Clinical Guidelines in Primary
Care 4th Edition Testbank/Study
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Chapter 1 Cardiovascular Disorders
Guide
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MULTIPLE CHOICE
pericardium.
c.
mediastinum.
d.
myocardium.
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ANS: D
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b.
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endocardium.
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a.
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1.The nurse is aware that the muscle layer of the heart, which is responsible for the hearts
contraction, is the:
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The myocardium is the specialized muscle layer that allows the heart to contract.
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2.The nurse clarifies that the master pacemaker of the heart is the:
left ventricle.
b.
atrioventricular (AV) node.
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a.
c.
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ANS: C
bundle of His.
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d.
sinoatrial (SA) node.
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The SA node is the master pacemaker of the heart.
3.The nurse is aware that the symptoms of an impending myocardial infarction (MI) differ in
women because acute chest pain is not present. Women are frequently misdiagnosed as having:
a.
hepatitis A.
b.
indigestion.
c.
urinary infection.
d.
menopausal complications.
ANS: B
Indigestion, gallbladder attack, anxiety attack, and depression are frequent misdiagnoses for
women having an MI.
a.
AV valves closing.
b.
closure of the semilunar valves.
c.
contraction of the papillary muscles.
d.
contraction of the ventricles.
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4.The nurse identifies the LUBB sound of the LUBB/DUBB of the cardiac cycle as the sound of
the:
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ANS: A
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The LUBB is the first sound of a low pitch heard when the AV valves close.
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5.A patient is admitted from the emergency department. The emergency department physician
notes the patient has a diagnosis of heart failure with a New York Heart Association (NYHA)
classification of IV. This indicates the patients condition as:
moderate heart failure.
b.
severe heart failure.
c.
congestive heart failure.
d.
negligible heart failure.
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a.
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ANS: B
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Class IV: Severe; patient unable to perform any physical activity without discomfort. Angina or
symptoms of cardiac inefficiency may develop at rest.
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a.
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6.The nurse assesses that the home health patient has no signs or symptoms of heart failure, but
does have a history of rheumatic fever and has been recently diagnosed with diabetes mellitus.
The nurse is aware that using the American College of Cardiology and the American Heart
Association (ACC/AHA) staging, this patient would be a:
stage A.
b.
stage B.
c.
stage C.
d.
stage D.
ANS: A
The ACC/AHA staging describes stage A as a person without symptoms of heart failure, but
with primary conditions associated with the development of the disease.
7.The nurse caring for a patient recovering from a myocardial infarct who is on remote telemetry
recognizes the need for added instruction when the patient says:
a.
I can ambulate in the hallway with this gadget on.
b.
I always take off the telemetry device when I shower.
c.
My EKG is being watched by one of the nurses in CCU on the home unit.
d.
I am able to sleep just fine with this device on.
ANS: B
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Remote telemetry allows the patient to be on a separate unit, but be monitored in a central
location. The patients can be ambulatory and can sleep with the monitor on. They
should not remove the monitor to shower.
c.
+3 edema.
d.
+4 edema.
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+2 edema.
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b.
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+1 edema.
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a.
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8.The nurse assesses pitting edema that can be depressed approximately inch and refills in 15
seconds. The nurse would document this assessment as:
ANS: B
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si
A +2 edema can be documented if the skin can be depressed inch and respond within 15
seconds.
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9.What do dark or cold spots on a thallium scan indicate?
Tissue with adequate blood supply
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a.
b.
Tissue that has inadequate perfusion
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ANS: D
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d.
Areas of neoplastic growth
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c.
Dilated vessels
Thallium scans show adequate perfused areas by the collection of thallium. Dark spots or cold
spots indicate tissues that have inadequate perfusion.
10.The nurse recognizes the echocardiogram report that shows an ejection factor of 42% as an
indication of:
a.
normal heart action.
b.
mild heart failure.
c.
moderate heart failure.
d.
severe heart failure.
ANS: C
An ejection factor (cardiac output) of 42% indicates moderate heart failure.
11.The nurse takes into consideration that age-related changes can affect the peripheral
circulation because of:
sclerosed blood vessels.
b.
hypotension.
c.
inactivity.
d.
poor nutrition.
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a.
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ANS: A
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Aging causes sclerotic changes in the blood vessels that lead to decreased elasticity and
narrowing of the vessel lumen.
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12.The nurse assessing a cardiac monitor notes that the cardiac complexes each have a P wave
followed by a QRS and a T. The rate is 120. The nurse recognizes this arrhythmia as:
sinus bradycardia.
b.
atrial fibrillation.
c.
sinus tachycardia.
d.
ventricular tachycardia.
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si
a.
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ANS: C
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Sinus tachycardia has a P wave followed by the QRS and the T. All the components of the
complex are present and in the correct order, but the rate is over 100 beats a minute.
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13.After an influenza-like illness, the patient complains of chills and small petechiae in his
mouth and his legs. A heart murmur is detectable. These are characteristic signs of:
a.
congestive heart failure.
b.
heart block.
c.
aortic stenosis.
d.
infective endocarditis.
ANS: D
Collection of subjective data includes noting patient complaints of influenza-like symptoms with
recurrent fever, undue fatigue, chest pain, and chills. Objective data may reveal the significant
signs of petechiae in the conjunctiva and mouth. Both subjective data and objective data are
indicative of infective endocarditis.
a.
atrial fibrillation and possible emboli.
b.
sinus tachycardia and syncope.
c.
ventricular tachycardia and death.
d.
sinus bradycardia and fatigue.
ANS: C
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PVCs are capable of progressing into ventricular tachycardia and death.
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14.The nurse notes a run of three ventricular contractions (PVC) that are not preceded by a P
wave. This particular arrhythmia can progress into:
b.
2 and 3.
c.
3 and 4.
d.
4 and 5.
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1 and 2.
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a.
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15.The nurse reminds the patient who is on Coumadin for the treatment of atrial fibrillation that
the ideal is to maintain the international normalized ratio (INR) at between:
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ANS: B
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The desired INR for the monitoring of anticoagulant therapy is between 2 and 3.
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16.What should a person with unstable angina avoid?
Walking outside
b.
Eating red meat
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a.
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ANS: D
Shoveling snow
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d.
Swimming in warm pool
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c.
The person with angina should avoid exposure to cold, heavy exercise, eating heavy meals, and
emotional stress.
17.The elderly patient with angina pectoris says she is unsure how she should take nitroglycerin
when she has an attack. The nurses most helpful response would be:
a.
Continue to take nitroglycerin sublingually at 5-minute intervals until the pain is relieved.
b.
If the pain is not relieved after three doses of nitroglycerin at 5-minute intervals, call your
physician and come to the hospital.
c.
When nitroglycerin is not relieving the pain, lie down and rest.
d.
Use oxygen at home to relieve pain when nitroglycerin is not successful.
ANS: B
Administer prescribed nitroglycerin. Repeat every 5 minutes, three times. If pain is unrelieved,
notify the physician. Nitroglycerin administered sublingually usually relieves angina symptoms
but does not relieve the pain from an MI. Administering nitroglycerin more than three times will
probably not relieve the pain.
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18.The patient has been hospitalized for hypertensive episodes three times in the last months.
While preparing the discharge teaching plan, the nurse assesses that he does not comply with his
medication regimen. The nurses immediate course of action would be to:
reteach him about his medications.
b.
have a serious talk with him and his family about compliance.
c.
arrange for home visits after discharge.
d.
collect more information to identify his reasons for noncompliance.
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a.
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ANS: D
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Nursing interventions include measures to prevent disease progression and complications.
Reteaching about medication will not identify the cause of noncompliance.
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19.What is the major cause of cardiac valve disease?
Rheumatic fever
b.
Long history of malnutrition
c.
Drug abuse
d.
Obesity
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a.
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ANS: A
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Rheumatic fever, a streptococcal infection, is the major cause of cardiac valve disease.
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20.The patient has a total cholesterol of 190 with a high-density lipid (HDL) of 110 and a lowdensity lipid (LDL) of 80. The nurses reaction is one of:
a.
satisfaction. This is good cholesterol control.
b.
determination. This is evidence that more instruction is necessary.
c.
inquiry. This needs to clarified as to the cause of noncompliance with the drug protocol.
d.
regret. This shows very poor cholesterol control.
ANS: A
Total cholesterol of less than 200 is desirable. The higher the number of HDLs the better. A high
number of LDLs puts the patient at risk for heart disease.
21.A patient, age 72, was admitted to the medical unit with a diagnosis of angina pectoris.
Characteristic signs and symptoms of angina pectoris include:
substernal pain that radiates down the left arm.
b.
epigastric pain that radiates to the jaw.
c.
indigestion, nausea, and eructation.
d.
fatigue, shortness of breath, and dyspnea.
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a.
ANS: A
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The pain often radiates down the left inner arm to the little finger and also upward to the
shoulder and jaw.
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22.A patient admitted to the emergency room with a possible myocardial infarction (MI) has
reports back from the laboratory. Which laboratory report is specific for myocardial damage?
CK-MB
b.
Elevated white count
c.
Elevated sedimentation rate
d.
Low level of sodium
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a.
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ANS: A
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The CK-MB is elevated when there is infarcted myocardial muscle. The elevated white count,
low sodium, and ESR are nonspecific.
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23.The patient, age 26, is hospitalized with cardiomyopathy. While obtaining a nursing history
from her, the nurse recognizes that the increased incidence of cardiomyopathy in young
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b.
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a.
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adults who have minimal risk factors for cardiovascular disease is related to which factor(s)?
Cocaine use
Viral infections
c.
Vitamin B1 deficiencies
d.
Pregnancy
ANS: A
Cardiomyopathy caused by cocaine abuse is seen more frequently than ever before. Cocaine also
causes high circulating levels of catecholamines, which may further damage myocardial cells,
leading to ischemic or dilated cardiomyopathy. The cardiomyopathy produced is difficult to
treat. Interventions deal mainly with the HF that ensues.
24.The patient has become very dyspneic, respirations are 32, and the pulse is 100. The patient is
coughing up frothy red sputum. What should be the initial nursing intervention?
a.
Lay the patient flat to reduce hypotension and the symptoms of cardiogenic shock.
b.
Place patient in side-lying position to reduce the symptoms of atrial fibrillation.
c.
Place patient upright with legs in dependent position to reduce the symptoms of pulmonary
edema.
d.
Lay the patient flat and elevate the feet to increase venous return in cardiogenic shock.
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ANS: C
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Signs and symptoms of pulmonary edema are restlessness; vague uneasiness; agitation;
disorientation; diaphoresis; severe dyspnea; tachypnea; tachycardia; pallor or cyanosis; cough
producing large quantities of blood-tinged, frothy sputum; audible wheezing and crackles; and
cold extremities. The legs in a dependent position will decrease venous return and ease the
pulmonary edema.
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25.The nurse caring for a patient recovering from a myocardial infarction (MI) teaches which
method to avoid the Valsalva maneuver during a bowel movement?
Mouth breathing
b.
Pursing the lips and whistling
c.
Taking a deep breath and holding it
d.
Breathing rapidly through the nose
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ng
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a.
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ANS: A
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Mouth breathing will lessen the severity of straining and will decrease the effect of the Valsalva
maneuver on intrathoracic pressure.
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b.
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a.
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26.The nurse reminds the patient that the National Heart, Lung, and Blood Institute recommends
a lipid study every _________ years.
2
3
c.
4
d.
5
ANS: D
The National Heart, Lung, and Blood Institute recommend a lipid study every 5 years for all
Americans, but especially for the older adult.
27.During a health interview by the home health nurse, which patient complaint suggests leftsided heart failure?
a.
I have to sleep in my recliner and I have this hacking cough.
b.
I have no appetite and I have lost 3 lb in the last week.
c.
I have to urinate every 2 hours, even during the night.
d.
I go barefoot most of the time because my feet are so hot.
ANS: A
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Left ventricular failure; the first is signs and symptoms of decreased cardiac output. The second
is pulmonary congestion. Signs and symptoms of this condition include dyspnea, orthopnea,
pulmonary crackles, hemoptysis, and cough.
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28.The home health nurse caring for a patient with infective endocarditis overhears the patient
making a dental appointment for an extraction next month. Which question is most important for
the nurse to ask?
Do you have a toothache?
b.
Have you contacted your physician about your dental appointment?
c.
Is your dentist board certified?
d.
Do you think you should wait that long for your tooth extraction?
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st
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a.
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ANS: B
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Patients with endocarditis are put on a protocol of prophylactic antibiotics for any invasive
procedure. The dentist and physician should be contacted before the extraction.
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29.The home health nurse warns the patient who is taking warfarin (Coumadin) for anticoagulant
therapy for thrombophlebitis to stop taking the herbal remedy of ginkgo because ginkgo can:
cause severe episodes of diarrhea.
b.
cause a severe skin eruption if taken with Coumadin.
c.
increase the action of the Coumadin.
d.
cause the Coumadin to be less effective.
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ANS: C
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a.
Herbal remedies such as ginkgo, garlic, angelica, and red clover can increase (potentiate) the
action of the Coumadin.
30.What is the difference between primary and secondary hypertension?
a.
Secondary hypertension is caused by another disorder like renal disease.
b.
Secondary hypertension is related to hereditary factors.
c.
Secondary hypertension cannot be treated effectively.
d.
Secondary hypertension is no real threat to health.
ANS: A
Secondary hypertension is a consistently elevated blood pressure that is caused by another
disorder, such as renal disease, diabetes, or Cushing syndrome.
MRI
b.
CT scan
c.
Thallium scan
d.
PET
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a.
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31.The nurse is treating a patient who has had a pacemaker inserted for the correction of atrial
fibrillation. Which diagnostic test is no longer available to the patient because of the implanted
device?
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ANS: A
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Because of the large magnets in the MRI cabinet, the pacemaker may be reset to a fixed mode
and interfere with the functioning of the pacemaker.
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32.Which assessment would lead the nurse to examine the leg closely for evidence of a stasis
ulcer?
Cool dry lower limb
b.
Edematous, red scaly skin on medial surface of the leg
c.
Lack of hair and shiny appearance of the lower leg
d.
Lack of a pedal pulse
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si
ng
a.
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ANS: B
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Suggestion of a stasis ulcer in the making is an edematous, dry scaly area on the medial surface
of the lower leg that has a darker pigmentation (rubor). Cool hairless limbs with absent or weak
pedal pulses are indicative of arterial insufficiency.
Walk 2 miles in less than 60 minutes after 12 weeks.
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a.
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33.What is the patient goal of the walking exercise program designed for the rehabilitation of a
post-MI patient?
b.
Jog mile in less than 30 minutes after 12 weeks.
c.
Fast walk 1 mile in less than 20 minutes after 12 weeks.
d.
Walk 1 mile in 15 minutes without dyspnea after 12 weeks.
ANS: A
The goal of the 12-week walking program is that the patient can walk 2 miles in less than 60
minutes.
34.The postsurgical patient has a painful and swollen right calf that appears to be larger than the
calf of the left leg. What is the nurse assessing for when she flexes the patients right leg and
dorsiflexes the foot?
a.
Pain, which would be a positive Homans sign
b.
Muscular spasm, which would be a sign of hypocalcemia
c.
Rigidity, which would be a sign of ankylosis
d.
Crepitus, which would be a sign of a joint disorder
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ANS: A
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A positive Homans sign for deep vein thrombosis (DVT) is a report of pain when the affected leg
is flexed and the foot is dorsiflexed.
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35.How should the nurse advise a patient with an international normalized ratio (INR) of 5.8?
Make arrangements to go to the emergency room immediately
b.
Increase fluid intake to 2000 mL/day
c.
Stop taking the anticoagulant and notify health care provider
d.
Add more leafy green vegetables to patient diet
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a.
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ANS: C
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si
The INR that is desired should be maintained between 2 and 3. A reading of 5.8 puts the patient
at risk for hemorrhage. The patient should stop taking the anticoagulant and contact the
physician for further instruction.
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36.The nurse making a teaching plan for a patient with Buerger disease (thromboangiitis
obliterans) will focus on the need for:
reduction of alcohol intake.
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a.
weight reduction.
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d.
cessation of smoking.
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c.
avoiding cold remedies.
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b.
ANS: C
The hazards of cigarette smoking and its relationship to Buerger disease are the primary focus of
patient teaching. None of the palliative treatments are effective if the patient does not stop
smoking. Nowhere are the cause and effect of smoking so dramatically seen as with Buerger
disease.
37.Which statement would lead the nurse to offer more instruction about taking warfarin
(Coumadin)?
a.
I eat a banana every morning with breakfast.
b.
I try to eat more green leafy vegetables, especially broccoli, spinach, and kale.
c.
I try to eat a well-balanced, low-fat diet.
d.
I dont drink alcohol or caffeine.
ANS: B
Avoid marked changes in eating habits, such as dramatically increasing foods high in vitamin K
(e.g., broccoli, spinach, kale, greens). Limit alcohol intake to small amounts.
thrombophlebitis.
c.
pulmonary emboli.
d.
heart failure.
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b.
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hypotension.
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a.
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38.The nurse caring for a 92-year-old patient with pneumonia who is receiving IV carefully
monitors the flow rate of the IV infusion because rapid infusion can cause:
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ANS: D
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Heart failure can result from rapid infusion of intravenous fluids in older adults.
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39.The nurse making the schedule for the daily dose of furosemide (Lasix) would schedule the
administration for which of the following times?
Late in the afternoon
b.
At bedtime
c.
With any meal
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si
a.
d.
In the morning
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ANS: D
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Diuretics should be scheduled for morning administration to avoid causing the patient nocturia.
Chapter 2 Dermatologic Disorders
MULTIPLE CHOICE
1.What should the nurse do when administering a therapeutic bath to a patient who has severe
pruritus?
Use Burows solution to help promote healing
b.
Rub the skin briskly to decrease pruritus
c.
Limit bathing to 3 times a week
d.
Ensure that bath area is at least 85 degrees and dehumidified
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a.
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ANS: A
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Pruritus is responsible for most of the discomfort. Wet dressings and using Burows solution help
promote the healing process. A cool environment with increased humidity decreases the pruritus.
Give daily baths with an application to cleanse the skin.
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2.A frail, older adult home health patient who had chickenpox as a child has been exposed to
varicella (chickenpox) several days ago. What should the nurse do?
Assess frequently for herpes zoster
b.
Be aware of the patients immunity to chickenpox
c.
Encourage the patient to have a pneumonia vaccine
d.
Arrange for the patient to receive gamma globulin
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si
ng
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a.
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ANS: A
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Herpes zoster is caused by the same virus that causes chickenpox (Herpes varicella). The greatest
risk occurs to patients who have a lowered resistance to infection, such as those on
chemotherapy, aging, or receiving large doses of prednisone, in whom the disease could be fatal
because of the patients compromised immune system.
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3.A patient has herpes zoster (shingles) and is being treated with acyclovir (Zovirax). What
should the nurse do when administering this drug?
a.
Apply lightly, being careful not to completely cover the lesion
b.
After application, wrap in warm wet dressings
c.
Use gloves
d.
Rub medication into lesions
ANS: C
The topical application requires that the nurse uses gloves, completely covers the lesion gently,
then leaves it open to the air.
4.A child has been sent to the school nurse with pruritus and honey-colored crusts on the lower
lip and chin. The nurse believes these lesions most likely are:
a.
chickenpox.
b.
impetigo.
c.
shingles.
d.
herpes simplex type I.
ANS: B
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Impetigo is seen at all ages, but is particularly common in children. The crust is honey-colored
and easily removed and is associated with pruritus. The disease is highly contagious and spreads
by contact.
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5.A school nurse assesses a child who has an erythematous circular patch of vesicles on her scalp
with alopecia and complains of pain and pruritus. Why would the nurse use a Woods lamp?
To dry out the lesions
b.
To reduce the pruritus
c.
To kill the fungus
d.
To cause fluorescence of the infected hairs
ng
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st
a.
si
ANS: D
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Tinea capitis is commonly known as ringworm of the scalp. Microsporum audouinii is the major
fungal pathogen. The use of the diagnostic Woods lamp causes the infected hairs to turn a
brilliant blue green.
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b.
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a.
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6.A patient, age 46, reports to his physicians office with urticaria with elevated lesions that are
white in the center with a pale red border on hands and arms. He says, It itches like crazy. Which
type of lesion would the nurse include in her documentation?
Macules
Plaques
c.
Wheals
d.
Vesicles
ANS: C
Urticaria is the term applied to the presence of wheals or hives in an allergic reaction commonly
caused by drugs, food, insect bites, inhalants, emotional stress, or exposure to heat or cold. The
lesions are elevated with a white center and a pale red border.
7.The home health nurse assessing skin lesions uses the PQRST mnemonic as a guide. What
does the S in this guide indicate?
a.
Severity of the symptoms
b.
Site of the lesions
c.
Symptomatology of the lesions
d.
Surface area of the lesions
ANS: A
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The mnemonic PQRST stands for Provocative factors (causes), Quantity, Region of the body,
Severity of the symptoms, Time (length of time the disorder has been present).
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8.What would the nurse stress to the 17-year-old girl who has been prescribed Accutane for her
acne?
Avoid alcoholic beverages
b.
Drink at least 1000 mL of fluid daily
c.
Use dependable birth control to avoid pregnancy
d.
Avoid exposure to the sun
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te
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ANS: C
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a.
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Accutane has a destructive effect on fetal development. Dependable birth control is important to
avoid a pregnancy.
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9.A 30-year-old African American had surgery 6 months ago and the incision site is now raised,
indurated, and shiny. This is most likely which type of tissue growth?
c.
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d.
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b.
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a.
Angioma
Keloid
Melanoma
Nevus
ANS: B
Keloids, which originate in scars, are hard and shiny and are seen more often in African
Americans than in whites.
10.A patient, age 37, sustained partial- and full-thickness burns to 26% of the body surface area.
When would the greatest fluid loss resulting from the burns occur?
a.
Within 12 hours after burn trauma
b.
24 to 36 hours after burn trauma
c.
24 to 48 hours after burn trauma
d.
48 to 72 hours after burn trauma
ANS: A
In a burn injury, usually the greatest fluid loss occurs within the first 12 hours.
infection.
b.
arrhythmias with cardiac arrest.
c.
hypovolemic shock and renal failure.
d.
adrenal failure.
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a.
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11.Most of the deaths from burn trauma in the emergent phase that require a referral to a burn
center result from:
ANS: C
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Hypovolemic shock is frequently lethal in the emergent period of a severe burn because of the
transfer of fluids into the interstitial tissue from the circulating volume.
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12.The nurse takes into consideration that carbon monoxide intoxication secondary to smoke
inhalation is often fatal because carbon monoxide:
binds with hemoglobin in place of oxygen.
b.
interferes with oxygen intake.
c.
is a respiratory depressant.
d.
is a toxic agent.
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si
a.
ANS: A
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Carbon monoxide poisoning is likely if the patient has been in an enclosed area. Carbon
monoxide displaces oxygen by binding with hemoglobin.
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13.A nurse arrives at an accident scene where the victim has just received an electrical burn.
What is the nurses primary concern?
a.
The extent and depth of the burn
b.
The sites of entry and exit
c.
The likelihood of cardiac arrest
d.
Control of bleeding
ANS: C
Most electrical burns result in cardiac arrest, and the patient will require CPR or acute cardiac
monitoring.
14.A patient, age 27, sustained thermal burns to 18% of her body surface area. After the first 72
hours, the nurse will have to observe for the most common cause of burn-related deaths, which
is:
a.
shock.
b.
respiratory arrest.
c.
hemorrhage.
d.
infection.
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ANS: D
Infection is the most common complication and cause of death after the first 72 hours.
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15.Two weeks after a severe burn of over 20% of the body, the patient vomits bright red blood.
Which condition is most likely?
Curling ulcer
b.
Paralytic ileus
c.
Hypoglycemia perforation of the stomach by the NG tube
d.
Gastritis
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st
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a.
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ANS: A
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Curling ulcer is a duodenal ulcer that develops 8 to 14 days after severe burns on the surface of
the body. The first sign is usually vomiting of bright red blood.
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16.When providing the open method of treatment for a patient who is 52 years old with burns to
the lower extremities, what would a nurse include in the nursing plan?
Change the dressing using good medical asepsis
b.
Provide an analgesic immediately after the dressing change
c.
Perform circulation checks every 2 to 4 hours
d.
Keep the room temperature at 85 F (29.4 C) to prevent chilling
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ANS: D
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a.
Chilling may be controlled by keeping the room temperature at 85 F (29.4 C). Strict surgical
protocol is observed and analgesia should be given before the treatment. Frequent circulation
checks are not a high priority with the open method.
17.The nurse has staged a pressure ulcer that has a shallow crater with a dry pink wound bed as
a:
a.
stage I
b.
stage II
c.
stage III
d.
stage IV
ANS: B
Stage II pressure ulcers have a shallow crater with a dry pink wound bed without slough.
18.What would the nurse dressing a necrotic pressure ulcer with a minimal exudate most likely
use?
Hydrocolloid dressing
b.
Alginate dressing
c.
Hydrofiber dressing
d.
Transparent film
ep
.c
om
a.
ANS: A
st
pr
Hydrocolloid dressings are useful in necrotic wounds with little exudate. Alginate and hydrofiber
dressings are used for wounds with copious exudate. Transparent film is not absorbent.
ng
te
19.The nurse is caring for a 26-year-old male patient who was burned 72 hours ago. He has
partial-thickness burns to 24% of his body surface area. He begins to excrete large amounts of
urine. What should the nurse do?
Increase the IV rate and monitor for burn shock
b.
Monitor for signs of seizure activity.
c.
Assess for signs of fluid overload
d.
Raise the foot of the bed and apply blankets
yn
ur
si
a.
.m
ANS: C
w
w
w
As the blood volume increases, the cardiac output increases to increase renal perfusion. The
result includes diuresis. However, a great risk for the patient includes fluid overload because of
the rapid movement of fluid back into the intravascular space.
20.A patient with severe eczema is starting a coal tar derivative treatment. What should the nurse
include in the teaching plan for the patient relative to this treatment?
a.
Drink at least 1000 mL of fluid daily
b.
Avoid exposure to sunlight for 72 hours after use
c.
Bathe with an astringent soap
d.
Reduce intake of high calcium foods
ANS: B
Persons using coal tar derivatives should avoid exposure to sunlight for 72 hours after use. The
product stains clothes and bathroom fixtures.
21.What should the nurse examine in assessing a patient for tinea corporis?
a.
Soles of the feet
b.
Scalp
c.
Armpits
d.
Abdomen
om
ANS: D
.c
Tinea corporis is known as ringworm of the body. It occurs on parts of the body with little or no
hair.
ep
22.What is the initial intervention for relief of the pruritus of dermatitis venenata?
Apply baking soda to lesions
b.
Wash area with copious amounts of water
c.
Apply cool compresses continuously
d.
Expose area to air
te
st
pr
a.
ng
ANS: B
ur
si
In dermatitis venenata (poison oak or ivy), the patient should wash the affected part immediately
after contact with the offending allergen.
yn
23.The nurse debriding a burn wound explains that the purpose of debridement is to:
increase the effectiveness of the skin graft.
b.
prevent infection and promote healing.
c.
promote suppuration of the wound.
w
w
ANS: B
promote movement in the affected area.
w
d.
.m
a.
Debridement is the removal of damaged tissue and cellular debris from a wound or burn to
prevent infection and to promote healing.
24.A patient has been admitted to the hospital with burns to the upper chest. The nurse notes
singed nasal hairs. The nurse needs to assess this patient frequently for which condition?
a.
Decreased activity
b.
Bradycardia
c.
Respiratory complications
d.
Hypertension
ANS: C
Signs and symptoms of inhalation injury include singed nasal hairs. Breathing difficulties may
take several hours to occur.
Even coloring of the mole
b.
Decrease in size of the mole
c.
Irregular border of the mole
d.
Symmetry of the mole
ep
.c
a.
om
25.Which may indicate a malignant melanoma in a nevus on a patients arm?
ANS: C
te
st
pr
Any change in color, size, or texture and any bleeding or pruritus of a nevus deserves
investigation. A malignant melanoma is a cancerous neoplasm in which pigment cells or
melanocytes invade the epidermis, dermis, and sometimes the subcutaneous tissue.
ng
26.A nurse can assess cyanosis in a dark-skinned patient by noting the color of the:
conjunctiva.
b.
sclera.
c.
lips and mucous membranes.
d.
soles of the feet.
yn
ur
si
a.
.m
ANS: C
w
Assessment of color is more easily made in areas where the epidermis is thin, such as the lips
and mucous membranes.
w
w
27.A patient developed a severe contact dermatitis of the hands, arms, and lower legs after
spending an afternoon picking strawberries. The patient states that the itching is severe and
cannot keep from scratching. Which instruction would be most helpful in managing the pruritus?
a.
Use cool, wet dressings and baths to promote vasoconstriction.
b.
Trim the fingernails short to prevent skin damage from scratching.
c.
Expose the areas to the sun to promote drying and healing of the lesions.
d.
Wear cotton gloves and cover all other affected areas with clothing to prevent environmental
irritation.
ANS: A
Wet dressings and using Burows solution help promote the healing process. Cold compresses
may be applied to decrease circulation to the area (vasoconstriction). Short nails prevent skin
damage, but not pruritus.
28.What is the best instruction by the nurse regarding reducing the risk factors for melanoma?
Avoid exposure to the sun and use protective measures when exposure occurs.
b.
Have all nevi removed.
c.
Watch for changes in moles, especially on the back.
d.
Use a sun lamp for tanning.
om
a.
ANS: A
pr
ep
.c
Encourage the patient to protect skin from the sun by wearing protective clothing, including a hat
with 4-inch brim, applying sunscreen all over the body, and avoiding the midday sun from 10 am
to 4 pm. Sun lamps are just as damaging as the sun.
te
st
29.Which patient instruction should the nurse include in the teaching plan relative to the
management of systemic lupus erythematosus?
Maintain a balance between rest and activity
b.
Increase activity to promote mobility
c.
Increase exposure to the sun to increase vitamin D absorption
d.
Increase sodium consumption
ur
si
ng
a.
yn
ANS: A
.m
Balanced rest, activity, and diet will support medication management. Limited sunlight exposure
is recommended to prevent photosensitivity. SLE often has kidney involvement, which would
require reduction of sodium.
My skin is cleared up. I dont think I need the medication anymore.
w
a.
w
w
30.Which patient statement indicates that more teaching is needed regarding antibiotic therapy
for the treatment of cellulitis?
b.
Cellulitis can come back at any time.
c.
If I had washed that scratch with soap and water, I probably would not have gotten cellulitis.
d.
Cellulitis is contagious.
ANS: A
The entire amount of antibiotic medication should be completed even if the symptoms have
abated to ensure the eradication of the infectious agent.
31.What should a patient be assessed for upon the diagnosis of genital herpes?
a.
Hepatitis B
b.
Syphilis
c.
Human immunodeficiency virus (HIV).
d.
Cirrhosis
ANS: C
Persons with genital herpes should be assessed for HIV because the therapy for herpes is
suppressive; persons with HIV are not candidates for suppressant therapy.
b.
dry scaly patches in body creases that itch.
c.
wavy threadlike lines on the body and pruritus.
d.
cluster of papular lesions with pruritus.
.c
small fluid filled blisters that sting when scratched.
pr
ep
a.
om
32.The school nurse recognizes the signs of scabies when a child presents with:
st
ANS: C
ng
te
Scabies is manifested by brown threadlike lines on the body, especially the hands, anus, and
body folds. Pruritus is severe.
ur
si
33.Melanocytes give rise to the pigment melanin, which is responsible for skin color. Where can
the melanocytes be found?
Dermis
b.
Superficial fascia
c.
Epidermis
.m
yn
a.
w
ANS: C
Loose connective tissue
w
d.
w
A layer in the epidermis contains highly specialized cells called melanocytes.
MULTIPLE RESPONSE
34.Which of the following are major functions of the skin? (Select all that apply.)
a.
Excretion of wastes
b.
Protection
c.
Vitamin C synthesis
d.
Temperature regulation
e.
Prevention of dehydration
ANS: A, B, D, E
Functions of the skin include protection from the environment (pathogenic organisms, foreign
substances, natural barrier against infection), temperature regulation, prevention of dehydration,
excretion of waste products, and vitamin D synthesis.
Urticaria
c.
Vomiting
d.
Headache
e.
Vertigo
f.
Unsteady gait
.c
b.
ep
Dizziness
pr
a.
om
35.During primary survey assessment of a burn patient, the nurse checks for which of the
following as early signs of carbon monoxide poisoning? (Select all that apply.)
st
ANS: C, D, F
w
w
w
.m
yn
ur
si
ng
te
Early signs of carbon monoxide poisoning include headache, nausea, vomiting, and unsteady
gait.
Chapter 3 Ear, Nose & Throat Disorders
MULTIPLE CHOICE
2.
Audiometry
3.
MRI of the brain
4.
Electroencephalogram
.c
Head CT scan
ep
1.
om
1.A client is not able to successfully pass the whisper test. Which of the following would be
indicated for this client?
ANS: 2
st
pr
Failure to pass the whisper test would indicate the need for formal audiometry testing. The client
would not need a head CT or MRI at this time. An electroencephalogram is not necessary.
ng
te
2.A client is prescribed a medication that is ototoxic. The nurse realizes that this medication may
cause:
permanent or temporary vision loss.
2.
permanent or temporary hearing loss.
3.
nausea and vomiting.
4.
central nervous system (CNS) depression.
ur
yn
.m
w
w
ANS: 2
si
1.
w
Although many drugs cause nausea and vomiting and central nervous system (CNS) depression,
ototoxic drugs cause hearing loss and the risks must be considered prior to suggesting these types
of medications.
3.The nurse is trying to communicate with a hearing-impaired client. The best way to do this is
to:
1.
write down all of the message.
2.
shout in the impaired ear.
3.
speak slowly and clearly while facing the client.
4.
talk in a regular voice in the good ear.
ANS: 3
ep
.c
om
When trying to communicate with the hearing-impaired client, the nurse should speak slowly and
clearly while facing the client to give her the opportunity to see and hear the words being spoken.
The nurse should not write down all of the messages. Shouting in the impaired ear will not
improve the clients hearing. Talking in a regular voice into the good ear will not improve
hearing.
3.
otitis media.
4.
pr
brain damage.
st
2.
te
cerumen.
si
ng
1.
ur
4.A client is diagnosed with a conductive hearing loss. The nurse realizes type of hearing loss
is notassociated with:
yn
otosclerosis.
.m
ANS: 2
w
w
Conductive hearing loss results in a blockage of sound waves in the external or middle portions
of the ear. Wax (cerumen) buildup and infections are a large part of conductive hearing loss.
Otosclerosis is associated with conductive hearing loss. Brain damage is not a cause of
conductive hearing loss.
w
5.A client is complaining of dizziness, unilateral ringing in the ear, feeling of pressure or fullness
in the ear, and unilateral hearing loss. The nurse would suspect the client is experiencing:
1.
Mnires disease.
2.
osteosclerosis.
3.
otitis media.
4.
mastoiditis.
ANS: 1
All of the clients complaints are signs and symptoms of Mnires disease. Although hearing
disorders may have similar signs and symptoms, they do not include all of them.
2.
Add mineral oil to kill the insect.
3.
Add lidocaine to kill the insect.
4.
Call an otologist for a referral.
.c
Add water to flush out the insect.
te
st
pr
ep
1.
om
6.A client complains of a slight itching, slight pain, and a scratching sound in the ear. The nurse
suspects that an insect may have entered the ear. Which of the following should not be done?
ANS: 1
si
ng
Avoid placing water in the ear canal, which will only make the insect swell, thereby making it
more difficult to remove. An otologist should be called for the removal. The audiologist may
prescribe mineral oil or lidocaine to be applied to the ear canal.
yn
ur
7.The hearing of an unresponsive client needs to be assessed. Which of the following will be
used to assess the hearing of this client?
Audiometer
2.
Brainstem auditory evoked responses (BAER) test
w
w
Rinne test
w
3.
.m
1.
4.
Weber test
ANS: 2
The BAER test calculates the ability to hear in a client who is unresponsive. The BAER
measures the sound impulse needed to evoke a brain response, which will indicate the clients
ability to hear. The other tests need the cooperation of the client and cannot be done at this time.
8.The nurse is planning to assess a client diagnosed with conductive hearing loss. When
performing the Weber test, the nurse would expect which of the following findings?
The sound will be louder in the affected ear.
2.
The sound will be louder in the good ear.
3.
Air conduction is shorter than bone conduction.
4.
No sounds will be heard.
.c
om
1.
ep
ANS: 1
st
pr
During a Weber test, which tests bone conduction, a client with a conductive hearing loss hears
louder sounds on the affected side. Hearing louder sounds on the unaffected side is sensorineural
loss. The Rinne test compares bone with air conduction. The client will hear sounds louder in the
affected ear.
ng
te
9.The nurse is performing postoperative teaching with a client recovering from a stapedectomy.
Which of the following instructions would the nurse want to include in the teaching?
It is okay to resume exercise the next day.
2.
It is okay to resume work the same day.
3.
It is okay to shower and shampoo the next day.
4.
It is okay to blow the nose gently one side at a time.
yn
.m
w
w
w
ANS: 4
ur
si
1.
Care must be taken not to disturb the ossicles from their position, so exercise and work should
not be resumed until healing is complete. It is also important to keep the ear dry. The client
should be taught to blow the nose gently on one side at a time so as not to increase the pressure
in the ear.
10.After a mastoidectomy, the most important complication for the nurse to assess for is:
1.
vomiting.
2.
headache.
3.
fever.
4.
stiff neck.
ANS: 3
.c
om
All are complications that can occur following this type of surgery. Fever is of extra importance
because of its possible link to infection. The mastoid bone is in direct contact with the brain, and
therefore any infection can travel to the brain.
ep
11.When instructing a client on cleaning the ear, the nurse should instruct the client to clean:
only the outer ear.
2.
all the way to the middle ear.
3.
all parts of the ear outer, middle, and inner ear.
4.
just the tympanic membrane.
ur
si
ng
te
st
pr
1.
yn
ANS: 1
.m
Only the outer portion of the ear should be cleaned. Inserting different objects into the ear canal
may result in injury and damage.
Fears sounds will be too loud
w
1.
w
w
12.Which of the following would prohibit an elderly client from wanting to obtain and use a
hearing aid?
2.
Thinks not necessary for a temporary problem
3.
Fears the cost
4.
Prefers silence
ANS: 3
Some of the problems encountered by clients obtaining hearing aids include appearance, cost,
education, unrealistic expectations, and difficulty with the care and maintenance of the hearing
aids. The other choices are not problems encountered by clients obtaining hearing aids.
13.Which of the following should the nurse instruct a client who is being fitted for a hearing aid?
Keep the appliance turned on at all times.
2.
Store the hearing aid in a warm, moist place.
3.
Batteries last for at least 1 month.
4.
Clean ear molds at least once a week.
ep
.c
om
1.
pr
ANS: 4
st
The nurse should instruct the client to turn off the appliance when not in use; store in a cool, dry
place; change the batteries at least once per week; and clean ear molds at least once per week.
te
MULTIPLE RESPONSE
si
ng
14.The nurse is instructing a client diagnosed with otitis media on management during the acute
phase. Which of the following should the nurse include in the teaching? (Select all that apply.)
Take the antibiotics as ordered.
2.
Take over-the-counter analgesics for mild pain as recommended.
3.
It is okay to go swimming.
4.
It is okay to go on vacation and trips that require flying.
w
w
w
.m
yn
ur
1.
5.
If excruciating pain develops, seek medical care.
6.
Limit fluids.
ANS: 1, 2, 5
Clients must complete the medication as ordered to kill the infection. Mild analgesics for pain
are often needed. If excruciating ear pain develops, the client should seek medical care to rule
out perforation of the eardrum. It is important to keep the ear dry, so the client should not swim
at this time. Flying is not recommended at this time. Limiting fluids is not necessary with otitis
media.
15.When caring for a client with total hearing loss, the nurse is instructing the client about the
many options that are available to function in a hearing world. Which of the following should the
nurse include? (Select all that apply.)
Flashing lights for alarms
2.
TV with closed captions
3.
Talking computer
4.
Lip reading and sign language
5.
Cell phones with headsets
6.
Loud ringers on telephones
ng
te
st
pr
ep
.c
om
1.
ANS: 1, 2, 4
w
.m
yn
ur
si
Patients who have no hearing have access to various mechanisms to alert them to various sounds.
Flashing lights for alarms to phones and doorbells, TV with closed captions for the hearing
impaired, and classes in lip reading and sign language are some options. Talking computers and
cell phones with headsets are advancements for the hearing, not for the hearing impaired. Loud
ringers on telephones would also be helpful to the client with some hearing and not a total
hearing loss.
w
w
16.A client is diagnosed with a congenital hearing loss. Which causes does the nurse realize are
reasons for this type of hearing loss? (Select all that apply.)
1.
Genetics
2.
Natal infections
3.
Physical deformities
4.
Noise levels
5.
Maternal ototoxic drugs
6.
Maternal TORCH infections
ANS: 1, 2, 3, 5, 6
om
Congenital hearing loss can be derived from genetics, natal infections, or physical deformities of
the ear in addition to maternal ototoxic drug use and maternal TORCH infections that include
toxoplasmosis, rubella, cytomegalovirus, and herpes virus type 2. Noise levels do not cause a
congenital hearing loss.
Turn down radio and television volume.
2.
Avoid noisy areas such as rock concerts.
3.
Wear protective devices.
4.
Use plain cotton balls in the ears.
5.
Avoid sun exposure.
6.
Flush the ears daily with mineral oil.
w
w
ANS: 1, 2, 3
.m
yn
ur
si
ng
te
st
pr
1.
ep
.c
17.A client with a family history of hearing loss asks the nurse what he can do to prevent this
disorder as he ages. Which of the following should the nurse instruct this client? (Select all that
apply.)
w
Measures to prevent hearing loss include turning down the volume on the radio and television,
avoiding noisy areas such as rock concerts, and wearing protective devices. Using cotton balls in
the ears does not decrease noise from reaching the middle ear. Sun exposure does not impact
hearing. Flushing the ears daily with mineral oil might decrease the buildup of cerumen;
however, it will not improve hearing.
18.Which of the following are indications that a client has been exposed to excessive noise?
(Select all that apply.)
1.
Raising the voice to talk in normal conversation
Clear drainage from the ears
3.
Inability to hear a conversation 2 feet away
4.
Sounds are muffled
5.
Ringing of the ears
6.
Short periods of pain in the ears
.c
om
2.
ep
ANS: 1, 3, 4, 5, 6
st
pr
Warning signs of excessive noise exposure include raising the voice to talk in normal
conversation, inability to hear a conversation 2 feet away, muffled sounds, ear ringing, and short
periods of ear pain. Clear drainage from the ears does not occur with excessive noise exposure.
te
MULTIPLE CHOICE
ng
19.A child is diagnosed with severe allergic rhinitis. Which of the following manifestations
would the nurse most likely assess in this client?
Edematous neck glands
2.
Reduced hearing
3.
Pruritis
4.
Frequent wiping of the nose with the palm of the hand
ur
yn
.m
w
w
w
ANS: 4
si
1.
Frequent wiping of the nose with the palm of the hand is one symptom seen in the client
diagnosed with severe allergic rhinitis. Edematous neck glands, reduced hearing, and pruritis are
not manifestations of severe allergic rhinitis.
20.A client tells the nurse that she experiences a stuffy nose, nasal pain, and postnasal drip every
time she works in her companys office. Which of the following types of allergic rhinitis is this
client most likely experiencing?
1.
Infectious
2.
Perennial
3.
Occupational
4.
Seasonal
ANS: 3
.c
om
Occupational allergic rhinitis occurs from airborne substances in the workplace. Seasonal
allergic rhinitis occurs during a specific time of the year. Perennial allergic rhinitis occurs in
response to exposure to environmental allergens that can occur throughout the year. Infectious
rhinitis is a nonallergic type of rhinitis.
pr
ep
21.A client asks the nurse if there is an antihistamine that does not cause drowsiness. Which of
the following medications would this client most likely prefer to treat allergic rhinitis?
Diphenhydramine
2.
Chlorpheniramine maleate
3.
Clemastine
4.
Fexofenadine
yn
ur
si
ng
te
st
1.
.m
ANS: 4
w
w
w
Fexofenadine (Allegra) is a second-generation antihistamine, and second-generation
antihistamines exhibit less sedation than first-generation medications such as diphenhydramine,
chlorpheniramine maleate, and clemastine.
22.A client diagnosed with hypertension is experiencing allergic rhinitis. The nurse realizes that
the medication that would not be indicated for this client would be:
1.
loratadine.
2.
montelukast.
3.
pseudoephedrine.
4.
zafirlukast.
ANS: 3
Pseudoephedrine can be contraindicated for the patient with hypertension. Loratadine,
montelukast, and zafirlukast should be used cautiously for patients with hepatic impairment.
ciprofloxacin.
4.
erythromycin.
.c
3.
ep
cefuroxime.
pr
2.
st
amoxicillin.
te
1.
om
23.A 16-year-old client is being prescribed a medication to treat acute sinusitis. The nurse
realizes that this client should not be prescribed:
ANS: 3
si
ng
Quinolones such as ciprofloxacin (Cipro) and levofloxacin (Levaquin) are contraindicated in
children younger than 17 years of age.
yn
ur
24.The nurse is caring for a client diagnosed with acute sinusitis. Which of the following
symptoms is the client most likely experiencing?
Anosmia
.m
1.
w
w
3.
w
2.
4.
Fever
Halitosis
Metallic taste
ANS: 1
Clients often complain of unilateral face pain, purulent nasal discharge, pain during mastication,
anosmia (absence of smell), and headache. Less common symptoms include fever, nasal
congestion, halitosis, toothache, metallic taste, and cough.
25.The nurse is planning care for the client diagnosed with viral rhinitis. Which of the following
would be the best goal of care for this client?
Prevent secondary bacterial infection.
2.
Prevent rhinitis medicamentosa.
3.
Refrain from use of analgesics.
4.
Encourage complete participation in activities.
om
1.
ANS: 1
pr
ep
.c
Treatment of acute rhinitis, or the common cold, is aimed at decreasing the impact of the
symptoms and preventing secondary bacterial infection. Rhinitis medicamentosa occurs from
misuse of nasal decongestants. Acetaminophen or a nonsteroidal anti-inflammatory agent is
useful for fever, aches, and pain. Rest is encouraged.
Difficulty swallowing
2.
Difficulty talking
3.
Excessive swallowing
4.
ur
si
ng
1.
yn
te
st
26.The nurse is instructing the mother of a client recovering from a tonsillectomy. Which of the
following should the nurse instruct the mother to report?
.m
Pain
w
ANS: 3
w
w
Excessive swallowing is a sign of bleeding and should be reported. Pain and difficulty talking
and swallowing are expected.
27.Which of the following should the nurse instruct a client recovering from a tonsillectomy?
1.
Drink milk to promote healing.
2.
Gargle with salt water.
3.
Maintain good hydration.
4.
Use a straw to drink.
ANS: 3
Drinking milk does not promote healing and may encourage production of mucus. Gargling and
drinking with a straw may disrupt the clot at the operative site and cause bleeding. Maintaining
good hydration and eating soft foods are encouraged.
om
28.A client is experiencing epistaxis. Which of the following interventions would the nurse
complete?
Call the doctor.
2.
Check laboratory test results.
3.
Obtain an emesis basin.
4.
Show the patient how to pinch the nose.
te
st
pr
ep
.c
1.
ng
ANS: 4
yn
ur
si
The initial intervention for a client with epistaxis is to show the client how to lean forward and
pinch the nose against the nasal septum for about 5 to 10 minutes continuously. The other
interventions are not necessary at this time.
Hemilaryngectomy
w
w
1.
w
.m
29.A client has been diagnosed with stage IV cancer of the larynx. The nurse realizes that which
of the following surgeries is recommended for this type of cancer?
2.
Partial laryngectomy
3.
Supraglottic laryngectomy
4.
Total laryngectomy
ANS: 4
In clients diagnosed with invasive or infiltrating tumors such as those of stage III or stage IV, the
entire larynx is removed. The other surgeries only remove portions of the larynx and would be
appropriate for lesser stages of the disease.
30.A client is recovering from a total laryngectomy with the placement of a tracheostomy. The
nurse should include which of the following instructions to this client?
Clean the tracheostomy tube with soap and water daily.
2.
Limit protein in the diet.
3.
Restrict fluids.
4.
The nasogastric tube will be in for 2 weeks.
pr
ep
.c
om
1.
ANS: 4
ng
te
st
Clients recovering from a laryngectomy are unable to take nutrition orally for about 10 to 14
days. During this time the client will receive nutrition via intravenous fluids, enteral feedings
through a nasogastric tube, or parenteral nutrition. Protein and fluids are not limited. The
tracheostomy tube is not cleaned with soap and water.
yn
ur
si
31.A client diagnosed with viral rhinitis tells the nurse that she has been using a decongestant
nasal spray for several weeks and the symptoms are getting worse. Which of the following does
the nurse suspect is occurring with this client?
Developing pneumonia
.m
1.
w
w
3.
Subacute rhinitis
w
2.
4.
Rhinitis medicamentosa
Chronic otitis media
ANS: 3
Rhinitis medicamentosa can occur with overuse of decongestant nasal sprays, and it leads to
rebound nasal congestion that is often worse that the original nasal congestion. The use of nasal
sprays does not cause pneumonia, subacute rhinitis, or chronic otitis media.
MULTIPLE RESPONSE
32.The nurse is teaching a client how to use a nasal spray. Which of the following should be
included in these instructions? (Select all that apply.)
Blow the nose before instilling the spray.
2.
Tilt the head back and angle the tip of the bottle to the side of the nostril.
3.
Use a finger to occlude the nostril that is not receiving the spray.
4.
Inhale gently and evenly while discharging the spray into the nostril.
5.
If a second spray is recommended, immediately repeat the procedure.
6.
Blow the nose after administration of the spray.
st
pr
ep
.c
om
1.
te
ANS: 1, 3, 4
ur
si
ng
For the steps to be correct, the head should be slightly forward, the second spray should be given
15 to 20 seconds after the spray, and the client should not blow the nose after the administration
of the spray. The client should be instructed to blow the nose before instilling the spray, to use a
finger to occlude the nostril that is not receiving the spray, and to gently inhale while the spray is
being delivered into the nostril.
yn
33.A client has been diagnosed with allergic rhinitis. Which of the following should the nurse
instruct the client regarding strategies to avoid this disorder? (Select all that apply.)
w
w
3.
Reduce the use of an air conditioner
w
2.
Remove home carpeting
.m
1.
Remove pets from the home
4.
Open windows in the spring and summer
5.
Use feather pillows
6.
Wash bed linens in cold water
ANS: 1, 3
Strategies to reduce the symptoms of allergic rhinitis include removing home carpeting and
removing pets from the home. The client should be instructed to use an air conditioner, keep
windows closed during allergy season, avoid feather pillows, and wash bed linens in hot water.
34.A client is demonstrating signs of chronic sinusitis. Which of the following will the nurse
most likely assess in this client? (Select all that apply.)
Facial pain
2.
Fever
3.
Headache
4.
Toothache
5.
Fatigue
6.
Swollen neck glands
ng
te
st
pr
ep
.c
om
1.
si
ANS: 1, 3, 4, 5
yn
ur
Manifestations of chronic sinusitis include facial pain, headache, toothache, and fatigue. Fever
and swollen neck glands would indicate the disorder has spread beyond the sinuses.
w
w
2.
Gargle with warm salt water.
w
1.
.m
35.With which of the following can the nurse instruct a client who is experiencing pain from a
sore throat? (Select all that apply.)
Eat salty foods.
3.
Suck on hard candy.
4.
Drink fluids.
5.
Avoid citrus fruits.
6.
Suck on popsicles.
ANS: 1, 3, 4, 6
Interventions to reduce the pain from a sore throat include gargling with warm salt water,
sucking on throat lozenges or hard candy, sucking on flavored frozen desserts or popsicles, using
a humidifier in the bedroom, and drinking fluids. The client should not be instructed to eat salty
foods or avoid citrus fruits.
om
36.A client is demonstrating signs of peritonsillar abscess. Which of the following will the nurse
most likely assess in this client? (Select all that apply.)
Bradypnea
2.
Drop in blood pressure
3.
Hot potato voice
4.
Trismus
5.
Dysphagia
6.
Sore throat
yn
ur
si
ng
te
st
pr
ep
.c
1.
w
.m
ANS: 3, 4, 5, 6Assessment findings consistent with peritonsillar abscess include: hot potato
voice; trismus, or difficulty fully opening the mouth; dysphagia, or painful swallowing; and sore
throat. Bradypnea and drop in blood pressure are not assessment findings consistent with
peritonsillar abscess.
w
w
Chapter 4 Endocrine Disorders
MULTIPLE CHOICE
1.The nurse explains that the negative feedback system controls hormone release by
communication between:
a.
the pituitary and the target organ.
b.
the thymus and the blood stream.
c.
lymphatic system and the target organ.
d.
central nervous system and the blood stream.
ANS: A
The amount of hormone released is controlled by a negative feedback system. When the level of
the particular hormone is appropriate, the target organ signals the pituitary to stop the stimulation
of the target organ.
Fasting blood sugar (FBS)
b.
Oral glucose tolerance test (OGT)
c.
Glycosylated hemoglobin (HbA1c)
d.
Postprandial glucose test (PPBG)
.c
a.
om
2.Which diagnostic test for diabetes mellitus provides a measure of glucose levels for the
previous 8 to 12 weeks?
ep
ANS: C
st
pr
Glycosylated hemoglobin (HbA1c)This blood test measures the amount of glucose that has
become incorporated into the hemoglobin within an erythrocyte. Because glycosylation occurs
constantly during the 120-day life span of the erythrocyte, this test reveals the effectiveness of
diabetes therapy for the preceding 8 to 12 weeks.
ng
te
3.Which test will furnish immediate feedback for a newly diagnosed diabetic who is not yet
under control?
Fasting blood sugar (FBS)
b.
Glycosylated hemoglobin (HgbA1c)
c.
Oral glucose tolerance test (OGTT)
d.
Clinitest
yn
ur
si
a.
.m
ANS: A
w
w
Diabetics should do a fingerstick blood glucose level test before each meal and at bedtime each
day until their disease is under control. The HgbA1c serum test reveals the effectiveness of
diabetes therapy for the preceding 8 to 12 weeks.
w
4.To which diet should a patient with Cushing syndrome adhere?
a.
Less sodium
b.
More calories
c.
Less potassium
d.
More carbohydrates
ANS: A
The diet should be lower in sodium to help decrease edema.
5.The patient is a 20-year-old college student who has type 1 diabetes and normally walks each
evening as part of an exercise regimen. The patient plans to enroll in a swimming class. Which
adjustment should be made based on this information?
Time the morning insulin injection so that the peak action will occur during swimming class.
b.
Delete normal walks on swimming class days.
c.
Delay the meal before the swimming class until the session is over.
d.
Monitor glucose level before, during, and after swimming to determine the need for alterations
in food or insulin.
om
a.
ANS: D
Renal failure
c.
Hypothyroidism
d.
Hyperglycemia
st
b.
te
Diverticulitis
ng
a.
pr
6.What is a long-term complication of diabetes mellitus?
ep
.c
Exercise can reduce insulin resistance and increase glucose uptake for as long as 72 hours, as
well as reducing blood pressure and lipid levels. However, exercise can carry some risks for
patients with diabetes, including hypoglycemia.
si
ANS: B
yn
ur
Long-term complications of diabetes include blindness, cardiovascular problems, and renal
failure.
w
c.
w
b.
severe nausea and vomiting.
w
a.
.m
7.A patient has returned to his room after a thyroidectomy with signs of thyroid crisis. During
thyroid crisis, exaggerated hyperthyroid manifestations may lead to the development of the
potentially lethal complication of:
d.
bradycardia.
delirium with restlessness.
congestive heart failure.
ANS: D
In thyroid crisis, all the signs and symptoms of hyperthyroidism are exaggerated. The patient
may develop congestive heart failure and die.
8.In diabetes insipidus, a deficiency of which hormone causes clinical manifestations?
a.
antidiuretic hormone (ADH)
b.
follicle-stimulating hormone (FSH)
c.
thyroid-stimulating hormone (TSH)
d.
adrenocorticotropic hormone (ACTH)
ANS: A
Diabetes insipidus is a transient or permanent metabolic disorder of the posterior pituitary in
which ADH is deficient.
om
9.What is an appropriate nursing diagnosis for a patient who has recently been diagnosed with
acromegaly?
Ineffective coping
b.
Activity intolerance
c.
Risk for trauma
d.
Chronic low self-esteem
pr
ep
.c
a.
st
ANS: C
te
Nursing interventions are mainly supportive. The presence of muscle weakness, joint pain, or
stiffness warrants assessment of the ability to perform activities of daily living (ADLs).
ng
10.The purpose of the use of radioactive iodine in the treatment of hyperthyroidism is to:
stimulate the thyroid gland.
b.
depress the pituitary.
c.
destroy some of the thyroid tissue.
d.
alter the stimulus from the pituitary.
yn
ur
si
a.
.m
ANS: C
w
w
Radioactive iodine 131 destroys some of the hyperactive thyroid gland to produce a more
normally functioning gland.
w
11.Which precaution(s) should the nurse take when caring for a patient who is being treated with
radioactive iodine 131 (RAIU)?
a.
Initiate radioactive safety precautions
b.
Avoid assigning any young woman to the patient
c.
Wait three days after dose before assigning a pregnant nurse to care for this patient
d.
Advise visitors to sit at least 10 feet away from the patient
ANS: C
The dose is patient specific and at a very low level. No radioactive safety precautions are
necessary and pregnant nurses can be assigned 3 days after the dose. RAIU is not harmful to
nonpregnant women.
12.Why would a patient with hyperthyroidism be prescribed the drug methimazole (Tapa-zole)?
To limit the effect of the pituitary on the thyroid
b.
To destroy part of the hyperactive thyroid tissue
c.
To stimulate the pineal gland
d.
To block the production of thyroid hormones
om
a.
ANS: D
ep
.c
Medical management for hyperthyroidism may include administration of drugs that block the
production of thyroid hormones, such as propylthiouracil or methimazole.
Semi-Fowler
c.
Side-lying
d.
Supine
si
ANS: B
st
b.
te
Prone
ng
a.
pr
13.What is the postoperative position for a person who has had a thyroidectomy?
yn
ur
Postoperative management of this patient includes keeping the bed in a semi-Fowler position,
with pillows supporting the head and shoulders. There should be a suction apparatus and
tracheotomy tray available for emergency use.
.m
14.What extra equipment should the nurse provide at the bedside of a new postoperative
thyroidectomy patient?
w
c.
Tracheotomy tray
w
b.
Large bandage scissors
w
a.
d.
Ventilator
Water-sealed drainage system
ANS: B
There should be a suction apparatus and tracheotomy tray available for emergency use.
15.As the nurse is shaving a patient who is 2 days postoperative from a thyroidectomy, the
patient has a spasm of the facial muscles. What should the nurse recognize this as?
a.
Chvostek sign
b.
Montgomery sign
c.
Trousseau sign
d.
Homans sign
ANS: A
The spasm of facial muscles when stimulated is the Chvostek sign, an indication of
hypocalcemic tetany.
b.
60
c.
15
d.
45
.c
30
ep
a.
om
16.The human insulin whose onset of action occurs within ____ minutes is lispro (Humalog).
ANS: C
te
st
pr
Humalog begins to take effect in less than half the time of regular, fast-acting insulin. The new
formula can be injected 15 minutes before a meal.
ng
17.What should the nurse caution a type I diabetic about excessive exercise?
It can increase the need for insulin and may result in hyperglycemia.
b.
It can decrease the need for insulin and may result in hypoglycemia.
c.
It can increase muscle bulk and may result in malabsorption of insulin.
d.
It can decrease metabolic demand and may result in metabolic acidosis.
yn
ur
si
a.
.m
ANS: B
w
w
The patient with diabetes should exercise regularly. Exercise can reduce insulin resistance and
increase glucose uptake for as long as 72 hours, as well as reducing blood pressure and lipid
levels. However, exercise can carry some risks for patients with diabetes, including
hypoglycemia.
w
18.What do the Chvostek sign and the Trousseau sign indicate?
a.
Low levels of serum calcium
b.
High levels of blood sugar
c.
Low levels of serum sodium
d.
High levels of serum aldosterone
ANS: A
Low levels of blood calcium may cause the Chvostek sign and Trousseau sign.
19.A patient has undergone tests that indicate a deficiency of the parathyroid hormone secretion.
She should be informed of which potential complication?
a.
Osteoporosis
b.
Lethargy
c.
Laryngeal spasms
d.
Kidney stones
ANS: C
.c
om
Decreased parathyroid hormone levels in the blood stream cause a decreased calcium level.
Severe hypocalcemia may result in laryngeal spasm, stridor, cyanosis, and increased possibility
of asphyxia.
b.
encouraging physical exercise.
c.
protecting patient from injury.
d.
discouraging daytime naps.
pr
limiting fluids to 1500 mL a day.
ng
te
st
a.
ep
20.The nurse caring for a 75-year-old man who has developed diabetes insipidus following a
head injury will include in the plan of care provisions for:
ANS: C
yn
ur
si
The patients need protection from injury because they are often exhausted from sleep deprivation
and having to get up frequently at night. Fluids should not be limited and their energy should be
preserved.
w
c.
w
b.
To improve nutrition
d.
To improve carbohydrate metabolism
w
a.
.m
21.The physician orders an 1800-calorie diabetic diet and 40 units of (Humulin N) insulin U-100
subcutaneously daily for a patient with diabetes mellitus. Why would a mid-afternoon snack of
milk and crackers be given?
To prevent an insulin reaction
To prevent diabetic coma
ANS: C
Humulin N insulin starts to peak in 4 hours. The nurse should be alert for signs of hypoglycemia
(a less-than-normal amount of glucose in the blood, usually caused by administration of too
much insulin, excessive secretion of insulin by the islet cells of the pancreas, or dietary
deficiency) at the peak of action of whatever type of insulin the patient is taking.
22.The nurse teaching a patient with type 1 diabetes mellitus (IDDM) about early signs of
insulin reaction would include information about:
a.
abdominal pain and nausea.
b.
dyspnea and pallor.
c.
flushing of the skin and headache.
d.
hunger and a trembling sensation.
ANS: D
om
The patient should be instructed to notify a member of the nursing staff if any signs of
hypoglycemic (low insulin) reaction occur: excessive perspiration or trembling.
.c
23.The nurse discovers the type 1 diabetic (IDDM) patient drowsy and tremulous, the skin is
cool and moist, and the respirations are 32 and shallow. These are signs of:
hypoglycemic reaction; give 6 oz of orange juice.
b.
hyperglycemic reaction; give ordered regular insulin.
c.
hyperglycemic hyperosmolar nonketotic reaction; squeeze glucagon gel in buccal cavity.
d.
hypoglycemic reaction; give ordered insulin.
te
st
pr
ep
a.
ANS: A
ur
si
ng
Hypoglycemic reaction is due to not enough food for the insulin. Quick acting carbohydratessuch
as orange juice or longer acting foods such as milk, crackers, and cheeseare beneficial.
yn
24.A patient has come to the clinic because of enlarged hands and feet, amenorrhea, and
increased hair growth. These symptoms most likely indicate problems with the:
pituitary gland.
.m
a.
thyroid gland.
pancreas.
w
d.
w
c.
adrenal glands.
w
b.
ANS: A
The pituitary gland may produce an overabundance of growth hormone. This overproduction of
hormones may cause changes throughout the patients body, including enlargement of the
pituitary gland and hands and feet. Female patients may develop a deepened voice, increased
facial hair growth, and amenorrhea.
25.What instructions should a nurse give to a diabetic patient to prevent injury to the feet?
a.
Soak feet in warm water every day.
b.
Avoid going barefoot and always wear shoes with soles.
c.
Use of commercial keratolytic agents to remove corns and calluses are preferred to cutting off
corns and calluses.
d.
Use a heating pad to warm feet when they feel cool to the touch.
ANS: B
Sturdy, properly fitting shoes should be worn. Use of corn removers and heating pads is not
beneficial to preserve the health of a diabetics feet.
om
26.The physician prescribes glyburide (Micronase, DiaBeta, Glynase) for a patient, age 57, when
diet and exercise have not been able to control type 2 diabetes. What should the nurse include in
the teaching plan about this medication?
It is a substitute for insulin and acts by directly stimulating glucose uptake into the cell.
b.
It does not cause the hypoglycemic reactions that may occur with insulin use.
c.
It is thought to stimulate insulin production and increase sensitivity to insulin at receptor sites.
d.
It lowers blood sugar by inhibiting glucagon release from the liver, preventing
gluconeogenesis.
st
pr
ep
.c
a.
te
ANS: C
ng
Oral hypoglycemics are compounds that stimulate the beta cells in the pancreas to increase
insulin release.
ur
si
27.A 27-year-old patient with hypothyroidism is referred to the dietitian for dietary consultation.
What should nutritional interventions include?
Frequent small meals high in carbohydrates
b.
Calorie-restricted meals
c.
Caffeine-rich beverages
d.
Fluid restrictions
.m
w
w
ANS: B
yn
a.
w
A high-protein, high-fiber, lower calorie diet is given.
28.What instructions should be included in the discharge instructions for a 47-year-old patient
with hypothyroidism?
a.
Taking medication whenever symptoms cause discomfort
b.
Decreasing fluid and fiber intake
c.
Consuming foods rich in iron
d.
Seeing the physician regularly for follow-up care
ANS: D Regular checkups are essential, because drug dosage may have to be adjusted from time
to time.
29.How should the nurse administer insulin to prevent lipohypertrophy?
a.
At room temperature
b.
At body temperature
c.
Straight from the refrigerator
d.
After rolling bottle between hands to warm
om
ANS: A In fact, it is now believed that insulin should be administered at room temperature, not
straight from the refrigerator, to help prevent insulin lipohypertrophy.
b.
Hypertensive crisis
c.
Thyroid storm
d.
Cushing crisis
pr
Pulmonary embolism
ng
te
st
a.
ep
.c
30.A patient with a history of Graves disease is admitted to the unit with shortness of breath. The
nurse notes the patients vital signs: T 103 F, P 160, R 24, BP 160/80. The nurse also notes
distended neck veins. What does the patient most likely have?
ur
si
ANS: C In a thyroid crisis, all the signs and symptoms of hyperthyroidism are exaggerated.
Additionally, the patient may develop nausea, vomiting, severe tachycardia, severe hypertension,
and occasionally hyperthermia up to 41 C (106 F). Extreme restlessness, cardiac arrhythmia, and
delirium may also occur. The patient may develop heart failure and may die.
yn
31.What is the master gland of the endocrine system?
Thyroid
.m
a.
d.
w
c.
w
b.
Parathyroid
Pancreas
Pituitary
w
ANS: D The pituitary gland, located in the brain, is the master gland of the endocrine system. It
has been called the master gland because through the negative feedback system, it exerts its
control over the other endocrine glands.
32.What information should be obtained from the patient before an iodine-131 test?
a.
Presence of metal in the body
b.
Allergy to sulfa drugs
c.
Status of possible pregnancy
d.
Use of prescription drugs for hypertension
ANS: C Iodine-131 is not a radiation hazard to the nonpregnant patient but is absolutely
contraindicated during pregnancy. Pregnant nurses should not care for this patient for several
days.
a.
Eggs
b.
Pork
c.
White bread
d.
Skinless chicken
om
33.The patient being treated for hypothyroidism should be instructed to eat well-balanced meals
including intake of iodine. Which of the following foods contains iodine?
.c
ANS: A
ep
The hypothyroid diet should be adequate in intake of iodine, in foods such as saltwater fish,
milk, and eggs; fluids should be increased to help prevent constipation.
st
pr
34.The nurse is caring for a patient who is receiving calcium gluconate for treatment of
hypoparathyroid tetany. Which assessment would indicate an adverse reaction to the drug?
Increase in heart rate
b.
Flushing of face and neck
c.
Drop in blood pressure
d.
Urticaria
si
ng
te
a.
yn
ur
ANS: C Indications of an adverse effect of calcium gluconate are dyspnea, bradycardia, and
hypotension.
.m
35.The nurse cautions the patient who is being instructed on self-medication with insulin to be
aware that there are 25-, 30-, 50-, and 100-unit syringes. How is the 100-unit syringe marked?
c.
w
d.
w
b.
1-unit increments
w
a.
2-unitt increments
4-unit increments
5-unit increments
ANS: B The 100-unit syringe is marked in 2-unit increments while the smaller syringes are
marked in 1-unit increments.
om
.c
ep
pr
st
te
ng
si
ur
yn
.m
w
w
w
Chapter 5 Gastrointestinal Disorders
MULTIPLE CHOICE
1.The nurse clarifies that the end product of carbohydrate metabolism is absorbed and put into
the blood stream by the:
a.
gastric lining of the stomach.
b.
villi of the small intestine.
c.
bile of the liver in the large intestine.
d.
excretion from the cecum.
ANS: B
The inner surface of the small intestine contains millions of tiny, fingerlike projections called
villi, which contain small blood vessels. They are responsible for absorbing the products of
digestion.
Chest pain
b.
Seizure
c.
Tachycardia
d.
Massive diarrhea
.c
a.
om
2.A 56 -year-old man is admitted to the emergency room with an acute attack of diverticulitis.
The patient has a temperature of 102 F, and has an elevated white count. Which assessment
would alert the nurse to impending septic shock?
ep
ANS: C
st
pr
The patient with diverticulitis who has fever and an elevated white count has an infection that
could lead to septic shock, which will present as tachycardia and hypotension.
te
3.Because bowel contents from an ileostomy are virtually liquid, what should the nurse include
in the plan of care?
Evaluation and assessment of dietary intake of fiber
b.
Evaluation and assessment of patient cleanliness
c.
Evaluation and assessment of periostomal skin integrity
d.
Evaluation and assessment of the adequacy of the collection device
yn
ur
si
ng
a.
ANS: C
.m
The nurse should assess the periostomal skin for impairment of integrity. The fecal material is
liquid and has a potential for severe skin excoriation from the digestive enzymes.
w
a.
w
w
4.The home health nurse caring for a patient who has dysarthria related to radiation therapy for
an oral cancer would recommend that the family provide:
a tablet and pencil as a communication aid.
b.
a TV for diversion.
c.
a bell to summon help.
d.
a walkie-talkie.
ANS: A
The provision of an alternative method of communicating will lessen the frustration of the
patient who has trouble speaking understandably. The call bell would be helpful also, but without
a way to communicate, the bell is not as essential as a method of communication.
5.Which recommendation is most appropriate for a patient who has had an esophageal dilation
related to achalasia?
a.
Consume only liquid
b.
Avoid fruit juices
c.
Drink 10 oz of fluid with each meal
d.
Lie down for 30 minutes after each meal
ANS: C
om
The patient should drink fluid with each meal to increase lower esophageal pressure to push food
into the stomach.
c.
Achalasia
d.
Peptic ulcer
pr
Gastritis
st
b.
te
Duodenal ulcer
ng
a.
ep
.c
6.A patient who is being evaluated for episodes of hematemesis and dyspepsia tells the nurse that
pain occurs when he eats, but pain does not waken him. The nurse recognizes a diagnostic sign
of which condition?
ANS: D
yn
ur
si
A significant subjective data assessment for a peptic ulcer is the patient report that pain is
associated with eating, but not with an empty stomach, because there would be pain with a
duodenal ulcer.
.m
7.The nurse anticipates that the patient who has had a subtotal gastrectomy will need
supplemental:
protein due to the loss of some of the digestive processes.
b.
vitamin B12 due to the loss of the intrinsic factor.
vitamin A due to the loss of the gastric lining.
w
d.
bulk to prevent constipation.
w
c.
w
a.
ANS: B
It is recommended that all patients with a gastrectomy have a blood serum vitamin B 12 level
measured every 1 to 2 years. Decreased absorption of vitamin B12 may cause pernicious anemia.
8.The home health nurse is caring for a patient who has frequent bouts of diverticulitis
accompanied by increased flatulence, diarrhea, and nausea. Which of the following is the most
appropriate suggestion to lessen these symptoms?
a.
Eat a diet high in fiber content
b.
Increase dietary fat intake
c.
Exercise to increase intra-abdominal pressure
d.
Take daily laxatives
ANS: A
The symptoms of diverticulitis can be reduced or prevented by eating a high-fiber diet, reduction
of meat and fats in the diet, and avoiding activities that increase intra-abdominal pressure.
Although laxatives might be prescribed sparingly, daily laxatives are not recommended.
Hiatal hernia
b.
Gastritis
c.
Perforation
d.
Bowel obstruction
st
pr
ep
a.
.c
om
9.The nurse caring for a patient with a peptic ulcer who has had a nasogastric tube inserted notes
bright blood in the tube; the patient complains of pain and has become hypotensive. Which
condition should the nurse recognize these as signs of?
te
ANS: C
si
ng
Perforation of the gastric wall causes pain, hypotension, and hematemesis. Immediate reporting
to the charge nurse/physician is essential as peritonitis, potentially lethal, is the result of a
perforation.
yn
ur
10.Dumping syndrome after a Billroth II procedure occurs when high-carbohydrate foods are
ingested over a period of less than 20 minutes. What would the nurse suggest to reduce the risk
of dumping syndrome?
Eating a high-carbohydrate diet
b.
Drinking 10 oz of fluids with meals
c.
Remaining upright for 2 hours after meals
w
w
ANS: D
Eating six small daily meals high in protein and fat
w
d.
.m
a.
Treatment for dumping syndrome includes eating six small meals daily that are high in protein
and fat, and low in carbohydrates. Fluids should be avoided during meals. If possible, the patient
should lie down for 1 hour after meals.
11.The patient has come to the PACU following an ileostomy for the treatment of ulcerative
colitis. The patient is conscious and has a nasogastric tube in place and a pouch over the stoma.
What should be the nurses initial action?
a.
Turn patient to right side
b.
Give patient ice chips to moisten mouth
c.
Attach NG tube to suction
d.
Irrigate NG tube
ANS: C
Initially, the NG tube should be attached to suction to decompress the stomach and prevent
nausea. Assessing the tube for the need of future irrigation will be part of the postoperative care.
om
12.The home health nurse evaluates a patient being treated for a peptic ulcer with Riopan
(antacid) and famotidine (histamine receptor blocker). Which statement made by the patient
indicates a need for further instruction?
I know famotidine will not interfere with my Coumadin.
b.
I take the Riopan at least 2 hours after any of my other drugs.
c.
Boy! That Riopan keeps my stomach happy!
d.
I take both those meds at the same time every morning.
pr
ep
.c
a.
st
ANS: D
ng
te
Antacids should not be taken with other drugs, because the absorption of the other drugs may be
affected.
si
13.What should a nurse do when obtaining a stool specimen to be examined for ova and
parasites?
Use an oil retention enema to facilitate collection
b.
Refrigerate the specimen immediately
c.
Obtain three different stool specimens on subsequent days
d.
Check the specimen for the presence of occult blood
yn
.m
w
ANS: C
ur
a.
w
w
Diagnosing a parasitic infection requires three different stool specimens on subsequent days. Use
only normal saline or tap water enemas to prevent alteration of results.
14.The nurse explains to the patient with Crohn disease that the tube feedings allow for:
a.
Rapid absorption in the upper GI tract
b.
Decompression of the stomach
c.
Reduction of diarrheic episodes
d.
A permanent nutritional support
ANS: A
The tube feedings allow for rapid absorption of the nutrients in the upper GI tract. The tube
feedings are not permanent and will be followed by oral intake of a low-residue, highprotein, high-calorie diet.
a.
Strangulated
b.
Hiatal
c.
Ventral
d.
Umbilical
om
15.A patient with a large inguinal hernia has abdominal distention and inguinal pain. The nurse
recognizes these as indicators of which type of hernia?
.c
ANS: A
pr
ep
The hernia is strangulated when the blood supply and intestinal flow are occluded, which results
in pain and distention.
te
st
16.A patient with a ruptured diverticulum in the descending colon has undergone a transverse
loop colostomy. The patient is upset and says, I didnt know it was going to be this awful. I hate
this! Which response made by the nurse would be most helpful?
This is a temporary solution. It will be closed in 6 weeks.
b.
This seems awful now, but you wont have the problems you had before.
c.
If everything goes well the surgeon can close this colostomy in about a year.
d.
With the appropriate pouch and loose clothing, no one will notice a thing.
yn
ur
si
ng
a.
ANS: A
.m
The loop colostomy is a temporary colostomy that allows for complete bowel rest. It can be
closed in as short a time as 6 weeks.
Encourage him to express his concern
w
a.
w
w
17.A male patient complains that he will never adjust to his colostomy. Which is the best action
for the nurse in this situation?
b.
Suggest that he discuss his concerns with his physician
c.
Counsel him that everything will be all right
d.
Assure him that his concerns will diminish when he is able to care for his colostomy
ANS: A
When a colostomy is performed, the patient or significant other should be able to verbalize and
demonstrate understanding of ostomy care to the nurse.
18.In caring for a patient with gastric bleeding who has a nasogastric tube in place, the nurse
should include in the plan of care to ensure that the NG tube is:
a.
Clamped for 10 minutes every hour
b.
Kept patent with irrigation
c.
Frequently repositioned to the opposite nostril
d.
Changed every 72 hours
ANS: B
om
Irrigating the NG tube PRN will keep the tube patent and ensure effective decompression.
.c
19.What should the nurse include in a teaching plan for a patient with a hiatal hernia to reduce
the frequency of heartburn?
Drinking 10 oz of milk with every meal
b.
Lie down after eating
c.
Panting through mouth when symptoms begin
d.
Eating small meals
te
st
pr
ep
a.
ANS: D
si
ng
Taking care not to overeat is the best defense again pyrosis (heartburn) for the person with a
hiatal hernia.
ur
20.The nurse points out which of the following as an example of a nonmechanical bowel
obstruction?
A paralytic ileus
b.
Narrowed bowel lumen from an inflammatory process
c.
Tumor of the bowel
d.
Fecal impaction
.m
w
w
w
ANS: A
yn
a.
A nonmechanical bowel obstruction can be caused by a paralytic ileus.
21.Bowel sound assessment on a patient with an obstruction who has distention, nausea, and
visible peristaltic waves would be:
a.
loud and clearly audible.
b.
high pitched.
c.
hyperactive.
d.
absent.
ANS: B
Because there are visible peristaltic waves, there will be bowel sounds that will be faint and high
pitched.
b.
Dark green
c.
Red-orange
d.
Yellow
om
22.The patient with a peptic ulcer has been placed on regular doses of bismuth salicylate (PeptoBismol) to combat H. pylori. What color will this drug turn the stool?
a.
Gray-black
.c
ANS: A
ep
Bismuth products turn the stool gray-black.
pr
23.Which of the following should be included in the patient teaching of a patient with a peptic
ulcer?
Introducing irritating foods in minute amounts to desensitize the stomach
b.
Restricting fluid to 1000 mL per day
c.
Eating 6 small meals a day
d.
Drinking alcohol and caffeine in moderation
ng
te
st
a.
si
ANS: C
yn
ur
The patient with a peptic ulcer should eat frequently to keep food in the stomach. Eating 6 small
meals daily is helpful. Restriction of fluid is not necessary and irritating foods, alcohol, and
caffeine should be discouraged.
b.
w
c.
Application of ice bag
d.
Administration of small tap water enema
w
a.
w
.m
24.Which of the following would be the most helpful nursing intervention to increase the
comfort of a patient with appendicitis?
Warm compress over entire abdomen
Ambulate for short periods in the room
ANS: A
Application of an ice bag will decrease the flow of blood to the area and impede the
inflammatory process.
25.To assist a family with a bowel training program to reduce fecal incontinence, the nurse
would suggest the use of a ___________ at an optimal time to stimulate defecation.
a.
Warm bath
b.
A tap water enema
c.
Glycerin suppository
d.
Large glass of warm lemonade
ANS: C
om
The use of a glycerin suppository for fecal stimulation is a helpful aid in a bowel-training
program. The suppository is administered at what the family and patient have determined is the
optimal time for a bowel movement.
26.What is the most lethal complication of a peptic ulcer?
Bleeding
b.
Perforation
c.
Severe pain
d.
Gastric outlet obstruction
te
st
ANS: B
pr
ep
.c
a.
si
ng
Perforation is considered the most lethal complication of peptic ulcer. Bleeding may occur when
the ulcer erodes into a blood vessel; however, perforation occurs when the ulcer crater penetrates
the entire thickness of the wall of the stomach or duodenum. Gastric outlet obstruction can occur
at any time and can be relieved by NG aspiration of stomach contents.
yn
ur
27.The nurse takes into consideration that a proton pump inhibitor drug, such as
______________, will completely eradicate gastric acid production.
a.
omeprazole (Prilosec)
ranitidine (Zantac)
.m
b.
w
ANS: A
olsalazine (Dipentum)
w
d.
sucralfate (Carafate)
w
c.
Omeprazole (Prilosec) is a proton pump inhibitor that interferes with the production of gastric
acid.
28.Which of the following is the purpose of antibiotic therapy in treating peptic ulcers?
a.
It eradicates H. pylori
b.
It inhibits gastric acid secretion
c.
It protects the gastric mucosa
d.
It neutralizes or reduces the acidity of stomach contents
ANS: A
Antibiotic therapy eradicates H. pylori.
29.Why are peptic ulcers a common problem of aging?
Because of overuse of antibiotics
b.
Because of overuse of antacids
c.
Because of overuse of NSAIDs
d.
Because of overuse of laxatives
om
a.
ANS: C
ep
.c
Medications such as aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) taken for arthritis
or degenerative joint conditions may contribute to ulcer formation.
pr
30.The patient with irritable bowel syndrome tells the home health nurse she is going to an
acupuncturist for therapy for her condition. Which of the following would be the best
st
nursing response?
Go for it. Alternative medicine does great things.
b.
YIKES! An acupuncturist?
c.
It may help, but there has been no clinical proof of its effectiveness.
d.
You should confirm that the acupuncturist is licensed.
si
ng
te
a.
ur
ANS: C
yn
While it is true that some have found relief there is no evidence that these therapies relieve the
symptoms of IBS.
.m
MULTIPLE RESPONSE
w
b.
w
a.
w
31.Which of the following are indicators of colorectal cancer? (Select all that apply.)
Constant diarrhea
Excessive flatulence
c.
Cachexia
d.
Cramps
e.
Rectal bleeding
f.
Anemia
ANS: B, C, D, E, F
The indicators for colorectal cancer are changing bowel habits between diarrhea and
constipation, flatulence, cachexia, cramps, rectal bleeding, and anemia.
32.How should the nurse counsel the 34-year-old woman who has been prescribed sulfasalazine
(Azulfidine) for Crohn disease? (Select all that apply.)
a.
Expose her to sunlight at least 30 minutes a day for vitamin D synthesis
b.
Tell her to drink at least 1500 mL of fluid a day
c.
Advise assessing self for rash
d.
Use alternate birth control methods to oral contraception
e.
Take drug on an empty stomach
om
ANS: B, C, D
ep
.c
Cautionary information about sulfasalazine (Azulfidine) would include having adequate fluid
intake to prevent crystallization in the kidneys, avoiding exposure to the sun, and using alternate
birth control methods as oral contraception is made unreliable by this drug. The drug should be
taken with meals and the patient should be assessing for rash.
st
pr
33.In designing a teaching plan to present to a group of older adults regarding the prevention of
esophageal cancer, the nurse would include information about the significance of (select all that
apply):
cessation of smoking.
b.
good oral care.
c.
regular checkups if dysphagia is present.
d.
reducing excessive weight.
e.
limiting alcohol consumption.
f.
reduction of consumption of citrus fruits.
yn
ur
si
ng
te
a.
.m
ANS: A, B, C, E
w
w
Preventative measures include cessation of smoking and alcohol consumption, good oral care,
and medical evaluation of dysphagia. Weight and reduction of citrus fruits are non-contributory
to prevention of esophageal cancer.
w
34.Which activities should the home health nurse suggest to an elderly patient to avoid
constipation? (Select all that apply.)
a.
Increasing physical activity
b.
Taking bulk-forming laxatives
c.
Increasing fiber intake
d.
Drinking at least 1000 mL fluid
e.
Taking a daily stool softener
f.
Using tap water enemas for persons with altered mobility
ANS: A, B, C, D
Inactivity and changes in diet and fluid intake can contribute to constipation. A nutritional diet
high in fiber and bulk-forming foods can promote normal elimination. Increasing fluids to 8 to
10 glasses per day will be beneficial in preventing constipation. A daily bowel routine will also
benefit elimination. Use of daily stool softeners is no longer recommended for the older adult.
Tap water enemas for persons with altered mobility are is helpful.
om
35.The home health nurse is caring for a patient who has frequent abdominal pain and diarrhea.
The nurse uses the Rome Criteria to direct assessment for irritable bowel syndrome. What is
included in the Rome Criteria? (Select all that apply.)
Discomfort at least 3 days a month
b.
Blood in stool
c.
Pain relieved by defecation
d.
Excessive flatulence
e.
Nausea and vomiting associated with onset
f.
Onset associated with change in stool consistency or frequency
st
pr
ep
.c
a.
te
ANS: A, C, F
.m
yn
ur
si
ng
The Rome Criteria include that the patient experience discomfort at least 3 days a month within
the last 3 months, pain relieved by defecation, onset associated with change in stool frequency,
and onset in association with a change in stool appearance. Although increased flatus is
associated with diverticulitis, it is not part of the Rome Criteria.
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w
Chapter 6 Genetic Disorders
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MULTIPLE CHOICE
1.A client is found to be heterozygous for a normal gene and an abnormal gene. The nurse
realizes this client would be considered a(n):
1.
affected individual.
2.
carrier.
3.
genetically defective.
4.
mutated individual.
ANS: 2
om
A carrier is unaware of the presence of a mutated gene. An affected individual exhibits the
disease or condition. The client is not genetically defective nor mutated.
conception.
2.
birth.
3.
meiosis.
4.
mitosis.
ur
si
ng
te
st
pr
1.
ep
.c
2.A client is diagnosed with a chromosomal abnormality that occurred during cell division and
resulted in the formation of two cells, each with the same chromosome complement as the parent
cell. The nurse realizes that the abnormality occurred during:
yn
ANS: 4
w
.m
Mitosis is the cell division resulting in two cells each with the same chromosome complement of
the parent cell. Meiosis is the division of cells to produce four gametes containing the haploid
number of chromosomes. Cell division occurs after conception. Cell division occurs during the
formation of the embryo and fetus and is complete upon birth.
w
w
3.From genetic testing, a client is found to have the correct number of chromosomes within cells.
The nurse would document this finding as being:
1.
aneuploidy.
2.
diploid.
3.
euploidy.
4.
haploid.
ANS: 3
Euploidy refers to the correct number of chromosomes in a cell. Diploid refers to two complete
sets of chromosomes. Haploid refers to having one complete set of chromosomes. Aneuploidy
refers to a condition in which the numerical deviation is not an exact multiple of the haploid
number and is the most common chromosomal abnormality to affect humans.
3.
Marfan syndrome.
4.
Patau syndrome.
.c
Edward syndrome.
ep
2.
pr
Down syndrome.
st
1.
om
4.From genetic testing, a fetus is determined to have genetic trisomy. The nurse realizes that the
most common trisomy condition is:
te
ANS: 1
si
ng
Down syndrome is caused by an additional chromosome 21. It occurs is approximately 1 in 660
births. Edward syndrome (trisomy 18) occurs in 1 in 3000 births. Patau syndrome (trisomy 13)
occurs in 1 in 5000 births. Marfan syndrome occurs from an autosomal dominant trait disorder.
yn
ur
5.A pregnant client is scheduled for a procedure to harvest stem cells from the fetuss umbilical
cord. Which of the following must occur before this procedure can be conducted?
Fetoscopy fails.
2.
Umbilical cord is visualized upon ultrasound.
w
w
Chorionic villus sampling test has been completed.
w
3.
.m
1.
4.
Placental biopsy is completed.
ANS: 2
Percutaneous umbilical blood sampling can be done as early as 16 to 18 weeks gestation if the
cord can be visualized by ultrasound. This test does not need to be done if the fetoscopy fails.
This test does not need to be done after chorionic villus sampling or placental biopsy.
6.The nurse is concerned that a pregnant client may deliver an infant with a teratogenic condition
when which of the following is assessed?
Client ingests two alcoholic drinks every night during pregnancy.
2.
Client exercises 3 days each week for 30 minutes.
3.
Client works 40 hours a week.
4.
Client eats six servings of fruits and vegetables each day.
.c
om
1.
ep
ANS: 1
pr
The most commonly used teratogenic agent is alcohol. The ingestion of alcohol while pregnant
can cause the teratogenic condition fetal alcohol syndrome. The other choices are positive
activities for the client to participate in while pregnant and are not teratogenic to the fetus.
ng
te
st
7.An adolescent female client being treated for cystic fibrosis is asking the nurse about birth
control. Which of the following should the nurse include in these instructions?
The chances that the client will become pregnant are small.
2.
Women with cystic fibrosis can transmit this disorder to their children.
3.
Pregnancy will cause the disease to go into remission.
4.
The client has a good chance of having children without the disorder.
ur
yn
.m
w
w
ANS: 2
si
1.
w
Infertility is not seen in women who are diagnosed with cystic fibrosis; therefore, a female with
cystic fibrosis can transmit the disorder to her children. Infertility is common in adult men with
cystic fibrosis. Pregnancy will not cause the disease to go into remission.
8.After genetic testing, a client is found to have the apolipoprotein E genotype. The nurse
realizes that this genotype predisposes the client to developing:
1.
diabetes mellitus.
2.
arthritis.
3.
cystic fibrosis.
4.
cardiovascular disease.
ANS: 4
.c
om
The apolipoprotein E genotype has an effect on a persons cholesterol level which can lead to the
development of cardiovascular disease. The apolipoprotein E genotype is not a factor with the
development of diabetes mellitus, arthritis, or cystic fibrosis.
ep
9.A client with a family history of cancer asks the nurse what he can do to prevent developing
the disease. Which of the following should the nurse respond to this client?
Everyone develops cancer sometime in his life.
2.
There are lifestyle changes that you can make to avert the development of cancer.
3.
If you have cancer in your family, you will also develop the disease.
4.
Cancer cannot be prevented.
ur
si
ng
te
st
pr
1.
yn
ANS: 2
w
.m
Individuals with a family history of cancer should review their family histories to identify cancer
patterns and learn about lifestyle changes that could be made early to avert the onset of cancer.
The other choices are incorrect and inappropriate for the nurse to respond to the client.
w
w
10.The nurse caring for a client diagnosed with sickle-cell anemia realizes that which of the
following interventions has been shown to increase clients life expectancy?
1.
Low-fat diet
2.
Moderate exercise
3.
Prophylactic antibiotic therapy
4.
Vitamin D therapy
ANS: 3
Treatment of sickle-cell disease with prophylactic antibiotic therapy has resulted in an increase
in life expectancy. Other treatments include fluid therapy, oxygen, pain management, blood
transfusions, and medications. Low-fat diet, moderate exercise, and vitamin D therapy are not
interventions associated with the treatment of sickle-cell anemia.
beneficence.
2.
autonomy.
3.
nonmaleficence.
4.
justice.
pr
st
te
ng
si
ANS: 2
ep
1.
.c
om
11.A client is diagnosed with a genetic disorder that could affect other members of her family.
The conflict that could occur if this information is shared with the clients family would be within
the ethical principle of:
.m
yn
ur
The law protects the autonomy of competent individuals in making health care decisions
regarding genetic testing and the lifestyle changes resulting from such tests. There may be a
conflict between the rights of the individual and the rights of the family for whom this
information may have relevance to health. The other choices do not apply to a conflict situation
with a client and the family.
w
1.
w
w
12.A client is receiving a vaccination against a known disease. The nurse realizes that the
vaccine was created through the use of:
gene therapy.
2.
pharmacogenomics.
3.
genetic engineering.
4.
oncogenomics.
ANS: 3
Genetic engineering has been used to develop synthetic insulins, drugs, and vaccines. Gene
therapy is the use of genes to treat disease. Pharmacogenomics is the study of how a persons
genetic traits affect the bodys response to drugs. Oncogenomics is the use of chemotherapy and
vaccines to treat and prevent cancer.
3.
database.
4.
pedigree.
.c
checklist.
ep
2.
pr
flow chart.
st
1.
om
13.The nurse is assessing a clients hereditary and nonhereditary cancer risk factors in order to
create a pictorial description of the incidence of cancer. The nurse is constructing a:
te
ANS: 4
ur
MULTIPLE RESPONSE
si
ng
A pedigree is a diagrammatic representation of a family history that identifies affected
individuals. The nurse is not constructing a flow chart, checklist, or database with the clients
assessment information.
w
w
2.
Drug development
w
1.
.m
yn
14.The nurse is caring for a client who is experiencing a disease process caused by a
malformation from a normal pattern of development. When reviewing the principles of
teratology to plan care for this client, the nurse reviews which basic principles? (Select all that
apply.)
Environmental influences
3.
Gestational age when the exposure occurred
4.
The agent
5.
The route of exposure
6.
Rate of placental transfer
ANS: 2, 3, 4, 5, 6
Basic principles of teratology include environmental influences, gestational age when the
exposure occurred, the agent, the route of exposure, and the rate of placental transfer. Drug
development is not a principle of teratology.
om
15.A pregnant client is scheduled for diagnostic tests which cannot occur until the fetus is older
than 18 weeks. Which of the following tests is this client most likely scheduled to have
performed? (Select all that apply.)
Amniocentesis
2.
Chorionic villus sampling
3.
Fetoscopy with fetal skin biopsy
4.
Periumbilical blood
5.
Placental biopsy
6.
Early amniocentesis
yn
ur
si
ng
te
st
pr
ep
.c
1.
.m
ANS: 3, 4
w
w
Periumbilical blood and fetoscopy with fetal skin biopsy both require gestation longer than 18
weeks. Placental biopsy requires gestation longer than 12 weeks. Early amniocentesis requires
that gestation be before 15 weeks. Amniocentesis requires that gestation be at 15 to 20 weeks,
and chorionic villus sampling requires gestation at 10 to 12 weeks.
w
16.A client is diagnosed with an autosomal recessive inherited disease. Which of the following
are examples of this type of inherited disease? (Select all that apply.)
1.
Cystic fibrosis
2.
D-resistant rickets
3.
Sickle-cell disease
4.
Tay-Sachs disease
5.
Phenylketonuria
6.
Galactosemia
ANS: 1, 3, 4, 5, 6
om
D-resistant rickets is an X-linked dominant disorder. The other choices are autosomal recessive
inherited diseases.
ep
.c
17.A client at 20 weeks gestation is scheduled for an ultrasound to diagnose fetal abnormalities.
The nurse realizes that this diagnostic test is used to identify which of the following fetal
anomalies? (Select all that apply.)
Diabetes mellitus
2.
Spina bifida
3.
Congestive heart failure
4.
Hydrocephaly
5.
Gastritis
.m
yn
ur
si
ng
te
st
pr
1.
Microcephaly
w
ANS: 2, 4, 6
w
6.
w
Ultrasound scanning is used to identify the fetal conditions of spina bifida, hydrocephaly, and
microcephaly. Ultrasound scanning is not used to identify fetal diabetes mellitus, congestive
heart failure, or gastritis.
18.The ethics committee is meeting to discuss treatment options for a client diagnosed with a
genetic disorder. When addressing the ethics of this clients treatment, the committee will focus
on which of the following ethical principles? (Select all that apply.)
1.
Autonomy
Timeliness
3.
Beneficence
4.
Cost-effectiveness
5.
Nonmaleficence
6.
Justice
.c
om
2.
ep
ANS: 1, 3, 5, 6
w
w
w
.m
yn
ur
si
ng
te
st
pr
The four principles that support the ethical decision-making process regarding the treatment of a
genetic disorder are: 1) autonomy, 2) beneficence, 3) nonmaleficence, and 4) justice. Timeliness
and cost-effectiveness are not ethical principles.
Chapter 7 Health Promotion: Pediatric
MULTIPLE CHOICE
1.The nurse stresses that regular physical activity has been identified as a leading health
indicator. Regular physical activity has which positive effect on children?
a.
Improves social skills
b.
Reduces fluid retention
c.
Increases bone and muscle strength
d.
Increases attention span
ANS: C
In children, regular physical activity increases bone and muscle strength.
b.
Alcohol addiction
c.
Cigarette smoking
d.
Malnutrition
.c
Drug use
ep
a.
om
2.What is the single most preventable cause of death and disease in the United States today?
pr
ANS: C
Cigarette smoking continues to be the single most preventable cause of death.
te
st
3.Smoking contributes to an increased risk of heart and lung disease in children by which
methods?
Air pollution
b.
Allergens in the environment
c.
Environmental smoke
d.
Lack of oxygen in the air
ur
si
ng
a.
yn
ANS: C
.m
Environmental smoke may result in an increased risk of heart and lung disease, particularly
asthma and bronchitis in children.
w
a.
w
w
4.Which factor is mostly associated with problems such as domestic violence, sexually
transmitted infections (STIs), school failure, and motor vehicle accidents (MVAs)?
Lack of supervision
b.
Psychological problems
c.
Substance abuse
d.
Physiological problems
ANS: C
Substance abuse is associated with many social problems such as domestic violence, STIs,
school failure, and MVAs.
5.Approximately half of all new HIV cases are among people under what age?
a.
50 years
b.
40 years
c.
30 years
d.
25 years
ANS: D
Approximately half of all new HIV cases are among people younger than 25.
b.
Children weighing between 20 and 30 lb
c.
Children weighing between 30 and 40 lb
d.
Children weighing more than 40 lb
.c
Children weighing up to 20 lb
ep
a.
om
6.Which children must be secured in the back seat in a rear-facing safety seat?
pr
ANS: A
te
st
The law states that a child from birth to 20 lb must be situated in a rear-facing safety seat that is
secured in the back seat when riding in an automobile.
ng
7.The pediatric nurse reminds the parents of a 2-year-old that by this age the child should be
protected against how many vaccine-preventable childhood diseases?
si
a.
ur
b.
yn
c.
6
8
10
.m
d.
4
ANS: D
w
w
Children who follow the immunization schedule are protected against 10 vaccine-preventable
childhood diseases by age 2.
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8.A major dental problem among very young children is bottle mouth caries. What is a
preventative measure the nurse should suggest?
a.
Juice at bedtime
b.
Milk at bedtime
c.
A sugar-coated pacifier
d.
Water at bedtime
ANS: D
Specific interventions can prevent bottle mouth caries, such as offering water in the bedtime
bottle.
9.What practice should be used by a pediatric nurse to remind parents of their responsibility in
reducing the number of accidents involving children?
Child awareness
b.
Good manners
c.
Anticipatory guidance
d.
Strict discipline
om
a.
ANS: C
ep
.c
Anticipatory guidance has been the most widely used approach to educating parents in accident
prevention.
b.
In the medicine cabinet
c.
In a locked cupboard
d.
On a high shelf
ng
si
ANS: C
st
In a dresser drawer
te
a.
pr
10.To prevent accidental poisoning of a child, where should medications be placed in the home?
ur
Medications should be kept in a locked cupboard.
yn
11.What is the leading cause of fatal injury in children younger than 1 year old?
Burns
b.
Poisons
.m
a.
w
ANS: C
Motor vehicle accidents
w
d.
Asphyxiation
w
c.
In children younger than 1 year, the leading cause of fatal injury is asphyxiation by aspiration of
foreign material into the respiratory tract.
12.What is the third leading cause of accidental death in children 1 to 4 years of age?
a.
Falls
b.
Asphyxiation
c.
Poisons
d.
Burns
ANS: D
Burns are the third leading cause of accidental death in children 1 to 4 years of age.
13.The school nurse recognizes that lack of physical activity and increased consumption of fast
food by children are causative factors contributing to which of the following problems?
Nutritional disorders
b.
Weight gain
c.
Type I diabetes
d.
Dental caries
om
a.
.c
ANS: B
ep
Many factors have contributed to the excess weight carried by children, including lack of
physical activity and increased consumption of fast food.
st
pr
14.The nurse sets up a sample physical activities schedule to fit the FDAs Dietary Guidelines for
Americans that recommends that children get at least how many minutes of physical activity per
day?
15
te
a.
30
ng
b.
c.
si
d.
60
ur
ANS: D
45
.m
yn
The Dietary Guidelines for Americans recommend that children get at least 60 minutes of
physical activity per day.
b.
w
c.
w
a.
w
15.What age group is experiencing the largest increase in drug use?
d.
7- to 9-year-olds
10- to 12-year-olds
12- to 13-year-olds
15- to 17-year-olds
ANS: C
Research shows an increase in children aged 12 to 13 years who are experimenting with drugs.
16.Because the water in the infants residential area is not fluoridated, when should the nurse
suggest that the infant receive supplemental fluoride?
a.
2 months old
b.
4 months old
c.
5 months old
d.
6 months old
ANS: D
Fluoride supplementation should be initiated at 6 months of age if the water in the infants
residential area is not fluoridated.
MULTIPLE RESPONSE
b.
To encourage healthy behavior
c.
To strengthen family bonds
d.
To improve nutrition
e.
To prevent accidents
ep
To identify health risks
te
st
pr
a.
.c
om
17.What are reasons that a pediatric nurse should stress that health promotion activities must be
ongoing? (Select all that apply.)
ANS: A, B, D, E
si
ng
Health promotion activities must be ongoing to identify health risks, to encourage healthy
behavior, to improve nutrition, and to prevent accidents. There is no link between health
promotion activities and strengthening family bonds.
yn
ur
18.The school nurse collaborates with the physical education instructor to increase the amount of
physical activity during the school day. What are major benefits of physical activity? (Select all
that apply.)
Reduced death rates as adults
.m
a.
w
d.
Reduced risk of hypertension
w
c.
Reduced risk of cardiovascular disease
w
b.
e.
Reduced risk of diabetes
Reduced self-esteem
ANS: A, B, C, D
Physical activity reduces death rates as adults, reduces the risk of cardiovascular disease, and
reduces the risk of diabetes and hypertension. Physical activity increases self-esteem.
19.Which are physical risks associated with excess weight? (Select all that apply.)
a.
Poor eyesight
b.
Heart disease
c.
Arthritis
d.
Stroke
e.
Appendicitis
ANS: B, C, D
Heart disease, arthritis, and stroke are physical risks that are associated with excess weight. Poor
eyesight and appendicitis are not associated with weight gain.
om
20.Which of the following interventions should be included when teaching a healthy behaviors
class for parents of adolescents? (Select all that apply.)
Always monitor the childs telephone conversations
b.
Insist on seatbelt use at all times
c.
Encourage tanning bed use versus exposure to the sun
d.
Maintain recommended immunization schedule
e.
Encourage good dental care
te
st
pr
ep
.c
a.
ANS: B, D, E
w
w
.m
yn
ur
si
ng
Adolescents should always wear seatbelts. Immunizations should be obtained according to the
recommended schedule. Good dental care is important. Parents should give the child privacy in
their telephone conversations. Tanning bed exposure is as detrimental to skin as exposure to the
sun and both should be avoided.
w
Chapter 8 Hematologic Disorders
MULTIPLE CHOICE
1.What is the process by which certain cells engulf and digest microorganisms and cellular
debris?
a.
Erythrocytosis
b.
Hematocrit
c.
Phagocytosis
d.
Hemostasis
ANS: C
Phagocytosis is the process by which bacteria, cellular debris, and solid particles are destroyed
and removed.
Hemoglobin
b.
Hematocrit
c.
Mean cell volume (MCV)
d.
Differential
.c
a.
om
2.The nurse explains that because it is a reliable and predictable indicator of the bodys level of
infection or recovery the _____________________ is a common diagnostic tool.
ep
ANS: D
te
st
pr
A differential white blood cell count is an examination in which the different kinds of WBCs are
counted and reported as percentages of the total examined. It is a common diagnostic tool
because of its reliability and the predictability of the bodys response to infection or its progress
in recovery.
ng
3.The nurse assessing a differential sees an increase in immature neutrophils (bands) and is
aware that this indicates:
a significant hemorrhage.
b.
aplastic anemia.
c.
an overwhelming bacterial infection.
d.
beginning recovery from an infection.
yn
ur
si
a.
.m
ANS: C
w
w
An increase in immature neutrophils (bands) is called bandemia, and it indicates an
overwhelming bacterial infection.
w
4.B cells and T cells fit under which classification?
a.
Erythrocytes
b.
Basophils
c.
Lymphocytes
d.
Monocytes
ANS: C
B cells and T cells, the major players in the antigen/antibody conflict, are both lymphocytes.
5.The nurse explains that in the event of an invasion of an allergen, the basophils release a strong
vasodilator, which is:
a.
lysozyme.
b.
prothrombin.
c.
hematocrit.
d.
histamine.
ANS: D
om
Histamine is released by the basophils during the invasion of an allergen.
b.
shift to the right.
c.
bone marrow aspiration.
d.
thrombocytosis.
pr
shift to the left.
st
a.
ep
.c
6.The presence of excess bands in the peripheral blood that indicate severe infection is called:
te
ANS: A
ng
The presence of excess bands in the peripheral blood is called a shift to the left (i.e., a shift
toward immature cells) and indicates severe infection.
ur
si
7.A patient who had a Schilling test shows a 20% excretion of the radioactive vitamin B 12. What
would this indicate?
a.
The patient has a low reserve of iron and has iron deficiency anemia.
The patient has a normal finding and does not have pernicious anemia.
c.
The patient has a deficiency of thrombocytes and has a clotting disorder.
d.
The patient has an excess of RBCs and has polycythemia.
.m
w
ANS: B
yn
b.
w
w
The Schilling test is a laboratory blood test for diagnosing pernicious anemia. The normal
reading 24 hours after the administration of radioactive vitamin B 12 is 8% to 40%. The test
measures the absorption of radioactive vitamin B12.
8.In an adult, where are erythrocytes continuously produced?
a.
Yellow bone marrow
b.
Lymphatic system
c.
Spleen
d.
Red bone marrow
ANS: D
Erythrocytes are continuously produced in the red bone marrow, principally in the vertebrae,
ribs, and sternum.
9.What does the elevation in the eosinophil count to 10% indicate?
a.
Anemia
b.
Allergy
c.
Infection
d.
Hypoxia
om
ANS: B
ep
.c
Normal values of eosinophils are 1% to 4%. An elevation to 10% would indicate the presence of
an allergic reaction.
pr
10.What would a nurse include in a teaching plan for a home health patient with a hemoglobin of
8.4 mg?
Exercising for periods of 30 minutes daily
b.
Limiting fluid intake
c.
Alternating activity with rest periods
d.
Avoiding the use of oxygen
si
ng
te
st
a.
ur
ANS: C
yn
Severely anemic persons need to conserve their energy. Observing a rest period after a period of
activity will reduce hypoxia. Oxygen may be used as necessary.
w
c.
w
b.
w
a.
.m
11.Approximately how much blood is stored in the spleen that can be released in a hypovolemic
emergency?
d.
100 mL
300 mL
500 mL
1000 mL
ANS: C
The spleen stores 1 pint of blood, approximately 500 mL, which can be released during
emergencies.
12.The nurse caring for a patient with pernicious anemia should make provisions for:
a.
frequent iced drinks.
b.
lightweight blanket.
c.
a fan to circulate the air.
d.
reverse isolation.
ANS: B
Persons with pernicious anemia are especially sensitive to cold. The provision of a light blanket
is beneficial.
om
13.When instructing the patient taking an oral liquid iron preparation, what should the nurse
include?
Information relative to taking the iron with milk
b.
Information relative to the bowel movement color changing to dark red
c.
Information relative to taking preparation through a straw to prevent staining of teeth
d.
Information relative to taking a drug with meals or a snack
pr
ep
.c
a.
st
ANS: C
te
Liquid iron preparations should be drunk through a straw to prevent tooth staining. All oral iron
preparations should be taken before meals. Dairy products interfere with the absorption of iron.
si
ng
14.When the 14-year-old African American boy comes into the emergency room in sickle cell
crisis, what should be the primary focus of care?
Instruct patient about transfusion procedure
b.
Starting of IV fluids
c.
Pain control
d.
Relief of dyspnea
.m
yn
ur
a.
w
ANS: C
w
w
Pain control during the crisis is the focus. Continuous opioids are the mainstay of pain
management. Certainly IV fluids to reduce viscosity of blood and oxygen for relief of dyspnea
are important, but pain control is paramount in the acute phase.
15.The mother of a 4-year-old child with leukemia says to the nurse, I dont understand why he is
crying about his legs hurting. The nurses most informative response would be based on the
information that bone pain is related to:
a.
Elevated WBCs in differential
b.
Long periods of inactivity
c.
Splenomegaly
d.
Bone marrow congested with white cells
ANS: D
Long bone pain is the result of bone marrow that is congested with immature white cells.
16.What must a patient undergo before a bone marrow transplant?
A thorough nutritional plan to support new marrow
b.
Total body irradiation to kill all the marrow cells
c.
A physical therapy program to strengthen the body
d.
Inhalation therapy to reduce possible pathogens in the lungs
om
a.
ANS: B
ep
.c
Before the actual marrow transplant, the patient must undergo total body irradiation or
chemotherapy to kill all the marrow cells and the leukemic cells. The patient is at a major risk for
infection at this time.
st
pr
17.The 9-year-old child with leukemia who is on palliative care has drawn a picture of a boy
under a huge black cloud that has lightning coming out of it. Which of the following would be an
appropriate intervention for the nurse?
What is this picture about?
b.
Are you afraid of lightning?
c.
I bet this is a picture of you, isnt it?
d.
Is it about to rain in your picture?
si
ng
te
a.
ur
ANS: A
.m
yn
Asking what the child has drawn is a neutral and nonthreatening question. Drawings can give a
clue to perceptions and emotions that a young child may not be able to verbalize. The nurse
should not try to interpret the drawing.
w
a.
w
w
18.The home health nurse recommends to the mother of a 12-year-old child with leukemia that
the child should have:
the series for prevention of hepatitis B.
b.
an annual influenza vaccine.
c.
an annual pneumococcal vaccine.
d.
vitamin B12 shots.
ANS: B
Children with leukemia should have an annual influenza vaccine and a pneumococcal vaccine
every 5 years.
19.Which patient statement from a 15-year-old girl with thrombocytopenia would require more
assessment to report to the charge nurse?
a.
I think these red spots on my skin are going away.
b.
I am so bored lying in bed I could scream.
c.
My bowel movement is brown and stinks.
d.
I have this really weird Coke-colored urine.
ANS: D
om
Coke-colored urine is hematuria that should be documented and reported to the charge nurse.
The purpura will fade as they are absorbed. Boredom and smelly stools are normal for a 14-yearold.
.c
20.A 23-year-old male patient with hemophilia A says, How can I keep my children from having
hemophilia A? Which of the following is the most informative response?
You need to select a very dependable mode of birth control.
b.
You can only pass hemophilia B to your sons.
c.
Your daughter may be a carrier and her children may have hemophilia A. Your son is not at
risk.
d.
Your sons should have coagulation studies.
te
st
pr
ep
a.
ng
ANS: C
si
Hemophilia A is an X-linked trait. Females are carriers; therefore, the patients daughter could
pass the disease to her sons. The patients sons are not at risk for hemophilia A.
yn
ur
21.The nurse caring for a child with hemophilia who is hospitalized with hemarthrosis should
include which of the following in the plan of care?
Splint the affected leg to maintain anatomic alignment
b.
Apply warm compresses to reduce hemorrhage in the joint
c.
Use analgesia sparingly
d.
Encourage vigorous ROM exercises several times a day to keep knee flexible
w
w
w
ANS: A
.m
a.
Splinting the affected knee is necessary to retain anatomic alignment while the pain is severe.
Analgesia should be given as needed. Physical therapy and ROM are appropriate after pain has
subsided.
22.In caring for a patient with multiple myeloma, what should the nurse include in the daily
care?
a.
Provisions for limiting fluid intake to less than 1000 mL/day
b.
Provisions for close supervision and assistance when ambulating
c.
Provisions for straining all urine
d.
Provisions for limiting use of an analgesic
ANS: B
Because of the constant threat of pathologic fractures, ambulation should be carefully supervised
and assisted. Uric acid is increased and may crystalize in the kidney, but straining is not
necessary. Analgesia is necessary for relief of bone pain.
b.
stage II
c.
stage III
d.
stage IV
.c
stage I
ep
a.
om
23.The nurse is aware that a person with Hodgkin disease, who has two or more abnormal lymph
nodes on the same side of the diaphragm and involvement of extranodal involvement on the
same side of the diaphragm, would be in:
pr
ANS: B
te
st
Stage II indicates that there are two or more abnormal lymph nodes on the same side of the
diaphragm and extranodal involvement on the same side of the diaphragm.
ng
24.The nurse explains that a positron emission tomography (PET) has been ordered to:
assess bone marrow depression.
b.
measure bone density.
c.
radiate and destroy diseased lymph nodes.
d.
measure lymph node response to therapy.
yn
ur
si
a.
.m
ANS: D
w
b.
w
a.
w
25.Which of the following foods would the nurse recommend to a person with iron deficiency
anemia as an excellent meat source for erythropoiesis?
Dark meat of chicken
Cured ham
c.
Pork chops
d.
Processed meat
ANS: A
The dark meat of poultry is a good meat source for erythropoiesis.
26.The peripheral smear is a diagnostic test that:
a.
assesses the level of hemoglobin.
b.
measures antibody production.
c.
examines the shape and structure of RBCs.
d.
identifies infection.
ANS: C
The peripheral smear allows the study of the size, structure, and shape of RBCs.
stimulate bone marrow.
b.
inhibit bone marrow activity.
c.
increase hemoglobin.
d.
reduce gout.
ep
.c
a.
om
27.The typical medical treatment of polycythemia vera involves repeated phlebotomies and
medications such as busulfan (Myleran) in order to:
pr
ANS: B
te
st
Repeated phlebotomy decreases blood viscosity, and myelosuppressive agents such as busulfan
(Myleran) are often given to inhibit bone marrow activity.
ng
28.Which of the following would the nurse explain as the most common type of leukemia that
affects children?
Chronic lymphocytic leukemia (CLL)
b.
Acute myeloid leukemia (AML)
c.
Acute lymphocytic leukemia (ALL)
d.
Chronic myeloid leukemia (CML)
yn
ur
si
a.
.m
ANS: C
w
w
The most common type of leukemia that affects children is the fast-advancing ALL. This
leukemia can also affect adults.
w
29.The nurse is aware that persons of the Jehovahs Witness faith accept which types of blood
transfusions?
a.
No type of blood transfusion
b.
Blood that has been blessed by their religious leader
c.
Transfusions only for persons who have not yet been baptized
d.
Autologous blood transfusions
ANS: D
Jehovahs Witness followers are accepting of autologous blood transfusions and some will accept
volume expanders such as colloids.
30.Which mandatory practice is the most effective and significant nursing practice to prevent the
spread of infection?
Strict and frequent handwashing by all people having contact with the patient
b.
Placement of patients in private rooms with high-efficiency particulate air (HEPA) filtration
c.
Administration of combinations of prophylactic antibiotics
d.
Creation of a sterile environment for the patient with the use of laminar airflow rooms
om
a.
ANS: A
.c
Meticulous handwashing by medical and nursing personnel and strict asepsis are mandatory.
7 days
b.
60 days
c.
120 days
d.
Up to several years
te
ng
ANS: C
st
pr
a.
ep
31.What is the average life span of an erythrocyte?
ur
si
The life span of an RBC is 120 days. A WBCs life span is days to several years. Platelets live 5
to 9 days.
yn
32.Because older adults suffer from conditions such as colonic diverticula, hiatal hernia, and
ulcerations that can cause occult bleeding, the nurse should assess for symptoms of:
leukemia.
.m
a.
b.
w
polycythemia.
w
d.
sickle cell anemia.
w
c.
iron deficiency anemia.
ANS: B
Blood loss is a major cause of iron deficiency in adults. The major sources of chronic blood loss
are from the GI and genitourinary systems.
33.The nurse explains that the treatment of hemophilia A has been revolutionized with the
advent of the use of:
a.
corticosteroids.
b.
large doses of testosterone.
c.
recombinant factor VIII.
d.
transfusion with packed red cells.
ANS: C
Recombinant factor VIII has been a major forward step in the treatment of hemophilia A.
Sternum
b.
Posterior superior iliac crest
c.
Posterior iliac crest
d.
Femur
ep
.c
a.
om
34.From which location would the bone marrow sample come in the aspiration of a 25-year-old
patient?
pr
ANS: C The preferred site for bone marrow aspiration puncture in adults is the posterior iliac
crest.
te
st
35.What are the most likely matches for a bone marrow transplant to a 10-year-old with
leukemia? (Select all that apply.)
Uncle
b.
Self
ng
a.
Mother
si
c.
Brother
ur
d.
e.
Sister
yn
f.
Father
w
w
.m
ANS: B, D, E Specimens from twins, siblings, or self (autologous) while in remission are
preferred.
w
Chapter 9 Lactation and Breastfeeding
MULTIPLE CHOICE
1.A client who has just given birth is planning on breastfeeding the baby. The nurse realizes that
which of the following hormones influences breast milk secretion?
1.
Follicle-stimulating hormone
2.
Luteinizing hormone
3.
Oxytocin
4.
Prolactin
ANS: 4
om
Prolactin is necessary for breast formation and the production of breast milk. Oxytocin is
responsible for uterine contractions and the breast milk let down. Follicle-stimulating hormone
stimulates the production of sperm and ova. In men, luteinizing hormone stimulates testosterone
needed for sperm production, and in women, it stimulates ovulation.
.c
2.The nurse is instructing a female client about breast self-examination. Which of the following
instructions would not be correct for the nurse to provide?
A menstruating woman should check her breast monthly 8 days following her menses.
2.
An inverted nipple is not a cause for alarm.
3.
During menopause, you should check your breasts once a month during the same time frame.
4.
Visually check the breasts in front of a mirror.
si
ng
te
st
pr
ep
1.
ur
ANS: 2
.m
yn
An inverted nipple is not necessarily a cause for alarm if it has been present since puberty, but
any change in the nipple or breast tissue should be evaluated. The other instructions would be
appropriate for the nurse to provide.
w
1.
w
w
3.A client who has been breastfeeding a newborn for the last 3 months is experiencing an
inflammation of the breast. The nurse realizes this client is experiencing:
intraductal papilloma.
2.
mastalgia.
3.
mastitis.
4.
mastodynia.
ANS: 3
Mastitis, inflammation of the breast, may be caused from irritation, injury, or infection, and it
most commonly occurs within the first 3 months after childbirth. Mastalgia and mastodynia are
terms that refer to breast pain. Intraductal papilloma is a small benign tumor that grows within
the terminal portion of a solitary milk duct of the breast.
4.During the examination of a female clients breasts, the nurse determines that which of the
following assessment findings would be normal?
Nipple discharge
2.
Masses
3.
Scaling
4.
Symmetrical nipples
pr
ep
.c
om
1.
st
ANS: 4
ng
te
Symmetrical nipples would be considered a normal finding. All the other options are abnormal
findings.
ur
si
5.The nurse is instructing a female client on the importance of having routine mammograms
because mammograms:
can detect masses before they become palpable.
2.
involves no radiation.
3.
has a 25% rate of false positives.
.m
w
w
combines a blood test with radiology.
w
4.
yn
1.
ANS: 1
Mammography is a radiological procedure that is useful because it allows visualization of benign
and malignant disorders before they become palpable. The rate of false positives is 5% to 10%.
Mammography does use radiation. Mammography does not include a blood test.
6.The nurse is instructing a female client on what should be done if a lump is discovered while
performing breast self-examination (BSE). What should the nurse instruct the client to do?
Call her physician and immediately schedule an appointment.
2.
Call to schedule an appointment next month.
3.
Take the antibiotics she has in her medicine cabinet.
4.
Wait until next months BSE to make sure the lump is still there.
om
1.
ANS: 1
ep
.c
Follow-up on a lump should begin immediately. The client should not wait to see if the lump
remains or changes, and she should not medicate herself.
3.
Obesity
4.
pr
Breastfeeding
st
2.
te
Alcohol intake
si
ng
1.
ur
7.The nurse determines that a female client has a lower risk for developing breast cancer when
which of the following is assessed?
yn
Smoking
.m
ANS: 2
w
Breastfeeding has consistently been shown to decrease a womans risk of breast cancer. The other
options increase a womans risk of breast cancer.
w
w
8.The nurse should instruct the client that when performing a breast self-examination, pay
particular attention to which of the following areas since the greatest number of malignancies are
found in this breast area?
1.
Upper outer quadrant of the breast to the axilla
2.
Portion of the breast closest to the xiphoid process
3.
Portion of the breast closest to the abdomen
4.
Portion of the breast closest to the neck
ANS: 1
The upper outer quadrant of the breast to the axilla is an area that needs to be evaluated since the
greatest proportion of malignancies are found in this area of the breast. The other breast areas
need to be examined; however, special attention should be given to the upper outer quadrant.
om
9.The nurse should instruct a client, diagnosed with mastalgia, to do which of the following?
Have an immediate mammogram.
2.
Expect to need a biopsy.
3.
Decrease the intake of caffeine.
4.
Determine if breast augmentation surgery is desired.
te
st
pr
ep
.c
1.
ng
ANS: 3
ur
si
Mastalgia refers to breast pain. Pain is not generally associated with breast cancer. Wearing a
well-fitting supportive brassiere during exercise and decreasing the intake of caffeine would be
beneficial. The client does not need an immediate mammogram, a biopsy, or breast
augmentation.
w
w
2.
Ineffective coping
w
1.
.m
yn
10.A female client tells the nurse that she is planning on having plastic surgery to correct a minor
facial defect and then have her breasts done. The nurse would identify which of the following
nursing diagnoses as being appropriate for this client?
Anxiety
3.
Hopelessness
4.
Body dysmorphic disorder
ANS: 4
Body dysmorphic disorder is characterized by a preoccupation with body image and the slight or
imagined defect in appearance that leads to impairment or distress in functioning in social
situations. Body dysmorphic disorder would be appropriate for the client who is planning on
having plastic surgery for a minor facial defect and then breast augmentation surgery. The other
nursing diagnoses would not be appropriate for the client at this time.
Smoking
2.
Caffeine use
3.
Alcohol intake
4.
Age 55
pr
ep
.c
1.
om
11.The nurse is determining if a female client is at risk for benign breast disease. Which of the
following is a risk factor for this disorder?
ANS: 2
ng
te
st
Risk factors for benign breast disease include caffeine use, imbalance between estrogen and
progesterone, estrogen excess, hyperprolactemia, and age between 20 to 50 years. Smoking and
alcohol intake are not risk factors for benign breast disease.
ur
si
12.A client is scheduled for a prophylactic mastectomy. The nurse should remind the client that
skin flaps will be left after the surgery for:
reconstruction.
2.
suturing to the chest wall.
3.
possible use for other skin disorders.
.m
w
w
donation for someone needing a skin transplant.
w
4.
yn
1.
ANS: 1 The goal of a mastectomy is to remove all breast tissue, including the nipple and areola,
while leaving well-perfused viable skin flaps for primary closure or reconstruction. The skin
flaps will not be sutured to the chest wall. The skin flaps are not for use for other skin disorders.
The skin flaps are not for donation for someone needing a skin transplant.
13.When instructing a client on breast self-examination, the nurse reviews the importance of
visual inspection of the breasts. Which of the following should the nurse instruct the client to
focus on when doing this part of the examination? (Select all that apply.)
Contour and symmetry of the breasts
2.
Skin changes
3.
Position of the nipples
4.
Presence or absence of masses
5.
Pain
6.
Size
ep
.c
om
1.
te
st
pr
ANS: 1, 2, 3, 4 Visual inspection of the breast self-examination focuses on the contour and
symmetry of the breasts; skin changes such as scaling, puckering, dimpling, or scars; the position
of the nipples; nipple discharge or retraction; and presence or absence of masses. This part of the
examination does not include pain or size of the breasts.
ng
14.The nurse is preparing to assess a clients nipples during a breast examination. Which of the
following are considered pathological conditions that affect the nipple? (Select all that apply.)
Bleeding
ur
si
1.
Lumps
yn
2.
w
w
5.
w
4.
.m
3.
6.
Discharge
Scars
Fissures
Large size
ANS: 1, 3, 5 The three primary pathological conditions of the nipple include bleeding, discharge,
and fissures. Lumps, scars, and size are not associated with pathological conditions of the nipple.
15.Which of the following should the nurse do if a female client is experiencing nipple
discharge? (Select all that apply.)
Note the color of the discharge.
2.
Determine if the discharge is from one or both breasts.
3.
Obtain a sample of the discharge with a sterile cotton-tipped swab.
4.
Assess the nipple drainage for occult blood
5.
Apply sterile bandages over the nipple.
6.
Pad the clients bra with gauze.
ep
.c
om
1.
te
st
pr
ANS: 1, 2, 3, 4 If a female client is assessed with abnormal nipple discharge, the nurse should
note the color of the discharge; determine if the discharge is from one or both breasts; obtain a
sample of the discharge with a sterile cotton-tipped swab; and assess the drainage for occult
blood. The nurse should not apply sterile bandages over the nipple nor pad the clients bra with
gauze.
si
ng
16.A client is experiencing galactorrhea. Which of the following should the nurse assess in this
client? (Select all that apply.)
Recent vigorous nipple stimulation
2.
Prescribed hormones, blood pressure medications, or antidepressants
3.
Intake of herbal remedies such as fennel or anise
4.
Use of street drugs such as opiates and marijuana
w
w
w
.m
yn
ur
1.
5.
Recent chest trauma
6.
Age of menarche
ANS: 1, 2, 3, 4, 5 Galactorrhea is the secretion of a milk-like fluid in a non-lactating breast. This
can occur because of recent vigorous nipple stimulation, prescribed hormones, blood pressure
medication, or antidepressants; intake of herbal remedies such as fennel or anise; use of street
drugs such as opiates and marijuana; and recent chest trauma. Age of menarche will not help
determine the cause for the disorder.
Change in sensation
2.
Development of a hematoma
3.
Fibrous tissue around the implant
4.
Heart palpitations
5.
High blood pressure
6.
Arm pain
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17.A client is considering breast augmentation surgery. Which of the following postoperative
complications should the nurse discuss with the client regarding this surgery? (Select all that
apply.)
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ANS: 1, 2, 3 Postoperative complications with breast augmentation include change in sensation,
development of a hematoma; and formation of fibrous tissue around the implant.
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Chapter 10 Men’s Health Disorders
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Avoid alcohol and caffeine.
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MULTIPLE CHOICE
1.The nurse is instructing a client diagnosed with acute prostatitis. Which of the following
instructions would be the least beneficial to the client?
2.
Sex should be avoided during the acute phase.
3.
Sit for as long as you can.
4.
Sitz baths may provide comfort.
ANS: 3
The patient should be encouraged to use sitz baths for comfort but not to sit in them for long
periods of time. Caffeine, alcohol, and sex should be avoided during the acute phase.
2.
Eating patterns
3.
Sleeping patterns
4.
Urinary patterns
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Bowel patterns
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1.
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2.The nurse is documenting the health history of a client diagnosed with benign prostatic
hyperplasia (BPH). In which of the following areas would the nurse take a careful history?
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ANS: 4
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A careful history on urinary patterns should be taken by the nurse. The ease with which the
stream of urine is started, the strength of the stream, and the perceived amount of urine
eliminated with each voiding, along with the patients sense about whether the bladder is
completely emptied and the presence of nocturia or dribbling, should be noted. The clients
bowel, eating, and sleeping patterns are also important; however, they are not as important as the
urinary patterns.
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3.A client, diagnosed with benign prostatic hyperplasia (BPH), should be instructed to do which
of the following?
Do nothing since this disorder does not require any follow-up.
2.
Decrease water intake to avoid dribbling.
3.
Void every 2 to 3 hours.
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4.
Wear scrotal support.
ANS: 3
Clients with BPH should void every 2 to 3 hours to flush the urinary tract. Water should not be
decreased because this will irritate the urinary mucosa. Scrotal support is not necessary, and BPH
does require follow-up visits.
4.A client, recovering from a transurethral resection of the prostate (TURP) with a continuous
bladder irrigation system to a three-way indwelling urinary catheter, tells the nurse he has to
void. What nursing intervention should the nurse perform?
Call the physician.
2.
Increase the flow of the irrigant.
3.
Irrigate the catheter.
4.
Tell the client to void.
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ANS: 3
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After a TURP, clots that can occlude the catheter and create a sensation to void in the client are
common. The nurse should irrigate the catheter to allow the urine to flow. The nurse does not
need to phone the physician, increase the flow of the irrigant, or tell the client to void.
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5.A client who is 12 hours postoperative after a transurethral resection of the prostate (TURP) is
concerned about the blood clots in the catheter and urinary collection bag. How should the nurse
respond?
I need to call your physician.
2.
I will need to stop the bladder irrigation.
3.
Blood clots are common during this time frame and will start to decrease in a day.
4.
You need to stop moving and irritating the catheter.
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ANS: 3
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1.
Blood clots are common during the first 36 hours following a TURP. The irrigant should not be
stopped because it is flushing the clots out of the urinary system. A large amount of bright red
blood would be an indication of hemorrhage. The nurse does not need to call the physician.
6.A client is being screened for prostate cancer. What tests would be completed at this time?
1.
Digital rectal examination and transrectal ultrasonography
2.
Biopsy of the prostate and magnetic resonance imagery
3.
Complete blood cell count and prostate-specific antigen
4.
Prostate-specific antigen (PSA) and digital rectal examination
ANS: 4
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Early screening for prostate cancer includes a digital rectal examination and a PSA test. Other
tests may be ordered later if either the PSA or digital rectal examination are abnormal.
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7.The nurse is instructing a client about testicular self-examination (TSE). Which of the
following would not be included in these instructions?
The testis should feel smooth and egg-shaped.
2.
Perform TSE after a bath or shower.
3.
TSE should be performed monthly by every male older than age 40.
4.
Any lumps and changes in the testicles should be reported.
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ANS: 3
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The highest risk group for testicular cancer is young men 15 to 35 years of age. TSE should be
taught and performed monthly from the teenage years. The other choices are appropriate for the
nurse to instruct the client.
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8.A male client is diagnosed with orchitis. The nurse should assess the client for which of the
following?
Recent infection with mumps
2.
Recent diagnosis of prostatitis
3.
History of type 2 diabetes mellitus
4.
Diagnosis of renal insufficiency
ANS: 1
Mumps is the most common viral cause of orchitis, with the orchitis occurring 4 to 7 days after
the onset of mumps. Orchitis is not associated with prostatitis, type 2 diabetes mellitus, or renal
insufficiency.
9.A client is diagnosed with a spermatocele. The nurse should instruct the client on which of the
following?
The use of heat to reduce the size of the inflamed area
2.
The potential need for surgery to correct the disorder
3.
The use of ice packs to reduce the size of the inflamed area
4.
The importance of using antibiotics to treat the disorder
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ANS: 2
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Spermatoceles may become significantly uncomfortable and require treatment. Surgical
correction may be done if infertility is associated with the spermatocele. Surgical removal of the
spermatocele is performed under local anesthesia. Heat, ice, and antibiotics are not the first line
treatments for the disorder.
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10.A client is diagnosed with a varicocele. The nurse realizes that this client is likely to develop:
hydrocele.
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1.
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3.
prostate cancer.
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2.
4.
prostatitis.
infertility.
ANS: 4
Infertility or subinfertility often occurs in conjunction with varicocele because the increased
blood flow in the varicocele raises the scrotal temperature about 93.2F, which is the ideal
temperature for spermatogenesis. The client is not likely to develop a hydrocele, prostate cancer,
or prostatitis from a varicocele.
11.A newborn male child is diagnosed with cryptorchidism. The nurse should prepare to
administer which of the following to this client?
Intravenous fluids
2.
Antipyretic medication
3.
Human chorionic gonadotropin medication
4.
Antibiotics
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ANS: 3
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Human chorionic gonadotropin may be given intramuscularly to promote bilateral testicular
descent. This medication is provided 2 to 3 times a week for up to 6 weeks. Intravenous fluids,
antipyretics, or antibiotics are not indicated in the treatment of this disorder.
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12.A client is experiencing priapism. Which of the following should the nurse do first to help the
client?
Apply ice packs to the perineum.
2.
Prepare for emergency surgery.
3.
Prepare for an aspiration of blood from the penis.
4.
Apply heat to the perineum.
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ANS: 1
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1.
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The goal of treating priapism is to resolve the condition before permanent damage occurs that
leaves the client unable to achieve an erection in the future. Ice packs to the perineum will
resolve some cases of the disorder. This is what the nurse should do first. The client does not
need emergency surgery. The client may need blood aspirated from the penis. Heat should not be
applied to the perineum.
MULTIPLE RESPONSE
13.A client is diagnosed with testicular torsion. Which of the following might be indicated for
this client? (Select all that apply.)
2.
Orchiopexy
3.
Testicle removal
4.
Pain management
5.
Application of ice and a scrotal support
6.
Prescribe medication
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Manually untwist the testicle
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ANS: 1, 2, 3, 4, 5
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The goal of the treatment for testicular torsion is to untwist the spermatic cord and reestablish
normal blood flow to the testicle. The testicle may be manually untwisted to promote blood flow.
If this is unsuccessful, the client may need an orchiopexy or a surgical procedure to untwist the
testicle. If surgical treatment occurs within 6 hours of the onset of pain, the testicle is salvaged. If
treatment is delayed for 12 hours or more, the testicle will begin to necrose and will need to be
removed. Pain medication is needed for this disorder. Ice and a scrotal support are used for this
disorder. No medications alone will cure this disorder.
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14.A client is diagnosed with epididymitis. The nurse should instruct the client on which of the
following as treatment for the disorder? (Select all that apply.)
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3.
NSAIDs
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2.
Broad spectrum antibiotics
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1.
Bed rest
4.
Elevate the scrotum
5.
Apply cold packs
6.
Apply heat
ANS: 1, 2, 3, 4, 5
Treatment for epididymitis includes broad spectrum antibiotics, NSAIDs, bed rest, elevation of
the scrotum, and application of cold packs. Heat is not recommended as treatment for this
disorder.
15.Which of the following should the nurse instruct a client who is recovering from a
vasectomy? (Select all that apply.)
Use ice packs to control postoperative bleeding.
2.
Wear cotton jockey type briefs for scrotal support.
3.
Use warm sitz baths to aid in comfort.
4.
Recognize the signs and symptoms of postoperative infection.
5.
A vasectomy protects the client from sexually transmitted illnesses.
6.
Ejaculate will be reduced after the procedure.
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1.
ANS: 1, 2, 3, 4
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The client recovering from a vasectomy should be instructed to use ice packs to control
postoperative bleeding, wear cotton jockey type briefs for scrotal support, use warm sitz baths to
aid in comfort, and recognize the signs and symptoms of postoperative infection. A vasectomy
does not protect the client from sexually transmitted illnesses. Ejaculate will not be reduced after
the procedure.
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16.The nurse is assessing a client diagnosed with balanitis and posthitis. Which of the following
will the nurse most likely assess in this client? (Select all that apply.)
Penile discharge
2.
Hematuria
3.
Pain
4.
Erythema
5.
Flank pain
6.
Edema
ANS: 1, 3, 4, 6
The typical manifestations for balanitis and posthitis include penile discharge, pain, erythema,
and edema. Hematuria and flank pain are not associated with this disorder.
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17.The nurse is assessing a client who is experiencing erectile dysfunction. For which of the
following should the nurse assess the client? (Select all that apply.)
Diagnosis of diabetes mellitus
2.
Thyroid disease
3.
Chronic renal failure
4.
Multiple sclerosis
5.
Parkinsons disease
6.
Gastroesophageal reflux disease
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ANS: 1, 2, 3, 4, 5
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1.
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Erectile dysfunction has been associated with diabetes mellitus, thyroid disease, chronic renal
failure, multiple sclerosis, and Parkinsons disease. Erectile dysfunction has not been associated
with gastroesophageal reflux disease.
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18. A male patient with possible fertility problems asks the nurse where sperm is produced. The
nurse knows that sperm production occurs in the:
a.
Testes.
b.
Prostate.
c.
Epididymis.
d.
Vas deferens.
ANS: A
Sperm production occurs in the testes, not in the other structures listed.
19. A 62-year-old man states that his physician told him that he has an inguinal hernia. He asks
the nurse to explain what a hernia is. The nurse should:
a.
Tell him not to worry and that most men his age develop hernias.
b.
Explain that a hernia is often the result of prenatal growth abnormalities.
c.
Refer him to his physician for additional consultation because the physician made the initial
diagnosis.
Explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal
muscles.
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d.
ANS: D
A hernia is a loop of bowel protruding through a weak spot in the musculature. The other options
are not correct responses to the patients question.
20. The mother of a 10-year-old boy asks the nurse to discuss the recognition of puberty. The
nurse should reply by saying:
a.
Puberty usually begins around 15 years of age.
The first sign of puberty is an enlargement of the testes.
c.
The penis size does not increase until about 16 years of age.
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b.
Increased pubic hair.
c.
Decreased penis size.
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b.
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d.
The development of pubic hair precedes testicular or penis enlargement.
ANS: B
Puberty begins sometime between age 9 for African Americans and age 10 for Caucasians and
Hispanics. The first sign is an enlargement of the testes. Pubic hair appears next, and then penis
size increases.
21. During an examination of an aging man, the nurse recognizes that normal changes to expect
would be:
a.
Enlarged scrotal sac.
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d.
Increased rugae over the scrotum.
ANS: C
In the aging man, the amount of pubic hair decreases, the penis size decreases, and the rugae
over the scrotal sac decreases. The scrotal sac does not enlarge.
22. An older man is concerned about his sexual performance. The nurse knows that in the
absence of disease, a withdrawal from sexual activity later in life may be attributable to:
a.
Side effects of medications.
b.
Decreased libido with aging.
c.
Decreased sperm production.
d.
Decreased pleasure from sexual intercourse.
ANS: A
In the absence of disease, a withdrawal from sexual activity may be attributable to side effects of
medications such as antihypertensives, antidepressants, sedatives, psychotropics, antispasmotics,
tranquilizers or narcotics, and estrogens. The other options are not correct.
23. A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic for
complaints of burning and pain during urination. He is experiencing:
a.
Dysuria.
b.
Nocturia.
c.
Polyuria.
Enuresis.
c.
Stress incontinence.
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d.
Hematuria.
ANS: A
Dysuria (burning with urination) is common with acute cystitis, prostatitis, and urethritis.
Nocturia is voiding during the night. Polyuria is voiding in excessive quantities. Hematuria is
voiding with blood in the urine.
24. A 45-year-old mother of two children is seen at the clinic for complaints of losing my urine
when I sneeze. The nurse documents that she is experiencing:
a.
Urinary frequency.
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d.
Urge incontinence.
ANS: C
Stress incontinence is involuntary urine loss with physical strain, sneezing, or coughing that
occurs as a result to weakness of the pelvic floor. Urinary frequency is urinating more times than
usual (more than five to six times per day). Enuresis is involuntary passage of urine at night after
age 5 to 6 years (bed wetting). Urge incontinence is involuntary urine loss from overactive
detrusor muscle in the bladder. It contracts, causing an urgent need to void.
25. When the nurse is conducting sexual history from a male adolescent, which statement would
be most appropriate to use at the beginning of the interview?
a.
Do you use condoms?
You dont masturbate, do you?
c.
Have you had sex in the last 6 months?
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b.
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d.
Often adolescents your age have questions about sexual activity.
ANS: D
The interview should begin with a permission statement, which conveys that it is normal and
acceptable to think or feel a certain way. Sounding judgmental should be avoided.
26. Which of these statements is most appropriate when the nurse is obtaining a genitourinary
history from an older man?
a.
Do you need to get up at night to urinate?
b.
Do you experience nocturnal emissions, or wet dreams?
c.
Do you know how to perform a testicular self-examination?
d.
Has anyone ever touched your genitals when you did not want them to?
ANS: A
The older male patient should be asked about the presence of nocturia. Awaking at night to
urinate may be attributable to a diuretic medication, fluid retention from mild heart failure or
varicose veins, or fluid ingestion 3 hours before bedtime, especially coffee and alcohol. The
other questions are more appropriate for younger men.
27. When the nurse is performing a genital examination on a male patient, the patient has an
erection. The nurses most appropriate action or response is to:
a.
Ask the patient if he would like someone else to examine him.
b.
Continue with the examination as though nothing has happened.
c.
Stop the examination, leave the room while stating that the examination will resume at a later
time.
Hair is without pest inhabitants.
c.
The skin is wrinkled and without lesions.
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b.
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d.
Reassure the patient that this is a normal response and continue with the examination.
ANS: D
When the male patient has an erection, the nurse should reassure the patient that this is a normal
physiologic response to touch and proceed with the rest of the examination. The other responses
are not correct and may be perceived as judgmental.
28. The nurse is examining the glans and knows which finding is normal for this area?
a.
The meatus may have a slight discharge when the glans is compressed.
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d.
Smegma may be present under the foreskin of an uncircumcised male.
ANS: D
The glans looks smooth and without lesions and does not have hair. The meatus should not have
any discharge when the glans is compressed. Some cheesy smegma may have collected under the
foreskin of an uncircumcised male.
29. When performing a genitourinary assessment, the nurse notices that the urethral meatus is
ventrally positioned. This finding is:
a.
Called hypospadias.
A result of phimosis.
c.
Probably due to a stricture.
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b.
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d.
Often associated with aging.
ANS: A
Normally, the urethral meatus is positioned just about centrally. Hypospadias is the ventral
location of the urethral meatus. The position of the meatus does not change with aging. Phimosis
is the inability to retract the foreskin. A stricture is a narrow opening of the meatus.
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30. The nurse is performing a genital examination on a male patient and notices urethral
drainage. When collecting urethral discharge for microscopic examination and culture, the nurse
should:
a.
Ask the patient to urinate into a sterile cup.
b.
Ask the patient to obtain a specimen of semen.
c.
Insert a cotton-tipped applicator into the urethra.
d.
Compress the glans between the examiners thumb and forefinger, and collect any discharge.
ANS: D
If urethral discharge is noticed, then the examiner should collect a smear for microscopic
examination and culture by compressing the glans anteroposteriorly between the thumb and
forefinger. The other options are not correct actions.
31. When assessing the scrotum of a male patient, the nurse notices the presence of multiple
firm, nontender, yellow 1-cm nodules. The nurse knows that these nodules are most likely:
a.
From urethritis.
b.
Sebaceous cysts.
c.
Subcutaneous plaques.
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d.
From an inflammation of the epididymis.
ANS: B
Sebaceous cysts are commonly found on the scrotum. These yellowish 1-cm nodules are firm,
nontender, and often multiple. The other options are not correct.
32. When performing a scrotal assessment, the nurse notices that the scrotal contents show a red
glow with transillumination. On the basis of this finding the nurse would:
a.
Assess the patient for the presence of a hernia.
Suspect the presence of serous fluid in the scrotum.
c.
Consider this finding normal, and proceed with the examination.
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d.
Refer the patient for evaluation of a mass in the scrotum.
ANS: B
Normal scrotal contents do not allow light to pass through the scrotum. However, serous fluid
does transilluminate and shows as a red glow. Neither a mass nor a hernia would transilluminate.
33. When the nurse is performing a genital examination on a male patient, which action
is correct?
a.
Auscultating for the presence of a bruit over the scrotum
c.
Palpating the inguinal canal only if a bulge is present in the inguinal region during inspection
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b.
Palpating for the vertical chain of lymph nodes along the groin, inferior to the inguinal
ligament
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Having the patient shift his weight onto the left (unexamined) leg when palpating for a hernia
d.
on the right side
ANS: D
When palpating for the presence of a hernia on the right side, the male patient is asked to shift
his weight onto the left (unexamined) leg. Auscultating for a bruit over the scrotum is not
appropriate. When palpating for lymph nodes, the horizontal chain is palpated. The inguinal
canal should be palpated whether a bulge is present or not.
34. The nurse is aware of which statement to be true regarding the incidence of testicular cancer?
a.
Testicular cancer is the most common cancer in men aged 30 to 50 years.
b.
The early symptoms of testicular cancer are pain and induration.
c.
Men with a history of cryptorchidism are at the greatest risk for the development of testicular
cancer.
d.
The cure rate for testicular cancer is low.
ANS: C
Men with undescended testicles (cryptorchidism) are at the greatest risk for the development of
testicular cancer. The overall incidence of testicular cancer is rare. Although testicular cancer has
no early symptoms, when detected early and treated before metastasizing, the cure rate is almost
100%.
35. The nurse is describing how to perform a testicular self-examination to a patient. Which
statement is most appropriate?
a.
A good time to examine your testicles is just before you take a shower.
If you notice an enlarged testicle or a painless lump, call your health care provider.
c.
The testicle is egg shaped and movable. It feels firm and has a lumpy consistency.
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b.
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Perform a testicular examination at least once a week to detect the early stages of testicular
d.
cancer.
ANS: B
If the patient notices a firm painless lump, a hard area, or an overall enlarged testicle, then he
should call his health care provider for further evaluation. The testicle normally feels rubbery
with a smooth surface. A good time to examine the testicles is during the shower or bath, when
ones hands are warm and soapy and the scrotum is warm. Testicular self-examination should be
performed once a month.
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36. A 2-month-old uncircumcised infant has been brought to the clinic for a well-baby checkup.
How would the nurse proceed with the genital examination?
a.
Eliciting the cremasteric reflex is recommended.
The glans is assessed for redness or lesions.
c.
Retracting the foreskin should be avoided until the infant is 3 months old.
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b.
Atrophic scrotum and a bilateral absence of the testis.
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d.
Any dirt or smegma that has collected under the foreskin should be noted.
ANS: C
If uncircumcised, then the foreskin is normally tight during the first 3 months and should not be
retracted because of the risk of tearing the membrane attaching the foreskin to the shaft. The
other options are not correct.
37. A 2-year-old boy has been diagnosed with physiologic cryptorchidism. Considering this
diagnosis, during assessment the nurse will most likely observe:
a.
Testes that are hard and painful to palpation.
c.
Absence of the testis in the scrotum, but the testis can be milked down.
d.
Testes that migrate into the abdomen when the child squats or sits cross-legged.
ANS: C
Migratory testes (physiologic cryptorchidism) are common because of the strength of the
cremasteric reflex and the small mass of the prepubertal testes. The affected side has a normally
developed scrotum and the testis can be milked down. The other responses are not correct.
38. The nurse knows that a common assessment finding in a boy younger than 2 years old is:
a.
Inflamed and tender spermatic cord.
b.
Presence of a hernia in the scrotum.
c.
Penis that looks large in relation to the scrotum.
d.
Presence of a hydrocele, or fluid in the scrotum.
ANS: D
A common scrotal finding in boys younger than 2 years of age is a hydrocele, or fluid in the
scrotum. The other options are not correct.
Decrease in the size of the penis.
c.
Enlargement of the testes and scrotum.
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b.
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39. During an examination of an aging man, the nurse recognizes that normal changes to expect
would be:
a.
Change in scrotal color.
c.
Genital herpes.
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Syphilitic chancres.
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b.
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d.
Increase in the number of rugae over the scrotal sac.
ANS: B
When assessing the genitals of an older man, the nurse may notice thinner, graying pubic hair
and a decrease in the size of the penis. The size of the testes may be decreased, they may feel less
firm, and the scrotal sac is pendulous with less rugae. No change in scrotal color is observed.
40. When performing a genital assessment on a middle-aged man, the nurse notices multiple soft,
moist, painless papules in the shape of cauliflower-like patches scattered across the shaft of the
penis. These lesions are characteristic of:
a.
Carcinoma.
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d.
Genital warts.
ANS: D
The lesions of genital warts are soft, pointed, moist, fleshy, painless papules that may be single
or multiple in a cauliflower-like patch. They occur on the shaft of the penis, behind the corona,
or around the anus, where they may grow into large grapelike clusters.
41. A 15-year-old boy is seen in the clinic for complaints of dull pain and pulling in the scrotal
area. On examination, the nurse palpates a soft, irregular mass posterior to and above the testis
on the left. This mass collapses when the patient is supine and refills when he is upright. This
description is consistent with:
a.
Epididymitis.
b.
Spermatocele.
c.
Testicular torsion.
d.
Varicocele.
ANS: D
A varicocele consists of dilated, tortuous varicose veins in the spermatic cord caused by
incompetent valves within the vein. Symptoms include dull pain or a constant pulling or
dragging feeling, or the individual may be asymptomatic. When palpating the mass, the examiner
will feel a soft, irregular mass posterior to and above the testis that collapses when the individual
is supine and refills when the individual is upright.
42. When performing a genitourinary assessment on a 16-year-old male adolescent, the nurse
notices a swelling in the scrotum that increases with increased intra-abdominal pressure and
decreases when he is lying down. The patient complains of pain when straining. The nurse
knows that this description is most consistent with a(n) ______ hernia.
a.
Femoral
b.
Incisional
c.
Direct inguinal
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d.
Indirect inguinal
ANS: D
With indirect inguinal hernias, pain occurs with straining and a soft swelling increases with
increased intra-abdominal pressure, which may decrease when the patient lies down. These
findings do not describe the other hernias.
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Chapter 11 Neurologic Disorders
MULTIPLE CHOICE
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c.
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b.
Somatic and the autonomic
d.
Cerebellum and the brainstem
w
a.
.m
1.What are the two divisions of the nervous system?
Medulla oblongata and the diencephalon
Central and the peripheral
ANS: D
The central and the peripheral are the two divisions of the nervous system. The autonomic and
the somatic are the division of the peripheral nervous system.
2.What is the cranial nerve that supplies most of the organs in the thoracic and abdominal
cavities and also carries motor fibers to glands that produce digestive juices and other secretions?
a.
Somatic motor nerve
b.
Visceral sensory nerve
c.
Abducens nerve
d.
Vagus nerve
ANS: D
The vagus nerve extends from the throat, larynx, and organs in the thoracic and abdominal
cavities. It is responsible for sensations and will accelerate peristalsis when stimulated.
b.
Head raised slightly with hips flexed
c.
Supine in gravity neutral position
d.
Turn on right side with head elevated
pr
Neck placed in a neutral position
te
st
a.
ep
.c
om
3.The newly admitted patient to the emergency room 30 minutes ago after a fall off a ladder has
gradually decreased in consciousness and has slowly reacting pupils, a widening pulse pressure,
and verbal responses that are slow and unintelligible. What is the most appropriate position for
the patient?
ng
ANS: A
Place the neck in a neutral position (not flexed or extended) to promote venous drainage.
ur
si
4.Which question is likely to elicit the most valid response from the patient who is being
interviewed about a neurologic problem?
Do you have any sensations of pins and needles in your feet?
b.
Does the pain radiate from your back into your legs?
c.
Can you describe the sensations you are having?
d.
Do you ever have any nausea or dizziness?
.m
w
w
ANS: C
yn
a.
w
For patients with suspected neurologic conditions, the presence of many symptoms or subjective
data may be significant. Offering leading questions is not beneficial and may allow the patient to
give misinformation. Questions should be specific about symptoms.
5.What is the cardinal sign of increased intracranial pressure in a brain injured patient?
a.
Pupil changes
b.
Ipsilateral paralysis
c.
Vomiting
d.
Decrease in the level of consciousness
ANS: D
Collection of objective data includes a change in level of consciousness. A change in the level of
consciousness is the earliest sign of increased intracranial pressure.
As a sum of the scores of the four categories
b.
As part of the Glasgow coma scale
c.
As individual scores in each category
d.
As progressive scores during a 24-hour period
.c
a.
om
6.The nurse is aware that when assessing a patient by the FOUR score coma scale, the patient is
assessed in four categories: eye response, brainstem reflexes, motor response, and respiration.
How are these results reported?
ep
ANS: C
st
pr
The FOUR score coma scale assesses the patient in four categories: eye response, brainstem
reflexes, motor response, and respiration. The scores are reported as individual scores in each
category. It is frequently done in conjunction with the Glasgow coma scale, not part of it.
ng
te
7.As the result of a stroke, a patient has difficulty discerning the position of his body without
looking at it. In the nurses documentation, which would best describe the patients inability to
assess spatial position of his body?
Agnosia
b.
Proprioception
c.
Apraxia
ur
si
a.
Sensation
yn
d.
.m
ANS: B
w
Patients may experience a loss of proprioception with a stroke. This may include apraxia and
agnosia (a total or partial loss of the ability to recognize familiar objects or people).
w
w
8.A patient, age 45, is to have a myelogram to confirm the presence of a herniated intervertebral
disk. Which nursing action should be planned with respect to this diagnostic test?
a.
Obtain an allergy history before the test.
b.
Ambulate the patient when returned to the room after the test.
c.
Use heated blanket to keep patient warm after procedure.
d.
Keep NPO for 6 to 8 hours after the test.
ANS: A
Before the dye is injected, patients must be asked whether they have any allergies, specifically
whether they have had any anaphylactic or hypotensive episodes from other dyes.
9.A patient has recently suffered a stroke with left-sided weakness and has problems with
choking, especially when drinking thin liquids. What nursing interventions would be most
helpful in assisting this patient to swallow safely?
Use a straw
b.
Tuck chin when swallowing
c.
Take a sip of liquid with each bite
d.
Turn head to the left
om
a.
ANS: B
10.What are surgical navigational systems?
ep
.c
The patient should sit at a 90-degree angle with the head up and chin slightly tucked.
Computerized devices that guide the surgeon
b.
A set of detailed anatomic maps pinpointing specific areas of the brain
c.
A written set of progressive processes for the resection of small brain tumors
d.
The use of radioactive materials to pinpoint small tumors of the brain
te
st
pr
a.
ng
ANS: A
ur
si
Surgical navigational systems are computerized devices that guide the surgeon and make
possible the resection of tumors that were once thought to be inoperable.
yn
11.A family member of a patient who has just suffered a tonic-clonic seizure is concerned about
the patients deep sleep. What is this behavior called?
Convalescent period
.m
a.
b.
w
Postictal period
w
d.
Sombulant period
w
c.
Neural recovery period
ANS: D
Seizures are followed by a rest period of variable length, called a postictal period.
12.How would a nurse record the behavior when a patient with Alzheimer disease attempts to eat
using a napkin rather than a fork?
a.
Apraxia
b.
Agnosia
c.
Aphasia
d.
Dysphagia
ANS: B
Agnosia is a total or partial loss of the ability to recognize familiar objects or people through
sensory stimuli as a result of organic brain damage.
13.Which symptom is specific to migraine headaches?
Tachycardia
b.
They become worse in the evening
c.
They involve the entire head
d.
They are preceded by an aura
.c
om
a.
ep
ANS: D
Migraine headaches are unusual in that signs and symptoms occur before the acute attack.
Hypotension
b.
Alzheimer disease
c.
Diabetes
d.
Parkinson disease
ur
si
ng
a.
te
st
pr
14.The nurse assures an anxious family member of a 92-year-old patient who is demonstrating
signs of dementia that many causes of dementia are reversible and preventable. What is one
example?
yn
ANS: A
.m
Some forms of dementia are reversible. Dementia caused by hypotension, anemia, drug toxicity,
metabolic disturbance, and malnutrition can all be corrected to abolish the dementia.
w
a.
w
w
15.What is the nurse assessing when asking the patient, Who is the president of the United
States? during a level of consciousness assessment?
Orientation
b.
Memory
c.
Calculation
d.
Fund of knowledge
ANS: D
Fund of knowledge is tested by questions such as Who is the president? or asking about current
events.
16.What Glasgow Coma Scale rating would a patient receive who opens the eyes spontaneously,
but has incomprehensible speech and obeys commands for movement?
a.
8
b.
10
c.
11
d.
12
ANS: D
.c
om
The Glasgow coma scale was developed in 1974, and it consists of three parts of the neurologic
assessment: eye opening, best motor response, and best verbal response. This patient gets a 4 for
eye opening, a 2 for incomprehensible speech, and a 6 for moving on demand.
ep
17.What is the nurse aware of when assessing a person with a craniocerebral injury?
Most injuries of this type are irreversible
b.
Open injuries are always more serious than closed injuries
c.
Signs and symptoms may not occur until several days after the trauma
d.
Trauma to the frontal lobe is more significant than to any other area
te
st
pr
a.
ng
ANS: C
si
If a patient who has been conscious for several days after head injury loses consciousness or
develops neurologic signs and symptoms, a subdural hematoma should be suspected.
yn
ur
18.The nurse is caring for a home health patient who had a spinal cord injury at C5 three years
ago. The nurse bases the plan of care on the knowledge that the patient will be able to:
feed self with setup and adaptive equipment.
b.
transfer self to wheelchair.
c.
stand erect with full leg braces.
w
w
ANS: A
sit with good balance.
w
d.
.m
a.
A cord injury at C5 allows for ability to drive an electric wheelchair with mobile hand supports
and feed self with adaptive equipment.
19.A frantic family member is distressed about the flaccid paralysis of her son following a spinal
cord injury several hours ago. What does the nurse know about this condition?
a.
It is an ominous indicator of permanent paralysis.
b.
It is possibly a temporary condition and will clear.
c.
It degenerates into a spastic paralysis.
d.
It will progress up the cord to cause seizures.
ANS: B
A period of flaccid paralysis following a cord injury is called areflexia, or spinal shock, and may
be temporary.
Place patient in flat position and check temperature
b.
Administer oxygen and check oxygen saturation
c.
Place on side and check for leg swelling
d.
Sit upright and check blood pressure
ep
.c
a.
om
20.A patient with a spinal cord injury at T1 complains of stuffiness of the nose and a headache.
The nurse notes a flushing of the neck and goose flesh. What should be the primary nursing
intervention based on these assessments?
pr
ANS: D
te
st
These are indicators of autonomic dysreflexia or hyperreflexia. It is a medical emergency. The
patient should be placed in an upright position to decrease blood pressure and the blood pressure
should be checked. Assessments for impaction, full bladder, or a urine infection can help to
evaluate this condition.
si
ng
21.The nurse is aware that the characteristic gait of the person with Parkinson disease is a
propulsive gait, which causes the patient to:
stagger and need support of a walker.
b.
shuffle with arms flexed.
c.
fall over to one wide when walking.
d.
take small steps balanced on the toes.
.m
yn
ur
a.
w
ANS: B
w
The propulsive gait causes the patient to shuffle with his arms flexed and with a loss of postural
reflexes.
w
22.What does the nurse know about the stroke patient who has expressive aphasia?
a.
Has difficulty comprehending spoken and written communication
b.
Cannot make any vocal sounds
c.
Has total loss and comprehension of language
d.
Can understand the spoken word, but cannot speak
ANS: D
The patient with expressive aphasia has difficulty articulating words, but can understand the
written and spoken word.
23.The nurse is aware that the drug t-PA (Activase), a tissue plasminogen activator, must be
given in____hours of the onset of symptoms to have maximum benefit.
3 hours
b.
4 hours
c.
6 hours
d.
8 hours
om
a.
ANS: A
.c
t-PA must be given within 3 hours of the onset of symptoms to be beneficial.
from the left side.
c.
from the center.
d.
from either side.
st
b.
te
from the right side.
ng
a.
pr
ep
24.An 83-year-old patient has had a stroke. He is right-handed and has a history of hypertension
and little strokes. He presents with right hemiplegia. To afford him the best visual field, the nurse
should approach him:
si
ANS: B
yn
ur
Another perceptual problem is hemianopia, which is characterized by defective vision or
blindness in half of the visual field. If the patient has hemianopia, which is common, the patient
should be approached from the nonparalyzed side for care.
w
b.
Cleanse nose with a soft cotton-tipped swab
w
a.
w
.m
25.The newly admitted patient to the emergency room after a motorcycle accident has
serosanguineous drainage coming from the nose. What is the most appropriate nursing response
to this assessment?
Gently suction the nasal cavity
c.
Gently wipe nose with absorbent gauze
d.
Ask patient to blow his nose
ANS: C
The patients ear and nose are checked carefully for signs of blood and serous drainage, which
indicate that the meninges are torn and spinal fluid is escaping. No attempt should be made to
clean out the orifice or to blow the nose. The drainage can be wiped away. The drainage can be
tested for the presence of glucose, which would confirm that the fluid is spinal fluid and not
mucus.
26.How would the nurse instruct a patient with Parkinson disease to improve activity level?
a.
To use a soft mattress to relax the spine
b.
To walk with a shuffling gait to avoid tripping
c.
To walk with hands clasped behind back to help balance
d.
To sit in hard chair with arms for posture control
ANS: C
.c
om
The patient with Parkinson disease can improve the activity level by sleeping on a firm mattress
without a pillow to prevent spinal curvature, hold hands clasped behind to keep better balance,
and keep the arms from hanging stiffly at the side. Walk with a lifting of the feet to avoid
tripping and freezing.
Changes in mood
b.
Misplacing things
c.
Memory loss that disrupts daily life
d.
Problems with words in speaking
te
st
a.
pr
ep
27.What is the basic problem that prompts most of the early signs of Alzheimer disease?
ng
ANS: C
si
Memory loss that disrupts daily life is the basic problem that prompts most of the early signs of
AD.
ur
28.A patient is in which stage of Alzheimer disease when she demonstrates sundowning?
Early stage
yn
a.
.m
b.
Final stage
w
ANS: B
Third stage
w
d.
w
c.
Second stage
Sundowning is seen in the AD patient in the second stage of the disease.
29.Why are the drugs neostigmine (Prostigmin) and pyridostigmine (Mestinon) helpful to the
person with myasthenia gravis?
a.
Improves speech
b.
Improves visual disturbances
c.
Reduces pain
d.
Promotes nerve impulse transmission
ANS: D
Prostigmine and Mestinon improve the nerve impulses and alleviate the symptoms.
30.What should the nurse do when the child arrives on the floor with the diagnosis of bacterial
meningitis?
Arrange for humidified oxygen per mask
b.
Place the child in respiratory isolation
c.
Inquire about drug allergy
d.
Hold NPO until orders arrive
om
a.
.c
ANS: B
ep
Persons with bacterial meningitis are placed in respiratory isolation until the pathogen can no
longer be cultured, usually 24 hours.
pr
31.What is the purpose of a drug holiday in the treatment of Parkinson disease?
Change all drugs
b.
Allow the natural dopamine levels to rise
c.
Restart drugs at a lower dosage with favorable results
d.
Reduce the extrapyramidal symptoms
ng
te
st
a.
si
ANS: C
yn
ur
A drug holiday is a period of time when all drugs are withdrawn from the person with Parkinson
disease. The drugs are then restarted at a lower dose with favorable results.
32.What is the first sign of Bells palsy?
Inability to wrinkle forehead and pucker lips on affected side
b.
Sudden pain in nostril on affected side
c.
Excessive salivation on the affected side
w
w
Excessive mucus running from nostril on affected side
w
d.
.m
a.
ANS: A
Unilateral weakness of the facial muscles usually occurs, resulting in a flaccidity of the affected
side of the face with inability to wrinkle the forehead, close the eyelid, pucker the lips, smile,
frown, whistle, or retract the mouth on that side. The face appears asymmetric.
33.Following a myelogram the nurse should include in the postprocedure care assessment for:
a.
elevation of blood pressure.
b.
urine retention.
c.
sensation in lower extremities.
d.
slurred speech.
ANS: C
Postmyelogram care includes the assessment to ensure there is no leakage of CSF, sensation and
strength of the lower extremities, or headache. To avoid a headache, the patient should be flat for
a few hours.
34.Why is the patient with suspected Guillain-Barre Syndrome (GBS) hospitalized immediately?
The infection needs to be treated with IV antibiotics to prevent paralysis
b.
The brain may swell quickly causing seizures
c.
The disease can rapidly progress into respiratory failure
d.
IV hydration is needed to prevent possible fatal hypotension
ep
.c
om
a.
pr
ANS: C
st
Hospitalization is necessary for GBS patients because the disease progresses very quickly and
respiratory failure may occur.
te
MULTIPLE RESPONSE
si
ng
35.Which foods should the person who suffers from migraine headaches avoid? (Select all that
apply.)
Yogurt
b.
Caffeine
c.
Beef
yn
ur
a.
Pears
.m
d.
e.
w
f.
Marinated foods
Milk
w
w
ANS: A, B, E
Some foods may cause or worsen headaches. Foods that may provoke headaches include
vinegar, chocolate, yogurt, alcohol, fermented or marinated foods, ripened cheese, cured
sandwich meat, caffeine, and pork.
36.What are the three signs of Cushing response? (Select all that apply.)
a.
Increased pulse rate
b.
Increased blood pressure
c.
Widened pulse pressure
d.
Bradycardia
e.
Increased systolic blood pressure
f.
Uncontrolled thermoregulation
ANS: C, D, E
ur
Chapter 12 Ophthalmic Disorders
si
ng
te
st
pr
ep
.c
om
A widened pulse pressure, increased systolic blood pressure, and bradycardia are together called
Cushing response. It is considered an important diagnostic sign of late-stage brain herniation.
.m
yn
MULTIPLE CHOICE
1. The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down
and back when administering eardrops. This portion of the ear is called the:
a.
Auricle.
Concha.
c.
Outer meatus.
w
w
b.
w
d.
Mastoid process.
ANS: A
The external ear is called the auricle or pinna and consists of movable cartilage and skin.
2. The nurse is examining a patients ears and notices cerumen in the external canal. Which of
these statements about cerumen is correct?
a.
Sticky honey-colored cerumen is a sign of infection.
b.
The presence of cerumen is indicative of poor hygiene.
c.
The purpose of cerumen is to protect and lubricate the ear.
d.
Cerumen is necessary for transmitting sound through the auditory canal.
ANS: C
The ear is lined with glands that secrete cerumen, which is a yellow waxy material that lubricates
and protects the ear.
3. When examining the ear with an otoscope, the nurse notes that the tympanic membrane should
appear:
a.
Light pink with a slight bulge.
b.
Pearly gray and slightly concave.
c.
Pulled in at the base of the cone of light.
st
pr
ep
.c
om
d.
Whitish with a small fleck of light in the superior portion.
ANS: B
The tympanic membrane is a translucent membrane with a pearly gray color and a prominent
cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The
tympanic membrane is oval and slightly concave, pulled in at its center by the malleus, which is
one of the middle ear ossicles.
4. The nurse is reviewing the structures of the ear. Which of these statements concerning the
eustachian tube is true?
a.
The eustachian tube is responsible for the production of cerumen.
It remains open except when swallowing or yawning.
c.
The eustachian tube allows passage of air between the middle and outer ear.
ng
te
b.
.m
yn
ur
si
d.
It helps equalize air pressure on both sides of the tympanic membrane.
ANS: D
The eustachian tube allows an equalization of air pressure on each side of the tympanic
membrane so that the membrane does not rupture during, for example, altitude changes in an
airplane. The tube is normally closed, but it opens with swallowing or yawning.
5. A patient with a middle ear infection asks the nurse, What does the middle ear do? The nurse
responds by telling the patient that the middle ear functions to:
a.
Maintain balance.
Interpret sounds as they enter the ear.
c.
Conduct vibrations of sounds to the inner ear.
w
w
b.
w
d.
Increase amplitude of sound for the inner ear to function.
ANS: C
Among its other functions, the middle ear conducts sound vibrations from the outer ear to the
central hearing apparatus in the inner ear. The other responses are not functions of the middle
ear.
6. The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for
conducting nerve impulses to the brain from the organ of Corti?
a.
I
b.
III
c.
VIII
d.
XI
ANS: C
The nerve impulses are conducted by the auditory portion of CN VIII to the brain.
7. The nurse is assessing a patient who may have hearing loss. Which of these statements
is true concerning air conduction?
a.
Air conduction is the normal pathway for hearing.
Vibrations of the bones in the skull cause air conduction.
c.
Amplitude of sound determines the pitch that is heard.
om
b.
st
pr
ep
.c
d.
Loss of air conduction is called a conductive hearing loss.
ANS: A
The normal pathway of hearing is air conduction, which starts when sound waves produce
vibrations on the tympanic membrane. Conductive hearing loss results from a mechanical
dysfunction of the external or middle ear. The other statements are not true concerning air
conduction.
8. A patient has been shown to have a sensorineural hearing loss. During the assessment, it
would be important for the nurse to:
a.
Speak loudly so the patient can hear the questions.
Assess for middle ear infection as a possible cause.
c.
Ask the patient what medications he is currently taking.
ng
te
b.
.m
yn
ur
si
d.
Look for the source of the obstruction in the external ear.
ANS: C
A simple increase in amplitude may not enable the person to understand spoken words.
Sensorineural hearing loss may be caused by presbycusis, which is a gradual nerve degeneration
that occurs with aging and by ototoxic drugs, which affect the hair cells in the cochlea.
9. During an interview, the patient states he has the sensation that everything around him is
spinning. The nurse recognizes that the portion of the ear responsible for this sensation is the:
a.
Cochlea.
CN VIII.
c.
Organ of Corti.
w
w
b.
w
d.
Labyrinth.
ANS: D
If the labyrinth ever becomes inflamed, then it feeds the wrong information to the brain, creating
a staggering gait and a strong, spinning, whirling sensation called vertigo.
10. A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these
statements is correct regarding the significance of this in relation to the infants hearing?
a.
Rubella may affect the mothers hearing but not the infants.
b.
Rubella can damage the infants organ of Corti, which will impair hearing.
c.
Rubella is only dangerous to the infant in the second trimester of pregnancy.
d.
Rubella can impair the development of CN VIII and thus affect hearing.
ANS: B
If maternal rubella infection occurs during the first trimester, then it can damage the organ of
Corti and impair hearing.
11. The mother of a 2-year-old is concerned because her son has had three ear infections in the
past year. What would be an appropriate response by the nurse?
a.
It is unusual for a small child to have frequent ear infections unless something else is wrong.
c.
Ear infections are not uncommon in infants and toddlers because they tend to have more
cerumen in the external ear.
om
b.
We need to check the immune system of your son to determine why he is having so many ear
infections.
Presbycusis.
c.
Trauma to the bones.
si
b.
ng
te
st
pr
ep
.c
Your sons eustachian tube is shorter and wider than yours because of his age, which allows for
d.
infections to develop more easily.
ANS: D
The infants eustachian tube is relatively shorter and wider than the adults eustachian tube, and its
position is more horizontal; consequently, pathogens from the nasopharynx can more easily
migrate through to the middle ear. The other responses are not appropriate.
12. A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He
says that it does seem to help when people speak louder or if he turns up the volume of a
television or radio. The most likely cause of his hearing loss is:
a.
Otosclerosis.
w
w
w
.m
yn
ur
d.
Frequent ear infections.
ANS: A
Otosclerosis is a common cause of conductive hearing loss in young adults between the ages of
20 and 40 years. Presbycusis is a type of hearing loss that occurs with aging. Trauma and
frequent ear infections are not a likely cause of his hearing loss.
13. A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing,
especially in large groups. He says that he cant always tell where the sound is coming from and
the words often sound mixed up. What might the nurse suspect as the cause for this change?
a.
Atrophy of the apocrine glands
b.
Cilia becoming coarse and stiff
c.
Nerve degeneration in the inner ear
d.
Scarring of the tympanic membrane
ANS: C
Presbycusis is a type of hearing loss that occurs in 60% of those older than 65 years of age, even
in those living in a quiet environment. This sensorineural loss is gradual and caused by nerve
degeneration in the inner ear. Words sound garbled, and the ability to localize sound is also
impaired. This communication dysfunction is accentuated when background noise is present.
14. During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky
cerumen in his canal. What is the significance of this finding? This finding:
a.
Is probably the result of lesions from eczema in his ear.
b.
Represents poor hygiene.
c.
Is a normal finding, and no further follow-up is necessary.
.c
om
d.
Could be indicative of change in cilia; the nurse should assess for hearing loss.
ANS: C
Asians and Native Americans are more likely to have dry cerumen, whereas Blacks and Whites
usually have wet cerumen.
15. The nurse is taking the history of a patient who may have a perforated eardrum. What would
be an important question in this situation?
a.
Do you ever notice ringing or crackling in your ears?
When was the last time you had your hearing checked?
c.
Have you ever been told that you have any type of hearing loss?
ep
b.
ng
te
st
pr
d.
Is there any relationship between the ear pain and the discharge you mentioned?
ANS: D
Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then
drainage occurs.
16. A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak
loudly to him. The nurse knows that this finding:
a.
Is normal for people of his age.
Is a characteristic of recruitment.
c.
May indicate a middle ear infection.
ur
si
b.
w
w
w
.m
yn
d.
Indicates that the patient has a cerumen impaction.
ANS: B
Recruitment is significant hearing loss occurring when speech is at low intensity, but sound
actually becomes painful when the speaker repeats at a louder volume. The other responses are
not correct.
17. While discussing the history of a 6-month-old infant, the mother tells the nurse that she took
a significant amount of aspirin while she was pregnant. What question would the nurse want to
include in the history?
a.
Does your baby seem to startle with loud noises?
b.
Has your baby had any surgeries on her ears?
c.
Have you noticed any drainage from her ears?
d.
How many ear infections has your baby had since birth?
ANS: A
Children at risk for a hearing deficit include those exposed in utero to a variety of conditions,
such as maternal rubella or to maternal ototoxic drugs.
18. The nurse is performing an otoscopic examination on an adult. Which of these actions
is correct?
a.
Tilting the persons head forward during the examination
b.
Once the speculum is in the ear, releasing the traction
c.
Pulling the pinna up and back before inserting the speculum
.c
om
d.
Using the smallest speculum to decrease the amount of discomfort
ANS: C
The pinna is pulled up and back on an adult or older child, which helps straighten the S-shape of
the canal. Traction should not be released on the ear until the examination is completed and the
otoscope is removed.
19. The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent
motor vehicle accident. Which of these statements indicates the most important reason for
assessing for any drainage from the ear canal?
a.
If the drum has ruptured, then purulent drainage will result.
Bloody or clear watery drainage can indicate a basal skull fracture.
c.
The auditory canal many be occluded from increased cerumen.
ep
b.
ng
te
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d.
Foreign bodies from the accident may cause occlusion of the canal.
ANS: B
Frank blood or clear watery drainage (cerebrospinal leak) after a trauma suggests a basal skull
fracture and warrants immediate referral. Purulent drainage indicates otitis externa or otitis
media.
20. In performing a voice test to assess hearing, which of these actions would the nurse perform?
a.
Shield the lips so that the sound is muffled.
Whisper a set of random numbers and letters, and then ask the patient to repeat them.
c.
Ask the patient to place his finger in his ear to occlude outside noise.
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d.
Stand approximately 4 feet away to ensure that the patient can really hear at this distance.
ANS: B
With the head 30 to 60 cm (1 to 2 feet) from the patients ear, the examiner exhales and slowly
whispers a set of random numbers and letters, such as 5, B, 6. Normally, the patient is asked to
repeat each number and letter correctly after hearing the examiner say them.
21. In performing an examination of a 3-year-old child with a suspected ear infection, the nurse
would:
a.
Omit the otoscopic examination if the child has a fever.
b.
Pull the ear up and back before inserting the speculum.
c.
Ask the mother to leave the room while examining the child.
d.
Perform the otoscopic examination at the end of the assessment.
ANS: D
In addition to its place in the complete examination, eardrum assessment is mandatory for any
infant or child requiring care for an illness or fever. For the infant or young child, the timing of
the otoscopic examination is best toward the end of the complete examination.
22. The nurse is preparing to perform an otoscopic examination of a newborn infant. Which
statement is true regarding this examination?
a.
Immobility of the drum is a normal finding.
b.
An injected membrane would indicate an infection.
c.
The normal membrane may appear thick and opaque.
c.
Shows a startle and acoustic blink reflex.
.c
Shows no obvious response to the noise.
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d.
The appearance of the membrane is identical to that of an adult.
ANS: C
During the first few days after the birth, the tympanic membrane of a newborn often appears
thickened and opaque. It may look injected and have a mild redness from increased vascularity.
The other statements are not correct.
23. The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected
response? The infant:
a.
Turns his or her head to localize the sound.
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d.
Stops any movement, and appears to listen for the sound.
ANS: A
With a loud sudden noise, the nurse should notice the infant turning his or her head to localize
the sound and to respond to his or her own name. A startle reflex and acoustic blink reflex is
expected in newborns; at age 3 to 4 months, the infant stops any movement and appears to listen.
24. The nurse is performing an ear examination of an 80-year-old patient. Which of these
findings would be considered normal?
a.
High-tone frequency loss
Increased elasticity of the pinna
c.
Thin, translucent membrane
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d.
Shiny, pink tympanic membrane
ANS: A
A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing
loss that occurs with aging. The pinna loses elasticity, causing earlobes to be pendulous. The
eardrum may be whiter in color and more opaque and duller in the older person than in the
younger adult.
25. An assessment of a 23-year-old patient reveals the following: an auricle that is tender and
reddish-blue in color with small vesicles. The nurse would need to know additional information
that includes which of these?
a.
Any change in the ability to hear
b.
Any recent drainage from the ear
c.
Recent history of trauma to the ear
d.
Any prolonged exposure to extreme cold
ANS: D
Frostbite causes reddish-blue discoloration and swelling of the auricle after exposure to extreme
cold. Vesicles or bullae may develop, and the person feels pain and tenderness.
26. While performing the otoscopic examination of a 3-year-old boy who has been pulling on his
left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is
not visible. The nurse interprets these findings to indicate a(n):
a.
Fungal infection.
b.
Acute otitis media.
c.
Perforation of the eardrum.
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d.
Cholesteatoma.
ANS: B
Absent or distorted light reflex and a bright red color of the eardrum are indicative of acute otitis
media.
27. The mother of a 2-year-old toddler is concerned about the upcoming placement of
tympanostomy tubes in her sons ears. The nurse would include which of these statements in the
teaching plan?
a.
The tubes are placed in the inner ear.
The tubes are used in children with sensorineural loss.
c.
The tubes are permanently inserted during a surgical procedure.
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d.
The purpose of the tubes is to decrease the pressure and allow for drainage.
ANS: D
Polyethylene tubes are surgically inserted into the eardrum to relieve middle ear pressure and to
promote drainage of chronic or recurrent middle ear infections. Tubes spontaneously extrude in 6
months to 1 year.
28. In an individual with otitis externa, which of these signs would the nurse expect to find on
assessment?
a.
Rhinorrhea
Periorbital edema
c.
Pain over the maxillary sinuses
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b.
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d.
Enlarged superficial cervical nodes
ANS: D
The lymphatic drainage of the external ear flows to the parotid, mastoid, and superficial cervical
nodes. The signs are severe swelling of the canal, inflammation, and tenderness. Rhinorrhea,
periorbital edema, and pain over the maxillary sinuses do not occur with otitis externa.
29. When performing an otoscopic examination of a 5-year-old child with a history of chronic
ear infections, the nurse sees that his right tympanic membrane is amber-yellow in color and that
air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss
and a popping sound with swallowing. The preliminary analysis based on this information is that
the child:
a.
Most likely has serous otitis media.
b.
Has an acute purulent otitis media.
c.
Has evidence of a resolving cholesteatoma.
d.
Is experiencing the early stages of perforation.
ANS: A
An amber-yellow color to the tympanic membrane suggests serum or pus in the middle ear. Air
or fluid or bubbles behind the tympanic membrane are often visible. The patient may have
feelings of fullness, transient hearing loss, and a popping sound with swallowing. These findings
most likely suggest that the child has serous otitis media. The other responses are not correct.
30. The nurse is performing an assessment on a 65-year-old man. He reports a crusty nodule
behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical
assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary
analysis in this situation is that this:
a.
Is most likely a benign sebaceous cyst.
Is most likely a keloid.
c.
Could be a potential carcinoma, and the patient should be referred for a biopsy.
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d.
Is a tophus, which is common in the older adult and is a sign of gout.
ANS: C
An ulcerated crusted nodule with an indurated base that fails to heal is characteristic of a
carcinoma. These lesions fail to heal and intermittently bleed. Individuals with such symptoms
should be referred for a biopsy.The other responses are not correct.
31. The nurse suspects that a patient has otitis media. Early signs of otitis media include which of
these findings of the tympanic membrane?
a.
Red and bulging
Hypomobility
c.
Retraction with landmarks clearly visible
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b.
Know that these are scars caused from frequent ear infections.
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d.
Flat, slightly pulled in at the center, and moves with insufflation
ANS: B
An early sign of otitis media is hypomobility of the tympanic membrane. As pressure increases,
the tympanic membrane begins to bulge.
32. The nurse is performing a middle ear assessment on a 15-year-old patient who has had a
history of chronic ear infections. When examining the right tympanic membrane, the nurse sees
the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is
pearly, with the light reflex at 5 oclock and landmarks visible. The nurse should:
a.
Refer the patient for the possibility of a fungal infection.
c.
Consider that these findings may represent the presence of blood in the middle ear.
d.
Be concerned about the ability to hear because of this abnormality on the tympanic membrane.
ANS: B
Dense white patches on the tympanic membrane are sequelae of repeated ear infections. They do
not necessarily affect hearing.
33. The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which one of
these reflects the correct procedure?
a.
Pulling the pinna down
b.
Pulling the pinna up and back
c.
Slightly tilting the childs head toward the examiner
b.
Air conditioning
c.
Excessive cerumen
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d.
Instructing the child to touch his chin to his chest
ANS: A
For an otoscopic examination on an infant or on a child under 3 years of age, the pinna is pulled
down. The other responses are not part of the correct procedure.
34. The nurse is conducting a child safety class for new mothers. Which factor places young
children at risk for ear infections?
a.
Family history
Viral infection
c.
Blood in the middle ear
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d.
Passive cigarette smoke
ANS: D
Exposure to passive and gestational smoke is a risk factor for ear infections in infants and
children.
35. During an otoscopic examination, the nurse notices an area of black and white dots on the
tympanic membrane and the ear canal wall. What does this finding suggest?
a.
Malignancy
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d.
Yeast or fungal infection
ANS: D
A colony of black or white dots on the drum or canal wall suggests a yeast or fungal infection
(otomycosis).
36. A 17-year-old student is a swimmer on her high schools swim team. She has had three bouts
of otitis externa this season and wants to know what to do to prevent it. The nurse instructs her
to:
a.
Use a cotton-tipped swab to dry the ear canals thoroughly after each swim.
Use rubbing alcohol or 2% acetic acid eardrops after every swim.
c.
Irrigate the ears with warm water and a bulb syringe after each swim.
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d.
Rinse the ears with a warmed solution of mineral oil and hydrogen peroxide.
ANS: B
With otitis externa (swimmers ear), swimming causes the external canal to become waterlogged
and swell; skinfolds are set up for infection. Otitis externa can be prevented by using rubbing
alcohol or 2% acetic acid eardrops after every swim.
37. During an examination, the patient states he is hearing a buzzing sound and says that it is
driving me crazy! The nurse recognizes that this symptom indicates:
a.
Vertigo.
b.
Pruritus.
c.
Tinnitus.
d.
Cholesteatoma.
ANS: C
Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing
sound. It accompanies some hearing or ear disorders.
38. During an examination, the nurse notices that the patient stumbles a little while walking, and,
when she sits down, she holds on to the sides of the chair. The patient states, It feels like the
room is spinning! The nurse notices that the patient is experiencing:
a.
Objective vertigo.
Subjective vertigo.
c.
Tinnitus.
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d.
Dizziness.
ANS: A With objective vertigo, the patient feels like the room spins; with subjective vertigo, the
person feels like he or she is spinning. Tinnitus is a sound that comes from within a person; it can
be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders.
Dizziness is not the same as true vertigo; the person who is dizzy may feel unsteady and
lightheaded.
39. A patient has been admitted after an accident at work. During the assessment, the patient is
having trouble hearing and states, I dont know what the matter is. All of a sudden, I cant hear
you out of my left ear! What should the nurse do next?
a.
Make note of this finding for the report to the next shift.
Prepare to remove cerumen from the patients ear.
c.
Notify the patients health care provider.
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b.
Progression of hearing loss is slow.
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d.
Irrigate the ear with rubbing alcohol.
ANS: C Any sudden loss of hearing in one or both ears that is not associated with an upper
respiratory infection needs to be reported at once to the patients health care provider. Hearing
loss associated with trauma is often sudden. Irrigating the ear or removing cerumen is not
appropriate at this time.
MULTIPLE RESPONSE
40. The nurse is testing the hearing of a 78-year-old man and is reminded of the changes in
hearing that occur with aging that include which of the following? Select all that apply.
a.
Hearing loss related to aging begins in the mid 40s.
c.
The aging person has low-frequency tone loss.
d.
The aging person may find it harder to hear consonants than vowels.
e.
Sounds may be garbled and difficult to localize.
f.
Hearing loss reflects nerve degeneration of the middle ear.
ANS: B, D, E Presbycusis is a type of hearing loss that occurs with aging and is found in 60% of
those older than 65 years. It is a gradual sensorineural loss caused by nerve degeneration in the
inner ear or auditory nerve, and it slowly progresses after the age of 50 years. The person first
notices a high-frequency tone loss; it is harder to hear consonants (high-pitched components of
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MULTIPLE CHOICE
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Chapter 13 Orthopedic Disorders
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speech) than vowels, which makes words sound garbled. The ability to localize sound is also
impaired.
1.What is the movement of an extremity away from the midline of the body called?
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a.
Adduction
Flexion
Extension
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c.
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b.
Abduction
ANS: A
Abduction is movement of an extremity away from the midline of the body.
2.What is the large, fan-shaped muscle that covers the anterior chest from the sternum to the
proximal end of the humerus and acts on the joint of the shoulder to flex, adduct, and rotate?
a.
Serratus anterior
b.
Intercostal
c.
Transversus abdominis
d.
Pectoralis major
ANS: D
Pectoralis major is the large, fan-shaped muscle that covers the anterior chest and is an adductor
muscle, which will cause the shoulder to flex.
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3.What should the nurse instruct the patient before a magnetic resonance imaging (MRI)
procedure?
Void to completely empty the bladder
b.
Omit all citrus food for 12 hours before the procedure
c.
Remove all metal, such as jewelry, glasses, and hair clips
d.
Wear only cotton garments for the procedure
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a.
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ANS: C
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MRI procedures require that the patient remove all metal because it will become magnetized.
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4.The nurse instructs the patient who is to have a unicompartmental knee replacement that a
major advantage of this partial knee replacement is that:
the patient will be up and walking 2 to 3 hours after the operation.
b.
the kneecap is completely removed.
c.
the procedure is especially helpful in the treatment of rheumatoid arthritis.
d.
a small titanium disk replaces the worn cartilage.
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a.
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ANS: A
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Unicompartmental knee arthroplasty is also referred to as partial knee replacement in which the
worn cartilage is replaced with a plastic disk. It is not as invasive as a full knee replacement and
does not disturb the kneecap so that the patient can be up and walking in 2 to 3 hours after
surgery. It is not recommended for RA patients.
5.A patient who has had a right below the knee amputation continues to complain of unpleasant
sensation in the right foot. What can the nurse explain about this phantom pain?
a.
It only exists in the mind.
b.
It is a complication following an amputation and can be clarified by the surgeon.
c.
It is related to the severed nerves that are still sending messages to the brain.
d.
It occurs when the person becomes focused on the loss of the limb.
ANS: C
Phantom pain (pain felt in the missing extremity as if it were still present) may occur and be
frightening to the patient. Phantom pain occurs because the nerve tracts that register pain in the
amputated area continue to send a message to the brain (this is normal).
6.The patient that has a bipolar hip replacement following an intracapsular fracture has an order
to be turned every 2 hours. The nurse understands that the correct nursing intervention is to keep
the legs:
together so they do not separate while turning.
b.
flexed to stabilize the prosthesis.
c.
abducted so the prosthesis does not become dislocated.
d.
adducted to prevent additional pain for the patient with turning.
.c
ANS: C
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Nursing interventions also involve postoperative maintenance of leg abduction by using an
abduction splint for 7 to 10 days to prevent dislocation of the prosthesis.
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7.A patient has been casted to stabilize a fracture of the right radius and ulna. The nurse assesses
a capillary refill of 5 seconds and cold fingers of the right hand. Which initial intervention should
the nurse deploy?
Notify the charge nurse of a probable compartment syndrome
b.
Apply a warm compress to the fingers to relieve swelling
c.
Elevate the right hand to heart level to maintain arterial pressure
d.
Cut the cast off to release constriction
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a.
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ANS: C
.m
The nurse should first elevate the right hand to heart level and notify the charge nurse.
Permanent damage can occur in as little time as 6 hours.
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8.A patient had an open reduction with internal fixation (ORIF) for a compound fracture of the
left tibia and has been placed in a long leg cast. The assessments by the nurse are: left foot
warm/pink, pedal pulse weaker than right, capillary refill 3 seconds, and small 1 cm area of
blood on cast. What should the nurse do?
a.
Notify charge nurse of impending compartment syndrome
b.
Document that all assessments are within normal limits
c.
Inform charge nurse about probable hemorrhage
d.
Place warm compresses on left foot
ANS: B
All of the assessments are within normal limits. A small amount of blood on the cast is expected
and should be monitored.
9.When a patient recovering from a fractured tibia asks what callus formation is, the nurse tells
her it is:
a.
when blood vessels of the bone are compressed.
b.
a part of the bone healing process after a fracture when new bone is being formed over the
fracture site.
c.
the formation of a clot over the fracture site.
d.
when the hematoma becomes organized and a fibrin meshwork is formed.
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ANS: B
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Callus formation occurs when the osteoblasts continue to lay the network for bone buildup and
osteoclasts destroy dead bone.
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10.Which patient statement indicates the need for additional teaching for a patient with
rheumatoid arthritis who is taking meloxicam (Mobic)?
I am keeping a daily record of my blood pressure.
b.
I take aspirin before I go to bed.
c.
I know I can take meloxicam with or without regard to meals.
d.
I weigh every day so I will be aware of any weight gain.
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a.
ANS: B
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Aspirin or products containing aspirin should be avoided while taking meloxicam.
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11.What should the nurse include in the plan of care for a patient following a myelogram?
Position in a semi-Fowler position for 8 hours to reduce potential of headache
b.
Place patient flat on back to compress puncture site
c.
Ambulate for brief periods to lessen postmyelogram headache
d.
Limit fluids to increase absorption of the dye
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ANS: A
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a.
The patient should be positioned in the semi-Fowler position for 8 hours to encourage the dye to
stay in the lower spine and to reduce headache.
12.Which finding would delay a computed tomography (CT) scan?
a.
Patients allergy to shellfish
b.
Patient in first trimester of a pregnancy
c.
Patients allergy to milk products
d.
Patients gluten intolerance
ANS: A
Allergy to shellfish predicts an allergy to the contrast media used in the CT scan.
13.Forty-eight hours after a patient sustained a fractured femur in a car accident, the nurse
assessed a pulse of 110, respirations at 25, and labored crackles in both lung fields. The nurse
immediately reports to the charge nurse the probability of a(n):
impending pneumonia.
b.
atelectasis.
c.
fat embolism.
d.
anxiety attack.
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a.
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ANS: C
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A pulmonary fat embolism involves the embolization of fat tissue with platelets and circulation
of free fatty acids within the pulmonary circulation. Dyspnea, tachypnea, and chest pain are
symptomatic of a fat embolus.
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14.What is the first priority nursing intervention for an impending fat embolism?
Administer oxygen in a respiratory emergency
b.
Increase intravenous fluids
c.
Position in flat position to ease decreased blood pressure
d.
Cover with warm blanket
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a.
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ANS: A
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The airway is always the first priority. If hypoxia is present, the physician will order the
administration of oxygen. It is important for the nurse to check the liter flow of oxygen and
educate patients and their families as to safety precautions necessary when oxygen is
administered.
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15.A patient, age 68, has suffered an intertrochanteric fracture of the right hip. Before surgery, to
provide support and comfort, an immobilizing device of a ______ is applied.
Thomas splint
b.
Bryant traction
c.
Russell traction
d.
Buck traction
ANS: D
Buck traction is a form of traction used as a temporary measure to provide support and comfort
to a fractured extremity until a more definite treatment is initiated.
16.Which foods should the home health nurse suggest for the patient with osteoporosis to help
slow the disease?
a.
Leafy green vegetables
b.
Foods high in sodium
c.
Tea and coffee
d.
Vitamin A
ANS: A
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To slow the bone loss, a patient with osteoporosis should eat green leafy vegetables, foods low in
sodium, and also avoid caffeine. Vitamin A does not help with the absorption of calcium.
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17.What should the nurse include in the teaching plan for a patient who is taking alendronate
(Fosamax)?
Take drug with any meal
b.
Take drug first thing in the morning
c.
Drink at least 5 oz of milk before taking drug
d.
Take drug with an antacid to avoid heartburn
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a.
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ANS: B
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Alendronate (Fosamax) should be taken on an empty stomach first thing in the morning with 6
oz of water, accompanied by no other medication.
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18.The patient has been diagnosed as having gouty arthritis. The patient asks the nurse to explain
the cause of the inflammation of the great toe. What is the most appropriate nursing response?
You have calcium oxalate deposits that are seen in gouty arthritis.
b.
The inflammation is from small accumulations of uric acid crystals, which are called tophi.
c.
The small nodules are not related to the arthritis condition.
d.
You have fat deposits that are common with gouty arthritis.
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ANS: B
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a.
Gout is a metabolic disease resulting from an accumulation of uric acid in the blood. It is an
acute inflammatory condition associated with ineffective metabolism of purines.
19.When the patient with rheumatoid arthritis complains about the daily exercise, the nurse
encouragingly reminds the patient that exercises:
a.
keeps the joints from freezing.
b.
will ensure better sleep.
c.
should be vigorous for joint stimulation.
d.
need not be done daily.
ANS: A
Daily gentle exercises keep the joints from freezing and keep the muscles from weakening.
immunoglobulin M.
b.
abnormal serum protein.
c.
increased inflammatory reaction in the body.
d.
C-reactive protein.
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a.
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20.The nurse clarifies to a patient who is being evaluated for possible rheumatoid arthritis that
the elevated erythrocyte sedimentation rate indicates the presence of:
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ANS: C
The ESR indicates an increase in the inflammatory reactions in the body.
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21.What should the nurse instruct the patient before the initiation of the antimalarial drug
hydroxychloroquine (Plaquenil)?
Get a complete blood count to assess anemia.
b.
Get a chest x-ray.
c.
Get an eye examination.
d.
Take prophylaxis for malaria.
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a.
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ANS: C
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An eye examination should be completed before starting the drug and an eye examination should
be done every 6 months while on the drug, because the drug can damage the retina and lead to
blindness.
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22.What should the nurse do when a patient with osteomyelitis is admitted with an open wound
that is draining?
Enforce a low calorie diet
b.
Initiate drainage and secretion precautions
c.
Frequently do passive ROM on the elbow
d.
Ambulate several times daily
ANS: B
The patient with osteomyelitis should be at least in drainage and secretion precaution. The limb
should be positioned for maximum comfort and left at rest. These patients are usually on bed rest
and require a high-calorie, high-protein diet.
23.A 16-year-old male patient presents in the emergency room with a pathologic fracture of the
left femur and complains of pain on weight bearing. These are cardinal indicators of:
a.
osteogenic sarcoma.
b.
osteoporosis.
c.
rheumatoid arthritis.
d.
osteochondroma.
ANS: A
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Osteogenic sarcoma occurs in young men aged 10 to 25. They are malignant bone tumors that
can cause a pathologic fracture and they are accompanied by pain on weight bearing.
Osteochondromas are benign and usually do not cause fractures.
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24.The 14-year-old boy who is scheduled for left leg amputation says to the nurse, What in the
world am I going to do with only one leg? What is the nurses most therapeutic response?
What are you thinking about right now?
b.
With a prosthesis, you will be as good as new.
c.
It is way too early to be concerned about that now.
d.
When my brother had his leg removed, he did great!
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a.
ANS: A
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The patients concern should be acknowledged and the patient encouraged to express feelings.
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25.A patient has undergone a bipolar hip repair (hemiarthroplasty). Which is the most
appropriate instruction?
Sit in whatever position is most comfortable
b.
Sit in a firm, straight-backed chair at a 90-degree angle
c.
Avoid crossing the legs
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ANS: C
Begin full weight bearing as soon as tolerated
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d.
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a.
Instructing the patient not to cross the legs is important because crossing the legs can adduct the
affected extremity and dislocate the hip.
26.The nurse explains to a patient who has had a knee replacement that warfarin (Coumadin) is
ordered to:
a.
increase the red blood cells.
b.
reduce the threat of hemorrhage.
c.
prevent formation of emboli.
d.
help stabilize the prosthesis.
ANS: C
Warfarin (Coumadin) is a standard postsurgical drug to prevent the formation of emboli.
27.What should the nurse stress to a posthip replacement patient in quadriceps setting exercises?
Push knee down to mattress and raise heel off the bed
b.
Flex knee and extend foot
c.
Adduct leg and flex foot
d.
Lift leg and heel off the bed
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a.
.c
ANS: A
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Pushing the knee down into the mattress and raising the heel will strengthen the quadriceps
muscles.
b.
Respiratory effort
c.
Sleep cycle
d.
Nutritional status
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Urinary output
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a.
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28.What should the home health nurse include assessment for in the plan of care for an 82-yearold female with severe kyphosis from ankylosis?
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ANS: B
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Severe kyphosis may hinder the patients ability to expand the ribcage and interfere with easy
respiration.
Lift the leg from the mattress and rotate the foot
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b.
Flex the knee and flex the foot
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a.
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29.What should the nurse stress to a patient who has had a hip replacement and is beginning
strengthening exercises for the unaffected leg?
c.
Pull knee to chest and extend the foot
d.
Push foot down against the footboard for a count of five
ANS: D
The unaffected leg should be strengthened by pushing the foot down against the footboard for a
count of five and repeating frequently during the day.
30.The office nurse has noted the presence of an increase in lumbar curvature in a 20-year-old
female patient. What is this condition known as?
a.
Scoliosis
b.
Lordosis
c.
Kyphosis
d.
Spondylitis
ANS: B
ep
31.How is rheumatoid arthritis distinguished from osteoarthritis?
.c
om
Common deformities include an increase in the curve at the lumbar space region that throws the
shoulder back, making the lordly or kingly appearance that is known as lordosis. Scoliosis
involves the S curvature of the spine. Kyphosis is the rounding of the thoracic spine.
Rheumatoid arthritis is an autoimmune, systemic disease; osteoarthritis is a degenerative
disease of the joints.
b.
Rheumatoid arthritis is an autoimmune, degenerative disease; osteoarthritis is a systemic
inflammatory disease.
c.
People with osteoarthritis are considered to be genetically predisposed; there is no known
genetic component to rheumatoid arthritis.
d.
Osteoarthritis is often caused by a virus; viruses play no part in the pathogenesis of rheumatoid
arthritis.
si
ng
te
st
pr
a.
ur
ANS: A
yn
RA is thought to be an autoimmune disorder. Degenerative joint disease is also known as
osteoarthritis.
w
c.
w
b.
43-year-old African American woman
d.
57-year-old white woman
w
a.
.m
32.Which patient is most likely to develop osteoporosis?
48-year-old African American man
62-year-old Latino woman
ANS: B
White and Asian women have a higher incidence of osteoporosis than African American women
or Hispanic women because of the greater bone density in the African American.
33.The patient, age 58, is diagnosed with osteoporosis after densitometry testing. She has been
menopausal for 5 years and has been concerned about her risk for osteoporosis because her
mother has osteoporosis. In teaching her about her osteoporosis, which information does the
nurse include?
a.
Even with a family history of osteoporosis, the calcium loss from bones can be slowed by
increased calcium intake and exercise.
b.
Estrogen replacement therapy must be started to prevent rapid progression of her osteoporosis.
c.
With a family history of osteoporosis, there is no way to prevent or slow bone reabsorption.
d.
Continuous, low-dose corticosteroid treatment is effective in stopping the course of
osteoporosis.
ANS: A
.c
om
To prevent osteoporosis, women are advised to have an adequate daily intake of calcium and
vitamin D; exercise regularly; avoid smoking; decrease coffee intake; decrease excess protein in
the diet; and engage in regular moderate activity such as walking, bike riding, or swimming at
least 3 days a week. A contributing factor may be use of steroids.
b.
Lettuce, corn, potatoes
c.
Beef, pork, chicken
d.
Fruits and fruit juices
st
Brain, liver, kidney
ng
te
a.
pr
ep
34.Certain foods may increase the pain associated with gout. Which foods have the highest
concentration of purines?
si
ANS: A
ur
Foods high in purines, such as brain, kidney, liver, and heart should be avoided, as well as
alcohol.
yn
35.In order for a patient to flex the lower leg, which muscle must be contracted?
Quadriceps
.m
a.
d.
Gastrocnemius
Biceps femoris
Rectus femoris
w
ANS: C
w
c.
w
b.
The contraction of the biceps femoris allows for the contraction of the lower leg.
36.Calcium is a mineral found in many foods that can slow bone loss during the aging process.
Which food is high in calcium?
a.
Oranges
b.
Bananas
c.
Spinach
d.
Eggs
ANS: C
ng
te
st
pr
ep
.c
om
Spinach and green vegetables, as well as yogurt, are considered calcium-rich foods. Fresh
oranges, bananas, and eggs are not good calcium choices.
Chapter 14 Pregnancy
si
MULTIPLE CHOICE
ur
1.Where does implantation of the fertilized ovum usually occur?
Lower uterine wall
yn
a.
Side of the uterus
.m
b.
w
ANS: C
Body of the uterus
w
d.
Fundus of the uterus
w
c.
Implantation usually occurs in the fundus of the uterus.
2.A patient has been diagnosed with a tubal pregnancy. What is the typical outcome of a tubal
pregnancy?
a.
The patient will carry the pregnancy to term and have a cesarean delivery.
b.
The patient will have to remain in bed for the remainder of the pregnancy.
c.
The patient will spontaneously abort this ectopic pregnancy.
d.
The patient will require surgery to remove the zygote.
ANS: D
Any pregnancy where implantation occurs outside the uterine cavity is called ectopic. Tubal
pregnancies usually must be resolved by surgical removal of the zygote.
a.
3 weeks
b.
4 weeks
c.
6 weeks
d.
8 weeks
om
3.How long does the embryonic stage of pregnancy typically last?
.c
ANS: D
ep
The embryonic stage encompasses the first 8 weeks.
pr
4.Why is the nurse concerned about a patient in her first trimester of pregnancy being exposed to
German measles?
The disease is capable of causing a spontaneous abortion.
b.
The disease is capable of causing birth defects.
c.
The disease is capable of causing high fever and convulsions.
d.
The disease is capable of interfering with placental implantation.
ng
te
st
a.
si
ANS: B
yn
ur
Rubella is a known teratogen, which can cause birth defects.
.m
5.Which hormone is secreted by the placenta?
a.
w
d.
w
c.
Alpha-fetoprotein (AFP)
Human chorionic gonadotropin (HCG)
w
b.
Follicle-stimulating hormone (FSH)
Luteinizing hormone (LH)
ANS: C
The placenta functions as an endocrine gland, secreting estrogen, progesterone, and HCG.
6.What protects the fetus from most bacterial infections?
a.
The yolk sac
b.
The placental barrier
c.
The cotyledons
d.
The chorionic villa
ANS: B
The placental barrier protects the embryo/fetus from most bacteria, but not from viruses or drugs.
The cotyledons are sections that make up the placenta. The chorionic villa are tiny vascular
projections on the chorionic surface that help form the placenta.
Beginning of pregnancy to midterm
b.
Conception to third trimester
c.
Onset of labor to delivery of the baby
d.
Onset of labor to delivery of the placenta
ep
ANS: D
.c
a.
om
7.What period of the maternity cycle does the intrapartal period cover?
te
st
pr
The intrapartal period of the maternity cycle covers the onset of labor to delivery of the placenta.
The antepartal period begins at conception and continues until the onset of labor. The postpartal
period begins after the delivery of the placenta and continues for approximately 6 weeks, until
the reproductive organs return to their prepregnancy state.
ng
8.A woman who has just discovered she is pregnant states that the first day of her last menstrual
period was July 10. What will be her expected date of birth (EDB)?
April 10
b.
April 17
ur
si
a.
May 10
yn
c.
d.
October 17
.m
ANS: B
w
w
To determine the EDB (estimated date of birth), the woman should count from the first day of
her last menstrual period. Count back 3 months and forward 7 days.
w
9.Which is a positive sign of pregnancy?
a.
Positive pregnancy test
b.
Positive Chadwick sign
c.
Ultrasonic tracing of the fetus
d.
Positive Goodell sign
ANS: C
A positive sign of pregnancy is an ultrasonic tracing of the fetus. A positive pregnancy test,
positive Chadwick sign, and positive Goodell sign are all probable signs of pregnancy.
10.What is the cause of frequent urination in early pregnancy?
a.
Increased fluid intake
b.
The fetuss kidneys functioning
c.
Retention of fluid
d.
Increased circulating volume
ANS: D
om
Early in pregnancy, the increase in circulating volume and the enlarging uterus placing pressure
on the bladder cause urinary frequency.
.c
11.A woman asks the nurse about the safety of sexual intercourse during her pregnancy. Which
response by the nurse is the most correct?
Sexual activity should be avoided after the first trimester.
b.
Sexual activity should be ceased in the case of vaginal bleeding.
c.
Sexual activity should be avoided in the second trimester.
d.
Sexual activity should be limited to activity that does not include intercourse.
te
st
pr
ep
a.
ANS: B
si
ng
Sexual intercourse can be enjoyed throughout pregnancy unless it is contraindicated by other
conditions. In the case of vaginal bleeding, sexual activity should cease until the cause of the
bleeding is determined by the doctor.
yn
ur
12.A woman tells the nurse that this is her third pregnancy. She has had twin girls at full term
and one miscarriage. How does the nurse record the information?
G2, T2, L3
.m
a.
d.
G3, T3, A2, L1
G3, T1, A1, L2
w
ANS: D
w
c.
G4, T3, A1, L1
w
b.
Standard obstetrical terminology is: G = gravida, T = term birth, P = preterm birth, A = abortion,
L = living children.
13.During which gestational week can a primigravida expect to first feel fetal movement?
a.
8
b.
10
c.
16
d.
20
ANS: C
At about 16 to 18 weeks, the sensation of the first movement is felt.
a.
10
b.
12
c.
14
d.
16
om
14.At what week of fetal development can the nurse expect to first hear fetal heart tones with an
amplified stethoscope?
.c
ANS: D
ep
During week 16, the fetal heart can be heard with an amplified stethoscope.
1 month
b.
3 months
c.
4 months
d.
6 months
si
ng
te
a.
st
pr
15.The nurse assures an anxious primigravida that during fetal development from week 34 and
beyond, maternal antibodies are transferred to the baby. How long will these antibodies provide
the baby with immunity?
ur
ANS: D
yn
The maternal antibodies that are transferred to the baby provide immunity for 6 months.
.m
16.Early in the first trimester, a woman complains of morning sickness. What does the nurse
suggest to aid with the discomfort?
c.
w
d.
Eating dry crackers before getting up
w
b.
Eating something with a high-fat content
w
a.
Eating three well-balanced meals
Getting rest and taking antiemetics
ANS: B
A remedy for morning sickness is to eat a few dry crackers before getting up.
17.What does the increase in circulating blood volume during pregnancy cause in the mother?
a.
Shortness of breath
b.
Frontal headaches
c.
Decreased white blood cell count
d.
Decreased hemoglobin
ANS: D
Maternal circulating volume increases 30% to 40%, causing a virtual decrease in hemoglobin.
Use heavy makeup
b.
Take extra doses of vitamin A
c.
Avoid exposure to the sun
d.
Reduce caffeine intake
.c
a.
om
18.A woman entering the 22nd week of pregnancy complains that she has become unsightly
because of chloasma. What should the nurse recommend to reduce the appearance of the
chloasma?
ep
ANS: C
st
pr
At week 22, skin pigment changes called chloasma are found. Avoiding exposure to the sun will
reduce the pigmentation.
ng
te
19.During the final weeks of pregnancy, urinary frequency may return due to the enlarged uterus,
compressing the bladder against the pelvic bones. What does the nurse suggest to aid in relieving
the urinary frequency?
Decrease fluid intake
b.
Use the knee-chest position
c.
Sleep on her side
d.
Avoid fluid intake in evening
yn
ur
si
a.
.m
ANS: C
w
w
The patient should decrease pressure on the bladder at night by sleeping on her side. Fluids
should not be decreased unless directed by a physician.
w
20.A pregnant teenager presents with the following complaints. Which complaint could be an
indicator of a serious complication?
a.
Painful hemorrhoids
b.
Linea nigra
c.
Visual disturbances
d.
Low back pain
ANS: C
Visual disturbances may be an indicator of increased blood pressure and retained fluids. These
are indicators of eclampsia. Hemorrhoids, linea nigra, and back pain are common discomforts of
pregnancy.
21.During the last trimester of pregnancy, the nurse recommends that the woman wear lowheeled shoes. What is the nurse trying to prevent with this recommendation?
Lower back pain
b.
Leg cramps
c.
Leg swelling
d.
Joint pain
om
a.
.c
ANS: A
ep
A remedy for backache is to wear low-heeled shoes.
Brain
b.
Lungs
c.
Hands
ng
te
a.
st
pr
22.The newly diagnosed primigravida who is 6 weeks pregnant states, I dont feel like I have a
real baby inside me. To reassure the mother, the nurse provides reassurance that which of the
following is functioning in the 6-week-old embryo?
Heart
si
d.
ur
ANS: D
.m
yn
At 6 weeks, the fetus has a pumping heart.
23.Smoking by the mother can have what effect in the fetus?
w
c.
w
b.
Hearing deficits
w
a.
d.
Neuromuscular deformities
Cerebral palsy
Low birth weight
ANS: D
Smoking has been proven to cause slow intrauterine growth and low birth weight.
24.When can the sex of the fetus be confirmed?
a.
Conception
b.
2 weeks
c.
6 weeks
d.
9 weeks
ANS: D
At 9 weeks the genitalia are well defined.
b.
Alpha-fetoprotein
c.
Amniocentesis
d.
Ultrasound
.c
Biophysical profile
ep
a.
om
25.The physician decides to send the mother for a test to determine the fetal lung maturity. What
is the name of this fetal well-being test?
pr
ANS: C
st
Amniocentesis helps determine the maturity of the fetal lungs.
ng
te
26.When the young primigravida asks about how to adjust her diet for her pregnancy, what
should the nurse suggest the mother add to her diet?
Leafy green vegetables and fruit
b.
Beef and poultry
c.
Foods high in sodium and potassium
d.
Bread and grains
yn
ur
si
a.
.m
ANS: A
w
A pregnant woman should eat foods containing roughage, such as raw fruits, vegetables, and
cereals with bran.
w
w
27.Which of the following discomforts of a pregnant woman should be reported to the physician
at the first occurrence?
a.
Leg cramps
b.
Pelvic discomfort
c.
Vaginal bleeding
d.
Urinary frequency
ANS: C
Vaginal bleeding at any time during pregnancy should be reported to the physician. Leg cramps,
pelvic discomfort, and urinary frequency are common discomforts of pregnancy and not a cause
for immediate concern.
28.What do the arteries in the umbilical cord carry?
Nutrients to the fetus from the placenta
b.
Oxygenated blood to perfuse the placenta
c.
Antibodies from the fetus to the mother
d.
Deoxygenated blood back to the placenta
om
a.
ANS: D
ep
.c
The arteries of the umbilical cord are unique in that they carry deoxygenated blood back to the
placenta.
pr
29.What should a nurse instruct the patient to do before assessing fundal height?
Press her lower back against the examination table
b.
Empty her bladder
c.
Take a deep breath and hold it
d.
Bear down
ng
te
st
a.
si
ANS: B
yn
MULTIPLE RESPONSE
ur
The bladder should be emptied before the measurement of the fundal height.
w
c.
w
b.
w
a.
.m
30.The nurse concludes that the prenatal patient has no need for further instruction when she
correctly states that amniocentesis can determine which of the babys characteristics? (Select all
that apply.)
Sex
Maturity
Approximate weight
d.
Health
e.
Genetic defects
ANS: A, B, D, E
The amniocentesis can reveal the sex, maturity, health, and some genetic defects.
31.Which of the following demonstrate culturally competent care of the pregnant patient? (Select
all that apply.)
a.
Discuss beliefs with the patient and incorporate them in the plan of care.
b.
Prohibit visits from anyone other than immediate family members.
c.
Require the patients participation in every aspect of the health care system.
d.
Maintain the patients modesty at all times.
e.
Strive to maintain a harmonious environment for the patient.
ANS: A, D, E
ep
.c
om
The nurse should discuss the patients cultural beliefs and incorporate as many as possible into
the plan of care. Modesty is important in almost all cultures, and the nurse should take measures
to ensure the patients modesty. Absence of a stressful environment is important for a positive
outcome for both mother and baby, and the nurse should strive to alleviate stress and maintain a
harmonious environment. Many cultures will foster relationships, and visits from extended
family members may be important. The patient may not participate in all aspects of the health
care system due to cultural issues.
pr
COMPLETION
te
st
32.The nurse instructor reminds the nursing student that the Shiny Schultz is a name given to the
_____________ side of the placenta.
ng
ANS:
fetal
ur
si
The fetal side of the placenta is called the Shiny Schultz and the maternal side is called the Dirty
Duncan.
.m
yn
36. Which factor is most important in diminishing maternal, fetal, and neonatal complications in
a pregnant client with diabetes?
a.
Evaluation of retinopathy by an ophthalmologist
The clients stable emotional and psychological status
c.
Degree of glycemic control before and during the pregnancy
w
b.
w
w
d.
Total protein excretion and creatinine clearance within normal limits
ANS: C
The occurrence of complications can be greatly diminished by maintaining normal blood glucose
levels before and during the pregnancy. Even nonpregnant diabetics should have an annual eye
examination. Assessing a clients emotional status is helpful. Coping with a pregnancy
superimposed on preexisting diabetes can be very difficult for the whole family. However, it is
not the top priority. Baseline renal function is assessed with a 24-hour urine collection and does
not diminish the clients risk for complications.
37. Which major neonatal complication is carefully monitored after the birth of the infant of a
diabetic mother?
a.
Hypoglycemia
b.
Hypercalcemia
c.
Hypoinsulinemia
Maternal age younger than 25 years
c.
Underweight prior to pregnancy
ep
b.
.c
om
d.
Hypobilirubinemia
ANS: A
The neonate is at highest risk for hypoglycemia because fetal insulin production is accelerated
during pregnancy to metabolize excessive glucose from the mother. At birth, the maternal
glucose supply stops, and the neonatal insulin exceeds the available glucose, leading to
hypoglycemia. Hypocalcemia is associated with preterm birth, birth trauma, and asphyxia, all
common problems of the infant of a diabetic mother. Because fetal insulin production is
accelerated during pregnancy, the neonate shows hyperinsulinemia. Excess erythrocytes are
broken down after birth, releasing large amounts of bilirubin into the neonates circulation, which
results in hyperbilirubinemia.
38. Which factor is known to increase the risk of gestational diabetes mellitus?
a.
Previous birth of large infant
ur
si
ng
te
st
pr
d.
Previous diagnosis of type 2 diabetes mellitus
ANS: A
Prior birth of a large infant suggests gestational diabetes mellitus. A client younger than 25 is not
at risk for gestational diabetes mellitus. Obesity (>90 kg [198 lb]) creates a higher risk for
gestational diabetes. The person with type 2 diabetes mellitus already is a diabetic and will
continue to be so after pregnancy. Insulin may be required during pregnancy because oral
hypoglycemia drugs are contraindicated during pregnancy.
39. Which disease process improves during pregnancy?
a.
Epilepsy
Bells palsy
c.
Rheumatoid arthritis
yn
b.
w
w
w
.m
d.
Systemic lupus erythematosus (SLE)
ANS: C
Although the reason is unclear, marked improvement is seen with rheumatoid arthritis in
pregnancy. Most women relapse 6 weeks to 6 months postpartum. With epilepsy, the effect of
pregnancy is variable and unpredictable. Seizures may increase, decrease, or remain the same.
Bells palsy was thought to be caused by a virus three times more common during pregnancy and
generally occurring in the third trimester. The client with SLE can have a normal pregnancy but
must be treated as high risk because 50% of all births will be premature. Pregnancy can
exacerbate SLE.
40. When a pregnant client with diabetes experiences hypoglycemia while hospitalized, which
should the nurse have the client do?
a.
Eat a candy bar.
b.
Eat six saltine crackers or drink 8 oz of milk.
c.
Drink 4 oz of orange juice followed by 8 oz of milk.
d.
Drink 8 oz of orange juice with 2 teaspoons of sugar added.
b.
increased throughout pregnancy and the postpartum period.
c.
decreased throughout pregnancy and the postpartum period.
om
ANS: B
Crackers provide carbohydrates in the form of polysaccharides. A candy bar provides only
monosaccharides. Milk is a disaccharide and orange juice is a monosaccharide. This will help
increase the blood sugar level but will not sustain it. Orange juice and sugar will increase the
blood sugar level but will not provide a slow-burning carbohydrate to sustain it.
41. Nursing intervention for pregnant clients with diabetes is based on the knowledge that the
need for insulin is:
a.
varied depending on the stage of gestation.
c.
Rheumatic heart disease
te
Mitral valve prolapse
ng
b.
st
pr
ep
.c
d.
should not change because the fetus produces its own insulin.
ANS: A
Insulin needs decrease during the first trimester, when nausea, vomiting, and anorexia are a
factor. Insulin needs increase during the second and third trimesters, when the hormones of
pregnancy create insulin resistance in maternal cells. Insulin needs change during pregnancy.
42. Which form of heart disease in women of childbearing years usually has a benign effect on
pregnancy?
a.
Cardiomyopathy
.m
yn
ur
si
d.
Congenital heart disease
ANS: B
Mitral valve prolapse is a benign condition that is usually asymptomatic. Cardiomyopathy
produces congestive heart failure during pregnancy. Rheumatic heart disease can lead to heart
failure during pregnancy. Some congenital heart diseases will produce pulmonary hypertension
or endocarditis during pregnancy.
43. Which instructions should the nurse include when teaching a pregnant client with Class II
heart disease?
a.
Advise her to gain at least 30 pounds.
Instruct her to avoid strenuous activity.
c.
Inform her of the need to limit fluid intake.
w
w
b.
w
d.
Explain the importance of a diet high in calcium.
ANS: B
Activity may need to be limited so that cardiac demand does not exceed cardiac capacity. Weight
gain should be kept at a minimum with heart disease. Iron and folic acid are important to prevent
anemia. Fluid intake is necessary to prevent fluid deficits. Fluid intake should not be limited
during pregnancy. The client may also be put on a diuretic.
44. The most important instruction to include in a teaching plan for a client in early pregnancy
who has Class I heart disease is she:
a.
must report any nausea or vomiting.
b.
may experience mild fatigue in early pregnancy.
c.
must report any chest discomfort or productive cough.
b.
postpartum infection.
c.
bacterial endocarditis.
om
d.
should plan to increase her daily exercise gradually throughout pregnancy.
ANS: C
Angina or a productive cough may signal congestive heart failure or pulmonary edema. Nausea
and vomiting are expected in early pregnancy. Mild fatigue is expected in early pregnancy.
Depending on the severity of the heart disease, the client may need to limit physical activity.
45. Antiinfective prophylaxis is indicated for a pregnant client with a history of mitral valve
stenosis related to rheumatic heart disease because the client is at risk of developing:
a.
hypertension.
ng
te
st
pr
ep
.c
d.
upper respiratory infections.
ANS: C Because of vegetations on the leaflets of the mitral valve and the increased demands of
pregnancy, the client is at greater risk of bacterial endocarditis. Pulmonary hypertension may
occur with mitral valve stenosis, but antiinfective medications will not prevent it from occurring.
Women with cardiac problems must be observed for possible infections during the postpartum
period but are not given prophylactic antibiotics to prevent them. Women are not put on
prophylactic antibiotics to prevent upper respiratory infections.
46. When planning intrapartum care for a client with heart disease, the nurse should include:
a.
taking vital signs according to standard protocols.
continuously monitoring cardiac rhythm with telemetry.
c.
massaging the uterus to hasten birth of the placenta.
si
b.
Toxoplasmosis
w
b.
w
w
.m
yn
ur
d.
maintaining the infusion of intravenous fluids to avoid dehydration.
ANS: B A client with heart disease should have a cardiac monitor and possibly an arterial line
for continuous blood pressure monitoring, as well as hemodynamic monitoring. Vital signs may
need to be taken more frequently because of the extra workload on the heart. The uterus should
not be massaged to hasten the birth of the placenta because this could cause undue overload on
the heart. Circulatory overload can occur, so IV fluids may not be used or may be used
minimally.
47. For which of the following infectious diseases can a woman be immunized?
a.
Rubella
c.
Cytomegalovirus
d.
Herpesvirus type 2
ANS: A Rubella is the only infectious disease for which a vaccine is available. There are no
vaccines available for toxoplasmosis, cytomegalovirus, or herpesvirus type 2.
48. A client, who delivered her third child yesterday, has just learned that her two school-age
children have contracted chickenpox. What should the nurse tell her?
a.
Her two children should be treated with acyclovir before she goes home from the hospital.
b.
The baby will acquire immunity from her and will not be susceptible to chickenpox.
c.
The children can visit their mother and baby in the hospital as planned but must wear gowns
and masks.
Plan for retesting during the third trimester.
c.
Discuss the recommendation to bottle feed her baby.
ep
b.
.c
om
She must make arrangements to stay somewhere other than her home until the children are no
d.
longer contagious.
ANS: D Varicella (chickenpox) is highly contagious. Although the baby inherits immunity from
the mother, it would not be safe to expose either the mother or the baby. Acyclovir is used to
treat varicella pneumonia. The baby is already born and has received the immunity. If the mother
never had chickenpox, she cannot transmit the immunity to the baby. Varicella infection
occurring in a newborn may be life threatening.
49. A client has a history of drug use and is screened for hepatitis B during the first trimester.
Which action is appropriate?
a.
Practice respiratory isolation.
ng
te
st
pr
d.
Anticipate administering the vaccination for hepatitis B as soon as possible.
ANS: B A person who has a history of high-risk behaviors should be rescreened during the third
trimester. Hepatitis B is transmitted through blood. The first trimester is too early to discuss
feeding methods with a woman in the high-risk category. The vaccine may not have time to
affect a person with high-risk behaviors.
50. A client has tested HIV-positive and has now discovered that she is pregnant. Which
statement indicates that she understands the risks of this diagnosis?
a.
I know I will need to have an abortion as soon as possible.
Even though my test is positive, my baby might not be affected.
c.
My baby is certain to have AIDS and die within the first year of life.
ur
si
b.
w
w
w
.m
yn
d.
This pregnancy will probably decrease the chance that I will develop AIDS.
ANS: B The fetus is likely to test positive for HIV in the first 6 months, until the inherited
immunity from the mother wears off. Many of these babies will convert to HIV-negative status.
With the newer drugs, the risk for infection of the fetus has decreased. Also, the life span of an
infected newborn has increased. The pregnancy will increase the chance of converting.
om
.c
ep
pr
st
te
ng
Chapter 15 Psychiatric Disorders, Violence, Abuse and Neglect Issues
si
MULTIPLE CHOICE
yn
ur
1.The nurse is discussing the differences between a patient with a neurosis and one with a
psychosis. What is true of the patient experiencing a neurosis?
The patient experiences a flight from reality.
b.
The patient usually needs hospitalization.
c.
The patient has insight that there is an emotional problem.
d.
The patient has severe personality deterioration.
w
w
w
ANS: C
.m
a.
An individual with a neurosis has insight that he has an emotional problem. A person with
psychosis is out of touch with reality and has severe personality deterioration. Treatment for
neurosis is usually completed in the outpatient setting, while treatment for psychosis often
requires hospitalization.
2.When the patient with a psychosis is thought to be a danger to self or others, by what method
should the patient be admitted to the hospital?
a.
Probating
b.
Nurses request
c.
Physicians order
d.
Family request
ANS: A
Probating can be done if the individual is thought to be a danger to self or others.
c.
Multiaxial system
d.
Evaluation system
.c
Hierarchical system
ep
b.
om
3.The Diagnostic and Statistical Manual of Psychiatric Disorders, V (DSM-V), is used by most
hospitals and is the current tool used to examine mental health and illness. What approach does
the DSM-V use to classify mental disorders?
a.
Holistic system
pr
ANS: C
Individualized
c.
Holistic
d.
Organic
ur
si
ng
b.
te
st
The DSM-V is a multiaxial system.
4.When all five axes of the Diagnostic and Statistical Manual of Psychiatric Disorders, V, are
used, it provides what type of assessment approach to comprehensive care?
a.
Personalized
yn
ANS: C
Using all five axes of the DSM-V provides a holistic assessment.
w
b.
w
a.
w
.m
5.A young man with malaria spikes a temperature of 105 F and begins to hallucinate. How
should the nurse assess this?
Delirium
Psychotic break
c.
Possible stroke
d.
Anxiety disorder
ANS: A
Delirium is an organic mental disorder that is frequently brought on by a severe physical illness,
such as fever.
6.A patient admitted for delirium demonstrates increased disorientation and agitation only during
the evening and nighttime. What is the term applied to this type of delirium?
a.
Disordered thinking
b.
Schizophrenia
c.
Dementia
d.
Sundowning syndrome
ANS: D
Chemical imbalance
b.
Emotional problems
c.
Circulatory impairment
d.
Cerebral disease
te
st
a.
pr
ep
.c
7.Dementia is an organic mental disease secondary to what problem?
om
A patient with sundowning syndrome displays increased disorientation and agitation only during
evening and nighttime. Disordered thinking occurs when an individual is not able to interpret
information being received in the brain. Disordered thinking is one characteristic of
schizophrenia, which is a large group of psychotic disorders that includes nonreality-based
thinking. Dementia is an altered mental state secondary to cerebral disease.
ng
ANS: D
Dementia describes an altered mental state secondary to cerebral disease.
ur
si
8.A profound, disabling mental illness is characterized by bizarre, nonreality thinking. What is
the illness?
Manic depressive
yn
a.
b.
Schizophrenia
Paranoia
.m
c.
w
ANS: B
Bipolar
w
d.
w
Schizophrenia, a thought process disorder, is one of the most profoundly disabling mental
illnesses.
9.A patient believes himself to be the president of the United States and that terrorists are trying
to kidnap him. The nurse records these observations as which type of behavior?
a.
Absent behavior
b.
Positive behavior
c.
Negative behavior
d.
False behavior
ANS: B
The behaviors of schizophrenic individuals can be categorized as positive (or excessive) or
negative (or absent). Examples of positive behaviors include hallucinations, delusions, and
disordered thinking. Examples of negative behaviors include apathy, social withdrawal, and flat
affect.
10.The patient talks with his dead brother and arranges furniture so that his brother will have a
place to sit. How should the nurse document this behavior?
Disordered thinking
b.
Anhedonia
c.
Hallucination
d.
Alogia
.c
om
a.
ep
ANS: C
st
pr
A hallucination is a sensory experience without a stimulus trigger. Disordered thinking occurs
when the individual is not able to interpret information being received in the brain. Anhedonia
describes lack of expressed feelings. Alogia is reduced content of speech.
b.
Poor
c.
Good
d.
te
Guarded
si
ng
a.
ur
11.What is the prognosis for a schizophrenic patient who is exhibiting positive behaviors?
yn
Repeatable
ANS: C
.m
Prognosis for schizophrenic patients who are exhibiting positive behavior patterns is good.
The patient immediately examines his watch.
w
b.
The patient fixedly begins to watch his feet.
w
a.
w
12.The nurse cautions a patient to watch his step. What response indicates concrete thinking?
c.
The patient begins to watch the nurses feet.
d.
The patient stands rigidly in one place without moving.
ANS: A
Concreteness is an indication of disordered thinking. The patient is unable to translate any words
except by a very concrete definition.
13.The nurse asks a patient with schizophrenia if he had any visitors on Sunday. Which response
indicates loose association?
a.
No.
b.
Yes! I had 90 visitors who came from every state in the union.
c.
Sunday is the Sabbath. Do we have visitors on the Sabbath?
d.
We visited Yellowstone Park last summer.
ANS: D
Loose association is a type of disordered thinking that occurs when the individual cannot
interpret information and the conversation does not flow.
om
14.The nurse is caring for a patient with a diagnosis of catatonic schizophrenia. What behavior is
consistent with this diagnosis?
Talks excitedly about going home
b.
Suspiciously watches the staff
c.
Stands on one foot for 15 minutes
d.
States he has a cat under his bed that talks to him
pr
ep
.c
a.
te
st
ANS: C
ng
Maintaining a rigid pose for long periods of time is an example of behavior expected with
catatonic schizophrenia.
ur
si
15.What is the term used for the beginning stage of schizophrenia, characterized by a lack of
energy and complaints of multiple physical problems?
a.
Prepsychotic
Residual
yn
b.
Acute
.m
c.
ANS: D
Prodromal
w
d.
w
w
The prodromal phase is the beginning stage of schizophrenia. Hallucinations and delusions
sometimes occur in the prepsychotic stage. In the acute phase, individuals often lose touch with
reality. The residual phase follows the acute phase and the symptoms of that phase are similar to
those of the prodromal stage.
16.For the past 3 weeks, the nurse has observed a patient interacting with staff and other patients,
helping decorate the dining room for a party, and leading the singing in the activity room. Today,
the patient tearfully refuses to dress or get out of bed. The nurse recognizes these behaviors as
evidence of which psychiatric disorder?
a.
Unipolar depression
b.
Dysthymic disorder
c.
Hypomanic episode
d.
Bipolar disorder
ANS: D
Bipolar disorder can cause the patient to experience a sudden shift in emotion from one extreme
to the other.
b.
20% to 30%
c.
35% to 50%
d.
60% to 80%
.c
10% to 15%
ep
a.
om
17.The nurse recognizes that researchers have identified that hereditary factors account for what
percentage of mood disorders?
pr
ANS: D
st
Research indicates that hereditary factors account for 60% to 80% of mood disorders.
ng
te
18.A home health nurse has a patient who is taking lithium. What should be included in the
teaching plan?
Examine her skin closely for eruptions
b.
Take her blood pressure twice a day to check for hypertension
c.
Have her drug blood level checked every month
d.
Avoid aged cheese and red wine
yn
ur
si
a.
ANS: C
w
.m
Lithium has a very narrow therapeutic window. The drug blood levels should be closely
monitored.
w
a.
w
19.The nurse alters the care plan for a patient with depression to include what type of activity?
Domino game with three other patients
b.
Ping-Pong game with one other patient
c.
Group outing to view wildflowers
d.
Magazine to read alone
ANS: C
The quiet, noncompetitive trip to view wildflowers would be the best option. Depressed people
should not be put in situations where they must concentrate or compete.
20.The nurse is assessing a female patient who has become rapidly and exceedingly anxious
because her fingernail polish is chipped. What type of anxiety should the nurse conclude that the
patient is exhibiting?
a.
Signal anxiety
b.
General anxiety
c.
Anxiety traits
d.
Panic disorder
om
ANS: C
.c
An individual with anxiety traits has anxious reactions to relatively nonstressful events. Signal
anxiety is a learned response to an event such as test taking. An individual with general anxiety
worries over many things. A panic attack occurs suddenly and typically peaks within 10 minutes.
b.
Depression
c.
Agoraphobia
d.
Anxiety
te
Mania
si
ng
a.
st
pr
ep
21.The home health nurse assesses a patient who creates elaborate excuses for not leaving home.
Further questioning reveals the patient had not left home for 6 months. How should this be
documented?
ur
ANS: C
yn
Agoraphobia is a high level of anxiety in which an anxiety attack could occur in individuals who
avoid other people, places, or events.
w
b.
w
a.
w
.m
22.When a patient demonstrates accelerated heart rate, trembling, choking, and chest pain along
with acute, intense, and overwhelming anxiety, the nurse should recognize that the patient is
most likely experiencing what condition?
Terror
Fright
c.
Fear
d.
Panic
ANS: D
Panic can be defined as an attack of acute, intense, and overwhelming anxiety.
23.When a patient is experiencing a panic attack, how should the nurse best assist the patient?
a.
Assist with reality orientation
b.
Aid in decision making
c.
Assist with rational thought
d.
Coach in deep breathing
ANS: D
Coaching in relaxation techniques such as deep breathing is an effective intervention for a patient
who is experiencing a panic attack.
om
24.A patient is frequently late for appointments because he goes back to his room numerous
times to assure himself that none of his belongings have been stolen. What does this behavior
represent?
Senseless behavior
b.
Controlled repetition
c.
Obsessive-compulsive
d.
Anxiety tension
pr
ep
.c
a.
st
ANS: C
ng
te
Obsessive-compulsive disorders have two features: thoughts that are recurrent, intrusive, and
senseless; and behaviors that are performed repeatedly and ritualistically.
si
25.A 14-year-old survivor of a school shooting screams and dives under a table when
firecrackers go off. What does this behavior represent?
Phobia
b.
Post-traumatic stress disorder
c.
Obsessive-compulsive disorder
d.
Disordered thinking
yn
.m
w
ANS: B
ur
a.
w
w
Post-traumatic stress disorder describes a response to an intense traumatic experience that is
beyond the usual range of human experience.
26.What should the nurse preparing a patient for a scheduled appointment for electroconvulsive
therapy (ECT) remind the patient to do?
a.
Drink plenty of fluids before ECT to ensure adequate hydration.
b.
Bring a change of clothes in case of incontinence.
c.
Be prepared for visual disturbances after the treatment.
d.
Arrange for transportation to and from the appointment.
ANS: D
If the patient has not arranged for adequate transportation to and from the appointment, the
treatment will be canceled because driving after ECT is dangerous. The patient is typically NPO
before the procedure. Incontinence and visual disturbances are not common following the
procedure.
a.
Homosexuality
b.
Transsexualism
c.
Heterosexuality
d.
Bisexuality
om
27.The nurse is told that a patient believes he was born into the wrong body. What is the correct
terminology for the desire to have the body of the opposite sex?
.c
ANS: B
pr
ep
Transsexualism is a persistent desire to be the opposite sex and to have the body of the opposite
sex.
Obsessive-compulsive disorder
b.
Phobia anxiety disorder
c.
Somatoform disorder
d.
Delusional disorder
ur
si
ng
te
a.
st
28.The patient complains of recurrent, multiple physical ailments for which there is no organic
cause. How should the nurse assess this?
yn
ANS: C Somatoform disorder is characterized by recurrent, multiple physical complaints for
which there is no organic cause.
.m
29.What disorder is a severe form of self-starvation that can lead to death?
c.
w
d.
w
b.
Bulimia nervosa
w
a.
Anorexia nervosa
Teenage nervosa
Obesity nervosa
ANS: B Anorexia nervosa is a severe form of self-starvation that can lead to death.
30.The patient is concerned about confidentiality and asks the nurse not to tell anyone what is
said. What is the best response by the nurse?
a.
I am required to report any intent to hurt yourself or others.
b.
Conversations between patient and nurse are confidential.
c.
What we say can be secret. What I write in the chart is available to the health team.
d.
I cant help you unless you trust me.
ANS: A No secrets are allowed to be kept by a member of the health care team.
a.
Adjunctive
b.
Behavior
c.
Psychoanalysis
d.
Cognitive
om
31.What is the term for a long-term and intense form of psychotherapy developed by Sigmund
Freud that allows a patients unconscious thoughts to be brought to the surface?
.c
ANS: C Psychoanalysis technique was developed by Sigmund Freud and is a long-term and
intense therapy.
ep
32.What is the typical schedule for electroconvulsive therapy (ECT)?
3 treatments over 2 weeks
b.
6 treatments over 2 months
c.
8 treatments over several weeks
d.
10 treatments over several weeks
ng
te
st
pr
a.
si
ANS: D ECT is done as a treatment for depression, mania, and schizoaffective disorders that
have not responded to other treatments. The usual protocol is 10 treatments over several weeks.
yn
ur
33.A patient who is taking a monoamine oxidase inhibitor (MAOI) asks the nurse about the
addition of St. Johns wort to help with his depression. What would be the best response of the
nurse?
That is a great idea. Alternative therapies can be very helpful.
b.
You will feel better sooner if you include phenylalanine.
c.
Did you know that St. Johns wort can raise your blood pressure dramatically?
d.
You will need to drink lots of water.
w
w
.m
a.
w
ANS: C S. Johns wort can raise blood pressure dramatically in people who are also taking
MAOIs.
34.Adjunctive therapies are used for which reasons? (Select all that apply.)
a.
To increase self-esteem
b.
To promote positive interaction
c.
To enhance reality orientation
d.
To stimulate communication
e.
To increase energy
ANS: A, B, C The purpose of adjunctive therapies is to increase self-esteem, promote positive
interaction, and enhance reality orientation.
35.What are considered warning signs of suicide? (Select all that apply.)
Talking about suicide
b.
Increased interactions with friends and family
c.
Drug or alcohol abuse
d.
Difficulty concentrating on work or school
e.
Personality changes
.c
om
a.
te
st
pr
ep
ANS: A, C, D, E Warning signs of suicide include talking about suicide, decreased interactions
with friends and family, drug/alcohol abuse, difficulty concentrating on work or school, and
personality changes.
ng
Chapter 16 Pulmonary Disorders
ur
1.What is the purpose of the cilia?
si
MULTIPLE CHOICE
Warm and moisturize inhaled air
b.
Sweep debris toward nasal cavity
c.
Stimulate cough reflex
.m
yn
a.
w
ANS: B
Produce mucus
w
d.
w
The cilia are fine hairlike processes on the outer surfaces of small cells that produce a motion
that sweeps the debris toward the nasal cavity. Large particles that are swept away stimulate the
cough reflex, but not the cilia themselves.
2.What happens when there is a decrease in the oxygen level in the blood?
a.
Pituitary stimulates the respiratory system to increase respiratory rate
b.
The alveoli diffuse more oxygen into the blood
c.
Chemoreceptors in the carotid body and aortic body stimulate the respiratory centers to modify
respiratory rates
d.
The parietal pleura increases the negative pressure
ANS: C
The chemoreceptors in the carotid bodies and the aortic bodies send a message to the respiratory
centers to modify respirations.
3.A nursing diagnosis for the patient with a new laryngectomy would be Social isolation related
to impaired verbal communication related to removal of the larynx. What is an appropriate
nursing intervention?
a.
Complete care quickly
Provide a pad and pencil or magic slate
c.
Refrain from conversations with the patient to reduce stress level
d.
Offer books or jigsaw puzzles for entertainment
om
b.
.c
ANS: B
pr
ep
Provide patient with implements for communication. Rapidly completing care and provision of
solitary activities does not reduce social isolation.
te
st
4.A 55-year-old man comes to the health nurse at his place of work with epistaxis. He reports he
has frequent nosebleeds that he can usually control himself. What would be the most helpful
assessment after the nurse has stopped the bleeding?
Obtain a blood pressure
b.
Record the approximate amount of blood lost
c.
Inquire about a headache
d.
Record the last episode of epistaxis
ur
si
ng
a.
yn
ANS: A
.m
Check the blood pressure for hypotension to assess for hypovolemic shock. Adults can lose as
much as 1 L of blood in an hour with heavy epistaxis.
w
a.
w
w
5.The nurse assessing an 11-year-old who is having an asthma attack expects to hear adventitious
sounds of:
friction rub.
b.
sibilant wheezes.
c.
crackles.
d.
sonorous wheezes.
ANS: B
The narrowed bronchioles characteristic of an asthma attack would produce sibilant wheezes,
which are high-pitched whistling sounds.
6.How will the kidneys behave in respiratory acidosis?
a.
Retain bicarbonate to increase the pH
b.
Excrete more urine to reduce potassium
c.
Concentrate the urine to conserve circulating fluid in the blood stream
d.
Lower the pH by excretion of bicarbonate
ANS: A
In respiratory acidosis the pH is low. The kidneys will retain bicarbonate to increase the pH.
Emphysema
c.
Sputum
d.
Empyema
.c
b.
ep
Emboli
pr
a.
om
7.An 83-year-old patient is admitted with a temperature of 102 F (38.8 C), chest pain, and
fatigue. What is the infected fluid that the physician removes called?
st
ANS: D
te
If the fluid between the lung and the membrane lining the pleural cavity becomes infected, it is
called empyema.
si
ng
8.Which instruction by the nurse is inappropriate for teaching the proper technique for collection
of a sputum specimen?
Bring the sputum up from the lungs
b.
Rinse mouth with water before expectorating in specimen cup
c.
Collect specimens before meals
d.
Send specimen to the lab without delay
.m
yn
ur
a.
w
ANS: C
w
Collecting specimens before meals will avoid possible emesis from coughing after eating.
w
9.When assessing the SaO2 with a pulse oximeter, the nurse will place the oximeter on a finger:
a.
on the same side as the blood pressure cuff.
b.
while exercising the arm to stimulate circulation.
c.
that is a normal temperature.
d.
on the same side as an arterial catheter.
ANS: C
The pulse oximeter should be placed on a finger of the hand that is normal temperature because
hypothermia will affect the reading. The device should not be put on a finger on the same side as
a blood pressure cuff or arterial line.
10.A patient, age 69, has emphysema. On assessment, the nurse notes the presence of a barrel
chest. What does this pathology result from?
a.
An increase in the lateromedial area from hypertrophy of mucous glands in the bronchi
b.
An increased anteroposterior diameter caused by overinflation of the alveoli
c.
A decrease in anteroposterior diameter caused by chronic dilation of the bronchi
d.
A widening of the sternocostal area secondary to chronic constriction of smooth muscles in the
airways leading to bronchospasms
om
ANS: B
.c
The patient will eventually appear barrel chested (an increased anteroposterior diameter caused
by overinflation).
pr
ep
11.A patient, age 22, is admitted with acute asthma. The patient shows a pulse oximetry level of
SaO2of 82%. How should the nurse interpret this?
a.
Only 82% of the red blood cells are able to use oxygen.
There is only 82% of oxygen bound to the hemoglobin compared with the amount available.
c.
Eighteen percent of oxygen is not dissolved in the blood.
d.
The muscular respiratory effort is only 18% effective.
te
st
b.
ng
ANS: B
si
An SaO2 indicates that only 82% of the available oxygen is bound to the hemoglobin.
yn
ur
12.What is the appropriate nursing intervention for a patient, age 40, who is diagnosed with
active tuberculosis?
Place the patient in drainage and secretion precautions
b.
Place the patient in acid-fast bacillus (AFB) Isolation Precautions
c.
Maintain the patient in enteric isolation
d.
Place the patient in any Isolation Precautions
w
w
w
ANS: B
.m
a.
If TB is suspected, permission to place the patient in acid-fast bacillus (AFB) Isolation
Precautions should be requested immediately.
13.How should the newly diagnosed patient who has been prescribed isoniazid (INH) for the
treatment of active tuberculosis (TB) be advised?
a.
Report redness and swelling of extremities
b.
Accept that the therapy is long term
c.
Monitor renal function every several months
d.
Rise slowly to avoid dizziness
ANS: B
INH therapy is long term. The patient should be advised to get regular liver studies and report
tingling and numbness of the extremities.
om
14.The patient has advanced emphysema and complains of dyspnea and fatigue. What would the
most appropriate nursing intervention be for the nursing diagnosis of Activity intolerance related
to an imbalance between the oxygen supply and demand?
a.
Direct patient in vigorous independent ROM.
Allow to exercise until respirations are over 20 breaths/min over baseline.
c.
Plan care to provide optimum rest.
d.
Provide frequent cool showers.
ep
.c
b.
pr
ANS: C
te
st
Nursing interventions will be directed at attempting to decrease the patients anxiety and promote
optimal air exchange. The nurse should allow sufficient rest periods and should assist the patient
in activities of daily living.
si
ng
15.A patient is on postoperative day 2 after undergoing a total hip replacement. The patient
suddenly complains of chest pain and is coughing up blood-tinged sputum. What should be the
nurses initial intervention?
Report signs to the charge nurse.
b.
Elevate head of bed and administer oxygen.
c.
Prevent patient from excessive coughing.
d.
Increase IV flow rate.
yn
.m
w
ANS: B
ur
a.
w
w
When a pulmonary embolus is suspected, the head of the bed should be elevated to facilitate
respiration and oxygen is administered. The charge nurse and the physician should be notified,
but only after the patient is stabilized and oxygenated.
16.What is true about activities such as walking for the patient with emphysema?
a.
Repair dilated alveoli
b.
Increase capacity to use oxygen
c.
Lessen the oxygen needs
d.
Lessen metabolic oxygen needs
ANS: B
Aerobic exercises such as walking will increase the bodys ability to use oxygen through
sustained rhythmic contractions of large muscles.
17.The patient with long-term emphysema is admitted with a secondary diagnosis of cor
pulmonale. What should the nurse anticipate?
b.
The patient will present with a dry hacking cough and chest pain due to constriction of the
pulmonary vein.
c.
The patient will present with hypertension and a headache related to pulmonary hypertension.
d.
The patient will present with unlabored respiration and cyanosis around the mouth.
.c
om
a.
The patient will present with edema of the lower extremities and extended neck veins due to
hypertension of the pulmonary circulation.
ep
ANS: A
te
st
pr
COPD can lead to cor pulmonale, an abnormal cardiac condition characterized by hypertrophy of
the right ventricle of the heart as a result of hypertension of the pulmonary circulation. Cor
pulmonale results in the presence of edema in the lower extremities, as well as in the sacral and
perineal area, distended neck veins, and enlargement of the liver with ascites.
ng
18.What is a major advantage of video assisted thoracoscopic surgery (VATS)?
The surgeon can record entire surgical procedure on a video.
b.
The surgeon can remove tumors of the lung through a small keyhole incision.
c.
The surgeon can x-ray and excise tumor in the same procedure.
d.
The surgeon can avoid the use of a closed chest drainage system after surgery.
yn
ur
si
a.
.m
ANS: B
w
w
The video assisted thoracoscopic surgery allows surgeons to remove tumors through a small
keyhole incision. Although the incisions are small, a closed chest drainage system will still be
necessary after the surgery.
w
19.How would the nurse examining a patient with pleurisy document a low-pitched grating lung
sound?
a.
Sonorous wheeze
b.
Friction rub
c.
Coarse crackles
d.
Crackles
ANS: B
A low-pitched grating sound in the presence of an inflammatory disorder is a friction rub.
20.What is inspiratory capacity?
a.
The amount of air in the lung after a maximal inhalation
b.
The amount of air moved with each normal inhalation and expiration
c.
The amount of air that can be inhaled in one breath from the resting expiratory level
d.
The amount of air that can be forcefully exhaled after maximum inhalation
ANS: C
om
Inspiratory capacity is the volume of air that can be inhaled in one breath from the resting
expiratory level.
ep
.c
21.The older adult patient with long-term emphysema complains of a sharp pleuritic pain after a
severe period of coughing. The patients heart rate and respiratory rate have increased.
Auscultation reveals no breath sounds on the left side. These are signs and symptoms of what
condition?
Pulmonary embolus
b.
Spontaneous pneumothorax
c.
Early signs of unilateral pneumonia
d.
An attack of asthma
ng
te
st
pr
a.
ANS: B
ur
si
Spontaneous pneumothorax can be caused by a ruptured bleb in a patient with long-term
emphysema. The disorder causes chest pain, dyspnea, and anxiety associated with air hunger.
yn
22.Which important precaution should the nurse include when instructing an emphysema patient
on the use of home oxygen?
Use oxygen only when extremely short of breath
b.
Keep the home oxygen regulator set on 6 L
w
Limit to 1 to 2 L oxygen flow
w
d.
Use home oxygen at night while sleeping
w
c.
.m
a.
ANS: D
Low-flow oxygen therapy is required for patients with COPD, because higher oxygen
concentrations depress the bodys own respiratory regulatory centers and can cause respiratory
failure.
23.The young man who had a bronchoscopy 1 hour ago asks when he can eat. Which response
would be most helpful?
a.
In 24 hours, but must take cold liquids for the rest of the day
b.
If there is no blood in his sputum
c.
In 8 hours after a period of nothing by mouth
d.
When the gag reflex returns
ANS: D
Following a bronchoscopy, the patient can eat as soon as the gag reflex returns, usually in about
2 hours.
om
24.The nurse caring for a patient who has a closed chest drainage system notes that there is
fluctuation (tidaling) in the water seal chamber. What is the most appropriate nursing action
based on this assessment?
Document the tidaling
b.
Elevate the head of the bed and notify charge nurse of malfunction of drainage system
c.
Add more sterile water to the water seal chamber
d.
Turn patient to the affected side
pr
ep
.c
a.
st
ANS: A
ng
te
Tidaling or fluctuation in the water seal drainage is an indicator that the negative pressure is
preserved and the system is working normally. Document this normal finding.
si
25.How does pursed lip breathing assist patients with asthma during an attack?
It distracts the patient with breathing technique to reduce anxiety.
b.
It gets rid of CO2 faster.
c.
It opens bronchioles by backflow air pressure.
d.
It increases PACO2..
.m
yn
ur
a.
w
ANS: C
w
The resistance or the expiration through the pursed lips causes a backflow of air and helps to
open the bronchioles.
w
26.How do leukotriene modifiers reduce the symptoms of asthma?
a.
By drying up mucus
b.
By causing bronchodilation and anti-inflammation effects
c.
By suppressing cough
d.
By liquefying mucus
ANS: B
Leukotriene modifiers reduce the symptoms of asthma by causing bronchodilation and antiinflammatory processes.
27.How should a patient be positioned after a thoracentesis is completed and the dressing
applied?
High Fowler
b.
Semi-Fowler
c.
Side lying on unaffected side
d.
Prone
om
a.
ANS: C
.c
After a thoracentesis the patient is placed in a side-lying position on the unaffected side.
ep
28.What should the nurse do to keep the chest tubes from becoming occluded?
Irrigate tubes as needed
b.
Prevent dependent loops
c.
Loop the tube over the bed rail
d.
Milk the tube frequently
st
te
ng
ANS: B
pr
a.
yn
ur
si
To keep the tubes patent, the tubes should be kept straight without dependent loops. These tubes
are not irrigated and should not be milked frequently.
29.Which patient assessment indicates the most severe respiratory distress?
Nasal flaring, symmetrical chest wall expansion, SaO 2 88%
b.
Abdominal breathing, SaO2 97%
w
Substernal retraction, SaO2 90%
w
d.
Substernal retraction, SaO2 84%
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c.
.m
a.
ANS: C
Observe the patients facial expressions and signs of respiratory distress, such as flaring nostrils,
substernal or clavicular retractions, asymmetrical chest wall expansion, and abdominal breathing.
The lower the SaO2, the more severe the respiratory distress.
MULTIPLE RESPONSE
30.Which preoperative teaching should a nurse include for a person scheduled for a partial
laryngectomy? (Select all that apply.)
a.
Tracheal suction will be frequent
b.
The presence of a temporary tracheotomy
c.
That isolation will be required for 24 hours
d.
The surgery involves removal of a diseased vocal cord
e.
Some speech will be retained
f.
The sense of smell and taste will be lost
ANS: A, B, D, E
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.c
om
A partial laryngectomy involves the removal of the diseased cord and possible thyroid cartilage.
There will be a temporary tracheostomy that will be closed once edema is under control.
Tracheal suctioning will be done frequently. There will be some vocal ability retained. Isolation
is not required. Sense of smell and taste are lost with a total laryngectomy.
st
pr
31.Which independent nursing measures are effective in aiding a patient to expectorate? (Select
all that apply.)
Positioning in orthopneic position
b.
Suctioning
c.
Assisting to cough
d.
Providing hydration
e.
Starting IV fluids
f.
Starting mucolytic agents
yn
ur
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te
a.
ANS: A, B, C, D
w
.m
Independent nursing intervention to help a patient to expectorate would include positioning,
assisting to cough, suctioning, and providing hydration IV therapy; provision of a mucolytic
agent requires a physicians order and is not an independent nursing action..
w
w
32.Identify the purposes of chest drainage. (Select all that apply.)
a.
Drains air, blood, and fluid from pleural space
b.
Restores positive pressure in chest cavity
c.
Restores negative intrapleural pressure
d.
Allows lung to collapse and rest
e.
Allows route for medication administration
ANS: A, C
A chest tube or tubes may be inserted for continuous drainage of fluid, blood, or air from the
pleural cavity and for medication instillation. To prevent the lung from collapsing, a closed
drainage system is used, which maintains the lung cavitys normal negative pressure. The chest
tubes are connected to a pleural drainage system with collection, water seal, and suction control
chambers to drain secretions and reestablish negative pressure in the pleural space.
Moist mucous membranes
b.
Kyphosis
c.
Decrease in pulmonary blood flow
d.
Stasis pooling of secretions
e.
Reduced number of cilia
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.c
a.
om
33.What are age-related changes in the older adult that make them at risk for respiratory
diseases? (Select all that apply.)
ANS: B, C, D, E
te
st
pr
Age-related changes that affect the respiratory system are dryer mucous membranes, which
reduce ability to humidify inspired air, kyphosis, which restricts the expansion of the lung, stasis
pooling of respiratory secretions, and reduced number of cilia, which make infection of the upper
and lower airway more likely.
si
ng
34.The nurse explains to the person with pneumonia in the left lung that being positioned in the
good lung down offers the advantage of (select all that apply):
PaO2 rising in the good lung.
b.
blood flow to bad lung being increased.
c.
the dependent lung being better perfused.
d.
dyspnea disappearing.
e.
decreased hypoxia.
w
ANS: A, C, E
.m
yn
ur
a.
w
w
The good lung down position increases the PaO 2 in the good lung and also allows for better
perfusion, consequently decreasing hypoxia, although dyspnea may still be evident.
COMPLETION
35.The _________ are the structures of the lung in which gas exchange occurs.
ANS:
alveoli
The end structures of the bronchial tree are called alveoli. It is in these terminal structures of the
bronchial tree that gas exchange takes place.
om
.c
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pr
st
Chapter 17 Sexually Transmitted Diseases
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MULTIPLE CHOICE
si
ng
1.When assigned to a newly admitted patient with AIDS, the nurse says, Im pregnant. It is not
safe for me or my baby if I am assigned to his case. Which is the most appropriate response by
the charge nurse?
This patient would not be a risk for your baby if you use standard precautions and avoid direct
contact with blood or body fluids.
b.
You should ask for a transfer to another unit because contact with this patient would put you
and your baby at risk for AIDS.
c.
Wear a mask, gown, and gloves every time you go into his room and use disposable trays,
plates, and utensils to serve his meals.
d.
We should recommend that this patient be transferred to an isolation unit.
yn
.m
w
w
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ANS: A
ur
a.
HIV is transmitted from human to human through infected blood, semen, cervicovaginal
secretions, and breast milk. The use of Standard Precautions by all staff members for all patients
all the time simplifies this issue.
2.The anxious male patient is fearful that he has been exposed to a person with an HIV infection.
He states he does not want to go to a laboratory for the ELISA tests because he does not want to
be identified. What would be the nurses most helpful response?
a.
There really is not an option, you will need to get the Western blot test first.
b.
There is an FDA-approved home test called OraQuick.
c.
The rapid test Reveal can identify all the HIV strains.
d.
You can be tested anonymously for ELISA. If you are seronegative, your concerns are over.
ANS: B
The OraQuick is a home OTC test approved by the FDA. One seronegative on the ELISA is not
evidence because seroconversion may not have taken place. The Western blot test follows if the
ELISA is positive.
om
3.The patient, age 21, has been treated for chlamydia and has a history of recurrent herpes. What
should the nurse counsel this patient about?
Sexual history, risk reduction measures, and testing for HIV
b.
Getting an appointment at a family planning clinic
c.
Testing for HIV and what the test results mean
d.
Abstinence and a monogamous relationship
pr
ep
.c
a.
ANS: A
te
st
Chlamydia is considered a sexually transmitted disease (STD). As such it requires further testing
and a sexual history to advise the sexual partners.
ng
4.A patient has just been diagnosed as HIV-positive. He asks the nurse, Does this mean I have
AIDS? Which response would be most informative?
Most people get AIDS within 3 to 12 weeks after they are infected with HIV.
b.
Dont worry. You may never get AIDS if you eat properly, exercise, and get plenty of rest.
c.
It varies with every individual, but the average time is 8 to 10 years from the time a person is
infected, and some go much longer.
d.
You can expect to develop signs and symptoms of AIDS within 6 months.
.m
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ur
si
a.
w
ANS: C
w
w
Typical progress of HIV includes a period of relative clinical latency, occurring immediately
after the primary infection, which can last for several years. Long-term nonprogressors remain
symptom-free for 8 to10 years.
5.Which of the following is a CDC criterion for the progression of HIV infection to AIDS?
a.
Increase in viral load
b.
Decreased ratio of CD8 to CD4
c.
Increase in white blood cells
d.
Increased reactivity to skin tests
ANS: A
AIDS is the end stage of an HIV infection. The CDC has developed criteria for the diagnosis of
AIDS, which are: increase in viral load even with pharmacologic interventions, increase in the
ratio of CD8 to CD4, decline in the WBCs, and a decreased reactivity to skin tests.
6.What should the nurse look for when reviewing a patients chart to determine whether she has
progressed from HIV disease to AIDS?
CD4+ count below 500, chronic fatigue, night sweats
b.
HIV-positive test result, CD4+ count below 200, history of opportunistic disease
c.
Weight loss, persistent generalized lymphadenopathy, chronic diarrhea
d.
Fever, chills, CD4+ count below 200
om
a.
.c
ANS: B
ep
Patients who have progressed from HIV disease to AIDS will have the condition in which the
CD4+ cell count drops to less than 200 cells/mm3 and have a history of opportunistic diseases.
st
pr
7.A male patient is advised to receive HIV antibody testing because of his multiple sexual
partners and injectable drug use. What should the nurse inform the patient to ensure
understanding?
The blood is tested with the highly sensitive test called the Western blot.
b.
The blood is tested with an ELISA; if positive, it is tested again with an ELISA, followed by a
Western blot if the second ELISA is positive.
c.
A series of HIV tests is performed to confirm if the patient has AIDS.
d.
If the HIV tests are seronegative, the patient can be assured that he is not infected.
ur
si
ng
te
a.
yn
ANS: B
w
w
w
.m
The individuals blood is tested with ELISA or enzyme immunoassay (ELA), antibody tests that
detect the presence of HIV antibodies. If the ELA is positive for HIV, then the same blood is
tested a second time. If the second ELA is positive, a more specific confirming test such as the
Western blot is done. Blood that is reactive or positive in all three steps is reported to be HIVpositive. A seronegative is not an assurance that the individual is free of infection since
seroconversion may not have yet occurred.
8.A 28-year-old married attorney with one child is in the first trimester of her second pregnancy.
The patient states that she is at no risk for HIV, so she would not need to be counseled about
testing for HIV. Which is the most appropriate response?
a.
Shes a professional woman in a monogamous relationship. She obviously is not at risk.
b.
Women are not at great risk. The greatest risk is with gay men.
c.
The fastest-growing segment of the population with AIDS is women and children. We need to
assess her risks.
d.
We need to review her chart to determine if her first child was infected.
ANS: C
Increases in AIDS cases in women and heterosexuals and a slowing of cases in the men who
have sex with men (MSM) category are a direct reflection of early educational efforts directed at
the MSM population, who were believed to be the only population at risk. Women need to be
assessed for different manifestations of HIV infection. It is the current recommendation for
voluntary HIV testing for all pregnant women.
9.A young gay patient being treated for his third sexually transmitted disease does not see why
he should use condoms, because they dont work. Which is the most appropriate response?
b.
You are correct. Condoms dont always work, so your best protection is to limit your number of
partners.
c.
Condoms do not provide 100% protection, so you should always discuss with your sexual
partners their HIV status or ask if they have any STD.
d.
Condoms do not provide 100% protection, but when used with a spermicide you can be assured
of complete protection against HIV and other STDs.
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st
pr
ep
.c
om
a.
Condoms may not provide 100% protection, but when used correctly and consistently with
every act of sexual intercourse they reduce your risk of getting infected with HIV or other
sexually transmitted diseases.
ng
ANS: A
ur
si
Risk-reducing sexual activities decrease the risk of contact with HIV through the use of barriers.
The most commonly used barrier is the male condom. Although not 100% effective, when used
correctly and consistently, male condoms are very effective in the prevention of HIV
transmission.
Use a gown, mask, and gloves to administer oral medications
w
c.
Wear a gown when assisting the patient to use the bedpan
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b.
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.m
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10.A 21-year-old male who has been an IV heroin user has been experiencing fever, weight loss,
and diarrhea and has been diagnosed as having AIDS. At this time, he has a low-grade fever,
severe diarrhea, and a productive cough. He is admitted with Pneumocystis jiroveci. What should
the nurse do when caring for the patient?
a.
Use a gown, mask, and gloves when assisting the patient with his bath
d.
Use a mask when taking the patients temperature
ANS: A
The use of Standard Precautions and body substance isolation has been shown not only to reduce
the risk of blood-borne pathogens, but also to reduce the risk of transmission of other disease
between the patient and the health care worker.
11.The nurse should instruct the patient who is diagnosed with AIDS to report signs of Kaposi
sarcoma, which include:
a.
Reddish-purple skin lesions
b.
Open, bleeding skin lesions
c.
Blood-tinged sputum
d.
Watery diarrhea
ANS: A
om
Kaposi sarcoma is a rare cancer of the skin and mucous membranes characterized by blue, red, or
purple raised lesions seen mainly in Mediterranean men. Kaposi sarcoma: firm, flat, raised or
nodular, hyperpigmented, multicentric lesions on the skin and mucous membranes.
b.
He experiences minor symptoms only.
c.
He experiences decreased immunity.
d.
He is contagious.
pr
He is not dangerous to anyone.
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st
a.
ep
.c
12.A patient states that he feels terrific, but a blood test shows that he is HIV-positive. It is
important for the nurse to discuss with him that HIV may remain dormant for several years.
What is true of the patient during this time?
ng
ANS: D
yn
ur
si
A prolonged period in which HIV is not readily detectable in the blood follows within a few
weeks or months of the initial infection. This titer, or viral load, falls dramatically as the immune
system responds and controls the HIV infection, and it may last 10 to 12 years. During this
period, there are few clinical symptoms of HIV infection, although an individual is still capable
of transmitting HIV to others.
A positive ELISA or Western blot test
Weight loss, fever, and generalized lymphedema
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c.
w
b.
Opportunistic infection
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a.
.m
13.To be diagnosed as having AIDS, the patient must be HIV-positive, have a compromised
immune system without known immune system disease or recent organ transplant, and present
with which of the following?
d.
CD4+ lymphocyte count less than 200 mm3
ANS: D
The 1993 expanded case definition of AIDS includes all HIV-infected people who have CD4+,
T-lymphocyte counts of less than 200 cells/mm3; this includes all people who have one or more
of these three clinical conditions: pulmonary tuberculosis, recurrent pneumonia, or invasive
cervical cancer, and it retains the 23 clinical conditions listed in the 1987 AIDS case definition.
14.Why should interventions such as promotion of nutrition, exercise, and stress reduction be
undertaken by the nurse for patients who have HIV infection?
a.
They will promote a feeling of well-being in the patient.
b.
They will improve immune function.
c.
They will prevent transmission of the virus to others.
d.
They will increase the patients strength and ability to care for himself or herself.
ANS: B
.c
om
HIV disease progression may be delayed by promoting a healthy immune system. Useful
interventions for HIV-infected patients include the following: nutritional changes that maintain
lean body mass, regular exercise, and stress reduction.
ep
15.A male patient is concerned about telling others he has HIV infection. What should the nurse
stress when discussing his concerns?
Care providers and sexual partners should be told about his diagnosis.
b.
There is no reason to hide his disease.
c.
Secrecy is a poor idea because it will lower his self-esteem.
d.
His diagnosis will be obvious to most people with whom he will come into contact.
ng
te
st
pr
a.
ANS: A
yn
ur
si
Nurses have a responsibility to assess each patients risk for HIV infection and counsel those at
risk about HIV testing and the behaviors that put them at risk, and about how to reduce or
eliminate those risks. The diagnosis needs to be carefully protected and shared only with
caregivers who need to know for the purpose of assessment and treatment.
asymptomatic phase, clinical latency, ARC, and AIDS.
w
b.
viremia, clinical latency, opportunistic diseases, and death.
w
a.
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.m
16.The HIV patient asks the nurse about what to expect in terms of disease progression. The
nurse tells this patient that although the disease can vary greatly among individuals, the usual
pattern of progression includes:
c.
acute retroviral syndrome, early infection, early symptomatic disease, and AIDS.
d.
transitional viral syndrome, inactive disease, early symptomatic infection, and opportunistic
diseases.
ANS: C
The progression from HIV to AIDS includes initial exposure, primary HIV infection,
asymptomatic HIV infection, early HIV disease, and AIDS.
17.While teaching community groups about AIDS, what should the nurse indicate as the most
common method of transmission of the HIV virus?
a.
Sexual contact with an HIV-infected partner
b.
Perinatal transmission
c.
Exposure to contaminated blood
d.
Nonsexual exposure to saliva and tears
ANS: A
om
Modes of transmission have remained constant throughout the course of the HIV pandemic. It is
also important for health care providers to remember that transmission of HIV occurs through
sexual practices, not sexual preferences. Worldwide, sexual intercourse is by far the most
common mode of HIV transmission.
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.c
18.What do the activated monocytes and macrophages produce in the presence of an
inflammatory process?
Reduction of red cells
b.
Increase in WBCs
c.
Neopterin
d.
Increase in T-helper cells increase natural killer (NK) cells
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st
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a.
ng
ANS: C
ur
si
Neopterin is produced in the presence of an inflammatory reaction and is increased in HIV
disease.
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19.For most people who are HIV-positive, marker antibodies are usually present 10 to 12 weeks
after exposure. What is the development of these antibodies called?
Immunocompetence
.m
a.
Immunodeficiency
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d.
Opportunistic infection
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c.
Seroconversion
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b.
ANS: B
Seroconversion is the development of antibodies from HIV, which takes place approximately 5
days to 3 months after exposure, generally within 1 to 3 weeks. Although the conversion has
taken place, the patient is not yet immunodeficient.
20.What should the nurse emphasize when counseling an anxious HIV-positive mother about the
care of her HIV-positive infant?
a.
The baby will develop AIDS and refer her to a local AIDS support group. The baby will remain
HIV-positive for the rest of its life.
b.
Although infants of HIV-infected mothers may test positive for HIV antibodies, not all infants
are infected with the virus.
c.
She has not yet developed AIDS, and that it is possible the baby will not develop AIDS for
many years.
d.
If the infant is started on zidovudine (AZT) within the first month after delivery, AIDS can be
prevented.
ANS: B
.c
om
The decline in pediatric AIDS incidence is associated with the increased compliance with
universal counseling and testing of pregnant women and the use of zidovudine by HIV-infected
pregnant women and their newborn infants. Infants born to HIV-infected mothers will have
positive HIV antibody results as long as 15 to 18 months after birth. This is caused by maternal
antibodies that cross the placenta during gestation and remain in the infants circulatory system.
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pr
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MULTIPLE CHOICE
21. The nurse cautions the homosexual man that his inflamed rectal tissue and rectal tear put him
at risk for:
a.
an abscess.
human immunodeficiency virus (HIV) infection.
c.
hemorrhoids.
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b.
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si
ng
d.
rectal hemorrhage.
ANS: B
Open lesions and inflamed tissue increase the risk of HIV infection.
22. The nurse instructs a sexually active teenager that frequent douching can cause:
a.
a sexually transmitted infection.
bacterial vaginosis.
c.
pelvic inflammatory disease.
.m
yn
b.
w
w
w
d.
purulent vaginitis.
ANS: B
Bacterial vaginosis is caused when frequent douching changes the pH of the vaginal vault and
creates an environment conducive to bacterial invasion. Sexually transmitted infections are not
transferred by douching. Pelvic inflammatory disease is a condition that most often results from
an untreated infection. Vaginitis is an inflammatory condition that does not result from douching.
23. The nurse is aware that women are at a greater risk for contracting sexually transmitted
infections (STIs) than men because:
of longer period of time during which male secretions are in contact with female mucous
a.
membranes.
b.
estrogens make vaginal membranes more susceptible.
c.
penile friction to the vaginal wall encourages STIs.
d.
changing hormonal levels create a conducive vaginal environment.
ANS: A
Male secretions are in contact with female mucous membranes longer than female secretions are
in contact with the penis. Estrogen provides for vaginal lubrication and therefore reduces friction
and tissue tearing.
24. The nurse cautions that infections can enter the upper genital tract as the mucous plug
becomes more permeable:
a.
during intercourse.
b.
during premenstrual period.
c.
during postmenstrual period.
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pr
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.c
om
d.
while on oral birth control pills.
ANS: B
The mucous plug in the cervix of women provides protection to the upper genital tract. The
hormonal changes make it become more permeable around the menstrual period. This change
can result in an increased risk for infections in the upper genital tract, such as pelvic
inflammatory disease (PID).
25. The nurse identifies a misconception about the vaccination against human papillomavirus
(HPV) when the patient says:
a.
I know I must have three doses of the vaccine.
Girls as young as 9 years of age may be vaccinated.
c.
I am relieved that the vaccine protects me from all HPV infections.
ng
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b.
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ur
si
d.
I know I should continue having regular Pap smears.
ANS: C
The vaccine protects against the most prevalent infections, genital warts and precancerous
cervical lesions, but not against all HPV infections. The remaining statements are correct.
26. The nurse affirms that many skin lesions associated with sexually transmitted infections are
in the genital area, but skin lesions of syphilis can be seen in which location?
a.
On palms of hands
Behind the ears
c.
At scalp margins
w
b.
w
w
d.
In the axillae
ANS: A
The rash that occurs in the secondary phase of syphilis is seen on the palms of the hands and the
soles of the feet.
27. On the diagnosis of syphilis in a young female patient, the nurse informs her that her illness
must be reported to:
a.
her parents.
b.
the Centers for Disease Control and Prevention (CDC).
c.
the hospital infection control department.
d.
the local public health agency.
ANS: D
STIs are reported to the local public health agency for accumulation by the CDC. The local
public health agency will get in touch with the sexual contacts of the patient and attempt to
initiate treatment.
28. A female patient comes to the emergency department with severe abdominal pain, a
temperature of 101 F, and a foul-smelling, purulent vaginal discharge. These assessments lead
the nurse to suspect:
a.
pelvic inflammatory disease (PID).
b.
gonorrhea.
c.
syphilis.
pr
ep
.c
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d.
vaginosis.
ANS: A
These are the cardinal indicators of PID. Gonorrhea most often presents in females with vaginal
discharge and burning with urination. The initial state of syphilis presents with chancre (hard,
painless sore) on the mucous membrane of the mouth or genitals. Vaginosis most often presents
with symptoms including a grayish-white discharge that has a fishy odor.
29. A gram-positive gonococcus is an organism that after being stained with crystal violet will:
a.
fluoresce after counterstain is applied.
accept the counterstain.
c.
retain the original stain after the counterstain is applied.
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st
b.
30 minutes
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c.
10 minutes
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b.
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.m
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si
ng
d.
turn dark after the counterstain is applied.
ANS: C
Staining procedures differentiate organisms by using dyes that have been found to stain some
bacteria in specific ways. An example of this would be a Gram stain, in which bacteria are first
stained with crystal violet, then treated with a strong iodine solution, decolorized with ethanol or
ethanol acetone, and then counterstained with contrasting dye. Those retaining the initial stain
are considered gram positive; those losing the stain but accepting the counterstain are considered
gram negative.
30. When collecting a urethral swab from a male patient suspected of having gonorrhea, the
nurse will collect the specimen ______ after voiding.
a.
immediately
d.
60 minutes
ANS: D
The specimen should be collected at least 1 hour after voiding as the urine will have flushed out
the organisms.
31. The young woman newly diagnosed with genital herpes is reminded that she should avoid
sexual intercourse until:
a.
she has been on medication for a week.
b.
she no longer has pain on urination.
c.
her partner has been on medication and is free of lesions.
d.
her lesions are gone.
ANS: D
People with genital herpes should avoid sex until all the lesions are gone.
32. The nurse explains to a patient who has genital herpes that she may experience a prodromal
signal of an impending outbreak, which most likely will include:
a.
elevation in temperature.
tingling sensation in the vagina.
c.
copious vaginal discharge.
om
b.
1 week
c.
2 weeks
ng
b.
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st
pr
ep
.c
d.
migraine-like headache.
ANS: B
Many women with herpes can predict an outbreak because of tingling or burning in the vagina.
Elevations in temperature, increased vaginal discharge, and headaches are not common
precursors of an outbreak of herpes.
33. The nurse interviewing a college student who believes he has been exposed to gonorrhea tells
him that the incubation period for gonorrhea is usually ______ after exposure.
a.
2 to 6 days
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si
d.
4 weeks
ANS: A
The incubation period is 2 to 6 days before symptoms may appear.
.m
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34. The nurse is aware that men with gonorrhea are more likely to seek medical attention
because their symptoms are more visible than those of women. Which clinical manifestation is
most consistent with symptoms of gonorrhea experienced by men?
a.
Copious purulent discharge from the penis
Hematuria at the beginning of the urination stream
c.
Ulcer on the penis
w
w
b.
w
d.
Scaly lesions on the scrotum
ANS: A
The man can see his sexual organ and evaluate his urine easily. The man with gonorrhea will
have a purulent discharge from the penis and scrotal pain. Vaginal discharges in women are not
investigated until there are more significant signs such as changes in odor or color of vaginal
secretions.
35. The nurse assessing a patient in the primary stage of syphilis can observe:
a.
copious vaginal discharge.
b.
generalized skin rash.
c.
a hard painless sore on the genitals.
positive serology.
c.
purulent skin rash.
.c
b.
om
d.
appearance of gumma.
ANS: C
Syphilis has three stages. The chancre is visible in the primary stage of syphilis. The primary
state refers to the first 3 weeks after infection. The chancre will disappear within a few weeks.
The secondary stages occur 6 weeks later. Symptoms vary and may include a generalized skin
rash. Tertiary is the late stage. It is the period 1 to 20 years after infection. At that time the
spirochetes have had access to all body tissues. Gumma, a soft encapsulated tumor, appears on
any organ, causing symptoms (including neurologic).
36. When the secondary stage of syphilis occurs, a sign that indicates the progression of the
disease is:
a.
foul-smelling penile discharge.
ng
te
st
pr
ep
d.
scrotal swelling.
ANS: B
A positive serology will appear in the secondary stage of syphilis. Penile discharge is not
associated with the secondary stage of syphilis. A generalized skin rash, not purulent, may be
seen in the secondary stage of syphilis. Scrotal swelling is not
37. A pregnant patient who is human immunodeficiency virus (HIV) positive should be
encouraged to:
a.
breast-feed baby to increase newborns antibody count.
have a vaginal birth.
c.
engage in oral, rather than vaginal, sex.
si
b.
.m
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ur
d.
remain on medication protocol.
ANS: D
Remaining on medication is essential. Certain prescribed drug combinations may significantly
reduce the transmission to the fetus. Patients with HIV should avoid breast-feeding and cesarean
birth. HIV can be spread by oral sex.
w
w
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38. A patient has been diagnosed with chlamydia for the second time in a 5-month period. Data
collection reveals that the patient was not compliant with the plan of treatment with the last
infection. Which will most likely be the best method of treatment?
a.
Doxycycline
b.
Erythromycin
c.
Diflucan
d.
Azithromycin
ANS: D
Chlamydia is best treated with a single dose of azithromycin for patients having a compliance
problem. Doxycycline requires a 7-day course of therapy and may not be best given this patients
history. Erythromycin is indicated to manage the disease in pregnant women. Diflucan is an
antifungal medication used in the management of candidiasis.
39. The nurse is collecting information from a patient during her annual pelvic examination. The
patient reports that she has noted a strong vaginal odor after intercourse. Which condition may be
present?
a.
Gonorrhea
b.
Bacterial vaginosis
c.
Chlamydia
c.
contact with infected blood.
d.
placenta to infant.
st
oral-genital route.
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b.
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d.
Syphilis
ANS: C
Chlamydia may cause a strong vaginal odor noted after sexual intercourse. Gonorrhea causes
vaginal discharge and a difficulty voiding. Bacterial vaginosis is associated with a fishy vaginal
odor and discharge. Syphilis causes a chancre sore.
MULTIPLE RESPONSE
40. The nurse clarifies that sexually transmitted infections (STIs) are transmitted by: (Select all
that apply.)
a.
sexual intercourse.
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si
ng
e.
contact with infected body fluids.
ANS: A, B, C, D, E
All options listed are possible transmission routes for STIs.
41. The nurse tells a high school senior who is newly diagnosed with herpes that the rise in the
number of sexually transmitted infections (STIs) can be attributed to: (Select all that apply.)
a.
an increase in the number of sexually active teenagers.
an increase in the opportunity to have multiple partners.
c.
knowledge deficit about signs and symptoms of STIs.
d.
teenagers being reluctant to report diseases.
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b.
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e.
young peoples inability to acquire confidential health care.
ANS: A, B, C, D, E
All options are valid reasons for the increasing incidence of STIs.
42. The nurse points out that the use of oral contraceptives has increased the risk of acquiring a
sexually transmitted infection (STI) because oral contraceptive pills: (Select all that apply.)
a.
increase the level of progesterone.
b.
cause an alkaline vaginal environment.
c.
may reduce the perception of the need for condom use.
d.
decrease the inflammatory response.
e.
alter cervical secretions.
ANS: B, C, E
The use of oral contraceptive pills causes the vaginal vault to become alkaline from cervical
secretions, which makes for a conducive environment for STIs. Oral birth control pills make the
need for a condom redundant as pregnancy will be averted by the medication.
43. The nurse reviews the list of sexually transmitted infections (STIs) that must be reported,
which include: (Select all that apply.)
a.
vaginitis.
b.
gonorrhea.
c.
pelvic inflammatory disease.
d.
chlamydia.
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e.
lymphogranuloma.
ANS: B, C, D, E
All STIs listed are reportable in all states except for vaginitis. Syphilis is also a reportable STI.
However, each state may add others to that list.
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44. A patient who has been diagnosed with chlamydia is started on a protocol of doxycycline and
is reminded by the nurse that: (Select all that apply.)
a.
her partner does not need treatment.
she should use a condom to protect partners from disease.
c.
the disease can develop into pelvic inflammatory disease.
d.
the entire prescription of antibiotics should be taken.
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b.
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e.
the disease can result in an ectopic pregnancy.
ANS: B, C, D, E
The partner should be under treatment as well.
45. The nurse urges a pregnant patient with gonorrhea to seek medical care because, if untreated,
gonorrhea can result in: (Select all that apply.)
a.
pelvic inflammatory disease.
sterility.
c.
obstructed fallopian tubes.
d.
ectopic pregnancy.
w
w
b.
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e.
ophthalmia neonatorum in the newborn.
ANS: A, B, C, D, E
All options are possible complications from untreated gonorrhea.
46. The nurse is providing information to a patient who has recently been diagnosed with genital
herpes. Which statements indicates the need for further instruction? (Select all that apply.)
a.
I am only contagious when I have open sores.
b.
The infection is limited to only my genital region.
c.
There is no permanent cure for this condition.
d.
I will need to contact my physician for antibiotic cream for the open lesions whenever I have an
outbreak.
om
e.
Washing my hands is going to be a good method to prevent introduction of bacteria to the area.
ANS: A, B, D
The disease may be spread during outbreaks. It is possible to spread the infection with viral
shedding between outbreaks. Herpes is a lifelong condition. There is no cure. The conditions
treatment can include the administration of antiviral medication. Antibiotics are not typically
indicated.
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Chapter 18 Urologic Disorders
MULTIPLE CHOICE
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1.What is the hormone from the posterior pituitary gland that influences the amount of water that
is eliminated with the urine?
Pitocin
b.
Renin hormone
c.
Antidiuretic hormone (ADH)
d.
ACTH
ng
si
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ANS: C
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a.
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ADH causes the cells of the distal convoluted tubules to increase their rate of water reabsorption.
.m
2.As the body breaks down protein, nitrogen wastes are broken down into urea, ammonia, and:
c.
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d.
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b.
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a.
nitrogen.
uric acid.
nitrates.
creatinine.
ANS: D
As proteins break down, nitrogenous wastesurea, ammonia, and creatinineare produced.
3.Because the kidneys are located in proximity to the vertebrae and are protected by the ribs,
their location in documentation is referred to as:
a.
retroperitoneal.
b.
diaphragm-vertebral.
c.
costovertebral.
d.
urachal-peritoneal.
ANS: A
The kidneys lie behind the parietal peritoneum (retroperitoneal).
4.A home health patient with end-stage renal disease (ESRD) has a nursing diagnosis of
powerlessness related to life-altering disease. Which nursing intervention would be most helpful?
Ensure restricted protein intake to prevent nitrogenous product accumulation.
b.
Include the patient in making the plan of care.
c.
Counsel patient about end-of-life provisions.
d.
Write out a detailed schedule of physicians appointments.
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a.
ANS: B
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Listen to the patient and allow time for discussion about concerns and the plan of care to return
some sense of control. End-of-life discussions are premature.
ng
5.What portion of the nephron is involved with filtration?
Glomerulus of the Bowman capsule
b.
Henle loop
c.
Proximal convoluted tubule
d.
Distal convoluted tubule
yn
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si
a.
.m
ANS: A
Filtration of water and blood products occurs in the glomerulus of the Bowman capsule.
w
w
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6.When the home health patient is started on dialysis, the home health nurse refers the patient to
a community support group that assists with the adjustments necessary to living with dialysis.
Which group offers this service?
a.
National Kidney Foundation
b.
American Association of Kidney Patients
c.
American Red Cross
d.
Veterans Administration
ANS: B
The American Association of Kidney Patients offer support to the patient and family as they
adapt to living with dialysis.
7.The nurse is aware that as a person ages there is a loss of the __________mechanism of the
kidney due to a decrease in blood supply to the kidneys and loss of nephrons.
a.
filtering
b.
reabsorption
c.
sterile water.
d.
concentrating
ANS: A
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The filtering mechanism is most affected with aging. By the age of 70, the filtering mechanism is
only 50% as efficient as at 40 years of age.
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8.A patient who is receiving continuous bladder irrigation following a transurethral resection of
the prostate (TURP) complains of spasm-like pain over his lower abdomen. What should the
initial intervention be by the nurse?
Inform the nurse in charge
b.
Decrease the continuous bladder irrigation flow
c.
Administer the prescribed analgesic
d.
Check the catheter and drainage system for obstruction
ng
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a.
ANS: D
yn
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The patient who has a TURP may have continuous closed bladder irrigation or intermittent
irrigation to prevent occlusion of the catheter with blood clots, which would cause bladder
spasms.
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9.A 56-year-old patient with cancer of the bladder is recovering from a cystectomy with an ileal
conduit. What is an important aspect in nursing interventions of the patient with an ileal conduit?
Instructing the patient to void when the urge is felt.
b.
Maintaining skin integrity.
Limiting acid-ash foods.
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d.
Limiting oral intake to 1000 mL/day
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c.
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a.
ANS: B
Care of the patient with an ileal conduit is a nursing challenge because of the continual drainage
of urine through the stoma. Complications of this procedure are wound infection, dehiscence,
and urinary leakage. The patient is urged to drink adequate fluids to flush the conduit.
10.It is 2 days after a 42-year-old male patients urinary diversion surgery. He continues to be
critical of the hospital and the nursing care, even though the staff has spent time explaining the
care to him. What is the most likely explanation for his behavior?
a.
He is angry about hospital policy.
b.
He is feeling neglected by the nursing staff.
c.
He is in denial of the effects of the surgery.
d.
He is reacting to the loss of self-esteem and altered body image.
om
ANS: D
.c
Persons with altered body image may react to the loss of self-esteem by behaving in a critical or
derogatory manner.
Increase his fluid intake
b.
Increase intake of dairy products
c.
Restrict his protein intake
d.
Take one baby aspirin daily
ng
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a.
pr
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11.What should the nurse encourage, barring any other contraindication, when teaching a patient
how to decrease the chance of further problems with urolithiasis?
ANS: A
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si
Fluid intake should be encouraged to at least 2000 mL of fluid in 24 hours, unless
contraindicated.
yn
12.The nurse notes the amount and color of the urine the patient with urolithiasis has voided.
While using Standard Precautions, what should be the nurses next action?
Discard the urine
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a.
Strain the urine
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d.
Send the urine to the laboratory
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c.
Add the urine to a 24-hour collector
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b.
ANS: D
All urine should be strained. Because stones may be any size, even the smallest speck must be
saved for assessment by the laboratory.
13.The nurse assessing a patient who is taking furosemide (Lasix) finds an irregular pulse. This
is likely a sign of:
a.
hypomagnesemia.
b.
hypernatremia.
c.
hypokalemia.
d.
hypercalcemia.
ANS: C
The loop diuretic prototype, furosemide (Lasix), affects electrolytes and causes hypokalemia; the
deficiency of the electrolyte can cause arrhythmias and muscle weakness.
The recumbent position may initiate diuresis.
b.
It preserves the skin integrity.
c.
It lowers the level of albuminuria.
d.
It saves stress on joints.
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a.
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14.The patient with nephrosis complains about the need for bed rest. How would the nurse
explain the benefit of bed rest?
pr
ANS: A
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15.What should the nurse instruct the patient to do before obtaining the urine specimen for a
urine culture?
Collect the urine for a 24-hour period
b.
Obtain a clean-catch specimen
c.
Bring in an early morning specimen
d.
Limit fluid intake to concentrate the urine
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a.
yn
ANS: B
Urine cultures are dependent on a clean-catch or catheterized specimen.
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b.
Red drainage from the catheter
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a.
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16.The patient is scheduled for a transurethral resection of the prostate. During preoperative
teaching, what should the nurse emphasize about what the patient can expect after the procedure?
Limited intake of fluids
c.
A sodium-restricted diet
d.
Incisional drainage
ANS: A
The patient and family need to know that hematuria is expected after prostatic surgery.
17.A male patient, age 71, has benign prostatic hypertrophy. He is recovering from a transurethral prostatic resection. The physician orders removal of the indwelling catheter 2 days after
the TURP procedure. What might the patient experience after the catheter is removed?
a.
Burning on urination
b.
Passing of blood clots in the urine
c.
Dribbling of urine
d.
Coffee-colored urine
ANS: C
The patient is informed that initially he may experience frequency and voiding small amounts
with some dribbling. There should be no hematuria or clots after 2 days.
High caffeine intake
b.
Cigarette smoking
c.
Use of artificial sweeteners
d.
Chronic cystitis
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a.
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18.A patient, age 69, is admitted to the hospital with gross hematuria and history of a 20-lb
weight loss during the last 3 months. The physician suspects renal cancer. In obtaining a nursing
history from this patient, the nurse recognizes which of the following as a significant risk factor
for renal cancer?
ng
ANS: B
si
Risk factors include smoking; familial incidence; and preexisting renal disorders, such as adult
polycystic kidney disease and renal cystic disease secondary to renal failure.
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yn
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19.As the nurse and the dietitian review a female patients diet plan with her, she shouts that with
her diabetes and now the kidney failure, there is just nothing she can eat. She says she might as
well eat what she wants, because there is nothing she can do to help herself. Based on the
patients response, which nursing diagnosis does the nurse identify?
Noncompliance, risk for, related to feelings of anger
b.
Imbalanced nutrition less than body requirements, related to knowledge deficit
c.
Anticipatory grieving, related to actual and perceived losses
w
Ineffective coping, related to sense of powerlessness
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d.
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a.
ANS: D
Ineffective coping due to the feeling of powerlessness against the multiorgan failure may result
in aggressive or infantile behavior.
20.The patient is on postoperative day 1 after having undergone a TURP procedure. He has
continuous bladder irrigation (CBI). Actual urine output during continuous bladder irrigation is
calculated by:
a.
measuring and recording all fluid output in the drainage bag.
b.
measuring the total output and deducting the total of the irrigating and intravenous solutions.
c.
adding the total of the intravenous and irrigating solutions and then deducting the amount of
output.
d.
measuring total output and deducting the amount of irrigating solution used.
ANS: D
To determine urine output, the nurse will subtract the amount of irrigation fluid used with the
Foley catheter output to calculate urine output.
I will need to increase protein and decrease sodium intake.
b.
I will need to drink more milk to get my calcium.
c.
Carbohydrate restriction will be difficult.
d.
Potassium restriction wont be hard since I dont like fruit.
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a.
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21.A patient has nephrotic syndrome. Which statement made by the patient indicates
understanding of the necessary diet modifications?
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ANS: A
ng
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Medical management for nephrotic syndrome depends on the extent of tissue involvement and
may include the use of corticosteroids and a low-sodium, high-protein diet.
si
22.What should the patient be encouraged to eat during the active phase of acute renal failure?
A diet high in sodium
b.
A diet high in potassium
c.
A diet high in fats
d.
A diet high in fluid sources
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a.
w
ANS: C
w
The patient with acute glomerulonephritis would need a high carbohydrate, high fat diet to
maintain weight. Potassium and sodium are restricted as well as excess fluids.
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23.The patient has end-stage renal disease (ESRD) and is admitted to the hospital with a blood
urea nitrogen (BUN) level of 48 mg/dL. An excessive elevation of BUN could result from:
a.
dehydration.
b.
disorientation.
c.
edema.
d.
catabolism.
ANS: B
If the BUN is elevated, preventive nursing measures should be instituted to protect the patient
from possible disorientation or seizures.
24.An intravenous pyelogram confirms the presence of a 4-mm renal calculus in the proximal
left ureter of a newly admitted patient. Physician orders include meperidine (Demerol) 100 mg
IM q4h PRN, strain all urine, and encourage fluids to 4000 mL/day. What should be the nurses
highest priority when planning care for this patient?
Pain related to irritation of a stone
b.
Anxiety related to unclear outcome of condition
c.
Ineffective health maintenance related to lack of knowledge about prevention of stones
d.
Risk for injury related to disorientation
om
a.
.c
ANS: A
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Nursing diagnoses directed at pain control are of primary importance at the early stages of care.
Opioid medications manage the pain well.
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25.A patient is receiving chlorothiazide (Diuril), a thiazide diuretic for hypertension. What
nursing action is most important for prevention of complications?
Measure output
b.
Increase fluid intake
c.
Assess for hypokalemia
d.
Assess for hypernatremia
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te
a.
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ANS: C
.m
The thiazide diuretic, chlorothiazide (Diuril), affects electrolytes to cause hypokalemia (extreme
potassium depletion in blood).
w
b.
Report this immediately
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a.
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26.A patient with cystitis is receiving phenazopyridine (Pyridium) for pain and is voiding a
bright red-orange urine. What should the nurse do?
Explain to the patient that this is normal
c.
Increase fluid intake
d.
Collect a specimen
ANS: B
Pyridium will turn the urine reddish-orange.
27.The patient, age 43, has cancer of the urinary bladder. He has received a cystectomy with an
ileal conduit. Which characteristics would be considered normal for his urine?
a.
Hematuria
b.
Clear amber with mucus shreds
c.
Dark bile-colored
d.
Dark amber
ANS: B
There will be mucus present in the urine from the intestinal secretions.
om
28.A patient, age 78, has been admitted to the hospital with dehydration and electrolyte
imbalance. She is confused and incontinent of urine on admission. Which nursing intervention
does the nurse include in developing a plan of care?
Restrict fluids after the evening meal
b.
Insert an indwelling catheter
c.
Assist the patient to the bathroom every 2 hours
d.
Apply absorbent incontinence pads
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st
ANS: D
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.c
a.
ng
Use of protective undergarments may help to keep the patient and the patients clothing dry.
Confused patients are high risk for falls. Restricting fluids will only decrease incontinence during
the night and will exacerbate the dehydration and electrolyte imbalance.
yn
ur
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29.The home health nurse suggests the use of complementary and alternative therapies to prevent
and/or treat urinary tract infections (UTIs). Which of the following is an example of such
therapies?
a.
Grape juice
Caffeine
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b.
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ANS: D
Cranberry juice
w
d.
Tea
w
c.
Cranberry (Cranberry Plus, Ultra Cranberry) has been used to prevent urinary tract infections
(UTIs), particularly in women prone to recurrent infection. It has also been used to treat acute
UTI. Monitor patients for lack of therapeutic effect. Caffeine and tea will increase diuresis but
not prevent UTI.
30.Which action can reduce the risk of skin impairment secondary to urinary incontinence?
a.
Decreasing fluid intake
b.
Catheterization of the elderly patient
c.
Limiting the use of medication (diuretics, etc.)
d.
Frequent toileting and meticulous skin care
ANS: D
Frequent toileting of the incontinent patient will prevent retained moisture in undergarments and
bed linens and will preserve the integrity of the skin.
31.Why are pediatric patients, especially girls, susceptible to urinary tract infections?
Genetically females have a weaker immune system
b.
Females have a short and proximal urethra in relation to the vagina
c.
Girls are more sexually active than males
d.
Girls have a weakened musculature and sphincter tone
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a.
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ANS: B
pr
Pediatric patients, especially girls, are susceptible to urinary tract infections because of the short
urethra.
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32.Which foods should the home health nurse counsel hypokalemic patients to include in their
diet?
Bananas, oranges, cantaloupe
b.
Carrots, summer squash, green beans
c.
Apples, pineapple, watermelon
d.
Winter squash, cauliflower, lettuce
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ng
a.
yn
ANS: A
.m
The use of most diuretics, with the exception of the potassium-sparing diuretics, requires adding
daily potassium sources (e.g., baked potatoes, raw bananas, apricots, or navel oranges,
cantaloupe, winter squash).
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a.
w
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33.To help a patient control incontinence, what should the nurse recommend the patient avoid?
Spicy foods
b.
Citrus fruits
c.
Organ meats
d.
Shellfish
ANS: A
Incontinence may be improved by omitting spicy foods, alcohol, and caffeine from the diet.
34.What should the nurse counsel the young man with chronic prostatitis to avoid?
a.
Cessation of intercourse
b.
Warm baths
c.
Stool softeners
d.
Continuing antibiotics when symptoms abate
ANS: A
om
Frequent intercourse may be beneficial to the treatment of chronic prostatitis. Warm baths, stool
softeners, and antibiotic therapy are also part of the medical treatment.
.c
MULTIPLE RESPONSE
oliguria
c.
hematuria
d.
anasarca
e.
oliguria
st
b.
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proteinuria
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ng
a.
pr
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35.The nurse reassures the patient recovering from acute glomerulonephritis that after all other
signs and symptoms of the disease subside, it is normal to have some residual (select all that
apply):
ur
ANS: A, C
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w
.m
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Proteinuria and hematuria may exist microscopically even when other symptoms subside.
Bones and liver
c.
Heart and blood vessels
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st
b.
pr
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MULTIPLE CHOICE
1. Which are the most common sites of breast cancer metastasis?
a.
Kidneys
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Chapter 19 Women’s Health Disorders
AIDS
c.
Chlamydia
.m
b.
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d.
Central nervous system
ANS: B
Metastasis occurs when the cancer cells spread to the vascular sites, commonly the lungs, liver,
and bones. Kidney metastasis is uncommon. Metastasis to the heart and blood vessels is
uncommon. The brain is one of the final areas to be reached by metastasis.
2. Which sexually transmitted disease can be cured?
a.
Herpes
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w
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d.
Venereal warts
ANS: C
The usual treatment for chlamydial bacterial infection is doxycycline hyclate or tetracycline.
Concurrent treatment of all sexual partners is needed to prevent recurrence. Because no cure is
known for herpes, treatment focuses on pain relief and preventing secondary infections. Because
no cure is known for AIDS, prevention and early detection are the main focus. Condylomata
acuminata is caused by the human papillomavirus. No treatment eradicates the virus.
3. Which statement by a client diagnosed with premenstrual syndrome indicates that further
health teaching is needed?
a.
I will not eat chips or pickles.
b.
Ill eat only three meals per day.
c.
Drinking alcohol makes me more depressed.
d.
Coffee and chocolate can make me more irritable and nervous.
ANS: B
The client should be encouraged to eat six small meals a day to decrease the risk of
hypoglycemia. Less intake of salty foods helps decrease fluid retention. Alcohol consumption
aggravates depression. Caffeine consumption increases irritability, insomnia, anxiety, and
nervousness.
4. A benign breast condition that includes dilation and inflammation of the collecting ducts is:
a.
fibroadenoma.
b.
ductal ectasia.
c.
intraductal papilloma.
pr
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.c
om
d.
chronic cystic disease.
ANS: B
Generally occurring in women approaching menopause, ductal ectasia results in a firm irregular
mass in the breast, enlarged axillary nodes, and nipple discharge. Fibroadenoma is evidenced by
fibrous and glandular tissues. They are felt as firm, rubbery, and freely mobile nodules.
Intraductal papillomas develop in the epithelium of the ducts of the breasts; as the mass grows, it
causes trauma or erosion within the ducts. Chronic cystic disease causes pain and tenderness.
The cysts that form are multiple, smooth, and well delineated.
Helen, 50 years old
c.
Mary, 16 years old
ng
b.
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st
5. Which client is most at risk for fibroadenoma of the breast?
a.
Janice, 38 years old
.m
yn
ur
si
d.
Anna, 27 years old
ANS: C
Although it may occur at any age, fibroadenoma is most common in the teenage years. Ductal
ectasia becomes more common as a client approaches menopause. Intraductal papilloma
develops most often just before or during menopause. Fibrocystic breast changes are more
common during the reproductive years.
6. Which statement is true about primary dysmenorrhea?
a.
Primary dysmenorrhea is experienced by all women.
It is unaffected by oral contraceptives.
c.
It occurs in young multiparous women.
w
w
b.
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d.
It may be caused by excessive endometrial prostaglandin.
ANS: D
Some women produce excessive endometrial prostaglandin during the luteal phase of the
menstrual cycle. Prostaglandin diffuses into endometrial tissue and causes uterine cramping.
Primary dysmenorrhea is not experienced by all women. Oral contraceptives can be a treatment
choice. It occurs in young nulliparous women.
7. A client states, Im sure that I am suffering from PMS. How can I get my doctor to take this
seriously? The nurses best response is:
a.
Men are not usually sympathetic to PMS sufferers.
b.
You are probably right. You should remind your doctor of your symptoms every time you visit.
c.
Since you feel certain you are right, you should just treat yourself with over-the-counter
medications.
Drink a small glass of wine with her evening meal.
c.
Decrease her fluid intake to prevent fluid retention.
.c
b.
om
d.
You should keep a daily record of the occurrence and severity of your symptoms for 3 months.
ANS: D
Symptom charting for at least 3 months is necessary to make an accurate diagnosis of PMS.
Suggesting lack of sympathy from men is an inaccurate statement and will not help the client
with the present problem. Reminding the physician of the symptoms will not assist in making a
diagnosis. Listing symptoms for 3 months will help the physician make the diagnosis better. The
client should not treat herself with over-the-counter medications.
8. Which should the nurse stress in teaching a client to deal with the symptoms of PMS?
a.
Decrease her consumption of caffeine.
ng
te
st
pr
ep
d.
Eat three large meals a day to maintain glucose levels.
ANS: A
Caffeine increases irritability, insomnia, anxiety, and nervousness. Alcohol aggravates
depression and should be avoided. Fluid intake should not be decreased. Six smaller meals a day
will help maintain glucose levels.
9. A client, age 49, confides in the nurse that she has started experiencing pain with intercourse.
She asks, Is there anything I can do about this? The nurses best response is:
a.
No, it is part of the aging process.
Water-soluble vaginal lubricants may provide relief.
c.
You need to be evaluated for a sexually transmitted disease.
ur
si
b.
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w
w
.m
yn
d.
You may have vaginal scar tissue that is producing the discomfort.
ANS: B
Loss of lubrication, with resulting discomfort in intercourse, is a symptom of estrogen
deficiency. It is part of the aging process, but the use of lubrication will help relieve the
symptoms. This is a normal occurrence with the aging process and does not indicate an STD. It
is caused by loss of lubrication with the decrease in estrogen. Scar tissue problems would have
occurred earlier.
10. Which client is most likely to have osteoporosis?
a.
A 50-year-old client on estrogen therapy
b.
A 55-year-old client with a sedentary lifestyle
c.
A 65-year-old client who walks 2 miles each day
d.
A 60-year-old client who takes supplemental calcium
ANS: B
Risk factors for the development of osteoporosis include smoking, alcohol consumption,
sedentary lifestyle, family history of the disease, and a high-fat diet. Hormone therapy may
prevent bone loss. Weight-bearing exercises have been shown to increase bone density.
Supplemental calcium will help prevent bone loss, especially when combined with vitamin D.
11. A client with a history of a cystocele should contact the physician if she experiences:
a.
backache.
b.
constipation.
c.
urinary frequency and burning.
Void every hour while awake.
c.
Drink 8 to 10 glasses of water each day.
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d.
involuntary loss of urine when she coughs.
ANS: C
Urinary frequency and burning are symptoms of cystitis, a common problem associated with
cystocele. Back pain is a symptom of uterine prolapse. Constipation may be a problem with
rectoceles. Involuntary loss of urine during coughing is stress incontinence and is not an
emergency.
12. Which should the nurse teach to assist a client to regain control of her urinary sphincter?
a.
Do Kegel exercises.
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d.
Allow the bladder to become distended before voiding.
ANS: A
Kegel exercises, tightening and relaxing the pubococcygeal muscle, will improve control of the
urinary sphincter. A prescribed schedule may help, but every hour is too frequent. Restricting
fluids will cause bladder irritation, which exacerbates the problem. Drinking adequate fluids will
not help the problem. Overdistention of the bladder will cause incontinence.
13. The physician diagnoses a 3-cm cyst in the ovary of a 28-year-old client. You expect the
initial treatment to include:
a.
beginning hormone therapy.
scheduling a laparoscopy to remove the cyst.
c.
examining the client after her next menstrual period.
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d.
aspirating the cyst and sending the fluid to pathology.
ANS: C
Most ovarian cysts regress spontaneously. Cysts in women of childbearing age may decrease
within one cycle, so treatment is not necessary at this point. It is too early to anticipate removal
of the cysts. Most ovarian cysts regress spontaneously within one cycle. A transvaginal
ultrasound examination will help determine if the cyst is fluid-filled or solid. The cyst can then
be removed if warranted.
14. The drug of choice to treat gonorrhea is:
a.
penicillin G (Pfizerpen).
b.
tetracycline (Achromycin).
c.
ceftriaxone (Rocephin).
d.
acyclovir (Zovirax).
ANS: C
Ceftriaxone is effective for treatment of all gonococcal infections. Penicillin G is used to treat
syphilis. Tetracycline is used to treat chlamydial infections. Acyclovir is used to treat herpes
genitalis.
15. Which option could be used for the treatment and management of a client who reports mild
pain associated with a clinical diagnosis of fibrocystic breast disease?
a.
Chamomile tea as a relaxant therapy
b.
Danazol (Danocrine)
c.
Tamoxifen (Nolvadex)
Radiation therapy
c.
Sentinel lymph node mapping
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d.
Over-the-counter nonsteroidal antiinflammatory drug (NSAID) therapy
ANS: D
Because the client is reporting mild pain, NSAIDs may provide adequate pain relief and comfort.
It is recommended that tea, coffee, and/or other stimulants be limited or restricted for clients with
fibrocystic breast disease. Danazol is typically used for moderate to severe pain for clients with
fibrocystic breast disease because its use is associated with more serious side effects. The client
reports mild pain so this would not be warranted. Tamoxifen is a selective estrogen receptor
modulator (SERM) used for the treatment of breast cancers and also for moderate to severe pain
in fibrocystic breast disease. The client reports mild pain, so this would not be warranted.
16. Which treatment option minimizes the development of lymphedema in the surgical
management of a client with breast cancer?
a.
Radical mastectomy procedure
Use of a cell saver for transfusion therapy in the postoperative period
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c.
Removal of vaginal packing as ordered by the physician
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b.
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d.
Ultrasound
ANS: C
The use of sentinel lymph node mapping identifies only those affected lymph node tissues that
require surgical removal so it helps minimize the development of lymphedema in the surgical
management of a client with breast cancer. Radical mastectomy is associated with lymphedema
in the postsurgical breast cancer client because of the removal of lymph node tissue. Radiation
therapy is not associated with a decrease in lymphedema for the breast cancer client. Ultrasound
as an intervention does not affect the development of lymphedema.
17. You are taking care of a client who has had a colporrhaphy. Which option would indicate a
priority assessment during the postoperative period?
a.
Documentation of a pessary in the operative procedure notes by the physician
d.
Order for removal of staples 2 to 3 days post-procedure
ANS: B
Vaginal packing is typically used in this type of pelvic surgery so it is a priority assessment that
its removal be verified and documented. A pessary would be used as a nonsurgical intervention
for a client who has had uterine prolapse and was not a surgical candidate based on medical
history. A cell saver is used in orthopedic surgeries that are at risk for blood loss so that the
clients own blood can be re-infused based on established protocol. There are no staples used in
this type of surgical procedure, which is also known as an A & P (anterior and posterior) repair.
18. In reviewing genetic testing for a female client, you note the presence of BRCA1,
BRCA2, and CHEK2.How should these findings be interpreted?
a.
There is no increased likelihood that the client will develop breast or ovarian cancer.
b.
There is an increased likelihood only for the development of breast cancer in a woman.
c.
More information is needed to interpret these findings based on the clients family history and
the clients current and past medical history.
A radical bilateral mastectomy is required immediately because the cancer may have already
undergone sub-metastasis.
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d.
ANS: C
The presence of genetic markers (BRCA1, BRCA2, and CHEK2) provides strong indicators of the
increased risk for the development of breast cancer in males and females and ovarian cancer. It is
important to obtain additional information so that a treatment plan can be developed and
implemented to improve client outcomes. There is an increased likelihood that the client will
develop breast or ovarian cancer, but stating that there is an increased likelihood only for the
development of breast cancer in a woman fails to include that men are also at risk of developing
breast cancer. At this point, surgical intervention is speculative because the presence of
biomarkers does not indicate that sub-metastasis has occurred or that the cancer has even
developed.
MULTIPLE RESPONSE
19. A 38-year-old client presents to the clinic office complaining of increased bilateral
tenderness of her breasts prior to the onset of menses. On questioning the client, this presentation
has occurred off and on for several years, but the pain has increased. Physical examination
reveals lumpy areas bilaterally on the upper outer quadrants of each breast tissue. The areas of
concern are approximately 2 cm in size. Based on this assessment, what diagnostic testing would
be required? (Select all that apply.)
a.
Ultrasound examination
Open biopsy
c.
Fine-needle aspiration (FNA) biopsy
d.
CBC with differential
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e.
Mammogram
ANS: A, C, E
Based on the clinical presentation, the client may have fibrocystic breast disease. Although this
condition is typically benign, the fact that the client has noted a change in tenderness should be
evaluated. Ultrasound, FNA, and mammography may be indicated to provide a baseline for
comparison and rule out any malignancy. An open or surgical biopsy is not indicated at the
present time but may be needed if the other test results indicate any pathology. Blood work is not
indicated at this time relative to the diagnosis
MULTIPLE CHOICE
20.A client tells the nurse that she experiences heavy menstrual bleeding. The nurse would
document this condition as being:
dysmenorrhea.
2.
menorrhagia.
3.
metrorrhagia.
4.
polymenorrhea.
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ANS: 2
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Menorrhagia is heavy menstrual bleeding. Metrorrhagia is bleeding between menses.
Dysmenorrhea is pain during the menstrual cycle, and polymenorrhea is having menstrual cycles
at 2- to 3-week intervals.
dysmenorrhea.
2.
primary amenorrhea.
3.
oligomenorrhea.
4.
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21.A client tells the nurse that she has not had menstrual cycles for 2 months since she has been
training for a marathon. The nurse would document this clients lack of regular menstrual cycles
as being:
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secondary amenorrhea.
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ANS: 4
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Secondary amenorrhea is when a woman has normal menstrual cycles but then stops.
Dysmenorrhea is pain during the menstrual cycle, and oligomenorrhea is the absence of
menstrual cycles for 3 months or longer. Primary amenorrhea is the lack of a menstrual cycle by
age 16.
22.The nurse is documenting that a female client is menopausal because the client has not had a
menstrual cycle in:
1.
6 months.
2.
9 months.
3.
12 months.
4.
15 months.
ANS: 3
Women are considered menopausal if they have not had a menstrual cycle for 12 months. A
perimenopausal state may exist prior to actual menopause.
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23.A female client is prescribed estrogen (Alora) for hot flashes associated with menopause.
Which of the following should the nurse instruct this client regarding this medication?
Hot flashes can increase.
2.
Weight gain can occur.
3.
Breast tenderness and spotting are side effects.
4.
Abdominal pain is to be expected.
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ANS: 3
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The nurse should instruct the client prescribed estrogen (Alora) that side effects include breast
tenderness, nausea, depression, headache, and spotting (bleeding). Hot flashes do not increase
with this medication. Weight gain is not a documented side effect of this medication. Abdominal
pain is not an expected side effect of this medication.
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complete hysterectomy.
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1.
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24.The nurse is caring for a female client recovering from surgery to remove the uterus, cervix,
ovaries, and fallopian tubes using a traditional approach. The nurse realizes this client has had a:
2.
laparoscopically assisted vaginal hysterectomy.
3.
partial hysterectomy.
4.
total abdominal hysterectomy and bilateral salpingo-oophorectomy.
ANS: 4
Removal of the uterus, ovaries, and fallopian tubes through an abdominal incision is called a
total abdominal hysterectomy and bilateral salpingo-oophorectomy. A hysterectomy performed
vaginally via laparoscope is a laparoscopically assisted vaginal hysterectomy. A partial
hysterectomy removes the body of the uterus without the cervix, and a complete hysterectomy is
the removal of the entire uterus.
Foul, fishy odor
2.
Gray, thin, watery discharge
3.
Thick, white discharge
4.
Yellow, green discharge
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25.A female client, experiencing vulvar itching and discomfort, is diagnosed with Candida.
What would the nurse expect to find when assessing this client?
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ANS: 3
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Candida typically produces a thick, white discharge. Bacterial vaginosis causes a white or gray,
thin, watery discharge and an odor. Trichomoniasis has a frothy, green/yellow/white discharge.
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26.A female client who has been menstruating has a temperature of 103.5F, blood pressure 88/56
mmHg, and a diffuse rash. The nurse realizes that this client is most likely experiencing:
pelvic inflammatory disease.
2.
herpes simplex virus.
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4.
human papillomavirus.
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3.
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toxic shock syndrome.
ANS: 4
Toxic shock syndrome is an acute illness associated with menstruation and tampon use.
Symptoms include a high fever, a diffuse rash, falling blood pressure, nausea, vomiting, diarrhea,
myalgia, disorientation, and coma. Herpes simplex virus usually results in a genital sore or ulcer.
The human papillomavirus is associated with genital warts. Pelvic inflammatory disease is an
inflammatory condition of the female pelvic organs.
27.The nurse is teaching a group of young adults about prevention of sexually transmitted
infections (STIs). Which of the following instructions would not be included during teaching?
Abstinence is the only way to completely prevent STIs.
2.
Condoms provide some protection against STIs.
3.
Make sure you and your partner finish the entire treatment regimen.
4.
Once one STI is diagnosed, you are less likely to have an infection with another STI.
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ANS: 4
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Once one STI is diagnosed, an individual is more likely to have an infection with another STI.
The person should be tested for all STIs. The other choices would be appropriate for the nurse to
instruct regarding STIs.
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28.A 52-year-old female client had been treated for human papillomavirus. After 3 years of
testing, the clients Pap smears are normal. The nurse realizes that the clients next Pap smear
should be in:
2 years
2.
3 years
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5 years
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3.
10 years
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ANS: 2
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If the client is between the ages of 30 to 70 and has three normal Pap smear results, the client
does not need to have another Pap smear for 3 years. If the client is between the ages of 21 to 30
and has normal Pap smear results, the client needs another Pap smear in 2 years. If the client is
over the age of 70 and the last three Pap smear results were normal, within 10 years, the Pap
smears can be discontinued.
29.A female client has had a type 1 female circumcision. The nurse realizes that which of the
following has been surgically removed on the client?
1.
Clitoris
2.
Clitoris and labia minora
3.
Clitoris, labia minora, inner surface of labia majora, and suturing of the vagina
4.
Clitoris and uterus
ANS: 1
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Type 1 female circumcision is the removal of the clitoris. Type II includes the removal of the
clitoris and labia minora. Type III is the removal of the clitoris, labia minora, inner surface of the
labia majora, and suturing of the labia majora together to cover the urethra and vagina. There is
not a type that is the removal of the clitoris and uterus.
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30.The nurse determines that a female client is at risk for developing a gynecological malignancy
because which of the following is assessed?
Alcohol intake of one drink every week
2.
Currently overweight
3.
Smoking history
4.
History of constipation
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ANS: 3
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Smoking increases the female clients risk of developing gynecological malignancies. Alcohol
intake, being overweight, and having a history of constipation do not increase a clients risk of
developing the disorder.
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31.A female client diagnosed with infertility is prescribed medication. The nurse would provide
instruction regarding which of the following medications?
1.
Viagra
2.
Delatestryl
3.
Testim
4.
Clomiphene citrate
ANS: 4
Clomiphene citrate is used to induce ovulation. When used, most pregnancies occur within the
first 3 cycles of use and almost all pregnancies occur within 6 months of use. The other
medications are used to treat sexual dysfunction and not infertility.
Feeling sad or hopeless
2.
Feeling anxious
3.
Mood swings
4.
Increased sleep
5.
Anger
6.
Thirst
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ANS: 1, 2, 3, 4, 5
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32.A female client is diagnosed with premenstrual dysphoric disorder. Which of the following
will the nurse most likely assess in this client? (Select all that apply.)
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To diagnose premenstrual dysphoric disorder, five or more symptoms must be present most of
the time during the last week of the menstrual luteal phase: feeling sad or hopeless; feeling
anxious; mood swings; increased sleep; and anger. Thirst is not a symptom of this disorder.
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33.A female client, diagnosed with pelvic inflammatory disease, is being considered for inpatient
treatment. Which of the following would indicate that the client should be admitted to the
hospital for care of this disorder? (Select all that apply.)
1.
The client is pregnant.
2.
The client will not adhere to the prescribed antibiotic therapy.
3.
The clients temperature is 103 degreesF.
4.
The client is experiencing symptoms of a tubo-ovarian abscess.
5.
The clients blood pressure is 120/80 mmHg.
6.
The client has purulent cervical discharge.
ANS: 1, 2, 3, 4
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Criteria for admission to treat pelvic inflammatory disease includes pregnancy, inability to
comply with outpatient therapy, failure of outpatient therapy, temperature greater than 102.2F,
and suspected tubo-ovarian abscess. Blood pressure and purulent cervical discharge are not
criteria for admission to treat pelvic inflammatory disease.
Bacteria vaginitis
2.
HPV
3.
HIV
4.
Chlamydia
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Gonorrhea
Syphilis
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6.
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34.A client is diagnosed with a sexually transmitted infection that the nurse needs to report to the
local health department. Which of the following sexually transmitted infections need to be
reported by the nurse? (Select all that apply.)
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ANS: 3, 4, 5, 6
Syphilis, gonorrhea, chlamydia, and HIV are infections that need to be reported to the local
health department in every state. Bacteria vaginitis and HPV do not need to be reported to the
local health department.
35.A female client is diagnosed with a cystocele. The nurse should prepare to instruct the client
on which of the following? (Select all that apply.)
Kegel exercises
2.
Pessary insertion
3.
Use of estrogen cream
4.
Operative repair
5.
Hysterectomy
6.
Antibiotics
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ANS: 1, 2, 3
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Treatment of a cystocele includes Kegels exercises, insertion of a pessary, and use of estrogen
cream. Operative repair, hysterectomy, and antibiotics are not treatments associated with this
disorder.
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36.A client is diagnosed with uterine fibroids. Which of the following would indicate that
surgery is needed for this client? (Select all that apply.)
Abnormal bleeding not responsive to other therapy
2.
Weight gain of 10 lbs over the last 3 months
3.
Growth of fibroids after menopause
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Chronic constipation
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5.
Client unable to conceive
6.
Diagnosed with iron deficiency anemia
ANS: 1, 3, 5, 6
Indications for surgical management of fibroids include abnormal bleeding that is not responding
to medical therapy, growth of fibroids after menopause, infertility, and iron deficiency anemia.
Weight gain and chronic constipation are not indications for surgery to remove uterine fibroids.
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