Health Disparities
Concept 54: Health Disparities
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
The nurse is caring for a Chinese patient diagnosed with cancer who is suffering from pain, yet refuses
analgesia administration. What type of health disparities is this patient exhibiting?
a.
Avoidable and acceptable
b.
Avoidable and unacceptable
c.
Unavoidable and acceptable
d.
Unavoidable and unacceptable
ANS:
B
Health disparities that are avoidable and unacceptable unfortunately occur in healthcare settings and these are the targets
of interventions. For example, a disparity in cancer pain management exists between Asians and Whites. This difference is
attributable to Asian cultural values and attitudes related to cancer pain and pain medication distinguished from the
cultural values of Whites. The disparity is avoidable if Asian cancer patients are adequately educated and instructed on
cancer pain management strategies including pain medication and complementary and alternative medicine. Also, this
disparity is unacceptable because this gives an unnecessary burden of pain to Asian cancer patients that could be easily
managed by using existing strategies.
REF:
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NCLEX® Client Needs Category: Safe and Effective Care Environment
2.
An experienced nurse tells the student nurse, “I have found that most Hispanic immigrants live in
unsanitary conditions but are hard workers.” How should the student nurse best classify this statement?
a.
Stereotyping
b.
Prejudice
c.
Discrimination
d.
Misinformed
ANS:
A
Stereotyping often leads to biased clinical decision-making. Stereotyping refers to the process by which people use social
categories (e.g., gender or race/ethnicity) in acquiring, processing, and recalling information about others. Both implicit
and explicit negative attitudes and stereotypes of healthcare providers significantly shape interactions with patients,
influence how information is recalled, and guide expectations and inferences in systematic ways. Stereotyping often
occurs subconsciously, unlike prejudice or discrimination. Prejudice, which refers to unjustified negative attitudes based
on a person’s group membership, is another source of biased clinical decision-making. Discrimination refers to the actual
mistreatment of individuals based on race, gender, ethnicity, etc. The nurse is not misinformed as the nurse has practiced
for some time and made a statement based on observation and experience.
REF:
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NCLEX® Client Needs Category: Safe and Effective Care Environment
3.
Which type of health disparities are most frequently encountered by nurses in clinical and community
settings?
a.
Avoidable and acceptable
b.
Avoidable and unacceptable
c.
Unavoidable and acceptable
d.
Unavoidable and unacceptable
ANS:
B
Although there are many types of health disparities, the avoidable and unacceptable health disparities are the ones that
healthcare providers, including nurses, frequently encounter in clinical and community settings. Furthermore, these are
the health disparities that healthcare providers need to target to intervene.
REF:
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NCLEX® Client Needs Category: Safe and Effective Care Environment
4.
The nurse is caring for diverse population groups at a health clinic. Which of the following patients
demonstrates a potential health disparity group?
a.
A 26-year-old woman who is receiving follow-up after a car accident.
b.
A 30-year-old immigrant who does not speak English.
c.
A 28-year-old man who needs a tetanus booster.
d.
A 12-month-old with an appointment for immunizations.
ANS:
B
Poor health literacy skills are an example of a health disparity that limits an individual’s ability to access or communicate
about health care needs. Patients who are receiving needed care are not experiencing a gap between health need and
actual care.
REF:
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NCLEX® Client Needs Category: Safe and Effective Care Environment
5.
Which is the best strategy the nurse manager should include when working to reduce health care
disparities on a medical-surgical unit?
a.
Less diverse workforce
b.
Increase interpreter availability
c.
Authoritarian leadership
d.
Annual staff training
ANS:
B
Key elements are cultural competence that can reduce health disparities include: a diverse workforce; interpreter
availability; finding common ground versus authoritarian leadership; frequent staff training and updating staff as needed
throughout the year.
REF:
OBJ:
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NCLEX® Client Needs Category: Safe and Effective Care Environment
a.
b.
c.
d.
6.
A new nurse requires further teaching when failing to identify which practice as a health disparity?
Annual mammogram
Early prenatal care
Blood pressure screening
Frequent fast food meals
ANS:
D
Preventive care, screening, and health promotion activities are not considered health disparities. Examples include
mammograms, prenatal care, and blood pressure checks. Frequent fast food meals, containing high fat content, is
considered a health disparity due to possible lack of money or access to healthy meals.
REF:
OBJ:
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NCLEX® Client Needs Category: Safe and Effective Care Environment
7.
first?
a.
b.
c.
d.
Before beginning work on a culturally diverse hospital unit, the nurse should perform which action
Improve self-awareness of one’s own biases
Attend an anti-discrimination rally or march
Build rapport and trust with the patients
Take a foreign language class
ANS:
A
Before working with culturally diverse groups, the nurse should first identify own biases and assumptions in order to
objectively and competently care for patients. Attending a rally or march may not raise awareness of various biases. The
nurse should establish rapport and trust when working with patients, after self-awareness is appreciated. Taking a foreign
language may be helpful; however the first step is self-awareness.
REF:
Page 506 OBJ:
NCLEX® Client Needs Category: Safe and Effective Care Environment
8.
The nurse who has been hired to work on an oncology unit identifies which group of women as being at
highest risk of developing breast cancer?
a.
African
b.
Caucasian
c.
Asian
d.
Hispanic
ANS:
C
Breast cancer is the most common cancer in Asian women in the U.S., but Asian women have relatively lower rates of
breast cancer screening than African American and white women in the U.S. Furthermore, disparities in breast cancer
screening reportedly result from: low income, lack of a local mammography center, lack of transportation to a
mammography center, lack of a usual healthcare provider, lack of a recommendation from a healthcare provider to get
mammography screening, lack of awareness of breast cancer risks and screening methods, and cultural and language
differences.
REF:
Page 506 OBJ:
NCLEX® Client Needs Category: Safe and Effective Care Environment
MULTIPLE RESPONSE
1.
A healthcare provider whose native country is India is explaining the treatment plan to a patient. The
patient tells the nurse she is having trouble understanding the provider but is embarrassed about asking to repeat the
information over and over. The nurse should assess for which results due to this disparity in provider-patient
communication? (Select all that apply.)
a.
Patient dissatisfaction
b.
Optimal health outcome
c.
Poor adherence
d.
Increased patient confidence
e.
Improved communication
ANS:
A, C
When sociocultural differences between healthcare providers and patients are not appreciated or communicated
effectively in clinical encounters, patient dissatisfaction, poor adherence, poorer health outcomes, and racial/ethnic
disparities in healthcare easily happen.
REF:
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NCLEX® Client Needs Category: Safe and Effective Care Environment
2.
The nurse in the immunization clinic should place emphasis on educating and reaching which groups
about the disease preventing effects of immunizations? (Select all that apply.)
a.
Caucasian
b.
African American
c.
Low income
d.
Middle income
e.
High income
ANS:
B, C, D
The 2013 National Healthcare Disparities Report documented that African American children or children from poor, lowincome, and middle-income households were less likely to receive all the recommended vaccinations compared with white
children or children from high-income households in 2011.
REF:
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NCLEX® Client Needs Category: Safe and Effective Care Environment
Chapter 14: Delegation in the Clinical Setting
Zerwekh: Evolve Resources for Nursing Today, 9th Edition
MULTIPLE CHOICE
a.
b.
c.
d.
1.
Which task could a staff nurse delegate to a certified nursing assistant (CNA)?
Evaluating a patient’s response to pain
Making rounds with a physician
Feeding a stroke patient who has minimal dysphagia
Assessing a patient’s central venous line site
ANS:
C
Feeding a stroke patient who has minimal dysphagia is an appropriate delegation of a nursing intervention to a CNA. The
nurse cannot delegate the task of assessing the patient or making rounds with the physician to the CNA. Nursing
interventions such as assessment and evaluation of pain, management of central line sites, or performing tracheotomy or
colostomy care are within the scope of professional nursing, as is making rounds with a physician.
PTS:
REF:
TOP:
MSC:
1
DIF:
Cognitive Level: Application/Applying
p. 306 |p. 308
OBJ:
Delegate tasks successfully based on outcomes.
Delegation in the clinical setting
NCLEX®: Safe and effective care environment—management of care
2.
The nurse has just given a patient an opioid medication for pain relief. Because the nurse must leave
the unit for lunch and a 1-hour meeting, the task of evaluating the patient’s response to the pain medication must be
delegated. To whom should the nurse delegate this responsibility?
a.
Nursing assistant
b.
Student nurse
c.
Licensed practical nurse
d.
Nurse manager
ANS:
D
Evaluating the patient’s response to pain medication is an activity within the scope of the registered professional nurse
(who in this situation is the nurse manager). The licensed practical nurse can administer the pain medication. The student
nurse could assist the professional nurse in the evaluation of the patient’s response to the pain medication; however, the
nurse leaving the unit cannot delegate this responsibility to a student. This nursing intervention is outside the scope of
practice of the nursing assistant.
PTS:
REF:
TOP:
MSC:
1
DIF:
Cognitive Level: Application/Applying
p. 308
OBJ:
Delegate tasks successfully based on outcomes.
Delegation in the clinical setting
NCLEX®: Safe and effective care environment—management of care
3.
The nurse has a full assignment. The charge nurse adds a newly admitted patient who will require close
monitoring. Which task can the nurse delegate to the CNA who is co-assigned to the same patients?
a.
Teaching insulin self-administration
b.
Updating a care plan
c.
Evaluating goal attainment for a patient who is learning to walk with a below-the-knee prosthesis
d.
Bathing an unconscious patient
ANS:
D
Bathing a patient is an appropriate nursing intervention within the role and responsibilities and scope of practice of the
CNA. Teaching clients, updating nursing care plans, and evaluating patient responses to treatment plans are within the
scope of practice of the registered professional nurse.
PTS:
REF:
TOP:
MSC:
1
DIF:
Cognitive Level: Application/Applying
p. 306 |p. 308
OBJ:
Delegate tasks successfully based on outcomes.
Delegation in the clinical setting
NCLEX®: Safe and effective care environment—management of care
4.
Based on the goal of making optimal use of the level of preparation of the licensed practical nurse
(LPN), which task should the nurse (RN) delegate to the LPN?
a.
Assisting with a lumbar puncture
b.
Transporting a patient to the radiology department
c.
Restocking the sterile supplies
d.
Distributing afternoon nutrition supplements
ANS:
A
Assisting with a procedure, such as a lumbar puncture, is within the scope of practice of the LPN. Transporting clients,
restocking supplies, and distributing nutrition supplements are nursing interventions that can be carried out by a certified
nursing assistant (CNA).
PTS:
REF:
TOP:
MSC:
1
DIF:
Cognitive Level: Application/Applying
p. 307
OBJ:
Delegate tasks successfully based on outcomes.
Delegation in the clinical setting
NCLEX®: Safe and effective care environment—management of care
5.
There is a temporary agency registered nurse assigned to the nursing unit. You have no knowledge of
this nurse’s skills, and you want to assign the nurse to a patient who has a fresh tracheostomy. How should you handle
this situation?
a.
Assign the nurse to the patient with the tracheostomy and hope for the best.
b.
Ask the nurse about his or her competency to care for the patient with the tracheostomy.
c.
Assign the patient to another nurse, and use the temporary agency nurse to do simple care tasks.
d.
Call the agency and ask for a nurse skilled in the care of a patient with a tracheostomy.
ANS:
B
Float and temporary nurses should be asked about their competency at the beginning of a shift or assignment. Never
assume that an individual knows something; be sure to ask. Delegation of an activity should always be followed by an
anticipated response from that nurse as to whether or not he/she feels capable of performing the task. It would be
appropriate to check on this nurse frequently to evaluate his/her delivery of care or to offer assistance. It would be okay to
call the agency to verify the nurse’s skill competencies, but talking with the nurse would still be the first action.
PTS:
REF:
TOP:
MSC:
1
DIF:
Cognitive Level: Application/Applying
p. 312
OBJ:
Understand and apply the five rights of delegation in nursing practice.
Delegation in the clinical setting
NCLEX®: Safe and effective care environment—management of care
a.
b.
c.
d.
6.
What would be the best example of delegation?
Transferring to another nurse the responsibility of caring for a patient requiring a blood transfusion
Providing guidance to an LPN to hang blood on a patient
Assigning a series of nursing unit tasks to the certified nursing assistant
Assisting a new nurse to understand the rules and regulations of the Nurse Practice Act
ANS:
A
Transferring to another nurse the responsibility of caring for a patient requiring a blood transfusion is the best example of
delegation. Delegation involves transferring to a competent nurse a specific task or responsibility for nursing care. The
person who delegated the responsibility maintains responsibility for following guidelines for appropriate delegation.
Providing guidance to an LPN and explaining to a new nurse about the Nurse Practice Act would be teaching and/or
supervision rather than delegating a specific task or responsibility. Assigning to a CNA certain tasks is not delegation
because there is no transferring of a specific task or responsibility of nursing care to that person.
PTS:
REF:
TOP:
MSC:
1
DIF:
Cognitive Level: Application/Applying
p. 302
OBJ:
Define the operational terms delegation, supervision, and accountability.
Definition of delegation
NCLEX®: Safe and effective care environment—management of care
a.
b.
c.
d.
7.
What would be the best example of supervision?
Assigning nursing care for a group of five patients to a nurse
Following up with a CNA on the assigned task of ambulation and feeding two patients
Assigning a urinary catheterization and collection of sterile culture to an LPN
Scheduling the LPN to administer medications on the unit for the afternoon
ANS:
B
Supervision is the provision of guidance, direction, and follow-up for the accomplishment of an assigned task. The nurse
would follow up with the CNA to determine whether the tasks were completed and whether any problems occurred.
Assigning nursing care for a group of patients or a specific procedure are examples of delegation, as is scheduling an LPN
to administer medications.
PTS:
REF:
TOP:
MSC:
1
DIF:
Cognitive Level: Application/Applying
p. 302
OBJ:
Define the operational terms delegation, supervision, and accountability.
Definition of supervision
NCLEX®: Safe and effective care environment—management of care
a.
b.
c.
d.
8.
What are potential causes of performance inadequacies?
The person to whom the task was assigned had appropriate educational qualifications to complete the task.
The task was assigned to a person capable of carrying out the assignment.
The person who delegated the task confirmed the recipient’s ability to perform the task.
The person to whom the task was assigned did not understand what the task involved.
ANS:
D
A potential cause of performance inadequacy would be where a person was assigned a task that he/she did not
understand. A principle of delegation is that the person to whom the task is assigned should verify that he/she
understands and can perform the task. When the person is capable, has appropriate educational qualifications, and the
nurse has confirmed that person is able to perform the task, then there would be no performance inadequacy.
PTS:
REF:
OBJ:
TOP:
MSC:
1
DIF:
Cognitive Level: Comprehension/Understanding
Critical Thinking Box 14.3
Understand and apply the five rights of delegation in nursing practice.
Evaluating performance
NCLEX®: Safe and effective care environment—management of care
a.
b.
c.
d.
9.
Which of the following represents appropriate feedback for an assignment to an LPN?
“Did you understand the assignment that you received in the staff report?”
“Have you completed the urinary catheterization and care of the new patient?”
“The patient in Room 430 looks much better, and you did a good job of making the patient comfortable.”
“I know you are busy; however, you need to get caught up with your pain medications.”
ANS:
C
Telling the LPN that he or she did a good job of making a patient comfortable is appropriate feedback on an assignment.
Feedback is a process of informing someone of how well or how poorly a delegated task was performed. Asking
understanding of an assignment or whether a procedure was performed is not giving feedback but determining if what is
supposed to be done is understood or whether the task (urinary catheterization) has been completed. The pain
medications may have been delegated; however, if this task was delegated, the feedback does not tell the LPN what he or
she is doing right or wrong.
PTS:
REF:
OBJ:
TOP:
MSC:
1
DIF:
Cognitive Level: Application/Applying
p. 309
Provide reciprocal feedback for the effective evaluation of the delegate’s performance.
Providing feedback
NCLEX®: Safe and effective care environment—management of care
10.
The nurse needs to discuss a problem with the nursing assistant. The nursing assistant has left several
rooms cluttered with trash and not cleaned appropriately. Which comment by the nurse would be the best way to approach
the problem?
a.
“I checked on the four rooms you were assigned, and they are really a mess.”
b.
“Have you had a problem completing your work assignment today?”
c.
“All four of the patient rooms assigned to you today are messy with a lot of trash in them.”
d.
“Family members have been really upset today. Why have you not cleaned up the rooms assigned to you?”
ANS:
B
Providing an open-ended question to determine if there was some difficulty with an assignment is an appropriate method
to assess this situation. When correcting or telling a person that he/she did something wrong, it is best to start by giving
that person an opportunity to provide some input into the situation. This can be accomplished by asking the nursing
assistant if there was any problems completing the assignment today. Asking why-type questions can put the person on
the defensive and does not allow the CNA to provide an explanation of why the rooms were cluttered. Telling the CNA that
the rooms were cluttered and messy does not address the issue of how it occurred.
PTS:
REF:
OBJ:
TOP:
MSC:
1
DIF:
Cognitive Level: Application/Applying
Critical Thinking Box 14.6
Provide reciprocal feedback for the effective evaluation of the delegate’s performance.
Providing feedback
NCLEX®: Safe and effective care environment—management of care
a.
b.
c.
d.
11.
Which of the following tasks can the nurse safely delegate to the nursing assistant?
Assessing the patients who are being discharged later today
Giving discharge instructions to a patient
Helping a patient select food according to the specified diet
Educating the patient on what foods to eat for his/her diet plan
ANS:
C
The nurse can safely delegate the job of helping the patient select food according to a specified diet. The nurse is
responsible for assessing patients, giving discharge instructions, and educating the patient on what foods to eat for the
diet plan.
PTS:
REF:
OBJ:
TOP:
1
DIF:
Cognitive Level: Application/Applying
p. 306 |p. 308
Understand and apply the five rights of delegation in nursing practice.
What does delegation mean?
MSC:
NCLEX®: Safe and effective care environment
a.
b.
c.
d.
12.
Determine how the registered nurse’s role is different from that of the LPN in assessment of the patient.
Collects data during the health history and physical exam
Contributes to the development of the care plan
Assist in updating the care plan
Uses findings from the assessment to create a care plan
ANS:
D
The registered nurse differs from the LPN in that the RN uses assessment findings to create a care plan for the patient.
The LPN focuses on collecting data during the health history and exam, contributes to the development of the care plan,
and assists in updating the care plan.
PTS:
REF:
TOP:
1
DIF:
p. 307
OBJ:
Delegation
Cognitive Level: Knowledge/Remembering
Understand and apply the five rights of delegation in nursing practice.
MSC:
NCLEX®: Safe and effective care environment
13.
A registered nurse is feeling overwhelmed. Which of the following would be most appropriate for the
registered nurse to delegate to an LPN?
a.
An initial assessment on a new patient
b.
Educational teaching on diabetes management
c.
Creating a care plan for a patient
d.
Updating the care plan for a patient who is postop day 2
ANS:
D
The registered nurse could delegate updating the care plan for a patient who is postop day 2. The RN should not delegate
an initial assessment, teaching, or creating a care plan for a patient. These responsibilities are not within the scope of
practice for the LPN and must be completed by the registered nurse.
PTS:
REF:
TOP:
1
DIF:
p. 307
OBJ:
Delegation
Cognitive Level: Application/Applying
Understand and apply the five rights of delegation in nursing practice.
MSC:
NCLEX®: Safe and effective care environment
14.
A day shift nurse has come into work and notices that the glucometers were not tested overnight as
they typically are. What is the best way for the nurse to question the nurse assistant in order to give feedback?
a.
“Why didn’t you test the glucometers?”
b.
“What did you do last night?”
c.
“How was your night? I noticed the glucometers weren’t tested.”
d.
“Couldn’t you have asked one of the nurses to check the glucometers if you were busy?”
ANS:
C
When giving an individual negative feedback, the nurse should also ask for the nurse assistant’s feedback. If the nurse
becomes accusatory, the nursing assistant may become defensive, which does not help solve the issue of the
glucometers not being tested. Asking, “How was your night? I noticed the glucometers weren’t tested” gives the nursing
assistant a chance to respond and explain what happened.
PTS:
REF:
OBJ:
TOP:
MSC:
1
DIF:
Cognitive Level: Application/Applying
Critical Thinking Box 14.6
Provide reciprocal feedback for the effective evaluation of the delegate’s performance.
The right supervision and delegation
NCLEX®: Safe and effective care environment
15.
A nurse is reviewing delegation with a graduate nurse. The nurse knows that the teaching has been
successful when the graduate nurse states which of the following?
a.
“The nurse can delegate assessments to the nurse assistants.”
b.
“The nurse must create the care plan based on assessment findings.”
c.
“The nursing assistants cannot perform bed baths on postsurgical patients.”
d.
“The LPN can perform discharge teaching.”
ANS:
B
The teaching has been successful when the graduate nurse states: “The nurse must create the care plan based on
assessment findings.” The nurse is solely responsible for this action. The nurse cannot delegate assessments to the
nursing assistants; this must be completed by the nurse. Performing discharge teaching is a requirement of the nurse, not
the LPN. Nursing assistants can perform bed baths on postsurgical patients.
PTS:
REF:
TOP:
1
DIF:
pp. 307-308
The right task
Cognitive Level: Evaluation/Evaluating
OBJ:
Understand and apply the five rights of delegation in nursing practice.
MSC:
NCLEX®: Safe and effective care environment
a.
b.
c.
d.
16.
What should the nurse do to assess competence before delegating a task to an LPN?
Ask if the LPN has previous experience performing the task.
Ask if the LPN is willing to perform the task.
Ask another nurse if the LPN is competent.
Assume the LPN is competent due to her years of service.
ANS:
A
In order to assess competence, the nurse should ask the LPN if he or she has experience performing the task. Based on
the answer, the nurse can then ask more questions if needed to determine competency.
PTS:
REF:
TOP:
1
DIF:
Cognitive Level: Application/Applying
p. 312
OBJ:
Understand and apply the five rights of delegation in nursing practice.
The right circumstances
MSC:
NCLEX®: Safe and effective care environment
17.
Which of the following statements indicates the nurse’s understanding of accountability in the
delegation process?
a.
“I am solely accountable for the actions of the delegate.”
b.
“I am accountable for assessing the delegate’s competency before delegation.”
c.
“The delegate is responsible for telling the nurse if he/she is competent.”
d.
“The manager is responsible for providing feedback to the delegate.”
ANS:
B
The nurse is accountable for assessing the delegate’s competency before delegation and providing feedback after the task
has been completed. The delegate is solely responsible for his or her actions, not the nurse.
PTS:
REF:
TOP:
1
DIF:
p. 304
OBJ:
Accountability
Cognitive Level: Evaluation/Evaluating
Define the operational terms delegation, supervision, and accountability.
MSC:
NCLEX®: Safe and effective care environment
18.
To optimally use the level of preparation of the LPN who previously worked in an emergency
department, which task should the registered nurse delegate to the LPN?
a.
Transporting a patient to the laboratory
b.
Assisting with a thoracentesis
c.
Restocking and counting the sterile supplies
d.
Passing afternoon nutrition supplements and waters
ANS:
B
Although the LPN/LVN could be delegated appropriately to do all of these tasks, assisting with procedures (e.g., the
thoracentesis) would make best use of the LPN’s emergency department educational preparation. The other activities
would be appropriate to delegate to a nursing assistant.
PTS:
REF:
TOP:
MSC:
1
DIF:
Cognitive Level: Application/Applying
p. 307
OBJ:
Understand and apply the five rights of delegation in nursing practice.
Delegation in the clinical setting
NCLEX®: Safe and effective care environment—management of care
19.
The charge nurse is assigning patients for care. There are two registered nurses (RNs), an LPN, and a
certified nursing assistant (CNA). The charge nurse would assign which of the following patients to the LPN?
a.
An older adult who is receiving IV chemotherapy through a central line and will need a dressing change
b.
An adult patient diagnosed with insulin-dependent diabetes who will need dressing changes on several stasis
ulcers on the lower extremities
c.
An adult patient with a right fractured femur and right arm in a cast who needs to urinate
d.
An older patient with terminal cancer who will be transferred to hospice
ANS:
B
The patient with diabetes will need stasis ulcer care, which is within the scope of practice of the LPN. The patient receiving
chemotherapy through a central line would be assigned to the registered nurse. The nursing assistant would help the
female patient with the fractures with the bedpan. The nurse should facilitate the transfer of the hospice patient.
PTS:
REF:
TOP:
MSC:
1
DIF:
Cognitive Level: Application/Applying
p. 307
OBJ:
Understand and apply the five rights of delegation in nursing practice.
Delegation in the clinical setting
NCLEX®: Safe and effective care environment—management of care
20.
The nurse is making assignments for the team. There are two LPNs and a nursing assistant on the
team. Which of the following assignments would the nurse choose for him/herself?
a.
A patient with left-sided paralysis who needs help with bathing
b.
A patient with a chest tube who is ambulating in the hall
c.
A patient receiving chemotherapy for bone cancer
d.
A patient receiving tube feedings with a J-tube
ANS:
C
The patient with the highest acuity would be the patient receiving chemotherapy for bone cancer. The nurse would be
managing delivery of chemotherapy drugs and pain control with narcotics as ordered. The other patients are within the
scope of care for the LPN and the nursing assistant.
PTS:
REF:
TOP:
MSC:
1
DIF:
Cognitive Level: Application/Applying
p. 309
OBJ:
Understand and apply the five rights of delegation in nursing practice.
Selecting right person
NCLEX®: Safe and effective care environment—management of care
21.
A patient in the medical-surgical unit is diagnosed with anemia and complains of weakness. Which of
the following assignments could be given to the nursing assistant?
a.
Organize the patient’s meal tray for dinner.
b.
Talk with the patient about managing rest and activities.
c.
d.
Get a diet history and list of the patient’s favorite foods.
Take an apical pulse and listen to the lungs for crackles.
ANS:
A
The only assignment that fits the scope of practice for the nursing assistant would be to organize the patient’s tray. Talking
with the patient and obtaining a diet history would be nurse functions, as would listening to the lungs for crackles.
PTS:
REF:
TOP:
MSC:
1
DIF:
Cognitive Level: Application/Applying
p. 308
OBJ:
Understand and apply the five rights of delegation in nursing practice.
Delegation in the clinical setting
NCLEX®: Safe and effective care environment—management of care
a.
b.
c.
d.
22.
An experienced nursing assistant could be assigned by the nurse to do which of the following?
Help teach new diabetic clients to give themselves injections.
Report on quality and quantity of urine, and adjust drip rate on continuous bladder irrigation.
Assist the client to obtain a clean-catch urine specimen.
Chart the dietary intake of a client with an eating disorder.
ANS:
C
The nursing assistant can be assigned activities that involve standard, unchanging procedures, such as helping to obtain
a clean-catch urine specimen from a client. Teaching, working with complicated procedures (continuous bladder
irrigation), and monitoring dietary intake of a person having an eating disorder would need to be assigned to the nurse
because they involve assessment and evaluation.
PTS:
REF:
TOP:
MSC:
1
DIF:
Cognitive Level: Application/Applying
Figure 14.1
OBJ:
Understand and apply the five rights of delegation in nursing practice.
Delegation in the clinical setting
NCLEX®: Safe and effective care environment—management of care
23.
The nurse is preparing assignments in a pediatric unit for the night shift. Which of the following would
be appropriate to assign the LPN?
a.
A 5-year-old child who had an appendectomy about 6 hours ago
b.
A 4-year-old child admitted for severe epiglottitis who is running a fever of 102° F
c.
A 6-year-old child admitted with dehydration and receiving IV therapy
d.
A 7-year-old child who received inhalation burns 2 days ago and has a tracheostomy
ANS:
A
The child who is postoperative for the appendectomy would be an appropriate assignment for the LVN/LPV. This child’s
problem has a predictable outcome. The children with epiglottitis, dehydration, and burns will need to be evaluated and
monitored for complications, which is the scope of practice and responsibility of the nurse.
PTS:
REF:
TOP:
MSC:
1
DIF:
Cognitive Level: Application/Applying
p. 307
OBJ:
Understand and apply the five rights of delegation in nursing practice.
Delegation in the clinical setting
NCLEX®: Safe and effective care environment—management of care
MULTIPLE RESPONSE
1.
Which of the following statements made by the charge nurse indicate appropriate delegation? (Select
all that apply.)
a.
The LPN can delegate dressing changes to the nursing assistant.
b.
The LPN can administer a DPT immunization to a child.
c.
The LPN can add a dose of chemotherapy to an existing IV infusion.
d.
The nursing assistant can transfer a paraplegic patient from a wheelchair to the bed.
e.
The nursing assistant can assess vital signs on a patient 15 minutes after the transfusion has been started.
ANS:
B, D
Only nurses can delegate to other personnel. LPNs can administer routine medications, such as immunization, but not
chemotherapy drugs. A nursing assistant can transfer patients, provide basic hygiene measures, and assess vital signs.
PTS:
REF:
TOP:
MSC:
1
DIF:
Cognitive Level: Application/Applying
Figure 14.1
OBJ:
Understand and apply the five rights of delegation in nursing practice.
Providing feedback
NCLEX®: Safe and effective care environment—management of care
2.
The Delegation Decision Tree, which was prepared and adopted by the ANA and NCSBN, has specific
steps. Identify the steps in this Decision Tree. (Select all that apply.)
a.
Monitoring
b.
Surveillance and supervision
c.
Read back and response
d.
Assessment and planning
e.
Evaluation
f.
Communication
ANS:
B, D, E, F
There are four steps to the ANA and NCSBN Delegation Decision Tree. They are in order as follows:
Step 1: Assessment and planning.
Step 2: Communication: Must be a two-way process involving the nurse who assesses the nursing assistive personnel’s
understanding of the delegated task and the nursing assistive person who asks questions regarding the delegation and
seeks clarification of expectations if needed.
Step 3: Surveillance and supervision: The purpose of surveillance and monitoring is related to nurse’s responsibility for
patient care within the context of a patient population. The nurse supervises the delegation by monitoring the performance
of the task or function and assures compliance with standards of practice, policies, and procedures. Frequency, level, and
nature of monitoring vary with needs of patient and experience of assistant.
Step 4: Evaluation and feedback: Evaluation is often the forgotten step in delegation and should include a determination if
the delegation was successful and discussion of parameters to determine the effectiveness of the delegation. (ANA 2012
pp.)
PTS:
1
DIF:
Cognitive Level: Application/Applying
REF:
pp. 302-304
OBJ:
Delegate tasks successfully based on outcomes.| Define the operational terms delegation, supervision, and
accountability.
TOP:
Delegation decision tree
MSC:
NCLEX®: Safe and effective care environment—management of care
3.
Which actions by the nurse show an understanding of what the nurse is accountable for? (Select all
that apply.)
a.
Assessing patients according to priority
b.
Determining the need to delegate a task to a nursing assistant
c.
Deciding that the nursing assistant is competent to perform the task delegated
d.
Following up to determine completion of the task that was delegated
e.
Delegating assessments of low-acuity patients to the nursing assistant
ANS:
A, B, C, D
Nurses show understanding of what they are accountable for by assessing patients according to priority, determining the
need to delegate, deciding whether the nursing assistant is competent to perform that task, and following up to determine
completion of the task that was delegated. Nurses should not delegate assessment of any patient to a nursing assistant.
Assessment must be completed by the nurse.
PTS:
REF:
TOP:
1
DIF:
pp. 304-305
Delegation
Cognitive Level: Application/Applying
OBJ:
Understand and apply the five rights of delegation in nursing practice.
MSC:
NCLEX®: Safe and effective care environment
4.
The charge nurse is determining tasks that can be delegated to keep the unit running smoothly. What
factors should the charge nurse consider before delegating? (Select all that apply.)
a.
Staff who are working
b.
Acuity of patients
c.
Unit tasks needing to be done
d.
Teaching obligations of the nurses
e.
How many patients are waiting for beds on the unit
ANS:
A, B, C, D
The charge nurse should consider other factors such as the staff that are working, acuity of patients, any unit tasks that
need to be done, and teaching obligations of the nurses before beginning to delegate. These factors will determine what
kind of delegation can be safely handled by the staff.
PTS:
REF:
TOP:
1
DIF:
pp. 302-304
Delegation
Cognitive Level: Application/Applying
OBJ:
Understand and apply the five rights of delegation in nursing practice.
MSC:
NCLEX®: Safe and effective care environment
5.
The nurse is preparing to delegate work to the nurse aide. What can be done to ensure that work is
delegated in a manner that is understood by the nurse aide? (Select all that apply.)
a.
Determine if the nurse aide understands what is being asked.
b.
c.
d.
e.
Ensure that the directions given are in accordance with policy.
Delegate more difficult tasks because the nurse aide is experienced.
Ask the nurse aide if he/she has the information needed to complete the task.
Refrain from delegating and complete the tasks him/herself.
ANS:
A, B, D
The nurse should determine if the nurse aide understands what is being asked. The nurse can do this by asking the nurse
aide to repeat the directions back, or read back. The nurse should also ensure that the directions given are in accordance
with policy and ask the nurse aide if he/she has the information needed to complete the task. The nurse should not
delegate more difficult tasks because the nurse aide is experienced or refrain from delegating and completing all tasks by
him/herself.
PTS:
REF:
OBJ:
TOP:
1
DIF:
Cognitive Level: Application/Applying
Critical Thinking Box 14.5
Apply the “four C’s” of initial direction for clear understanding of your expectations.
Delegation
MSC:
NCLEX®: Safe and effective care environment
a.
b.
c.
d.
e.
6.
Which statement(s) will help the nurse give feedback to a coworker? (Select all that apply.)
“Can you tell me what happened?”
“You did a great job positioning the postoperative patient.”
“What do you think can be done to ensure that the blood pressures are charted?”
“I don’t understand why you didn’t do what I asked you to do.”
“I only gave you one job to complete.”
ANS:
A, B, C
When giving feedback, the nurse should practice using the feedback formula. This includes asking for the other person’s
input (“Can you tell me what happened?”), giving credit for accomplishments (“You did a great job positioning the
postoperative patient”), and asking for the other person’s thoughts on resolutions (“What do you think can be done to
ensure that the blood pressures are charted?”). The statements “I don’t understand why you didn’t do what I asked you to
do” and “I only gave you one job to complete” would not be helpful in providing feedback to the coworker because they
could cause the coworker to become defensive.
PTS:
REF:
OBJ:
TOP:
MSC:
1
DIF:
Cognitive Level: Application/Applying
Critical Thinking Box 14.6
Provide reciprocal feedback for the effective evaluation of the delegate’s performance.
The right supervision and evaluation
NCLEX®: Safe and effective care environment
7.
The nurse manager understands the causes of performance weaknesses when making which of the
following statements? (Select all that apply.)
a.
“The employee does not know what is expected.”
b.
“The employee is getting adequate feedback.”
c.
“The employee requires additional education.”
d.
“The employee lacks motivation.”
e.
“The employee needs additional supervision.”
ANS:
A, C, D, E
There are several causes of performance weaknesses, including not knowing what the expectations are, not getting
adequate feedback, not having enough education to perform the job, lack of motivation, and requiring additional
supervision.
PTS:
REF:
OBJ:
TOP:
1
DIF:
Cognitive Level: Comprehension/Understanding
Critical Thinking Box 14.3
Provide reciprocal feedback for the effective evaluation of the delegate’s performance.
The right circumstances
MSC:
NCLEX®: Safe and effective care environment
8.
A nurse manager is discussing the “five rights of clinical delegation.” Which statements indicates
understanding? (Select all that apply.)
a.
“The nurse should determine if the task can safely be delegated.”
b.
“The nurse should determine if this is a task that will fit into the schedule.”
c.
“The nurse should delegate the task to the right person.”
d.
“The nurse should determine whether this is a task that would enhance learning.”
e.
“The nurse should provide feedback to the delegate.”
ANS:
A, C, E
To safely delegate, the nurse manager should determine the following:
The right task—determining whether the task can be delegated
The right circumstance—according to the NCSBN, the appropriate client setting, available resources, and consideration of
other relevant factors
The right person—matching the task to the right (qualified) person
The right direction and communication—clear expectations of what needs to be done
The right supervision and evaluation—acknowledgment that the person understands the information and is capable of
completing the task and giving them feedback and evaluation
PTS:
REF:
TOP:
MSC:
1
DIF:
Cognitive Level: Comprehension/Understanding
p. 305
OBJ:
Understand and apply the five rights of delegation in nursing practice.
Definition of delegation
NCLEX®: Safe and effective care environment—management of care
Anxiety
Concept 34: Anxiety
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
A patient complains of insomnia during his stay in the hospital. Which nursing diagnosis would be a
top priority for this patient?
a.
Anxiety related to hospitalization
b.
Ineffective Coping related to hospitalization
c.
Denial related to hospitalization
d.
High Risk for Insomnia related to hospitalization
ANS:
A
The information about the patient indicates that anxiety is an appropriate nursing diagnosis. The patient’s data do not
support Defensive Coping, Ineffective Denial, or Risk-Prone Health Behavior as problems for this patient.
REF:
Page 327 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
2.
A female patient is anxious after receiving the news that she needs a breast biopsy to rule out breast
cancer. The nurse is assisting with a breast biopsy. Which relaxation technique will be best to use at this time?
a.
Massage
b.
Meditation
c.
Guided imagery
d.
Relaxation breathing
ANS:
D
Relaxation breathing is the easiest of the relaxation techniques to use. It will be difficult for the nurse to provide massage
while assisting with the biopsy. Meditation and guided imagery require more time to practice and learn.
REF:
Page 332 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
3.
The nurse is teaching a hospitalized patient to use mindfulness to reduce anxiety. Which statement by
the nurse is appropriate?
a.
“How do you feel about what happened to you as a child?”
b.
“How do you feel about what is going on right now?”
c.
“Remember a time when you were calm.”
d.
“Tap your hands until the feeling goes away.”
ANS:
B
Mindfulness trains the mind to think in the here and now, and emphasizes attentiveness to all sensations and feelings
related to these experiences. Recalling and remembering being calm or previous experiences is not included in
mindfulness training. Eye movement desensitization and reprocessing (EMDR) includes expression of feelings and
memories while focusing on other stimuli such as sounds, hand taps, and/or eye movements.
REF:
Page 332 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
4.
The nurse is assessing the social support of a patient who is recently divorced and has moved from
their hometown to the city due to change in jobs. Which response related to social support would be most therapeutic?
a.
Encourage the patient to begin dating again, perhaps with members of her church.
b.
Discuss how divorce support groups could increase coping and social support.
c.
Note that being so particular about potential friends reduces social contact.
d.
Discuss using the Internet as a way to find supportive others with similar values.
ANS:
B
High-quality social support enhances mental and physical health and acts as a significant buffer against distress. Lowquality support relationships are known to affect a person’s coping effectiveness negatively. Resuming dating soon after a
divorce could place additional stress on the patient rather than helping them cope with existing stressors. Developing
relationships on the Internet probably would not substitute fully for direct contact with other humans and could expose the
patient to predators misrepresenting themselves to take advantage of vulnerable persons.
REF:
Page 332 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
5.
A patient reports that he is overwhelmed with anxiety. Which question would be most important to use
in assessing the patient during your first meeting?
a.
“What kinds of things do you do to reduce or cope with your stress?”
b.
“Tell me about your family history—do any relatives have problems with stress?”
c.
“Tell me about exercise—how far do you typically run when you go jogging?”
d.
“Stress can interfere with sleep. How much did you sleep last night?”
ANS:
A
The most important data to collect during an initial assessment is that which reflects how stress is affecting the patient
and how he is coping with stress at present. This data would indicate whether his distress is placing him in danger (e.g.,
by elevating his blood pressure dangerously or via maladaptive responses such as drinking) and would help you
understand how he copes and how well his coping strategies and resources are serving him. Therefore, of the choices
presented, the highest priority would be to determine what he is doing to cope at present, preferably via an open-ended or
broad-opening inquiry. Family history, the extent of his use of exercise, and how much sleep he is getting are all helpful
but seek data that is less of a priority. Also, the manner in which such data is sought here is likely to provide only brief
responses (e.g., how much sleep he got on one particular night is probably less important than how much he is sleeping in
general).
REF:
Page 333 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
6.
A patient is newly diagnosed with anxiety and placed on a selective serotonin reuptake inhibitors
(SSRIs). The nurse is developing the plan of care for this patient. How long will it take for this medication to become
effective?
a.
The medication will become effective immediately.
b.
The medication may take up to 12 weeks to become effective.
c.
The medication may take up to 6 weeks to become effective.
d.
The medication may take up to 4 weeks to become effective.
ANS:
B
Efficacy may take at least 8 to 12 weeks. The other options are not realistic.
REF:
Page 332 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
MULTIPLE RESPONSE
1.
The nurse knows that which of the following medical conditions are most commonly associated with
anxiety? (Select all that apply.)
a.
Cancer
b.
Pancreatitis
c.
Hypothyroidism
d.
Dysrhythmias
e.
Encephalitis
f.
Hyperthyroidism
ANS:
A, C, D, E, F
Cancer, COPD, dysrhythmias, encephalitis, hypothyroidism, and hyperthyroidism are all associated with anxiety.
Pancreatitis is not listed as a condition most commonly associated with anxiety.
REF:
Page 330 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
2.
The nurse wishes to use guided imagery to help an anxious patient relax. Which comment would be
appropriate to include in the guided imagery script? (Select all that apply.)
a.
“Imagine others treating you the way they should, the way you want to be treated…”
b.
“With each breath, you are feeling calmer, more relaxed, almost as if you are floating…”
c.
“You are alone on a beach; the sun is warm; and you hear only the sound of the surf…”
d.
“You have taken control; nothing can hurt you now; everything is going your way…”
e.
“You have grown calm; your mind is still; there is nothing to disturb your well-being…”
f.
“You will feel better as work calms down, as your boss becomes more understanding…”
ANS:
B, C, E
The intent of guided imagery for managing stress is to lead the patient to envision images that are calming and health
enhancing. Statements that involve the patient calming progressively with breathing, feeling increasingly relaxed, being in
a calm and pleasant location, being away from stressors, and having a peaceful and calm mind are therapeutic and should
be included in the script. However, words that raise stressful images or memories or that involve unrealistic expectations
or elements beyond the patient’s control (e.g., that others will treat the patient as he desires, that everything is going the
patient’s way, that bosses are understanding) interfere with relaxation and/or do not promote effective coping. These
attempts are not health promoting and should not be included in the script.
REF:
Page 332 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
Cognition
Concept 35: Cognition
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
A nurse working in a pediatric clinic recognizes that which child is most at risk for cognitive
impairment?
a.
An infant who is being fed reconstituted powdered formula
b.
A toddler living in an older home that is being remodeled
c.
A preschooler who attends a play group 3 days a week
d.
A school-age child who rides a school bus 5 days a week
ANS:
B
Older homes frequently have lead-based paint; paint chips generated by remodeling put toddlers, who often put foreign
objects in their mouths, at risk for exposure to lead which is a known toxic substance that can affect cognitive function.
Powdered formulas, attendance at play groups, or riding on a school bus are not known to impair cognitive development.
REF:
Page 341 OBJ:
NCLEX® Client Needs Category: Safe and Effective Care Environment
2.
The nurse is reviewing new medication orders for several patients in a long-term care facility. Which
patient does the nurse recognize as being at the highest risk for having cognitive impairment related to prescribed
medications?
a.
The patient prescribed an antibiotic for a urinary tract infection.
b.
The patient prescribed a cholinesterase inhibitor for early Alzheimer’s disease.
c.
The patient prescribed a beta-blocker for hypertension.
d.
The patient prescribed a bisphosphonate for osteoporosis.
ANS:
C
Anti-hypertensives such as the beta-blockers can cause adverse changes in cognition. While an infection can affect
cognition, antibiotics do not generally cause cognitive changes. The cholinesterase inhibitors are prescribed to slow the
progression in cognitive decline for patients diagnosed with Alzheimer’s disease. Bisphosphonates are used for
osteoporosis and are not generally a risk for altered cognition.
REF:
Page 341 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
3.
The nurse is developing a care plan for a patient newly admitted to a unit that cares for patients with
cognitive impairment. What is an important component of care for the patients on this unit?
a.
Allow food selections from a menu with several choices.
b.
Schedule frequent field trips off the unit for cognitive stimulation.
c.
Plan for attendance at activities with several other patients on the unit.
d.
Plan for a structured daily routine of events and caregivers.
ANS:
D
Patients with a cognitive impairment benefit from a predictable routine and consistent caregivers. Trips off of the unit may
confuse the patient and disrupt their normal routine. Offering too many selections causes confusion and can lead to
agitation. Being in large groups for activities can overstimulate the patient and lead to agitation and fear.
REF:
Page 344 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
4.
A patient who is dehydrated has been experiencing confusion. The daughter is concerned about taking
the patient home in a confused state. What statement by the nurse is correct?
a.
“Don’t worry; the patient should be fine once they are in a familiar environment.”
b.
“I can make a referral for a home health aide to assist with the patient.”
c.
“Once the dehydration is corrected, the patient’s confusion should improve.”
d.
“I can show you how to care for the patient once you return home.”
ANS:
C
The confusion caused by an underlying medical condition is a temporary condition that can be corrected once the
underlying condition is treated, in this case once the patient is rehydrated. It is not necessary to teach home care or make
a referral to home health because it is not expected that the patient will be confused at discharge. Telling the daughter that
there is nothing to worry about diminishes her concern and may decrease her trust in the nurse.
REF:
OBJ:
Page 344 |Page 345
NCLEX® Client Needs Category: Physiological Integrity
5.
An older adult who is cognitively impaired is admitted to the hospital with pneumonia. Which sign or
symptom would the nurse expect to be exhibited by the patient?
a.
Severe headache
b.
Flank pain
c.
Increased confusion
d.
Decreased blood glucose
ANS:
C
Increased confusion is a symptom that occurs in cognitively impaired patients who experience an infection. Severe
headache occurs with migraines, meningitis, and other conditions. Flank pain occurs with pyelonephritis. Blood glucose
typically increases with an infection.
REF:
OBJ:
Page 344 |Page 345
NCLEX® Client Needs Category: Physiological Integrity
6.
The nurse is sitting with the family of a patient who has just received the diagnosis of dementia. The
family asks for information on what treatment will be needed to cure the condition. What is the nurse’s best response?
a.
“Hormone therapy will reverse the condition.”
b.
“Vitamin C and zinc will reverse the condition.”
c.
“There is no treatment that reverses dementia.”
d.
“Dementia can be reversed with diet, exercise, and medications.”
ANS:
C
Currently there is no proven treatment that has been shown to reverse dementia, although some treatments can slow the
progression of the illness. Hormone therapy, vitamin therapy, diet, and exercise are all important for overall health but do
not reverse the progression of dementia.
REF:
Page 344 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
7.
A cognitively impaired patient newly admitted to the hospital is experiencing signs of sundown
syndrome. Which intervention is best for the nurse to implement?
a.
Leave a night light on in the room at all times.
b.
Leave the television on at night with the volume up.
c.
Restrain the patient to maintain safety during the confusion.
d.
Administer a sleeping medication to help the patient sleep.
ANS:
A
Having a night light on for the patient can help orient them to their surroundings. Having the flickering light and sound
from a television will not help a confused patient remain calm or oriented. Restraining a patient will increase their agitation
and actually increase their risk of injury if they try to get out of bed. Sleeping medications often increase confusion in
cognitively impaired patients.
REF:
Page 346 OBJ:
NCLEX® Client Needs Category: Safe and Effective Care Environment
8.
An 82-year-old patient who is in the hospital awakens from sleep and is disoriented to where she is at
the present time. The nurse reorients the patient to her surroundings and helps the patient return to sleep. What data does
the nurse consider as a probable cause of the patient’s confusion?
a.
Pain medication received earlier in the night
b.
The death of the patient’s spouse 2 years ago
c.
The patient’s history of diabetes
d.
The age of the patient
ANS:
A
Medications such as narcotics, hypertensives, sleeping meds, and others can cause disorientation and symptoms of
delirium. The death of a spouse is more likely to cause depression than disorientation. A history of diabetes alone does
not cause disorientation. Normal aging alone does not cause disorientation, although it is a risk factor.
REF:
OBJ:
Page 344 |Page 345
NCLEX® Client Needs Category: Physiological Integrity
MULTIPLE RESPONSE
1.
The nurse is teaching primary prevention of cognitive impairment at a community health fair. Which
topics would be included in the presentation? (Select all that apply.)
a.
Do not use substances such as cannabis and alcohol.
b.
Wear helmets when riding bicycles and motorcycles.
c.
Complete a Mini Mental Status Exam (MMSE) yearly.
d.
Correct acid-base imbalances related to underlying disease processes.
e.
Wear a seat belt whenever riding in a motorized vehicle.
f.
Complete a Confusion Assessment Method (CAM) scale yearly.
ANS:
A, B, E
Primary prevention attempts to prevent injury. Not using chemical substances, wearing a helmet, and wearing a seat belt
are all measures to prevent injury to the brain, which protects cognitive function. An MMSE and CAM are secondary
prevention, or screening tools performed once symptoms are present. Correcting acid-base imbalances from underlying
disease processes is a tertiary prevention level, aimed at minimizing complications for disease already present.
REF:
OBJ:
Page 340 |Page 341
NCLEX® Client Needs Category: Health Promotion and Maintenance
Chapter 59: Dementia and Delirium
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1.
A patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission.
Which information indicates that the patient is experiencing delirium rather than dementia?
a.
The patient was oriented and alert when admitted.
b.
The patient’s speech is fragmented and incoherent.
c.
The patient is oriented to person but disoriented to place and time.
d.
The patient has a history of increasing confusion over several years.
ANS:
A
The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia.
Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with
either delirium or dementia.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
1400
Nursing Process: Assessment
MSC:
NCLEX: Physiological Integrity
2.
Which intervention will the nurse include in the plan of care for a patient with moderate dementia who
had a fractured hip repair 2 days ago?
a.
Provide complete personal hygiene care for the patient.
b.
Remind the patient frequently about being in the hospital.
c.
Reposition the patient frequently to avoid skin breakdown.
d.
Place suction at the bedside to decrease the risk for aspiration.
ANS:
B
The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about
the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty
with swallowing, self-care, and immobility.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1403
NCLEX: Physiological Integrity
a.
b.
c.
d.
3.
When administering a mental status examination to a patient with delirium, the nurse should
wait until the patient is well-rested.
administer an anxiolytic medication.
choose a place without distracting stimuli.
reorient the patient during the examination.
ANS:
C
Because overstimulation by environmental factors can distract the patient from the task of answering the nurse’s
questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the
delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety
medications may increase the patient’s delirium.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1416
NCLEX: Psychosocial Integrity
4.
The nurse is concerned about a postoperative patient’s risk for injury during an episode of delirium.
The most appropriate action by the nurse is to
a.
secure the patient in bed using a soft chest restraint.
b.
ask the health care provider to order an antipsychotic drug.
c.
instruct family members to remain at the patient’s bedside and prevent injury.
d.
assign unlicensed assistive personnel (UAP) to stay with and reorient the patient.
ANS:
D
The priority goal is to protect the patient from harm. Having a UAP stay with the patient will ensure the patient’s safety.
Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting
patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these
medications have many side effects. Restraints are not recommended because they can increase the patient’s agitation
and disorientation.
DIF:
TOP:
Cognitive Level: Analyze (analysis) Apply (application) REF:
1412
Nursing Process: Implementation
MSC:
NCLEX: Safe and Effective Care Environment
5.
A patient seen in the outpatient clinic is diagnosed with mild cognitive impairment (MCI). Which action
will the nurse include in the plan of care?
a.
Suggest a move into an assisted living facility.
b.
Schedule the patient for more frequent appointments.
c.
Ask family members to supervise the patient’s daily activities.
d.
Discuss the preventive use of acetylcholinesterase medications.
ANS:
B
Ongoing monitoring is recommended for patients with MCI. MCI does not usually interfere with activities of daily living,
acetylcholinesterase drugs are not used for MCI, and an assisted living facility is not indicated for a patient with MCI.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1405
NCLEX: Psychosocial Integrity
6.
The nurse is administering a mental status examination to a patient who has hypertension. The nurse
suspects depression when the patient responds to the nurse’s questions with
a.
“Is that right?”
c.
“Wait, let me think about that.”
b.
“I don’t know.”
d.
“Who are those people over there?”
ANS:
B
Answers such as “I don’t know” are more typical of depression than dementia. The response “Who are those people over
there?” is more typical of the distraction seen in a patient with delirium. The remaining two answers are more typical of a
patient with mild to moderate dementia.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1400
NCLEX: Psychosocial Integrity
7.
A patient is diagnosed with moderate dementia after multiple strokes. During assessment of the patient,
the nurse would expect to find
a.
excessive nighttime sleepiness.
b.
difficulty eating and swallowing.
c.
loss of recent and long-term memory.
d.
fluctuating ability to perform simple tasks.
ANS:
C
Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent
nighttime awakening. Dementia is progressive, and the patient’s ability to perform tasks would not have periods of
improvement. Difficulty eating and swallowing is characteristic of severe dementia.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
1401
Nursing Process: Assessment
MSC:
NCLEX: Psychosocial Integrity
8.
Which action will help the nurse determine whether a new patient’s confusion is caused by dementia or
delirium?
a.
Ask about a family history of dementia.
b.
Administer the Mini-Mental Status Exam.
c.
Use the Confusion Assessment Method tool.
d.
Obtain a list of the patient’s usual medications.
ANS:
C
The Confusion Assessment Method tool has been extensively tested in assessing delirium. The other actions will be
helpful in determining cognitive function or risk factors for dementia or delirium, but they will not be useful in
differentiating between dementia and delirium.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1415
NCLEX: Psychosocial Integrity
9.
A 72-yr-old patient is brought to the clinic by the patient’s spouse, who reports that the patient is unable
to solve common problems around the house. To obtain information about the patient’s current mental status, which
question should the nurse ask the patient?
a.
“Are you sad right now?” c.
“What did you eat for lunch?”
b.
“How is your self-image?” d.
“Where were you were born?”
ANS:
C
This question tests the patient’s short-term memory, which is decreased in the mild stage of Alzheimer’s disease or
dementia. Asking the patient about her birthplace tests for remote memory, which is intact in the early stages. Questions
about the patient’s emotions and self-image are helpful in assessing emotional status, but they are not as helpful in
assessing mental state.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1406
NCLEX: Psychosocial Integrity
10.
A patient is being evaluated for Alzheimer’s disease (AD). The nurse explains to the patient’s adult
children that
a.
the most important risk factor for AD is a family history of the disorder.
b.
a diagnosis of AD is made only after other causes of dementia are ruled out.
c.
new drugs have been shown to reverse AD deterioration dramatically in some patients.
d.
brain atrophy detected by magnetic resonance imaging (MRI) would confirm the diagnosis of AD.
ANS:
B
The diagnosis of AD is usually one of exclusion. Age is the most important risk factor for development of AD. Drugs may
slow the deterioration but do not reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in
other diseases as well and does not confirm a diagnosis of AD.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
1405
Nursing Process: Implementation
MSC:
NCLEX: Psychosocial Integrity
11.
mild dementia?
Which nursing action will be most effective in ensuring daily medication compliance for a patient with
a.
b.
c.
d.
Setting the medications up monthly in a medication box
Having the patient’s family member administer the medication
Posting reminders to take the medications in the patient’s house
Calling the patient weekly with a reminder to take the medication
ANS:
B
Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate
nursing action is to have someone else administer the drug. The other nursing actions will not be as effective in ensuring
that the patient takes the medications.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Implementation
MSC:
REF:
1413
NCLEX: Physiological Integrity
12.
A patient who has severe Alzheimer’s disease (AD) is being admitted to the hospital for surgery. Which
intervention will the nurse include in the plan of care?
a.
Encourage the patient to discuss events from the past.
b.
Maintain a consistent daily routine for the patient’s care.
c.
Reorient the patient to the date and time every 2 to 3 hours.
d.
Provide the patient with current newspapers and magazines.
ANS:
B
Providing a consistent routine will decrease anxiety and confusion for the patient. Reorientation to time and place will not
be helpful to the patient with severe AD, and the patient will not be able to read. The patient with severe AD will probably
not be able to remember events from the past.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1414
NCLEX: Psychosocial Integrity
13.
A patient with Alzheimer’s disease (AD) who is being admitted to a long-term care facility has had
several episodes of wandering away from home. Which action will the nurse include in the plan of care?
a.
Reorient the patient several times daily.
b.
Have the family bring in familiar items.
c.
Place the patient in a room close to the nurses’ station.
d.
Ask the patient why the wandering episodes have occurred.
ANS:
C
Patients at risk for problems with safety require close supervision. Placing the patient near the nurse’s station will allow
nursing staff to observe the patient more closely. The use of “why” questions can be frustrating for patients with AD
because they are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patient’s
short-term memory loss, reorientation will not help prevent wandering behavior. Because the patient had wandering
behavior at home, familiar objects will not prevent wandering.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1412
NCLEX: Safe and Effective Care Environment
14.
The day shift nurse at the long-term care facility learns that a patient with dementia experienced
sundowning late in the afternoon on the previous two days. Which action should the nurse take?
a.
Have the patient take a mid-morning nap.
b.
Keep window blinds open during the day.
c.
Provide hourly orientation to time and place.
d.
Move the patient to a quiet room in the afternoon.
ANS:
B
A likely cause of sundowning is a disruption in circadian rhythms, and keeping the patient active and in daylight will help
reestablish a more normal circadian pattern. Moving the patient to a different room might increase confusion. Taking a nap
will interfere with nighttime sleep. Hourly orientation will not be helpful in a patient with dementia.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1411
NCLEX: Psychosocial Integrity
15.
The nurse’s initial action for a patient with moderate dementia who develops increased restlessness
and agitation should be to
a.
reorient the patient to time, place, and person.
b.
administer a PRN dose of lorazepam (Ativan).
c.
assess for factors that might be causing discomfort.
d.
assign unlicensed assistive personnel (UAP) to stay in the patient’s room.
ANS:
C
Increased motor activity in a patient with dementia is frequently the patient’s only way of responding to factors such as
pain, so the nurse’s initial action should be to assess the patient for any precipitating factors. Administration of sedative
drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and
any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia.
Assigning UAP to stay with the patient may also be necessary, but any physical changes that may be causing the agitation
should be addressed first.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1411
Nursing Process: Implementation
16.
When administering the Mini-Cog exam to a patient with possible Alzheimer’s disease, which action will
the nurse take?
a.
Check the patient’s orientation to time and date.
b.
Obtain a list of the patient’s prescribed medications.
c.
Ask the person to use a clock drawing to indicate a specific time.
d.
Determine the patient’s ability to recognize a common object such as a pen.
ANS:
C
In the Mini-Cog, patients illustrate a specific time stated by the examiner by drawing the time on a clock face. The other
actions may be included in assessment for Alzheimer’s disease but are not part of the Mini-Cog exam.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
1408
Nursing Process: Assessment
MSC:
NCLEX: Physiological Integrity
a.
b.
c.
d.
17.
Which hospitalized patient will the nurse assign to the room closest to the nurses’ station?
Patient with Alzheimer’s disease who has long-term memory deficit
Patient with vascular dementia who takes medications for depression
Patient with new-onset confusion, restlessness, and irritability after surgery
Patient with dementia who has an abnormal Mini-Mental State Examination
ANS:
C
This patient’s history and clinical manifestations are consistent with delirium. The patient is at risk for safety problems and
should be placed near the nurses’ station for ongoing observation. The other patients have chronic symptoms that are
consistent with their diagnoses but are not at immediate risk for safety issues.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Multiple Patients
NCLEX: Safe and Effective Care Environment
REF:
TOP:
1415
Nursing Process: Planning
18.
After change-of-shift report on the Alzheimer’s disease/dementia unit, which patient will the nurse
assess first?
a.
Patient who has not had a bowel movement for 5 days
b.
Patient who has a stage II pressure ulcer on the coccyx
c.
Patient who is refusing to take the prescribed medications
d.
Patient who developed a new cough after eating breakfast
ANS:
D
A new cough after a meal in a patient with dementia suggests possible aspiration, and the patient should be assessed
immediately. The other patients also require assessment and intervention but not as urgently as a patient with possible
aspiration or pneumonia.
DIF:
OBJ:
TOP:
Cognitive Level: Analyze (analysis)
REF:
1413
Special Questions: Prioritization | Special Questions: Multiple Patients
Nursing Process: Assessment
MSC:
NCLEX: Safe and Effective Care Environment
19.
After reviewing the health record shown in the accompanying figure for a patient who has multiple risk
factors for Alzheimer’s disease (AD), which topic will be most important for the nurse to discuss with the patient?
a.
b.
Tobacco use
Family history
c.
d.
Cholesterol level
Head injury history
ANS:
A
Tobacco use is a modifiable risk factor for AD. The patient will not be able to modify the increased risk associated with
family history of AD and past head injury. While the total cholesterol is borderline high, the high HDL indicates that no
change is needed in cholesterol management.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
TOP:
NCLEX: Health Promotion and Maintenance
REF:
1402
Nursing Process: Assessment
MULTIPLE RESPONSE
1.
The spouse of a 67-yr-old male patient with early stage Alzheimer’s disease (AD) tells the nurse, “I am
exhausted from worrying all the time. I don’t know what to do.” Which actions are best for the nurse to take next (select all
that apply)?
a.
Suggest that a long-term care facility be considered.
b.
Offer ideas for ways to distract or redirect the patient.
c.
Teach the spouse about adult day care as a possible respite.
d.
Suggest that the spouse consult with the physician for antianxiety drugs.
e.
Ask the spouse what she knows and has considered about dementia care options.
ANS:
B, C, E
The stress of being a caregiver can be managed with a multicomponent approach. This includes respite care, learning
ways to manage challenging behaviors, and further assessment of what the spouse may already have considered for care
options. The patient is in the early stages and does not need long-term placement. Antianxiety medications may be
appropriate, but other measures should be tried first.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1411
NCLEX: Psychosocial Integrity
2.
Which actions could the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) who is part
of the team caring for a patient with Alzheimer’s disease (select all that apply)?
a.
Develop a plan to minimize difficult behavior.
b.
Administer the prescribed memantine (Namenda).
c.
Remove potential safety hazards from the patient’s environment.
d.
Refer the patient and caregivers to appropriate community resources.
e.
Help the patient and caregivers choose memory enhancement methods.
f.
Evaluate the effectiveness of the prescribed enteral feedings on patient nutrition.
ANS:
B, C
LPN/LVN education and scope of practice includes medication administration and monitoring for environmental safety in
stable patients. Planning of interventions such as ways to manage behavior or improve memory, referrals, and evaluation
of the effectiveness of interventions require registered nurse (RN)–level education and scope of practice.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Delegation
TOP:
NCLEX: Safe and Effective Care Environment
REF:
1412
Nursing Process: Planning
Varcarolis’ Foundations of Psych Mental Health: A Clinical Approach: Halter Therapeutic
Communication Techniques Chapter 8 pp. 138-139, Communication Skills for Nurses pp. 151-158
and Cultural Considerations, pp. 158-159
Sexuality
Concept 22: Sexuality
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
A 55-year-old male patient post–myocardial infarction (MI) asks the nurse whether he will be healthy
enough for sexual activity after discharge from the hospital. The patient has been prescribed anti-hypertensives and betablockers. During health teaching, the nurse understands that the three phases of the four-stage model of the human
sexual response cycle that are of concern for this patient include which phases?
a.
Excitement, plateau, and orgasmic
b.
Plateau, orgasmic, and resolution
c.
Excitement, orgasmic, and resolution
d.
Arousal, excitement, and plateau
ANS:
A
During these three phases, heart rate, blood pressure, and respirations increase steadily, increasing stress to the heart
muscle. This would be the period of greatest concern for a patient who has recently experienced an MI. The plateau and
orgasmic phases may be of physiologic concern to this patient, but during the resolution phase, vital signs return to
normal, and muscles relax. Arousal is not a phase in the four-stage model of the human sexual response cycle, although
some researchers feel this should be added.
REF:
Page 208 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
2.
In order to fully assess the patient and plan appropriate care including health teaching regarding
sexuality the nurse should realize that which patient is most at risk for sexual abuse?
a.
A recently divorced 50-year-old woman
b.
A Hispanic teenage girl
c.
A 30-year-old African-American male
d.
An individual with intellectual or developmental disabilities
ANS:
D
As more of these individuals move into mainstream society, it is important that sexual health is promoted, including
teaching regarding sexual norms. Otherwise these individuals are likely victims of unhealthy sexual practices or sexual
abuse. In today’s society, the newly unpartnered are likely to begin dating and acquire one or more new sexual partners.
This group is at significant risk for exposure to sexually transmitted infections and requires health teaching related to
safer sexual practices. The Hispanic teenage girl is at increased risk for unintended teen pregnancy. Adolescent
pregnancy puts an undue burden on the young woman during a crucial period of growth and development. Hispanic teens
experience double the rate of pregnancy of Caucasian adolescents. Major health disparities continue to exist between
African-Americans and their Caucasian counterparts—in particular a significantly increased risk for human
immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and other sexually transmitted diseases.
REF:
Page 211 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
3.
A 37-year-old heterosexual African-American man has come for his annual health screening. Which test
must the nurse ensure is ordered for this patient?
a.
Human papilloma virus (HPV)
b.
Prostate-specific antigen (PSA)
c.
HIV
d.
Venereal disease research laboratory (VDRL)
ANS:
B
PSA testing is recommended annually for men at increased risk for prostate cancer. This includes men with a family
history or those of African-American descent. HPV testing would likely be ordered for patients with genital warts. This
might not be necessary for this patient. Tests for HIV should be ordered for patients that belong to high-risk populations,
including men who have sex with men, and all pregnant women. All sexually active men and women should have a VDRL
and rapid plasma reagin performed.
REF:
Page 213 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
4.
The school nurse is developing a curriculum for a junior human sexuality class. In order to provide the
most up-to-date information, the nurse should be aware that which is the single most effective primary prevention strategy
for preventing sexually transmitted infections (STIs)?
a.
A vaccine to prevent HPV infection
b.
HIV screening
c.
Abstinence
d.
The male condom
ANS:
C
The single most effective (100%) way to prevent sexually transmitted infections is abstinence. When used correctly, the
male condom is an effective method for preventing sexually transmitted infections as well as being a very highly effective
contraceptive agent. A significant primary prevention strategy is the recent introduction of a vaccine used to prevent
cervical cancer and genital warts caused by HPV. One of two FDA-approved vaccines should be routinely administered to
11- and 12-year-old girls and can be given up to the age of 26. HIV screening is recommended for all sexually active teens
by the Centers for Disease Control and Prevention. Screening for existing infection is a secondary prevention strategy. By
educating teens towards behavior change related to high-risk behaviors, nurses may be able to reduce the risk for
contracting sexually transmitted infections.
REF:
Page 213 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
5.
The nurse is caring for a 44-year-old married woman who is complaining of painful intercourse and
incontinence due to prolapse of reproductive organs. Clinical evaluation reveals that the patient has a cystocele. Which
treatment option is most appropriate for this patient?
a.
Pelvic floor training
b.
Vaginal pessaries
c.
Surgical correction
d.
Lifestyle changes
ANS:
C
Depending on the cause, a cystocele can be readily corrected by surgery. Pelvic muscle floor training (Kegel exercises)
will most definitely help with symptoms of urinary incontinence. This alone is not adequate treatment for this patient.
Vaginal pessaries are an excellent treatment modality for uterine prolapse. Lifestyle changes such as weight loss, avoiding
constipation, and reducing high-impact exercise, such as running, will all help the patient with pelvic organ prolapse.
Although these modalities will provide relief, they will not correct the cystocele without surgical intervention.
REF:
Page 215 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
6.
When assessing high-risk behaviors, which question specifically identifies a blood-related risk for a
sexually transmitted infection?
a.
“Have you ever received donor semen, eggs, or transplanted tissue?”
b.
“Have you ever exchanged sex for drugs, money, or shelter?”
c.
“How do you protect yourself from HIV and sexually transmitted infections?”
d.
“Have you ever injected drugs using shared equipment?”
ANS:
A
Receipt of any donated organ, tissue, semen, or eggs is considered a blood-related risk. Other blood-related risks include
blood transfusion, sex with a person with hemophilia, or sharing equipment for tattoos and body piercing. The exchange
of sex for money, drugs, or shelter is considered a drug use-related risk. Other drug use-related risks include having sex
with a person who uses or shares, and having sex while stoned, high, or drunk so that you cannot remember the details.
By using male condoms, female condoms, or other barriers, patient can protect themselves against sexual risk. Other
high-risk behaviors in this category include: having sex against one’s will, failing to use protection, having sex with a
partner who is bisexual or gay, having anal intercourse, and sexual activity with an increased number of partners. Sharing
equipment to inject street drugs or steroids is a drug use-related risk.
REF:
Page 212 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
MULTIPLE RESPONSE
a.
b.
c.
d.
e.
1.
Which statements related to sexual dysfunction are correct? (Select all that apply.)
Biological factors play a more significant role than psychologic factors.
Sexual dysfunction is more prevalent among men than women.
The best predictor of sexual health is emotional well-being.
The patient with sexual dysfunction is at risk for anxiety and depression.
Sexual dysfunction remains uncommon.
ANS:
C, D
The best predictor of sexual health is emotional well-being rather than the impairment of the physical aspects of sexual
arousal and function. Nurses must remain cognizant that sexual dysfunction, regardless of the cause, is likely to result in
a number of negative consequences including anxiety, stress, and depression. Although sexual arousal may be
diminished by biological factors such as illness and hormone levels, psychologic factors such as anxiety, mood disorders,
or stress play a more significant role in sexual health. Sexual dysfunction is more common in women, with 40 to 45% of
women reporting symptoms as opposed to 20 to 30% of men. It appears that sexual dysfunction is very common among
the general population, with rates varying from 20 to 50%.
REF:
Page 214 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
Chapter 52: Sexually Transmitted Infections
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1.
A male patient who has a profuse, purulent urethral discharge with painful urination is seen at the
clinic. Which information will be most important for the nurse to obtain?
a.
Sexual orientation c.
Recent sexual contacts
b.
Immunization history
d.
Contraceptive preference
ANS:
C
Information about sexual contacts is needed to help establish whether the patient has been exposed to a sexually
transmitted infection and because sexual contacts also will need treatment. The other information also may be gathered
but is not as important in determining the plan of care for the patient’s current symptoms.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1237
NCLEX: Physiological Integrity
2.
A 20-yr-old female patient who is being seen in the family medicine clinic for an annual physical
examination reports being sexually active. The nurse will plan to teach the patient about
a.
testing for Chlamydia infection.
b.
immunization for herpes simplex.
c.
infertility associated with the human papillomavirus (HPV).
d.
the relationship between the herpes virus and cervical cancer.
ANS:
A
Testing for Chlamydia is recommended by the Centers for Disease Control and Prevention for all sexually active women
younger than age 25 years. HPV infection does not cause infertility. There is no vaccine available for herpes simplex, and
herpes simplex infection does not cause cervical cancer.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1230
NCLEX: Health Promotion and Maintenance
3.
A patient with gonorrhea is treated with a single IM dose of ceftriaxone (Rocephin) and is given a
prescription for doxycycline (Vibramycin) 100 mg bid for 7 days. The nurse explains to the patient that this combination is
prescribed to
a.
prevent reinfection during treatment.
b.
treat any coexisting chlamydial infection.
c.
eradicate resistant strains of N. gonorrhoeae.
d.
prevent the development of resistant organisms.
ANS:
B
Because there is a high incidence of co-infection with gonorrhea and Chlamydia, patients are usually treated for both. The
other explanations about the purpose of the antibiotic combination are not accurate.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1229
NCLEX: Physiological Integrity
4.
A 46-yr-old patient who has had blood drawn for an insurance screening has a positive Venereal
Disease Research Laboratory (VDRL) test. Which action should the nurse take next?
a.
Ask the patient about past treatment for syphilis.
b.
Explain the need for blood and spinal fluid cultures.
c.
Schedule fluorescent treponemal antibody absorption (FAT-Abs) testing.
d.
Assess for the presence of chancres, flulike symptoms, or a rash on the trunk.
ANS:
A
When antibody testing is positive for syphilis, the antibodies remain present for an indefinite period of time even after
successful treatment, so the nurse should inquire about previous treatment before doing other assessments or testing.
Culture, FAT-Abs testing, and assessment for symptoms may be appropriate based on whether the patient has been
previously treated for syphilis.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1236
NCLEX: Physiological Integrity
5.
A 48-yr-old male patient who has been diagnosed with gonococcal urethritis tells the nurse he had
recent sexual contact with a woman but says she did not appear to have any disease. In responding to the patient, the
nurse explains that
a.
women do not develop gonorrhea infections but can serve as carriers to spread the disease to men.
b.
women may not be aware they have gonorrhea because they often do not have symptoms of infection.
c.
women develop subclinical cases of gonorrhea that do not cause tissue damage or clinical manifestations.
d.
when gonorrhea infections occur in women, the disease affects only the ovaries and not the genital organs.
ANS:
B
Many women with gonorrhea are asymptomatic or have minor symptoms that are overlooked. The disease may affect both
the genitals and the other reproductive organs and cause complications such as pelvic inflammatory disease. Women who
can transmit the disease have active infections.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1230
NCLEX: Physiological Integrity
6.
A patient admitted with chest pain is also found to have positive Venereal Disease Research Laboratory
(VDRL) and fluorescent treponemal antibody absorption (FAT-Abs) tests, rashes on the palms and the soles of the feet, and
moist papules in the anal and vulvar area. Which action will the nurse include in the plan of care?
a.
Assess for arterial aneurysms.
b.
Wear gloves for patient contact.
c.
Place the patient in a private room.
d.
Apply antibiotic ointment to the perineum.
ANS:
B
Exudate from any lesions with syphilis is highly contagious. Systemic antibiotics, rather than local treatment of lesions,
are used to treat syphilis. The patient does not require a private room because the disease is spread through contact with
the lesions. This patient has clinical manifestations of secondary syphilis and does not need to be monitored for
manifestations of tertiary syphilis.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1240
NCLEX: Safe and Effective Care Environment
7.
Which statement by a 24-yr-old patient indicates that the nurse’s teaching about management of
primary genital herpes has been effective?
a.
“I will use acyclovir ointment on the area to relieve the discomfort.”
b.
“I will use condoms for intercourse until the medication is all gone.”
c.
“I will take the acyclovir (Zovirax) every 8 hours for the next week.”
d.
“I will need to take all of the medication to be sure the infection is cured.”
ANS:
C
The treatment regimen for primary genital herpes infections includes acyclovir 400 mg 3 times daily for 7 to 10 days. The
patient is taught to abstain from intercourse until the lesions are gone. (Condoms should be used even when the patient is
asymptomatic.) Acyclovir ointment is not effective in treating lesions or reducing pain. Herpes infection is chronic and
recurrent.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
1233
NCLEX: Physiological Integrity
8.
Which infection, reported in the health history of a female patient who is having difficulty conceiving,
will the nurse identify as a risk factor for infertility?
a.
N. gonorrhoeae
c.
Condyloma acuminatum
b.
Treponema pallidum
d.
Herpes simplex virus type 2
ANS:
A
Complications of gonorrhea include scarring of the fallopian tubes, which can lead to tubal pregnancies and infertility.
Syphilis, genital warts, and genital herpes do not lead to problems with conceiving, although transmission to the fetus
(syphilis) or newborn (genital warts or genital herpes) is a concern.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1230
NCLEX: Physiological Integrity
9.
A patient is diagnosed with primary syphilis during her eighth week of pregnancy. The nurse will plan to
teach the patient about the
a.
likelihood of a stillbirth.
b.
plans for cesarean section
c.
d.
intramuscular injection of penicillin.
antibiotic eye drops for the newborn.
ANS:
C
A single injection of penicillin is recommended to treat primary syphilis. This will treat the mother and prevent
transmission of the disease to the fetus. Instillation of erythromycin into the eyes of the newborn is used to prevent
gonorrheal eye infections. C-section is used to prevent the transmission of herpes to the newborn. Although stillbirth can
occur if the fetus is infected with syphilis, treatment before the 10th week of gestation will eliminate in utero transmission
to the fetus.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1237
NCLEX: Physiological Integrity
10.
A 19-yr-old patient has genital warts around her external genitalia and perianal area. She tells the nurse
that she has not sought treatment until now because “the warts are so disgusting.” Which nursing diagnosis is consistent
with these data?
a.
Disturbed body image related to feelings about the genital warts
b.
Ineffective coping related to denial of increased risk for infection
c.
Risk for infection related to lack of knowledge about transmission
d.
Anxiety related to impact of condition on interpersonal relationships
ANS:
A
The patient’s statement that her lesions are disgusting suggests that disturbed body image is the major concern. There is
no evidence to indicate ineffective coping or lack of knowledge about mode of transmission. The patient may be
experiencing anxiety, but there is nothing in the data indicating that the genital warts are impacting interpersonal
relationships.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Analysis MSC:
REF:
1239
NCLEX: Psychosocial Integrity
11.
When a 31-yr-old male patient returns to the clinic for follow-up after treatment for gonococcal
urethritis, a purulent urethral discharge is still present. Which question will the nurse ask to identify a possible cause of
recurrent infection?
a.
“Did you take the prescribed antibiotic for a week?”
b.
“Did you drink at least 3 quarts of fluids every day?”
c.
“Were your sexual partners treated with antibiotics?”
d.
“Do you wash your hands after using the bathroom?”
ANS:
C
A common reason for recurrence of symptoms is reinfection because infected partners have not been simultaneously
treated. Because gonorrhea is treated with one dose of antibiotic, antibiotic therapy for a week is not needed. An adequate
fluid intake is important, but a low fluid intake is not a likely cause for failed treatment. Poor hygiene may cause
complications such as ocular trachoma but will not cause a failure of treatment.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1239
NCLEX: Physiological Integrity
12.
A 29-yr-old female patient is diagnosed with Chlamydia during a routine pelvic examination. The nurse
knows that teaching regarding the management of the condition has been effective when the patient says which of the
following?
a.
“My partner will need to take antibiotics at the same time I do.”
b.
“Go ahead and give me the antibiotic injection, so I will be cured.”
c.
“I will use condoms during sex until I finish taking all the antibiotics.”
d.
“I do not plan on having children, so treating the infection is not important.”
ANS:
A
Sex partners should be treated simultaneously to prevent reinfection. Chlamydia is treated with oral antibiotics.
Abstinence from sexual intercourse is recommended for 7 days after treatment, and condoms should be recommended
during all sexual contacts to prevent infection. Chronic pelvic pain, as well as infertility, can result from untreated
Chlamydia.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
1239
NCLEX: Physiological Integrity
13.
A patient in the sexually transmitted infection (STI) clinic tells the nurse that she is concerned she may
have been exposed to gonorrhea. To determine whether the patient has gonorrhea, the nurse will plan to
a.
b.
c.
d.
interview the patient about symptoms of gonorrhea.
take a sample of cervical discharge for Gram staining.
draw a blood specimen or rapid plasma reagin (RPR) testing.
obtain secretions for a nucleic acid amplification test (NAAT).
ANS:
D
NAAT has a high sensitivity (similar to a culture) for gonorrhea. Because women have few symptoms of gonorrhea, asking
the patient about symptoms may not be helpful in making a diagnosis. Smears and Gram staining are not useful because
the female genitourinary tract has many normal flora that resemble Neisseria gonorrhoeae. RPR testing is used to detect
syphilis.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1229
NCLEX: Physiological Integrity
14.
A 32-yr-old patient who is diagnosed with Chlamydia tells the nurse that she is very angry because her
husband is her only sexual partner. Which response should the nurse make first?
a.
“You may need professional counseling to help resolve your anger.”
b.
“It is understandable that you feel angry about contracting an infection.”
c.
“Your feelings are justified and you should share them with your husband.”
d.
“It is important that both you and your husband be treated for the infection.”
ANS:
B
This response expresses the nurse’s acceptance of the patient’s feelings and encourages further discussion and problem
solving. The patient may need professional counseling, but more assessment of the patient is needed before making this
judgment. The nurse should also assess further before suggesting that the patient share her feelings with the husband
because problems such as abuse might be present in the relationship. Although it is important that both partners be
treated, the patient’s anger suggests that the feelings need to be acknowledged first.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Psychosocial Integrity
a.
b.
c.
d.
15.
Which patient will the nurse plan on teaching about the Gardasil vaccine?
A 24-yr-old female patient who has not been sexually active
A 34-yr-old female patient who has multiple sexual partners
A 24-yr-old female patient who is pregnant for the first time
A 34-yr-old female patient who is in a monogamous relationship
TOP:
REF:
1239
Nursing Process: Implementation
ANS:
A
Gardasil is recommended for female patients ages 9 through 26 years, preferably those who have never been sexually
active. It is not recommended for women during pregnancy or for older women.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Multiple Patients
NCLEX: Health Promotion and Maintenance
REF:
TOP:
1235
Nursing Process: Planning
16.
After the nurse has taught a patient with a newly diagnosed sexually transmitted infection (STI) about
expedited partner therapy, which patient statement indicates that the teaching has been effective?
a.
“I will tell my partner that it is important to be examined at the clinic.”
b.
“I will have my partner take the antibiotics if any STI symptoms occur.”
c.
“I will make sure that my partner takes all of the prescribed medication.”
d.
“I will have my partner use a condom until I have finished the antibiotics.”
ANS:
C
With expedited partner therapy, the patient is given a prescription or medications for the partner. The partner does not
need to be evaluated by the health care provider but is presumed to be infected and should be treated concurrently with
the patient. Use of a condom will not treat the presumed STI in the partner.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
1239
NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1.
A 39-yr-old patient with a history of IV drug use is seen at a community clinic. The patient reports
difficulty walking, stating, “I don’t know where my feet are.” Diagnostic screening reveals positive Venereal Disease
Research Laboratory (VDRL) and fluorescent treponemal antibody absorption (FTA-Abs) test results. Based on the patient
history, what will the nurse assess (select all that apply)?
a.
Heart sounds
b.
Genitalia for lesions
c.
Joints for swelling and inflammation
d.
Mental state for judgment and orientation
e.
Skin and mucous membranes for gummas
ANS:
A, D, E
The patient’s clinical manifestations and laboratory tests are consistent with tertiary syphilis. Valvular insufficiency,
gummas, and changes in mentation are other clinical manifestations of this stage.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1236
NCLEX: Physiological Integrity
2.
Which topics will the nurse include when preparing to teach a patient with recurrent genital herpes
simplex (select all that apply)?
a.
Infected areas should be kept moist to speed healing.
b.
Sitz baths may be used to relieve discomfort caused by the lesions.
c.
Genital herpes can be cured by consistent use of antiviral medications.
d.
Recurrent genital herpes episodes usually are shorter than the first episode.
e.
The virus can infect sexual partners even when you do not have symptoms.
ANS:
B, D, E
Patients are taught that shedding of the virus and infection of sexual partners can occur even in asymptomatic periods,
that recurrent episodes resolve more quickly, and that sitz baths can be used to relieve pain caused by the lesions.
Antiviral medications decrease the number of outbreaks but do not cure herpes simplex infections. Infected areas may be
kept dry if this decreases pain and itching.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1233
NCLEX: Physiological Integrity
3.
The nurse in the outpatient clinic notes that the following patients have not received the human
papillomavirus (HPV) vaccine. Which patients should the nurse plan to teach about benefits of the vaccine (select all that
apply)?
a.
A 24-yr-old male patient who has a history of genital warts
b.
An 18-yr-old male patient who has had one male sexual partner
c.
A 38-yr-old female patient who has never been sexually active
d.
A 20-yr-old female patient who has a newly diagnosed Chlamydia infection
e.
A 30-yr-old female patient whose sexual partner has a history of genital warts
ANS:
A, B, D
The HPV vaccines are recommended for male and female patients between ages 9 through 26 years. There are several
types of HPV. Ideally, the vaccines are administered before patients are sexually active, but they offer benefit even to those
who already have HPV infection because the vaccines protect against HPV types not already acquired.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Multiple Patients
NCLEX: Health Promotion and Maintenance
REF:
TOP:
1235
Nursing Process: Planning
Chapter 04: Reproductive System Concerns
MULTIPLE CHOICE
a.
b.
c.
d.
16.
The two primary areas of risk for sexually transmitted infections (STIs) are:
Sexual orientation and socioeconomic status.
Age and educational level.
Large number of sexual partners and race.
Risky sexual behaviors and inadequate preventive health behaviors.
ANS:
D
Risky sexual behaviors and inadequate preventive health behaviors put a person at risk for acquiring or transmitting an
STI. Although low socioeconomic status may be a factor in avoiding purchasing barrier protection, sexual orientation does
not put one at higher risk. Younger individuals and individuals with less education may be unaware of proper prevention
techniques; however, these are not the primary areas of risk for STIs. Having a large number of sexual partners is a risk-
taking behavior, but race does not increase the risk for STIs.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
83-84
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
17.
When evaluating a patient for sexually transmitted infections (STIs), the nurse should be aware that the
most common bacterial STI is:
a.
Gonorrhea.
c.
Chlamydia.
b.
Syphilis. d.
Candidiasis.
ANS:
C
Chlamydia is the most common and fastest spreading STI among American women, with an estimated 3 million new cases
each year. Gonorrhea and syphilis are bacterial STIs, but they are not the most common ones among American women.
Candidiasis is caused by a fungus, not by bacteria.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
85
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
a.
b.
c.
d.
18.
The viral sexually transmitted infection (STI) that affects most people in the United States today is:
Herpes simplex virus type 2 (HSV-2).
Human papillomavirus (HPV).
Human immunodeficiency virus (HIV).
Cytomegalovirus (CMV).
ANS:
B
HPV infection is the most prevalent viral STI seen in ambulatory health care settings. HSV-2, HIV, and CMV all are viral STIs
but are not the most prevalent viral STIs.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
90
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
19.
The U.S. Centers for Disease Control and Prevention (CDC) recommends that HPV be treated with
client-applied:
a.
Miconazole ointment.
b.
Topical podofilox 0.5% solution or gel.
c.
Penicillin given intramuscularly for two doses.
d.
Metronidazole by mouth.
ANS:
B
Available treatments are imiquimod, podophyllin, and podofilox. Miconazole ointment is used to treat athlete’s foot.
Intramuscular penicillin is used to treat syphilis. Metronidazole is used to treat bacterial vaginosis.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
91
Nursing Process: Implementation
MSC:
Client Needs: Physiologic Integrity
20.
A woman has a thick, white, lumpy, cottage cheese–like discharge, with patches on her labia and in her
vagina. She complains of intense pruritus. The nurse practitioner would order which preparation for treatment?
a.
Fluconazole
c.
Clindamycin
b.
Tetracycline
d.
Acyclovir
ANS:
A
Fluconazole, metronidazole, and clotrimazole are the drugs of choice to treat candidiasis. Tetracycline is used to treat
syphilis. Clindamycin is used to treat bacterial vaginosis. Acyclovir is used to treat genital herpes.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
96-97
Nursing Process: Implementation
MSC:
Client Needs: Physiologic Integrity
a.
b.
21.
To detect human immunodeficiency virus (HIV), most laboratory tests focus on the:
virus.
c.
CD4 counts.
HIV antibodies.
d.
CD8 counts.
ANS:
B
The screening tool used to detect HIV is the enzyme immunoassay, which tests for the presence of antibodies to the virus.
CD4 counts are associated with the incidence of acquired immunodeficiency syndrome (AIDS) in HIV-infected individuals.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
94
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
22.
Care management of a woman diagnosed with acute pelvic inflammatory disease (PID) most likely
would include:
a.
Oral antiviral therapy.
b.
Bed rest in a semi-Fowler position.
c.
Antibiotic regimen continued until symptoms subside.
d.
Frequent pelvic examination to monitor the progress of healing.
ANS:
B
A woman with acute PID should be on bed rest in a semi-Fowler position. Broad-spectrum antibiotics are used. Antibiotics
must be taken as prescribed, even if symptoms subside. Few pelvic examinations should be conducted during the acute
phase of the disease.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
90
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
23.
On vaginal examination of a 30-year-old woman, the nurse documents the following findings: profuse,
thin, grayish white vaginal discharge with a “fishy” odor; complaint of pruritus. On the basis of these findings, the nurse
suspects that this woman has:
a.
Bacterial vaginosis (BV).
c.
Trichomoniasis.
b.
Candidiasis.
d.
Gonorrhea.
ANS:
A
Most women with BV complain of a characteristic “fishy” odor. The discharge usually is profuse; thin; and white, gray, or
milky in color. Some women also may have mild irritation or pruritus. The discharge associated with candidiasis is thick,
white, and lumpy and resembles cottage cheese. Trichomoniasis may be asymptomatic, but women commonly have a
characteristic yellowish-to-greenish, frothy, mucopurulent, copious, and malodorous discharge. Women with gonorrhea
are often asymptomatic. They may have a purulent endocervical discharge, but discharge usually is minimal or absent.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
96
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
24.
The recommended treatment for the prevention of human immunodeficiency virus (HIV) transmission to
the fetus during pregnancy is:
a.
Acyclovir.
c.
Podophyllin.
b.
Ofloxacin.
d.
Zidovudine.
ANS:
D
Perinatal transmission of HIV has decreased significantly in the past decade as a result of prophylactic administration of
the antiretroviral drug zidovudine to pregnant women in the prenatal and perinatal periods. Acyclovir is an antiviral
treatment for HSV. Ofloxacin is an antibacterial treatment for gonorrhea. Podophyllin is a solution used in the treatment of
human papillomavirus.
PTS:
OBJ:
MSC:
1
DIF:
Cognitive Level: Knowledge REF:
Nursing Process: Planning, Implementation
Client Needs: Health Promotion and Maintenance
95
25.
Which viral sexually transmitted infection is characterized by a primary infection followed by recurrent
episodes?
a.
Herpes simplex virus (HSV)-2
b.
Human papillomavirus (HPV)
c.
Human immunodeficiency virus (HIV)
d.
Cytomegalovirus (CMV)
ANS:
A
The initial HSV genital infection is characterized by multiple painful lesions, fever, chills, malaise, and severe dysuria; it
may last 2 to 3 weeks. Recurrent episodes of HSV infection commonly have only local symptoms that usually are less
severe than the symptoms of the initial infection. With HPV infection, lesions are a chronic problem. HIV is a retrovirus.
Seroconversion to HIV positivity usually occurs within 6 to 12 weeks after the virus has entered the body. Severe
depression of the cellular immune system associated with HIV infection characterizes acquired immunodeficiency
syndrome (AIDS). AIDS has no cure. In most adults, the onset of CMV infection is uncertain and asymptomatic. However,
the disease may become a chronic, persistent infection.
PTS:
1
DIF:
Cognitive Level: Comprehension
REF:
91
OBJ:
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
26.
The nurse should know that once human immunodeficiency virus (HIV) enters the body, seroconversion
to HIV positivity usually occurs within:
a.
6 to 10 days.
c.
6 to 8 weeks.
b.
2 to 4 weeks.
d.
6 months.
ANS:
C
Seroconversion to HIV positivity usually occurs within 6 to 8 weeks after the virus has entered the body.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
94
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
27.
A 25-year-old single woman comes to the gynecologist’s office for a follow-up visit related to her
abnormal Papanicolaou (Pap) smear. The test revealed that the patient has human papillomavirus (HPV). The client asks,
“What is that? Can you get rid of it?” Your best response is:
a.
“It’s just a little lump on your cervix. We can freeze it off.”
b.
“HPV stands for ‘human papillomavirus.’ It is a sexually transmitted infection (STI) that may lead to cervical
cancer.”
c.
“HPV is a type of early human immunodeficiency virus (HIV). You will die from this.”
d.
“You probably caught this from your current boyfriend. He should get tested for this.”
ANS:
B
It is important to inform the patient about STIs and the risks involved with HPV. The health care team has a duty to provide
proper information to the patient, including information related to STIs. HPV and HIV are both viruses that can be
transmitted sexually, but they are not the same virus. The onset of HPV can be insidious. Often STIs go unnoticed.
Abnormal bleeding frequently is the initial symptom. The client may have had HPV before her current boyfriend. You
cannot make any deductions from this limited information.
PTS:
OBJ:
1
DIF:
Cognitive Level: Analysis REF:
91
Nursing Process: Planning MSC:
Client Needs: Health Promotion and Maintenance
a.
b.
c.
d.
28.
Which of the following statements about the various forms of hepatitis is accurate?
A vaccine exists for hepatitis C but not for hepatitis B.
Hepatitis A is acquired by eating contaminated food or drinking polluted water.
Hepatitis B is less contagious than human immunodeficiency virus (HIV).
The incidence of hepatitis C is decreasing.
ANS:
B
Contaminated milk and shellfish are common sources of infection with hepatitis A. A vaccine exists for hepatitis B but not
for hepatitis C. Hepatitis B is more contagious than HIV. The incidence of hepatitis C is increasing.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
92
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
29.
An essential component of counseling women regarding safe sex practices includes discussion
regarding avoiding the exchange of body fluids. The physical barrier promoted for the prevention of sexually transmitted
infections and human immunodeficiency virus is the condom. Nurses can help motivate clients to use condoms by
initiating a discussion related to a number of aspects of condom use. The most important of these is:
a.
Strategies to enhance condom use.
b.
Choice of colors and special features.
c.
Leaving the decision up to the male partner.
d.
Places to carry condoms safely.
ANS:
A
When the nurse opens discussion on safe sex practices, it gives the woman permission to clear up any concerns or
misapprehensions that she may have regarding condom use. The nurse can also suggest ways that the woman can
enhance her condom negotiation and communications skills. These include role-playing, rehearsal, cultural barriers, and
situations that put the client at risk. Although women can be taught the differences among condoms, such as size ranges,
where to purchase, and price, this is not as important as negotiating the use of safe sex practices. Women must address
the issue of condom use with every sexual contact. Some men need time to think about this. If they appear reluctant, the
woman may want to reconsider the relationship. Although not ideal, women may safely choose to carry condoms in shoes,
wallets, or inside their bra. They should be taught to keep the condom away from heat. This information is important;
however, it is not germane if the woman cannot even discuss strategies on how to enhance condom use.
PTS:
1
DIF:
Cognitive Level: Analysis
REF:
92
OBJ:
Nursing Process: Planning MSC:
Client Needs: Health Promotion and Maintenance
a.
b.
31.
Which diagnostic test is used to confirm a suspected diagnosis of breast cancer?
Mammogram
c.
Fine-needle aspiration (FNA)
Ultrasound
d.
CA 15.3
ANS:
C
When a suspicious mammogram is noted or a lump is detected, diagnosis is confirmed by FNA, core needle biopsy, or
needle localization biopsy. Mammography is a clinical screening tool that may aid early detection of breast cancers.
Transillumination, thermography, and ultrasound breast imaging are being explored as methods of detecting early breast
carcinoma. CA 15.3 is a serum tumor marker that is used to test for residual disease.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
98
Nursing Process: Diagnosis MSC:
Client Needs: Physiologic Integrity
40.
The nurse providing care in a women’s health care setting must be aware regarding which sexually
transmitted infection that can be successfully treated and cured?
a.
Herpes
b.
Acquired immunodeficiency syndrome (AIDS)
c.
Venereal warts
d.
Chlamydia
ANS:
D
The usual treatment for infection by the bacterium Chlamydia is doxycycline or azithromycin. Concurrent treatment of all
sexual partners is needed to prevent recurrence. There is no known cure for herpes, and treatment focuses on pain relief
and preventing secondary infections. Because there is no known cure for AIDS, prevention and early detection are the
primary focus of care management. Condylomata acuminata are caused by human papillomavirus. No treatment
eradicates the virus.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
85
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
a.
b.
43.
The drug of choice for treatment of gonorrhea is:
Penicillin G.
c.
Ceftriaxone.
Tetracycline.
d.
Acyclovir.
ANS:
C
Ceftriaxone is effective for treatment of all gonococcal infections. Penicillin is used to treat syphilis. Tetracycline is
prescribed for chlamydial infections. Acyclovir is used to treat herpes genitalis.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
86
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
44.
The nurse providing education regarding breast care should explain to the woman that fibrocystic
changes in breasts are:
a.
A disease of the milk ducts and glands in the breasts.
b.
A premalignant disorder characterized by lumps found in the breast tissue.
c.
Lumpiness with pain and tenderness found in varying degrees in the breast tissue of healthy women during
menstrual cycles.
d.
Lumpiness accompanied by tenderness after menses.
ANS:
C
Fibrocystic changes are palpable thickenings in the breast usually associated with pain and tenderness. The pain and
tenderness fluctuate with the menstrual cycle. Fibrocystic changes are not premalignant changes.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
98
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
Reproduction
Concept 21: Reproduction
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
A female college student is planning to become sexually active. She is considering birth control options
and desires a method in which ovulation will be prevented. To prevent ovulation while reaching 99% effectiveness in
preventing pregnancy, which option should be given the strongest consideration?
a.
Intrauterine device
b.
Coitus interruptus
c.
Natural family planning
d.
Oral contraceptive pills
ANS:
D
Oral contraceptive pills prevent ovulation and are 99% effective in preventing pregnancy when taken as directed.
Intrauterine devices, coitus interruptus, and natural family planning will not prevent ovulation while reaching 99%
effectiveness in preventing pregnancy, so they are not recommended for this college student.
REF:
Page 201
OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance and Physiological Integrity:
Pharmacological and Parenteral Therapies
2.
The nurse at the family planning clinic conducts a male history for infertility evaluation. Which finding
has the greatest implication for this patient’s care?
a.
Practice of nightly masturbation
b.
Primary anovulation
c.
High testosterone levels
d.
Impotence due to alcohol ingestion
ANS:
D
Factors affecting male infertility include impotence due to alcohol. Nightly masturbation and high testosterone levels do
not have the greatest implication on male infertility in a patient with admitted alcohol issues. Primary anovulation refers to
female infertility, so it is not a consideration for male infertility.
REF:
Page 201 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
3.
The emergency department nursing assessment of a pregnant female at 35 weeks gestation reveals
back pain, blood pressure 150/92, and leaking of clear fluid from the vagina. Which complication of pregnancy does the
nurse suspect?
a.
Ectopic pregnancy
b.
Spontaneous abortion
c.
Premature rupture of membranes
d.
Supine hypotension
ANS:
C
Leaking of clear fluid from the vagina with back pain and elevated BP is associated with premature rupture of membranes,
a complication of pregnancy. An ectopic pregnancy usually manifests as unilateral pain early in the pregnancy. Vaginal
bleeding is a classic sign of miscarriage, or spontaneous abortion, not leaking of clear fluid. This patient’s blood pressure
is elevated. Supine hypotension occurs when the woman is lying supine; then low blood pressure occurs due to the
decrease in venous return from the gravid uterus placing pressure on the vena cava.
REF:
OBJ:
Page 201
NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4.
The nurse is admitting a prenatal patient for diagnostic testing. While eliciting the psychosocial history,
the nurse learns the patient smokes a pack of cigarettes daily, drinks a cup of cappuccino with breakfast, has smoked
marijuana in the remote past, and is a social drinker. Which action should the nurse first take?
a.
Strongly advise immediate tobacco cessation
b.
Elimination of all caffeinated beverages
c.
Serum and urine testing for drug use and alcohol use
d.
Referral to a 12-step program
ANS:
A
There are numerous risk factors for women and men affecting reproductive health and pregnancy outcomes. These can be
categorized into biophysical, psychosocial, sociodemographic, and environmental factors. Some of the risk factors for
human reproduction fit into multiple categories. Psychosocial factors cover smoking, excessive caffeine, alcohol and drug
abuse, psychologic status including impaired mental health, addictive lifestyles, spouse abuse, and noncompliance with
cultural norms. Drinking a cup of a caffeinated beverage a day is not associated with adverse fetal outcomes usually.
Serum and urine testing for drug/alcohol use is not required for stated marijuana use in the remote past. Patient referral to
a 12-step program is usually advisable for current alcohol and/or drug use.
REF:
OBJ:
Page 204
NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5.
A female infertility patient is found to be hypoestrogenic at the preconceptual clinic visit. She asks the
nurse why she has never been able to get pregnant. Which response is best?
a.
Circulating estrogen contributes to secondary sex characteristics.
b.
Estrogen deficiency prevents the ovum from reaching the uterus and may be a factor in infertility.
c.
Hyperestrogen may be preventing the zona pellucida from forming an ovum protective layer.
d.
The corona radiata is preventing fertilization of the ovum.
ANS:
B
The cilia in the tubes are stimulated by high estrogen levels, which propel the ovum toward the uterus. Without estrogen,
the ovum won’t reach the uterus. The results of a series of events occurring in the ovary cause an expulsion of the oocyte
from the ovarian follicle known as ovulation. The ovarian cycle is driven by multiple important hormones: (1) gonadotropic
hormone, (2) follicle stimulating hormone (FSH), and (3) luteinizing hormone (LH). The cilia in the tubes are stimulated by
high (4) estrogen levels, which propel the ovum toward the uterus. The zona pellucida (inner layer) and corona radiata
(outer layer) form protective layers around the ovum. If an ovum is not fertilized within 24 hours of ovulation by a sperm, it
is usually reabsorbed into a woman’s body. A patient who is hypoestrogenic would not have excess circulating estrogen. A
patient with low estrogen would not be classified as hyperestrogenic. Without sufficient estrogen, there can be no
fertilization of the ovum.
REF:
OBJ:
Page 199
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
6.
An obstetric multipara with triplets is placed on bed rest at 24 weeks’ gestation. Her perinatologist is
managing intrauterine growth restriction with serial ultrasounds. This prescribed treatment is an example of which type of
care?
a.
Antenatal diagnostics
b.
Primary prevention
c.
Secondary prevention
d.
Collaborative intervention
ANS:
D
An example of collaborative intervention relating to reproductive health would be managing fetal intrauterine growth
restriction by serial ultrasounds. This type of diagnostic maternal/fetal monitoring is performed to determine the best time
for delivery due to potential fetal nutritional, circulatory, or pulmonary compromise. A cesarean section (operative delivery)
may be performed if maternal or fetal conditions indicate that delivery is necessary. Antenatal diagnostics refers to prior to
pregnancy. An example of primary prevention is teaching a high school class about reproductive health. An example of
secondary prevention is prenatal care in the second trimester of pregnancy to prevent problems for the developing fetus.
REF:
Page 204 OBJ:
NCLEX® Client Needs Category: Safe and Effective Care Environment
7.
A female patient comes to the clinic after missing one menstrual period. She lives in a house beneath
electrical power lines which is located near an oil field. She drinks two caffeinated beverages a day, is a daily beer drinker,
and has not stopped eating sweets. She takes a multivitamin and exercises daily. She denies drug use. Which finding in
the history has the greatest implication for this patient’s plan of care?
a.
Electrical power lines are a potential hazard to the woman and her fetus.
b.
Living near an oil field may mean the water supply is polluted.
c.
Alcohol exposure should be avoided during pregnancy due to teratogenicity.
d.
Eating sweets may cause gestational diabetes or miscarriage.
ANS:
C
Stages of development include ovum, embryonic, and fetal. The beginning of the fourth week to the end of the eighth week
comprise the embryonic period. Teratogenicity is a major concern because all external and internal structures are
developing in the embryonic period. A pregnant woman should avoid exposure to all potential toxins during pregnancy,
especially alcohol, tobacco, radiation, and infections during embryonic development. Living in a house beneath power
lines is not the greatest implication in this patient’s plan of care as there are no definite risks to the developing fetus.
Living near an oil field has no definite risks to the fetus. Eating sweets may contribute to maternal obesity, large for
gestational age fetus, and maternal gestational diabetes but does not have the immediate implication of a daily beer
drinker which can cause fetal alcohol syndrome.
REF:
OBJ:
Page 200
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
Chapter 50: Assessment of Reproductive System
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1.
Which question should the nurse ask when assessing a 60-yr-old patient who has a history of benign
prostatic hyperplasia (BPH)?
a.
“Have you noticed any unusual discharge from your penis?”
b.
“Has there been any change in your sex life in the past year?”
c.
“Has there been a decrease in the force of your urinary stream?”
d.
“Have you been experiencing any difficulty in achieving an erection?”
ANS:
C
Enlargement of the prostate blocks the urethra, leading to urinary changes such as a decrease in the force of the urinary
stream. The other questions address possible problems with infection or sexual difficulties, but they would not be helpful
in determining whether there were functional changes caused by BPH.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1194
NCLEX: Physiological Integrity
2.
After a 26-yr-old patient has been treated for pelvic inflammatory disease, the nurse will plan to teach
about the
a.
use of hormone therapy (HT).
b.
potential complication of infertility.
c.
irregularities in the menstrual cycle.
d.
changes in secondary sex characteristics.
ANS:
B
Pelvic inflammatory disease may cause scarring of the fallopian tubes and result in difficulty in fertilization or implantation
of the fertilized egg. Because ovarian function is not affected, the patient will not require HT, have irregular menstrual
cycles, or experience changes in secondary sex characteristics.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1194
NCLEX: Physiological Integrity
3.
A 68-yr-old male patient tells the nurse that he is worried because he does not respond to sexual
stimulation the same way he did when he was younger. Which is the nurse’s best response to the patient’s concern?
a.
“Interest in sex frequently decreases as men get older.”
b.
“Many men need additional sexual stimulation with aging.”
c.
“Erectile dysfunction is a common problem with older men.”
d.
“Tell me more about how your sexual response has changed.”
ANS:
D
The initial response by the nurse should be further assessment of the problem. The other statements by the nurse are
accurate but may not respond to the patient’s concerns.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Assessment
MSC:
REF:
1191
NCLEX: Psychosocial Integrity
4.
The nurse is providing teaching by telephone to a patient who is scheduled for a pelvic examination
and Pap test next week. The nurse instructs the patient that she should
a.
not have sexual intercourse the day before the Pap test.
b.
shower, but not take a tub bath, before the examination.
c.
avoid douching for at least 24 hours before the examination.
d.
schedule to have the Pap test just after her menstrual period.
ANS:
C
Because the results of a Pap test may be affected by douching, the patient should not douche before the examination. The
examination may be scheduled without regard to the menstrual period. The patient may shower or bathe before the
examination. Sexual intercourse does not affect the results of the examination or Pap test.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1199
NCLEX: Physiological Integrity
5.
A 22-yr-old patient reports her concern about not having a menstrual period for the past 7 months.
Which statement by the patient indicates a possible related factor to the amenorrhea?
a.
“I drink at least 3 glasses of nonfat milk every day.”
b.
“I run 7 to 8 miles every day to manage my weight.”
c.
“I am not sexually active but currently I have an IUD.”
d.
“I was treated for a sexually transmitted infection 2 years ago.”
ANS:
B
Intense endurance exercise can cause amenorrhea. The other statements by the patient do not suggest any urgent
teaching needs.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1194
NCLEX: Health Promotion and Maintenance
6.
The nurse is assessing the sexual-reproductive functional health pattern of a 32-yr-old woman. Which
question is most useful in determining the patient’s sexual orientation and related risk factors?
a.
“Do you have sex with men, women, or both?”
b.
“Which gender do you prefer to have sex with?”
c.
“What types of sexual activities do you prefer?”
d.
“Are you heterosexual, homosexual, or bisexual?”
ANS:
A
This question is the most simply stated and will increase the likelihood of obtaining the relevant information about sexual
orientation and possible risk factors associated with sexual activity. A patient who prefers sex with women may also have
intercourse at times with men. The types of sexual activities engaged in may not indicate sexual orientation. Many patients
who have sex with both men and women do not identify themselves as homosexual or bisexual.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Assessment
a.
b.
c.
d.
7.
The nurse explains to a patient being prepared for colposcopy with a cervical biopsy that the procedure
involves dilation of the cervix and biopsy of the tissue lining the uterus.
will take place in a same-day surgery center so that local anesthesia can be used.
requires that the patient have nothing to eat or drink for 6 hours before the procedure.
is similar to a speculum examination of the cervix and should result in little discomfort.
MSC:
REF:
1194
NCLEX: Health Promotion and Maintenance
ANS:
D
Colposcopy involves visualization of the cervix with a binocular microscope and is similar to a speculum examination.
Anesthesia is not required and fasting is not necessary. A cervical biopsy may cause a minimal amount of pain.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1201
NCLEX: Physiological Integrity
8.
A couple is scheduled to have a Huhner test for infertility. In preparation for the test, the nurse will
instruct the couple about
a.
being sedated during the procedure.
b.
determining the estimated time of ovulation.
c.
experiencing shoulder pain after the procedure.
d.
refraining from intercourse before the appointment.
ANS:
B
For the Huhner test, the couple should have intercourse at the estimated time of ovulation and then arrive for the test 2 to
8 hours after intercourse. The other instructions would be used for other types of fertility testing.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1194
NCLEX: Physiological Integrity
9.
A patient in the sexually transmitted infection clinic has a positive Venereal Disease Research
Laboratory (VDRL) test, but no chancre is visible on assessment. The nurse will plan to send specimens for
a.
Gram stain.
b.
cytologic studies.
c.
rapid plasma reagin (RPR) agglutination.
d.
fluorescent treponemal antibody absorption (FTA-Abs).
ANS:
D
Because false positives are common with VDRL and RPR testing, FTA-Abs testing is recommended to confirm a diagnosis
of syphilis. Gram staining is used for other sexually transmitted infections (STIs) such as gonorrhea and Chlamydia and
cytologic studies are used to detect abnormal cells (e.g., neoplastic cells).
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1198
NCLEX: Physiological Integrity
10.
A 24-yr-old woman says she wants to begin using oral contraceptives. Which information from the
nursing assessment is important to report to the health care provider before a prescription is considered?
a.
The patient quit smoking 5 months previously.
b.
The patient’s blood pressure is 150/86 mm Hg.
c.
The patient has not been vaccinated for rubella.
d.
The patient has chronic iron-deficiency anemia.
ANS:
B
Because hypertension increases the risk for morbidity and mortality in women taking oral contraceptives, the patient’s
blood pressure should be controlled before oral contraceptives are prescribed. The other information will not affect the
choice of contraceptive.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1193
NCLEX: Health Promotion and Maintenance
11.
A 49-yr-old man who has type 2 diabetes, high blood pressure, hyperlipidemia, and gastroesophageal
reflux tells the nurse that he has had recent difficulty in achieving an erection. Which of the following drugs from his
current medications list may cause erectile dysfunction (ED)?
a.
Ranitidine (Zantac)
c.
Propranolol (Inderal)
b.
Atorvastatin (Lipitor)
d.
Metformin (Glucophage)
ANS:
C
Some antihypertensives may cause ED, and the nurse should anticipate a change in antihypertensive therapy. The other
medications will not affect erectile function.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1192
NCLEX: Physiological Integrity
12.
A 19-yr-old patient calls the school clinic and tells the nurse, “My menstrual period is very heavy this
time. I have to change my tampon every 4 hours.” Which action should the nurse take next?
a.
Tell the patient that her flow is not unusually heavy.
b.
Schedule the patient for an appointment later that day.
c.
Ask the patient how heavy her usual menstrual flow is.
d.
Have the patient call again if the heavy flow continues.
ANS:
C
Because a heavy menstrual flow is usually indicated by saturating a pad or tampon in 1 to 2 hours, the nurse should first
assess how heavy the patient’s usual flow is. There is no need to schedule the patient for an appointment that day. The
patient may need to call again, but this is not the first action that the nurse should take. Telling the patient that she does
not have a heavy flow implies that the patient’s concern is not important.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1190
NCLEX: Health Promotion and Maintenance
13.
After scheduling a patient with a possible ovarian cyst for ultrasound, the nurse will teach the patient
that she should
a.
expect to receive IV contrast during the procedure.
b.
drink several glasses of fluids before the procedure.
c.
experience mild abdominal cramps after the procedure.
d.
discontinue taking aspirin for 7 days before the procedure.
ANS:
B
A full bladder is needed for many ultrasound procedures, so the nurse will have the patient drink fluids before arriving for
the ultrasound. The other instructions are not accurate for this procedure.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
14.
a(n)
a.
b.
c.
d.
MSC:
REF:
1200
NCLEX: Physiological Integrity
The nurse will plan to teach a 51-yr-old man who is scheduled for an annual physical examination about
increased risk for testicular cancer.
possible changes in erectile function.
normal decreases in testosterone level.
prostate specific antigen (PSA) testing.
ANS:
D
PSA testing may be recommended annually for men, starting at age 50. There is no indication that the other patient
teaching topics are appropriate for this patient.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1199
NCLEX: Health Promotion and Maintenance
15.
An 18-yr-old female patient who has been admitted to the emergency department after a motor vehicle
crash is scheduled for chest and abdominal x-rays. Which information may alter the plans for the x-rays?
a.
Report of abdominal pain
b.
Positive result of hCG test
c.
Blood pressure of 172/88 mm Hg
d.
Temperature of 102.1°F (38.9°C)
ANS:
B
Positive hCG testing indicates that the patient is pregnant and that abdominal x-rays should be avoided if possible. The
other information is also important to report promptly, but it will not affect whether the x-rays should be done.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Assessment
a.
b.
c.
d.
16.
The following patients call the outpatient clinic. Which phone call should the nurse return first?
A 44-yr-old patient who has bloody discharge after a hysteroscopy earlier today
A 64-yr-old patient who is experiencing shoulder pain after a laparoscopy yesterday
A 34-yr-old patient who is short of breath after having a pelvic CT with contrast dye
A 54-yr-old patient who has severe breast tenderness following a needle aspiration breast biopsy
MSC:
REF:
1199
NCLEX: Physiological Integrity
ANS:
C
The patient’s dyspnea suggests a delayed reaction to the iodine dye used for the CT scan. The other patient’s symptoms
are not unusual after the procedures they had done.
DIF:
OBJ:
TOP:
Cognitive Level: Analyze (analysis)
REF:
1200
Special Questions: Prioritization | Special Questions: Multiple Patients
Nursing Process: Assessment
MSC:
NCLEX: Safe and Effective Care Environment
17.
A woman calls the clinic because she is having an unusually heavy menstrual flow. She tells the nurse
that she has saturated three tampons in the past 2 hours. The nurse estimates that the amount of blood loss over the past
2 hours is _____ mL.
a.
20 to 30 c.
40 to 60
b.
30 to 40 d.
60 to 90
ANS:
D
The average tampon absorbs 20 to 30 mL.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
1190
Nursing Process: Assessment
MSC:
NCLEX: Physiological Integrity
18.
Which finding from the nurse’s physical assessment of a 42-yr-old male patient should be reported to
the health care provider?
a.
One testis hangs lower than the other.
b.
Genital hair distribution is diamond shaped.
c.
Clear discharge is present at the penile meatus.
d.
Inguinal lymph nodes are nonpalpable bilaterally.
ANS:
C
Clear penile discharge may be indicative of a sexually transmitted infection (STI). The other findings are normal and do not
need to be reported.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1198
NCLEX: Physiological Integrity
19.
Which information shown in the accompanying figure and obtained by the nurse about a 72-yr-old man
who is complaining of erectile dysfunction is most important to communicate to the health care provider?
a.
b.
Recent knee surgery
Use of antihypertensives
c.
d.
Low position of left testis
Pulse and blood pressure level
ANS:
B
Many medications used for hypertension can cause erectile dysfunction. More information is needed regarding the
specific medications. The other assessment data will not impact erectile function (recent knee surgery) or are normal for a
70-yr-old man (physical examination data and vital signs).
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1192
Nursing Process: Assessment
Chapter 07: Anatomy and Physiology of Pregnancy
MULTIPLE CHOICE
1.
A woman’s obstetric history indicates that she is pregnant for the fourth time and all of her children
from previous pregnancies are living. One was born at 39 weeks of gestation, twins were born at 34 weeks of gestation,
and another child was born at 35 weeks of gestation. What is her gravidity and parity using the GTPAL system?
a.
3-1-1-1-3 c.
3-0-3-0-3
b.
4-1-2-0-4 d.
4-2-1-0-3
ANS:
B
The correct calculation of this woman’s gravidity and parity is 4-1-2-0-4. The numbers reflect the woman’s gravidity and
parity information. Using the GPTAL system, her information is calculated as:
G: The first number reflects the total number of times the woman has been pregnant; she is pregnant for the fourth time.
T: This number indicates the number of pregnancies carried to term, not the number of deliveries at term; only one of her
pregnancies has resulted in a fetus at term.
P: This is the number of pregnancies that resulted in a preterm birth; the woman has had two pregnancies in which she
delivered preterm.
A: This number signifies whether the woman has had any abortions or miscarriages before the period of viability; she has
not.
L: This number signifies the number of children born that currently are living; the woman has four children.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
169
Nursing Process: Diagnosis MSC:
Client Needs: Health Promotion and Maintenance
2.
A woman at 10 weeks of gestation who is seen in the prenatal clinic with presumptive signs and
symptoms of pregnancy likely will have:
a.
Amenorrhea.
c.
Chadwick’s sign.
b.
Positive pregnancy test.
d.
Hegar’s sign.
ANS:
A
Amenorrhea is a presumptive sign of pregnancy. Presumptive signs of pregnancy are felt by the woman. A positive
pregnancy test, the presence of Chadwick’s sign, and the presence of Hegar’s sign all are probable signs of pregnancy.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
170
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
3.
The nurse teaches a pregnant woman about the presumptive, probable, and positive signs of
pregnancy. The woman demonstrates understanding of the nurse’s instructions if she states that a positive sign of
pregnancy is:
a.
A positive pregnancy test.
b.
Fetal movement palpated by the nurse-midwife.
c.
Braxton Hicks contractions.
d.
Quickening.
ANS:
B
Positive signs of pregnancy are attributed to the presence of a fetus, such as hearing the fetal heartbeat or palpating fetal
movement. A positive pregnancy test and Braxton Hicks contractions are probable signs of pregnancy. Quickening is a
presumptive sign of pregnancy.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
170
Nursing Process: Planning MSC:
Client Needs: Health Promotion and Maintenance
a.
b.
c.
d.
4.
A woman is at 14 weeks of gestation. The nurse would expect to palpate the fundus at which level?
Not palpable above the symphysis at this time
Slightly above the symphysis pubis
At the level of the umbilicus
Slightly above the umbilicus
ANS:
B
In normal pregnancies, the uterus grows at a predictable rate. It may be palpated above the symphysis pubis sometime
between the twelfth and fourteenth weeks of pregnancy. As the uterus grows, it may be palpated above the symphysis
pubis sometime between the twelfth and fourteenth weeks of pregnancy. The uterus rises gradually to the level of the
umbilicus at 22 to 24 weeks of gestation.
PTS:
1
DIF:
Cognitive Level: Comprehension
REF:
171
OBJ:
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
5.
During a client’s physical examination the nurse notes that the lower uterine segment is soft on
palpation. The nurse would document this finding as:
a.
Hegar’s sign
c.
Chadwick’s sign
b.
McDonald’s sign d.
Goodell’s sign
ANS:
A
At approximately 6 weeks of gestation, softening and compressibility of the lower uterine segment occur; this is called
Hegar’s sign. McDonald’s sign indicates a fast food restaurant. Chadwick’s sign is the blue-violet coloring of the cervix
caused by increased vascularity; this occurs around the fourth week of gestation. Softening of the cervical tip is called
Goodell’s sign, which may be observed around the sixth week of pregnancy.
PTS:
OBJ:
MSC:
1
DIF:
Cognitive Level: Comprehension
Nursing Process: Assessment, Implementation
Client Needs: Health Promotion and Maintenance
REF:
172
6.
Cardiovascular system changes occur during pregnancy. Which finding would be considered normal
for a woman in her second trimester?
a.
Less audible heart sounds (S1, S2)
b.
Increased pulse rate
c.
Increased blood pressure
d.
Decreased red blood cell (RBC) production
ANS:
B
Between 14 and 20 weeks of gestation, the pulse increases about 10 to 15 beats/min, which persists to term. Splitting of S1
and S2 is more audible. In the first trimester, blood pressure usually remains the same as at the prepregnancy level, but it
gradually decreases up to about 20 weeks of gestation. During the second trimester, both the systolic and the diastolic
pressures decrease by about 5 to 10 mm Hg. Production of RBCs accelerates during pregnancy.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
175
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
7.
birth?
a.
b.
Numerous changes in the integumentary system occur during pregnancy. Which change persists after
Epulis c.
Chloasma
Telangiectasia
d.
Striae gravidarum
ANS:
D
Striae gravidarum, or stretch marks, reflect separation within the underlying connective tissue of the skin. They usually
fade after birth, although they never disappear completely. An epulis is a red, raised nodule on the gums that bleeds easily.
Chloasma, or mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead,
especially in dark-complexioned pregnant women. Chloasma usually fades after the birth. Telangiectasia, or vascular
spiders, are tiny, star-shaped or branchlike, slightly raised, pulsating end-arterioles usually found on the neck, thorax,
face, and arms. They occur as a result of elevated levels of circulating estrogen. These usually disappear after birth.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
180
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
8.
The musculoskeletal system adapts to the changes that occur during pregnancy. A woman can expect
to experience what change?
a.
Her center of gravity will shift backward.
b.
She will have increased lordosis.
c.
She will have increased abdominal muscle tone.
d.
She will notice decreased mobility of her pelvic joints.
ANS:
B
An increase in the normal lumbosacral curve (lordosis) develops, and a compensatory curvature in the cervicodorsal
region develops to help the woman maintain her balance. The center of gravity shifts forward. She will have decreased
muscle tone. She will notice increased mobility of her pelvic joints.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
181
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
9.
A 31-year-old woman believes that she may be pregnant. She took an OTC pregnancy test 1 week ago
after missing her period; the test was positive. During her assessment interview, the nurse inquires about the woman’s
last menstrual period and asks whether she is taking any medications. The woman states that she takes medicine for
epilepsy. She has been under considerable stress lately at work and has not been sleeping well. She also has a history of
irregular periods. Her physical examination does not indicate that she is pregnant. She has an ultrasound scan, which
reveals that she is not pregnant. What is the most likely cause of the false-positive pregnancy test result?
a.
She took the pregnancy test too early.
b.
She takes anticonvulsants.
c.
She has a fibroid tumor.
d.
She has been under considerable stress and has a hormone imbalance.
ANS:
B
Anticonvulsants may cause false-positive pregnancy test results. OTC pregnancy tests use enzyme-linked immunosorbent
assay technology, which can yield positive results 4 days after implantation. Implantation occurs 6 to 10 days after
conception. If the woman were pregnant, she would be into her third week at this point (having missed her period 1 week
ago). Fibroid tumors do not produce hormones and have no bearing on hCG pregnancy tests. Although stress may
interrupt normal hormone cycles (menstrual cycles), it does not affect human chorionic gonadotropin levels or produce
positive pregnancy test results.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
170
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
10.
A woman is in her seventh month of pregnancy. She has been complaining of nasal congestion and
occasional epistaxis. The nurse suspects that:
a.
This is a normal respiratory change in pregnancy caused by elevated levels of estrogen.
b.
This is an abnormal cardiovascular change, and the nosebleeds are an ominous sign.
c.
The woman is a victim of domestic violence and is being hit in the face by her partner.
d.
The woman has been using cocaine intranasally.
ANS:
A
Elevated levels of estrogen cause capillaries to become engorged in the respiratory tract. This may result in edema in the
nose, larynx, trachea, and bronchi. This congestion may cause nasal stuffiness and epistaxis. Cardiovascular changes in
pregnancy may cause edema in lower extremities. Determining that the woman is a victim of domestic violence and was
hit in the face cannot be made on the basis of the sparse facts provided. If the woman had been hit in the face, she most
likely would have additional physical findings. Determination of the use of cocaine by the woman cannot be made on the
basis of the sparse facts provided.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
179
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
11.
The nurse caring for the pregnant client must understand that the hormone essential for maintaining
pregnancy is:
a.
Estrogen.
b.
Human chorionic gonadotropin (hCG).
c.
Oxytocin.
d.
Progesterone.
ANS:
D
Progesterone is essential for maintaining pregnancy; it does so by relaxing smooth muscles. This reduces uterine activity
and prevents miscarriage. Estrogen plays a vital role in pregnancy, but it is not the primary hormone for maintaining
pregnancy. hCG levels increase at implantation but decline after 60 to 70 days. Oxytocin stimulates uterine contractions.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
184
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
12.
A patient at 24 weeks of gestation contacts the nurse at her obstetric provider’s office to complain that
she has cravings for dirt and gravel. The nurse is aware that this condition is known as ________ and may indicate anemia.
a.
Ptyalism c.
Pica
b.
Pyrosis d.
Decreased peristalsis
ANS:
C
Pica (a desire to eat nonfood substances) is an indication of iron deficiency and should be evaluated. Ptyalism (excessive
salivation), pyrosis (heartburn), and decreased peristalsis are normal findings of gastrointestinal change during
pregnancy. Food cravings during pregnancy are normal.
PTS:
OBJ:
1
DIF:
Cognitive Level: Analysis
Nursing Process: Assessment
MSC:
REF:
183
Client Needs: Health Promotion and Maintenance
a.
b.
c.
d.
13.
Appendicitis may be difficult to diagnose in pregnancy because the appendix is:
Displaced upward and laterally, high and to the right.
Displaced upward and laterally, high and to the left.
Deep at McBurney point.
Displaced downward and laterally, low and to the right.
ANS:
A
The appendix is displaced high and to the right, beyond McBurney point.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
183
Nursing Process: Diagnosis MSC:
Client Needs: Physiologic Integrity
14.
A woman who has completed one pregnancy with a fetus (or fetuses) reaching the stage of fetal
viability is called a:
a.
Primipara.
c.
Multipara.
b.
Primigravida.
d.
Nulligravida.
ANS:
A
A primipara is a woman who has completed one pregnancy with a viable fetus. To remember terms, keep in mind: gravida
is a pregnant woman; para comes from parity, meaning a viable fetus; primi means first; multi means many; and null
means none. A primigravida is a woman pregnant for the first time. A multipara is a woman who has completed two or
more pregnancies with a viable fetus. A nulligravida is a woman who has never been pregnant.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
168
Nursing Process: Diagnosis MSC:
Client Needs: Health Promotion and Maintenance
a.
b.
c.
d.
15.
Which time-based description of a stage of development in pregnancy is accurate?
Viability—22 to 37 weeks since the last menstrual period (LMP) (assuming a fetal weight >500 g)
Term—pregnancy from the beginning of week 38 of gestation to the end of week 42
Preterm—pregnancy from 20 to 28 weeks
Postdate—pregnancy that extends beyond 38 weeks
ANS:
B
Term is 38 to 42 weeks of gestation. Viability is the ability of the fetus to live outside the uterus before coming to term, or
22 to 24 weeks since LMP. Preterm is 20 to 37 weeks of gestation. Postdate or postterm is a pregnancy that extends
beyond 42 weeks or what is considered the limit of full term.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
168
Nursing Process: Diagnosis MSC:
Client Needs: Health Promotion and Maintenance
16.
Human chorionic gonadotropin (hCG) is an important biochemical marker for pregnancy and the basis
for many tests. A maternity nurse should be aware that:
a.
hCG can be detected 2.5 weeks after conception.
b.
The hCG level increases gradually and uniformly throughout pregnancy.
c.
Much lower than normal increases in the level of hCG may indicate a postdate pregnancy.
d.
A higher than normal level of hCG may indicate an ectopic pregnancy or Down syndrome.
ANS:
D
Higher levels also could be a sign of multiple gestation. hCG can be detected 7 to 8 days after conception. The hCG level
fluctuates during pregnancy: peaking, declining, stabilizing, and increasing again. Abnormally slow increases may indicate
impending miscarriage.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
169
Nursing Process: Diagnosis MSC:
Client Needs: Health Promotion and Maintenance
17.
To reassure and educate pregnant clients about changes in the uterus, nurses should be aware that:
a.
Lightening occurs near the end of the second trimester as the uterus rises into a different position.
b.
The woman’s increased urinary frequency in the first trimester is the result of exaggerated uterine antireflexion
caused by softening.
c.
Braxton Hicks contractions become more painful in the third trimester, particularly if the woman tries to exercise.
d.
The uterine souffle is the movement of the fetus.
ANS:
B
The softening of the lower uterine segment is called Hegar’s sign. Lightening occurs in the last 2 weeks of pregnancy,
when the fetus descends. Braxton Hicks contractions become more defined in the final trimester but are not painful.
Walking or exercise usually causes them to stop. The uterine souffle is the sound made by blood in the uterine arteries; it
can be heard with a fetal stethoscope.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
172
Nursing Process: Planning MSC:
Client Needs: Health Promotion and Maintenance
18.
To reassure and educate pregnant clients about changes in the cervix, vagina, and position of the fetus,
nurses should be aware that:
a.
Because of a number of changes in the cervix, abnormal Papanicolaou (Pap) tests are much easier to evaluate.
b.
Quickening is a technique of palpating the fetus to engage it in passive movement.
c.
The deepening color of the vaginal mucosa and cervix (Chadwick’s sign) usually appears in the second trimester
or later as the vagina prepares to stretch during labor.
d.
Increased vascularity of the vagina increases sensitivity and may lead to a high degree of arousal, especially in
the second trimester.
ANS:
D
Increased sensitivity and an increased interest in sex sometimes go together. This frequently occurs during the second
trimester. Cervical changes make evaluation of abnormal Pap tests more difficult. Quickening is the first recognition of
fetal movements by the mother. Ballottement is a technique used to palpate the fetus. Chadwick’s sign appears from the
sixth to eighth weeks.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
173
Nursing Process: Planning MSC:
Client Needs: Health Promotion and Maintenance
a.
b.
19.
The mucous plug that forms in the endocervical canal is called the:
Operculum.
c.
Funic souffle.
Leukorrhea.
d.
Ballottement.
ANS:
A
The operculum protects against bacterial invasion. Leukorrhea is the mucus that forms the endocervical plug (the
operculum). The funic souffle is the sound of blood flowing through the umbilical vessels. Ballottement is a technique for
palpating the fetus.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
173
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
20.
To reassure and educate pregnant clients about changes in their breasts, nurses should be aware that:
a.
The visibility of blood vessels that form an intertwining blue network indicates full function of Montgomery’s
tubercles and possibly infection of the tubercles.
b.
The mammary glands do not develop until 2 weeks before labor.
c.
Lactation is inhibited until the estrogen level declines after birth.
d.
Colostrum is the yellowish oily substance used to lubricate the nipples for breastfeeding.
ANS:
C
Lactation is inhibited until after birth. The visible blue network of blood vessels is a normal outgrowth of a richer blood
supply. The mammary glands are functionally complete by midpregnancy. Colostrum is a creamy, white-to-yellow premilk
fluid that can be expressed from the nipples before birth.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
174
Nursing Process: Planning MSC:
Client Needs: Health Promotion and Maintenance
21.
To reassure and educate pregnant clients about changes in their cardiovascular system, maternity
nurses should be aware that:
a.
A pregnant woman experiencing disturbed cardiac rhythm, such as sinus arrhythmia requires close medical and
obstetric observation, no matter how healthy she otherwise may appear.
b.
Changes in heart size and position and increases in blood volume create auditory changes from 20 weeks to
term.
c.
Palpitations are twice as likely to occur in twin gestations.
d.
All of the above changes likely will occur.
ANS:
B
Auscultatory changes should be discernible after 20 weeks of gestation. A healthy woman with no underlying heart
disease does not need any therapy. The maternal heart rate increases in the third trimester, but palpitations may not occur.
Auditory changes are discernible at 20 weeks.
PTS:
1
DIF:
Cognitive Level: Comprehension
REF:
175
OBJ:
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
22.
To reassure and educate their pregnant clients about changes in their blood pressure, maternity nurses
should be aware that:
a.
A blood pressure cuff that is too small produces a reading that is too low; a cuff that is too large produces a
reading that is too high.
b.
Shifting the client’s position and changing from arm to arm for different measurements produces the most
accurate composite blood pressure reading at each visit.
c.
The systolic blood pressure increases slightly as pregnancy advances; the diastolic pressure remains constant.
d.
Compression of the iliac veins and inferior vena cava by the uterus contributes to hemorrhoids in the later stage
of term pregnancy.
ANS:
D
Compression of the iliac veins and inferior vena cava also leads to varicose veins in the legs and vulva. The tightness of a
cuff that is too small produces a reading that is too high; similarly the looseness of a cuff that is too large results in a
reading that is too low. Because maternal positioning affects readings, blood pressure measurements should be obtained
in the same arm and with the woman in the same position. The systolic blood pressure generally remains constant but
may decline slightly as pregnancy advances. The diastolic blood pressure first decreases and then gradually increases.
PTS:
OBJ:
MSC:
1
DIF:
Cognitive Level: Comprehension
Nursing Process: Planning, Implementation
Client Needs: Physiologic Integrity
REF:
176
23.
Some pregnant clients may complain of changes in their voice and impaired hearing. The nurse can tell
these clients that these are common reactions to:
a.
A decreased estrogen level.
b.
Displacement of the diaphragm, resulting in thoracic breathing.
c.
Congestion and swelling, which occur because the upper respiratory tract has become more vascular.
d.
Increased blood volume.
ANS:
C
Estrogen levels increase, causing the upper respiratory tract to become more vascular producing swelling and congestion
in the nose and ears leading to voice changes and impaired hearing. The diaphragm is displaced, and the volume of blood
is increased. However, the main concern is increased estrogen levels.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
179
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
24.
To reassure and educate pregnant clients about the functioning of their kidneys in eliminating waste
products, maternity nurses should be aware that:
a.
Increased urinary output makes pregnant women less susceptible to urinary infection.
b.
Increased bladder sensitivity and then compression of the bladder by the enlarging uterus results in the urge to
urinate even if the bladder is almost empty.
c.
Renal (kidney) function is more efficient when the woman assumes a supine position.
d.
Using diuretics during pregnancy can help keep kidney function regular.
ANS:
B
First bladder sensitivity and then compression of the bladder by the uterus result in the urge to urinate more often.
Numerous anatomic changes make a pregnant woman more susceptible to urinary tract infection. Renal function is more
efficient when the woman lies in the lateral recumbent position and less efficient when she is supine. Diuretic use during
pregnancy can overstress the system and cause problems.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
180
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
a.
b.
c.
d.
25.
Which statement about a condition of pregnancy is accurate?
Insufficient salivation (ptyalism) is caused by increases in estrogen.
Acid indigestion (pyrosis) begins early but declines throughout pregnancy.
Hyperthyroidism often develops (temporarily) because hormone production increases.
Nausea and vomiting rarely have harmful effects on the fetus and may be beneficial.
ANS:
D
Normal nausea and vomiting rarely produce harmful effects, and nausea and vomiting periods may be less likely to result
in miscarriage or preterm labor. Ptyalism is excessive salivation, which may be caused by a decrease in unconscious
swallowing or stimulation of the salivary glands. Pyrosis begins in the first trimester and intensifies through the third
trimester. Increased hormone production does not lead to hyperthyroidism in pregnant women.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
183
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
26.
A first-time mother at 18 weeks of gestation comes for her regularly scheduled prenatal visit. The client
tells the nurse that she is afraid that she is going into premature labor because she is beginning to have regular
contractions. The nurse explains that this is the Braxton Hicks sign and teaches the client that this type of contraction:
a.
Is painless.
c.
Causes cervical dilation.
b.
Increases with walking.
d.
Impedes oxygen flow to the fetus.
ANS:
A
Uterine contractions can be felt through the abdominal wall soon after the fourth month of gestation. Braxton Hicks
contractions are regular and painless and continue throughout the pregnancy. Although they are not painful, some women
complain that they are annoying. Braxton Hicks contractions usually cease with walking or exercise. They can be mistaken
for true labor; however, they do not increase in intensity or frequency or cause cervical dilation. In addition, they facilitate
uterine blood flow through the intervillous spaces of the placenta and promote oxygen delivery to the fetus.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
172
Nursing Process: Planning MSC:
Client Needs: Health Promotion and Maintenance
a.
b.
27.
Which finding in the urine analysis of a pregnant woman is considered a variation of normal?
Proteinuria
c.
Bacteria in the urine.
Glycosuria
d.
Ketones in the urine.
ANS:
B
Small amounts of glucose may indicate “physiologic spilling.” The presence of protein could indicate kidney disease or
preeclampsia. Urinary tract infections are associated with bacteria in the urine. An increase in ketones indicates that the
patient is exercising too strenuously or has an inadequate fluid and food intake.
PTS:
OBJ:
1
DIF:
Cognitive Level: Analysis
Nursing Process: Assessment
MSC:
REF:
180
Client Needs: Physiologic Integrity
a.
b.
c.
d.
28.
The maternity nurse understands that vascular volume increases 40% to 60% during pregnancy to:
Compensate for decreased renal plasma flow.
Provide adequate perfusion of the placenta.
Eliminate metabolic wastes of the mother.
Prevent maternal and fetal dehydration.
ANS:
B
The primary function of increased vascular volume is to transport oxygen and nutrients to the fetus via the placenta. Renal
plasma flow increases during pregnancy. Assisting with pulling metabolic wastes from the fetus for maternal excretion is
one purpose of the increased vascular volume.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
172
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
a.
b.
c.
d.
29.
Physiologic anemia often occurs during pregnancy as a result of:
Inadequate intake of iron.
Dilution of hemoglobin concentration.
The fetus establishing iron stores.
Decreased production of erythrocytes.
ANS:
B
When blood volume expansion is more pronounced and occurs earlier than the increase in red blood cells, the woman has
physiologic anemia, which is the result of dilution of hemoglobin concentration rather than inadequate hemoglobin.
Inadequate intake of iron may lead to true anemia. There is an increased production of erythrocytes during pregnancy.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
177
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
30.
A patient in her first trimester complains of nausea and vomiting. She asks, “Why does this happen?”
The nurse’s best response is:
a.
“It is due to an increase in gastric motility.”
b.
“It may be due to changes in hormones.”
c.
“It is related to an increase in glucose levels.”
d.
“It is caused by a decrease in gastric secretions.”
ANS:
B
Nausea and vomiting are believed to be caused by increased levels of hormones, decreased gastric motility, and
hypoglycemia. Gastric motility decreases during pregnancy. Glucose levels decrease in the first trimester. Although
gastric secretions decrease, this is not the main cause of nausea and vomiting.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
183
Nursing Process: Implementation
MSC:
Client Needs: Physiologic Integrity
MULTIPLE RESPONSE
a.
b.
c.
d.
e.
31.
The diagnosis of pregnancy is based on which positive signs of pregnancy (Select all that apply)?
Identification of fetal heartbeat
Palpation of fetal outline
Visualization of the fetus
Verification of fetal movement
Positive hCG test
ANS:
A, C, D
Identification of fetal heartbeat, visualization of the fetus, and verification of fetal movement all are positive, objective
signs of pregnancy. Palpation of fetal outline and a positive hCG test are probable signs of pregnancy. A tumor also can be
palpated. Medication and tumors may lead to false-positive results on pregnancy tests.
PTS:
OBJ:
MSC:
1
DIF:
Cognitive Level: Analysis REF:
Nursing Process: Assessment, Diagnosis
Client Needs: Health Promotion and Maintenance
184
32.
A woman is in for a routine prenatal checkup. You are assessing her urine for proteinuria. Which
findings are considered normal (Select all that apply)?
a.
Dipstick assessment of trace to +1
c.
Dipstick assessment of +2
b.
<300 mg/24 hours d.
>300 mg/24 hours
ANS:
A, B
Small amounts of protein in the urine are acceptable during pregnancy. The presence of protein in greater amounts may
indicate renal problems. A dipstick assessment of +2 and >300 mg/24 hours are excessive amounts of protein in the urine
and should be evaluated further.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
180
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
33.
During pregnancy, many changes occur as a direct result of the presence of the fetus. Which of these
adaptations meet this criteria?
a.
Leukorrhea
b.
Development of the operculum
c.
Quickening
d.
Ballottement
e.
Lightening
ANS:
C, D, E
Leukorrhea is a white or slightly gray vaginal discharge that develops in response to cervical stimulation by estrogen and
progesterone. Quickening is the first recognition of fetal movements or “feeling life.” Quickening is often described as a
flutter and is felt earlier in multiparous women than in primiparas. Lightening occurs when the fetus begins to descend
into the pelvis. This occurs 2 weeks before labor in the nullipara and at the start of labor in the multipara. Mucus fills the
cervical canal creating a plug otherwise known as the operculum. The operculum acts as a barrier against bacterial
invasion during the pregnancy. Passive movement of the unengaged fetus is referred to as ballottement.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
173
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
COMPLETION
34.
A woman is 6 weeks pregnant. She has had a previous spontaneous abortion at 14 weeks of gestation
and a pregnancy that ended at 38 weeks with the birth of a stillborn girl. What is her gravidity and parity using the GTPAL
system?
___________________
ANS:
3-1-0-1-0
The correct calculation of this woman’s gravidity and parity is 3-1-0-1-0. Using the GPTAL system, this client’s gravidity
and parity information is calculated as follows:
G: Total number of times the woman has been pregnant (she is pregnant for the third time)
T: Number of pregnancies carried to term (she has had only one pregnancy that resulted in a fetus at term)
P: Number of pregnancies that resulted in a preterm birth (none)
A: Abortions or miscarriages before the period of viability (she has had one)
L: Number of children born who are currently living (she has no living children)
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
168
Nursing Process: Diagnosis MSC:
Client Needs: Health Promotion and Maintenance
Chapter 08: Nursing Care of the Family During Pregnancy
MULTIPLE CHOICE
a.
b.
c.
d.
1.
The nurse caring for a newly pregnant woman would advise her that ideally prenatal care should begin:
Before the first missed menstrual period.
After the first missed menstrual period.
After the second missed menstrual period.
After the third missed menstrual period.
ANS:
B
Prenatal care ideally should begin soon after the first missed menstrual period. Regular prenatal visits offer opportunities
to ensure the health of the expectant mother and her infant.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
186
Nursing Process: Planning MSC:
Client Needs: Health Promotion and Maintenance
a.
b.
c.
d.
2.
Prenatal testing for human immunodeficiency virus (HIV) is recommended for:
All women, regardless of risk factors.
A woman who has had more than one sexual partner.
A woman who has had a sexually transmitted infection.
A woman who is monogamous with her partner.
ANS:
A
Testing for the antibody to HIV is strongly recommended for all pregnant women. A HIV test is recommended for all
women, regardless of risk factors. Women who test positive for HIV can be treated, reducing the risk of transmission to the
fetus.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
195
Nursing Process: Planning MSC:
Client Needs: Health Promotion and Maintenance
3.
Which symptom is considered a first-trimester warning sign and should be reported immediately by the
pregnant woman to her health care provider?
a.
Nausea with occasional vomiting
c.
Urinary frequency
b.
Fatigue d.
Vaginal bleeding
ANS:
D
Signs and symptoms that must be reported include severe vomiting, fever and chills, burning on urination, diarrhea,
abdominal cramping, and vaginal bleeding. These symptoms may be signs of potential complications of the pregnancy.
Nausea with occasional vomiting, fatigue, and urinary frequency are normal first-trimester complaints. Although they may
be worrisome or annoying to the mother, they usually are not indications of pregnancy problems.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
208
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
4.
A pregnant woman at 10 weeks of gestation jogs three or four times per week. She is concerned about
the effect of exercise on the fetus. The nurse should inform her:
a.
“You don’t need to modify your exercising any time during your pregnancy.”
b.
“Stop exercising because it will harm the fetus.”
c.
“You may find that you need to modify your exercise to walking later in your pregnancy, around the seventh
month.”
d.
“Jogging is too hard on your joints; switch to walking now.”
ANS:
C
Typically running should be replaced with walking around the seventh month of pregnancy. The nurse should inform the
woman that she may need to reduce her exercise level as the pregnancy progresses. Physical activity promotes a feeling
of well-being in pregnant women. It improves circulation, promotes relaxation and rest, and counteracts boredom. Simple
measures should be initiated to prevent injuries, such as warm-up and stretching exercises to prepare the joints for more
strenuous exercise.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
204
Nursing Process: Planning MSC:
Client Needs: Health Promotion and Maintenance
a.
b.
5.
The multiple marker test is used to assess the fetus for which condition?
Down syndrome c.
Congenital cardiac abnormality
Diaphragmatic hernia
d.
Anencephaly
ANS:
A
The maternal serum level of alpha-fetoprotein is used to screen for Down syndrome, neural tube defects, and other
chromosome anomalies. The multiple marker test would not detect diaphragmatic hernia, congenital cardiac abnormality,
or anencephaly. Additional testing, such as ultrasonography and amniocentesis, would be required to diagnose these
conditions.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
199
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
a.
b.
c.
d.
6.
A woman who is 32 weeks’ pregnant is informed by the nurse that a danger sign of pregnancy could be:
Constipation.
Alteration in the pattern of fetal movement.
Heart palpitations.
Edema in the ankles and feet at the end of the day.
ANS:
B
An alteration in the pattern or amount of fetal movement may indicate fetal jeopardy. Constipation, heart palpitations, and
ankle and foot edema are normal discomforts of pregnancy that occur in the second and third trimesters.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
213
Nursing Process: Planning MSC:
Client Needs: Health Promotion and Maintenance
7.
A woman who is 14 weeks pregnant tells the nurse that she always had a glass of wine with dinner
before she became pregnant. She has abstained during her first trimester and would like to know if it is safe for her to
have a drink with dinner now. The nurse would tell her:
a.
“Since you’re in your second trimester, there’s no problem with having one drink with dinner.”
b.
“One drink every night is too much. One drink three times a week should be fine.”
c.
“Since you’re in your second trimester, you can drink as much as you like.”
d.
“Because no one knows how much or how little alcohol it takes to cause fetal problems, the best course is to
abstain throughout your pregnancy.”
ANS:
D
The statement “Because no one knows how much or how little alcohol it takes to cause fetal problems, the best course is
to abstain throughout your pregnancy” is accurate. A safe level of alcohol consumption during pregnancy has not yet
been established. Although the consumption of occasional alcoholic beverages may not be harmful to the mother or her
developing fetus, complete abstinence is strongly advised.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
208
Nursing Process: Planning MSC:
Client Needs: Health Promotion and Maintenance
8.
A pregnant woman at 18 weeks of gestation calls the clinic to report that she has been experiencing
occasional backaches of mild-to-moderate intensity. The nurse would recommend that she:
a.
Do Kegel exercises.
c.
Use a softer mattress.
b.
Do pelvic rock exercises.
d.
Stay in bed for 24 hours.
ANS:
B
Pelvic rock exercises may help stretch and strengthen the abdominal and lower back muscles and relieve low back pain.
Kegel exercises increase the tone of the pelvic area, not the back. A softer mattress may not provide the support needed to
maintain proper alignment of the spine and may contribute to back pain. Stretching and other exercises to relieve back
pain should be performed several times a day.
PTS:
1
DIF:
Cognitive Level: ApplicationREF:
211
OBJ:
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
a.
b.
c.
d.
9.
For what reason would breastfeeding be contraindicated?
Hepatitis B
Everted nipples
History of breast cancer 3 years ago
Human immunodeficiency virus (HIV) positive
ANS:
D
Women who are HIV positive are discouraged from breastfeeding. Although hepatitis B antigen has not been shown to be
transmitted through breast milk, as an added precaution infants born to HBsAg-positive women should receive the
hepatitis B vaccine and immune globulin immediately after birth. Everted nipples are functional for breastfeeding. Newly
diagnosed breast cancer would be a contraindication to breastfeeding.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
201
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
10.
A woman is 3 months pregnant. At her prenatal visit, she tells the nurse that she doesn’t know what is
happening; one minute she’s happy that she is pregnant, and the next minute she cries for no reason. Which response by
the nurse is most appropriate?
a.
“Don’t worry about it; you’ll feel better in a month or so.”
b.
“Have you talked to your husband about how you feel?”
c.
“Perhaps you really don’t want to be pregnant.”
d.
“Hormonal changes during pregnancy commonly result in mood swings.”
ANS:
D
The statement “Hormonal changes during pregnancy commonly result in mood swings” is accurate and the most
appropriate response by the nurse. The statement “Don’t worry about it; you’ll feel better in a month or so” dismisses the
client’s concerns and is not the most appropriate response. Although women should be encouraged to share their
feelings, “Have you talked to your husband about how you feel” is not the most appropriate response and does not
provide the client with a rationale for the psychosocial dynamics of her pregnancy. “Perhaps you really don’t want to be
pregnant” is completely inappropriate and deleterious to the psychologic well-being of the woman. Hormonal and
metabolic adaptations often cause mood swings in pregnancy. The woman’s responses are normal. She should be
reassured about her feelings.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
187
Nursing Process: Diagnosis MSC:
Client Needs: Psychosocial Integrity
a.
b.
c.
d.
11.
The nurse should be aware that the partner’s main role in pregnancy is to:
Provide financial support.
Protect the pregnant woman from “old wives’ tales.”
Support and nurture the pregnant woman.
Make sure the pregnant woman keeps prenatal appointments.
ANS:
C
The partner’s main role in pregnancy is to nurture the pregnant woman and respond to her feelings of vulnerability. In
older societies, the man enacted the ritual couvade. Changing cultural and professional attitudes have encouraged fathers’
participation in the birth experience over the past 30 years.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
189
Nursing Process: Assessment
MSC:
Client Needs: Psychosocial Integrity
a.
b.
c.
d.
12.
During the first trimester, a woman can expect which of the following changes in her sexual desire?
An increase, because of enlarging breasts
A decrease, because of nausea and fatigue
No change
An increase, because of increased levels of female hormones
ANS:
B
Maternal physiologic changes such as breast enlargement, nausea, fatigue, abdominal changes, perineal enlargement,
leukorrhea, pelvic vasocongestion, and orgasmic responses may affect sexuality and sexual expression. Libido may be
depressed in the first trimester but often increases during the second and third trimesters. During pregnancy, the breasts
may become enlarged and tender; this tends to interfere with coitus, decreasing the desire to engage in sexual activity.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
189
Nursing Process: Diagnosis MSC:
Client Needs: Health Promotion and Maintenance
a.
b.
13.
Which behavior indicates that a woman is “seeking safe passage” for herself and her infant?
She keeps all prenatal appointments. c.
She drives her car slowly.
She “eats for two.”
d.
She wears only low-heeled shoes.
ANS:
A
The goal of prenatal care is to foster a safe birth for the infant and mother. Although eating properly, driving carefully, and
using proper body mechanics all are healthy measures that a mother can take, obtaining prenatal care is the optimal
method for providing safety for both herself and her baby.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
189
Nursing Process: Evaluation
MSC:
Client Needs: Health Promotion and Maintenance
a.
b.
14.
A 3-year-old girl’s mother is 6 months pregnant. What concern is this child likely to verbalize?
How the baby will “get out” c.
Whether her mother will die
What the baby will eat
d.
What color eyes the baby has
ANS:
B
By age 3 or 4, children like to be told the story of their own beginning and accept its comparison with the present
pregnancy. They like to listen to the fetal heartbeat and feel the baby move. Sometimes they worry about how the baby is
being fed and what it wears. School-age children take a more clinical interest in their mother’s pregnancy and may want to
know, “How did the baby get in there?” and “How will it get out?” Whether her mother will die does not tend to be the
focus of a child’s questions about the impending birth of a sibling. The baby’s eye color does not tend to be the focus of
children’s questions about the impending birth of a sibling.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
191
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
15.
In her work with pregnant women of various cultures, a nurse practitioner has observed various
practices that seemed strange or unusual. She has learned that cultural rituals and practices during pregnancy seem to
have one purpose in common. Which statement best describes that purpose?
a.
To promote family unity
b.
To ward off the “evil eye”
c.
To appease the gods of fertility
d.
To protect the mother and fetus during pregnancy
ANS:
D
The purpose of all cultural practices is to protect the mother and fetus during pregnancy. Although many cultures consider
pregnancy normal, certain practices are expected of women of all cultures to ensure a good outcome. Cultural
prescriptions tell women what to do, and cultural proscriptions establish taboos. The purposes of these practices are to
prevent maternal illness resulting from a pregnancy-induced imbalanced state and to protect the vulnerable fetus.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
216
Nursing Process: Assessment
MSC:
Client Needs: Psychosocial Integrity
a.
b.
16.
What type of cultural concern is the most likely deterrent to many women seeking prenatal care?
Religion c.
Ignorance
Modesty d.
Belief that physicians are evil
ANS:
B
A concern for modesty is a deterrent to many women seeking prenatal care. For some women, exposing body parts,
especially to a man, is considered a major violation of their modesty. Many cultural variations are found in prenatal care.
Even if the prenatal care described is familiar to a woman, some practices may conflict with the beliefs and practices of a
subculture group to which she belongs.
PTS:
OBJ:
1
DIF:
Cognitive Level: Analysis
Nursing Process: Evaluation
MSC:
REF:
216
Client Needs: Psychosocial Integrity
a.
b.
c.
d.
17.
Which statement about pregnancy is accurate?
A normal pregnancy lasts about 10 lunar months.
A trimester is one third of a year.
The prenatal period extends from fertilization to conception.
The estimated date of confinement (EDC) is how long the mother will have to be bedridden after birth.
ANS:
A
A lunar month lasts 28 days, or 4 weeks. Pregnancy spans 9 calendar months but 10 lunar months. A trimester is one third
of a normal pregnancy, or about 13 to 14 weeks. The prenatal period covers the full course of pregnancy (prenatal means
before birth). The EDC is now called the EDB, or estimated date of birth. It has nothing to do with the duration of bed rest.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
186
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
18.
In understanding and guiding a woman through her acceptance of pregnancy, a maternity nurse should
be aware that:
a.
Nonacceptance of the pregnancy very often equates to rejection of the child.
b.
Mood swings most likely are the result of worries about finances and a changed lifestyle as well as profound
hormonal changes.
c.
Ambivalent feelings during pregnancy usually are seen only in emotionally immature or very young mothers.
d.
Conflicts such as not wanting to be pregnant or childrearing and career-related decisions need not be addressed
during pregnancy because they will resolve themselves naturally after birth.
ANS:
B
Mood swings are natural and are likely to affect every woman to some degree. A woman may dislike being pregnant, refuse
to accept it, and still love and accept the child. Ambivalent feelings about pregnancy are normal for mature or immature
women, younger or older women. Conflicts such as not wanting to be pregnant or childrearing and career-related
decisions need to be resolved. The baby ends the pregnancy but not all the issues.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
187
Nursing Process: Diagnosis MSC:
Client Needs: Psychosocial Integrity
19.
With regard to a woman’s reordering of personal relationships during pregnancy, the maternity nurse
should understand that:
a.
Because of the special motherhood bond, a woman’s relationship with her mother is even more important than
with the father of the child.
b.
Nurses need not get involved in any sexual issues the couple has during pregnancy, particularly if they have
trouble communicating them to each other.
c.
Women usually express two major relationship needs during pregnancy: feeling loved and valued and having the
child accepted by the father.
d.
The woman’s sexual desire is likely to be highest in the first trimester because of the excitement and because
intercourse is physically easier.
ANS:
C
Love and support help a woman feel better about her pregnancy. The most important person to the pregnant woman is
usually the father. Nurses can facilitate communication between partners about sexual matters if, as is common, they are
nervous about expressing their worries and feelings. The second trimester is the time when a woman’s sense of wellbeing, along with certain physical changes, increases her desire for sex. Desire is decreased in the first and third
trimesters.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
188
Nursing Process: Planning MSC:
Client Needs: Psychosocial Integrity
20.
What represents a typical progression through the phases of a woman’s establishing a relationship with
the fetus?
a.
Accepts the fetus as distinct from herself—accepts the biologic fact of pregnancy—has a feeling of caring and
responsibility
b.
Fantasizes about the child’s gender and personality—views the child as part of herself—becomes introspective
c.
Views the child as part of herself—has feelings of well-being—accepts the biologic fact of pregnancy
d.
“I am pregnant.”—“I am going to have a baby.”—“I am going to be a mother.”
ANS:
D
The woman first centers on herself as pregnant, then on the baby as an entity separate from herself, and then on her
responsibilities as a mother. The expressions, “I am pregnant,” “I am going to have a baby,” and “I am going to be a
mother” sum up the progression through the three phases.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
189
Nursing Process: Diagnosis MSC:
Client Needs: Psychosocial Integrity
21.
As relates to the father’s acceptance of the pregnancy and preparation for childbirth, the maternity
nurse should know that:
a.
The father goes through three phases of acceptance of his own.
b.
The father’s attachment to the fetus cannot be as strong as that of the mother because it does not start until after
birth.
c.
In the last 2 months of pregnancy, most expectant fathers suddenly get very protective of their established
lifestyle and resist making changes to the home.
d.
Typically men remain ambivalent about fatherhood right up to the birth of their child.
ANS:
A
A father typically goes through three phases of development to reach acceptance of fatherhood: the announcement phase,
the moratorium phase, and the focusing phase. The father-child attachment can be as strong as the mother-child
relationship and can also begin during pregnancy. In the last 2 months of pregnancy, many expectant fathers work hard to
improve the environment of the home for the child. Typically the expectant father’s ambivalence ends by the first trimester,
and he progresses to adjusting to the reality of the situation and then to focusing on his role.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
189
Nursing Process: Diagnosis MSC:
Client Needs: Psychosocial Integrity
22.
With regard to the initial visit with a client who is beginning prenatal care, nurses should be aware that:
a.
The first interview is a relaxed, get-acquainted affair in which nurses gather some general impressions.
b.
If nurses observe handicapping conditions, they should be sensitive and not inquire about them because the
client will do that in her own time.
c.
Nurses should be alert to the appearance of potential parenting problems, such as depression or lack of family
support.
d.
Because of legal complications, nurses should not ask about illegal drug use; that is left to physicians.
ANS:
C
Besides these potential problems, nurses need to be alert to the woman’s attitude toward health care. The initial interview
needs to be planned, purposeful, and focused on specific content. A lot of ground must be covered. Nurses must be
sensitive to special problems, but they do need to inquire because discovering individual needs is important. People with
chronic or handicapping conditions forget to mention them because they have adapted to them. Getting information on
drug use is important and can be done confidentially. Actual testing for drug use requires the client’s consent.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
194
Nursing Process: Assessment
MSC:
Client Needs: Psychosocial Integrity
23.
With regard to the initial physical examination of a woman beginning prenatal care, maternity nurses
should be cognizant of:
a.
Only women who show physical signs or meet the sociologic profile should be assessed for physical abuse.
b.
The woman should empty her bladder before the pelvic examination is performed.
c.
The distribution, amount, and quality of body hair are of no particular importance.
d.
The size of the uterus is discounted in the initial examination.
ANS:
B
An empty bladder facilitates the examination; this is also an opportunity to get a urine sample easily for a number of tests.
All women should be assessed for a history of physical abuse, particularly because the likelihood of abuse increases
during pregnancy. Noting body hair is important because body hair reflects nutritional status, endocrine function, and
hygiene. Particular attention is paid to the size of the uterus because it is an indication of the duration of gestation.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
195
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
24.
With regard to follow-up visits for women receiving prenatal care, nurses should be aware that:
a.
The interview portions become more intensive as the visits become more frequent over the course of the
pregnancy.
b.
Monthly visits are scheduled for the first trimester, every 2 weeks for the second trimester, and weekly for the
third trimester.
c.
During the abdominal examination, the nurse should be alert for supine hypotension.
d.
For pregnant women, a systolic blood pressure (BP) of 130 and a diastolic BP of 80 is sufficient to be considered
hypertensive.
ANS:
C
The woman lies on her back during the abdominal examination, possibly compressing the vena cava and aorta, which can
cause a decrease in blood pressure and a feeling of faintness. The interview portion of follow-up examinations is less
extensive than in the initial prenatal visits, during which so much new information must be gathered. Monthly visits are
routinely scheduled for the first and second trimesters; visits increase to every 2 weeks at week 28 and to once a week at
week 36. For pregnant women hypertension is defined as a systolic BP of 140 or greater and a diastolic BP of 90 or greater.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
197
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
25.
While teaching the expectant mother about personal hygiene during pregnancy, maternity nurses
should be aware that:
a.
Tub bathing is permitted even in late pregnancy unless membranes have ruptured.
b.
The perineum should be wiped from back to front.
c.
Bubble bath and bath oils are permissible because they add an extra soothing and cleansing action to the bath.
d.
Expectant mothers should use specially treated soap to cleanse the nipples.
ANS:
A
The main danger from taking baths is falling in the tub. The perineum should be wiped from front to back. Bubble baths
and bath oils should be avoided because they may irritate the urethra. Soap, alcohol, ointments, and tinctures should not
be used to cleanse the nipples because they remove protective oils. Warm water is sufficient.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
200
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
a.
b.
c.
d.
26.
The nurse should have knowledge of the purpose of the pinch test. It is used to:
Check the sensitivity of the nipples.
Determine whether the nipple is everted or inverted.
Calculate the adipose buildup in the abdomen.
See whether the fetus has become inactive.
ANS:
B
The pinch test is used to determine whether the nipple is everted or inverted. Nipples must be everted to allow
breastfeeding.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
201
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
27.
To provide the patient with accurate information about dental care during pregnancy, maternity nurses
should be aware that:
a.
Dental care can be dropped from the priority list because the woman has enough to worry about and is getting a
lot of calcium anyway.
b.
Dental surgery, in particular, is contraindicated because of the psychologic stress it engenders.
c.
If dental treatment is necessary, the woman will be most comfortable with it in the second trimester.
d.
Dental care interferes with the expectant mother’s need to practice conscious relaxation.
ANS:
C
The second trimester is best for dental treatment because that is when the woman will be able to sit most comfortably in
the dental chair. Dental care such as brushing with fluoride toothpaste is especially important during pregnancy because
nausea during pregnancy may lead to poor oral hygiene. Emergency dental surgery is permissible, but the mother must
clearly understand the risks and benefits. Conscious relaxation is useful, and it may even help the woman get through any
dental appointments; it is not a reason to avoid them.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
202
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
28.
When discussing work and travel during pregnancy with a pregnant patient, nurses should instruct
them that:
a.
Women should sit for as long as possible and cross their legs at the knees from time to time for exercise.
b.
Women should avoid seat belts and shoulder restraints in the car because they press on the fetus.
c.
Metal detectors at airport security checkpoints can harm the fetus if the woman passes through them a number
of times.
d.
While working or traveling in a car or on a plane, women should arrange to walk around at least every hour or so.
ANS:
D
Periodic walking helps prevent thrombophlebitis. Pregnant women should avoid sitting or standing for long periods and
crossing the legs at the knees. Pregnant women must wear lap belts and shoulder restraints. The most common injury to
the fetus comes from injury to the mother. Metal detectors at airport security checkpoints do not harm fetuses.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
207
Nursing Process: Planning MSC:
Client Needs: Health Promotion and Maintenance
29.
With regard to medications, herbs, shots, and other substances normally encountered by pregnant
women, the maternity nurse should be aware that:
a.
Both prescription and over-the-counter (OTC) drugs that otherwise are harmless can be made hazardous by
metabolic deficiencies of the fetus.
b.
The greatest danger of drug-caused developmental deficits in the fetus is seen in the final trimester.
c.
Killed-virus vaccines (e.g., tetanus) should not be given during pregnancy, but live-virus vaccines (e.g., measles)
are permissible.
d.
No convincing evidence exists that secondhand smoke is potentially dangerous to the fetus.
ANS:
A
Both prescription and OTC drugs that otherwise are harmless can be made hazardous by metabolic deficiencies of the
fetus. This is especially true for new medications and combinations of drugs. The greatest danger of drug-caused
developmental defects exists in the interval from fertilization through the first trimester, when a woman may not realize
that she is pregnant. Live-virus vaccines should be part of postpartum care; killed-virus vaccines may be administered
during pregnancy. Secondhand smoke is associated with fetal growth restriction and increases in infant mortality.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
207
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
a.
b.
c.
d.
30.
Which statement about multifetal pregnancy is inaccurate?
The expectant mother often develops anemia because the fetuses have a greater demand for iron.
Twin pregnancies come to term with the same frequency as single pregnancies.
The mother should be counseled to increase her nutritional intake and gain more weight.
Backache and varicose veins often are more pronounced.
ANS:
B
Twin pregnancies often end in prematurity. Serious efforts should be made to bring the pregnancy to term. A woman with a
multifetal pregnancy often develops anemia, suffers more or worse backache, and needs to gain more weight. Counseling
is needed to help her adjust to these conditions.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
219
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
31.
The phenomenon of someone other than the mother-to-be experiencing pregnancy-like symptoms such
as nausea and weight gain applies to the:
a.
Mother of the pregnant woman.
c.
Sister of the pregnant woman.
b.
Couple’s teenage daughter. d.
Expectant father.
ANS:
D
An expectant father’s experiencing pregnancy-like symptoms is called the couvade syndrome.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
189
Nursing Process: Diagnosis MSC:
Client Needs: Psychosocial Integrity
32.
In response to requests by the U.S. Public Health Service for new models of prenatal care, an innovative
new approach to prenatal care known as centering pregnancy was developed. Which statement would accurately apply to
the centering model of care?
a.
Group sessions begin with the first prenatal visit.
b.
At each visit, blood pressure, weight, and urine dipsticks are obtained by the nurse.
c.
Eight to 12 women are placed in gestational-age cohort groups.
d.
Outcomes are similar to those of traditional prenatal care.
ANS:
C
Gestational age cohorts comprise the groups, with approximately 8 to 12 women in each group. This group remains intact
throughout the pregnancy. Individual follow-up visits are scheduled as needed. Group sessions begin at 12 to 16 weeks of
gestation and end with an early postpartum visit. Before group sessions the client has an individual assessment, physical
examination, and history. At the beginning of each group meeting, clients measure their own blood pressure, weight, and
urine dips and enter these in their record. Fetal heart rate assessment and fundal height are obtained by the nurse. Results
evaluating this approach have been very promising. In a study of adolescent clients, there was a decrease in low-birthweight infants and an increase in breastfeeding rates.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
193
Nursing Process: Implementation
MSC:
Client Needs: Health Promotion and Maintenance
33.
While you are assessing the vital signs of a pregnant woman in her third trimester, the patient
complains of feeling faint, dizzy, and agitated. Which nursing intervention is appropriate?
a.
Have the patient stand up and retake her blood pressure.
b.
Have the patient sit down and hold her arm in a dependent position.
c.
d.
Have the patient lie supine for 5 minutes and recheck her blood pressure on both arms.
Have the patient turn to her left side and recheck her blood pressure in 5 minutes.
ANS:
D
Blood pressure is affected by maternal position during pregnancy. The supine position may cause occlusion of the vena
cava and descending aorta. Turning the pregnant woman to a lateral recumbent position alleviates pressure on the blood
vessels and quickly corrects supine hypotension. Pressures are significantly higher when the patient is standing. This
option causes an increase in systolic and diastolic pressures. The arm should be supported at the same level of the heart.
The supine position may cause occlusion of the vena cava and descending aorta, creating hypotension.
PTS:
OBJ:
1
DIF:
Cognitive Level: Analysis
Nursing Process: Implementation
MSC:
REF:
195
Client Needs: Physiologic Integrity
MULTIPLE RESPONSE
34.
Signs and symptoms that a woman should report immediately to her health care provider include
(Select all that apply):
a.
Vaginal bleeding.
b.
Rupture of membranes.
c.
Heartburn accompanied by severe headache.
d.
Decreased libido.
e.
Urinary frequency.
ANS:
A, B, C
Vaginal bleeding, rupture of membranes, and severe headaches all are signs of potential complications in pregnancy.
Clients should be advised to report these signs to the health care provider. Decreased libido and urinary frequency are
common discomforts of pregnancy that do not require immediate health care interventions.
PTS:
OBJ:
MSC:
1
DIF:
Cognitive Level: Analysis
Nursing Process: Planning, Implementation
Client Needs: Physiologic Integrity
REF:
208
35.
A woman has just moved to the United States from Mexico. She is 3 months pregnant and has arrived
for her first prenatal visit. During her assessment interview, you discover that she has not had any immunizations. Which
immunizations should she receive at this point in her pregnancy (Select all that apply)?
a.
Tetanus
b.
Diphtheria
c.
Chickenpox
d.
Rubella
e.
Hepatitis B
ANS:
A, B, E
Immunization with live or attenuated live viruses is contraindicated during pregnancy because of potential teratogenicity.
Vaccines consisting of killed viruses may be used. Immunizations that may be administered during pregnancy include
tetanus, diphtheria, recombinant hepatitis B, and rabies vaccines. Live-virus vaccines include those for measles (rubeola
and rubella), chickenpox, and mumps.
PTS:
OBJ:
1
DIF:
Cognitive Level: Analysis
Nursing Process: Implementation
MSC:
REF:
208
Client Needs: Health Promotion and Maintenance
MATCHING
All pregnant women should be instructed to recognize and report potential complications for each trimester of pregnancy.
Match the sign or symptom with a possible cause.
a.
Severe vomiting in early pregnancy d.
Decreased fetal movement
b.
Epigastric pain in late pregnancy
e.
Glycosuria
c.
Severe backache and flank pain
36.
Fetal jeopardy or intrauterine fetal death
37.
Kidney infection or stones
38.
Gestational diabetes
39.
Hyperemesis gravidarum
40.
Hypertension, preeclampsia
36.
ANS:
D
PTS:
1
DIF:
Cognitive Level: Comprehension
REF:
198
OBJ:
Nursing Process: Implementation
MSC:
Client Needs: Health Promotion and Maintenance
NOT:
It is essential for the nurse to plan education needed by the pregnant woman to recognize and report these
potential complications a timely manner. A trusting relationship contributes to a positive outcome for the pregnancy.
37.
ANS:
C
PTS:
1
DIF:
Cognitive Level: Comprehension
REF:
198
OBJ:
Nursing Process: Implementation
MSC:
Client Needs: Health Promotion and Maintenance
NOT:
It is essential for the nurse to plan education needed by the pregnant woman to recognize and report these
potential complications a timely manner. A trusting relationship contributes to a positive outcome for the pregnancy.
38.
ANS:
E
PTS:
1
DIF:
Cognitive Level: Comprehension
REF:
198
OBJ:
Nursing Process: Implementation
MSC:
Client Needs: Health Promotion and Maintenance
NOT:
It is essential for the nurse to plan education needed by the pregnant woman to recognize and report these
potential complications a timely manner. A trusting relationship contributes to a positive outcome for the pregnancy.
39.
ANS:
A
PTS:
1
DIF:
Cognitive Level: Comprehension
REF:
198
OBJ:
Nursing Process: Implementation
MSC:
Client Needs: Health Promotion and Maintenance
NOT:
It is essential for the nurse to plan education needed by the pregnant woman to recognize and report these
potential complications a timely manner. A trusting relationship contributes to a positive outcome for the pregnancy.
40.
ANS:
B
PTS:
1
DIF:
Cognitive Level: Comprehension
REF:
198
OBJ:
Nursing Process: Implementation
MSC:
Client Needs: Health Promotion and Maintenance
NOT:
It is essential for the nurse to plan education needed by the pregnant woman to recognize and report these
potential complications a timely manner. A trusting relationship contributes to a positive outcome for the pregnancy.
COMPLETION
41.
A woman arrives at the clinic for a pregnancy test. The first day of her last menstrual period (LMP) was
September 10, 2013. Her expected date of birth (EDB) would be?
___________________
ANS:
June 17, 2014
Using Nägele’s rule, June 17, 2014, is the correct EDB. The EDB is calculated by subtracting 3 months from the first day of
the LMP and adding 7 days + 1 year to the day of the LMP. Therefore, with an LMP of September 10, 2013:
September 10, 2013 – 3 months = June 10, 2013 + 7 days = June 17, 2013 + 1 year = June 17, 2014
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
187
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
Chapter 09: Maternal and Fetal Nutrition
MULTIPLE CHOICE
1.
A 22-year-old woman pregnant with a single fetus has a preconception body mass index (BMI) of 24.
When she was seen in the clinic at 14 weeks of gestation, she had gained 1.8 kg (4 lb) since conception. How would the
nurse interpret this?
a.
This weight gain indicates possible gestational hypertension.
b.
This weight gain indicates that the woman’s infant is at risk for intrauterine growth restriction (IUGR).
c.
This weight gain cannot be evaluated until the woman has been observed for several more weeks.
d.
The woman’s weight gain is appropriate for this stage of pregnancy.
ANS:
D
The statement “The woman’s weight gain is appropriate for this stage of pregnancy” is accurate. This woman’s BMI is
within the normal range. During the first trimester, the average total weight gain is only 1 to 2.5 kg. Although weight gain
does indicate possible gestational hypertension, it does not apply to this patient. The desirable weight gain during
pregnancy varies among women. The primary factor to consider in making a weight gain recommendation is the
appropriateness of the prepregnancy weight for the woman’s height. A commonly used method of evaluating the
appropriateness of weight for height is the BMI. Although weight gain does indicate risk for IUGR, this does not apply to
this patient. Weight gain should occur at a steady rate throughout the pregnancy. The optimal rate of weight gain also
depends on the stage of the pregnancy.
PTS:
OBJ:
1
DIF:
Cognitive Level: Analysis
Nursing Process: Assessment
MSC:
REF:
231
Client Needs: Health Promotion and Maintenance
a.
b.
c.
d.
2.
Which meal would provide the most absorbable iron?
Toasted cheese sandwich, celery sticks, tomato slices, and a grape drink
Oatmeal, whole wheat toast, jelly, and low-fat milk
Black bean soup, wheat crackers, orange sections, and prunes
Red beans and rice, cornbread, mixed greens, and decaffeinated tea
ANS:
C
Food sources that are rich in iron include liver, meats, whole grain or enriched breads and cereals, deep green leafy
vegetables, legumes, and dried fruits. In addition, the vitamin C in orange sections aids absorption. Dairy products and tea
are not sources of iron.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
236
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
3.
Which nutrient’s recommended dietary allowance (RDA) is higher during lactation than during
pregnancy?
a.
Energy (kcal)
c.
Vitamin A
b.
Iron
d.
Folic acid
ANS:
A
Needs for energy, protein, calcium, iodine, zinc, the B vitamins, and vitamin C remain greater than nonpregnant needs.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
239
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
4.
A pregnant woman’s diet consists almost entirely of whole grain breads and cereals, fruits, and
vegetables. The nurse would be most concerned about this woman’s intake of:
a.
Calcium. c.
Vitamin B12.
b.
Protein. d.
Folic acid.
ANS:
C
This diet is consistent with that followed by a strict vegetarian (vegan). Vegans consume only plant products. Because
vitamin B12 is found in foods of animal origin, this diet is deficient in vitamin B12.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
246
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
a.
b.
c.
d.
5.
A pregnant woman experiencing nausea and vomiting should:
Drink a glass of water with a fat-free carbohydrate before getting out of bed in the morning.
Eat small, frequent meals (every 2 to 3 hours).
Increase her intake of high-fat foods to keep the stomach full and coated.
Limit fluid intake throughout the day.
ANS:
B
Eating small, frequent meals is the correct suggestion for a woman experiencing nausea and vomiting. A pregnant woman
experiencing nausea and vomiting should avoid consuming fluids early in the day or when nauseated, but should
compensate by drinking fluids at other times. A pregnant woman experiencing nausea and vomiting should reduce her
intake of fried and other fatty foods.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
245
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
6.
A pregnant woman reports that she is still playing tennis at 32 weeks of gestation. The nurse would be
most concerned that during and after tennis matches this woman consumes:
a.
Several glasses of fluid.
b.
Extra protein sources such as peanut butter.
c.
Salty foods to replace lost sodium.
d.
Easily digested sources of carbohydrate.
ANS:
A
If no medical or obstetric problems contraindicate physical activity, pregnant women should get 30 minutes of moderate
physical exercise daily. Liberal amounts of fluid should be consumed before, during, and after exercise because
dehydration can trigger premature labor. The woman’s calorie intake should be sufficient to meet the increased needs of
pregnancy and the demands of exercise.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
239
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
7.
Which statement made by a lactating woman would lead the nurse to believe that the woman might
have lactose intolerance?
a.
“I always have heartburn after I drink milk.”
b.
“If I drink more than a cup of milk, I usually have abdominal cramps and bloating.”
c.
“Drinking milk usually makes me break out in hives.”
d.
“Sometimes I notice that I have bad breath after I drink a cup of milk.”
ANS:
B
Abdominal cramps and bloating are consistent with lactose intolerance. One problem that can interfere with milk
consumption is lactose intolerance, which is the inability to digest milk sugar because of a lack of the enzyme lactose in
the small intestine. Milk consumption may cause abdominal cramping, bloating, and diarrhea people who are lactose
intolerant, although many affected individuals can tolerate small amounts of milk without symptoms.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
237
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
8.
A pregnant woman’s diet history indicates that she likes the following list of foods. The nurse would
encourage this woman to consume more of which food to increase her calcium intake?
a.
Fresh apricots
c.
Spaghetti with meat sauce
b.
Canned clams
d.
Canned sardines
ANS:
D
Sardines are rich in calcium. Fresh apricots, canned clams, and spaghetti with meat sauce are not high in calcium.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
229
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
9.
A 27-year-old pregnant woman had a preconceptual body mass index (BMI) of 18.0. The nurse knows
that this woman’s total recommended weight gain during pregnancy should be at least:
a.
20 kg (44 lb).
c.
12.5 kg (27.5 lb).
b.
16 kg (35 lb).
d.
10 kg (22 lb).
ANS:
C
This woman has a normal BMI and should gain 11.5 to 16 kg during pregnancy. A weight gain of 20 kg would be unhealthy
for most women. A weight gain 35 lb is the high end of the range of weight this woman should gain in her pregnancy. A
weight gain of 22 lb would be appropriate for an obese woman.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
231
Nursing Process: Planning MSC:
Client Needs: Health Promotion and Maintenance
10.
A woman in week 34 of pregnancy reports that she is very uncomfortable because of heartburn. The
nurse would suggest that the woman:
a.
Substitute other calcium sources for milk in her diet.
b.
Lie down after each meal.
c.
Reduce the amount of fiber she consumes.
d.
Eat five small meals daily.
ANS:
D
Eating small, frequent meals may help with heartburn, nausea, and vomiting. Substituting other calcium sources for milk,
lying down after eating, and reducing fiber intake are inappropriate dietary suggestions for all pregnant women and do not
alleviate heartburn.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
246
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
11.
A woman has come to the clinic for preconception counseling because she wants to start trying to get
pregnant in 3 months. She can expect the following advice:
a.
“Discontinue all contraception now.”
b.
“Lose weight so that you can gain more during pregnancy.”
c.
“You may take any medications you have been taking regularly.”
d.
“Make sure that you include adequate folic acid in your diet.”
ANS:
D
A healthy diet before conception is the best way to ensure that adequate nutrients are available for the developing fetus. A
woman’s folate or folic acid intake is of particular concern in the periconception period. Neural tube defects are more
common in infants of women with a poor folic acid intake. Depending on the type of contraception used, discontinuing all
contraception may not be appropriate advice. Losing weight is not appropriate advice. Depending on the type of
medication the woman is taking, continuing its use may not be appropriate.
PTS:
OBJ:
1
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Cognitive Level: ApplicationREF:
227
Nursing Process: Planning MSC:
Client Needs: Health Promotion and Maintenance
a.
b.
12.
To prevent gastrointestinal upset, clients should be instructed to take iron supplements:
On a full stomach. c.
After eating a meal.
At bedtime.
d.
With milk.
ANS:
B
Clients should be instructed to take iron supplements at bedtime. Iron supplements are best absorbed if they are taken
when the stomach is empty. Bran, tea, coffee, milk, and eggs may reduce absorption. Iron can be taken at bedtime if
abdominal discomfort occurs when it is taken between meals.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
237
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
13.
with:
a.
b.
Women with an inadequate weight gain during pregnancy are at higher risk of giving birth to an infant
Spina bifida.
c.
Diabetes mellitus.
Intrauterine growth restriction.
d.
Down syndrome.
ANS:
B
Both normal-weight and underweight women with inadequate weight gain have an increased risk of giving birth to an
infant with intrauterine growth restriction. Spina bifida, diabetes mellitus, and Down syndrome are not associated with
inadequate maternal weight gain.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
231
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
14.
After you complete your nutritional counseling for a pregnant woman, you ask her to repeat your
instructions so you can assess her understanding of the instructions given. Which statement indicates that she
understands the role of protein in her pregnancy?
a.
“Protein will help my baby grow.”
b.
“Eating protein will prevent me from becoming anemic.”
c.
“Eating protein will make my baby have strong teeth after he is born.”
d.
“Eating protein will prevent me from being diabetic.”
ANS:
A
Protein is the nutritional element basic to growth. An adequate protein intake is essential to meeting the increasing
demands of pregnancy. These demands arise from the rapid growth of the fetus; the enlargement of the uterus, mammary
glands, and placenta; the increase in the maternal blood volume; and the formation of amniotic fluid. Iron intake prevents
anemia. Calcium intake is needed for fetal bone and tooth development. Glycemic control is needed in diabetics; protein is
one nutritional factor to consider, but this is not the primary role of protein intake.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
232
Nursing Process: Evaluation
MSC:
Client Needs: Health Promotion and Maintenance
15.
Pregnant adolescents are at high risk for _____ because of lower body mass indices (BMIs) and “fad”
dieting.
a.
Obesity c.
Low-birth-weight babies
b.
Diabetes d.
High-birth-weight babies
ANS:
C
Adolescents tend to have lower BMIs because they are still developing and may follow unsafe nutritional practices. In
addition, the fetus and still-growing mother appear to compete for nutrients. These factors, along with inadequate weight
gain, lend themselves to a higher incidence of low-birth-weight babies. Obesity, diabetes, and high-birth-weight babies are
conditions associated with higher BMIs.
PTS:
OBJ:
MSC:
1
DIF:
Cognitive Level: ApplicationREF:
Nursing Process: Assessment, Diagnosis
Client Needs: Health Promotion and Maintenance
329
16.
Maternal nutritional status is an especially significant factor of the many factors that influence the
outcome of pregnancy because:
a.
It is very difficult to adjust because of people’s ingrained eating habits.
b.
It is an important preventive measure for a variety of problems.
c.
Women love obsessing about their weight and diets.
d.
A woman’s preconception weight becomes irrelevant.
ANS:
B
Nutritional status draws so much attention not only for its effect on a healthy pregnancy and birth but also because
significant changes are within relatively easy reach.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
248
Nursing Process: Evaluation
MSC:
Client Needs: Physiologic Integrity
17.
Which statement regarding acronyms in nutrition is accurate?
a.
Dietary reference intakes (DRIs) consist of recommended dietary allowances (RDAs), adequate intakes (AIs), and
upper limits (ULs).
b.
RDAs are the same as ULs except with better data.
c.
AIs offer guidelines for avoiding excessive amounts of nutrients.
d.
They all refer to green leafy vegetables, whole grains, and fruit.
ANS:
A
DRIs consist of RDAs, AIs, and ULs. AIs are similar to RDAs except that they deal with nutrients about which data are
insufficient for certainty (RDA status). ULs are guidelines for avoiding excesses of nutrients for which excess is toxic.
Green leafy vegetables, whole grains, and fruit are important, but they are not the whole nutritional story.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
228
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
a.
b.
c.
d.
18.
With regard to protein in the diet of pregnant women, nurses should be aware that:
Many protein-rich foods are also good sources of calcium, iron, and B vitamins.
Many women need to increase their protein intake during pregnancy.
As with carbohydrates and fat, no specific recommendations exist for the amount of protein in the diet.
High-protein supplements can be used without risk by women on macrobiotic diets.
ANS:
A
Good protein sources such as meat, milk, eggs, and cheese have a lot of calcium and iron. Most women already eat a highprotein diet and do not need to increase their intake. Protein is sufficiently important that specific servings of meat and
dairy are recommended. High-protein supplements are not recommended because they have been associated with an
increased incidence of preterm births.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
234
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
a.
b.
c.
d.
19.
Which nutritional recommendation about fluids is accurate?
A woman’s daily intake should be eight to ten glasses (2.3 L) of water, milk, or juice.
Coffee should be limited to no more than two cups, but tea and cocoa can be consumed without worry.
Of the artificial sweeteners, only aspartame has not been associated with any maternity health concerns.
Water with fluoride is especially encouraged because it reduces the child’s risk of tooth decay.
ANS:
A
Eight to ten glasses is the standard for fluids; however, they should be the right fluids. All beverages containing caffeine,
including tea, cocoa, and some soft drinks, should be avoided or drunk only in limited amounts. Artificial sweeteners,
including aspartame, have no ill effects on the normal mother or fetus; however, mothers with phenylketonuria should
avoid aspartame. No evidence indicates that prenatal fluoride consumption reduces childhood tooth decay.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
235
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
a.
20.
Which minerals and vitamins usually are recommended to supplement a pregnant woman’s diet?
Fat-soluble vitamins A and D
c.
Iron and folate
b.
Water-soluble vitamins C and B6
d.
Calcium and zinc
ANS:
C
Iron generally should be supplemented, and folic acid supplements often are needed because folate is so important. Fatsoluble vitamins should be supplemented as a medical prescription, as vitamin D might be for lactose-intolerant women.
Water-soluble vitamin C sometimes is consumed in excess naturally; vitamin B6 is prescribed only if the woman has a
very poor diet. Zinc sometimes is supplemented. Most women obtain enough calcium through their regular diet.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
235
Nursing Process: Planning MSC:
Client Needs: Health Promotion and Maintenance
21.
Which vitamins or minerals can lead to congenital malformations of the fetus if taken in excess by the
mother?
a.
Zinc
c.
Folic acid
b.
Vitamin D
d.
Vitamin A
ANS:
D
Zinc, vitamin D, and folic acid are vital to good maternal and fetal health and are highly unlikely to be consumed in excess.
Vitamin A taken in excess causes a number of problems. An analog of vitamin A appears in prescribed acne medications,
which must not be taken during pregnancy.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
238
Nursing Process: Planning MSC:
Client Needs: Health Promotion and Maintenance
a.
b.
c.
d.
22.
With regard to nutritional needs during lactation, a maternity nurse should be aware that:
The mother’s intake of vitamin C, zinc, and protein now can be lower than during pregnancy.
Caffeine consumed by the mother accumulates in the infant, who may be unusually active and wakeful.
Critical iron and folic acid levels must be maintained.
Lactating women can go back to their prepregnant calorie intake.
ANS:
B
A lactating woman needs to avoid consuming too much caffeine. Vitamin C, zinc, and protein levels need to be moderately
higher during lactation than during pregnancy. The recommendations for iron and folic acid are lower during lactation.
Lactating women should consume about 500 kcal more than their prepregnancy intake, at least 1800 kcal daily overall.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
240
Nursing Process: Planning MSC:
Client Needs: Health Promotion and Maintenance
23.
While taking a diet history, the nurse might be told that the expectant mother has cravings for ice chips,
cornstarch, and baking soda. This represents a nutritional problem known as:
a.
Preeclampsia.
c.
Pica.
b.
Pyrosis. d.
Purging.
ANS:
C
The consumption of foods low in nutritional value or of nonfood substances (e.g., dirt, laundry starch) is called pica.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
239
Nursing Process: Diagnosis MSC:
Client Needs: Health Promotion and Maintenance
a.
b.
c.
d.
24.
When counseling a client about getting enough iron in her diet, the maternity nurse should tell her that:
Milk, coffee, and tea aid iron absorption if consumed at the same time as iron.
Iron absorption is inhibited by a diet rich in vitamin C.
Iron supplements are permissible for children in small doses.
Constipation is common with iron supplements.
ANS:
D
Constipation can be a problem. Milk, coffee, and tea inhibit iron absorption when consumed at the same time as iron.
Vitamin C promotes iron absorption. Children who ingest iron can get very sick and even die.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
245
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
25.
The labor and delivery nurse is preparing a bariatric patient for an elective cesarean birth. Which piece
of “specialized” equipment is unnecessary when providing care for this pregnant woman.
a.
Extra long surgical instruments
b.
c.
d.
Wide surgical table
Temporal thermometer
Increased diameter blood pressure cuff
ANS:
C
Obstetricians today are seeing more morbidly obese pregnant women weighing 400, 500, and 600 pounds. To manage their
conditions and to meet their logistical needs, a new medical subspecialty “bariatric obstetrics” has arisen. Extra-wide
blood pressure cuffs, scales that can accommodate up to 880 pounds, and extra-wide surgical tables designed to hold the
weight of these women are used. Special techniques for ultrasound examination and longer surgical instruments for
cesarean birth are also required. A temporal thermometer can be used for a pregnant patient of any size.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
233
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
26.
that she:
a.
b.
c.
d.
To help a woman reduce the severity of nausea caused by morning sickness, the nurse might suggest
Try a tart food or drink such as lemonade or salty foods such as potato chips.
Drink plenty of fluids early in the day.
Brush her teeth immediately after eating.
Never snack before bedtime.
ANS:
A
Some women can tolerate tart or salty foods when they are nauseous. The woman should avoid drinking too much when
nausea is most likely, but she should make up the fluid levels later in the day when she feels better. The woman should
avoid brushing her teeth immediately after eating. A small snack of cereal and milk or yogurt before bedtime may help the
stomach in the morning.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
245
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
27.
Three servings of milk, yogurt, or cheese plus two servings of meat, poultry, or fish adequately supply
the recommended amount of protein for a pregnant woman. Many patients are concerned about the increased levels of
mercury in fish and may be afraid to include this source of nutrients in their diet. Sound advice by the nurse to assist the
client in determining which fish is safe to consume would include:
a.
Canned white tuna is a preferred choice.
b.
Avoid shark, swordfish, and mackerel.
c.
Fish caught in local waterways are the safest.
d.
Salmon and shrimp contain high levels of mercury.
ANS:
B
As a precaution, the pregnant patient should avoid eating all of these and the less common tilefish. High levels of mercury
can harm the developing nervous system of the fetus. It is essential for the nurse to assist the client in understanding the
differences between numerous sources of this product. A pregnant client can 12 ounces a week of canned light tuna;
however, canned white, albacore, or tuna steaks contain higher levels of mercury and should be limited to no more than 6
ounces per week. It is a common misconception that fish caught in local waterways are the safest. Pregnant women and
mothers of young children should check with local advisories about the safety of fish caught by families and friends in
nearby bodies of water. If no information is available, these fish sources should be avoided, limited to less than 6 ounces,
or the only fish consumed that week. Commercially caught fish that are low in mercury include salmon, shrimp, pollock, or
catfish.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
235
Nursing Process: Planning MSC:
Client Needs: Health Promotion and Maintenance
28.
Nutrition is one of the most significant factors influencing the outcome of a pregnancy. It is an alterable
and important preventive measure for various potential problems, such as low birth weight and prematurity. While
completing the physical assessment of the pregnant client, the nurse can evaluate the client’s nutritional status by
observing a number of physical signs. Which sign would indicate that the client has unmet nutritional needs?
a.
Normal heart rate, rhythm, and blood pressure
b.
Bright, clear, shiny eyes
c.
Alert, responsive, and good endurance
d.
Edema, tender calves, and tingling
ANS:
D
The physiologic changes of pregnancy may complicate the interpretation of physical findings. Lower extremity edema
often occurs when caloric and protein deficiencies are present; however, it may also be a common physical finding during
the third trimester. It is essential that the nurse complete a thorough health history and physical assessment and request
further laboratory testing if indicated. A malnourished pregnant patient may display rapid heart rate, abnormal rhythm,
enlarged heart, and elevated blood pressure. A patient receiving adequate nutrition has bright, shiny eyes with no sores
and moist, pink membranes. Pale or red membranes, dryness, infection, dull appearance of the cornea, or blue sclerae all
are signs of poor nutrition. This client is well nourished. Cachexia, listlessness, and tiring easily would be indications of
poor nutritional status.
PTS:
OBJ:
1
DIF:
Cognitive Level: Analysis
Nursing Process: Assessment
MSC:
REF:
243
Client Needs: Physiologic Integrity
a.
b.
c.
d.
29.
Which pregnant woman should restrict her weight gain during pregnancy?
Woman pregnant with twins
Woman in early adolescence
Woman shorter than 62 inches or 157 cm
Woman who was 20 pounds overweight before pregnancy
ANS:
D
A weight gain of 5 to 9 kg will provide sufficient nutrients for the fetus. Overweight and obese women should be advised to
lose weight before conception to achieve the best pregnancy outcomes. A higher weight gain in twin gestations may help
prevent low birth weights. Adolescents need to gain weight toward the higher acceptable range, which provides for their
own growth as well as for fetal growth. In the past, women of short stature were advised to restrict their weight gain;
however, evidence to support these guidelines has not been found.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
231
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
a.
b.
30.
The major source of nutrients in the diet of a pregnant woman should be composed of:
Simple sugars
c.
Fiber
Fats
d.
Complex carbohydrates
ANS:
D
Complex carbohydrates supply the pregnant woman with vitamins, minerals, and fiber. The most common simple
carbohydrate is table sugar, which is a source of energy but does not provide any nutrients. Fats provide 9 kcal in each
gram, in contrast to carbohydrates and proteins, which provide only 4 kcal in each gram. Fiber is supplied primarily by
complex carbohydrates.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
245
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
a.
b.
31.
A pregnant woman’s diet may not meet her need for folates. A good source of this nutrient is:
Chicken c.
Potatoes
Cheese d.
Green leafy vegetables
ANS:
D
Sources of folates include green leafy vegetables, whole grains, fruits, liver, dried peas, and beans. Chicken and cheese
are excellent sources of protein but are poor in folates. Potatoes contain carbohydrates and vitamins and minerals but are
poor in folates.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
230
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
a.
b.
32.
When providing care to the prenatal patient, the nurse understands that pica is defined as:
Intolerance of milk products c.
Ingestion of nonfood substances
Iron deficiency anemia
d.
Episodes of anorexia and vomiting
ANS:
C
The practice of eating substances not normally thought of as food is called pica. Clay or dirt and solid laundry starch are
the substances most commonly ingested. Intolerance of milk products is referred to as lactose intolerance. Pica may
produce iron deficiency anemia if proper nutrition is decreased. Pica is not related to anorexia and vomiting.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
239
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
a.
b.
c.
33.
The most important reason for evaluating the pattern of weight gain in pregnancy is to:
Prevent excessive adipose tissue deposits
Identify potential nutritional problems or complications of pregnancy
Assess the need to limit caloric intake in obese women
d.
Determine cultural influences on the woman’s diet
ANS:
B
Maternal and fetal risks in pregnancy are increased when the mother is significantly overweight. Excessive adipose tissue
may occur with excess weight gain; however, this is not the reason for monitoring the weight gain pattern. It is important
to monitor the pattern of weight gain to identify complications. The pattern of weight gain is not influenced by cultural
influences.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
231
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
34.
If a patient’s normal prepregnancy diet contains 45 g of protein daily, how many more grams of protein
should she consume per day during pregnancy?
a.
5
c.
25
b.
10
d.
30
ANS:
C
The recommended intake of protein for the pregnant woman is 70 g. Intakes of 5, 10, or 15 g would be inadequate to meet
protein needs during pregnancy. A protein intake of 30 g is more than is necessary and would add extra calories.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
234
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
35.
A pregnant patient would like to know a good food source of calcium other than dairy products. Your
best answer is:
a.
Legumes
c.
Lean meat
b.
Yellow vegetables d.
Whole grains
ANS:
A
Although dairy products contain the greatest amount of calcium, it also is found in legumes, nuts, dried fruits, and some
dark green leafy vegetables. Yellow vegetables are rich in vitamin A. Lean meats are rich in protein and phosphorus. Whole
grains are rich in zinc and magnesium.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
237
Nursing Process: Implementation
MSC:
Client Needs: Physiologic Integrity
a.
b.
c.
d.
36.
To determine the cultural influence on a patient’s diet, the nurse should first:
Evaluate the patient’s weight gain during pregnancy
Assess the socioeconomic status of the patient
Discuss the four food groups with the patient
Identify the food preferences and methods of food preparation common to that culture
ANS:
D
Understanding the patient’s food preferences and how she prepares food will assist the nurse in determining whether the
patient’s culture is adversely affecting her nutritional intake. Evaluation of a patient’s weight gain during pregnancy should
be included for all patients, not just for patients who are culturally different. The socioeconomic status of the patient may
alter the nutritional intake but not the cultural influence. Teaching the food groups to the patient should come after
assessing food preferences.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
246
Nursing Process: Assessment
MSC:
Client Needs: Psychosocial Integrity
37.
Identify a goal of a patient with the following nursing diagnosis: Imbalanced Nutrition: Less Than Body
Requirements related to diet choices inadequate to meet nutrient requirements of pregnancy.
a.
Gain a total of 30 lb.
b.
Take daily supplements consistently.
c.
Decrease intake of snack foods.
d.
Increase intake of complex carbohydrates.
ANS:
A
A weight gain of 30 lb is one indication that the patient has gained a sufficient amount for the nutritional needs of
pregnancy. A daily supplement is not the best goal for this patient. It does not meet the basic need of proper nutrition
during pregnancy. Decreasing snack foods may be a problem and should be assessed; however, assessing weight gain is
the best method of monitoring nutritional intake for this pregnant patient. Increasing the intake of complex carbohydrates
is important for this patient, but monitoring the weight gain should be the end goal.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
244
Nursing Process: Planning MSC:
Client Needs: Health Promotion and Maintenance
a.
b.
c.
d.
38.
In teaching the pregnant adolescent about nutrition, the nurse should:
Emphasize the need to eliminate common teen snack foods because they are too high in fat and sodium.
Determine the weight gain needed to meet adolescent growth and add 35 lb.
Suggest that she not eat at fast-food restaurants to avoid foods of poor nutritional value.
Realize that most adolescents are unwilling to make dietary changes during pregnancy.
ANS:
B
Adolescents should gain in the upper range of the recommended weight gain. They also need to gain weight that would be
expected for their own normal growth. Changes in the diet should be kept at a minimum. Snack foods can be included in
moderation, and other foods can be added to make up for the lost nutrients. Eliminating fast foods would make the
adolescent appear different to her peers. The patient should be taught to choose foods that add needed nutrients.
Adolescents are willing to make changes; however, they still have the need to be similar to their peers.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
239
Nursing Process: Implementation
MSC:
Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
39.
Most women with uncomplicated pregnancies can use the nurse as their primary source for nutritional
information. The nurse or midwife should refer a client to a registered dietitian for in-depth nutritional counseling in the
following situations (Select all that apply).
a.
Preexisting or gestational illness such as diabetes
b.
Ethnic or cultural food patterns
c.
Obesity
d.
Vegetarian diet
e.
Allergy to tree nuts
ANS:
A, B, C, D
The nurse should be especially aware that conditions such as diabetes can require in-depth dietary planning and
evaluation. To prevent issues with hypoglycemia and hyperglycemia and an increased risk for perinatal morbidity and
mortality, this patient would benefit from a referral to a dietitian. Consultation with a dietitian may ensure that cultural food
beliefs are congruent with modern knowledge of fetal development and that adjustments can be made to ensure that all
nutritional needs are met. The obese pregnant patient may be under the misapprehension that because of her excess
weight little or no weight gain is necessary. According to the Institute of Medicine, a client with a body mass index in the
obese range should gain at least 7 kg to ensure a healthy outcome. This patient may require in-depth counseling on
optimal food choices. The vegetarian client needs to have her dietary intake carefully assessed to ensure that the optimal
combination of amino acids and protein intake is achieved. Very strict vegetarians (vegans) who consume only plant
products may also require vitamin B and mineral supplementation. A patient with a food allergy would not alter that
component of her diet during pregnancy; therefore, no additional consultation is necessary.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
239
Nursing Process: Implementation
MSC:
Client Needs: Physiologic Integrity
COMPLETION
40.
A newly pregnant patient visits her provider’s office for the first prenatal appointment. To estimate
accurate weight gain throughout the pregnancy, the nurse will be evaluating the appropriateness of weight for height using
the body mass index (BMI). The patient weighs 51 kg and is 1.57 m tall.
The BMI is:
___________________
ANS:
20.7
BMI = weight divided by height squared. BMI = 51 kg/(1.57m)2, or 20.7. Prepregnant BMI can be classified into the following
categories: <18.5, underweight or low; 18.5-24.9, normal; 25-29.9 overweight or high; and >30, obese
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
231
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
Unit 2
Coping/ Stress
Concept 31: Stress
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
An older patient presents to the outpatient clinic with a chief complaint of headache and insomnia. In
gathering the history, the nurse notes which factors as contributing to this patient's chief complaint?
a.
The patient is responsible for caring for two school-age grandchildren.
b.
The patient’s daughter works to support the family.
c.
The patient is being treated for hypertension and is overweight.
d.
The patient has recently lost her spouse and needed to move in with her daughter.
ANS:
D
The stress of losing a loved one and having to move are important contributing factors for stress-related symptoms in
older people. Caring for children will increase the patient's sense of worth. Being overweight and being treated for
hypertension are not the most likely causes of insomnia or headache. The patient's daughter may have added stress due
to working, but this should not directly affect the patient.
REF:
OBJ:
Page 303 |Page 304
NCLEX® Client Needs Category: Psychosocial Integrity
2.
A patient who was recently diagnosed with diabetes is having trouble concentrating. This patient is
usually very organized and laid back. Which action should the nurse take?
a.
Ask the health care provider for a psychiatric referral.
b.
Administer the PRN sedative medication every 4 hours.
c.
Suggest the use of a home caregiver to the patient's family.
d.
Plan to reinforce and repeat teaching about diabetes management.
ANS:
D
Because behavioral responses to stress include temporary changes such as irritability, changes in memory, and poor
concentration, patient teaching will need to be repeated. Psychiatric referral or home caregiver referral will not be needed
for these expected short-term cognitive changes. Sedation will decrease the patient's ability to learn the necessary
information for self-management.
REF:
Page 303 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
3.
A diabetic patient who is hospitalized tells the nurse, “I don’t understand why I can keep my blood
sugar under control at home with diet alone, but when I get sick, my blood sugar goes up.” Which response by the nurse
is appropriate?
a.
“It is probably just coincidental that your blood sugar is high when you are ill.”
b.
“Stressors such as illness cause the release of hormones that increase blood sugar.”
c.
“Increased blood sugar occurs because the kidneys are not able to metabolize glucose as well during stressful
times.”
d.
“Your diet is different here in the hospital than at home, and that is the most likely cause of the increased
glucose level.”
ANS:
B
The release of cortisol, epinephrine, and norepinephrine increases blood glucose levels. The increase in blood sugar is
not coincidental. The kidneys do not control blood glucose. A diabetic patient who is hospitalized will be on an appropriate
diet to help control blood glucose.
REF:
Page 303 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
4.
A patient has not been sleeping well because he is worried about losing his job and not being able to
support his family. The nurse takes the patient's vital signs and notes a pulse rate of 112 beats/min, respirations are 26
breaths/min, and his blood pressure is 166/88 instead his usual 110-120/76-84 range. Which nursing intervention or
recommendation should be used first?
a.
Go to sleep 30 to 60 minutes earlier each night to increase rest.
b.
c.
d.
Relax by spending more time playing with his pet dog.
Slow and deepen breathing via use of a positive, repeated word.
Consider that a new job might be better than his present one.
ANS:
C
The patient is responding to stress with increased arousal of the sympathetic nervous system, as evident in his elevated
vital signs. These will have a negative effect on his health and increase his perception of being anxious and stressed.
Stimulating the parasympathetic nervous system (i.e., Benson's relaxation response) will counter the sympathetic nervous
system's arousal, normalizing these vital-sign changes and reducing the physiologic demands stress is placing on his
body. Other options do not address his physiologic response pattern as directly or immediately.
REF:
OBJ:
Page 306
NCLEX® Client Needs Category: Psychosocial Integrity and Physiological Integrity
5.
The nurse is planning to teach a patient how to use relaxation techniques to prevent elevation of blood
pressure and heart rate. The nurse is teaching the patient to control which physiological function?
a.
Switch from the sympathetic mode of the autonomic nervous system to the parasympathetic mode.
b.
Alter the internal state by modifying electronic signals related to physiologic processes.
c.
Replace stress-producing thoughts and activities with daily stress-reducing thoughts and activities.
d.
Reduce catecholamine production and promote the production of additional beta-endorphins.
ANS:
A
When the sympathetic nervous system is operative, the individual experiences muscular tension and an elevated pulse,
blood pressure, and respiratory rate. Relaxation is achieved when the sympathetic nervous system is quieted and the
parasympathetic nervous system is operative. Modifying electronic signals is the basis for biofeedback, a behavioral
approach to stress reduction. Altering thinking and activities from more-stressful to less-stressful reflects the cognitive
approach to stress management. Reducing catecholamine production is the basis for guided imagery's effectiveness.
REF:
Page 306 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
6.
A patient tells the nurse, “I'm told that I should reduce the stress in my life, but I have no idea where to
start.” Which would be the best initial nursing response?
a.
“Why not start by learning to meditate? That technique will cover everything.”
b.
“In cases like yours, physical exercise works to elevate mood and reduce anxiety.”
c.
“Reading about stress and how to manage it might be a good place to start.”
d.
“Let’s talk about what is going on in your life and then look at possible options.”
ANS:
D
In this case, the nurse lacks information about what stressors the patient is coping with or about what coping skills are
already possessed. As a result, further assessment is indicated before potential solutions can be explored. Suggesting
further exploration of the stress facing the patient is the only option that involves further assessment rather than
suggesting a particular intervention.
REF:
Page 306 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
7.
A patient tells the nurse “My doctor thinks my problems with stress relate to the negative way I think
about things, and he wants me to learn a new way of thinking.” Which response would be in keeping with the doctor's
recommendations?
a.
Teaching the patient to recognize, reconsider, and reframe irrational thoughts
b.
Encouraging the patient to imagine being in calming circumstances
c.
Teaching the patient to use instruments that give feedback about bodily functions
d.
Provide the patient with a blank journal and guidance about journaling
ANS:
A
Cognitive reframing focuses on recognizing and correcting maladaptive patterns of thinking that create stress or interfere
with coping. Cognitive reframing involves recognizing the habit of thinking about a situation or issue in a fixed, irrational,
and unquestioning manner. Helping the patient to recognize and reframe (reword) such thoughts so that they are realistic
and accurate promotes coping and reduces stress. Thinking about being in calming circumstances is a form of guided
imagery. Instruments that give feedback about bodily functions are used in biofeedback. Journaling is effective for helping
to increase self-awareness. However, none of these last three interventions is likely to alter the patient's manner of
thinking.
REF:
Page 306 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
8.
A patient who had been complaining of intolerable stress at work has demonstrated the ability to use
progressive muscle relaxation and deep breathing techniques. He will return to the clinic for follow-up evaluation in 2
weeks. Which data will best suggest that the patient is successfully using these techniques to cope more effectively with
stress?
a.
The patient's wife reports that he spends more time sitting quietly at home.
b.
He reports that his appetite, mood, and energy levels are all good.
c.
His systolic blood pressure has gone from the 140s to the 120s (mm Hg).
d.
He reports that he feels better and that things are not bothering him as much.
ANS:
C
Objective measures tend to be the most reliable means of gauging progress. In this case, the patient's elevated blood
pressure, an indication of the body's physiologic response to stress, has diminished. The wife's observations regarding
his activity level are subjective, and his sitting quietly could reflect his having given up rather than improved. Appetite,
mood, and energy levels are also subjective reports that do not necessarily reflect physiologic changes from stress and
may not reflect improved coping with stress. The patient's report that he feels better and is not bothered as much by his
circumstances could also reflect resignation rather than improvement.
REF:
OBJ:
Page 306
NCLEX® Client Needs Category: Psychosocial Integrity and Physiological Integrity
MULTIPLE RESPONSE
1.
Which action should the nurse take to monitor the effects of an acute stressor on a hospitalized
patient? (Select all that apply.)
a.
Assess for bradycardia.
b.
Ask about epigastric pain.
c.
Observe for increased appetite.
d.
Check for elevated blood glucose levels.
e.
Monitor for a decrease in respiratory rate.
ANS:
B, C, D
The physiologic changes associated with the acute stress response can cause changes in appetite, increased gastric acid
secretion, and elevation of blood glucose levels. Stress causes an increase in the respiratory and heart rates.
REF:
OBJ:
Page 302 |Page 303
NCLEX® Client Needs Category: Psychosocial Integrity and Physiological Integrity
2.
The nurse is working with a patient who recently lost her spouse after a lengthy illness. The patient
shares that she would like to sell her home and move to another state now that her spouse has passed away. Which of the
following interventions would be considered a priority for this patient? (Select all that apply.)
a.
Notify the provider to evaluate for antidepressant therapy.
b.
Suggest that the patient consider a support group for widows.
c.
Suggest that the patient learn stress reduction breathing exercises.
d.
Suggest that the patient take prescribed antianxiety medications.
e.
Assist the patient in identifying support systems.
f.
Notify the provider to evaluate the need for antianxiety medications.
ANS:
B, C, E
Stress prevention management involves counseling, education, and implementation of techniques to manage problemoriented and emotion-oriented stress. To prevent physical symptoms, relaxation and deep breathing are effective and
individuals can learn to prevent the stress response through cognitive behavioral strategies. Medications are not indicated
for patients with known stressors unless the stress is prolonged or the patient has ineffective coping mechanisms.
REF:
Page 303 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
Concept 32: Coping
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
The nurse is reviewing the care plan for a patient experiencing difficulty coping with stress. The nurse
recognizes that an example of initiating a cognitive restructuring intervention to enhance coping abilities is known as
which of the following?
a.
Identifying the cause of fear
b.
Accessing a community support group
c.
Identifying relaxation methods
d.
Reviewing an educational pamphlet
ANS:
A
Identifying the cause of a negative perception is the first step in restructuring how a patient perceives a stressor, also
called cognitive restructuring. Accessing a community support group is an example of accessing resources to enhance
coping. Identifying relaxation methods is an example of developing an action plan. Reviewing an educational pamphlet is
an example of using education to enhance coping.
REF:
Page 310 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
2.
The nurse is developing a care plan for a patient with ineffective coping skills. Which intervention
would be an example of a problem-focused coping strategy?
a.
Scheduling a regular exercise program
b.
Attending a seminar on treatment options
c.
Identifying a confidant to share feelings
d.
Attending a support group for families
ANS:
C
Problem-focused strategies are used to find solutions or improvement to the underlying stressor, such as accessing
community resources or attending educational seminars. Exercise, emotional support, and support groups are emotionbased strategies that create a feeling of well-being.
REF:
Page 310 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
3.
The school nurse is assessing coping skills of high school students who attend an alternative school
for students at high risk to not graduate. What is the priority concern that the nurse has for this student population?
a.
Altered vital sign readings
b.
Inaccurate perceptions of stressors
c.
Increased risk for suicide
d.
Decreased access to alcoholic beverages
ANS:
C
Adolescents with poor coping have increased risk for drug and alcohol use, risky sexual behaviors, and suicide. Pulse,
respiratory rate, and blood pressure may change during stress, but patient safety is the priority concern. Adolescents may
have inaccurate perceptions of stressors, and this actually increases the risk for unsafe behaviors. Adolescents under
stress are more at risk for increasing their access to alcohol and illegal drugs.
REF:
Page 311 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
4.
A patient is the primary caregiver for a disabled family member at home, and has now been
unexpectedly hospitalized for surgery. What action can the nurse take to enhance the coping ability of the patient?
a.
Ask if there is another family member who can help at home while the patient is in the hospital.
b.
Plan to transfer the patient to a rehabilitation unit after surgery to allow uninterrupted time to recover.
c.
Coordinate an ambulance transfer of the family member to an alternate family member's home.
d.
Ask social services to assess what the patient's needs will be after discharge to home.
ANS:
A
The best action by the nurse is to help the patient develop an action plan to assess what resources may already be
available to meet responsibilities at home. A long absence from the home on a rehabilitation unit does not address the
immediate need to provide care for the disabled family member. An ambulance transfer to another family member is
premature until the placement is identified as an appropriate placement based on the disabled person's needs, availability
to provide the care by another, and distance of the transfer. Assessing the patient's needs after discharge does not
address the immediate need to provide care for the disabled family person.
REF:
OBJ:
Page 312 |Page 313 |Page 314
NCLEX® Client Needs Category: Psychosocial Integrity
5.
After a management decision to admit terminal care patients to a medical unit, the nursing manager
notes that nursing staff on the unit appear tired and anxious. Staff absences from work are increasing. The nurse manager
is concerned that staff may be experiencing stress and burnout at work. What action would be best for the manager to take
that will help the staff?
a.
Ask administration to require staff to meditate daily for at least 30 minutes.
b.
Have a staff psychologist available on the unit once a week for required counseling.
c.
Have training sessions to help the staff understand their new responsibilities.
d.
Ask support staff from other disciplines to complete some nursing tasks to provide help.
ANS:
C
Feeling unprepared for work responsibilities contributes to stress and poor coping in the workplace. Administration
cannot require that staff participate in meditation or counseling sessions, although these can be recommended and
encouraged. Asking other disciplines to assume nursing tasks is not appropriate for their scope of practice.
REF:
Page 313 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
6.
The nurse has been asked to administer a coping measurement instrument to a patient. What education
would the nurse present to the patient related to this tool?
a.
“This tool will let us compare your stress to other patients in the hospital.”
b.
“This tool is short because it only measures the negative stressors you are experiencing.”
c.
“You will need to ask your parents about stressors you had as a child to complete this tool.”
d.
“This tool will help assess recent positive and negative events you are experiencing.”
ANS:
D
Coping measurement tools measure recent positive and negative life events as perceived by the individual. There is no
objective scale for comparison with other patients because each person reacts differently to stressors. Both negative and
positive events are assessed. Childhood stressors are not part of this type of evaluation as they are intended to measure
recently occurring events.
REF:
OBJ:
Page 313 |Page 314
NCLEX® Client Needs Category: Psychosocial Integrity
MULTIPLE RESPONSE
1.
The nurse is assessing the coping patterns of a newly admitted patient. What will the nurse include in
this assessment? (Select all that apply.)
a.
Current stressors as perceived by the patient
b.
Use of drugs or alcohol
c.
Recent weight changes
d.
Age and height
e.
Temperature
ANS:
A, B, C
Stressors are subjective based on patient perception and assessment of stressors as part of a patient history. Stressors
trigger coping behaviors that can include negative uses of drugs and alcohol and appetite changes that affect weight. Age,
height, and temperature are not typically altered with coping, although pulse, respiratory rate, and blood pressure may be
affected.
REF:
Page 315 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
Chapter 36: Chronic Illness, Disability, and End-of-Life Care
MULTIPLE CHOICE
3.
Approach behaviors are coping mechanisms that result in a family’s movement toward adjustment and
resolution of the crisis of having a child with a chronic illness or disability. What is considered an approach behavior in
parents?
a.
Are unable to adjust to a progression of the disease or condition
b.
Anticipate future problems and seek guidance and answers
c.
Look for new cures without a perspective toward possible benefit
d.
Fail to recognize seriousness of child’s condition despite physical evidence
ANS:
B
The parents who anticipate future problems and seek guidance and answers are demonstrating approach behaviors. They
are demonstrating positive actions in caring for their child. Avoidance behaviors include being unable to adjust to a
progression of the disease or condition, looking for new cures without a perspective toward possible benefit, and failing to
recognize the seriousness of the child’s condition despite physical evidence. These behaviors would suggest that the
parents are moving away from adjustment or adaptation in the crisis of a child with chronic illness or disability.
PTS:
OBJ:
1
DIF:
Cognitive Level: Analysis
Nursing Process: Assessment
MSC:
REF:
1057
Client Needs: Psychosocial Integrity
4.
Families progress through various stages of reactions when a child is diagnosed with a chronic illness
or disability. After the shock phase, a period of adjustment usually follows. This is often characterized by:
a.
Denial. c.
Social reintegration.
b.
Guilt and anger. d.
Acceptance of child’s limitations.
ANS:
B
For most families, the adjustment phase is accompanied by several responses that are normally part of the adjustment
process. Guilt, self-accusation, bitterness, and anger are common reactions. The initial diagnosis of a chronic illness or
disability often is often met with intense emotion and characterized by shock and denial. Social reintegration and
acceptance of the child’s limitations is the culmination of the adjustment process.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1058
Nursing Process: Planning MSC:
Client Needs: Psychosocial Integrity
5.
The nurse comes into the room of a child who was just diagnosed with a chronic disability. The child’s
parents begin to yell at the nurse about a variety of concerns. The nurse’s best response is:
a.
“What is really wrong?”
b.
“Being angry is only natural.”
c.
“Yelling at me will not change things.”
d.
“I will come back when you settle down.”
ANS:
B
Parental anger after the diagnosis of a child with a chronic disability is a common response. One of the most common
targets for parental anger is members of the staff. The nurse should recognize the common response of anger to the
diagnosis and allow the family to ventilate. “What is really wrong?” “Yelling at me will not change things,” and “I will come
back when you settle down” are all possible responses, but they are not the likely reasons for this anger.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1058
Nursing Process: Assessment
MSC:
Client Needs: Psychosocial Integrity
6.
A common parental reaction to a child with special needs is parental overprotection. Parental behavior
suggestive of this includes:
a.
Giving inconsistent discipline.
b.
Providing consistent, strict discipline.
c.
Forcing child to help self, even when not capable.
d.
Encouraging social and educational activities not appropriate to child’s level of capability.
ANS:
A
Parental overprotection is manifested by the parents’ fear of letting the child achieve any new skill, avoiding all discipline,
and catering to the child’s every desire to prevent frustration. The overprotective parents usually do not set limits and or
institute discipline, and they usually prefer to remain in the role of total caregiver. They do not allow the child to perform
self-care or encourage the child to try new activities.
PTS:
OBJ:
1
DIF:
Cognitive Level: Analysis
Nursing Process: Assessment
MSC:
7.
by:
a.
b.
c.
d.
REF:
1058
Client Needs: Psychosocial Integrity
Most parents of children with special needs tend to experience chronic sorrow. This is characterized
Lack of acceptance of the child’s limitation.
Lack of available support to prevent sorrow.
Periods of intensified sorrow when experiencing anger and guilt.
Periods of intensified sorrow and loss that occur in waves over time.
ANS:
D
Chronic sorrow is manifested by feelings of sorrow and loss that recur in waves over time. The sorrow is in response to
the recognition of the child’s limitations. The family should be assessed in an ongoing manner to provide appropriate
support as the needs of the family change. The sorrow is not preventable. The chronic sorrow occurs during the
reintegration and acknowledgment stage.
PTS:
OBJ:
1
DIF:
Cognitive Level: Analysis REF:
1058
Nursing Process: Diagnosis MSC:
Client Needs: Psychosocial Integrity
MSC:
Client Needs: Physiologic Integrity: Basic Care and Comfort
MULTIPLE RESPONSE
37.
Which describe avoidance behaviors a parent may exhibit when learning that his or her child has a
chronic condition (select all that apply)?
a.
Refuses to agree to treatment
b.
c.
d.
e.
Shares burden of disorder with others
Verbalizes possible loss of child
Withdraws from outside world
Punishes self because of guilt and shame
ANS:
A, D, E
A parent who refuses to agree to treatment, withdraws from the outside world, and punishes self because of guilt and
shame is exhibiting avoidance coping behaviors. A parent who shares the burden of disorder with others and verbalizes
possible loss of child is exhibiting approach coping behaviors.
PTS:
OBJ:
1
DIF:
Cognitive Level: Analysis
Nursing Process: Evaluation
MSC:
REF:
1057
Client Needs: Psychosocial Integrity
Chapter 27: Family, Social, Cultural, and Religious Influences on Child Health Promotion
MULTIPLE CHOICE
4.
The mother of a school-age child tells the school nurse that she and her spouse are going through a
divorce. The child has not been doing well in school and sometimes has trouble sleeping. The nurse should recognize this
as:
a.
Indicative of maladjustment.
b.
Common reaction to divorce.
c.
Suggestive of lack of adequate parenting.
d.
Unusual response that indicates need for referral.
ANS:
B
Parental divorce affects school-age children in many ways. In addition to difficulties in school, they often have profound
sadness, depression, fear, insecurity, frequent crying, loss of appetite, and sleep disorders. Uncommon responses to
parental divorce include indications of maladjustment, the suggestion of lack of adequate parenting, and the need for
referral.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
735
Nursing Process: Assessment
MSC:
Client Needs: Psychosocial Integrity
Clotting
Concept 20: Clotting
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
a.
b.
c.
d.
1.
Which nursing observation would indicate that the nurse hold the medication warfarin (Couma-din)?
An INR (international normalize ratio) of 1.8
An INR of 4.8
A partial thromboplastin time (APTT) level of 25 seconds
An APTT level of 35 seconds
ANS:
B
The INR of 4.8 is too high. The dosage of warfarin is adjusted to maintain an INR between 2 and 3. A level of 4.8 indicates
that the patient is at risk for excessive bleeding. An INR of 1.8 is below the therapeutic range and would indicate the need
for warfarin. APPT is not used to monitor effec-tiveness of the dose for warfarin.
REF:
OBJ:
Page 193
NCLEX® Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
a.
2.
Which statement by a patient indicates additional teaching is required about the medication warfarin?
“I will continue my diabetic diet and restrict sugar.”
b.
c.
d.
“I will increase the intake of green, leafy vegetables for a more healthful diet.”
“I will restrict the intake of foods high in vitamin C.”
“I will increase the amount of protein in my diet to protect my kidneys.”
ANS:
B
Foods such as green, leafy vegetables have high levels of vitamin K. Warfarin is an anticoagulant that acts by interfering
with vitamin K-dependent clotting factors. If the amount of vitamin K is in-creased in the diet, the medication dose may
need to be adjusted. A diabetic diet would be contin-ued as indicated for a patient receiving warfarin. Vitamin C is not
related to warfarin.
REF:
OBJ:
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NCLEX® Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
3.
A patient states that his legs have pain with walking that decreases with rest. The nurse observes
absence of hair on the patient’s lower leg and the patient has a thready, posterior tibial pulse. How would the nurse
position the patient's legs?
a.
Elevated
b.
Crossed at the knee
c.
Slightly bent with a pillow under the knees
d.
Dependent position
ANS:
D
A patient with arterial insufficiency is taught to position their legs in a dependent position to use gravity to help perfuse
the tissues. Crossing legs at the knee may interfere with blood flow. Slight-ly bent legs do not enhance blood flow.
REF:
Page 192 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
a.
b.
c.
d.
4.
The nurse would expect to administer an anticoagulant to a patient following which surgery?
Hip replacement
Hysterectomy
Abdominal aorta aneurism (AAA) repair
Appendectomy
ANS:
A
Prophylactic anticoagulation is used for hip replacement because of the high risk of developing a deep vein thrombosis
after hip replacement. Anticoagulants are not routinely administered to pa-tients with hysterectomies, AAA repairs, and
appendectomies.
REF:
OBJ:
Page 194
NCLEX® Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
5.
A patient on a medical surgical unit has a platelet count of 90,000 per mm3. The nurse knows to include
which of the following precautions in discharge instructions?
a.
Use a standard safety razor for shaving.
b.
Use a soft bristle toothbrush.
c.
Have aggressive dental care immediately to prevent dental caries.
d.
Do not eat fresh fruit.
ANS:
B
The use of a soft bristle toothbrush will help prevent bleeding of the gums in a patient with thrombocytopenia. The blade
of a safety razor can nick or cut the skin and cause bleeding. Dental care can cause gum bleeding. The consumption of
fresh fruit is not part of bleeding precautions.
REF:
Page 194 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
6.
The nurse would anticipate that which of the following patient conditions will be treated with the
collaborative treatment of regular phlebotomies?
a.
Hemophilia
b.
Thrombocytopenia
c.
Eosinophilia
d.
Polycythemia
ANS:
D
The removal of blood by using phlebotomy is used for thrombocytopenia to decrease the blood volume and decrease
blood viscosity to prevent the formation of blood clots. Hemophilia and thrombocytopenia would not benefit from
phlebotomy; eosinophilia is an overproduction of eosinophils from an abnormal allergic reaction and is treated with
removal of the agent the person is allergic to and possibly administration of steroids.
REF:
Page 195 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
MULTIPLE RESPONSE
1.
The nurse is making a home visit to a patient who was discharged from the hospital on Lovenox and
warfarin following replacement of the patient's pacemaker. Which observation indicates excessive bleeding? (Select all
that apply.)
a.
New ecchymosis on the abdomen
b.
A nosebleed that does not stop with pressure
c.
Pain of the lower extremity with flexion
d.
Extreme fatigue
e.
Pallor
f.
Sudden onset of severe headache
ANS:
A, B, D, E, F
Excessive bleeding includes large bruises that may be increasing in size, nosebleeds, extreme fatigue from decreased
tissue oxygenation due to decreased hemoglobin, and sudden onset of a severe headache, which may indicate a cerebral
hemorrhage. Pain in the lower extremity may be a result of a deep vein thrombosis. Pain of the legs with flexion may be
associated with venous thrombosis.
REF:
Page 191 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
Perfusion
Concept 18: Perfusion
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
The nurse is explaining to a student nurse about impaired central perfusion. The nurse knows the
student understands this problem when the student makes which statement?
a.
“Central perfusion is monitored only by the physician.”
b.
“Central perfusion involves the entire body.”
c.
“Central perfusion is decreased with hypertension.”
d.
“Central perfusion is toxic to the cardiac system.”
ANS:
B
Central perfusion does involve the entire body as all organs are supplied with oxygen and vital nutrients. The physician
does not control the body’s ability for perfusion. Central perfusion is not decreased with hypertension. Central perfusion is
not toxic to the cardiac system.
REF:
Page 167 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
2.
A patient diagnosed with hypertension asks the nurse how this disease could have happened to them.
What is the nurse’s best response?
a.
“Hypertension happens to everyone sooner or later. Don't be concerned about it.”
b.
“Hypertension can happen from eating a poor diet, so change what you are eating.”
c.
“Hypertension can happen from arterial changes that block the blood flow.”
d.
“Hypertension happens when people do not exercise, so you should walk every day.”
ANS:
C
Hardening of the arteries from atherosclerosis can cause hypertension in the patient. Hypertension does not happen to
everyone. Changing the patient's diet and exercising may be a positive life change, but these answers do not explain to the
patient how the disease could have happened.
REF:
Page 170 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
3.
The patient asks the nurse to explain the function of the sinoatrial node in the heart. What is the nurse’s
best response?
a.
“The sinoatrial node stimulates the heart to beat in a normal rhythm.”
b.
“The sinoatrial node protects the heart from atherosclerotic changes.”
c.
d.
“The sinoatrial node provides the heart with oxygenated blood.”
“The sinoatrial node protects the heart from infection.”
ANS:
A
The sinoatrial node is the natural pacemaker of the heart, and it assists the heart to beat in a normal rhythm. The sinoatrial
node does not protect from atherosclerotic changes or infection, and it does not directly provide the heart with
oxygenated blood.
REF:
OBJ:
Page 167
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
4.
The patient is brought to the emergency department after a motor vehicle accident. The patient is
diagnosed with internal bleeding. What is the priority of care for this patient?
a.
Mental alertness
b.
Perfusion
c.
Pain
d.
Reaction to medications
ANS:
B
Perfusion is the correct answer, because with internal bleeding, the nurse should monitor vital signs to be sure perfusion
is happening. Mental alertness, pain, and medication reactions are important but not the primary concern.
REF:
OBJ:
Page 167
NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5.
A patient's serum electrolytes are being monitored. The nurse notices that the potassium level is low.
What should the nurse monitor for in this patient?
a.
Tissue ischemia
b.
Brain malformations
c.
Intestinal blockage
d.
Cardiac dysrhythmia
ANS:
D
Cardiac dysrhythmia is a possibility when serum potassium is high or low. Tissue ischemia, brain malformations, or
intestinal blockage do not have a direct correlation to potassium irregularities.
REF:
OBJ:
Page 173
NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6.
A nurse is explaining to a student nurse about perfusion. The nurse knows the student understands the
concept of perfusion when the student makes which statement?
a.
“Perfusion is a normal function of the body, and I don't have to be concerned about it.”
b.
“Perfusion is monitored by the physician.”
c.
“Perfusion is monitored by vital signs and capillary refill.”
d.
“Perfusion varies as a person ages, so I would expect changes in the body.”
ANS:
C
The best method to monitor perfusion is to monitor vital signs and capillary refill. This allows the nurse to know if
perfusion is adequate to maintain vital organs. The nurse does have to be concerned about perfusion. Perfusion is not
only monitored by the physician but the nurse too. Perfusion does not always change as the person ages.
REF:
Page 171 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
7.
The nurse is conducting a patient assessment. The patient tells the nurse that he has smoked two
packs of cigarettes per day for 27 years. The nurse may find which data upon assessment?
a.
Elevated blood pressure
b.
Bounding pedal pulses
c.
Night blindness
d.
Reflux disease
ANS:
A
Smokers have a constriction of the blood vessels due to the tar and nicotine in cigarettes. This constriction may lead to
hypertension. Bounding pulses, night blindness, and reflux disease do not have a direct link to smoking.
REF:
Page 172 |Page 173 |Page 175
OBJ:
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
Chapter 32: Hypertension
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1.
Which action will the nurse in the hypertension clinic take to obtain an accurate baseline blood
pressure (BP) for a new patient?
a.
Deflate the BP cuff at a rate of 5 to 10 mm Hg per second.
b.
Have the patient sit in a chair with the feet flat on the floor.
c.
Assist the patient to the supine position for BP measurements.
d.
Obtain two BP readings in the dominant arm and average the results.
ANS:
B
The patient should be seated with the feet flat on the floor. The BP is obtained in both arms, and the results of the two
arms are not averaged. The patient does not need to be in the supine position. The cuff should be deflated at 2 to 3 mm Hg
per second.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
696
Nursing Process: Assessment
MSC:
NCLEX: Health Promotion and Maintenance
2.
The nurse obtains the following information from a patient newly diagnosed with prehypertension.
Which finding is most important to address with the patient?
a.
Low dietary fiber intake
b.
No regular physical exercise
c.
Drinks a beer with dinner every night
d.
Weight is 5 pounds above ideal weight
ANS:
B
The recommendations for preventing hypertension include exercising aerobically for 30 minutes most days of the week. A
weight that is 5 pounds over the ideal body weight is not a risk factor for hypertension. The Dietary Approaches to Stop
Hypertension (DASH) diet is high in fiber, but increasing fiber alone will not prevent hypertension from developing. The
patient’s alcohol intake is within guidelines and will not increase the hypertension risk.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Planning MSC:
REF:
689
NCLEX: Health Promotion and Maintenance
3.
Which action should the nurse take when giving the initial dose of oral labetalol to a patient with
hypertension?
a.
Encourage the use of hard candy to prevent dry mouth.
b.
Teach the patient that headaches often occur with this drug.
c.
Instruct the patient to call for help if heart palpitations occur.
d.
Ask the patient to request assistance before getting out of bed.
ANS:
D
Labetalol decreases sympathetic nervous system activity by blocking both - and -adrenergic receptors, leading to
vasodilation and a decrease in heart rate, which can cause severe orthostatic hypotension. Heart palpitations, dry mouth,
dehydration, and headaches are possible side effects of other antihypertensives.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
692
NCLEX: Physiological Integrity
4.
After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be
implemented, which diet choice indicates that the teaching has been most effective?
a.
The patient avoids eating nuts or nut butters.
b.
The patient restricts intake of chicken and fish.
c.
The patient drinks low-fat milk with each meal.
d.
The patient has two cups of coffee in the morning.
ANS:
C
For the prevention of hypertension, the Dietary Approaches to Stop Hypertension (DASH) recommendations include
increasing the intake of calcium-rich foods. Caffeine restriction and decreased protein intake are not included in the
recommendations. Nuts are high in beneficial nutrients and 4 to 5 servings weekly are recommended in the DASH diet.
DIF:
Cognitive Level: Apply (application)
REF:
687
TOP:
Nursing Process: Evaluation
MSC:
NCLEX: Physiological Integrity
5.
A patient has just been diagnosed with hypertension and has been started on captopril . Which
information is most important to include when teaching the patient about this drug?
a.
Include high-potassium foods such as bananas in the diet.
b.
Increase fluid intake if dryness of the mouth is a problem.
c.
Change position slowly to help prevent dizziness and falls.
d.
Check blood pressure (BP) in both arms before taking the drug.
ANS:
C
The angiotensin-converting enzyme (ACE) inhibitors frequently cause orthostatic hypotension, and patients should be
taught to change position slowly to allow the vascular system time to compensate for the position change. Increasing fluid
intake may counteract the effect of the drug, and the patient is taught to use gum or hard candy to relieve dry mouth. The
BP should be taken in the nondominant arm by newly diagnosed patients in the morning, before taking the drug, and in the
evening. Because ACE inhibitors cause potassium retention, increased intake of high-potassium foods is inappropriate.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
691
NCLEX: Physiological Integrity
6.
Propranolol (Inderal) is prescribed for a patient diagnosed with hypertension. The nurse should consult
with the health care provider before giving this drug when the patient reveals a history of
a.
daily alcohol use. c.
reactive airway disease.
b.
peptic ulcer disease.
d.
myocardial infarction (MI).
ANS:
C
Nonselective -blockers block 1- and 2-adrenergic receptors and can cause bronchospasm, especially in patients with a
history of asthma. -Blockers will have no effect on the patient’s peptic ulcer disease or alcohol use. -Blocker therapy is
recommended after MI.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
692
NCLEX: Physiological Integrity
7.
A 56-yr-old patient who has no previous history of hypertension or other health problems suddenly
develops a blood pressure (BP) of 198/110 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the
patient that
a.
a BP recheck should be scheduled in a few weeks.
b.
dietary sodium and fat content should be decreased.
c.
diagnosis, treatment, and ongoing monitoring will be needed.
d.
there is an immediate danger of a stroke, requiring hospitalization.
ANS:
C
A sudden increase in BP in a patient older than age 50 years with no previous hypertension history or risk factors
indicates that the hypertension may be secondary to some other problem. The BP will need treatment and ongoing
monitoring. If the patient has no other risk factors, a stroke in the immediate future is unlikely. There is no indication that
dietary salt or fat intake have contributed to this sudden increase in BP, and reducing intake of salt and fat alone will not
be adequate to reduce this BP to an acceptable level.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
684
NCLEX: Physiological Integrity
8.
Which action will be included in the plan of care when the nurse is caring for a patient who is receiving
nicardipine (Cardene) to treat a hypertensive emergency?
a.
Organize nursing activities so that the patient has undisturbed sleep for 8 hours at night.
b.
Keep the patient NPO to prevent aspiration caused by nausea and possible vomiting.
c.
Assist the patient up in the chair for meals to avoid complications associated with immobility.
d.
Use an automated noninvasive blood pressure machine to obtain frequent measurements.
ANS:
D
Frequent monitoring of BP is needed when the patient is receiving rapid-acting IV antihypertensive medications. This can
be most easily accomplished with an automated BP machine or arterial line. The patient will require frequent assessments,
so allowing 8 hours of undisturbed sleep is not reasonable. When patients are receiving IV vasodilators, bed rest is
maintained to prevent decreased cerebral perfusion and fainting. There is no indication that this patient is nauseated or at
risk for aspiration, so an NPO status is unnecessary.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
699
NCLEX: Physiological Integrity
9.
The nurse has just finished teaching a hypertensive patient about the newly prescribed drug, ramipril
(Altace). Which patient statement indicates that more teaching is needed?
a.
“The medication may not work well if I take aspirin.”
b.
“I can expect some swelling around my lips and face.”
c.
“The doctor may order a blood potassium level occasionally.”
d.
“I will call the doctor if I notice that I have a frequent cough.”
ANS:
B
Angioedema occurring with angiotensin-converting enzyme (ACE) inhibitor therapy is an indication that the ACE inhibitor
should be discontinued. The patient should be taught that if any swelling of the face or oral mucosa occurs, the health
care provider should be immediately notified because this could be life threatening. The other patient statements indicate
that the patient has an accurate understanding of ACE inhibitor therapy.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
692
NCLEX: Physiological Integrity
10.
During change-of-shift report, the nurse obtains the following information about a hypertensive patient
who received the first dose of nadolol (Corgard) during the previous shift. Which information indicates that the patient
needs immediate intervention?
a.
The patient’s pulse has dropped from 68 to 57 beats/min.
b.
The patient complains that the fingers and toes feel quite cold.
c.
The patient has developed wheezes throughout the lung fields.
d.
The patient’s blood pressure (BP) reading is now 158/91 mm Hg.
ANS:
C
The most urgent concern for this patient is the wheezes, which indicate that bronchospasm (a common adverse effect of
the noncardioselective -blockers) is occurring. The nurse should immediately obtain an O2 saturation measurement, apply
supplemental O2, and notify the health care provider. The mild decrease in heart rate and complaint of cold fingers and
toes are associated with -receptor blockade but do not require any change in therapy. The BP reading may indicate that a
change in medication type or dose may be indicated. However, this is not as urgently needed as addressing the
bronchospasm.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Evaluation
MSC:
REF:
692
NCLEX: Physiological Integrity
11.
An older patient has been diagnosed with possible white coat hypertension. Which planned action by
the nurse best addresses the suspected cause of the hypertension?
a.
Instruct the patient about the need to decrease stress levels.
b.
Teach the patient how to self-monitor and record BPs at home.
c.
Schedule the patient for regular blood pressure (BP) checks in the clinic.
d.
Inform the patient and caregiver that major dietary changes will be needed.
ANS:
B
In the phenomenon of “white coat” hypertension, patients have elevated BP readings in a clinical setting and normal
readings when BP is measured elsewhere. Having the patient self-monitor BPs at home will provide a reliable indication
about whether the patient has hypertension. Regular BP checks in the clinic are likely to be high in a patient with white
coat hypertension. There is no evidence that this patient has elevated stress levels or a poor diet, and those factors do not
cause white coat hypertension.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
687
NCLEX: Physiological Integrity
12.
Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a
48-yr-old patient with newly diagnosed hypertension?
a.
98/56 mm Hg
c.
128/92 mm Hg
b.
128/76 mm Hg
d.
142/78 mm Hg
ANS:
B
The 8th Joint National Committee’s recommended goal for antihypertensive therapy for a 30- to 59-yr-old patient with
hypertension is a BP below 140/90 mm Hg. The BP of 98/56 mm Hg may indicate overtreatment of the hypertension and an
increased risk for adverse drug effects. The other two blood pressures indicate a need for modifications in the patient’s
treatment.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
684
NCLEX: Physiological Integrity
13.
Which information is most important for the nurse to include when teaching a patient with newly
diagnosed hypertension?
a.
Most people are able to control BP through dietary changes.
b.
Annual BP checks are needed to monitor treatment effectiveness.
c.
Hypertension is usually asymptomatic until target organ damage occurs.
d.
Increasing physical activity alone controls blood pressure (BP) for most people.
ANS:
C
Hypertension is usually asymptomatic until target organ damage has occurred. Lifestyle changes (e.g., physical activity,
dietary changes) are used to help manage BP, but drugs are needed for most patients. Home BP monitoring should be
taught to the patient and findings checked by the health care provider frequently when starting treatment for hypertension
and then every 3 months when stable.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
685
NCLEX: Physiological Integrity
14.
The nurse on the intermediate care unit received change-of-shift report on four patients with
hypertension. Which patient should the nurse assess first?
a.
48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain
b.
52-yr-old with a blood pressure of 198/90 mm Hg who has intermittent claudication
c.
50-yr-old with a blood pressure of 190/104 mm Hg who has a creatinine of 1.7 mg/dL
d.
43-yr-old with a blood pressure of 172/98 mm Hg whose urine shows microalbuminuria
ANS:
A
The patient with chest pain may be experiencing acute myocardial infarction and rapid assessment and intervention are
needed. The symptoms of the other patients also show target organ damage but are not indicative of acute processes.
DIF:
OBJ:
TOP:
Cognitive Level: Analyze (analysis)
REF:
695
Special Questions: Prioritization | Special Questions: Multiple Patients
Nursing Process: Assessment
MSC:
NCLEX: Safe and Effective Care Environment
15.
The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with
hypertension. Which result is most important to communicate to the health care provider?
a.
Serum creatinine of 2.8 mg/dL
c.
Serum hemoglobin of 14.7 g/dL
b.
Serum potassium of 4.5 mEq/L
d.
Blood glucose level of 96 mg/dL
ANS:
A
The elevated serum creatinine indicates renal damage caused by the hypertension. The other laboratory results are
normal.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
686
Nursing Process: Assessment
16.
A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme
(ACE) inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a blood
pressure (BP) of 238/118 mm Hg. Which question should the nurse ask to follow up on these findings?
a.
“Have you recently taken any antihistamines?”
b.
“Have you consistently taken your medications?”
c.
“Did you take any acetaminophen (Tylenol) today?”
d.
“Have there been recent stressful events in your life?”
ANS:
B
Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis. Although
many over-the-counter medications can cause hypertension, antihistamines and acetaminophen do not increase BP.
Stressful events will increase BP but not usually to the level seen in this patient.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
691
NCLEX: Physiological Integrity
17.
The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a
hypertensive emergency. Which finding is most important to report to the health care provider?
a.
Urine output over 8 hours is 250 mL less than the fluid intake.
b.
The patient cannot move the left arm and leg when asked to do so.
c.
Tremors are noted in the fingers when the patient extends the arms.
d.
The patient complains of a headache with pain at level 7 of 10 (0 to 10 scale).
ANS:
B
The patient’s inability to move the left arm and leg indicates that a stroke may be occurring and will require immediate
action to prevent further neurologic damage. The other clinical manifestations are also likely caused by the hypertension
and will require rapid nursing actions, but they do not require action as urgently as the neurologic changes.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
699
Nursing Process: Assessment
18.
A patient with hypertension who has just started taking atenolol (Tenormin) returns to the health clinic
after 2 weeks for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which action should the
nurse take first?
a.
Tell the patient why a change in drug dosage is needed.
b.
Ask the patient if the medication is being taken as prescribed.
c.
Inform the patient that multiple drugs are often needed to treat hypertension.
d.
Question the patient regarding any lifestyle changes made to help control BP.
ANS:
B
Because nonadherence with antihypertensive therapy is common, the nurse’s initial action should be to determine
whether the patient is taking the atenolol as prescribed. The other actions also may be implemented, but these would be
done after assessing patient adherence with the prescribed therapy.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
695
Nursing Process: Implementation
19.
The registered nurse (RN) is caring for a patient with a hypertensive crisis who is receiving sodium
nitroprusside . Which nursing action can the nurse delegate to an experienced licensed practical/vocational nurse
(LPN/LVN)?
a.
Evaluate effectiveness of nitroprusside therapy on blood pressure (BP).
b.
Assess the patient’s environment for adverse stimuli that might increase BP.
c.
Titrate nitroprusside to decrease mean arterial pressure (MAP) to 115 mm Hg.
d.
Set up the automatic noninvasive BP machine to take readings every 15 minutes.
ANS:
D
LPN/LVN education and scope of practice include the correct use of common equipment such as automatic noninvasive
blood pressure machines. The other actions require advanced nursing judgment and education, and should be done by
RNs.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Delegation
TOP:
NCLEX: Safe and Effective Care Environment
REF:
696
Nursing Process: Planning
20.
The charge nurse observes a new registered nurse (RN) doing discharge teaching for a patient with
hypertension who has a new prescription for enalapril (Vasotec). The charge nurse will need to intervene if the new RN
tells the patient to
a.
increase the dietary intake of high-potassium foods.
b.
make an appointment with the dietitian for teaching.
c.
check the blood pressure (BP) at home at least once a day.
d.
move slowly when moving from lying to sitting to standing.
ANS:
A
The ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible adverse effect. The other
teaching by the new RN is appropriate for a patient with newly diagnosed hypertension who has just started therapy with
enalapril.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Delegation
TOP:
NCLEX: Safe and Effective Care Environment
REF:
691
Nursing Process: Implementation
21.
Which assessment finding for a patient who is receiving IV furosemide (Lasix) to treat stage 2
hypertension is most important to report to the health care provider?
a.
Blood glucose level of 175 mg/dL
b.
Serum potassium level of 3.0 mEq/L
c.
d.
Orthostatic systolic BP decrease of 12 mm Hg
Most recent blood pressure (BP) reading of 168/94 mm Hg
ANS:
B
Hypokalemia is a frequent adverse effect of the loop diuretics and can cause life-threatening dysrhythmias. The health
care provider should be notified of the potassium level immediately and administration of potassium supplements
initiated. The elevated blood glucose and BP also indicate a need for collaborative interventions but will not require action
as urgently as the hypokalemia. An orthostatic drop of 12 mm Hg will require intervention only if the patient is
symptomatic.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
688
Nursing Process: Evaluation
22.
Which nursing action should the nurse take first to assist a patient with newly diagnosed stage 1
hypertension in making needed dietary changes?
a.
Collect a detailed diet history.
b.
Provide a list of low-sodium foods.
c.
Help the patient make an appointment with a dietitian.
d.
Teach the patient about foods that are high in potassium.
ANS:
A
The initial nursing action should be assessment of the patient’s baseline dietary intake through a thorough diet history.
The other actions may be appropriate, but assessment of the patient’s baseline should occur first.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
694
Nursing Process: Assessment
23.
The nurse is caring for a 70-yr-old patient who uses hydrochlorothiazide and enalapril (Norvasc) but
whose self-monitored blood pressure (BP) continues to be elevated. Which patient information may indicate a need for a
change?
a.
Patient takes a daily multivitamin tablet.
b.
Patient checks BP daily just after getting up.
c.
Patient drinks wine three to four times a week.
d.
Patient uses ibuprofen (Motrin) treat osteoarthritis.
ANS:
D
Because use of nonsteroidal antiinflammatory drugs (NSAIDs) can prevent adequate BP control, the patient may need to
avoid the use of ibuprofen. A multivitamin tablet will help supply vitamin D, which may help lower BP. BP decreases while
sleeping, so self-monitoring early in the morning will result in obtaining pressures that are at their lowest. The patient’s
alcohol intake is not excessive.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
691
NCLEX: Physiological Integrity
SHORT ANSWER
1.
pressure (MAP)?
The nurse obtains a blood pressure of 176/82 mm Hg for a patient. What is the patient’s mean arterial
ANS:
113 mm Hg
MAP = (SBP + 2 DBP)/3
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
699
NCLEX: Physiological Integrity
Chapter 57: Stroke
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1.
After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects,
the nurse anticipates teaching the patient about
a.
cerebral aneurysm clipping. c.
oral low-dose aspirin therapy.
b.
heparin intravenous infusion.
d.
tissue plasminogen activator (tPA).
ANS:
C
The patient’s symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are
prescribed after a TIA to prevent a stroke. Continuous heparin infusion is not routinely used after TIA or with acute
ischemic stroke. The patient’s symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic
stroke, not for TIA.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1353
NCLEX: Physiological Integrity
2.
A patient is being admitted with a possible stroke. Which information from the assessment indicates
that the nurse should consult with the health care provider before giving the prescribed aspirin?
a.
The patient has dysphasia.
b.
The patient has atrial fibrillation.
c.
The patient reports that symptoms began with a severe headache.
d.
The patient has a history of brief episodes of right-sided hemiplegia.
ANS:
C
A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation,
dysphasia, and transient ischemic attack are not contraindications to aspirin use.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1348
NCLEX: Physiological Integrity
3.
A patient with a stroke experiences facial drooping on the right side and right-sided arm and leg
paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find?
a.
Impulsive behavior
b.
Right-sided neglect
c.
Hyperactive left-sided tendon reflexes
d.
Difficulty comprehending instructions
ANS:
D
Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language.
The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1350
NCLEX: Physiological Integrity
4.
During the change of shift report, a nurse is told that a patient has an occluded left posterior cerebral
artery. The nurse will anticipate that the patient may have
a.
dysphasia.
c.
visual deficits.
b.
confusion.
d.
poor judgment.
ANS:
C
Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery
involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
a.
b.
c.
d.
5.
When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis
to monitor and record the blood pressure daily.
to call the health care provider if stools are tarry.
that clopidogrel will dissolve clots in the cerebral arteries.
that clopidogrel will reduce cerebral artery plaque formation.
MSC:
REF:
1350
NCLEX: Physiological Integrity
ANS:
B
Clopidogrel inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to
notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease
plaque formation, or dissolve clots.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1353
NCLEX: Physiological Integrity
6.
A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which
response by the nurse is accurate?
a.
“The obstructing plaque is surgically removed from inside an artery in the neck.”
b.
“The diseased portion of the artery in the brain is replaced with a synthetic graft.”
c.
“A wire is threaded through an artery in the leg to the clots in the carotid artery, and the clots are removed.”
d.
“A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the
plaque.”
ANS:
A
In a carotid endarterectomy, the carotid artery is incised, and the plaque is removed. The response beginning, “The
diseased portion of the artery in the brain is replaced” describes an arterial graft procedure. The answer beginning, “A
catheter with a deflated balloon is positioned at the narrow area” describes an angioplasty. The final response beginning,
“A wire is threaded through the artery” describes the mechanical embolus removal in cerebral ischemia (MERCI)
procedure.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
1353
Nursing Process: Implementation
MSC:
NCLEX: Physiological Integrity
7.
A patient admitted with possible stroke has been aphasic for 3 hours, and his current blood pressure
(BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question?
a.
Keep head of bed elevated at least 30 degrees.
b.
Infuse normal saline intravenously at 75 mL/hr.
c.
Start a labetalol drip to keep BP less than 140/90 mm Hg.
d.
Administer tissue plasminogen activator (tPA) intravenously per protocol.
ANS:
C
Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is
recommended only if mean arterial pressure (MAP) is greater than130 mm Hg or systolic pressure is greater than 220 mm
Hg. Fluid intake should be 1500 to 2000 mL/day to maintain cerebral blood flow. The head of the bed should be elevated to
at least 30 degrees unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient
meets the other criteria for tPA use.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1354
NCLEX: Physiological Integrity
8.
A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours
previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing
the patient for
a.
surgical endarterectomy.
b.
transluminal angioplasty.
c.
intravenous heparin drip administration.
d.
tissue plasminogen activator (tPA) infusion.
ANS:
D
The patient’s history and clinical manifestations suggest an acute ischemic stroke, and a patient who is seen within 4.5
hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency
phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is
having an acute ischemic stroke.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1355
NCLEX: Physiological Integrity
9.
A female patient who had a stroke 24 hours ago has expressive aphasia. An appropriate nursing
intervention to help the patient communicate is to
a.
ask questions that the patient can answer with “yes” or “no.”
b.
develop a list of words that the patient can read and practice reciting.
c.
have the patient practice her facial and tongue exercises with a mirror.
d.
prevent embarrassing the patient by answering for her if she does not respond.
ANS:
A
Communication will be facilitated and less frustrating to the patient when questions that require a “yes” or “no” response
are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will
frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of
the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to
respond.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
10.
manage
a.
b.
c.
d.
MSC:
REF:
1361
NCLEX: Physiological Integrity
For a patient who had a right hemisphere stroke, the nurse anticipates planning interventions to
impaired physical mobility related to right-sided hemiplegia.
risk for injury related to denial of deficits and impulsiveness.
impaired verbal communication related to speech-language deficits.
ineffective coping related to depression and distress about disability.
ANS:
B
The patient with right-sided brain damage typically denies any deficits and has poor impulse control, leading to risk for
injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left
hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with
depression and distress about the disability.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Diagnosis MSC:
REF:
1350
NCLEX: Physiological Integrity
11.
When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke,
which intervention should the nurse include in the plan of care?
a.
Apply an eye patch to the right eye.
b.
Approach the patient from the right side.
c.
Place needed objects on the patient’s left side.
d.
Teach the patient that the left visual deficit will resolve.
ANS:
C
During the acute period, the nurse should place objects on the patient’s unaffected side. Because there is a visual defect
in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The
visual deficit may not resolve, although the patient can learn to compensate for the defect.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1362
NCLEX: Physiological Integrity
12.
A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention
should the nurse include in the plan of care?
a.
Provide a wide variety of food choices.
b.
Provide oral care before and after meals.
c.
Assist the patient to eat with the right hand.
d.
Teach the patient the “chin-tuck” technique.
ANS:
C
Because the patient has difficulty feeding himself, the appropriate interventions will focus on teaching the patient to use
the right hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced
nutrition.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1361
NCLEX: Physiological Integrity
13.
A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the
nurse include in the plan of care?
a.
Apply intermittent pneumatic compression stockings.
b.
Assist to dangle on edge of bed and assess for dizziness.
c.
Encourage patient to cough and deep breathe every 4 hours.
d.
Insert an oropharyngeal airway to prevent airway obstruction.
ANS:
A
The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further
bleeding and is at risk for venous thromboembolism. Activities such as coughing and sitting up that might increase
intracranial pressure or decrease cerebral blood flow are avoided. Because there is no indication that the patient is
unconscious, an oropharyngeal airway is inappropriate.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
14.
REF:
1359
NCLEX: Physiological Integrity
A patient will attempt oral feedings for the first time after having a stroke. The nurse should assess the
gag reflex and then
a.
order a varied pureed diet. c.
b.
assess the patient’s appetite.
assist the patient into a chair.
d.
offer the patient a sip of juice.
ANS:
C
The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration
risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not
recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be
attempted.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1360
NCLEX: Physiological Integrity
15.
A male patient who has right-sided weakness after a stroke is making progress in learning to use the
left hand for feeding and other activities. The nurse observes that when the patient’s wife is visiting, she feeds and dresses
him. Which nursing diagnosis is most appropriate for the patient?
a.
Interrupted family processes related to effects of illness of a family member
b.
Situational low self-esteem related to increasing dependence on spouse for care
c.
Disabled family coping related to inadequate understanding by patient’s spouse
d.
Impaired nutrition: less than body requirements related to hemiplegia and aphasia
ANS:
C
The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation
program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not
support an interruption in family processes because this may be a typical pattern for the couple. There is no indication
that the patient has impaired nutrition.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Diagnosis MSC:
REF:
1362
NCLEX: Psychosocial Integrity
16.
Several weeks after a stroke, a 50-yr-old male patient has impaired awareness of bladder fullness,
resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training
program?
a.
Limit fluid intake to 1200 mL daily to reduce urine volume.
b.
Assist the patient onto the bedside commode every 2 hours.
c.
Perform intermittent catheterization after each voiding to check for residual urine.
d.
Use an external “condom” catheter to protect the skin and prevent embarrassment.
ANS:
B
Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A
1200-mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are
appropriate in the acute phase of stroke, but should not be considered solutions for long-term management because of
the risks for urinary tract infection and skin breakdown.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1360
NCLEX: Physiological Integrity
17.
A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily.
When the nurse is administering medications, the patient says, “I don’t need the aspirin today. I don’t have a fever.” Which
action should the nurse take?
a.
Document that the aspirin was refused by the patient.
b.
Tell the patient that the aspirin is used to prevent a fever.
c.
Explain that the aspirin is ordered to decrease stroke risk.
d.
Call the health care provider to clarify the medication order.
ANS:
C
Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient’s refusal to take
the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider.
The aspirin is not ordered to prevent aches and pains.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1353
NCLEX: Physiological Integrity
18.
A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that
resolved after 2 hours. The nurse will anticipate teaching the patient about
a.
tPA.
c.
warfarin (Coumadin).
b.
aspirin . d.
nimodipine
ANS:
B
After a transient ischemic attack, patients typically are started on medications such as aspirin to inhibit platelet function
and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial
fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
19.
should
a.
b.
c.
d.
REF:
1353
NCLEX: Physiological Integrity
A patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse
use a calm voice to ask the patient to stop the crying behavior.
explain to the family that depression is normal following a stroke.
have the family members leave the patient alone for a few minutes.
teach the family that emotional outbursts are common after strokes.
ANS:
D
Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional
state of the patient. Depression after a stroke is common, but the suddenness of the patient’s outburst suggests that
depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the
patient’s control, and asking the patient to stop will lead to embarrassment.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1364
NCLEX: Psychosocial Integrity
20.
Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to
address?
a.
The patient is 25 lb above the ideal weight.
b.
The patient drinks a glass of red wine with dinner daily.
c.
The patient’s usual blood pressure (BP) is 170/94 mm Hg.
d.
The patient works at a desk and relaxes by watching television.
ANS:
C
Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men)
alcoholic beverages a day may increase their risk for hypertension. Physical inactivity and obesity contribute to stroke risk
but not as much as hypertension.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
TOP:
NCLEX: Health Promotion and Maintenance
REF:
1347
Nursing Process: Assessment
21.
A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an
intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care
provider?
a.
The patient’s speech is difficult to understand.
b.
The patient’s blood pressure (BP) is 144/90 mm Hg.
c.
The patient takes a diuretic because of a history of hypertension.
d.
The patient has atrial fibrillation and takes warfarin (Coumadin).
ANS:
D
The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding.
Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to
correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient’s
care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred
speech is consistent with a left-sided stroke, and no change in therapy is indicated.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1349
Nursing Process: Assessment
22.
A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency
department and diagnostic tests are ordered. Which test should be done first?
a.
Complete blood count (CBC)
b.
Chest radiograph (chest x-ray)
c.
Computed tomography (CT) scan
d.
12-Lead electrocardiogram (ECG)
ANS:
C
Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which
must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the less
brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be
completed as urgently as the CT scan.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1354
Nursing Process: Implementation
23.
Nurses in change-of-shift report are discussing the care of a patient with a stroke who has
progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has
the highest priority for the patient?
a.
Impaired physical mobility related to weakness
b.
Disturbed sensory perception related to brain injury
c.
Risk for impaired skin integrity related to immobility
d.
Risk for aspiration related to inability to protect airway
ANS:
D
Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also
appropriate, but interventions to prevent aspiration are the priority at this time.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1354
Nursing Process: Analysis
24.
Which information about the patient who has had a subarachnoid hemorrhage is most important to
communicate to the health care provider?
a.
The patient complains of having a stiff neck.
b.
The patient’s blood pressure (BP) is 90/50 mm Hg.
c.
The patient reports a severe and unrelenting headache.
d.
The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).
ANS:
B
To prevent cerebral vasospasm and maintain cerebral perfusion, BP needs to be maintained at a level higher than 90 mm
Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or
vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical
manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1350
Nursing Process: Assessment
25.
The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which
action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?
a.
Assess the patient’s gag and cough reflexes.
b.
Determine when the stroke symptoms began.
c.
Administer the prescribed short-acting insulin.
d.
Infuse the prescribed IV metoprolol (Lopressor).
ANS:
C
Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. The other actions
require more education and scope of practice and should be done by the registered nurse (RN).
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Delegation
TOP:
NCLEX: Safe and Effective Care Environment
26.
first?
a.
b.
c.
d.
REF:
1359
Nursing Process: Planning
After receiving change-of-shift report on the following four patients, which patient should the nurse see
A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed
A 50-yr-old patient who has atrial fibrillation and a new order for warfarin (Coumadin)
A 30-yr-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled
A 40-yr-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due
ANS:
A
tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain
injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical.
DIF:
OBJ:
TOP:
Cognitive Level: Analyze (analysis)
REF:
1355
Special Questions: Prioritization | Special Questions: Multiple Patients
Nursing Process: Implementation
MSC:
NCLEX: Safe and Effective Care Environment
27.
The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and
stenting. Which assessment information is of most concern to the nurse?
a.
The pulse rate is 102 beats/min.
b.
The patient has difficulty speaking.
c.
The blood pressure is 144/86 mm Hg.
d.
There are fine crackles at the lung bases.
ANS:
B
Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during
the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the
procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure. The nurse
should have the patient take some deep breaths.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1351
Nursing Process: Assessment
28.
A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the emergency
department. Which action should the nurse take first?
a.
Take the patient’s blood pressure.
b.
Check the respiratory rate and effort.
c.
Assess the Glasgow Coma Scale score.
d.
Send the patient for a computed tomography (CT) scan.
ANS:
B
The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other
activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1354
Nursing Process: Implementation
29.
The home health nurse is caring for an 81-yr-old who had a stroke 2 months ago. Based on information
shown in the accompanying figure from the history, physical assessment, and physical and occupational therapy, which
problem is the highest priority?
History Physical Assessment
Physical/Occupational Therapy
• Well controlled type 2 diabetes for 10 years
•Married 45 years; spouse has heart failure and chronic obstructive pulmonary disease
•Oriented to time, place,
person
•Speech clear
•Minimal left leg weakness •Uses cane with walking
•Spouse does household cleaning and cooking and assists patient with bathing and dressing
a.
b.
Risk for hypoglycemia
Impaired transfer ability
c.
d.
Risk for caregiver role strain
Ineffective health maintenance
ANS:
C
The spouse’s household and patient care responsibilities, in combination with chronic illnesses, indicate a high risk for
caregiver role strain. The nurse should further assess the situation and take appropriate actions. The data about the
control of the patient’s diabetes indicates that ineffective health maintenance and risk for unstable blood glucose are not
priority concerns at this time. Because the patient is able to ambulate with a cane, the nursing diagnosis of impaired
transfer ability is not supported.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Psychosocial Integrity
TOP:
REF:
1362
Nursing Process: Diagnosis
OTHER
1.
A 63-yr-old patient who began experiencing right arm and leg weakness is admitted to the emergency
department. In which order will the nurse implement these actions included in the stroke protocol? (Put a comma and a
space between each answer choice [A, B, C, D].)
a. Obtain CT scan without contrast.
b. Infuse tissue plasminogen activator (tPA).
c. Administer oxygen to keep O2 saturation >95%.
d. Use National Institute of Health Stroke Scale to assess patient.
ANS:
C, D, A, B
The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments
should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1354
Nursing Process: Implementation
Chapter 37: Vascular Disorders
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
4.
A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which group of
drugs will the nurse plan to include when teaching about PAD management?
a.
Statins c.
Thrombolytics
b.
Antibiotics
d.
Anticoagulants
ANS:
A
Research indicates that statin use by patients with PAD improves multiple outcomes. There is no research that supports
the use of the other drug categories in PAD.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
805
NCLEX: Physiological Integrity
8.
When evaluating the discharge teaching for a patient with chronic peripheral artery disease (PAD), the
nurse determines a need for further instruction when the patient says, “I will
a.
use a heating pad on my feet at night to increase the circulation.”
b.
buy some loose clothes that do not bind across my legs or waist.”
c.
walk to the point of pain, rest, and walk again for at least 30 minutes 3 times a week.”
d.
change my position every hour and avoid long periods of sitting with my legs crossed.”
ANS:
A
Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns. The
other patient statements are correct and indicate that teaching has been successful.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
804
NCLEX: Physiological Integrity
20.
While working in the outpatient clinic, the nurse notes that a patient has a history of intermittent
claudication. Which statement by the patient would support this information?
a.
“When I stand too long, my feet start to swell.”
b.
“My legs cramp when I walk more than a block.”
c.
“I get short of breath when I climb a lot of stairs.”
d.
“My fingers hurt when I go outside in cold weather.”
ANS:
B
Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication. Finger pain
associated with cold weather is typical of Raynaud’s phenomenon. Shortness of breath that occurs with exercise is not
typical of intermittent claudication, which is reproducible. Swelling associated with prolonged standing is typical of
venous disease.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
803
NCLEX: Physiological Integrity
26.
The nurse is caring for a patient with critical limb ischemia who has just arrived on the nursing unit
after having percutaneous transluminal balloon angioplasty. Which action should the nurse perform first?
a.
Obtain vital signs. c.
Assess pedal pulses.
b.
Teach wound care.d.
Check the wound site.
ANS:
A
Bleeding is a possible complication after catheterization of the femoral artery, so the nurse’s first action should be to
assess for changes in vital signs that might indicate hemorrhage. The other actions are also appropriate but can be done
after determining that bleeding is not occurring.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
804
Nursing Process: Implementation
27.
A patient who is 2 days post femoral popliteal bypass graft to the right leg is being cared for on the
vascular unit. Which action by a licensed practical/vocational nurse (LPN/LVN) caring for the patient requires the
registered nurse (RN) to intervene?
a.
The LPN/LVN has the patient to sit in a chair for 2 hours.
b.
The LPN/LVN gives the prescribed aspirin after breakfast.
c.
The LPN/LVN assists the patient to walk 40 feet in the hallway.
d.
The LPN/LVN places the patient in Fowler’s position for meals.
ANS:
A
The patient should avoid sitting for long periods because of the increased stress on the suture line caused by leg edema
and because of the risk for venous thromboembolism (VTE). The other actions by the LPN/LVN are appropriate.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Delegation
TOP:
NCLEX: Safe and Effective Care Environment
REF:
806
Nursing Process: Implementation
35.
The nurse is admitting a patient newly diagnosed with peripheral artery disease. Which admission order
should the nurse question?
a.
Cilostazol drug therapy
b.
Omeprazole drug therapy
c.
Use of treadmill for exercise
d.
Exercise to the point of discomfort
ANS:
B
Because the antiplatelet effect of clopidogrel is reduced when it is used with omeprazole, the nurse should clarify this
order with the health care provider. The other interventions are appropriate for a patient with peripheral artery disease.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
805
NCLEX: Physiological Integrity
COMPLETION
1.
When assessing a patient with possible peripheral artery disease (PAD), the nurse obtains a brachial
blood pressure (BP) of 147/82 mm Hg and an ankle pressure of 112/74 mm Hg. The nurse calculates the patient’s anklebrachial index (ABI) as ________ (round up to the nearest hundredth).
ANS:
0.76
The ABI is calculated by dividing the ankle systolic BP by the brachial systolic BP.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
805
NCLEX: Physiological Integrity
Chapter 11: Pregnancy at Risk: Preexisting Conditions
MULTIPLE CHOICE
17.
has:
a.
b.
Prophylaxis of subacute bacterial endocarditis is given before and after birth when a pregnant woman
Valvular disease. c.
Congestive heart disease.
Arrhythmias.
d.
Postmyocardial infarction.
ANS:
A
Prophylaxis for intrapartum endocarditis and pulmonary infection may be provided for women who have mitral valve
stenosis. Prophylaxis for intrapartum endocarditis is not indicated for congestive heart disease, arrhythmias, or after
myocardial infarction.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
285
Nursing Process: Implementation
MSC:
Client Needs: Physiologic Integrity
Chapter 42: Cardiovascular Dysfunction
MULTIPLE CHOICE
a.
b.
4.
Which defect results in increased pulmonary blood flow?
Pulmonic stenosis c.
Atrial septal defect
Tricuspid atresia d.
Transposition of the great arteries
ANS:
C
Atrial septal defect results in increased pulmonary blood flow. Blood flows from the left atrium (higher pressure) into the
right atrium (lower pressure) and then to the lungs via the pulmonary artery. Pulmonic stenosis is an obstruction to blood
flowing from the ventricles. Tricuspid atresia results in decreased pulmonary blood flow. Transposition of the great
arteries results in mixed blood flow.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1322
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
a.
b.
c.
d.
5.
Which structural defects constitute tetralogy of Fallot?
Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy
ANS:
A
Tetralogy of Fallot has these four characteristics: pulmonary stenosis, ventricular septal defect, overriding aorta, and right
ventricular hypertrophy. There is pulmonic stenosis but not aortic stenosis in tetralogy of Fallot. Right ventricular
hypertrophy, not left ventricular hypertrophy, is present in tetralogy of Fallot. There is a ventricular septal defect, not an
atrial septal defect, and overriding aorta, not aortic hypertrophy, is present.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1327
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
47.
A nurse is teaching nursing students the physiology of congenital heart defects. Which defect results in
decreased pulmonary blood flow?
a.
Atrial septal defectc.
Ventricular septal defect
b.
Tetralogy of Fallot d.
Patent ductus arteriosus
ANS:
B
Tetralogy of Fallot results in decreased blood flow to the lungs. The pulmonic stenosis increases the pressure in the right
ventricle, causing the blood to go from right to left across the interventricular septal defect. Atrial and ventricular septal
defects and patent ductus arteriosus result in increased pulmonary blood flow.
PTS:
1
DIF:
Cognitive Level: Comprehension
REF:
1327
OBJ:
MSC:
Nursing Process: Assessment
Client Needs: Physiologic Integrity: Physiologic Adaptation
Gas Exchange
Concept 19: Gas Exchange
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
The nurse is assigned a group of patients. Which patient finding would the nurse identify as a factor
leading to increased risk for impaired gas exchange?
a.
Blood glucose of 350 mg/dL
b.
Anticoagulant therapy for 10 days
c.
Hemoglobin of 8.5 g/dL
d.
Heart rate of 100 beats/min and blood pressure of 100/60
ANS:
C
The hemoglobin is low (anemia), therefore the ability of the blood to carry oxygen is decreased. High blood glucose and/or
anticoagulants do not alter the oxygen carrying capacity of the blood. A heart rate of 100 beats/min and blood pressure of
100/60 are not indicative of oxygen carrying capacity of the blood.
REF:
Page 178
OBJ:
NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential and Physiological
Adaptation
2.
The nurse is reviewing the patient's arterial blood gas results. The PaO2 is 96 mm Hg, pH is 7.20, PaCO2
is 55 mm Hg, and HCO3 is 25 mEq/L. What might the nurse expect to observe on assessment of this patient?
a.
Disorientation and tremors
b.
Tachycardia and decreased blood pressure
c.
Increased anxiety and irritability
d.
Hyperventilation and lethargy
ANS:
A
The patient is experiencing respiratory acidosis (pH and PaCO2) which may be manifested by disorientation, tremors,
possible seizures, and decreased level of consciousness. Tachycardia and decreased blood pressure are not
characteristic of a problem of respiratory acidosis. Increased anxiety and hyperventilation will cause respiratory alkalosis,
which is manifested by an increase in pH and a decrease in PaCO2.
REF:
OBJ:
Page 182
NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3.
The nurse would identify which patient condition as a problem of impaired gas exchange secondary to
a perfusion problem?
a.
Peripheral arterial disease of the lower extremities
b.
Chronic obstructive pulmonary disease (COPD)
c.
Chronic asthma
d.
Severe anemia secondary to chemotherapy
ANS:
A
Perfusion relates to the ability of the blood to deliver oxygen to the cellular level and return the carbon dioxide to the lung
for removal. COPD and asthma are examples of a ventilation problem. Severe anemia is an example of a transport problem
of gas exchange.
REF:
OBJ:
Page 179 |Page 180
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
4.
The nurse is assessing a patient's differential white blood cell count. What implications would this test
have on evaluating the adequacy of a patient's gas exchange?
a.
An elevation of the total white cell count indicates generalized inflammation.
b.
Eosinophil count will assist to identify the presence of a respiratory infection.
c.
White cell count will differentiate types of respiratory bacteria.
d.
Level of neutrophils provides guidelines to monitor a chronic infection.
ANS:
A
Elevation of total white cell count is indicative of inflammation that is often due to an infection. Upper respiratory
infections are common problems in altering a patient's gas exchange. Eosinophil cells are increased in an allergic
response. Neutrophils are more indicative of an acute inflammatory response. White cells do not assist to differentiate
types of respiratory bacteria. Monocytes are an indicator of progress of a chronic infection.
REF:
OBJ:
Page 182
NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5.
The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse
identify as having an increased risk for the development of respiratory acidosis?
a.
Chronic lung disease with increased carbon dioxide retention
b.
Acute anxiety, hyperventilation, and decreased carbon dioxide retention
c.
Decreased cardiac output with increased serum lactic acid production
d.
Gastric drainage with increased removal of gastric acid
ANS:
A
Respiratory acidosis is caused by an increase in retention of carbon dioxide, regardless of the underlying disease. A
decrease in carbon dioxide retention may lead to respiratory alkalosis. An increase in production of lactic acid leads to
metabolic acidosis. Removal of an acid (gastric secretions) will lead to a metabolic alkalosis.
REF:
OBJ:
Page 182
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
a.
b.
c.
d.
6.
Which patient finding would the nurse identify as being a risk factor for altered transport of oxygen?
Hemoglobin level of 8.0
Bronchoconstriction and mucus
Peripheral arterial disease
Decreased thoracic expansion
ANS:
A
Altered transportation of oxygen refers to patients with insufficient red blood cells to transport the oxygen present.
Bronchoconstriction and decreased thoracic expansion (spinal cord injury) would result in impairment of ventilation.
Peripheral vascular disease would result in inadequate perfusion.
REF:
OBJ:
Page 180 |Page 182
NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential
7.
A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which
principle contributing to this risk?
a.
The infant is becoming more active.
b.
There is an increase in intake of breast milk or formula.
c.
The infant is unable to maintain an adequate iron intake.
d.
A depletion of fetal hemoglobin occurs.
ANS:
D
Fetal hemoglobin is present for about 5 months. The fetal hemoglobin begins deteriorating, and around 2 to 3 months the
infant is at increased risk of developing an anemia due to decreasing levels of hemoglobin. Breast milk or formula is the
primary food intake up to around 6 months. Often iron supplemented formula is offered, and/or an iron supplement is
given if the infant is breastfed.
REF:
Page 180 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
8.
Which clinical management prevention concept would the nurse identify as representative of secondary
prevention?
a.
Decreasing venous stasis and risk for pulmonary emboli
b.
Implementation of strict hand washing routines
c.
Maintaining current vaccination schedules
d.
Prevention of pneumonia in patients with chronic lung disease
ANS:
D
Prevention of and treatment of existing health problems to avoid further complications is an example of secondary
prevention. Primary prevention includes infection control (hand washing), smoking cessation, immunizations, and
prevention of postoperative complications.
REF:
OBJ:
Pages 183-184
NCLEX® Client Needs Category: Health Promotion and Maintenance
MULTIPLE RESPONSE
1.
The nurse would identify which body systems as directly involved in the process of normal gas
exchange? (Select all that apply.)
a.
Neurologic system
b.
Endocrine system
c.
Pulmonary system
d.
Immune system
e.
Cardiovascular system
f.
Hepatic system
ANS:
A, C, E
The neurologic system controls respiratory drive; the respiratory system controls delivery of oxygen to the lung
capillaries; and the cardiac system is responsible for the perfusion of vital organs. These systems are primarily
responsible for the adequacy of gas exchange in the body. The endocrine and hepatic systems are not directly involved
with gas exchange. The immune system primarily protects the body against infection.
REF:
OBJ:
Page 178
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
2.
The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would
indicate the patient has good ventilation? (Select all that apply.)
a.
Respiratory rate is 24 breaths/min.
b.
Oxygen saturation level is 98%.
c.
The right side of the thorax expands slightly more than the left.
d.
Trachea is just to the left of the sternal notch.
e.
Nail beds are pink with good capillary refill.
f.
There is presence of quiet, effortless breath sounds at lung base bilaterally.
ANS:
B, E, F
Oxygen saturation level should be between 95 and 100%; nail beds should be pink with capillary refill of about 3 seconds;
and breath sounds should be present at base of both lungs. Normal respiratory rate is between 12 and 20 breaths/min. The
trachea should be in midline with the sternal notch. The thorax should expand equally on both sides.
REF:
OBJ:
Page 178
NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential
Chapter 25: Assessment of Respiratory System
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1.
A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take
during the initial assessment of the patient?
a.
Ask the patient to lie down to complete a full physical assessment.
b.
Briefly ask specific questions about this episode of respiratory distress.
c.
Complete the admission database to check for allergies before treatment.
d.
Delay the physical assessment to first complete pulmonary function tests.
ANS:
B
When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more
thorough assessment is deferred until later. Obtaining a comprehensive health history or full physical examination is
unnecessary until the acute distress has resolved. Brief questioning and a focused physical assessment should be done
rapidly to help determine the cause of the distress and suggest treatment. Checking for allergies is important, but it is not
appropriate to complete the entire admission database at this time. The initial respiratory assessment must be completed
before any diagnostic tests or interventions can be ordered.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
459
NCLEX: Physiological Integrity
2.
The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse
position the patient?
a.
High-Fowler’s position with the left arm extended
b.
Supine with the head of the bed elevated 30 degrees
c.
On the right side with the left arm extended above the head
d.
Sitting upright with the arms supported on an over bed table
ANS:
D
The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and
expands the intercostal space so that access to the pleural space is easier. The other positions would increase the work of
breathing for the patient and make it more difficult for the health care provider performing the thoracentesis.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
471
NCLEX: Physiological Integrity
3.
A diabetic patient’s arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg;
HCO3– 18 mEq/L. The nurse would expect which finding?
a.
Intercostal retractions
c.
Low oxygen saturation (SpO2)
b.
Kussmaul respirations
d.
Decreased venous O2 pressure
ANS:
B
Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The low pH and low
bicarbonate result indicate metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in
venous O2 pressure would not be caused by acidosis.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
467
NCLEX: Physiological Integrity
4.
On auscultation of a patient’s lungs, the nurse hears low-pitched, bubbling sounds during inhalation in
the lower third of both lungs. How should the nurse document this finding?
a.
Inspiratory crackles at the bases
b.
Expiratory wheezes in both lungs
c.
Abnormal lung sounds in the apices of both lungs
d.
Pleural friction rub in the right and left lower lobes
ANS:
A
Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-pitched sounds. They can be
heard during the expiratory or inspiratory phase of the respiratory cycle. The lower third of both lungs are the bases, not
apices. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
468
NCLEX: Physiological Integrity
5.
The nurse palpates the posterior chest while the patient says “99” and notes absent fremitus. Which
action should the nurse take next?
a.
Palpate the anterior chest and observe for barrel chest.
b.
Encourage the patient to turn, cough, and deep breathe.
c.
Review the chest x-ray report for evidence of pneumonia.
d.
Auscultate anterior and posterior breath sounds bilaterally.
ANS:
D
To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient
repeats a word or phrase such as “99.” After noting absent fremitus, the nurse should then auscultate the lungs to assess
for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The
vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion.
Turning, coughing, and deep breathing is an appropriate intervention for atelectasis, but the nurse needs to first assess
breath sounds. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest). The
anterior of the chest is more difficult to palpate for fremitus because of the presence of large muscles and breast tissue.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
464
NCLEX: Physiological Integrity
6.
A patient with a chronic cough is scheduled to have a bronchoscopy with biopsy. Which intervention
will the nurse implement directly after the procedure?
a.
Encourage the patient to drink clear liquids.
b.
Place the patient on bed rest for at least 4 hours.
c.
Keep the patient NPO until the gag reflex returns.
d.
Maintain the head of the bed elevated 90 degrees.
ANS:
C
Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used to suppress the gag
and cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the
patient to take oral fluids or food. The patient does not need to be on bed rest, and the head of the bed does not need to be
in the high-Fowler’s position.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
470
NCLEX: Physiological Integrity
7.
The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When
auscultating the patient’s lungs, which finding would the nurse most likely hear?
a.
Continuous rumbling, snoring, or rattling sounds mainly on expiration
b.
Continuous high-pitched musical sounds on inspiration and expiration
c.
Discontinuous, high-pitched sounds of short duration during inspiration
d.
A series of long-duration, discontinuous, low-pitched sounds during inspiration
ANS:
C
Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, high-pitched
sounds of short duration heard on inspiration. Course crackles are a series of long-duration, discontinuous, low-pitched
sounds during inspiration. Wheezes are continuous high-pitched musical sounds on inspiration and expiration.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
468
NCLEX: Physiological Integrity
8.
The nurse observes that a patient with respiratory disease experiences a decrease in SpO2 from 93% to
88% while the patient is ambulating. What is the priority action of the nurse?
a.
Notify the health care provider.
b.
Administer PRN supplemental O2.
c.
Document the response to exercise.
d.
Encourage the patient to pace activity.
ANS:
B
The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental O2 when exercising. The other
actions are also important, but the first action should be to correct the hypoxemia.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
459
Nursing Process: Implementation
9.
The nurse teaches a patient about pulmonary spirometry testing. Which statement, if made by the
patient, indicates teaching was effective?
a.
“I should use my inhaler right before the test.”
b.
“I won’t eat or drink anything 8 hours before the test.”
c.
“I will inhale deeply and blow out hard during the test.”
d.
“My blood pressure and pulse will be checked every 15 minutes.”
ANS:
C
For spirometry, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not
needed. The administration of inhaled bronchodilators should be avoided 6 hours before the procedure.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
472
NCLEX: Physiological Integrity
10.
The nurse observes a student who is listening to a patient’s lungs. Which action by the student
indicates a need to review respiratory assessment skills?
a.
The student compares breath sounds from side to side at each level.
b.
The student listens during the inspiratory phase, then moves the stethoscope.
c.
The student starts at the apices of the lungs, moving down toward the lung bases.
d.
The student instructs the patient to breathe slowly and deeply through the mouth.
ANS:
B
Listening only during inspiration indicates the student needs a review of respiratory assessment skills. At each placement
of the stethoscope, listen to at least one cycle of inspiration and expiration. During chest auscultation, instruct the patient
to breathe slowly and a little deeper than normal through the mouth. Auscultation should proceed from the lung apices to
the bases, comparing opposite areas of the chest, unless the patient is in respiratory distress or will tire easily.
DIF:
Cognitive Level: Apply (application)
REF:
466
TOP:
Nursing Process: Assessment
MSC:
NCLEX: Safe and Effective Care Environment
11.
A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for
increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which
action by the nurse will be most effective in improving compliance with discharge teaching?
a.
Have the patient repeat the instructions immediately after teaching.
b.
Accomplish the patient teaching just before the scheduled discharge.
c.
Arrange for the patient’s caregiver to be present during the teaching.
d.
Start giving the patient discharge teaching during the admission process.
ANS:
C
Hypoxemia interferes with the patient’s ability to learn and retain information, so having the patient’s caregiver present will
increase the likelihood that discharge instructions will be followed. Having the patient repeat the instructions will indicate
that the information is understood at the time, but it does not guarantee retention of the information. Because the patient
is likely to be distracted just before discharge, giving discharge instructions just before discharge is not ideal. The patient
is likely to be anxious and even more hypoxemic than usual on the day of admission, so teaching about discharge should
be postponed.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Planning MSC:
REF:
462
NCLEX: Physiological Integrity
12.
A patient admitted to the emergency department complaining of sudden onset shortness of breath is
diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm
the diagnosis?
a.
Ensure that the patient has been NPO.
b.
Start an IV so contrast media may be given.
c.
Inform radiology that radioactive glucose preparation is needed.
d.
Instruct the patient to expect to inspire deeply and exhale forcefully.
ANS:
B
Spiral computed tomography scans are the most commonly used test to diagnose pulmonary emboli and contrast media
may be given IV. Bronchoscopy is used to detect changes in the bronchial tree, not to assess for vascular changes, and
the patient should be NPO 6 to 12 hours before the procedure. Positron emission tomography scans are most useful in
determining the presence of malignancy and a radioactive glucose preparation is used. For spirometry, the patient is
asked to inhale deeply and exhale as long, hard, and fast as possible.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
470
NCLEX: Physiological Integrity
13.
The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates
that the patient may need teaching regarding medication use?
a.
“I have not had any acute asthma attacks during the past year.”
b.
“I became short of breath an hour before coming to the hospital.”
c.
“I’ve been taking Tylenol 650 mg every 6 hours for chest wall pain.”
d.
“I’ve been using my albuterol inhaler more frequently over the last 4 days.”
ANS:
D
The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may be imminent and
that a change in therapy may be needed. The patient should be taught to contact a health care provider if this occurs. The
other data do not indicate any need for additional teaching.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
460
NCLEX: Physiological Integrity
14.
A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which
information obtained by the nurse is a priority to communicate to the health care provider before the CT?
a.
Allergy to shellfishc.
Respiratory rate of 30
b.
Apical pulse of 104
d.
O2 saturation of 90%
ANS:
A
Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without
contrast or be premedicated before injection of the contrast media. The increased pulse, low oxygen saturation, and
tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT
procedure.
DIF:
Cognitive Level: Analyze (analysis)
REF:
470
OBJ:
MSC:
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
Nursing Process: Implementation
15.
The nurse analyzes the results of a patient’s arterial blood gases (ABGs). Which finding would require
immediate action?
a.
The bicarbonate level (HCO3–) is 31 mEq/L.
b.
The arterial oxygen saturation (SaO2) is 92%.
c.
The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg.
d.
The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
ANS:
D
All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation
curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation.
The nurse should intervene immediately to improve the patient’s oxygenation.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
a.
b.
16.
Which assessment finding indicates that the nurse should take immediate action for an older patient?
Weak cough effort c.
Dry mucous membranes
Barrel-shaped chest
d.
Bilateral basilar crackles
TOP:
REF:
457
Nursing Process: Assessment
ANS:
D
Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse
should immediately accomplish further assessments, such as O2 saturation, and notify the health care provider. A barrelshaped chest, hyperresonance to percussion, and a weak cough effort are associated with aging. Further evaluation may
be needed, but immediate action is not indicated. An older patient has a less forceful cough and fewer and less functional
cilia. Mucous membranes tend to be drier.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
468
Nursing Process: Assessment
17.
A patient in metabolic alkalosis is admitted to the emergency department and pulse oximetry (SpO2)
indicates that the O2 saturation is 94%. Which action should the nurse expect to take next?
a.
Complete a head-to-toe assessment.
b.
Administer an inhaled bronchodilator.
c.
Place the patient on high-flow oxygen.
d.
Obtain repeat arterial blood gases (ABGs).
ANS:
C
Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will decrease the amount of
O2 delivered to tissues, so high oxygen concentrations should be given. A head-to-toe assessment and repeat ABGs may
be implemented later. Bronchodilators are not needed for metabolic alkalosis and there is no indication that the patient is
having difficulty with airflow.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
a.
b.
c.
d.
18.
After the nurse has received change-of-shift report, which patient should the nurse assess first?
A patient with pneumonia who has crackles in the right lung base
A patient with chronic bronchitis who has a low forced vital capacity
A patient with possible lung cancer who has just returned after bronchoscopy
A patient with hemoptysis and a 16-mm induration after tuberculin skin testing
TOP:
REF:
457
Nursing Process: Implementation
ANS:
C
Because the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway patency. The
other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse.
DIF:
OBJ:
TOP:
Cognitive Level: Analyze (analysis)
REF:
463
Special Questions: Prioritization | Special Questions: Multiple Patients
Nursing Process: Assessment
MSC:
NCLEX: Safe and Effective Care Environment
19.
The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is
most important for the nurse to report immediately to the health care provider?
a.
pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%
b.
pH 7.35, PaO2 85 mm Hg, PaCO2 50 mm Hg, and O2 sat 95%
c.
pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98%
d.
pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
ANS:
D
These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other
values are normal, close to normal, or compensated.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
456
Nursing Process: Implementation
20.
The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been
admitted with increasing dyspnea over the past 3 days. Which finding is important for the nurse to report to the health care
provider?
a.
Respirations are 36 breaths/min.
b.
Anterior-posterior chest ratio is 1:1.
c.
Lung expansion is decreased bilaterally.
d.
Hyperresonance to percussion is present.
ANS:
A
The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of
O2 or medications. The other findings are common chronic changes occurring in patients with COPD.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
460
NCLEX: Physiological Integrity
21.
Using the illustrated technique, the nurse is assessing for which finding in a patient with chronic
obstructive pulmonary disease (COPD)?
a.
b.
Hyperresonance c.
Tripod positioning d.
Reduced excursion
Accessory muscle use
ANS:
C
The technique for palpation for chest excursion is shown in the illustrated technique. Reduced chest movement would be
noted on palpation of a patient’s chest with COPD. Hyperresonance would be assessed through percussion. Accessory
muscle use and tripod positioning would be assessed by inspection.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
467
Nursing Process: Assessment
MSC:
NCLEX: Physiological Integrity
a.
b.
c.
d.
22.
Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
Listen to a patient’s lung sounds for wheezes or crackles.
Label specimens obtained during percutaneous lung biopsy.
Instruct a patient about how to use home spirometry testing.
Measure induration at the site of a patient’s intradermal skin test.
ANS:
B
Labeling of specimens is within the scope of practice of UAP. The other actions require nursing judgment and should be
done by licensed nursing personnel.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Delegation
TOP:
NCLEX: Safe and Effective Care Environment
REF:
471
Nursing Process: Assessment
Chapter 16: Fluid, Electrolyte, and Acid-Base Imbalances
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
10.
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for
continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85
mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
a.
Metabolic acidosis c.
Respiratory acidosis
b.
Metabolic alkalosis
d.
Respiratory alkalosis
ANS:
D
The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are
incorrect based on the pH and the normal HCO3.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
288
NCLEX: Physiological Integrity
11.
The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep
respirations. Which action should the nurse take?
a.
Give the prescribed PRN lorazepam (Ativan).
b.
Encourage the patient to take deep slow breaths.
c.
Start the prescribed PRN oxygen at 2 to 4 L/min.
d.
Administer the prescribed normal saline bolus and insulin.
ANS:
D
The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a
saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells. Oxygen
therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The
respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Lorazepam administration
will slow the respiratory rate and increase the level of acidosis.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
289
NCLEX: Physiological Integrity
15.
A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas
(ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these
results?
a.
Metabolic acidosis c.
Respiratory acidosis
b.
Metabolic alkalosis
d.
Respiratory alkalosis
ANS:
A
The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
288
NCLEX: Physiological Integrity
19.
A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely
cause of this value?
a.
Daily alcohol intake
b.
Dietary protein intake
c.
Multivitamin/mineral use
d.
Over-the-counter (OTC) laxative use
ANS:
A
Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level.
OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements tend to increase magnesium
levels.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
286
NCLEX: Physiological Integrity
25.
A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and
has decreased deep tendon reflexes. Family members report that the patient has been taking aluminum
hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. Which action should the nurse take first?
a.
Notify the patient’s health care provider.
b.
Obtain an order to draw a potassium level.
c.
Review the last magnesium level on the patient’s chart.
d.
Teach the patient about magnesium-containing antacids.
ANS:
A
The health care provider should be notified immediately. The patient has a history and manifestations consistent with
hypermagnesemia. The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent
to the laboratory for immediate electrolyte and chemistry determinations. Dialysis should correct the high magnesium
levels. The patient needs teaching about the risks of taking magnesium-containing antacids. Monitoring of potassium
levels also is important for patients with renal failure, but the patient’s current symptoms are not consistent with
hyperkalemia.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
286
Nursing Process: Implementation
26.
A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. The
patient complains of anxiety and incisional pain. The patient’s respiratory rate is 32 breaths/min, and the arterial blood
gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?
a.
Check to make sure the nasogastric tube is patent.
b.
Give the patient the PRN IV morphine sulfate 4 mg.
c.
Notify the health care provider about the ABG results.
d.
Teach the patient how to take slow, deep breaths when anxious.
ANS:
B
The patient’s respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The
nurse’s first action should be to medicate the patient for pain. The health care provider may be notified about the ABGs but
is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when
experiencing pain. Checking the nasogastric tube can wait until the patient has been medicated for pain.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
288
Nursing Process: Implementation
31.
When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which
finding should the nurse report to the health care provider immediately?
a.
The bibasilar breath sounds are decreased.
b.
The patellar and triceps reflexes are absent.
c.
The patient has been sleeping most of the day.
d.
The patient reports feeling “sick to my stomach.”
ANS:
B
The loss of the deep tendon reflexes indicates that the patient’s magnesium level may be reaching toxic levels. Nausea
and lethargy are also side effects associated with magnesium elevation and should be reported, but they are not as
significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and
deep breathe to prevent atelectasis.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
a.
b.
c.
d.
36.
After receiving change-of-shift report, which patient should the nurse assess first?
Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping
Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water
Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes
Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates
TOP:
REF:
286
Nursing Process: Assessment
ANS:
C
The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures. The other
patients have mild electrolyte disturbances or symptoms that require action, but they are not at risk for life-threatening
complications.
DIF:
OBJ:
TOP:
Cognitive Level: Analyze (analysis)
REF:
286
Special Questions: Prioritization | Special Questions: Multiple Patients
Nursing Process: Planning MSC:
NCLEX: Safe and Effective Care Environment
37.
During the admission process, the nurse obtains information about a patient through a physical
assessment and diagnostic testing. Based on the data shown in the accompanying figure, which nursing diagnosis is
appropriate?
a.
Deficient fluid volume
c.
Risk for injury: seizures
b.
Impaired gas exchange
d.
Risk for impaired skin integrity
ANS:
C
The patient’s muscle cramps and low serum calcium level indicate that the patient is at risk for seizures, tetany, or both.
The other diagnoses are not supported by the data because the skin turgor is good. The lungs are clear, arterial blood
gases are normal, and there is no evidence of edema or dehydration that might suggest that the patient is at risk for
impaired skin integrity.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Diagnosis MSC:
REF:
284
NCLEX: Physiological Integrity
Chapter 29: Assessment of Hematologic System
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
4.
A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which
action would be important for the nurse to take after the procedure?
a.
Elevate the head of the bed to 45 degrees.
b.
Have the patient lie on the left side for 1 hour.
c.
Apply a sterile 2-inch gauze dressing to the site.
d.
Use a half-inch sterile gauze to pack the wound.
ANS:
B
To decrease the risk for bleeding, the patient should lie on the left side for 30 to 60 minutes. After a bone marrow biopsy,
the wound is small and will not be packed with gauze. A pressure dressing is used to cover the aspiration site. There is no
indication to elevate the patient’s head.
PTS:
REF:
MSC:
1
DIF:
Cognitive Level: Apply (application)
599
TOP:
Nursing Process: Implementation
NCLEX: Physiological Integrity
11.
The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the
nurse include in the plan of care?
a.
Avoid intramuscular injections.
c.
Check temperature every 4 hours.
b.
Encourage increased oral fluids.
d.
Increase intake of iron-rich foods.
ANS:
A
Thrombocytopenia is a decreased number of platelets, which places the patient at high risk for bleeding. Neutropenic
patients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. Encouraging
fluid intake and iron-rich food intake is not indicated in a patient with thrombocytopenia.
PTS:
REF:
MSC:
1
DIF:
Cognitive Level: Apply (application)
600
TOP:
Nursing Process: Assessment
NCLEX: Physiological Integrity
12.
The health care provider’s progress note for a patient states that the complete blood count (CBC)
shows a “shift to the left.” Which assessment finding will the nurse expect?
a.
Cool extremities c.
Elevated temperature
b.
Pallor and weakness
d.
Low oxygen saturation
ANS:
C
The term “shift to the left” indicates that the number of immature polymorphonuclear neutrophils (bands) is elevated and
that finding is a sign of infection. There is no indication that the patient is at risk for hypoxemia, pallor or weakness, or
cool extremities.
PTS:
REF:
MSC:
1
DIF:
Cognitive Level: Apply (application)
600
TOP:
Nursing Process: Assessment
NCLEX: Physiological Integrity
15.
The nurse reviews the laboratory test results of a patient admitted with abdominal pain. Which
information will be most important for the nurse to communicate to the health care provider?
a.
Monocytes 4%
b.
Hemoglobin 13.6 g/dL
c.
Platelet count 168,000/µL
d.
White blood cell (WBC) count 15,500/µL
ANS:
D
The elevation in WBCs indicates that the patient has an inflammatory or infectious process ongoing, which may be the
cause of the patient’s pain, and that further diagnostic testing is needed. The monocytes are at a normal level. The
hemoglobin and platelet counts are normal.
PTS:
REF:
TOP:
1
DIF:
Cognitive Level: Analyze (analysis)
599
OBJ:
Special Questions: Prioritization
Nursing Process: Assessment
MSC:
NCLEX: Physiological Integrity
Chapter 30: Hematologic Problems
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1.
A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at
rest. The nurse would expect the patient’s laboratory test findings to include
a.
an RBC count of 4,500,000/L.
b.
a hematocrit (Hct) value of 38%.
c.
normal red blood cell (RBC) indices.
d.
a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).
ANS:
D
The patient’s clinical manifestations indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other
values are all within the range of normal.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
607
Nursing Process: Assessment
MSC:
NCLEX: Physiological Integrity
2.
Which menu choice indicates that the patient understands the nurse’s teaching about recommended
dietary choices for iron-deficiency anemia?
a.
Omelet and whole wheat toast
c.
Strawberry and banana fruit plate
b.
Cantaloupe and cottage cheese
d.
Cornmeal muffin and orange juice
ANS:
A
Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are
not the best choice for a patient with iron-deficiency anemia.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
610
NCLEX: Physiological Integrity
3.
A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic
anemia. The nurse will anticipate teaching the patient about increasing oral intake of
a.
iron.
c.
cobalamin (vitamin B12).
b.
folic acid.
d.
ascorbic acid (vitamin C).
ANS:
B
Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment.
The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
612
NCLEX: Physiological Integrity
4.
A 52-yr-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient
understands the teaching about the disorder when the patient states,
a.
“I need to start eating more red meat and liver.”
b.
“I will stop having a glass of wine with dinner.”
c.
“I could choose nasal spray rather than injections of vitamin B12.”
d.
“I will need to take a proton pump inhibitor such as omeprazole (Prilosec).”
ANS:
C
Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal
administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the
absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents
absorption of the vitamin.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
a.
b.
c.
d.
5.
An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to
provide a diet high in vitamin K.
alternate periods of rest and activity.
teach the patient how to avoid injury.
place the patient on protective isolation.
MSC:
REF:
612
NCLEX: Physiological Integrity
ANS:
B
Nursing care for patients with anemia should alternate periods of rest and activity to encourage activity without causing
undue fatigue. There is no indication that the patient has a bleeding disorder, so a diet high in vitamin K or teaching about
how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not
indicated for hemolytic anemia.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
608
NCLEX: Physiological Integrity
6.
Which patient statement to the nurse indicates a need for additional instruction about taking oral
ferrous sulfate?
a.
“I will call my health care provider if my stools turn black.”
b.
“I will take a stool softener if I feel constipated occasionally.”
c.
“I should take the iron with orange juice about an hour before eating.”
d.
“I should increase my fluid and fiber intake while I am taking iron tablets.”
ANS:
A
It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the health care
provider about this. The other patient statements are correct.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
609
NCLEX: Physiological Integrity
7.
Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital
with idiopathic aplastic anemia?
a.
Potential complication: seizures
b.
Potential complication: infection
c.
Potential complication: neurogenic shock
d.
Potential complication: pulmonary edema
ANS:
B
Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no
increased risk for seizures, neurogenic shock, or pulmonary edema.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
614
NCLEX: Physiological Integrity
a.
b.
c.
d.
8.
It is important for the nurse providing care for a patient with sickle cell crisis to
limit the patient’s intake of oral and IV fluids.
evaluate the effectiveness of opioid analgesics.
encourage the patient to ambulate as much as tolerated.
teach the patient about high-protein, high-calorie foods.
ANS:
B
Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for
control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to
decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, highcalorie diets are not emphasized.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
618
NCLEX: Physiological Integrity
9.
Which statement by a patient indicates good understanding of the nurse’s teaching about prevention of
sickle cell crisis?
a.
“Home oxygen therapy is frequently used to decrease sickling.”
b.
“There are no effective medications that can help prevent sickling.”
c.
“Routine continuous dosage narcotics are prescribed to prevent a crisis.”
d.
“Risk for a crisis is decreased by having an annual influenza vaccination.”
ANS:
D
Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal
pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be
administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a
medication used to decrease the number of sickle cell crises.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
617
NCLEX: Physiological Integrity
10.
Which instruction will the nurse plan to include in discharge teaching for a patient admitted with a
sickle cell crisis?
a.
Take a daily multivitamin with iron.
b.
Limit fluids to 2 to 3 quarts per day.
c.
Avoid exposure to crowds when possible.
d.
Drink only two caffeinated beverages daily.
ANS:
C
Exposure to crowds increases the patient’s risk for infection, the most common cause of sickle cell crisis. There is no
restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
617
NCLEX: Physiological Integrity
11.
The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan
to check the laboratory results for the
a.
Schilling test.
c.
gastric analysis.
b.
bilirubin level.
d.
stool occult blood.
ANS:
B
Jaundice is caused by the elevation of bilirubin level associated with red blood cell hemolysis. The other tests would not
be helpful in monitoring or treating a hemolytic anemia.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
615
NCLEX: Physiological Integrity
22.
A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion
of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient?
a.
Infuse the PRBCs slowly over 4 hours.
b.
Transfuse only leukocyte-reduced PRBCs.
c.
Administer the scheduled diuretic before the transfusion.
d.
Give the PRN dose of antihistamine before the transfusion.
ANS:
B
TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and
capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic
reactions, but they will not prevent TRALI.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
651
NCLEX: Physiological Integrity
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
650
NCLEX: Physiological Integrity
30.
A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after
a transfusion of packed red blood cells is started. The nurse’s first action should be to
a.
administer oxygen therapy at a high flow rate.
b.
obtain a urine specimen to send to the laboratory.
c.
notify the health care provider about the symptoms.
d.
disconnect the transfusion and infuse normal saline.
ANS:
D
The patient’s symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be
to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
a.
b.
c.
d.
31.
Which patient should the nurse assign as the roommate for a patient who has aplastic anemia?
A patient with chronic heart failure
A patient who has viral pneumonia
A patient who has right leg cellulitis
A patient with multiple abdominal drains
TOP:
REF:
650
Nursing Process: Implementation
ANS:
A
Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this
type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.
DIF:
Cognitive Level: Apply (application)
OBJ:
Special Questions: Multiple Patients
SHORT ANSWER
REF:
614
1.
A patient is to receive an infusion of 250 mL of platelets over 2 hours through tubing that is labeled: 1
mL equals 10 drops. How many drops per minute will the nurse infuse?
ANS:
21
To infuse 250 mL over 2 hours, the calculated drip rate is 20.8 drops/min or 21 drops/min.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
649
NCLEX: Physiological Integrity
Chapter 28: Obstructive Pulmonary Diseases
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1.
The nurse teaches a patient with chronic bronchitis about a new prescription for Advair Diskus
(combined fluticasone and salmeterol). Which action by the patient would indicate to the nurse that teaching about
medication administration has been successful?
a.
The patient shakes the device before use.
b.
The patient rapidly inhales the medication.
c.
The patient attaches a spacer to the Diskus.
d.
The patient performs huff coughing after inhalation.
ANS:
B
The patient should inhale the medication rapidly. Otherwise the dry particles will stick to the tongue and oral mucosa and
not get inhaled into the lungs. Advair Diskus is a dry powder inhaler; shaking is not recommended. Spacers are not used
with dry powder inhalers. Huff coughing is a technique to move mucus into larger airways to expectorate. The patient
should not huff cough or exhale forcefully after taking Advair in order to keep the medication in the lungs.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
552
NCLEX: Physiological Integrity
2.
The nurse teaches a patient how to administer formoterol (Perforomist) through a nebulizer. Which
action by the patient indicates good understanding of the teaching?
a.
b.
c.
d.
The patient attaches a spacer before using the inhaler.
The patient coughs vigorously after using the inhaler.
The patient removes the facial mask when misting stops.
The patient activates the inhaler at the onset of expiration.
ANS:
C
A nebulizer is used to administer aerosolized medication. A mist is seen when the medication is aerosolized, and when all
of the medication has been used, the misting stops. The other options refer to inhaler use. Coughing vigorously after
inhaling and activating the inhaler at the onset of expiration are both incorrect techniques when using an inhaler.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
551
NCLEX: Physiological Integrity
3.
A patient is scheduled for spirometry. Which action should the nurse take to prepare the patient for this
procedure?
a.
Give the rescue medication immediately before testing.
b.
Administer oral corticosteroids 2 hours before the procedure.
c.
Withhold bronchodilators for 6 to 12 hours before the examination.
d.
Ensure that the patient has been NPO for several hours before the test.
ANS:
C
Bronchodilators are held before spirometry so that a baseline assessment of airway function can be determined. Testing is
repeated after bronchodilator use to determine whether the decrease in lung function is reversible. There is no need for
the patient to be NPO. Oral corticosteroids should be held before spirometry. Rescue medications (which are
bronchodilators) would not be given until after the baseline pulmonary function was assessed.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
a.
b.
c.
d.
4.
Which information will the nurse include in the asthma teaching plan for a patient being discharged?
Use the inhaled corticosteroid when shortness of breath occurs.
Inhale slowly and deeply when using the dry powder inhaler (DPI).
Hold your breath for 5 seconds after using the bronchodilator inhaler.
Tremors are an expected side effect of rapidly acting bronchodilators.
MSC:
REF:
543
NCLEX: Physiological Integrity
ANS:
D
Tremors are a common side effect of short-acting 2-adrenergic (SABA) medications and not a reason to avoid using the
SABA inhaler. Inhaled corticosteroids do not act rapidly to reduce dyspnea. Rapid inhalation is needed when using a DPI.
The patient should hold the breath for 10 seconds after using inhalers.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
550
NCLEX: Physiological Integrity
5.
The emergency department nurse is evaluating the effectiveness of therapy for a patient who has
received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been
effective?
a.
No wheezes are audible.
b.
O2 saturation is >90%.
c.
Accessory muscle use has decreased.
d.
Respiratory rate is 16 breaths/minute.
ANS:
B
The goal for treatment of an asthma attack is to keep the O2 saturation above 90%. The other patient data may occur when
the patient is too fatigued to continue with the increased work of breathing required in an asthma attack.
DIF:
MSC:
Cognitive Level: Analyze (apply)
NCLEX: Physiological Integrity
REF:
545
TOP:
Nursing Process: Evaluation
6.
A patient seen in the asthma clinic has recorded daily peak flow rates that are 75% of the baseline.
Which action will the nurse plan to take next?
a.
Increase the dose of the leukotriene inhibitor.
b.
Teach the patient about the use of oral corticosteroids.
c.
Administer a bronchodilator and recheck the peak flow.
d.
Instruct the patient to keep the scheduled follow-up appointment.
ANS:
C
The patient’s peak flow reading indicates that the condition is worsening (yellow zone). The patient should take the
bronchodilator and recheck the peak flow. Depending on whether the patient returns to the green zone, indicating wellcontrolled symptoms, the patient may be prescribed oral corticosteroids or a change in dosing of other medications.
Keeping the next appointment is appropriate, but the patient also needs to be taught how to control symptoms now and
use the bronchodilator.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
555
NCLEX: Physiological Integrity
7.
The nurse teaches a patient who has asthma about peak flow meter use. Which action by the patient
indicates that teaching was successful?
a.
The patient inhales rapidly through the peak flow meter mouthpiece.
b.
The patient takes montelukast (Singulair) for peak flows in the red zone.
c.
The patient calls the health care provider when the peak flow is in the green zone.
d.
The patient uses an albuterol (Ventolin HFA) inhaler for peak flows in the yellow zone.
ANS:
D
Readings in the yellow zone indicate a decrease in peak flow. The patient should use short-acting 2-adrenergic (SABA)
medications. Readings in the green zone indicate good asthma control. The patient should exhale quickly and forcefully
through the peak flow meter mouthpiece to obtain the readings. Readings in the red zone do not indicate good peak flow,
and the patient should take a fast-acting bronchodilator and call the health care provider for further instructions. Singulair
is not indicated for acute attacks but rather is used for maintenance therapy.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
556
NCLEX: Physiological Integrity
8.
A young adult patient who denies any history of smoking is seen in the clinic with a new diagnosis of
chronic obstructive pulmonary disease (COPD). The nurse should plan to teach the patient about
a.
1-antitrypsin testing.
c.
use of the nicotine patch.
b.
leukotriene modifiers.
d.
continuous pulse oximetry.
ANS:
A
When COPD occurs in young patients, especially without a smoking history, a genetic deficiency in 1-antitrypsin should be
suspected. Because the patient does not smoke, a nicotine patch would not be ordered. There is no indication that the
patient requires continuous pulse oximetry. Leukotriene modifiers would be used in patients with asthma, not with COPD.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
558
NCLEX: Physiological Integrity
9.
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which
information obtained from the patient would prompt the nurse to consult with the health care provider before
administering the prescribed theophylline?
a.
The patient reports a recent 15-lb weight gain.
b.
The patient denies shortness of breath at present.
c.
The patient takes cimetidine (Tagamet HB) daily.
d.
The patient complains of coughing up green mucus.
ANS:
C
Cimetidine interferes with the metabolism of theophylline, and concomitant administration may lead rapidly to theophylline
toxicity. The other patient information would not affect whether the theophylline should be administered or not.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
549
NCLEX: Physiological Integrity
10.
The home health nurse is visiting a patient with chronic obstructive pulmonary disease (COPD). Which
nursing action is appropriate to implement for a nursing diagnosis of impaired breathing pattern related to anxiety?
a.
Titrate O2 to keep saturation at least 90%.
b.
Teach the patient how to use pursed-lip breathing.
c.
Discuss a high-protein, high-calorie diet with the patient.
d.
Suggest the use of over-the-counter sedative medications.
ANS:
B
Pursed-lip breathing techniques assist in prolonging the expiratory phase of respiration and decrease air trapping. There
is no indication that the patient requires O2 therapy or an improved diet. Sedative medications should be avoided because
they decrease respiratory drive.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
554
NCLEX: Physiological Integrity
11.
A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced
nutrition: less than body requirements. Which intervention would be most appropriate for the nurse to include in the plan
of care?
a.
Encourage increased intake of whole grains.
b.
Increase the patient’s intake of fruits and fruit juices.
c.
Offer high-calorie protein snacks between meals and at bedtime.
d.
Assist the patient in choosing foods with high vegetable content.
ANS:
C
Eating small amounts more frequently (as occurs with snacking) will increase caloric intake by decreasing the fatigue and
feelings of fullness associated with large meals. Patients with COPD should rest before meals. Foods that have a lot of
texture such as whole grains may take more energy to eat and get absorbed and lead to decreased intake. Although fruits,
juices, and minerals are not contraindicated, foods high in protein are a better choice.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
571
NCLEX: Physiological Integrity
12.
The nurse interviews a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD).
Which information is most specific in confirming a diagnosis of chronic bronchitis?
a.
The patient tells the nurse about a family history of bronchitis.
b.
The patient indicates a 30 pack-year cigarette smoking history.
c.
The patient reports a productive cough for 3 months every winter.
d.
The patient denies having respiratory problems until the past 12 months.
ANS:
C
A diagnosis of chronic bronchitis is based on a history of having a productive cough for 3 months for at least 2
consecutive years. There is no family tendency for chronic bronchitis. Although smoking is the major risk factor for
chronic bronchitis, a smoking history does not confirm the diagnosis.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
557
NCLEX: Physiological Integrity
13.
The nurse teaches a patient about pursed-lip breathing. Which action by the patient would indicate to
the nurse that further teaching is needed?
a.
The patient inhales slowly through the nose.
b.
The patient puffs up the cheeks while exhaling.
c.
The patient practices by blowing through a straw.
d.
The patient’s ratio of inhalation to exhalation is 1:3.
ANS:
B
The patient should relax the facial muscles without puffing the cheeks while doing pursed-lip breathing. The other actions
by the patient indicate a good understanding of pursed-lip breathing.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
554
NCLEX: Physiological Integrity
14.
Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most
useful in evaluating the effectiveness of treatment?
a.
Even, unlabored respirations
c.
Absence of wheezes or crackles
b.
Pulse oximetry reading of 92%
d.
Respiratory rate of 18 breaths/min
ANS:
B
For the nursing diagnosis of impaired gas exchange, the best data for evaluation are arterial blood gases (ABGs) or pulse
oximetry. The other data may indicate either improvement or impending respiratory failure caused by fatigue.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Evaluation
MSC:
REF:
543
NCLEX: Physiological Integrity
15.
The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient for which
expected finding?
a.
Chest pain
c.
Peripheral edema
b.
Finger clubbing
d.
Elevated temperature
ANS:
C
Cor pulmonale causes clinical manifestations of right ventricular failure, such as peripheral edema. The other clinical
manifestations may occur in the patient with other complications of chronic obstructive pulmonary disease but are not
indicators of cor pulmonale.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
560
NCLEX: Physiological Integrity
16.
The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive
pulmonary disease (COPD). How should the nurse determine the appropriate O2 flow rate?
a.
Minimize O2 use to avoid O2 dependency.
b.
Maintain the pulse oximetry level at 90% or greater.
c.
Administer O2 according to the patient’s level of dyspnea.
d.
Avoid administration of O2 at a rate of more than 2 L/min.
ANS:
B
The best way to determine the appropriate O2 flow rate is by monitoring the patient’s oxygenation either by arterial blood
gases (ABGs) or pulse oximetry. An O2 saturation of 90% indicates adequate blood O2 level without the danger of
suppressing the respiratory drive. For patients with an exacerbation of COPD, an O2 flow rate of 2 L/min may not be
adequate. Because O2 use improves survival rate in patients with COPD, there is no concern about O2 dependency. The
patient’s perceived dyspnea level may be affected by other factors (e.g., anxiety) besides blood O2 level.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
565
NCLEX: Physiological Integrity
17.
A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on
O2 therapy. Which instruction should the nurse include in the discharge teaching?
a.
Travel is not possible with the use of O2 devices.
b.
O2 flow should be increased if the patient has more dyspnea.
c.
O2 use can improve the patient’s prognosis and quality of life.
d.
Storage of O2 requires large metals tanks that each last 4 to 6 hours.
ANS:
C
The use of home O2 improves quality of life and prognosis. Because increased dyspnea may be a symptom of an acute
process such as pneumonia, the patient should notify the health care provider rather than increasing the O2 flow rate if
dyspnea becomes worse. O2 can be supplied using liquid, storage tanks, or concentrators, depending on individual
patient circumstances. Travel is possible using portable O2 concentrators.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
568
NCLEX: Physiological Integrity
18.
A patient is receiving 35% O2 via a Venturi mask. To ensure the correct amount of O2 delivery, which
action by the nurse is important?
a.
Teach the patient to keep the mask on during meals.
b.
Keep the air entrainment ports clean and unobstructed.
c.
Give a high enough flow rate to keep the bag from collapsing.
d.
Drain moisture condensation from the corrugated tubing every hour.
ANS:
B
The air entrainment ports regulate the O2 percentage delivered to the patient, so they must be unobstructed. The other
options refer to other types of O2 devices. A high O2 flow rate is needed when giving O2by partial rebreather or
nonrebreather masks. Draining O2 tubing is necessary when caring for a patient receiving mechanical ventilation. The
mask can be removed or changed to a nasal cannula at a prescribed setting when the patient eats.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
567
NCLEX: Physiological Integrity
19.
Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic
bronchitis. Which intervention should the nurse include in the plan of care?
a.
Schedule the procedure 1 hour after the patient eats.
b.
Maintain the patient in the lateral position for 20 minutes.
c.
Give the prescribed albuterol (Ventolin HFA) before the therapy.
d.
Perform percussion before assisting the patient to the drainage position.
ANS:
C
Bronchodilators are administered before chest physiotherapy. Postural drainage, percussion, and vibration should be
done 1 hour before or 3 hours after meals. Patients remain in each postural drainage position for 5 minutes. Percussion is
done while the patient is in the postural drainage position.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
569
NCLEX: Physiological Integrity
20.
The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with
severe chronic obstructive pulmonary disease (COPD). Which instructions would be appropriate for the nurse to include in
the plan of care?
a.
Stop exercising when you feel short of breath.
b.
Walk until pulse rate exceeds 130 beats/minute.
c.
Limit exercise to activities of daily living (ADLs).
d.
Walk 15 to 20 minutes a day at least 3 times/week.
ANS:
D
Encourage the patient to walk 15 to 20 minutes a day at least three times a week with gradual increases. Shortness of
breath is normal with exercise and not an indication that the patient should stop. Limiting exercise to ADLs will not
improve the patient’s exercise tolerance. A 70-yr-old patient should have a pulse rate of 120 beats/min or less with exercise
(80% of the maximal heart rate of 150 beats/min ).
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
573
NCLEX: Physiological Integrity
21.
A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, “I wish I were
dead! I’m just a burden on everybody.” Based on this information, which nursing diagnosis is most appropriate?
a.
Complicated grieving related to expectation of death
b.
Chronic low self-esteem related to physical dependence
c.
Ineffective coping related to unknown outcome of illness
d.
Deficient knowledge related to lack of education about COPD
ANS:
B
The patient’s statement about not being able to do anything for himself or herself supports this diagnosis. Although
deficient knowledge, complicated grieving, and ineffective coping may also be appropriate diagnoses for patients with
COPD, the data for this patient do not support these diagnoses.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Diagnosis MSC:
REF:
571
NCLEX: Psychosocial Integrity
22.
A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by
the nurse would support the patient’s ventilation?
a.
Have the patient rest in bed with the head elevated to 15 to 20 degrees.
b.
Encourage the patient to sit up at the bedside in a chair and lean forward.
c.
Ask the patient to rest in bed in a high-Fowler’s position with the knees flexed.
d.
Place the patient in the Trendelenburg position with pillows behind the head.
ANS:
B
Patients with COPD improve the mechanics of breathing by sitting up in the “tripod” position. Resting in bed with the head
elevated in a semi-Fowler’s position would be an alternative position if the patient was confined to bed, but sitting in a
chair allows better ventilation. The Trendelenburg position or sitting upright in bed with the knees flexed would decrease
the patient’s ability to ventilate well.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
561
NCLEX: Physiological Integrity
23.
A 55-yr-old patient with increasing dyspnea is being evaluated for a possible diagnosis of chronic
obstructive pulmonary disease (COPD). When teaching a patient about pulmonary spirometry for this condition, what is
the most important question the nurse should ask?
a.
“Are you claustrophobic?”
b.
“Are you allergic to shellfish?”
c.
“Have you taken any bronchodilators today?”
d.
“Do you have any metal implants or prostheses?”
ANS:
C
Spirometry will help establish the COPD diagnosis. Bronchodilators should be avoided at least 6 hours before the test.
Spirometry does not involve being placed in an enclosed area such as for magnetic resonance imaging (MRI). Contrast
dye is not used for spirometry. The patient may still have spirometry done if metal implants or prostheses are present
because they are contraindications for an MRI.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
561
NCLEX: Physiological Integrity
29.
Which instruction should the nurse include in an exercise teaching plan for a patient with chronic
obstructive pulmonary disease (COPD)?
a.
“Avoid upper body exercise to prevent dyspnea.”
b.
“Stop exercising if you start to feel short of breath.”
c.
“Use the bronchodilator before you start to exercise.”
d.
“Breathe in and out through the mouth while you exercise.”
ANS:
C
Use of a bronchodilator before exercise improves airflow for some patients and is recommended. Shortness of breath is
normal with exercise and not a reason to stop. Patients should be taught to breathe in through the nose and out through
the mouth (using a pursed-lip technique). Upper-body exercise can improve the mechanics of breathing in patients with
COPD.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
573
NCLEX: Physiological Integrity
30.
The nurse completes an admission assessment on a patient with asthma. Which information given by
patient is indicates a need for a change in therapy?
a.
The patient uses albuterol (Ventolin HFA) before aerobic exercise.
b.
The patient says that the asthma symptoms are worse every spring.
c.
The patient’s heart rate increases after using the albuterol (Ventolin HFA) inhaler.
d.
The patient’s only medications are albuterol (Ventolin HFAl) and salmeterol (Serevent).
ANS:
D
Long-acting 2-agonists should be used only in patients who also are using an inhaled corticosteroid for long-term control.
Salmeterol should not be used as the first-line therapy for long-term control. Using a bronchodilator before exercise is
appropriate. The other information given by the patient requires further assessment by the nurse but is not unusual for a
patient with asthma.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
547
NCLEX: Physiological Integrity
31.
The nurse takes an admission history on a patient with possible asthma who has new-onset wheezing
and shortness of breath. Which information may indicate a need for a change in therapy?
a.
The patient has chronic inflammatory bowel disease.
b.
The patient has a history of pneumonia 6 months ago.
c.
The patient takes propranolol (Inderal) for hypertension.
d.
The patient uses acetaminophen (Tylenol) for headaches.
ANS:
C
-Blockers such as propranolol can cause bronchospasm in some patients with asthma. The other information will be
documented in the health history but does not indicate a need for a change in therapy.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
554
NCLEX: Physiological Integrity
32.
A patient newly diagnosed with asthma is being discharged. The nurse anticipates including which
topic in the discharge teaching?
a.
Use of long-acting -adrenergic medications
b.
Side effects of sustained-release theophylline
c.
Self-administration of inhaled corticosteroids
d.
Complications associated with O2 therapy
ANS:
C
Inhaled corticosteroids are more effective in improving asthma than any other drug and are indicated for all patients with
persistent asthma. The other therapies would not typically be first-line treatments for newly diagnosed asthma.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
552
NCLEX: Physiological Integrity
33.
A patient with cystic fibrosis (CF) has blood glucose levels that are consistently between 180 to 250
mg/dL. Which nursing action will the nurse plan to implement?
a.
Discuss the role of diet in blood glucose control.
b.
Evaluate the patient’s use of pancreatic enzymes.
c.
Teach the patient about administration of insulin.
d.
Give oral hypoglycemic medications before meals.
ANS:
C
The glucose levels indicate that the patient has developed CF-related diabetes, and insulin therapy is required. Because
the etiology of diabetes in CF is inadequate insulin production, oral hypoglycemic agents are not effective. Patients with
CF need a high-calorie diet. Inappropriate use of pancreatic enzymes would not be a cause of hyperglycemia in a patient
with CF.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
577
NCLEX: Physiological Integrity
34.
The nurse assesses a patient with a history of asthma. Which assessment finding indicates that the
nurse should take immediate action?
a.
Pulse oximetry reading of 91%
b.
Respiratory rate of 26 breaths/min
c.
Use of accessory muscles in breathing
d.
Peak expiratory flow rate of 240 L/min
ANS:
C
Use of accessory muscle indicates that the patient is experiencing respiratory distress, and rapid intervention is needed.
The other data indicate the need for ongoing monitoring and assessment but do not suggest that immediate treatment is
required.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
545
Nursing Process: Assessment
35.
A patient who has been experiencing an asthma attack develops bradycardia and a decrease in
wheezing. Which action should the nurse take first?
a.
Notify the health care provider.
b.
Document changes in respiratory status.
c.
Encourage the patient to cough and deep breathe.
d.
Administer IV methylprednisolone (Solu-Medrol).
ANS:
A
The patient’s assessment indicates impending respiratory failure, and the nurse should prepare to assist with intubation
and mechanical ventilation after notifying the health care provider. IV corticosteroids require several hours before having
any effect on respiratory status. The patient will not be able to cough or deep breathe effectively. Documentation is not a
priority at this time.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
546
Nursing Process: Implementation
36.
A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which
assessment should the nurse complete first?
a.
Listen to the patient’s breath sounds.
b.
Ask about inhaled corticosteroid use.
c.
Determine when the dyspnea started.
d.
Obtain the forced expiratory volume (FEV) flow rate.
ANS:
A
Assessment of the patient’s breath sounds will help determine how effectively the patient is ventilating and whether rapid
intubation may be necessary. The length of time the attack has persisted is not as important as determining the patient’s
status at present. Most patients having an acute attack will be unable to cooperate with an FEV measurement. It is
important to know about the medications the patient is using but not as important as assessing the breath sounds.
DIF:
Cognitive Level: Analyze (analysis)
REF:
539
OBJ:
MSC:
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
Nursing Process: Assessment
37.
Which assessment finding in a patient who has received omalizumab (Xolair) is most important to
report immediately to the health care provider?
a.
Pain at injection site
c.
Peak flow reading 75% of normal
b.
Flushing and dizziness
d.
Respiratory rate 24 breaths/minute
ANS:
B
Flushing and dizziness may indicate that the patient is experiencing an anaphylactic reaction, and immediate intervention
is needed. The other information should also be reported, but do not indicate possibly life-threatening complications of
omalizumab therapy.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
548
Nursing Process: Assessment
38.
The nurse in the emergency department receives arterial blood gas results for four recently admitted
patients with obstructive pulmonary disease. The results for which patient will require the most rapid action by the nurse?
a.
pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg
b.
pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg
c.
pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg
d.
pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg
ANS:
A
The pH, PaCO2, and PaO2 indicate that the patient has severe uncompensated respiratory acidosis and hypoxemia. Rapid
action will be required to prevent increasing hypoxemia and correct the acidosis.
DIF:
OBJ:
TOP:
Cognitive Level: Analyze (analysis)
REF:
543
Special Questions: Prioritization | Special Questions: Multiple Patients
Nursing Process: Assessment
MSC:
NCLEX: Safe and Effective Care Environment
39.
Which nursing action for a patient with chronic obstructive pulmonary disease (COPD) could the nurse
delegate to experienced unlicensed assistive personnel (UAP)?
a.
Obtain O2 saturation using pulse oximetry.
b.
Monitor for increased O2 need with exercise.
c.
Teach the patient about safe use of O2 at home.
d.
Adjust O2 to keep saturation in prescribed parameters.
ANS:
A
UAP can obtain O2 saturation (after being trained and evaluated in the skill). The other actions require more education and
a scope of practice that licensed practical/vocational nurses (LPN/LVNs) or registered nurses (RNs) would have.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Delegation
TOP:
NCLEX: Safe and Effective Care Environment
REF:
568
Nursing Process: Planning
40.
The clinic nurse makes a follow-up telephone call to a patient with asthma. The patient reports having a
baseline peak flow reading of 600 L/min, and the current peak flow is 420 L/min. Which action should the nurse take first?
a.
Tell the patient to go to the hospital emergency department.
b.
Instruct the patient to use the prescribed albuterol (Ventolin HFA).
c.
Ask about recent exposure to any new allergens or asthma triggers.
d.
Question the patient about use of the prescribed inhaled corticosteroids.
ANS:
B
The patient’s peak flow is 70% of normal, indicating a need for immediate use of short-acting 2-adrenergic SABA
medications. Assessing for correct use of medications or exposure to allergens is also appropriate, but would not address
the current decrease in peak flow. Because the patient is currently in the yellow zone, hospitalization is not needed.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
546
Nursing Process: Implementation
41.
The nurse reviews the medication administration record (MAR) for a patient having an acute asthma
attack. Which medication should the nurse administer first?
a.
Methylprednisolone (Solu-Medrol) 60 mg IV
b.
c.
d.
Albuterol (Ventolin HFA) 2.5 mg per nebulizer
Salmeterol (Serevent) 50 mcg per dry-powder inhaler (DPI)
Ipratropium (Atrovent) 2 puffs per metered-dose inhaler (MDI)
ANS:
A
Albuterol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in acute asthma
attacks. The other medications work more slowly.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
548
Nursing Process: Implementation
42.
The nurse receives a change-of-shift report on the following patients with chronic obstructive
pulmonary disease (COPD). Which patient should the nurse assess first?
a.
A patient with loud expiratory wheezes
b.
A patient with a respiratory rate of 38 breaths/min
c.
A patient who has a cough productive of thick, green mucus
d.
A patient with jugular venous distention and peripheral edema
ANS:
B
A respiratory rate of 38/min indicates severe respiratory distress, and the patient needs immediate assessment and
intervention to prevent possible respiratory arrest. The other patients also need assessment as soon as possible, but they
do not need to be assessed as urgently as the patient with tachypnea.
DIF:
OBJ:
TOP:
Cognitive Level: Analyze (analysis)
REF:
545
Special Questions: Prioritization | Special Questions: Multiple Patients
Nursing Process: Assessment
MSC:
NCLEX: Safe and Effective Care Environment
COMPLETION
1.
A patient with asthma has a personal best peak expiratory flow rate (PEFR) of 400 L/min. When
explaining the asthma action plan, the nurse will teach the patient that a change in therapy is needed when the PEFR is
less than ___ L/minute
ANS:
320
A PEFR less than 80% of the personal best indicates that the patient is in the yellow zone where changes in therapy are
needed to prevent progression of the airway narrowing.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
555
NCLEX: Physiological Integrity
Chapter 40: Respiratory Dysfunction
MULTIPLE CHOICE
a.
b.
18.
Asthma in infants is usually triggered by:
Medications.
c.
Exposure to cold air.
A viral infection. d.
Allergy to dust or dust mites.
ANS:
B
Viral illnesses cause inflammation that causes increased airway reactivity in asthma. Medications such as aspirin,
nonsteroidal antiinflammatory drugs, and antibiotics may aggravate asthma, but not frequently in infants. Exposure to
cold air may exacerbate already existing asthma. Allergy is associated with asthma, but 20% to 40% of children with
asthma have no evidence of allergic disease.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1223
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
19.
A child has a chronic, nonproductive cough and diffuse wheezing during the expiratory phase of
respiration. This suggests:
a.
Asthma. c.
Bronchiolitis.
b.
Pneumonia.
d.
Foreign body in the trachea.
ANS:
A
Children with asthma usually have these chronic symptoms. Pneumonia appears with an acute onset and fever and
general malaise. Bronchiolitis is an acute condition caused by respiratory syncytial virus. Foreign body in the trachea will
manifest with acute respiratory distress or failure and maybe stridor.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1223
Nursing Process: Diagnosis MSC:
Client Needs: Physiologic Integrity
a.
b.
c.
d.
31.
An appropriate nursing intervention when caring for a child with pneumonia is to:
Encourage rest.
Encourage the child to lie on the unaffected side.
Administer analgesics.
Place the child in the Trendelenburg position.
ANS:
A
Encouraging rest by clustering care and promoting a quiet environment is the best intervention for a child with
pneumonia. Lying on the affected side may promote comfort by splinting the chest and reducing pleural rubbing.
Analgesics are not indicated. Children should be placed in a semi-erect position or position of comfort.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
1213
Nursing Process: Implementation
MSC:
Client Needs: Physiologic Integrity
Chapter 11: Pregnancy at Risk: Preexisting Conditions
MULTIPLE CHOICE
18.
While providing care in an obstetric setting, the nurse should understand that postpartum care of the
woman with cardiac disease:
a.
Is the same as that for any pregnant woman.
b.
Includes rest, stool softeners, and monitoring of the effect of activity.
c.
Includes ambulating frequently, alternating with active range of motion.
d.
Includes limiting visits with the infant to once per day.
ANS:
B
Bed rest may be ordered, with or without bathroom privileges. Bowel movements without stress or strain for the woman
are promoted with stool softeners, diet, and fluid. Care of the woman with cardiac disease in the postpartum period is
tailored to the woman’s functional capacity. The woman will be on bed rest to conserve energy and reduce the strain on
the heart. Although the woman may need help caring for the infant, breastfeeding and infant visits are not contraindicated.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
290
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
a.
b.
c.
d.
25.
As related to the care of the patient with anemia, the nurse should be aware that:
It is the most common medical disorder of pregnancy.
It can trigger reflex brachycardia.
The most common form of anemia is caused by folate deficiency.
Thalassemia is a European version of sickle cell anemia.
ANS:
A
Combined with any other complication, anemia can result in congestive heart failure. Reflex bradycardia is a slowing of
the heart in response to the blood flow increases immediately after birth. The most common form of anemia is iron
deficiency anemia. Both thalassemia and sickle cell hemoglobinopathy are hereditary but not directly related or confined
to geographic areas.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
290
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
37.
In caring for a pregnant woman with sickle cell anemia, the nurse is aware that signs and symptoms of
sickle cell crisis include:
a.
Anemia. c.
Fever and pain.
b.
Endometritis.
d.
Urinary tract infection.
ANS:
C
Women with sickle cell anemia have recurrent attacks (crisis) of fever and pain, most often in the abdomen, joints, and
extremities. These attacks are attributed to vascular occlusion when RBCs assume the characteristic sickled shape. Crises
are usually triggered by dehydration, hypoxia, or acidosis. Women with sickle cell anemia are not iron deficient. Therefore,
routine iron supplementation, even that found in prenatal vitamins, should be avoided in order to prevent iron overload.
Women with sickle cell trait usually are at greater risk for postpartum endometritis (uterine wall infection); however, this is
not likely to occur in pregnancy and is not a sign of crisis. These women are at an increased risk for UTIs; however, this is
not an indication of sickle cell crisis.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
291
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
Chapter 43: Hematologic and Immunologic Dysfunction
MULTIPLE CHOICE
5.
When teaching the mother of a 9-month-old infant about administering liquid iron preparations, the
nurse should include that:
a.
They should be given with meals.
b.
They should be stopped immediately if nausea and vomiting occur.
c.
Adequate dosage will turn the stools a tarry green color.
d.
Preparation should be allowed to mix with saliva and bathe the teeth before swallowing.
ANS:
C
The nurse should prepare the mother for the anticipated change in the child’s stools. If the iron dose is adequate, the
stools will become a tarry green color. The lack of the color change may indicate insufficient iron. The iron should be given
in two divided doses between meals, when the presence of free hydrochloric acid is greatest. Iron is absorbed best in an
acidic environment. Vomiting and diarrhea may occur with iron administration. If these occur, the iron should be given with
meals, and the dosage reduced and gradually increased as the child develops tolerance. Liquid preparations of iron stain
the teeth. They should be administered through a straw, and the mouth rinsed after administration.
PTS:
OBJ:
1
DIF:
Cognitive Level: Analysis
Nursing Process: Implementation
MSC:
6.
include:
a.
b.
c.
d.
REF:
1366
Client Needs: Physiologic Integrity
Iron dextran is ordered for a young child with severe iron deficiency anemia. Nursing considerations
Administering with meals.
Administering between meals.
Injecting deeply into a large muscle.
Massaging injection site for 5 minutes after administration of drug.
ANS:
C
Iron dextran is a parenteral form of iron. When administered intramuscularly, it must be injected into a large muscle using
the Z-track method. Iron dextran is for intramuscular or intravenous administration; it is not taken orally. The site should
not be massaged to prevent leakage, potential irritation, and staining of the skin.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1366
Nursing Process: Implementation
MSC:
Client Needs: Physiologic Integrity
7.
The nurse is recommending how to prevent iron deficiency anemia in a healthy, term, breastfed infant.
What should she or he suggest?
a.
Iron (ferrous sulfate) drops after age 1 month.
b.
Iron-fortified commercial formula can be used by ages 4 to 6 months.
c.
Iron-fortified infant cereal can be introduced at age 2 months.
d.
Iron-fortified infant cereal can be introduced at approximately 6 months of age.
ANS:
D
Breast milk supplies inadequate iron for growth and development after age 5 months. Supplementation is necessary at
this time. Iron supplementation or the introduction of solid foods in a breastfed baby is not indicated. Introducing ironfortified infant cereal at 2 months should be done only if the mother is choosing to discontinue breastfeeding.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
1366
Nursing Process: Implementation
MSC:
Client Needs: Physiologic Integrity
8.
A condition in which the normal adult hemoglobin is partly or completely replaced by abnormal
hemoglobin is:
a.
Aplastic anemia. c.
Thalassemia major.
b.
Sickle cell anemia. d.
Iron deficiency anemia.
ANS:
B
Sickle cell anemia is one of a group of diseases collectively called hemoglobinopathies, in which normal adult hemoglobin
is replaced by abnormal hemoglobin. Aplastic anemia is a lack of cellular elements being produced. Hemophilia refers to a
group of bleeding disorders in which there is deficiency of one of the factors necessary for coagulation. Iron deficiency
anemia affects size and depth of color of hemoglobin and does not involve abnormal hemoglobin.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1367
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
Unit 3
Immunity
Concept 23: Immunity
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
The nurse is caring for a patient who is being discharged home after a splenectomy. What information
on immune function needs to be included in this patient’s discharge planning?
a.
The mechanisms of the inflammatory response
b.
Basic infection control techniques
c.
The importance of wearing a face mask in public
d.
Limiting contact with the general population
ANS:
B
The spleen is one of the major organs of the immune system. Without the spleen, the patient is at higher risk for infection;
so, the nurse must be sure that the patient understands basic principles of infection control. The patient with a
splenectomy does not need to understand the mechanisms of inflammatory response. The patient with a splenectomy
does not need to wear a face mask in public as long as the patient understands and maintains the basic principles of
infection control. The patient who has had a splenectomy does not need to limit contact with the general population as
long as the patient understands and maintains the basic principles of infection control.
REF:
Page 219 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
2.
An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10 months. The
physician notes that the child’s growth rate has decreased from the 60th percentile for height and weight to the 15th
percentile over that same time period. The child has been treated for thrush consistently since the third ear infection. The
nurse understands that the patient is at risk for which condition?
a.
Primary immunodeficiency
b.
Secondary immunodeficiency
c.
Cancer
d.
Autoimmunity
ANS:
A
Primary immunodeficiency is a risk for patients with two or more of the listed problems. Secondary immunodeficiency is
induced by illness or treatment. Cancer is caused by abnormal cells that will trigger an immune response. Autoimmune
diseases are caused by hyperimmunity.
REF:
OBJ:
Page 221
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
3.
The nurse is caring for a postoperative patient who had an open appendectomy. The nurse understands
that this patient should have some erythema and edema at the incision site 12 to 24 hours post operation dependent on
which condition?
a.
b.
c.
d.
His immune system is functioning properly.
He is properly vaccinated.
He has an infection.
The suppressor T-cells in his body are activated.
ANS:
A
Tissue integrity is closely associated with immunity. Openings in the integumentary system allow for the entrance of
pathogens. If the immune response is functioning optimally, the body responds to the insult to the tissue by protecting the
area from invasion of microorganisms and pathogens with inflammation. Routine vaccinations have no bearing on the
body’s response to intentional tissue impairment. The redness and swelling at the incision site in the first 12 to 24 hours is
part of optimal immune functioning. A patient with erythema and edema that persist or worsen should be evaluated for
infection. Suppressor T-cells help to control the immune response in the body.
REF:
OBJ:
Page 225
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
4.
While caring for a patient preparing for a kidney transplant, the nurse knows that the patient
understands teaching on immunosuppression when she makes which statement?
a.
“My body will treat the new kidney like my original kidney.”
b.
“I will have to make sure that I avoid being around people.”
c.
“The medications that I take will help prevent my body from attacking my new kidney.”
d.
“My body will only have a problem with my new kidney if the donor is not directly related to me.”
ANS:
C
Immunosuppressant therapy is initiated to inhibit optimal immune response. This is necessary in the case of
transplantation, because the normal immune response would cause the body to recognize the new tissue as foreign and
attack it. The body will identify the new kidney as foreign and will not treat it as the original kidney. While patients with
transplants must be careful about exposure to others, especially those who are or might be ill, and practice adequate and
consistent infection control techniques, they don’t have to avoid people or social interaction. The new kidney brings
foreign cells regardless of relationship between donor and recipient.
REF:
Page 222 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
5.
The nurse is caring for a patient who was started on intravenous antibiotic therapy earlier in the shift.
As the second dose is being infused, the patient reports feeling dizzy and having difficulty breathing and talking. The
nurse notes that the patient’s respirations are 26 breaths/min with a weak pulse of 112 beats/min. The nurse suspects that
the patient is experiencing which condition?
a.
Suppressed immune response
b.
Hyperimmune response
c.
Allergic reaction
d.
Anaphylactic reaction
ANS:
D
The patient is exhibiting signs and symptoms of an anaphylactic reaction to the medication. These signs and symptoms
during administration of a medication do not correspond to a suppressed immune response but a type of hyperimmune
response. While the patient is experiencing a hyperimmune response, the signs and symptoms allow for a more specific
response. While the patient is experiencing an allergic reaction, the signs and symptoms presented in the scenario allow
for a more specific response.
REF:
OBJ:
Page 221 |Page 225
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
6.
The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA). The nurse
should explain which goal of treatment to the patient?
a.
Eradicate the disease
b.
Enhance immune response
c.
Control inflammation
d.
Manage pain
ANS:
C
Medications for RA are intended to control the inflammation that results from the body’s hyperimmune response.
Autoimmune diseases like RA are chronic and currently have no curative treatments. Autoimmune diseases like RA are
caused by hyperimmune response. The immune system needs to be suppressed, not enhanced. While the medications
used for RA might help with pain management, the goal of medication intervention is to manage the inflammation.
REF:
Page 223 |Page 224
OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
MULTIPLE RESPONSE
1.
The parents of a newborn question the nurse about the need for vaccinations: “Why does our baby
need all those shots? He’s so small, and they have to cause him pain.” The nurse can explain to the parents that which of
the following are true about vaccinations? (Select all that apply.)
a.
Are only required for infants
b.
Are part of primary prevention for system disorders
c.
Prevent the child from getting childhood diseases
d.
Help protect individuals and communities
e.
Are risk free
f.
Are recommended by the Centers for Disease Control and Prevention (CDC)
ANS:
B, D, F
Immunizations are considered part of primary prevention, help protect individuals from contracting specific diseases and
from spreading them to the community at large, and are recommended by the CDC. Immunizations are recommended for
people at various ages from infants to older adults. Vaccination does not guarantee that the recipient won’t get the
disease, but it decreases the potential to contract the illness. No medication is risk free.
REF:
Page 224 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
Chapter 14: Infection and Human Immunodeficiency Virus Infection
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1.
The nurse is advising a clinic patient who was exposed a week ago to human immunodeficiency virus
(HIV) through unprotected sexual intercourse. The patient’s antigen and antibody test has just been reported as negative
for HIV. What instructions should the nurse give to this patient?
a.
“You will need to be retested in 2 weeks.”
b.
“You do not need to fear infecting others.”
c.
“Since you don’t have symptoms and you have had a negative test, you do not have HIV).”
d.
“We won’t know for years if you will develop acquired immunodeficiency syndrome (AIDS).”
ANS:
A
HIV screening tests detect HIV-specific antibodies or antigens, but typically it takes a several week delay after initial
infection before HIV can be detected on a screening test. Combination antibody and antigen tests (also known as fourthgeneration tests) decrease the window period to within 3 weeks after infection. It is not known based on this information
whether the patient is infected with HIV or can infect others.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
221
NCLEX: Physiological Integrity
2.
A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the
hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/L. Based on
diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is
correct?
a.
“The patient will develop symptomatic HIV infection within 1 year.”
b.
“The patient meets the criteria for a diagnosis of acute HIV infection.”
c.
“The patient will be diagnosed with asymptomatic chronic HIV infection.”
d.
“The patient has developed acquired immunodeficiency syndrome (AIDS).”
ANS:
D
Development of PCP meets the diagnostic criteria for AIDS. The other responses indicate earlier stages of HIV infection
than is indicated by the PCP infection.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
221
Nursing Process: Assessment
MSC:
NCLEX: Physiological Integrity
3.
A patient informed of a positive rapid antibody test result for human immunodeficiency virus (HIV) is
anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time?
a.
Teach the patient how to reduce risky behaviors.
b.
Inform the patient about the available treatments.
c.
Remind the patient about the need to return for retesting to verify the results.
d.
Ask the patient to identify individuals who had intimate contact with the patient.
ANS:
C
After an initial positive antibody test result, the next step is retesting to confirm the results. A patient who is anxious is not
likely to be able to take in new information or be willing to disclose information about the HIV status of other individuals.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Implementation
MSC:
REF:
222
NCLEX: Psychosocial Integrity
4.
A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, “I feel
obsessed with morbid thoughts about dying.” Which response by the nurse is appropriate?
a.
“Thinking about dying will not improve the course of AIDS.”
b.
“Do you think that taking an antidepressant might be helpful?”
c.
“Can you tell me more about the thoughts that you are having?”
d.
“It is important to focus on the good things about your life now.”
ANS:
C
More assessment of the patient’s psychosocial status is needed before taking any other action. The statements, “Thinking
about dying will not improve the course of AIDS” and “It is important to focus on the good things in life” or suggesting an
antidepressant discourage the patient from sharing any further information with the nurse and decrease the nurse’s ability
to develop a trusting relationship with the patient.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
227
NCLEX: Psychosocial Integrity
5.
A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at
the clinic. The patient states, “I am very nervous about making my baby sick.” Which information will the nurse include
when teaching the patient?
a.
The antiretroviral medications used to treat HIV infection are teratogenic.
b.
Most infants born to HIV-positive mothers are not infected with the virus.
c.
Because it is an early stage of HIV infection, the infant will not contract HIV.
d.
Her newborn will be born with HIV unless she uses antiretroviral therapy (ART).
ANS:
B
Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use ART during
pregnancy. The percentage drops to 2% when ART is used. Perinatal transmission can occur at any stage of HIV infection
(although it is less likely to occur when the viral load is lower). ART can safely be used in pregnancy, although some ART
drugs should be avoided.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
219
Nursing Process: Implementation
MSC:
NCLEX: Health Promotion and Maintenance
6.
Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the
patient’s human immunodeficiency virus (HIV) status is unknown?
a.
Needle stick injury with a suture needle during a surgery
b.
Splash into the eyes while emptying a bedpan containing stool
c.
Needle stick with a needle and syringe used for a venipuncture
d.
Contamination of open skin lesions with patient vaginal secretions
ANS:
C
Puncture wounds are the most common means for workplace transmission of blood-borne diseases, and a needle with a
hollow bore that had been contaminated with the patient’s blood would be a high-risk situation. The other situations
described would be much less likely to result in transmission of the virus.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Implementation
MSC:
REF:
219
NCLEX: Safe and Effective Care Environment
7.
A young adult female patient who is human immunodeficiency virus (HIV) positive has a new
prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan?
a.
Take this medication on an empty stomach.
b.
Take this medication with a full glass of water.
c.
You may have vivid and bizarre dreams as a side effect.
d.
Continue to use contraception while taking this medication.
ANS:
D
To prevent harm, it is most critical to inform patients that efavirenz can cause fetal anomalies and should not be used in
patients who may be or may become pregnant. The other information is also accurate, but it does not directly prevent
harm. The medication should be taken on an empty stomach with water and patients should be informed that many people
who use the drug have reported vivid and sometimes bizarre dreams.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Implementation
MSC:
REF:
224
NCLEX: Physiological Integrity
8.
A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/µL. Which
factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient?
a.
CD4+ cell count trajectory
b.
HIV genotype and phenotype
c.
Patient’s tolerance for potential medication side effects
d.
Patient’s ability to follow a complex medication regimen
ANS:
D
Drug resistance develops quickly unless the patient takes ART medications on a strict, regular schedule. In addition, drug
resistance endangers both the patient and community. The other information is also important to consider, but patients
who are unable to manage and follow a complex drug treatment regimen should not be considered for ART.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Assessment
MSC:
REF:
223
NCLEX: Physiological Integrity
9.
The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for
which patient?
a.
Patient who is currently HIV negative but has unprotected sex with multiple partners
b.
Patient who was infected with HIV 15 years ago and now has a CD4+ count of 840/µL
c.
HIV-positive patient with a CD4+ count of 160/µL who drinks a fifth of whiskey daily
d.
Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis
ANS:
D
CMV retinitis is an AIDS-defining illness and indicates that the patient is appropriate for ART even though the HIV infection
period is relatively short. An HIV-negative patient would not be offered ART. A patient with a CD4+ count in the normal
range would not typically be started on ART. A patient who drinks alcohol heavily would be unlikely to be able to manage
the complex drug regimen and would not be appropriate for ART despite the low CD4+ count.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Multiple Patients
NCLEX: Physiological Integrity
REF:
TOP:
221
Nursing Process: Planning
10.
The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human
immunodeficiency virus (HIV) infection. Which action would be appropriate for the nurse to take?
a.
Instruct the patient to apply ice to the neck.
b.
Explain to the patient that this is an expected finding.
c.
Request that an antibiotic be prescribed for the patient.
d.
Advise the patient that this indicates influenza infection.
ANS:
B
Persistent generalized lymphadenopathy is common in the early stages of HIV infection. No antibiotic is needed because
the enlarged nodes are probably not caused by bacteria. Lymphadenopathy is common with acute HIV infection and is
therefore not likely the flu. Ice will not decrease the swelling in persistent generalized lymphadenopathy
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
225
NCLEX: Physiological Integrity
11.
Which information about a patient population would be most useful to help the nurse plan for human
immunodeficiency virus (HIV) testing needs?
a.
Age
c.
Symptoms
b.
Lifestyle d.
Sexual orientation
ANS:
A
The current Centers for Disease Control and Prevention policy is to offer routine testing for HIV to all individuals age 13 to
64 years. Although lifestyle, symptoms, and sexual orientation may suggest increased risk for HIV infection, the goal is to
test all individuals in this age range.
DIF:
Cognitive Level: Apply (application)
REF:
226
TOP:
Nursing Process: Planning MSC:
NCLEX: Health Promotion and Maintenance
12.
A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency
syndrome (AIDS). Which response by the nurse is best?
a.
“Clean drug injection equipment before each use.”
b.
“Ask those who share equipment to be tested for HIV.”
c.
“Consider participating in a needle-exchange program.”
d.
“Avoid sexual intercourse when using injectable drugs.”
ANS:
C
Participation in needle-exchange programs has been shown to decrease and control the rate of HIV infection. Cleaning
drug equipment before use also reduces risk, but it might not be consistently practiced. HIV antibodies do not appear for
several weeks to months after exposure, so testing drug users would not be very effective in reducing risk for HIV
exposure. It is difficult to make appropriate decisions about sexual activity when under the influence of drugs.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Implementation
MSC:
REF:
226
NCLEX: Health Promotion and Maintenance
13.
Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed
antiretroviral therapy (ART) regimen?
a.
Give the patient detailed information about possible medication side effects.
b.
Remind the patient of the importance of taking the medications as scheduled.
c.
Encourage the patient to join a support group for students who are HIV positive.
d.
Check the patient’s class schedule to help decide when the drugs should be taken.
ANS:
D
The best approach to improve adherence is to learn about important activities in the patient’s life and adjust the ART
around those activities. The other actions are also useful, but they will not improve adherence as much as individualizing
the ART to the patient’s schedule.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
228
NCLEX: Physiological Integrity
14.
A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium
complex infection. Which outcome would be appropriate for the nurse to include in the plan of care?
a.
The patient will be free from injury.
b.
The patient will receive immunizations.
c.
The patient will have adequate oxygenation.
d.
The patient will maintain intact perineal skin.
ANS:
D
The major manifestation of M. avium infection is loose, watery stools, which would increase the risk for perineal skin
breakdown. The other outcomes would be appropriate for other complications (e.g., pneumonia, dementia, influenza)
associated with HIV infection.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
222
NCLEX: Physiological Integrity
15.
A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat
redistribution to the trunk with wasting of the arms, legs, and face. What recommendation will the nurse give to the
patient?
a.
Review foods that are higher in protein.
b.
Teach about the benefits of daily exercise.
c.
Discuss a change in antiretroviral therapy.
d.
Talk about treatment with antifungal agents.
ANS:
C
A frequent first intervention for metabolic disorders is a change in antiretroviral therapy (ART). Treatment with antifungal
agents would not be appropriate because there is no indication of fungal infection. Changes in diet or exercise have not
proven helpful for this problem.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
230
NCLEX: Physiological Integrity
16.
The nurse prepares to administer the following medications to a hospitalized patient with human
immunodeficiency (HIV). Which medication is most important to administer at the scheduled time?
a.
b.
c.
d.
Nystatin tablet
Oral acyclovir (Zovirax)
Oral saquinavir (Invirase)
Aerosolized pentamidine (NebuPent)
ANS:
C
It is important that antiretrovirals be taken at the prescribed time every day to avoid developing drug-resistant HIV. The
other medications should also be given as close as possible to the correct time, but they are not as essential to receive at
the same time every day.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Implementation
MSC:
REF:
228
NCLEX: Physiological Integrity
17.
To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse
review?
a.
Viral load testing c.
Rapid HIV antibody testing
b.
Enzyme immunoassay
d.
Immunofluorescence assay
ANS:
A
The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood. The other tests are
used to detect HIV antibodies, which remain positive even with effective ART.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
222
NCLEX: Physiological Integrity
18.
The nurse is caring for a patient who is human immunodeficiency virus (HIV) positive and taking
antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care?
a.
The patient complains of feeling “constantly tired.”
b.
The patient can’t explain the effects of indinavir (Crixivan).
c.
The patient reports missing some doses of zidovudine (AZT).
d.
The patient reports having no side effects from the medications.
ANS:
C
Because missing doses of ART can lead to drug resistance, this patient statement indicates the need for interventions
such as teaching or changes in the drug scheduling. Fatigue is a common side effect of ART. The nurse should discuss
medication actions and side effects with the patient, but this is not as important as addressing the skipped doses of AZT.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
228
Nursing Process: Planning
19.
Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+
cell count of 800/µL and an undetectable viral load. What is the priority nursing intervention at this time?
a.
Encourage adequate nutrition, exercise, and sleep.
b.
Teach about the side effects of antiretroviral agents.
c.
Explain opportunistic infections and antibiotic prophylaxis.
d.
Monitor symptoms of acquired immunodeficiency syndrome (AIDS).
ANS:
A
The CD4+ level for this patient is in the normal range, indicating that the patient is the stage of asymptomatic chronic
infection when the body is able to produce enough CD4+ cells to maintain a normal CD4+ count. Maintaining healthy
lifestyle behaviors is an important goal in this stage. AIDS and increased incidence of opportunistic infections typically
develop when the CD4+ count is much lower than normal. Although the initiation of ART is highly individual, it would not
be likely that a patient with a normal CD4+ level would receive ART.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
220
Nursing Process: Implementation
20.
Which of these patients who have arrived at the human immunodeficiency virus (HIV) clinic should the
nurse assess first?
a.
Patient whose rapid HIV-antibody test is positive
b.
Patient whose latest CD4+ count has dropped to 250/µL
c.
Patient who has had 10 liquid stools in the last 24 hours
d.
Patient who has nausea from prescribed antiretroviral drugs
ANS:
C
The nurse should assess the patient for dehydration and hypovolemia. The other patients also will require assessment and
possible interventions, but do not require immediate action to prevent complications such as hypovolemia and shock.
DIF:
OBJ:
TOP:
Cognitive Level: Analyze (analysis)
REF:
229
Special Questions: Prioritization | Special Questions: Multiple Patients
Nursing Process: Assessment
MSC:
NCLEX: Safe and Effective Care Environment
21.
An older adult with chronic human immunodeficiency virus (HIV) infection who takes medications for
coronary artery disease and hypertension has chosen to begin early antiretroviral therapy (ART). Which information will
the nurse include in patient teaching?
a.
Many drugs interact with antiretroviral medications.
b.
HIV infections progress more rapidly in older adults.
c.
Less frequent CD4+ level monitoring is needed in older adults.
d.
Hospice care is available for patients with terminal HIV infection.
ANS:
A
The nurse will teach the patient about potential interactions between antiretrovirals and the medications that the patient is
using for chronic health problems. Treatment and monitoring of HIV infection is not affected by age. A patient beginning
early ART is not a candidate for hospice. Progression of HIV is not affected by age although it may be affected by chronic
disease.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
228
NCLEX: Physiological Integrity
22.
The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate
which action to unlicensed assistive personnel (UAP)?
a.
Teach the patient how to dispose of tissues with respiratory secretions.
b.
Stock the patient’s room with the necessary personal protective equipment.
c.
Interview the patient to obtain the names of family members and close contacts.
d.
Tell the patient’s family members the reason for the use of airborne precautions.
ANS:
B
A patient diagnosed with tuberculosis would be placed on airborne precautions. Because all health care workers are
taught about the various types of infection precautions used in the hospital, the UAP can safely stock the room with
personal protective equipment. Obtaining contact information and patient teaching are higher-level skills that require RN
education and scope of practice.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Delegation
TOP:
NCLEX: Safe and Effective Care Environment
REF:
218
Nursing Process: Implementation
23.
The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV)
infection in the adolescent and young adult populations. Which information should the nurse assign as the highest
priority?
a.
Methods to prevent perinatal HIV transmission
b.
Ways to sterilize needles used by injectable drug users
c.
Prevention of HIV transmission between sexual partners
d.
Means to prevent transmission through blood transfusions
ANS:
C
Sexual transmission is the most common way that HIV is transmitted. The nurse should also provide teaching about
perinatal transmission, needle sterilization, and blood transfusion, but the rate of HIV infection associated with these
situations is lower.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
218
Nursing Process: Planning
MULTIPLE RESPONSE
1.
The nurse is caring for a patient infected with human immunodeficiency virus (HIV) who has just been
diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of
care (select all that apply)?
a.
Hepatitis B vaccine
b.
Pneumococcal vaccine
c.
d.
e.
Influenza virus vaccine
Trimethoprim-sulfamethoxazole
Varicella zoster immune globulin
ANS:
A, B, C
Asymptomatic chronic HIV infection is a stage between acute HIV infection and a diagnosis of symptomatic chronic HIV
infection. Although called asymptomatic, symptoms (e.g., fatigue, headache, low-grade fever, night sweats) often occur.
Prevention of other infections is an important intervention in patients who are HIV positive, and these vaccines are
recommended as soon as the HIV infection is diagnosed. Antibiotics and immune globulin are used to prevent and treat
infections that occur later in the course of the disease when the CD4+ counts have dropped or when infection has
occurred.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
220
NCLEX: Health Promotion and Maintenance
2.
According to the Center for Disease Control and Prevention (CDC) guidelines, which personal
protective equipment will the nurse put on before assessing a patient who is on contact precautions for Clostridium
difficile diarrhea (select all that apply)?
a.
Mask
b.
Gown
c.
Gloves
d.
Shoe covers
e.
Eye protection
ANS:
B, C
Because the nurse will have substantial contact with the patient and bedding when doing an assessment, gloves and
gowns are needed. Eye protection and masks are needed for patients in contact precautions only when spraying or
splashing is anticipated. Shoe covers are not recommended in the CDC guidelines.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
218
NCLEX: Safe and Effective Care Environment
3.
The nurse plans a presentation for community members about how to decrease the risk for antibioticresistant infections. Which information will the nurse include in the teaching plan (select all that apply)?
a.
Antibiotics may sometimes be prescribed to prevent infection.
b.
Continue taking antibiotics until all of the prescription is gone.
c.
Unused antibiotics that are more than a year old should be discarded.
d.
Antibiotics are effective in treating influenza associated with high fevers.
e.
Hand washing is effective in preventing many viral and bacterial infections.
ANS:
A, B, E
All prescribed doses of antibiotics should be taken. In some situations, such as before surgery, antibiotics are prescribed
to prevent infection. There should not be any leftover antibiotics because all prescribed doses should be taken. However,
if there are leftover antibiotics, they should be discarded immediately because the number left will not be enough to treat a
future infection. Hand washing is generally considered the single most effective action in decreasing infection
transmission. Antibiotics are ineffective in treating viral infections such as influenza.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
216
NCLEX: Health Promotion and Maintenance
Chapter 04: Reproductive System Concerns
MULTIPLE CHOICE
a.
b.
21.
To detect human immunodeficiency virus (HIV), most laboratory tests focus on the:
virus.
c.
CD4 counts.
HIV antibodies.
d.
CD8 counts.
ANS:
B
The screening tool used to detect HIV is the enzyme immunoassay, which tests for the presence of antibodies to the virus.
CD4 counts are associated with the incidence of acquired immunodeficiency syndrome (AIDS) in HIV-infected individuals.
PTS:
OBJ:
1
DIF:
Cognitive Level: Knowledge REF:
94
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
24.
The recommended treatment for the prevention of human immunodeficiency virus (HIV) transmission to
the fetus during pregnancy is:
a.
Acyclovir.
c.
Podophyllin.
b.
Ofloxacin.
d.
Zidovudine.
ANS:
D
Perinatal transmission of HIV has decreased significantly in the past decade as a result of prophylactic administration of
the antiretroviral drug zidovudine to pregnant women in the prenatal and perinatal periods. Acyclovir is an antiviral
treatment for HSV. Ofloxacin is an antibacterial treatment for gonorrhea. Podophyllin is a solution used in the treatment of
human papillomavirus.
PTS:
OBJ:
MSC:
1
DIF:
Cognitive Level: Knowledge REF:
Nursing Process: Planning, Implementation
Client Needs: Health Promotion and Maintenance
95
26.
The nurse should know that once human immunodeficiency virus (HIV) enters the body, seroconversion
to HIV positivity usually occurs within:
a.
6 to 10 days.
c.
6 to 8 weeks.
b.
2 to 4 weeks.
d.
6 months.
ANS:
C
Seroconversion to HIV positivity usually occurs within 6 to 8 weeks after the virus has entered the body.
PTS:
OBJ:
include
a.
b.
c.
d.
e.
1
DIF:
Cognitive Level: Knowledge REF:
94
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
46.
Examples of sexual risk behaviors associated with exposure to a sexually transmitted infection (STI)
(Select all that apply):
Fellatio.
Unprotected anal intercourse.
Multiple sex partners.
Dry kissing.
Abstinence.
ANS:
A, B, C
Engaging in these sexual activities increases the exposure risk and the possibility of acquiring an STI. Dry kissing and
abstinence are considered “safe” sexual practices.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
94
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
Chapter 43: Hematologic and Immunologic Dysfunction
MULTIPLE CHOICE
a.
b.
c.
d.
26.
A common clinical manifestation of Hodgkin’s disease is:
Petechiae.
Bone and joint pain.
Painful, enlarged lymph nodes.
Enlarged, firm, nontender lymph nodes.
ANS:
D
Asymptomatic, enlarged, cervical or supraclavicular lymphadenopathy is the most common presentation of Hodgkin’s
disease. Petechiae are usually associated with leukemia. Bone and joint pain are not likely in Hodgkin’s disease. The
enlarged nodes are rarely painful.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1385
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
27.
T-cells?
a.
b.
c.
d.
Which condition is caused by a virus that primarily infects a specific subset of T lymphocytes, the CD4+
Wiskott-Aldrich syndrome
Idiopathic thrombocytopenic purpura (ITP)
Acquired immunodeficiency syndrome (AIDS)
Severe combined immunodeficiency disease
ANS:
C
AIDS is caused by the human immunodeficiency virus, which primarily attacks the CD4+ T-cells. Wiskott-Aldrich
syndrome, ITP, and severe combined immunodeficiency disease are not viral illnesses.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
1386
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
28.
A young child with human immunodeficiency virus is receiving several antiretroviral drugs. The
purpose of these drugs is to:
a.
Cure the disease.
b.
Delay disease progression.
c.
Prevent spread of disease.
d.
Treat Pneumocystis jiroveci pneumonia.
ANS:
B
Although not a cure, these antiviral drugs can suppress viral replication, preventing further deterioration of the immune
system, and delay disease progression. At this time cure is not possible. These drugs do not prevent the spread of the
disease. Pneumocystis jiroveci prophylaxis is accomplished with antibiotics.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1386
Nursing Process: Implementation
MSC:
Client Needs: Physiologic Integrity
29.
virus?
a.
b.
Which immunization should be given with caution to children infected with human immunodeficiency
Influenza c.
Varicella d.
Pneumococcus
Inactivated poliovirus
ANS:
B
The children should be carefully evaluated before giving live viral vaccines such as varicella, measles, mumps, and
rubella. The child must be immunocompetent and not have contact with other severely immunocompromised individuals.
Influenza, pneumococcus, and inactivated poliovirus are not live vaccines.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
1387
Nursing Process: Implementation
MSC:
Client Needs: Physiologic Integrity
30.
The nurse is planning care for an adolescent with acquired immunodeficiency syndrome. The priority
nursing goal is to:
a.
Prevent infection. c.
Restore immunologic defenses.
b.
Prevent secondary cancers. d.
Identify source of infection.
ANS:
A
As a result of the immunocompromise that is associated with human immunodeficiency virus infection, the prevention of
infection is paramount. Although certain precautions are justified in limiting exposure to infection, these must be balanced
with the concern for the child’s normal developmental needs. Restoring immunologic defenses is not currently possible.
Current drug therapy is affecting the disease progression; although not a cure, these drugs can suppress viral replication,
preventing further deterioration. Case finding is not a priority nursing goal.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
1387
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
31.
An inherited immunodeficiency disorder characterized by absence of both humoral and cell-mediated
immunity is:
a.
Severe combined immunodeficiency syndrome (SCIDS).
b.
Acquired immunodeficiency syndrome.
c.
Wiskott-Aldrich syndrome.
d.
Fanconi syndrome.
ANS:
A
Severe SCIDS is a genetic disorder that results in deficits of both humoral and cellular immunity. Acquired
immunodeficiency syndrome is not inherited. Wiskott-Aldrich syndrome is an X-linked recessive disorder with selected
deficiencies of T and B lymphocytes. Fanconi syndrome is a hereditary disorder of red cell production.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1388
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
36.
What is the most common mode of transmission of human immunodeficiency virus (HIV) in the
pediatric population?
a.
Perinatal transmission
c.
Blood transfusions
b.
Sexual abuse
d.
Poor hand washing
ANS:
A
Perinatal transmission accounts for the highest percentage (91%) of HIV infections in children. Infected women can
transmit the virus to their infants across the placenta during pregnancy, at delivery, and through breastfeeding. Cases of
HIV infection from sexual abuse have been reported; however, perinatal transmission accounts for most pediatric HIV
infections. In the past some children became infected with HIV through blood transfusions; however, improved laboratory
screening has significantly reduced the probability of contracting HIV from blood products. Poor hand washing is not an
etiology of HIV infection.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
1385
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
43.
The school nurse is informed that a child with human immunodeficiency virus (HIV) will be attending
school soon. Which is an important nursing intervention?
a.
Carefully follow universal precautions.
b.
Determine how the child became infected.
c.
Inform the parents of the other children.
d.
Reassure other children that they will not become infected.
ANS:
A
Universal precautions are necessary to prevent further transmission of the disease. It is not the role of the nurse to
determine how the child became infected. Informing the parents of other children and reassuring other children that they
will not become infected is a violation of the child’s right to privacy.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
1387
Nursing Process: Implementation
MSC:
Client Needs: Physiologic Integrity
46.
Which home care instructions should the nurse provide to the parents of a child with acquired
immunodeficiency syndrome (AIDS) (Select all that apply)?
a.
Give supplemental vitamins as prescribed.
b.
Yearly influenza vaccination should be avoided.
c.
Administer trimethoprim-sulfamethoxazole (Bactrim) as prescribed.
d.
Notify the physician if the child develops a cough or congestion.
e.
Missed doses of antiretroviral medication do not need to be recorded.
ANS:
A, C, D
The parents should be taught that supplemental vitamins will be prescribed to aid in nutritional status. Bactrim is
administered to prevent the opportunistic infection of Pneumocystis jiroveci pneumonia. The physician should be notified
if the child with AIDS develops a cough and congestion. The yearly influenza vaccination is recommended, and any missed
doses of antiretroviral medication need to be recorded and reported.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
1387
Nursing Process: Implementation
MSC:
Client Needs: Health Promotion and Maintenance
Inflammation
Concept 24: Inflammation
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
A nurse is instructing her patient with ulcerative colitis regarding the need to avoid enteric coated
medications. The nurse knows that the patient understands the reason for this teaching when he states which of the
following?
a.
“The coating on these medications is irritating to my intestines.”
b.
“I need a more immediate response from my medications than can be obtained from enteric coated medications.”
c.
“Enteric coated medications are absorbed lower in the digestive tract and can be irritating to my intestines or
inadequately absorbed by my inflamed tissue.”
d.
“I don’t need to use these medications because they cause diarrhea, and I have had enough trouble with diarrhea
and rectal bleeding over the past weeks.”
ANS:
C
Enteric coatings on medications are designed to prevent breakdown and absorption of the medication until lower in the
digestive tract, usually to prevent stomach irritation or to reach a certain point in the digestive tract for optimal absorption.
For the patient with ulcerative colitis, the intestinal lining is inflamed or susceptible to inflammation and can have impaired
absorption; therefore, enteric coated medications should be avoided. The coating is not irritating, but the medication can
be. The response time of the medication is not a concern in this instance. Enteric coated medicines do not cause diarrhea
simply because they are enteric coated.
REF:
OBJ:
Page 238
NCLEX® Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
2.
A patient is diagnosed with a sprain to her right ankle after a fall. The patient asks the nurse about
using ice on her injured ankle. What is the nurse’s best response?
a.
“Use ice only when the ankle hurts.”
b.
“Ice should be applied for 15 to 20 minutes every 2 to 3 hours over the next 1 to 2 days.”
c.
“Wrap an ice pack around the injured ankle for the next 24 to 48 hours.”
d.
“Ice is not recommended for use on the sprain because it would inhibit the inflammatory response.”
ANS:
B
Ice is used on areas of injury during the first 24 to 48 hours after the injury occurs to prevent damage to surrounding
tissues from excessive inflammation. Ice should be used for a maximum of 20 minutes at a time every 2 to 3 hours. Ice
must be used according to a schedule for it to be effective and not be overused. Using ice more often or for longer periods
of time can cause additional tissue damage. Ice is recommended to inhibit the inflammatory process from damaging
surrounding tissue.
REF:
Page 235 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
3.
A patient is being treated with an antibiotic for an infected orthopedic injury. What explanation should
the nurse give to the patient about this medication?
a.
“Antibiotics will decrease the pain at the site.”
b.
“An antibiotic helps to kill the infection causing the inflammation.”
c.
“An antibiotic inhibits cyclooxygenase, an enzyme in the body.”
d.
“Antibiotics will reduce the patient’s fever.”
ANS:
B
Antimicrobials treat the underlying cause of the infection which leads to inflammation. Analgesics and nonsteroidal
antiinflammatory drugs (NSAIDs) help to treat pain. NSAIDs and other antipyretics are cyclooxygenase inhibitors.
Antipyretics help to reduce fever.
REF:
OBJ:
Page 236
NCLEX® Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4.
On admission to the clinic, the nurse notes a moderate amount of serous exudate leaking from the
patient’s wound. The nurse realizes what information about this fluid?
a.
Contains the materials used by the body in the initial inflammatory response.
b.
Indicates that the patient has an infection at the site of the wound.
c.
Is destroying healthy tissue.
d.
Results from ineffective cleansing of the wound area.
ANS:
A
Exudate is fluid moved from the vascular spaces to the area around a wound. It contains the proteins, fluid, and white
blood cells (WBCs) needed to contain possible pathogens at the site of injury. Exudate appears as part of all inflammatory
responses and does not mean an infection is present. Exudate is part of normal inflammatory responses which contain
self-monitoring mechanisms to help prevent damage to healthy tissue. Exudate appears at wound sites regardless of
cleaning done to the area of injury.
REF:
OBJ:
Page 234
NCLEX® Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5.
The nurse reviews the patient’s complete blood count (CBC) results and notes that the neutrophil levels
are elevated, but monocytes are still within normal limits. This indicates what type of inflammatory response?
a.
Chronic
b.
Resolved
c.
Early stage acute
d.
Late stage acute
ANS:
C
Elevated neutrophils and monocytes within normal limits are findings indicative of early inflammatory response.
Neutrophils increase in just a few hours, while it takes the body days to increase the monocyte levels. Chronic
inflammation results in varying elevations in WBCs dependent on multiple issues. Elevated neutrophils are not indicative
of resolved inflammation. Elevations in monocytes occur later in the inflammatory response.
REF:
OBJ:
Page 232
NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6.
A patient comes to the clinic with a complaint of painful, itchy feet. On interview, the patient tells the
nurse that he is a college student living in a dormitory apartment that he shares with five other students. What teaching
should the nurse provide for this patient?
a.
“Don’t eat with the other students.”
b.
“Avoid sharing razors and other personal items.”
c.
“Have a complete blood count (CBC) checked monthly.”
d.
“Disinfect showers and bathroom floors weekly after use.”
ANS:
B
Avoidance of sharing personal items like razors and hairbrushes can decrease the spread of pathogens that cause
inflammation and infection. Not eating with the others in his college apartment won’t relieve or prevent the spread of
infection. A CBC monthly will not treat or prevent inflammation. Showers should be disinfected before and after each use.
REF:
Page 234 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
MULTIPLE RESPONSE
1.
The nurse assesses the patient and notes all of the following. Select all of the findings that indicate the
systemic manifestations of inflammation.
a.
Oral temperature 38.6° C/101.5° F
b.
Thick, green nasal discharge
c.
Patient complaint of pain at 6 on a 0 to 10 scale on palpation of frontal and maxillary sinuses
d.
WBC 20 cells/McL 109/L
e.
Patient reports, “I’m tired all the time. I haven’t felt like myself in days.”
ANS:
A, D, E
Systemic manifestations of inflammatory response include elevated temperature, leukocytosis, and malaise and fatigue.
Purulent exudates and pain are both considered local manifestations of inflammation.
REF:
OBJ:
Page 234
NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential
Chapter 64: Arthritis and Connective Tissue Diseases
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
a.
b.
c.
d.
1.
Which finding will the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee?
Presence of Heberden’s nodules
Discomfort with joint movement
Redness and swelling of the knee joint
Stiffness that increases with movement
ANS:
B
Initial symptoms of OA include pain with joint movement. Heberden’s nodules occur on the fingers. Redness of the joint is
associated with inflammatory arthritis such as rheumatoid arthritis. Stiffness in OA is worse right after the patient rests
and decreases with joint movement.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
1518
Nursing Process: Assessment
MSC:
NCLEX: Physiological Integrity
2.
Which assessment finding for a patient using naproxen (Naprosyn) to treat osteoarthritis is likely to
require a change in medication?
a.
The patient has gained 3 lb.
b.
The patient has dark-colored stools.
c.
The patient’s pain affects multiple joints.
d.
The patient uses capsaicin cream (Zostrix).
ANS:
B
Dark-colored stools may indicate the patient is experiencing gastrointestinal bleeding caused by the naproxen. The
patient’s ongoing pain and weight gain will also be reported and may indicate a need for a different treatment and/or
counseling about avoiding weight gain, but these are not as large a concern as the possibility of gastrointestinal bleeding.
Use of capsaicin cream with oral medications is appropriate.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1521
NCLEX: Physiological Integrity
3.
After the nurse has finished teaching a patient with osteoarthritis (OA) of the right hip about how to
manage the OA, which patient statement indicates a need for more teaching?
a.
“I can exercise every day to help maintain joint motion.”
b.
“I will take 1 g of acetaminophen (Tylenol) every 4 hours.”
c.
“I will take a shower in the morning to help relieve stiffness.”
d.
“I can use a cane to decrease the pressure and pain in my hip.”
ANS:
B
No more than 4 g of acetaminophen (1 g every 6 hours) should be taken daily to decrease the risk for liver damage.
Regular exercise, moist heat, and supportive equipment are recommended for OA management.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
1523
NCLEX: Physiological Integrity
4.
The nurse will anticipate the need to teach a patient who has osteoarthritis (OA) about which
medication?
a.
Prednisone
c.
Capsaicin cream (Zostrix)
b.
Adalimumab (Humira)
d.
Sulfasalazine (Azulfidine)
ANS:
C
Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA. The other
medications would be used for patients with rheumatoid arthritis.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1520
NCLEX: Physiological Integrity
10.
The nurse teaching a support group of women with rheumatoid arthritis (RA) about how to manage
activities of daily living suggests they should
a.
avoid activities requiring repetitive use of the same muscles and joints.
b.
protect the knee joints by sleeping with a small pillow under the knees.
c.
stand rather than sit when performing daily household and yard chores.
d.
strengthen small hand muscles by wringing out sponges or washcloths.
ANS:
A
Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress
on joints. Wringing water out of sponges would increase joint stress. Patients are encouraged to position joints in the
extended (neutral) position. Sleeping with a pillow behind the knees would decrease the ability of the knee to extend and
also decrease knee range of motion.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1524
NCLEX: Physiological Integrity
39.
Which patient seen by the nurse in the outpatient clinic is most likely to require teaching about ways to
reduce the risk for osteoarthritis (OA)?
a.
A 56-yr-old man who has a sedentary office job
b.
A 38-yr-old man who plays on a summer softball team
c.
A 56-yr-old woman who works on an automotive assembly line
d.
A 38-yr-old woman who is newly diagnosed with diabetes mellitus
ANS:
C
OA is more likely to occur in women as a result of estrogen reduction at menopause and in individuals whose work
involves repetitive movements and lifting. Moderate exercise, such as softball, reduces the risk for OA. Diabetes is not a
risk factor for OA. Sedentary work is not a risk factor for OA.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1518
Nursing Process: Planning
Chapter 42: Lower Gastrointestinal Problems
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
9.
A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain
and passing 15 or more bloody stools a day. The nurse will plan to
a.
administer IV metoclopramide (Reglan).
b.
discontinue the patient’s oral food intake.
c.
administer cobalamin (vitamin B12) injections.
d.
teach the patient about total colectomy surgery.
ANS:
B
An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient
NPO. Metoclopramide increases peristalsis and will worsen symptoms. Cobalamin (vitamin B12) is absorbed in the ileum,
which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that
this patient is a candidate.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
946
NCLEX: Physiological Integrity
10.
Which nursing action will the nurse include in the plan of care for a 35-yr-old male patient admitted with
an exacerbation of inflammatory bowel disease (IBD)?
a.
Restrict oral fluid intake.
c.
Ambulate six times daily.
b.
Monitor stools for blood.
d.
Increase dietary fiber intake.
ANS:
B
Because anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other
actions would not be appropriate for the patient with IBD. Dietary fiber may increase gastrointestinal motility and
exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
949
NCLEX: Physiological Integrity
11.
Which patient statement indicates that the nurse’s teaching about sulfasalazine (Azulfidine) for
ulcerative colitis has been effective?
a.
“The medication will be tapered if I need surgery.”
b.
“I will need to use a sunscreen when I am outdoors.”
c.
“I will need to avoid contact with people who are sick.”
d.
“The medication prevents the infections that cause diarrhea.”
ANS:
B
Sulfasalazine may cause photosensitivity in some patients. It is not used to treat infections. Sulfasalazine does not reduce
immune function. Unlike corticosteroids, tapering of sulfasalazine is not needed.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
947
NCLEX: Physiological Integrity
12.
A 22-yr-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and
has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has
been effective?
a.
The patient uses incontinence briefs to contain loose stools.
b.
The patient uses witch hazel compresses to soothe irritation.
c.
The patient asks for antidiarrheal medication after each stool.
d.
The patient cleans the perianal area with soap after each stool.
ANS:
B
Witch hazel compresses are suggested to reduce anal irritation and discomfort. Incontinence briefs may trap diarrhea and
increase the incidence of skin breakdown. Antidiarrheal medications are not given 15 to 20 times a day. The perianal area
should be washed with plain water or pH balanced cleanser after each stool.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
950
NCLEX: Physiological Integrity
13.
Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD)
indicates a need for more teaching?
a.
Scrambled eggs c.
Oatmeal with cream
b.
White toast and jam
d.
Pancakes with syrup
ANS:
C
During acute exacerbations of IBD, the patient should avoid high-fiber foods such as whole grains. High-fat foods also
may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
949
NCLEX: Physiological Integrity
15.
A patient has a new diagnosis of Crohn’s disease after having frequent diarrhea and a weight loss of 10
lb (4.5 kg) over 2 months. The nurse will plan to teach about
a.
medication use. c.
enteral nutrition.
b.
fluid restriction. d.
activity restrictions.
ANS:
A
Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased
activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration.
There is no advantage to enteral feedings.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
30.
need for
a.
b.
c.
d.
REF:
947
NCLEX: Physiological Integrity
The nurse will plan to teach a patient with Crohn’s disease who has megaloblastic anemia about the
iron dextran infusions
oral ferrous sulfate tablets.
routine blood transfusions.
cobalamin (B12) supplements.
ANS:
D
Crohn’s disease frequently affects the ileum, where absorption of cobalamin occurs. Cobalamin must be administered
regularly by nasal spray or IM to correct the anemia. Iron deficiency does not cause megaloblastic anemia. The patient
may need occasional transfusions but not regularly scheduled transfusions.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
946
NCLEX: Physiological Integrity
34.
A patient in the emergency department has just been diagnosed with peritonitis caused by a ruptured
diverticulum. Which prescribed intervention will the nurse implement first?
a.
Insert a urinary catheter to drainage.
b.
Infuse metronidazole (Flagyl) 500 mg IV.
c.
Send the patient for a computerized tomography scan.
d.
Place a nasogastric (NG) tube to intermittent low suction.
ANS:
B
Because peritonitis can be fatal if treatment is delayed, the initial action should be to start antibiotic therapy (after any
ordered cultures are obtained). The other actions can be done after antibiotic therapy is initiated.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
47.
care?
a.
b.
c.
d.
TOP:
REF:
947
Nursing Process: Implementation
A patient is awaiting surgery for acute peritonitis. Which action will the nurse include in the plan of
Position patient with the knees flexed.
Avoid use of opioids or sedative drugs.
Offer frequent small sips of clear liquids.
Assist patient to breathe deeply and cough.
ANS:
A
There is less peritoneal irritation with the knees flexed, which will help decrease pain. Opioids and sedatives are typically
given to control pain and anxiety. Preoperative patients with peritonitis are given IV fluids for hydration. Deep breathing
and coughing will increase the patient’s discomfort.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
944
NCLEX: Physiological Integrity
48.
A 72-yr-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5%
dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health
care provider?
a.
Patient has not voided for the last 4 hours.
b.
Skin is dry with poor turgor on all extremities.
c.
Crackles are heard halfway up the posterior chest.
d.
Patient has had 5 loose stools over the previous 6 hours.
ANS:
C
The presence of crackles in an older patient receiving IV fluids at a high rate suggests volume overload and a need to
reduce the rate of the IV infusion. The other data will also be reported but are consistent with the patient’s age and
diagnosis and do not require a change in the prescribed treatment.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
a.
b.
c.
d.
53.
Which information will the nurse teach a patient with lactose intolerance?
Ice cream is relatively low in lactose.
Live-culture yogurt is usually tolerated.
Heating milk will break down the lactose.
Nonfat milk is tolerated better than whole milk.
TOP:
REF:
948
Nursing Process: Assessment
ANS:
B
Lactose-intolerant individuals can usually eat yogurt without experiencing discomfort. Ice cream, nonfat milk, and milk
that has been heated are all high in lactose.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
949
Nursing Process: Planning MSC:
NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1.
Which information will the nurse include when teaching a patient how to avoid chronic constipation
(select all that apply)?
a.
Stimulant and saline laxatives can be used regularly.
b.
Bulk-forming laxatives are an excellent source of fiber.
c.
Walking or cycling frequently will help bowel motility.
d.
e.
A good time for a bowel movement may be after breakfast.
Some over-the-counter (OTC) medications cause constipation.
ANS:
B, C, D, E
Stimulant and saline laxatives should be used infrequently. Use of bulk-forming laxatives, regular early morning timing of
defecation, regular exercise, and avoiding many OTC medications will help the patient avoid constipation.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
935
Nursing Process: Planning MSC:
NCLEX: Physiological Integrity
14.
After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, “I cannot manage all
these changes. I don’t want to look at the stoma.” What is the best action by the nurse?
a.
Reassure the patient that ileostomy care will become easier.
b.
Ask the patient about the concerns with stoma management.
c.
Postpone any teaching until the patient adjusts to the ileostomy.
d.
Develop a detailed written list of ostomy care tasks for the patient.
ANS:
B
Encouraging the patient to share concerns assists in helping the patient adjust to the body changes. Acknowledgment of
the patient’s feelings and concerns is important rather than offering false reassurance. Because the patient indicates that
the feelings about the ostomy are the reason for the difficulty with the many changes, development of a detailed ostomy
care plan will not improve the patient’s ability to manage the ostomy. Although detailed ostomy teaching may be
postponed, the nurse should offer teaching about some aspects of living with an ostomy.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Implementation
MSC:
REF:
959
NCLEX: Psychosocial Integrity
19.
The nurse is providing preoperative teaching for a patient scheduled for an abdominal-perineal
resection. Which information will the nurse include?
a.
The patient will begin sitting in a chair at the bedside on the first postoperative day.
b.
IV antibiotics will be started at least 24 hours before surgery to reduce the bowel bacteria.
c.
An additional surgery in 8 to 12 weeks will be used to create an ileal-anal reservoir.
d.
The site where the stoma will be located will be marked on the abdomen preoperatively.
ANS:
D
A WOCN should select the site where the ostomy will be positioned and mark the abdomen preoperatively. The site should
be within the rectus muscle, on a flat surface, and in a place that the patient is able to see. A permanent colostomy is
created with this surgery. Sitting is contraindicated after an abdominal-perineal resection. Oral antibiotics (rather than IV
antibiotics) are given to reduce colonic and rectal bacteria.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
960
NCLEX: Physiological Integrity
22.
A patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The
nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. The nurse should
a.
place ice packs around the stoma.
b.
notify the surgeon about the stoma.
c.
monitor the stoma every 30 minutes.
d.
document stoma assessment findings.
ANS:
D
The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed
or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery, and an ice
pack is not needed.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
960
NCLEX: Physiological Integrity
23.
Which information will the nurse include in teaching a patient who had a proctocolectomy and
ileostomy for ulcerative colitis?
a.
Restrict fluid intake to prevent constant liquid drainage from the stoma.
b.
Use care when eating high-fiber foods to avoid obstruction of the ileum.
c.
d.
Irrigate the ileostomy daily to avoid having to wear a drainage appliance.
Change the pouch every day to prevent leakage of contents onto the skin.
ANS:
B
High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with
ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be
drained frequently but is changed every 5 to 7 days. The drainage from an ileostomy is liquid and continuous, so control
by irrigation is not possible.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
962
NCLEX: Physiological Integrity
24.
A patient with a new ileostomy asks how much drainage to expect. The nurse explains that after the
bowel adjusts to the ileostomy, the usual drainage will be about _____ cups daily.
a.
2
c.
4
b.
3
d.
5
ANS:
A
After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 500 mL
daily. One cup is about 240 mL.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
958
Nursing Process: Implementation
MSC:
NCLEX: Physiological Integrity
39.
Which activity in the care of a patient with a new colostomy could the nurse delegate to unlicensed
assistive personnel (UAP)?
a.
Document the appearance of the stoma.
b.
Place a pouching system over the ostomy.
c.
Drain and measure the output from the ostomy.
d.
Check the skin around the stoma for breakdown.
ANS:
C
Draining and measuring the output from the ostomy is included in UAP education and scope of practice. The other actions
should be implemented by LPNs or RNs.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Delegation
TOP:
NCLEX: Safe and Effective Care Environment
REF:
960
Nursing Process: Planning
41.
Which care activity for a patient with a paralytic ileus is appropriate for the registered nurse (RN) to
delegate to unlicensed assistive personnel (UAP)?
a.
Auscultation for bowel sounds
b.
Nasogastric (NG) tube irrigation
c.
Applying petroleum jelly to the lips
d.
Assessment of the nares for irritation
ANS:
C
UAP education and scope of practice include patient hygiene such as oral care. The other actions require education and
scope of practice appropriate to the RN.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Delegation
TOP:
NCLEX: Safe and Effective Care Environment
REF:
960
Nursing Process: Implementation
45.
A 33-yr-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is
formed as shown in the accompanying figure. Which information will be included in patient teaching?
a.
b.
Stool will be expelled from both stomas.
This type of colostomy is usually temporary.
c.
d.
Soft, formed stool can be expected as drainage.
Irrigations can regulate drainage from the stomas.
ANS:
B
A loop, or double-barrel stoma, is usually temporary. Stool will be expelled from the proximal stoma only. The stool from
the transverse colon will be liquid and regulation through irrigations will not be possible.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
959
NCLEX: Physiological Integrity
Chapter 41: Gastrointestinal Dysfunction
MULTIPLE CHOICE
20.
What is characterized by a chronic inflammatory process that may involve any part of the
gastrointestinal (GI) tract from mouth to anus?
a.
Crohn’s disease c.
Meckel’s diverticulum
b.
Ulcerative colitis d.
Irritable bowel syndrome
ANS:
A
The chronic inflammatory process of Crohn’s disease involves any part of the GI tract from the mouth to the anus but most
often affects the terminal ileum. Ulcerative colitis, Meckel’s diverticulum, and irritable bowel syndrome do not affect the
entire GI tract.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1278
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
a.
b.
21.
What is used to treat moderate-to-severe inflammatory bowel disease?
Antacids c.
Corticosteroids
Antibiotics
d.
Antidiarrheal medications
ANS:
C
Corticosteroids such as prednisone and prednisolone are used in short bursts to suppress the inflammatory response in
inflammatory bowel disease. Antacids and antidiarrheals are not drugs of choice to treat the inflammatory process of
inflammatory bowel disease. Antibiotics may be used as adjunctive therapy to treat complications.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1279
Nursing Process: Implementation
MSC:
Client Needs: Physiologic Integrity
41.
colitis?
a.
b.
c.
d.
What should the nurse stress in a teaching plan for the mother of an 11-year-old boy with ulcerative
Preventing the spread of illness to others
Nutritional guidance and preventing constipation
Teaching daily use of enemas
Coping with stress and avoiding triggers
ANS:
D
Coping with the stress of chronic illness and the clinical manifestations associated with ulcerative colitis (diarrhea, pain)
are important teaching foci. Avoidance of triggers can help minimize the impact of the disease and its effect on the child.
Ulcerative colitis is not infectious. Although nutritional guidance is a priority teaching focus, diarrhea is a problem with
ulcerative colitis, not constipation. Daily enemas are not part of the therapeutic plan of care.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
1278
Nursing Process: Implementation
MSC:
Client Needs: Physiologic Integrity
Infection
Concept 25: Infection
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
The nurse is working on a plan of care with her patient which includes turning and positioning and
adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks
the chain of infection by eliminating which element?
a.
Host
b.
Mode of transmission
c.
Portal of entry
d.
Reservoir
ANS:
C
Broken or impaired skin creates a portal of entry for pathogens. By maintaining intact tissue, the patient and the nurse
have broken the chain of infection by eliminating a portal of entry. Host is incorrect because you are not eliminating the
person or organism. Intact tissue does not eliminate the mode of transmission. Skin can still be used to transfer
pathogens regardless of it being intact or broken. Intact skin does not eliminate the location for pathogens to live and
grow.
REF:
OBJ:
Page 243
NCLEX® Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
2.
While reviewing the complete blood count (CBC) of a patient on her unit, the nurse notes elevated
basophil and eosinophil readings. The nurse realizes that this is most indicative of which type of infection?
a.
Bacterial
b.
Fungal
c.
Parasitic
d.
Viral
ANS:
C
Parasitic infections are frequently indicated on a CBC by elevated basophil and eosinophil levels. Bacterial infections do
not lead to elevated basophil and eosinophil levels but elevated B and T lymphocytes, neutrophils, and monocytes. Fungal
infections do not lead to elevated basophil and eosinophil levels. Viral infections create elevations in B and T
lymphocytes, neutrophils, and monocytes.
REF:
OBJ:
Page 246
NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3.
Which set of assessment data is consistent for a patient with severe infection that could lead to system
failure?
a.
Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in
past 24 hours
b.
BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours
c.
BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours
d.
BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours
ANS:
B
The patient with severe infection presents with low BP and compensating elevations in pulse to move lower volumes of
blood more rapidly and respiration to increase access to oxygen. Urine output decreases to counteract the decreased
circulating blood volume and hypotension. These vital signs are all too low: Blood pressure (BP) 92/52, pulse (P) 56
beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours. The patient with severe infection
does have a low BP, but the pulse and respiratory rate increase to compensate. This data is all within normal limits: BP
112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours. This set of data reflects an elevated BP
with a decrease in pulse and respiratory rates along with normal urine output: BP 152/90, P 52 beats/min, RR 12
breaths/min, urine output 4800 mL in past 24 hours. None of these is a typical response to severe infection.
REF:
OBJ:
Page 241
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
4.
A nurse is teaching a group of business people about disease transmission. He knows that he needs to
reeducate when one of the participants states which of the following?
a.
“When traveling outside of the country, I need to be sure that I receive appropriate vaccinations.”
b.
“Food and water supplies in foreign countries can contain microorganisms to which my body is not accustomed
and has no resistance.”
c.
“If I don’t feel sick, then I don’t have to worry about transmitted diseases.”
d.
“I need to be sure to have good hygiene practices when traveling in crowded planes and trains.”
ANS:
C
People can transmit pathogens even if they don’t currently feel ill. Some carriers never experience the full symptoms of a
pathogen. Travelers may need different vaccinations when traveling to countries outside their own because of variations in
prevalent microorganisms. Food and water supplies in foreign countries can contain microorganisms that will affect a
body unaccustomed to their presence. Adequate hygiene is essential when in crowded, public spaces like planes and
other forms of public transportation.
REF:
OBJ:
Page 245 |Page 246
NCLEX® Client Needs Category: Health Promotion and Maintenance
5.
In order to provide the best intervention for a patient, the nurse is often responsible for obtaining a
sample of exudate for culture. What information will this provide?
a.
Whether a patient has an infection.
b.
Where an infection is located.
c.
What cells are being utilized by the body to attack an infection.
d.
What specific type of pathogen is causing an infection.
ANS:
D
People can transmit pathogens even if they don’t currently feel ill. Some carriers never experience the full symptoms of a
pathogen. A CBC will identify that the patient has an infection. Inspection and radiography will help identify where an
infection is located. The CBC with differential will identify the white blood cells being used by the body to fight an
infection. The culture will grow the microorganisms in the sample for identification of the specific type of pathogen.
REF:
OBJ:
Page 246
NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential
MULTIPLE RESPONSE
1.
The nurse is caring for a patient with a diagnosed case of Clostridium difficile. The nurse expects to
implement which of the following interventions? (Select all that apply.)
a.
Administration of protease inhibitors
b.
Use of personal protective equipment
c.
Patient teaching on methods to inhibit transmission
d.
Preventing visitors from entering the room
e.
Administration of intravenous fluids
f.
Strict monitoring of intake and output
ANS:
B, C, E, F
Protease inhibitors are used for treatment of viral infections, not bacterial infections. The nurse wants to protect visitors
from exposure to the bacteria and protect the patient from secondary infection while immunocompromised, but the patient
will need the support of family and close friends. Contact isolation precautions must be strictly followed along with the
use of personal protective equipment and teaching on methods to inhibit transmission to help break the chain of infection.
Intravenous fluids and strict intake and output monitoring will be important for the patient suffering the effects of
Clostridium difficile, because it causes diarrhea with fluid loss.
REF:
OBJ:
Page 246 |Page 247
NCLEX® Client Needs Category: Physiological Integrity: Basic Care and Comfort and Physiological Adaptation
2.
Individuals of low socioeconomic status are at an increased risk for infection because of which of the
following? (Select all that apply.)
a.
Uninsured or underinsured status
b.
Easy access to health screenings
c.
High cost of medications
d.
Inadequate nutrition
e.
Mostly female gender
ANS:
A, C, D
Individuals of low socioeconomic status tend to be part of the underinsured or uninsured population. Lack of insurance
decreases accessibility to health care in general and health screening services specifically. High costs of medication and
nutritious food also make this population at higher risk for infection. Gender has not been shown to be an increased risk
factor for infection in the lower socioeconomic population.
REF:
OBJ:
Page 243
NCLEX® Client Needs Category: Physiological Integrity: Basic Care and Comfort and Psychosocial Integrity
Chapter 21: Visual and Auditory Problems
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
17.
A patient diagnosed with external otitis is being discharged from the emergency department with an ear
wick in place. Which statement by the patient indicates a need for further teaching?
a.
“I will apply the eardrops to the cotton wick in the ear canal.”
b.
“I can use aspirin or acetaminophen (Tylenol) for pain relief.”
c.
“I will clean the ear canal daily with a cotton-tipped applicator.”
d.
“I can use warm compresses to the outside of the ear for comfort.”
ANS:
C
Insertion of instruments such as cotton-tipped applicators into the ear should be avoided. The other patient statements
indicate that the teaching has been successful.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
a.
b.
18.
The nurse will instruct a patient who has undergone a left tympanoplasty to
remain on bed rest.
c.
avoid blowing the nose.
keep the head elevated.
d.
irrigate the left ear canal.
MSC:
REF:
384
NCLEX: Physiological Integrity
ANS:
C
Coughing or blowing the nose increases pressure in the eustachian tube and middle ear cavity and disrupts postoperative
healing. There is no postoperative need for prolonged bed rest, elevation of the head, or continuous antibiotic irrigation.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
385
NCLEX: Physiological Integrity
19.
The nurse is assessing a patient who was recently treated with amoxicillin for acute otitis media of the
right ear. Which finding is a priority to report to the health care provider?
a.
The patient has a temperature of 100.6° F.
b.
The patient complains of “popping” in the ear.
c.
Clear fluid is visible through the tympanic membrane.
d.
The patient frequently asks the nurse to repeat information.
ANS:
A
The fever indicates that the infection may not be resolved, and the patient might need further antibiotic therapy. A feeling
of fullness, “popping” of the ear, decreased hearing, and fluid in the middle ear are indications of otitis media with
effusion. These symptoms are normal for weeks to months after an episode of acute otitis media and usually resolve
without treatment.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
a.
b.
c.
d.
43.
Which action will the nurse take when performing ear irrigation for a patient with cerumen impaction?
Assist the patient to a supine position for the irrigation.
Fill the irrigation syringe with body-temperature solution.
Use a sterile applicator to clean the ear canal before irrigating.
Occlude the ear canal completely with the syringe while irrigating.
TOP:
REF:
384
Nursing Process: Evaluation
ANS:
B
Solution at body temperature is used for ear irrigation. The patient should be sitting for the procedure. Use of cottontipped applicators to clear the ear may result in forcing the cerumen deeper into the ear canal. The ear should not be
completely occluded with the syringe.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
384
Nursing Process: Implementation
MSC:
NCLEX: Safe and Effective Care Environment
Chapter 45: Renal and Urologic Problems
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
2.
The nurse determines that instruction regarding prevention of future urinary tract infections (UTIs) has
been effective for a 22-yr-old female patient with cystitis when the patient states which of the following?
a.
“I can use vaginal antiseptic sprays to reduce bacteria.”
b.
c.
d.
“I will drink a quart of water or other fluids every day.”
“I will wash with soap and water before sexual intercourse.”
“I will empty my bladder every 3 to 4 hours during the day.”
ANS:
D
Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be
emptied before and after intercourse, but cleaning with soap and water is not necessary to prevent UTI. A quart of fluids is
insufficient to provide adequate urine output to decrease risk for UTI.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
1038
NCLEX: Health Promotion and Maintenance
3.
Which information will the nurse include when teaching the patient with a urinary tract infection (UTI)
about the use of phenazopyridine?
a.
Take phenazopyridine for at least 7 days.
b.
Phenazopyridine may cause photosensitivity
c.
Phenazopyridine may change the urine color
d.
Take phenazopyridine before sexual intercourse.
ANS:
C
Patients should be taught that phenazopyridine will color the urine deep orange. Urinary analgesics should only be needed
for a few days until the prescribed antibiotics decrease the bacterial count. Phenazopyridine does not cause
photosensitivity. Taking phenazopyridine before intercourse will not be helpful in reducing the risk for UTI.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1036
NCLEX: Physiological Integrity
4.
Which finding by the nurse will be most helpful in determining whether a 67-yr-old patient with benign
prostatic hyperplasia has an upper urinary tract infection (UTI)?
a.
Bladder distention c.
Suprapubic discomfort
b.
Foul-smelling urine
d.
Costovertebral tenderness
ANS:
D
Costovertebral tenderness is characteristic of pyelonephritis. Bladder distention, foul-smelling urine, and suprapubic
discomfort are characteristic of a lower UTI and are likely to be present if the patient also has an upper UTI.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Assessment
MSC:
REF:
1038
NCLEX: Physiological Integrity
14.
A young adult male patient seen at the primary care clinic complains of feeling continued fullness after
voiding and a split, spraying urine stream. The nurse will ask about a history of
a.
recent kidney trauma.
c.
recurrent bladder infection.
b.
gonococcal urethritis.
d.
benign prostatic hyperplasia.
ANS:
B
The patient’s clinical manifestations are consistent with urethral strictures, a possible complication of gonococcal
urethritis. These symptoms are not consistent with benign prostatic hyperplasia, kidney trauma, or bladder infection.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
a.
b.
27.
Which assessment data reported by a patient is consistent with a lower urinary tract infection (UTI)?
Low urine output c.
Nausea and vomiting
Bilateral flank pain d.
Burning on urination
MSC:
REF:
1039
NCLEX: Physiological Integrity
ANS:
D
Pain with urination is a common symptom of a lower UTI. Urine output does not decrease, but frequency may be
experienced. Flank pain and nausea are associated with an upper UTI.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1035
NCLEX: Physiological Integrity
28.
Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most
important for the nurse to report to the health care provider?
a.
b.
Complaint of flank pain
c.
Blood pressure 90/48 mm Hg
Cloudy and foul-smelling urine
d.
Temperature 100.1° F (57.8° C)
ANS:
B
The low blood pressure indicates that urosepsis and septic shock may be occurring and should be immediately reported.
The other findings are typical of pyelonephritis.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1038
Nursing Process: Assessment
34.
A patient is unable to void after having an open loop resection and fulguration of the bladder. Which
nursing action should be implemented?
a.
Assist the patient to soak in a 15-minute sitz bath.
b.
Restrict oral fluids to equal previous urine volume.
c.
Insert a straight urethral catheter and drain the bladder.
d.
Teach the patient how to do isometric perineal exercises.
ANS:
A
Sitz baths will relax the perineal muscles and promote voiding. The patient should be to drink fluids. Kegel exercises are
helpful in the prevention of incontinence, but would not be helpful for a patient experiencing retention. Catheter insertion
increases the risk for urinary tract infection and should be avoided when possible
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1039
NCLEX: Physiological Integrity
39.
A patient seen in the clinic for a bladder infection describes the following symptoms. Which information
is most important for the nurse to report to the health care provider?
a.
Urinary urgency c.
Intermittent hematuria
b.
Left-sided flank pain
d.
Burning with urination
ANS:
B
Flank pain indicates that the patient may have developed pyelonephritis as a complication of the bladder infection. The
other clinical manifestations are consistent with a lower urinary tract infection.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1035
Nursing Process: Assessment
40.
A patient in the urology clinic is diagnosed with monilial urethritis. Which action will the nurse include
in the plan of care?
a.
Teach the patient about the use of antifungal medications.
b.
Tell the patient to avoid tub baths until the symptoms resolve.
c.
Instruct the patient to refer recent sexual partners for treatment.
d.
Teach the patient to avoid nonsteroidal antiinflammatory drugs (NSAIDs).
ANS:
A
Monilial urethritis is caused by a fungus and antifungal medications such as nystatin or fluconazole are usually used as
treatment. Because monilial urethritis is not sexually transmitted, there is no need to refer sexual partners. Warm baths
and NSAIDS may be used to treat symptoms.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1039
NCLEX: Physiological Integrity
Chapter 40: Respiratory Dysfunction
MULTIPLE CHOICE
8.
Chronic otitis media with effusion (OME) is differentiated from acute otitis media (AOM) because it is
usually characterized by:
a.
Fever as high as 40° C (104° F).
c.
Nausea and vomiting.
b.
Severe pain in the ear.
d.
A feeling of fullness in the ear.
ANS:
D
OME is characterized by an immobile or orange-discolored tympanic membrane and nonspecific complaints and does not
cause severe pain. Fever and severe pain may be signs of AOM. Nausea and vomiting are associated with otitis media.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1205
Nursing Process: Diagnosis MSC:
Client Needs: Physiologic Integrity
a.
b.
c.
d.
9.
Which statement is characteristic of acute otitis media (AOM)?
The etiology is unknown.
Permanent hearing loss often results.
It can be treated by intramuscular antibiotics.
It is treated with a broad range of antibiotics.
ANS:
D
Historically AOM has been treated with a range of antibiotics, and it is the most common disorder treated with antibiotics
in the ambulatory setting. The etiology of AOM may be bacterial, such as Streptococcus pneumoniae, Haemophilus
influenzae, and Moraxella catarrhalis, or a viral agent. Recent concerns about drug-resistant organisms have caused
authorities to recommend judicious use of antibiotics and that antibiotics are not required for initial treatment. Permanent
hearing loss is not a frequent cause of properly treated AOM. Intramuscular antibiotics are not necessary. Oral amoxicillin
is the treatment of choice.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1205
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
10.
An infant’s parents ask the nurse about preventing otitis media (OM). What should the nurse
recommend?
a.
Avoid tobacco smoke.
b.
Use nasal decongestant.
c.
Avoid children with OM.
d.
Bottle-feed or breastfeed in supine position.
ANS:
A
Eliminating tobacco smoke from the child’s environment is essential for preventing OM and other common childhood
illnesses. Nasal decongestants are not useful in preventing OM. Children with uncomplicated OM are not contagious
unless they show other upper respiratory infection symptoms. Children should be fed in an upright position to prevent
OM.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
1207
Nursing Process: Implementation
MSC:
Client Needs: Physiologic Integrity
39.
An 18-month-old child is seen in the clinic with AOM. Trimethoprim-sulfamethoxazole (Bactrim) is
prescribed. Which statement made by the parent indicates a correct understanding of the instructions?
a.
“I should administer all the prescribed medication.”
b.
“I should continue medication until the symptoms subside.”
c.
“I will immediately stop giving medication if I notice a change in hearing.”
d.
“I will stop giving medication if fever is still present in 24 hours.”
ANS:
A
Antibiotics should be given for their full course to prevent recurrence of infection with resistant bacteria. Symptoms may
subside before the full course is given. Hearing loss is a complication of AOM. Antibiotics should continue to be given.
Medication may take 24 to 48 hours to make symptoms subside. It should be continued.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
1206
Nursing Process: Implementation
MSC:
Client Needs: Physiologic Integrity
Chapter 44: Genitourinary Dysfunction
MULTIPLE CHOICE
1.
Which diagnostic test allows visualization of the renal parenchyma and renal pelvis without exposure to
external beam radiation or radioactive isotopes?
a.
Renal ultrasound c.
Intravenous pyelography
b.
Computed tomography
d.
Voiding cystourethrography
ANS:
A
The transmission of ultrasonic waves through the renal parenchyma allows visualization of the renal parenchyma and
renal pelvis without exposure to external beam radiation or radioactive isotopes. Computed tomography uses external
radiation, and sometimes contrast media are used. Intravenous pyelography uses contrast medium and external radiation
for x-ray films. Contrast medium is injected into the bladder through the urethral opening for voiding cystourethrography.
External radiation for x-ray films is used before, during, and after voiding.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1396
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
a.
b.
3.
Which factor predisposes a child to urinary tract infections?
Increased fluid intake
c.
Prostatic secretions in males
Short urethra in young girls d.
Frequent emptying of the bladder
ANS:
B
The short urethra in females provides a ready pathway for invasions of organisms. Increased fluid intake and frequent
bladder emptying offer protective measures against urinary tract infections. Prostatic secretions have antibacterial
properties that inhibit bacteria.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1399
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
a.
b.
c.
d.
4.
What should the nurse recommend to prevent urinary tract infections in young girls?
Wearing cotton underpants
Limiting bathing as much as possible
Increasing fluids; decreasing salt intake
Cleansing the perineum with water after voiding
ANS:
A
Cotton underpants are preferable to nylon underpants. No evidence exists that limiting bathing, increasing fluids,
decreasing salt intake, or cleansing the perineum with water decreases urinary tract infections in young girls.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1401
Nursing Process: Implementation
MSC:
Client Needs: Physiologic Integrity
5.
The nurse is assisting the pediatric provider with a newborn examination. The provider notes that the
infant has hypospadias. The nurse understands that hypospadias refers to:
a.
Absence of a urethral opening.
b.
Penis shorter than usual for age.
c.
Urethral opening along dorsal surface of penis.
d.
Urethral opening along ventral surface of penis.
ANS:
D
33.
A preschool child is being admitted to the hospital with dehydration and a urinary tract infection (UTI).
Which urinalysis result should the nurse expect with these conditions?
a.
WBC <1; specific gravity 1.008
c.
WBC >2; specific gravity 1.016
b.
WBC <2; specific gravity 1.025
d.
WBC >2; specific gravity 1.030
ANS:
D
The white blood cell count (WBC) in a routine urinalysis should be <1 or 2. Over that amount indicates a urinary tract
inflammatory process. The urinalysis specific gravity for children with normal fluid intake is 1.016 to 1.022. When the
specific gravity is high, dehydration is indicated. A low specific gravity is seen with excessive fluid intake, distal tubular
dysfunction, or insufficient antidiuretic hormone secretion.
PTS:
OBJ:
1
DIF:
Cognitive Level: Analysis
Nursing Process: Assessment
MSC:
REF:
1398
Client Needs: Physiologic Integrity
37.
The nurse is caring for an infant with a suspected urinary tract infection. Which clinical manifestations
would be observed (Select all that apply)?
a.
Vomiting
b.
Jaundice
c.
Failure to gain weight
d.
Swelling of the face
e.
Back pain
f.
Persistent diaper rash
ANS:
A, C, F
Vomiting, failure to gain weight, and persistent diaper rash are clinical manifestations observed in an infant with a urinary
tract infection. Jaundice, swelling of the face, and back pain would not be observed in an infant with a urinary tract
infection.
PTS:
OBJ:
1
DIF:
Cognitive Level: Analysis
Nursing Process: Assessment
MSC:
REF:
1400
Client Needs: Physiologic Integrity
38.
A child with secondary enuresis who complains of dysuria or urgency should be evaluated for what
condition (Select all that apply)?
a.
Hypocalciuria
b.
Nephrotic syndrome
c.
Glomerulonephritis
d.
Urinary tract infection (UTI)
e.
Diabetes mellitus
ANS:
D, E
Complaints of dysuria or urgency from a child with secondary enuresis suggest the possibility of a UTI. If accompanied by
excessive thirst and weight loss, these symptoms may indicate the onset of diabetes mellitus. An excessive loss of
calcium in the urine (hypercalciuria) can be associated with complaints of painful urination, urgency, frequency, and
wetting. Nephrotic syndrome is not usually associated with complaints of dysuria or urgency. Glomerulonephritis is not a
likely cause of dysuria or urgency.
PTS:
OBJ:
1
DIF:
Cognitive Level: Analysis
Nursing Process: Evaluation
MSC:
REF:
1395
Client Needs: Physiologic Integrity
Thermoregulation
Concept 10: Thermoregulation
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
The nursery nurse should identify which newborn at significant risk for hypothermic alteration in
thermoregulation?
a.
Large for gestational age
b.
Low birth weight
c.
Born at term
d.
Well nourished
ANS:
B
Low birth weight and poorly nourished infants (particularly premature infants) and children are at greatest risk for
hypothermia. A large for gestational age infant would not be malnourished. An infant born at term is not considered at
significant risk. A well nourished infant is not at significant risk.
REF:
OBJ:
Page 88
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
2.
A volunteer at the senior center asks the visiting nurse why the senior citizens always seem to be
complaining about the temperature. What is the nurse’s best response?
a.
Older people have a diminished ability to regulate body temperature because of active sweat glands.
b.
Older people have a diminished ability to regulate body temperature because of increased circulation.
c.
Older people have a diminished ability to regulate body temperature because of peripheral vasoconstriction.
d.
Older people have a diminished ability to regulate body temperature because of slower metabolic rates.
ANS:
D
Slower metabolic rates are one factor that reduces the ability of older adults to regulate temperature and be comfortable
when there are any temperature changes. As the body ages, the sweat glands decrease in number and efficiency. Older
adults have reduced circulation. The body conserves heat through peripheral vasoconstriction, and older adults have a
decreased vasoconstrictive response, which impacts ability to respond to temperature changes.
REF:
OBJ:
Page 88
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
3.
The nurse admitting a patient to the emergency department on a very hot summer day would suspect
hyperthermia when the patient demonstrates which assessment finding?
a.
Decreased respirations
b.
Low pulse rate
c.
Red, sweaty skin
d.
Slow capillary refill
ANS:
C
With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch. There is an
increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. With hypothermia there is slow
capillary refill.
REF:
OBJ:
Page 89
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
a.
b.
c.
d.
4.
What is the priority nursing action for a patient suspected to be hypothermic?
Assess vital signs.
Hydrate with intravenous (IV) fluids.
Provide a warm blanket.
Remove wet clothes.
ANS:
D
The first thing to do with a patient suspected to be hypothermic is to remove wet clothes, because heat loss is five times
greater when clothing is wet. Assessing vital signs is important, but the wet clothes should be removed first. Hydration is
very important with hyperthermia and the associated danger of dehydration, but there is not a similar risk with
hypothermia. A warm blanket over wet clothes would not be an effective warming strategy.
REF:
OBJ:
Page 90
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
5.
Which strategies should the nurse include in a community program for senior citizens related to dealing
with cold winter temperatures?
a.
Avoiding hot beverages
b.
Shopping at an indoor mall
c.
Using a fan at low speed
d.
Walking slowly in the park
ANS:
B
Shopping indoors where there is protection from the elements and temperature control is one strategy to avoid cold
temperatures. Hot beverages can help an individual deal with cold weather. Avoiding breezes and air currents is
recommended to conserve body temperature. Physical activity can increase body temperature, and if the senior is going to
walk in the park, weather-appropriate (warm) clothing and a usual or brisk pace, not a slow pace, would be recommended.
REF:
OBJ:
Page 90
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
6.
During orientation to an emergency department, the nurse educator would be concerned if the new
nurse listed which of the following as a risk factor for impaired thermoregulation?
a.
Impaired cognition
b.
Occupational exposure
c.
Physical agility
d.
Temperature extremes
ANS:
C
Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use this information to plan
additional teaching to include medical conditions and gait disturbance as risk factors for hypothermia, because their
bodies have a reduced ability to generate heat. Impaired cognition is a risk factor. Recreational or occupational exposure
is a risk factor. Temperature extremes are risk factors for impaired thermoregulation.
REF:
Page 88 |Page 89
OBJ:
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
7.
What is the most appropriate measure for a nurse to use in assessing core body temperature when
there are suspected problems with thermoregulation?
a.
Oral thermometer
b.
Rectal thermometer
c.
Temporal thermometer scan
d.
Tympanic membrane sensor
ANS:
B
The most reliable means available for assessing core temperature is a rectal temperature, which is considered the
standard of practice. An oral temperature is a common measure but not the most reliable. A temporal thermometer scan
has some limitations and is not the standard. The tympanic membrane sensor could be used as a second source for
temperature assessment.
REF:
OBJ:
Page 89
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
a.
b.
c.
d.
8.
The nurse planning care for a patient with hypothermia should consider what similar exemplar?
Heat exhaustion
Heat stroke
Infection
Prematurity
ANS:
D
Prematurity, frost bite, environmental exposure, and brain injury are considered exemplars of hypothermia. Heat
exhaustion is an exemplar of hyperthermia. Heat stroke is an exemplar of hyperthermia. Infection is an exemplar of
hyperthermia.
REF:
OBJ:
Page 89
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
Unit 4
Tissue Integrity
Concept 27: Tissue Integrity
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
An older patient has developed age spots and is concerned about skin cancer. How would the nurse
instruct the patient to perform skin checks to assess for signs of skin cancer?
a.
“Limit the time you spend in the sun.”
b.
“Monitor for signs of infection.”
c.
“Monitor spots for color change.”
d.
“Use skin creams to prevent drying.”
ANS:
C
The ABCD method (check for asymmetry, border irregularity, color variation, and diameter) should be used to assess
lesions for signs associated with cancer. Color change could be a sign of cancer and needs to be looked at by a
dermatologist. Limiting time spent in the sun is a preventative measure but will not assist the patient in checking the skin
or detecting skin cancer. Infection is usually not found in skin cancer. Skin creams have not been shown to prevent cancer
nor would they assist in detecting skin cancer.
REF:
Page 266 OBJ:
2.
patient?
a.
b.
c.
d.
NCLEX® Client Needs Category: Health Promotion and Maintenance
A patient is to receive phototherapy for the treatment of psoriasis. What is the nursing priority for this
Obtaining a complete blood count (CBC)
Protection from excessive heat
Protection from excessive ultraviolet (UV) exposure
Instructing the patient to take their multivitamin prior to treatment
ANS:
C
Protection from excessive UV exposure is important to prevent tissue damage. Protection from heat is not the most
important priority for this patient. There is no need for vitamins or a CBC for patients with psoriasis.
REF:
OBJ:
Page 267
NCLEX® Client Needs Category: Safe and Effective Care Environment Safety: Safety and Infection Control
3.
A patient was given a patch test to determine what allergen was responsible for their atopic dermatitis.
The provider prescribes a steroid cream. What important instructions should the nurse give to the patient?
a.
Apply the cream generously to affected areas.
b.
Apply a thin coat to affected areas, especially the face.
c.
Apply a thin coat to affected areas; avoid the face and groin.
d.
Apply an antihistamine along with applying a thin coat of steroid to affected areas.
ANS:
C
The patient should avoid the face and groin area as these areas are sensitive and may become irritated or excoriated. An
antihistamine cream would also excoriate the area if the pruritus is cause by an allergen. There may be a need to
administer oral steroid if the rash is generalized.
REF:
OBJ:
Pages 266-267
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
4.
A patient in the outpatient setting was diagnosed with atopic dermatitis. What interventions will the plan
of care focus primarily on?
a.
Decreasing pain
b.
Decreasing pruritus
c.
Preventing infection
d.
Promoting drying of lesions
ANS:
B
Pruritus is the major manifestation of atopic dermatitis and causes the greatest morbidity. The urge to scratch may be mild
and self-limiting, or it may be intense, leading to severely excoriated lesions, infection, and scarring.
REF:
OBJ:
Page 267
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
5.
To help decrease the threat of a melanoma in a blonde-haired, fair-skinned patient at risk, the nurse
would advise the patient to do which of the following?
a.
Apply sunscreen 1 hour prior to exposure.
b.
Drink plenty of water to prevent hot skin.
c.
Use vitamins to help prevent sunburn by replacing lost nutrients.
d.
Apply sunscreen 30 minutes prior to exposure.
ANS:
D
Wearing sunglasses and sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat
exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in
minimizing the risk of developing melanoma; however, vitamins do not prevent burn.
REF:
Page 266 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
6.
A nurse is educating a 21-year-old lifeguard about the risk of skin cancer and the need to wear
sunscreen. Which statement by the patient indicates that the need for further teaching?
a.
“I wear a hat and sit under the umbrella when not in the water.”
b.
“I don’t bother with sunscreen on overcast days.”
c.
“I use a sunscreen with the highest SPF number.”
d.
“I wear a UV shirt and limit exposure to the sun by covering up.”
ANS:
B
The sun’s rays are as damaging to skin on cloudy, hazy days as on sunny days. The other options will all prevent skin
cancer.
REF:
Page 266 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
7.
A patient has cellulitis on the right forearm. The nurse would anticipate orders to administer
medications to eradicate which organism?
a.
b.
c.
d.
Candida albicans
Group A beta-hemolytic streptococci
Staphylococcus aureus
E. Coli
ANS:
C
Staphylococcus aureus is the usual cause of cellulitis, although other pathogens may be responsible. A small abrasion or
lesion can provide a portal for opportunistic or pathogenic infectious organisms to infect deeper tissues.
REF:
OBJ:
Page 268
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
8.
A nurse is conducting community education classes on skin cancer. One participant says to the nurse:
“I read that most melanomas occur on the face and arms in fair-skinned women. Is this true?” The nurse’s most helpful
response would be which of the following?
a.
“That is not correct. Melanoma is more commonly found on the torso or the lower legs of women.”
b.
“That is correct, because the face and arms are exposed more often to the sun.”
c.
“That is not correct. Melanoma occurs on the top of the head in men but is rare in women.”
d.
“That is incorrect. Melanoma is most commonly seen in dark-skinned individuals.”
ANS:
A
Melanoma is more commonly found on the torso or the lower legs in women. Melanoma can occur anywhere and is not
associated with direct exposure. For example, an individual can have melanoma under the skin and on the soles of the
feet. Dark-skinned individuals are less likely to get melanoma.
REF:
Page 264 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
9.
The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient. Which
action indicates the nursing assistant has understood the nurse’s teaching?
a.
Bathing and drying the skin vigorously to stimulate circulation
b.
Keeping the head of the bed elevated 30 degrees
c.
Limiting intake of fluid and offer frequent snacks
d.
Turning the patient at least every 2 hours
ANS:
D
The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment
reveals a stage I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently. Limiting fluids will
prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because
protein plays a role in healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if
not actually encourage, dermal decline.
REF:
OBJ:
Page 164
NCLEX® Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
10.
A patient asks the nurse what the purpose of the Wood’s light is. Which response by the nurse is
accurate?
a.
“We will put an anesthetic on your skin to prevent pain.”
b.
“The lamp can help detect skin cancers.”
c.
“Some patients feel a pressure-like sensation.”
d.
“It is used to identify the presence of infectious organisms and proteins associated with specific skin
conditions.”
ANS:
D
The Wood’s light examination is the use of a black light and darkened room to assist with physical examination of the skin.
The examination does not cause discomfort.
REF:
Page 265 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
Chapter 19: Postoperative Care
Lewis: Medical-Surgical Nursing, 10th Edition
21.
Which finding would indicate to the nurse that a postoperative patient is at increased risk for poor
wound healing?
a.
Potassium 3.5 mEq/L
c.
Hemoglobin 10.2 g/dL
b.
Albumin level 2.2 g/dL
d.
White blood cells 11,900/µL
ANS:
B
Because proteins are needed for an appropriate inflammatory response and wound healing, the low serum albumin level
(normal level, 3.5 to 5.0 g/dL) indicates a risk for poor wound healing. The potassium level is normal. Because a small
amount of blood loss is expected with surgery, the hemoglobin level is not indicative of an increased risk for wound
healing. WBC count is expected to increase after surgery as a part of the normal inflammatory response.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
343
NCLEX: Physiological Integrity
22.
The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a
perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon?
a.
Tympanic temperature 99.2° F (37.3° C)
b.
Fine crackles audible at both lung bases
c.
Redness and swelling along the suture line
d.
200 mL sanguineous fluid in the wound drain
ANS:
D
Wound drainage should decrease and change in color from sanguineous to serosanguineous by the second postoperative
day. The color and amount of drainage for this patient are abnormal and should be reported. Redness and swelling along
the suture line and a slightly elevated temperature are normal signs of postoperative inflammation. Atelectasis is common
after surgery. The nurse should have the patient cough and deep breathe, but there is no urgent need to notify the
surgeon.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
TOP:
NCLEX: Safe and Effective Care Environment
REF:
343
Nursing Process: Assessment
23.
After receiving change-of-shift report about these postoperative patients, which patient should the
nurse assess first?
a.
Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating
b.
Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery
c.
Patient who has bibasilar crackles and a temperature of 100° F (37.8 °C) on the first postoperative day after chest
surgery
d.
Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) was
given
ANS:
A
The patient’s history and assessment suggests possible wound dehiscence, which should be reported immediately to the
surgeon. Although the information about the other patients indicates a need for ongoing assessment and possible
intervention, the data do not suggest any acute complications. Small amounts of red drainage are common in the first
postoperative hours. Bibasilar crackles and a slightly elevated temperature are common after surgery, although the nurse
will need to have the patient deep breathe and cough. Oral medications typically take more than 15 minutes for effective
pain relief.
DIF:
OBJ:
TOP:
Cognitive Level: Analyze (analysis)
REF:
343
Special Questions: Prioritization | Special Questions: Multiple Patients
Nursing Process: Assessment
MSC:
NCLEX: Safe and Effective Care Environment
Chapter 11: Inflammation and Wound Healing
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1.
The nurse assesses a patient’s surgical wound on the first postoperative day and notes redness and
warmth around the incision. Which action by the nurse is appropriate?
a.
Obtain wound cultures.
c.
Notify the health care provider.
b.
Document the assessment. d.
Assess the wound every 2 hours.
ANS:
B
The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary
intention. The nurse should document the wound appearance and continue to monitor the wound. Notification of the
health care provider, assessment every 2 hours, and obtaining wound cultures are not indicated because the healing is
progressing normally.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
165
NCLEX: Physiological Integrity
5.
A patient’s 4 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by yellowgreen semiliquid material. Which dressing should the nurse apply to the wound?
a.
Dry gauze dressing
c.
Hydrocolloid dressing
b.
Nonadherent dressing
d.
Transparent film dressing
ANS:
C
The wound requires debridement of the necrotic areas and absorption of the yellow-green slough. A hydrocolloid dressing
such as DuoDerm would accomplish these goals. Transparent film dressings are used for clean wounds or approximated
surgical incisions. Dry dressings will not debride the necrotic areas. Nonadherent dressings will not absorb wound
drainage or debride the wound.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
169
NCLEX: Physiological Integrity
6.
The nurse notes that a patient’s open abdominal wound widens as it extends deeper into the abdomen.
How would the nurse document this characteristic?
a.
Eschar c.
Maceration
b.
Slough d.
Undermining
ANS:
D
Undermining is evident when a cotton-tipped applicator is placed in the wound and there is a narrower “lip” around the
wound, which widens as the wound deepens. Eschar is a crusted cover over a wound. Slough and maceration refer to
loosening friable tissue.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
166
Nursing Process: Assessment
MSC:
NCLEX: Physiological Integrity
a.
b.
c.
d.
8.
The nurse should plan to use a wet-to-dry dressing for which patient?
A patient who has a pressure ulcer with pink granulation tissue
A patient who has a surgical incision with pink, approximated edges
A patient who has a full-thickness burn filled with dry, black material
A patient who has a wound with purulent drainage and dry brown areas
ANS:
D
Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-thickness wound filled with eschar will
require interventions such as surgical debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on
approximated surgical incisions. Wet-to-dry dressings are not used on uninfected granulating wounds because of the
damage to the granulation tissue.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
170
NCLEX: Physiological Integrity
9.
A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base
of the wound involves subcutaneous tissue. How should the nurse classify this pressure ulcer?
a.
Stage I c.
Stage III
b.
Stage II d.
Stage IV
ANS:
C
A stage III pressure ulcer has full-thickness skin damage and extends into the subcutaneous tissue. A stage I pressure
ulcer has intact skin with some observable damage such as redness or a boggy feel. Stage II pressure ulcers have partialthickness skin loss. Stage IV pressure ulcers have full-thickness damage with tissue necrosis, extensive damage, or
damage to bone, muscle, or supporting tissues.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
173
Nursing Process: Assessment
MSC:
NCLEX: Physiological Integrity
10.
A young male patient with paraplegia has a stage II sacral pressure ulcer and is being cared for at home
by his family. To prevent further tissue damage, what instructions are most important for the nurse to teach the patient and
family?
a.
Change the patient’s bedding frequently.
b.
c.
d.
Apply a hydrocolloid dressing over the ulcer.
Change the patient’s position every 1 to 2 hours.
Record the size and appearance of the ulcer weekly.
ANS:
C
The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning. The other
interventions may also be included in family teaching.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Implementation
MSC:
REF:
174
NCLEX: Physiological Integrity
11.
The nurse will perform which action when doing a wet-to-dry dressing change on a patient’s stage III
sacral pressure ulcer?
a.
Administer prescribed PRN hydrocodone 30 minutes before the change.
b.
Pour sterile saline onto the new dry dressings after the wound has been packed.
c.
Apply antimicrobial ointment before repacking the wound with moist dressings.
d.
Soak the old dressings with sterile saline 30 minutes before the dressing change
ANS:
A
Mechanical debridement with wet-to-dry dressings is painful, and patients should receive pain medications before the
dressing change begins. The new dressings are moistened with saline before being applied to the wound but not soaked
after packing. Soaking the old dressings before removing them will eliminate the wound debridement that is the purpose
of this type of dressing. Application of antimicrobial ointments is not indicated for a wet-to-dry dressing.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
170
NCLEX: Physiological Integrity
12.
A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new
nurse indicates a need for further teaching about pressure ulcer care?
a.
The new nurse cleans the ulcer with half-strength peroxide.
b.
The new nurse uses a hydrocolloid dressing (DuoDerm)on the ulcer.
c.
The new nurse irrigates the pressure ulcer with saline using a 30-mL syringe.
d.
The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer.
ANS:
A
Pressure ulcers should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide. The other actions by
the new nurse are appropriate.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
175
NCLEX: Safe and Effective Care Environment
13.
A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action
by the nurse is appropriate?
a.
Elevate the ankle above heart level.
b.
Apply a warm moist pack to the ankle.
c.
Ask the patient to try bearing weight on the ankle.
d.
Assess the ankle’s passive range of motion (ROM).
ANS:
A
Soft tissue injuries are treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue
swelling. Moving the ankle through the ROM will increase swelling and risk further injury. Cold packs should be applied the
first 24 hours to reduce swelling. The nurse should not ask the patient to move or bear weight on the swollen ankle
because immobilization of the inflamed or injured area promotes healing by decreasing metabolic needs of the tissues.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
165
NCLEX: Physiological Integrity
14.
When admitting a patient with stage III pressure ulcers on both heels, which information obtained by
the nurse will have the most impact on wound healing?
a.
The patient has had the heel ulcers for 6 months.
b.
The patient takes oral hypoglycemic agents daily.
c.
The patient states that the ulcers are very painful.
d.
The patient has several incisions that formed keloids.
ANS:
B
The use of oral hypoglycemics indicates diabetes, which can interfere with wound healing. The persistence of the ulcers
over the past 6 months is a concern, but changes in care may be effective in promoting healing. Keloids are not disabling
or painful, although the cosmetic effects may be distressing for some patients. Actions to reduce the patient’s pain will be
implemented, but pain does not directly affect wound healing.
DIF:
TOP:
Cognitive Level: Analyze (analysis) Apply
Nursing Process: Assessment
MSC:
REF:
167
NCLEX: Physiological Integrity
a.
b.
c.
d.
16.
The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)?
The patient who reports increased tenderness and swelling around a leg wound
The patient who was just admitted after suturing of a full-thickness arm wound
The patient who needs teaching about home care for a draining abdominal wound
The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer
ANS:
D
LPN/LVN education and scope of practice include sterile dressing changes for stable patients. Initial wound assessments,
patient teaching, and evaluation for possible poor wound healing or infection should be done by the registered nurse (RN).
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Delegation
TOP:
NCLEX: Safe and Effective Care Environment
REF:
170
Nursing Process: Planning
17.
The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is
most important for the nurse to report to the health care provider?
a.
Blood glucose of 136 mg/dL
b.
Oral temperature of 101° F (38.3° C)
c.
Separation of the proximal wound edges
d.
Patient complaint of increased incisional pain
ANS:
C
Wound separation 3 days postoperatively indicates possible wound dehiscence and should be immediately reported to the
health care provider. The other findings will also be reported but do not require intervention as rapidly.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
167
Nursing Process: Assessment
18.
A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When
planning interventions to promote wound healing, what is the nurse’s highest priority?
a.
Maintaining the patient’s blood glucose within a normal range
b.
Ensuring that the patient has an adequate dietary protein intake
c.
Giving antipyretics to keep the temperature less than 102° F (38.9° C)
d.
Redressing the surgical incision with a dry, sterile dressing twice daily
ANS:
A
Elevated blood glucose will have an impact on multiple factors involved in wound healing. Ensuring adequate nutrition is
also important for the postoperative patient, but a higher priority is blood glucose control. A temperature of 102° F will not
impact adversely on wound healing, although the nurse may administer antipyretics if the patient is uncomfortable.
Application of a dry, sterile dressing daily may be ordered, but frequent dressing changes for a wound healing by primary
intention is not necessary to promote wound healing.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
167
Nursing Process: Planning
19.
Which finding is most important for the nurse to communicate to the health care provider when caring
for a patient who is receiving negative-pressure wound therapy?
a.
Low serum albumin level
b.
Serosanguineous drainage
c.
Deep red and moist wound bed
d.
Cobblestone appearance of wound
ANS:
A
With negative pressure therapy, serum protein levels may decrease, which will adversely affect wound healing. The other
findings are expected with wound healing.
DIF:
OBJ:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
MSC:
REF:
169
NCLEX: Physiological Integrity
20.
After the home health nurse teaches a patient’s family member about how to care for a sacral pressure
ulcer, which finding indicates that additional teaching is needed?
a.
The family member uses a lift sheet to reposition the patient.
b.
The family member uses clean tap water to clean the wound.
c.
The family member dries the wound using a hair dryer on a low setting.
d.
The family member places contaminated dressings in a plastic grocery bag.
ANS:
C
Pressure ulcers need to be kept moist to facilitate wound healing. The other actions indicate a good understanding of
pressure ulcer care.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
175
NCLEX: Physiological Integrity
Cellular Regulation
Concept 12: Cellular Regulation
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
The nurse would incorporate which of the following into the plan of care as a primary prevention
strategy for reduction of the risk for cancer?
a.
Yearly mammography for women aged 40 years and older
b.
Using skin protection during sun exposure while at the beach
c.
Colonoscopy at age 50 and every 10 years as follow-up
d.
Yearly prostate specific antigen (PSA) and digital rectal exam for men aged 50 and over
ANS:
B
Primary prevention of cancer involves avoidance to known causes of cancer, such as sun exposure. Secondary screening
involves physical and diagnostic examination.
REF:
Page 109 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
2.
While collecting a health history on a patient admitted for colon cancer, which of the following
questions would be a priority to ask this patient?
a.
“Have you noticed any blood in your stool?”
b.
“Have you been experiencing nausea?”
c.
“Do you have back pain?”
d.
“Have you noticed any swelling in your abdomen?”
ANS:
A
Early colon cancer is often asymptomatic, with occult or frank blood in the stool being an assessment finding in a patient
diagnosed with colon cancer. If pain is present, it is usually lower abdominal cramping. Constipation and diarrhea are
more frequent findings than nausea or ascites.
REF:
Page 109 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
3.
While planning care for a patient experiencing fatigue due to chemotherapy, which of the following is
the most appropriate nursing intervention?
a.
Prioritization and administration of nursing care throughout the day
b.
Completing all nursing care in the morning so the patient can rest the remainder of the day
c.
Completing all nursing care in the evening when the patient is more rested
d.
Limiting visitors, thus promoting the maximal amount of hours for sleep
ANS:
A
Pacing activities throughout the day conserves energy, and nursing care should be paced as well. Fatigue is a common
side effect of cancer and treatment; and while adequate sleep is important, an increase in the number of hours slept will
not resolve the fatigue. Restriction of visitors does not promote healthy coping and can result in feelings of isolation.
REF:
Page 111 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
4.
The nurse is caring for a patient who received a bone marrow transplant 10 days ago. The nurse would
monitor for which of the following clinical manifestations that could indicate a potentially life-threatening situation?
a.
Mucositis
b.
Confusion
c.
Depression
d.
Mild temperature elevation
ANS:
D
During the first 100 days after a bone marrow transplant, patients are at high risk for life-threatening infections. The
earliest sign of infection in an immunosuppressed patient can be a mild fever. Mucositis, confusion, and depression are
possible clinical manifestations but are representative of less life-threatening complications.
REF:
Page 111 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
5.
While the nurse is obtaining the health history of a 75-year-old female patient, which of the following
has the greatest implication for the development of cancer?
a.
Being a woman
b.
Family history of hypertension
c.
Cigarette smoking as a teenager
d.
Advancing age
ANS:
D
According to the American Cancer Society, the most important risk factor for cancer development is advancing age.
REF:
Page 112 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
6.
In caring for a patient following lobectomy for lung cancer, which of the following should the nurse
include in the plan of care?
a.
Position the patient on the operative side only.
b.
Avoid administering narcotic pain medications.
c.
Keep the patient on strict bed rest.
d.
Instruct the patient to cough and deep breathe.
ANS:
D
Postoperative deep breathing and coughing is important to promote oxygenation and clearing of secretions. Pain
medications will be given to lessen pain and allow for deep breathing and coughing. Strict bed rest is not instituted,
because early ambulation will help lessen postoperative complications such as deep vein thrombosis. Prolonged lying on
the operative side is avoided.
REF:
Page 110 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
7.
A female patient complains of a “scab that just won’t heal” under her left breast. During your
conversation, she also mentions chronic fatigue, loss of appetite, and slight cough, attributed to allergies. What is the
nurse’s best action?
a.
Continue to conduct a symptom analysis to better understand the patient’s symptoms and concerns.
b.
End the appointment and tell the patient to use skin protection during sun exposure.
c.
Suggest further testing with a cancer specialist and provide the appropriate literature.
d.
Tell her to put a bandage on the scab and set a follow-up appointment in one week.
ANS:
A
A comprehensive health history is vital to treating and caring for the patient. Often times, symptoms are vague. The nurse
should conduct a symptom analysis to gather as much information as possible. Questions should address the duration of
the symptoms and include the location, characteristics, aggravating and relief factors, and any treatments taken thus far.
REF:
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NCLEX® Client Needs Category: Health Promotion and Maintenance
a.
b.
c.
8.
What is the priority nursing diagnosis for a patient experiencing chemotherapy-induced anemia?
Risk for injury related to poor blood clotting
Fatigue related to decreased cellular oxygenation
Disturbed body image related to skin color changes
d.
Imbalanced nutrition, less than body requirements related to anorexia
ANS:
B
Decreased numbers of red blood cells (RBCs) result in decreased cellular oxygenation and less energy. Decreased
numbers of RBCs alone do not change the patient’s blood-clotting ability. Although skin color changes and altered
nutrition also occur with anemia, fatigue due to decreased cellular oxygenation is a priority nursing diagnosis.
REF:
Page 106 OBJ:
NCLEX® Client Needs Category:
9.
A patient with prostate cancer is taking estrogen daily to control tumor growth. He reports that his left
calf is swollen and painful. Which of the following would be the nurse’s best action?
a.
Instruct the client to keep the leg elevated.
b.
Measure the calf circumference and compare the measurement with the right calf circumference measurement.
c.
Apply ice to the calf after a 10-minute massage of the area.
d.
Document assessment findings as an expected response with estrogen therapy.
ANS:
B
An adverse reaction to hormonal manipulation therapy is the development of thrombus formation. Massaging a calf that is
swollen and painful is never correct, because this action might break a clot, causing formation of an embolus, which could
then travel to the lungs.
REF:
N/A
OBJ:
NCLEX® Client Needs Category:
10.
A patient is not certain whether she and her family should participate in a genetic screening plan. She
asks the nurse why the X-linked recessive disorder that has been noted in some of her family members is expressed in
males more frequently than in females. What is the nurse’s best response?
a.
“The disease tends to show up in males because they do not have a second X chromosome to balance the
expression of the gene.”
b.
“One X chromosome of a pair is always inactive in females. This inactivity effectively negates the effects of the
gene.”
c.
“Females are known to have more effective DNA repair mechanisms than males, thus negating the damage
caused by the recessive gene.”
d.
“Expression of genes from the male’s Y chromosome does not occur in females, so they are essentially immune
to the effects of the gene.”
ANS:
A
Because the number of X chromosomes in males and females is not the same (1:2), the number of X-linked chromosome
genes in the two genders is also unequal. Males have only one X chromosome for any gene on the X chromosome. As a
result, X-linked recessive genes have a dominant expressive pattern of inheritance in males and a recessive expressive
pattern of inheritance in females. This difference in expression occurs because males do not have a second X
chromosome to balance the expression of any recessive gene on the first X chromosome. It is incorrect to say that one X
chromosome of a pair is always inactive in females or that females have more effective DNA repair mechanisms than
males. Also, it is not true that females can be immune to the effects of a gene, because genes from the male’s Y
chromosome are not expressed in females.
REF:
N/A
OBJ:
NCLEX® Client Needs Category:
11.
A cancer patient’s susceptibility to the syndrome of inappropriate antidiuretic hormone (SIADH) can be
suspected with which of the following laboratory results?
a.
Serum potassium of 5.2 mmol/L
b.
Serum sodium of 120 mmol/L
c.
Hematocrit of 40%
d.
Blood urea nitrogen (BUN) of 10 mg/dL
ANS:
B
In SIADH, there is increased secretion of antidiuretic hormone (ADH) from the posterior pituitary gland, leading to
increased water reabsorption from the distal convoluted tubule and collecting duct. As a result, weight increases and
serum sodium and hematocrit levels are diluted, and, hence, a low serum sodium level is seen. ADH has no direct effect on
serum potassium, because potassium is primarily an intracellular electrolyte and changes in the serum concentration of
potassium rarely occur in SIADH. The blood urea nitrogen is normal.
REF:
N/A
OBJ:
NCLEX® Client Needs Category
Chapter 54: Male Reproductive and Genital Problems
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1.
To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH), the
nurse will ask the patient about
a.
blood in the urine. c.
force of urinary stream.
b.
lower back or hip pain.
d.
erectile dysfunction (ED).
ANS:
C
The American Urological Association Symptom Index for a patient with BPH asks questions about the force and frequency
of urination, nocturia, and so on. Blood in the urine, ED, and back or hip pain are not typical symptoms of BPH.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1268
NCLEX: Physiological Integrity
2.
A patient who has been recently diagnosed with benign prostatic hyperplasia (BPH) tells the nurse that
he does not want to have a transurethral resection of the prostate (TURP) because it might affect his ability to have sexual
intercourse. Which action should the nurse take?
a.
Discuss alternative methods of sexual expression.
b.
Teach about medication for erectile dysfunction (ED).
c.
Clarify that TURP does not commonly affect erection.
d.
Offer reassurance that fertility is not affected by TURP.
ANS:
C
ED is not a concern with TURP, although retrograde ejaculation is likely, and the nurse should discuss this with the patient.
Erectile function is not usually affected by a TURP, so the patient will not need information about penile implants or
reassurance that other forms of sexual expression may be used. Because the patient has not asked about fertility,
reassurance about sperm production does not address his concerns.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1272
NCLEX: Physiological Integrity
3.
The health care provider prescribes finasteride (Proscar) for a patient who has benign prostatic
hyperplasia (BPH). When teaching the patient about the drug, the nurse informs him that
a.
he should change position from lying to standing slowly to avoid dizziness.
b.
his interest in sexual activity may decrease while he is taking the medication.
c.
improvement in the obstructive symptoms should occur within about 2 weeks.
d.
he will need to monitor his blood pressure frequently to assess for hypertension.
ANS:
B
A decrease in libido is a side effect of finasteride because of the androgen suppression that occurs with the drug.
Although orthostatic hypotension may occur if the patient is also taking a medication for erectile dysfunction, it should not
occur with finasteride alone. Improvement in symptoms of obstruction takes about 6 months. The medication does not
cause hypertension.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1271
NCLEX: Physiological Integrity
4.
The nurse will anticipate that a 61-yr-old patient who has an enlarged prostate detected by digital rectal
examination (DRE) and an elevated prostate specific antigen (PSA) level will need teaching about
a.
cystourethroscopy.
b.
uroflowmetry studies.
c.
magnetic resonance imaging (MRI).
d.
transrectal ultrasonography (TRUS).
ANS:
D
In a patient with an abnormal DRE and elevated PSA, transrectal ultrasound is used to visualize the prostate for biopsy.
Uroflowmetry studies help determine the extent of urine blockage and treatment, but there is no indication that this is a
problem for this patient. Cystoscopy may be used before prostatectomy but will not be done until after the TRUS and
biopsy. MRI is used to determine whether prostatic cancer has metastasized but would not be ordered at this stage of the
diagnostic process.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1270
NCLEX: Physiological Integrity
5.
Which information about continuous bladder irrigation will the nurse teach to a patient who is being
admitted for a transurethral resection of the prostate (TURP)?
a.
Bladder irrigation decreases the risk of postoperative bleeding.
b.
Hydration and urine output are maintained by bladder irrigation.
c.
Antibiotics are infused continuously through the bladder irrigation.
d.
Bladder irrigation prevents obstruction of the catheter after surgery.
ANS:
D
The purpose of bladder irrigation is to remove clots from the bladder and prevent obstruction of the catheter by clots. The
irrigation does not decrease bleeding or improve hydration. Antibiotics are given by the IV route, not through the bladder
irrigation.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
1274
Nursing Process: Implementation
MSC:
NCLEX: Physiological Integrity
a.
b.
c.
d.
6.
The nurse will plan to teach the patient scheduled for photovaporization of the prostate (PVP)
that urine will appear bloody for several days.
how to care for an indwelling urinary catheter.
that symptom improvement takes 2 to 3 weeks.
about complications associated with urethral stenting.
ANS:
B
The patient will have an indwelling catheter for 24 to 48 hours and will need teaching about catheter care. There is minimal
bleeding with this procedure. Symptom improvement is almost immediate after PVP. Stent placement is not included in the
procedure.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1272
NCLEX: Physiological Integrity
7.
A 53-yr-old patient is scheduled for an annual physical examination. The nurse will plan to teach the
patient about the purpose of
a.
urinalysis collection.
b.
uroflowmetry studies.
c.
prostate specific antigen (PSA) testing.
d.
transrectal ultrasound scanning (TRUS).
ANS:
C
An annual digital rectal exam (DRE) and PSA are usually recommended starting at age 50 years for men who have an
average risk for prostate cancer. Urinalysis and uroflowmetry studies are done if patients have symptoms of urinary tract
infection or changes in the urinary stream. TRUS may be ordered if the DRE or PSA results are abnormal.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1273
NCLEX: Physiological Integrity
9.
The nurse will plan to teach the patient who is incontinent of urine following a radical retropubic
prostatectomy to
a.
restrict oral fluid intake.
b.
do pelvic muscle exercises.
c.
perform intermittent self-catheterization.
d.
use belladonna and opium suppositories.
ANS:
B
Pelvic floor muscle training (Kegel) exercises are recommended to strengthen the pelvic floor muscles and improve
urinary control. Belladonna and opium suppositories are used to reduce bladder spasms after surgery. Intermittent selfcatheterization may be taught before surgery if the patient has urinary retention, but it will not be useful in reducing
incontinence after surgery. The patient should have a daily oral intake of 2 to 3 L.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1278
NCLEX: Physiological Integrity
10.
A 70-yr-old patient who has had a transurethral resection of the prostate (TURP) for benign prostatic
hyperplasia (BPH) is being discharged from the hospital today. Which patient statement indicates a need for the nurse to
provide additional instruction?
a.
“I should call the doctor if I have incontinence at home.”
b.
“I will avoid driving until I get approval from my doctor.”
c.
d.
“I should schedule yearly appointments for prostate examinations.”
“I will increase fiber and fluids in my diet to prevent constipation.”
ANS:
A
Because incontinence is common for several weeks after a TURP, the patient does not need to call the health care provider
if this occurs. The other patient statements indicate that the patient has a good understanding of post-TURP instructions.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
1274
NCLEX: Physiological Integrity
18.
A patient with urinary obstruction from benign prostatic hyperplasia (BPH) tells the nurse, “My
symptoms are much worse this week.” Which response by the nurse is appropriate?
a.
“Have you taken any over-the-counter (OTC) medications recently?”
b.
“I will talk to the doctor about a prostate specific antigen (PSA) test.”
c.
“Have you talked to the doctor about surgery such as transurethral resection of the prostate (TURP)?”
d.
“The prostate gland changes in size from day to day, and this may be making your symptoms worse.”
ANS:
A
Because the patient’s increase in symptoms has occurred abruptly, the nurse should ask about OTC medications that
might cause contraction of the smooth muscle in the prostate and worsen obstruction. The prostate gland does not vary in
size from day to day. A TURP may be needed, but more assessment about possible reasons for the sudden symptom
change is a more appropriate first response by the nurse. PSA testing is done to differentiate BPH from prostatic cancer.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1273
NCLEX: Physiological Integrity
21.
A patient who has benign prostatic hyperplasia (BPH) with urinary retention is admitted to the hospital
with elevated blood urea nitrogen (BUN) and creatinine. Which prescribed therapy should the nurse implement first?
a.
Infuse normal saline at 50 mL/hr.
b.
Insert a urinary retention catheter.
c.
Draw blood for a complete blood count.
d.
Schedule pelvic magnetic resonance imaging
ANS:
B
The patient data indicate that the patient may have acute kidney injury caused by the BPH. The initial therapy will be to
insert a catheter. The other actions are also appropriate, but they can be implemented after the acute urinary retention is
resolved.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1269
Nursing Process: Implementation
23.
After a transurethral resection of the prostate (TURP), a 64-yr-old patient with continuous bladder
irrigation complains of painful bladder spasms. The nurse observes clots in the urine. Which action should the nurse take
first?
a.
Increase the flow rate of the bladder irrigation.
b.
Administer the prescribed IV morphine sulfate.
c.
Give the patient the prescribed belladonna and opium suppository.
d.
Manually instill and then withdraw 50 mL of saline into the catheter.
ANS:
D
The assessment suggests that obstruction by a clot is causing the bladder spasms, and the nurse’s first action should be
to irrigate the catheter manually and to try to remove the clots. IV morphine will not decrease the spasm, although pain
may be reduced. Increasing the flow rate of the irrigation will further distend the bladder and may increase spasms. The
belladonna and opium suppository will decrease bladder spasms but will not remove the obstructing blood clot.
DIF:
OBJ:
MSC:
Cognitive Level: Analysis (analyze)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1272
Nursing Process: Implementation
27.
Which assessment information collected by the nurse may present a contraindication to a testosterone
replacement therapy (TRT)?
a.
The patient has noticed a decrease in energy level for a few years.
b.
The patient’s symptoms have increased steadily over the past few years.
c.
The patient has been using sildenafil (Viagra) several times every week.
d.
The patient has had a gradual decrease in the force of his urinary stream.
ANS:
D
The decrease in urinary stream may indicate benign prostatic hyperplasia (BPH) or prostate cancer, which are
contraindications to the use of testosterone replacement therapy (TRT). The other patient data indicate that TRT may be a
helpful therapy for the patient.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1269
NCLEX: Physiological Integrity
28.
A patient who has been diagnosed with stage 2 prostate cancer chooses the option of active
surveillance. The nurse will plan to
a.
vaccinate the patient with sipuleucel-T (Provenge).
b.
provide the patient with information about cryotherapy.
c.
teach the patient about placement of intraurethral stents.
d.
schedule the patient for annual prostate-specific antigen testing.
ANS:
D
Patients who opt for active surveillance need to have annual digital rectal examinations and prostate-specific antigen
testing. Vaccination with sipuleucel-T, cryotherapy, and stent placement are options for patients who choose to have active
treatment for prostate cancer.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
1269
Nursing Process: Planning MSC:
NCLEX: Physiological Integrity
33.
Which action by the unlicensed assistive personnel (UAP) who are assisting with the care of male
patients with reproductive problems indicates that the nurse should provide more teaching?
a.
The UAP apply a cold pack to the scrotum for a patient with mumps orchitis.
b.
The UAP help a patient who has had a prostatectomy to put on antiembolism hose.
c.
The UAP leave the foreskin pulled back after cleaning the glans of a patient who has a retention catheter.
d.
The UAP encourage a high oral fluid intake for patient who had transurethral resection of the prostate yesterday.
ANS:
C
Paraphimosis can be caused by failing to replace the foreskin back over the glans after cleaning. The other actions by UAP
are appropriate.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Delegation
NCLEX: Physiological Integrity
TOP:
REF:
1274
Nursing Process: Planning
34.
When caring for a patient with continuous bladder irrigation after having transurethral resection of the
prostate, which action could the nurse delegate to unlicensed assistive personnel (UAP)?
a.
Teach the patient how to perform Kegel exercises.
b.
Report any complaints of pain or spasms to the nurse.
c.
Monitor for increases in bleeding or presence of clots.
d.
Increase the flow rate of the irrigation if clots are noted.
ANS:
B
UAP education and role includes reporting patient concerns to supervising nurses. Patient teaching, assessments for
complications, and actions such as bladder irrigation require more education and should be done by licensed nursing
staff.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Delegation
TOP:
NCLEX: Safe and Effective Care Environment
REF:
1274
Nursing Process: Planning
35.
After reviewing the electronic medical record shown in the accompanying figure for a patient who had
transurethral resection of the prostate the previous day, which information requires the most rapid action by the nurse?
a.
b.
c.
d.
Elevated temperature and pulse
Bladder spasms and urine output
Respiratory rate and lung crackles
No prescription for antihypertensive drugs
ANS:
B
Bladder spasms and lack of urine output indicate that the nurse needs to assess the continuous bladder irrigation for
kinks and may need to manually irrigate the patient’s catheter. The other information will also require actions, such as
having the patient take deep breaths and cough and discussing the need for antihypertensive medication prescriptions
with the health care provider, but the nurse’s first action should be to address the problem with the urinary drainage
system.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1274
Nursing Process: Assessment
Mobility/ Pain
Concept 26: Mobility
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
A patient who has been in the hospital for several weeks is about to be discharged. The patient is weak
from the hospitalization and asks the nurse to explain why this is happening. What is the nurse’s best response?
a.
“Your iron level is low. This is known as anemia.”
b.
“Your immobility in the hospital is known as deconditioning.”
c.
“Your poor appetite is known as malnutrition.”
d.
“Your medications have caused drug induced weakness.”
ANS:
B
When a person is ill and immobile the body becomes weak. This is known as deconditioning. Anemia, malnutrition, and
medications may have an adverse effect on the body, but this is not known as deconditioning which is the most likely
cause in this patient’s situation.
REF:
OBJ:
Page 252
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
2.
An older patient is talking with the nurse about hip fractures. The patient would like to know the best
approach to strengthen the bones. What is the nurse’s best response?
a.
“Walk at least 5 miles every day for exercise.”
b.
“Wear proper fitting shoes to prevent tripping.”
c.
“Talk with your physician about a calcium supplement.”
d.
“Stand up slowly so you don’t feel faint.”
ANS:
C
Calcium strengthens the bones. A calcium supplement will help strengthen bones as they may be affected by aging,
illness, or trauma. Walking several miles will help strengthen the bones, but the patient should consult with the healthcare
provider before any exercise regimen is implemented for the older adult. Wearing proper shoes and standing slowly to
prevent dizziness is important but they will not prevent fractures.
REF:
Page 253 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
3.
Mobility for the patient changes throughout the life span. What is the term that best describes this
process?
a.
Aging and illness
b.
Illness and disease
c.
Health and wellness
d.
Growth and development
ANS:
D
Growth and development happens from infancy to death. Muscular changes are always happening, and these changes
affect the individual and his or her performance in life. Aging, illness, health, and wellness do have an effect on a person,
but they don’t always affect mobility.
REF:
Page 253 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
4.
The nurse is talking to the unlicensed assistive personnel about moving a patient in bed. The nurse
knows the unlicensed assistive personnel understands the concept of mobility and proper moving techniques when
making which statement?
a.
“Patients must have a trapeze over the bed to move properly.”
b.
“Patients should move themselves in bed to prevent immobility.”
c.
“Patients should always have a two-person assist to move in bed.”
d.
“Patients must be moved correctly in bed to prevent shearing.”
ANS:
D
Patients must be moved properly in bed to prevent shearing of the skin. Having a trapeze over the bed is only functional if
the patient can assist in the moving process. A two-person assist is good, but the patient still needs to be moved properly.
A patient may move himself or herself if he or she is able; but shearing may still occur.
REF:
Page 254 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
5.
The nurse and a student nurse are discussing the effects of bed immobility on patients. The nurse
knows that the student nurse understands the concept of mobility when making which statement?
a.
“Patients with impaired bed mobility have an increased risk for pressure ulcers.”
b.
“Patients with impaired bed mobility like to have extra visitors.”
c.
“Patients with impaired bed mobility need to have a mechanical soft diet.”
d.
“Patients with impaired bed mobility are prone to constipation.”
ANS:
A
Patients who cannot move themselves in bed are more susceptible to pressure ulcers because they cannot relieve the
pressure they feel. Extra visitors or diet consistency do not have any bearing on mobility. Constipation should not be a byproduct of immobility if a bowel regimen is instituted.
REF:
Page 254 OBJ:
a.
b.
c.
d.
6.
50%
80%
90%
100%
NCLEX® Client Needs Category: Health Promotion and Maintenance
What percentage of hip fractures is the result of falls?
ANS:
C
About 90% of falls end with a hip fracture.
REF:
Page 255 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
a.
b.
c.
d.
7.
The lack of weight bearing leads to what effects on the skeletal system?
Demineralization, calcium loss
Thickened bones
Increased range of motion
Increased calcium deposition in the bones
ANS:
A
Weight bearing helps to strengthen the bone. Lack of weight bearing means that the bone is losing minerals and calcium
that strengthen it. Thickened bones will not occur with the lack of weight bearing. Range of motion may be decreased with
a lack of weight bearing movements.
REF:
Page 257 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
Concept 29: Pain
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
A 62-year-old male has fallen while trimming tree branches sustaining tissue injury. He describes his
condition as an aching, throbbing back. This is characteristic of what type of pain?
a.
Neuropathic pain
b.
Nociceptive pain
c.
d.
Chronic pain
Mixed pain syndrome
ANS:
B
Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli
(tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is
pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the
brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting. Chronic pain
is constant and unrelenting such as pain associated with cancer. Mixed pain syndrome is not easily recognized, is unique
with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain.
REF:
OBJ:
Page 283
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
2.
A 19-year-old male has sustained a transection of C-7 in a motor vehicle crash rendering him a
quadriplegic. He describes his pain as burning, sharp, and shooting. What type of pain is this patient describing?
a.
Neuropathic pain
b.
Ghost pain
c.
Mixed pain syndrome
d.
Nociceptive pain
ANS:
A
Neuropathic pain results from the abnormal processing of sensory input by the nervous system as a result of damage to
the brain, spinal cord, or peripheral nerves. Simply put, neuropathic pain is pathologic. Examples of neuropathic pain
include postherpetic neuralgia, diabetic neuropathy, phantom pain, and post stroke pain syndrome. Patients with
neuropathic pain use very distinctive words to describe their pain, such as “burning,” “sharp,” and “shooting.” Ghost pain
is pain associated with loss of a limb or digit. Mixed pain syndrome is not easily recognized, is unique with multiple
underlying and poorly understood mechanisms like fibromyalgia and low back pain. Nociceptive pain refers to the normal
functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful.
Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is pathologic and results from
abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral
nerves. Patients describe this type of pain as burning, sharp, and shooting.
REF:
OBJ:
Page 285
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
3.
Controlling pain is important to promoting wellness. Unrelieved pain has been associated with
complication?
a.
Prolonged stress response and a cascade of harmful effects system-wide
b.
Large tidal volumes and decreased lung capacity
c.
Decreased tumor growth and longevity
d.
Decreased carbohydrate, protein, and fat destruction
ANS:
A
Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress
response and produce a cascade of harmful effects in all body systems. The stress response causes the endocrine system
to release excessive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and testosterone
levels decrease. Increased endocrine activity in turn initiates a number of metabolic processes, in particular, accelerated
carbohydrate, protein, and fat destruction, which can result in weight loss, tachycardia, increased respiratory rate, shock,
and even death. The immune system is also affected by pain as demonstrated by research showing a link between
unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth. Large tidal volumes are not
associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth and
longevity are not associated with unrelieved pain. Decreased carbohydrate, protein, and fat are not associated with pain or
stress response.
REF:
OBJ:
Page 285
NCLEX® Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4.
An elderly Chinese woman is interested in biologically based therapies to relieve osteoarthritis (OA)
pain. You are preparing a plan of care for her OA. Options most conducive to her expressed wishes may include which
actions or activities?
a.
Pilates, breathing exercises, and aloe vera
b.
Guided imagery, relaxation breathing, and meditation
c.
Herbs, vitamins, and tai chi
d.
Alternating ice and heat to relieve pain and inflammation
ANS:
C
Nonpharmacologic strategies encompass a wide variety of nondrug treatments that may contribute to comfort and pain
relief. These include the body-based (physical) modalities, such as massage, acupuncture, and application of heat and
cold, and the mind-body methods, such as guided imagery, relaxation breathing, and meditation. There are also
biologically based therapies which involve the use of herbs and vitamins, and energy therapies such as reiki and tai chi.
Pilates, breathing exercises, aloe vera, guided imagery, relaxation breathing, meditation, and alternating ice and heat are
multimodal therapies for pain management. They are not exclusively biologically based, which involves the use of herbs
and vitamins.
REF:
OBJ:
Page 289
NCLEX® Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
5.
A 70-year-old retired nurse is interested in nondrug, mind-body therapies, self-management, and
alternative strategies to deal with joint discomfort from rheumatoid arthritis. What options should you consider in her plan
of care considering her expressed wishes?
a.
Stationary exercise bicycle, free weights, and spinning class
b.
Mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided
imagery, relaxation techniques, and pet therapy
c.
Chamomile tea and IcyHot gel
d.
Acupuncture and attending church services
ANS:
B
Mind-body therapies are designed to enhance the mind’s capacity to affect bodily function and symptoms and include
music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet
therapy, among many others. Stationary exercise bicycle, free weights, and spinning are not mind-body therapies. They
are classified as exercise therapies. Chamomile tea and IcyHot gel are not mid-body therapies per se. They are classified
as herbal and topical thermal treatments. Acupuncture is an ancient Chinese complementary therapy, while attending
church services is a religious prayer mind-body therapy capable of enhancing the mind’s capacity to affect bodily function
and symptoms.
REF:
Page 289 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
6.
A 30-year-old male is admitted to the hospital with acute pancreatitis. He is in acute pain described as a
10/10, which is localized to the abdomen, periumbilical area, and some radiation to his back. The abdomen is grossly
distended so it is difficult to assess. He is restless and agitated, with elevated pulse and blood pressure. An appropriate
pain management plan of care may include which medication(s)?
a.
IV Dilaudid q 4 hours prn, hydrocodone 5/500 PO q 6 hours prn, and acetaminophen
b.
Norco 5/500 q 4 hours PO and Benadryl 25 mg PO q 6 hours
c.
Phenergan 25 mg IM q 6 hours
d.
Tylenol 325 mg q 6 hours
ANS:
A
A variety of routes of administration are used to deliver analgesics. A principle of pain management is to use the oral route
of administration whenever feasible. All of the first-line analgesics used to manage pain are available in short-acting and
long-acting formulations. For patients who have continuous pain, a long-acting analgesic, such as modified-release oral
morphine, oxycodone, or hydromorphone, or transdermal fentanyl, is used to treat the persistent baseline pain. A fastonset, short-acting analgesic (usually the same drug as the long-acting) is used to treat breakthrough pain if it occurs.
When the oral route is not possible, such as in patients who cannot swallow or are NPO or nauseated, other routes of
administration are used, including intravenous (IV), subcutaneous, transdermal, and rectal. Norco, Benadryl, Phenergan,
and Tylenol are not appropriate solo choices for acute pancreatitis with pain reported as 10/10.
REF:
OBJ:
Page 289
NCLEX® Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
7.
An 80-year-old male patient is in the intensive care unit has suffered a fractured femur. You are making
rounds and notice he is somnolent, with no response to verbal or physical stimulation. He has been on round the clock
opioid doses q 4 hours. What is the nurse’s first action?
a.
Call the rapid response team to care for the patient immediately.
b.
Discontinue the opioids on the medication administration record.
c.
Assess the patient’s blood pressure and pain level.
d.
Start a second intravenous line with a large bore catheter.
ANS:
B
After establishing unresponsiveness, the next action is to call a Rapid Response. The patient is not able to subjectively
describe pain if unresponsive. Another IV line may be needed, but first the nurse should call for help. The opioids should
be discontinued on the MAR; however the priority action is to call for help.
REF:
OBJ:
Page 289 |Page 291
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
Chapter 62: Musculoskeletal Trauma and Orthopedic Surgery
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
4.
ankle?
a.
b.
c.
d.
Which discharge instruction will the emergency department nurse include for a patient with a sprained
Keep the ankle loosely wrapped with gauze.
Apply a heating pad to reduce muscle spasms.
Use pillows to elevate the ankle above the heart.
Gently move the ankle through the range of motion.
ANS:
C
Elevation of the leg will reduce swelling and pain. Compression bandages are used to decrease swelling. For the first 24 to
48 hours, cold packs are used to reduce swelling. The ankle should be rested and kept immobile to prevent further
swelling or injury.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
a.
b.
c.
d.
6.
The nurse will instruct the patient with a fractured left radius that the cast will need to remain in place
for several months.
for at least 3 weeks.
until swelling of the wrist has resolved.
until x-rays show complete bony union.
MSC:
REF:
1472
NCLEX: Physiological Integrity
ANS:
B
Bone healing starts immediately after the injury, but because ossification does not begin until 3 weeks after injury, the cast
will need to be worn for at least 3 weeks. Complete union may take up to 1 year. Resolution of swelling does not indicate
bone healing.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1477
NCLEX: Physiological Integrity
7.
A patient with a fracture of the left femoral neck has Buck’s traction in place while waiting for surgery.
To assess for pressure areas on the patient’s back and sacral area and to provide skin care, the nurse should
a.
loosen the traction and help the patient turn onto the unaffected side.
b.
place a pillow between the patient’s legs and turn gently to each side.
c.
have the patient lift the buttocks slightly by using a trapeze over the bed.
d.
turn the patient partially to each side with the assistance of another nurse.
ANS:
C
The patient can lift the buttocks slightly off the bed by using a trapeze. This will not affect the fracture fragments on the
right leg. Turning the patient will tend to move the fracture fragments, causing pain and possible nerve impingement.
Disconnecting the traction will interrupt the weight needed to decrease muscle spasms.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1481
NCLEX: Safe and Effective Care Environment
8.
Which nursing intervention will be included in the plan of care after a patient with a right femur fracture
has a hip spica cast applied?
a.
Avoid placing the patient in prone position.
b.
Ask the patient about abdominal discomfort.
c.
Discuss remaining on bed rest for several weeks.
d.
Use the cast support bar to reposition the patient.
ANS:
B
Assessment of bowel sounds, abdominal pain, and nausea and vomiting will detect the development of abdominal cast
syndrome. To avoid breakage, the cast support bar should not be used for repositioning. After the cast dries, the patient
can begin ambulating with the assistance of physical therapy personnel and may be turned to the prone position.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1473
NCLEX: Physiological Integrity
9.
A patient has a long-arm plaster cast applied for fracture immobilization. Until the cast has completely
dried, the nurse should
a.
keep the left arm in dependent position.
b.
avoid handling the cast using fingertips.
c.
place gauze around the cast edge to pad any roughness.
d.
cover the cast with a small blanket to absorb the dampness.
ANS:
B
Until a plaster cast has dried, using the palms rather than the fingertips to handle the cast helps prevent creating
protrusions inside the cast that could place pressure on the skin. The left arm should be elevated to prevent swelling. The
edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be
misshapen. The cast should not be covered until it is dry because heat builds up during drying.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1472
NCLEX: Physiological Integrity
10.
Which statement by the patient indicates a good understanding of the nurse’s teaching about a new
short-arm synthetic cast?
a.
“I can get the cast wet as long as I dry it right away with a hair dryer.”
b.
“I should avoid moving my fingers and elbow until the cast is removed.”
c.
“I will apply an ice pack to the cast over the fracture site off and on for 24 hours.”
d.
“I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast.”
ANS:
C
Ice application for the first 24 hours after a fracture will help reduce swelling and can be placed over the cast. Plaster casts
should not get wet. The patient should be encouraged to move the joints above and below the cast. Patients should not
insert objects inside the cast.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
1477
NCLEX: Physiological Integrity
11.
A patient who is to have no weight bearing on the left leg is learning to walk using crutches. Which
observation by the nurse indicates the patient can safely ambulate independently?
a.
The patient moves the right crutch with the right leg and then the left crutch with the left leg.
b.
The patient advances the left leg and both crutches together and then advances the right leg.
c.
The patient uses the bedside chair to assist in balance as needed when ambulating in the room.
d.
The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.
ANS:
B
Patients are usually taught to move the crutches and the injured leg forward at the same time and then to move the
unaffected leg. Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place
weight on the hands, not in the axilla, to avoid brachial plexus damage. If the 2- or 4-point gaits are to be used, the crutch
and leg on opposite sides move forward, not the crutch and same-side leg.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
1484
NCLEX: Safe and Effective Care Environment
12.
A patient who has had open reduction and internal fixation (ORIF) of left lower leg fractures continues
to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and
the foot is cool to the touch. Which action should the nurse take next?
a.
Notify the health care provider.
b.
Assess the incision for redness.
c.
Reposition the left leg on pillows.
d.
Check the patient’s blood pressure.
ANS:
A
The patient’s clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to
severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will
decrease arterial flow and further reduce perfusion.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1479
NCLEX: Physiological Integrity
13.
A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which nursing
assessment finding indicates a potential complication of the fracture?
a.
The patient states the pelvis feels unstable.
b.
Abdomen is distended and bowel sounds are absent.
c.
The patient complains of pelvic pain with palpation.
d.
Ecchymoses are visible across the abdomen and hips.
ANS:
B
The abdominal distention and absent bowel sounds may be due to complications of pelvic fractures such as paralytic ileus
or hemorrhage or trauma to the bladder, urethra, or colon. Pelvic instability, abdominal pain with palpation, and abdominal
bruising would be expected with this type of injury.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1481
NCLEX: Physiological Integrity
14.
Which action will the nurse take in order to evaluate the effectiveness of Buck’s traction for a patient
who has an intracapsular fracture of the right femur?
a.
Assess for hip pain.
c.
Check peripheral pulses.
b.
Assess for contractures.
d.
Monitor for hip dislocation.
ANS:
A
Buck’s traction keeps the leg immobilized and reduces painful muscle spasm. Hip contractures and dislocation are
unlikely to occur in this situation. The peripheral pulses will be assessed, but this does not help in evaluating the
effectiveness of Buck’s traction.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
1482
NCLEX: Physiological Integrity
15.
A patient with a right lower leg fracture will be discharged home with an external fixation device in
place. Which information will the nurse teach?
a.
“Check and clean the pin insertion sites daily.”
b.
“Remove the external fixator for your shower.”
c.
“Remain on bed rest until bone healing is complete.”
d.
“Take prophylactic antibiotics until the fixator is removed.”
ANS:
A
Pin insertion sites should be cleaned daily to decrease risk for infection at the site. An external fixator allows the patient to
be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the
bone is stable. Prophylactic antibiotics are not routinely given during external fixator use.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1476
NCLEX: Physiological Integrity
16.
A patient who has had open reduction and internal fixation (ORIF) of a hip fracture tells the nurse he is
ready to get out of bed for the first time. Which action should the nurse take?
a.
Check the patient’s prescribed weight-bearing status.
b.
Use a mechanical lift to transfer the patient to the chair.
c.
Delegate the transfer to nursing assistive personnel (NAP).
d.
Decrease the pain medication before getting the patient up.
ANS:
A
The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts
are not typically needed after this surgery. Pain medications should be given because the movement is likely to be painful
for the patient. The registered nurse (RN) should supervise the patient during the initial transfer to evaluate how well the
patient is able to accomplish the transfer.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1477
NCLEX: Physiological Integrity
17.
The nurse’s discharge teaching for a patient who has had a repair of a fractured mandible will include
information about
a.
administration of nasogastric tube feedings.
b.
how and when to cut the immobilizing wires.
c.
the importance of high-fiber foods in the diet.
d.
the use of sterile technique for dressing changes.
ANS:
B
The jaw will be wired for stabilization, and the patient should know what emergency situations require the wires to be cut
to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to
chew high-fiber foods. Initially, the patient may receive nasogastric tube feedings, but by discharge, the patient will
swallow liquid through a straw.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1486
NCLEX: Physiological Integrity
18.
After the health care provider recommends amputation for a patient who has nonhealing ischemic foot
ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse is best?
a.
“You are upset, but you may lose the foot anyway.”
b.
“Many people are able to function with a foot prosthesis.”
c.
“Tell me what you know about your options for treatment.”
d.
“If you do not want an amputation, you do not have to have it.”
ANS:
C
The initial nursing action should be to assess the patient’s knowledge and feelings about the available options. Discussion
about the patient’s option to refuse the procedure, seriousness of the condition, or rehabilitation after the procedure may
be appropriate after the nurse knows more about the patient’s current knowledge and emotional state.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Implementation
MSC:
REF:
1487
NCLEX: Psychosocial Integrity
19.
The day after a having a right below-the-knee amputation, a patient complains of pain in the missing
right foot. Which action is most important for the nurse to take?
a.
Explain the reasons for the pain.
b.
Administer prescribed analgesics.
c.
Reposition the patient to assure good alignment.
d.
Inform the patient that this pain will diminish over time.
ANS:
B
Acute phantom limb sensation is treated as any other type of postoperative pain would be treated. Explanations of the
reason for the pain may be given, but the nurse should still medicate the patient. Alignment is important but is unlikely to
relieve the pain. Although the pain may decrease over time, it currently requires treatment.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Implementation
MSC:
REF:
1488
NCLEX: Physiological Integrity
20.
Which statement by a patient who has had an above-the-knee amputation indicates the nurse’s
discharge teaching has been effective?
a.
“I should elevate my residual limb on a pillow 2 or 3 times a day.”
b.
“I should lie flat on my abdomen for 30 minutes 3 or 4 times a day.”
c.
“I should change the limb sock when it becomes soiled or each week.”
d.
“I should use lotion on the stump to prevent skin drying and cracking.”
ANS:
B
The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limb sock should
be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would
encourage hip flexion contracture.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
1489
NCLEX: Physiological Integrity
21.
The nurse is caring for a patient who is to be discharged from the hospital 4 days after insertion of a
femoral head prosthesis using a posterior approach. Which statement by the patient indicates a need for additional
instruction?
a.
“I should not cross my legs while sitting.”
b.
“I will use a toilet elevator on the toilet seat.”
c.
“I will have someone else put on my shoes and socks.”
d.
“I can sleep in any position that is comfortable for me.”
ANS:
D
The patient needs to sleep in a position that prevents excessive internal rotation or flexion of the hip. The other patient
statements indicate the patient has understood the teaching.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
1483
NCLEX: Physiological Integrity
24.
When giving home care instructions to a patient who has comminuted left forearm fractures and a longarm cast, which information should the nurse include?
a.
Keep the left shoulder elevated on a pillow or cushion.
b.
Avoid nonsteroidal antiinflammatory drugs (NSAIDs).
c.
Call the health care provider for numbness of the hand.
d.
Keep the hand immobile to prevent soft tissue swelling.
ANS:
C
Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be
notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints
above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be
elevated to reduce swelling. NSAIDs are appropriate to treat mild to moderate pain after a fracture.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1475
NCLEX: Physiological Integrity
25.
A patient who slipped and fell in the shower at home has a proximal left humerus fracture immobilized
with a long-arm cast and a sling. Which nursing intervention will be included in the plan of care?
a.
Use surgical net dressing to hang the arm from an IV pole.
b.
Immobilize the fingers of the left hand with gauze dressings.
c.
Assess the left axilla and change absorbent dressings as needed.
d.
Assist the patient in passive range of motion (ROM) for the right arm.
ANS:
C
The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply
absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be
encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do
active ROM on the uninjured side.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1481
NCLEX: Physiological Integrity
26.
A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient
action requires intervention by the nurse?
a.
The patient uses crutches with a swing-to gait.
b.
The patient leans over to pull on shoes and socks.
c.
The patient sits straight up on the edge of the bed.
d.
The patient bends over the sink while brushing teeth.
ANS:
B
Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient
actions are appropriate and do not require any immediate action by the nurse to protect the patient.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1483
NCLEX: Physiological Integrity
27.
After being hospitalized for 3 days with a right femur fracture, a patient suddenly develops shortness of
breath and tachypnea. The patient tells the nurse, “I feel like I am going to die!” Which action should the nurse take first?
a.
Stay with the patient and offer reassurance.
b.
Administer prescribed PRN O2 at 4 L/min.
c.
Check the patient’s legs for swelling or tenderness.
d.
Notify the health care provider about the symptoms.
ANS:
B
The patient’s clinical manifestations and history are consistent with a pulmonary embolism, and the nurse’s first action
should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic
need for O2 is a higher priority. The health care provider should be notified after the O2 is started and pulse oximetry
obtained concerning suspected fat embolism or venous thromboembolism.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1480
Nursing Process: Implementation
30.
Which nursing action for a patient who has had right hip arthroplasty can the nurse delegate to
experienced unlicensed assistive personnel (UAP)?
a.
Reposition the patient every 1 to 2 hours.
b.
Assess for skin irritation on the patient’s back.
c.
Teach the patient quadriceps-setting exercises.
d.
Determine the patient’s pain intensity and tolerance.
ANS:
A
Repositioning of orthopedic patients is within the scope of practice of UAP (after they have been trained and evaluated in
this skill). The other actions should be done by licensed nursing staff members.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Delegation
TOP:
NCLEX: Safe and Effective Care Environment
REF:
1471
Nursing Process: Planning
34.
The day after a 60-yr-old patient has open reduction and internal fixation (ORIF) for an open, displaced
tibial fracture, the nurse identifies the priority nursing diagnosis as
a.
activity intolerance related to deconditioning.
b.
risk for constipation related to prolonged bed rest.
c.
risk for impaired skin integrity related to immobility.
d.
risk for infection related to disruption of skin integrity.
ANS:
D
A patient having ORIF is at risk for problems such as wound infection and osteomyelitis. After ORIF, patients typically are
mobilized starting the first postoperative day, so the other problems caused by immobility are not as likely.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1478
Nursing Process: Analysis
35.
The second day after admission with a fractured pelvis, a patient suddenly develops confusion. Which
action should the nurse take first?
a.
Take the blood pressure.
c.
Check the O2 saturation.
b.
Assess patient orientation. d.
Observe for facial asymmetry.
ANS:
C
The patient’s history and clinical manifestations suggest a fat embolism. The most important assessment is oxygenation.
The other actions are also appropriate but will be done after the nurse assesses O2 saturation.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1480
Nursing Process: Assessment
41.
Which finding in a patient with a Colles’ fracture of the left wrist is most important to communicate
immediately to the health care provider?
a.
Swelling is noted around the wrist.
b.
The patient is reporting severe pain.
c.
The wrist has a deformed appearance.
d.
Capillary refill to the fingers is prolonged.
ANS:
D
Swelling, pain, and deformity are common findings with a Colles’ fracture. Prolonged capillary refill indicates decreased
circulation and risk for ischemia. This is not an expected finding and should be immediately reported.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1480
Nursing Process: Assessment
42.
Which information obtained by the nurse about a patient with a lumbar vertebral compression fracture
requires an immediate report to the health care provider?
a.
Patient refuses to be turned due to back pain.
b.
Patient has been incontinent of urine and stool.
c.
Patient reports lumbar area tenderness to palpation.
d.
Patient frequently uses oral corticosteroids to treat asthma.
ANS:
B
Changes in bowel or bladder function indicate possible spinal cord compression and should be reported immediately
because surgical intervention may be needed. The other findings are also pertinent but are consistent with the patient’s
diagnosis and do not require immediate intervention.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1485
NCLEX: Physiological Integrity
43.
When a patient arrives in the emergency department with a facial fracture, which action will the nurse
take first?
a.
Assess for nasal bleeding and pain.
b.
Apply ice to the face to reduce swelling.
c.
Use a cervical collar to stabilize the spine.
d.
Check the patient’s alertness and orientation.
ANS:
C
Patients who have facial fractures are at risk for cervical spine injury, and should be treated as if they have a cervical spine
injury until this is ruled out. The other actions are also necessary, but the most important action is to prevent cervical
spine injury.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
a.
b.
c.
d.
44.
After change-of-shift report, which patient should the nurse assess first?
Patient with a repaired mandibular fracture who is complaining of facial pain
Patient with an unrepaired intracapsular left hip fracture whose leg is externally rotated
Patient with an unrepaired Colles’ fracture who has right wrist swelling and deformity
Patient with repaired right femoral shaft fracture who is complaining of tightness in the calf
TOP:
REF:
1486
Nursing Process: Planning
ANS:
D
Calf swelling after a femoral shaft fracture suggests hemorrhage and risk for compartment syndrome. The nurse should
assess the patient rapidly and then notify the health care provider. The other patients have symptoms that are typical for
their injuries but do not require immediate intervention.
DIF:
OBJ:
TOP:
Cognitive Level: Analyze (analysis)
REF:
1479
Special Questions: Prioritization | Special Questions: Multiple Patients
Nursing Process: Assessment
MSC:
NCLEX: Safe and Effective Care Environment
45.
When caring for a patient who is using Buck’s traction after a hip fracture, which action can the nurse
delegate to unlicensed assistive personnel (UAP)?
a.
Remove and reapply traction periodically.
b.
Ensure the weight for the traction is hanging freely.
c.
Monitor the skin under the traction boot for redness.
d.
Check for intact sensation and movement in the affected leg.
ANS:
B
UAP can be responsible for maintaining the integrity of the traction after it has been established. The RN should assess
the extremity and assure manual traction is maintained if the traction device has to be removed and reapplied. Assessment
of skin integrity and circulation should be done by the registered nurse (RN).
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Delegation
TOP:
NCLEX: Safe and Effective Care Environment
Chapter 58: Chronic Neurologic Problems
Lewis: Medical-Surgical Nursing, 10th Edition
REF:
1471
Nursing Process: Planning
MULTIPLE CHOICE
11.
Which action will the nurse plan to take for a patient with multiple sclerosis who has urinary retention
caused by a flaccid bladder?
a.
Encourage a decreased evening intake of fluid.
b.
Teach the patient how to use the Credé method.
c.
Suggest the use of adult incontinence briefs for nighttime only.
d.
Assist the patient to the commode every 2 hours during the day.
ANS:
B
The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying
and may increase risk for urinary tract infection and dehydration. The use of incontinence briefs and frequent toileting will
not improve bladder emptying.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
12.
care?
a.
b.
c.
d.
REF:
1387
NCLEX: Physiological Integrity
A patient with Parkinson’s disease has bradykinesia. Which action will the nurse include in the plan of
Instruct the patient in activities that can be done while lying or sitting.
Suggest that the patient rock from side to side to initiate leg movement.
Have the patient take small steps in a straight line directly in front of the feet.
Teach the patient to keep the feet in contact with the floor and slide them forward.
ANS:
B
Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue
exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The
patient should lift the feet and avoid a shuffling gait.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1392
NCLEX: Physiological Integrity
13.
A 62-yr-old patient who has Parkinson’s disease is taking bromocriptine (Parlodel). Which information
obtained by the nurse may indicate a need for a decrease in the dosage?
a.
The patient has a chronic dry cough.
b.
The patient has four loose stools in a day.
c.
The patient develops a deep vein thrombosis.
d.
The patient’s blood pressure is 92/52 mm Hg.
ANS:
D
Hypotension is an adverse effect of bromocriptine, and the nurse should check with the health care provider before giving
the medication. Diarrhea, cough, and deep vein thrombosis are not associated with bromocriptine use.
DIF:
Cognitive Level: Apply (application)
REF:
1390
18.
When a 74-yr-old patient is seen in the health clinic with new development of a stooped posture,
shuffling gait, and pill rolling–type tremor, the nurse will anticipate teaching the patient about
a.
oral corticosteroids.
b.
antiparkinsonian drugs.
c.
magnetic resonance imaging (MRI).
d.
electroencephalogram (EEG) testing.
ANS:
B
The clinical diagnosis of Parkinson’s is made when tremor, rigidity, and akinesia, and postural instability are present. The
confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. MRI
and EEG are not useful in diagnosing Parkinson’s disease, and corticosteroid therapy is not used to treat it.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1389
NCLEX: Physiological Integrity
26.
A patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson’s disease. Which
information indicates a need for change in the medication or dosage?
a.
Shuffling gait
c.
Cogwheel rigidity of limbs
b.
Tremor at rest
d.
Uncontrolled head movement
ANS:
D
Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other
findings are typical with Parkinson’s disease.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1390
NCLEX: Physiological Integrity
27.
Which nursing diagnosis is of highest priority for a patient with Parkinson’s disease who is unable to
move the facial muscles?
a.
Activity intolerance
b.
Self-care deficit: toileting
c.
Ineffective self-health management
d.
Imbalanced nutrition: less than body requirements
ANS:
D
The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other
diagnoses may also be appropriate for a patient with Parkinson’s disease, but the data do not indicate that they are current
problems for this patient.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1391
Nursing Process: Analysis
2.
A patient with Parkinson’s disease is admitted to the hospital for treatment of pneumonia. Which
nursing interventions will be included in the plan of care (select all that apply)?
a.
Provide an elevated toilet seat.
b.
Cut patient’s food into small pieces.
c.
Serve high-protein foods at each meal.
d.
Place an armchair at the patient’s bedside.
e.
Observe for sudden exacerbation of symptoms.
ANS:
A, B, D
Because the patient with Parkinson’s disease has difficulty chewing, food should be cut into small pieces. An armchair
should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An
elevated toilet seat will facilitate getting on and off the toilet. High-protein foods will decrease the effectiveness of L-dopa.
Parkinson’s disease is a steadily progressive disease without acute exacerbations.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1391
NCLEX: Physiological Integrity
Chapter 48: Musculoskeletal or Articular Dysfunction
MULTIPLE CHOICE
4.
A young girl has just injured her ankle at school. In addition to calling the child’s parents, the most
appropriate immediate action by the school nurse is to:
a.
Apply ice.
b.
Observe for edema and discoloration.
c.
Encourage child to assume a comfortable position.
d.
Obtain parental permission for administration of acetaminophen or aspirin.
ANS:
A
Soft-tissue injuries should be iced immediately. In addition to ice, the extremity should be rested, be elevated, and have
compression applied. Observing for edema and discoloration, encouraging the child to assume a comfortable position,
and obtaining parental permission or administration of acetaminophen or aspirin are not immediate priorities.
PTS:
OBJ:
1
DIF:
Cognitive Level: Analysis
Nursing Process: Implementation
MSC:
REF:
1537
Client Needs: Physiologic Integrity
a.
b.
5.
Which term is used to describe a type of fracture that does not produce a break in the skin?
Simple c.
Complicated
Compound
d.
Comminuted
ANS:
A
If a fracture does not produce a break in the skin, it is called a simple or closed fracture. A compound or open fracture is
one with an open wound through which the bone protrudes. A complicated fracture is one in which the bone fragments
damage other organs or tissues. A comminuted fracture occurs when small fragments of bone are broken from the
fractured shaft and lie in the surrounding tissue. These are rare in children.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1538
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
a.
b.
6.
An advantage to using a fiberglass cast instead of a plaster cast is that a fiberglass cast:
Is less expensive. c.
Molds closely to body parts.
Dries rapidly.
d.
Has a smooth exterior.
ANS:
B
A synthetic casting material dries in 5 to 30 minutes as compared with a plaster cast, which takes 10 to 72 hours to dry.
Synthetic casts are more expensive. Plaster casts mold closer to body parts. Synthetic casts have a rough exterior, which
may scratch surfaces.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
1540
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
7.
The nurse is teaching the parents of a 7-year-old child who has just had a cast applied for a fractured
arm with the wrist and elbow immobilized. Which instructions should be included in the teaching?
a.
Swelling of the fingers is to be expected for the next 48 hours.
b.
Immobilize the shoulder to decrease pain in the arm.
c.
Allow the affected limb to hang down for 1 hour each day.
d.
Elevate casted arm when resting and when sitting up.
ANS:
D
The injured extremity should be kept elevated while resting and in a sling when upright. This will increase venous return.
Swelling of the fingers may indicate neurovascular damage and should be reported immediately. Permanent damage can
occur within 6 to 8 hours. Joints above and below the cast on the affected extremity should be moved. The child should
not engage in strenuous activity for the first few days. Rest with elevation of the extremity is encouraged.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
1541
Nursing Process: Implementation
MSC:
Client Needs: Physiologic Integrity
a.
b.
8.
The nurse uses the palms of the hands when handling a wet cast to:
Assess dryness of the cast. c.
Keep the patient’s limb balanced.
Facilitate easy turning.
d.
Avoid indenting the cast.
ANS:
D
Wet casts should be handled by the palms of the hands, not the fingers, to prevent creating pressure points. Assessing
dryness, facilitating easy turning, or keeping the patient’s limb balanced are not reasons for using the palms of the hand
rather than the fingers when handling a wet cast.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1541
Nursing Process: Implementation
MSC:
Client Needs: Physiologic Integrity
a.
b.
9.
What would cause a nurse to suspect that an infection has developed under a cast?
Complaint of paresthesia
c.
Increased respirations
Cold toes
d.
“Hot spots” felt on cast surface
ANS:
D
If hot spots are felt on the cast surface, they usually indicate infection beneath the area. This should be reported so a
window can be made in the cast to observe the site. The "five Ps" of ischemia from a vascular injury include pain, pallor,
pulselessness, paresthesia, and paralysis. Paresthesia is an indication of vascular injury, not infection. Cold toes may be
indicative of too tight a cast and need further evaluation. Increased respirations may indicate a respiratory infection or
pulmonary emboli. This should be reported, and the child should be evaluated.
PTS:
OBJ:
1
DIF:
Cognitive Level: Analysis REF:
1541
Nursing Process: Diagnosis MSC:
Client Needs: Physiologic Integrity
10.
A child is upset because, when the cast is removed from her leg, the skin surface is caked with
desquamated skin and sebaceous secretions. What should the nurse suggest to remove this material?
a.
Soak in a bathtub. c.
Apply powder to absorb material.
b.
Vigorously scrub the leg.
d.
Carefully pick material off of the leg.
ANS:
A
Simple soaking in the bathtub is usually sufficient for the removal of the desquamated skin and sebaceous secretions. It
may take several days to eliminate the accumulation completely. The parents and child should be advised not to scrub the
leg vigorously or forcibly remove this material because it may cause excoriation and bleeding. Oil or lotion, but not
powder, may provide comfort for the child.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
1542
Nursing Process: Implementation
MSC:
Client Needs: Physiologic Integrity
a.
b.
11.
Which type of traction uses skin traction on the lower leg and a padded sling under the knee?
Dunlop c.
Russell
Bryant's d.
Buck's extension
ANS:
C
Russell traction uses skin traction on the lower leg and a padded sling under the knee. The combination of longitudinal
and perpendicular traction allows realignment of the lower extremity and immobilizes the hips and knees in a flexed
position. Dunlop traction is an upper extremity traction used for fractures of the humerus. Bryant's traction is skin traction
with the legs flexed at a 90-degree angle at the hip. Buck's extension traction is a type of skin traction with the legs in an
extended position. It is used primarily for short-term immobilization, before surgery with dislocated hips, for correcting
contractures, or for bone deformities such as Legg-Calvé-Perthes disease.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1543
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
a.
b.
c.
d.
13.
An appropriate nursing intervention when caring for a child in traction is to:
Remove adhesive traction straps daily to prevent skin breakdown.
Assess for tightness, weakness, or contractures in uninvolved joints and muscles.
Provide active range-of-motion exercises to affected extremity 3 times a day.
Keep child in one position to maintain good alignment.
ANS:
B
Traction places stress on the affected bone, joint, and muscles. The nurse must assess for tightness, weakness, or
contractures developing in the uninvolved joints and muscles. The adhesive straps should be released/replaced only when
absolutely necessary. Active, passive, or active with resistance exercises should be carried out for the unaffected
extremity only. Movement is expected with children. Each time the child moves, the nurse should check to ensure that
proper alignment is maintained.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
1545
Nursing Process: Implementation
MSC:
Client Needs: Physiologic Integrity
a.
b.
c.
d.
25.
When infants are seen for fractures, which nursing intervention is a priority?
No intervention is necessary. It is not uncommon for infants to fracture bones.
Assess the family’s safety practices. Fractures in infants usually result from falls.
Assess for child abuse. Fractures in infants are often nonaccidental.
Assess for genetic factors.
ANS:
C
Fractures in infants warrant further investigation to rule out child abuse. Fractures in children younger than 1 year are
unusual because of the cartilaginous quality of the skeleton; a large amount of force is necessary to fracture their bones.
Infants should be cared for in a safe environment and should not be falling. Fractures in infancy are usually nonaccidental
rather than related to a genetic factor.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
1537
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
26.
Which nursing intervention is appropriate to assess for neurovascular competency in a child who fell
off the monkey bars at school and hurt his arm?
a.
The degree of motion and ability to position the extremity.
b.
The length, diameter, and shape of the extremity.
c.
The amount of swelling noted in the extremity and pain intensity.
d.
The skin color, temperature, movement, sensation, and capillary refill of the extremity.
ANS:
D
A neurovascular evaluation includes assessing skin color and temperature, ability to move the affected extremity, degree
of sensation experienced, and speed of capillary refill in the extremity. The degree of motion in the affected extremity and
ability to position the extremity are incomplete assessments of neurovascular competency. The length, diameter, and
shape of the extremity are not assessment criteria in a neurovascular evaluation. Although the amount of swelling is an
important factor in assessing an extremity, it is not a criterion for a neurovascular assessment.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
1545
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
37.
The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which
assessment findings indicate possible compartment syndrome (Select all that apply)?
a.
Palpable distal pulse
b.
Capillary refill to extremity of <3 seconds
c.
Severe pain not relieved by analgesics
d.
Tingling of extremity
e.
Inability to move extremity
ANS:
C, D, E
Indications of compartment syndrome are severe pain not relieved by analgesics, tingling of extremity, and inability to
move extremity. A palpable distal pulse and capillary refill to the extremity of <3 seconds are expected findings.
PTS:
OBJ:
MSC:
1
DIF:
Cognitive Level: ApplicationREF:
1540
Nursing Process: Assessment
Client Needs: Physiologic Integrity: Reduction of Risk Potential
Mood and affect
Concept 33: Mood and Affect
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
A patient has been prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant. After
taking the new medication, the patient states, “This medication isn’t working. I don’t feel any different.” What is the best
response by the nurse?
a.
“I will call your care provider. Perhaps you need a different medication.”
b.
“Don’t worry. You can try taking it at a different time of day to help it work better.”
c.
“It usually takes a few weeks for you to notice improvement from this medication.”
d.
“Your life is much better now. You will feel better soon.”
ANS:
C
Seeing a response to antidepressants takes 3 to 6 weeks. No change in medications is indicated at this point of treatment
because there is no report of adverse effects from the medication. If nausea is present, taking the medication with food
may help, but this is not reported by the patient, so a change in administration time is not needed. Telling a depressed
patient that their life is better does not acknowledge their feelings.
REF:
Page 322 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
2.
A patient who has been diagnosed with depression is scheduled for cognitive therapy in addition to
receiving prescribed antidepressant medication. The nurse understands that the goal of cognitive therapy will be met
when what is reported by the patient?
a.
“I will tell myself that I am a good person when things don’t go well at work.”
b.
“My medications will make my problems go away.”
c.
“My family will help take care of my children while I am in the hospital.”
d.
“This therapy will improve my response to neurotransmitter impulses.”
ANS:
A
Cognitive therapy helps patients restructure their patterns of thinking to various events or thoughts in a more healthy way.
Medication alters neurotransmitters but does not make problems go away. Family support is important but is not the goal
of cognitive therapy. Neurotransmitters are affected by medication and brain stimulation therapy, not by cognitive therapy.
REF:
Page 322 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
3.
A patient has been resistant to treatment with antidepressant therapy. The care provider prescribes a
monoamine oxidase inhibitor (MAOI) medication. What teaching is critical for the nurse to give the patient?
a.
Serum blood levels must be regularly monitored to assess for toxicity.
b.
To prevent side effects, the medication should be administered as an intramuscular injection.
c.
Eating foods such as blue cheese or red wine will cause side effects.
d.
This medication class may only be used safely for a few days at a time.
ANS:
C
MAOIs have serious food interactions when ingested with tyramine-containing foods such as aged or processed foods.
Serum levels are routinely monitored when mood stabilizers such as lithium carbonate are prescribed. It is not necessary
to administer this class intramuscularly. This medication takes several weeks to show effectiveness and should not be
stopped abruptly; short-term use will not be effective.
REF:
Page 323 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
4.
A patient with a diagnosis of depression and suicidal ideation was started on an antidepressant 1
month ago. When the patient comes to the community health clinic for a follow-up appointment he is cheerful and
talkative. What priority assessment must the nurse consider for this patient?
a.
The medication dose needs to be decreased.
b.
Treatment is successful, and medication can be stopped.
c.
The patient is ready to return to work.
d.
Specific assessment for suicide plan must be evaluated.
ANS:
D
Energy levels increase as depression lifts; this may increase the risk of completing a suicide plan. An increase in mood
would not indicate a decrease or discontinuation of prescribed medication. The patient may be ready to return to work, but
assessment for suicide risk in a patient who has had suicidal ideation is the priority assessment.
REF:
OBJ:
Page 323 |Page 324
NCLEX® Client Needs Category: Safe and Effective Care Environment
5.
A patient who is taking prescribed lithium carbonate is exhibiting signs of diarrhea, blurred vision,
frequent urination, and an unsteady gait. Which serum lithium level would the nurse expect for this patient?
a.
0 to 0.5 mEq/L
b.
0.6 to 0.9 mEq/L
c.
1.0 to 1.4 mEq/L
d.
1.5 or higher mEq/L
ANS:
D
Diarrhea, blurred vision, ataxia, and polyuria are all signs of lithium toxicity, which generally occurs at serum levels above
1.5 mEq/L. Serum levels within the normal range of 0.8 to 1.4 mEq/L are not likely to cause signs of toxicity.
REF:
Page 323 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
6.
A patient newly diagnosed with depression states, “I have had other people in my family say that they
have depression. Is this an inherited problem?” What is the nurse’s best response?
a.
“There are a lot of mood disorders that are caused by many different causes. Inheriting these disorders is not
likely.”
b.
“Current research is focusing on fluid and electrolyte disorders as a cause for mood disorders.”
c.
“All of your family members raised in the same area have probably learned to respond to problems in the same
way.”
d.
“Members of the same family may have the same biological predisposition to experiencing mood disorders.”
ANS:
D
Research is showing a genetic or hereditary role in the predisposition of experiencing mood disorders. These tendencies
can be inherited by family members. Fluid and electrolyte imbalances cause many problems, but neurotransmitters in the
brain are more directly linked to mood disorders. Mood disorders are not a learned behavior, but are linked to
neurotransmitters in the brain.
REF:
Page 319 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
7.
As a nurse in the emergency department, you are caring for a patient who is exhibiting signs of
depression. What is a priority nursing intervention you should perform for this patient?
a.
Assess for depression and ask directly about suicide thoughts.
b.
Ask the care provider to prescribe blood lab work to assess for depression.
c.
d.
Focus on the presenting problems and refer the patient for a mental health evaluation.
Interview the patient’s family to identify their concerns about the patient’s behaviors.
ANS:
A
Assessing directly for thoughts of harm to self or others is a priority intervention for any patient exhibiting signs of a
mental health disorder. It is estimated that 50% of individuals who succeed in suicide had visited a health care provider
within the previous 24 hours. Currently there is no serum lab that identifies depression. The risk of self-harm is a priority
safety issue that is monitored in all health care within the scope of the nurse. It is important to obtain information directly
from the patient when possible, and then validate the information from family or other secondary sources.
REF:
OBJ:
Page 319 |Page 322
NCLEX® Client Needs Category: Psychosocial Integrity
8.
An older adult has experienced severe depression for many years and is unable to tolerate most
antidepressant medications due to adverse effects of the medications. He is scheduled for electroconvulsive therapy
(ECT) as a treatment for his depression. What teaching should the nurse give the patient regarding this treatment?
a.
There are no special preparations needed before this treatment.
b.
Common side effects include headache and short-term memory loss.
c.
One treatment will be needed to cure the depression.
d.
This treatment will leave you unconscious for several hours.
ANS:
B
Common side effects of ECT include headache, sleepiness, short-term memory loss, nausea, and muscle aches.
Preparations before and after the procedure are the same as any operative procedure involving the patient receiving
anesthesia. Treatment is typically three sessions a week for 4 weeks, not once. Patients are not unconscious after the
procedure due to the use of precisely placed electrodes and the use of anesthesia.
REF:
Page 322 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
MULTIPLE RESPONSE
1.
A nurse is developing a plan of care for a patient admitted with a diagnosis of bipolar disorder, manic
phase. Which nursing diagnoses address priority needs for the patient? (Select all that apply.)
a.
Risk for caregiver strain
b.
Impaired verbal communication
c.
Risk for injury
d.
Imbalanced nutrition, less than body requirements
e.
Ineffective coping
f.
Sleep deprivation
ANS:
C, D, F
Risk for injury, poor nutrition, and impaired sleep are priority needs of the patient experiencing mania related to their
impulsivity, inability to attend to activities of daily living such as diet and hygiene, and disruption of sleep. Caregiver strain
is important to be addressed but is not a priority need on admission for the patient. Verbal communication improves when
the mania is managed, and racing thoughts return to normal patterns. Ineffective coping will require stabilization of the
acute phase along with cognitive therapy over time.
REF:
OBJ:
Page 322 |Page 323
NCLEX® Client Needs Category: Safe and Effective Care Environment
Unit 5
Sensory Perception
Concept 28: Sensory Perception
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
A 75-year-old woman walks into the emergency department with complaints of “not feeling well.” Her
blood pressure is 145/95, pulse 85 beats/min, respirations 24 breaths/min, and blood sugar 300. Upon inspection, the
nurse notices that the woman has an open wound on the bottom of her foot, but the patient states she is not aware of this.
How should the nurse interpret these findings?
a.
Normal in the older adult
b.
A need for the patient to be evaluated for cognitive impairment
c.
A side effect of anti-hypertensive medication
d.
Pathologic impairment of sensory responses
ANS:
D
This degree of sensory impairment at this age is not expected. Lack of sensation does not imply lack of knowledge, but
rather decreased ability to perceive the stimuli. Anti-hypertensive medication does not typically cause decreased skin
sensation. This is more common in antineoplastic drugs. Most likely the patient has diabetes, which is causing decreased
sensation. Not feeling well is secondary to a change in blood sugar as a result of the wound response.
REF:
OBJ:
Page 273 |Page 274
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
2.
The nurse requests that a mother give permission for a hearing test in a newborn infant. The mother
questions the importance of such a test. The nurse correctly responds with which of the following statements?
a.
“This will help us to identify your baby’s risk for ear infections the first year of life.”
b.
“Hearing is important so your baby hears and responds to your voice, which makes you feel like a mother.”
c.
“Socialization skills include the need to hear in order to interpret the emotional aspect of the words that are
spoken to your child.”
d.
“Imitation of sounds is the first step in language development, and it is important to identify alterations early.”
ANS:
D
Newborn screening of hearing does not identify risk of infection but only of sensory responses. The baby’s response to
the mother is important to bonding, but this not the most important reason to evaluate hearing. Likewise, socialization and
tone recognition are functions of hearing, but the most significant reason to test hearing is to identify losses and provide
compensatory ways to encourage language development.
REF:
Page 274 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
3.
An adult male patient is complaining of decreased appetite. He states he just finished taking his
antibiotics for an episode of pneumonia. What is the nurse’s best response?
a.
“Your wife should increase the spices in your food, as the pneumonia changes your sense of smell.”
b.
“Notify your doctor immediately, because this is a concerning reaction to the medication.”
c.
“You need to take an appetite stimulant, as your body will need good nutrition to recover from the infection.”
d.
“You should see an improvement in the next week or so. Call if this continues.”
ANS:
D
Many medications cause a change in sense of taste, including antibiotics. This is temporary and does not require
interventions. Pneumonia affects the lower respiratory tract, and is less likely to cause change in smell. The short-term
effects of the antibiotic should not necessitate major concern regarding diet intake, including stimulants.
REF:
OBJ:
Page 276
NCLEX® Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4.
An 80-year-old patient is being discharged after he was diagnosed with diabetes mellitus and
retinopathy. His daughter has been part of the discharge instruction process. Understanding of the instructions is evident
when the daughter says which of the following?
a.
“I will make sure that Dad always wears warm socks.”
b.
“Dad needs to wear his glasses so he can delay the onset of macular degeneration.”
c.
“I will ask the home health aide to carefully inspect Dad’s feet every day when she helps him bathe.”
d.
“We will give him only warm foods, so that he doesn’t burn his mouth.”
ANS:
C
Diabetes increases risk of peripheral neuropathy, and it is hard to inspect one’s own feet. Though socks that fit well are
important, warmth is not the main issue. Glasses do not affect the onset of eye disorders, including macular degeneration.
The sensory deficit regarding perception of heat and cold is usually associated with the distal extremities.
REF:
OBJ:
Page 277 |Page 278
NCLEX® Client Needs Category: Health Promotion and Maintenance
5.
The patient who had a hip replacement yesterday has a visual acuity of 20/200 after correction. What is
the nurse’s best action to provide recreational activities during the rehabilitation phase?
a.
Place the television to the left or right of patient’s visual field.
b.
Encourage the patient to learn braille.
c.
Suggest use of talking books.
d.
Provide headphones for listening to music.
ANS:
C
Talking books would provide a quick, short-term means of entertainment. Braille might be recommended as a long-term
solution to visual deficits. The placement of the television is not helpful with low acuity, unless the patient has macular
degeneration. Headphones may be nice, but the patient has a visual deficit and no indication that hearing is a problem.
REF:
Page 277 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
6.
The nurse is examining the eyes of a newborn infant. If the nurse notes the absence of the red reflex,
what is the next best action?
a.
Notify the physician.
b.
Document the finding in the records.
c.
Recheck the reflex after several hours.
d.
Monitor the eye movements and pupil reactions closely.
ANS:
A
The absence of the red reflex suggests the presence of congenital cataracts, which is an abnormal finding. It will not
change in several hours, nor do the eye movements and pupil reaction provide significant changes in this situation.
REF:
Page 277 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
7.
The nurse is providing health teaching to a group of mothers of school-aged children. Which statement
by a mother indicates the need for additional instruction?
a.
“I will take my child to the audiologist because he doesn’t seem to hear me except when I look directly at him.”
b.
“Both of my children have the same eye medication, which is a real bonus, because I only need to buy one
bottle.”
c.
“Making my child wear ear plugs when she goes to a rock concert may save her hearing!”
d.
“I see now why when my child has a cold, he complains about everything tasting blah!”
ANS:
B
Each person should always have their own eye medication to prevent infection transfer between them. The child who only
hears with direct visional contacts may be lip-reading and have a hearing loss. Exposure to loud noises is known to cause
hearing loss. Sense of taste and smell can be altered by upper respiratory infections.
REF:
OBJ:
Page 274 |Page 275
NCLEX® Client Needs Category: Health Promotion and Maintenance
8.
During the examination of the ear, a dark yellow substance is noted in the ear canal. The tympanic
membrane is not visible. The patient’s wife complains that he never hears what she says lately. These findings would
suggest that the nurse prepare the patient for which procedure?
a.
Tympanoplasty
b.
Irrigation of the ear
c.
Pure tone test
d.
Otoscopic exam by a specialist
ANS:
B
The symptoms are consistent with blockage of the ear canal with cerumen, which then needs to be removed by irrigation,
so that further examination of the ear drum and hearing can be accomplished. A tympanoplasty is only warranted if there
has been a perforation, which is unknown at the present.
REF:
Page 278 OBJ:
NCLEX® Client Needs Category:
Chapter 21: Visual and Auditory Problems
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
8.
Which topic will the nurse teach after a patient has had outpatient cataract surgery and lens
implantation?
a.
Use of oral opioids for pain control
b.
Administration of corticosteroid drops
c.
Importance of coughing and deep breathing exercises
d.
Need for bed rest for the first 1 to 2 days after the surgery
ANS:
B
Antibiotic and corticosteroid eye drops are commonly prescribed after cataract surgery. The patient should be able to
administer them using safe technique. Pain is not expected after cataract surgery, and opioids will not be needed.
Coughing and deep breathing exercises are not needed because a general anesthetic agent is not used. There is no bed
rest restriction after cataract surgery.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
374
NCLEX: Physiological Integrity
9.
In reviewing a patient’s medical record, the nurse notes that the last eye examination revealed an
intraocular pressure of 28 mm Hg. The nurse will plan to assess
a.
visual acuity.
c.
color perception.
b.
pupil reaction.
d.
peripheral vision.
ANS:
D
The patient’s increased intraocular pressure indicates glaucoma, which decreases peripheral vision. Because central
visual acuity is unchanged by glaucoma, assessment of visual acuity could be normal even if the patient has worsening
glaucoma. Color perception and pupil reaction to light are not affected by glaucoma.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
379
NCLEX: Physiological Integrity
11.
A 72-yr-old patient with age-related macular degeneration (AMD) has just had photodynamic therapy.
Which statement by the patient indicates that the discharge teaching has been effective?
a.
“I will use drops to keep my pupils dilated until my appointment.”
b.
“I will need to use brighter lights to read for at least the next week.”
c.
“I will not use facial lotions near my eyes during the recovery period.”
d.
“I will cover up with long-sleeved shirts and pants for the next 5 days.”
ANS:
D
The photosensitizing drug used for photodynamic therapy is activated by exposure to bright light and can cause burns in
areas exposed to light for 5 days after the treatment. There are no restrictions on the use of facial lotions, medications to
keep the pupils dilated would not be appropriate, and bright lights would increase the risk for damage caused by the
treatment.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
379
NCLEX: Physiological Integrity
12.
To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the
nurse can evaluate the patient for improvement by
a.
questioning the patient about blurred vision.
b.
noting any changes in the patient’s visual field.
c.
asking the patient to rate the pain using a 0 to 10 scale.
d.
assessing the patient’s depth perception when climbing stairs.
ANS:
B
POAG develops slowly and without symptoms except for a gradual loss of visual fields. Acute closed-angle glaucoma may
present with excruciating pain, colored halos, and blurred vision. Problems with depth perception are not associated with
POAG.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
379
NCLEX: Physiological Integrity
13.
A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse
that the eye drops cause eye burning and visual blurriness for a short time after administration. The best response to the
patient’s statement is
a.
“Those symptoms may indicate a need for a change in dosage of the eye drops.”
b.
“The drops are uncomfortable, but it is important to use them to retain your vision.”
c.
“These are normal side effects of the drug, which should be less noticeable with time."
d.
“Notify your health care provider so that different eye drops can be prescribed for you.”
ANS:
B
Patients should be instructed that eye discomfort and visual blurring are expected side effects of the ophthalmic drops but
that the drops must be used to prevent further visual-field loss. The temporary burning and visual blurriness might not
lessen with ongoing use and do not indicate a need for a dosage or medication change.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
381
NCLEX: Physiological Integrity
14.
The nurse is completing the admission database for a patient admitted with abdominal pain and notes a
history of hypertension and glaucoma. Which prescribed medication should the nurse question?
a.
Morphine sulfate 4 mg IV
b.
Diazepam (Valium) 5 mg IV
c.
Betaxolol (Betoptic) 0.25% eyedrops
d.
Scopolamine patch (Transderm Scop) 1.5 mg
ANS:
D
Scopolamine is a parasympathetic blocker and will relax the iris, causing blockage of aqueous humor outflow and an
increase in intraocular pressure. The other medications are appropriate for this patient.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
380
NCLEX: Physiological Integrity
15.
A patient who has bacterial endophthalmitis in the left eye is restless, frequently asking whether the eye
is healing and whether removal of the eye will be necessary. Based on the assessment data, which nursing diagnosis is
appropriate at this time?
a.
Grieving related to current loss of functional vision
b.
Ineffective health management related to inability to see
c.
Anxiety related to the possibility of permanent vision loss
d.
Situational low self-esteem related to loss of visual function
ANS:
C
The patient’s restlessness and questioning of the nurse indicate anxiety about the future possible loss of vision. Because
the patient can see with the right eye, functional vision is relatively intact. There is no indication of impaired self-esteem at
this time.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Diagnosis MSC:
REF:
382
NCLEX: Physiological Integrity
16.
To decrease the risk for future hearing loss, which action should the nurse implement with college
students at the on-campus health clinic?
a.
Perform tympanometry.
b.
Schedule otoscopic examinations.
c.
Administer influenza immunizations.
d.
Discuss exposure to amplified music.
ANS:
D
The nurse should discuss the impact of amplified music on hearing with young adults and discourage listening to very
amplified music, especially for prolonged periods. Tympanometry measures the ability of the eardrum to vibrate and would
not help prevent future hearing loss. Although students are at risk for the influenza virus, being vaccinated does not help
prevent future hearing loss. Otoscopic examinations are not necessary for all patients.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
388
NCLEX: Health Promotion and Maintenance
17.
A patient diagnosed with external otitis is being discharged from the emergency department with an ear
wick in place. Which statement by the patient indicates a need for further teaching?
a.
“I will apply the eardrops to the cotton wick in the ear canal.”
b.
“I can use aspirin or acetaminophen (Tylenol) for pain relief.”
c.
“I will clean the ear canal daily with a cotton-tipped applicator.”
d.
“I can use warm compresses to the outside of the ear for comfort.”
ANS:
C
Insertion of instruments such as cotton-tipped applicators into the ear should be avoided. The other patient statements
indicate that the teaching has been successful.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
a.
b.
18.
The nurse will instruct a patient who has undergone a left tympanoplasty to
remain on bed rest.
c.
avoid blowing the nose.
keep the head elevated.
d.
irrigate the left ear canal.
ANS:
C
MSC:
REF:
384
NCLEX: Physiological Integrity
Coughing or blowing the nose increases pressure in the eustachian tube and middle ear cavity and disrupts postoperative
healing. There is no postoperative need for prolonged bed rest, elevation of the head, or continuous antibiotic irrigation.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
385
NCLEX: Physiological Integrity
19.
The nurse is assessing a patient who was recently treated with amoxicillin for acute otitis media of the
right ear. Which finding is a priority to report to the health care provider?
a.
The patient has a temperature of 100.6° F.
b.
The patient complains of “popping” in the ear.
c.
Clear fluid is visible through the tympanic membrane.
d.
The patient frequently asks the nurse to repeat information.
ANS:
A
The fever indicates that the infection may not be resolved, and the patient might need further antibiotic therapy. A feeling
of fullness, “popping” of the ear, decreased hearing, and fluid in the middle ear are indications of otitis media with
effusion. These symptoms are normal for weeks to months after an episode of acute otitis media and usually resolve
without treatment.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
384
Nursing Process: Evaluation
20.
A patient with Ménière’s disease is admitted with vertigo, nausea, and vomiting. Which nursing
intervention will be included in the care plan?
a.
Dim the lights in the patient’s room.
b.
Encourage increased oral fluid intake.
c.
Change the patient’s position every 2 hours.
d.
Keep the head of the bed elevated 45 degrees.
ANS:
A
A darkened, quiet room will decrease the symptoms of the acute attack of Ménière’s disease. Because the patient will be
nauseated during an acute attack, fluids are administered IV. Position changes will cause vertigo and nausea. The head of
the bed can be positioned for patient comfort.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
386
NCLEX: Physiological Integrity
21.
Which statement by the patient to the home health nurse indicates a need for more teaching about selfadministering eardrops?
a.
“I will leave the ear wick in place while administering the drops.”
b.
“I will hold the tip of the dropper above the ear to administer the drops.”
c.
“I will refrigerate the medication until I am ready to administer the drops.”
d.
“I should lie down before and for 5 minutes after administering the drops.”
ANS:
C
Administration of cold eardrops can cause dizziness because of stimulation of the semicircular canals. The other patient
actions are appropriate.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
383
NCLEX: Physiological Integrity
22.
An older patient who is being admitted to the hospital repeatedly asks the nurse to “speak up so that I
can hear you.” Which action should the nurse take?
a.
Increase the speaking volume.
b.
Overenunciate while speaking.
c.
Speak normally but more slowly.
d.
Use more facial expressions when talking.
ANS:
C
Patient understanding of the nurse’s speech will be enhanced by speaking at a normal tone, but more slowly. Increasing
the volume, overenunciating, and exaggerating facial expressions will not improve the patient’s ability to comprehend.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
390
NCLEX: Physiological Integrity
23.
A patient with presbycusis is fitted with binaural hearing aids. Which information will the nurse include
when teaching the patient how to use the hearing aids?
a.
Keep the volume low on the hearing aids for the first week.
b.
Experiment with volume and hearing in a quiet environment.
c.
Add the second hearing aid after making adjustments to the first hearing aid.
d.
Begin wearing the hearing aids for an hour a day, gradually increasing the use.
ANS:
B
Initially the patient should use the hearing aids in a quiet environment such as the home, experimenting with increasing
and decreasing the volume as needed. There is no need to gradually increase the time of wear. The patient should
experiment with the level of volume to find what works well in various situations. Both hearing aids should be used.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
391
NCLEX: Physiological Integrity
a.
b.
c.
d.
24.
Which information will the nurse include for a patient contemplating a cochlear implant?
Cochlear implants are not useful for patients with congenital deafness.
Cochlear implants are most helpful as an early intervention for presbycusis.
Cochlear implants improve hearing in patients with conductive hearing loss.
Cochlear implants require extensive training in order to reach the full benefit.
ANS:
D
Extensive rehabilitation is required after cochlear implants for patients to receive the maximum benefit. Hearing aids,
rather than cochlear implants, are used initially for presbycusis. Cochlear implants are used for sensorineural hearing loss
and would not be helpful for conductive loss. They are appropriate for some patients with congenital deafness.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
390
Nursing Process: Planning MSC:
NCLEX: Physiological Integrity
a.
b.
c.
d.
25.
Which statement by a patient with bacterial conjunctivitis indicates a need for further teaching?
“I will wash my hands often during the day.”
“I will remove my contact lenses at bedtime.”
“I will not share towels with my friends or family.”
“I will monitor my family for eye redness or drainage.”
ANS:
B
Contact lenses should not be used when patients have conjunctivitis because they can further irritate the conjunctiva.
Hand washing is the major means to prevent the spread of conjunctivitis. Infection may be spread by sharing towels or
other contact. It is common for bacterial conjunctivitis to spread through a family or other group in close contact.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
a.
b.
c.
d.
26.
Which information will the nurse include when teaching a patient with herpes simplex type 1 keratitis?
Use of natamycin (Natacyn) antifungal eyedrops
Application of corticosteroid ophthalmic ointment
Avoidance of nonsteroidal antiinflammatory drugs (NSAIDs)
Completion of the prescribed series of oral acyclovir (Zovirax)
MSC:
REF:
368
NCLEX: Physiological Integrity
ANS:
D
Oral acyclovir may be ordered for herpes simplex infections. Corticosteroid ointments are usually contraindicated because
they prolong the course of the infection. Herpes simplex type 1 is viral, not parasitic or fungal. Natamycin may be used for
Acanthamoeba keratitis caused by a parasite. NSAIDs can be used to treat the pain associated with keratitis.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
372
NCLEX: Physiological Integrity
27.
The nurse at the outpatient surgery unit obtains the following information about a patient who is
scheduled for cataract extraction and implantation of an intraocular lens. Which information is important to report to the
health care provider at this time?
a.
The patient has had blurred vision for 3 years.
b.
The patient has not eaten anything for 8 hours.
c.
The patient takes 2 antihypertensive medications.
d.
The patient gets nauseated with general anesthesia.
ANS:
C
Mydriatic medications used for pupil dilation are sympathetic nervous system stimulants and may increase heart rate and
blood pressure. Using punctal occlusion when administering the mydriatic and monitoring of blood pressure are indicated
for this patient. Blurred vision is an expected finding with cataracts. Patients are expected to be NPO before the surgical
procedure. Cataract extraction and intraocular lens implantation are done using local anesthesia.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
374
Nursing Process: Assessment
28.
During the preoperative assessment of a patient scheduled for a right cataract extraction and
intraocular lens implantation, it is important for the nurse to assess
a.
the visual acuity of the patient’s left eye.
b.
how long the patient has had the cataract.
c.
for presence of a white pupil in the right eye.
d.
for a history of reactions to general anesthetics.
ANS:
A
Because it can take several weeks before the maximum improvement in vision occurs in the right eye, patient safety and
independence are determined by the vision in the left eye. A white pupil in the operative eye would not be unusual for a
patient scheduled for cataract removal and lens implantation. The length of time that the patient has had the cataract will
not affect the perioperative care. Cataract surgery is done using local anesthetics rather than general anesthetics.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Prioritization
TOP:
NCLEX: Safe and Effective Care Environment
REF:
375
Nursing Process: Assessment
32.
Unlicensed assistive personnel (UAP) perform all the following actions when caring for a patient with
Ménière’s disease who is experiencing an acute attack. Which action by UAP indicates that the nurse should intervene?
a.
UAP raise the side rails on the bed.
b.
UAP turn on the patient’s television.
c.
UAP place an emesis basin at the bedside.
d.
UAP helps the patient turn to the right side.
ANS:
B
Watching television may exacerbate the symptoms of an acute attack of Ménière’s disease. The other actions are
appropriate because the patient will be at high fall risk and may suffer from nausea during the acute attack.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Delegation
TOP:
NCLEX: Safe and Effective Care Environment
REF:
386
Nursing Process: Implementation
33.
The nurse at the eye clinic made a follow-up telephone call to a patient who underwent cataract
extraction and intraocular lens implantation the previous day. Which information is the priority to communicate to the
health care provider?
a.
The patient requests a prescription refill for next week.
b.
The patient feels uncomfortable wearing an eye patch.
c.
The patient complains that the vision has not improved.
d.
The patient reports eye pain rated 5 (on a 0 to 10 scale).
ANS:
D
Postoperative cataract surgery patients usually experience little or no pain, so pain at a level 5 on a 10-point pain scale
may indicate complications such as hemorrhage, infection, or increased intraocular pressure. The other information given
by the patient indicates a need for patient teaching or follow-up does not indicate that complications of the surgery may be
occurring.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
376
Nursing Process: Implementation
35.
The charge nurse observes a newly hired nurse performing all the following interventions for a patient
who has just undergone right cataract removal and an intraocular lens implant. Which one requires that the charge nurse
intervene?
a.
The nurse leaves the eye shield in place.
b.
The nurse encourages the patient to cough.
c.
The nurse elevates the patient’s head to 45 degrees.
d.
The nurse applies corticosteroid drops to the right eye.
ANS:
B
Because coughing will increase intraocular pressure, patients are generally taught to avoid coughing during the acute
postoperative time. The other actions are appropriate for a patient after having this surgery.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Delegation
NCLEX: Physiological Integrity
TOP:
REF:
375
Nursing Process: Implementation
36.
Which nursing activity is appropriate for the registered nurse (RN) working in the eye clinic to delegate
to experienced unlicensed assistive personnel (UAP)?
a.
Instilling antiviral drops for a patient with a corneal ulcer
b.
Application of a warm compress to a patient’s hordeolum
c.
Instruction about hand washing for a patient with herpes keratitis
d.
Looking for eye irritation in a patient with possible conjunctivitis
ANS:
B
Application of cold and warm packs is included in UAP education and the ability to accomplish this safely would be
expected for UAP working in an eye clinic. Medication administration, patient teaching, and assessment are high-level
skills appropriate for the education and legal practice level of the RN.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Delegation
TOP:
NCLEX: Safe and Effective Care Environment
REF:
370
Nursing Process: Implementation
37.
A patient with a head injury after a motorcycle crash arrives in the emergency department (ED)
complaining of shortness of breath and severe eye pain. Which action will the nurse take first?
a.
Assess cranial nerve functions.
b.
Administer the prescribed analgesic.
c.
Check the patient’s oxygen saturation.
d.
Examine the eye for evidence of trauma.
ANS:
C
The priority action for a patient after a head injury is to assess and maintain airway and breathing. Because the patient is
complaining of shortness of breath, it is essential that the nurse assess the oxygen saturation. The other actions are also
appropriate but are not the first action the nurse will take.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
371
Nursing Process: Implementation
38.
Which prescribed medication should the nurse give first to a patient who has just been admitted to a
hospital with acute angle-closure glaucoma?
a.
Morphine sulfate 4 mg IV
b.
Mannitol (Osmitrol) 100 mg IV
c.
Betaxolol (Betoptic) 1 drop in each eye
d.
Acetazolamide (Diamox) 250 mg orally
ANS:
B
The most immediate concern for the patient is to lower intraocular pressure, which will occur most rapidly with IV
administration of a hyperosmolar diuretic such as mannitol. The other medications are also appropriate for a patient with
glaucoma but would not be the first medication administered.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
a.
b.
c.
d.
39.
The priority nursing diagnosis for a patient experiencing an acute attack with Meniere’s disease is
risk for falls related to episodic dizziness.
impaired verbal communication related to tinnitus.
self-care deficit (bathing and dressing) related to vertigo.
imbalanced nutrition: less than body requirements related to nausea.
ANS:
A
TOP:
REF:
380
Nursing Process: Implementation
All the nursing diagnoses are appropriate, but because sudden attacks of vertigo can lead to “drop attacks,” the major
focus of nursing care is to prevent injuries associated with dizziness.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
386
Nursing Process: Diagnosis
40.
Which information about a patient who had a stapedotomy yesterday is most important for the nurse to
communicate to the health care provider?
a.
Oral temperature is 100.8° F (38.1° C).
b.
The patient complains of ear “fullness.”
c.
Small amount of dried drainage on dressing.
d.
The patient reports that hearing has gotten worse.
ANS:
A
An elevated temperature may indicate a postoperative infection. Although the nurse would report all the data, a temporary
decrease in hearing, bloody drainage on the dressing, and a feeling of congestion (because of the accumulation of blood
and drainage in the ear) are common after this surgery.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
376
Nursing Process: Assessment
41.
A 75-yr-old patient who lives alone at home tells the nurse, “I am afraid of losing my independence
because my eyes don’t work as well they used to.” Which action should the nurse take first?
a.
Discuss the increased risk for falls that is associated with impaired vision.
b.
Ask the patient about what type of vision problems are being experienced.
c.
Explain that there are many ways to compensate for decreases in visual acuity.
d.
Suggest ways of improving the patient’s safety, such as using brighter lighting.
ANS:
B
The nurse’s initial action should be further assessment of the patient’s concerns and visual problems. The other actions
may be appropriate, depending on what the nurse finds with further assessment.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
TOP:
NCLEX: Safe and Effective Care Environment
REF:
369
Nursing Process: Assessment
a.
b.
c.
d.
43.
Which action will the nurse take when performing ear irrigation for a patient with cerumen impaction?
Assist the patient to a supine position for the irrigation.
Fill the irrigation syringe with body-temperature solution.
Use a sterile applicator to clean the ear canal before irrigating.
Occlude the ear canal completely with the syringe while irrigating.
ANS:
B
Solution at body temperature is used for ear irrigation. The patient should be sitting for the procedure. Use of cottontipped applicators to clear the ear may result in forcing the cerumen deeper into the ear canal. The ear should not be
completely occluded with the syringe.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
384
Nursing Process: Implementation
MSC:
NCLEX: Safe and Effective Care Environment
44.
Which action will the nurse include in the plan of care for a patient with benign paroxysmal positional
vertigo (BPPV)?
a.
Teach the patient about use of medications to reduce symptoms.
b.
Place the patient in a dark, quiet room to avoid stimulating BPPV attacks.
c.
Teach the patient that canalith repositioning may be used to reduce dizziness.
d.
Speak with a low-pitched voice so that the patient is able to hear instructions.
ANS:
C
The Epley maneuver is used to reposition “ear rocks” in BPPV. Medications and placement in a dark room may be used to
treat Ménière’s disease, but are not necessary for BPPV. There is no hearing loss with BPPV.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
387
NCLEX: Physiological Integrity
45.
about
a.
b.
When teaching a patient about the treatment of acoustic neuroma, the nurse will include information
applying sunscreen.
preventing fall injuries.
c.
d.
decreasing dietary sodium.
chemotherapy side effects.
ANS:
B
Intermittent vertigo occurs with acoustic neuroma, so the nurse should include information about how to prevent falls.
Diet is not a risk factor for acoustic neuroma and no dietary changes are needed. Sunscreen would be used to prevent
skin cancers on the external ear. Acoustic neuromas are benign and do not require chemotherapy.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
387
NCLEX: Physiological Integrity
Chapter 37: Impact of Cognitive or Sensory Impairment on the Child and Family
MULTIPLE CHOICE
a.
b.
12.
Distortion of sound and problems in discrimination are characteristic of which type of hearing loss?
Conductive
c.
Mixed conductive-sensorineural
Sensorineural
d.
Central auditory imperceptive
ANS:
B
Sensorineural hearing loss, also known as perceptive or nerve deafness, involves damage to the inner ear structures or
the auditory nerve. It results in distortion of sounds and problems in discrimination. Conductive hearing loss involves
mainly interference with loudness of sound. Mixed conductive-sensorineural hearing loss manifests as a combination of
both sensorineural and conductive loss. The central auditory imperceptive category includes all hearing losses that do not
demonstrate defects in the conduction or sensory structures.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1093
Nursing Process: Assessment
MSC:
Client Needs: Psychosocial Integrity
13.
The most common type of hearing loss, which results from interference of transmission of sound to the
middle ear, is called:
a.
Conductive.
c.
Mixed conductive-sensorineural.
b.
Sensorineural.
d.
Central auditory imperceptive.
ANS:
A
Conductive or middle-ear hearing loss is the most common type. It results from interference of transmission of sound to
the middle ear, most often from recurrent otitis media. Sensorineural, mixed conductive-sensorineural, and central
auditory imperceptive are less common types of hearing loss.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1093
Nursing Process: Assessment
MSC:
Client Needs: Psychosocial Integrity
15.
The nurse is talking with a 10-year-old boy who wears bilateral hearing aids. The left hearing aid is
making an annoying whistling sound that the child cannot hear. The most appropriate nursing action is to:
a.
Ignore the sound.
b.
Ask him to reverse the hearing aids in his ears.
c.
Suggest that he reinsert the hearing aid.
d.
Suggest that he raise the volume of the hearing aid.
ANS:
C
The whistling sound is acoustic feedback. The nurse should have the child remove the hearing aid and reinsert it, making
sure that no hair is caught between the ear mold and the ear canal. Ignoring the sound and suggesting that he raise the
volume of the hearing aid would be annoying to others. The hearing aids are molded specifically for each ear.
PTS:
OBJ:
1
DIF:
Cognitive Level: Analysis
Nursing Process: Implementation
MSC:
REF:
1094
Client Needs: Psychosocial Integrity
a.
b.
16.
An implanted ear prosthesis for children with sensorineural hearing loss is a(n):
Hearing aid.
c.
Auditory implant.
Cochlear implant. d.
Amplification device.
ANS:
B
Cochlear implants are surgically implanted, and they provide a sensation of hearing for individuals who have severe or
profound hearing loss of sensorineural origin. Hearing aids are external devices for enhancing hearing. An auditory
implant does not exist. An amplification device is an external device for enhancing hearing.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1094
Nursing Process: Assessment
MSC:
Client Needs: Psychosocial Integrity
38.
A nurse is preparing a teaching session for parents on prevention of childhood hearing loss. The nurse
should include that the most common cause of hearing impairment in children is:
a.
Auditory nerve damage.
c.
Congenital rubella.
b.
Congenital ear defects.
d.
Chronic otitis media.
ANS:
D
Chronic otitis media is the most common cause of hearing impairment in children. It is essential that appropriate
measures be instituted to treat existing infections and prevent recurrences. Auditory nerve damage, congenital ear
defects, and congenital rubella are rarer causes of hearing impairment.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1093
Nursing Process: Implementation
MSC:
Client Needs: Health Promotion and Maintenance
Elimination
Concept 17: Elimination
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
A patient who was diagnosed with senile dementia has become incontinent of urine. The patient’s
daughter asks the nurse why this is happening. What is the nurse’s best response?
a.
“The patient is angry about the dementia diagnosis.”
b.
“The patient is losing sphincter control due to the dementia.”
c.
“The patient forgets where the bathroom is located due to the dementia.”
d.
“The patient wants to leave the hospital.”
ANS:
B
Anger, wanting to leave the hospital, and forgetting where the bathroom is really have no bearing on the urinary
incontinence. The patient is incontinent due to the mental ability to voluntarily control the sphincter. This is happening
because of the dementia.
REF:
Page 159 OBJ:
NCLEX® Client Needs Category: Psychosocial Integrity
2.
The nurse is caring for a patient who has suffered a spinal cord injury and is concerned about the
patient's elimination status. What is the nurse’s best action?
a.
Speak with the patient's family about food choices.
b.
Establish a bowel and bladder program for the patient.
c.
Speak with the patient about past elimination habits.
d.
Establish a bedtime ritual for the patient.
ANS:
B
Establishing a bowel and bladder program for the patient is a priority to be sure that adequate elimination is happening for
the patient with a spinal cord injury. Speaking with the family to determine food choices is not the primary concern.
Speaking with the patient to know past elimination habits does not apply, because the spinal cord injury changes
elimination habits. Establishing a bedtime ritual does not apply to elimination.
REF:
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NCLEX® Client Needs Category: Physiological Integrity
3.
The process of digestion is important for every living organism for the purpose of nourishment. Where
does most digestion take place in the body?
a.
Large intestine
b.
Stomach
c.
Small intestine
d.
Pancreas
ANS:
C
Most digestion takes place in the small intestine. The main function of the large intestine is water absorption. The
pancreas contains digestive enzymes; the stomach secrets hydrochloric acid to assist with food breakdown.
REF:
OBJ:
Page 157
NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation
4.
The nurse is listening for bowel sounds in a postoperative patient. The bowel sounds are slow, as they
are heard only every 3 to 4 minutes. The patient asks the nurse why this is happening. What is the nurse’s best response?
a.
“Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel.”
b.
“Some people have a slower bowel than others, and this is nothing to be concerned about.”
c.
“The foods you eat contribute to peristalsis, so you should eat more fiber in your diet.”
d.
“Bowel peristalsis is slow because you are not walking. Get more exercise during the day.”
ANS:
A
Anesthesia and pain medication used in conjunction with the surgery are affecting the peristalsis of the bowel. Having a
slower bowel, eating certain food, or lack of exercise will not have a direct effect on the bowel.
REF:
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NCLEX® Client Needs Category: Physiological Integrity
a.
b.
c.
d.
5.
What is a primary prevention tool used for colon cancer screening?
Abdominal x-rays
Blood, urea, and nitrogen (BUN) testing
Serum electrolytes
Occult blood testing
ANS:
D
Occult blood testing will reveal unseen blood in the stool, and this may signal a potentially serious bowel problem like
colon cancer. BUN is used to evaluate kidney function. Serum electrolytes and abdominal x-rays are not related to colon
cancer screening.
REF:
Page 162 OBJ:
NCLEX® Client Needs Category: Health Promotion and Maintenance
MULTIPLE RESPONSE
1.
During an assessment, the patient states that his bowel movements cause discomfort because the
stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with
improving the quality of his bowel movement? (Select all that apply.)
a.
Increase fiber intake.
b.
Increase water consumption.
c.
Decrease physical exercise.
d.
Refrain from alcohol.
e.
Refrain from smoking.
ANS:
A, B
Increasing fiber assists in adding bulk to the stool. Increasing water assists in softening the stool and moving it through
the large intestine. Decreasing exercise will have the opposite effect of slowing bowel movements. Refraining from alcohol
and smoking have no direct effect on the quality of bowel movements.
REF:
OBJ:
Page 162
NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care
2.
When conducting a health history assessment, the nurse would want to know what most important
information about the patient's elimination status? (Select all that apply.)
a.
Recent changes in elimination patterns
b.
Changes in color, consistency, or odor of stool or urine
c.
Time of day patient defecates
d.
Discomfort or pain with elimination
e.
List of medications taken by patient
f.
Patient's preferences for toileting
ANS:
A, B, D, E
Recent changes in elimination patterns, color, consistency, or odor are important for the nurse to know concerning
elimination. Discomfort or pain during elimination is important for the nurse to know. A nurse should also know which
medications the patient is on as this may affect elimination. Personal preferences are not the most important data the
nurse needs to collect.
REF:
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NCLEX® Client Needs Category: Physiological Integrity
Chapter 45: Renal and Urologic Problems
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
9.
A 56-yr-old female patient is admitted to the hospital with new-onset nephrotic syndrome. Which
assessment data will the nurse expect?
a.
Poor skin turgor c.
Elevated urine ketones
b.
Recent weight gain
d.
Decreased blood pressure
ANS:
B
The patient with a nephrotic syndrome will have weight gain associated with edema. Hypertension is a clinical
manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high. Ketones are not
related to nephrotic syndrome.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
1044
Nursing Process: Assessment
MSC:
NCLEX: Physiological Integrity
38.
A patient with a history of polycystic kidney disease is admitted to the surgical unit after having
shoulder surgery. Which of the routine postoperative orders is most important for the nurse to discuss with the health care
provider?
a.
Give ketorolac 10 mg PO PRN for pain.
b.
Infuse 5% dextrose in normal saline at 75 mL/hr.
c.
Order regular diet after patient is awake and alert.
d.
Draw blood urea nitrogen (BUN) and creatinine in 2 hours.
ANS:
A
The nonsteroidal antiinflammatory drugs (NSAIDs) should be avoided in patients with decreased renal function because
nephrotoxicity is a potential adverse effect. The other orders do not need any clarification or change.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1044
NCLEX: Physiological Integrity
39.
A patient seen in the clinic for a bladder infection describes the following symptoms. Which information
is most important for the nurse to report to the health care provider?
a.
Urinary urgency c.
Intermittent hematuria
b.
Left-sided flank pain
d.
Burning with urination
ANS:
B
Flank pain indicates that the patient may have developed pyelonephritis as a complication of the bladder infection. The
other clinical manifestations are consistent with a lower urinary tract infection.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1035
Nursing Process: Assessment
MULTIPLE RESPONSE
1.
A patient has been diagnosed with urinary tract calculi that are high in uric acid. Which foods will the
nurse teach the patient to avoid (select all that apply)?
a.
Milk
b.
Liver
c.
Spinach
d.
Chicken
e.
Cabbage
f.
Chocolate
ANS:
B, D
Meats contain purines, which are metabolized to uric acid. The other foods might be restricted in patients who have
calcium or oxalate stones.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
1046
Nursing Process: Planning MSC:
NCLEX: Physiological Integrity
Fluid and Electrolyte
Concept 08: Fluid and Electrolyte Balance
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
The nurse is admitting an older adult with decompensated congestive heart failure. The nursing
assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor’s order?
a.
Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
b.
Furosemide (Lasix) 20 mg PO now
c.
Oxygen via face mask at 8 L/min
d.
KCl 20 mEq PO two times per day
ANS:
A
A patient with decompensated heart failure has extracellular fluid volume (ECV) excess. The IV of 0.9% NaCl is normal
saline, which should be questioned because it would expand ECV and place an additional load on the failing heart.
Diuretics such as furosemide are appropriate to decrease the ECV during heart failure. Increasing the potassium intake
with KCl is appropriate, because furosemide increases potassium excretion. Oxygen administration is appropriate in this
situation of near pulmonary edema from ECV excess.
REF:
Page 66 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
2.
The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report
immediately to the physician?
a.
Swollen ankles in patient with compensated heart failure
b.
Positive Chvostek’s sign in patient with acute pancreatitis
c.
Dry mucous membranes in patient taking a new diuretic
d.
Constipation in patient who has advanced breast cancer
ANS:
B
Positive Chvostek’s sign indicates increased neuromuscular excitability, which can progress to dangerous laryngospasm
or seizures and thus needs to be reported first. The other assessment findings are less urgent and need further
assessment. Bilateral ankle edema is a sign of ECV excess, and follow-up is needed, but the situation is not immediately
life-threatening. Dry mucous membranes in a patient taking a diuretic may be associated with ECV deficit; however,
additional assessments of ECV deficit are required before reporting to the physician. Constipation has many causes,
including hypercalcemia and opioid analgesics, and it needs action, but not as urgently as a positive Chvostek’s sign.
REF:
Page 70 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
3.
The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it. Which
assessment finding should cause the nurse to hold the IV solution and contact the physician?
a.
Weight gain of 2 pounds since last week
b.
Dry mucous membranes and skin tenting
c.
Urine output 8 mL/hr
d.
Blood pressure 98/58
ANS:
C
Administering IV potassium to a patient who has oliguria is not safe, because potassium intake faster than potassium
output can cause hyperkalemia with dangerous cardiac dysrhythmias. Dry mucous membranes, skin tenting, and blood
pressure 98/58 are consistent with the need for IV 0.9% NaCl. Weight gain of 2 pounds in a week does not necessarily
indicate fluid overload, because it can be from increased nutritional intake. An overnight weight gain indicates a fluid gain.
REF:
Page 66 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
4.
At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which patient
should the nurse assess most carefully for development of hyponatremia?
a.
Vomiting all day and not replacing any fluid
b.
Tumor that secretes excessive antidiuretic hormone (ADH)
c.
Tumor that secretes excessive aldosterone
d.
Tumor that destroyed the posterior pituitary gland
ANS:
B
ADH causes renal reabsorption of water, which dilutes the body fluids. Excessive ADH thus causes hyponatremia.
Excessive aldosterone causes ECV excess rather than hyponatremia. The posterior pituitary gland releases ADH; lack of
ADH causes hypernatremia. Vomiting without fluid replacement causes ECV deficit and hypernatremia.
REF:
Page 64 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
5.
The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should
prompt the nurse to request an order for serum sodium concentration?
a.
Development of ankle or sacral edema
b.
Increased skin tenting and dry mouth
c.
Postural hypotension and tachycardia
d.
Decreased level of consciousness
ANS:
D
Tube feedings pose a risk for hypernatremia unless adequate water is administered between tube feedings. Hypernatremia
causes the level of consciousness to decrease. The serum sodium concentration is a laboratory measure for osmolality
imbalances, not ECV imbalances. Edema is a sign of ECV excess, not hypernatremia. Skin tenting, dry mouth, postural
hypotension, and tachycardia all can be signs of ECV deficit.
REF:
Page 70 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
6.
The patient with which diagnosis should have the highest priority for teaching regarding foods that are
high in magnesium?
a.
Severe hemorrhage
b.
Diabetes insipidus
c.
Oliguric renal disease
d.
Adrenal insufficiency
ANS:
C
When renal excretion is decreased, magnesium intake must be decreased also, to prevent hypermagnesemia. The other
conditions are not likely to require adjustment of magnesium intake.
REF:
OBJ:
Page 64 |Page 70
NCLEX® Client Needs Category: Physiological Integrity
7.
The patient’s laboratory report today indicates severe hypokalemia, and the nurse has notified the
physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for
this patient now?
a.
Raise bed side rails due to potential decreased level of consciousness and confusion.
b.
Examine sacral area and patient’s heels for skin breakdown due to potential edema.
c.
Establish seizure precautions due to potential muscle twitching, cramps, and seizures.
d.
Institute fall precautions due to potential postural hypotension and weak leg muscles.
ANS:
D
Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of
these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures.
REF:
OBJ:
Page 69 |Page 70
NCLEX® Client Needs Category: Physiological Integrity
MULTIPLE RESPONSE
1.
The home health nurse is caring for a patient with a diagnosis of acute immunodeficiency syndrome
(AIDS) who has chronic diarrhea. Which assessments should the nurse use to detect the fluid and electrolyte imbalances
for which the patient has high risk? (Select all that apply.)
a.
Bilateral ankle edema
b.
Weaker leg muscles than usual
c.
Postural blood pressure and heart rate
d.
Positive Trousseau’s sign
e.
Flat neck veins when upright
f.
Decreased patellar reflexes
ANS:
B, C, D
Chronic diarrhea has high risk of causing ECV deficit, hypokalemia, hypocalcemia, and hypomagnesemia because it
increases fecal excretion of sodium-containing fluid, potassium, calcium, and magnesium. Appropriate assessments
include postural blood pressure and heart rate for ECV deficit; weaker leg muscles than usual for hypokalemia; and
positive Trousseau’s sign for hypocalcemia and hypomagnesemia. Bilateral ankle edema is a sign of ECV excess, which is
not likely with chronic diarrhea. Flat neck veins when upright is a normal finding. Decreased patellar reflexes is associated
with hypermagnesemia, which is not likely with chronic diarrhea.
REF:
Page 68 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
2.
The patient has recent bilateral, above-the-knee amputations and has developed C. difficile diarrhea.
What assessments should the nurse use to detect ECV deficit in this patient? (Select all that apply.)
a.
Test for skin tenting.
b.
Measure rate and character of pulse.
c.
Measure postural blood pressure and heart rate.
d.
Check Trousseau’s sign.
e.
Observe for flatness of neck veins when upright.
f.
Observe for flatness of neck veins when supine.
ANS:
A, B, F
ECV deficit is characterized by skin tenting; rapid, thready pulse; and flat neck veins when supine, which can be assessed
in this patient. Although ECV deficit also causes postural blood pressure drop with tachycardia, this assessment is not
appropriate for a patient with recent bilateral, above-the-knee amputations. Trousseau’s sign is a test for increased
neuromuscular excitability, which is not characteristic of ECV deficit. Flat neck veins when upright is a normal finding.
REF:
Page 70 OBJ:
NCLEX® Client Needs Category: Physiologi
Chapter 16: Fluid, Electrolyte, and Acid-Base Imbalances
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1.
The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which
assessment data will be of most concern to the nurse?
a.
Urine output is 30 mL/hr.
b.
Blood pressure is 90/40 mm Hg.
c.
Oral fluid intake is 100 mL for the past 8 hours.
d.
There is prolonged skin tenting over the sternum.
ANS:
B
The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid loss
because of the burn injury. This finding will require immediate intervention to prevent the complications associated with
systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing
the patient’s fluid intake but not as urgently as the hypotension.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Assessment
MSC:
REF:
276
NCLEX: Physiological Integrity
2.
A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic
hormone (SIADH). The nurse should notify the health care provider about which assessment finding?
a.
Serum hematocrit of 42%
b.
Serum sodium level of 120 mg/dL
c.
Reported weight gain of 2.2 lb (1 kg)
d.
Urinary output of 280 mL during past 8 hours
ANS:
B
Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level.
Hyponatremia can cause confusion and other central nervous system effects. A critically low value likely needs to be
treated. At least 30 mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is
expected with SIADH because of water retention.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
279
NCLEX: Physiological Integrity
3.
A patient with multiple draining wounds is admitted for hypovolemia. Which assessment would be the
most accurate way for the nurse to evaluate fluid balance?
a.
Skin turgor
c.
Urine output
b.
Daily weight
d.
Edema presence
ANS:
B
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably
with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes
edema. Urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the
gastrointestinal tract or wounds.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Evaluation
MSC:
REF:
277
NCLEX: Physiological Integrity
4.
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration.
Which instructions should the nurse give this patient related to fluid intake?
a.
“Drink more fluids in the late evening.”
b.
“Increase fluids if your mouth feels dry.”
c.
“More fluids are needed if you feel thirsty.”
d.
“If you feel confused, you need more to drink.”
ANS:
B
An alert older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing
mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older
patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and
act appropriately when changes in level of consciousness occur.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
277
NCLEX: Health Promotion and Maintenance
5.
A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of
generalized weakness. Which action is appropriate for the nurse to take?
a.
Assess for facial muscle spasms.
b.
Ask the patient about loose stools.
c.
Recommend the patient avoid drinking orange juice with meals.
d.
Suggest that the health care provider order a basic metabolic panel.
ANS:
D
Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the
nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in
potassium and would be advisable to drink if the patient is hypokalemic. Loose stools are associated with hyperkalemia.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
281
NCLEX: Physiological Integrity
6.
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by
the patient indicates that the teaching about this medication has been effective?
a.
“I will try to drink at least 8 glasses of water every day.”
b.
“I will use a salt substitute to decrease my sodium intake.”
c.
“I will increase my intake of potassium-containing foods.”
d.
“I will drink apple juice instead of orange juice for breakfast.”
ANS:
D
Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose low-potassium foods (e.g.,
apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is using
spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid
salt substitutes, which are high in potassium.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
281
NCLEX: Physiological Integrity
7.
A patient with new-onset confusion and hyponatremia is being admitted. When making room
assignments, the charge nurse should take which action?
a.
Assign the patient to a semi-private room.
b.
Assign the patient to a room near the nurse’s station.
c.
Place the patient in a room nearest to the water fountain.
d.
Place the patient on telemetry to monitor for peaked T waves..
ANS:
B
The patient should be placed near the nurse’s station if confused for the staff to closely monitor the patient. To help
improve serum sodium levels, water intake is restricted. Therefore a confused patient should not be placed near a water
fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and
disruptive for another patient in a semiprivate room.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
280
NCLEX: Physiological Integrity
8.
IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia.
Which action should the nurse take?
a.
Administer the KCl as a rapid IV bolus.
b.
Infuse the KCl at a rate of 10 mEq/hour.
c.
Only give the KCl through a central venous line.
d.
Discontinue cardiac monitoring during the infusion.
ANS:
B
IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. KCl can cause
inflammation of peripheral veins, but it can be administered by this route. Cardiac monitoring should be continued while
patient is receiving potassium because of the risk for dysrhythmias.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
282
NCLEX: Physiological Integrity
9.
A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric
suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy
should the nurse question?
a.
Infuse 5% dextrose in water at 125 mL/hr.
b.
Administer 3% saline at 50 mL/hr for a total of 200 mL.
c.
Administer IV morphine sulfate 4 mg every 2 hours PRN.
d.
Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.
ANS:
A
Because the patient’s gastric suction has been depleting electrolytes, the IV solution should include electrolyte
replacement. Solutions such as lactated Ringer’s solution would usually be ordered for this patient. The other orders are
appropriate for a postoperative patient with gastric suction.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
276
NCLEX: Physiological Integrity
10.
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for
continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85
mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
a.
Metabolic acidosis c.
Respiratory acidosis
b.
Metabolic alkalosis
d.
Respiratory alkalosis
ANS:
D
The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are
incorrect based on the pH and the normal HCO3.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
288
NCLEX: Physiological Integrity
12.
An older adult patient who is malnourished presents to the emergency department with a serum protein
level of 5.2 g/dL. The nurse would expect which clinical manifestation?
a.
Pallor
c.
Confusion
b.
Edema d.
Restlessness
ANS:
B
The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure
and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with
low serum protein levels.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
273
NCLEX: Physiological Integrity
13.
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most
important for the nurse to monitor for while the patient is receiving this infusion?
a.
Lung sounds
c.
Peripheral pulses
b.
Urinary output
d.
Peripheral edema
ANS:
A
Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in
the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Peripheral pulses,
peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but
they do not indicate acute respiratory or cardiac decompensation.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
274
NCLEX: Physiological Integrity
14.
The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident
who has a low serum total protein level. Which assessment finding indicates that the patient’s condition has improved?
a.
Hematocrit 28%
c.
Decreased peripheral edema
b.
Absence of skin tenting
d.
Blood pressure 110/72 mm Hg
ANS:
C
Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an
improvement in the patient’s protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low
hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring
protein status.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
273
NCLEX: Physiological Integrity
15.
A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas
(ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these
results?
a.
Metabolic acidosis c.
Respiratory acidosis
b.
Metabolic alkalosis
d.
Respiratory alkalosis
ANS:
A
The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
288
NCLEX: Physiological Integrity
16.
A patient who has been receiving diuretic therapy is admitted to the emergency department with a
serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on
which medication?
a.
Digoxin (Lanoxin) 0.25 mg/day
b.
Metoprolol (Lopressor) 12.5 mg/day
c.
Ibuprofen (Motrin) 400 mg every 6 hours
d.
Lantus insulin 24 U subcutaneously every evening
ANS:
A
Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do
more assessment regarding the other medications, but they are not of as much concern with the potassium level.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
283
NCLEX: Physiological Integrity
17.
The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should
the nurse include on the care plan?
a.
Maintain the patient on bed rest.
b.
Auscultate lung sounds every 4 hours.
c.
Monitor for Trousseau’s and Chvostek’s signs.
d.
Encourage fluid intake up to 4000 mL every day.
ANS:
D
To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps
decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau’s and Chvostek’s
signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent
assessment of lung sounds, although these would be assessed every shift.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
283
NCLEX: Physiological Integrity
20.
A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a
peripherally inserted central catheter was inserted. Which response by the nurse is accurate?
a.
“The prescribed infusion can be given more rapidly when the patient has a central line.”
b.
“The hypertonic solution will be more rapidly diluted when given through a central line.”
c.
“There is a decreased risk for infection when 25% dextrose is infused through a central line.”
d.
“The required blood glucose monitoring is based on samples obtained from a central line.”
ANS:
B
The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose
concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are
obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or
concentrated IV solutions are not given rapidly.
DIF:
TOP:
Cognitive Level: Apply (application)
REF:
273
Nursing Process: Implementation
MSC:
NCLEX: Physiological Integrity
22.
An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and
weakness. Which laboratory result should the nurse report to the health care provider immediately?
a.
K+ 3.4 mEq/L (3.4 mmol/L) c.
Na+ 154 mEq/L (154 mmol/L)
b.
Ca+2 7.8 mg/dL (1.95 mmol/L)
d.
PO4-3 4.8 mg/dL (1.55 mmol/L)
ANS:
C
The elevated serum sodium level is consistent with the patient’s neurologic symptoms and indicates a need for immediate
action to prevent further serious complications such as seizures. The potassium, phosphate, and calcium levels vary
slightly from normal but do not require immediate action by the nurse.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
276
Nursing Process: Assessment
23.
The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving
normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a
priority for the nurse to report to the health care provider?
a.
Oral temperature of 100.1°F
b.
Serum sodium level of 138 mEq/L (138 mmol/L)
c.
Gradually decreasing level of consciousness (LOC)
d.
Weight gain of 2 pounds (1 kg) over the admission weight
ANS:
C
The patient’s history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF)
excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is
needed to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated
temperature, crackles, and serum sodium level also will be reported but do not indicate a need for rapid action to avoid
complications.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
271
Nursing Process: Assessment
24.
A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed
medications and seems confused. The patient has peripheral edema and shortness of breath. Which assessment should
the nurse complete first?
a.
Skin turgor
c.
Mental status
b.
Heart sounds
d.
Capillary refill
ANS:
C
Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing
confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds may also be
affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral
edema.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
279
Nursing Process: Assessment
30.
A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory
studies are done. Which laboratory value will require the most immediate action by the nurse?
a.
Arterial blood pH is 7.32.
b.
Serum calcium is 18 mg/dL.
c.
Serum potassium is 5.1 mEq/L.
d.
Arterial oxygen saturation is 91%.
ANS:
B
The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. The nurse should
initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH are also
abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life
threatening.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
283
Nursing Process: Assessment
34.
A patient comes to the clinic complaining of frequent, watery stools for the past 2 days. Which action
should the nurse take first?
a.
Obtain the baseline weight.
b.
Check the patient’s blood pressure.
c.
Draw blood for serum electrolyte levels.
d.
Ask about extremity numbness or tingling.
ANS:
B
Because the patient’s history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is
the highest priority. The other actions are also appropriate, but are not as essential as determining the patient’s perfusion
status.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
TOP:
NCLEX: Safe and Effective Care Environment
REF:
276
Nursing Process: Assessment
Chapter 41: Gastrointestinal Dysfunction
MULTIPLE CHOICE
a.
b.
1.
Nurses must be alert for increased fluid requirements when a child has:
Fever.
c.
Congestive heart failure.
Mechanical ventilation.
d.
Increased intracranial pressure (ICP).
ANS:
A
Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid
volume. Respiratory rate influences insensible fluid loss and should be monitored in the mechanically ventilated child.
Congestive heart failure is a case of fluid overload in children. ICP does not lead to increased fluid requirements in
children.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1255
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
a.
b.
2.
Which type of dehydration results from water loss in excess of electrolyte loss?
Isotonic dehydration
c.
Hypotonic dehydration
Isosmotic dehydration
d.
Hypertonic dehydration
ANS:
D
Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of
dehydration. It is caused by feeding children fluids with high amounts of solute. Isotonic dehydration occurs in conditions
in which electrolyte and water deficits are present in balanced proportion. Isosmotic dehydration is another term for
isotonic dehydration. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the
serum hypotonic.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1256
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
3.
An infant is brought to the emergency department with poor skin turgor, weight loss, lethargy, and
tachycardia. This is suggestive of:
a.
Overhydration.
c.
Sodium excess.
b.
Dehydration.
d.
Calcium excess.
ANS:
B
These clinical manifestations indicate dehydration. Symptoms of overhydration are edema and weight gain. Regardless of
extracellular sodium levels, total body sodium is usually depleted in dehydration. Symptoms of hypocalcemia are a result
of neuromuscular irritability and manifest as jitteriness, tetany, tremors, and muscle twitching.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1256
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
a.
b.
4.
Acute diarrhea is often caused by:
Hirschsprung’s disease.
c.
Hypothyroidism.
Antibiotic therapy. d.
Meconium ileus.
ANS:
B
Acute diarrhea is a sudden increase in frequency and change in consistency of stools and may be associated with
antibiotic therapy. Hirschsprung’s disease, hypothyroidism, and meconium ileus are usually manifested with constipation
rather than diarrhea.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
1259
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity
COMPLETION
52.
A child has a nasogastric (NG) tube to continuous low intermittent suction. The physician’s prescription
is to replace the previous 4-hour NG output with a normal saline piggyback over a 2-hour period. The NG output for the
previous 4 hours totaled 50 mL. What milliliter/hour rate should the nurse administer to replace with a normal saline
piggyback? _____ Record your answer as a whole number.
ANS:
25
The previous total 4-hour output was 50 mL. To run the 50 mL over a 2-hour period, the nurse would divide 50 by 2 = 25.
The normal saline replacement fluid would be run at 25 mL/hr.
PTS:
OBJ:
1
DIF:
Cognitive Level: ApplicationREF:
1256
Nursing Process: Planning MSC:
Client Needs: Physiologic Integrity
Unit 6
Glucose Regulation
Concept 15: Glucose Regulation
Giddens: Concepts for Nursing Practice, 2nd Edition
MULTIPLE CHOICE
1.
The nurse instructs a patient with type 1 diabetes mellitus to avoid which of the following drugs while
taking insulin?
a.
Furosemide (Lasix)
b.
Dicumarol (Bishydroxycoumarin)
c.
Reserpine (Serpasil)
d.
Cimetidine (Tagamet)
ANS:
A
Furosemide is a loop diuretic and can increase serum glucose levels; its use is contraindicated with insulin. Dicumarol, an
anticoagulant; reserpine, an anti-hypertensive; and cimetidine, an H2 receptor antagonist, do not affect blood glucose
levels.
REF:
OBJ:
Page 135 |Page 141
NCLEX® Client Needs Category: Physiological Integrity
2.
When a diabetic patient asks about maintaining adequate blood glucose levels, which of the following
statements by the nurse relates most directly to the necessity of maintaining blood glucose levels no lower than about 74
mg/dL?
a.
“Glucose is the only type of fuel used by body cells to produce the energy needed for physiologic activity.”
b.
“The central nervous system cannot store glucose and needs a continuous supply of glucose for fuel.”
c.
“Without a minimum level of glucose circulating in the blood, erythrocytes cannot produce ATP.”
d.
“The presence of glucose in the blood counteracts the formation of lactic acid and prevents acidosis.”
ANS:
B
The brain cannot synthesize or store significant amounts of glucose; thus a continuous supply from the body’s circulation
is needed to meet the fuel demands of the central nervous system.
REF:
Page 134 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
a.
b.
c.
d.
3.
The nurse associates which assessment finding in the diabetic patient with decreasing renal function?
Ketone bodies in the urine during acidosis
Glucose in the urine during hyperglycemia
Protein in the urine during a random urinalysis
White blood cells in the urine during a random urinalysis
ANS:
C
Urine should not contain protein. Proteinuria in a diabetic heralds the beginning of renal insufficiency or diabetic
nephropathy with subsequent progression to end stage renal disease. Chronic elevated blood glucose levels can cause
renal hypertension and excess kidney perfusion with leakage from the renal vasculature. This leaking allows protein to be
filtered into the urine.
REF:
Page 138 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
4.
What is the nurse’s best response about developing diabetes to the patient whose father has type 1
diabetes mellitus?
a.
“You have a greater susceptibility for development of the disease because of your family history.”
b.
“Your risk is the same as the general population, because there is no genetic risk for development of type 1
diabetes.”
c.
“Type 1 diabetes is inherited in an autosomal dominant pattern. Therefore the risk for becoming diabetic is 50%.”
d.
“Because you are a woman and your father is the parent with diabetes, your risk is not increased for eventual
development of the disease. However, your brothers will become diabetic.”
ANS:
A
Even though type 1 diabetes does not follow a specific genetic pattern of inheritance, those with one parent with type 1
diabetes are at an increased risk for development of the disease.
REF:
Page 142 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
a.
b.
c.
d.
5.
The nurse recognizes which patient as having the greatest risk for undiagnosed diabetes mellitus?
Young white man
Middle-aged African-American man
Young African-American woman
Middle-aged Native American woman
ANS:
D
The highest incidence of diabetes in the United States occurs in Native Americans. With age, the incidence of diabetes
increases in all races and ethnic groups.
REF:
Page 137 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
6.
A diabetic patient is brought into the emergency department unresponsive. The arterial pH is 7.28.
Besides the blood pH, which clinical manifestation is seen in uncontrolled diabetes mellitus and ketoacidosis?
a.
Decreased hunger sensation
b.
Report of no urine output
c.
Increased respiratory rate
d.
Decreased thirst
ANS:
C
Ketoacidosis decreases the pH of the blood, stimulating the respiratory control area of the brain to buffer the effects of the
increasing acidosis. The rate and depth of respirations are increased (Kussmaul's respirations) to excrete more acids by
exhalation. Usually polydipsia (increased thirst), polyphagia (increased hunger), and polyuria (increased urine output) are
seen with hyperglycemia and ketoacidosis.
REF:
OBJ:
Page 135 |Page 137
NCLEX® Client Needs Category: Physiological Integrity
MULTIPLE RESPONSE
1.
Which of the following would be included in the assessment of a patient with diabetes mellitus who is
experiencing a hypoglycemic reaction? (Select all that apply.)
a.
Tremors
b.
Nervousness
c.
Extreme thirst
d.
Flushed skin
e.
Profuse perspiration
f.
Constricted pupils
ANS:
A, B, E
When hypoglycemia occurs, blood glucose levels fall, resulting in sympathetic nervous system responses such as
tremors, nervousness, and profuse perspiration. Dilated pupils would also occur, not constricted pupils. Extreme thirst,
flushed skin, and constricted pupils are consistent with hyperglycemia.
REF:
Page 135 OBJ:
NCLEX® Client Needs Category: Physiological Integrity
Chapter 48: Diabetes Mellitus
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
a.
b.
c.
d.
1.
Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is correct?
Insulin is not used to control blood glucose in patients with type 2 diabetes.
Complications of type 2 diabetes are less serious than those of type 1 diabetes.
Changes in diet and exercise may control blood glucose levels in type 2 diabetes.
Type 2 diabetes is usually diagnosed when the patient is admitted with a hyperglycemic coma.
ANS:
C
For some patients with type 2 diabetes, changes in lifestyle are sufficient to achieve blood glucose control. Insulin is
frequently used for type 2 diabetes, complications are equally severe as for type 1 diabetes, and type 2 diabetes is usually
diagnosed with routine laboratory testing or after a patient develops complications such as frequent yeast infections.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
1134
Nursing Process: Implementation
MSC:
NCLEX: Physiological Integrity
2.
A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L).
The nurse will plan to teach the patient about
a.
self-monitoring of blood glucose.
b.
using low doses of regular insulin.
c.
lifestyle changes to lower blood glucose.
d.
effects of oral hypoglycemic medications.
ANS:
C
The patient’s impaired fasting glucose indicates prediabetes, and the patient should be counseled about lifestyle changes
to prevent the development of type 2 diabetes. The patient with prediabetes does not require insulin or oral hypoglycemics
for glucose control and does not need to self-monitor blood glucose.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1133
NCLEX: Physiological Integrity
3.
A 28-yr-old male patient with type 1 diabetes reports how he manages his exercise and glucose control.
Which behavior indicates that the nurse should implement additional teaching?
a.
The patient always carries hard candies when engaging in exercise.
b.
The patient goes for a vigorous walk when his glucose is 200 mg/dL.
c.
The patient has a peanut butter sandwich before going for a bicycle ride.
d.
The patient increases daily exercise when ketones are present in the urine.
ANS:
D
When the patient is ketotic, exercise may result in an increase in blood glucose level. Patients with type 1 diabetes should
be taught to avoid exercise when ketosis is present. The other statements are correct.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1134
NCLEX: Physiological Integrity
4.
The nurse is assessing a 22-yr-old patient experiencing the onset of symptoms of type 1 diabetes. To
which question would the nurse anticipate a positive response?
a.
“Are you anorexic?”
c.
“Have you lost weight lately?”
b.
“Is your urine dark colored?”
d.
“Do you crave sugary drinks?”
ANS:
C
Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for
energy. The patient is thirsty but does not necessarily crave sugar-containing fluids. Increased appetite is a classic
symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1121
NCLEX: Physiological Integrity
5.
A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now.
Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient?
a.
Fasting blood glucose
c.
Glycosylated hemoglobin
b.
Oral glucose tolerance
d.
Urine dipstick for glucose
ANS:
C
The glycosylated hemoglobin (A1C) test shows the overall control of glucose over 90 to 120 days. A fasting blood level
indicates only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and
does not reflect the glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes but is not
used for monitoring glucose control after diabetes has been diagnosed.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1124
NCLEX: Physiological Integrity
6.
The nurse is assessing a 55-yr-old female patient with type 2 diabetes who has a body mass index (BMI)
of 31 kg/m2.Which goal in the plan of care is most important for this patient?
a.
The patient will reach a glycosylated hemoglobin level of less than 7%.
b.
The patient will follow a diet and exercise plan that results in weight loss.
c.
The patient will choose a diet that distributes calories throughout the day.
d.
The patient will state the reasons for eliminating simple sugars in the diet.
ANS:
A
The complications of diabetes are related to elevated blood glucose and the most important patient outcome is the
reduction of glucose to near-normal levels. A BMI of 30?9?kg/m2 or above is considered obese, so the other outcomes are
appropriate but are not as high in priority.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1124
Nursing Process: Planning
7.
A patient who has type 1 diabetes plans to swim laps for an hour daily at 1:00 PM. The clinic nurse will
plan to teach the patient to
a.
check glucose level before, during, and after swimming.
b.
delay eating the noon meal until after the swimming class.
c.
increase the morning dose of neutral protamine Hagedorn (NPH) insulin.
d.
time the morning insulin injection so that the peak occurs while swimming.
ANS:
A
The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the
need for changes in diet and insulin administration. Because exercise tends to decrease blood glucose, patients are
advised to eat before exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to
hypoglycemia, especially with the increased exercise.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1132
NCLEX: Physiological Integrity
8.
The nurse determines a need for additional instruction when the patient with newly diagnosed type 1
diabetes says which of the following?
a.
“I will need a bedtime snack because I take an evening dose of NPH insulin.”
b.
“I can choose any foods, as long as I use enough insulin to cover the calories.”
c.
“I can have an occasional beverage with alcohol if I include it in my meal plan.”
d.
“I will eat something at meal times to prevent hypoglycemia, even if I am not hungry.”
ANS:
B
Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin
therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and
alcohol. The other patient statements are correct and indicate good understanding of the diet instruction.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
1132
NCLEX: Physiological Integrity
9.
To assist an older patient with diabetes to engage in moderate daily exercise, which action is most
important for the nurse to take?
a.
Determine what types of activities the patient enjoys.
b.
Remind the patient that exercise improves self-esteem.
c.
Teach the patient about the effects of exercise on glucose level.
d.
Give the patient a list of activities that are moderate in intensity.
ANS:
A
Because consistency with exercise is important, assessment for the types of exercise that the patient finds enjoyable is
the most important action by the nurse in ensuring adherence to an exercise program. The other actions may be helpful
but are not the most important in improving compliance.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
a.
b.
c.
d.
10.
Which statement by the patient indicates a need for additional instruction in administering insulin?
“I need to rotate injection sites among my arms, legs, and abdomen each day.”
“I can buy the 0.5-mL syringes because the line markings will be easier to see.”
“I do not need to aspirate the plunger to check for blood before injecting insulin.”
“I should draw up the regular insulin first, after injecting air into the NPH bottle.”
TOP:
REF:
1134
Nursing Process: Implementation
ANS:
A
Rotating sites is no longer recommended because there is more consistent insulin absorption when the same site is used
consistently. The other patient statements are accurate and indicate that no additional instruction is needed.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
1128
NCLEX: Health Promotion and Maintenance
11.
Which patient action indicates good understanding of the nurse’s teaching about administration of
aspart (NovoLog) insulin?
a.
The patient avoids injecting the insulin into the upper abdominal area.
b.
The patient cleans the skin with soap and water before insulin administration.
c.
The patient stores the insulin in the freezer after administering the prescribed dose.
d.
The patient pushes the plunger down while removing the syringe from the injection site.
ANS:
B
Cleaning the skin with soap and water is acceptable. Insulin should not be frozen. The patient should leave the syringe in
place for about 5 seconds after injection to be sure that all the insulin has been injected. The upper abdominal area is one
of the preferred areas for insulin injection.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
1128
NCLEX: Physiological Integrity
12.
A patient receives aspart (NovoLog) insulin at 8:00 AM. At which time would the nurse anticipate the
highest risk for hypoglycemia?
a.
10:00 AM c.
2:00 PM
b.
12:00 AM d.
4:0 PM
ANS:
A
The rapid-acting insulins peak in 1 to 3 hours. The patient is not at a high risk for hypoglycemia at the other listed times,
although hypoglycemia may occur.
DIF:
TOP:
Cognitive Level: Understand (comprehension) REF:
1132
Nursing Process: Evaluation
MSC:
NCLEX: Physiological Integrity
13.
pump?
a.
b.
c.
d.
Which patient action indicates a good understanding of the nurse’s teaching about the use of an insulin
The patient programs the pump for an insulin bolus after eating.
The patient changes the location of the insertion site every week.
The patient takes the pump off at bedtime and starts it again each morning.
The patient plans a diet with more calories than usual when using the pump.
ANS:
A
In addition to the basal rate of insulin infusion, the patient will adjust the pump to administer a bolus after each meal, with
the dosage depending on the oral intake. The insertion site should be changed every 2 or 3 days. There is more flexibility
in diet and exercise when an insulin pump is used, but it does not provide for consuming a higher calorie diet. The pump
will deliver a basal insulin rate 24 hours a day.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
1129
NCLEX: Health Promotion and Maintenance
14.
A patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse
discuss using for mealtime coverage?
a.
Lispro (Humalog) c.
Detemir (Levemir)
b.
Glargine (Lantus) d.
NPH (Humulin N)
ANS:
A
Rapid- or short-acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine,
or detemir will be used as the basal insulin.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1125
NCLEX: Physiological Integrity
15.
Which information will the nurse include when teaching a patient who has type 2 diabetes about
glyburide ?
a.
Glyburide decreases glucagon secretion from the pancreas.
b.
Glyburide stimulates insulin production and release from the pancreas.
c.
Glyburide should be taken even if the morning blood glucose level is low.
d.
Glyburide should not be used for 48 hours after receiving IV contrast media.
ANS:
B
The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient
should contact the health care provider before taking glyburide because hypoglycemia can occur with this class of
medication. Metformin should be held for 48 hours after administration of IV contrast media, but this is not necessary for
glyburide. Glucagon secretion is not affected by glyburide.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1130
NCLEX: Physiological Integrity
16.
The nurse has been teaching a patient with type 2 diabetes about managing blood glucose levels and
taking glipizide (Glucotrol). Which patient statement indicates a need for additional teaching?
a.
“If I overeat at a meal, I will still take the usual dose of medication.”
b.
“Other medications besides the Glucotrol may affect my blood sugar.”
c.
“When I am ill, I may have to take insulin to control my blood sugar.”
d.
“My diabetes won’t cause complications because I don’t need insulin.”
ANS:
D
The patient should understand that type 2 diabetes places the patient at risk for many complications and that good
glucose control is as important when taking oral agents as when using insulin. The other statements are accurate and
indicate good understanding of the use of glipizide.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
1130
NCLEX: Physiological Integrity
17.
When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash
from an unknown cause, the health care provider prescribes prednisone. The nurse will anticipate that the patient may
a.
need a diet higher in calories while receiving prednisone.
b.
develop acute hypoglycemia while taking the prednisone.
c.
require administration of insulin while taking prednisone.
d.
have rashes caused by metformin-prednisone interactions.
ANS:
C
Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose.
Hypoglycemia is not a side effect of prednisone. Rashes are not an adverse effect caused by taking metformin and
prednisone simultaneously. The patient may have an increased appetite when taking prednisone but will not need a diet
that is higher in calories.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1124
NCLEX: Physiological Integrity
18.
A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been
away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia,
the best action by the nurse is to
a.
save the lunch tray for the patient’s later return to the unit.
b.
ask that diagnostic testing area staff to start a 5% dextrose IV.
c.
send a glass of milk or orange juice to the patient in the diagnostic testing area.
d.
request that if testing is further delayed, the patient be returned to the unit to eat.
ANS:
D
Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at
the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia. Administration of an IV solution is
unnecessarily invasive for the patient. A glass of milk or juice will keep the patient from becoming hypoglycemic but will
cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items.
DIF:
TOP:
Cognitive Level: Analyze (analysis)
Nursing Process: Implementation
19.
glucose
a.
b.
c.
d.
MSC:
REF:
1127
NCLEX: Physiological Integrity
The nurse identifies a need for additional teaching when the patient who is self-monitoring blood
washes the puncture site using warm water and soap.
chooses a puncture site in the center of the finger pad.
hangs the arm down for a minute before puncturing the site.
says the result of 120 mg indicates good blood sugar control.
ANS:
B
The patient is taught to choose a puncture site at the side of the finger pad because there are fewer nerve endings along
the side of the finger pad. The other patient actions indicate that teaching has been effective.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
1136
NCLEX: Health Promotion and Maintenance
20.
The nurse is preparing to teach a 43-yr-old man who is newly diagnosed with type 2 diabetes about
home management of the disease. Which action should the nurse take first?
a.
Ask the patient’s family to participate in the diabetes education program.
b.
Assess the patient’s perception of what it means to have diabetes mellitus.
c.
Demonstrate how to check glucose using capillary blood glucose monitoring.
d.
Discuss the need for the patient to actively participate in diabetes management.
ANS:
B
Before planning teaching, the nurse should assess the patient’s interest in and ability to self-manage the diabetes. After
assessing the patient, the other nursing actions may be appropriate, but planning needs to be individualized to each
patient.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
TOP:
NCLEX: Health Promotion and Maintenance
REF:
1139
Nursing Process: Planning
21.
An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed
with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to
a.
give 50% dextrose.
c.
initiate O2 by nasal cannula.
b.
insert an IV catheter.
d.
administer glargine (Lantus) insulin.
ANS:
B
HHS is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a longacting insulin. There is no indication that the patient requires O2. Dextrose solutions will increase the patient’s blood
glucose and would be contraindicated.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1145
NCLEX: Physiological Integrity
22.
A 26-yr-old female with type 1 diabetes develops a sore throat and runny nose after caring for her sick
toddler. The patient calls the clinic for advice about her symptoms and a blood glucose level of 210 mg/dL despite taking
her usual glargine (Lantus) and lispro (Humalog) insulin. The nurse advises the patient to
a.
use only the lispro insulin until the symptoms are resolved.
b.
limit intake of calories until the glucose is less than 120 mg/dL.
c.
monitor blood glucose every 4 hours and notify the clinic if it continues to rise.
d.
decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%.
ANS:
C
Infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently, treat
elevations appropriately with lispro insulin, and call the health care provider if glucose levels continue to be elevated.
Discontinuing the glargine will contribute to hyperglycemia and may lead to diabetic ketoacidosis (DKA). Decreasing
carbohydrate or caloric intake is not appropriate because the patient will need more calories when ill. Glycosylated
hemoglobin testing is not used to evaluate short-term alterations in blood glucose.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1139
NCLEX: Physiological Integrity
23.
The health care provider suspects the Somogyi effect in a 50-yr-old patient whose 6:00 AM blood
glucose is 230 mg/dL. Which action will the nurse teach the patient to take?
a.
Avoid snacking at bedtime.
b.
Increase the rapid-acting insulin dose.
c.
Check the blood glucose during the night
d.
Administer a larger dose of long-acting insulin.
ANS:
C
If the Somogyi effect is causing the patient’s increased morning glucose level, the patient will experience hypoglycemia
between 2:00 and 4:00 AM. The dose of insulin will be reduced, rather than increased. A bedtime snack is used to prevent
hypoglycemic episodes during the night.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1129
NCLEX: Physiological Integrity
24.
Which action should the nurse take after a patient treated with intramuscular glucagon for
hypoglycemia regains consciousness?
a.
Assess the patient for symptoms of hyperglycemia.
b.
Give the patient a snack of peanut butter and crackers.
c.
Have the patient drink a glass of orange juice or nonfat milk.
d.
Administer a continuous infusion of 5% dextrose for 24 hours.
ANS:
B
Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates
plus protein and fat will help prevent hypoglycemia. Orange juice and nonfat milk will elevate blood glucose rapidly, but
the cheese and crackers will stabilize blood glucose. Administration of IV glucose might be used in patients who were
unable to take in nutrition orally. The patient should be assessed for symptoms of hypoglycemia after glucagon
administration.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1129
NCLEX: Physiological Integrity
25.
Which question during the assessment of a patient who has diabetes will help the nurse identify
autonomic neuropathy?
a.
“Do you feel bloated after eating?”
b.
“Have you seen any skin changes?”
c.
“Do you need to increase your insulin dosage when you are stressed?”
d.
“Have you noticed any painful new ulcerations or sores on your feet?”
ANS:
A
Autonomic neuropathy can cause delayed gastric emptying, which results in a bloated feeling for the patient. The other
questions are also appropriate to ask but would not help in identifying autonomic neuropathy.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1150
NCLEX: Physiological Integrity
26.
Which information will the nurse include in teaching a female patient who has peripheral arterial
disease, type 2 diabetes, and sensory neuropathy of the feet and legs?
a.
Choose flat-soled leather shoes.
b.
Set heating pads on a low temperature.
c.
Use callus remover for corns or calluses.
d.
Soak feet in warm water for an hour each day.
ANS:
A
The patient is taught to avoid high heels and that leather shoes are preferred. The feet should be washed, but not soaked,
in warm water daily. Heating pad use should be avoided. Commercial callus and corn removers should be avoided. The
patient should see a specialist to treat these problems.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1151
NCLEX: Physiological Integrity
27.
Which finding indicates a need to contact the health care provider before the nurse administers
metformin (Glucophage)?
a.
The patient’s blood glucose level is 174 mg/dL.
b.
The patient is scheduled for a chest x-ray in an hour.
c.
The patient has gained 2 lb (0.9 kg) in the past 24 hours.
d.
The patient’s blood urea nitrogen (BUN) level is 52 mg/dL.
ANS:
D
The BUN indicates possible renal failure, and metformin should not be used in patients with renal failure. The other
findings are not contraindications to the use of metformin.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1130
NCLEX: Physiological Integrity
28.
A patient who has diabetes and reported burning foot pain at night receives a new prescription. Which
information should the nurse teach the patient about amitriptyline ?
a.
Amitriptyline decreases the depression caused by your foot pain.
b.
Amitriptyline helps prevent transmission of pain impulses to the brain.
c.
Amitriptyline corrects some of the blood vessel changes that cause pain.
d.
Amitriptyline improves sleep and makes you less aware of nighttime pain.
ANS:
B
Tricyclic antidepressants (TCAs) decrease the transmission of pain impulses to the spinal cord and brain. TCAs also
improve sleep quality and are used for depression, but that is not the major purpose for their use in diabetic neuropathy.
The blood vessel changes that contribute to neuropathy are not affected by TCAs.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1150
NCLEX: Physiological Integrity
29.
A patient who has type 2 diabetes is being prepared for an elective coronary angiogram. Which
information would the nurse anticipate might lead to rescheduling the test?
a.
The patient’s most recent A1C was 6.5%.
b.
The patient’s blood glucose is 128 mg/dL.
c.
The patient took the prescribed metformin today.
d.
The patient took the prescribed captopril this morning.
ANS:
C
To avoid lactic acidosis, metformin should be discontinued a day or 2 before the coronary angiogram and should not be
used for 48 hours after IV contrast media are administered. The other patient data will also be reported but do not indicate
any need to reschedule the procedure.
DIF:
Cognitive Level: Apply (application)
REF:
1130
TOP:
Nursing Process: Assessment
MSC:
NCLEX: Physiological Integrity
30.
Which action by a patient indicates that the home health nurse’s teaching about glargine and regular
insulin has been successful?
a.
The patient administers the glargine 30 minutes before each meal.
b.
The patient’s family prefills the syringes with the mix of insulins weekly.
c.
The patient discards the open vials of glargine and regular insulin after 4 weeks.
d.
The patient draws up the regular insulin and then the glargine in the same syringe.
ANS:
C
Insulin can be stored at room temperature for 4 weeks. Glargine should not be mixed with other insulins or prefilled and
stored. Short-acting regular insulin is administered before meals, and glargine is given once daily.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
1127
NCLEX: Physiological Integrity
31.
A patient with diabetes rides a bicycle to and from work every day. Which site should the nurse teach
the patient to use to administer the morning insulin?
a.
thigh.
c.
abdomen.
b.
buttock. d.
upper arm.
ANS:
C
Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate
of absorption. The thigh, buttock, and arm are all exercised by riding a bicycle.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Implementation
MSC:
REF:
1128
NCLEX: Physiological Integrity
32.
The nurse is interviewing a new patient with diabetes who takes rosiglitazone (Avandia). Which
information would the nurse anticipate resulting in the health care provider discontinuing the medication?
a.
The patient’s blood pressure is 154/92.
b.
The patient’s blood glucose is 86 mg/dL.
c.
The patient reports a history of emphysema.
d.
The patient has chest pressure when walking.
ANS:
D
Rosiglitazone can cause myocardial ischemia. The nurse should immediately notify the health care provider and expect
orders to discontinue the medication. A blood glucose level of 86 mg/dL indicates a positive effect from the medication.
Hypertension and a history of emphysema do not contraindicate this medication.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1130
NCLEX: Physiological Integrity
33.
The nurse is taking a health history from a 29-yr-old pregnant patient at the first prenatal visit. The
patient reports that she has no personal history of diabetes, but her mother has diabetes. Which action will the nurse plan
to take?
a.
Teach the patient about administering regular insulin.
b.
Schedule the patient for a fasting blood glucose level.
c.
Teach about an increased risk for fetal problems with gestational diabetes.
d.
Schedule an oral glucose tolerance test for the twenty-fourth week of pregnancy.
ANS:
B
Patients at high risk for gestational diabetes should be screened for diabetes on the initial prenatal visit. An oral glucose
tolerance test may also be used to check for diabetes, but it would be done before the twenty-fourth week. Teaching plans
would depend on the outcome of a fasting blood glucose test and other tests.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1138
Nursing Process: Planning
34.
A 27-yr-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL
and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse take first?
a.
Place the patient on a cardiac monitor.
b.
Administer IV potassium supplements.
c.
Ask the patient about home insulin doses.
d.
Start an insulin infusion at 0.1 units/kg/hr.
ANS:
A
Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which
would be detected with electrocardiogram (ECG) monitoring. Because potassium must be infused over at least 1 hour, the
nurse should initiate cardiac monitoring before infusion of potassium. Insulin should not be administered without cardiac
monitoring because insulin infusion will further decrease potassium levels. Discussion of home insulin and possible
causes can wait until the patient is stabilized.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1146
Nursing Process: Implementation
35.
A patient with diabetic ketoacidosis is brought to the emergency department. Which prescribed action
should the nurse implement first?
a.
Infuse 1 L of normal saline per hour.
b.
Give sodium bicarbonate 50 mEq IV push.
c.
Administer regular insulin 10 U by IV push.
d.
Start a regular insulin infusion at 0.1 units/kg/hr.
ANS:
A
The most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis (DKA), and the priority is to
infuse IV fluids. The other actions can be done after the infusion of normal saline is initiated.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1144
Nursing Process: Implementation
36.
A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been
weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the
nurse take first?
a.
Infuse dextrose 50% by slow IV push.
b.
Administer 1 mg glucagon subcutaneously.
c.
Obtain a glucose reading using a finger stick.
d.
Have the patient drink 4 ounces of orange juice.
ANS:
C
The patient’s clinical manifestations are consistent with hypoglycemia, and the initial action should be to check the
patient’s glucose with a finger stick or order a stat blood glucose. If the glucose is low, the patient should ingest a rapidacting carbohydrate, such as orange juice. Glucagon or dextrose 50% might be given if the patient’s symptoms become
worse or if the patient is unconscious.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1135
Nursing Process: Implementation
37.
A female patient is scheduled for an oral glucose tolerance test. Which information from the patient’s
health history is important for the nurse to communicate to the health care provider regarding this test?
a.
The patient uses oral contraceptives.
b.
The patient runs several days a week.
c.
The patient has been pregnant three times.
d.
The patient has a family history of diabetes.
ANS:
A
Oral contraceptive use may falsely elevate oral glucose tolerance test (OGTT) values. Exercise and a family history of
diabetes both can affect blood glucose but will not lead to misleading information from the OGTT. History of previous
pregnancies may provide informational about gestational glucose tolerance but will not lead to misleading information
from the OGTT.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1124
NCLEX: Physiological Integrity
38.
Which laboratory value reported to the nurse by the unlicensed assistive personnel (UAP) indicates an
urgent need for the nurse’s assessment of the patient?
a.
Bedtime glucose of 140 mg/dL
b.
Noon blood glucose of 52 mg/dL
c.
Fasting blood glucose of 130 mg/dL
d.
2-hr postprandial glucose of 220 mg/dL
ANS:
B
The nurse should assess the patient with a blood glucose level of 52 mg/dL for symptoms of hypoglycemia and give the
patient a carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range or not
immediately dangerous for a patient with diabetes.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1152
NCLEX: Physiological Integrity
39.
When a patient with type 2 diabetes is admitted for a cholecystectomy, which nursing action can the
nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?
a.
Communicate the blood glucose level and insulin dose to the circulating nurse in surgery.
b.
Discuss the reason for the use of insulin therapy during the immediate postoperative period.
c.
Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery.
d.
Plan strategies to minimize the risk for hypoglycemia or hyperglycemia during the postoperative period.
ANS:
C
LPN/LVN education and scope of practice includes administration of insulin. Communication about patient status with
other departments, planning, and patient teaching are skills that require RN education and scope of practice.
DIF:
OBJ:
MSC:
Cognitive Level: Apply (application)
Special Questions: Delegation
TOP:
NCLEX: Safe and Effective Care Environment
REF:
1152
Nursing Process: Planning
40.
An active 32-yr-old male who has type 1 diabetes is being seen in the endocrine clinic. Which finding
indicates a need for the nurse to discuss a possible a change in therapy with the health care provider?
a.
Hemoglobin A1C level of 6.2%
b.
Blood pressure of 140/88 mmHg
c.
Heart rate at rest of 58 beats/minute
d.
High density lipoprotein (HDL) level of 65 mg/dL
ANS:
B
To decrease the incidence of macrovascular and microvascular problems in patients with diabetes, the goal blood
pressure is usually 130/80 mm Hg. An A1C less than 6.5%, a low resting heart rate (consistent with regular aerobic
exercise in a young adult), and an HDL level of 65 mg/dL all indicate that the patient’s diabetes and risk factors for vascular
disease are well controlled.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1148
NCLEX: Physiological Integrity
41.
A 30-yr-old patient has a new diagnosis of type 2 diabetes. The nurse will discuss the need to schedule
a dilated eye examination
a.
every 2 years.
c.
when the patient is 39 years old.
b.
as soon as possible.
d.
within the first year after diagnosis.
ANS:
B
Because many patients have some diabetic retinopathy when they are first diagnosed with type 2 diabetes, a dilated eye
examination is recommended at the time of diagnosis and annually thereafter. Patients with type 1 diabetes should have
dilated eye examinations starting 5 years after they are diagnosed and then annually.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1149
NCLEX: Physiological Integrity
42.
After the nurse has finished teaching a patient who has a new prescription for exenatide (Byetta), which
patient statement indicates that the teaching has been effective?
a.
“I may feel hungrier than usual when I take this medicine.”
b.
“I will not need to worry about hypoglycemia with the Byetta.”
c.
“I should take my daily aspirin at least an hour before the Byetta.”
d.
“I will take the pill at the same time I eat breakfast in the morning.”
ANS:
C
Because exenatide slows gastric emptying, oral medications should be taken at least 1 hour before the exenatide to avoid
slowing absorption. Exenatide is injected and increases feelings of satiety. Hypoglycemia can occur with this medication.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Evaluation
MSC:
REF:
1132
NCLEX: Physiological Integrity
43.
A few weeks after an 82-yr-old patient with a new diagnosis of type 2 diabetes has been placed on
metformin (Glucophage) therapy and taught about appropriate diet and exercise, the home health nurse makes a visit.
Which finding should the nurse promptly discuss with the health care provider?
a.
Hemoglobin A1C level is 7.9%.
b.
Last eye examination was 18 months ago.
c.
Glomerular filtration rate is decreased.
d.
Patient has questions about the prescribed diet.
ANS:
C
The decrease in renal function may indicate a need to adjust the dose of metformin or change to a different medication. In
older patients, the goal for A1C may be higher in order to avoid complications associated with hypoglycemia. The nurse
will plan on scheduling the patient for an eye examination and addressing the questions about diet, but the area for
prompt intervention is the patient’s decreased renal function.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Assessment
MSC:
REF:
1130
NCLEX: Physiological Integrity
44.
The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL.
Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next?
a.
Give the patient 4 to 6 oz more orange juice.
b.
Administer the PRN glucagon (Glucagon) 1 mg IM.
c.
Have the patient eat some peanut butter with crackers.
d.
Notify the health care provider about the hypoglycemia.
ANS:
A
The “rule of 15” indicates that administration of quickly acting carbohydrates should be done two or three times for a
conscious patient whose glucose remains less than 70 mg/dL before notifying the health care provider. More complex
carbohydrates and fats may be used after the glucose has stabilized. Glucagon should be used if the patient’s level of
consciousness decreases so that oral carbohydrates can no longer be given.
DIF:
OBJ:
MSC:
Cognitive Level: Analyze (analysis)
Special Questions: Prioritization
NCLEX: Physiological Integrity
TOP:
REF:
1146
Nursing Process: Implementation
45.
Which nursing action can the nurse delegate to experienced unlicensed assistive personnel (UAP) who
are working in the diabetic clinic?
a.
Measure the ankle-brachial index.
b.
Check for changes in skin pigmentation.
c.
Assess for unilateral or bilateral foot drop.
d.
Ask the patient about symptoms of depression.
ANS:
A
Checking systolic pressure at the ankle and brachial areas and calculating the ankle-brachial index is a procedure that can
be done by UAP who have been trained in the procedure. The other assessments require more education and critical
thinking and should be done by the registered nurse (RN).
DIF:
OBJ:
MSC:
a.
b.
c.
d.
pain
Cognitive Level: Apply (application)
Special Questions: Delegation
TOP:
NCLEX: Safe and Effective Care Environment
REF:
1152
Nursing Process: Planning
46.
After change-of-shift report, which patient will the nurse assess first?
A 19-yr-old patient with type 1 diabetes who was admitted with possible dawn phenomenon
A 35-yr-old patient with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL
A 60-yr-old patient with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa
A 68-yr-old patient with type 2 diabetes who has severe peripheral neuropathy and complains of burning foot
ANS:
C
The patient’s diagnosis of HHS and signs of dehydration indicate that the nurse should rapidly assess for signs of shock
and determine whether increased fluid infusion is needed. The other patients also need assessment and intervention but
do not have life-threatening complications.
DIF:
Cognitive Level: Analyze (analysis)
REF:
1146
OBJ:
TOP:
Special Questions: Multiple Patients | Special Questions: Prioritization
Nursing Process: Planning MSC:
NCLEX: Safe and Effective Care Environment
a.
b.
c.
d.
47.
After change-of-shift report, which patient should the nurse assess first?
A 19-yr-old patient with type 1 diabetes who has a hemoglobin A1C of 12%
A 23-yr-old patient with type 1 diabetes who has a blood glucose of 40 mg/dL
A 40-yr-old patient who is pregnant and whose oral glucose tolerance test is 202 mg/dL
A 50-yr-old patient who uses exenatide (Byetta) and is complaining of acute abdominal pain
ANS:
B
Because the brain requires glucose to function, untreated hypoglycemia can cause unconsciousness, seizures, and death.
The nurse will rapidly assess and treat the patient with low blood glucose. The other patients also have symptoms that
require assessments or interventions, but they are not at immediate risk for life-threatening complications.
DIF:
OBJ:
TOP:
Cognitive Level: Analyze (analysis)
REF:
1146
Special Questions: Prioritization | Special Questions: Multiple Patients
Nursing Process: Planning MSC:
NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
1.
To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic
clinic schedule at least annually (select all that apply)?
a.
Chest x-ray
b.
Blood pressure
c.
Serum creatinine
d.
Urine for microalbuminuria
e.
Complete blood count (CBC)
f.
Monofilament testing of the foot
ANS:
B, C, D, F
Blood pressure, serum creatinine, urine testing for microalbuminuria, and monofilament testing of the foot are
recommended at least annually to screen for possible microvascular and macrovascular complications of diabetes. Chest
x-ray and CBC might be ordered if the patient with diabetes presents with symptoms of respiratory or infectious problems
but are not routinely included in screening.
DIF:
TOP:
Cognitive Level: Apply (application)
Nursing Process: Planning MSC:
REF:
1148
NCLEX: Physiological Integrity
Chapter 11: Pregnancy at Risk: Preexisting Conditions
a.
b.
c.
d.
31.
Which factor is known to increase the risk of gestational diabetes mellitus?
Underweight before pregnancy
Maternal age younger than 25 years
Previous birth of large infant
Previous diagnosis of type 2 diabetes mellitus
ANS:
C
Previous birth of a large infant suggests gestational diabetes mellitus. Obesity (BMI of 30 or greater) creates a higher risk
for gestational diabetes. A woman younger than 25 years generally is not at risk for gestational diabetes mellitus. The
person with type 2 diabetes mellitus already has diabetes and will continue to have it after pregnancy. Insulin may be
required during pregnancy because oral hypoglycemia drugs are contraindicated during pregnancy.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
279
Nursing Process: Assessment
MSC:
Client Needs: Health Promotion and Maintenance
a.
b.
c.
d.
32.
Glucose metabolism is profoundly affected during pregnancy because:
Pancreatic function in the islets of Langerhans is affected by pregnancy.
The pregnant woman uses glucose at a more rapid rate than the nonpregnant woman.
The pregnant woman increases her dietary intake significantly.
Placental hormones are antagonistic to insulin, thus resulting in insulin resistance.
ANS:
D
Placental hormones, estrogen, progesterone, and human placental lactogen (HPL) create insulin resistance. Insulin also is
broken down more quickly by the enzyme placental insulinase. Pancreatic functioning is not affected by pregnancy. The
glucose requirements differ because of the growing fetus. The pregnant woman should increase her intake by 200 calories
a day.
PTS:
OBJ:
1
DIF:
Cognitive Level: Comprehension
REF:
279
Nursing Process: Assessment
MSC:
Client Needs: Physiologic Integrity