Table 33-11
MSC: CRNE: CH-6
12. During the admission assessment of a patient who has an Hb of 4.7 mmol/L (7.6 g/dL) and
jaundice of the sclera, what laboratory results would the nurse assess?
a. Stool occult blood
b. Bilirubin level
c. Schilling test
d. Gastric analysis testing
ANS: B
Jaundice is caused by the elevation of bilirubin level associated with RBC hemolysis. The
presence of jaundice suggests a hemolytic anemia, rather than gastrointestinal bleeding or
cobalamin deficiency, as the cause of the anemia.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 797
MSC: CRNE: CH-6
13. The physician orders transfusion with packed RBCs for a patient who has severe anemia
resulting from a bleeding peptic ulcer. What is the most important nursing action to prevent a
transfusion reaction when administering the blood?
a. Verify and document patient identification.
b. Keep the blood chilled during administration.
c. Administer the blood at a rate of no more than 2 mL/min.
d. Stay with the patient during the first 15 minutes of the transfusion.
ANS: A
Improper identification is responsible for 90% of hemolytic transfusion reactions.
PTS: 1
OBJ: 16
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 832
MSC: CRNE: CH-54
14. A patient receiving a transfusion of whole blood develops chills and fever, headache, and
anxiety 30 minutes after the transfusion is started. Which of the following does the nurse
implement after stopping the transfusion?
a. Send a urine specimen to the laboratory.
b. Administer acetaminophen (Tylenol).
c. Give diphenhydramine (Benadryl).
d. Draw blood for a new crossmatch.
ANS: B
The patient’s clinical manifestations are consistent with a febrile, nonhemolytic transfusion
reaction. The transfusion should be stopped and antipyretics administered for the fever as
ordered.
PTS: 1
OBJ: 16
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 834, Table 33-35
MSC: CRNE: CH-54
15. Fifteen minutes after a transfusion of packed RBCs is started, a patient develops tachycardia
and tachypnea, and complains of back pain and feeling warm. What is the nurse’s priority
action?
a. Discontinue transfusion, and infuse normal saline.
b. Administer oxygen therapy at a high flow rate.
c. Slow the transfusion rate, and reassess the patient in 15 minutes.
d. Stop the blood, and discard the used bag and tubing in a biohazard container.
ANS: A
The first action should be to disconnect the transfusion and infuse normal saline to keep the
line open and maintain the patient’s blood pressure. The other actions are also needed but are
not the highest priority.
PTS: 1
OBJ: 16
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 833
MSC: CRNE: CH-54
16. A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep-vein
thrombosis is diagnosed with heparin-induced thrombocytopenia and thrombosis syndrome
(HITTS). What does the nurse anticipate that the physician will order?
a. Use saline for flushing intravenous (IV) lines.
b. Give low–molecular weight (LMW) heparin.
c. Discontinue the warfarin.
d. Administer platelet transfusions.
ANS: A
All heparin is discontinued when the HITTS is diagnosed. The patient should be instructed
never to receive heparin or LMW heparin; therefore, saline will be ordered for flushing IV
lines.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 804
MSC: CRNE: CH-8
17. During treatment of the patient with an acute exacerbation of polycythemia vera, what is a
critical nursing intervention?
a. Administer oxygen.
b. Evaluate fluid balance.
c. Administer anticoagulants.
d. Administer parenteral iron.
ANS: B
Monitoring hydration status is important during an acute exacerbation because the patient is at
risk for fluid overload or underhydration.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 803
MSC: CRNE: CH-34
18. For which one of the following lab results would the nurse expect to see abnormal results in a
patient who has hemophilia?
a. Thrombin time
b. Platelet count
c. Prothrombin time
d. Partial thromboplastin time
ANS: D
Partial thromboplastin time is prolonged in patients with hemophilia because of a deficiency
in any intrinsic clotting system factor. Prothrombin time, thrombin time, and platelet count are
expected to be normal in a patient with hemophilia.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 811, Table 33-19
MSC: CRNE: CH-8
19. Of the following patients waiting to be admitted by the emergency department nurse, which
one requires the most rapid assessment and care by the nurse?
a. The patient with a history of sickle cell anemia who has had nausea and diarrhea
for 24 hours
b. The patient who has chemotherapy-induced neutropenia and a temperature of 38°C
c. The patient with thrombocytopenia who has oozing after having a tooth extracted
d. The patient with hemophilia A who has ankle swelling after twisting the ankle
ANS: C
A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly
developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 815
MSC: CRNE: CH-22
20. While a patient with severe acquired thrombocytopenia is receiving platelet transfusions, the
nurse recognizes that a platelet transfusion reaction may be present when the patient
experiences which of the following signs?
a. Flushing, itching, and urticaria
b. Sudden onset of chills and fever
c. Urticaria, wheezing, and hypotension
d. Tachycardia, tachypnea, and hemoglobinuria
ANS: B
Sudden onset of both chills and fever indicates a transfusion reaction.
PTS: 1
OBJ: 16
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 834, Table 33-35
MSC: CRNE: CH-54
21. The nurse identifies a nursing diagnosis of risk for injury related to medical interventions for
a patient with immune thrombocytopenic purpura. What is an appropriate nursing intervention
that addresses the etiology of this nursing diagnosis?
a. Use a soft-bristled toothbrush and cotton swabs for mouth care.
b. Limit the number of venipunctures by using an intermittent-infusion device.
c. Assess the patient during the platelet transfusion for symptoms of transfusion
reactions.
d. Assess the patient’s mucous membranes and skin each shift to detect the presence
of bleeding.
ANS: B
Limit the number of venipunctures; intramuscular or subcutaneous injections should be
avoided because of the risk for bleeding.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 808
MSC: CRNE: HW-24
22. When preparing a patient for a blood transfusion, the nurse will prepare the blood. Which IV
solution would the nurse prepare to administer in a Y-type tubing adjacent to the blood?
a. Dextrose 5%
b. Lactated Ringer’s
c. Normal saline
d. Dextrose 10%
ANS: C
When preparing a patient for a blood transfusion, the nurse will prepare the blood and attach
normal saline to Y-type tubing adjacent to the blood for administration.
PTS: 1
OBJ: 16
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 832
MSC: CRNE: CH-54
23. A patient with type A hemophilia has been admitted to the hospital with severe pain and
swelling in his right knee. To prevent joint deformity during the initial care of the patient,
what should the nurse do?
a. Immobilize the knee.
b. Elevate the right lower limb on pillows.
c. Perform passive range of motion to the knee.
d. Have the patient perform isometric exercises of the affected leg against a
footboard.
ANS: A
The initial action should be total rest of the knee to minimize bleeding.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 811
MSC: CRNE: CH-40
24. Laboratory studies related to coagulation are performed on a patient with a bleeding disorder.
The nurse explains to the patient that von Willebrand’s disease can be differentiated from
other types of hemophilia by evaluating which of the following laboratory results?
a. Bleeding time
b. Platelet count
c. Prothrombin time
d. Partial thromboplastin time
ANS: A
The bleeding time is affected by von Willebrand’s disease. Platelet count, prothrombin time,
and partial thromboplastin time are normal in von Willebrand’s disease.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 811, Table 33-19
MSC: CRNE: CH-6
25. When caring for a patient with hemophilia, the nurse teaches the patient to seek immediate
medical attention on experiencing which of the following signs?
a. Fever
b. A sore throat
c. Bleeding gums
d. Dark, tarry stools (melena)
ANS: D
Melena is a sign of gastrointestinal bleeding and requires further assessment.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 812
MSC: CRNE: CH-8
26. A patient’s family member asks the nurse what caused the patient to develop disseminated
intravascular coagulation (DIC). What does the nurse tell the family member about DIC?
a. It is caused by an abnormal activation of clotting.
b. It occurs when the immune system attacks platelets.
c. It is a complication of cancer chemotherapy.
d. It is caused when hemolytic processes destroy erythrocytes.
ANS: A
DIC is an abnormal response of the clotting cascade stimulated by a variety of diseases or
disorders.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 812
MSC: CRNE: CH-8
27. During treatment of the patient who has sepsis-induced DIC with moderate bleeding, on what
would the nurse expect the initial collaborative care will focus?
a. Administration of heparin to reduce intravascular clotting
b. Treatment of the infectious process with IV antibiotics
c. Infusion of whole blood to replace clotting factors and RBCs
d. Supportive management of symptoms until the DIC is resolved
ANS: B
Treatment of the acute sepsis is essential to resolving the DIC and will be the major focus of
collaborative care. Heparin administration is controversial in DIC, although it may be used if
the DIC does not resolve and clotting factors continue to decrease.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: pages 814-815
MSC: CRNE: CH-22
28. A patient with myelodysplastic syndrome has laboratory values that indicate total bone
marrow suppression. The nurse identifies a nursing diagnosis of risk for infection based on
which of the following findings?
a. Basophils 120 cells/mL
b. Monocytes 360 cells/mL
c. Neutrophils 4000 cells/mL
d. White blood cell (WBC) count 2.8  109 cells/L (2800 cells/microlitre)
ANS: D
The low WBC count indicates a risk for infection. The nurse should notify the physician and
expect an order to check the differential WBC count.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 819
MSC: CRNE: CH-6
29. What is the most appropriate nursing intervention to assess for the presence of infection in a
patient with neutropenia?
a. Monitor WBCs daily.
b. Monitor temperature every 4 hours.
c. Monitor the skin for temperature and diaphoresis.
d. Monitor the mouth and perianal area every shift for signs of redness and swelling.
ANS: B
The earliest sign of infection in a neutropenic patient is an elevation in temperature. Patients
with neutropenia (low neutrophil count) are susceptible to infection and may be febrile.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 817
MSC: CRNE: CH-13
30. A patient receiving chemotherapy for acute lymphocytic leukemia has pancytopenia, and
filgrastim (Neupogen) is prescribed. The nurse teaches the patient that the reason for the use
of the medication is which of the following?
a. Remission of the leukemia
b. Improvement in the number and function of neutrophils
c. Replacement of abnormal stem cells in the bone marrow with normal cells
d. Prevention of hemorrhage complications in patients with thrombocytopenia
ANS: B
Filgrastim increases the neutrophil count and function in neutropenic patients.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 818
MSC: CRNE: CH-44
31. A 64-year-old patient with newly diagnosed acute myelogenous leukemia (AML) is
undergoing induction therapy with chemotherapeutic agents. He tells the nurse that he is so
sick from the induction therapy that he wonders if it is worth it. What is the best response to
this patient?
a. “I know you feel really ill right now, but after this therapy, your disease will go
into a remission, and you will feel normal again.”
b. “Induction therapy is very aggressive and causes the most side effects, so when
this phase is completed, you won’t feel so ill.”
c. “Your type of leukemia has a survival rate of up to 10 years if aggressive therapy
is started, so the effects of treatment should be worth it to you.”
d. “I know that this phase is very difficult for you, but the treatment is necessary to
achieve control of your disease so that you will have some time to make choices
about your life.”
ANS: D
AML is very aggressive, and survival after diagnosis is short without treatment.
PTS: 1
OBJ: 11
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 820
MSC: CRNE: CH-8
32. A patient with chemotherapy-induced neutropenia is placed in a private room, and protective
isolation is instituted. The care plan the nurse develops with the patient is based on the
knowledge that which of the following sources of infection is the most common in patients
with neutropenia?
a. Normally nonpathogenic microorganisms of the patient’s own flora
b. Microorganisms that are not sensitive to broad-spectrum antibiotics
c. Microorganisms transmitted to the patient by the hands of health care providers
d. Microorganisms transmitted to the patient by health care providers with
transmissible infections
ANS: A
An important consideration in the care of a neutropenic patient is the determination of the best
means to protect the patient whose own defences against infection are compromised. To
accomplish this goal, the following principles must be kept in mind: (1) the patient’s normal
flora are the most common source of microbial colonization and infection; (2) transmission of
organisms from humans most commonly occurs by direct contact with the hands; (3) air, food,
water, and equipment provide additional opportunities for infection transmission; and (4)
health care providers with transmissible illnesses and other patients with infections can also be
sources of infection transmission under certain conditions.
PTS: 1
OBJ: CH-9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 818
MSC: CRNE: CH-8
33. A patient with neutropenia has a nursing diagnosis of risk for infection. What is the most
important nursing intervention in the prevention of transmission of harmful pathogens to the
patient?
a. Prohibiting the oral intake of fresh fruits and vegetables
b. Maintaining strict administration schedules of prophylactic antibiotics
c. Strict and frequent handwashing by all persons having contact with the patient
d. Creating a “sterile” environment for the patient with the use of laminar airflow
rooms
ANS: C
Infection control measures such as handwashing are necessary for the patient with
neutropenia.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 816, Table 33-24
MSC: CRNE: HW-2
34. A 45-year-old woman with chronic myelogenous leukemia is considering the possibility of
treatment with a bone marrow transplant from a human leukocyte antigen–matched sibling.
To assist the patient with treatment decisions, what is the best approach for the nurse to use?
a. Emphasize the positive outcomes of a bone marrow transplant.
b. Ensure that the patient understands the risks of treatment-related death or treatment
failure.
c. Explain that a cure is not possible with any other type of treatment except a bone
marrow transplant.
d. Encourage the patient to ask the physician about new, experimental treatments for
leukemia that do not involve total body irradiation.
ANS: B
Offering the patient an opportunity to ask questions or discuss concerns about hematopoietic
stem cell transplantation will encourage the patient to voice concerns about this treatment and
will also allow the nurse to assess whether the patient needs more information about the
procedure.
PTS: 1
OBJ: 12
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 823
MSC: CRNE: HW-26
35. During care of the patient with multiple myeloma, what is an important nursing intervention?
a. Limiting activity to prevent pathological fractures
b. Maintaining a fluid intake of 3 to 4 L/day to dilute calcium load
c. Assessing for changes in size and characteristics of lymph nodes
d. Administering narcotic analgesics continuously to control bone pain
ANS: B
A high fluid intake and urinary output help prevent the complications of kidney stones arising
from hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal
tubules.
PTS: 1
OBJ: 14
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 831
MSC: CRNE: CH-8
36. A patient with non-Hodgkin’s lymphoma develops a platelet count of 10,000 cells/microlitre
during chemotherapy. Based on this finding, what is an appropriate nursing intervention for
the patient?
a. Provide oral hygiene every 2 hours.
b. Check the temperature every 4 hours.
c. Check all stools for occult blood.
d. Encourage fluids to 3000 mL/day.
ANS: C
Because the patient is at risk for spontaneous bleeding, the nurse should check stools for
occult blood.
PTS: 1
DIF: Cognitive Level: Application
REF: page 808, Nursing Care Plan 33-2 OBJ: 13
TOP: Nursing Process: Implementation
MSC: CRNE: CH-13
37. A 26-year-old patient with stage II Hodgkin’s disease asks the nurse how long he probably
has to live. What is the best response to the patient?
a. “No one can predict when someone will die, so try to focus on the present.”
b. “It will depend on how your disease responds to chemotherapy, but most patients
do well.”
c. “If your initiation chemotherapy is effective, it is possible to have at least a 5-year
remission.”
d. “Most patients with your stage of Hodgkin’s disease are treated successfully.”
ANS: D
The survival rate is almost 90% in patients with the early stages of Hodgkin’s lymphoma.
PTS: 1
OBJ: 13
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 827
MSC: CRNE: CH-8
38. Which nutrient plays a role in helping mature RBCs in erythropoiesis?
a. Iron
b. Folic acid
c. Pyridoxine
d. Ascorbic acid
ANS: B
Folic acid’s role in erythropoiesis is to cause RBC maturation.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 790, Table 33-5
MSC: CRNE: CH-8
Chapter 34: Nursing Assessment: Cardiovascular System
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. While monitoring a patient’s cardiac activity, the nurse recognizes that stimulation of which
of the following is a normal physiological mechanism responsible for an increase in heart rate
(HR) and force of cardiac contractions?
a. The vagus nerve
b. Baroreceptors in the aortic arch and carotid sinus
c. -Adrenergic receptors in the vascular system
d. Chemoreceptors in the aortic arch and carotid body
ANS: D
Chemoreceptors located in the aortic arch and carotid body are capable of initiating changes in
HR and arterial pressure in response to decreased arterial O2 pressure, increased arterial
carbon dioxide pressure, and decreased plasma pH.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 847
MSC: CRNE: CH-8
2. While assessing a patient who has just arrived in the emergency department, the nurse notes a
pulse deficit. Which of the following does the nurse anticipate that the patient may require?
a. Hourly blood pressure (BP) checks
b. A coronary arteriogram
c. Electrocardiographic (ECG) monitoring
d. A two-dimensional echocardiogram
ANS: C
Pulse deficit is a difference between simultaneously obtained apical and radial pulses and
indicates that dysrhythmias might be detected with ECG monitoring.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 852, Table 34-3
MSC: CRNE: CH-8
3. A patient has a BP of 142/84 mm Hg. The nurse will calculate and document the patient’s
mean arterial pressure (MAP) as being which following amount?
a. 103 mm Hg
b. 113 mm Hg
c. 123 mm Hg
d. 131 mm Hg
ANS: A
MAP  Diastolic BP  1/3 Pulse pressure.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 847
MSC: CRNE: CH-15
4. The nurse is monitoring a patient with possible coronary artery disease who is undergoing
exercise (stress) testing on a treadmill. Which symptom has the most immediate implications
for the patient’s care during the exercise testing?
a. BP rising from 134/68 to 150/80 mm Hg
b. HR increasing from 80 to 96 beats/min
c. Patient complaining of feeling short of breath
d. ECG indicating the presence of coronary ischemia
ANS: D
ECG changes associated with coronary ischemia (such as T-wave inversions and ST-segment
depression) indicate that the myocardium is not getting adequate oxygen delivery and that the
exercise test should be terminated immediately.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 856, Table 34-5
MSC: CRNE: CH-30
5. During physical examination of a 56-year-old man, the nurse palpates the point of maximal
impulse (PMI) in the sixth intercostal space lateral to the midclavicular line. What is the most
appropriate interpretation of this finding?
a. The PMI is in the normal location.
b. The patient may have left ventricular hypertrophy.
c. The patient has age-related downward displacement of the heart.
d. The patient should be observed for signs of left atrial enlargement.
ANS: B
The PMI should be felt at the intersection of the fifth intercostal space and the midclavicular
line. A PMI located outside these landmarks indicates possible cardiac enlargement, such as
with left ventricular hypertrophy.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 852
MSC: CRNE: CH-8
6. To auscultate for extra heart sounds in the mitral area, with what part of the stethoscope will
the nurse listen?
a. The bell of the stethoscope with the patient in the left lateral position
b. The diaphragm of the stethoscope with the patient in a reclining position
c. The diaphragm of the stethoscope with the patient lying flat on the left side
d. The bell of the stethoscope with the patient sitting and leaning to the right side
ANS: A
Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the
stethoscope. Sounds associated with the mitral valve are accentuated by turning the patient to
the left side, which brings the heart closer to the chest wall.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 852
MSC: CRNE: CH-4
7. The standard orders on the cardiac unit state, “Notify the physician for MAP less than 70 mm
Hg.” For which patient would the nurse call the physician?
a. The patient with left ventricular failure who has a BP of 110/70 mm Hg
b. The patient with a myocardial infarction who has a BP of 114/50 mm Hg
c. The postoperative patient with a BP of 116/42 mm Hg
d. The newly admitted patient with a BP of 122/60 mm Hg
ANS: C
The MAP is calculated using the formula MAP = (Diastolic BP + 1/3 Pulse Pressure). The
MAP for the postoperative patient in C is 67 mm Hg. The MAP in the other three patients is
higher than 70 mm Hg.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 847
MSC: CRNE: CH-23
8. During physical examination of a 72-year-old patient, the nurse observes pulsation of the
abdominal aorta in the epigastric area just below the xiphoid process. How will the nurse
interpret this finding?
a. Normal assessment data in a thin person
b. Sclerosis and inelasticity of the aorta
c. A possible abdominal aortic aneurysm
d. Evidence of elevated systemic arterial pressure
ANS: A
Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin
individuals.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 852
MSC: CRNE: CH-6
9. A patient is scheduled for cardiac catheterization with coronary angiography. Before the test,
about which of the following should the nurse inform the patient?
a. A catheter will be inserted into a vein in the arm or leg and advanced to the heart.
b. ECG monitoring will be required for 24 hours following the test to detect any
dysrhythmias.
c. A feeling of warmth and a fluttering sensation may be experienced as the catheter
is advanced.
d. Complications of the test include breaking of the catheter, air or blood embolism,
and puncture of the ventricles.
ANS: C
A sensation of warmth or flushing is common when the iodine-based contrast material is
injected, which can produce anxiety unless it has been discussed with the patient.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 854, Table 34-5
MSC: CRNE: CH-30
10. Which of the following is a normal cardiac index (CI) assessment finding?
a. 2 L/min
b. 3 L/min/m2
c. 6 L/min
d. 8 L/min/m2
ANS: B
The normal range for a CI reading is 2.8 to 4.2 L/min/m2.
PTS: 1
DIF: Cognitive Level: Application
REF: page 845
OBJ: 5
TOP: Nursing Process: Implementation
MSC: CRNE: CH-6
11. What should the nurse teach the patient being evaluated for rhythm disturbances with a Holter
monitor to do?
a. Remove the electrodes to shower or bathe.
b. Exercise as much as possible while his monitor is in place.
c. Keep a diary of his activities as long as he wears the monitor.
d. Attach the recorder, and call the assigned number if an episode of irregular
heartbeats occurs.
ANS: C
The patient is instructed to keep a diary describing daily activities while Holter monitoring is
being accomplished to help correlate any rhythm disturbances with patient activities.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 860, Table 34-5
MSC: CRNE: CH-30
12. When auscultating over the patient’s abdominal aorta, the nurse hears a humming sound. How
will the nurse document this finding?
a. Bruit
b. Thrill
c. Heave
d. Arterial obstruction
ANS: A
A bruit is the sound created by turbulent blood flow in an artery.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 850
MSC: CRNE: CH-15
13. The physician orders serum troponin levels in a patient with a possible myocardial infarction.
What will the nurse explain to the patient about this test?
a. It is the most specific indicator for myocardial damage available.
b. It measures the amount of myoglobin released from damaged myocardial cells.
c. It can provide evidence of myocardial damage more quickly than can enzyme tests.
d. It is diagnostic for myocardial damage only when used in combination with
creatinine kinase-MB isoenzymes.
ANS: C
Cardiac troponins start to elevate 1 hour after myocardial injury and are specific to
myocardium.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 854, Table 34-5
MSC: CRNE: CH-30
14. Which of the following is a normal age-related change in the heart?
a. Increased elastin
b. Decreased collagen
c. Decreased cardiac output
d. Increased stroke volume
ANS: C
A normal age-related change in the heart is a decrease in cardiac output. Elastin and stroke
volume are decreased, and collagen is increased.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 848, Table 34-1
MSC: CRNE: CH-8
15. The nurse hears a murmur between the S1 and S2 heart sounds at the patient’s left fifth
intercostal space and midclavicular line. What is the best way to record this information?
a. “Systolic murmur heard at mitral area.”
b. “Diastolic murmur heard at aortic area.”
c. “Systolic murmur heard at Erb’s point.”
d. “Diastolic murmur heard at tricuspid area.”
ANS: A
The S1 sound is created by closure of the mitral and tricuspid valves and signifies the onset of
ventricular systole. S2 is caused by the closure of the aortic and pulmonic valves and signifies
the onset of diastole. A murmur occurring between these two sounds is a systolic murmur.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 848, Table 34-1
MSC: CRNE: CH-15
16. What should the nurse expect as a possible etiology in a patient who exhibits a positive
Homans sign?
a. Thyrotoxicosis
b. Thrombophlebitis
c. Incompetent valves
d. Intermittent claudication
ANS: B
The nurse should suspect thrombophlebitis in a patient who exhibits a positive Homans sign.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 851, Table 34-3
MSC: CRNE: CH-8
17. Upon auscultation, the nurse identifies an arterial bruit. What is a possible cause?
a. Cardiac dysrhythmias
b. Aneurysm
c. Pericarditis
d. Cardiac valve disorder
ANS: B
An arterial bruit is suggestive of wither an aneurysm or an arterial obstruction.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 852, Table 34-3
MSC: CRNE: CH-8
18. The registered nurse (RN) is observing a student nurse who is doing a physical assessment on
a patient. The RN will need to intervene immediately if the student does which of the
following?
a. Presses on the skin over the tibia for 10 seconds to check for edema
b. Palpates both carotid arteries simultaneously to compare pulse quality
c. Places the patient in the left lateral position to check for the PMI
d. Uses the palm of the hand to assess extremity skin temperature
ANS: B
The carotid pulses should never be palpated at the same time to avoid vagal stimulation,
dysrhythmias, and decreased cerebral blood flow. The other assessment techniques also need
to be corrected; however, they are not dangerous to the patient.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: pages 849-850
MSC: CRNE: PP-19
19. A patient with syncope is scheduled for Holter monitoring. When teaching the patient about
the purpose of the procedure, the nurse explains that Holter monitoring provides information
about which of the following?
a. Ventricular ejection fraction during usual daily activities
b. Cardiovascular response to high-intensity exercise
c. Changes in cardiac output when the patient is resting
d. HR and rhythm during normal patient activities
ANS: D
Holter monitoring is used to assess for possible changes in HR or rhythm over a 24- to 48hour period. The patient is usually instructed to continue with usual daily activities rather than
changing exercise or activity level.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 854, Table 34-5
MSC: CRNE: CH-30
20. A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis.
Which of these actions included in the standard TEE orders will the nurse need to accomplish
first?
a. Make the patient nothing by mouth (NPO) status.
b. Start a large-gauge IV line.
c. Administer O2 per mask.
d. Give lorazepam (Ativan) 1 mg IV.
ANS: A
The patient will need to be NPO status for 6 hours preceding the TEE, so the nurse should
place the patient on NPO status as soon as the order is received.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 857, Table 34-5
MSC: CRNE: CH-30
21. Which one of the following central venous pressure (CVP) readings would the nurse report to
the physician as being abnormal?
a. 3 mm Hg
b. 6 mm Hg
c. 9 mm Hg
d. 12 mm Hg
ANS: D
The normal CVP reading is 2 to 9 mm Hg.
PTS: 1
DIF: Cognitive Level: Application
REF: page 864
OBJ: 10
TOP: Nursing Process: Assessment
MSC: CRNE: CH-23
Chapter 35: Nursing Management: Hypertension
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A new patient is seen at an outpatient clinic for a routine health examination. During the
patient’s initial visit, which technique would the nurse use to assess the patient’s blood
pressure (BP)?
a. Have the patient sit with the arm supported at heart level, and measure the BP in
each arm first.
b. Average all the BP readings obtained in both arms to establish a baseline BP for
the patient.
c. Measure the first BP with the patient lying supine, and repeat the measurement in 5
minutes in the opposite arm.
d. Take additional measurements if there is a difference of more than 10 mm Hg
between the first and second BP readings.
ANS: A
To obtain the baseline BP, the patient’s arm should be at the level of the heart. The BP is
obtained in both arms; if there is a difference, the arm with the higher pressure should be used
to monitor BP.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 885, Table 35-13
MSC: CRNE: CH-4
2. The nurse assesses the risk factors for hypertension in a patient with high normal BP. Which
risk factor would the nurse identify from the health history and advise the patient to change, in
order to prevent hypertension?
a. Little or no regular exercise
b. No use of relaxation techniques
c. High dietary intake of simple sugars
d. Drinking wine with dinner once a week
ANS: A
The recommendations for preventing hypertension include exercising aerobically for 30
minutes most days of the week.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 873, Table 35-3
MSC: CRNE: HW-2
3. The nurse measures the BP of a 78-year-old patient and finds it to be 168/86 mm Hg in both
arms. What will the nurse include in the teaching plan for this patient?
a. Increased BP is a normal finding in older adults.
b. Prehypertension indicates the need for lifestyle changes.
c. It is important to address the increased BP.
d. A high probability of kidney and heart disease exists.
ANS: C
Although an increase in systolic BP (SBP) is a common finding in older adults, the
recommendations for treating elevated BP are unchanged. An SBP of >140 mm Hg is a more
important cardiovascular risk factor than diastolic BP (DBP) in individuals older than 50. The
diagnosis of prehypertension indicates a systolic BP between 120 and 139 mm Hg and a DBP
between 80 and 89 mm Hg.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 884, Table 35-11
MSC: CRNE: HW-2
4. Why should the nurse teach a patient who is taking labetalol (Normodyne) for treatment of
hypertension to change position slowly?
a. The medication blocks the vasoconstrictive and sodium-retaining properties
initiated by the presence of angiotensin.
b. The medication paralyzes the smooth muscle of blood vessels, and they cannot
constrict in response to sympathetic stimulation.
c. The medication blocks the normal sympathetic nervous system response to
position changes in vasoconstriction and increased heart rate.
d. The medication blocks the movement of calcium into the cardiac cells, and cardiac
output cannot increase in response to decreased BP.
ANS: C
Labetalol decreases sympathetic nervous system activity by blocking both - and adrenergic receptors, leading to vasodilation and a decrease in heart rate, which lower BP.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 881, Table 35-8
MSC: CRNE: CH-44
5. A patient with hypertension asks the nurse why lifestyle changes are needed when the patient
has no symptoms from the high BP. Which response is most likely to improve patient’s
compliance with therapy?
a. “High BP damages the blood vessels, leading to risk for heart attack, stroke, and
kidney failure.”
b. “High BP increases blood flow to the kidneys, leading to increased workload for
the renal system.”
c. “High BP may not cause any problems for some people but does cause symptoms
in many others.”
d. High BP is probably causing the damage, but the patient does not recognize that
they are occurring.
ANS: A
Teaching the patient that hypertension can damage blood vessels and eventually causes severe
health problems is most likely to improve patient compliance with needed lifestyle changes.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 873
MSC: CRNE: HW-2
6. During assessment of a patient who has stage 2 hypertension, the nurse recognizes that it is
common for the patient to experience which of the following?
a. Nosebleeds
b. No symptoms
c. Blurred vision
d. Dyspnea on exertion
ANS: B
Hypertension is largely asymptomatic until damage to target organs has occurred.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 873
MSC: CRNE: CH-8
7. The nurse teaches the patient with stage 1 hypertension about diet modifications that should
be implemented to manage BP. Which diet choice indicates that the teaching has been
effective?
a. The patient has a glass of low-fat milk with each meal.
b. The patient has only one cup of coffee in the morning.
c. The patient restricts intake of dietary protein.
d. The patient has tomato juice and bacon for breakfast.
ANS: A
The DASH (Dietary Approaches to Stop Hypertension) recommendations for prevention of
hypertension include increasing the intake of calcium-rich foods.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Evaluation
REF: page 877, Table 35-7
MSC: CRNE: HW-11
8. The nurse is planning patient teaching for a patient who has just been diagnosed with
hypertension and has a new prescription for captopril (Capoten). Which of the following
information is important to include when teaching the patient?
a. Increase fluid intake if dryness of the mouth is a problem.
b. Check BP daily before taking the medication.
c. Include high-potassium foods such as citrus fruits in the diet.
d. Change position slowly to help prevent dizziness and falls.
ANS: D
Angiotensin-converting enzyme (ACE) inhibitors frequently cause orthostatic hypotension,
and patients should be taught to change position slowly to allow the vascular system time to
compensate for the position change.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 879, Table 35-8
MSC: CRNE: CH-44
9. During assessment of a 50-year-old patient who has newly diagnosed stage 1 hypertension,
the patient admits he uses a lot of salt on his foods and has not been able to lose the 13.6 kg he
has gained in the last 10 years. He does not understand why he has hypertension because he is
not an anxious person. What is an appropriate nursing diagnosis for the nurse to document for
the patient?
a. Noncompliance related to lack of motivation
b. Disturbed self-esteem related to diagnosis of hypertension
c. Ineffective health maintenance related to lack of knowledge of disease process and
management
d. Anxiety related to complexity of management regimen and lifestyle changes
associated with hypertension
ANS: C
This patient’s subjective and objective assessment data indicate that lack of knowledge about
hypertension will need to be addressed to allow the patient to improve the BP.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 884, Table 35-12
MSC: CRNE: CH-15
10. Laboratory testing is ordered for a patient during a clinic visit for routine assessment of
hypertension. When the results of the testing are available, the nurse recognizes that target
organ damage is indicated by which of the following results?
a. Blood urea nitrogen (BUN) of 5.4 mmol/L (15 mg/dL)
b. Serum uric acid of 464 mol/L (7.8 mg/dL)
c. Serum creatinine of 230 mol/L (2.6 mg/dL)
d. Serum potassium of 3.2 mmol/L (3.2 mEq/L)
ANS: C
BUN and creatinine are useful in determining whether renal failure is developing as a result of
hypertension. The BUN level is normal. The serum creatinine is elevated and will require
further investigation.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 875
MSC: CRNE: CH-6
11. A 62-year-old patient is admitted to the hospital with a BP of 240/118 mm Hg. The patient
has been taking clonidine hydrochloride (Catapres) and hydrochlorothiazide (HydroDIURIL)
for 10 years for hypertension. What is the most appropriate question the nurse can ask at this
time?
a. “Have you recently taken any antihistamine medications?”
b. “Have you been taking the clonidine and hydrochlorothiazide lately?”
c. “Did you have any recent stressful events in your life?”
d. “Did you take any acetaminophen yet today?”
ANS: B
Sudden withdrawal of antihypertensive medications can cause rebound hypertension and
hypertensive crisis.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 881, Table 35-8
MSC: CRNE: CH-48
12. Which of the following amounts of exercise recommended by the Canadian Hypertension
Education Program (CHEP) to reduce the possibility of a person becoming hypertensive?
a. 30 minutes of light exercise daily
b. 60 minutes of moderate exercise, twice a day, three times per week
c. 30 to 60 minutes of moderate exercise, four to seven times per week
d. 30 to 45 minutes of heavy exercise, three times per week
ANS: C
CHEP recommends 30 to 60 minutes of moderate-intensity exercise four to seven times per
week. Higher intensities of exercise are no more effective.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 878
MSC: CRNE: HW-2
13. A 69-year-old woman is diagnosed with hypertension and placed on acebutolol (Sectral).
After reviewing the patient’s history, the nurse consults with the physician about the use of
this medication upon finding which of the following conditions?
a. Asthma
b. Peptic ulcer disease
c. Alcohol dependency
d. Myocardial infarction
ANS: A
Acebutolol is a -adrenergic agent that blocks 1-adrenergic receptors. It may cause
bronchospasm so you would use it with caution, especially in patients with a history of
asthma.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 879, Table 35-8
MSC: CRNE: CH-23
14. A 52-year-old woman has no history of hypertension and no risk factors related to
hypertension. During an annual physical examination, her blood pressure is 188/106 mm Hg.
After reconfirming her BP, it is appropriate for the nurse to tell the patient which of the
following?
a. She should have her BP rechecked in 2 months.
b. She is in imminent danger of a stroke and should be hospitalized immediately.
c. She needs to reduce the sodium and fat content in her diet and exercise more
vigorously.
d. Her increased BP might be due to a specific disease and may require further
diagnostic testing.
ANS: D
A sudden increase in BP in a patient with no previous hypertension history or risk factors
indicates that the hypertension may be secondary to some other problem and requires further
diagnostic testing.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: pages 871-872
MSC: CRNE: CH-8
15. An 86-year-old widow is a retired homemaker who lives alone and is on a fixed income. She
tells the nurse the names of her medications and when she takes them. She has labelled and
filled an egg carton with her medications to keep on schedule. Over time, however, it is
apparent that her BP is not well controlled, and she does not always take her medication
regularly. What is a possible cause of the lack of responsiveness to therapy that the nurse
should explore with the patient?
a. A lack of teaching about hypertension
b. A lack of money to purchase the medication
c. A complex and inconvenient dosing schedule
d. The development of confusion and memory deficit
ANS: B
The cost of medications is a common cause of lack of medication compliance in older patients
with fixed incomes.
PTS: 1
DIF: Cognitive Level: Application
REF: page 884, Table 35-12
OBJ: 6
TOP: Nursing Process: Assessment
MSC: CRNE: HW-19
16. A patient with stage 1 hypertension who received a new prescription for methyldopa returns
to the health clinic after 2 weeks for a follow-up visit. BP is unchanged from the previous
clinic visit. What is the nurse’s first action?
a. Ask the patient about whether the medication is actually being taken.
b. Teach the patient about the reasons for an increase in the medication dose.
c. Provide information about the use of multiple drugs to treat hypertension.
d. Remind the patient that lifestyle changes are also important in BP control.
ANS: A
Methyldopa can cause adverse effects (such as impotence, decreased libido, fatigue, and
depression) in some patients, leading to noncompliance. It is important to determine whether
the patient has stopped taking the medication before initiating any changes in therapy, such as
increasing the dose or adding a second medication.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 879, Table 35-8
MSC: CRNE: CH-44
17. The charge nurse observes a new registered nurse (RN) doing discharge teaching for a
hypertensive patient who has a new prescription for enalapril (Vasotec). The charge nurse will
need to intervene if the new RN tells the patient to do which of the following?
a. Increase the dietary intake of high-potassium foods.
b. Move slowly when moving from a lying to a standing position.
c. Check the BP with a home BP monitor every day.
d. Make an appointment with the dietitian for teaching about a low-sodium diet.
ANS: A
ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible
adverse effect.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 879, Table 35-8
MSC: CRNE: PP-19
18. Which of the following is a correct mechanism action of aldosterone?
a. Increased sodium reabsorption
b. Decreased water reabsorption
c. Decreased blood volume
d. Increased potassium excretion
ANS: A
The mechanisms of aldosterone include an increase in sodium and water reabsorption and an
increase in blood volume and cardiac output.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 870, Figure 35-3
MSC: CRNE: CH-8
19. When teaching a patient about nutritional therapy related to hypertension, the nurse tells the
patient to consume how many servings per day of whole grains?
a. Two to three
b. Four to five
c. Six to eight
d. Avoid intake of whole grains.
ANS: C
Hypertensive diet indicates that patients should have a daily intake of six to eight servings of
whole grains.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 877, Table 35-7
MSC: CRNE: CH-35
20. Which diuretic would the nurse anticipate that the patient with renal insufficiency would be
prescribed?
a. Metolazone (Zaroxolyn)
b. Indapamide (Lozide)
c. Bumetanide (Burinex)
d. Chlorthalidone hydrochlorothiazide
ANS: C
The patient with renal insufficiency would be prescribed a loop diuretic such as bumetanide
rather than a thiazide or other related diuretic.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 879, Table 35-8
MSC: CRNE: CH-8
21. A patient with hypertension has just developed an abrupt elevation in BP. Which of the
following would indicate that the patient is in a hypertensive crisis?
a. Widening pulse pressure
b. Systolic above 110 mm Hg
c. Diastolic above 120 mm Hg
d. Mean arterial pressure of 82 mm Hg
ANS: C
Hypertensive crisis is a severe and abrupt elevation in BP and is defined as a DBP above 120
to 130 mm Hg.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 887
MSC: CRNE: CH-8
22. During the change-of-shift report, the nurse obtains all of this information about a
hypertensive patient who received the first dose of nadolol pindolol (Visken) during the
previous shift. Which of the following information will be of most concern to the nurse?
a. The patient’s heart rate has dropped from 64 to 58 beats/min.
b. The patient has developed wheezes throughout the lung fields.
c. The patient complains that the fingers and toes feel quite cold.
d. The patient’s most recent BP is 156/94 mm Hg.
ANS: B
The most urgent concern for this patient is the wheezes, which indicate that bronchospasm (a
common adverse effect) is occurring. The nurse should immediately obtain an oxygen
saturation measurement, apply supplemental oxygen, and notify the physician.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 879, Table 35-8
MSC: CRNE: CH-22
Chapter 36: Nursing Management: Coronary Artery Disease and Acute Coronary
Syndrome
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. When developing a health teaching plan for a 65-year-old patient with all of these risk
factors for coronary artery disease (CAD), which of the following will the nurse focus on?
a. A family history of heart disease
b. Increased risk associated with the patient’s ethnicity
c. A high incidence of cardiovascular disease in older people
d. A low activity level reported by the patient
ANS: D
Because family history, ethnicity, and age are nonmodifiable risk factors, the nurse should
focus on the patient’s activity level. An increase in activity will help reduce the patient’s
risk for developing CAD.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 896
MSC: CRNE: HW-1
2. To assist the patient with CAD to make the appropriate dietary changes, which of these
nursing interventions will be most effective?
a. Help the patient modify favourite high-fat recipes by using monounsaturated oils
when possible.
b. Provide the patient with a list of low-sodium, low-cholesterol foods that should be
included in the diet.
c. Instruct the patient that a diet containing no saturated fat and minimal sodium will
be necessary.
d. Emphasize the increased risk for cardiac problems unless the patient makes the
dietary changes.
ANS: A
Lifestyle changes are more likely to be successful when consideration is given to patient’s
preferences. The highest percentage of calories from fat should come from monounsaturated
fats.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 900
MSC: CRNE: CH-35
3. The nurse is admitting a patient who is complaining of chest pain to the emergency
department (ED). Which information collected by the nurse suggests that the pain is caused
by an acute myocardial infarction (AMI)?
a. The pain worsens when the patient raises the arms.
b. The pain increases with deep breathing.
c. The pain is relieved after the patient takes nitroglycerin.
d. The pain has persisted longer than 30 minutes.
ANS: D
Chest pain that lasts for 20 minutes or more is characteristic of AMI.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 910
MSC: CRNE: CH-60
4. A 45-year-old man is admitted to the ED after developing severe chest pain while raking
leaves. On admission, he has midchest dullness and a normal electrocardiogram (ECG). The
physician schedules the patient for cardiac catheterization with coronary angiography and
possible percutaneous coronary intervention (PCI). The nurse prepares the patient for the
procedure by explaining that, in his case, it is used for which of the following purposes?
a. To determine whether the walls or chambers of the patient’s heart have any
structural defects
b. To determine whether any obstructions are present in his coronary arteries and to
test for an allergy to thrombolytic agents
c. To measure the amount of blood being pumped from his heart with each
contraction to determine whether the heart is damaged
d. To visualize any blockages in the coronary arteries and, if necessary, to dilate an
obstructed artery with the use of a small balloon
ANS: D
In this case, PCI is used for visualization of the coronary arteries, and possible balloon
dilation is scheduled for this patient.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 912
MSC: CRNE: CH-30
5. During assessment of a patient with chest pain, how will the nurse recognize the chest pain
associated with stable angina?
a. It is severe, persistent, and unrelieved by rest.
b. Cold, clammy skin accompanied by a feeling of doom.
c. It is aggravated by inspiration, coughing, and movement of the upper body.
d. It is accompanied by a residual soreness in the chest, which lasts for several days.
ANS: B
Stable angina chest pain is usually abrupt, and the patient has a feeling of impending doom.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 913, Table 36-14
OBJ: 4
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
6. While observing the ECG monitor of a patient admitted to the ED with chest pain, the nurse
suspects that the patient is having a myocardial infarction (MI) rather than angina on finding
which of the following data?
a. Sinus tachycardia
b. Depressed R wave
c. Pathological Q wave
d. Occasional premature ventricular contractions
ANS: C
Patients with ST-segment–elevation myocardial infarction (STEMI) tend to have a more
extensive MI associated with prolonged and complete coronary occlusion and the
development of a pathological Q wave on the ECG. Patients with unstable angina or non–
ST-segment–elevation myocardial infarction (NSTEMI) usually have transient thrombosis
or incomplete coronary occlusion and usually do not develop pathological Q waves.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 912
MSC: CRNE: CH-6
7. Which of the following determinants of health is true in relation to CAD in Canada?
a. Native-born Canadians have better cardiovascular health than immigrants to
Canada.
b. Immigrants from South Asia have a very high risk for cardiovascular disease.
c. Asian Indians experience lower rates of cardiovascular disease, regardless of
where they live.
d. Chinese immigrants have a very low rate of cardiovascular disease.
ANS: D
Immigrants from China have a particularly low rate of cardiovascular disease. Immigrants to
Canada have better cardiovascular health than do native-born Canadians. Immigrants from
South Asia have a particularly high risk for cardiovascular disease. Regardless of where
they live, Asian Indians appear to suffer high rates of cardiovascular disease.
PTS: 1
DIF: Cognitive Level: Knowledge
REF: page 892, Determinants of Health box
OBJ: 1
TOP: Nursing Process: Assessment
MSC: CRNE: HW-19
8. In developing a teaching plan for a patient who has stable angina and is started on
sublingual nitroglycerin, which one of the following would the nurse identify as an expected
patient outcome?
a. States nitroglycerin is to be taken only if chest pain develops
b. Lists the side effects of nitroglycerin as gastric upset and dry mouth
c. Identifies the need to seek medical attention if chest pain persists 5 minutes after
taking nitroglycerin
d. Identifies the need for lifelong use of nitroglycerin to prevent the development of
an MI
ANS: C
The emergency medical services system should be activated when chest pain or other
symptoms are not completely relieved 5 minutes after taking nitroglycerin.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 906
MSC: CRNE: NCP-14
9. While teaching a patient and his wife about the dietary modifications that should be made to
reduce the risk of CAD, what should the nurse explain?
a. Margarine can be used in any amount, but butter should be avoided.
b. Fish is preferable to red meats as sources of protein.
c. All vegetable fats are unsaturated and are preferable to meat and dairy fats.
d. Polyunsaturated and monounsaturated fats should be restricted to 50% of the total
daily calories.
ANS: B
Fish and skinless chicken are preferable as sources of protein, as red meat is high in animal
(saturated) fat, and patients are advised to reduce their saturated fat intake.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: pages 900-901
MSC: CRNE: CH-35
10. The nurse determines that outcomes for teaching regarding precipitating factors of angina
have been met when the patient states which of the following?
a. “I will stop my sexual activities.”
b. “I will rest for 1 to 2 hours after a heavy meal.”
c. “I will take my medication before doing my daily walk.”
d. “I will limit my coffee intake, but I may substitute regular cola products.”
ANS: B
Adequate rest should be planned for 1 to 2 hours after eating because blood is shunted to the
gastrointestinal tract to aid digestion and absorption.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 917
MSC: CRNE: NCP-14
11. After the nurse teaches the patient about the use of atenolol (Tenormin) in preventing
anginal episodes, which statement by the patient indicates that the teaching has been
effective?
a. “Atenolol will increase the strength of my heart muscle.”
b. “I can expect to feel short of breath when taking atenolol.”
c. “Atenolol will improve the blood flow to my coronary arteries.”
d. “It is important not to suddenly stop taking the atenolol.”
ANS: D
Patients who have been taking -blockers can develop intense and frequent angina if the
medication is suddenly discontinued.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Evaluation
REF: page 908
MSC: CRNE: CH-8
12. In developing a teaching plan for the patient with angina, the nurse recognizes that teaching
about the first line of drug therapy for angina will include instructions about using which of
the following medications?
a. One aspirin a day
b. Transdermal nitrates
c. Lovastatin (Mevacor)
d. Metoprolol (Lopressor)
ANS: A
Daily aspirin is recommended in the absence of contraindications.
PTS:
1
DIF:
Cognitive Level: Comprehension
REF: page 905
OBJ: 7
TOP: Nursing Process: Implementation
MSC: CRNE: CH-44
13. Which of the following is the earliest lesion of atherosclerosis and is characterized by lipidfilled smooth muscle cells?
a. Fatty streak
b. Fibrous plaque
c. C-reactive lesion
d. Complication lesion
ANS: A
Fatty streaks, the earliest lesions of atherosclerosis, are characterized by lipid-filled smooth
muscle cells.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 893
MSC: CRNE: HW-19
14. Nadolol (Corgard) is prescribed for a patient with CAD. In evaluating the effectiveness of
the drug, the nurse would monitor for which of the following?
a. Improvement in the quality of the peripheral pulses
b. Ability to do daily activities without chest discomfort
c. Decreased blood pressure and apical pulse rate
d. Fewer complaints of having cold hands and feet
ANS: B
Because the medication is ordered to improve the patient’s angina, effectiveness is indicated
if the patient’s angina is stable.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 918
MSC: CRNE: CH-44
15. A patient admitted to the critical care unit (CCU) with an MI has a physician’s orders for
continuous amiodarone (Cordarone) infusion, intravenous (IV) nitroglycerin, and morphine
sulphate 2 mg IV every 5 minutes until relief of pain occurs, in addition to the standard
CCU protocol. The patient is having frequent, multifocal premature ventricular contractions,
and he tells the nurse that the pain is worse than he has ever had and asks if he is going to
die. On admission to the CCU, the nurse identifies which of the following nursing diagnoses
as a priority?
a. Acute pain related to myocardial ischemia
b. Anxiety related to perceived threat of death
c. Decreased cardiac output related to cardiogenic shock
d. Activity intolerance related to decreased cardiac output
ANS: A
All the nursing diagnoses may be appropriate for this patient, but the data indicate that the
priority diagnosis is pain, a physiological stressor. The patient’s anxiety will also be reduced
if the pain is resolved.
PTS: 1
DIF: Cognitive Level: Application
REF: page 918, Nursing Care Plan 36-1 OBJ: 6
TOP: Nursing Process: Planning
MSC: CRNE: CH-22
16. A diagnosis of acute coronary syndrome (ACS) is the admission diagnosis for a patient
transferred to the CCU. The nurse knows that this diagnosis indicates that the patient has
experienced which of the following?
a. Unstable angina (UA) or an MI
b. Resuscitation following sudden cardiac death
c. Onset of any severe cardiac-related chest pain
d. MI accompanied by ST-segment elevation
ANS: A
ACS develops and encompasses the spectrum of UA, NSTEMI, and STEMI.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 912
MSC: CRNE: CH-8
17. While caring for a patient with an AMI, the nurse monitors the patient closely, knowing that
which of the following conditions is the most common complication of MI?
a. Pericarditis
b. Dysrhythmias
c. Cardiogenic shock
d. Congestive heart failure
ANS: B
Dysrhythmias are the most common complication of MI.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 910
MSC: CRNE: CH-8
18. The nurse administers IV nitroglycerin to a patient with an MI. In evaluating the effect of
this intervention, the nurse recognizes that which of the following is an expected outcome of
the administration of the medication?
a. Relief of pain
b. Decreased heart rate
c. Increased cardiac output
d. Control of cardiac dysrhythmias
ANS: A
The goal of IV nitroglycerin administration in AMI is relief of chest pain by improving the
balance between myocardial oxygen supply and demand.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 915
MSC: CRNE: CH-48
19. The MB isoenzyme of creatine kinase (CK-MB) level is markedly elevated in a patient with
chest pain 12 hours after admission. Of what would the nurse interpret this finding as being
evidence?
a. Lactic acidosis
b. A need for thrombolytic therapy
c. Deterioration of cardiac function
d. Cellular necrosis of myocardial tissue
ANS: D
The CK-MB levels increase as the necrotic myocardial cells release CK-MB enzymes into
the circulation after perfusion has been restored to the area.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 912
MSC: CRNE: CH-8
20. The physician has ordered determination of CK-MB and troponin levels for a patient who
has experienced chest pain and aching for the last 4 days. What does the nurse expect on
reading this order?
a. Myoglobin levels will also have to be determined to confirm myocardial damage.
b. CK-MB enzyme levels will be the most reliable indicator of any myocardial
necrosis that has occurred.
c. Any serum cardiac marker will be inconclusive in determining myocardial injury
that is several days old.
d. The presence of myocardial damage occurring several days earlier can be validated
best by the troponin level determination.
ANS: D
The heart has two troponin subtypes: cardiac-specific troponin T (cTnT) and cardiacspecific troponin I (cTnI). These markers are highly specific indicators of MI and have
greater sensitivity and specificity for myocardial injury than CK-MB (Pagana & Pagana,
2006). Troponin rises as quickly as CK. It is usually used for diagnostic purposes in
conjunction with total CK and the MB fraction. Serum levels of cTnI and cTnT increase 3 to
12 hours after the onset of MI, peak at 24 to 48 hours, and return to baseline over 5 to 14
days.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 912
MSC: CRNE: CH-8
21. Fibrinolytic therapy is prescribed for a 64-year-old patient with an STEMI. During the
administration of the fibrinolytic agent, the nurse recognizes that the therapy should be
stopped when the patient experiences which of the following signs?
a. Bleeding from the gums
b. Surface bleeding from the IV site
c. A sudden decrease in the level of consciousness
d. Premature ventricular contractions and ventricular tachycardia
ANS: C
The change in the level of consciousness indicates that the patient may be experiencing
intracranial bleeding, a possible complication of fibrinolytic therapy.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 914
MSC: CRNE: CH-60
22. Which of the following signs would the patient experience when the nurse evaluates that
fibrinolytic therapy has not been successful in restoring perfusion to the myocardium?
a. Continuing chest pain
b. Dyspnea and tachycardia
c. A marked, rapid rise in the CK enzyme
d. An increase in premature ventricular contractions
ANS: A
If the patient’s chest pain continues, it is an indication that perfusion has not been restored
to the myocardium.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Evaluation
REF: page 914
MSC: CRNE: CH-48
23. Three days after an MI, the patient develops chest pain that radiates to the back and left arm
and is relieved by sitting in a forward position. On auscultation of the patient’s chest, what
would the nurse expect to hear?
a. Distant heart sounds
b. S3 or S4 heart sounds
c. A pericardial friction rub
d. A loud holosystolic apical murmur
ANS: C
The patient’s symptoms are consistent with the development of pericarditis, a possible
complication of MI. The other assessments listed are not consistent with the description of
the patient’s symptoms.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 911
MSC: CRNE: CH-6
24. For which of the following patient conditions is the use of garlic as a complementary
therapy to help lower blood pressure contraindicated?
a. Pre-existing hypertension
b. Diabetes
c. Obesity
d. Osteoarthritis
ANS: B
Garlic is a relatively safe herb but is contradicted in people with bleeding disorders, GI
infections, diabetes, and inflammation.
PTS: 1
DIF: Cognitive Level: Application
REF: page 902, Complementary and Alternative Therapies box OBJ: 4
TOP: Nursing Process: Implementation MSC: CRNE: CH-11
25. Which of the following is a mnemonic to assist the nurse in obtaining thorough information
from a patient who has chest pain?
a. ABCDEF
b. PAIN
c. PQRST
d. AQSP
ANS: C
PQRST can be used as a mnemonic to assist in obtaining information for the patient who
has chest pain as follows: P, precipitating events; Q, quality of pain; R, radiation of pain; S,
severity of pain; and T, timing.
PTS: 1
DIF: Cognitive Level: Application
REF: page 904, Table 36-9
OBJ: 4
TOP: Nursing Process: Assessment
MSC: CRNE: CH-3
26. A patient has had an elevated temperature of 38.2°C for 3 days since experiencing an MI.
What does the nurse understand that this fever indicates?
a. A normal response to the necrotic tissue of infarction
b. A need for concern only if a leukocytosis is also present
c. Beginning congestive heart failure from increased myocardial oxygen demand
d. Developing pericarditis as a complication of myocardial necrosis
ANS: A
Fever and elevated white blood cell count are normal occurrences after MI as a result of
inflammation that occurs after tissue necrosis.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 910
MSC: CRNE: CH-8
27. When caring for a patient who has survived a sudden cardiac death event and has no
evidence of an AMI, what will the nurse anticipate teaching the patient?
a. That sudden cardiac death events rarely recur
b. The purpose of outpatient Holter monitoring
c. How to self-administer low–molecular weight heparin
d. The need to limit activities after discharge to prevent future events
ANS: B
Holter monitoring is used to determine whether the patient is experiencing dysrhythmias
such as ventricular tachycardia during normal daily activities.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 924
MSC: CRNE: CH-60
28. During the initial stages of hospitalization for an MI, the patient has been in denial, stating
“I just had a little chest pain.” What is the most appropriate intervention for the nurse to plan
for the patient at this time?
a. Have the patient’s family encourage him to talk about his plans for the future.
b. Allow the patient to use denial as a coping mechanism until he asks questions
about his condition.
c. Implement reality orientation by reminding the patient several times a day that he
has had major cardiac damage.
d. Begin teaching the patient about the anatomy and physiology of the heart so that
he can understand what has happened to him.
ANS: B
The patient is experiencing progression through the normal stages of loss and grief that
often occur after an MI.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 920
MSC: CRNE: CH-60
29. The nurse evaluates the outcomes of preoperative teaching with a patient scheduled for a
coronary artery bypass graft using the internal mammary artery. Which of the following
statements by the patient helps the nurse identify that additional teaching is needed?
a. “I will need to take an aspirin a day after the surgery to keep the graft open.”
b. “I will have incisions in my leg where they removed the vein.”
c. “They will stop my heart and circulate my blood with a machine during the
surgery.”
d. “They will cut between my ribs and use a scope to attach a different artery to the
artery that is blocked in my heart.”
ANS: B
When the internal mammary artery is used, it will not be necessary to remove a saphenous
vein from the leg.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 915
MSC: CRNE: CH-8
30. Three weeks after his hospitalization for an AMI, a patient returns to the cardiac centre for
follow-up. When the nurse asks about his sleep patterns, the patient tells the nurse that he
sleeps fine but that his wife moved into the spare bedroom to sleep when he returned home.
He states, “I guess we will never have sex again after this.” What is the best response to the
patient?
a. “Sexual intercourse will be too strenuous on your heart, but closeness and intimacy
can be maintained with holding and cuddling.”
b. “You should discuss your questions about your sexual activity with your doctor
because the activity it requires is a medical concern.”
c. “Sexual activity can be resumed whenever you and your wife feel like it. Most
sexual response is emotional rather than physical.”
d. “Sexual activity can be gradually resumed like other forms of activity. A good
comparison of energy expenditure is climbing two flights of stairs.”
ANS: D
All activity has to be gradually resumed. A good guide for patients is to tell them that sexual
activity places about as much physical stress on the cardiovascular system as climbing two
flights of stairs.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 917
MSC: CRNE: HW-13
31. In preparing a patient for discharge from the hospital following an MI, which of the
following statements by the patient indicates to the nurse that further instruction is needed?
a. “Exercise will increase the efficiency of my heart.”
b. “I can control several risk factors of CAD just by exercising.”
c. “My heart will be as good as new when I finish a cardiac rehabilitation program.”
d. “I should do more exercises that move my joints than exercises that require static
force.”
ANS: C
It is important for the patient to understand that CAD is a chronic disease that can be
managed but cannot be cured.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 921
MSC: CRNE: NCP-14
32. Which of the following is the mechanism of action of aspirin that is commonly prescribed
for patients that have had acute coronary syndrome?
a. Inhibits platelet aggregation
b. Promotes coronary artery vasodilation
c. Promotes peripheral vasodilation
d. Inhibits cyclooxygenase
ANS: D
Aspirin is used as an antiplatelet agent in the treatment of acute coronary syndrome; it
inhibits cyclooxygenase which produces thromboxane A2, a potent platelet activator.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 924, Table 36-13
OBJ: 7
TOP: Nursing Process: Implementation MSC: CRNE: CH-44
33. During early assessment of the patient with an MI, the nurse is aware that which of the
following diagnostic tests is the most important to determine the extent and treatment of an
MI?
a. Serial ECGs
b. A chest X-ray
c. Treadmill exercising
d. Serum cardiac markers
ANS: A
When the initial ECG is nondiagnostic, serial ECGs are done every 2 to 4 hours to
determine the extent and treatment of an MI.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 911
MSC: CRNE: CH-8
34. A patient who has recently started taking rosuvastatin (Crestor) and niacin (Nicobid) reports
all the following symptoms to the nurse. Which one is most important to communicate to
the physician?
a. Skin flushing after taking the medications
b. Dizziness when changing positions quickly
c. Nausea when taking the drugs before eating
d. Generalized muscle aches and pains
ANS: D
Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused
acute kidney injury and death in some patients who have taken the statin medications. These
symptoms indicate that the rosuvastatin may have to be discontinued.
PTS:
1
DIF:
Cognitive Level: Application
REF: pages 901-902
OBJ: 7
TOP: Nursing Process: Implementation
MSC: CRNE: CH-44
35. A patient who has chest pain is admitted to the ED, and the following diagnostic tests are
ordered. Which one will the nurse arrange to be completed first?
a. Chest X-ray
b. Troponin level
c. Computed tomography scan
d. ECG
ANS: D
The priority for the patient is to determine whether an AMI is occurring so that reperfusion
therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary
artery occlusion.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 908
MSC: CRNE: CH-22
36. For a patient who was admitted the previous day to the CCU with an AMI, the nurse will
anticipate teaching the patient about which one of the following?
a. The pathophysiology of CAD
b. When patient cardiac rehabilitation will begin
c. Home-discharge drugs such as aspirin and b-blockers
d. Typical emotional responses to MI
ANS: B
At this time, the patient’s anxiety level or denial will prevent good understanding of
complex information such as CAD pathophysiology.
PTS: 1
DIF: Cognitive Level: Application
REF: page 920, Table 36-17
OBJ: 8
TOP: Nursing Process: Planning
MSC: CRNE: CH-17
37. Which of the following is an absolute contraindication for the use of fibrinolytic therapy?
a. Diabetes
b. Pregnancy
c. Intercranial neoplasm
d. Laser eye surgery
ANS: C
An absolute contraindication for the use of fibrinolytic therapy is intercranial neoplasm.
Diabetes is not a contraindication. Pregnancy and laser eye surgery are relative
contraindications but not absolute ones.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 914, Table 36-15
OBJ: 7
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
38. A patient who is being admitted to the ED with severe chest pain gives the nurse the
following list of medications taken at home. Which medication has the most immediate
implications for the patient’s care?
a.
b.
c.
d.
Captopril (Capoten)
Furosemide (Lasix)
Sildenafil (Viagra)
Diazepam (Valium)
ANS: C
The nurse will need to avoid giving nitrates to the patient because nitrate administration is
contraindicated in patients who are using sildenafil because of the risk of sudden death
caused by vasodilation.
PTS: 1
DIF: Cognitive Level: Application
REF: page 923, Table 36-21
OBJ: 5
TOP: Nursing Process: Assessment
MSC: CRNE: CH-48
39. The nurse has just received a change-of-shift report about the following four patients. Which
patient should the nurse assess first?
a. A 38-year-old patient who has pericarditis and is complaining of sharp, stabbing
chest pain
b. A 45-year-old patient who had an MI 4 days ago and is anxious about the planned
discharge
c. A 51-year-old patient who has just returned to the unit after a coronary arteriogram
and PCI
d. A 60-year-old patient who is due for a scheduled dose of atenolol 25 mg orally
ANS: C
After PCI, the patient is at risk for bleeding from the arterial access site for the PCI, so the
nurse should assess the patient immediately. The other patients also should be assessed as
quickly as possible, but assessment of this patient has the highest priority.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 914
MSC: CRNE: CH-8
Chapter 37: Nursing Management: Heart Failure
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A patient with a history of chronic congestive heart failure is hospitalized with severe dyspnea
and a dry, hacking cough. She has pitting edema in both ankles, and her vital signs are blood
pressure (BP) 170/100 mm Hg, pulse 92 beats/min, and respiration 28 breaths/min. What is
the most important assessment for the nurse to conduct next?
a. Auscultate the lung sounds.
b. Assess the orientation.
c. Check the capillary refill.
d. Palpate the abdomen.
ANS: A
When caring for a patient with severe dyspnea, the nurse should use the ABCs (airway,
breathing, circulation) to guide initial care. This patient’s severe dyspnea and cough indicate
that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as
pulmonary edema, which should be detected and treated immediately to prevent ongoing
hypoxemia and cardiac or respiratory arrest. The other assessments will provide useful data
about the patient’s volume status and should also be accomplished rapidly, but detection (and
treatment) of fluid-filled alveoli is the priority.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 931
MSC: CRNE: CH-22
2. A patient with chronic heart failure tells the nurse at the clinic that he has gained 2.26 kg in
the last 3 days, even though he has continued to follow a low-sodium diet. What is the priority
nursing action?
a. Ask the patient to recall the dietary intake for the last 3 days because the patient’s
diet contains hidden sources of sodium.
b. Instruct the patient in a low-calorie, low-fat diet because the weight gain has likely
been caused by excessive intake of inappropriate foods.
c. Assess the patient for clinical manifestations of acute heart failure because an
exacerbation of the chronic heart failure may be occurring.
d. Educate the patient about the use of diuretic therapy because it is likely that the
patient will need medications to reduce the hypervolemia.
ANS: C
The 2.26-kg weight gain over 3 days indicates that the patient’s chronic heart failure may be
worsening. It is important that the patient be immediately assessed for other clinical
manifestations of decompensation, such as lung crackles.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 933
MSC: CRNE: CH-22
3. During assessment of a 72-year-old man with swelling in his ankles, the nurse finds jugular
venous distension with the head of the bed elevated 45 degrees. What does the nurse know
this finding indicates?
a. Decreased fluid volume
b. Elevated right atrial pressure
c. Incompetent jugular vein valves
d. Atherosclerosis of the jugular veins
ANS: B
Right-sided heart failure causes backward blood flow to the right atrium and venous
circulation. Venous congestion in the systemic circulation results in peripheral edema,
hepatomegaly, splenomegaly, vascular congestion of the gastrointestinal tract, and jugular
venous distension.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 931
MSC: CRNE: CH-6
4. The nurse monitors a patient receiving intravenous (IV) furosemide (Lasix) and enalapril
(Vasotec) 5 mg orally twice daily for an acute exacerbation of chronic heart failure. Which of
the following findings indicates to the nurse that the treatment is effective?
a. A weight loss of 0.9 kg
b. An increase in urinary output
c. A decrease in systolic BP
d. Fewer crackles on lung auscultation
ANS: D
Because the patient’s major clinical manifestation of ADHF is orthopnea (caused by the
presence of fluid in the alveoli), the best indicator that the medications are effective is a
decrease in crackles.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 932
MSC: CRNE: CH-48
5. When the nurse is developing a teaching plan to prevent the development of heart failure in a
patient with stage 1 hypertension, what information is most likely to improve compliance with
antihypertensive therapy?
a. Hypertensive crisis may lead to development of acute heart failure in some
patients.
b. Hypertension eventually will lead to heart failure by overworking the heart muscle.
c. High BP increases the risk for rheumatic heart disease.
d. High systemic pressure precipitates papillary muscle rupture.
ANS: B
Hypertension is a primary cause of heart failure because the increase in ventricular afterload
leads to ventricular hypertrophy and dilation.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 929, Table 37-1
MSC: CRNE: HW-2
6. A patient with acute heart failure has severe dyspnea and is extremely anxious. The nurse
anticipates that increased cardiac output and decreased anxiety may be promoted by the IV
administration of which of the following medications?
a. Morphine
b. Diazepam (Valium)
c. Dopamine (Intropin)
d. Nitroglycerin (Tridil)
ANS: A
Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular
preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of
dyspnea.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 936
MSC: CRNE: CH-49
7. IV nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the
initial administration of the drug, the nurse should monitor the patient for which of the
following?
a. Bradycardia
b. Hypotension
c. Cyanide toxicity
d. Ventricular dysrhythmias
ANS: B
Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe
hypotension.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 935
MSC: CRNE: Ch-44
8. A patient admitted to the hospital with an exacerbation of her chronic heart failure tells the
nurse she was fine when she went to bed but woke up feeling as if she were suffocating. What
is the best way for the nurse to document this assessment information?
a. Pulsus alternans
b. Paroxysmal nocturnal dyspnea
c. Two-pillow orthopnea
d. Acute bilateral pleural effusion
ANS: B
Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body
areas when the patient is sleeping and is characterized by waking up suddenly with the feeling
of suffocation.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 932
MSC: CRNE: CH-15
9. Which IV medication will the nurse expect to administer to a patient who has ADHF, to
increase stroke volume?
a. Milrinone (Primacor)
b. Nesiritide (Natrecor)
c. Dobutamine (Dobutrex)
d. Nitroprusside (Nipride)
ANS: C
Dobutamine is administered IV to increase stroke volume.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 939, Table 37-9
MSC: CRNE: CH-44
10. When working in the heart failure clinic, the nurse knows that teaching for a 74-year-old
patient with newly diagnosed heart failure has been effective when the patient does which of
the following?
a. Says that the nitroglycerin patch will be used for any chest pain that develops
b. Calls when the weight increases from 56 to 59 kg in 2 days
c. Tells the home care nurse that furosemide is taken daily at bedtime
d. Makes an appointment to see the doctor at least once yearly
ANS: B
Teaching for a patient with heart failure includes information about the need to weigh daily
and notify the physician about an increase of 2 kg in 2 days.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 945, Table 37-15
MSC: CRNE: CH-13
11. To promote more efficient ventricular emptying by decreasing preload in the patient with
chronic heart failure, the nurse should implement which of the following actions?
a. Administer oxygen per mask.
b. Encourage active leg exercises to increase venous return.
c. Administer sedatives to promote rest and decrease myocardial oxygen demand.
d. Position the patient in a high-Fowler’s position with the feet horizontal in the bed.
ANS: D
The high-Fowler’s position helps decrease venous return because of the pooling of blood in
the extremities. This position also increases the thoracic capacity, allowing for improved
ventilation. IV nitroglycerin is a vasodilator used in the treatment of ADHF. It reduces
circulating volume by decreasing preload and increases coronary artery circulation by dilating
the coronary arteries.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 935
MSC: CRNE: CH-32
12. When teaching the patient with congestive heart failure about a 2-g sodium diet, the nurse
explains that which of the following foods must be restricted?
a. Eggs
b. Canned fruit
c. Frozen vegetables
d. Milk and milk products
ANS: D
Milk and yogurt naturally contain a significant amount of sodium, and intake of these should
be limited for patients on a diet that limits sodium to 2 g daily. Other milk products, such as
processed cheeses, have very high levels of sodium and are not appropriate for a 2-g sodium
diet.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 939
MSC: CRNE: CH-35
13. The nurse plans discharge teaching for a patient with chronic heart failure who is to be
maintained on digoxin (Lanoxin), a diuretic, and a potassium supplement. What would
appropriate instructions for the patient include?
a.
b.
c.
d.
Avoid dietary sources of potassium because too much can cause digitalis toxicity.
Take the diuretic before bedtime to prevent drowsiness during the day.
Notify the physician immediately if nausea or difficulty breathing occurs.
Take the pulse rate before taking all medications.
ANS: C
Difficulty breathing is an indication of ADHF and suggests that the medications are not
achieving the desired effect. Nausea is an indication of digoxin toxicity and should be
reported so that the health care provider can assess the patient for toxicity and adjust the
digoxin dose, if necessary.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 945, Table 37-15
MSC: CRNE: CH-8
14. The nurse identifies the collaborative problem of “potential complication: pulmonary edema
for a patient in chronic heart failure.” Which assessment will the nurse be most concerned
about?
a. Apical pulse 106 beats/min
b. Weight gain of 1 kg over 24 hours
c. Oxygen saturation of 88% on room air
d. Decreased hourly urinary output
ANS: C
A decrease in oxygen saturation to less than 92% indicates hypoxemia. The nurse should
administer supplemental oxygen immediately to the patient.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 936
MSC: CRNE: CH-60
15. When the nurse is admitting an 80-year-old woman with chronic heart failure to the medical
unit, the patient says she lives alone and that she thinks she confuses her “water pill” with her
“heart pill.” The nurse makes a note that which of the following discharge plans for this
patient should be included?
a. A referral for a home care nurse
b. Placement in a skilled nursing care facility
c. Transfer to a special unit for individuals with dementia
d. Arrangements for a family member to be with the patient around the clock
ANS: A
The data about the patient suggest that assistance is needed in developing a system for taking
medications correctly at home. A home health care nurse will assess the patient’s home
situation and help the patient develop a method for taking the two medications as directed.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 942
MSC: CRNE: HW-4
16. After successful digitalization, a patient is to begin oral maintenance of digoxin and
furosemide for control of chronic heart failure. To prevent digitalis toxicity, what does the
nurse understand is the most important parameter to monitor in the patient?
a. Body weight
b. Liver function
c. Blood pressure
d. Serum potassium
ANS: D
Hypokalemia potentiates the actions of digoxin and increases the risk for digoxin toxicity,
which can cause life-threatening dysrhythmias.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 938
MSC: CRNE: CH-44
17. Following an acute myocardial infarction, a 67-year-old man develops heart failure. What
does the nurse anticipate will be the first-line therapy for the patient?
a. Digitalis preparation, such as digoxin
b. Diuretic, such as hydrochlorothiazide (HydroDIURIL)
c. -Adrenergic agonist, such as dobutamine
d. Angiotensin-converting enzyme (ACE) inhibitor, such as captopril (Capoten)
ANS: D
ACE inhibitor therapy is currently recommended to prevent the development of heart failure
in patients who have had a myocardial infarction and as a first-line therapy for patients with
chronic heart failure.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 937
MSC: CRNE: CH-44
18. Which of the following is a common cause of chronic heart failure?
a. Anemia
b. Dysrhythmias
c. Myocarditis
d. Hypertensive crisis
ANS: A
Anemia is a common cause of chronic heart failure. Dysrhythmias, myocarditis, and
hypertensive crisis are all common causes of acute heart failure.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 929, Table 37-1
MSC: CRNE: CH-8
19. An outpatient who has developed heart failure after having an acute myocardial infarction has
a new prescription for carvedilol (Coreg). After 2 weeks, the patient returns to the clinic.
Which assessment finding causes the nurse the most concern?
a. The patient has a BP of 88/42 mm Hg.
b. The patient has an apical pulse rate of 56 beats/min.
c. The patient complains of feeling tired.
d. The patient has 2+ pedal edema.
ANS: A
The patient’s BP indicates that the dose of carvedilol may have to be decreased because the
mean arterial pressure is only 57.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 938
MSC: CRNE: CH-44
20. Which of the following determinants of health is true in relation to heart failure?
a. Men compose more new cases of heart failure than women.
b. Women tend to be diagnosed with heart failure at an older age as compared to
men.
c. Men are more likely to be diabetic as compared to women.
d. Women are less likely to have high BP than men.
ANS: B
Women tend to be diagnosed with heart failure at an older age than men; women are more
likely to be diabetic and to have high BP.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 930, Determinants of Health box
OBJ: 4
TOP: Nursing Process: Assessment
MSC: CRNE: HW-19
21. What is the most common form of initial heart failure?
a. Left-sided
b. Right-sided
c. Biventricular
d. All types occur equally; there is no one common form of heart failure.
ANS: A
Left-sided heart failure is the most common form of initial failure.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 931
MSC: CRNE: CH-8
22. Which of the following symptoms would the nurse expect to observe in a patient with left-
sided heart failure?
a. Nausea
b. Dyspnea
c. Anorexia
d. Dependent edema
ANS: B
Dyspnea is a symptom of left-sided heart failure. Nausea, anorexia and dependent edema are
all symptoms of right-sided heart failure.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 933, Table 37-3
MSC: CRNE: CH-8
Chapter 38: Nursing Management: Dysrhythmias
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. In analyzing a patient’s electrocardiogram (ECG) rhythm strip, the nurse uses the knowledge
that the time of the conduction of an impulse through the Purkinje fibres is represented by
which of the following changes?
a. P wave
b. PR interval
c. QT interval
d. QRS complex
ANS: B
The PR interval represents depolarization of the atria, atrioventricular (AV) node, bundle of
His, bundle branches, and Purkinje fibres, up to the point of depolarization of the ventricular
cells.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 951
MSC: CRNE: CH-8
2. Which of the following is an abnormal ECG value for a PR interval duration?
a. 0.6 second
b. 0.12 second
c. 0.24 second
d. 0.30 second
ANS: B
The normal duration of a PR interval is 0.12 to 0.20 seconds.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 955, Table 38-2
MSC: CRNE: CH-8
3. A patient has a sinus arrest with a junctional escape rhythm. What would the nurse expect the
patient’s pulse rate to be?
a. 15 to 20 beats/min
b. 20 to 40 beats/min
c. 40 to 60 beats/min
d. 60 to 100 beats/min
ANS: C
If the sinoatrial node fails to discharge, the junction will automatically discharge at the normal
junctional rate of 40 to 60 beats/min.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 961
MSC: CRNE: CH-8
4. A patient who is complaining of a “racing” heart and nervousness comes to the emergency
department. The patient’s blood pressure (BP) is 102/68 mm Hg. The nurse places the patient
on a cardiac monitor and obtains the following ECG tracing:
Which action should the nurse take next?
a. Have the patient perform the Valsalva manoeuvre.
b. Prepare to administer -blocker medication to slow the heart rate.
c. Get ready to perform electrical cardioversion.
d. Obtain further information about possible causes for the heart rate.
ANS: D
The patient has sinus tachycardia, which can be caused by multiple stressors such as pain,
dehydration, or myocardial ischemia. Further assessment is needed before determining the
treatment.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
REF: pages 958-959
MSC: CRNE: CH-22
5. A patient has a dysrhythmia that requires careful monitoring of atrial activity. Which lead will
be best to use for continuous monitoring?
a. MCL1
b. AVF
c. V6
d. I
ANS: A
Leads II and MCL1 are the best leads for visualization of P waves, which reflect atrial
activity.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 952
MSC: CRNE: CH-8
6. The nurse obtains a monitor strip on a patient admitted to the coronary care unit with a
myocardial infarction (MI) and makes the following analysis: P wave not apparent;
ventricular rate 142 beats/min, R-R interval regular; PR interval not measurable; and QRS
complex wide and distorted, greater than 0.14 second. The nurse interprets this patient’s
cardiac rhythm as which of the following?
a. Atrial fibrillation
b. Sinus tachycardia
c. Ventricular fibrillation
d. Ventricular tachycardia
ANS: D
The absence of P waves, wide QRS, rate greater than 150 beats/min, and regularity of the
rhythm indicate ventricular tachycardia.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 958, Table 38-7
MSC: CRNE: CH-8
7. The nurse determines that a patient has ventricular bigeminy when the rhythm strip indicates
which of the following changes?
a. Conduction is originating in the AV node.
b. Every other QRS complex is wide and starts prematurely.
c. The ventricular rate is between 150 and 250 beats/min.
d. The rhythm of the SA node is coupled with long pauses between every two beats.
ANS: B
Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and
bizarre looking.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Diagnosis
REF: page 963, Figure 38-17
MSC: CRNE:
8. A patient has a normal cardiac rhythm strip, except that the PR interval is 0.34 seconds. What
is the appropriate nursing intervention?
a. Notify the physician.
b. Administer atropine per protocol.
c. Prepare the patient for temporary pacemaker insertion.
d. Document the finding, and continue to monitor the patient.
ANS: D
First-degree AV block is asymptomatic and requires ongoing monitoring because it may
progress to more serious forms of heart block.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
REF: page 962
MSC: CRNE: CH-8
9. A patient with diabetes mellitus is admitted unresponsive to the emergency department (ED).
Initial laboratory findings are serum potassium 2.8 mmol/L, serum sodium 138 mmol/L,
serum chloride 90 mmol/L, and blood glucose 34.9 mmol/L (628 mg/dL). Cardiac monitoring
shows multifocal premature ventricular contractions (PVCs). What does the nurse understand
that the patient’s PVCs are most likely caused by?
a. Hypoxemia
b. Dehydration
c. Hypokalemia
d. Hyperglycemia
ANS: C
Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular
tachycardia, and ventricular fibrillation.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 963
MSC: CRNE: CH-8
10. The nurse retrieves data from the cardiac monitor that indicates that a patient with an MI
experienced a 45-second episode of ventricular tachycardia before a normal sinus rhythm and
a heart rate of 98 were re-established. What is the most appropriate initial nursing action?
a. Notify the physician.
b. Administer antidysrhythmic drugs per protocol.
c. Elevate the head of the bed, and administer oxygen at 6 L/min.
d. Continue to monitor the patient’s cardiac rhythm without other interventions at this
time.
ANS: B
The burst of sustained ventricular tachycardia indicates that the patient has significant
ventricular irritability, and antidysrhythmic medication administration is needed to prevent
further episodes.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 964
MSC: CRNE: CH-44
11. A patient is seen in the emergency department after experiencing dizziness and shortness of
breath for several days. During cardiac monitoring in the ED, the nurse notes the following
findings: atrial rate 82 beats/min, P-P interval regular; ventricular rate 42 beats/min, R-R
interval regular; PR interval variable with no relationship between P and QRS; and QRS
complex 0.06 second with normal contour. The following ECG tracing was obtained:
The nurse interprets this cardiac rhythm as which of the following?
a. Third-degree heart block
b. Premature atrial contractions
c. PVCs
d. Paroxysmal supraventricular tachycardia
ANS: A
The inconsistency between the atrial and ventricular rates and the variable PR interval indicate
that the rhythm is third-degree AV block.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: pages 962-963, Figure 38-16
MSC: CRNE: CH-8
12. A patient with myocardial damage develops a type I, second-degree AV block. The nurse
administers IV atropine as prescribed. The nurse determines that the medication has been
effective on finding which of the following changes?
a. A decrease in ventricular response
b. A decrease in premature contractions
c. An increase in the patient’s heart rate
d. Increased carotid and peripheral pulse volume
ANS: C
Atropine will increase the heart rate and conduction through the AV node.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 962
MSC: CRNE: CH-44
13. What is the most accurate way to calculate the heart rate from an ECG?
a. Count the number of R-R intervals in 6 seconds, and multiply by 10.
b. Count the number of small squares between the R-R interval, and divide by 1500.
c. Count the number of QRS complexes in 1 minute.
d. Count the large squares between one R-R interval, and divide by 300.
ANS: C
The most accurate way to obtain a heart rate from an ECG is to count the number of QRS
complexes in 1 minute.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: pages 952-953
MSC: CRNE: CH-4
14. The cardiac monitor alarm goes off for a patient being monitored in the coronary care unit,
and the nurse notes a cardiac pattern of undulations of varying contours and amplitude with no
measurable ECG pattern. The patient is unconscious, with no pulse or respirations. After
calling for assistance, what should the nurse do?
a. Start basic cardiopulmonary resuscitation (CPR).
b. Administer a bolus dose of epinephrine.
c. Prepare the patient for endotracheal intubation.
d. Wait for the defibrillator to arrive at the bedside.
ANS: A
The patient’s rhythm and assessment indicate ventricular fibrillation and cardiac arrest;
therefore, the initial actions include calling for help and initiating CPR until defibrillation is
possible.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 957, Table 38-6
MSC: CRNE: CH-64
15. During the change-of-shift report, the nurse learns that a patient with a large MI has been
having frequent PVCs. What will the nurse check when monitoring the patient for the effects
of PVCs?
a. The patient’s medications
b. The patient’s oxygen saturation
c. The patient’s apical–radial heart rate
d. The patient’s recent electrolyte values
ANS: C
It is important to assess the patient’s apical–radial pulse rate because PVCs often do not
generate a sufficient ventricular contraction to result in a peripheral pulse, which can lead to a
pulse deficit.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 964
MSC: CRNE: CH-4
16. How would the nurse document a dysrhythmia pattern that has a sawtooth-shape P wave, a
variable PR interval, and a normal QRS complex?
a. Junctional rhythms
b. Atrial flutter
c. Sinus bradycardia
d. Atrial fibrillation
ANS: B
A dysrhythmia pattern that has a sawtooth-shape P wave, a variable PR interval, and a normal
QRS complex is an atrial flutter.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 958, Table 38-7
MSC: CRNE: CH-15
17. Which classification of antidysrhythmia drugs has no effect on ECG?
a. Class I: sodium channel blockers
b. Class II: -adrenergic blockers
c. Class III: potassium channel blockers
d. Class IV: calcium channel blockers
ANS: A
Class I: sodium channel blockers have no effect on ECG.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 966, Table 38-8
MSC: CRNE: CH-44
18. The nurse is doing discharge teaching with a patient who is going home with an implantable
cardioverter–defibrillator (ICD). Which of the following instructions should the nurse give the
patient?
a. Keep the incision dry for at least 2 weeks after ICD insertion.
b. The ICD will not set off a metal detector in an airport, so it is all right to travel.
c. You should have a routine ICD check every 2 to 3 months.
d. It is all right to drive as soon as you are discharged.
ANS: C
Routine ICD check with interrogator–programmer device is needed every 2 to 3 months.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 968, Table 38-9
MSC: CRNE: HW-26
19. A patient has a permanent pacemaker inserted for treatment of chronic atrial fibrillation with
slow ventricular response. The nurse recognizes that the pacemaker is used for the patient to
do which of the following?
a. Prevent ventricular irritability.
b. Override the ectopic stimulus in the atria.
c. Fire an impulse every second to maintain a heart rate of 60 beats/min.
d. Discharge an electrical stimulus when no ventricular depolarization is sensed.
ANS: D
The permanent pacemaker will discharge when the ventricular rate drops below the set rate.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: pages 968-969
MSC: CRNE: CH-8
20. A patient has received instruction on the management of her permanent pacemaker before
discharge from the hospital. The nurse recognizes that teaching has been effective when the
patient makes which of the following statements?
a. “I won’t lift the arm on the pacemaker side up very high until I see the doctor.”
b. “I will notify the airlines when I make a reservation that I have a pacemaker.”
c. “I must avoid cooking with a microwave oven or being near a microwave in use.”
d. “It will be 6 weeks before I can take a bath or return to my usual activities.”
ANS: A
The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to
avoid displacing the pacemaker leads.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 970, Table 38-12
MSC: CRNE: NCP-14
21. A patient who has been successfully resuscitated twice following sudden cardiac death has a
transvenous ICD implanted for management of ventricular dysrhythmias. When performing
discharge teaching with the patient, what is most important for the nurse to instruct the patient
and family about?
a. He will no longer need to take medications to control his dysrhythmias.
b. If the ICD fires and he loses consciousness, 911 should be called.
c. His family will not need to learn CPR because he has the automatic defibrillator
available.
d. The ICD device rarely sets off airport security alarms, and travel without
restrictions is allowed.
ANS: B
If the ICD fires and the patient continues to have symptoms of cardiac arrest, activation of the
emergency response system is indicated.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 968, Table 38-9
MSC: CRNE: CH-60
22. A patient with supraventricular tachycardia is to receive cardioversion. What should the nurse
know about the use of cardioversion?
a. A defibrillator is programmed to deliver a countershock on the T wave.
b. The amount of voltage used is 400 J.
c. The patient should be sedated before the procedure, if possible.
d. The procedure is the same as defibrillation, except that the patient is more
hemodynamically stable.
ANS: C
When a patient has a nonemergency cardioversion, sedation is used just before the procedure.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 967
MSC: CRNE: CH-30
23. A patient’s sinus rhythm rate is 62 beats/min. The PR interval is 0.18 seconds at 0100 hours,
0.20 seconds at 1230 hours, and 0.23 seconds at 1600 hours. Which action should the nurse
take?
a. Document the patient’s rhythm, and continue to monitor.
b. Prepare for possible pacemaker insertion.
c. Hold the ordered metoprolol (Lopressor), and call the physician.
d. Give the as-needed dose of lidocaine (Xylocaine).
ANS: C
The patient has progressive first-degree AV block, and the -blocker should be held until
discussing the medication with the physician.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 962
MSC: CRNE: CH-44
24. A patient develops sinus bradycardia at a rate of 32 beats/min, has a BP of 80/36 mm Hg, and
is complaining of feeling faint. Which action should the nurse take?
a. Continue to monitor the rhythm and BP.
b. Obtain and apply the transcutaneous pacemaker.
c. Give the scheduled dose of diltiazem (Cardizem).
d. Have the patient perform the Valsalva manoeuvre.
ANS: B
The patient is experiencing symptomatic bradycardia, and treatment with the transcutaneous
pacemaker is appropriate.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: pages 969, Table 38-11
MSC: CRNE: CH-60
25. A 21-year-old college student arrives at the student health centre at the end of the quarter
complaining, “My heart is skipping beats.” The nurse obtains an ECG and notes the presence
of occasional PVCs. What action should the nurse take first?
a. Ask the patient about any history of coronary artery disease.
b. Question the patient about current stress level and coffee use.
c. Have the patient transported to the hospital ED.
d. Administer O2 to the patient at 2 to 3 L/min using nasal prongs.
ANS: B
In a patient with a normal heart, occasional PVCs are a benign finding. The timing of the
PVCs suggests stress or caffeine as a possible etiological factor.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 959
MSC: CRNE: CH-1
26. A 19-year-old student has a mandatory ECG before participating on a university swim team
and is found to have sinus bradycardia, rate 52 beats/min. BP is 114/54 mm Hg, and the
student denies any health problems. Which nursing action is appropriate?
a. Refer the student to a cardiologist for further assessment.
b. Allow the student to participate on the swim team.
c. Obtain more detailed information about the student’s health history.
d. Tell the student to stop swimming immediately if any dyspnea occurs.
ANS: B
In an aerobically trained individual, sinus bradycardia is normal. The student’s normal BP and
negative health history indicate that a cardiology referral or more detailed information about
the health history is not necessary. Dyspnea during an aerobic activity such as swimming is
normal.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 957
MSC: CRNE: CH-8
27. When analyzing the waveforms of a patient’s ECG, which finding will the nurse need to
investigate further?
a. PR interval of 0.18 second
b. QRS interval of 0.14 second
c. T wave of 0.16 second
d. QT interval of 0.34 second
ANS: B
Because the normal QRS interval is 0.06 to 0.10 second, the patient’s QRS interval of 0.14
second indicates that the conduction through the ventricular conduction system is prolonged.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 955, Table 38-2
MSC: CRNE: CH-6
Chapter 39: Nursing Management: Inflammatory and Structural Heart Disorders
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. The nurse obtains a health history from a patient with a prosthetic mitral valve who has
symptoms of infective endocarditis (IE). Which is the most appropriate question for the nurse
to ask?
a. “Do you have a history of a heart attack?”
b. “Have you had any recent immunizations?”
c. “Have you been to the dentist lately?”
d. “Do you have a family history of endocarditis?”
ANS: C
Dental procedures place the patient with a prosthetic mitral valve at risk for IE.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 977
MSC: CRNE: CH-3
2. The physician writes the following admitting orders for a patient with suspected IE who has
fever and chills: ceftriaxone (Rocephin) 1.0 g intravenous (IV) piggyback every 12 hours,
aspirin for a temperature above 38.9°C, blood cultures  3, complete blood count, and
electrocardiogram (ECG). When admitting the patient, to which of the following orders
should the nurse give the highest priority?
a. Scheduling the ECG
b. Initiating the intravenous (IV) antibiotic
c. Obtaining the blood cultures
d. Administering the antipyretic agent
ANS: C
Treatment of the IE with antibiotics should be started as quickly as possible, but it is essential
to obtain blood cultures before initiating antibiotic therapy to obtain accurate sensitivity
results.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 979
MSC: CRNE: CH-22
3. During the assessment of a patient with IE, what would the nurse expect to find?
a. A new regurgitant murmur
b. Splinter hemorrhages of the lips
c. Dyspnea and a dry, hacking cough
d. Substernal chest pain and pressure
ANS: A
New regurgitant murmurs occur in IE because vegetation on the valves prevents valve
closure.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 978
MSC: CRNE: CH-8
4. A patient is admitted to hospital with a diagnosis of myocarditis. The nurse knows that early
cardiac manifestations will appear approximately how long after viral infection?
a. 24 to 48 hours
b. 3 to 5 days
c. 7 to 10 days
d. 2 to 3 weeks
ANS: C
Early cardiac manifestations appear 7 to 10 days after viral infection.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 985
MSC: CRNE: CH-8
5. A patient hospitalized with a streptococcal IE tells the nurse that the physician said treatment
would require 4 to 6 weeks of antibiotic therapy and says she needs to get back to work as
soon as possible. In advising the patient about the expected regimen for IE, what should the
nurse explain about the treatment?
a. After 2 weeks of IV antibiotic therapy, she may be discharged with oral antibiotics
to take for another 4 weeks.
b. Hospitalization for 4 to 6 weeks will be necessary to prevent a relapse while she
receives IV antibiotic therapy.
c. She may be able to receive outpatient IV antibiotic therapy with home nursing care
if complications do not develop.
d. She will be able to return to work as soon as her fever subsides if she does not
develop any symptoms of heart failure.
ANS: C
Treatment for IE involves 4 to 6 weeks of IV antibiotic therapy to eradicate the bacteria, but
patients frequently receive IV antibiotics on an outpatient basis.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 979, Table 39-5
MSC: CRNE: CH-13
6. A patient who is hospitalized with IE develops sharp left flank pain and hematuria. The nurse
notifies the physician, recognizing that these symptoms may indicate which of the following
complications?
a. Bacterial colonization in the kidneys
b. Vegetative embolization to the kidneys
c. Septicemia resulting in decreased glomerular blood flow
d. Hemolysis of red blood cells by hemolytic microorganisms
ANS: B
The patient’s clinical manifestations and history of IE indicate embolization. Sudden-onset
flank pain is not typical of pyelonephritis, septicemia, or glomerulonephritis.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 978
MSC: CRNE: CH-27
7. A patient is admitted to the hospital with possible acute pericarditis. The nurse explains to the
patient that to confirm a diagnosis of acute pericarditis, the physician will most likely use
which of the following tests?
a. Multiple ECGs
b. Daily blood cultures
c. Cardiac catheterization
d. Fluid obtained by pericardiocentesis
ANS: A
Pericarditis causes changes such as ST-segment elevation in multiple leads on the ECG,
which evolve over the course of the inflammatory process, so multiple ECGs are warranted.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: pages 983-984
MSC: CRNE: CH-30
8. To assess the patient with pericarditis for the presence of a pericardial friction rub, the nurse
should undertake which of the following actions?
a. Place the diaphragm of the stethoscope at the lower left sternal border of the chest.
b. Ask the patient to stop breathing during auscultation to distinguish the sound from
a pleural rub.
c. Use the diaphragm of the stethoscope to listen for a rumbling, low-pitched sound
that occurs during systole.
d. Palpate the precordial area with the tips of the fingers to detect a vibration that
occurs with each cardiac contraction.
ANS: A
Pericardial friction rubs are heard best with the diaphragm at the lower left sternal border.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 982
MSC: CRNE: CH-4
9. The nurse suspects the development of cardiac tamponade in a patient with acute pericarditis
on finding which of the following data?
a. Blood pressure 166/96 mm Hg
b. Jugular vein distension (JVD) to the level of the jaw
c. A pulsus paradoxus of 8 mm Hg
d. Level 6 chest pain on a 10-point scale with deep inspiration
ANS: B
The JVD indicates that the patient may have developed cardiac tamponade and may need
rapid intervention to maintain adequate cardiac output.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 982
MSC: CRNE: CH-27
10. Cardiac tamponade is suspected in a patient who has acute pericarditis. To assess for the
presence of pulsus paradoxus, what should the nurse do?
a. Subtract one third of the diastolic BP from the systolic BP.
b. Auscultate for a pericardial friction rub that increases in volume during inspiration.
c. Evaluate the rhythm of the pulse in relation to the patient’s inspiration and
expiration.
d. Note the first Korotkoff sound occurring during both inspiration and expiration
while deflating the blood pressure cuff.
ANS: D
Pulsus paradoxus exists with a gap of greater than 10 mm Hg between when Korotkoff sounds
can be heard during only expiration and when they can be heard throughout the respiratory
cycle.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 982, Table 39-8
MSC: CRNE: CH-4
11. The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for
a patient with acute pericarditis. What is the most appropriate nursing intervention for this
problem?
a. Force fluids to 3000 mL/day to decrease fever and inflammation.
b. Teach the patient to take deep, slow respirations to control the pain.
c. Position the patient in a Fowler’s position, leaning forward on a padded overbed
table.
d. Consult with the physician to provide patient-controlled analgesia with a narcotic
analgesic.
ANS: C
Sitting upright and leaning forward frequently will decrease the pain associated with
pericarditis.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 985
MSC: CRNE: CH-32
12. While obtaining a nursing history from a 23-year-old man with rheumatic fever, what
information related by the patient does the nurse recognize as the most significant?
a. Has used illicit IV drugs within the last 3 months
b. Has been unemployed for 6 months and has been eating poorly
c. Suffered chest trauma with a fractured rib during a fight 2 weeks ago
d. Has had a recent sore throat
ANS: D
Rheumatic fever occurs as a result of an abnormal immune response to a streptococcal
infection.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 987
MSC: CRNE: CH-8
13. A 22-year-old patient with rheumatic fever has subcutaneous nodules, erythema marginatum,
and polyarthritis of multiple joints. What would the nurse document as an appropriate nursing
diagnosis based on these findings?
a. Activity intolerance related to fatigue and arthralgia
b. Risk for infection related to open skin lesions
c. Risk for impaired skin integrity related to pruritus and scratching
d. Risk for impaired physical mobility related to permanent joint fixation
ANS: A
The clinical manifestations of rheumatic fever include fatigue and arthralgia.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
REF: page 987
MSC: CRNE: CH-15
14. The nurse establishes the nursing diagnosis of ineffective therapeutic regimen management
related to lack of knowledge concerning long-term management of rheumatic fever when a
patient recovering from rheumatic endocarditis makes which of the following remarks?
a. “I will have to take prophylactic monthly antibiotic injections for at least 5 years.”
b. “I should see my physician if I develop excessive fatigue or difficulty breathing.”
c. “I will need to let my dentist know that I have had this rheumatic fever.”
d. “I will be immune to further episodes of rheumatic fever after this infection.”
ANS: D
Patients with a history of rheumatic fever are more susceptible to a second episode.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: pages 988-989
MSC: CRNE: CH-12
15. The community health nurse involved in programs to prevent rheumatic fever knows that
which of the following interventions is the most important to decrease the incidence of the
disease?
a. Immunizing susceptible groups of people with streptococcal vaccine
b. Providing prophylactic antibiotics to people with a family history of rheumatic
fever
c. Teaching people to seek medical diagnosis and treatment for streptococcal
pharyngitis
d. Promoting hygienic measures to prevent the transmission of streptococcal
infections
ANS: C
Prevention involves early detection and immediate treatment of group A -hemolytic
streptococcal pharyngitis. Adequate treatment of streptococcal pharyngitis prevents initial
attacks of rheumatic fever.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 989
MSC: CRNE: HW-2
16. Which assessment information obtained by the nurse for a patient with aortic stenosis would
be most important to report to the physician?
a. A loud systolic murmur is audible along the right sternal border.
b. The patient complains of chest pain associated with ambulation.
c. The point of maximum impulse is at the left midclavicular line.
d. A thrill is palpable at the second intercostal space, right sternal border.
ANS: B
Chest pain occurring with aortic stenosis is caused by cardiac ischemia, and reporting this
information would be a priority.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Implementation
REF: page 993
MSC: CRNE: CH-23
17. During assessment of a patient with mitral valve stenosis, which findings would the nurse
recognize are characteristic of the pressure gradient differences occurring with mitral valve
stenosis?
a. Angina and syncope
b. Dyspnea and hemoptysis
c. JVD and peripheral edema
d. Hypotension and paroxysmal nocturnal dyspnea
ANS: B
The pressure gradient changes in mitral stenosis lead to fluid backup into the lungs, resulting
in dyspnea and hemoptysis.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 990
MSC: CRNE: CH-8
18. A 21-year-old female student is scheduled for an open mitral valve commissurotomy for
treatment of a mitral stenosis resulting from rheumatic endocarditis when she was a child.
Which factor supports the choice of valve repair over valve replacement in this patient?
a. No artificial valves are available yet to replace mitral valves.
b. Valve repair has a lower operative mortality rate than does valve replacement.
c. Biological replacement valves necessitate long-term immunosuppressive therapy.
d. Long-term anticoagulation is necessary with mechanical valve replacement.
ANS: D
Long-term anticoagulation therapy is needed after mechanical valve replacement.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 995
MSC: CRNE: CH-12
19. While caring for a patient with mitral valve prolapse with mild valvular regurgitation, the
nurse determines that discharge teaching has been effective when the patient tells the nurse
that she will do which of the following?
a. Take one aspirin a day to prevent embolization.
b. Limit her physical activity to avoid stressing her heart valves.
c. Schedule an appointment with her doctor every 6 months.
d. Discuss the diagnosis of mitral valve prolapse with the dentist.
ANS: D
Mitral valve prolapse with regurgitation is a risk factor for IE, and the patient needs to discuss
the need for antibiotic prophylaxis with the health care provider before any invasive medical
or dental procedure is done.
PTS: 1
DIF: Cognitive Level: Application
REF: page 997, Nursing Care Plan 39-1 OBJ: 2
MSC: CRNE: HW-4
TOP: Nursing Process: Evaluation
20. Which pulse pattern would the nurse expect to diagnose on assessment of a patient who has
mitral valve regurgitation?
a. Bounding radial pulse
b. Irregular radial pulse
c. Thready peripheral pulses
d. Absent peripheral pulses
ANS: C
Patients with acute mitral valve regurgitation will have thready, peripheral pulses and cool,
clammy extremities.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 990
MSC: CRNE: CH-8
21. During postoperative teaching with a patient who has had a mitral valve replacement with a
mechanical valve, what should the nurse instruct the patient about?
a. The need to avoid high-voltage electrical fields
b. The need for anticoagulation therapy for the duration of the valve
c. The probability that the valve will need to be replaced in 7 to 10 years
d. The need to check the pulse daily to determine the functioning of the valve
ANS: B
Anticoagulation with warfarin (Coumadin) is needed for a patient with mechanical valves to
prevent clotting on the valve.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 995, Table 39-16
MSC: CRNE: CH-31
22. A few days after an acute myocardial infarction, a patient complains of stabbing chest pain
that increases with deep breathing. Which action will the nurse take first?
a. Notify the patient’s physician.
b. Auscultate the heart sounds.
c. Check the patient’s oral temperature.
d. Give the ordered acetaminophen (Tylenol).
ANS: B
The patient’s clinical manifestations and history are consistent with pericarditis, and the
nurse’s first action should be to listen for a pericardial friction rub.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 982
MSC: CRNE: CH-4
23. A patient who has had recent cardiac surgery develops pericarditis and complains of severe
chest pain with deep breathing. Which of these ordered as-needed medications should the
nurse administer?
a. Oral acetaminophen (Tylenol) 650 mg
b. Oral ibuprofen (Motrin) 800 mg
c. IV morphine sulphate 6 mg
d. Fentanyl (Sublimaze) 2 mg IV
ANS: B
The pain associated with pericarditis is caused by inflammation, so nonsteroidal antiinflammatory medications such as ibuprofen are most effective.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 983, Table 39-9
MSC: CRNE: CH-49
24. Which information obtained by the nurse when assessing a patient admitted with mitral valve
stenosis should be communicated to the physician immediately?
a. The patient has a loud diastolic murmur all across the precordium.
b. The patient has crackles audible to the lung apices.
c. The patient has a palpable thrill felt over the left anterior chest.
d. The patient has 4+ peripheral edema in both legs.
ANS: B
Crackles that are audible throughout the lungs indicate that the patient is experiencing severe
left ventricular failure and needs immediate interventions such as diuretics.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 996, Table 39-17
MSC: CRNE: CH-23
25. Which of the following is the primary symptom of mitral stenosis?
a. Tachypnea
b. Exertional dyspnea
c. Atrial fibrillation
d. Hemoptysis
ANS: B
The primary symptom of mitral stenosis is exertional dyspnea, owing to reduced lung
compliance. Patients may also have atrial fibrillation and hemoptysis, but these are not the
primary symptoms of mitral stenosis.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 990
MSC: CRNE: CH-8
26. A patient who has developed acute pulmonary edema is hospitalized and diagnosed with
dilated cardiomyopathy. Which information will the nurse plan to include when teaching the
patient about management of this disorder?
a. Careful compliance with diet and medications will control the patient’s symptoms.
b. Notify the doctor about any symptoms of heart failure such as shortness of breath.
c. No more than one or two alcoholic drinks daily are permitted.
d. Elevating the legs above the heart will help relieve angina.
ANS: B
The patient should be instructed to notify the physician about any worsening of heart failure
symptoms. Because dilated cardiomyopathy does not respond well to therapy, even patients
with good compliance with therapy may have recurrent episodes of heart failure.
PTS: 1
OBJ: 12
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1002, Table 39-21
MSC: CRNE: CH-12
27. What is the term for flat, painless, small red spots on the palms and soles of a patient who has
IE?
a.
b.
c.
d.
Osler’s nodes
Roth’s spots
Janeway’s lesions
Palmar surface paradoxus
ANS: C
Janeway’s lesions is the term for the appearance of flat, painless, small red spots on the palms
and soles of a patient with IE.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 978
MSC: CRNE: CH-8
28. Which of the following is the hallmark finding in a patient with acute pericarditis?
a. Severe sharp chest pain.
b. Pericardial friction rub.
c. Referred pain to the trapezius muscle.
d. Dyspnea
ANS: B
The hallmark finding in acute pericarditis is the pericardial friction rub.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 982
MSC: CRNE: CH-8
Chapter 40: Nursing Management: Vascular Disorders
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A patient with a history of a 4-cm fusiform abdominal aortic aneurysm (AAA) is admitted to
the emergency department with severe back pain and bilateral flank ecchymosis. His vital
signs are blood pressure (BP) 90/58 mm Hg, pulse 138 beats/min, and respiration 34
breaths/min. The nurse plans interventions for the patient based on the expectation that which
of the following treatments will be included?
a. Immediate surgery
b. An immediate angiogram
c. A paracentesis when vital signs are stabilized with fluid replacement
d. Admission to the intensive care unit for observation while diagnostic tests are
completed
ANS: A
The patient’s history and clinical manifestations are consistent with rupture into the
retroperitoneal space, and the patient will need immediate surgery to have a chance at
survival.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1008
MSC: CRNE: CH-13
2. A 69-year old man is admitted to the hospital for elective repair of an AAA. His history
includes hypertension for 25 years, dyslipidemia for 15 years, and smoking for 50 years. The
patient’s wife asks the nurse what caused her husband’s aneurysm. The nurse’s best response
will include which following information?
a. A congenital weakness of an artery wall results in dilation of the artery after many
years.
b. Aneurysms are a type of vascular disease in which atherosclerotic plaques damage
the artery.
c. Chronic infections of the walls of the blood vessels are the most common cause of
aneurysms.
d. If her husband did not smoke or have hypertension and dyslipidemia, he would not
have an aneurysm.
ANS: B
The patient’s gender, age, and risk factor history indicate that the aneurysm was probably
caused by atherosclerosis rather than a congenital weakness or chronic infection.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1007
MSC: CRNE: CH-8
3. A 65-year-old patient has a 5-cm thoracic aortic aneurysm that was discovered during a
routine chest X-ray examination. When obtaining a nursing history from the patient, what
would the nurse specifically ask the patient about?
a. Abdominal pain
b. Dysphagia
c. Intermittent back pain
d. Weakness and palpitations
ANS: B
Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the
esophagus.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1007
MSC: CRNE: CH-1
4. Several hours following an endovascular aneurysm repair, the patient develops left flank pain,
and his urinary output has been 20 mL/hour for the past 2 hours. The nurse recognizes that
these findings may indicate which of the following complications?
a. Infection
b. Hypovolemia
c. Intestinal ischemia
d. Renal artery occlusion
ANS: D
The pain and decreased urinary output suggest a renal artery occlusion.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1010
MSC: CRNE: CH-8
5. How frequently should the nurse check the operative extremity in the immediate postoperative
period for a patient who has had surgical intervention for peripheral artery disease?
a. Every 10 minutes
b. Every 15 minutes
c. Every 30 minutes
d. Every 60 minutes
ANS: B
After surgical intervention, the patient is moved to the critical care unit, and the operative
extremity is assessed every 15 minutes initially.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1018
MSC: CRNE: CH-31
6. After repair of an AAA, the nurse notes that the patient does not have popliteal, posterior
tibial, or dorsalis pedis pulses. The legs are cool and mottled. Which action is appropriate for
the nurse to take first?
a. Review the preoperative assessment form for data about the pulses.
b. Notify the surgeon and anaesthesiologist.
c. Document that the pulses are absent, and recheck in 30 minutes.
d. Elevate the lower extremities on pillows.
ANS: A
Many patients with aortic aneurysms also have peripheral arterial disease (PAD), so the nurse
should check the preoperative assessment to determine whether pulses were present before
surgery before notifying the physicians about the absent pulses.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1011
MSC: CRNE: CH-3
7. What is a nursing intervention that is indicated for the collaborative problem of “potential
complication: cardiac dysrhythmia” in a patient who has had a repair of a descending thoracic
aortic aneurysm?
a. Assess neurological signs hourly.
b. Titrate oxygen to keep oxygen saturation greater than 90%.
c. Maintain the patient on complete bed rest.
d. Monitor urinary output and daily blood urea nitrogen and serum creatinine levels.
ANS: B
Hypoxemia may precipitate dysrhythmias in patients after aneurysm repair.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1010
MSC: CRNE: CH-32
8. When caring for a patient following an AAA repair, which information is most helpful to the
nurse in assessing the patient’s gastrointestinal function?
a. Serum lipase
b. Bowel sounds
c. Stool character
d. Central venous pressure
ANS: B
The passing of flatus is the best indicator of returning bowel function.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1011
MSC: CRNE: CH-31
9. A 72-year-old man is hospitalized for an aortic dissection of the abdominal aorta that
stabilizes with treatment. What emphasis should the nurse include when developing a teaching
plan for the patient’s discharge?
a. Performing leg exercises to increase peripheral collateral circulation
b. Using nonsteroidal anti-inflammatory drugs (NSAIDs) to control his chronic pain
c. Daily home monitoring of BP and pulse for signs of increased bleeding
d. Using prescribed antihypertensive medications to keep his BP as low as possible to
maintain vital perfusion
ANS: D
Antihypertensive medications are prescribed to help control BP and prevent redissection,
leaking, or rupture.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1013
MSC: CRNE: HW-14
10. Which one of the following therapies is not recommended to treat claudication?
a. Green tea
b. Diet low in fruits and vegetables
c. Vitamin E supplementation
d. Treadmill exercise training
ANS: C
Vitamin E is not recommended to treat claudication.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1017
MSC: CRNE: CH-11
11. During an assessment of a 63-year-old man at the clinic, the patient tells the nurse that for
years he has taken an evening walk, but lately even a short walk causes leg pain and muscle
cramps. If he stops for a while, the pain goes away. What should the nurse do?
a. Ask about any skin colour changes that occur in response to cold.
b. Check for the presence of tortuous veins bilaterally on the legs.
c. Assess for unilateral swelling, redness, and tenderness of either leg.
d. Attempt to palpate the dorsalis pedis and posterior tibial pulses.
ANS: D
The nurse should assess for other clinical manifestations of PAD in a patient who describes
intermittent claudication, including palpating the dorsalis pedis and posterior tibial pulses.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1014
MSC: CRNE: CH-8
12. When performing an assessment with a patient who has chronic PAD, what should the nurse
expect to find?
a. Edema around the ankles and feet
b. Ulceration around the medial malleoli
c. Draining ulcer on the heel
d. Prolonged capillary refill
ANS: D
Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the
periphery.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1014, Table 40-2
MSC: CRNE: CH-6
13. To determine the extent of a patient’s PAD, how does the nurse perform an ankle–brachial
index?
a. By subtracting the mean ankle BP from the mean brachial BP
b. By dividing the Doppler ultrasound-obtained ankle systolic BP by the highest
brachial systolic BP
c. By comparing the amplitude of blood flow of the brachial artery with that of the
posterior tibial artery using a Doppler ultrasonograph
d. By using a Doppler ultrasonograph to take blood pressures at the brachial artery,
thigh, and ankle to determine the change in pressures
ANS: B
The ankle–brachial index is determined by dividing the Doppler-obtained ankle systolic BP
by the highest brachial systolic BP.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1015
MSC: CRNE: CH-4
14. The nurse identifies the nursing diagnosis of ineffective peripheral perfusion related to
decreased arterial blood flow for a patient with chronic PAD. In evaluating the patient
outcomes following patient teaching, the nurse determines a need for further instruction when
the patient makes which of the following statements?
a. “I will wear loose clothing that does not bind across my legs or waist.”
b. “I will change my position every hour and avoid long periods of sitting with my
legs down.”
c. “I will use a heating pad on my feet at night to increase the circulation and warmth
in my feet.”
d. “For about 40 minutes each day, I will walk to the point of pain, rest, and then
walk again until I develop pain.”
ANS: C
Because the patient has impaired circulation and sensation to the feet, the use of a heating pad
could lead to burns.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1019, Nursing Care Plan 40-1
OBJ: 5
TOP: Nursing Process: Evaluation
MSC: CRNE: NCP-14
15. Which of the following is a characteristic of PAD?
a. Normal peripheral pulse
b. Capillary refill 2 seconds
c. Ankle–brachial index 0.98
d. No lower leg edema
ANS: D
A characteristic of PAD is the absence of lower leg edema as compared to lower leg edema in
venous disease.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1014, Table 40-2
MSC: CRNE: CH-8
16. A 36-year-old patient who has a history of thromboangiitis obliterans (Buerger’s disease) is
admitted to the hospital with a gangrenous lesion of his right small toe. In planning expected
outcomes with the patient, which outcome should the nurse give the highest priority?
a. Cessation of smoking
b. Maintenance of appropriate weight
c. Control of serum lipid levels
d. Demonstration of meticulous foot care
ANS: A
Absolute cessation of nicotine use is needed to reduce the risk for amputation in patients with
Buerger’s disease.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1021
MSC: CRNE: HW-13
17. When teaching a patient with Raynaud’s phenomenon how to manage the condition, which of
the following behaviours by the patient indicates that the teaching has been effective?
a. The patient places the hands in hot water when they turn pale.
b. The patient exercises indoors during the winter months.
c. The patient takes pseudoephedrine (Sudafed) for cold symptoms.
d. The patient avoids the use of aspirin and NSAIDs.
ANS: B
Patients should avoid temperature extremes by exercising indoors when it is cold.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Evaluation
REF: page 1022
MSC: CRNE: CH-40
18. A patient admitted to the hospital with a chronic venous insufficiency has physician’s orders
for bed rest with the feet elevated. How should the nurse elevate the patient’s feet?
a. Place two pillows under the calf of her affected leg.
b. Elevate the foot of the bed above the level of her heart.
c. Elevate the bed at the knee, and place pillows under her feet.
d. Place one pillow under her thighs and two pillows under her lower legs.
ANS: B
The purpose of elevation of the feet is to enhance venous flow from the feet to the right
atrium, which is best accomplished by elevating the foot of the bed above the level of the
heart.
PTS: 1
OBJ: 12
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1034
MSC: CRNE: CH-13
19. Duplex scanning confirms the presence of a large deep-vein thrombosis (DVT), and the
physician orders continuous IV heparin infusion for a patient who has swelling and pain of the
upper leg. While the patient is receiving the heparin infusion, what should the nurse do?
a. Avoid any intramuscular (IM) medications to prevent localized bleeding.
b. Notify the physician if the partial thromboplastin time value is greater than 50
seconds.
c. Have vitamin K available in case the patient bleeds from the action of heparin.
d. Start instruction for self-administered subcutaneous heparin injections for longterm home therapy.
ANS: A
IM injections are avoided in patients receiving anticoagulation.
PTS: 1
OBJ: 11
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1030, Table 40-12
MSC: CRNE: CH-47
20. Which of the following is a characteristic of a venous ulcer?
a. Capillary refill 5 seconds
b. Smooth, uniform ulcer margin.
c. Skin warm to touch
d. No dermatitis
ANS: C
Skin temperature is warm with no temperature gradient with a venous ulcer. Capillary refill is
less than 3 seconds, the ulcer margin is irregularly shaped, and the patient frequently has
complaints of dermatitis.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 1014, Table 40-2
OBJ: 8
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
21. The nurse has identified the collaborative problem of “potential complication: pulmonary
embolism” for a patient with DVT. What is an appropriate nursing intervention to prevent
embolization of a thrombus?
a. Maintain bed rest until edema resolves.
b. Monitor vital signs and pulmonary status every 4 hours.
c. Apply compression-gradient stockings while the patient is on bed rest.
d. Perform passive range of motion of the affected extremity to increase venous
return.
ANS: A
Decreasing muscle activity of the leg will help prevent thrombus dislodgement, so bed rest is
warranted.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1030
MSC: CRNE: CH-13
22. A patient has been receiving IV heparin therapy for 6 days for treatment of DVT. The
physician now orders warfarin (Coumadin) without discontinuing the heparin. The patient
questions the nurse about the use of both drugs. What is the best response to the patient?
a. “I will check with the doctor about this. You could be at risk for bleeding with
both drugs.”
b. “Because of the potential for a pulmonary embolism, it is important for you to
have additional anticoagulants.”
c. “It takes several days for the warfarin to have an effect, so we need to keep you on
the heparin for a few more days.”
d. “Because you are allowed more activity now, the heparin is metabolized faster and
must be supplemented with the warfarin.”
ANS: C
IV heparin is used because of the immediate effect on coagulation and is discontinued once
the international normalized ratio value indicates that the warfarin has reached a therapeutic
level.
PTS: 1
OBJ: 11
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1026
MSC: CRNE: CH-44
23. The nurse has initiated discharge teaching for a patient who is to be maintained on warfarin
following hospitalization for DVT. The nurse determines that additional teaching is needed
when the patient makes which of the following statements?
a. “I should change my diet to include more green, leafy vegetables.”
b. “I will check with my physician before I begin or stop any medication.”
c. “I should wear a MedicAlert bracelet to indicate I am on anticoagulant therapy.”
d. “I will need to have my blood drawn routinely to monitor the effects of the
warfarin.”
ANS: A
Patients taking warfarin are taught to follow a consistent diet with regard to foods that are
high in vitamin K, such as green, leafy vegetables.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1031
OBJ: 11
TOP: Nursing Process: Evaluation
MSC: CRNE: CH-48
24. A 42-year-old service counter worker undergoes sclerotherapy for treatment of superficial
varicose veins at an outpatient centre. What should the nurse teach the patient before
discharge?
a. Her exercise should be limited to leg raising and deep knee bends.
b. She needs to revise her work station so that she can sit rather than stand at work.
c. Taking one aspirin a day will help prevent clotting around incompetent venous
valves.
d. Elastic compression stockings should be applied before getting out of bed in the
morning.
ANS: D
Compression stockings are applied with the legs elevated to reduce pressure in the lower legs.
PTS: 1
OBJ: 12
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1032
MSC: CRNE: CH-33
25. In planning care for a patient with a venous stasis ulcer on the right lower leg, what does the
nurse understand is the most important intervention in promoting healing of the ulcer?
a. Adequate dietary intake of proteins and vitamins
b. Prevention of infection with prophylactic antibiotics
c. Application of external compression to the lower leg
d. Keeping the ulcer moist with hydrocolloid dressings
ANS: C
Although all the above interventions are used, the most essential is compression of the leg to
prevent the ulcer from becoming wider and deeper.
PTS: 1
OBJ: 12
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1033
MSC: CRNE: CH-41
26. A patient is admitted to the hospital with a diagnosis of chronic venous insufficiency. Which
of the following statements by the patient is most consistent with this diagnosis?
a. “I have burning leg pains after I walk three blocks.”
b. “I wake up during the night because my legs hurt.”
c. “I can’t get my shoes on at the end of the day.”
d. “I can never seem to get my feet warm enough.”
ANS: C
Because the edema associated with venous insufficiency increases when the patient has been
standing, shoes will feel tighter at the end of the day.
PTS: 1
OBJ: 12
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1026
MSC: CRNE: CH-8
27. Which statement by a patient who is being discharged on anticoagulant therapy 5 days after an
AAA repair and graft indicates that the discharge teaching has been effective?
a. “I will call the doctor if my temperature is higher than 38.8°C.”
b. “I will tell my dentist about my anticoagulant therapy the next time I have an
appointment.”
c. “I should not need to take anything but acetaminophen (Tylenol) for my pain.”
d. “I am eager to get home so that I can pick up my 6-year-old granddaughter.”
ANS: B
Prophylactic antibiotics may be ordered to prevent graft infection when the patient has any
invasive procedures, including dental procedures.
PTS: 1
OBJ: 11
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1030, Table 40-12
MSC: CRNE: NCP-14
28. A patient with PAD has a new prescription for clopidogrel (Plavix). Which information
should the nurse include when teaching the patient about this medication?
a. “Call if you notice that your stools are black or have blood in them.”
b. “Take the clopidogrel on an empty stomach as soon as you get up.”
c. “Change position slowly to avoid dizziness while you are taking clopidogrel.”
d. “You should never use aspirin while you are taking clopidogrel.”
ANS: A
Clopidogrel inhibits platelet function and increases the risk for gastrointestinal bleeding;
therefore, patients should know that if their stools are black or have blood in them, they need
to call their physician.
PTS: 1
OBJ: 11
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1030, Table 40-12
MSC: CRNE: CH-44
29. A patient who is seen in the clinic tells the physician about experiencing cold, numb fingers
when running during the winter and is diagnosed with Raynaud’s phenomenon. The nurse will
anticipate teaching the patient about screening tests for which of the following conditions?
a. Coronary artery disease
b. Familial dyslipidemia
c. High BP
d. Immune disorders
ANS: D
Secondary Raynaud’s phenomenon may occur in conjunction with autoimmune diseases such
as rheumatoid arthritis, and patients should be screened for autoimmune disorders.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1022
MSC: CRNE: CH-8
30. While working in the outpatient clinic, the nurse notes that the chart states that a patient has
intermittent claudication. Which of these statements by the patient would be consistent with
this information?
a. “My fingers hurt when I go outside in cold weather.”
b. “Sometimes I get tired when I climb a lot of stairs.”
c. “When I stand too long, my feet start to swell up.”
d. “My legs cramp whenever I walk more than a block.”
ANS: D
Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent
claudication.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1014
OBJ: 6
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
31. Which of the following results of a D-dimer test would suggest that the patient has venous
thromboembolism?
a. 100 mcg/L
b. 175 mcg/L
c. 225 mcg/L
d. 300 mcg/L
ANS: D
A normal D-dimer result is less than 250 mcg/L; an elevation indicates that the patient may
have venous thromboembolism.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 1025, Table 40-8
MSC: CRNE: CH-6
Chapter 41: Nursing Assessment: Gastrointestinal System
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. Which of the following is an abnormal finding when performing an assessment of an 80year-old patient?
a. Loss of appetite and anorexia
b. Difficulty chewing and swallowing food
c. Complaints of indigestion and stomach fullness
d. Consistent weight loss without change in dietary habits
ANS: D
Unintentional weight loss is not a normal finding in older patients and may indicate a
problem such as cancer or depression.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1066
MSC: CRNE: CH-1
2. To promote bowel evacuation in a patient with irregular bowel elimination, what should the
nurse teach the patient about how to initiate the gastrocolic and duodenocolic reflexes, to
facilitate bowel elimination when the patient attempts defecation?
a. Try defecating after physical exercise.
b. Try defecating after the first daily meal.
c. Try defecating on arising in the morning.
d. Try defecating on seeing and smelling food.
ANS: B
These reflexes are most active after the first daily meal.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1046
MSC: CRNE: CH-38
3. Upon doing a physical assessment of a patient’s gastrointestinal (GI) system, the nurse
would expect to find the cecum and appendix in which quadrant?
a. Right upper quadrant
b. Left upper quadrant
c. Right lower quadrant
d. Left lower quadrant
ANS: C
The cecum and appendix are found in the right lower quadrant.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1051, Table 41-9
OBJ: 5
TOP: Nursing Process: Assessment
MSC: CRNE: CH-4
4. A patient with an obstructed common bile duct has a T-tube placed in the common bile duct
to drain bile produced by the liver. How much would the nurse expect the daily bile
drainage to be?
a. 50 mL
b. 400 mL
c. 1000 mL
d. 2500 mL
ANS: C
The normal excretion of bile by the liver is about 1000 mL daily.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1044, Table 41-1
OBJ: 2
TOP: Nursing Process: Assessment
MSC: CRNE: CH-56
5. A patient is complaining of heartburn and a burning sensation in the epigastric area. What is
a possible etiology for these complaints?
a. Cancer of the esophagus
b. Hiatal hernia
c. Peptic ulcer
d. GI infection
ANS: B
A patient who is complaining of heartburn and a burning in the epigastric area may have a
hiatal hernia, esophagitis, or an incompetent lower esophageal sphincter.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 1054, Table 41-11
OBJ: 7
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
6. A 68-year-old patient awakens at night with heartburn and belching. The nurse recognizes
that these symptoms may occur when which of the following structures relaxes abnormally?
a. Epiglottis
b. Ileocecal valve
c. Pyloric sphincter
d. Lower esophageal sphincter (LES)
ANS: D
The LES at the distal end of the esophagus remains contracted except during swallowing,
belching, or vomiting. The LES is an important barrier that prevents reflux of acidic gastric
contents into the esophagus; therefore, with these symptoms, the patient is experiencing an
abnormal relaxation of the LES.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1043
MSC: CRNE: CH-8
7. A patient has an abnormally high serum ammonia level. Which of the following does the
nurse recognize this finding to be indicative of?
a. A decreased bile flow into the intestine
b. A decrease in the number of bowel bacteria that deaminate amino acids
c. Failure of the liver to convert ammonia absorbed from the bowel to urea
d. An increased reabsorption of urobilinogen from the bowel into the blood
ANS: C
Conversion of ammonia to urea normally occurs in the liver. Elevation can result in hepatic
encephalopathy secondary to liver cirrhosis.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 1062, Table 41-13
OBJ: 2
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
8. Following an episode of vomiting bright red blood, a patient is hospitalized for evaluation.
During physical assessment of the patient, which of the following findings does the nurse
identify as abnormal?
a. Tympany on percussion of the abdomen
b. The liver edge 3 cm below the costal margin
c. Aortic pulsations visible in the epigastric area
d. Bowel sounds of 30 per minute in each quadrant
ANS: B
Normally, the lower border of the liver is not palpable below the ribs, so this finding
suggests hepatomegaly. If the liver is palpable, it is not to extend beyond 1 to 2 cm below
the ribs to remain within normal assessment findings.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 1054, Table 41-11
OBJ: 7
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
9. A patient returns to the nursing unit following an esophagogastroduodenoscopy (EGD).
During postprocedure care, what is it most important for the nurse to do?
a. Position the patient on the right side.
b. Assess the patient’s respiratory pattern.
c. Keep the patient on nothing by mouth (NPO) status until the gag reflex returns.
d. Provide mouth care with saline rinses and gargles.
ANS: C
Immediately after EGD, patients will have a decreased gag reflex and are at risk for
aspiration; therefore, they are to be kept on NPO status until the gag reflex returns (usually 2
to 4 hours).
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 1057, Table 41-12
OBJ: 8
TOP: Nursing Process: Implementation MSC: CRNE: CH-31
10. While obtaining a nursing history from a patient, which over-the-counter medication that the
patient uses does the nurse recognize as being significant to liver disorders?
a. Aspirin
b. Antacids
c. Acetaminophen
d. Cough suppressants
ANS: C
Chronic use of high doses of acetaminophen can be hepatotoxic.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 1049, Table 41-6
OBJ: 5
TOP: Nursing Process: Assessment
MSC: CRNE: CH-48
11. How should the nurse palpate the liver?
a. Press slowly and firmly over the right costal margin with one hand, and withdraw
the fingers quickly after the liver edge is felt.
b. Place one hand on top of the other, and use the upper fingers to apply pressure and
the bottom fingers to feel for the liver edge.
c. Place one hand on the patient’s back, and press upward and inward with the other
hand below the patient’s right costal margin.
d. Place one hand under the patient’s lower ribs, and press the left lower rib cage
forward, palpating below the costal margin with the other hand.
ANS: C
The liver is normally not palpable below the costal margin. The nurse needs to push inward
below the right costal margin while lifting the patient’s back slightly with the left hand.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1052
MSC: CRNE: CH-4
12. Which following finding would the nurse expect to be present during auscultation of the
abdomen of a patient with a bowel obstruction?
a. Decreased, low-pitched bowel sounds
b. Frequent clicking sounds
c. Absence of bowel sounds
d. Loud gurgles
ANS: C
Normal bowel sounds occur 5 to 35 times per minute. The nurse should listen for bowel
sounds in each quadrant for 2 to 5 minutes. With a bowel obstruction, there is an absence of
bowel sounds.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 1054, Table 41-11
OBJ: 7
TOP: Nursing Process: Assessment
MSC: CRNE: CH-38
13. When caring for a patient following a needle biopsy of the liver at the bedside, what should
the nurse do?
a. Elevate the head of the bed to facilitate breathing.
b. Check the patient’s postbiopsy coagulation studies.
c. Place the patient on the right side with the bed flat.
d. Instruct the patient to take shallow breaths to avoid pressure on the liver.
ANS: C
After a biopsy, the patient lies on the right side with the bed flat to splint the biopsy site.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 1059, Table 41-12
OBJ: 8
TOP: Nursing Process: Implementation MSC: CRNE: CH-20
14. The nurse documents the absence of bowel sounds in all quadrants of a patient’s abdomen.
How long should the nurse have auscultated the patient’s abdomen?
a. 8 minutes
b. 10 minutes
c. 16 minutes
d. 20 minutes
ANS: D
To document absent bowel sounds, the nurse should listen to each quadrant for 5 minutes,
for a total of 20 minutes.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1050
MSC: CRNE: CH-4
15. A healthy adult produces approximately how much saliva on a daily basis?
a. 500 mL
b. 1000 mL
c. 1500 mL
d. 2000 mL
ANS: B
Approximately 1 L of saliva is produced each day.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1043
MSC: CRNE: CH-8
16. Which major GI hormone is responsible for stimulating pancreatic bicarbonate secretion?
a. Gastrin
b. Secretin
c. Cholecystokinin
d. Gastric inhibitory peptide
ANS: B
Secretin is responsible for stimulating pancreatic bicarbonate secretion, as well as inhibiting
gastric motility and acid secretion.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 1045, Table 41-3
OBJ: 1
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
17. Which one of the following is an age-related change in the GI system?
a. Increased sense of smell
b. Increased sensitivity of taste buds
c. Atrophy of gingival tissue
d. Increased motility of small intestine
ANS: C
A normal age-related change in the GI system is atrophy of gingival tissue. Other agerelated changes include a decreased sense of smell, a decreased sensitivity of taste buds, and
decreased motility of the small intestine.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 1048, Table 41-5
OBJ: 4
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
Chapter 42: Nursing Management: Nutritional Problems
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. The nurse is teaching a community group to evaluate the nutritional content of food. If the
label on a jar of peanut butter states that each serving contains 16 g of fat and 190 calories,
what is the percentage of fat per serving?
a. 34%
b. 59%
c. 76%
d. 88%
ANS: C
One gram of fat yields 9 calories; 16 multiplied by 9 and divided by 190 (calories per serving)
equals 76%.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
REF: page 1067
MSC: CRNE: CH-8
2. What is the daily recommended intake of fibre for a 38-year-old healthy female?
a. 21 g
b. 25 g
c. 30 g
d. 38 g
ANS: B
The recommended daily fibre intake for women aged 19 to 50 years of age is 25 g.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 1067, Table 42-1
MSC: CRNE: CH-8
3. To determine the underlying factors relating to the undernourishment of an older adult patient,
what is the most appropriate question the nurse can ask?
a. “Do you have a history of any malabsorption diseases?”
b. “Do you have a way to get to a grocery store to buy your food?”
c. “Are you taking any medications that alter your taste or tolerance of foods?”
d. “Can you give me an example of what you normally eat throughout the day?”
ANS: D
This is an open-ended question and will elicit the most information related to the normal daily
eating habits of this patient. The most common method of obtaining information about dietary
intake is the 24-hour recall. The individual or family member is asked to recall everything
eaten within the last 24 hours. Food diaries require asking the individual or family member to
write down everything consumed for a certain period of time.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1072
MSC: CRNE: CH-1
4. A woman weighs 66 kg and asks the nurse how much protein she should include in her diet
each day. What should the nurse recommend that the woman’s diet should include?
a.
b.
c.
d.
36 g protein
53 g protein
75 g protein
98 g protein
ANS: B
The recommended daily protein intake is 0.8 to 1 g/kg of body weight, which for this patient
is 66 kg  0.8 g = 52.8 or 53 g/day.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
REF: page 1067
MSC: CRNE: CH-8
5. During assessment of a patient who is a vegan, the nurse observes for signs of nutritional
deficiency. What is the most common nutritional deficiency related to a strict vegan diet that
would be manifested?
a. Muscle wasting
b. Bleeding gums and loose teeth
c. Pallor and changes in sensation of the extremities
d. Dry, scaly skin and cracked mucous membranes
ANS: C
Cobalamin (vitamin B12) cannot be obtained in foods of plant origin, so the patient will be
most at risk for signs of cobalamin deficiency, such as anemia and peripheral neuropathy.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1068
MSC: CRNE: CH-8
6. When assessing anthropometric measurements on a 28-year-old male, the patient asks what
information is obtained from the measurement of his midarm muscle circumference. The
nurse’s response is based on which following information regarding this measurement?
a. It is a measurement of subcutaneous fat stores.
b. It is used to calculate the body mass index (BMI).
c. It is an indicator of protein stores.
d. It is an indicator of hydration status.
ANS: C
Anthropometric measurements consist of measures of skinfold thickness at various sites,
which are an indicator of subcutaneous fat stores; midarm muscle circumference is an
indicator of protein stores.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1073
MSC: CRNE: CH-8
7. How often would the nurse flush a feeding tube for the patient who is on continuous enteral
nutrition (EN)?
a. Every 2 hours
b. Every 4 hours
c. Every 6 hours
d. Every 12 hours
ANS: B
Feeding tubes should be flushed every 4 hours during continuous feeding.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1078
MSC: CRNE: CH-36
8. A 72-year-old patient is seen at the clinic for symptoms of a urinary tract infection. She is 155
cm tall and weighs 42 kg. The nursing history reveals that she drinks tea and eats toast twice a
day for her meals because it is easy to fix and she has no appetite. Laboratory results include
hemoglobin 6.5 mmol/L (10.5 g/dL) and albumin 20 g/L (2.0 g/dL). The nurse determines that
the patient is near starvation with severe protein depletion when which of the following
additional findings is observed?
a. A small, nodular liver
b. Generalized weakness
c. Edema of the face and extremities
d. Increased blood urea nitrogen and serum creatinine levels
ANS: C
Edema occurs when serum albumin levels and plasma oncotic pressure decrease, as occurs
when a stressor such as infection is imposed on pre-existing poor nutritional status.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1071
MSC: CRNE: CH-8
9. When using a nutrition screening tool, how can the nurse identify a patient at nutritional risk
without further assessment?
a. Pressure ulcers
b. A recent hip fracture
c. Vomiting for 3 days
d. A laparoscopic cholecystectomy 1 week ago
ANS: A
Malnutrition is a major risk factor for pressure ulcers; therefore, the presence of a pressure
ulcer indicates that the patient is at nutritional risk.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1075
MSC: CRNE: CH-4
10. In evaluating a patient outcome of “identifies high-protein foods,” the nurse knows that the
outcome has been met when for lunch, the patient selects which of the following foods from
the hospital menu?
a. Bacon and tomato sandwich, bean soup, and coffee
b. Peanut butter and jelly sandwich, French fries, and whole milk
c. Chicken noodle soup, grilled cheese sandwich, and apple juice
d. Barbecued chicken breast sandwich, fruit yogurt, and skim milk
ANS: D
The poultry and dairy selected are all high in complete protein. Although the other responses
have some high-protein foods, they are not as high in protein.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1068, Table 42-2
MSC: CRNE: CH-8
11. A high-calorie, high-protein diet is provided for a patient with a fractured hip and severe
protein–calorie depletion, but the patient is not able to ingest enough food to correct the
malnutrition. To meet the patient’s nutritional needs, the nurse recognizes that during the
patient’s recovery, the patient will most likely require which of the following?
a. Arrange for smaller portions to be served on patient trays.
b. Serve multiple small feedings of high-calorie, high-protein foods.
c. Give continuous tube feedings of liquid nutritional supplements.
d. Administer intravenous (IV) feeding with parenteral nutrition (PN) solutions.
ANS: B
Eating small amounts of food frequently throughout the day is less fatiguing and will improve
the patient’s ability to take in more nutrients.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1074
MSC: CRNE: CH-35
12. While caring for an older adult patient hospitalized with dehydration and moderate protein–
calorie malnutrition, the nurse identifies a nursing diagnosis of risk for infection based on
what knowledge?
a. Lymphocyte activity and phagocytosis are decreased.
b. Anemia of malnutrition contributes to susceptibility to infection.
c. Weakness of muscles leads to impaired ability to clear the lungs.
d. Wound healing is delayed if protein is not available for tissue building.
ANS: A
The patient’s moderate protein–calorie malnutrition will decrease leukocyte activity and
phagocytosis.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
REF: page 1071
MSC: CRNE: CH-8
13. A 66-year-old patient preparing for surgery for cancer of the lung is very thin and has a very
low-normal position on the BMI chart. The nurse plans preoperative care for the patient with
the knowledge that his nutritional needs include which of the following?
a. An increase in both calories and protein immediately following his surgical
recovery
b. An increase in protein and calorie intake several weeks before surgery
c. A normal amount of calories for a man his age but increased protein to prepare for
healing during the postoperative period
d. Fewer calories than normal for a man his age and weight because his activity will
be decreased during the postoperative period
ANS: B
For patients undergoing major surgery, or those with or at risk of malnutrition, several weeks
of increased protein and calorie intake are needed preoperatively to promote healing and
replenish body stores.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1074
MSC: CRNE: CH-31
14. A patient with difficulty swallowing is started on continuous tube feedings of a full-strength
commercial formula at 100 mL/hour. The patient has six diarrhea stools the first day. What is
the action that is most appropriate for the nurse to take first?
a. Slow the feeding flow rate.
b. Discontinue any water intake.
c. Notify the physician for a change in formula.
d. Check the amount of residual feeding in the stomach.
ANS: A
Loose stools indicate poor absorption of nutrients and a need to slow the feeding rate or
decrease the concentration of the feeding.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1067, Table 42-1
MSC: CRNE: CH-36
15. A patient is commencing continuous tube feedings through a percutaneous endoscopic
gastrostomy tube. To maintain safe and effective delivery of the tube feeding, what should the
nurse do?
a. Flush the tube with 50 mL of water every 8 hours.
b. Obtain a daily X-ray film for verification of tube placement.
c. Check residual volume every 4 hours.
d. Position the patient on the left side with the head of the bed elevated 45 degrees.
ANS: C
Checking gastric residual volumes maybe important when feedings are administered into the
stomach. Check gastric residual volumes every 4 hours during the first 48 hours for gastrically
fed patients.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1077
MSC: CRNE: CH-36
16. PN containing amino acids and dextrose was ordered and begun 24 hours ago for a
malnourished patient. The nurse observes that about 50 mL remain in the PN container.
Which action is appropriate at this time?
a. Infuse the remaining 50 mL, and then hang a new container of PN.
b. Hang a new container of PN, and change the IV tubing and filter.
c. Continue to use the same tubing and filter, and hang a new container of PN.
d. Clarify with the physician if the new PN also requires a tubing and filter change.
ANS: C
All PN solutions are changed at 24 hours. PN solutions containing dextrose and amino acids
require a change in tubing and filter every 72 hours rather than daily.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1085
MSC: CRNE: CH-36
17. Total parenteral nutrition (TPN) with a peripherally inserted central catheter is initiated for a
patient who has tar burns and multiple fractures from a roofing accident. After 6 hours of TPN
infusion, the nurse checks the patient’s capillary blood glucose level and finds it to be 8.9
mmol/L (160 mg/dL). What is the most appropriate nursing action?
a. Notify the physician of the blood glucose level.
b. Recheck the capillary blood glucose in 4 hours.
c. Check the catheter insertion site for signs of inflammation.
d. Slow the rate of the TPN solution to prevent hyperglycemia.
ANS: B
Hyperglycemia can be a metabolic complication of TPN in both those with and those without
diabetes. Uncontrolled hyperglycemia may result in hyperglycemia hyperosmolar syndrome,
coma, and possible death resulting from osmotic diuresis. An increase in blood glucose is
expected on initiation of TPN.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
REF: page 1086
MSC: CRNE: CH-36
18. A feeding tube has been inserted, and the patient is started on continuous EN. As part of the
insertion procedure, the tube was externally secured to the patient. How often should the
nurses assess the patient to ensure that the tube stays secured to the patient’s body and does
not move?
a. Every 4 hours
b. Every 8 hours
c. Every 12 hours
d. Every 24 hours
ANS: D
To ensure that the tube does not move distally, the nurse is to properly secure the tube before
beginning the feeding. Further assessment is to either check before each feed for intermittent
nutrition, and to assess every 24 hours if feedings are continuous.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1080, Table 42-8
MSC: CRNE: CH-36
19. A patient with a central catheter placed in the right subclavian vein for administration of TPN
is very anxious about the catheter and is reluctant to move her right arm or turn her head.
Initially, what should the nurse do?
a. Ask her why she is reluctant to move with the catheter in place.
b. Describe the placement, retention, and rationale for care of the catheter.
c. Reassure her that the TPN line is temporary so that she can anticipate the end of
the treatment.
d. Provide passive range of motion to her right arm and shoulder to demonstrate that
movement will not dislodge the catheter.
ANS: B
Offering the patient information—for example, the placement, retention, and rationale for care
of the catheter—will assist to reduce the patient’s anxiety.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1086, Nursing Care Plan 42-2
OBJ: 4
TOP: Nursing Process: Implementation
MSC: CRNE: CH-12
20. What percentage of the patient’s caloric needs should be met before the nurse would
anticipate discontinuation of the PN?
a. 25%
b. 30%
c. 60%
d. 75%
ANS: C
A general rule is that 60% of caloric needs should be met orally before discontinuation of
either PN or EN.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1086
MSC: CRNE: CH-36
21. The hospital nurse educator is observing a new registered nurse (RN) who is caring for a
patient receiving PN through a single-lumen central line inserted in the right subclavian vein.
Which action by the new RN indicates that the RN can safely care for the patient?
a. Flushes the line after drawing a blood specimen
b. Reminds the patient to keep the right arm straight
c. Checks capillary blood glucose every 8 hours
d. Infuses the PN solution using an infusion pump
ANS: D
An infusion pump is used for PN administration. A single-lumen catheter should not be used
to draw blood because of the risk for infection or clotting.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 1086, Nursing Care Plan 42-2
OBJ: 5
TOP: Nursing Process: Implementation
MSC: CRNE: CH-36
22. A 22-year-old woman is admitted to the hospital with a diagnosis of anorexia nervosa. She is
163 cm tall and weighs 41 kg. On admission, her laboratory tests reveal hypokalemia,
hypercholesterolemia, and iron-deficiency anemia. In planning care for the patient, the nurse
places the highest priority on which of the following nursing diagnoses?
a. Risk for activity intolerance related to anemia and weakness
b. Ineffective health maintenance related to obsession with body image
c. Risk for decreased cardiac output related to electrolyte imbalance
d. Imbalanced nutrition: less than body requirements related to refusal to eat
ANS: C
The patient’s hypokalemia may lead to life-threatening cardiac dysrhythmias, so the patient is
at risk for a decreased cardiac output related to electrolyte imbalance.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1086, Nursing Care Plan 42-2
OBJ: 6
TOP: Nursing Process: Planning
MSC: CRNE: CH-22
23. Which of the following behaviours in a young woman with bulimia would cause the nurse the
most concern?
a. The patient eats only about 20% of breakfast.
b. The patient ambulates continuously in the hallway.
c. The patient goes into the bathroom after each meal.
d. The patient asks for laxatives to treat constipation.
ANS: C
Self-induced vomiting after eating is a hallmark of bulimia and may lead to further electrolyte
disturbances and associated problems, such as cardiac dysrhythmias; therefore, the nurse
would be concerned about the patient who goes into the bathroom after each meal.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1070
MSC: CRNE: CH-35
24. A patient who has a wound infection after major surgery has been taking in only about 50% to
75% of the ordered meals and states, “Nothing on the menu really appeals to me.” Which
nursing action will be most effective in improving the patient’s oral intake?
a. Order at least six small meals daily.
b. Have family members bring in favourite foods from home.
c. Teach the patient about high-calorie, high-protein foods.
d. Make a referral to the dietitian.
ANS: B
The patient’s statement that the hospital foods are unappealing indicates that favourite, homecooked foods might improve intake.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1074
MSC: CRNE: CH-19
25. When using a soft silicone nasogastric tube for enteral feedings, the nurse will need to do
which of the following?
a. Flush the tubing after checking for residual volumes.
b. Administer continuous feedings using an infusion pump.
c. Replace the tube every 3 to 5 days to avoid mucosal damage.
d. Avoid giving medications through the feeding tube.
ANS: A
The soft silicone feeding tubes are small in diameter and can easily become clogged unless
they are flushed after the nurse checks the residual volume.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1078
MSC: CRNE: CH-36
26. A patient who is receiving a continuous tube feeding through a small-bore silicone feeding
tube has a computed tomography (CT) scan ordered and will have to be placed in a flat
position for the scan. What will the nurse plan to do?
a. Ask the physician to reschedule the CT scan.
b. Send the patient for a CT scan with oral suction in case of aspiration.
c. Suspend the feeding 30 to 60 minutes before the scan.
d. Connect the feeding tube to continuous suction during the scan.
ANS: C
Check institution policy for suspending feeding while the patient is supine; however, in
keeping with the guideline that if intermittent delivery is used, the head should remain
elevated for 30 to 60 minutes after feeding, this should be the minimum amount of time that
the tube feeding should be stopped before any procedure requiring the patient to lie flat.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1078
MSC: CRNE: CH-30
27. The nurse notes that the peripheral PN bag is almost empty, and a new PN bag has not yet
arrived from the pharmacy. Which following action is appropriate?
a. Decreasing the rate of the current PN infusion to 10 mL/hour until the new bag
arrives
b. Infusing 5% dextrose in water until the new PN bag is delivered from the
pharmacy
c. Flushing the peripheral line with saline and waiting until the new PN bag is
available
d. Monitoring the patient’s capillary blood glucose until a new PN bag is hung
ANS: B
To prevent hypoglycemia, the nurse should infuse a 5% dextrose solution until the next PN
bag can be started.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1082
MSC: CRNE: CH-36
Chapter 43: Nursing Management: Obesity
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. The nurse is assessing patients at the outpatient clinic. Which of these patients is at risk for
health complications related to weight?
a. A 24-year-old patient with a waist measurement of 75 cm and a hip measurement
of 85 cm
b. A 33-year-old patient who has a body mass index (BMI) of 24 kg/m2
c. A 56-year-old patient who is 180 cm tall and weighs 68 kg
d. A 71-year-old patient who is 160 cm, weighs 55 kg, and carries most of the weight
in the thighs
ANS: A
The waist-to-hip ratio for this patient is 0.88, which exceeds the recommended level of less
than 0.80. A BMI of 24 kg/m2 is normal.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1092
MSC: CRNE: CH-2
2. When taking the health history from a patient with obesity, which information obtained by
the nurse is most helpful in determining whether the patient will be successful in losing
weight?
a. The patient’s BMI is 39 kg/m2.
b. The patient has a history of losing weight successfully in the past.
c. The patient says, “I am ready to make some changes in my lifestyle.”
d. The patient rides a stationary bicycle.
ANS: C
Motivation is essential for a successful outcome and will predict the chance for success
more than the patient’s initial BMI, previous history of weight loss, and activity level.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1099
MSC: CRNE: HW-13
3. The obese patient is at risk for which of the following types of cancer?
a. Lung
b. Pancreas
c. Colorectal
d. Liver
ANS: C
Obese patients are especially at risk for endometrial, breast, cervical, ovarian, uterine,
gallbladder, colorectal, and prostate cancers.
PTS: 1
DIF: Cognitive Level: Knowledge
REF: page 1096, Figure 43-5
OBJ: 3
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
4. The nurse is developing a weight loss plan for a 21-year-old patient with obesity. Which
statement is most likely to help the patient in losing weight on the planned 800-calorie diet?
a. “You will decrease your risk for future health problems such as diabetes by losing
weight now.”
b. “You are likely to start to notice changes in how you feel with just a few weeks of
diet and exercise.”
c. “Most of the weight that you lose during the first weeks of dieting is water weight
rather than fat.”
d. “It will be necessary to change lifestyle habits permanently to maintain weight
loss.”
ANS: B
Motivation is a key factor in successful weight loss, and short-term goals provide a higher
motivation. Once the patient has achieved one goal, subsequent progressive goals are set.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1099
MSC: CRNE: CH-35
5. The nurse teaches the patient that medical monitoring will be required for how long after
bariatric surgery?
a. 6 months
b. 1 year
c. 5 years
d. Lifelong
ANS: D
Bariatric surgery requires lifelong medical monitoring.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1098, Figure 43-6
OBJ: 5
TOP: Nursing Process: Implementation MSC: CRNE: HW-13
6. When working with an obese patient who is enrolled in a behaviour modification program,
which nursing action is most appropriate?
a. Having the patient write down the caloric intake of each meal
b. Asking the patient about situations that tend to increase appetite
c. Suggesting that the patient have a reward, such as a piece of sugarless candy, after
achieving a weight-loss goal
d. Encouraging the patient to eat small amounts throughout the day rather than
having scheduled meals
ANS: B
Behaviour modification programs focus on how and when the person eats and de-emphasize
aspects such as calorie counting.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1102
MSC: CRNE: CH-35
7. After discussing appropriate exercise activities with a patient who is overweight who is
starting to exercise as part of a weight-loss program, the nurse will determine that the
instructions have been understood when the patient reports which of the following?
a. Playing soccer for an hour on the weekend
b. Running for 10 to 15 minutes three times a week
c. Walking for 40 minutes 6 or 7 days a week
d. Lifting weights with friends three times a week
ANS: C
Exercise should be done daily for 30 minutes to an hour.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1102
MSC: CRNE: HW-13
8. When teaching a patient about recording the weight during a weight-loss program, how
often would the nurse recommend that the patient get weighed?
a. Daily for the first 2 weeks, and then weekly thereafter
b. Every other day, in the morning
c. Once a week
d. Twice a week
ANS: C
A weekly check of body weight is a good method of monitoring progress. Daily weighing is
not recommended.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1101
MSC: CRNE: CH-35
9. A patient has been taking orlistat (Xenical) for several months as part of a weight loss
program that also includes a low-fat diet. Which of these data obtained by the nurse
indicates that a change in therapy may be needed?
a. The patient complains of abdominal bloating after meals.
b. The patient has lost 14 kg of the original 30-kg goal.
c. The patient frequently has liquid stools.
d. The patient is pale and has many bruises.
ANS: D
Orlistat may decrease the absorption of fat-soluble vitamins so the patient may not be
receiving an adequate amount of vitamin K, resulting in a decrease in clotting factors,
exhibiting a patient that is pale and has many bruises.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 1102
MSC: CRNE: CH-44
10. Which one of the following represents a “healthy plate”?
a. One-fourth meat, one-fourth grain, one-fourth vegetables, one-fourth
carbohydrates
b. One-half vegetables, one-half meat and meat alternatives
c. One-fourth carbohydrates, one-half meat, one-fourth fruits and vegetables
d. One-fourth meat, one-fourth grain, one-half vegetables and fruits
ANS: D
A “healthy plate” is considered to be one-fourth meat, one-fourth grain, one-half vegetables
and fruits.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1101
MSC: CRNE: CH-8
11. A few months after bariatric surgery, the patient tells the nurse, “My skin is hanging in
folds. I think I need cosmetic surgery.” Which following response by the nurse is most
appropriate?
a. “The skinfolds will gradually disappear once most of the weight is lost.”
b. “The important thing is that your weight loss is improving your health.”
c. “Perhaps you would like to talk to a counsellor about your body image.”
d. “Cosmetic surgery is certainly a possibility once your weight has stabilized.”
ANS: D
Reconstructive surgery may be used to eliminate excess skinfolds after at least a year has
passed since the surgery.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1105
MSC: CRNE: HW-26
12. When developing a weight-reduction plan for a patient with obesity who is starting a
weight-loss program, which question is it most important for the nurse to ask?
a. “What kind of physical activities do you enjoy?”
b. “How long have you been overweight?”
c. “Why do you want to lose weight?”
d. “Have you been on any previous diets?”
ANS: C
The patient should be encouraged to focus on the reasons for wanting to lose weight as he or
she faces the challenges in dealing with obesity.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1109
MSC: CRNE: CH-35
13. A patient with obesity asks the nurse about using orlistat for weight reduction. What does
the nurse tell the patient?
a. This drug can cause serious depletion of fat-soluble vitamins and should be used
only for a few weeks.
b. Weight-reduction drugs of any type are used only for those who do not have the
will power to reduce their intake of food.
c. Drugs may be helpful in weight loss, but weight gain is likely to recur unless
changes in diet and exercise are maintained.
d. The long-term effect of orlistat is not known, and the drug may cause serious side
effects, such as heart valve problems.
ANS: C
Drugs have been used in the treatment of obesity but only as adjuncts to a good diet and
exercise program that is maintained as a way of life.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1102
MSC: CRNE: CH-44
14. In planning preoperative teaching for a patient undergoing a Roux-en-Y gastric bypass as
treatment for morbid obesity, on what does the nurse place the highest priority?
a. Demonstrating passive range-of-motion exercises to the legs
b. Teaching the patient about the postoperative presence of a nasogastric (NG) tube
connected to suction
c. Teaching the patient proper coughing and deep breathing techniques and methods
of turning and positioning
d. Discussing the necessary postoperative modifications in lifestyle
ANS: C
Coughing, deep breathing, and turning can prevent major postoperative complications such
as carbon monoxide retention, hypoxemia, and deep-vein thrombosis.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1104
MSC: CRNE: CH-31
15. A patient returns to the surgical nursing unit following a vertical banded gastroplasty with
an NG tube to low, intermittent suction and a patient-controlled analgesia (PCA) machine
for pain control. During the postoperative care of the patient, the nurse recognizes the need
for which of the following?
a. Promoting return of bowel sounds by discouraging excessive PCA use
b. Maintaining patency of the NG tube with frequent normal saline irrigations
c. Supporting the surgical incision during coughing to prevent dehiscence of the
wound
d. Positioning the patient flat in bed on the right side to promote normal stomach
emptying
ANS: C
Wound dehiscence is a more common problem in patients with obesity postoperatively, and
the patient should cough and breathe deeply every 2 hours.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: pages 1106-1107
MSC: CRNE: CH-32
16. The nurse provides discharge instructions to a patient following gastric bypass surgery for
treatment of obesity. What does the nurse teach the patient?
a. Avoid foods high in carbohydrates, and do not drink fluids with meals.
b. Maintain a liquid diet for about 6 weeks until gastric healing is complete.
c. Eat a high-carbohydrate, high-roughage diet to promote bowel function when solid
foods are allowed.
d. Use exercise and massage to prevent the development of flabby skin resulting from
massive weight loss.
ANS: A
The diet generally prescribed should be high in protein and low in carbohydrates, fat, and
roughage and consist of six small feedings daily. Fluids should not be ingested with the
meal, and in some cases, fluids should be restricted to less than 1000 mL per day.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1107
MSC: CRNE: CH-35
17. In the clinic, the nurse is assessing a new patient who has abdominal obesity and
hypertension. What further assessment should the nurse do to assess for possible metabolic
syndrome?
a. Take the patient’s apical pulse.
b. Ask the patient about dietary intake.
c. Measure the patient’s waist size.
d. Determine the patient’s ethnic origin.
ANS: C
Waist size greater than 101 cm in men or 89 cm in women is one of the diagnostic criteria
for metabolic syndrome. The other criteria are increased triglycerides, low high-density
lipoprotein, hypertension, and increased fasting glucose.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1108, Table 43-10
OBJ: 7
TOP: Nursing Process: Assessment
MSC: CRNE: CH-4
18. A patient is being evaluated at the clinic for possible metabolic syndrome. The nurse will
explain the purpose of which test to the patient?
a. Resting electrocardiogram
b. Fasting blood glucose test
c. Postural blood pressures
d. Cardiac enzyme tests
ANS: B
A fasting blood glucose test result of 10 mmol/L or higher is one of the diagnostic criteria
for metabolic syndrome.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1108, Table 43-10
OBJ: 7
TOP: Nursing Process: Assessment
MSC: CRNE: CH-30
19. A patient has been on a 1000-calorie diet with a daily exercise routine to promote weight
reduction. During the first 2 months of her program, she lost 9 kg of a goal of 23 kg, but she
is discouraged that she has not lost any weight for the last 2 weeks. What should the nurse
inform the patient about?
a. She has probably been unconsciously returning to her former eating habits.
b. She has reached the weight considered by her body to be most efficient for her.
c. Plateaus where no weight is lost normally occur during a weight-loss program.
d. Her steady weight may be due to water gain from eating foods that are high in
sodium content.
ANS: C
During a weight-loss program, normally, a period occurs when the patient reaches a plateau
and does not lose weight.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1101
MSC: CRNE: HW-13
20. In developing a weight-reduction plan for an obese patient who is motivated to lose weight,
it is most important for the nurse to assess which of the following data first?
a. The patient’s current level of physical activity
b. The length of time that the patient has been obese
c. The patient’s social, emotional, and behavioural etiologies of obesity
d. Anthropometric measurements of height, weight, BMI, waist-to-hip ratio, and
skinfold thickness
ANS: C
It is important for the nurse to assess the patient’s thoughts related to what has caused the
obesity, including social, emotional, and behavioural areas.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 1099, Table 43-6
OBJ: 4
TOP: Nursing Process: Assessment
MSC: CRNE: CH-1
21. The nurse has completed initial instruction with a patient regarding a weight-loss program.
The nurse determines that the teaching has been effective when the patient makes which
following statement?
a. “I will keep a diary of daily weights to illustrate my weight loss.”
b. “I plan to lose 1.8 kg a week until I have lost the 27-kg goal.”
c. “I should not exercise more than what is required because increased activity
increases the appetite.”
d. “I plan to join a behaviour modification group to help establish long-term
behaviour changes necessary for weight control.”
ANS: D
The person who is on any type of restrictive dietary program is often encouraged to join a
group of other obese persons who are receiving professional counselling to help them
modify their eating habits. Many self-help groups are available to the person who wants to
learn more about successful dieting and who likes the support of others with the same
problems and experiences.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Evaluation
REF: page 1101
MSC: CRNE: HW-13
22. Which of the following is a hormone in the body that stimulates appetite?
a. Leptin
b. Insulin
c. Ghrelin
d. Cholecystokinin
ANS: C
Ghrelin is produced in the stomach and stimulates appetite.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 1094, Table 43-3
OBJ: 1
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
23. A 47-year-old woman has experienced continual weight gain since her early twenties and is
seeking assistance for weight reduction. She is 155 cm tall and weighs 85 kg. The nurse
calculates her BMI at 35.3 and classifies her weight condition as which of the following?
a. Obesity
b. Overweight
c. Severe obesity
d. Morbid obesity
ANS: A
The obesity category is divided into three classes: a BMI of 30.0 to 34.9 kg/m2 is considered
high risk, a BMI of 35.0 to 39.9 kg/m2 is very high risk, and a BMI of 40.0 kg/m2 and over
is extremely high risk according to Canadian guidelines.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 1092, Table 43-1
OBJ: 2
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
Chapter 44: Nursing Management: Upper Gastrointestinal Problems
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. Which information about a patient who has just been admitted to the hospital with nausea and
vomiting will require the most rapid nursing intervention?
a. The patient has been vomiting several times a day for the last 4 days.
b. The patient is lethargic and difficult to arouse.
c. The patient’s chart indicates a recent resection of the small intestine.
d. The patient has taken only sips of water.
ANS: B
A lethargic patient is at risk for aspiration, and the nurse will need to position the patient to
decrease aspiration risk.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1115
MSC: CRNE: CH-20
2. What is the location of the vomiting centre that coordinates the multiple components involved
in vomiting?
a. Chemoreceptor zone
b. Brainstem
c. Vestibular area
d. Visceral receptors from afferent fibres in the gastrointestinal (GI) tract
ANS: B
The vomiting centre in the brainstem coordinates the multiple components involved in
vomiting.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 1114
MSC: CRNE: CH-8
3. The nurse identifies the nursing diagnosis of deficient fluid volume for a patient with
prolonged vomiting. Which of the following nursing assessments is most helpful in
determining the source of the vomiting?
a. Ask the times when the vomiting occurs.
b. Determine the amount and character of the vomitus.
c. Measure the intake and output, and daily weight patterns.
d. Assess the serum sodium, potassium, and chloride levels.
ANS: A
When assessing vomiting, it is important for the nurse to assess when the vomiting occurs to
help in understanding the cause.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1115
MSC: CRNE: CH-1
4. A patient who has been on nothing by mouth (NPO) status during treatment for nausea and
vomiting related to gastric irritation is to start oral intake of clear liquids. To promote
tolerance to oral fluids, what should the nurse first offer the patient?
a.
b.
c.
d.
Orange juice
Hot chicken broth
A dish of lemon gelatin
Coffee with cream and sugar
ANS: C
Clear liquids are usually the first foods started after a patient has been nauseated. Acidic foods
such as orange juice, very hot foods, and coffee are poorly tolerated when patients have been
nauseated.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1116
MSC: CRNE: CH-34
5. When a patient with persistent nausea and severe vomiting is admitted to the hospital for
control of the symptoms, what is the first order that the nurse should act on?
a. Provide oral care with moistened swabs.
b. Infuse normal saline at 250 mL/hour.
c. Insert a 16-gauge nasogastric (NG) tube.
d. Administer intravenous (IV) ondansetron (Zofran).
ANS: B
Because the patient has severe dehydration, rehydration with IV fluids is the priority. The
other orders should be accomplished as quickly as possible after the IV fluids are initiated.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 1115
MSC: CRNE: CH-22
6. A patient who is on NPO status and has been receiving parenteral nutrition for 2 weeks
develops bilateral pain in the area of the ears. The nurse recognizes that the patient is at risk
for development of which of the following conditions?
a. Parotitis
b. Stomatitis
c. Oral candidiasis
d. Vincent’s infection (trench mouth)
ANS: A
Clinical manifestations of parotitis include pain and swelling in the area of the gland and ear,
absence of salivation, purulent exudate from the gland, erythema, and ulcer.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1119, Table 44-3
MSC: CRNE: CH-8
7. The nurse teaches a patient who is trying to stop the use of smokeless tobacco to examine the
mouth routinely for the danger signs of oral cancer, especially for the presence of which of the
following signs?
a. Acutely sore ulcers
b. A red, velvety patch
c. White, curdlike plaques
d. Reddened and swollen tongue
ANS: B
A red, velvety patch suggests erythroplasia, which has a high incidence (greater than 50%) of
progression to squamous cell carcinoma.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1120
MSC: CRNE: CH-8
8. A 62-year-old man with weight loss, difficulty chewing, and malaise has been diagnosed with
squamous cell carcinoma of the oral cavity. Which of the following information obtained
from the patient during the nursing history is the most significant risk factor for oral cancer?
a. Use of tobacco
b. Neglected oral hygiene
c. Chronic overexposure to the sun
d. Recurrent herpes simplex infections
ANS: A
Tobacco use greatly increases the risk for oral cancer. A history of acute infections such as
strep throat is not a risk factor for oral cancer, although chronic irritation of the oral mucosa
does increase risk.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1119
MSC: CRNE: HW-13
9. A patient with oral squamous cell carcinoma is transferred to the postoperative surgical unit
after a hemiglossectomy and radical neck procedure. When planning care, the nurse will
anticipate the need to do which of the following?
a. Insert a long-term central venous catheter for parenteral nutrition.
b. Use an alphabet board to assist the patient with communication.
c. Administer chemotherapy starting the first postoperative day.
d. Reinforce pressure dressings at the surgical incision.
ANS: B
The patient will have a tracheostomy after having a radical neck procedure, and the nurse
should plan ways to allow the patient to communicate.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1121
MSC: CRNE: NCP-2
10. A patient with chronic gastroesophageal reflux disease (GERD) is experiencing increasing
discomfort. During assessment of the patient’s current management of the problem, the nurse
determines that further teaching is needed when the patient makes which following statement?
a. “I use antacids between meals and at bedtime.”
b. “I quit smoking several years ago, but I still chew a lot of gum.”
c. “I’ve learned to sleep with the head of the bed elevated on 10-cm blocks.”
d. “I eat small meals throughout the day and have a bedtime snack.”
ANS: D
GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to
avoid eating at bedtime.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1124
MSC: CRNE: CH-35
11. When admitting a patient with a stroke who is unconscious and unresponsive to stimuli, the
nurse learns from the patient’s wife that the patient has a history of GERD. About which of
the following will the nurse complete frequent assessments?
a. Bowel sounds
b. Breath sounds
c. Apical pulse
d. Abdominal girth
ANS: B
Because GERD may cause aspiration, the unconscious patient is at risk for developing
aspiration pneumonia, so the nurse should frequently assess breath sounds.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1123
MSC: CRNE: CH-8
12. A patient with recurring heartburn tells the nurse that he has used over-the-counter antacids
and famotidine (Pepcid), but the physician has now prescribed esomeprazole (Nexium). In
teaching the patient about this medication, what should the nurse explain about this drug?
a. It reduces the reflux of gastric acid into the esophagus by increasing the rate of
gastric emptying.
b. It coats the stomach and protects the stomach lining and esophagus from the
effects of increased gastric acid.
c. It is used to treat GERD by decreasing stomach acid production.
d. It provides a quick, but short-lived, relief of symptoms and is an inexpensive
means of treating gastroesophageal reflux.
ANS: C
The proton pump inhibitors decrease the rate of gastric acid secretion; therefore, production is
decreased.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1124
MSC: CRNE: CH-44
13. When teaching a patient with GERD about recommended dietary modifications, the nurse
explains that which of the following foods decreases lower esophageal sphincter (LES)
pressure and should be avoided?
a. Acidic and pickled foods
b. Coffee, tea, and chocolate
c. Milk and other dairy products
d. Spicy and highly seasoned foods
ANS: B
Foods that decrease LES pressure such as chocolate, peppermint, coffee, and tea should be
avoided, because they predispose to reflux.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1124
MSC: CRNE: CH-8
14. A patient returns to the surgical unit following an abdominal Nissen fundoplication for
treatment of GERD. Four hours postoperatively, which one of the following is it most
important for the nurse to address?
a. The patient has dyspnea and absent breath sounds throughout the left lung.
b. The patient complains of level 6 (of a 0 to 10 scale) abdominal pain.
c. The patient has decreased bowel sounds in all four quadrants.
d. The patient is experiencing intermittent waves of nausea.
ANS: A
Decreased breath sounds on one side may indicate a pneumothorax, which requires rapid
diagnosis and treatment.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1124
MSC: CRNE: CH-8
15. A patient who has recently been experiencing frequent heartburn is seen in the clinic. The
nurse will anticipate teaching the patient about which of the following?
a. Endoscopy procedures
b. Barium swallow
c. Radionuclide tests
d. Proton pump inhibitors
ANS: D
Because diagnostic testing for heartburn that is probably caused by GERD is expensive and
uncomfortable, proton pump inhibitors are frequently used for a short period as the first step
in the diagnosis of GERD.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 1124
MSC: CRNE: CH-44
16. A patient tells the nurse that when he feels nauseous, he takes ginger. The nurse should
instruct the patient that he should not take ginger if he is also taking which one of the
following medications?
a. Digoxin
b. Penicillin
c. Tetracycline
d. Protein pump inhibitor
ANS: A
He should not be taking ginger if he is also taking digoxin or hypoglycemic agents, or is on
anticoagulant therapy.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1116, Complementary and Alternative Therapies box
OBJ: 1
TOP: Nursing Process: Implementation
MSC: CRNE: CH-11
17. Which information will the nurse include when teaching a patient with newly diagnosed
GERD?
a. “Peppermint tea may be helpful in reducing your symptoms.”
b. “You will need to keep the head of your bed elevated on blocks.”
c. “You should avoid eating between meals to reduce acid secretion.”
d. “Vigorous physical activities may increase the incidence of reflux.”
ANS: B
Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1125
MSC: CRNE: CH-20
18. A patient undergoes an esophagectomy with a synthetic graft replacement for treatment of
esophageal cancer. Following his return to the surgical unit, why should the nurse place the
patient in a semi-Fowler’s position?
a. To facilitate respiratory function
b. To prevent reflux of gastric secretions
c. To promote drainage from the NG tube
d. To promote movement of fluids through the GI tract
ANS: B
Postoperatively, the patient is to be in a semi-Fowler’s position to prevent reflux of gastric
secretions.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1129
MSC: CRNE: CH-31
19. Which of the following will the nurse plan to teach the patient with newly diagnosed
achalasia?
a. Drinking fluids with meals should be avoided.
b. Lying down and resting after meals is recommended.
c. A liquid or blenderized diet will be necessary.
d. Endoscopic procedures may be used for treatment.
ANS: D
Endoscopic and laparoscopic procedures are the most effective therapy for improving
symptoms caused by achalasia.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1129
MSC: CRNE: CH-8
20. A 62-year-old patient develops an acute gastritis caused by the nonsteroidal anti-inflammatory
drug (NSAID) she uses to treat her arthritis. In teaching the patient about the effects of these
drugs on the stomach’s mucosal barrier, what should the nurse explain?
a. “NSAIDs stimulate histamine receptors, which increase the release of hydrochloric
acid.”
b. “NSAIDs inhibit the synthesis of prostaglandins that normally decrease acid
secretion in the stomach.”
c. “NSAIDs stimulate the parietal cells of the stomach to release pepsin, which is
capable of digesting stomach tissue.”
d. “The inflammatory response stimulated by prostaglandin release in the stomach is
increased with the use of NSAIDs.”
ANS: B
NSAIDs are known to inhibit the synthesis of prostaglandins that are protective to the gastric
mucosa.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1132
MSC: CRNE: CH-44
21. Cobalamin injections have been prescribed for a patient with chronic atrophic gastritis. The
nurse determines that teaching regarding the injections has been effective when the patient
makes which following statement?
a. “These injections will decrease my risk of stomach cancer.”
b. “These injections will increase the hydrochloric acid in my stomach.”
c. “The cobalamin injections need to be taken until my inflamed stomach heals.”
d. “I must take these injections to prevent me from becoming anemic.”
ANS: D
Cobalamin supplementation prevents the development of pernicious anemia.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1133
MSC: CRNE: NCP-14
22. A patient with chronic gastritis associated with the presence of Helicobacter pylori is treated
with triple-drug therapy. Which of the following medications should the nurse explain to the
patient are commonly included in this regimen?
a. Tetracycline, bismuth subsalicylate (Pepto-Bismol), and amoxicillin
b. Tetracycline, metronidazole (Flagyl), and bismuth subsalicylate (Pepto-Bismol)
c. Amoxicillin, clarithromycin (Biaxin), and omeprazole (Losec)
d. Metronidazole (Flagyl), clarithromycin (Biaxin), and omeprazole (Losec)
ANS: C
The drugs used in triple-drug therapy include a proton pump inhibitor such as omeprazole and
the antibiotics amoxicillin and clarithromycin.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1133, Table 44-13
MSC: CRNE: CH-8
23. Which one of the following drug classifications increases lower esophageal sphincter pressure
and is used in the treatment of GERD?
a. Prokinetic
b. Antacids
c. Cholinergic
d. H2-receptor blockers
ANS: C
The mechanism of action of cholinergic drugs is to increase lower esophageal sphincter
pressure.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1124, Table 44-9
MSC: CRNE: CH-44
24. A patient is hospitalized with vomiting of “coffee grounds” emesis of unknown cause. The
patient is very anxious about the source of the bleeding and asks the nurse whether it is
possible to find the cause. Which of the following diagnostic tests should the nurse explain
can most accurately identify the source of the bleeding?
a. An endoscopy
b. An angiography
c. A gastric analysis
d. Barium contrast studies
ANS: A
Endoscopy is the primary tool for visualization and diagnosis of upper GI bleeding.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1135
MSC: CRNE: CH-8
25. What information is most important for the nurse to obtain during the initial assessment of a
patient admitted to the emergency department with vomiting of bright-red blood?
a. Current medical problems
b. Medications the patient is taking
c. History of prior bleeding episodes
d. Vital signs and symptoms of hypovolemia
ANS: D
The nurse is concerned about blood loss and possible hypovolemic shock in a patient with
acute GI bleeding. Blood pressure and pulse are the best indicators of these complications.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1136
MSC: CRNE: CH-62
26. The physician orders IV vasopressin (Pitressin) to be administered to a patient with
esophageal bleeding. The nurse monitors for which of the following during administration of
this medication?
a. Polyuria
b. Metabolic alkalosis
c. Intention tremors
d. Chest pain
ANS: D
Vasopressin decreases coronary artery perfusion and may cause coronary ischemia.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1136
MSC: CRNE: CH-44
27. The physician orders IV ranitidine (Zantac) every 6 hours for a patient with an acute
exacerbation of his chronic peptic ulcer disease. As the nurse administers the drug, the patient
asks about it, saying that the only ulcer drug he had been given IV before was cimetidine
(Tagamet). In responding to the patient, what should the nurse explain?
a. Both drugs neutralize stomach acid, but ranitidine has fewer side effects than does
cimetidine.
b. Ranitidine and cimetidine work the same way to decrease the effect of histamine
and decrease acidity.
c. Ranitidine blocks histamine receptors to decrease acid production, but cimetidine
acts on the nervous system to decrease gastric motility and secretions.
d. Cimetidine creates a protective pastelike complex covering the ulcer during
healing, whereas ranitidine coats the entire stomach and duodenum.
ANS: B
Ranitidine is an H2-receptor blocker, which decreases the secretion of gastric acid.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1136, Table 44-16
MSC: CRNE: CH-44
28. The family member of a patient who has suffered massive abdominal trauma in an automobile
accident asks the nurse why the patient is receiving famotidine. The nurse will explain that the
medication will do which of the following?
a. Decrease the risk for nausea and vomiting.
b. Prevent aspiration of gastric contents.
c. Inhibit the development of stress ulcers.
d. Lower the chance for H. pylori infection.
ANS: C
Famotidine is administered to prevent the development of physiological stress ulcers, which
are associated with a major physiological insult such as massive trauma.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1136
MSC: CRNE: CH-44
29. A patient with a bleeding duodenal ulcer has an NG tube in place, and the physician orders 30
mL of aluminum hydroxide–magnesium hydroxide (Maalox) to be instilled through the tube
every hour. How can the nurse evaluate the effectiveness of this treatment?
a. Monitor arterial blood gas values.
b. Check each stool for the presence of occult blood.
c. Periodically aspirate and test stomach contents for pH.
d. Measure the amount of residual stomach contents hourly.
ANS: C
The purpose of antacids is to increase gastric pH. Checking gastric pH is the most direct way
of evaluating the effectiveness of the medication.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1145
MSC: CRNE: CH-44
30. A patient with a peptic ulcer who has an NG tube develops sudden, severe upper abdominal
pain, diaphoresis, and a very firm abdomen. Which action should the nurse take next?
a. Irrigate the NG tube.
b. Obtain the vital signs.
c. Give the ordered antacid.
d. Listen for bowel sounds.
ANS: B
The patient’s symptoms suggest acute perforation, and the nurse should assess for signs of
hypovolemic shock.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1146
MSC: CRNE: CH-6
31. A patient undergoes a gastroduodenostomy (Billroth I) for treatment of a perforated ulcer.
Postoperative orders include morphine with a patient-controlled analgesia (PCA) device and
NPO status with low, intermittent NG suction in addition to IV fluids and antibiotics. Twenty
four hours after the patient returns to the surgical unit, she complains of increasing abdominal
pain. The nursing assessment reveals absence of bowel sounds and 200 mL of bright-red NG
drainage in the last hour. What is the most appropriate nursing action?
a. Notify the physician.
b. Irrigate the NG tube per orders.
c. Assess the patient’s use of the PCA.
d. Splint the abdomen to relieve pressure on the incision.
ANS: A
Increased pain and 200 mL of bright-red NG drainage 12 hours after surgery indicate possible
postoperative hemorrhage, and immediate actions such as blood transfusion, a return to
surgery, or both are needed.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1153
MSC: CRNE: CH-27
32. The nurse implements discharge teaching for a patient following a gastroduodenostomy for
treatment of a peptic ulcer. Which patient statement indicates that the teaching has been
effective?
a. “I will need to choose foods that are low in fat and high in carbohydrate.”
b. “I will try to drink liquids along with my meals.”
c. “Vitamin injections may be needed to prevent problems with anemia.”
d. “The surgery has cured my peptic ulcer disease.”
ANS: C
Cobalamin deficiency may occur after partial gastrectomy, and the patient may need to
receive cobalamin injections.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1153
MSC: CRNE: NCP-14
33. A patient recovering from a gastrojejunostomy (Billroth II) for treatment of a duodenal ulcer
develops dizziness, weakness, and palpitations, with an urge to defecate about 20 minutes
after eating. To avoid recurrence of these symptoms, what should the nurse teach the patient
to do?
a. Increase fluid intake with meals.
b. Lie down for about 30 minutes after each meal.
c. Drink sugared fluids or eat candy after each meal.
d. Eat a high-carbohydrate, low-fat diet in six small feedings a day.
ANS: B
The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying
down after eating.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1152
MSC: CRNE: CH-20
34. The following orders are received for a patient who has vomited 1500 mL of bright-red blood.
Which order will the nurse act on first?
a. Infuse 1000 mL of lactated Ringer’s solution.
b. Administer IV famotidine 40 mg.
c. Insert an NG tube, and connect it to suction.
d. Type and crossmatch for 4 units of packed red blood cells.
ANS: A
Because the patient has vomited a large amount of blood, correction of hypovolemia and
prevention of hypovolemic shock are the priorities.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1138
MSC: CRNE: CH-22
35. A patient who uses an NSAID for management of severe osteoarthritis has recently developed
melena. Which of the following changes in the treatment plan would the nurse expect to be
made by the physician?
a. Administration of ranitidine
b. Substitution of corticosteroids for the NSAID
c. Substitution of acetaminophen for the NSAID
d. Administration of misoprostol (Cytotec) with the NSAID
ANS: D
Misoprostol, a prostaglandin analogue, is the only drug approved for preventing gastric ulcers
induced by NSAIDs.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1154
MSC: CRNE: CH-44
36. The physician prescribes antacids and sucralfate (Carafate) for treatment of a patient’s peptic
ulcer. To promote the effects of these drugs, what should the nurse teach the patient to take?
a. Sucralfate and antacids together 30 minutes before each meal
b. Antacids every 2 hours while awake and sucralfate at bedtime
c. Antacids 1 hour before each meal and sucralfate between meals
d. Sucralfate 30 minutes before each meal and antacids 1 and 3 hours after meals and
at bedtime
ANS: D
Sucralfate is most effective when the pH is low and should not be given with or soon after an
antacid. Antacids are most effective when taken after eating. Administration of sucralfate 30
minutes before eating and antacids just after eating will ensure that both drugs can be most
effective.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1145
MSC: CRNE: CH-44
37. In teaching a patient with peptic ulcer disease about nutritional management of the disorder,
what should the nurse stress that the patient should do?
a. Avoid raw fruits and vegetables.
b. Avoid foods that cause discomfort.
c. Eat six small meals a day with bland foods.
d. Eliminate milk and milk products from the diet.
ANS: B
The best information is that each individual should choose foods that are not associated with
postprandial discomfort.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1150
MSC: CRNE: CH-8
38. A patient with acute GI bleeding is receiving normal saline IV at a rate of 500 mL/hour.
Which of the following assessment data obtained by the nurse are most important to
communicate immediately to the physician?
a. The NG suction is returning “coffee grounds” material.
b. The patient’s lungs have crackles audible to the midline.
c. The patient’s blood pressure has increased to 142/94 mm Hg.
d. The bowel sounds are very hyperactive in all four quadrants.
ANS: B
The patient’s lung sounds indicate that pulmonary edema may be developing as a result of the
rapid infusion of IV fluid and that the fluid infusion rate should be slowed.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1138
MSC: CRNE: CH-23
39. A 68-year-old patient has had intermittent epigastric distress, anorexia, and weight loss over a
period of 6 months. She is hospitalized with anemia and ascites, and an endoscopic
examination reveals cancer located in the fundus of the stomach. The nurse plans care for the
patient with the knowledge that these findings indicate which of the following?
a. The patient has a poor prognosis with any therapy.
b. Surgical intervention is not indicated for the patient.
c. Radiation therapy is the treatment of choice for the patient.
d. The patient has a good prognosis with the use of combination chemotherapy.
ANS: A
The survival rate for patients with stomach cancer is low, and the presence of ascites indicates
metastasis and is a poor prognostic sign.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1154
MSC: CRNE: CH-8
40. Which of the following foods are associated with an increased incidence of gastric cancer that
the nurse should specifically question the patient about when obtaining a nursing history?
a. Milk and milk products
b. Raw fruits and vegetables
c. Smoked, highly salted, or spiced foods
d. Beans and other gas-forming foods
ANS: C
Smoked foods such as bacon, ham, and smoked sausage, highly salted foods, and spiced foods
increase the risk for stomach cancer.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1154
MSC: CRNE: CH-8
41. Which agent that causes bacterial food poisoning is known to have the quickest onset of
symptoms?
a. Listeria
b. Escherichia coli
c. Clostridium botulinum
d. Staphylococcus aureus
ANS: D
S. aureus has the quickest onset of symptoms, as early as 30 minutes to 7 hours after
ingestion.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1157, Table 44-27
MSC: CRNE: CH-8
42. A patient tells the nurse that she frequently buys canned foods at a discount price because they
are dented. She asks if there is a way to prevent food poisoning from using improperly canned
products. Which of the following would be the nurse’s best response?
a. Discard the canned food if the smell is abnormal.
b. Boil the canned food for 15 minutes before serving.
c. There is no known way to prevent food poisoning from improperly canned foods.
d. Open the cans immediately after purchase, and place the contents in plastic
containers in the freezer for 48 hours.
ANS: B
If there is suspicion that the food is improperly canned, it should be boiled for at least 15
minutes before serving.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1157, Table 44-27
MSC: CRNE: HW-13
43. The nurse suspects the possibility of E. coli food poisoning when several individuals eating at
the same establishment develop the onset of which of the following symptoms?
a. Fever and chills
b. Nausea and vomiting
c. Hemorrhagic diarrhea
d. Headache, dizziness, and muscular incoordination
ANS: C
E. coli O157:H7 causes hemorrhagic colitis with bloody diarrhea.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1158
MSC: CRNE: CH-20
Chapter 45: Nursing Management: Lower Gastrointestinal Problems
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A patient with acute diarrhea of 24 hours’ duration calls the clinic to ask for directions for
care. In talking with the patient, what should the nurse do?
a. Ask the patient to describe the character of the stools and any associated
symptoms.
b. Advise the patient to use over-the-counter loperamide (Imodium) to slow
gastrointestinal motility.
c. Inform the patient that laboratory testing of blood and stool specimens will be
necessary.
d. Advise the patient to drink clear liquid fluids with electrolytes, such as Gatorade or
Pedialyte.
ANS: A
The nurse’s initial response should be further assessment of the patient. The other responses
may be appropriate, depending on what is learned in the assessment.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1164
MSC: CRNE: CH-3
2. A 78-year-old patient is transferred to the hospital from a nursing home on developing
abdominal pain and watery, incontinent diarrhea following a course of antibiotic therapy for
pneumonia. Stool cultures reveal the presence of Clostridium difficile. In planning care for the
patient, the nurse will do which of the following?
a. Order a diet with no dairy products for the patient.
b. Place the patient in a private room with contact isolation.
c. Explain to the patient why antibiotics are not being used.
d. Teach the patient about proper food handling and storage.
ANS: B
Because C. difficile is highly contagious, the patient should be placed in a private room and
contact precautions should be used.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1165
MSC: CRNE: HW-8
3. An older adult man is hospitalized with a diagnosis of Giardia lamblia infection. He
frequently has explosive diarrhea stools that he is unable to control. He closes his eyes and
will not talk to the nurse when his linens are changed and skin care is performed. To help
maintain the patient’s self-esteem, what should the nurse implement?
a. Use incontinence briefs for the patient so that cleaning him is less cumbersome and
embarrassing.
b. Request an order for an antidiarrheal drug from the physician to help control the
diarrhea episodes.
c. Assure the patient that his lack of control is temporary and will resolve with
treatment of the disorder.
d. Acknowledge his behaviour as reflective of a difficult situation for him, and
provide privacy during hygiene.
ANS: D
Acknowledging the difficulty of the situation and providing privacy will decrease the patient’s
embarrassment about the incontinence.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1186, Nursing Care Plan 45-3
OBJ: 1
TOP: Nursing Process: Implementation
MSC: CRNE: PP-1
4. Which of the following is a neoplastic polyp of the large intestine?
a. Familial juvenile polyps
b. Pseudopolyps
c. Hereditary polyposis syndromes
d. Leiomyomas
ANS: C
Hereditary polyposis syndromes are neoplastic polyps of the large intestine. Familial juvenile
polyps, pseudopolyps, and leiomyomas are non-neoplastic polyps of the large intestine.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 1169, Table 45-28
MSC: CRNE: CH-8
5. Psyllium (Metamucil) is prescribed for a patient with chronic constipation. In teaching the
patient about chronic constipation, what should the nurse stress?
a. The use of bulk-forming laxatives is safe, and they do not cause any adverse
effects.
b. At least 3000 mL of fluid daily must be taken to prevent impaction or bowel
obstruction.
c. Dietary sources of fibre should be eliminated from the diet to prevent excessive
gas formation.
d. Supplemental fat-soluble vitamins must be taken because the medication blocks
absorption of these vitamins.
ANS: B
A high fluid intake is needed to prevent hardened stools leading to impaction or bowel
obstruction. Although bulk-forming laxatives are generally safe, the nurse should emphasize
the possibility of constipation or obstipation if inadequate fluid intake occurs.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1171, Table 45-11
MSC: CRNE: CH-38
6. A patient is admitted to the emergency department with severe abdominal pain, anorexia, and
chills. His vital signs include temperature 38.3°C, pulse 130 beats/min, respiration 34
breaths/min, and blood pressure (BP) 82/50 mm Hg. His pain is more intense in the left lower
quadrant but radiates throughout the entire abdomen, with rebound tenderness and abdominal
rigidity. The nurse plans care for the patient based on the knowledge that management of his
condition initially involves which of the following actions?
a. Intravenous (IV) fluid resuscitation
b. Exploratory laparotomy
c. Administration of IV antibiotics
d. Diagnostic testing with barium studies and endoscopy
ANS: A
The priority for this patient is to treat the patient’s hypovolemic shock with fluid infusion. The
other actions should be implemented after starting the fluid infusion.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1171, Table 45-14
MSC: CRNE: CH-22
7. A patient is being evaluated in the emergency department for acute lower abdominal pain with
diarrhea and vomiting. During the nursing history, what is the most helpful question to obtain
information regarding the patient’s condition?
a. “What do you usually eat?”
b. “Can you tell me about your pain?”
c. “What is your usual elimination pattern?”
d. “When did the diarrhea and vomiting start?”
ANS: B
A complete description of the pain provides clues about the cause of the problem.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1176
MSC: CRNE: CH-1
8. Two days following an exploratory laparotomy with a resection of a short segment of small
bowel, the patient complains of gas pains and abdominal distension. Which nursing action is
most appropriate to take at this time?
a. Assisting the patient to ambulate
b. Administering the ordered IV morphine sulphate
c. Giving a return-flow enema
d. Inserting the ordered promethazine (Phenergan) suppository
ANS: A
Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1174, Nursing Care Plan 45-2
OBJ: 2
TOP: Nursing Process: Implementation
MSC: CRNE: CH-31
9. Which stool consistency would the nurse expect to see in a patient with a sigmoid colostomy?
a. Semiliquid
b. Semiformed
c. Formed
d. Pasty
ANS: C
A patient with a sigmoid colostomy would be expected to have a formed soot consistency. A
semiliquid or semiformed stool consistency would be expected with a transverse colostomy. A
pasty stool consistency would be expected with an ileostomy.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1202, Table 45-33
MSC: CRNE: CH-38
10. A patient is brought to the emergency department following an automobile accident in which
she suffered blunt trauma to the abdomen. She is splinting her abdomen and complaining of
pain, and bowel sounds are decreased. A peritoneal lavage returns brown drainage. Based on
the results of the lavage, what should the nurse plan for?
a. Preparation for a paracentesis
b. Administration of pain medications
c. Continued monitoring of the patient’s condition
d. Immediate preparation of the patient for surgery
ANS: D
Return of brown drainage suggests perforation of the bowel and the need for immediate
surgery.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
REF: page 1175, Table 45-14
MSC: CRNE: CH-27
11. A patient is brought to the emergency department with a knife impaled in his abdomen
following a domestic fight. During the initial assessment of the patient, what is it most
important for the nurse to do?
a. Assess the BP and pulse.
b. Remove the knife to assess the wound.
c. Determine the presence of Rovsing’s sign.
d. Palpate the abdomen for distension and rigidity.
ANS: A
The initial assessment is focused on determining whether the patient has hypovolemic shock;
therefore, the priority action is to assess the BP and pulse.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1175, Table 45-14
MSC: CRNE: CH-1
12. A 20-year-old university student is admitted to the emergency department for evaluation of
abdominal pain with nausea and vomiting. She has a white blood cell count of 14,000
cells/microlitre with a shift to the left. Which one of the following actions is appropriate for
the nurse to take?
a. Encourage the patient to take sips of clear liquids.
b. Apply an ice pack to the right lower quadrant.
c. Check for rebound tenderness every 30 minutes.
d. Teach the patient how to cough and breathe deeply.
ANS: B
The patient’s clinical manifestations are consistent with appendicitis, and application of an ice
pack will decrease inflammation at the area. Heat is never to be applied to the area because it
may cause the appendix to rupture.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1177
MSC: CRNE: CH-42
13. The nurse identifies the collaborative problem of potential complication: hypovolemic shock
related to loss of circulatory volume for a patient with bacterial peritonitis resulting from a
ruptured appendix. The nurse recognizes that the major loss of circulating fluid volume occurs
as a result of which of the following?
a.
b.
c.
d.
Nasogastric suctioning
Increased production of stress hormones
Extracellular fluid shift into the peritoneal cavity
Drainage of excessive fluids from the appendix into the peritoneal cavity
ANS: C
The inflammatory process causes the shift of fluids into the peritoneal space.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1193
MSC: CRNE: CH-62
14. A woman diagnosed with irritable bowel syndrome (IBS) tells the nurse that her friends say
her problem is “all in [her] head.” In caring for the woman, what is it most important for the
nurse to do?
a. Advise her that new medications are available to treat the condition.
b. Reassure her that IBS has a specific, identifiable cause.
c. Explain that modifications to increase dietary fibre can control the symptoms.
d. Develop a trusting relationship with her to allow for the expression of her
concerns.
ANS: D
Because psychological and emotional factors can impact on the symptoms of IBS,
encouraging the patient to discuss emotions and ask questions is an important intervention.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: pages 1176-1177
MSC: CRNE: NCP-1
15. A patient hospitalized with an acute exacerbation of ulcerative colitis is having 14 to 16
bloody stools a day and crampy abdominal pain associated with the diarrhea. Which of the
following will the nurse plan to implement?
a. Place the patient on NPO status.
b. Administer cobalamin (vitamin B12) injections.
c. Start bowel preparation for colonoscopy.
d. Administer IV metoclopramide.
ANS: A
An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the
bowel by making the patient NPO status.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1184
MSC: CRNE: CH-38
16. While obtaining a nursing history from a patient with IBD, which of the following data leads
the nurse to suspect that the patient most likely has ulcerative colitis rather than Crohn’s
disease?
a. Weight loss
b. Bloody diarrhea
c. Abdominal pain and cramping
d. Onset of the disease at age 20
ANS: B
Because ulcerative colitis affects the colon, blood in the stools is more common with this form
of IBD.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1181
MSC: CRNE: CH-8
17. Sulphasalazine (Salazopyrin) is prescribed for a patient who has been diagnosed with
ulcerative colitis. The nurse recognizes that teaching about this drug has been effective when
the patient states which of the following?
a. “The medication will prevent infections that cause the diarrhea.”
b. “The medication suppresses the inflammation in my large intestine.”
c. “I will need lab tests to be sure that I can still fight infections.”
d. “I will take the sulphasalazine as an enema or suppository.”
ANS: B
Sulphasalazine suppresses the inflammatory process that causes the symptoms of ulcerative
colitis.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1189
MSC: CRNE: NCP-14
18. The nurse identifies a nursing diagnosis of impaired skin integrity related to diarrhea for a
patient with ulcerative colitis. The nurse recognizes that teaching regarding perianal care has
been effective when the patient implements which of the following actions?
a. Takes a sitz bath for 40 minutes following each stool
b. Asks for antidiarrheal medication after each diarrhea stool
c. Applies barrier cream after each cleansing of the perianal area
d. Cleans her perianal area with soap and water after each diarrhea stool
ANS: C
The patient should apply barrier cream after cleansing, to protect skin and promote healing.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1166, NCP 45-1
MSC: CRNE: CH-41
19. Surgery is recommended by the physician for a patient with severe ulcerative colitis who has
not responded to conservative treatment. The patient tells the nurse that she does not know
what decision to make about the proposed surgery or how to choose among the surgical
alternatives offered by the surgeon. In responding to the patient’s concerns, what should the
nurse explain?
a. Surgery for ulcerative colitis involves the formation of a temporary ileostomy to
divert fecal contents until the large bowel heals.
b. In a total proctocolectomy with a continent ileostomy, a pouch is created that holds
bowel contents and is emptied once a day with the use of a catheter.
c. A total colectomy and ileal reservoir provide the most normal elimination function,
but this surgery consists of two procedures, requiring a temporary ileostomy for 8
to 12 weeks.
d. Any proposed surgery for treatment of ulcerative colitis should be given serious
consideration because the disease often recurs in previously unaffected parts of the
bowel.
ANS: C
The total colectomy and ileal reservoir enable the patient to pass stool rectally but require two
procedures 8 to 12 weeks apart.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1183
MSC: CRNE: CH-12
20. After teaching a patient with IBD about the recommended low-residue diet, the nurse
identifies a need for further instruction when the patient chooses which of the following foods
from the menu?
a. Boiled shrimp
b. Ham hocks and beans
c. Spaghetti with tomato sauce
d. Poached eggs and crisp bacon
ANS: B
The patient is taught to avoid high-fibre foods such as beans.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1185, Table 45-21
MSC: CRNE: NCP-14
21. A total proctocolectomy with a continent ileostomy is performed for a patient with ulcerative
colitis. Postoperatively, a catheter is in place in the stoma, and irrigations are performed every
4 hours. The patient is very upset and tells the nurse that the stoma is ugly, and she does not
think she can live with all the alterations in her body. What is the best response to the patient’s
remarks?
a. Reassure the patient that the stoma will shrink, and she will get used to caring for
the ileostomy.
b. Consult with the patient and the surgeon to arrange a visitor from a local ostomy
support group.
c. Develop a detailed written plan for the patient, which includes all the information
she will need to care for her ileostomy.
d. Recognize that this is a difficult period for the patient, and avoid intervening until
she has had time to adjust to her situation.
ANS: B
A visitor from an ostomy support group who has had similar experiences may be helpful to
the patient.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1203
MSC: CRNE: HW-10
22. The nurse identifies a nursing diagnosis of imbalanced nutrition: less than body requirements
for a patient who is hospitalized with an acute exacerbation of Crohn’s disease based on
which of the following findings?
a. Fatigue and weakness
b. A hemoglobin of 6.2 mmol/L (10 g/dL)
c. A weight loss of 0.9 kg in 2 days
d. A 24-hour diet history that reveals a 1500-calorie intake
ANS: B
A hemoglobin count of 6.2 mmol/L (10 g/dL) indicates that the patient’s iron is low; anemia
is a common complication of Crohn’s disease.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
REF: page 1189
MSC: CRNE: CH-6
23. A 26-year-old woman is diagnosed with Crohn’s disease after having frequent diarrhea and a
weight loss of 4.5 kg over 2 months. When the patient asks what will happen, the nurse
explains that initial therapy usually includes which of the following treatments?
a. Bed rest
b. Fluid restriction
c. Use of corticosteroids
d. Small, frequent feedings of a high-calorie diet
ANS: C
Corticosteroids are used to achieve remission in IBD, and systemic corticosteroids will be
used in Crohn’s disease to affect the small intestine.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1190
MSC: CRNE: CH-8
24. A patient newly diagnosed with Crohn’s disease asks the nurse what to expect in the future.
What is the best response?
a. “You need to know that lifelong, unpredictable periods of remissions and
recurrences are probable.”
b. “You can expect to lead a normal life and may have long periods without episodes
of diarrhea or other symptoms.”
c. “Most patients with Crohn’s disease require an ostomy to control the disease, but
you can adjust to that.”
d. “After about 10 years, patients with Crohn’s disease have a high risk for colon
cancer unless the colon is removed.”
ANS: A
Crohn’s disease has recurrent acute exacerbations that occur at unpredictable intervals.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1181
MSC: CRNE: CH-18
25. A patient with Crohn’s disease develops a fever and symptoms of a urinary tract infection.
The nurse recognizes that this complication may occur as a result of which of the following
events?
a. Perianal irritation from frequent diarrhea
b. Fistula formation between the bowel and the bladder
c. Extraintestinal manifestations of the bowel disease
d. Impaired immunological response to infectious microorganisms
ANS: B
Fistulas between the bowel and the bladder occur in Crohn’s disease and can lead to urinary
tract infection.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1189
MSC: CRNE: CH-8
26. A patient is hospitalized with severe vomiting and colicky abdominal pain that is somewhat
relieved with the vomiting. The physician suspects an intussusception and orders placement of
an nasogastric (NG) tube while determining whether surgery is indicated. What is an
appropriate collaborative problem for the nurse to identify for the patient at this time?
a. Potential complication: volvulus
b. Potential complication: thromboembolism
c. Potential complication: renal insufficiency
d. Potential complication: metabolic alkalosis
ANS: D
Metabolic alkalosis is a complication of NG suction resulting from loss of hydrochloric acid
from the stomach.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1193
MSC: CRNE: CH-9
27. An 81-year-old patient has a large bowel obstruction that occurred as a result of a fecal
impaction. During nursing assessment of the patient, which of the following findings is
consistent with a large bowel obstruction?
a. Metabolic alkalosis
b. Referred pain to the back
c. Bile-coloured vomiting
d. Abdominal distension
ANS: D
Abdominal distension is seen in lower intestinal obstruction.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1194
MSC: CRNE: CH-8
28. A recent colonoscopy revealed an increased number of polyps in a patient with a history of
moderately severe familial adenomatous polyposis (FAP). In planning care for the patient,
what does the nurse recognize that the medical recommendation for patients with FAP will
include?
a. A total colectomy with ileostomy to prevent colon cancer
b. Annual colonoscopy until the age of 40
c. Routine periodic polypectomies via a colonoscope to remove abnormal growths
d. Biannual colonoscopy for life because of a 50% chance of developing colon cancer
ANS: A
Patients with FAP have a high likelihood of developing colorectal cancer by age 40; therefore,
total colectomy with ileostomy is recommended for these patients.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1196
MSC: CRNE: CH-8
29. While obtaining a nursing history from a patient scheduled for a colonoscopy, what would the
nurse be most concerned about?
a. Lifelong constipation
b. Nausea and vomiting
c. History of an appendectomy
d. Recent blood in the stools
ANS: D
Rectal bleeding is associated with colorectal cancer. Recent changes in bowel patterns are a
clinical manifestation of colorectal cancer, but lifelong constipation is not an indication.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1197
MSC: CRNE: CH-8
30. During preoperative teaching for a patient scheduled for an abdominal–perineal resection,
which intervention will the nurse perform?
a. Give IV antibiotics starting 24 hours before surgery to reduce the number of bowel
bacteria.
b. Teach the patient that activities such as sitting at the bedside will be started the
first postoperative day.
c. Instruct the patient that another surgery in 8 to 12 weeks will be used to create an
ileal–anal reservoir.
d. Administer enemas and laxatives to ensure that the bowel is empty before the
surgery.
ANS: D
A bowel-cleansing agent is used to empty the bowel before surgery to reduce the risk for
infection.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1203
MSC: CRNE: CH-31
31. Before undergoing a colon resection for cancer of the colon, a patient has an elevated
carcinoembryonic antigen (CEA) test result. What should the nurse explain that the test is
used to do?
a. Identify the extent of cancer spread.
b. Confirm the diagnosis of colon cancer.
c. Monitor the tumour status after surgery.
d. Identify the need for radiation or chemotherapy.
ANS: C
CEA is used to monitor for cancer recurrence after surgery.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1198
MSC: CRNE: CH-30
32. A patient returns from surgery following an abdominal–perineal resection with a sigmoid
colostomy and abdominal and perineal incisions. The colostomy is dressed with petroleum
jelly gauze and dry-gauze dressings. The perineal incision is partially closed and has two
drains attached to Jackson-Pratt suction. During the early postoperative period, to what should
the nurse give the highest priority?
a. Teaching about a low-residue diet
b. Monitoring drainage from the colostomy stoma
c. Assessing perineal drainage and incision
d. Encouraging acceptance of the colostomy site
ANS: C
Because the perineal wound is at high risk for infection, the initial care is focused on
assessment and care of this wound.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1201
MSC: CRNE: CH-31
33. During the initial postoperative assessment of a patient’s stoma formed with a transverse
colostomy, the nurse finds it to be red with moderate edema and a small amount of bleeding.
What is the most appropriate nursing action?
a. Document the stoma assessment.
b. Notify the surgeon about the stoma appearance.
c. Monitor the stoma every 30 minutes.
d. Place an ice pack on the stoma to reduce swelling.
ANS: A
The stoma appearance indicates good circulation to the stoma.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1203
MSC: CRNE: CH-38
34. A patient has a newly formed ileostomy for treatment of ulcerative colitis. In teaching the
patient about the care of her ileostomy, what should the nurse advise the patient to do?
a. Restrict fluid intake to prevent constant liquid drainage from the stoma.
b. Change the pouch every day to prevent leakage of contents onto the skin.
c. Use care when eating high-fibre foods to avoid obstruction of the ileum.
d. Irrigate the ileostomy daily to avoid having to wear a drainage appliance.
ANS: C
High-fibre foods are introduced gradually and should be well chewed to avoid obstruction of
the ileostomy.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1205
MSC: CRNE: CH-35
35. When teaching a patient to irrigate a new colostomy, the nurse recognizes that additional
teaching is needed when the patient indicates which of the following?
a. “I should hang the irrigating container about 46 to 60 cm above the stoma.”
b. “Irrigation will help control and train my bowel.”
c. “I should use a hard plastic catheter for irrigating.”
d. “If resistance is met, force is not to be used.”
ANS: C
A hard plastic catheter is not recommended because of the risk of intestinal perforation.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Evaluation
REF: page 1204
MSC: CRNE: NCP-14
36. The nurse explains to a patient with a new ileostomy that after her system adjusts to the
ileostomy, the usual drainage will be about which following amount?
a. 250 mL
b. 500 mL
c. 800 mL
d. 1400 mL
ANS: C
After the proximal small bowel adapts to reabsorb more fluid, the average amount of
ileostomy drainage is about 800 mL daily.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1205
MSC: CRNE: CH-34
37. When implementing the initial plan of care for a patient admitted with acute diverticulosis,
what should the nurse implement for the patient?
a. Administer IV fluids.
b. Order a diet high in fibre and fluids.
c. Give stool softeners.
d. Prepare the patient for colonoscopy.
ANS: A
A patient with acute diverticulitis will be NPO status with parenteral fluids, so the nurse must
administer IV fluids.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1209, Table 45-37
MSC: CRNE: CH-58
38. The nurse identifies a nursing diagnosis of acute pain related to edema and surgical incision
for a patient who has had a herniorrhaphy performed for an incarcerated inguinal hernia. What
is an appropriate nursing intervention for this problem?
a. Apply moist heat to the abdomen.
b. Administer stool softeners as ordered.
c. Provide warm sitz baths several times a day.
d. Apply a scrotal support with application of ice.
ANS: D
Because swelling is likely to affect the scrotum, a scrotal support and ice are used to reduce
edema.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1210
MSC: CRNE: CH-42
39. A 42-year-old patient recently developed abdominal distension, weight loss, steatorrhea, and
flatulence. A diagnosis of adult celiac disease is made, and treatment is initiated. The nurse
identifies that teaching about the treatment of the disease has been effective when the patient
makes which of the following statements?
a. “I must take maintenance folic acid for the rest of my life.”
b. “I must avoid all sources of wheat, rye, and oats in my diet.”
c. “A course of antibiotics is usually effective in treating this disorder.”
d. “To control the fatty, greasy stools, I should eat only very low-fat or fat-free
foods.”
ANS: B
Avoidance of gluten-containing foods is the only treatment for celiac disease.
PTS: 1
DIF: Cognitive Level: Application
REF: pages 1190-1191
OBJ: 10
TOP: Nursing Process: Evaluation
MSC: CRNE: CH-35
40. In providing discharge teaching for a patient who has undergone a hemorrhoidectomy at an
outpatient surgical centre, what should the nurse instruct the patient to do?
a. Maintain a low-residue diet until the surgical area is healed.
b. Use ice packs on the perianal area to relieve pain and swelling.
c. Take prescribed pain medications before a bowel movement is expected.
d. Delay having a bowel movement for several days until healing has occurred.
ANS: C
Bowel movements may be very painful, and patients may avoid defecation unless pain
medication is taken before the bowel movement.
PTS: 1
OBJ: 11
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1211
MSC: CRNE: CH-52
41. A patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is
formed as illustrated. What should the nurse explain to the patient?
a.
b.
c.
d.
This type of colostomy is usually temporary.
Soft, formed stool can be expected as drainage.
The drainage is liquid at this site but less odorous than at higher sites.
Colostomy irrigations can help regulate the drainage from the proximal stoma.
ANS: A
A loop or double-barrel stoma is usually temporary.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1202
MSC: CRNE: CH-12
42. After being treated for a respiratory tract infection with a 10-day course of antibiotics, a 69-
year-old patient calls the clinic and tells the nurse about developing frequent, watery diarrhea.
What will the nurse anticipate that the patient will need to do?
a. Prepare for colonoscopy by taking laxatives.
b. Have blood drawn for blood cultures.
c. Bring a stool specimen in to be tested for C. difficile.
d. Schedule a barium enema to check for inflammation.
ANS: C
The patient’s age and history of antibiotic use suggest a C. difficile infection. There is no
indication that the patient needs a colonoscopy, blood cultures, or a barium enema.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1165
MSC: CRNE: CH-8
43. A patient with Crohn’s disease has a megaloblastic anemia. The nurse will anticipate teaching
the patient about the ongoing need for which of the following?
a. Oral ferrous sulphate tablets
b. Cobalamin (vitamin B12) injections
c. Iron dextran (Imferon) injections
d. Regular blood transfusions
ANS: B
Crohn’s disease frequently affects the ileum, where absorption of vitamin B12 occurs, and the
B12 must be administered regularly by the intramuscular route to correct the anemia.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1189
MSC: CRNE: CH-44
44. A patient presents at the emergency department with complaints of diarrhea and weight loss.
Upon further assessment, steatorrhea is noted and the patient is found to have oxalate kidney
stones. The nurse knows that these signs and symptoms are common with which following
condition?
a. Intestinal obstruction
b. Short-bowel syndrome (SBS)
c. Lactase deficiency
d. Colorectal cancer
ANS: B
The predominant manifestations of SBS are diarrhea, steatorrhea, and weight loss. Oxalate
kidney stones may form from increased colonic absorption of oxalate.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1192
MSC: CRNE: CH-8
45. Which of the following is a clinical manifestation of an obstruction in the small intestine as
opposed to the large intestine?
a. Gradual onset
b. Immediate and frequent vomiting
c. Low-grade cramping abdominal pain
d. Complete constipation
ANS: B
Clinical manifestations of a small intestine obstruction include a rapid onset, frequent and
copious vomiting, colicky, cramplike, intermittent pain, feces for a short time, and minimal
abdominal distension.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1194, Table 45-27
MSC: CRNE: CH-8
Chapter 46: Nursing Management: Liver, Pancreas, and Biliary Tract Problems
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A physician who has never been immunized for hepatitis B is exposed to the hepatitis B virus
(HBV) through a needle stick from an infected patient. What should the infection control
nurse inform both the physician and patient that treatment for the exposure should include?
a. Evaluation of liver function tests in 60 days
b. Active immunization with hepatitis B vaccine
c. Hepatitis B immunoglobulin (HBIG) injection
d. Both the hepatitis B vaccine and HBIG
ANS: D
The recommended treatment for exposure to hepatitis B in unvaccinated individuals is to
receive both HBIG and the hepatitis B vaccine, which would provide temporary passive
immunity and promote active immunity.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: pages 1223-1224
MSC: CRNE: HW-8
2. A patient contracts hepatitis from food contaminated by a worker with hepatitis in a fast-food
restaurant. During the icteric phase of the patient’s illness, what should the nurse expect
serological testing to reveal?
a. HBsAg (hepatitis B surface antigen)
b. Anti-HBc IgM (antibody to HBV core antigen)
c. Anti-HAV IgG (antibody to hepatitis A virus, immunoglobulin G)
d. Anti-HAV IgM (antibody to hepatitis A virus, immunoglobulin M)
ANS: D
Hepatitis A virus (HAV) is transmitted through the oral–fecal route, and antibody to HAV
IgM appears during the acute phase of hepatitis A.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1220
MSC: CRNE: CH-8
3. While the nurse is obtaining a nursing history from a patient diagnosed with hepatitis C, what
information reported by the patient indicates the highest risk factor for hepatitis C?
a. Sexual exposure
b. Injection drug use
c. Eating contaminated shellfish
d. Recent travel to an underdeveloped country
ANS: B
One of the highest risk factors for contracting hepatitis C is injection drug use.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1225
MSC: CRNE: HW-2
4. During evaluation of a patient at an outpatient clinic, the nurse determines that administration
of hepatitis B vaccine has been effective when a specimen of the patient’s blood reveals which
of the following results?
a. HBsAg
b. Anti-HBs (antibody to hepatitis B surface antigen)
c. Anti-HBcAg (antibody to hepatitis B core antigen)
d. Anti-HBc IgM (antibody to hepatitis B core antigen, immunoglobulin M)
ANS: B
The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the
vaccine.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1223
MSC: CRNE: HW-25
5. Serological testing of a patient reveals the presence of antibodies to the hepatitis C virus (anti-
HCV). Which following nursing action is appropriate?
a. Schedule the patient for HCV genotype testing.
b. Teach the patient that the HCV infection will resolve in 2 to 4 months.
c. Administer immunoglobulin and the HCV vaccine.
d. Instruct the patient on self-administration of -interferon.
ANS: A
Genotyping of HCV has an important role in managing treatment and is done before drug
therapy with -interferon or other medications is started.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1225
MSC: CRNE: CH-8
6. A person who is homeless is hospitalized with severe anorexia and fatigue. She has mild
jaundice and hepatomegaly, and her liver function tests are abnormal. The physician suspects
viral hepatitis. In planning care for the patient, to which patient outcome should the nurse
assign the highest priority?
a. Maintains adequate nutrition
b. Adapts to changes in appearance
c. Gradually increases tolerance for activity
d. Identifies source of exposure to hepatitis virus
ANS: A
The highest priority outcome is to maintain nutrition and collaborate with health care
providers and family to provide an appropriate diet so that proper nutritional requirements can
be provided.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1229, NCP 46-1
MSC: CRNE: CH-22
7. A patient with acute hepatitis B asks the nurse if treatment is available for the condition. What
should the nurse explain to the patient?
a. Patients with acute hepatitis B can be given HBIG to help reduce the symptoms.
b. A variety of antiviral medications are available to treat acute hepatitis B, but
serious side effects limit their use.
c. No medication is available for treatment of HBV infection.
d. Chronic HBV infection can be treated with interferon and lamivudine (Heptovir)
and adefovir (Hepsera).
ANS: C
No drug therapies are available to treat acute hepatitis, although -interferon and nucleoside
analogues (i.e., lamivudine) may be used to treat chronic hepatitis B.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1223
MSC: CRNE: CH-8
8. Combination therapy of -interferon and ribavirin (Rebetol) is being used to treat hepatitis C
in a patient infected with human immunodeficiency virus (HIV). What will the nurse monitor
for in the patient?
a. Blood glucose
b. Lymphocyte count
c. Potassium level
d. Serum creatinine
ANS: B
HCV treatment with a combination of interferon and ribavirin may reduce CD4+ counts,
worsen leukopenia, and increase the patient’s risk for anemia. HIV medications may have to
be altered because of the potential for drug interactions between some HIV medications and
ribavirin.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1230
MSC: CRNE: CH-8
9. During the acute phase of hepatitis, what would the nurse expect the patient’s laboratory
results to include?
a. Increased stool urobilinogen
b. Decreased urinary urobilinogen
c. Decreased prothrombin time
d. Increased total serum bilirubin
ANS: D
During the acute phase of hepatitis, the nurse would expect the patient to have an increase in
total serum bilirubin.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1228, Table 46-9
MSC: CRNE: CH-6
10. A 68-year-old patient has an abrupt onset of anorexia, nausea and vomiting, hepatomegaly,
and abnormal liver function studies. Serological testing is negative for viral causes of
hepatitis. During assessment of the patient, what is it most important for the nurse to ask the
patient about?
a. Any prior exposure to people with jaundice
b. The use of all prescription and over-the-counter medications
c. Treatment of chronic diseases with corticosteroids
d. Exposure to children recently immunized for hepatitis B
ANS: B
The patient’s symptoms, the lack of antibodies for hepatitis, and the abrupt onset of symptoms
suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such
as acetaminophen (Tylenol).
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1231
MSC: CRNE: CH-48
11. When teaching a patient recovering from hepatitis B about management of the illness, the
nurse determines that additional teaching is needed when the patient makes which of the
following statements?
a. “I should not drink alcohol for at least a year.”
b. “When I have recovered from this infection, I should have lifelong immunity to the
virus.”
c. “When the jaundice is gone, I have recovered from my illness and the infection is
cured.”
d. “I should use a condom during sexual intercourse until my tests for the virus are
negative.”
ANS: C
After the acute (icteric) phase, there is a convalescent phase lasting several months.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1219
MSC: CRNE: NCP-14
12. The nurse assesses a patient with cirrhosis and finds 4+ pitting edema of the feet and legs and
massive ascites. The data indicate that the nurse should monitor which of the following?
a. Temperature
b. Albumin level
c. Hemoglobin
d. Activity level
ANS: B
The low oncotic pressure caused by hypoalbuminemia is a major pathophysiological factor in
the development of ascites and edema.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1235
MSC: CRNE: CH-8
13. A 32-year-old patient has early alcoholic cirrhosis diagnosed by a liver biopsy. In teaching the
patient about the disease, it important for the nurse to inform her that the disease may be
reversed at this point with which of the following interventions?
a. Vitamin B supplements
b. Abstinence from alcohol
c. Maintenance of a nutritious diet
d. Long-term, low-dose corticosteroids
ANS: B
The disease progression can be stopped or reversed by alcohol abstinence.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1244, Table 46-18
MSC: CRNE: HW-2
14. Which hepatitis virus has DNA as its characteristic virus type?
a. Hepatitis A
b. Hepatitis B
c. Hepatitis C
d. Hepatitis E
ANS: B
Hepatitis B virus has DNA as the virus type; all of the others have RNA as the virus type.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1218, Table 46-1
MSC: CRNE: CH-8
15. When assessing a patient for signs of impending coma resulting from hepatic encephalopathy,
what should the nurse ask the patient to do?
a. Stand on one foot.
b. Extend both arms.
c. Ambulate with the eyes closed.
d. Perform the Valsalva manoeuvre.
ANS: B
Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic
encephalopathy.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1236
MSC: CRNE: CH-4
16. When lactulose (Cephulac) 30 mL four times per day is ordered for a patient with advanced
cirrhosis, he complains that it causes diarrhea. The nurse explains to the patient that it is still
important for him to take the drug because the drug will create which of the following
actions?
a. Promote fluid loss
b. Prevent constipation
c. Prevent gastrointestinal (GI) bleeding
d. Improve nervous system function
ANS: D
The purpose for lactulose in the patient with cirrhosis is to lower ammonia levels and prevent
encephalopathy. Although the medication may promote fluid loss through the stool, prevent
constipation, and prevent bearing down during bowel movements (which could lead to
esophageal bleeding), the medication is not ordered for these purposes for this patient.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1240, Table 46-16
MSC: CRNE: CH-44
17. A patient with advanced liver disease has marked ascites and signs of hepatic encephalopathy.
Following instruction about his diet, the nurse determines that teaching has been effective
when the patient’s choice of foods from the menu includes which of the following?
a. Cheese omelette with mushrooms and milk
b. Pancakes with butter and honey and orange juice
c. Baked beans with ham, cornbread, sweet potatoes, and coffee
d. Baked chicken with French-fried potatoes, low-protein bread, and tea
ANS: B
The patient with acute hepatic encephalopathy is placed on a low-protein diet to decrease
ammonia levels; therefore, the best choice is pancakes with butter and honey and orange juice.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1241
MSC: CRNE: CH-35
18. A patient with cirrhosis has a massive hemorrhage from esophageal varices. In planning care
for the patient, to what goal does the nurse give the highest priority?
a. Control of the bleeding
b. Maintenance of the airway
c. Maintenance of fluid volume
d. Relief of the patient’s anxiety
ANS: B
Maintaining gas exchange has the highest priority because oxygenation is essential for life.
The airway is compromised by the bleeding in the esophagus, and aspiration easily occurs.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1234
MSC: CRNE: CH-22
19. During treatment of a patient with a Minnesota balloon tamponade for bleeding esophageal
varices, what nursing responsibilities should be included?
a. Encourage the patient to cough and breathe deeply.
b. Insert the tube and verify its position every 4 hours.
c. Monitor the patient for shortness of breath.
d. Deflate the gastric balloon every 8 to 12 hours.
ANS: C
If the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the
airway; therefore, it is important for the nurse to monitor the patient for shortness of breath.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1234
MSC: CRNE: CH-24
20. A patient with cirrhosis has an episode of bleeding esophageal varices that is controlled with
administration of vasopressin and endoscopic sclerotherapy. To detect possible complications
of the bleeding episode, what is it most important for the nurse to monitor?
a. Prothrombin time
b. Serum bilirubin levels
c. Serum ammonia levels
d. Serum potassium levels
ANS: C
The blood in the GI tract will be absorbed as protein and may result in an increase in ammonia
level because the liver cannot metabolize protein well.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1234
MSC: CRNE: CH-2
21. The nurse identifies a nursing diagnosis of risk for impaired skin integrity for a patient with
cirrhosis who has ascites and 4+ pitting edema of the feet and legs. What is an appropriate
nursing intervention for this problem?
a. Restrict dietary protein intake.
b. Turn the patient every 4 hours.
c. Perform passive range of motion four times per day.
d. Arrange for a special pressure-relieving mattress.
ANS: D
The pressure-relieving mattress will decrease the risk for skin breakdown for this patient.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1243
MSC: CRNE: CH-41
22. A shunting procedure is considered for a patient with cirrhosis following an episode of
bleeding esophageal varices. The nurse understands which of the following about these
procedures?
a. They improve patient survival rates.
b. They increase the risk of hepatic encephalopathy.
c. They require surgery to redirect blood flow around the liver.
d. They are first-line therapies for portal hypertension and esophageal varices.
ANS: B
The risk for hepatic encephalopathy increases after shunt procedures because blood bypasses
the portal system and ammonia is diverted past the liver and into the systemic circulation.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1236
MSC: CRNE: CH-8
23. A patient with cancer of the liver has severe ascites that is causing shortness of breath and
difficulty breathing. The physician plans a paracentesis to relieve the fluid pressure on the
diaphragm. To prepare the patient for the procedure, what should the nurse do?
a. Ask the patient to empty the bladder.
b. Position the patient flat on the right side.
c. Obtain informed consent for the procedure.
d. Have the patient lie flat with a small pillow under the small of the back.
ANS: A
The patient should empty the bladder to decrease the risk of bladder perforation during the
procedure.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1243
MSC: CRNE: CH-30
24. When interpreting HBV serological profile results, the nurse would anticipate the hepatitis B
surface antigen (HBsAg) to be positive in which one of the following circumstances?
a. Chronic infection
b. Immunity from vaccination
c. Past exposure
d. Occult HBV infection
ANS: A
When interpreting HBV serological profile results, the nurse would anticipate the HBsAg to
be positive in both acute and chronic infection.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1222, Table 46-5
MSC: CRNE: CH-6
25. A patient hospitalized with possible acute pancreatitis has severe abdominal pain and nausea
and vomiting. Which of the following elevated serum levels would the nurse expect the
diagnosis to be confirmed by?
a. Calcium
b. Bilirubin
c. Potassium
d. Amylase
ANS: D
Amylase is elevated early in acute pancreatitis.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1249
MSC: CRNE: CH-8
26. In planning care for a patient with acute pancreatitis, to which of the following patient
outcomes would the nurse assign the highest priority?
a. Develops no complications
b. Maintains normal respiratory function
c. Expresses satisfaction with pain control
d. Maintains adequate fluid and electrolyte balance
ANS: B
Respiratory failure can occur as a complication of acute pancreatitis, and maintenance of
adequate respiratory function is the priority goal.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1252
MSC: CRNE: CH-22
27. The nurse knows that levels of which one of the following should be monitored when the
patient is receiving adefovir?
a. Potassium
b. Sodium
c. Creatinine
d. Urea
ANS: C
Serum creatinine levels should be monitored, especially in patients at risk, including those
with pre-existing renal disease and those taking nephrotoxic drugs.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1224, Safety Alert
MSC: CRNE: CH-44
28. The nurse identifies the collaborative problem of “potential complication: electrolyte
imbalance” for a patient with severe acute pancreatitis. What assessment findings would alert
the nurse to electrolyte imbalances associated with acute pancreatitis?
a. Hypotension
b. Hyperglycemia
c. Muscle cramps and tetany
d. Paralytic ileus and abdominal distension
ANS: C
Muscle cramps and tetany indicate hypocalcemia, a potential complication of acute
pancreatitis.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 1250
MSC: CRNE: CH-8
29. When obtaining a health history from a patient with acute pancreatitis, what history should the
nurse specifically ask the patient about?
a. Smoking
b. Alcohol use
c. Diabetes mellitus
d. High-fat dietary intake
ANS: B
Alcohol use is one of the most common risk factors for pancreatitis.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1246
MSC: CRNE: CH-8
30. The physician prescribes pancreatin (Viokase) for a patient with chronic pancreatitis. The
nurse teaches the patient that the drug is considered effective if the patient experiences which
of the following findings?
a. Normal stools
b. Decreased jaundice
c. An improved appetite
d. Decreased abdominal pain
ANS: A
The patient’s steatorrhea should improve if the treatment with pancreatic enzymes is effective,
and the patient would experience normal stools.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1251
MSC: CRNE: CH-44
31. Which nursing diagnosis is a priority when the nurse is caring for the patient with pancreatic
cancer?
a. Chronic pain related to tumour pressure on abdominal structures
b. Imbalanced nutrition: less than required related to anorexia
c. Impaired skin integrity related to itching secondary to jaundice
d. Grieving related to potentially terminal diagnosis
ANS: A
All of these nursing diagnoses are appropriate for a patient with pancreatic cancer, but treating
the patient’s pain is the priority because the patient will be unable to meet outcomes for the
other nursing diagnoses unless the pain is controlled.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1251
OBJ: 9
TOP: Nursing Process: Diagnosis
MSC: CRNE: CH-51, CH-52
32. A patient is admitted to the hospital with a sudden onset of severe right upper quadrant pain
that radiates to the right shoulder. She has a history of fat intolerance and heartburn. The nurse
recognizes that the patient most likely has a biliary tract obstruction when the patient reports
experiencing which of the following?
a. Spider angiomas
b. Clay-coloured stools
c. Dilute, bright-yellow urine
d. Epigastric pain relieved by vomiting
ANS: B
The clay-coloured stools indicate biliary obstruction, which requires rapid intervention to
resolve.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1256, Table 46-22
MSC: CRNE: CH-8
33. When caring for a patient following an incisional cholecystectomy for cholelithiasis, on what
patient outcome should the nurse place the highest priority?
a. Turning, coughing, and deep-breathing every 2 hours to prevent respiratory
complications
b. Choosing low-fat foods from the menu to prevent weight gain
c. Performing leg exercises every hour while awake to prevent foot drop
d. Ambulating the evening of the operative day to prevent constipation
ANS: A
Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory
complications because the surgical incision is high in the abdomen and impairs coughing and
deep breathing.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1259
MSC: CRNE: CH-31
34. Although acetaminophen is a common analgesic that patients consume, it does have toxic
effects. When teaching a patient about acetaminophen use, the nurse tells the patient that
doses in excess of how many grams a day lead to acute liver failure?
a. 2 g
b. 5 g
c. 7.5 g
d. 10 g
ANS: D
Ingestion of more than 10 grams per day of acetaminophen leads to acute liver failure.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1231, Safety Alert
MSC: CRNE: CH-48
35. When providing discharge instructions to a patient following a laparoscopic cholecystectomy
at an outpatient surgical centre, the nurse recognizes that teaching has been effective when the
patient makes which of the following comments?
a. “I should plan to limit my activities and not return to work for 4 to 6 weeks.”
b. “I can expect some reddish yellow drainage from the incisions for a few days.”
c. “I should remove the bandages on my incisions tomorrow and take a shower.”
d. “I will always need to maintain a low-fat diet because I no longer have a
gallbladder.”
ANS: C
After a laparoscopic cholecystectomy, the patient will have bandages in place over the
incisions. Patients are discharged the same (or next) day and have few restrictions on activities
of daily living.
PTS: 1
OBJ: 11
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1257
MSC: CRNE: NCP-14
36. Which data obtained by the nurse during the assessment of a patient with cirrhosis will be of
most concern?
a. The patient’s skin has multiple spider-shaped blood vessels on the abdomen.
b. The patient has ascites and a 2-kg weight gain from the previous day.
c. The patient complains of right upper quadrant pain with abdominal palpation.
d. The patient’s hands flap back and forth when the arms are extended.
ANS: D
The asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may
occur.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1236
MSC: CRNE: CH-8
37. A patient with severe cirrhosis has a new prescription for propranolol (Inderal). The nurse will
teach the patient that the medication is ordered to do which one of the following?
a. Decrease systemic blood pressure (BP)
b. Prevent the development of ischemia
c. Lower the risk for bleeding varices
d. Reduce fluid retention and edema
ANS: C
-Adrenergic blockers have been shown to decrease the risk for bleeding in esophageal
varices. Although propranolol will reduce BP and prevent cardiac ischemia, these are not the
purposes for this patient.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1240, Table 46-16
MSC: CRNE: CH-44
38. Management of ascites is focused on which one of the following actions?
a. Limiting intake
b. Sodium restriction
c. Administering antibiotics
d. Ensuring adequate rest
ANS: B
Management of ascites is focused on sodium restriction, diuretics, and fluid removal.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1239
OBJ: 5
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
39. When taking the BP of a patient with severe acute pancreatitis, the nurse notices carpal spasm
of the patient’s hand. Which action should the nurse take next?
a. Notify the physician immediately.
b. Retake the patient’s BP.
c. Check the calcium level on the chart.
d. Ask the patient about any arm pain.
ANS: C
The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data
indicate a positive Trousseau sign.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
REF: page 1250
MSC: CRNE: CH-8
40. A patient is admitted with a diagnosis of hepatic encephalopathy with the following
symptoms: lethargy, drowsiness, disorientation, asterixic with abnormal reflexes. Which grade
on the scale for hepatic encephalopathy would the nurse document for this patient?
a. Grade 1
b. Grade 2
c. Grade 3
d. Grade 4
ANS: B
The nurse would document this patient’s hepatic encephalopathy as being grade 2.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1237, Table 46-14
MSC: CRNE: CH-15
41. When the nurse is caring for a patient with acute pancreatitis, which of these assessment data
should be of most concern?
a. Absent bowel sounds
b. Abdominal tenderness
c. Left upper quadrant pain
d. Palpable abdominal mass
ANS: D
A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will
require rapid surgical drainage to prevent sepsis.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: pages 1249-1250
MSC: CRNE: CH-27
Chapter 47: Nursing Assessment: Urinary System
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. When reading a patient’s chart, the nurse notes that the patient has had dysuria. To assess
whether there is any improvement, which question will the nurse ask?
a. “Do you have any blood in your urine?”
b. “Do you have to get up at night to urinate?”
c. “Do you have any pain when you urinate?”
d. “Do you have to urinate very frequently?”
ANS: C
Dysuria is painful urination.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 1278, Table 47-7
MSC: CRNE: CH-1
2. When admitting a patient who has a history of paraplegia as a result of a spinal cord injury,
the nurse will plan to do which of the following?
a. Check the patient for urinary incontinence every 2 hours to maintain skin integrity.
b. Assist the patient to the toilet on a scheduled basis to help ensure bladder
emptying.
c. Use intermittent catheterization on a regular schedule to avoid the risk of infection.
d. Ask the patient about the usual urinary pattern and measures used for bladder
control.
ANS: D
Before planning any interventions, the nurse should complete the assessment and determine
the patient’s normal bladder pattern and the usual measures used by the patient at home.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1275, Table 47-4
MSC: CRNE: CH-1
3. A patient’s urine dipstick reveals a large amount of protein in the urine. What is the next
nursing action?
a. Check which medications the patient is currently taking.
b. Ask the patient about any family history of chronic renal failure.
c. Send a urine specimen to the laboratory to test for ketones and glucose.
d. Obtain a clean-catch urine specimen for culture and sensitivity testing.
ANS: A
Normally, the urinalysis will show zero to trace amounts of protein, but some medications
may give false-positive readings.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1279, Table 47-8
TOP: Nursing Process: Diagnosis
MSC: CRNE: CH-3
4. A creatinine clearance test is ordered for a hospitalized patient with possible renal
insufficiency. Which equipment will the nurse need to obtain?
a. Foley catheter and drainage bag
b. Towelettes for perineal cleaning
c. Basin of ice
d. Sterile specimen cup
ANS: C
Creatinine clearance testing involves a 24-hour urine specimen collection. The urine should be
refrigerated or cooled, or a preservative should be used.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1279, Table 47-8
MSC: CRNE: CH-30
5. A 20-year-old patient who is employed as a hairdresser and has a 10-pack-year history of
cigarette smoking is scheduled for an annual physical examination. The nurse will plan to
teach the patient about the increased risk for which of the following?
a. Bladder cancer
b. Renal failure
c. Pyelonephritis
d. Kidney stones
ANS: A
Exposure to the chemicals involved when working as a hairdresser and smoking both increase
the risk of bladder cancer, and the nurse should assess whether the patient understands this
risk.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1274
MSC: CRNE: HW-13
6. During assessment of a patient with a disorder of the urinary system, the nurse identifies a
potentially nephrotoxic agent when the patient reports the use of which of the following
drugs?
a. Anticoagulants
b. Vitamin supplements
c. Nonsteroidal anti-inflammatory drugs (NSAIDs)
d. Prophylactic penicillin therapy
ANS: C
NSAIDs are nephrotoxic and should be avoided in patients with renal insufficiency.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1274, Table 47-3
MSC: CRNE: CH-44
7. Which one of the following tests identifies changes in cellular structures that are indicative of
malignancy?
a. Concentration test
b. Residual urine
c. Quantitative test
d. Urine cytology
ANS: D
Urine cytology is a test used to identify changes in cellular structure that is indicative of
malignancy, especially bladder cancer.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1279, Table 47-8
MSC: CRNE: CH-8
8. While assessing a patient’s urinary system, the nurse cannot palpate either kidney. What is the
most appropriate interpretation of this finding?
a. It is a normal finding.
b. It is suggestive of hydronephrosis.
c. It is diagnostic for polycystic disease.
d. It indicates the presence of atrophied kidneys.
ANS: A
The kidneys are protected by the abdominal organs, ribs, and muscles of the back and may not
be palpable under normal circumstances, so it is a normal finding.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1276
MSC: CRNE: CH-8
9. How will the nurse assess the flank area for tenderness?
a. Percuss the area between the iliac crest and ribs along the midaxillary line.
b. Palpate along both sides of the lumbar vertebral column.
c. Place one hand flat at the costovertebral angle (CVA), and strike it with the other
fist.
d. Push gently into the two lowest intercostal spaces.
ANS: C
This technique is performed by striking the fist (kidney punch) of one hand against the dorsal
surface of the other hand, which is placed flat along the posterior CVA margin. Normally, a
firm blow in the flank area should not elicit pain. If CVA tenderness and pain are present, they
may indicate a kidney infection or polycystic kidney disease.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1277
MSC: CRNE: CH-4
10. The result of a patient’s creatinine clearance test is 60 mL/min. The nurse equates this finding
to which of the following glomerular filtration rates (GFRs)?
a. 30 mL/min
b. 60 mL/min
c. 120 mL/min
d. 240 mL/min
ANS: B
The creatinine clearance approximates the GFR, in this case, 60 mL/min.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1279, Table 47-8
MSC: CRNE: CH-6
11. For what purpose does the nurse use auscultation during assessment of the urinary system?
a. To determine the position of the kidneys
b. To assess fluid wave patterns in the bladder
c. To determine the level of a distended bladder
d. To identify renal artery and abdominal aortic bruits
ANS: D
The presence of a bruit may indicate problems such as renal artery tortuosity or abdominal
aortic aneurysm.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 1277, Focused Assessment
OBJ: 5
TOP: Nursing Process: Assessment
MSC: CRNE: CH-4
12. When analyzing the results of a patient’s urinalysis, the nurse recognizes that a urinary tract
infection is indicated by which of the following findings?
a. Protein 4+
b. Glucose 3+
c. White blood cell (WBC) count 20 to 26 cells per high-power field
d. Specific gravity 1.01
ANS: C
The increased number of WBCs indicates the presence of urinary tract infection or
inflammation.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1279, Table 47-8
MSC: CRNE: CH-6
13. A patient with a possible renal cell tumour who is scheduled for an intravenous pyelogram
(IVP) and computed tomography (CT) scanning of the abdomen gives the nurse all the
following data. Which information has the most immediate implications for the patient’s care?
a. The patient has not had anything to eat or drink for 8 hours.
b. The patient used a bisacodyl (Dulcolax) tablet the previous night.
c. The patient describes allergies to shellfish and penicillin.
d. The patient complains of CVA tenderness.
ANS: C
Iodine-based contrast dye is used during IVP and for many CT scans. As with all contrast
studies, possible iodine and shellfish allergies should be determined before the study. The
nurse will need to notify the physician before the procedures so that the patient can receive
medications such as antihistamines or corticosteroids before the procedures are started.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1283
MSC: CRNE: CH-23
14. When teaching a patient scheduled for a cystogram via a cystoscope about the procedure,
which following statement would the nurse make to the patient?
a. “Your doctor will place a catheter into an artery in your groin and inject a dye that
will visualize the blood supply to the kidneys.”
b. “Your doctor will insert a lighted tube into the bladder and inject a dye into your
kidneys through little catheters inserted into the ureters.”
c. “Your doctor will insert a lighted tube into the bladder through your urethra,
inspect the bladder, and instill a dye that will outline your bladder on radiography.”
d. “Your doctor will inject a dye into a vein in your arm that is carried to the urinary
system. Then a lighted tube in your bladder will be used to see when the dye
appears.”
ANS: C
In a cystoscope and cystogram procedure, a cystoscope is inserted into the bladder for direct
visualization, and then contrast solution is injected through the scope so that X-ray films can
be made.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1279, Table 47-8
MSC: CRNE: CH-30
15. The nurse should tell the patient undergoing cystoscopy that which of the following will occur
following the procedure?
a. He will receive narcotics as necessary for pain.
b. He will be on nothing by mouth (NPO) status for 8 hours to prevent nausea and
vomiting.
c. He may experience blood-tinged urine and urinary frequency.
d. He will be on bed rest for 12 to 24 hours following the procedure.
ANS: C
Pink-tinged urine and urinary frequency are expected after cystoscopy. Burning on urination
is common, but pain that requires narcotics for relief is not expected.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1285
MSC: CRNE: CH-30
16. A patient with an elevated BUN and serum creatinine is scheduled for a renal arteriogram.
The nurse should question an order from the radiology department for which of the following
bowel preparations?
a. Castor oil
b. Fleet enema
c. Tap-water enemas
d. Bisacodyl tablets
ANS: B
High-phosphate enemas, such as Fleet enemas, should be avoided in patients with renal
insufficiency (as evidenced by an increased BUN and creatinine).
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1284
MSC: CRNE: PP-19
17. The physician orders a clean-catch urine specimen for culture and sensitivity testing for a
female patient with a suspected urinary tract infection. When teaching the patient to obtain the
specimen, what should the nurse instruct the patient to do?
a. Sit on a bedpan, and after she starts to urinate, the nurse will catch the remaining
urine in a specimen cup.
b. Clean the urethral area, void a small amount into the toilet, and then void into a
sterile specimen cup.
c. Insert a short, small, “mini” catheter attached to a collecting container into the
urinary meatus to obtain urine for testing.
d. Wash the perineal area with soap and water, start the stream of urine, and then pass
a clean specimen cup into the urine flow to catch the remainder of the urine.
ANS: B
This answer describes the technique for obtaining a clean-catch specimen.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1279, Table 47-8
MSC: CRNE: CH-30
18. Which component of the nephron is responsible for the reabsorption of sodium and chloride?
a. Glomerulus
b. Proximal tubule
c. Loop of Henle
d. Distal tubule
ANS: C
Part of the function of the loop of Henle is the reabsorption of sodium and chloride.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1270, Table 47-1
MSC: CRNE: CH-8
19. Which of the following is an age-related change in the urinary system?
a. Increased amount of renal tissue
b. Increased number of nephrons
c. Decreased function of the loop of Henle
d. Decreased prevalence of unstable bladder contractions
ANS: C
A normal age-related change in the urinary system is a decrease in the function of the loop of
Henle.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1273, Table 47-2
MSC: CRNE: CH-8
20. Which of the following is an abnormal finding of the urinary system?
a. CVA tenderness
b. Nonpalpable kidney
c. No palpable masses
d. Nonpalpable bladder
ANS: A
A normal finding in the urinary system is no CVA tenderness.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1277, Table 47-6
MSC: CRNE: CH-8
21. What one of the following would the nurse document when the physical assessment reveals a
passage of urine containing gas?
a. Anuria
b. Enuresis
c. Pneumaturia
d. Polyuria
ANS: C
Pneumaturia is the term that describes a passage of urine containing gas.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1278, Table 47-7
MSC: CRNE: CH-8
Chapter 48: Nursing Management: Renal and Urological Problems
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. Which of the following assessment findings would the nurse expect in the patient with a lower
urinary tract infection (UTI)?
a. Flank pain
b. Dysuria
c. Oliguria
d. Nausea
ANS: B
Pain with urination is a common symptom of a lower UTI. Urinary output does not decrease,
but frequency may be experienced.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1291, Table 48-3
MSC: CRNE: CH-8
2. What is one of the most important ways to prevent the development of acute post-
streptococcal glomerulonephritis?
a. Control of blood pressure with exercise
b. Early diagnosis and treatment of sore throat
c. Ensuring complete bladder emptying when the patient voids
d. Daily intake of high-potency multivitamins
ANS: B
One of the most important ways to prevent the development of acute post-streptococcal
glomerulonephritis is to encourage early diagnosis and treatment of sore throats and skin
lesions.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1300
MSC: CRNE: CH-8
3. The nurse determines that instruction regarding prevention of future UTIs for a patient with
cystitis has been effective when the patient gives which of the following responses?
a. “I will limit my fluid intake to 1000 mL/day to prevent symptoms of frequency
and urgency.”
b. “I will increase my fluid intake and empty my bladder every 2 to 4 hours during
waking hours.”
c. “I should use an antiseptic vaginal deodorant spray twice a day to reduce the
bacterial growth in the perineal area.”
d. “I will wash my perineal area with soap and water after each bowel movement and
before and after sexual intercourse.”
ANS: B
Voiding every 2 to 4 hours is recommended to prevent UTIs.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1295, Table 48-6
MSC: CRNE: NCP-14
4. To relieve the symptoms of a lower UTI for which the patient is taking prescribed antibiotics,
the nurse suggests that the patient use the over-the-counter urinary analgesic of
phenazopyridine (Pyridium), but should give the patient which of the following cautions?
a. This preparation contains methylene blue, which turns the urine blue or green.
b. This preparation must be taken with food to prevent gastrointestinal irritation.
c. This preparation causes the urine to turn reddish orange and can stain
underclothing.
d. This preparation frequently causes allergic reactions and should be stopped if a
rash occurs.
ANS: C
Patients should be taught that phenazopyridine will colour the urine deep orange and stain
underclothing.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1292
MSC: CRNE: CH-44
5. A 34-year-old patient with diabetes mellitus is hospitalized with fever, anorexia, and
confusion. The physician suspects acute pyelonephritis when the urinalysis reveals
bacteriuria. Which of the following is an appropriate collaborative problem identified by the
nurse for this patient?
a. Potential complication: urosepsis
b. Potential complication: hydronephrosis
c. Potential complication: acute kidney injury
d. Potential complication: chronic pyelonephritis
ANS: A
Infection can easily spread from the kidney to the circulation, causing urosepsis.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1295
MSC: CRNE: CH-20
6. A 72-year-old man has benign prostatic hypertrophy, which has contributed to repeated bouts
of cystitis. He is now admitted to the hospital with chills, fever, and nausea and vomiting. A
urinalysis is positive for bacteria, red blood cells, and white blood cells. The nurse suspects
the presence of an upper UTI when assessment of the patient reveals which of the following
findings?
a. Suprapubic pain
b. Foul-smelling urine
c. A distended bladder
d. Costovertebral angle (CVA) tenderness
ANS: D
CVA tenderness is characteristic of pyelonephritis.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1295
MSC: CRNE: CH-6
7. After teaching a patient with interstitial cystitis about management of the condition, the nurse
determines that further instruction is needed when the patient makes which of the following
comments?
a. “I will avoid eating citrus products and aged cheese.”
b. “I should take a high-potency multivitamin daily.”
c. “I should report the development of bladder pain or odorous urine.”
d. “I can use the dietary supplement calcium glycerophosphate (Prelief) to control my
symptoms.”
ANS: B
High-potency multivitamins may irritate the bladder and increase symptoms.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1298
MSC: CRNE: NCP-14
8. When admitting a patient with acute glomerulonephritis, the nurse inquires about which of the
following?
a. History of high blood pressure
b. Frequency of UTIs
c. Recent sore throat and fever
d. Family history of kidney disease
ANS: C
Acute glomerulonephritis frequently occurs after a streptococcal infection such as strep throat,
so it is appropriate for the nurse to ask about recent sore throat and fever.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1300
MSC: CRNE: CH-8
9. The nurse establishes a nursing diagnosis of excess fluid volume related to decreased
glomerular filtration rate in a patient with acute post-streptococcal glomerulonephritis. Which
of the following clinical data support this nursing diagnosis?
a. Proteinuria
b. Elevated blood urea nitrogen
c. Periorbital edema
d. Hematuria with smoky urine
ANS: C
Resolution of the excess fluid volume is best evaluated by changes in edema.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
REF: page 1300
MSC: CRNE: CH-7
10. A patient with nephrotic syndrome develops flank pain. The nurse will anticipate treatment
with which of the following?
a. Antibiotics
b. Antihypertensives
c. Anticoagulants
d. Corticosteroids
ANS: C
Flank pain in a patient with nephrosis suggests a renal vein thrombosis, and anticoagulation is
needed.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1290
MSC: CRNE: CH-8
11. One week after using an over-the-counter nonsteroidal anti-inflammatory drug to treat aches
resulting from a fall, a patient noticed the development of progressive edema throughout his
body. Diagnostic studies confirmed a diagnosis of nephrotic syndrome. When teaching the
patient about his condition, the nurse uses the knowledge that the edema results from which of
the following changes?
a. Increased serum oncotic pressure exerted by dyslipidemia
b. Loss of protein through the kidney, resulting in a fall in plasma colloid osmotic
pressure
c. Loss of albumin in the urine, creating an osmotic diuresis and low tissue
hydrostatic pressure
d. Fluid retention caused by decreased glomerular filtration rate through kidneys
damaged by trauma
ANS: B
The increased glomerular membrane permeability found in nephrotic syndrome is responsible
for the massive excretion of protein in the urine. This results in decreased serum protein and
subsequent edema formation and low tissue hydrostatic pressure.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1290
MSC: CRNE: CH-8
12. Which of the following actions will assist the nurse in evaluating the effectiveness of
treatment for the patient with nephrotic syndrome?
a. Monitoring the blood pressure every 4 hours
b. Measuring the abdominal girth daily
c. Measuring daily dietary protein intake
d. Checking the urine of each voiding for protein
ANS: B
It is important to assess the edema by weighing the patient daily, accurately recording intake
and output, and measuring abdominal girth or extremity size. Comparing this information
daily provides the nurse with a tool for assessing the effectiveness of treatment.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1291
MSC: CRNE: CH-4
13. The nurse notes that the results of an intravenous pyelogram indicate a left hydroureter and
hydronephrosis in a female patient who was hospitalized with a markedly distended bladder.
A catheterization for residual urine obtained 1650 mL. What does the nurse understand about
these findings that are characteristic of a urinary tract obstruction?
a. They are located at the bladder neck.
b. They are caused by ureteral calculi.
c. They are situated at the ureteropelvic junction.
d. They are caused by a ureteral stricture.
ANS: A
When obstruction occurs at the level of the bladder neck or prostate, significant bladder
changes can occur and are characteristic of a urinary tract obstruction.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1291
MSC: CRNE: CH-8
14. A patient with a history of renal calculi is hospitalized with gross hematuria and severe
colicky left flank pain that radiates to his left testicle. In planning care for the patient, the
nurse gives the highest priority to which of the following nursing diagnoses?
a. Acute pain related to irritation of stone
b. Deficient fluid volume related to inadequate intake
c. Risk for infection related to urinary system damage
d. Altered health maintenance related to lack of knowledge about prevention of
stones
ANS: A
Although all the diagnoses are appropriate, the initial nursing actions should focus on relief of
the acute pain.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
REF: page 1309, NCP 48-2
MSC: CRNE: CH-52
15. The nurse instructs a patient seen in the outpatient clinic with symptoms of renal calculi to
strain all urine for which of the following primary purposes?
a. To validate the diagnosis of kidney stones
b. To obtain a stone for analysis of composition
c. To determine when a stone has passed from the system
d. To determine the extent of damage to the urinary system
ANS: B
Patients should strain their urine to obtain a stone. The patient saves the stone for analysis of
the stone composition, which will help in determining treatment.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1309, NCP 48-2
MSC: CRNE: CH-12
16. A patient with a confirmed renal calculus in the proximal left ureter undergoes extracorporeal
shock wave lithotripsy, which successfully shatters the stone. After the lithotripsy, the nurse
encourages fluids to 3000 mL/day and knows that the interventions for the patient have been
effective based on which of the following findings?
a. Free flow of urine is present.
b. Adequate fluid balance is maintained.
c. The patient verbalizes a decrease in pain.
d. There is no indication of UTI.
ANS: A
Because lithotripsy breaks the stone into fine sand, which could cause obstruction, it is
important to monitor the urinary output to ensure it is flowing freely.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1307
MSC: CRNE: CH-37
17. The composition of a patient’s renal calculi is identified as uric acid. To prevent recurrence of
stones, what should the nurse teach the patient to avoid?
a. Milk and dairy products
b. Legumes and dried fruits
c. Spinach, chocolate, and tomatoes
d. Organ meats and fish with fine bones
ANS: D
Organ meats and fish such as sardines increase purine levels and uric acid.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1306, Table 48-13
MSC: CRNE: CH-8
18. To prevent the recurrence of renal calculi, what should the nurse teach the patient to do?
a. Avoid all sources of dietary calcium.
b. Drink fluids such as cranberry juice and colas, which will acidify the urine.
c. Maintain fluid intake at 3000 mL a day, especially when physically active.
d. Empty the bladder every 2 to 4 hours to prevent urinary stasis and precipitation of
urates.
ANS: C
A fluid intake of 3000 mL daily is recommended to help flush out minerals before stones can
form.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1308
MSC: CRNE: CH-37
19. In planning teaching for a patient with nephrosclerosis, what should the nurse include
instructions about?
a. Monitoring of daily intake and output amounts
b. Maintenance of fluid restriction at 1000 mL/day
c. Techniques of monitoring and recording blood pressure
d. Prevention and detection of bleeding from anticoagulation therapy
ANS: C
Hypertension is the major symptom of nephrosclerosis; therefore, the patient should be able to
monitor and record his or her blood pressure.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1310
MSC: CRNE: CH-8
20. The nurse advises genetic counselling for the children of which of the following patients?
a. A patient with interstitial cystitis
b. A patient with horseshoe kidney
c. A patient with polycystic kidney disease
d. A patient with Goodpasture syndrome
ANS: C
The adult form of polycystic kidney disease is an autosomal dominant disorder; therefore,
genetic counselling is warranted.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1311
MSC: CRNE: HW-13
21. When assessing a patient who complains of a feeling of incomplete bladder emptying and a
split, spraying urine stream, what history should the nurse ask about more specifically?
a. Renal calculi
b. Kidney trauma
c. Bladder infection
d. Gonococcal urethritis
ANS: D
The patient’s clinical manifestations are consistent with urethral strictures, a possible
complication of gonococcal urethritis.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1299
MSC: CRNE: CH-3
22. The physician suspects transitional-cell bladder cancer in a 69-year-old patient who has gross
hematuria and history of a 9-kg weight loss during the last 3 months, and schedules diagnostic
testing. When obtaining a nursing history from the patient, the nurse identifies a significant
risk factor for bladder cancer when the patient reports which of the following histories?
a. Chronic cystitis
b. Cigarette smoking
c. High caffeine intake
d. Use of artificial sweeteners
ANS: B
Cigarette smoking is a risk factor for bladder cancer.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1313
MSC: CRNE: HW-2
23. To promote muscle relaxation and induce voiding after the patient has undergone an open
loop resection and fulguration of the bladder, what is an appropriate intervention for the nurse
to use?
a. Sitz baths four times per day
b. Encouraging fluids to 3000 mL/day
c. Isometric exercises of the perineal muscles every 2 hours
d. Application of warm compresses to the suprapubic area four times per day
ANS: A
Sitz baths will relax the perineal muscles and promote voiding.
PTS: 1
OBJ: 12
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1314
MSC: CRNE: CH-20
24. A 78-year-old woman is admitted to the hospital with dehydration and electrolyte imbalance.
She is confused and incontinent of urine on admission. In developing a plan of care for the
patient, what is an appropriate nursing intervention for the patient’s incontinence?
a. Insert an in-dwelling catheter.
b. Apply absorbent incontinence pads.
c. Restrict fluids after the evening meal.
d. Assist the patient to the bathroom every 2 hours.
ANS: D
In older or confused patients, incontinence may be avoided by using scheduled toileting times.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1318, Table 48-18
OBJ: 10
TOP: Nursing Process: Implementation
MSC: CRNE: CH-37
25. After her bath, a 62-year-old woman asks the nurse for a perineal pad, saying that she uses
them because sometimes she leaks urine when she laughs or coughs. Which of the following
interventions is most appropriate to include in a teaching plan to assist the patient with this
problem?
a. Performance of Kegel exercises
b. Performance of Credé manoeuvre
c. Use of bladder neck support devices
d. Establishment of a pattern of urinating every 3 hours
ANS: A
Exercises to strengthen the pelvic floor muscles, such as Kegel exercises, will help reduce
stress incontinence.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1316
MSC: CRNE: CH-37
26. Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes. Which
nursing action is most appropriate?
a. Use an ultrasound scanner to check for residual urine after voiding.
b. Have the patient take small amounts of fluid frequently throughout the day.
c. Reassure the patient that this is normal after rectal surgery because of the
anaesthesia.
d. Monitor the patient’s intake and output over the next few hours.
ANS: A
An ultrasound scanner can be used to check for residual urine after the patient voids because
the patient’s history and clinical manifestations are consistent with overflow.
PTS: 1
OBJ: 12
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1321, Table 48-21
MSC: CRNE: CH-4
27. What is the most common type of urinary tract calculi?
a. Uric acid
b. Cystine
c. Calcium oxalate
d. Struvite
ANS: C
Calcium oxalate is the most common urinary stone with an incidence of 30% to 40%.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1305, Table 48-12
MSC: CRNE: CH-8
28. A patient with a neurogenic bladder is to be taught intermittent catheterization for bladder
emptying. What should the nurse teach the patient to do?
a. Use a clean procedure with a new catheter each day.
b. Use a new, sterile catheter and sterile gloves and procedure for each
catheterization.
c. Request prophylactic antibiotics if clean, rather than sterile, technique is going to
be used.
d. Wash and rinse the catheter and the hands with soap and water before and after
each catheterization.
ANS: D
Patients who are at home can use a clean technique for intermittent self-catheterization and
change the catheter every 7 days.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1323
MSC: CRNE: CH-8
29. To prevent the incidence of UTIs in a catheterized patient, which of the following actions
should the nurse implement?
a. Irrigate the catheter with an antiseptic solution.
b. Apply an antiseptic solution to the perineum daily.
c. Perform perineal cleansing with mild soap and water twice daily and as needed.
d. Apply an antibiotic ointment around the catheter at the urinary meatus at least
twice a day.
ANS: C
Perineal care (two times per day and when necessary) should include cleaning of the meatus–
catheter junction with soap and water.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1322
MSC: CRNE: CH-37
30. A patient undergoes a nephrectomy for massive trauma to the kidney resulting from a fall
from a scaffold. Immediately postoperatively, which of the following assessment data is most
important to communicate to the surgeon?
a. Blood pressure is 102/48 mm Hg.
b. Urinary output is 20 mL/hour for 2 hours.
c. Crackles are heard at both lung bases.
d. Incisional pain level is 8 on a scale of 10.
ANS: B
Because the urinary output should be at least 0.5 mL/kg/hour, a 40-mL output for 2 hours
indicates that the patient may have decreased renal perfusion because of bleeding, inadequate
fluid intake, or obstruction at the suture site.
PTS: 1
OBJ: 12
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1324, NCP 48-3
MSC: CRNE: CH-23
31. A patient undergoing a left ureterolithotomy returns to the surgical unit with a left ureteral
catheter and a urethral catheter in place. To care for the catheters, what should the nurse do?
a. Irrigate the ureteral catheter with 5 mL normal saline hourly.
b. Clamp the ureteral catheter when drainage is less than 10 mL/hour.
c. Keep the patient on bed rest until the catheter is removed.
d. Alternately clamp and unclamp the ureteral catheter every other hour to determine
total urinary output.
ANS: C
To avoid displacing the ureteral catheter, the patient is usually on bed rest until the catheter is
removed.
PTS: 1
OBJ: 12
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1323
MSC: CRNE: CH-31
32. Which of the following is considered a storage symptom of a lower UTI?
a. Dysuria
b. Hesitancy
c. Intermittency
d. Urgency
ANS: D
Urgency is a storage symptom of an infection of the lower urinary tract.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1291, Table 48-3
MSC: CRNE: CH-8
33. When teaching a patient about adequate fluid intake, what does the nurse tell the patient
regarding an appropriate amount of daily intake per kilogram of body weight?
a. 25 mL
b. 33 mL
c. 42 mL
d. 50 mL
ANS: B
To maintain adequate hydration the patient should drink at least 33 mL per kg of body weight.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1295, Table 48-6
MSC: CRNE: CH-34
34. The nurse anticipates that the patient with Goodpasture syndrome will be prescribed which
one of the following medications?
a. A diuretic
b. An antihypertensive
c. A corticosteroid
d. Vitamin K injections
ANS: C
The patient with Goodpasture syndrome will be prescribed corticosteroids,
immunosuppressive drugs, plasmapheresis, and dialysis.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1301
MSC: CRNE: CH-8
Chapter 49: Nursing Management: Acute Kidney Injury and Chronic Kidney Disease
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A patient is hospitalized with a severe myocardial infarction (MI) accompanied by
cardiogenic shock. A week following his MI, his urinary output falls to 380 mL/day, and his
blood urea nitrogen (BUN) and serum creatinine levels indicate that he is in the maintenance
phase of acute renal failure (ARF). Which clinical finding would the nurse expect during this
phase?
a. Hypotension
b. Hypernatremia
c. Low urine specific gravity
d. Epithelial cell casts in the urine
ANS: C
The maintenance phase may last from days to weeks. During this phase, patients may be
anuric, oliguric, or nonoliguric. In this case, a diluted urine (low specific gravity) is being
made, but uremic toxins are not being removed.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1335
MSC: CRNE: CH-8
2. A patient with ARF has an arterial blood pH of 7.30. Which of the following will the nurse
assess for?
a. Tachycardia
b. Rapid respirations
c. Poor skin turgor
d. Vasodilation
ANS: B
Patients with metabolic acidosis caused by ARF may have Kussmaul’s respirations as the
lungs try to regulate carbon dioxide.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1336
MSC: CRNE: CH-70
3. A patient with congestive heart failure and pulmonary edema develops early symptoms of
ARF. The nurse plans care for the patient based on the knowledge that collaborative care of
the renal failure will be directed toward which of the following goals?
a. Promoting diuresis
b. Replacing fluid volume
c. Maintaining cardiac output
d. Diluting nephrotoxic substances
ANS: C
The primary goal of treatment for ARF is to eliminate the cause and provide supportive care
while the kidneys recover. Because this patient’s heart failure is causing ARF, the care will be
directed toward treatment of the heart failure.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1337
MSC: CRNE: CH-70
4. The nurse would expect that the most pronounced elevations in serum potassium and BUN
would occur in patients who have ARF resulting from which of the following conditions?
a. Cardiogenic shock
b. Nephrotoxic drugs
c. Severe crushing injuries
d. Renal vascular obstruction
ANS: C
The hyperkalemia associated with crushing injuries may cause cardiac arrest and should be
treated immediately.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1336
MSC: CRNE: CH-68
5. A patient admitted with sepsis has had several episodes of severe hypotension. Laboratory
results indicate a BUN of 10.7 mmol/L (30 mg/dL), serum creatinine of 177 micromol/L (2.0
mg/dL), urine sodium of 70 mmol/L, urine specific gravity of 1.01, and cellular casts and
debris in the urine. The nurse knows these findings are consistent with which condition?
a. Uremia
b. Prerenal failure
c. Post renal failure
d. Acute tubular necrosis
ANS: D
The specific gravity and presence of casts and debris in the urinalysis suggest intrarenal
failure and acute tubular necrosis.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
REF: page 1335
MSC: CRNE: CH-8
6. A patient in the oliguric phase of ARF has a 24-hour fluid output of 150 mL emesis and 250
mL urine. The nurse plans for which amount of fluid replacements for the following day?
a. 400 mL
b. 800 mL
c. 1000 mL
d. 1400 mL
ANS: C
Usually, fluid replacement should be based on the patient’s measured output plus 600 mL/day
for insensible losses.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1337
MSC: CRNE: CH-34
7. When administering treatment for a patient who has hyperkalemia, the nurse will anticipate
administration of which of the following to cause the potassium to move into the cells?
a. Calcium gluconate
b. Sodium bicarbonate
c. Furosemide
d. Insulin
ANS: D
Regular intravenous (IV) insulin administration causes potassium to move into cells.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1337, Table 49-4
MSC: CRNE: CH-70
8. A patient in ARF has a gradual increase in urinary output to 3400 mL a day with a BUN of 33
mmol/L (92 mg/dL) and a serum creatinine of 371 micromol/L (4.2 mg/dL). The nurse should
plan to do which of the following?
a. Use a urine dipstick to monitor for proteinuria.
b. Auscultate the lungs to assess for pulmonary edema.
c. Take the blood pressure to check for hypotension.
d. Draw blood to monitor for hyperkalemia.
ANS: C
During the diuretic phase of ARF, fluid and electrolyte losses may cause hypovolemia,
hypotension, hyponatremia, and hypokalemia; therefore, the nurse should monitor the blood
pressure to assess for hypotension.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1337
MSC: CRNE: CH-70
9. To prevent the most common cause of death of patients in acute kidney injury (AKI), what
should the nurse do?
a. Restrict fluids to 500 to 600 mL/day.
b. Monitor cardiac function to detect early dysrhythmia.
c. Observe and accurately record all fluid intake and output.
d. Maintain meticulous medical and surgical asepsis in the delivery of all care.
ANS: D
Because infection is the leading cause of death overall in AKI, meticulous aseptic technique is
critical. The patient should be protected from other individuals with infectious diseases.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1339
MSC: CRNE: CH-70
10. After noting increasing QRS intervals in a patient with ARF, which action should the nurse
take first?
a. Notify the patient’s physician.
b. Check the chart for the most recent blood potassium level.
c. Look at the patient’s current BUN and creatinine levels.
d. Document the QRS interval.
ANS: B
The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the
most recent potassium and then notify the patient’s physician.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1345
MSC: CRNE: CH-6
11. Chronic uremia affects multiple body systems. Which of the following is a clinical
manifestation of the integumentary system that is often seen in patients with chronic uremia?
a. Petechiae
b. Dermatitis
c. Ecchymosis
d. Spider nevi
ANS: C
There are three common integumentary clinical manifestations of chronic uremia: pruritus,
ecchymosis, and dry, scaly skin.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1341, Figure 49-3
MSC: CRNE: CH-8
12. A patient is diagnosed with stage 3 chronic kidney disease (CKD). The patient is treated with
conservative management, including erythropoietin injections. After teaching the patient
about management of CKD, the nurse determines that teaching has been effective when the
patient states which of the following?
a. “I will measure my urinary output each day to help calculate the amount I can
drink.”
b. “I need to take the erythropoietin to boost my immune system and help prevent
infection.”
c. “I need to try to get more protein from dairy products.”
d. “I will try to increase my intake of fruits and vegetables.”
ANS: A
The patient with CKD who is not receiving dialysis is generally taught to restrict fluids. The
patient would need to measure urinary output and then add 600 mL for insensible losses to
calculate an appropriate oral intake.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1347
MSC: CRNE: CH-34
13. A patient with CKD has a nursing diagnosis of disturbed sensory perception related to central
nervous system changes induced by uremic toxins. What is an appropriate nursing intervention
for this problem?
a. Convey a caring attitude and foster the nurse–patient relationship.
b. Avoid fruits and vegetables as sources of high potassium in the diet.
c. Ensure restricted protein intake to prevent nitrogenous product accumulation.
d. Provide an opportunity for the patient to discuss concerns about his condition.
ANS: C
Uremia is caused by the products of protein breakdown, and protein restriction is used to
decrease uremia.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1346
MSC: CRNE: CH-35
14. As the nurse and the dietitian review a diet plan with a patient with diabetes with newly
diagnosed renal insufficiency, the patient becomes very angry, shouting 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 these diseases will kill her anyway. Based on the patient’s response,
the nurse identifies which of the following nursing diagnoses?
a. Ineffective coping related to emotional lability
b. Risk for noncompliance related to feelings of anger
c. Anticipatory grieving related to actual and perceived losses
d. Risk for ineffective health maintenance related to complexity of therapeutic
regimen
ANS: C
The patient’s statements that there is nothing that is good to eat and that death is unavoidable
indicate grieving about the losses being experienced as a result of the diabetes and CKD.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1349, Nursing Care Plan 49-1
OBJ: 8
TOP: Nursing Process: Diagnosis
MSC: CRNE: CH-17
15. Before administering sodium polystyrene sulphonate (Kayexalate) to a patient with
hyperkalemia, what should the nurse assess for?
a. BUN and creatinine
b. Blood glucose level
c. Patient’s bowel sounds
d. Level of consciousness
ANS: C
Sodium polystyrene sulphonate should not be given to a patient with a paralytic ileus (as
indicated by absent bowel sounds) because bowel necrosis can occur.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1337
MSC: CRNE: CH-44
16. The nurse has instructed a patient who is receiving hemodialysis about dietary management.
Which diet choice by the patient indicates that the teaching has been successful?
a. Scrambled eggs, English muffin, and apple juice
b. Cheese sandwich, tomato soup, and cranberry juice
c. Split-pea soup, whole-wheat toast, and nonfat milk
d. Oatmeal with cream, half a banana, and herbal tea
ANS: A
Scrambled eggs would provide high-quality protein, and apple juice is low in potassium.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Evaluation
REF: page 1347, Table 49-9
MSC: CRNE: CH-8
17. Before administration of calcitriol (Rocaltrol) to a patient with CKD, the nurse should check
the laboratory value for which of the following?
a. Serum phosphate
b. Total cholesterol
c. Creatinine
d. Potassium
ANS: A
If serum phosphate is elevated, the calcium and phosphate can cause soft tissue calcification.
The calcitriol should not be given until the phosphate level is lowered.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
REF: page 1346
MSC: CRNE: CH-6
18. A patient is being initiated on peritoneal dialysis. What should the nurse teach the patient in
relation to fluid allowance?
a. Limit intake to 1000 mL per day.
b. Adjust intake to equal output plus 300 mL per day.
c. Adjust intake to equal output plus 600 mL per day.
d. Often there is no fluid restriction.
ANS: D
With peritoneal dialysis, there is often no restriction on fluid allowance.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1347, Table 49-8
MSC: CRNE: CH-34
19. A patient needing vascular access for hemodialysis asks the nurse what the differences are
between an arteriovenous fistula and a graft. What should the nurse explain is one advantage
of the fistula over the graft?
a. It increases patient mobility.
b. It is much less likely to clot.
c. It can accommodate larger needles.
d. It can be used sooner after the surgery.
ANS: B
Arteriovenous fistulas are much less likely to clot than grafts, although it takes longer for
them to mature to the point where they can be used for dialysis.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1354
MSC: CRNE: CH-8
20. In preparation for hemodialysis, a patient has an arteriovenous native fistula created in the left
forearm. To assess and maintain the patency of the fistula postoperatively, what should the
nurse do?
a. Auscultate the fistula site for a bruit.
b. Assess the rate and quality of the radial pulse.
c. Assess the blood pressure in the affected arm.
d. Irrigate the fistula site daily with low-dose heparin.
ANS: A
The presence of a thrill and bruit indicates adequate blood flow through the fistula.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1354
MSC: CRNE: CH-4
21. When teaching a patient about potassium-containing foods, which of the following foods
would the nurse recommend as having an extremely high amount of potassium (>10 mmol per
serving)?
a. Apple juice
b. Tomatoes
c. Carrots
d. Squash
ANS: D
Although all of the foods listed contain potassium, squash has the highest amount, with
greater than 10 mmol of potassium per serving.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1347, Table 49-9
MSC: CRNE: CH-35
22. A patient with CKD is started on hemodialysis, and after the first treatment, the patient
complains of nausea and a headache. The nurse notes mild jerking and twitching of the
patient’s extremities. The nurse will anticipate the need to do which of the following?
a. Increase the time for the next dialysis to remove wastes more completely.
b. Switch to continuous renal replacement therapy to improve dialysis efficiency.
c. Administer medications to control these symptoms before the next dialysis.
d. Slow the rate for the next dialysis to decrease the speed of solute removal.
ANS: D
The patient has symptoms of disequilibrium syndrome, which can be prevented by slowing
the rate of dialysis so that fewer solutes are removed during the dialysis.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1358
MSC: CRNE: CH-70
23. A 54-year-old patient with diabetes and CKD is considering using continuous ambulatory
peritoneal dialysis (CAPD) as her renal failure becomes worse. In discussing this treatment
option with the patient, what should the nurse tell the patient?
a. Patients with diabetes respond better to CAPD than to hemodialysis.
b. Home CAPD requires more extensive equipment than does home hemodialysis.
c. CAPD is contraindicated for patients who may eventually want a kidney
transplant.
d. Patients receiving CAPD have more dietary restrictions than are required with
hemodialysis.
ANS: A
Patients with diabetes have better control of blood pressure, less hemodynamic instability, and
fewer problems with retinal hemorrhages when using peritoneal dialysis than when using
hemodialysis.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1354
MSC: CRNE: CH-8
24. A patient who has been on CAPD for 8 months is hospitalized with a detached retina. She is
receiving CAPD with four exchanges a day while she is hospitalized. During the dialysate
inflow, the patient tells the nurse that she is having abdominal pain and pain in her right
shoulder. What should the nurse do?
a.
b.
c.
d.
Massage the patient’s abdomen.
Decrease the rate of dialysate infusion.
Stop the infusion and notify the physician.
Ask the patient whether she can empty her bowel.
ANS: B
Abdominal pain and referred shoulder pain can be caused by a rapid infusion of dialysate; the
nurse should slow the rate of the infusion.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1353
MSC: CRNE: CH-8
25. The nurse is assessing a patient who is receiving peritoneal dialysis with 2-L inflows. Which
information should be reported immediately to the physician?
a. The patient is complaining of feeling bloated after the inflow.
b. The patient’s peritoneal effluent appears cloudy.
c. The patient has abdominal pain during the inflow phase.
d. The patient has an outflow volume of 1600 mL.
ANS: B
Cloudy-appearing peritoneal effluent is a sign of peritonitis and should be reported
immediately so that treatment with antibiotics can be started.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1353
MSC: CRNE: CH-23
26. In the immediate postoperative period, when caring for a patient who is a recipient of a kidney
transplant, the nurse would expect that fluid therapy would involve administration of which of
the following IV fluid infusion principles?
a. Maintain at a minimum rate of 100 mL/hour to perfuse the kidney.
b. Maintain at a rate to keep blood pressure within a normal range.
c. Determine rate maintenance hourly, based on every millilitre of urinary output.
d. Administer at a rate to keep urine clear, without evidence of blood clots.
ANS: C
Fluid volume is replaced based on urinary output after transplant because the urinary output
can be as high as a litre an hour.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1362
MSC: CRNE: CH-34
27. A patient is receiving immunosuppressive drugs following a living related-donor kidney
transplant. To monitor for corticosteroid-related complications, the nurse teaches the patient to
report which of the following?
a. Pain at the donor kidney site
b. Dizziness with position change
c. Changes in the character of the urine
d. Pain in the hips, knees, and other joints
ANS: D
Aseptic necrosis of the weight-bearing joints can occur when patients take corticosteroids
over a prolonged period.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1363
MSC: CRNE: CH-50
28. Two hours after a kidney transplant, the nurse obtains all of the following data when assessing
the patient. Which information is most important to communicate to the physician?
a. The BUN and creatinine levels are elevated.
b. The urinary output is 900 to 1100 mL/hour.
c. The patient’s central venous pressure (CVP) is decreased.
d. The patient has level 8 (on a 10-point scale) incision pain when coughing.
ANS: C
The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent renal
hypoperfusion and acute tubular necrosis.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1362
MSC: CRNE: CH-23
29. Which data obtained when assessing a patient who had a kidney transplant 8 years ago and
who is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune),
and prednisone (Deltasone) will be of most concern to the nurse?
a. The blood glucose is 8 mmol/L (144 mg/dL).
b. The patient has a round, moonlike face.
c. The patient has a nontender lump in the axilla.
d. The patient’s blood pressure is 150/92 mm Hg.
ANS: C
A nontender lump suggests a malignancy such as a lymphoma, which could occur as a result
of chronic immunosuppressive therapy.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1363
MSC: CRNE: CH-48
30. A patient with CKD brings all home medications to the clinic to be reviewed by the nurse.
Which medication being used by the patient indicates that patient teaching is required?
a. Milk of magnesia 30 mL administered orally
b. Oral acetaminophen (Tylenol) 650 mg
c. Multivitamin with iron
d. Calcium phosphate (PhosLo)
ANS: A
Magnesium is excreted by the kidneys, and patients with CKD should not use over-thecounter products containing magnesium.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1342
MSC: CRNE: CH-48
31. A patient with hypertension and stage 2 CKD is receiving captopril (Capoten). Before
administration of the medication, the nurse will check the level of which of the following?
a. Creatinine
b. Glucose
c. Phosphate
d. Potassium
ANS: D
Angiotensin-converting enzyme inhibitors are frequently used in patients with CKD because
they delay the progression of the CKD, but they cause potassium retention; therefore, careful
monitoring of potassium levels is needed in patients who are at risk for hyperkalemia.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1334
MSC: CRNE: CH-44
32. A new order for IV gentamicin (Garamycin) 60 mg twice daily is received for a patient with
diabetes who has pneumonia. When evaluating for adverse effects of the medication, the nurse
will plan to monitor the patient for which of the following?
a. Blood glucose
b. Serum potassium
c. BUN and creatinine
d. Urine osmolality
ANS: C
When a patient at risk for CKD receives a nephrotoxic medication, it is important to monitor
renal function with BUN and creatinine levels.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1334
MSC: CRNE: CH-48
33. A patient receiving peritoneal dialysis using 2 L of dialysate per exchange has an outflow of
1200 mL. Which of the following actions should the nurse take first?
a. Infuse 1200 mL of dialysate during the inflow.
b. Assist the patient in changing position.
c. Administer a laxative to the patient.
d. Notify the physician about the outflow problem.
ANS: B
Outflow problems may occur because the peritoneal catheter is collapsed by a portion of the
intestine, and repositioning the patient will move the catheter and allow outflow to occur.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: pages 1353-1354
MSC: CRNE: CH-34
34. Which of the following is the preferred hemodialysis vascular access site?
a. Nontunnelled central venous catheter
b. Arteriovenous fistula
c. Tunnelled central venous catheter
d. Arteriovenous graft
ANS: B
Although all four vascular access sites can be used for hemodialysis, the preferred one is the
arteriovenous fistula.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1354
MSC: CRNE: CH-55
35. A patient complains of leg cramps during hemodialysis. What should the nurse do?
a. Give acetaminophen.
b. Infuse a bolus of normal saline.
c. Massage the patient’s legs.
d. Reposition the patient.
ANS: B
Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment
includes infusion of normal saline.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1357
MSC: CRNE: CH-34
Chapter 50: Nursing Assessment: Endocrine System
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. When evaluating the laboratory findings of a patient with increased secretion of the anterior
pituitary hormones, what would the nurse expect to find?
a. Increased urinary free cortisol
b. Decreased serum thyroxine (T4) levels
c. Low urinary excretion of catecholamines
d. Increased serum aldosterone levels
ANS: A
Increased secretion of adrenocorticotropic hormone by the anterior pituitary gland will lead to
an increase in serum and urinary cortisol levels.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1372, Table 50-1
MSC: CRNE: CH-6
2. When obtaining the health history, which of the following statements by a patient indicates
that the nurse should assess further for a possible problem with the thyroid gland?
a. “I have noticed difficulty in swallowing.”
b. “I get up several times at night to urinate.”
c. “I have noticed my breasts are tender lately.”
d. “I drink about 6 L of water a day.”
ANS: A
Difficulty swallowing can occur with a goitre.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1381, Table 50-6
MSC: CRNE: CH-1
3. What is the most common type of feedback system in the regulation of hormones?
a. Negative
b. Positive
c. Complex
d. Chemical
ANS: A
The most common type of feedback system is negative feedback, in which the gland responds
by increasing or decreasing the secretion of a hormone on the basis of feedback from various
factors (e.g., insulin).
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1373
MSC: CRNE: CH-8
4. During a patient assessment, which of the following is a question the nurse can ask that
addresses thyroid function?
a. “Do you have to get up at night to urinate?”
b. “Have you experienced any blurring or double vision?”
c. “Do you experience fatigue even if you have slept a long time?”
d. “Can you describe the amount of stress you have at home and work?”
ANS: C
Fatigue may be a sign of hypothyroidism.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1384, Table 50-6
MSC: CRNE: CH-8
5. The physician has ordered a serum cortisol level to rule out adrenal dysfunction in a patient
who is a night security guard who works from 2300 hours to 0700 hours and normally sleeps
from 0800 hours to 1600 hours. To ensure the most reliable test results, when does the nurse
arrange the blood specimen to be drawn?
a. At 0300 hours
b. At 2300 hours
c. In the early morning
d. In the late afternoon
ANS: D
Cortisol levels are usually drawn in the morning, when levels are highest. In a patient who
sleeps during the day, the highest level would be soon after awakening in the late afternoon.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1389, Table 50-8
MSC: CRNE: CH-30
6. A patient has a total serum calcium level of 3.3 mmol/L (13.3 mg/dL; 6.7 mEq/L). The nurse
understands that this level of calcium normally does which of the following?
a. Indicates hypothyroidism
b. Stimulates the secretion of calcitonin
c. Occurs when the parathyroid gland is surgically removed
d. Can be caused by oversecretion of calcitonin from the thyroid gland
ANS: B
Calcitonin is secreted by the C cells of the thyroid gland in response to elevated blood calcium
levels.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1377
MSC: CRNE: CH-8
7. Which action taken by a nursing student when caring for a patient with thyroiditis and a goitre
requires that the supervising nurse intervene immediately?
a. The student nurse checks the blood pressure on both arms.
b. The student nurse lowers the thermostat to decrease the temperature in the room.
c. The student nurse palpates the neck to check thyroid size.
d. The student nurse orders nonmedicated eyedrops to lubricate the patient’s eyes.
ANS: C
Palpation can cause the release of thyroid hormones in a patient with an enlarged thyroid and
should be avoided.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1382
MSC: CRNE: PP-19
8. During a physical examination, the nurse finds that a patient’s thyroid gland cannot be
palpated. What does the nurse interpret this finding as?
a. A normal finding
b. Evidence of an atrophied thyroid gland
c. Insignificant in a patient with elevated triiodothyronine (T3) and T4 levels
d. Abnormal, and confirmation of the finding by another experienced health care
provider is necessary
ANS: A
The thyroid is frequently nonpalpable. The nurse should simply document the finding.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1382
MSC: CRNE: CH-8
9. Which hormone is an example of positive feedback in the regulation of hormonal secretion?
a. Insulin
b. Oxytocin
c. Thyroid-stimulating hormone (TSH)
d. Thyroid-releasing hormone
ANS: B
An example of a positive-feedback hormone is oxytocin during the birth process. Insulin is an
example of a negative-feedback hormone. Thyroid hormones are an example of complex
feedback.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1373
MSC: CRNE: CH-8
10. When working with a patient who has diabetes mellitus, the nurse uses the results of testing
for glycosylated hemoglobin to evaluate which of the following?
a. Glucose levels 2 hours after a meal
b. Glucose control over the past 3 months
c. Circulating, nonfasting glucose levels
d. Episodes of hypoglycemia in the past 2 months
ANS: B
Glycosylated hemoglobin testing measures glucose control over the last 3 months.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Evaluation
REF: page 1385, Table 50-8
MSC: CRNE: CH-4
11. Which of the following is an age-related change affecting the endocrine system?
a. Increase in TSH secretion
b. Decreased parathyroid secretion
c. Increased glucose intolerance
d. Decreased secretion of norepinephrine
ANS: C
A normal age-related change in assessment findings of the endocrine system is an increased
glucose intolerance leading to a decreased sensitivity to insulin.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 1380, Table 50-5
OBJ: 7
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
12. A patient is scheduled for a growth hormone (GH) stimulation test. In preparation for the test,
which of the following will the nurse obtain?
a. Vial of 50% dextrose solution
b. Vial of glargine insulin
c. Cardiac monitor
d. Basin of ice
ANS: A
Hypoglycemia is induced during the GH stimulation test, and the nurse should be ready to
administer 50% dextrose immediately.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1385, Table 50-8
MSC: CRNE: CH-30
13. To confirm the diagnosis of reactive hypoglycemia in a patient experiencing symptoms of the
disorder, the nurse would expect the patient to be scheduled for which of the following tests?
a. Fasting blood glucose test
b. 2-hour glucose tolerance test
c. 5-hour glucose tolerance test
d. 24-hour urine test for glucose and ketones
ANS: C
Patients with reactive hypoglycemia have adrenergic symptoms and glucose levels less than
3.3 mmol/L with a 5-hour glucose tolerance test.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 1390, Table 50-8
MSC: CRNE: CH-30
14. Which of the following factors stimulates the secretion of insulin?
a. Decreased glucose levels
b. Increased somatostatin levels
c. Decreased amino acid levels
d. Increased vagal stimulation
ANS: D
Increased vagal stimulation is a factor that will stimulate the secretion of insulin. All of the
others inhibit the secretion of insulin.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1379, Table 50-4
MSC: CRNE: CH-8
15. When the nurse is describing the effects of insulin on the body to a patient newly diagnosed
with diabetes mellitus, which of the following is the best explanation?
a. “Insulin promotes the breakdown of fatty tissue into triglycerides, which can be
used for energy.”
b. “When proteins are taken into the body, insulin promotes their breakdown and
conversion to fats.”
c. “Insulin stimulates the conversion of stored sugars into blood glucose and the
conversion of proteins into glucose.”
d. “When carbohydrates, fats, and proteins are eaten, insulin promotes cellular
transport and storage of all these nutrients.”
ANS: D
Insulin is an anabolic hormone that assists with the transport of nutrients into cells and their
synthesis into glycogen, triglycerides, and proteins.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1379
MSC: CRNE: CH-8
16. Use of nursing interventions to decrease the patient’s physical and emotional stress is most
important when the patient is undergoing which of the following tests?
a. A water deprivation test
b. Testing for serum T3 and T4 levels
c. A 24-hour urine test for free cortisol
d. A radioactive iodine uptake test
ANS: C
Physical and emotional stress can affect the results for the free cortisol test. The other tests are
not impacted by stress.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1391, Table 50-8
MSC: CRNE: CH-8
17. A patient is scheduled for a 24-hour urine collection for 17-ketosteroids. The nurse will plan
to do which of the following?
a. Insert a retention catheter.
b. Keep the specimen on ice.
c. Have the patient void and save that specimen to start the collection.
d. Encourage the patient to drink 2 to 3 L of fluid during the 24 hours.
ANS: B
The specimen must be kept on ice or refrigerated until the collection is finished.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1389, Table 50-8
MSC: CRNE: CH-30
18. When caring for a patient having a water deprivation test, which assessment obtained by the
nurse will be of greatest concern?
a. The patient complains of intense thirst.
b. The patient has experienced a 2.5-kg weight loss.
c. The patient feels dizzy when sitting up on the edge of the bed.
d. The patient’s urine osmolality does not change after antidiuretic hormone is given.
ANS: B
A drop in the weight of more than 2 kg indicates severe dehydration, and the test should be
discontinued.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1386, Table 50-8
MSC: CRNE: CH-30
19. Which of the following is a common characteristic of most hormones?
a.
b.
c.
d.
Secretion at unpredictable rates
Circulation through the blood
Binding to receptors only on the cell membrane
Binding only to receptors within the cell
ANS: B
Most hormones have three common characteristics: secretion in small amounts at variable but
predictable rates, circulation through the blood, and binding to specific receptors in the cell
membrane or within the cell.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 1371
MSC: CRNE: CH-8
Chapter 51: Nursing Management: Endocrine Problems
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A patient seeks care at the clinic because of increasing speech difficulties and hoarseness,
telling the nurse his tongue has gotten so big that he can hardly talk. The physician suspects
acromegaly. During the nursing history, which of the following should the nurse specifically
ask the patient whether he has experienced?
a. A recent head injury
b. An increase in shoe size
c. A family history of endocrine problems
d. Symptoms of hypoglycemia, such as hunger and nervousness
ANS: B
Acromegaly causes an enlargement of the hands and feet.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1394
MSC: CRNE: CH-1
2. During preoperative teaching for a patient scheduled for transsphenoidal hypophysectomy for
treatment of a pituitary adenoma, what should the nurse instruct the patient that she will have
to do?
a. Take replacement growth hormone for the rest of her life
b. Not brush her teeth for at least 10 days after the surgery
c. Be expected to cough and breathe deeply every 2 hours postoperatively
d. Be positioned flat in bed with sandbags at her head to prevent head movement
ANS: B
To avoid disruption of the suture line, the patient should avoid brushing the teeth for 10 days
after surgery.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1396
MSC: CRNE: CH-31
3. Following a transsphenoidal resection of a pituitary tumour, the nurse suspects that the patient
has developed diabetes insipidus on finding which of the following data?
a. A urine specific gravity of 1.001
b. A consistent rise in blood pressure
c. Fluid retention with dependent edema
d. A serum sodium of 130 mmol/L
ANS: A
After pituitary surgery, the patient is at risk for diabetes insipidus caused by cerebral edema,
and monitoring of urinary output and urine specific gravity is essential.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1396
MSC: CRNE: CH-8
4. A patient is suspected of having a pituitary tumour causing panhypopituitarism. During
assessment of the patient, the nurse would expect to find which of the following changes?
a.
b.
c.
d.
Elevated plasma glucose levels and dyslipidemia
Changes in secondary sex characteristics and loss of libido
Hypertension resulting from increased water reabsorption in the kidney
Evidence of hypofunction of the adrenal, thyroid, and parathyroid glands
ANS: B
Changes in secondary sex characteristics are associated with decreases in follicle-stimulating
hormone and luteinizing hormone. Fasting hypoglycemia and hypotension occur in
panhypopituitarism as a result of decreases in adrenocorticotropic hormone and cortisol.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1397
MSC: CRNE: CH-8
5. Which of the following effects on the cardiovascular system would a patient with a
hypofunction of the parathyroid gland most likely exhibit?
a. Hypertension
b. Increased cardiac output
c. Decreased contractility of heart muscle
d. Dysrhythmias
ANS: C
A patient with a hypofunction of their parathyroid gland would most likely exhibit a decrease
in the contractibility of their heart muscle.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1397
MSC: CRNE: CH-8
6. A patient with an antidiuretic hormone (ADH)–secreting small cell cancer of the lung is
treated to control the symptoms of syndrome of inappropriate ADH (SIADH). The nurse
determines that treatment is effective on finding which of the following data?
a. The patient’s weight is stable.
b. The urine specific gravity is increased.
c. The patient’s urinary output is increased.
d. The patient’s edema is reduced.
ANS: C
Treatment is aimed at blocking the action of ADH on the renal tubules, causing an increase in
urinary output.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1398
MSC: CRNE: CH-48
7. When teaching a patient with chronic SIADH about long-term management of the disorder,
the nurse determines that additional instruction is needed when the patient gives which of the
following responses?
a. “I need to maintain a sodium-restricted diet at home.”
b. “I should weigh myself daily and report a sudden loss or gain.”
c. “I need to limit my fluid intake to no more than 950 mL of liquids a day.”
d. “I will eat foods high in potassium because the diuretics cause potassium loss.”
ANS: A
Patients with SIADH are at risk for hyponatremia, and a sodium supplement may be
prescribed; therefore, more teaching would be required to the patient who indicated that he or
she would have to maintain a sodium-restricted diet.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1399
MSC: CRNE: NCP-14
8. A 73-year-old woman is hospitalized with possible SIADH. She is confused and reports a
headache, muscle cramps, and twitching. Initially, which of the following laboratory results
would the nurse expect to find?
a. Hematocrit of 0.52 (52%)
b. Blood urea nitrogen of 7.9 mmol/L (22 mg/dL)
c. Serum sodium of 124 mmol/L
d. Serum chloride of 111 mmol/L
ANS: C
When water is retained, the serum sodium level will drop below normal, causing the clinical
manifestations reported by the patient.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1398
MSC: CRNE: CH-6
9. A patient with symptoms of diabetes insipidus is admitted to the hospital for evaluation and
treatment of the condition. What is an appropriate nursing diagnosis that the nurse would
document for the patient based on an understanding of this condition?
a. Disturbed sleep pattern related to nocturia
b. Risk for impaired skin integrity related to edema
c. Excess fluid volume related to intake greater than output
d. Activity intolerance related to muscle cramps and weakness
ANS: A
Nocturia occurs as a result of the polyuria caused by diabetes insipidus, which leads to a
disturbed sleep pattern.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
REF: page 1401, Table 51-4
MSC: CRNE: CH-15
10. Which information obtained when caring for a patient who has just been admitted for
evaluation of diabetes insipidus will be of greatest concern to the nurse?
a. Has a urinary output of 800 mL/hour
b. Has a urine specific gravity of 1.003
c. Had a recent head injury
d. Is confused and lethargic
ANS: D
Patients with diabetes insipidus compensate for fluid losses by drinking copious amounts of
fluids, but a patient who is lethargic will be unable to drink enough fluids and will become
hypovolemic.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
REF: page 1400
MSC: CRNE: CH-15
11. When teaching a patient newly diagnosed with Graves’ disease about the disorder, the nurse
explains which of the following?
a. Restriction of iodine intake is needed to reduce thyroid activity.
b. Exercise is contraindicated to avoid increasing the metabolic rate.
c. Surgery will eventually be required to remove the thyroid gland.
d. Antithyroid medications may take several weeks to have an effect.
ANS: D
Improvement usually begins in 1 to 2 weeks, with good results at 4 to 8 weeks.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1404
MSC: CRNE: CH-22
12. Which one of the following effects on the integumentary system would a patient with a
hyperfunction of the parathyroid gland most likely exhibit?
a. Lack of tooth enamel
b. Hair loss on scalp and body
c. Brittle nails
d. Moist skin
ANS: D
A patient with a hyperfunction of the parathyroid gland would most likely exhibit the
integumentary change of moist skin and skin necrosis. The other choices are symptoms of
hypofunction of the parathyroid gland.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1405, Table 51-6
MSC: CRNE: CH-15
13. During the nursing assessment of a patient with Graves’ disease, the nurse notes a bounding,
rapid pulse and systolic hypertension. What is an additional manifestation of the disorder that
the nurse would expect to find?
a. Chest pain
b. Constipation
c. Decreased appetite
d. Muscle aches
ANS: A
Angina is a possible complication of Graves’ disease, especially for a patient with tachycardia
and hypertension; therefore, the nurse would expect to assess the patient for chest pain.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1405, Table 51-6
MSC: CRNE: CH-8
14. While assessing a patient who has just arrived in the postanaesthesia recovery unit after a
thyroidectomy, the nurse obtains the following data. Which information is most important to
communicate to the surgeon?
a. Complaining of level 7 incisional pain on a 10-point scale
b. Cardiac monitor showing a heart rate of 112 beats/min
c. Increasing swelling of the neck
d. A weak, hoarse voice
ANS: C
The neck swelling may lead to respiratory difficulty, and rapid intervention is needed to
prevent airway obstruction.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1409
MSC: CRNE: CH-27
15. A few hours after returning to the surgical nursing unit, a patient who has undergone a
subtotal thyroidectomy develops laryngeal stridor and a cramp in the right hand. What
intervention would the nurse anticipate?
a. An immediate tracheostomy
b. Administration of intravenous morphine
c. Administration of intravenous calcium gluconate
d. Endotracheal intubation with mechanical ventilation
ANS: C
The patient’s clinical manifestations are consistent with tetany caused by hypocalcemia
resulting from damage to the parathyroid glands during surgery.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1409
MSC: CRNE: CH-8
16. The nurse identifies a nursing diagnosis of risk for injury: corneal ulceration related to
inability to close the eyelids secondary to exophthalmos for a patient with Graves’ disease.
What is an appropriate nursing intervention to prevent this problem?
a. Teach the patient to blink every few seconds to lubricate the cornea.
b. Elevate the head of the patient’s bed to reduce periorbital fluid.
c. Apply eye patches to protect the cornea from irritation.
d. Place cold packs on the eyes to relieve pain and swelling.
ANS: B
The patient should sit upright as much as possible to promote fluid drainage from the
periorbital area.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1410
MSC: CRNE: CH-20
17. Which of the following is the first nursing action indicated when a patient returns to the
surgical nursing unit after a thyroidectomy?
a. Check the back of the neck for hemorrhage.
b. Assess respiratory rate and effort.
c. Determine whether the patient can speak normally.
d. Ask the patient whether he or she experiences any tingling in the toes or fingers.
ANS: B
Airway obstruction is a possible complication after thyroidectomy because of swelling or
bleeding at the site or tetany, and the priority nursing action is to assess the airway.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1409
MSC: CRNE: CH-31
18. A patient with hyperthyroidism is treated with radioactive iodine at a clinic. Before the patient
is discharged, what should the nurse instruct the patient about?
a. Symptoms of hyperthyroidism should be relieved in about a week
b. Radioactive precautions to take with urine, stool, and other body secretions
c. Monitoring for symptoms of hypothyroidism, such as easy bruising and cold
intolerance
d. Discontinuing the antithyroid medications and propranolol (Inderal) taken before
the radioactive therapy
ANS: C
There is a high incidence of postradiation hypothyroidism after radioactive iodine, and the
patient should be monitored for symptoms of hypothyroidism.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1406
MSC: CRNE: CH-77
19. After 5 years of experiencing depression, fatigue, and lethargy, an older adult woman is
diagnosed with hypothyroidism, and levothyroxine (Synthroid) is prescribed. During initiation
of thyroid replacement for the patient, it is most important for the nurse to assess which of the
following functions?
a. Mental status
b. Nutritional status
c. Cardiovascular function
d. Fluid and electrolyte balance
ANS: C
In older adult patients, initiation of levothyroxine therapy can increase myocardial oxygen
demand and cause angina or dysrhythmias.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1411
MSC: CRNE: CH-48
20. While a 68-year-old woman is hospitalized for a fractured femur, she is diagnosed with
hypothyroidism. Which of the following medications ordered for the patient at the time of
admission does the nurse recognize should not be administered without consulting the
physician?
a. A stool softener
b. A sedative
c. An analgesic
d. An antibiotic
ANS: B
Worsening of mental status and myxedema coma can be precipitated in patients with
hypothyroidism by the use of sedatives, especially in older adults.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1411, Table 51-11
MSC: CRNE: CH-23
21. When teaching a patient with newly diagnosed hypothyroidism about management of the
condition, the nurse should do which of the following?
a. Schedule daily home visits by home care nurses to repeat the necessary
instructions.
b. Delay teaching about the condition until the patient has responded to replacement
therapy.
c. Provide written handouts of all instructions for continued reference as the patient
improves.
d. Designate a family member to teach the patient about the condition when
forgetfulness has improved.
ANS: C
Written instructions will be helpful to the patient because, initially, the hypothyroid patient
may be unable to remember to take medications and other aspects of self-care.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1411
MSC: CRNE: CH-77
22. When admitting a patient who has just recently fallen and broken his hip, the nurse notes
hypertension, muscle wasting, and a large buffalo hump. The nurse knows that these findings
are consistent with the patient having which following diagnosis?
a. Addison’s disease
b. SIADH
c. Cushing’s syndrome
d. Pheochromocytoma
ANS: C
These assessment findings are consistent with a diagnosis of Cushing’s syndrome—
particularly the classic buffalo hump, which is visible as fat deposits on the back of the neck
and on the shoulders.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Assessment
TOP: Nursing Process: Assessment
REF: page 1417, Table 51-14
MSC: CRNE: CH-6
23. Following a thyroidectomy, a patient develops generalized muscle cramps and mild tetany.
The patients’ calcium levels are decreased. Which nursing action is appropriate?
a. Administer the ordered muscle relaxant.
b. Have the patient rebreathe using a paper bag.
c. Start oxygen at 2 to 3 L/min per cannula.
d. Give the ordered oral calcium supplement.
ANS: B
Rebreathing may partially alleviate acute neuromuscular symptoms associated with
hypocalcemia, such as generalized muscle cramps, or mild tetany. Patients who can cooperate
should be instructed to breathe in and out of a paper bag or breathing mask. This reduces
carbon dioxide excretion from the lungs, increases carbonic acid levels in the blood, and
lowers the pH.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1415
MSC: CRNE: CH-32
24. Following a thyroidectomy, the patient develops hypoparathyroidism. The nurse teaches the
patient that maintenance therapy for the hypoparathyroidism will include which of the
following?
a. Calcium supplements
b. A diet high in oxalic acid
c. Phosphorus supplements
d. Parenteral parathyroid hormone
ANS: A
Oral calcium supplements are used to maintain the serum calcium in the normal range and
prevent the complications of hypocalcemia.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1414
MSC: CRNE: CH-77
25. A patient with hypoparathyroidism receives instructions from the nurse regarding symptoms
of hypo- and hypercalcemia. The nurse teaches the patient that if mild symptoms of
hypocalcemia occur, the patient should do which of the following?
a. Increase the daily fluid intake to twice the usual amount.
b. Self-administer intramuscular calcium before calling the doctor.
c. Call an ambulance because the symptoms will progress to seizures.
d. Breathe in and out of a paper bag to temporarily relieve the symptoms, and then
seek medical assistance.
ANS: D
Rebreathing may help alleviate mild symptoms, but it will only temporarily increase ionized
calcium level, so the patient should call the physician.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1415
MSC: CRNE: CH-32
26. A nursing assessment of a patient with Cushing’s syndrome reveals that the patient has truncal
obesity and thin arms and legs. What is an additional manifestation of Cushing’s syndrome
that the nurse would expect to find?
a. Hypotension
b. Decreased axillary and pubic hair
c. Purplish red striae on the abdomen
d. Bronzed hyperpigmentation of the skin
ANS: C
Purplish red striae on the abdomen are a common clinical manifestation of Cushing’s
syndrome.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1416, Table 51-14
MSC: CRNE: CH-8
27. A patient with Cushing’s syndrome is admitted to the hospital in preparation for surgery to
remove an adrenal tumour. During the admission assessment, the patient tells the nurse that
she looks so awful she does not want anyone to be around her. What is the best response to
the patient?
a. “Let me show you how to dress so that the changes are not so noticeable.”
b. “I do not think you look bad. Your appearance is just altered by your disease.”
c. “You really should not worry about how you look in the hospital. We see many
worse things.”
d. “Most of the physical and mental changes caused by the disease will gradually
improve after surgery.”
ANS: D
The most reassuring communication to the patient is that the physical and emotional changes
caused by the Cushing’s syndrome will resolve after hormone levels return to normal
postoperatively.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1419
MSC: CRNE: CH-17
28. When providing postoperative care for a patient who has had a bilateral adrenalectomy, which
assessment information obtained by the nurse is most important to communicate to the
physician?
a. The blood glucose is 8 mmol/L.
b. The patient’s blood pressure is 102/50 mm Hg.
c. The patient has level 6 incisional pain on a 10-point scale.
d. The lungs have bibasilar crackles.
ANS: B
During the immediate postoperative period, marked fluctuation in cortisol levels may occur,
and the nurse must be alert for signs of acute adrenal insufficiency such as hypotension.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1416
MSC: CRNE: CH-23
29. A patient with Cushing’s syndrome returns to the surgical unit following an adrenalectomy.
During the initial postoperative period, the nurse gives the highest priority to which of the
following actions?
a. Monitoring for infection
b. Protecting the patient’s skin
c. Monitoring fluid and electrolyte status
d. Preventing severe emotional disturbances
ANS: C
After adrenalectomy, the patient is at risk for circulatory instability caused by fluctuating
hormone levels, and the focus of care is to assess and maintain fluid and electrolyte status
through the use of intravenous fluids and corticosteroids.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1418
MSC: CRNE: CH-31
30. A patient is hospitalized with acute adrenal insufficiency. Which of the following findings
assists the nurse to determine that the patient is responding favourably to treatment?
a. Decreasing blood glucose
b. Increasing urinary output
c. Decreasing serum sodium
d. Decreasing serum potassium
ANS: D
Clinical manifestations of Addison’s disease include hyperkalemia, and a decrease in
potassium level indicates improvement.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1417, Table 51-14
MSC: CRNE: CH-8
31. A patient is admitted to the hospital in addisonian crisis 1 month following a diagnosis of
Addison’s disease. The nurse documents the nursing diagnosis of ineffective therapeutic
regimen management related to lack of knowledge of management of condition when the
patient gives which of the following responses?
a. “I double my dose of hydrocortisone if I am experiencing moderate stress.”
b. “I had the stomach flu earlier this week and couldn’t take the hydrocortisone.”
c. “I frequently eat at restaurants, so my food has a lot of added salt.”
d. “I do yoga exercises almost every day to help me reduce stress and relax.”
ANS: B
The need for hydrocortisone replacement is increased with stressors such as illness, and the
patient needs to be taught to call the physician because medication and intravenous fluids and
electrolytes may have to be given.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1421
MSC: CRNE: CH-15
32. A patient who uses every-other-day prednisone therapy for rheumatoid arthritis complains of
not feeling as well on the nonprednisone days and asks the nurse about taking prednisone
daily instead. What is the best response to the patient?
a. An every-other-day schedule mimics the normal pattern of cortisol secretion from
the adrenal gland.
b. Glucocorticoids are taken on a daily basis only when they are being used for
replacement therapy.
c. If it improves the symptoms, it would be acceptable to take half the usual dose
every day.
d. When prednisone is taken every other day, the effect on normal adrenal function is
less.
ANS: D
An alternate-day regimen is given to minimize the impact of exogenous corticosteroids on
adrenal gland function.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1416
MSC: CRNE: CH-44
33. A patient is taking high doses of prednisone to control the symptoms of an acute exacerbation
of systemic lupus erythematosus. When teaching the patient about the use of prednisone,
which information is most important for the nurse to include?
a. Call the doctor if you experience any mood alterations with the prednisone.
b. Do not stop taking the prednisone suddenly; it should be decreased gradually.
c. Weigh yourself daily to monitor for weight gain caused by water or increased fat.
d. Check your temperature daily because prednisone can hide signs of infection.
ANS: B
Acute adrenal insufficiency may occur if exogenous corticosteroids are suddenly stopped.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1416
MSC: CRNE: CH-44
34. A patient has an adenoma of the adrenal zona glomerulosa causing hyperaldosteronism and is
scheduled for surgery to remove the affected gland. During care before surgery, the nurse
should do which of the following?
a. Limit fluids to 1000 mL/day.
b. Provide a potassium-restricted diet.
c. Monitor the blood pressure every 4 hours.
d. Elevate the patient’s extremities to relieve edema.
ANS: C
Hypertension caused by sodium retention is a common complication of hyperaldosteronism;
therefore, the blood pressure should be monitored frequently.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1424
MSC: CRNE: CH-8
35. A patient with a possible pheochromocytoma is admitted to the hospital for evaluation and
diagnostic testing. During an attack, what would the nurse expect the patient to experience?
a. Persistent hypoglycemia
b. Severe bradycardia refractory to drug therapy
c. Severe hypotension with sympathoadrenal blockade
d. Severe, pounding headache, tachycardia, and profuse sweating
ANS: D
The classic clinical manifestations of pheochromocytoma are hypertension, tachycardia,
severe headache, diaphoresis, and abdominal or chest pain.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1425
MSC: CRNE: CH-8
36. After a patient with a pituitary adenoma has had a hypophysectomy, the nurse will plan to do
discharge teaching about the need for which of the following?
a. Insulin use to maintain blood glucose at normal levels
b. Sodium restriction to prevent fluid retention and hypertension
c. Oral corticosteroids to replace endogenous cortisol
d. Chemotherapy to prevent recurrence of the tumour
ANS: C
ADH, cortisol, and thyroid hormone replacement will be needed for life after
hypophysectomy.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1423
MSC: CRNE: CH-17
37. A patient is admitted with possible SIADH. Which information obtained by the nurse is most
important to communicate rapidly to the physician?
a. Complains of a severe headache
b. Complains of severe thirst
c. Has a urine specific gravity of 1.025
d. Has a serum sodium level of 119 mmol/L
ANS: D
A serum sodium of less than 120 mmol/L increases the risk for complications such as seizures
and needs rapid correction.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1398
MSC: CRNE: CH-27
38. Which type of diabetes insipidus results from excessive water intake?
a. Central
b. Neurogenic
c. Nephrogenic
d. Primary
ANS: D
Primary diabetes insipidus results from excessive water intake.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1400, Table 51-3
MSC: CRNE: CH-8
39. After receiving a change-of-shift report about the following four patients, which patient
should the nurse assess first?
a. A 22-year-old patient admitted with SIADH who has a serum sodium level of 130
mmol/L
b. A 31-year-old patient who has iatrogenic Cushing’s syndrome with a capillary
blood glucose level of 13.6 mmol/L (244 mg/dL)
c. A 53-year-old patient who has Addison’s disease and is due for a scheduled dose
of hydrocortisone (Solu-Cortef)
d. A 70-year-old patient who recently started levothyroxine to treat hypothyroidism
and has an irregular pulse of 134 beats/min
ANS: D
Initiation of thyroid replacement in older adults may cause angina and cardiac dysrhythmias.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1411
MSC: CRNE: CH-22
Chapter 52: Nursing Management: Diabetes Mellitus
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A patient with newly diagnosed type 2 diabetes asks the nurse what “type 2” means in relation
to diabetes. Which of the following statements best explains to the patient how type 2 diabetes
primarily differs from type 1 diabetes?
a. “With type 2 diabetes, the patient is totally dependent on an outside source of
insulin.”
b. “With type 2 diabetes, decreased insulin secretion, cellular resistance to insulin, or
both are produced.”
c. “With type 2 diabetes, islet cell antibodies and insulin autoantibodies destroy beta
cells in the pancreas.”
d. “With type 2 diabetes, the C-peptide chain of proinsulin secreted by the pancreas
cannot be removed by the liver, resulting in a lack of active insulin.”
ANS: B
In type 2 diabetes, the pancreas produces insulin, but the insulin is insufficient for the body’s
needs or the cells do not respond to the insulin appropriately.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1432
MSC: CRNE: CH-8
2. A patient screened for diabetes at a clinic has a fasting plasma glucose of 6.7 mmol/L (120
mg/dL). What will the nurse plan to teach the patient about?
a. Use of low doses of regular insulin
b. Self-monitoring of blood glucose
c. Oral hypoglycemic medications
d. Maintenance of a healthy weight
ANS: D
The patient’s impaired fasting glucose indicates prediabetes, and the patient should be
counselled about lifestyle changes, for example, a healthy weight, to prevent the development
of type 2 diabetes.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 1431
MSC: CRNE: HW-13
3. During a diabetes screening program, a young woman tells the nurse that her mother died of
complications of diabetes and asks whether she will inherit the disease. After determining that
the woman’s mother most likely had type 2 diabetes, what should the nurse explain?
a. Her 60% chance of developing type 2 diabetes can be prevented by maintaining a
normal weight and a low-carbohydrate diet.
b. The patient has a higher familial risk for developing type 2 diabetes than for type 1
diabetes, and she should have her glucose level tested periodically.
c. She would have a higher risk for developing diabetes if her father, rather than her
mother, had diabetes, but she should still be tested periodically.
d. Although there is a familial tendency for children or siblings of individuals with
type 2 diabetes to develop diabetes, the inherited risk is not as high as it is for type
1 diabetes.
ANS: B
The offspring of people with type 2 diabetes are at higher risk for developing type 2 diabetes.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1433 (Genetics in Clinical Practice box)
OBJ: 2
TOP: Nursing Process: Implementation
MSC: CRNE: CH-8
4. A program of weight loss and exercise is recommended for a patient with insulin resistance
syndrome. When the patient asks why these measures are necessary when she really does not
have diabetes, what should the nurse explain?
a. The high insulin levels associated with this syndrome damage the lining of blood
vessels and cause osmotic diuresis.
b. Although her fasting plasma glucose levels do not indicate diabetes, she has
impaired glucose tolerance, which is characteristic of the syndrome.
c. The liver is inappropriately producing glucose, which will eventually exhaust the
ability of the pancreas to produce insulin, and exercise will normalize glucose
production.
d. She has a variety of abnormalities associated with diabetes, which indicate a very
high risk for cardiovascular disease, and the onset of diabetes can be delayed or
prevented by weight loss and exercise.
ANS: D
The patient with impaired fasting glucose is at risk for developing type 2 diabetes, but this risk
can be decreased with lifestyle changes.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1433
MSC: CRNE: HW-13
5. When assessing the patient experiencing the onset of type 1 diabetes, which question should
the nurse ask?
a. “Have you lost any weight lately?”
b. “Do you crave fluids containing sugar?”
c. “How long have you felt anorexic?”
d. “Is your urine unusually dark-coloured?”
ANS: A
Weight loss occurs because the body is no longer able to absorb glucose and starts to break
down protein and fat for energy.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1430, Table 52-1
MSC: CRNE: CH-1
6. During a clinic visit 3 months following a diagnosis of type 2 diabetes, the patient reports that
she has been following her reduced-calorie diet, but she has not lost any weight, and she has
neglected to bring her record of glucose monitoring results. What does the nurse recognize as
the best indicator of the patient’s control of her diabetes since her initial diagnosis and
instruction?
a. A fasting glucose level
b. Analysis for microalbuminuria
c. A glycosylated hemoglobin (HbA1C) level
d. The patient’s verbal report of her symptoms
ANS: C
The HbA1C test shows the overall control of glucose over 90 to 120 days.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1434
MSC: CRNE: CH-6
7. A patient is diagnosed with type 2 diabetes at the clinic. A nursing assessment of the patient
reveals vital signs of blood pressure 158/96 mm Hg, heart rate 88 beats/min, respiration 18
breaths/min, temperature 37.1°C, height 160 cm, and weight 82 kg. The physician prescribes a
1200-calorie diet with a daily exercise program as initial therapy for the patient. The nurse
refers the patient to the dietitian for initial diet planning and teaching with the knowledge that
which of the following is the primary goal of nutritional therapy for the patient?
a. Control of dietary intake to achieve ideal body weight
b. Elimination of simple sugars in exchange for complex carbohydrate in the diet
c. Reduction in dietary calories and fat to normalize glucose, lipid, and blood
pressure levels
d. Maintenance of equal distribution of carbohydrate throughout the day with strict
adherence to consistency in daily intake
ANS: C
A nutritionally adequate meal plan with a reduction in total fat (especially saturated fats), an
increase in fibre, and a decrease in simple sugars can bring about decreased calorie and
carbohydrate consumption.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1444
MSC: CRNE: CH-35
8. A 20-year-old university student who has type 1 diabetes normally walks each evening as part
of her exercise regimen. She now plans to enroll in a swimming class to meet her physical
education requirement. What should the nurse teach the patient that adjustments to her
treatment plan should include?
a. Delaying the normal meal before the swimming class until the session is over
b. Adding 10 units of regular insulin to her usual morning dose on the days she plans
to swim
c. Timing her morning insulin injection so that the peak action will occur during her
swimming class
d. Monitoring her glucose level before, during, and after swimming to determine the
need for alterations in food or insulin
ANS: D
The change in exercise will affect blood glucose, and the patient will need to monitor glucose
carefully to determine the need for changes in diet and insulin administration.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1445
MSC: CRNE: CH-35
9. A patient with type 1 diabetes has received diet instruction as part of his treatment plan. The
nurse determines a need for additional instruction when the patient makes which one of the
following comments?
a. “I may have an occasional alcoholic drink if I include it in my meal plan.”
b. “I will need a bedtime snack because I take an evening dose of NPH insulin.”
c. “I may eat whatever I want as long as I cover the calories with sufficient insulin.”
d. “I should eat meals as scheduled, even if I am not hungry, to prevent
hypoglycemia.”
ANS: C
Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are
using intensified insulin therapy have considerable flexibility in diet choices but still should
restrict dietary intake of items such as fat, protein, and alcohol.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1444
MSC: CRNE: CH-35
10. A 1200-calorie diet and exercise are prescribed for a patient with newly diagnosed type 2
diabetes. The patient tells the nurse that she hates to exercise and asks whether just following
her diet would control her diabetes. What primary reason should the nurse stress to the patient
for planning a pleasant, regular exercise routine?
a. It will give her increased energy and a sense of well-being.
b. It will facilitate weight loss, which will decrease peripheral insulin resistance.
c. It will improve cardiovascular and respiratory fitness, which is important for all
individuals.
d. It will set a pattern for the other routines of dietary changes and meal scheduling
necessary for diabetes control.
ANS: B
Exercise is essential to decrease insulin resistance and improve blood glucose control.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1444
MSC: CRNE: HW-13
11. The nurse has been teaching the patient to administer a dose of 10 units regular insulin and 28
units Lente insulin. Which of the following statements by the patient indicates a need for
additional instruction?
a. “I should rotate injection sites among my arms, legs, and abdomen each day.”
b. “I may reuse my insulin syringes for more injections if I recap them after use.”
c. “I should draw up the regular insulin first after injecting air into the Lente bottle.”
d. “I do not have to pull back on the plunger to check for blood before I inject the
insulin.”
ANS: A
Rotating sites is no longer necessary because all insulin is now purified human insulin, and
the risk for lipodystrophy is low.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1438
MSC: CRNE: CH-44
12. What should the nurse emphasize when teaching a patient with type 1 diabetes about the
Somogyi effect and dawn phenomenon?
a. The Somogyi effect occurs early at night, and the dawn phenomenon occurs on
arising.
b. The Somogyi effect is characterized by hyperglycemia and the dawn phenomenon
by hypoglycemia.
c. The Somogyi effect occurs when the patient is asleep, and the dawn phenomenon
occurs after the patient awakens.
d. In the Somogyi effect, hyperglycemia results from too much insulin, and the dawn
phenomenon results from too little insulin.
ANS: D
In the Somogyi effect, hyperglycemia results from too much insulin, and the dawn
phenomenon results from too little insulin.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1441
MSC: CRNE: CH-8
13. A patient receives a daily injection of 70/30 NPH/regular insulin premix at 0700 hours. The
nurse expects that a hypoglycemic reaction is most likely to occur between which of the
following times?
a. 0800 and 1000 hours
b. 1600 and 1800 hours
c. 1900 and 2100 hours
d. 2200 and 2400 hours
ANS: B
The greatest insulin effect with this combination occurs in midafternoon.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 1437, Table 52-4
MSC: CRNE: CH-48
14. A patient using a split mixed-dose insulin regimen tells the nurse that he is interested in using
intensive insulin therapy because he has read that it promotes fewer and less severe
complications of diabetes. In response to the patient’s comment, what should the nurse
explain?
a. Intensive insulin therapy requires three or more injections a day in addition to an
injection of a basal long-acting insulin.
b. Intensive insulin therapy is indicated only for patients who have recently received
a diagnosis of type 1 diabetes and who have never experienced ketoacidosis.
c. Studies have shown that intensive insulin therapy is most effective in preventing
the macrovascular complications characteristic of type 2 diabetes.
d. The use of an insulin pump does not require as much attention as intensive insulin
therapy and offers the same protection against long-term complications.
ANS: A
Patients using intensive insulin therapy must check their glucose level four to six times daily
and administer insulin accordingly.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1436
MSC: CRNE: CH-8
15. When intensive insulin therapy is used for control of diabetes, the nurse recognizes that which
of the following types of insulin is preferred for mealtime coverage?
a.
b.
c.
d.
NPH insulin
Lispro insulin
Lente insulin
Insulin glargine
ANS: B
Rapid- or short-acting insulin is used for mealtime coverage for patients receiving intensive
insulin therapy.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1436
MSC: CRNE: CH-44
16. Glyburide (Diabeta) is prescribed for a patient when her type 2 diabetes has not been
controlled with diet and exercise. When teaching the patient about glyburide, what should the
nurse explain?
a. Glyburide is thought to stimulate insulin production and release from the pancreas.
b. Glyburide is a substitute for insulin and acts by directly stimulating glucose uptake
into the cell.
c. Glyburide, like all oral antidiabetes agents, does not cause the hypoglycemic
reactions that may occur with insulin use.
d. Glyburide and other sulphonylureas lower blood sugar by decreasing the rate of
hepatic glucose production, preventing gluconeogenesis.
ANS: A
The sulphonylureas stimulate the production and release of insulin from the pancreas.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1442, Table 52-7
MSC: CRNE: CH-8
17. When teaching a patient with type 2 diabetes about taking an oral antihyperglycemic
medication, the nurse determines that additional teaching about the medication is needed
when the patient gives which of the following responses?
a. “If I overeat at a meal, I should not take an extra dose of my medication.”
b. “If I become ill or especially stressed, I may have to take insulin to control my
blood sugar.”
c. “Given that I can take oral drugs rather than insulin, my diabetes is not serious and
won’t cause many complications.”
d. “I should check with my doctor before taking any other medications because there
are many that will affect glucose levels.”
ANS: C
The patient should understand that type 2 diabetes places the patient at risk for many
complications and that good glucose control is as important when taking oral agents, as when
using insulin.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1452
MSC: CRNE: NCP-14
18. A patient with type 2 diabetes that is controlled with diet and metformin (Glucophage) also
has severe rheumatoid arthritis. During an acute exacerbation of the patient’s arthritis, the
physician prescribes prednisone (Deltasone) to control inflammation. What will the nurse
anticipate?
a.
b.
c.
d.
Administration of insulin while taking prednisone
Development of acute hypoglycemia during the rheumatoid arthritis exacerbation
Evidence of rashes caused by metformin–prednisone interactions
Requirement of a diet higher in calories while receiving prednisone
ANS: A
Glucose levels increase when patients are taking corticosteroids, and insulin may be required
to control blood glucose.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 1434
MSC: CRNE: CH-8
19. A hospitalized patient with diabetes receives 12 units of regular insulin mixed with 34 units of
NPH insulin at 0700 hours. The patient is away from the nursing unit for diagnostic testing at
noon, when lunch trays are distributed. What is the most appropriate nursing action?
a. Save the lunch tray to be provided on the patient’s return to the unit.
b. Call the diagnostic testing area, and ask the physician to start an intravenous (IV)
line of 5% dextrose solution.
c. Ensure that the patient drinks a glass of milk or orange juice at noon in the
diagnostic testing area.
d. Request that the patient be returned to the unit to eat lunch if testing will not be
completed promptly.
ANS: D
Consistency for mealtimes assists with regulation of blood glucose, so the best option is for
the patient to have lunch at the usual time.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
REF: page 1437, Table 52-4
MSC: CRNE: CH-35
20. A patient with type 1 diabetes has been using self-capillary blood glucose monitoring
(CBGM) as part of his diabetes management. During evaluation of his technique of CBGM,
the nurse identifies a need for additional teaching when the patient does which of the
following actions?
a. Chooses a puncture site in the centre of the finger pad
b. Washes his hands with soap and water to cleanse the puncture site
c. Tells the nurse that the result of 130 mg indicates good control of his diabetes
d. Hangs his arm down before a second puncture site attempt for an adequate drop of
blood
ANS: A
The patient is taught to choose a puncture site at the side of the finger pad.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1447, Table 52-11
MSC: CRNE: CH-20
21. The nurse is preparing a mixed insulin dose for administration. After injecting air into both
vials, what would be the immediate next step?
a. Gently rotate the NPH insulin bottle.
b. Invert and draw up regular insulin.
c. Swab the tops of both vials with alcohol sponge or swab.
d. Invert and draw up NPH insulin.
ANS: B
After the nurse has injected air into both vials, the next action is to invert the regular insulin
vial and withdraw the ordered amount.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1438, Figure 52-4
MSC: CRNE: CH-44
22. A patient with type 1 diabetes is found unresponsive in the morning by his wife and is
admitted to the emergency department. On admission, the patient is unresponsive to stimuli
and has fruity, sweet breath with Kussmaul’s respirations. Laboratory results include arterial
blood gases of pH 7.32, PCO2 34 mm Hg, and HCO3 11 mmol/L, and a plasma glucose of
28.8 mmol/L (518 mg/dL). Which of the following interventions does the nurse anticipate will
be prescribed initially for the patient?
a. IV fluid and electrolyte replacement therapy
b. Administration of an IV bolus of regular insulin
c. Low-dose insulin infusion in a normal saline solution
d. IV administration of sodium bicarbonate to replace bicarbonate and reverse the
acidosis
ANS: A
The priority action is to administer IV fluid and electrolyte replacement therapy.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1457
MSC: CRNE: CH-66
23. Cardiac monitoring is initiated for a patient in diabetic ketoacidosis. The nurse recognizes that
this measure is important to identify which of the following complications?
a. Electrocardiogram (ECG) changes and dysrhythmias related to hypokalemia
b. Fluid overload resulting from aggressive fluid replacement
c. The presence of hypovolemic shock related to osmotic diuresis
d. Cardiovascular collapse resulting from the effects of excess glucose on cardiac
muscle
ANS: A
The hypokalemia associated with metabolic acidosis can lead to potentially fatal dysrhythmias
such as ventricular tachycardia and ventricular fibrillation, which would be detected with
ECG monitoring.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1457, Table 52-17
MSC: CRNE: CH-8
24. A patient with diabetes is admitted with ketoacidosis, and the physician writes all of the
following orders. Which order should the nurse implement first?
a. Start an infusion of regular insulin at 50 units/hour.
b. Give sodium bicarbonate 50 mmol/L IV push.
c. Infuse 1 L of normal saline per hour.
d. Administer regular IV insulin 30 units.
ANS: C
The most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis,
and the priority is to infuse IV fluids.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1458
MSC: CRNE: CH-22
25. Which of the following is a common side effect of metformin?
a. Nausea and diarrhea
b. Edema and weight gain
c. Upper respiratory tract infections
d. Hypoglycemia
ANS: A
Nausea and diarrhea are common side effects of metformin; others include upset stomach, less
weight gain than with sulphonylureas, no hypoglycemia, and potential lactic acidosis in renal
or hepatic impairment.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1442, Table 52-7
MSC: CRNE: CH-44
26. A patient with type 1 diabetes develops a sore throat, cough, and fever. He calls the clinic
when he finds his blood glucose level to be 11.67 mmol/L (210 mg/dL) with his monitor.
What should the nurse advise the patient to do?
a. Hold all food and insulin until his fever is relieved.
b. Measure his urinary output, and test his urine for ketones.
c. Reduce his carbohydrate intake until his glucose level is about 8.33 mmol/L (150
mg/dL).
d. Monitor his blood glucose every 4 hours, and notify the clinic if it continues to
rise.
ANS: D
Infection and other stressors increase blood glucose levels, and the patient will need to test
blood glucose frequently, treat elevations appropriately with insulin, and call the physician if
glucose levels continue to be elevated.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1447
MSC: CRNE: CH-77
27. While hospitalized and recovering from an episode of diabetic ketoacidosis, the patient calls
the nurse and reports feeling anxious, nervous, and sweaty. Based on the patient’s report, what
should the nurse do?
a. Obtain a glucose reading using a finger stick.
b. Administer 1 mg glucagon subcutaneously.
c. Have the patient eat a chocolate bar.
d. Have the patient drink 113 g of orange juice.
ANS: A
The patient’s clinical manifestations are consistent with hypoglycemia, and the initial action
should be to check the patient’s glucose with a finger stick or order an immediate blood
glucose test.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1447
MSC: CRNE: CH-66
28. A patient recovering from diabetic ketoacidosis asks the nurse how acidosis occurs. What is
the best response?
a. Excess glucose in the blood is metabolized by the liver into acetone, which is
acidic in nature.
b. An insulin deficit promotes metabolism of fat stores, which produces large
amounts of acidic ketones.
c. Insufficient insulin leads to cellular starvation, and as cells rupture, they release
organic acids into the blood.
d. When an insulin deficit causes hyperglycemia, then proteins are deaminated by the
liver, causing acidic by-products.
ANS: B
Ketoacidosis is caused by the breakdown of fat stores when glucose is not available for
intracellular metabolism.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1455
MSC: CRNE: CH-8
29. Intramuscular glucagon is administered to an unresponsive patient for treatment of
hypoglycemia. Which action should the nurse take after the patient regains consciousness?
a. Give the patient a snack of cheese and crackers.
b. Have the patient drink a glass of orange juice or nonfat milk.
c. Administer a continuous infusion of 5% dextrose for 24 hours.
d. Assess the patient for symptoms of hyperglycemia.
ANS: A
Rebound hypoglycemia can occur after glucagon administration, but having a meal containing
complex carbohydrates plus protein and fat, such as cheese and crackers, will help prevent
hypoglycemia.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1460
MSC: CRNE: CH-35
30. A patient with diabetes was admitted to the emergency department when he was found
unresponsive at his desk at work. A capillary blood glucose level was 2.2 mmol/L (38
mg/dL), and he was treated for hypoglycemia. When he recovers, he tells the nurse that he had
no warning of the hypoglycemia. Which of the following questions will help identify a
possible reason for the patient’s hypoglycemic unawareness?
a. “Do you use any calcium channel–blocking drugs for blood pressure?”
b. “Have you observed any recent skin changes?”
c. “Do you notice any bloating feeling after eating?”
d. “Have you noticed any painful new ulcerations or sores on your feet?”
ANS: C
Hypoglycemic unawareness is caused by autonomic neuropathy, which would also cause
delayed gastric emptying, making the patient feel bloated after eating.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1464
MSC: CRNE: CH-12
31. A patient with type 2 diabetes has sensory neuropathy of the feet and legs and peripheral
vascular disease evidenced by decreased peripheral pulses and dependent rubor. What will the
nurse teach the patient?
a. The feet should be soaked in warm water on a daily basis.
b. Flat-soled leather shoes are the best choice to protect the feet from injury.
c. Heating pads should always be set at a very low temperature.
d. Over-the-counter callus remover may be used to remove calluses and prevent
pressure.
ANS: B
The patient is taught to avoid high heels and that leather shoes are preferred.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1465, Table 52-21
MSC: CRNE: CH-20
32. A patient newly diagnosed with type 1 diabetes likes to run 5 km several mornings a week.
Which teaching will the nurse implement about exercise for this patient?
a. “You should not take the morning NPH insulin before you run.”
b. “Plan to eat breakfast about an hour before your run.”
c. “Afternoon running is less likely to cause hypoglycemia.”
d. “You may want to run a little farther if your glucose is very high.”
ANS: B
Blood sugar increases after meals, so this will be the best time to exercise.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1430, Figure 52-1
MSC: CRNE: CH-35
33. Amitriptyline (Elavil) is prescribed for a patient with diabetes with peripheral neuropathy who
has burning foot pain occurring mostly at night. Which information should the nurse include
when teaching the patient about the new medication?
a. Amitriptyline will help prevent the transmission of pain impulses to the brain.
b. Amitriptyline will improve sleep and make you less aware of nighttime pain.
c. Amitriptyline will decrease the depression caused by the pain.
d. Amitriptyline will correct some of the blood vessel changes that cause pain.
ANS: A
Tricyclic antidepressants decrease the transmission of pain impulses to the spinal cord and
brain. Tricyclic antidepressants are also moderately effective in treating the symptoms of
diabetic neuropathy. They work by inhibiting the reuptake of norepinephrine and serotonin,
which are neurotransmitters that are believed to play a role in the transmission of pain through
the spinal cord.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1463
MSC: CRNE: CH-44
34. A patient with type 2 diabetes is scheduled for an outpatient coronary arteriogram. Which
information obtained by the nurse when admitting the patient indicates a need for a change in
the patient’s regimen?
a. The patient’s most recent HbA1C result was 6%.
b. The patient takes metformin every morning.
c. The patient uses captopril (Capoten) for hypertension.
d. The patient’s admission blood glucose is 7.1 mmol/L (128 mg/dL).
ANS: B
To avoid lactic acidosis, metformin should not be used for 48 hours after IV contrast medium
is administered.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1442, Table 52-7
MSC: CRNE: CH-30
35. Which of the following is true of type 2 diabetes?
a. Diet modifications and insulin are required for glucose control.
b. Uniform timing of meals is crucial.
c. Reduction in caloric intake is desirable to control weight.
d. Intermeal and bedtime snacks are frequently necessary.
ANS: C
Reduction in caloric intake is desirable for the patient with type 2 diabetes to control weight,
whereas in type 1 diabetes, total calories may be increased to achieve a desirable body weight
and restore body tissues.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1443, Table 52-8
MSC: CRNE: CH-8
36. Which of these laboratory values noted by the nurse when reviewing the chart of a patient
with diabetes indicates the need for further assessment of the patient?
a. Fasting blood glucose of 6.5 mmol/L
b. Noon blood glucose of 2.6 mmol/L
c. HbA1C of 6.9%
d. HbA1C of 5.8%
ANS: B
The nurse should assess the patient with a blood glucose level of 2.6 mmol/L for symptoms of
hypoglycemia and give the patient a carbohydrate-containing beverage such as orange juice.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1455, Table 52-16
MSC: CRNE: CH-66
37. Which of the following is a characteristic of type 1 diabetes?
a. Incidence in young people is increasing
b. Insidious onset
c. Absent islet-cell antibodies
d. Patient prone to ketosis at onset
ANS: D
Patients are prone to ketosis at onset in type 1 diabetes but in type 2 diabetes are resistant
except during infections or stress.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1430, Table 52-1
MSC: CRNE: CH-8
38. Which of the following is an example of a short-acting insulin?
a. Lispro (Humalog)
b. Glulisine (Apidra)
c. Regular (Novolin)
d. Detemir (Levemir)
ANS: C
Regular insulin is a short-acting insulin.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1436, Table 52-3
MSC: CRNE: CH-44
Chapter 53: Nursing Assessment: Reproductive System
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. What is the name of the process that reduces the number of primordial follicles from 2 to 4
million at birth to approximately 300,000 to 400,000 at menarche?
a. Phagocytosis
b. Pinocytosis
c. Atresia
d. Active transport
ANS: C
Atresia is the name of the process that reduces the number of primordial follicles from 2 to 4
million at birth to approximately 300,000 to 400,000 at menarche.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 1472
MSC: CRNE: CH-8
2. Because of the location of the prostate gland in the male reproductive system, when caring for
a patient with prostate problems, the nurse should monitor the patient for which of the
following?
a. Constipation
b. Low back pain
c. Penile discharge
d. Urinary symptoms
ANS: D
Enlargement of the prostate blocks the urethra, leading to urinary retention and difficulty
initiating a urinary stream.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1472
MSC: CRNE: CH-8
3. What is the range of length of a menstrual cycle?
a. 5 to 7 days
b. 21 to 28 days
c. 20 to 40 days
d. 21 to 35 days
ANS: C
The range of length of the menstrual cycle is 20 to 40 days, the average being 28 days.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1477
MSC: CRNE: CH-8
4. A patient with a possible ovarian cyst is scheduled for ultrasonography. The nurse will teach
the patient which of the following?
a. She should not eat or drink for 4 hours before the procedure.
b. She will experience minimal discomfort during the procedure.
c. She should discontinue taking aspirin before the procedure.
d. She will receive intravenous contrast solution during the procedure.
ANS: B
Ultrasonography measures high-frequency sound waves as they pass through various tissues
and should cause very little discomfort.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1490, Table 53-12
MSC: CRNE: CH-30
5. During the nursing assessment of a 62-year-old man, the patient tells the nurse that he does
not respond to sexual stimulation the way he did when he was younger. What is the best
response to the patient’s comment?
a. “Erectile dysfunction is a common problem with older men.”
b. “Tell me more about how your response has changed.”
c. “Interest in sex frequently decreases as men get older.”
d. “Many men need more sexual stimulation with aging.”
ANS: B
The nurse’s initial response should be further assessment of the problem. The other statements
are accurate but might not respond to the patient’s concerns.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1478
MSC: CRNE: CH-1
6. When the nurse obtains a health history from a patient, the patient reports that she had
cryosurgery 1 year ago. What does the nurse anticipate that the patient most likely has a
history of?
a. Obstructed fallopian tubes
b. Abnormal menstrual cycles
c. Abnormal cells detected by a Pap smear
d. A protrusion of the urinary bladder through the vaginal wall
ANS: C
Cryosurgery is done to destroy abnormal cells, such as might be found in a Pap smear.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1480, Table 53-5
MSC: CRNE: CH-8
7. A patient considering a vasectomy as a means of contraception asks the nurse what is
involved in the procedure. The nurse explains that which of the following structures is
partially removed?
a. Epididymis
b. Spermatic cord
c. Ductus deferens
d. Ejaculatory duct
ANS: C
A vasectomy involves partial removal of the vas deferens or ductus deferens.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1480, Table 53-5
MSC: CRNE: CH-8
8. When scheduling a patient for a pelvic examination and Pap smear, what should the nurse
instruct the patient to do?
a. The patient should not douche for 24 hours before the examination.
b. The patient should not have sexual intercourse for 2 days before the examination.
c. The patient should schedule the examination for the first day of her menstrual
period.
d. The patient should shower before the examination but avoid tub baths the day
before the examination.
ANS: A
The results of a Pap smear may be affected by douching, so the patient should not douche
before the examination.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 1489, Table 53-12
TOP: Nursing Process: Implementation
MSC: CRNE: CH-30
9. When is menopause usually considered to be complete?
a. Cessation of menses for a period of 1 year
b. Once a woman turns 55 years of age
c. When estrogen levels drop 10% below normal
d. Once ovulation has ceased for a period of 2 years
ANS: A
Menopause is usually considered complete after 1 year of amenorrhea.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1477
MSC: CRNE: CH-8
10. When the nurse is performing a physical assessment of a male patient’s reproductive system,
which of the following findings does the nurse identify as abnormal?
a. Absence of a prepuce
b. Clear penile discharge
c. One testis descended lower than the other
d. Ability to palpate the abdominal wall along the inguinal canal
ANS: B
Clear penile discharge may be indicative of a sexually transmitted infection.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1485, Table 53-11
MSC: CRNE: CH-8
11. Which of the following is an age-related change in male sexual functioning?
a. Increased force of ejaculation
b. Increased rigidity of erection
c. Increased interest in sex
d. Decreased libido
ANS: D
An age-related change in sexual functioning for the male includes requiring an increase in
stimulation for an erection, decreased force of ejaculation, decreased ability to attain erection,
decreased size and rigidity of the penis at full erection, and a decreased libido and interest in
sex.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1479, Table 53-4
MSC: CRNE: CH-8
12. During the physical assessment of a 68-year-old woman, which of the following is a finding
that the nurse considers abnormal?
a. Pendulous breasts
b. Nonpalpable ovaries
c. Serous nipple drainage
d. Atrophy of vaginal tissue
ANS: C
Serous drainage may indicate an intraductal papilloma and should be investigated further.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1484, Table 53-9
MSC: CRNE: CH-8
13. A woman calls the clinic because she is having an unusually heavy menstrual flow. She tells
the nurse that she has saturated two pads in the past 2 hours. At which of the following
approximate amounts does the nurse estimate the amount of blood loss?
a. 10 to 20 mL
b. 20 to 30 mL
c. 30 to 40 mL
d. 40 to 60 mL
ANS: D
The average pad absorbs 20 to 30 mL, so two pads would indicate 40 to 60 mL.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1478, Table 53-2
MSC: CRNE: CH-4
14. When preparing a patient for colposcopy with a cervical biopsy, what should the nurse explain
to the patient about the procedure?
a. It requires surgical anaesthesia and overnight hospitalization.
b. It involves dilation of the cervix and biopsy of the tissue lining the uterus.
c. It is similar to a speculum examination of the cervix and should result in little or
no pain.
d. It is a surgical procedure that permits visualization of the uterus, ovaries, and
fallopian tubes.
ANS: C
Colposcopy involves visualization of the cervix with a binocular microscope and is similar to
a speculum examination.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1489, Table 53-12
MSC: CRNE: CH-30
15. A couple who has not been able to conceive is scheduled for a Huhner test for infertility. In
preparation for the test, what should the nurse inform the couple to do?
a. Refrain from sexual intercourse for 1 week before the test to allow sperm counts to
increase.
b. Have intercourse at the estimated time of ovulation and come to the health clinic 2
to 8 hours after intercourse.
c. Expect to have sexual intercourse at the clinic so that sperm evaluation can be
made immediately following intercourse.
d. Bring the man’s semen specimen no older than 2 hours to be implanted into the
woman’s cervix at the clinic.
ANS: B
For the Huhner test, the couple should have intercourse at the estimated time of conception
and then arrive for the test 2 to 8 hours after intercourse.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1490, Table 53-12
MSC: CRNE: CH-30
16. A young man is suspected of having syphilis. Which of the following tests does the nurse
recognize as the one most commonly used for initial screening for syphilis as it yields
information in the fastest way possible?
a. Venereal Disease Research Laboratory (VDRL) testing for antibodies
b. A blood culture of the microorganism
c. A dark-field microscopy direct examination culture of a specimen of drainage from
an active chancre
d. Fluorescent treponemal antibody absorption (FTA-Abs) testing for antibodies to
treponema
ANS: C
If the patient has an active chancre, the Treponema pallidum bacteria can be visualized. The
VDRL, rapid plasma regain (blood culture of the microorganism), and FTA-Abs tests will
take longer.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1485, Table 53-10
MSC: CRNE: CH-8
17. Before a woman uses oral contraceptives, the nurse should question the patient about a history
of which one of the following disorders?
a. Rubella
b. Anemia
c. Mumps
d. Cholecystitis
ANS: D
Cholecystitis is aggravated by oral contraceptives.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1480
MSC: CRNE: CH-48
18. A 42-year-old man tells the nurse that he has not been able to function sexually for about the
last year. The nurse asks the patient specifically about medications he is taking, with the
knowledge that erectile dysfunction may occur with the use of which of the following drugs?
a. Antilipemics
b. Antihypertensives
c. Oral hypoglycemic agents
d. H2-receptor blocking agents
ANS: B
Some antihypertensives may cause erectile dysfunction, and the nurse should anticipate a
change in antihypertensive therapy.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1480
MSC: CRNE: CH-48
19. The nurse’s best response to the patient who asks “what is a varicocelectomy” is which one of
the following?
a. Removal of part of the ductus deferens
b. Correction of axial rotation of the spermatic cord
c. Repair of a varicose vein of the scrotum
d. Skin graft to repair an injury to the testicle
ANS: C
A varicocelectomy is the repair of varicose veins of the scrotum.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1480, Table 53-5
MSC: CRNE: CH-8
Chapter 54: Nursing Management: Breast Disorders
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A woman asks the nurse which area of the breast most commonly develops breast cancer. The
nurse’s response is based upon knowledge that about 50% of all breast cancers occur in which
quadrant of the breast?
a. Upper inner quadrant
b. Upper outer quadrant
c. Lower inner quadrant
d. Lower outer quadrant
ANS: B
About half of all breast cancers occur in the upper outer quadrant of the breast.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1501, Figure 54-5
MSC: CRNE: CH-8
2. A 52-year-old woman has found a small lump in her breast during self-examination of her
breasts. While obtaining a nursing history from the patient, which of the following risk factors
for breast cancer should the nurse question the patient about?
a. Smoking
b. Trauma to the breasts
c. Fibrocystic breast changes
d. Age at onset of menarche and menopause
ANS: D
Early menarche and late menopause are risk factors for breast cancer because of the prolonged
exposure to estrogen that occurs.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1499, Table 54-2
MSC: CRNE: CH-8
3. A 62-year-old patient complains to the nurse that mammograms are painful and a source of
radiation exposure. She says she examines her breasts monthly and asks whether it is
necessary to have an annual mammogram. What is the best response to the patient?
a. “If your mammogram was painful, it is especially important that you have it done
annually.”
b. “An ultrasound examination of the breasts, which is not painful or a source of
radiation, can be substituted for a mammogram.”
c. “Because the incidence of breast cancer increases markedly after the age of 60, it is
very important for you to have annual mammograms.”
d. “Unless you find a lump while examining your breasts, a mammogram every 2
years is recommended after age 50.”
ANS: D
For women aged 50 to 69, mammograms are recommended every 2 years, as long as the
women are in good health.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1494
MSC: CRNE: HW-8
4. A patient with a small breast lump is advised to have a fine-needle aspiration (FNA) biopsy.
What should the nurse explain is an advantage to this procedure?
a. Only a small incision is necessary, resulting in minimal scarring.
b. If the specimen is positive for malignancy, the patient can be told at the visit.
c. If the specimen is negative for malignancy, the patient’s fears of cancer can be put
to rest.
d. A mammogram is used to guide the extraction of a sample of tissue, ensuring that
cells are taken from the lesion.
ANS: B
An FNA biopsy should be done only when an experienced cytologist is available to read the
specimen immediately. If the specimen is positive for malignancy, the patient can be given
this information immediately.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1495
MSC: CRNE: CH-30
5. During examination of a 33-year-old patient’s breasts, the nurse feels several movable, tender
nodules. The patient tells the nurse that she has fibrocystic breasts, but reducing her sodium
and caffeine intake, and other measures, have not made a difference in her breast pain and
lumps. What is an appropriate patient outcome for the nurse to establish with the patient?
a. Performs daily breast self-examination
b. Arranges for immediate examination and biopsy of any new lesion
c. Monitors changes in the size and tenderness of all lumps in relation to her
menstrual cycle
d. Consults with her physician about having a bilateral simple mastectomy to prevent
the cysts from becoming malignant
ANS: C
Because fibrocystic breasts may increase in size and tenderness during the premenstrual
phase, the patient is taught to monitor for this change and to call if the changes persist after
menstruation.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1497
MSC: CRNE: CH-8
6. A 20-year-old university student comes to the student health centre because she has
discovered a small lump in her right breast. She is very worried that she may have cancer
because her mother had cervical cancer. The nurse’s response to the patient is based on the
knowledge that what is the most common cause of breast lumps in women her age?
a. Breast cysts
b. Fibroadenoma
c. Breast abscesses
d. Adenocarcinoma
ANS: B
Fibroadenoma is the most frequent cause of breast lumps in women under 25 years of age.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1497
OBJ: 3
TOP: Nursing Process: Implementation
MSC: CRNE: CH-8
7. During examination of a 67-year-old man, the nurse notes bilateral enlargement of the breasts.
What should the nurse do?
a. Palpate the breasts for any discrete, circumscribed masses.
b. Explain that this is not unusual in older men and is no reason for concern.
c. Refer the patient to a primary physician for mammography and biopsy of the
breast tissue.
d. Explain to the patient that this is normal in older men because of conversion of
androgens to estrogens.
ANS: A
If discrete, circumscribed lumps are present, the patient should be referred for further testing
to determine whether breast cancer is present.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1498
MSC: CRNE: CH-4
8. Which stage of breast cancer is depicted by the TNM designation of T2 N0 M0?
a. Stage I
b. Stage IIA
c. Stage IIB
d. Stage IIIA
ANS: B
The TNM system (T, tumor size; N, nodal involvement; M, presence of metastasis)
designation of T2 N0 M0 indicates that the patient is in stage IIA.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1504, Table 54-7
MSC: CRNE: CH-8
9. At a routine health examination, a woman whose mother had breast cancer asks the nurse
about the genetic basis of breast cancer and the genes involved. What should the nurse
explain?
a. Her risk of inheriting BRCA gene mutations is small unless her mother had both
ovarian and breast cancer.
b. Changes in BRCA genes that normally suppress cancer growth can be passed to
offspring, increasing the risk for breast cancer.
c. Because her mother had breast cancer, she has inherited a 50% to 85% chance of
developing breast cancer due to mutated genes.
d. BRCA1 and BRCA2 are genes that promote cancer growth, although only a small
percentage of women with breast cancer have this genetic abnormality.
ANS: B
Family history is a risk factor for breast cancer, and the nurse should discuss testing for BRCA
genes with the patient. Although the BRCA gene is associated with increased risk for breast
and ovarian cancer, the patient may be at risk if her mother had either one.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1499, Table 54-2
MSC: CRNE: CH-8
10. When counselling a patient about breast cancer prevention, the nurse considers that the patient
has a significant family history of breast cancer if she has which of the following?
a. A sister who died from ovarian cancer at the age of 29
b. A paternal grandmother who died from breast cancer at the age of 72
c. A cousin who was diagnosed with breast cancer at the age of 60 and ovarian
cancer at the age of 68
d. A mother who was diagnosed with breast cancer at the age of 42
ANS: D
A significant family history of breast cancer means that the patient has a first-degree relative
who developed breast cancer, especially if the relative was premenopausal.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1499, Table 54-2
MSC: CRNE: CH-8
11. A patient with a breast biopsy positive for cancer is to undergo lymphatic mapping and
sentinel lymph node biopsy. What should the nurse explain about this procedure?
a. It reduces the need for extensive lymph node dissection for pathological
examination.
b. It can identify specific lymph nodes that have malignant cells, so only involved
nodes have to be excised.
c. It eliminates the need for excision of more than one lymph node for staging of
breast cancer.
d. It will confirm the absence of tumour spread if the sentinel lymph node is negative
for malignant changes.
ANS: A
The sentinel lymph node biopsy may eliminate further lymph node dissection if the initial
nodes are negative for malignancy. The procedure identifies which lymph nodes drain first
from the tumour site but not which ones are malignant.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1501
MSC: CRNE: CH-30
12. A woman with a positive biopsy for breast cancer is considering whether to have a modified
radical mastectomy or breast conservation surgery (lumpectomy) with radiation therapy. She
asks the nurse what she should do. What information should the nurse provide in response?
a. The survival rate for each is about the same, but the mastectomy prevents
recurrence of the tumour in that breast.
b. The lumpectomy and radiation will preserve the breast, but this method can cause
changes in breast sensitivity.
c. Arm mobility is not affected with the lumpectomy and radiation, and recovery is
more rapid than with a mastectomy.
d. The treatment period for the mastectomy is shorter, and breast reconstruction can
provide a normal-appearing breast.
ANS: B
The impact on breast function and appearance is less with lumpectomy and radiation, but
there is some effect on breast sensitivity.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1506
OBJ: 6
TOP: Nursing Process: Implementation
MSC: CRNE: CH-8
13. Following a modified radical mastectomy for cancer of the breast in a 39-year-old woman, the
physician recommends chemotherapy even though the lymph nodes were negative for cancer
cells. The patient tells the nurse that she does not know what to do about chemotherapy
because she has heard the side effects from the drugs are very uncomfortable. What nursing
diagnosis would the nurse document that best reflects the patient’s problem?
a. Anxiety related to prospect of additional cancer therapy
b. Fear related to uncomfortable side effects of chemotherapy
c. Decisional conflict related to lack of knowledge about treatment options and
prognosis risks
d. Risk for ineffective therapeutic regimen management related to reluctance to
consider additional treatment
ANS: C
The patient’s statements indicate that she is having difficulty making a decision about
treatment because of a lack of understanding about prognosis and treatment. Although she
may have some anxiety and fear, these are not the priorities at this time.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
REF: page 1509
MSC: CRNE: CH-15
14. Which surgical procedure for breast cancer has a prolonged postoperative recovery period?
a. Modified radical mastectomy
b. Lumpectomy with radiation
c. Tissue expansion and breast implants
d. Breast reconstruction flap procedures
ANS: D
Breast reconstruction flap procedures identify a patient issue as a prolonged postoperative
recovery.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1506, Table 54-8
MSC: CRNE: CH-8
15. A 64-year-old woman has undergone a modified radical mastectomy for a breast tumour. The
pathology report identified the tumour as a stage II, estrogen receptor–positive
adenocarcinoma. What would the nurse expect the first choice of treatment for the patient
following the mastectomy to be?
a. Chemotherapy
b. Biological therapy
c. Radiation therapy
d. Hormone therapy with tamoxifen
ANS: D
Tamoxifen is used for estrogen-dependent breast tumours in premenopausal women.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 1503, Table 54-6
MSC: CRNE: CH-44
16. A patient returns to the surgical unit following a right modified radical mastectomy with
dissection of axillary lymph nodes. Postoperative orders include diet as tolerated, up to ad
libitum, Hemovac drain, and patient-controlled analgesia (PCA) at 1 mg morphine every 10
minutes. What is an appropriate intervention for the nurse to include in implementing
postoperative care for the patient?
a. Teaching the patient to use the PCA every 10 minutes for the best pain relief
b. Insisting that the patient examine the surgical incision when the dressings are
removed
c. Posting a sign at the bedside warning against blood pressures or venipunctures on
the right arm
d. Encouraging the patient to obtain a permanent breast prosthesis as soon as she is
discharged from the hospital
ANS: C
The patient is at risk for lymphedema and infection if blood pressure or venipuncture is done
on the right arm.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1510
MSC: CRNE: CH-20
17. The nurse provides discharge teaching for a patient who has had a left modified radical
mastectomy and axillary lymph node dissection. When teaching the patient about care of the
affected arm, the nurse determines that teaching has been successful when the patient gives
which of the following responses?
a. “I should keep my right arm supported in a sling when I am up and around until
my incision is healed.”
b. “I may expose my arm to the sun for several hours each day to increase circulation
and promote healing.”
c. “I can do whatever exercises and activities I want as long as I do not elevate my
right hand above my head.”
d. “I should continue to exercise my arm several times a day with finger-walking up
the wall or combing my hair.”
ANS: D
The patient should continue with arm exercises to regain strength and range of motion, such
as combing the hair and finger-walking up the wall.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1510, Figure 54-9
MSC: CRNE: CH-40
18. Which one of the following statements is true regarding nipple-areolar reconstruction?
a. All breast reconstructive surgery requires nipple-areolar reconstruction.
b. The function of lactation is maintained.
c. It is not possible to have the nipples project away from the breast.
d. It is usually completed a few months after breast reconstructive surgery.
ANS: D
Nipple-areolar reconstruction is usually done a few months after breast reconstructive surgery.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 1515
MSC: CRNE: CH-8
19. After the nurse completes discharge teaching for a patient who has had a left modified radical
mastectomy and lymph node dissection, which statement by the patient indicates that no
further teaching is needed?
a. “I will avoid reaching over the stove with my left hand.”
b. “I will need to do breast self-examination on my right breast monthly.”
c. “I will keep my left arm elevated until I go to bed.”
d. “I will remember to use my right arm and to rest the left one.”
ANS: A
The patient should avoid any activity that might injure the left arm, such as reaching over a
burner.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1511, Nursing Care Plan 54-1
OBJ: 7
TOP: Nursing Process: Evaluation
MSC: CRNE: CH-20
20. A patient has a permanent breast implant inserted in an outpatient surgery area. What should
the nurse include in the discharge teaching?
a. Resume normal activities 2 to 3 days after the mammoplasty.
b. Check wound drains for excessive blood or any foul odour.
c. Wear a loose-fitting bra to decrease irritation of the sutures.
d. Take aspirin every 4 hours to reduce inflammation.
ANS: B
The patient should be taught drain care because the drains will be in place for 2 or 3 days after
surgery.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1510
MSC: CRNE: CH-56
21. Following a modified radical mastectomy, a patient tells the nurse the physician has
recommended a flap procedure for breast reconstruction, but she did not understand how this
is done. The nurse explains that the most common procedure, a transverse rectus abdominis
musculocutaneous (TRAM) flap, involves which of the following?
a. Relocating muscle tissue from the back to form a breast
b. Removing a portion of an abdominal muscle and using it as breast tissue
c. Pulling part of the rectus abdominis muscle up to the breast area through a tunnel
in the chest
d. Relocating the arteries from the rectus abdominis muscle to the breast area to
promote growth of implanted muscle tissue
ANS: C
In the TRAM flap, part of the rectus abdominis muscle is tunnelled to the breast area and
moulded to form a breast.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1514
MSC: CRNE: CH-8
22. Which breast disorder is most common between the ages of 35 and 50?
a. Lactational mastitis
b. Fibrocystic changes
c. Fibroadenoma
d. Duct ectasia
ANS: B
Fibrocystic breast changes are most common between the ages of 35 and 50 years.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 1496, Table 54-1
MSC: CRNE: CH-8
23. Which statement by a 32-year-old patient newly diagnosed with stage I breast cancer indicates
to the nurse that the goals of therapy are being met?
a. “I am not sure how my husband will react when I tell him about this cancer.”
b. “I am ready to die if that is God’s plan for me.”
c. “I need to know all the options before making a decision about treatment.”
d. “I will do whatever the doctor thinks is best.”
ANS: C
One goal for the patient with breast cancer is active participation in the decision-making
process.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1509
MSC: CRNE: NCP-9
Chapter 55: Nursing Management: Sexually Transmitted Infections
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A young man seeks care at the health clinic because he has developed a profuse, purulent
urethral discharge with painful urination. During assessment of the patient, what is it most
important that the nurse gather information about?
a. Recent sexual contacts
b. A history of previous similar symptoms
c. All of his sexual contacts within the past year
d. A history of bladder infections or mumps affecting the testicles
ANS: A
The patient’s symptoms indicate gonorrhea. All sexual contacts of patients with gonorrhea
must be examined and treated to prevent re-infection after resumption of sexual relations. The
“ping-pong” effect of re-exposure, treatment, and reinfection can cease only when infected
partners are treated simultaneously.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
REF: page 1521
MSC: CRNE: HW-15
2. During the nursing assessment of a 23-year-old female patient, the nurse considers the
patient’s risk for sexually transmitted infections (STIs). Which of the following findings
indicates a need for patient teaching?
a. Has a stable, monogamous relationship with her boyfriend
b. Has never been tested for syphilis or Chlamydia
c. Has annual pelvic examinations with Pap smears
d. Has multiple sex partners but uses oral contraceptives
ANS: D
The patient’s statement indicates that she may have multiple partners, a risk factor for STIs.
Oral contraceptives do not protect against STIs.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1520
MSC: CRNE: HW-13
3. A patient with gonorrhea is treated with a single intramuscular dose of ceftriaxone (Rocephin)
and is given a prescription for doxycycline (Vibramycin) 100 mg twice daily for 7 days. What
should the nurse explain to the patient about this combination of antibiotics?
a. They are prescribed to treat any coexisting chlamydial infection.
b. They will eradicate resistant strains of Neisseria gonorrhoeae.
c. They prevent the development of resistant organisms.
d. They prevent reinfection in addition to treating the original infection.
ANS: A
Given that the incidence of concurrent infection with gonorrhea and chlamydia is high,
patients are usually treated for both.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1526
MSC: CRNE: CH-12
4. A patient who has undergone laboratory tests for an insurance screening has a positive
Venereal Disease Research Laboratory test. What is the nurse’s first action?
a. Ask the patient about past treatment for syphilis.
b. Discuss the need for blood and spinal fluid cultures.
c. Obtain a specimen for fluorescent treponemal antibody absorption testing.
d. Assess for the presence of chancres, flulike symptoms, or a bilateral rash on the
trunk.
ANS: A
Once antibody testing is positive for syphilis, the antibodies remain after successful treatment,
so the nurse should inquire about previous treatment before doing other assessments or
testing.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1531, Table 55-8
MSC: CRNE: CH-1
5. A Gram-stained smear of a patient’s urethral discharge reveals the presence of N.
gonorrhoeae. The patient 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 infection.
In responding to the patient, what should the nurse explain?
a. Women develop subclinical cases of gonorrhea that do not cause tissue damage or
symptoms.
b. Women do not develop gonorrhea infections but can serve as carriers to spread the
infection to males.
c. Many women are not aware they have gonorrhea because they often do not have
symptoms of infection.
d. When gonorrhea infections occur in women, the infection affects only the ovaries
and not the other genital organs.
ANS: C
Many women with gonorrhea are asymptomatic or have minor symptoms that are overlooked.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1522
MSC: CRNE: HW-8
6. A patient with secondary syphilis has a rash on her palms and the soles of her feet and moist
papules in the anal and vulvar area. While caring for the patient, what is it important for the
nurse to do?
a. Wear gloves when touching the patient.
b. Wash the perianal area with an antiseptic solution.
c. Place the patient in a private room for protective isolation.
d. Assess the patient for the presence of gummas in the skin and soft tissue.
ANS: A
Exudate from any lesions with syphilis is highly contagious; therefore, gloves should be worn.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1525, Table 55-3
MSC: CRNE: HW-8
7. Primary genital herpes is diagnosed in a patient seeking care for lesions on her vulva and
perineum. After the nurse teaches the patient about management of the disease, which
statement by the patient indicates that the teaching has been effective?
a. “I will take the acyclovir (Zovirax) every 8 hours for the next week.”
b. “I will use condoms for intercourse until the medication is all gone.”
c. “I will use the acyclovir ointment on the area to relieve the pain.”
d. “I will need to take all of the medication to be sure the infection is cured.”
ANS: A
The treatment regimen for primary genital herpes infections includes acyclovir 400 mg three
times daily for 7 to 10 days.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Evaluation
REF: page 1529, Table 55-7
MSC: CRNE: CH-44
8. The nurse should inform women who have a history of STIs that the risk of infertility or
ectopic pregnancies is highest following infection by which of the following STIs?
a. Treponema pallidum
b. N. gonorrhoeae
c. Condylomata acuminata
d. Herpes simplex virus type 2 (HSV-2)
ANS: B
Complications of gonorrhea include scarring of the fallopian tubes, which can lead to tubal
pregnancies and infertility.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1521
MSC: CRNE: CH-8
9. A woman who is 20 weeks pregnant is diagnosed with primary syphilis. She tells the nurse
that she is very worried about the effect of the infection on the baby. What is the most
appropriate response to the patient’s concern?
a. “Syphilis will not affect the baby in any way because the microorganism does not
cross the placental barrier.”
b. “Instillation of erythromycin into the eyes of the newborn will prevent any
problems of transmission to the baby.”
c. “A single intramuscular injection of penicillin at this point in your pregnancy will
cure both you and the fetus of syphilis.”
d. “If you have active genital lesions at the time you begin labour, a Caesarean
delivery will be performed to prevent transmission to the baby.”
ANS: C
A single injection of penicillin is recommended to treat primary syphilis, and this will treat the
mother and prevent transmission of the disease to the fetus.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1524
MSC: CRNE: CH-44
10. Which of the following is the recommended therapy for treatment of small external genital
warts?
a. Penicillin
b. Podophyllin resin
c. Cryotherapy
d. Aluminum salts
ANS: B
Podophyllin resin (10% to 25%), a cytotoxic agent, is recommended therapy for small
external genital warts.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1530
MSC: CRNE: CH-8
11. A patient returns to the clinic for follow-up after treatment for nongonococcal urethritis.
Direct fluorescent antibody tests are positive for chlamydia. What should the nurse recognize
is the most likely cause of the continued infection?
a. The microorganisms developed resistance to the antibiotic.
b. The patient did not take the full course of antibiotics as directed.
c. The patient did not advise his sexual partners of the need for treatment.
d. The patient failed to wash his hands and perform basic hygiene measures.
ANS: C
A common reason for recurrence of symptoms is reinfection because infected partners have
not been simultaneously treated.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1533, Ethical Dilemmas box OBJ: 7
TOP: Nursing Process: Assessment
MSC: CRNE: HW-21
12. Which virus is responsible for genital warts?
a. Cytomegalovirus
b. HSV
c. Human immunodeficiency virus
d. Human papillomavirus (HPV)
ANS: D
HPV is the virus that causes genital warts.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 1521, Table 55-1
MSC: CRNE: CH-8
13. The incidence of syphilis has steadily increased in Canada since 1999. Which of the following
groups would be at highest risk of contracting syphilis?
a. Men having sex with men
b. Married men having casual affairs
c. Women having sex with women
d. University students
ANS: A
Infectious syphilis rates are highest among men having sex with men, among sex trade
workers, and in situations in which sex is exchanged for food, shelter, or protection.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: pages 1522-1523
MSC: CRNE: CH-8
14. Which of the following is the most appropriate question for the nurse to ask when obtaining a
detailed and accurate sexual history?
a. “Are you a homosexual?”
b. “Do you only have sex with those of the opposite sex?”
c. “Do you have sex with men or women or both?”
d. “Have you ever had anal sex?”
ANS: C
The most appropriate question to ask is whether the patient has had sex with men or women or
both; this question is nonjudgemental and is not value-laden.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1532
MSC: CRNE: NCP-4
15. Cervarix, an HPV vaccine, is recommended for which of the following populations?
a. Females before sexual intercourse
b. Males and females between the ages of 9 and 26
c. Females between the ages of 13 and 20
d. Any sexually active female
ANS: B
Cervarix is recommended for administration to females and males between the ages of 9 and
26.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1531
MSC: CRNE: HW-25
Chapter 56: Nursing Management: Female Reproductive Problems
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. During a routine health examination, a 32-year-old woman tells the nurse that she uses oral
contraceptives because her husband wants to delay having children for a few more years.
What is the most appropriate response?
a. “It is more difficult for women to conceive the older they become.”
b. “I’m sure you will have plenty of time to have a family in a few years when you
are ready.”
c. “Long-term use of oral contraceptives causes uterine changes that make it more
difficult for you to conceive.”
d. “Pregnancy is no problem when women pass the age of 30 because their sexual
response peak is at about the age of 35.”
ANS: A
The probability of successfully becoming pregnant decreases after age 35, although some
patients may have no difficulty becoming pregnant.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1539
MSC: CRNE: HW-26
2. A young woman has arrived at the clinic and tells the nurse she is 15 weeks pregnant and
wants an abortion. What does the nurse tell the patient about in relation to having an abortion
at 15 weeks’ gestation?
a. A methotrexate with misoprostol injection is available for a pregnancy that is at 15
weeks gestation.
b. Abortion at 15 weeks would require a dilation and evacuation.
c. Abortion beyond the first trimester is not routinely available in Canada,
d. Abortion at 15 weeks can be performed via suction curettage.
ANS: B
Abortion at 15 weeks would require a dilation and evacuation; it is the only approved
procedure in Canada for a pregnancy that is beyond 14 weeks gestation.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1542, Table 56-3
MSC: CRNE: CH-8
3. A young woman who is trying to become pregnant asks the nurse about ways to determine
when she is most likely to conceive. What should the nurse explain?
a. She should take her body temperature daily and have intercourse when it drops.
b. She will need to bring a specimen of cervical mucus to the clinic for testing.
c. Ovulation prediction kits provide accurate information about ovulation.
d. Ovulation is difficult to predict unless she has regular menstrual periods.
ANS: C
Ovulation prediction kits indicate when luteinizing hormone levels first rise, and ovulation
occurs about 28 to 36 hours after the first rise of luteinizing hormone. The kits can be used to
determine the best time for intercourse.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1539
MSC: CRNE: HW-26
4. A woman has an induced abortion with suction curettage at an ambulatory surgical centre.
During discharge teaching for the patient, what should the nurse instruct the patient to do?
a. Avoid sexual intercourse for 2 weeks.
b. Douche with a mild vinegar solution twice a day.
c. Expect heavy vaginal bleeding for about 2 weeks.
d. Expect an absence of normal menstrual periods for the next month or two.
ANS: A
Because infection is a possible complication of this procedure, the patient is advised to avoid
intercourse until the re-examination in 2 weeks.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1542, Table 56-3
MSC: CRNE: CH-31
5. A 31-year-old woman tells the nurse that she has noticed increasing headaches with dizziness,
abdominal bloating, and unexplained anxiety occurring before her menstrual periods. The
nurse plans care for the patient based on what knowledge?
a. The symptoms the patient has can be controlled with vitamin B6 supplements.
b. These symptoms are stress related, indicating a need for stress management
teaching.
c. The patient has premenstrual syndrome (PMS) and should be treated with
prostaglandin inhibitors.
d. The patient should have further evaluation of her symptoms with a menstrual diary
for 2 to 3 months.
ANS: D
Having the patient keep a menstrual diary for 2 or 3 months will help in making a diagnosis of
PMS.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1543
MSC: CRNE: CH-2
6. A 19-year-old community college student requests a prescription for birth control pills at the
student health centre. She tells the nurse she always has painful periods with diarrhea and
headaches and has heard from her friends that birth control pills stop painful menstruation.
What is the most appropriate response?
a. “Birth control pills are prescribed only for contraceptive uses. Are you sexually
active?”
b. “You should try distraction and guided imagery to control the pain before any type
of drug therapy is used.”
c. “Birth control pills can be effective treatment for painful menstruation, and it may
be possible for you to use them.”
d. “Birth control pills shouldn’t be used casually because they cause many side
effects that should be avoided if at all possible.”
ANS: C
Oral contraceptives decrease dysmenorrhea and are appropriate for the patient’s symptoms.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1544
MSC: CRNE: CH-44
7. When teaching a patient about ways to prevent primary dysmenorrhea, which of the following
will the nurse suggest?
a. Avoid aerobic exercise during her menstrual period.
b. Use cold packs on the abdomen and back for pain relief.
c. Start taking nonsteroidal anti-inflammatory drugs (NSAIDs) regularly when her
menstrual period starts.
d. Talk with her health care provider about antidepressant therapy.
ANS: C
NSAIDs should be started as soon as the menstrual period begins and taken at regular
intervals during the usual time frame in which pain occurs.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1544
MSC: CRNE: CH-8
8. A 26-year-old woman is admitted to the emergency department with abdominal cramping and
vaginal bleeding. When the patient learns that the results of a vaginal ultrasonogram confirm
the presence of an ectopic pregnancy in the left fallopian tube, she begins to cry and says she
has been trying to get pregnant for several years. In caring for the patient, what is the most
important nursing intervention?
a. Assess the patient’s emotional status frequently.
b. Monitor the patient’s vital signs closely.
c. Reassure the patient that she will be able to have future pregnancies.
d. Inform the patient that immediate surgery will be needed to implant the fetus in the
uterus.
ANS: B
Because the patient is at risk for rupture of the fallopian tube and hemorrhage, frequent
monitoring of vital signs is needed.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1547
MSC: CRNE: CH-13
9. When advising a patient with persistent menorrhagia, the nurse recognizes that all patients
with this condition should be evaluated for which of the following?
a. Anemia
b. Pregnancy
c. Anovulation
d. Endometrial cancer
ANS: A
Anemia is a likely complication of menorrhagia.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1546
MSC: CRNE: CH-8
10. A 46-year-old woman tells the nurse that she has not had a menstrual period for 3 months and
asks whether she is going into menopause. What is the best response?
a. “What other signs of decreasing estrogen production have you been
experiencing?”
b. “What was your menstrual pattern before the absence of your periods the last 3
months?”
c. “You are probably starting menopause, but it will be several years before your
periods stop completely.”
d. “You are too young to be menopausal, and you should see your physician to
determine whether other factors are causing the absence of periods.”
ANS: B
The nurse’s initial response should be to assess the patient’s baseline menstrual pattern.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1549
MSC: CRNE: CH-1
11. A 42-year-old woman has developed amenorrhea. If the woman is experiencing menopause,
what would the nurse expect the laboratory findings to include?
a. Decreased estrogen levels
b. Increased progesterone levels
c. Presence of human chorionic gonadotropin in the urine
d. Marked decrease in serum follicle-stimulating hormone (FSH)
ANS: A
When the ovarian follicles no longer respond to FSH, ovarian production of estrogen and
progesterone decreases.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1548
MSC: CRNE: CH-6
12. To help a 53-year-old woman make an informed decision about the use of hormone
replacement therapy (HRT) to control the effects of menopause, what should the nurse
explain?
a. The safest and most effective method of HRT is the use of estrogen vaginal
creams.
b. HRT has minimal risks and should be used to prevent the increased incidence of
osteoporosis in older women.
c. Recent studies have indicated that estrogen–progesterone combination therapy
increases the risk for breast cancer and cardiovascular disease.
d. HRT will help control hot flashes and genitourinary changes associated with
decreased estrogen, but these problems will recur in 3 to 5 years.
ANS: C
Data indicate an increased risk for cardiovascular disease and breast cancer in women taking
combination HRT but a decrease in hip fractures.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1549
MSC: CRNE: CH-12
13. After teaching a perimenopausal patient who has started using HRT, the nurse determines that
the teaching has been effective when the patient says which of the following?
a. “If I take a daily aspirin, I will not need to worry about blood clots.”
b. “Now that I have started taking HRT, I can stop taking calcium supplements.”
c. “My breasts may feel tender when I am taking the HRT.”
d. “I will continue to have menstrual periods, but the blood flow will be lighter.”
ANS: C
Breast tenderness is a potential side effect of HRT.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Asessment
REF: page 1549
MSC: CRNE: CH-48
14. A perimenopausal woman does not want to use hormone therapy but is interested in
complementary and alternative therapies. Which of the following herbal or supplemental
preparations should the nurse suggest is the safest to control menopausal symptoms?
a. Valerian
b. Dong quai
c. Black cohosh
d. Dietary soy products
ANS: C
Good scientific evidence exists to suggest that black cohosh is used to decrease menopausal
symptoms. Until more is known about soy’s effect on estrogen levels, women who have a
history of breast, ovarian, or uterine cancer or endometriosis (hormone-sensitive conditions)
should consult with their health care provider before using soy or soy products. Soy may
interact with warfarin. Patients taking warfarin should consult their health care provider
before using soy or soy products. Therefore, the safest herbal preparation to suggest to the
patient is black cohosh.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1550
MSC: CRNE: CH-11
15. After having been sexually assaulted, a woman is brought to the emergency department by a
friend. The patient is confused and has a large laceration and ecchymosis above the left eye.
Which action should the nurse take first?
a. Ask the patient to describe what occurred during the assault.
b. Assist the patient in removing her clothing.
c. Contact the sexual assault nurse examiner.
d. Assess the patient’s neurological status.
ANS: D
The first priority is to treat urgent medical problems associated with the sexual assault. The
patient’s head injury may be associated with a skull fracture, subdural hematoma, or other
condition. Therefore, her neurological status should be assessed first.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1569, Table 56-14
MSC: CRNE: CH-22
16. Six months after being raped, a woman tells the nurse that she has nightmares about the
incident and develops acute anxiety if she finds herself alone in situations where several men
are present. What is an appropriate nursing diagnosis that the nurse will document for this
patient?
a. Anxiety related to effects of being raped
b. Rape-trauma syndrome related to rape experience
c. Disturbed sleep pattern related to frightening dreams
d. Ineffective coping related to inability to resolve rape incident
ANS: B
The patient’s symptoms are most consistent with the nursing diagnosis of rape-trauma
syndrome.
PTS: 1
OBJ: 10
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
REF: page 1568
MSC: CRNE: CH-15
17. A diagnosis of vulvovaginal candidiasis is made when a patient with an abnormal vaginal
discharge is seen at the clinic, and an antifungal vaginal cream is prescribed. As she prepares
to leave the clinic, which of the following statements by the patient indicates to the nurse that
further teaching about her condition is needed?
a. “I should avoid sexual intercourse for at least 1 week.”
b. “I should clean my perineal area carefully after each urination and bowel
movement.”
c. “I should douche with warm water several times a day to flush out the
microorganisms.”
d. “Warm tub baths several times a day will help relieve the itching and inflammation
I have.”
ANS: C
Douching should be avoided. Douching disrupts the normal protective mechanisms within the
vagina and may force pathogens higher into the genital tract.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1552, Table 56-8
MSC: CRNE: NCP-14
18. While obtaining a health history from a patient hospitalized with pelvic inflammatory disease,
the nurse recognizes that which of the following risk factors related by the patient is
significant?
a. The use of oral contraceptives
b. Sexual exposure to a partner with urethritis
c. The use of superabsorbent tampons during menstruation
d. Long-term or high-dosage treatment with broad-spectrum antibiotics
ANS: B
Exposure to a male partner with urethritis (which suggests infection with a sexually
transmitted infection) introduces the bacteria into the vagina and cervix, allowing the
organism to ascend to the other reproductive structures.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1554, Table 56-9
MSC: CRNE: CH-8
19. When the nurse is caring for a patient with pelvic inflammatory disease requiring
hospitalization, which of the following interventions is used to promote healing and prevent
complications?
a. Encouraging fluid intake of 3000 mL/day
b. Promoting bed rest in a semi-Fowler’s position
c. Promoting frequent ambulation to increase pelvic circulation
d. Teaching pelvic-strengthening exercises to be performed six to eight times a day
ANS: B
The head of the bed should be elevated to at least 30 degrees to promote drainage of the pelvic
cavity and prevent abscess formation higher in the abdomen.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1554
MSC: CRNE: CH-42
20. A patient with pelvic inflammatory disease is treated on an outpatient basis with oral
antibiotics. When teaching the patient about follow-up care and management of her condition,
what should the nurse instruct the patient to do?
a. Avoid sexual intercourse for 1 week.
b. Return for follow-up within 2 to 3 days.
c. Wear a vaginal tampon to absorb the drainage.
d. Use over-the-counter anti-inflammatory drugs to help prevent scarring of pelvic
organs.
ANS: B
The patient is instructed to return for follow-up in 48 to 72 hours.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1554
MSC: CRNE: CH-20
21. A 31-year-old woman has been diagnosed with endometriosis. In teaching the patient about
the disorder, what should the nurse explain?
a. Endometriosis can be cured with the use of hormone therapy to prevent ovulation.
b. The only treatment for endometriosis is removal of the uterus and all ectopic
endometrial tissue.
c. Endometriosis occurs when endometrial tissue outside the uterus bleeds in
response to the menstrual cycle.
d. Backflow of endometrial tissue into the fallopian tubes causes the spasms and
abdominal pain associated with endometriosis.
ANS: C
The tissue responds to the hormones of the ovarian cycle and undergoes a “mini-menstrual
cycle” similar to the uterine endometrium.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1555
MSC: CRNE: CH-8
22. A patient with endometriosis is treated with medroxyprogesterone (Depo-Provera). What
should the nurse explain that this therapy does?
a. Suppresses ovulation and creates a hyperhormonal amenorrhea
b. Produces a pseudomenopause with atrophy of the ectopic tissue
c. Increases the production of estrogen to stop the production of FSH
d. Causes a hypoestrogenic state resulting in amenorrhea with menopause symptoms
ANS: A
Medroxyprogesterone induces a pseudopregnancy, which suppresses ovulation and causes
shrinkage of endometrial tissue.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: pages 1555-1556
MSC: CRNE: CH-44
23. When caring for a patient being treated for polycystic ovary syndrome, what should the nurse
emphasize is necessary?
a. Treatment of acne
b. Monitoring for jaundice
c. Regular cervical Pap tests
d. Maintenance of normal weight
ANS: D
Obesity exacerbates the problems associated with polycystic ovary syndrome, such as insulin
resistance and type 2 diabetes.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1558
MSC: CRNE: HW-13
24. A 58-year-old woman calls the health clinic when she has a moderate amount of vaginal
bleeding after 6 years of menopause. The nurse makes an appointment for the patient and tells
her to expect which of the following treatments?
a. A biopsy of uterine tissue
b. A pelvic examination with a Pap test
c. A prescription for estrogen replacement therapy
d. Admission to the hospital for a total hysterectomy
ANS: A
A postmenopausal woman with vaginal bleeding should be evaluated for endometrial cancer,
and endometrial biopsy is the primary test for endometrial cancer.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1560
MSC: CRNE: CH-30
25. Stage III ovarian cancer is diagnosed in a 63-year-old woman. Based on the nurse’s
understanding of this disorder, what nursing diagnosis would the nurse document as being
likely to be appropriate for this patient?
a. Sexual dysfunction related to loss of vaginal sensation
b. Risk for infection related to impaired immune function
c. Anxiety related to threat of a malignancy and lack of knowledge about the disease
process and prognosis
d. Situational low self-esteem related to guilt about delaying medical care
ANS: C
The patient with stage III ovarian cancer is likely to be anxious about the poor prognosis and
about the need to make decisions about the multiple treatments that may be used.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
REF: page 1564
MSC: CRNE: CH-15
26. Which of the following is a clinical manifestation of perimenopause?
a. Cessation of menses
b. Breast tenderness
c. Osteoporosis
d. Insomnia
ANS: C
Osteoporosis is a clinical manifestation of perimenopause.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1548, Table 56-6
MSC: CRNE: CH-8
27. During assessment of a patient with suspected endometrial cancer, what does the nurse
identify in the patient’s history as an important risk factor for cancer of the endometrium?
a. Cigarette smoking
b. Multiple pregnancies
c. Long-standing obesity
d. Early sexual activity with multiple partners
ANS: C
Because adipose cells store estrogen, obesity is a risk factor for endometrial cancer.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1558
MSC: CRNE: HW-13
28. A patient with stage 0 carcinoma of the cervix that was determined by cervical conization has
been told by her physician she needs no further treatment at this time. She is concerned about
the cancer and asks the nurse whether she should seek a second opinion. What is the most
appropriate response?
a. “Because of your age, further treatment of the cervical cancer is not indicated.”
b. “Stage 0 tumours take many years to spread, so you only need periodic
examinations at this time.”
c. “Conization is used both to diagnose and to treat cervical cancer, so no further
treatment is needed.”
d. “Unless the human papillomavirus tests are positive, there is no indication that
more treatment is needed.”
ANS: C
Because conization involves excision of the abnormal area of the cervix, it can be used for
both diagnosis and treatment.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1559
MSC: CRNE: CH-12
29. A patient’s Pap test reveals cervical cells characteristic of adenocarcinoma of the cervix. What
information obtained during the patient’s health history is a major risk factor for cervical
cancer?
a. The patient’s use of oral contraceptives for 15 years
b. A history of four pregnancies with one spontaneous abortion
c. Smoking coupled with infection with human papillomavirus (HPV)
d. Use of estrogen replacement therapy for menopausal symptoms
ANS: C
Smoking and HPV infection are both associated with increased cervical cancer risk.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1558
MSC: CRNE: HW-13
30. A total abdominal hysterectomy is scheduled for a 42-year-old woman with multiple uterine
leiomyomas. During preoperative teaching about postoperative expectations, it is important
for the nurse to inform the patient about which of the following?
a. A retention catheter will be used to help her maintain bed rest during the first
several postoperative days.
b. Correct use of the patient-controlled analgesia device will prevent her from
experiencing postoperative pain.
c. She will need to take estrogen replacement therapy postoperatively to prevent
symptoms of surgical menopause.
d. Leg exercises with early and frequent ambulation are necessary to minimize stasis
and pooling of blood.
ANS: D
Deep-vein thrombosis (DVT) is a potential complication after the surgery, and the nurse will
instruct the patient about ways to prevent DVT.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1565
MSC: CRNE: CH-31
31. When assessing a patient on the patient’s return to the surgical unit following a total
abdominal hysterectomy, what would the nurse expect to find?
a. Complaints of abdominal pain and burning at the incision site
b. Urinary output of 20 mL in 1 hour related to temporary bladder atony
c. A perineal pad with a moderate amount of serosanguineous drainage
d. A moderate amount of sanguineous drainage on the abdominal dressing
ANS: A
Abdominal pain after this surgery is expected.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: pages 1564-1565
MSC: CRNE: CH-31
32. A patient who has undergone a vaginal hysterectomy has not voided for 10 hours following
surgery and is complaining of bladder distension. What is the most appropriate action?
a. Catheterize the patient for residual urine.
b. Increase the patient’s oral fluid intake to 200 mL/hour.
c. Notify the physician of the patient’s inability to void.
d. Ambulate the patient short distances every hour to increase peristalsis.
ANS: C
After hysterectomy, the patient may experience urinary retention caused by temporary bladder
atony. Catheterization is needed if the patient has not voided for 8 hours; therefore, the
physician will have to be contacted.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1565
MSC: CRNE: CH-23
33. The nurse obtains the following data when assessing a patient who returned to the surgical
unit after having a total abdominal hysterectomy and bilateral salpingo-oophorectomy 5 hours
ago. Which information is most important to communicate to the surgeon?
a. The abdominal dressing has a 1-cm area of dark red drainage.
b. The catheter drainage bag shows a total of 100 mL of urine since surgery.
c. The patient is complaining of level 5 (on a 10-point scale) continuous abdominal
pain.
d. The patient has decreased bowel tones and abdominal distension.
ANS: B
The low urine output may indicate that a ureter has been ligated during the surgery, and the
patient may need to return to surgery. Another possibility is that she is hypovolemic
secondary to blood loss.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1565
MSC: CRNE: CH-23
34. Which of the following is a symptom of estrogen deficiency?
a. Increased rapid-eye-movement sleep
b. Decreased fracture rate in upper femur
c. Increased high-density lipoproteins
d. Incontinence
ANS: D
Incontinence is a symptom of estrogen deficiency.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 1548, Table 56-7
MSC: CRNE: CH-8
35. A 56-year-old mother of nine children undergoes an anterior and posterior colporrhaphy for
repair of a cystocele and a rectocele. When assessing the patient on her return from the
postanaesthesia care unit, what would the nurse expect to find?
a. A rectal tube
b. Perineal dressings
c. Gauze vaginal packing
d. An in-dwelling catheter
ANS: D
The patient will have a retention catheter for several days after surgery to keep the bladder
empty and decrease strain on the suture.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1567
MSC: CRNE: CH-8
36. A 56-year-old woman tells the nurse that she is postmenopausal but has occasional spotting.
Which response is most appropriate?
a. “Breakthrough bleeding is normal in women your age.”
b. “Are you using prescription hormone replacement therapy?”
c. “How long has it been since your last menstrual period?”
d. “A frequent cause of spotting is endometrial cancer.”
ANS: B
In postmenopausal women, a common cause of spotting is HRT.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1549
MSC: CRNE: CH-48
37. An 18-year-old visits the health clinic for a routine checkup. To determine whether a Pap test
is needed, which question should the nurse ask?
a. “How old were you when your menstrual periods started?”
b. “Do you have any pain or cramping with your menstrual periods?”
c. “Have you ever had sexual intercourse?”
d. “Do you use any illegal substances?”
ANS: C
The current recommendation is that a Pap test be done every 1 to 3 years in sexually active
women aged 21 to 69.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1559
MSC: CRNE: HW-20
38. Which information will the nurse include when developing a patient teaching plan for a 48-
year-old patient with uterine bleeding caused by a leiomyoma?
a. Over-the-counter pain relievers such as aspirin are appropriate to use if mild pain
occurs.
b. The tumour size is likely to increase throughout the patient’s lifetime.
c. The patient will need frequent monitoring to detect any malignant changes.
d. The symptoms may decrease after the patient undergoes menopause.
ANS: D
Leiomyomas appear to depend on ovarian hormones and will atrophy after menopause,
leading to a decrease in symptoms.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1557
MSC: CRNE: CH-8
39. Which medication is a gonadotropin-releasing hormone (GnRH) agonist used in the treatment
of infertility?
a. Clomiphene (Clomid)
b. Repronex
c. Cetrorelix (Cetrotide)
d. Nafarelin (Synarel)
ANS: D
Nafarelin is a GnRh agonist used in the treatment of infertility.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 1541, Table 56-2
MSC: CRNE: CH-44
40. Which age group has the highest rate of induced abortion?
a. 13- to 16-year-olds
b. 16- to 18-year-olds
c. 20- to 24-year-olds
d. 35- to 40-year-olds
ANS: C
The highest rate of induced abortion is in those aged 20 to 24 years of age.
PTS: 1
DIF: Cognitive Level: Knowledge
REF: page 1541
OBJ: 7
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
Chapter 57: Nursing Management: Male Reproductive Problems
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. When obtaining a nursing history from a patient with benign prostatic hyperplasia (BPH),
which of the following data would the nurse expect the patient to report?
a. Grossly bloody urine
b. Difficulty maintaining an erection
c. A weak urinary stream and dribbling at the end of urination
d. Lower back pain that radiates to the hips during urination
ANS: C
The American Urological Association (AUA) Symptom Index for a patient with BPH asks
questions about the force and frequency of urination, as well as other symptoms.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1577
MSC: CRNE: CH-1
2. A patient scheduled for a transurethral resection of the prostate (TURP) for BPH tells the
nurse that he has delayed having surgery because he is afraid it will affect his sexual function.
When responding to his concern, what should the nurse explain?
a. Many methods of sexual expression can be used as alternatives to sexual
intercourse.
b. Sperm production is not affected by this surgery, so he should not worry about
sterility.
c. With this type of surgery, erectile problems are rare, but retrograde ejaculation
may occur.
d. Information about penile implants used for erectile dysfunction is available if he is
interested.
ANS: C
Erectile problems are rare, but retrograde ejaculation may occur after TURP.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1580, Table 57-3
MSC: CRNE: CH-12
3. A 41-year-old man asks the nurse what he can do to decrease the risk of BPH. What should
the nurse explain?
a. Foods high in zinc have been shown to delay the development of BPH.
b. Decreasing butter and margarine and increasing fruits in the diet may help.
c. He can do nothing to prevent the disease because it is a fact of aging.
d. Taking a daily vitamin E supplement has reduced prostate size in some men.
ANS: B
A diet high in saturated fats, found in foods such as butter, is associated with an increased risk
for BPH. Individuals who eat more fruits and vegetables may be at lower risk.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1581, Table 57-4
MSC: CRNE: HW-13
4. The physician prescribes finasteride (Proscar) for a 56-year-old male patient who has a BPH
symptom score of 12 on the AUA Symptom Index. When teaching the patient about the
medication, of what should the nurse inform him?
a. His interest in sexual activity may decrease while he is taking the medication.
b. He should change position from lying to standing slowly to avoid dizziness.
c. Improvement in the obstructive symptoms should occur within about 2 weeks.
d. He will need to monitor his blood pressure frequently to assess for hypertension.
ANS: A
A decrease in libido is a side effect of finasteride because of the androgen suppression that
occurs with the medication.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1578
MSC: CRNE: CH-44
5. A patient with irritative and obstructive bladder symptoms has an enlarged prostate on a
digital rectal examination (DRE). To differentiate BPH from prostate cancer, which of the
following tests should the nurse anticipate that the patient would be scheduled to undergo?
a. Uroflowmetry
b. Cystourethroscopy
c. Transrectal ultrasonography
d. Prostate-specific antigen (PSA) testing
ANS: C
In a patient with an abnormal DRE and elevated PSA, transrectal ultrasonography is used to
help differentiate BPH from prostatic cancer.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1578
MSC: CRNE: CH-8
6. A patient undergoing a TURP returns from surgery with a three-way Foley catheter with
continuous bladder irrigation in place. Other postoperative orders include morphine 8 mg
intravenous every 3 to 4 hours as needed for pain, belladonna and opium suppository every 4
hours as needed, and strict intake and output. The patient is complaining of painful bladder
spasms, and the nurse observes blood-tinged urine on his sheets. What is the most appropriate
nursing action?
a. Administer the morphine.
b. Warm the irrigation solution to body temperature.
c. Administer the belladonna and opium suppository.
d. Manually instill 50 mL of saline and try to remove clots.
ANS: D
The assessment suggests that obstruction by a clot is causing the bladder spasms, and the
nurse’s first action should be to irrigate the catheter manually and to try to remove the clots.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1579
MSC: CRNE: CH-31
7. The wife of a patient who has undergone a TURP and has continuous bladder irrigation asks
the nurse whether the irrigation can be stopped because it seems to increase her husband’s
pain. What is the best response to the patient’s wife?
a. “The bladder irrigation is needed to stop the bleeding in the bladder.”
b. “The irrigation is needed to keep the catheter from being occluded by blood clots.”
c. “Normal production of urine is maintained with the irrigations until healing
occurs.”
d. “Antibiotics are being administered into the bladder with the irrigation solution to
prevent infection.”
ANS: B
The purpose of bladder irrigation is to remove clots from the bladder and to prevent
obstruction of the catheter by clots.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1583
MSC: CRNE: CH-19
8. A patient with symptomatic BPH is undergoing visual laser ablation of the prostate at an
outpatient surgical centre. Preoperatively, what should the nurse explain to the patient will
occur after the procedure?
a. A urinary catheter will be necessary for up to a week.
b. He should expect to have blood clots in his urine for several days.
c. A three-way catheter with slow-drip irrigation will be needed for 6 to 8 hours.
d. His voiding patterns may persist, but the irritative symptoms will be improved
immediately.
ANS: A
The patient will have an in-dwelling catheter for up to a week and will need to be instructed
on catheter care to avoid problems such as infection.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1580, Table 57-3
MSC: CRNE: CH-31
9. The physician orders a blood test for PSA when an enlarged prostate is palpated during a
routine examination of a 56-year-old man. When the patient asks the nurse the purpose of the
test, the nurse’s response is based on what knowledge?
a. PSA levels may be elevated in patients with cancer of the prostate.
b. Elevated levels of PSA are indicative of metastatic cancer of the prostate.
c. Variations in PSA levels can be used to differentiate between BPH and prostatic
cancer.
d. Baseline PSA levels are necessary to evaluate the success of treatment of prostatic
cancer.
ANS: A
PSA levels are usually elevated in patients with prostate cancer.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1585
MSC: CRNE: CH-30
10. Which medication does the nurse anticipate will be ordered for the patient to block the action
of testosterone by competing with receptor sites for the treatment of prostate cancer?
a. Goserelin (Zoladex)
b. Buserelin (Suprefact)
c. Leuprolide (Lupron)
d. Flutamide (Euflex)
ANS: D
Flutamide mechanism of action is to block the action of testosterone by competing with
receptor sites.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1589, Table 57-7
MSC: CRNE: CH-44
11. Following a radical retropubic prostatectomy for prostate cancer, the patient is incontinent of
urine. What is an appropriate nursing intervention to teach this patient?
a. Pelvic floor muscle training
b. The use of herbal saw palmetto
c. How to perform intermittent self-catheterization
d. To avoid heavy lifting, which increases the incidence of incontinence
ANS: A
Pelvic floor muscle training (Kegel) exercises are recommended to strengthen the pelvic floor
muscles and improve urinary control.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1590
MSC: CRNE: CH-37
12. Following discharge teaching for a patient who has had a TURP for BPH, the nurse
determines that additional instruction is needed when the patient gives which of the following
responses?
a. “I will increase fibre and fluids in my diet to prevent constipation.”
b. “I should notify my physician if I experience incontinence at home.”
c. “I will avoid heavy lifting or driving until I get approval from my physician.”
d. “I will have an annual prostate examination because I have prostatic tissue that
could enlarge or become malignant.”
ANS: B
Incontinence is common for several weeks after a TURP.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1579
MSC: CRNE: NCP-14
13. Leuprolide and bicalutamide (Casodex) are prescribed for a patient with cancer of the
prostate. In teaching the patient about these drugs, the nurse informs the patient that which of
the following side effects may occur?
a. Low blood pressure
b. Decreased sexual drive
c. Urinary incontinence
d. Frequent infections
ANS: B
Hormone therapy blocks the effects of testosterone and decreases libido.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1589
MSC: CRNE: CH-44
14. Which of the following will the nurse teach to a patient with chronic bacterial prostatitis?
a. PSA elevation indicates that he has concurrent prostate cancer.
b. Nonsteroidal anti-inflammatory drugs usually provide adequate pain control.
c. Sexual intercourse and masturbation will relieve symptoms.
d. Antibiotics should be taken for 7 to 10 days.
ANS: C
Ejaculation helps drain the prostate and relieve pain.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1592
MSC: CRNE: CH-51
15. A married couple is seen at the infertility clinic because they have not been able to conceive.
The nurse includes examination of the man’s testicles early in the assessment of the couple
based on the knowledge that which of the following testicular problems is related to
infertility?
a. Hydrocele
b. Varicocele
c. Epididymitis
d. Spermatocele
ANS: B
Persistent varicoceles are commonly associated with infertility.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1600
MSC: CRNE: CH-8
16. In teaching a male patient to perform testicular self-examination, the nurse includes
information about which of the following?
a. The only structure felt in the scrotal sac is the testis.
b. The examination should be done when the scrotum is warm.
c. If one testis is larger than the other, the patient should consult his physician.
d. Unlike breast self-examination, testicular self-examination should be performed
every other month.
ANS: B
The testes will hang lower in the scrotum when the temperature is warm and will be easier to
palpate.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1595, Table 57-9
MSC: CRNE: HW-20
17. A 32-year-old man scheduled for a unilateral orchiectomy for testicular cancer is admitted to
the hospital the morning of surgery. He is accompanied by his wife but does not talk to her
and does not initiate interaction with the nurse. What is the most appropriate nursing action?
a. Assess the patient’s concerns related to his diagnosis and treatment.
b. Ask the patient’s wife whether he is worried about his future sexual functioning.
c. Set a patient outcome that the patient will verbalize his concerns about his
diagnosis.
d. Identify the patient’s problem with the nursing diagnosis of impaired
communication related to diagnosis of cancer.
ANS: A
The nurse’s initial action should be assessment for any anxiety or questions about the surgery
or postoperative care. The nurse should address the patient, not the spouse, when discussing
the diagnosis and any possible concerns.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1590, Table 57-8
MSC: CRNE: CH-18
18. When performing discharge teaching for a patient who has undergone a vasectomy in the
physician’s office, what should the nurse instruct the patient about?
a. He will not be able to maintain an erection for about 2 months.
b. He should not have sexual intercourse until his 6-week follow-up visit.
c. He should continue the use of other methods of birth control for 6 weeks.
d. His ejaculate will be about half the previous volume.
ANS: C
Because it takes about 6 weeks to evacuate sperm that are distal to the vasectomy site, the
patient should use contraception for 6 weeks.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1596
MSC: CRNE: CH-31
19. At the health clinic, a 22-year-old man tells the nurse that he has recently become unable to
achieve an erection. The nurse assesses the patient with the knowledge that the increased
incidence of erectile dysfunction in young men is related to which of the following factors?
a. Stress
b. Postpriapism
c. Recreational drug use
d. Social sexual expectation
ANS: C
A common etiological factor for erectile dysfunction in younger men is use of recreational
drugs or alcohol.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1597
MSC: CRNE: HW-15
20. A 53-year-old man tells the nurse he has not been able to function sexually for several years.
He is now interested in using sildenafil (Viagra) to treat his erectile dysfunction. In
responding to the patient’s interest, what should the nurse explain?
a. Question the patient about any prescription medications he is taking.
b. Tell the patient that sildenafil is an appropriate treatment for only a few types of
erectile dysfunction.
c. Ask the patient about any previous treatment for hydrocele.
d. Reassure the patient that a gradual decline in erectile function is common with
aging.
ANS: A
Because some medications can cause erectile dysfunction and patients using nitrates should
not take sildenafil, the nurse should ask about prescription medication use.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1597
MSC: CRNE: CH-44
21. Which of the following is the term given to a narrowing of the retracted uncircumcised
foreskin that prevents its normal return over the glans and can cause strangulation?
a. Phimosis
b. Priapism
c. Paraphimosis
d. Hypospadias
ANS: C
Paraphimosis is the term given to a narrowing of the retracted uncircumcised foreskin that
prevents normal return over the glans and can cause strangulation.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 1592
MSC: CRNE: CH-8
22. A patient with a spinal cord tumour has developed a priapism that has lasted for 8 hours. The
nurse notifies the physician, recognizing that the disorder can cause which of the following
complications?
a. Epididymitis
b. Renal artery sclerosis
c. Penile tissue necrosis
d. Decreased production of sperm
ANS: C
Priapism can cause complications such as necrosis or hydronephrosis, and this patient should
be treated immediately.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1593
MSC: CRNE: CH-27
23. The doctor is considering whether to prescribe testosterone replacement therapy for a 62-year-
old man who is concerned about a gradual decrease in sexual performance. Which information
obtained from the patient is most important to communicate to the doctor?
a. States that he has noticed a decrease in energy level for a few years
b. Has had a gradual decrease in the force of his urinary stream
c. Has been using sildenafil several times every week
d. Says that symptoms have increased steadily over the last few years
ANS: B
The decrease in his urinary stream may indicate BPH or prostate cancer, which are
contraindications to use of testosterone replacement therapy.
PTS: 1
OBJ: 6
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1577
MSC: CRNE: CH-23
24. What of the following does the nurse tell a patient who asks what the best treatment option is
for treating BPH?
a. Transurethral incision of the prostate
b. TURP
c. Transurethral microwave thermotherapy
d. Transurethral needle ablation
ANS: B
A TURP has the best long-term relief of prostatic obstruction, and erectile dysfunction is
unlikely.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1580, Table 57-3
MSC: CRNE: CH-8
25. When counselling a First Nations patient about male reproductive cancers, the nurse tells the
patient that First Nations men have a higher mortality than the overall Canadian population
from which following type of cancer?
a. Penile cancer
b. Testicular cancer
c. Prostate cancer
d. Scrotal cancer
ANS: C
Prostate cancer is the only cancer for which First Nations people have a higher mortality rate
than the overall Canadian population.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1585, Determinants of Health OBJ: 5
TOP: Nursing Process: Implementation
MSC: CRNE: HW-19
26. A patient has been diagnosed with prostate cancer. He has large tumours involving the
seminal vesicle and adjacent structures. According to the Whitmore-Jewett staging
classification of prostate cancer, what stage would the nurse document this patient as currently
experiencing?
a. Stage A2
b. Stage B1
c. Stage C2
d. Stage D1
ANS: C
A patient with large tumours involving the seminal vesicle and adjacent structures is in stage
C2.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1586, Table 57-5
MSC: CRNE: CH-15
Chapter 58: Nursing Assessment: Nervous System
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A patient with a deep, large laceration of the left forearm, which has damaged nerve fibres as
well as other tissue, asks the nurse to explain what the effect of the nerve damage will be.
What is the best response to the patient?
a. Nerve cells cannot regenerate, and the sensory and motor loss will be permanent.
b. He will probably have return of normal motor and sensory function because
peripheral nerve cells can regenerate.
c. Only nerve fibres within the central nervous system are capable of regeneration,
and the nerve loss he has distal to his injury will be permanent.
d. There is a chance that some nervous function will return because peripheral nerve
fibres can slowly regenerate if cell bodies have not been damaged.
ANS: D
In the peripheral nervous system, regeneration of injured nerve fibres is possible if the cell
body is intact. The final result depends on the connections the axon sprouts make with endorgans and other nerves.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1608
MSC: CRNE: CH-8
2. When interviewing an acutely confused patient who has a head injury, which question will
provide the most useful information?
a. “Have you ever been hospitalized for a neurological problem?”
b. “Do you have any pain at the present time?”
c. “What have you had to eat in the last 24 hours?”
d. “Can you describe your usual pattern for coping with injury?”
ANS: B
The acutely confused patient will be able to state whether he currently has pain. The patient
may not be able to provide accurate information about his history of hospitalization, 24-hour
dietary recall, or usual coping patterns.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1610
MSC: CRNE: CH-1
3. When the nurse administers a drug that increases the synaptic release of -aminobutyric acid
(GABA), what is the effect the nurse would expect?
a. Widespread increases in nervous system activity
b. Suppression of nervous system activity
c. Increased patient alertness and arousal
d. Excitation of the affected postsynaptic neurons
ANS: B
GABA is a neurotransmitter that has inhibitory activity on action-potential generation and
decreases nervous system activity.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1610
MSC: CRNE: CH-48
4. For a patient who has a corticospinal tract lesion, the nurse should assess for which of the
following?
a. Extremity movement and strength
b. Cranial nerve function
c. Peripheral sensitivity to pain
d. Level of consciousness
ANS: A
The corticospinal tract carries impulses from the cortex to the peripheral nerves that control
voluntary muscle movement.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1611
MSC: CRNE: CH-8
5. A patient has a lesion that affects lower motor neurons. During assessment of the patient’s
lower extremities, what does the nurse expect to find?
a. Spasticity
b. Flaccidity
c. Hyperreflexia
d. Loss of sensation
ANS: B
Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the
neuron will decrease motor activity of the affected muscles, and the nurse would assess
flaccidity.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1611
MSC: CRNE: CH-8
6. Which of the following assessment findings would the nurse expect when examining a patient
with a lesion of the left posterior temporal lobe?
a. Inability to reason or problem solve
b. Loss of sensation on the left side of the body
c. Inability to comprehend written or oral language
d. Inability to voluntarily move the right side of the body
ANS: C
The posterior temporal lobe integrates the visual and auditory input for language
comprehension.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1613, Table 58-2
MSC: CRNE: CH-8
7. What is the path of intervention with cranial nerve VI (abducens nerve) that is connected to
the brain via the pons?
a. Motor path
b. Sensory path
c. Sympathetic path
d. Parasympathetic path
ANS: A
Cranial nerve VI (abducens nerve) that is connected to the brain via the pons has a motor path
of intervention.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1617, Table 58-3
MSC: CRNE: CH-8
8. When obtaining a health history from a patient with a neurological problem, the nurse is likely
to elicit the most valid response from the patient by asking the patient which of the following
questions?
a. “Do you ever have any nausea or dizziness?”
b. “Does the pain radiate from your back into your legs?”
c. “Do you have any sensations of pins and needles in your feet?”
d. “Can you describe the sensations you are having in your chest?”
ANS: D
The most useful and valid information is obtained through the use of open-ended questions
that allow the patient to describe symptoms.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1620
MSC: CRNE: CH-1
9. When admitting a patient with acute confusion to the hospital, the nurse will interview the
patient about health problems and health history primarily for which of the following reasons?
a. To determine the patient’s motivation for self-care
b. To include the patient in health care decisions
c. To use the information given by the patient to guide care
d. To assess the patient’s baseline cognitive abilities
ANS: D
The appropriateness of the patient’s response and the patient’s use of language will help the
nurse assess the baseline cognitive abilities of the patient.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1621
MSC: CRNE: CH-1
10. A 71-year-old patient reports a change in sleep patterns occurring over the past 2 to 3 years.
Based on knowledge of the effects of aging on the reticular activating system, what would the
nurse expect the patient to exhibit?
a. Increased rapid-eye-movement sleep
b. Longer cycles of sleep
c. Increased sleep apnea
d. Increased spontaneous awakening
ANS: D
Normal changes in the reticular activating system and autonomic nervous system lead to more
spontaneous awakening and less sleep time in older adults.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1620, Table 58-5
MSC: CRNE: CH-8
11. To assess the functioning of the optic nerve (cranial nerve II), what should the nurse do?
a. Apply a cotton wisp strand to the cornea.
b. Perform a confrontational test for visual fields.
c. Evaluate pupil response to light and accommodation.
d. Ask the patient to follow a finger with the eyes as it is moved vertically,
horizontally, and diagonally.
ANS: B
The optic nerve is responsible for visual fields and visual acuity.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1623
MSC: CRNE: CH-4
12. Neurological testing of the patient by the nurse indicates impaired functioning of the left
glossopharyngeal nerve (cranial nerve IX) and the vagus nerve (cranial nerve X). Based on
these findings, what should the nurse plan to do?
a. Insert an oral airway.
b. Withhold oral fluid or foods.
c. Provide highly seasoned foods.
d. Apply artificial tears to protect the cornea.
ANS: B
The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. A
patient with impaired function of these nerves is at risk for aspiration.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1625
MSC: CRNE: CH-8
13. The following orders are received for a patient who is unconscious after a head injury caused
by an automobile accident. Which one should the nurse question?
a. Perform neurological checks every 15 minutes.
b. Prepare the patient for lumbar puncture.
c. Obtain X-ray films of the skull and spine.
d. Do computed tomography scanning with and without contrast.
ANS: B
After a head injury, the patient may be experiencing intracranial bleeding and increased
intracranial pressure, which could lead to herniation of the brain with lumbar puncture.
PTS: 1
OBJ: 11
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: pages 1626-1627
MSC: CRNE: PP-15
14. The charge nurse is observing a new staff nurse who is assessing a patient with a possible
spinal cord lesion for sensation. Which action by the new nurse indicates a need for further
teaching about neurological assessment?
a. Tests for light touch before testing for pain
b. Has the patient close the eyes during testing
c. Tells the patient, “You may feel a pinprick now.”
d. Uses an irregular pattern to test for intact touch
ANS: C
When performing a sensory assessment, the nurse should not provide verbal or visual clues.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1625
MSC: CRNE: PP-19
15. To prepare a patient who is to have a lumbar puncture performed for analysis of cerebrospinal
fluid, what should the nurse inform him about?
a. He will be given a mild sedative to help control muscle spasms.
b. He should cough as soon as he feels the needle enter the spinal canal.
c. He may be required to lie flat on his back for 24 hours following the test.
d. He will be positioned on his side with his knees drawn to the chest and his head
flexed to the chest.
ANS: D
For a lumbar puncture, the patient lies in the lateral recumbent position, with the knees drawn
to the chest and the head flexed to the chest to separate the vertebrae.
PTS: 1
OBJ: 11
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1629, Table 58-9
MSC: CRNE: CH-30
16. When reviewing the results of a patient’s cerebrospinal fluid analysis obtained from a lumbar
puncture, which of the following does the nurse identify as abnormal?
a. pH 7.35
b. White blood cell count 4 cells/microlitre (0.004 cells/L)
c. Protein 0.30 g/L (30 mg/dL)
d. Glucose 1.7 mmol/L (30 mg/dL)
ANS: D
The glucose level is low.
PTS: 1
OBJ: 11
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1630, Table 58-10
MSC: CRNE: CH-6
17. Which of the following is an age-related change in the nervous system?
a. Increased efficiency of temperature-regulating mechanism
b. Decreased size of ventricles in the brain
c. Decrease in electrical activity
d. Increase in deep-tendon reflexes
ANS: C
A normal age-related change is a decrease in electrical activity. The temperature-regulating
mechanism is decreased in efficiency in aging. The size of the ventricles increases with age.
The deep-tendon reflexes either remain the same or decrease in aging.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1620, Table 58-5
MSC: CRNE: CH-8
18. During the neurological assessment, the patient cooperates with the nurse’s directions to grip
with the hands and to move the feet, but does not respond to the nurse’s questions. The nurse
will suspect which of the following?
a. A temporal lobe lesion
b. Injury to the cerebellum
c. A brainstem lesion
d. Damage to the frontal lobe
ANS: D
Expressive speech is controlled by Broca’s area in the frontal lobe.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1612
MSC: CRNE: CH-8
19. Which neurotransmitter is involved in emotions, moods, and regulating motor control?
a. Serotonin
b. Epinephrine
c. Dopamine
d. Substance P
ANS: C
Dopamine is involved in emotions, moods, and regulating motor activity. Serotonin is also
involved with moods and emotions but has no relevance to regulating motor control.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1610, Table 58-1
MSC: CRNE: CH-8
20. Which internal structure arises from the basilar and two internal carotid arteries?
a. Reticular formation
b. Blood–brain barrier
c. Circle of Willis
d. Anterior communicating centre
ANS: C
The circle of Willis arises from the basilar and two internal carotid arteries.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1616
MSC: CRNE: CH-8
21. Which area of the cerebrum would the nurses suspect is injured when the patient is unable to
understand spoken words?
a. Broca’s area
b. Precentral gyrus
c. Wernicke’s area
d. Postcentral gyrus
ANS: C
The function of Wernicke’s area is to integrate auditory language, that is, understanding of
spoken words.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1613, Table 58-2
MSC: CRNE: CH-8
Chapter 59: Nursing Management: Acute Intracranial Problems
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A patient has a systemic blood pressure of 120/60 mm Hg and an intracranial pressure (ICP)
of 24 mm Hg. What does the nurse determine that the cerebral perfusion pressure (CPP) of
this patient indicates?
a. High blood flow to the brain
b. Normal ICP
c. Impaired blood flow to the brain
d. Adequate autoregulation of cerebral blood flow
ANS: C
The patient’s CPP is 56 mm Hg, below the normal of 70 to 100 mm Hg and approaching the
level of ischemia and neuronal death.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1636
MSC: CRNE: CH-6
2. ICP monitoring is instituted for a patient with a head injury. The patient’s arterial blood
pressure is 92/50 mm Hg, and her ICP is 18 mm Hg. Which nursing action is most
appropriate?
a. Document and continue to monitor the parameters.
b. Elevate the head of the patient’s bed.
c. Notify the physician about the assessments.
d. Check the patient’s pupillary response to light.
ANS: C
The patient’s CPP is only 46 mm Hg, which will rapidly lead to cerebral ischemia and
neuronal death unless rapid action is taken to reduce ICP and increase arterial blood pressure,
so the most appropriate action is to contact the physician.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
REF: page 1636, Table 59-1
MSC: CRNE: CH-27
3. Patient manifestations of a headache, CSF leakage, and cranial nerve deficit are signs of
which one of the following indications for cranial surgery?
a. Brain tumour
b. Skull fracture
c. Hydrocephalus
d. Intracranial infection
ANS: B
Patient manifestations of a headache, CSF leakage, and cranial nerve deficit indicate a skull
fracture, which requires cranial surgery.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1661, Table 59-12
MSC: CRNE: CH-8
4. A patient with a serum sodium level of 115 mmol/L has a decreasing level of consciousness
(LOC) and complains of a headache. Which of the following orders should be the priority?
a. Administer acetaminophen (Tylenol) 650 mg orally.
b. Administer 5% hypertonic saline intravenously.
c. Draw blood for arterial blood gases (ABGs).
d. Send the patient to the radiology department for computed tomography of the
head.
ANS: B
The patient’s low sodium indicates that hyponatremia may be causing the cerebral edema, and
the nurse’s first action should be to correct the low sodium level.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1643
MSC: CRNE: CH-22
5. The wife of a patient who is in a coma is optimistic about her husband’s recovery because he
opens his eyes and appears to be awake. What is the most appropriate response to the wife’s
comment?
a. “Your husband’s behaviour is only a reflex and does not really show improvement
in his condition.”
b. “Sleep–wake cycles are encouraging signs of recovery, and you should be
optimistic about your husband’s condition.”
c. “You are right to be optimistic. When patients begin to recover from a coma, the
first behaviours seen are those of wakefulness.”
d. “Your husband may show sleep–wake patterns if the part of the brain responsible
for arousal is not injured, but these patterns do not reflect activity of the higher
brain centres.”
ANS: D
Arousal is controlled by the reticular activating system in the brainstem and will allow the
patient to maintain wakefulness even though the damage to the cerebral cortex is severe.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1645, Table 59-5
MSC: CRNE: HW-26
6. When assessing a patient with a head injury, what will the nurse recognize as an early
indication of increased ICP?
a. Vomiting
b. Headache
c. Change in the LOC
d. Sluggish pupillary response to light
ANS: C
LOC is the most sensitive indicator of the patient’s neurological status and possible changes
in ICP.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1638
MSC: CRNE: CH-8
7. A patient is admitted to the hospital with a head injury resulting from an automobile accident.
On admission, the patient’s vital signs are temperature 37°C, blood pressure 128/68 mm Hg,
pulse 110 beats/min, and respiration 26 breaths/min. One hour after admission, which of the
following vital signs does the nurse note indicates the presence of Cushing’s triad?
a. Blood pressure 140/60 mm Hg, pulse 60 beats/min, respiration 14 breaths/min
b. Blood pressure 130/72 mm Hg, pulse 90 beats/min, respiration 24 breaths/min
c. Blood pressure 148/78 mm Hg, pulse 112 beats/min, respiration 28 breaths/min
d. Blood pressure 110/70 mm Hg, pulse 120 beats/min, respiration 30 breaths/min
ANS: A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes
represent Cushing’s triad and indicate that the ICP has increased and brain herniation may be
imminent unless immediate action is taken to reduce the ICP.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1638
MSC: CRNE: CH-8
8. Which of the following assessment data of the oculomotor nerve make the nurse suspicious of
a possible supratentorial herniation and compression of the brainstem?
a. Absent corneal reflexes
b. Development of nystagmus
c. Right pupil does not react to light
d. Left pupil is 10 mm in size
ANS: C
A dilated pupil on the ipsilateral side in a patient with an acute brain injury indicates
herniation.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1639
MSC: CRNE: CH-8
9. When the nurse applies a painful stimulus to an unconscious patient, the patient responds by
stiffly extending and abducting the arms and hyperpronating the wrists. How should the nurse
interpret this finding?
a. Decorticate posturing indicating an interruption of voluntary motor tracts
b. Decerebrate posturing indicating an interruption of voluntary motor tracts
c. Decorticate posturing indicating a disruption of motor fibres in the midbrain and
brainstem
d. Decerebrate posturing indicating a disruption of motor fibres in the midbrain and
brainstem
ANS: D
With decerebrate posturing, the arms are stiffly extended, adducted, and hyperpronated.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1639
MSC: CRNE: CH-61
10. When a patient’s ICP is being monitored with an intraventricular catheter, what is a priority
nursing intervention?
a. Maintaining strict aseptic technique to prevent infection
b. Maintaining the patient’s head in a fixed position
c. Continuous monitoring of the ICP waveform
d. Removing CSF to keep pressure at normal levels
ANS: A
Infection is a serious consideration with ICP monitoring, especially with intraventricular
catheters; therefore, a priority intervention would be strict aseptic technique at all times.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1643
MSC: CRNE: CH-55
11. The charge nurse observes a new graduate nurse who is caring for a patient who has had a
craniotomy for a brain tumour. Which action by the new graduate requires the charge nurse to
intervene and provide additional teaching?
a. The new nurse has the patient breathe deeply and cough.
b. The new nurse assesses neurological status every hour.
c. The new nurse elevates the head of the bed to 30 degrees.
d. The new nurse administers an analgesic before turning the patient.
ANS: A
Coughing can increase ICP and is generally discouraged in patients at risk for increased ICP.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1648
MSC: CRNE: PP-19
12. A patient is brought to the emergency department by ambulance after she was found
unconscious on the bathroom floor by her husband. In admitting the patient, what is it most
important for the nurse to assess first?
a. Health history
b. Airway patency
c. Neurological status
d. Status of bodily functions
ANS: B
Airway patency and breathing are the most vital functions and should be assessed first.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1654, Table 59-9
MSC: CRNE: CH-3
13. Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for
a patient with a head injury. Which of the following should the nurse do to evaluate the
effectiveness of the therapy?
a. Monitor oxygen saturation.
b. Check ABGs.
c. Monitor ICP.
d. Assess the patient’s breath sounds.
ANS: C
The purpose of hyperventilation for a patient with a head injury is reduction of ICP, and ICP
should be monitored to evaluate whether the therapy is effective.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1646, Figure 59-12
MSC: CRNE: CH-25
14. The physician prescribes intravenous (IV) mannitol (Osmitrol) for an unconscious patient.
What would the nurse expect the therapeutic effect of this drug to result in?
a. Decreased seizure activity
b. Decreased cerebral edema
c. Decreased cerebral metabolism
d. Decreased cerebral inflammation
ANS: B
Mannitol is an osmotic diuretic and will reduce cerebral edema and ICP.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1643
MSC: CRNE: CH-44
15. A patient with a severe head injury has been maintained on IV fluids of 5% dextrose in water
(D5W) at 50 mL/hour for 4 days. The nurse will anticipate the need for which of the
following?
a. Continue the D5W to provide the needed glucose for brain function.
b. Decrease the rate of IV infusion to avoid increasing cerebral edema.
c. Insert an enteral feeding tube to provide nutritional replacement.
d. Administer IV 5% albumin to increase serum protein levels.
ANS: C
The patient is in a hypermetabolic and hypercatabolic state, and enteral feedings will provide
nutrients for brain function and for healing and immune function. D5W does not provide
adequate nutrition to meet patient needs and can lead to lower serum osmolarity and cerebral
edema.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1644
MSC: CRNE: CH-36
16. When assessing a patient with a head injury, which assessment information is of most concern
to the nurse?
a. The blood pressure increases from 120/54 to 136/62 mm Hg.
b. The patient is more difficult to arouse.
c. The patient complains of a headache at pain level 5 of a 10-point scale.
d. The patient’s apical pulse is slightly irregular.
ANS: B
The change in the LOC is an indicator of increased ICP and suggests that action by the nurse
is needed to prevent complications.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1638
MSC: CRNE: CH-61
17. A patient with a head injury opens his eyes when his name is called, curses when he is
stimulated, and does not respond to a verbal command to move but attempts to remove a
painful stimulus. How should the nurse record the patient’s Glasgow Coma Scale score?
a. 9
b. 11
c. 13
d. 15
ANS: B
The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor
response.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1645, Table 59-5
MSC: CRNE: CH-4
18. The nurse identifies a nursing diagnosis of ineffective breathing pattern related to loss of
central nervous system integrative function for a patient who has post-traumatic brain
swelling based on which of the following findings?
a. Apneustic breathing
b. Crackles on inspiration
c. Glasgow Coma Scale score less than 8
d. CPP less than 60 mm Hg
ANS: A
Apneustic breathing is caused by loss of central nervous system integration in the pons and is
not effective in maximizing gas exchange.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1646, Figure 59-12
MSC: CRNE: CH-8
19. A woman is admitted unconscious to the emergency department after striking her head on a
boulder while hiking. Her husband and three teenaged children will not leave her side and
constantly ask about the treatment being given. What is the best approach to the patient’s
family?
a. Call the family’s pastor or spiritual advisor to support them while initial care is
given.
b. Refer the family members to the hospital counselling service to deal with their
anxiety.
c. Allow the family to stay with the patient, and explain all procedures thoroughly to
them.
d. Ask the family to wait in the waiting room until the initial assessment can be
completed and care can be started.
ANS: C
The need for information about the diagnosis and care is very high in family members of
acutely ill patients, and the nurse should allow the family to observe care and explain the
procedures.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1656
MSC: CRNE: CH-19
20. An unconscious patient has a nursing diagnosis of ineffective tissue perfusion (cerebral)
related to cerebral tissue swelling. What is an appropriate nursing intervention for this
problem?
a. Elevate the head of the bed 30 degrees.
b. Provide a position of comfort with the knees and hips flexed.
c. Cluster nursing interventions to provide uninterrupted periods of rest.
d. Teach the patient to cough and breathe deeply to prevent the necessity for
suctioning.
ANS: A
The patient with increased ICP should be maintained in the head-up position to help reduce
ICP.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1648
MSC: CRNE: CH-61
21. The nurse notes that a patient with a head injury has a clear nasal drainage. What is the most
appropriate nursing action for this finding?
a. Obtain a specimen of the fluid for culture and sensitivity.
b. Check the nasal drainage for glucose with a Dextrostix or Tes-Tape.
c. Take the patient’s temperature to determine whether a fever is present.
d. Instruct the patient to blow his nose and then check the nares for inflammation.
ANS: B
If the drainage is CSF leakage from a dural tear, glucose will be present.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1650
MSC: CRNE: CH-4
22. A patient was brought to the emergency department when he became faint and disoriented
after being hit in the head with a baseball bat during a company picnic. On admission, he has
a headache and cannot remember being hit, but he has no other signs of neurological deficit.
What would the nurse expect treatment for the patient to include?
a. Diagnostic testing with magnetic resonance imaging
b. Hospitalization for observation for 24 hours
c. Discharge with observation and monitoring instructions
d. Administration of a narcotic for the headache, followed by observation for several
hours
ANS: C
A patient with a minor head trauma is usually discharged with instructions about neurological
monitoring and the need to return if neurological status deteriorates.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1650
MSC: CRNE: CH-13
23. A victim of an automobile accident was found unconscious at the scene of the accident but
regained consciousness during transport to the hospital. Shortly after admission, her Glasgow
Coma Scale score is 8, and an acute epidural hematoma is suspected. The nurse plans care for
the patient based on the expectation that which of the following treatments will be included?
a. Immediate craniotomy
b. Administration of IV furosemide (Lasix)
c. Administration of IV corticosteroids
d. Endotracheal intubation with mechanical ventilation
ANS: A
As the Glasgow Coma Scale indicates a severe head injury, the principal treatment for
epidural hematoma is rapid surgery to remove the hematoma and prevent herniation;
therefore, an immediate craniotomy is expected.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1645, Table 59-5
OBJ: 8
TOP: Nursing Process: Planning
MSC: CRNE: CH-61
24. The nurse notes clear drainage from the nose of a patient with a frontal skull fracture and
recognizes that which of the following interventions is absolutely contraindicated for this
patient?
a. Lying flat
b. Eating solid food
c. Inserting a nasogastric tube
d. Cold packs for facial bruising
ANS: C
Rhinorrhea may indicate a dural tear with CSF leakage, and insertion of a nasogastric tube
will increase the risk for infections such as meningitis.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1650
MSC: CRNE: CH-61
25. In planning long-term care for the patient following brain trauma, what is the primary reason
the nurse includes teaching and support for the family?
a. Patients will always have some residual deficits of the brain damage.
b. Most patients experience seizure disorders in the weeks or even years following
head injury.
c. Families become dysfunctional and unable to cope with the role reversals required
during convalescence.
d. Patients with head injuries with unconsciousness often have changes in personality
with loss of concentration and memory processing.
ANS: D
Changes in personality, concentration, and memory are common after severe head injury and
require anticipatory guidance for the patient and family.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1651
MSC: CRNE: CH-19
26. During the assessment of a patient who has a tumour of the left frontal lobe, what would the
nurse expect to find?
a. Speech disturbances
b. Ataxic gait and vertigo
c. Personality and judgement changes
d. Papilledema and vision disturbances
ANS: C
The frontal lobes control intellectual activities such as judgement.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1658, Table 59-11
MSC: CRNE: CH-8
27. A patient with increasing headaches who is having diagnostic testing for a brain tumour asks
the nurse what type of treatment will be used if a tumour is discovered. Which response is
most appropriate?
a. “If the tumour is benign, treatment may not be necessary.”
b. “Therapy to remove or reduce the tumour size will be recommended.”
c. “Surgery will initially be used to reduce or remove the tumour.”
d. “Chemotherapy is used to shrink the tumour, followed by craniotomy.”
ANS: B
Treatment is designed to reduce tumour size or remove the tumour.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1659
MSC: CRNE: CH-8
28. Which one of the following types of cranial surgery is done to remove a bone flap?
a. Burr hole
b. Craniotomy
c. Craniectomy
d. Cranioplasty
ANS: C
A craniectomy is an excision into the cranium to cut away a bone flap.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1661, Table 59-13
MSC: CRNE: CH-8
29. Which one of the following can be caused by bacteria, fungi, a parasite, or a virus?
a. Meningitis
b. Brain abscess
c. Encephalitis
d. Brain hemorrhage
ANS: C
Encephalitis can be caused by bacteria, fungi, a parasite, or a virus.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1664, Table 59-14
MSC: CRNE: CH-8
30. Following a craniotomy with a craniectomy and left anterior fossa incision, the patient has a
nursing diagnosis of ineffective protection related to decreased level of consciousness and
weakness. What does an appropriate nursing intervention for the patient include?
a. Assessing for changes in motor ability daily
b. Performing range-of-motion exercises every 4 hours
c. Turning and repositioning the patient side to side every 4 hours
d. Eliminating extraneous noise to prevent sensory overload
ANS: B
Range-of-motion exercises will help prevent the complications of immobility.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 1667, Nursing Care Plan 59-2
OBJ: 8
TOP: Nursing Process: Implementation
MSC: CRNE: CH-40
31. Direct extension from a local infection in which of the following locations can be a primary
cause of a brain abscess?
a. Eye
b. Ear
c. Lung
d. Endocardium
ANS: B
Direct extension from a local ear infection can be a primary cause of a brain abscess; others
include tooth, mastoid, or sinus infection.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1668
MSC: CRNE: CH-8
32. Rabies manifests as which of the following?
a. Bacterial meningitis
b. Viral encephalitis
c. Viral meningitis
d. Bacterial encephalitis
ANS: B
The cause of rabies is an RNA virus that produces an acute, progressive viral encephalitis.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1668
MSC: CRNE: CH-8
33. A patient admitted with bacterial meningitis and a temperature of 38.9°C has orders for all of
these collaborative interventions. Which one should the nurse accomplish first?
a. IV ceftizoxime (Cefizox) 1 g now and every 6 hours
b. IV dexamethasone (Decadron) 4 mg now
c. Hypothermia blanket to keep the temperature less than 38.7°C
d. Nasopharyngeal swab for culture and sensitivity
ANS: D
Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be
done before antibiotics are started.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1663
MSC: CRNE: CH-22
34. The community health nurse is developing a program to decrease the incidence of meningitis
in adolescents and young adults. Which nursing action is most important?
a. Emphasize the importance of handwashing to prevent the spread of infection.
b. Immunize adolescents and college freshmen against Neisseria meningitidis.
c. Vaccinate 11- and 12-year-old children against Haemophilus influenzae.
d. Encourage adolescents and young adults to avoid crowded areas in the winter.
ANS: B
The N. meningitidis vaccination is recommended for children ages 11 and 12, unvaccinated
teens entering high school, and college/university freshmen.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1663
MSC: CRNE: HW-25
Chapter 60: Nursing Management: Stroke
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. The nurse obtains all of the following information about a 65-year-old patient in the clinic.
When developing a plan to decrease stroke risk, which risk factor is most important for the
nurse to address?
a. The patient smokes a pack of cigarettes daily.
b. The patient’s blood pressure is chronically between 150/80 and 170/90 mm Hg.
c. The patient works at a desk and relaxes by watching television.
d. The patient is 11.3 kg above the ideal weight.
ANS: B
Hypertension is the most important modifiable risk factor.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1674
MSC: CRNE: HW-2
2. A patient with right-sided weakness that started 1 hour ago is admitted to the emergency
department, and the following diagnostic tests are ordered. Which order should the nurse act
on first?
a. Chest radiograph
b. Electrocardiogram
c. Complete blood count
d. Noncontrast computed tomography (CT) scan
ANS: D
Rapid screening with a noncontrast CT scan is needed before administration of tissue
plasminogen activator (tPA), which must be given within 3 hours of the onset of clinical
manifestations of the stroke.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1680
MSC: CRNE: CH-61
3. The nurse expects that management of the patient who experiences a brief episode of tinnitus,
diplopia, and dysarthria with no residual effects will include which of the following
treatments?
a. Oral administration of clopidogrel (Plavix)
b. Heparin via continuous intravenous (IV) infusion
c. Prophylactic clipping of cerebral aneurysms
d. Therapy with tPA
ANS: A
The patient’s symptoms are consistent with transient ischemic attack (TIA), and medications
that inhibit platelet aggregation are prescribed after a TIA to prevent stroke.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1676
MSC: CRNE: CH-44
4. Aspirin is ordered for a patient who is admitted with a possible stroke. Which information
obtained during the admission assessment indicates that the nurse should consult with the
physician?
a. The patient has atrial fibrillation.
b. The patient has dysphasia.
c. The patient states, “I suddenly developed a terrible headache.”
d. The patient has a history of brief episodes of right hemiplegia.
ANS: C
A sudden-onset headache is typical of a subarachnoid hemorrhage and ruptured aneurysm; the
physician should be notified immediately.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1678, Safety Alert
MSC: CRNE: CH-61
5. A patient with a stroke caused by thrombosis of the middle cerebral artery experiences left-
sided paralysis of the upper and lower extremities and facial drooping on the left side. When
obtaining admission assessment data about the patient’s clinical manifestations, it is most
important for the nurse to assess which of the following?
a. The patient’s ability to follow commands
b. The patient’s visual fields
c. The patient’s left-sided reflexes
d. The patient’s emotional state
ANS: A
Because the patient with a right-sided brain stroke may have difficulty with comprehension
and use of language, it is important to obtain baseline data about the ability to follow
commands.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1679
MSC: CRNE: CH-8
6. On the medical unit, the nurse receives a verbal report from the emergency department nurse
that a patient has an occlusion of the left posterior cerebral artery. When admitting the patient
to the medical floor, which of the following will the nurse anticipate that the patient may be
experiencing?
a. Visual deficits
b. Dysphasia
c. Confusion
d. Poor judgement
ANS: A
Visual disturbances are expected with posterior cerebral artery occlusion.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 1678, Table 60-3
MSC: CRNE: CH-61
7. Which one of the following manifestations would the nurse expect to assess on a patient with
right-brain damage from a stroke?
a. Right-sided hemiplegia
b. Slow performance, cautiousness
c. Aware of deficits, depression
d. Impulsive behaviour
ANS: D
A patient with right-brain damage from a stroke would manifest impulsive behaviour, thus
safety is a main priority of care.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1679, Figure 60-5
MSC: CRNE: CH-8
8. The physician recommends a carotid endarterectomy for a patient with carotid atherosclerosis
and a history of TIAs. The patient asks the nurse whether this procedure involves brain
surgery. In responding to the patient, what should the nurse include information about?
a. An endarterectomy involves brain surgery because plaques in arteries at the base
of the brain are removed.
b. This surgery involves resection of a diseased portion of the artery in the brain and
replacing it with a synthetic graft.
c. A carotid endarterectomy involves removal of plaques in an artery in the neck and
does not involve surgery in the brain.
d. In this surgery, a burr hole is drilled in the skull to connect an artery outside the
skull to one inside the brain, bypassing a blockage.
ANS: C
In a carotid endarterectomy, the carotid artery is incised and the plaque is removed.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1681, Figure 60-6
MSC: CRNE: CH-12
9. On initial assessment of a patient hospitalized following a stroke, the nurse finds the patient’s
blood pressure to be 180/90 mm Hg. What should the nurse anticipate?
a. IV fluids will be withheld until the blood pressure is within the normal range.
b. Unless the blood pressure is lowered, the patient is at risk for another stroke.
c. IV fluids will be administered to promote hydration to maintain cerebral perfusion.
d. IV antihypertensive agents will be administered to maintain a mean arterial
pressure of 140 mm Hg.
ANS: C
Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
REF: page 1682
MSC: CRNE: CH-34
10. A 68-year-old man has had several TIAs with temporary hemiparesis and dysarthria that have
lasted up to an hour. The nurse encourages the patient to seek immediate medical assistance
for any symptoms that last longer than an hour, explaining that permanent disability from a
stroke may be reduced if therapy is initiated within 3 hours with the use of which of the
following treatments?
a. IV heparin
b. Transluminal angioplasty
c. A surgical endarterectomy
d. tPA
ANS: D
The patient’s history and clinical manifestations suggest an acute ischemic stroke, and a
patient who is seen within 3 hours of stroke onset is likely to receive tPA (after screening with
a CT scan).
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1683
MSC: CRNE: CH-61
11. The nurse identifies the nursing diagnosis of impaired verbal communication for a patient
with expressive aphasia. What is an appropriate nursing intervention to help the patient
communicate?
a. Ask simple questions that can be answered with “yes” or “no.”
b. Develop a list of simple words that she can read and practise reciting.
c. Have her practise facial and tongue exercises to improve motor control necessary
for speech.
d. Prevent embarrassing her by changing the subject if she does not respond in a
timely manner.
ANS: A
Communication will be facilitated and less frustrating to the patient when questions that
require a “yes” or “no” response are used.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1692, Table 60-9
MSC: CRNE: NCP-2
12. Twenty-four hours after admission, a patient with a stroke has progressive development of
neurological deficits with increasing weakness and decreased level of consciousness. What is
the primary goal of nursing management of the patient at this time?
a. Protecting the skin from breakdown
b. Monitoring for changes in neurological status
c. Maintaining the patient’s respiratory function
d. Preventing joint contractures and muscle atrophy
ANS: C
Protection of the airway is the priority of nursing care for a patient having an acute stroke.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1687
MSC: CRNE: CH-61
13. Which classification of stroke is the most common one, representing approximately 80% of
all strokes?
a. Intercerebral stroke
b. Ischemic stroke
c. Hemorrhagic stroke
d. Subarachnoid stroke
ANS: B
Ischemic strokes account for approximately 80% of all strokes.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 1676
MSC: CRNE: CH-8
14. A patient with homonymous hemianopsia resulting from a stroke has a nursing diagnosis of
disturbed sensory perception related to hemianopsia. What is an appropriate nursing
intervention that will help the patient learn to compensate for the deficit during the
rehabilitation period?
a. Apply an eye patch to the affected eye.
b. Approach the patient on the unaffected side.
c. Place objects necessary for activities of daily living on the affected side.
d. Teach the patient to exercise the eye muscles with full range of motion at least
twice a day.
ANS: C
During the rehabilitation period, placing objects on the affected side will encourage the
patient to use the scanning technique to visualize the affected side.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1694
MSC: CRNE: CH-77
15. During the acute phase of a patient with an ischemic stroke, the nurse monitors the patient’s
neurological status closely with the knowledge that following a stroke, increased intracranial
pressure from cerebral edema is most likely to peak in which of the following time periods?
a. 12 hours
b. 24 hours
c. 48 hours
d. 72 hours
ANS: D
Increased intracranial pressure from cerebral edema usually peaks in 72 hours and may cause
brain herniation.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1683
MSC: CRNE: CH-61
16. The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body
requirements related to inability to feed self for a patient with right-sided hemiplegia. What is
an appropriate nursing intervention to help improve the patient’s nutrition?
a. Assist the patient to eat with her left hand.
b. Provide a puréed diet that is easy for the patient to swallow.
c. Stroke the patient’s throat while feeding her to stimulate swallowing of food.
d. Provide a wide variety of food choices on the meal tray to stimulate her appetite.
ANS: A
Because the nursing diagnosis indicates that the patient’s imbalanced nutrition is related to the
right-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use
the left hand for self-feeding.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1693
MSC: CRNE: CH-74
17. The nurse is assisting the patient who is recovering from an acute stroke and has right-sided
hemiplegia to transfer from the bed to the wheelchair. Which nursing action is appropriate?
a. Positioning the wheelchair next to the bed on the patient’s right side
b. Placing the wheelchair parallel to the bed on the patient’s left side
c. Setting the wheelchair directly in front of the patient, who is sitting on the side of
the bed
d. Moving the wheelchair a few steps from the bed and having the patient walk to the
chair
ANS: B
Placing the wheelchair on the patient’s left side will allow the patient to use the left hand to
grasp the left arm of the chair to transfer. If the chair is placed on the patient’s right side or in
front of the patient, it will be awkward to use the strong arm, and the patient will be at
increased risk for a fall.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1693
MSC: CRNE: CH-40
18. A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid
hemorrhage. Which intervention will be included in the care plan?
a. Encouraging the patient to cough and breathe deeply every 4 hours
b. Inserting an oropharyngeal airway to prevent airway obstruction
c. Assisting the patient to dangle on the edge of the bed and assessing for dizziness
d. Applying intermittent pneumatic compression stockings
ANS: D
The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral
vasospasm or further bleeding and is at risk for deep-vein thrombosis.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1691
MSC: CRNE: CH-20
19. When initiating oral feedings for a patient with a stroke, the nurse determines that the patient
has an intact gag reflex and then does which of the following actions?
a. Offers the patient a sip of juice
b. Orders a varied puréed diet
c. Assesses the patient’s appetite
d. Assists the patient into a chair
ANS: D
The patient should be as upright as possible before attempting feeding to make swallowing
easier and decrease aspiration risk.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: pages 1691-1692
MSC: CRNE: CH-35
20. A patient has right-sided paresis and aphasia as a result of a stroke but is attempting to use his
left hand for feeding and other activities. When his wife visits, she insists on doing everything
for him. What is a nursing diagnosis that is most appropriate in this situation?
a. Situational low self-esteem related to increasing dependence on others
b. Interrupted family processes related to effects of illness of a family member
c. Disabled family coping related to inadequate understanding by primary person
d. Risk for ineffective therapeutic regimen management related to functional and
communication limitations
ANS: C
The information supports the diagnosis of disabled family coping because the wife does not
understand the rehabilitation program.
PTS: 1
OBJ: 9
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1693
MSC: CRNE: CH-19
21. Following a stroke, a patient has urinary incontinence with an impaired impulse to void. What
should a bladder retraining program for the patient include?
a. Limiting fluid intake to 1000 mL/day to reduce urine volume
b. Assisting the patient onto the bedpan or the bedside commode every 2 hours
c. Performing intermittent catheterization after each voiding to check for residual
urine
d. Inserting an in-dwelling catheter and clamping and draining the catheter every 4
hours to re-establish bladder tone
ANS: B
Developing a regular voiding schedule will prevent incontinence and may increase patient
awareness of a full bladder.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1689
MSC: CRNE: CH-37
22. A 72-year-old man is being discharged home following a stroke. He is able to walk with
assistance but needs help with hygiene, dressing, and eating. The patient’s 70-year-old wife
has received instruction and practice in necessary areas of care. Which of the following
statements by the patient’s wife indicates to the nurse that the outcomes for discharge
planning have been met?
a. “I can handle all of my husband’s needs with the instruction provided.”
b. “I have arranged for a home health aide to provide all the care my husband will
need.”
c. “I can provide the care my husband needs if I use the support and resources
available in the community.”
d. “Because my husband will have continuous improvement in his condition, I won’t
need outside assistance in his care for very long.”
ANS: C
The statement that community resources will be used indicates a realistic outcome. The
patient is unlikely to continue to improve to the point of needing no assistance.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1693
MSC: CRNE: CH-76
23. A patient who has a history of a TIA has an order for aspirin 160 mg daily. When the nurse is
administering the medications, the patient says, “I don’t need the aspirin today. I don’t have
any aches or pains.” Which action should the nurse take?
a. Document that the aspirin was refused by the patient.
b. Call the physician to clarify the medication order.
c. Explain that the aspirin is ordered to decrease stroke risk.
d. Tell the patient that the aspirin is used to prevent aches.
ANS: C
Aspirin is ordered to prevent stroke in patients who have experienced TIAs.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1680
MSC: CRNE: CH-44
24. A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a
few hours. The nurse will anticipate teaching the patient about which of the following
medications?
a. Alteplase (tPA)
b. Aspirin (Aggrenox)
c. Warfarin (Coumadin)
d. Nimodipine (Nimotop)
ANS: B
Following a TIA, patients typically are started on medications such as aspirin to inhibit
platelet function and decrease stroke risk.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1680
MSC: CRNE: CH-8
25. In order to assess a patient’s receptive speech, what should the nurse do?
a. Ask the patient where she is right now.
b. Show the patient three items, and ask the patient to name them.
c. Instruct the patient to close the eyes, ask if a stone sinks in water, and get her to
point to the ceiling.
d. Ask the patient the time of day, what month, and what year it is.
ANS: C
Instructing the patient to close her eyes, asking if a stone sinks in water, and getting her to
point to the ceiling is the assessment for receptive speech that the nurse would implement.
PTS: 1
OBJ: 8
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1687, Figure 60-11
MSC: CRNE: CH-4
26. A patient with left-sided hemiparesis arrives by ambulance at the emergency department.
Which action should the nurse take first?
a. Obtain the Glasgow Coma Scale score.
b. Check the respiratory rate.
c. Monitor the blood pressure.
d. Send the patient for a CT scan.
ANS: B
The initial nursing action should be to assess the airway and take any needed actions to ensure
a patent airway.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1686
MSC: CRNE: CH-61
27. Obesity is a modifiable risk factor for the prevention of stroke. What is the prevalence of
obesity in Canada among those aged 18 years and older?
a. 30%
b. 50%
c. 60%
d. 75%
ANS: C
Over half (60%) of all Canadians aged 18 years and older are obese.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 1675
MSC: CRNE: HW-13
28. Which one of the following manifestations would the nurse expect to assess on a patient with
left-brain damage from a stroke?
a. Left-sided hemiplegia
b. Spatial–perceptual deficits
c. Impaired speech–language
d. Impaired time concepts
ANS: C
A patient with left-brain damage will manifest impaired speech–language.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1679, Figure 60-5
MSC: CRNE: CH-8
Chapter 61: Nursing Management: Chronic Neurological Problems
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A patient with a headache describes it as affecting both sides of his head with a moderate
intensity that becomes worse when he is physically active. The nurse knows that the patient’s
clinical manifestations are characteristic of which of the following disorders?
a. Cluster headaches
b. Migraine headaches
c. Tension-type headaches
d. Headaches associated with trigeminal neuralgia
ANS: C
The International Headache Society (2004) classification system defines tension-type
headache as involving at least two of the following characteristics: pressure or tightness
sensation, mild to moderate severity, bilateral location, or worsening with physical activity.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1701, Table 61-1
MSC: CRNE: CH-8
2. A 20-year-old woman is seen at the health clinic with a severe migraine headache. The
headaches began 3 months ago, and she has had four headaches since that time. During
assessment, the patient tells the nurse she is afraid to make social plans because she never
knows when she will be incapacitated with the pain. What is the most appropriate nursing
intervention in response to the patient’s comments?
a. Refer the patient for counselling to assist her with conflict resolution and stress
reduction.
b. Suggest that the patient keep a diary of headache episodes to identify precipitating
factors.
c. Encourage the patient to learn the holistic techniques of meditation and
biofeedback to minimize the pain.
d. Reassure the patient that the headaches are not serious and the pain can be
controlled with a variety of drugs.
ANS: B
The initial nursing action should be further assessment of the precipitating causes of the
headaches, quality and location of pain, and so on, which can be accomplished by the patient
keeping a diary of the headache episodes.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1705
MSC: CRNE: CH-2
3. When teaching a patient about management of her migraine headaches, the nurse determines
that teaching has been effective when the patient gives which of the following responses?
a. “I will take the topiramate as soon as any headaches start.”
b. “The sumatriptan will help increase the blood flow to my brain.”
c. “I will try to lie down someplace dark and quiet when the headaches begin.”
d. “A glass of wine might help me relax and prevent headaches from developing.”
ANS: C
It is recommended that the patient with a migraine rest in a dimly lit, quiet area.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1702
MSC: CRNE: NCP-14
4. What is the most important nursing tool in diagnosing a cluster headache?
a. Magnetic resonance imaging (MRI) of the brain
b. Electromyography
c. The patient history
d. Computed tomography (CT) imaging of the brain
ANS: C
Diagnosis of cluster headache is made primarily on the basis of the patient’s symptoms;
therefore, a thorough patient history is required.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1703
MSC: CRNE: CH-1
5. A patient experiences cluster headaches that occur about every year for 2 months. During
assessment of the patient during an episode of the headache, what would the nurse expect to
find?
a. Nuchal rigidity
b. Nausea and vomiting
c. Unilateral eyelid edema and ptosis
d. A severe, throbbing, bilateral headache
ANS: C
Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1701, Table 61-1
MSC: CRNE: CH-8
6. Which one of the following should the nurse teach the patient to avoid because it may trigger
a headache?
a. Tylenol
b. Popsicles
c. Hot dogs
d. Fried chicken
ANS: C
Patients should be taught to avoid foods containing amines, nitrates, vinegar, onions, or MSG.
Hot dogs contain nitrates.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1706, Table 61-6
MSC: CRNE: HW-13
7. When caring for a patient with epilepsy who was hospitalized and successfully treated for
status epilepticus, what is a precaution that the nurse should institute as part of the care?
a. Placing oxygen and suction equipment at the bedside
b. Assigning an assistant to stay with the patient at all times
c. Keeping a tongue blade available to insert in case of a seizure
d. Instructing the patient to stay in bed and call for assistance to go to the bathroom
ANS: A
Oxygen and suction equipment should be available at the bedside for a patient who has
epilepsy.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
REF: page 1714
MSC: CRNE: CH-61
8. A patient has a tonic–clonic seizure while the nurse is in the patient’s room. During the
seizure, what is it important for the nurse to do?
a. Insert an oral airway during the seizure to maintain a patent airway.
b. Restrain the patient’s arms and legs to prevent injury during the seizure.
c. Avoid touching the patient to prevent further stimulation of the nervous system.
d. Time the seizure, and observe and record the details of the seizure and the postictal
phase.
ANS: D
Because diagnosis and treatment of seizures are frequently based on the description of the
seizure, recording the length and details of the seizure is important.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1714
MSC: CRNE: CH-61
9. The nurse witnesses a patient with a seizure disorder as he suddenly jerks his arms and legs,
falls to the floor, and regains consciousness immediately. What type of seizure is
demonstrated by this patient that the nurse must document?
a. An atonic seizure
b. A myoclonic seizure
c. A complex partial seizure with automatisms
d. A simple partial seizure with motor symptoms
ANS: A
An atonic (“drop attack”) seizure involves either a tonic episode or a paroxysmal loss of
muscle tone and begins suddenly with the person falling to the ground. Consciousness usually
returns by the time the person hits the ground, and normal activity can be resumed
immediately.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1708
MSC: CRNE: CH-15
10. After experiencing a generalized tonic–clonic seizure in the classroom, a 25-year-old high
school teacher is evaluated and diagnosed with idiopathic epilepsy. The patient cries when
told of the diagnosis and tells the nurse that she can never go back to teaching after
experiencing the seizure in front of her students. What is an appropriate nursing diagnosis for
the patient?
a. Anxiety related to loss of control during seizures
b. Hopelessness related to diagnosis of chronic illness
c. Disturbed body image related to new diagnosis of epilepsy
d. Ineffective role performance related to misinformation about epilepsy
ANS: D
The data indicate that the patient has ineffective role performance caused by inadequate
information about the disease because most patients are able to control seizures with
medication.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
REF: page 1707
MSC: CRNE: CH-12
11. Following recovery from a stroke, a 68-year-old patient developed complex partial seizures
with motor symptoms beginning in the right arm with progression to unconsciousness. The
physician prescribes phenytoin (Dilantin) for control of the seizures. Which of the following
statements by the patient indicates understanding of what self-care related to this drug
includes?
a. “I should use soft swabs rather than a toothbrush to clean my mouth.”
b. “If I have a seizure, I should call an ambulance to take me to the hospital.”
c. “I will take the medication at the beginning of the seizure before I lose
consciousness.”
d. “As I start this medication, I will need to have my blood taken frequently to check
the level of the drug.”
ANS: D
Serum levels of phenytoin may be checked to ascertain that a therapeutic level of the
medication is achieved.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1714, Table 61-13
MSC: CRNE: CH-44
12. When a patient experiences a generalized tonic–clonic seizure in the emergency department
after a head injury, all of the following orders are received. Which one will the nurse
implement first?
a. Send patient to radiology department for a CT scan.
b. Administer midazolam (Versed).
c. Check capillary blood glucose.
d. Monitor level of consciousness.
ANS: B
To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure
medications such as the benzodiazepines.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1710, Table 61-9
MSC: CRNE: CH-22
13. A patient found in a tonic–clonic seizure reports, after gaining consciousness, that the seizure
was preceded by numbness and tingling of the arm. What does the nurse know that this
finding indicates?
a. An absence seizure
b. A simple partial seizure
c. A complex partial seizure
d. A generalized myoclonic seizure
ANS: C
The initial symptoms of a complex partial seizure involve clinical manifestations that are
localized to a particular part of the body or brain. In addition, an alteration in consciousness is
always manifested.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1708
MSC: CRNE: CH-8
14. A patient has newly diagnosed multiple sclerosis (MS) and asks many questions about the
disease. When teaching the patient about MS, what should the nurse explain?
a. MS is an untreatable viral disease that destroys the basal ganglia in the brain.
b. Nerve impulses travel too quickly over nerves that have lost their myelin coat,
overloading the brain.
c. An autoimmune process causes gradual destruction of the myelin sheath of nerves
in the brain and spinal cord.
d. In MS, antibodies are produced against acetylcholine receptors, resulting in
blocked muscle contraction.
ANS: C
The primary pathology in MS is an autoimmune process that leads to loss of the myelin sheath
and results in decreased nerve transmission.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1715
MSC: CRNE: CH-8
15. When the nurse is obtaining a health history from a patient undergoing diagnostic testing for
MS, which of the following is a finding identified as characteristic of early MS?
a. Memory lapses
b. Intermittent fever
c. Constipation
d. Weakness of the legs
ANS: D
Extremity weakness or spasms are common motor symptoms of MS.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 1716
MSC: CRNE: CH-8
16. A 28-year-old woman has had MS for 3 years and wants to have children before her disease
becomes worse. When she asks about the risks associated with pregnancy, the nurse should
explain which of the following information?
a. The stress of pregnancy is likely to accelerate the course of the disease.
b. She may experience an acute, long-lasting exacerbation of the disease during
pregnancy.
c. Because MS is genetically transmitted, she should consider the risks to future
generations.
d. MS has no apparent effect on pregnancy and lactation, but the risk for an
exacerbation after the pregnancy is increased.
ANS: D
During the postpartum period, women with MS are at greater risk for exacerbation of
symptoms.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1718
MSC: CRNE: HW-26
17. A patient with MS is to begin treatment with glatiramer acetate (Copaxone). In planning the
patient teaching necessary with the use of the drug, the nurse recognizes the patient will need
to be taught which of the following information?
a. Self-injection techniques for subcutaneous injections
b. To use contraceptive methods other than oral contraceptives for birth control
c. To plan laboratory monitoring of complete blood count, chemistries, and liver
function every 3 months
d. That the drug will control symptoms but has no effect on the progression of the
disease
ANS: A
Glatiramer acetate is administered by self-injection.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1718, Table 61-16
MSC: CRNE: CH-74
18. According to the International Classification of Seizure Disorders, what would be the
classification of a clonic seizure?
a. Simple partial
b. Generalized
c. Complex partial
d. Unclassified
ANS: B
A clonic seizure is classified as a generalized seizure.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1707, Table 61-7
MSC: CRNE: CH-8
19. A patient with MS has a nursing diagnosis of urinary retention related to sensorimotor
deficits. What is an appropriate nursing intervention for this problem?
a. Decrease fluid intake in the evening.
b. Teach the patient how to use the Credé manoeuvre.
c. Suggest the use of incontinence briefs for nighttime use only.
d. Assist the patient to the commode every 2 hours during the day.
ANS: B
The Credé manoeuvre can be used to improve bladder emptying.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1721, Nursing Care Plan 61-2
OBJ: 2
TOP: Nursing Process: Implementation
MSC: CRNE: CH-37
20. The nurse identifies the nursing diagnosis of impaired physical mobility related to
bradykinesia for a patient with Parkinson’s disease. To assist the patient to ambulate safely,
what should the nurse do?
a. Allow the patient to ambulate only with assistance.
b. Teach the patient to rock back and forth to initiate leg movement.
c. Have the patient take small steps in a straight line directly in front of the feet.
d. Teach the patient to slide the feet forward with each step, always keeping the feet
in contact with the floor.
ANS: B
Rocking the body from side to side stimulates balance and improves mobility.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1726, Nursing Care Plan 61-3
OBJ: 2
TOP: Nursing Process: Implementation
MSC: CRNE: CH-74
21. For which classification of drug that is used in the treatment of MS does the nurse know to
teach the patient about the importance of restricting their sodium intake?
a. Cholinergics
b. Acetylcholinesterase
c. Corticosteroids
d. Anticholinergics
ANS: C
Patient teaching with the administration of corticosteroids includes restricting salt intake, not
stopping therapy abruptly, and being aware of drug interactions.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1718, Table 61-16
MSC: CRNE: CH-44
22. A patient with Parkinson’s disease has decreased tongue mobility and an inability to move his
facial muscles. The nurse documents which of the following nursing diagnoses that reflects
these impairments?
a. Disuse syndrome related to loss of muscle control
b. Self-care deficit related to bradykinesia and rigidity
c. Impaired verbal communication related to difficulty swallowing
d. Impaired oral mucous membranes related to inability to swallow saliva
ANS: C
The inability to use the tongue and facial muscles decreases the patient’s ability to socialize or
communicate needs.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1726, Nursing Care Plan 61-3
OBJ: 2
TOP: Nursing Process: Diagnosis
MSC: CRNE: CH-15
23. A patient with Parkinson’s disease tells the nurse that she is having increasing problems with
constipation. The nurse explains that constipation occurring with Parkinson’s disease is most
often a result of which of the following factors?
a. Advanced age
b. Decreased physical activity
c. Side effects of dopaminergic agents
d. Diminished nerve conduction to the bowel
ANS: B
Promotion of physical exercise and a well-balanced diet are major concerns for nursing care.
Exercise for patients with Parkinson’s disease can limit the consequences of decreased
mobility, such as muscle atrophy, contractures, and constipation.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1726
MSC: CRNE: HW-13
24. Which of the following is a clinical manifestation of myasthenia gravis (MG)?
a. Bulging eyes
b. Scotoma
c. Unstable gait
d. Hypertension
ANS: C
A clinical manifestation of MG is unstable or unusual gait.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1728, Table 61-21
MSC: CRNE: CH-8
25. A patient with MG is admitted to the hospital with severe weakness and acute respiratory
insufficiency. The physician performs a Tensilon test to distinguish between myasthenic crisis
and cholinergic crisis. During the test, it will be most important to monitor which of the
following?
a. Pupillary size
b. Muscle strength
c. Respiratory function
d. Level of consciousness
ANS: C
The Tensilon test in a patient with MG reveals improved muscle contractility after intravenous
injection of the anticholinesterase agent edrophonium chloride (Tensilon); therefore,
respiratory function must be monitored. (Anticholinesterase blocks the enzyme
acetylcholinesterase.) This test also aids in the diagnosis of cholinergic crisis (secondary to
overdose of anticholinesterase medication). In this condition, Tensilon does not improve
muscle weakness but may actually increase it. Atropine, a cholinergic antagonist, should be
readily available to counteract Tensilon effects when it is used diagnostically.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1728
MSC: CRNE: CH-32
26. When teaching a patient with MG about management of the disease, the nurse advises the
patient to do which of the following?
a. Anticipate the need for weekly plasmapheresis treatments.
b. Protect the extremities from injury due to poor sensory perception.
c. Do frequent weight-bearing exercise to prevent muscle atrophy.
d. Perform necessary physically demanding activities in the morning.
ANS: D
Muscles are generally strongest in the morning, and activities involving muscle activity
should be scheduled then.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1728
MSC: CRNE: CH-74
27. A patient with MG has a nursing diagnosis of altered nutrition: less than body requirements
related to impaired swallowing. To promote nutrition, the nurse suggests that before meals,
the patient should avoid which of the following actions?
a. Writing letters
b. Talking on the telephone
c. Typing on the computer
d. Taking pyridostigmine (Mestinon)
ANS: B
The same muscles are used for talking and swallowing, so the patient should avoid fatiguing
the muscles of the mouth and throat before meals.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1728
MSC: CRNE: CH-35
28. A patient with restless legs syndrome (RLS) tells the nurse, “My leg pain and twitching keep
me awake so much of the night, I am tired most of the day. Is there anything I can do?” Based
on this information, which nursing diagnosis is most appropriate?
a. Ineffective role performance related to fatigue
b. Chronic pain related to RLS
c. Anxiety related to lack of knowledge about RLS treatment
d. Sleep deprivation related to leg pain and involuntary movement
ANS: D
The patient’s statement indicates that daytime fatigue caused by lack of sleep is the major
concern.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Diagnosis
REF: page 1730
MSC: CRNE: CH-8
29. A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which
nursing action will be included in the plan of care?
a. Observing for agitation and paranoia
b. Assisting the patient with active range of motion (ROM)
c. Using simple words and phrases to explain procedures
d. Administering muscle relaxants as needed for muscle spasms
ANS: B
ALS causes progressive muscle weakness, but assisting the patient to perform active ROM
will help maintain strength as long as possible.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1731
MSC: CRNE: CH-77
30. A 42-year-old patient who was adopted at birth is diagnosed with early Huntington’s disease.
When teaching the patient and her family about this disorder, what should the nurse explain
about Huntington’s disease?
a. It is characterized by retarded voluntary and involuntary movement, resulting in
immobility.
b. Genetic testing is available to determine the risk for your children.
c. It can be controlled by replacing the neurotransmitters acetylcholine and -
aminobutyric acid.
d. It will result in limited physical and mental deterioration, requiring some planning
and support for care.
ANS: B
Genetic testing is available to determine whether an asymptomatic individual has the
Huntington’s disease gene. The patient and family should be informed of the benefits and
problems associated with genetic testing.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1731, Genetics in Clinical Practice box
OBJ: 3
TOP: Nursing Process: Implementation
MSC: CRNE: CH-8
31. A hospitalized 24-year-old patient with a history of cluster headache awakens during the night
with a severe stabbing headache. Which action should the nurse take first?
a. Notify the patient’s physician immediately.
b. Start the ordered as-needed oxygen at 9 L/min.
c. Give the ordered as-needed acetaminophen (Tylenol).
d. Put a moist hot pack on the patient’s neck.
ANS: B
Acute treatment for cluster headache is administration of 100% oxygen at 7 to 9 L/min. If the
patient obtains relief with the oxygen, there is no immediate need to notify the physician.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1703
MSC: CRNE: CH-61
32. The patient tells the nurse that he has a constant, squeezing tightness at the base of his skull
and that his neck is stiff. Which type of headache is the patient most likely experiencing?
a. Migraine headache
b. Cluster headache
c. Ocular headache
d. Tension-type headache
ANS: D
A tension-type headache manifests with constant, squeezing tightness, bandlike pressure at the
base of the skull, in the face, or both.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1701, Table 61-1
MSC: CRNE: CH-8
33. A patient is seen in the health clinic with symptoms of a stooped posture, shuffling gait, and
pill rolling–type tremor. The nurse will anticipate teaching the patient about which of the
following?
a. Preparation for an MRI scan
b. The purpose of electroencephalographic testing
c. Antiparkinsonian drugs
d. Oral corticosteroids
ANS: C
The diagnosis of Parkinson’s diagnosis is made when two of the three characteristic signs of
tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on
the basis of improvement when antiparkinsonian drugs are administered.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
REF: page 1724
MSC: CRNE: CH-8
Chapter 62: Nursing Management: Delirium, Alzheimer’s Disease, and Other
Dementias
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. A 72-year-old woman hospitalized with pneumonia becomes disoriented and confused 2
days after admission. Which assessment information obtained by the nurse about the patient
indicates that the patient is experiencing delirium rather than dementia?
a. The patient is disoriented to place and time but oriented to person.
b. The patient has a history of increasing confusion over several years.
c. The patient’s speech is fragmented and incoherent.
d. The patient was oriented and alert when admitted.
ANS: D
The onset of delirium occurs acutely. The degree of disorientation does not differentiate
between delirium and dementia.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1738, Table 62-2
OBJ: 1
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
2. Which of the following is a rare and fatal infectious brain disorder that progresses rapidly to
death within 1 year?
a. Vascular dementia
b. Dementia with Lewy bodies
c. Creutzfeldt-Jakob disease
d. Neurofibrillary tangle disease
ANS: C
Creutzfeldt-Jakob disease is a rare and fatal infectious brain disorder that progresses rapidly
to death within 1 year.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1743
MSC: CRNE: CH-8
3. Which of the following is a modifiable risk factor for reducing the risk for getting
Alzheimer’s disease?
a. Type 1 diabetes
b. Hypotension
c. Inadequate intellectual stimulation
d. Inadequate nutrition
ANS: C
Inadequate intellectual stimulation is a modifiable risk factor for reducing risk for
Alzheimer’s disease.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 1741, Table 62-6
OBJ: 7
TOP: Nursing Process: Assessment
MSC: CRNE: HW-19
4. What does the nurse document when assessment findings indicate that a patient with
dementia has lost her ability to initiate purposeful movement?
a. Amnesia
b. Agnosia
c. Apraxia
d. Anosognosia
ANS: C
Apraxia is the loss of ability to initiate purposeful movement; inability to perform
previously learned tasks; difficulty understanding terms.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1744, Table 62-7
OBJ: 7
TOP: Nursing Process: Implementation MSC: CRNE: CH-15
5. A family member of a patient with possible Alzheimer’s disease asks the nurse the purpose
of the MMSE. Which response is appropriate?
a. “The MMSE helps in establishing the diagnosis of Alzheimer’s disease.”
b. “The MMSE is useful in determining the degree of mental impairment.”
c. “The MMSE determines the choice of the most appropriate treatment.”
d. “The MMSE aids in differentiating acute delirium from chronic dementia.”
ANS: B
The MMSE establishes the degree of mental impairment at the time it is given.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1745
MSC: CRNE: CH-30
6. When administering a mental status examination to a patient, the nurse suspects depression
when the patient gives which of the following responses?
a. “I don’t know.”
b. “Is that the right answer?”
c. “Wait, let me think about that.”
d. “What are those people doing over there?”
ANS: A
Answers such as “I don’t know” are more typical of depression.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1738
MSC: CRNE: CH-1
7. A 71-year-old patient is diagnosed with moderate dementia as a result of multiple strokes.
During assessment of the patient, what would the nurse expect to find?
a. Extreme suspiciousness
b. Irritability and withdrawal
c. Difficulty eating and swallowing
d. Loss of recent and long-term memory
ANS: D
Loss of both recent and long-term memory is characteristic of moderate dementia.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1744, Table 62-7
OBJ: 7
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
8. Some patients with dementia have a pattern of behavioural disturbance that occurs
consistently in the late afternoon. How does the nurse document this assessment finding?
a. Turning the tide
b. Sundowning
c. Worsening symptoms of dementia
d. Disorientation to time of day
ANS: B
Sundowning is a pattern of behavioural disturbance that occurs consistently in the late
afternoon.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1752
MSC: CRNE: CH-8
9. A 62-year-old woman is brought to the clinic by her daughter, who is concerned about her
mother’s increasing sleep disturbances and inability to solve common problems. To obtain
information about the patient’s current mental status, which question should the nurse ask
the patient?
a. “Where were you were born?”
b. “Do you have any feelings of sadness?”
c. “What day of the week is it today?”
d. “How positive is your self-image?”
ANS: C
This question tests the patient’s orientation to time, which is decreased in early Alzheimer’s
disease or dementia.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 1745, Table 62-8
OBJ: 7
TOP: Nursing Process: Assessment
MSC: CRNE: CH-4
10. When teaching the husband of a woman who is being evaluated for Alzheimer’s disease
about the disorder, what should the nurse explain?
a. “The most important risk factor for Alzheimer’s disease is a family history of the
disorder.”
b. “A diagnosis of Alzheimer’s disease can be made only when other causes of
dementia have been ruled out.”
c. “New medications, such as donepezil (Aricept), have been shown to dramatically
reverse Alzheimer’s disease in some patients.”
d. “The presence of brain atrophy and enlarged ventricles detected by magnetic
resonance imaging confirms the diagnosis of Alzheimer’s disease in patients with
dementia.”
ANS: B
The diagnosis of Alzheimer’s disease is one of exclusion.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1741
MSC: CRNE: CH-8
11. A home care patient with Alzheimer’s disease and mild dementia has a new prescription for
donepezil. Which nursing action will be most effective in ensuring compliance with the
medication?
a. Setting the medications up weekly in a medication box
b. Calling the patient daily with a reminder to take the medication
c. Having the patient’s spouse administer the medication
d. Posting reminders to take the medications in the patient’s house
ANS: C
Because the patient with mild dementia will have difficulty with learning new skills and
forgetfulness, the most appropriate nursing action is to have someone else administer the
donepezil.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1745
MSC: CRNE: CH-19
12. Risperidone (Risperdal) is prescribed for a patient with moderate Alzheimer’s disease. In
evaluating the effectiveness of this medication, what would the nurse expect the patient to
demonstrate?
a. Less agitation and aggression
b. Enhanced functional abilities
c. Improved memory and judgement
d. Stabilization of mood and sleep patterns
ANS: A
Risperidone is an antipsychotic used to treat the agitation, aggression, and behavioural
problems associated with Alzheimer’s disease.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1747
MSC: CRNE: CH-44
13. The nurse has identified the nursing diagnosis of disturbed thought processes related to
effects of dementia for a patient with late-stage Alzheimer’s disease. What is an appropriate
intervention for this problem?
a. Maintain a consistent daily routine.
b. Keep the television in the room on all day.
c. Reorient the patient to the date and time every few hours.
d. Provide the patient with current newspapers and magazines.
ANS: A
Providing a consistent routine will decrease anxiety and confusion for the patient.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1749, Nursing Care Plan 62-1
OBJ: 7
TOP: Nursing Process: Implementation MSC: CRNE: CH-77
14. A 70-year-old woman visits her 72-year-old husband who has advanced Alzheimer’s
disease and is hospitalized with pneumonia. She tells the nurse that it is a relief to have
someone besides herself care for her husband because she is physically and mentally
exhausted from caring for him at home. She says she has no family to help her and that they
cannot afford institutional care for her husband. What is an appropriate nursing diagnosis for
the patient’s wife?
a. Anxiety related to financial insecurity
b. Ineffective health maintenance related to chronic stress
c. Caregiver role strain related to limited resources for caregiving
d. Social isolation related to unrelieved caregiving responsibilities
ANS: C
The spouse’s statements are most consistent with caregiver role strain.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
REF: page 1754
MSC: CRNE: CH-76
15. A long-term care patient with moderate dementia develops increased restlessness and
agitation. What is the nurse’s initial action?
a. Administer the as-needed dose of lorazepam (Ativan).
b. Reorient the patient to time and place.
c. Assess the patient for anything that might be causing discomfort.
d. Have a nursing assistant stay with the patient to ensure safety.
ANS: C
Increased motor activity in a patient with dementia is frequently the patient’s only way of
responding to factors such as pain, so the nurse’s initial action should be to assess the
patient for any precipitating factors.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1778
MSC: CRNE: CH-1
16. When assessing a patient with Alzheimer’s disease who is being admitted to a long-term
care facility, the nurse learns that the patient has had several episodes of wandering away
from home. Which nursing action will the nurse include in the plan of care?
a. Ask the patient why the wandering episodes have occurred.
b. Reorient the patient to the new living situation several times daily.
c. Place the patient in a room close to the nurses’ station.
d. Have the family bring in familiar items from the patient’s home.
ANS: C
Patients at risk for problems with safety require close supervision. Placing the patient near
the nurses’ station will allow nursing staff to observe the patient more closely.
PTS: 1
DIF: Cognitive Level: Application
REF: page 1749, Nursing Care Plan 62-1
OBJ: 7
TOP: Nursing Process: Implementation MSC: CRNE: HW-24
17. In which of the following conditions does the patient have fluctuations in consciousness
throughout the course of the disease?
a. Delirium
b. Depression
c. Psychosis
d. Dementia
ANS: A
Delirium manifests with fluctuations in consciousness throughout the course of the disease,
whereas with dementia it is clear until late in the course of the illness and with depression it
is unimpaired.
PTS: 1
DIF: Cognitive Level: Comprehension
REF: page 1738, Table 62-2
OBJ: 4
TOP: Nursing Process: Assessment
MSC: CRNE: CH-8
Chapter 63: Nursing Management: Peripheral Nerve and Spinal Cord Problems
Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition
MULTIPLE CHOICE
1. When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the
patient about which of the following?
a. Triggers that lead to facial pain
b. Visual problems caused by ptosis
c. Poor appetite caused by a loss of taste
d. Decreased sensation on the affected side
ANS: A
The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered
by cutaneous stimulation of the nerve.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
REF: page 1761
MSC: CRNE: CH-8
2. During assessment of the patient with a recurrence of symptoms of trigeminal neuralgia, what
should the nurse do?
a. Examine the oral cavity for the state of hygiene.
b. Observe the extent of facial weakness and eye closure.
c. Identify trigger zones by lightly tickling the affected side of the face.
d. Gently palpate the affected side of the face for warmth and swelling.
ANS: A
Oral hygiene is frequently neglected because of fear of triggering facial pain.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1763
MSC: CRNE: CH-20
3. A patient with a long history of trigeminal neuralgia recently had a glycerol rhizotomy for
control of symptoms. During a follow-up visit after the rhizotomy, what finding indicates to
the nurse that the patient has made a successful adjustment to the surgical intervention?
a. The patient uses an eye shield to protect the cornea from injury.
b. The patient develops and implements a daily routine of facial exercises.
c. The patient is careful to chew foods on the unaffected side of the mouth.
d. The patient returns to previous interpersonal and social relationships with family
and friends.
ANS: D
Because withdrawal from social activities is a common manifestation of trigeminal neuralgia,
enjoyment of social activities indicates successful reduction of symptoms and should be
included in the plan of care for this patient.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
REF: page 1764
MSC: CRNE: CH-18
4. When planning care for a patient during an acute episode of trigeminal neuralgia, what is an
appropriate intervention to include?
a.
b.
c.
d.
Evaluation of hydration and nutrition status
Exercise of the muscles of the face and jaw
Application of ice packs to the affected area
Regular exercise regimen
ANS: A
The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so
assessment of nutritional and hydration status is important.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1762
MSC: CRNE: CH-35
5. When teaching patients who are at risk for Bell’s palsy because of previous herpes simplex
infection, which information should the nurse include?
a. “You should call the doctor if pain or herpes lesions occur near the ear.”
b. “Treatment of herpes with antiviral agents will prevent development of Bell’s
palsy.”
c. “Medications to treat Bell’s palsy work only if started before paralysis onset.”
d. “You may be able to prevent Bell’s palsy by doing facial exercises regularly.”
ANS: A
Pain or herpes lesions near the ear may indicate the onset of Bell’s palsy, and rapid
corticosteroid treatment may reduce the duration of Bell’s palsy symptoms.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1764
MSC: CRNE: HW-26
6. A patient with Bell’s palsy refuses to eat while others are present. What is the best response to
the patient’s behaviour?
a. Respect her desire for privacy, and leave her alone while she eats.
b. Provide a liquid diet high in protein and calories, which she can easily swallow.
c. Assure the patient that it does not bother others to observe her while she eats.
d. Teach the patient to chew her food on the unaffected side of the mouth for better
control.
ANS: A
The patient’s desire for privacy should be respected to encourage adequate nutrition and
reduce patient embarrassment.
PTS: 1
OBJ: 1
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1765
MSC: CRNE: PP-1
7. A patient with Guillain-Barré syndrome asks the nurse what has caused the disease. In
responding to the patient, what should the nurse explain about Guillain-Barré syndrome?
a. Results from an acute infection and inflammation of the peripheral nerves
b. Is due to an immune reaction that attacks the covering of the peripheral nerves
c. Is caused by destruction of the peripheral nerves after exposure to a viral infection
d. Results from degeneration of the peripheral nerve caused by viral attacks
ANS: B
Guillain-Barré syndrome is believed to result from an immunological reaction that damages
the myelin sheath of the peripheral nerves.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1765
MSC: CRNE: CH-8
8. A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this
phase of the patient’s illness, what is the most essential assessment for the nurse to carry out?
a. Monitoring the vital signs every 2 hours
b. Determining the patient’s level of consciousness every 2 hours
c. Performing constant evaluation of respiratory function
d. Evaluating sensory and motor function of the extremities
ANS: C
The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse
should monitor respiratory function continuously.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1766
MSC: CRNE: CH-22
9. When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained
by the nurse will require the most immediate action?
a. The patient complains of severe tingling pain in the feet.
b. The patient has continuous drooling of saliva.
c. The patient’s blood pressure is 106/50 mm Hg.
d. The patient’s quadriceps and triceps reflexes are absent.
ANS: B
Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration
and requires rapid nursing and collaborative actions such as suctioning and possible
endotracheal intubation.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1767
MSC: CRNE: CH-24
10. A 45-year-old woman is hospitalized with Guillain-Barré syndrome. What treatment will the
nurse explain will most likely be included during the first 2 to 3 weeks of her illness?
a. Hemodialysis
b. Mechanical ventilation
c. Administration of immune globulin (Sandoglobulin)
d. Administration of methylprednisolone (Solu-Medrol)
ANS: C
Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms),
use of high-dose immune globulin is appropriate to reduce the extent and length of symptoms.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1769
MSC: CRNE: CH-44
11. A patient admitted to the emergency department is diagnosed with botulism poisoning, and
botulinum antitoxin is to be administered. Before administration of the antitoxin, what should
the nurse do?
a. Obtain baseline vital signs.
b. Administer an intradermal test dose.
c. Ask the patient about a history of allergies.
d. Document the presence of neurological symptoms.
ANS: B
To prevent allergic reactions, an intradermal test dose of the antitoxin should be administered.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1768
MSC: CRNE: CH-47
12. A patient arrives at an urgent care centre after stepping on a nail that was embedded in some
old lumber in a field. The patient reports having had a tetanus booster 7 years ago. What will
the nurse anticipate for care?
a. Intravenous (IV) infusion of tetanus immune globulin
b. Initiation of the tetanus–diphtheria (Td) immunization series
c. Intradermal injection of an immune globulin test dose
d. Administration of the Td toxoid booster
ANS: D
If the patient has not been immunized within 5 years, administration of the Td booster is
indicated because the wound is deep.
PTS: 1
OBJ: 2
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
REF: page 1769
MSC: CRNE: HW-25
13. A patient with a cervical neck fracture at the C5 level is admitted to the critical care unit
following initial treatment in the emergency department. During initial assessment of the
patient, the nurse recognizes the presence of spinal shock on finding which of the following
data?
a. Hypotension, bradycardia, and warm extremities
b. Involuntary, spastic movements of the arms and legs
c. Flaccid paralysis and lack of sensation below the level of the injury
d. Loss of voluntary motor control but the presence of reflex activity below the level
of the injury
ANS: C
Clinical manifestations of spinal shock include decreased reflexes, loss of sensation, and
flaccid paralysis below the area of injury.
PTS: 1
OBJ: 3
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
REF: page 1771
MSC: CRNE: CH-62
14. When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough
effort, bibasilar crackles, and decreased breath sounds, the initial nursing intervention should
be to do which of the following?
a. Administer oxygen at 7 to 9 L/min with a face mask.
b. Place the hands on the epigastric area, and push upward when the patient coughs.
c. Encourage the patient to use an incentive spirometer every 2 hours during the day.
d. Suction the patient’s oral and pharyngeal airway.
ANS: B
The nurse has identified that the cough effort is poor, so the initial action should be to use
assisted coughing techniques to improve the ability to mobilize secretions.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1773
MSC: CRNE: CH-32
15. A patient with a spinal cord transection at T1 is in spinal shock. While monitoring the patient,
the nurse recognizes that alterations in sympathetic nervous system function may cause which
of the following reactions?
a. Tachycardia
b. Bladder hyperirritability
c. Fluctuating body temperature
d. Hypermotility of the gastrointestinal system
ANS: C
Temperature control is largely external to the patient because no vasoconstriction,
piloerection, or heat loss through perspiration has occurred below the level of injury. The
nurse must monitor the environment closely to maintain an appropriate temperature.
PTS: 1
OBJ: 4
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1776
MSC: CRNE: CH-8
16. As a result of a gunshot wound, a patient has an incomplete right spinal cord lesion at the
level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included
in the plan of care?
a. Assessment of the patient for left leg pain
b. Assessment of the patient for left arm weakness
c. Positioning the patient’s right leg when turning the patient
d. Teaching the patient to look at the left leg to verify its position
ANS: C
The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side
and will require the nurse to move the right leg.
PTS: 1
OBJ: 5
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
REF: page 1771
MSC: CRNE: CH-42
17. The nurse is aware that which one of the following is the most common cause of premature
death in a patient with tetraplegia?
a. Diabetes
b. Acute renal failure
c. Pneumonia
d. Hypertension
ANS: C
The most common cause of premature death in a patient with tetraplegia is pneumonia,
urinary tract infections, and pressure ulcers, or any combination of them.
PTS: 1
OBJ: 7
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
REF: page 1770
MSC: CRNE: CH-8
18. During the initial phase of care for a patient with spinal cord trauma at C5, why must the
nurse give high priority to maintaining respiratory function?
a. At the C5 level, diaphragmatic and intercostal muscle function is lost.
b. Extension of edema above the site of the injury may affect phrenic nerv