Linton: Medical-Surgical Nursing, 7th Edition
Answer Keys: In-Text Review Questions—NCLEX
Chapter 01: Aspects of Medical-Surgical Nursing
1. ANS: 2
The state board of nursing defines the scope of practice for nurses.
2. ANS: 1, 3, 4
Leadership does not require a specific degree in nursing or other field. Various leadership styles
may be used depending on the situation. However, an autocratic approach is not always the most
effective.
3. ANS: 1
Nonmaleficence means to do no harm. By confirming the right drug and patient identity, the
nurse reduces the risk of harm posed by a drug error.
4. ANS: 4
A tort is a civil wrong against a person which can include an invasion of privacy. Posting the
patient’s photo on social media violates the patient’s right to privacy in the health care setting.
5. ANS: 1, 2, 3, 5
Only option 4 is incorrect. The nurse is not required to directly supervise tasks assigned to others
although he or she may observe at some point to confirm that the individual performs correctly.
Chapter 02: Medical-Surgical Practice Settings
1. ANS: 1, 3, 4
Medicare reimburses nursing care in the home as long as the care given is skilled and of a type
that only a nurse trained in that kind of care could be expected to do. Sterile technique to clean
and dress a wound, performing a venipuncture, and teaching a client how to inject insulin are all
skilled nursing care. Taking a frail couple for a walk for exercise and removing outdated food
from a refrigerator and pantry are not considered skilled interventions.
2. ANS: 1, 3, 4, 5
Community health nursing focuses on improving the health status of communities or groups of
people through public education, screening for early detection of disease, and providing services
for people who need care outside the acute care setting. The activities include conducting health
education in a senior citizen center, arranging blood pressure screening at a shopping center,
seeing clients in a clinic to monitor chronic illness problems, and giving flu vaccines at a public
location. Monitoring the recovery of a postoperative client at home is a role for the home health
care nurse.
3. ANS: 1
Community-based nursing is based on the delivery of health care services that meet the needs of
citizens at certain levels of wellness and illness based on specific community needs. Meeting
with residents of low-income housing to identify their health needs is an example of
community-based nursing. Phoning a client at home after discharge form the hospital is an
example of hospital-based nursing. Asking nurses to identify health services lacking in their
communities is not client but nursing directed. Developing a hospital-based home health service
is an example of community health nursing.
4. ANS: 2
Handicapped individuals are those who are not able to perform one or more activities of daily
living (ADL). Impaired individuals have a disturbance in functioning that could be either
physiologic or psychologic. Disabled individuals have a measurable loss of function and
generally a diminished capacity to work. Disadvantaged individuals are people who lack certain
opportunities and services such as those of the general population.
5. ANS: 2
The Americans with Disabilities Act prohibits private employers with 15 or more employees,
state and local governments, employment agencies, and labor unions from discriminating against
qualified individuals with disabilities. The Social Security Act gives additional aid to states for
both direct relief and vocational rehabilitation. The Rehabilitation Act and the Vocational Act
gave a comprehensive approach to problems experienced by the disabled, expanded available
resources for vocational training, and defined services to be included in rehabilitation programs.
6. ANS: 2, 3, 4, 5
Medicare reimbursement for home health nursing care must be necessary, skilled, reasonable,
and intermittent. Short-term care is not one of the reimbursement criteria for Medicare.
7. ANS: 4
To care for a head injury client who is having difficulty feeding herself, the best response is to be
sure that her food is accessible and give her praise for her efforts at self-feeding. Offering to feed
her and ordering a liquid diet so she does not have to use utensils does not help the client to
rehabilitate herself. Telling the client that the sooner she feeds herself, the sooner she can go
home is putting extra stress on the client and is not a therapeutic comment.
8. ANS: 2
A client who is only able to perform 25% of his usual job activities is considered disabled. A
handicapped client is one who is not able to perform one or more activities of daily living
(ADL). An incapacitated client is someone who is unable to work, move, or function in the usual
way. An impaired client has a disturbance in functioning that could be either physiologic or
psychologic.
9. ANS: 1
These efforts are a way to prevent the client from feeling depersonalized. Maintaining the
resident’s dignity is to professionally treat the resident as a person with thoughts and feelings.
This effort is not focused on preventing regression or social withdrawal.
10. ANS: 3
Dependence on activities of daily living (ADLs) is the primary reason why clients need nursing
home placement. The care delivered there is based upon promotion of independence,
maintenance of function, and maintenance of autonomy. It could be a short stay after a surgical
procedure or a temporary admission because of an illness of the family caregiver. It is not based
on one’s medical diagnosis, and the availability of family caregivers would not necessarily
eliminate a client receiving home health nursing services. Nursing home care is not
independently based upon financial resources.
Chapter 03: Medical-Surgical Patients: Individuals, Families, and Communities
1. ANS: 1
Upon an analysis of interactions, often it is discovered that a family member described as a
scapegoat or a problem member tends to divert attention from family problems. There is no
specific name for an individual who brings attention to a family member who contributes the
least, but a blocker is a family member who opposes and rejects all ideas and so probably does
the least for the family. There is no specific name for someone who tests the bonds of loyalty
within the family. A go-between may also be involved with motivating children to compete with
siblings, but this type of interaction is often considered dysfunctional because it interferes with
direct communication among family members.
2. ANS: 4
A statement made by survivors of a life-threatening crisis that “we lost everything but each other
and this has taught us what is really important in life” is an example of attaching meaning to the
experience. It is not an example of dealing directly with the cause of the problem or of providing
comfort to each other. This serious statement does not deny the severe gravity of the situation.
3. ANS: 3
External coping strategies involve the use of social support systems to solve problems. Ministers
and church members visiting and praying with the family of a critically ill client is an example of
an external family coping strategy. Internal coping requires positive family communication
patterns. Social support interventions are not examples of internal family coping strategies or
related to anticipatory grieving. It is not an example of unrealistic thinking but a rational activity.
4. ANS: 2, 3, 5
Developmental tasks for the traditional two-parent family in later life include maintaining a
satisfying living arrangement, adjusting to a reduced income, and maintaining intergenerational
ties. Communicating openly between parents and children is a developmental task needed for
families with adolescents. Reorganization of the family into a continuing unit is the launching
children and moving on stage, when mature young people are released into lives of their own.
5. ANS: 2
Emotional family roles include leader, nurturer, and protector. Performance-oriented roles
include breadwinner, homemaker, handyman or handywoman, or gardener. Developmental
family roles include predictable stages of growth and development. Maternal role often refers to
the promotion and maintenance of optimal family health to ensure cycles of optimal childbearing
and child rearing.
6. ANS: 1, 2, 3, 5
All options except 4 have been found to be typical among Euro-Americans. The emphasis on
individuality overrides the value of harmony.
7. ANS: 1
Primary prevention focuses on health maintenance, i.e., the prevention of disease or injury.
8. ANS: 4
According to Erikson, older people examine their life. If the review results in a feeling of
accomplishment and fulfillment, the person achieves ego integrity. Older persons who are
regretful and bitter about their life accomplishments experience feelings of despair.
Chapter 04: Health, Illness, Stress, and Coping
1. ANS: 2
The affective dimension involves an individual’s ability to experience and express feelings and
emotions. The cognitive dimension involves an individual’s ability to formulate thoughts,
process information, and solve problems. The behavioral dimension reflects a person’s
individuality and involves integration of the physical, cognitive, and affective dimensions. The
social dimension involves an individual’s skills in living as a member of a family and
community. All together, these dimensions form a complete or total person.
2. ANS: 1, 4
Options 1 and 4 are correct. Moderate intensity exercise for 150 minutes per week is
recommended. Adults need 7 and 9 hours of sleep each night. Older adults should sleep 7 and 8
hours nightly. Women should limit alcohol intake to one drink daily whereas men should have
no more than 2 drinks daily.
3. ANS: 1, 2, 3, 4
A person’s level of health is directly related to the ability to adjust or adapt to a variety of
internal and external stressors. A stressor can be positive or negative and necessitates an adaptive
response on the part of the individual. Stressors can originate in any or all of the dimensions of
the self. Perceptions of stress and coping mechanisms are highly individualized. Without
effective coping strategies, individuals can be caught in a vicious cycle of ineffective coping and
increased stress that will stop only at the point of total exhaustion and may result in death.
4. ANS: 4
The words fear and anxiety often are used interchangeably. Anxiety is evoked by a nonspecific
threat rather than a specific threat. The body’s physiologic reaction to fear is similar to its
response to anxiety, although fear is generally more disabling than anxiety. Anxiety does not
mean that the person has poor coping skills, nor does it interfere with effective problem solving.
As people develop, they learn to cope with anxiety. Individuals continually regulate their
behavior based on their level of perceived anxiety.
5. ANS: 4
Defense mechanisms are strategies used in an effort to reduce or diminish anxiety. Identification
is a defense mechanism used to emulate admirable qualities in another to enhance one’s
self-esteem. Denial is a defense mechanism that refuses to acknowledge a real situation.
Repression is an unconscious defense mechanism where unacceptable ideas, impulses, and
memories are kept out of consciousness.
6. ANS: 3
Identification is the emulation of admirable qualities in another to enhance one’s self-esteem.
Regression is withdrawing to an earlier level of development to benefit from the associated
comfort levels of the previous level, as when a child starts sucking her thumb when her new baby
brother comes home from the hospital. Introjection is internalizing or taking on the values and
beliefs of another person, as when a child takes on the values and beliefs of a parent. Projection
is transferring unacceptable feelings or impulses to another, as when a partner who is jealous of
her significant other accuses the partner of being jealous.
7. ANS: 1
Exacerbation is when symptoms of a chronic disease return. Full recovery is when the disease
has been cured, and remission is when symptoms will soon reappear. End of life is when the
terminal stage of the disease has begun.
8. ANS: 2
The problem that would be included in the first priority (physiologic) of Maslow’s basic human
needs hierarchy is shortness of breath. This hierarchy involves five levels, and physiologic needs
must be satisfied first before a person can progress to the next levels. Ability to breathe is a basic
physiologic human need that is essential to sustain life. Low self-esteem is a problem related to
one of the fourth priority (self-esteem and esteem of others) needs. Both unstable gait and
impaired speech are examples of problems in the second priority (safety and security) needs
related to the need for protection from harm.
9. ANS: 4
The most appropriate nursing intervention to help the client and his family cope with this
stressful situation is to determine the client’s previously successful coping strategies. This
assessment will give the nurse information about what interventions might be needed to help the
client and his family deal with this new stressful situation. Dealing and coping with this new
condition will require the client to make some decisions. The decision to use complementary and
alternative therapies is the decision of the client and family. It is not up to the nurse to convey
personal beliefs and discourage the client from using these therapies.
Chapter 05: Immunity, Inflammation, and Infection
1. ANS: 3
Autoimmunity is a condition in which the body’s immune system attacks its own tissues.
Immunodeficiency, also called immunocompromised or immunosuppressed, is when the body is
unable to launch an adequate immune response and is at great risk for infection. Health
care–associated infections (HAIs) that are acquired within a health care facility used to be called
nosocomial infections. Now they are HAIs and can affect both the client and health care worker.
Inflammation is a process that includes a series of cellular changes that signal the body’s
response to injury or infection.
2. ANS: 1, 3, 5
The classic signs of local inflammation include heat, redness, and swelling at the site, and
precede infection. Inflammation does not include drainage or fever, which are signs of infection
and tissue injury.
3. ANS: 3
In the first stage of the inflammatory process, capillary permeability increases, allowing
monocytes and neutrophils to move into the inflamed tissue. Bradykinin helps mediate blood
vessel dilation and permeability. Cortisol is a hormone produced by the adrenal cortex that is an
anti-inflammatory substance that helps to impede the inflammatory process and helps to
counteract bronchoconstriction in antigen–antibody reactions.
4. ANS: 4
There are few antiviral drugs because replication of the virus occurs within the host cell, so
killing the virus will harm the host cell. Viruses do not have more advanced ability to develop
resistance to drugs. The profitable cost of antibacterial drugs has nothing to do with the number
of viruses. Current antiretroviral drugs do not kill but help to suppress viral reproduction or
growth. They do not cure the virus.
5. ANS: 1
Characteristics of the incubation period include the infected person being very contagious.
Generally the client is asymptomatic and fever is not present. The recovery phase occurs after the
infection phase.
6. ANS: 4
Health care–associated infections (HAIs) related to multidrug-resistant organisms (MDROs)
include vancomycin-resistant Enterococcus (VRE). Gonorrhea is a sexually transmitted disease.
Tuberculosis is an airborne infection. Hepatitis B, and not hepatitis A, is an HAI that can be
transmitted by a needle puncture. Streptococcal pharyngitis is a contagious infection, spread
through close contact with an infected individual. A definitive diagnosis is made based on the
results of a throat culture, and antibiotics are given to both prevent complications and speed
recovery.
7. ANS: 2, 4, 5
Measures that help to protect against the development of bacterial resistance include
antimicrobial selection is based on results of culture and sensitivity tests, and antimicrobials are
prescribed only for serious infections. Vaccinations are encouraged for infectious disease. To
prevent recurrence of illness, antimicrobials should be continued until the entire course has been
completed or the health care provider orders them to be discontinued. Overuse of broad-spectrum
antimicrobials encourages the development of resistance, which eventually decreases their range
of effectiveness.
8. ANS: 1
Soiled caregiver hands are the primary mode of transmission of health care–associated infections
(HAIs). This includes hand washing with use of running water, use of an alcohol-based waterless
antiseptic, or a surgical scrub when assisting with operative procedures. Direct contact between
clients is not a great threat, but hand hygiene and use of antiseptic solution need to be
encouraged with all clients. Visitors are encouraged to use antiseptics when entering and leaving
a client’s room, and additional precautions are needed if clients are on Transmission-Based
Precautions. Faulty sterilization procedures are not a viable threat to transmission of HAIs.
9. ANS: 2
Standard Precautions need to be used when caring for any client in any setting.
Transmission-Based Precautions are used when caring for clients with open wounds,
tuberculosis, hepatitis, and HIV infection, and also for clients who are highly susceptible to
infection.
10. ANS: 2
High-efficiency particulate absorption (HEPA) filter respirators rather than surgical masks need
to be used to protect the caregiver by filtering inspired air, and are used when caring for a client
with tuberculosis and other airborne infections. They are not used to protect the client and are
more expensive than surgical masks.
11. ANS: 3
The client’s ability to resist the measles virus is called active acquired immunity, which develops
after direct contact with an antigen through illness or vaccination. Innate immunity is present in
the body at birth and is not dependent on a specific immune response or previous contact with an
infection. Nonspecific defense mechanisms or natural immunity includes physical and chemical
barriers, phagocytosis, and the inflammatory process. Passive acquired immunity is temporary
and what newborns receive from their mothers through the placenta or through ingestion of
breast milk.
12. ANS: 4
Nursing care of the immunosuppressed client includes emphasizing the need for proper hand
washing by clients, visitors, and staff. Rectal thermometers should be avoided because of the
potential for damage to the rectal mucosa. Fresh produce may be eliminated from the diet if the
client’s white blood count is too low. Flowers and plants do not increase oxygen in the room and
are not allowed because they provide a reservoir for bacterial growth.
Chapter 06: Fluid, Electrolyte, and Acid–Base Balance
1. ANS: interstitial
Extracellular fluid is fluid outside the cell. These fluids are found in the blood vessels in the form
of plasma or serum (called intravascular fluid) and in the fluid surrounding the cells (called
interstitial fluid).
2. ANS: 1
Water makes up the largest portion of the body weight. Fat, bone, and muscle all contribute to
body weight, but water makes up 50% to 60%.
3. ANS: 2
Osmosis is the movement of water across a membrane from a less concentrated solution to a
more concentrated solution. Diffusion is the random movement of particles in all directions.
Filtration is the transfer of water and solutes through a membrane from an area of high pressure
to an area of low pressure. Active transport is the process by which carrier proteins transport
substances from an area of lower concentration to an area of equal or greater concentration.
4. ANS: 4
Atrial natriuretic factor (ANF) is a hormone released in response to stretching of the atria by
increased blood flow. ANF stimulates the kidneys to release sodium and water and causes
decreased stimulus of renin and aldosterone, and vasodilation. The net effect is reduced blood
volume and lower blood pressure. Antidiuretic hormone (ADH) replenishes fluid in the body.
Renin is a hormone that is secreted when blood pressure falls. Decreased synthesis of renin and
decreased release of aldosterone help lower blood pressure.
5. ANS: 2
Older people have limited reserves with which to maintain fluid balance when abnormal losses
occur because many older adults have a reduced sense of thirst, resulting in lower total body
water. Older adults therefore cannot maintain fluid and electrolyte balance as well as younger
adults. Body water decreases, not increases, with age. The amount of intracellular fluid, not
extracellular fluid, declines in older adults.
6. ANS: two (2) liters
One (1) liter of fluid weighs two and two-tenths pounds (2.2 lbs). Therefore, 4.4 lbs must equal
two (2) liters of fluid loss.
7. ANS: 3
Tenting is a term sometimes used to describe skin that does not flatten promptly after being
gently pinched into a tent shape. This is an indicator of dehydration. This is not an appropriate
test of skin turgor in older adults, because the skin of older adults generally has a slower return to
normal. This measurement is not appropriate for recent weight loss, excessive sun exposure, or
the need for increased diuretics.
8. ANS: 3
When assessing a potassium imbalance, either deficit or excess, monitoring the client’s heart rate
and rhythm is most important. Both deficits and excesses can cause potentially fatal abnormal
arrhythmias. Abnormal bowel sounds, reduced muscle strength, and abnormal reflexes may all
present as signs and symptoms of potassium imbalance, but are not the most important nursing
assessments to monitor.
9. ANS: 2, 3, 1
Normal acid–base balance is maintained by three primary, complex mechanisms: (1) buffers, (2)
respiratory control of carbon dioxide, and (3) renal regulation of bicarbonate.
10. ANS: 4
Deep, rapid respirations, also called hyperventilation, function to blow off carbon dioxide and
lower partial pressure of carbon dioxide (PaCO2) levels, which raises the acidity (pH) of the
blood. Respiratory alkalosis eliminates excess carbon dioxide formed in the presence of acidosis.
Raising the PaO2 does not reduce the pH of the blood. Metabolic acidosis also does not supply
additional oxygen needed because of the increased metabolic rate.
Chapter 07: The Patient with Cancer
1. ANS: 1
Benign and malignant tumors are alike because both press on normal tissue and compete with
normal cells for nutrients. Benign tumors usually grow slowly, while malignant tumors typically
grow rapidly but may grow slowly. Benign tumors may enlarge and expand but do not invade
nearby tissues or disperse cells or colonize distant parts of the body like malignant tumors do.
Benign tumor cells closely resemble those of the tissue of origin, whereas malignant tumor cells
are not readily identifiable to the tissue of origin.
2. ANS: carcinogen
A carcinogen is a chemical, viral, or radioactive substance that can cause cancer.
3. ANS: 1, 3, 4, 5
Dietary recommendations believed to reduce the risk of some cancers include limited alcohol
consumption; high-fiber, low-fat and low-calorie diet; a variety of fruits and vegetables; and
limited smoking and consumption of nitrate-preserved foods. Ingesting dairy products and red
meat does not have an increased risk for cancer.
4. ANS: 3
Oncofetal antigens or tumor markers are substances found on fetal cells and the surface of cancer
cells. Elevations of these antigens are associated with certain cancers. They are often used to
monitor response to cancer treatments. Blood levels will continue to rise if the cancer is still
growing despite chemotherapy. If the levels continue to rise with chemotherapy, it means that the
chemotherapy is not effective. This antigen level does not have any relationship to an adverse
response to chemotherapy, nor does it reflect a strengthening of the patient’s immune system.
5. ANS: 1, 4, 5
Safety precautions when caring for a patient with an internal radiation source include always
wearing a gown when giving direct care to the patient, not allowing pregnant visitors or staff to
enter the patient’s room, and keeping the patient in a private room. If the radiation source comes
out of the patient’s body, then immediately notify the physician and the radiation safety
personnel and do not touch it with bare hands. Forceps and a lead container are always kept in
the patient’s room to retrieve and contain the source. When not providing direct care, the amount
of radiation exposure is reduced by limiting the amount of time spent in the room and by
working as far as possible from the radiation source and not at least 3 feet away.
6. ANS: 4
Radiation therapy adversely affects bone marrow, hair follicles, and the gastrointestinal tract
because these tissues regenerate rapidly. These tissues do not have a special inadequate defense
against harmful substances, and do not attract radioactive substances. Also, sensitivity of these
tissues to the adverse effects of chemotherapy is not related to the circulation within these
tissues.
7. ANS: 1, 3
Colony-stimulating factors (CSFs) are also called hematopoietic growth factors. Because
antineoplastic drugs suppress the bone marrow, CSFs can be used to stimulate the bone marrow
to produce platelets, red blood cells, and white blood cells in patients receiving chemotherapy.
CSFs help to reduce the risk of infection by shortening the period of neutropenia, when white
blood cells are low, and reducing the risk of anemia that is also associated with chemotherapy.
CSFs do not have any effect upon the dose of chemotherapy given, nor do they reduce the need
for bone marrow or stem cell transplantation. CSFs have no antiemetic properties to reduce
nausea and vomiting associated with chemotherapy.
8. ANS: 3
Bone marrow suppression is the most dangerous side effect of antineoplastic drugs. Nausea and
vomiting are likely to be the most distressing to patients because antineoplastic drugs
simultaneously irritate the lining of the digestive tract and stimulate the vomiting center in the
brain. Gastrointestinal bleeding is not a significant side effect of these drugs. Neurotoxic effects
of these drugs are mostly associated with numbness and tingling of extremities, paralytic ileus,
and loss of deep tendon reflexes but do not increase the patient’s intracranial pressure.
9. ANS: 2
Biologic response modifiers (BRMs) are used to promote and boost the body’s existing defenses
against cancer cells. BRMs act directly on malignant cells or stimulate the immune system to act
against them. They are most effective if the immune system is functioning adequately. A skin
test can be performed to evaluate the immune response before therapy is started. Examples of
BRMs are interferons and interleukins. Generalized side effects of BRMs include flu-like
symptoms. BRMs have no actions that can help treat mental depression or immunize patients
against certain types of cancer. BRMs also do not prevent any metastasis of cancer.
10. ANS: 4
All of these patients are experiencing normal reactions to grief. Normal reactions to grief include
being sad or tearful, verbalization of feelings of loss, talking about the loss and looking at or
touching the affected part, asking many questions, and planning a personal schedule around
treatments. Some patients exhibit anger, and others are stunned and unable to accept any more
information.
Chapter 08: Pain
1. ANS: 1
According to McCaffrey, “Pain is whatever the person experiencing it says it is and exists
whenever he says it does.” It is not defined by the nurse, the physician, or the physiologist.
2. ANS: 2
Nociceptors, or pain receptors, are stimulated and afferent pathways that send impulses to the
spinal cord and then to the brain. Nociceptors are stimulated first and then afferent pathways are
activated. Efferent (descending) pathways do not stimulate nociceptors but are nerves that carry
messages away from the brain to the rest of the body via the spinal cord. The brain does not
stimulate nociceptors. Nociceptors are part of the afferent pathways.
3. ANS: 3
Clients with a lower pain threshold experience pain more readily with fewer stimuli. With
hospitalization or illness, complaints of anxiety, fatigue, or loss of sleep can lower the client’s
pain threshold or lead to the client experiencing pain more easily. Labeling Mr. B. a complainer
is not appropriate. Mr. B. has a lower pain tolerance and not a higher one. There is no indication
that Mr. B. is more anxious.
4. ANS: 2, 4
Autonomic nervous system responses to pain include constipation and increased heart rate as
well as increased blood pressure, perspiration, and pallor. Pain also causes increased and not
decreased respiratory rate, dilated and not constricted pupils, and urinary retention and not
urinary frequency.
5. ANS: 4
Complaints of increased pain when bending over is an example of an aggravating factor.
Location involves specifically where the pain is located. Alleviating factors include what makes
the pain lessen or go away. Quality describes what type of pain the client is experiencing, such as
sharp, dull, cramping, or aching.
6. ANS: 1, 2
Safe and effective heat therapy includes using the heating pad intermittently rather than
continuously and not applying heat to any area that lacks normal sensation or circulation. The
heating pad should never be set at the highest temperature the client can tolerate. Limit the
application time to 30 minutes and not 15 minutes. Also, heat therapy, if performed
appropriately, is a safe and effective strategy for pain management.
7. ANS: 1
Imagery is a nonpharmacologic approach to pain control. Distraction is most helpful during brief
periods of pain and not chronic pain. Relaxation is a self-hypnotic technique to reduce pain and
does not require the nurse to hypnotize the client. Client education may help to lessen anxiety but
is not all that is needed to reduce anxiety. In fact, depending upon the person, some clients do not
want to know information about the pain experience.
8. ANS: 4
Nonopioid analgesics are used cautiously in clients with hypertension because these drugs can
cause fluid retention. Other side effects include stomach irritation and increased bleeding time.
They do not cause peripheral vasoconstriction, potassium loss, or sleep disturbances.
9. ANS: 3
Nonsteroidal anti-inflammatory drugs (NSAIDs) can affect platelet activity and bleeding time, so
clients need to be asked if they are taking any anticoagulants. NSAIDs do not have any side
effects related to also taking antibiotics, decongestants, or hormone replacements.
10. ANS: 3
The nurse’s first priority when a client is taking opioids is to assess the client’s respiratory
system. Unwanted side effects of opioids include decreased respiration, drowsiness, constipation,
urinary retention, and nausea. Hydration status may be affected if the patient experiences nausea
and vomiting.
Chapter 09: Shock
1. ANS: 4
A patient with peritonitis after a traumatic abdominal injury is at risk for hypovolemic shock. It
is the most common type of shock and most often occurs as a result of rapid blood loss.
Cardiogenic shock occurs when the heart fails as a pump. Other conditions that lead to
ineffective myocardial cell function include dysrhythmias, cardiomyopathy, myocarditis,
valvular disease, and structural disorders. Anaphylactic shock occurs as a result of a severe
allergic reaction leading to the release of chemicals that dilate blood vessels and increase
capillary permeability. Neurogenic shock occurs when a nervous system disruption affects the
vasomotor center in the medulla.
2. ANS: 1, 3, 4
Distributive shock refers to widespread vasodilation. This type of shock causes the blood to be
improperly distributed. Distributive shock is not related to blood or fluid loss. Antigen–antibody
reaction is related to anaphylactic shock, which is a type of distributive shock. Cardiogenic shock
is when the heart fails as a pump.
3. ANS: 1
Massive edema with anaphylactic shock is related to increased capillary permeability resulting
from the release of chemicals that dilate vessels in response to a severe allergic reaction. Pooling
of blood occurs in all peripheral tissues and not just in dependent parts of the body, leading to
decreased venous return and a decrease in cardiac output. The kidneys do not retain excess
water, but kidney output is decreased due to the decrease in cardiac output. There is not
overproduction of antidiuretic hormone.
4. ANS: 3
Anaphylactic, septic, and neurogenic shocks are all types of distributive shock and all are related
to vasodilation. Infection is related to septic shock but not to anaphylactic or neurogenic shock.
Allergic reactions are related to anaphylactic shock but not to neurogenic or septic shock. Heart
failure is related to cardiogenic shock.
5. ANS: 3
As shock progresses, cells are deprived of oxygen and resort to anaerobic metabolism, with
production of lactic acid resulting in metabolic acidosis. Metabolic alkalosis results from an
increase in bicarbonate levels or a loss of hydrogen ions caused by prolonged nasogastric
suctioning, excessive vomiting, diuretics, and electrolyte disturbances. Respiratory alkalosis is
generally caused by hyperventilation and is marked by a low PaCO2 with a resultant rise in pH.
Respiratory acidosis occurs when the respiratory system doesn’t eliminate enough carbon
dioxide to keep the normal acid–base balance, leading to a buildup in carbonic acid and a
decrease in pH.
6. ANS: 2
With shock, a decrease in cerebral perfusion leads to ischemia and a decrease in cerebral blood
flow. Therefore, assessing the patient’s level of consciousness is the best, first action.
Assessment of reflexes may be done after the level of consciousness is determined. The patient’s
emotional state would be included in the level of consciousness assessment. Determining a
patient’s mean arterial pressure is included in hemodynamic monitoring and is not as easy or
adequate an assessment as determining a patient’s level of consciousness.
7. ANS: 4
Blood, crystalloids, and osmotic agents all serve to increase the blood volume. Increased pulse
volume, increased blood pressure, and rales and crackles in the lungs in the shock patient suggest
circulatory overload. With sepsis, blood pressure normally falls and heart rate increases. Changes
in lung sounds occur with pneumonia, but the change in blood pressure (BP) is not expected;
heart rate would probably be increased more than 80 bpm. MODS is characterized by
tachycardia, and hypotension is more likely than normal to elevated BP.
8. ANS: 3
Acute myocardial infarction is the most common cause of cardiogenic shock due to the problem
of cardiac pump failure occurring. Shock related to pancreatitis and gastrointestinal bleed is
generally hypovolemic shock. Shock related to anaphylaxis, or anaphylactic shock, is a type of
distributive shock.
9. ANS: 4
Signs of circulatory overload include full, bounding pulse; dilute urine; increased respiratory
rate; abnormal lung sounds; dyspnea; and edema. Signs of sepsis leading to septic shock include
documented or suspected infection; inadequate tissue perfusion related to metabolic acidosis;
hypotension; acute encephalopathy; oliguria; or coagulation disorders. Signs of multiple organ
failure occur when the tissues of major organs are not perfused and lactic acid builds up, leading
to organ dysfunction such as systemic inflammatory response syndrome (SIRS) and multiple
organ dysfunction syndrome (MODS). Pneumonia can lead to septic shock, hypotension
unresponsive to fluid resuscitation, and signs of inadequate tissue perfusion with a decrease in
lung sounds.
10. ANS: 1, 2, 4, 5
Interventions that reduce the risk of systemic inflammatory response syndrome (SIRS) and
multiple organ dysfunction syndrome (MODS) in a patient with pancreatitis include maintaining
strict asepsis with invasive procedures, providing frequent oral care with chlorhexidine
gluconate, practicing scrupulous hand washing, and administering enteral feedings as ordered.
The patient should be in a semi-Fowler or semirecumbent position and not a high Fowler
position. This position helps to reduce the risk of ventilator-associated pneumonia.
Chapter 10: The Older Adult Patient
1. ANS: 1
Older adults who have liked sexual activity during their lives are quite likely to retain that
interest, although they may engage in sexual activity less often than younger people. Most older
adults do not lack extended family and support networks and do have those resources. Only 5%
to 7%, and not 50%, of people over 60 have dementia. Only 1% of the people between the ages
of 65 and 74, 3% of people ages 75 to 84, and 11% of those over 85 years live in nursing homes.
2. ANS: 1, 4
Neurologic changes found in healthy older adults are related to a slowing of brain impulse
conduction. Short-term memory is impaired, and this group is easily distracted from tasks. In the
absence of disease, most older adults maintain normal intellectual capability, sound judgment,
and creativity.
3. ANS: 3
This man’s normal activity state does not return because, with increasing age, the ability to
maintain physiologic functions in the face of acute illness is reduced. In this case, the client’s
acute illness has overwhelmed his already limited cardiac and renal function. Immune function is
not severely impaired at age 90, nor is his condition related to not seeking treatment for the
pneumonia soon enough. The reason this client has not improved is not because he wants to
continue receiving the same attention he received when he was acutely ill.
4. ANS: 1, 2, 4, 5
Skin care instructions that should be included when teaching active older people are using
sunscreen to reduce the risk of cancer, reporting any changes in existing skin lesions to a nurse or
physician, using moisturizers and little soap to prevent dry skin, and being aware that any
generalized itching could be a symptom of a serious illness. Hot baths, harsh soaps, and vigorous
scrubbing contribute to dryness and do not remove dead skin.
5. ANS: kyphosis
Kyphosis is a common condition with older adults. It is an increased curvature of the thoracic
spine that can limit chest expansion.
6. ANS: 2
Presbycusis is related to hearing loss with old age and includes atrophic changes in the cochlea,
auditory nerve, and auditory brainstem pathways. It also includes temporal lobe pain. It results in
being less able than young people to hear high-pitched sounds and consonants, so a lower voice
tone is generally heard better than a high-pitched voice. It is not related to vision or room
lighting. Blood pressure is not affected with presbycusis, and body fluid precautions are not
indicated.
7. ANS: 4
A statement that a person can’t run marathons anymore, but still enjoys a brisk walk, is an
example of ego integrity. Ego integrity is present when an individual reviews his or her life and
gains a feeling of accomplishment and fulfillment. Options 1 and 2 are examples of an older
person being unable to cope effectively with loss, leading to an altered self-concept and loss of
personal identity, fulfillment, and meaningfulness in life. Option 3 is an example of the
continuity theory, wherein older people behave in later years much as they had throughout life.
8. ANS: 2, 3
Being able to perform instrumental activities of daily living (IADL) includes cooking and
shopping. These activities are essential for a person to continue or to return to independent
living. Bathing, eating, and elimination are examples of activities of daily living.
9. ANS: 1
Respiratory depression is an example of an adverse central nervous system effect of pain
medication in an older, postoperative client. Drug therapy for anxiety, pain, or sleep can produce
respiratory depression in the older adult client. Excessive drowsiness could also be an adverse
effect in the older adult client, although difficulty sleeping and agitation are not. Vomiting and
diarrhea are not adverse effects of pain medication in older adults.
10. ANS: 4
Aspirin could be related to the client’s bruising and oozing of blood after a cut, since it tends to
enhance the effect of anticoagulants. A side effect of spironolactone is hyperkalemia, and
hypotension can result after taking verapamil. Taking Maalox would not result in bleeding or
bruising.
Chapter 11: Falls
1. ANS: 1
Deep tissue damage or concussion occurs in approximately 5% of patients living in residential
care facilities. Contusions, cuts, or lacerations occur in 25% to 30% of all reported falls of
patients living in residential care facilities.
2. ANS: 1
The strongest predictor of falling for a resident of an assisted living facility is that the resident is
someone who has fallen before. Other risk factors include reduced visual acuity, impaired dark
adaptation, impacted cerumen, presbycusis, musculoskeletal disorders, balance disorders,
peripheral neuropathy, foot disorders, postural hypotension, stroke, and slowed time reaction.
Diagnosis of heart disease, recent weight loss, and urinary incontinence individually are not the
strongest predictors of falls.
3. ANS: 1
A restraint is anything that restricts an individual’s movement. Restraints are classified as either
physical (anything that restricts movement and that cannot be removed by the patient) or
chemical (a drug that is given to subdue agitated or confused patients). Physical restraints do not
reduce the potential for injury but actually can increase the potential for injury to a patient. Full
side rails up is considered a restraint and is often related to falls when patients attempt to climb
over them to get out of bed. If safety restraints are applied, they must be removed and released
every 2 hours for 10 minutes to provide for range of motion, toileting, nourishment, and comfort
measures.
4. ANS: 3
Psychotropic drugs, including antidepressants, sedatives/hypnotics (e.g., benzodiazepines), and
antipsychotic drugs, are the most commonly prescribed chemical restraints, and can have serious
adverse effects, such as greater confusion, agitation, postural hypotension, and an increased
number of falls in older persons. They do not cause hallucination or delusions, constipation, or
insomnia.
5. ANS: 1, 3, 4
Intrinsic risk factors, or factors related to the functioning of the individual, are part of the fall risk
assessment conducted on a patient. These factors include confusion, weakness, and poor vision.
Inadequate lighting and broken wheelchair brakes are examples of extrinsic or environmental
risk factors.
6. ANS: 1, 2
The Omnibus Budget Reconciliation Act (OBRA) guidelines that apply to a physician’s order for
the use of restraints include duration that restraints may be used and circumstances under which
restraints may be used. These guidelines in OBRA were passed in 1987 to protect patients from
unnecessary restraint in long-term care (LTC) facilities. It specifically refers to giving patients
the right to be free from restraint use for purposes of discipline or convenience and when
restraint is not required to treat patients’ medical symptoms. OBRA guidelines do not include
recorded nursing assessment data, measures to be taken for injury, or patient consent to be
restrained for safety reasons.
7. ANS: every 2 hours
A restraint applied to a confused postoperative patient who is pulling on her intravenous (IV) and
surgical dressing must be released every 2 hours for 10 minutes to provide for range of motion,
toileting, nourishment, and comfort measures.
8. ANS: 1, 2, 3
Classes of drugs that may be used as chemical restraints include antipsychotic drugs,
sedative/hypnotic drugs, and antidepressants. Analgesics and skeletal muscle relaxants have no
chemical restraint properties.
9. ANS: 3, 4
Nutritional supplements that may reduce the risk of fall-related fractures include vitamin D and
calcium. It is thought that people with low vitamin D levels had a greater risk of fractures and
that calcium may also help to prevent osteoporosis. Vitamin C, iron, and vitamin B12 do not have
any known effect on reducing the risk of fall-related fractures.
10. ANS: 1, 2, 3
Regular exercise and physical training can help prevent falls by improving muscle strength,
balance, and flexibility. They include walking, balance, coordination, and functional exercises;
muscle strengthening; and multiple exercise types. Regular exercise and physical training do not
have any effect on patient alertness or on bone mass.
Chapter 12: Immobility
1. ANS: 3
Passive exercises are movements of the patient’s body by another person. Isometric exercises are
performed without moving the joint and are done to maintain muscle tone. Active exercises are
performed by the person himself or herself. Isotonic exercises mean that the tension remains
unchanged and the muscle’s length changes, such as when lifting an object at a constant speed
and causing an isotonic contraction.
2. ANS: 1
When moving patients, use a draw sheet or transfer device to avoid tissue trauma and damage to
the uppermost layers of the skin caused by shearing of the skin. The purpose of using a draw
sheet is to avoid friction and prevent tissue damage to the upper most layers of the patient’s skin.
It is not to prevent strain on the caregiver or extension contractures of the patient’s spine.
Caregivers can still experience a strain when using a draw sheet if they are not lifting properly or
are lifting someone who is too heavy. Bed linens are always disturbed when repositioning a
patient, and after movement, the caregiver needs to make sure that the bed linens are dry,
smooth, and free of wrinkles.
3. ANS: 2
Skin integrity is best maintained by repositioning the patient at least every 2 hours. Keeping
joints in functional positions is directed toward making sure joints are not abnormally flexed or
extended. The purpose of range-of-motion exercises is to put each joint that is at risk for loss of
motion through its full range of motion to the highest degree possible. Giving eight 8-ounce
glasses of water does not prevent skin breakdown. Better to offer the patient a glass of water with
each position change.
4. ANS: 1
The first action to take when recognizing an erythematous area on a patient is to document the
erythema and instruct nursing assistants to keep the patient off his back. The Norton scale could
also be used to identify if the patient is at risk for developing a pressure injury. Reddened areas
should never be massaged because that could cause damage to fragile capillaries. Inflatable rings
also should not be used because they can cause a concentrated area of pressure and place the
patient at a higher risk for developing pressure injury. Heat should not be used because it can
increase the patient’s temperature and the metabolic demands of the tissue and put additional
stress on the affected area.
5. ANS: 4
Some coughing strategies include taking a single deep breath followed with 3 consecutive
coughs in an effort to clear all the air from the lungs with each cough. Another effective
coughing strategy is to have the patient take 4 to 6 deep breaths and then cough deeply. The
abdominal muscles and diaphragm can be used to expand the lower chest during deep-breathing
exercises. After abdominal surgery, have the patient support the abdomen with a pillow to
minimize discomfort. Have the patient focus on how much air can be exhaled rather than the
force with which it is exhaled. Coughing and deep breathing are most effective in a sitting
position and not with the patient positioned on his side.
6. ANS: 1
Constipated patients may strain to defecate, leading to an increase in intraabdominal pressure.
The most likely cause is related to the Valsalva maneuver or vasovagal reflex. Especially in older
adults, this can lead to cardiovascular alterations, including lightheadedness and fainting. The
vasovagal reflex is not related to internal hemorrhage, dehydration, or wound dehiscence (suture
line separation).
7. ANS: 2
Urine flows downward from the kidneys by gravity, so when the patient is in a reclining or
supine position, the urine flow gets sluggish and urine pools, putting the patient at risk for a
urinary tract infection (UTI). Immobility itself does not affect the amount of urine produced by
the kidneys, but the peristaltic action of the ureters is not strong enough to maintain a constant
flow of urine. There is not increased blood flow to the kidneys. Without the downward pressure
on a full bladder against the sphincter muscles, awareness of the need to void is less.
Chapter 13: Delirium and Dementia
1. ANS: 1
The primary difference between delirium and dementia is that delirium is typically reversible
while dementia is usually irreversible. Agitation is not constant with delirium, and delirious
people may be hyperactive, hypoactive, or alternate between the two. With dementia, agitation is
constant with a gradual slow progression to combativeness, delusions, hallucinations, and
wandering in later stages. Delirium develops over a short period of time while dementia has an
insidious onset with gradual steady progression in cognitive and behavioral symptoms. Delirium
can last for quite a while and depends upon managing the symptoms and treating or removing the
cause while maintaining safety and comfort to reduce anxiety. Dementia is not reversible and is
defined as a progressive and significant cognitive decline from a previous level of performance.
2. ANS: 3
The best intervention is to be honest and tell the patient where she is and that her daughter is not
there. Frequent orientation to the surroundings and the situation is important for patients with
delirium. Sedatives and antipsychotic drugs should be used with great caution with older adult
patients because they can increase the risk of death. Calling her daughter in the middle of the
night and asking her to come to see her mother, and scolding the patient and telling her to be
quiet because she is disturbing other patients, are not reasonable or appropriate interventions.
3. ANS: 1
When a patient with Alzheimer disease (AD) wanders way from the table during meals, the nurse
should consult a dietitian to see if finger foods can be provided for the patient. Avoid physical
restraints, which can cause anxiety and agitation in confused patients and often can result in
patient injuries. Arguing and ordering the patient to sit down and finish his meal does not convey
respect and dignity and is not an appropriate action. Asking another patient for help can put the
other patient at risk for injury.
4. ANS: 2
When addressing a patient with dementia, it is best to be direct and keep instructions simple.
Telling the patient he needs to be dressed in 30 minutes to go to church is too detailed, and
telling him to “put his shirt” on needs to be more direct. Also, asking him what he wants to wear
can be too confusing and cause anxiety.
5. ANS: 3
Tell the new nurse that frequent attempts at orientation can agitate patients with Alzheimer
disease (AD). It is best to try to weave orienting phrases into the conversation. Waiting 5 minutes
to ask the patient the same question can also cause anxiety. Consistently telling or asking the
patient to repeat the date, time, and place after you say them can also cause anxiety.
6. ANS: 4
The cognitive developmental approach (CDA) is based upon adapting expectations and
interventions to the patient’s abilities and not consistently using the same interventions for all
patients. It does not include having the patient confront irrational fears, but has the nurse
recognize irrational fears so that alternative ways to give personal care can be arranged. Also,
insisting that the patient behave as a mature adult at all times is scolding and disrespectful of the
patient and can cause anxiety.
7. ANS: Alzheimer disease
Alzheimer disease is the most common type of dementia.
8. ANS: acetylcholine
Acetylcholine is the major neurotransmitter in the brain. Most Alzheimer disease (AD) drugs act
to increase the amount of this neurotransmitter in the brain.
9. ANS: 3, 4, 5
Drug therapy for Alzheimer disease (AD) is not used for moderate dementia, and the benefits
gained vary among individuals. A combination of drugs usually arrests the progression of the
disease. None of the drugs are curative of the disease and all of the drugs have significant side
effects that some patients are not able to tolerate.
10. ANS: 1, 3, 4, 5
Drugs that can cause confusion include digoxin for heart failure, first-generation H2 receptor
blockers for peptic ulcer disease, anticholinergics for seasonal allergies, and nonsteroidal
anti-inflammatory drugs for arthritis. Antacids for heartburn do not have any properties that can
cause confusion in patients.
Chapter 14: Incontinence
1. ANS: 1, 4
Habit training or timed voiding is similar to bladder training, but the voiding schedule is based
on the patient’s usual pattern. It is used to treat a patient with urinary incontinence and includes
checking the patient for wetness every 2 hours, asking the patient to state whether he or she is
wet or dry, and having the patient practice interrupting urine flow by contracting the perineal
muscles. The patient is not encouraged to void every 2 hours but to void when the patient has the
urge and not delay voiding.
2. ANS: 3, 5
Pelvic muscle exercises include strengthening perineal muscles to improve urinary control and
continuing the exercises indefinitely to maintain control. The muscles are contracted either for a
short time (2 to 4 seconds with brief period of relaxation) or a long time (6 to 12 seconds
followed by relaxation for 6 to 12 seconds) and not for 30 seconds and relaxed for 30 seconds.
Improvement in urinary control may be noticed after 3 weeks or by up to 6 to 8 weeks and not
after just 1 week. The patient does not have to be in a standing position but can also do the
exercises effectively while sitting at a desk or while driving.
3. ANS: 1
Intermittent self-catheterization in the home setting is different from institutional catheterization
because clean technique may be used at home but not in the hospital setting. As far as health
care–associated infections are concerned, it is not necessary for the patient to use sterile
technique at home. Clean technique cannot be used in the hospital, even if patients catheterize
themselves, or in long-term care facilities because those patients are at much greater risk for a
health care–associated infection. Sterile technique must always be used for catheterization of
patients in hospitals and in long-term care facilities.
4. ANS: 2
Document that the patient has a pessary to ensure that it will not be forgotten. A pessary is a
device that is inserted into the vagina to hold the pelvic organs in place. It is sometimes used as a
tool to treat incontinence in women with relaxation of the pelvic structures. A doughnut-shaped
pessary exerts pressure on the vaginal wall, lifting the uterus and holding it in the pelvis. When
incontinence occurs as a result of the bladder prolapsing into the vagina, other types of pessaries
may be used to support the urethra as well. Within 24 hours, and not 1 week, after pessary
placement, the patient must be reexamined to ensure proper placement and to rule out urinary
obstruction. Bowel obstruction is not a problem with pessaries. The device does not have to be
removed every time perineal care is given but removed periodically for cleansing and
replacement.
5. ANS: 1, 3, 5
Urge incontinence commonly is the result of an overactive bladder muscle, and medications are
often effective in reducing bladder overactivity. Urge incontinence is the involuntary loss of
urine shortly after a strong, abrupt urge to urinate. Anticholinergic and muscarinic antagonists
(antispasmodics) are the drugs most commonly used for urge incontinence. Urge incontinence is
not related to the bladder overfilling, resulting in small amounts of urine being passed to relieve
pressure. Urinary tract infection and fecal impaction sometimes cause temporary urge
incontinence. Treatment of urge incontinence is aimed at correcting the cause, if possible, and
includes antibiotics for infection and the removal of impaction. When the problem is not related
to reversible conditions, behavioral techniques, drug therapy, or surgical intervention may be
used.
6. ANS: overflow
Reflex urinary overflow incontinence is the involuntary loss of urine associated with an
overdistended bladder. Small amounts of urine are lost either continually or at frequent intervals.
In addition to passing out through the urethra, urine may flow out of the bladder back into the
ureters and kidneys and cause hydronephrosis. Patients who have normal sensation usually feel
uncomfortable because of bladder distention. Factors that contribute to overflow incontinence are
obstruction to urine flow, an underactive detrusor muscle, and impaired transmission of nerve
impulses. In addition, some women have overflow incontinence after surgery to treat other types
of incontinence.
7. ANS: 1
Stress incontinence is usually caused by relaxation of the pelvic floor muscles and is the
involuntary loss of small amounts of urine during physical activity that increases abdominal
pressure. Coughing, laughing, sneezing, and lifting are some activities that can cause urine loss.
In women, stress incontinence is usually caused by a relaxation of the pelvic floor muscles and
the ureterovesical juncture related to pregnancy, childbirth, obesity, and aging. Urethral trauma,
sphincter injury, congenital sphincter weakness, urinary infection, neurologic disorders, and
stress can cause stress incontinence in both men and women. It can occur after prostatectomy or
radiation therapy. It may be successfully treated with behavioral methods such as scheduled
voiding and pelvic muscle exercises. The patient is advised to maintain a fluid intake of at least
2000 mL/day and not just 1000 mL/day. If the patient has hypertension, heart failure, or renal
disease, a registered nurse (RN) should be consulted about the appropriate recommended fluid
intake. Older adults whose fluid intake has been low will need to increase fluid intake gradually
to prevent fluid volume overload. Fluids with caffeine (e.g., tea, coffee, cola) have a diuretic
effect and should be avoided. These fluids do not stimulate contraction. Surgical repair is not the
only form of treatment. The most common surgical interventions now are retropubic
urethropexies, pubovaginal slings, and collagen injections. These procedures have largely
replaced anterior colporrhaphy and needle suspension. Drug therapy may include
alpha-adrenergic drugs such as pseudoephedrine hydrochloride (Sudafed) to increase bladder
outlet resistance or oral or topical estrogen to strengthen the bladder outlet in postmenopausal
women.
8. ANS: 2
The patient needs to avoid foods that stimulate the anal sphincters to relax. These include
chocolate, coffee, tea, and other caffeinated beverages. Raw fruits, fruit juices (especially prune
and grape juice), raw vegetables, cabbage, sweets, alcohol, and highly spicy foods stimulate stool
production. Conversely, foods that thicken the stool include bananas, rice, bread, potatoes,
cheese, yogurt, oatmeal, oat bran, boiled milk, and pasta.
9. ANS: 1
Assessment of fecal incontinence includes determining the last formed stool, recording the usual
bowel pattern, stool characteristics, related symptoms, activity, diet, fluid intake, medications,
and use of aids to help elimination. An abdominal assessment should also be performed. Urinary
output, temperature, or mental status is not necessary to include in the assessment of fecal
incontinence.
Chapter 15: Nutrition
1. ANS: 1, 2
Only added sugar and saturated fats should be limited to less than 10% of the total daily calorie
intake.
2. ANS: 2
Fats provide 9 kcal of energy per gram. Carbohydrates and protein provide only 4 kcal of energy
per gram.
3. ANS: 3
A daily value is the percentage of the recommended daily intake of that nutrient that is provided
by one serving of the labeled food.
4. ANS: 3, 5
Older people who are less active need fewer calories than they did when they were younger, and
moderately active older woman need 300 fewer calories per day than when they were younger. It
is not possible for older adults to eliminate all sodium from their diets. Sodium is abundant in
most foods except fruit. It is recommended for persons 51 and over who are African Americans
or have hypertension, diabetes, or chronic kidney disease to reduce sodium intake to 1500 mg
daily. When compared to younger adults, older men need to reduce their daily calories by 600
daily. The use of megavitamins is generally not considered beneficial and could even be harmful
to clients.
5. ANS: 4
Lactovegetarian diets include milk, cheese, and other dairy products but exclude meat, fish,
poultry, and eggs.
6. ANS: 2
Clients receiving total parenteral nutrition (TPN), which is a nutritional supplement that is
administered parenterally into the superior vena cava, need to be closely monitored for air
embolism. Other complications include pulmonary-related problems, injury to veins and arteries
near the catheter site, infection, electrolyte imbalance, mineral deficiencies, and hyperglycemia,
and not hypoglycemia, unless the treatment is suddenly stopped. Vomiting and aspiration are not
complications associated with the administration of TPN.
7. ANS: 1
Nutritional recovery syndrome is characterized by hypophosphatemia due to the shift of
phosphorus from the plasma into the cells. Potassium levels can also be affected as potassium
moves into cells with the glucose during refeeding. Hypocalcaemia, hypernatremia, and
hypoglycemia are not related to this syndrome.
8. ANS: 4
The optimal BMI is 20 to 25.
9. ANS: 2
Cognitive restructuring is used to teach patients to identify, challenge, and correct negative
thoughts. Stimulus control focuses on the settings or chain of events that precede eating, the
kinds of foods consumed, and the consequences of eating. Problem solving is used to identify
issues related to eating, set goals, implement interventions, and evaluate outcomes.
10. ANS: 1 = c; 2 = b, 3 = a
Persons with anorexia nervosa restrict their food intake so much that they lose excessive body
weight. Bulimia is characterized by self-induced vomiting to prevent absorption of food
consumed. With binge eating disorders, the individual consumes huge quantities of food at
intervals.
Chapter 16: Intravenous Therapy
1. ANS: 1
The smaller the gauge, the larger the inside diameter of the cannula. Therefore, a 12-gauge
cannula is the largest of the options. A 14-gauge, an 18-gauge, and a 22-gauge cannula are all
smaller than a 12-gauge cannula.
2. ANS: 2
A hypotonic solution (less than 285 milliequivalents per liter, or 285 mEq/L) is used if the body
fluids are concentrated due to water loss. A hypotonic solution increases fluid in the tissues.
Solutions that have the same concentration of electrolytes as normal body fluids have
approximately 285 mEq/L; these solutions are called isotonic. An isotonic solution contains
0.9% sodium chloride (normal saline). Hypertonic solutions contain more than 300 mEq/L and
increase blood volume when given, drawing fluid from the tissues. A concentrated solution may
refer to a hypertonic solution, or a solution that has a higher tonicity than the blood. More
concentrated hypertonic solutions are needed when a client has had excessive losses of both
sodium and chloride.
3. ANS: isotonic
Isotonic fluids are used to supply balanced amounts of water and sodium chloride.
4. ANS: hypertonic
Hypertonic fluids are needed when the patient has had excessive losses of both sodium and
chloride.
5. ANS: 1, 4
A central line is used when irritating (vesicant) fluids are to be administered, when the client has
poor peripheral veins, and when long-term therapy is required. Peripheral veins are used for
short-term therapy, when a client has healthy veins and when nonirritating fluids are given.
Central lines are contraindicated with infants. Peripheral lines are used for short-term therapy.
Some, but not all, antibiotics are infused via a central line.
6. ANS: 4
If the IV infusion is running too slowly, adjust the flow rate and reset the infusion rate to 34
drops/minute. Do not attempt to “catch up” by administering extra fluid rapidly. If the fluid is
running too quickly, slow the rate and assess the patient for signs of fluid volume excess.
7. ANS: 3
Fluid volume excess related to fluid overload may cause or be consistent with shortness of
breath, a 20-point increase in systolic blood pressure (BP), and a heart rate of 100 bpm. Shock
caused by a fluid volume deficit would result in a decreased BP. Anxiety related to
hospitalization would not present with symptoms similar to fluid volume excess. Renal failure
caused by circulatory collapse would not result in signs and symptoms of circulatory overload
and fluid volume excess.
8. ANS: 1, 2, 4
Recommended interventions for an older adult receiving peripheral intravenous therapy include
padding the armboard if used, protecting the skin from adhesive tape, and using a blood pressure
cuff rather than a tourniquet. Never apply an immobilizer over an infusion site but rather below
the site. Do not release traction on the vein after the needle pierces the skin but anchor the vein
with the thumb of your nondominant hand to maintain traction until the catheter is inserted to the
hub.
9. ANS: superior vena cava
A peripherally inserted central catheter (PICC) is a type of central line threaded through a
peripheral vein and then advanced, with the tip of the catheter resting in the superior vena cava.
10. ANS: 1
The greatest danger of irrigating an obstructed intravenous (IV) line is forcing blood clots or
emboli into the bloodstream, and with central lines the greatest danger is air entering the line and
causing an air embolism. Irrigating an obstructed IV line according to protocol should not cause
trauma to the blood vessel or rupture to the cannula or infusion site irritation.
Chapter 17: Surgery
1. ANS: 2
Older adults in good health who have surgery have positive outcomes similar to younger adults.
They are not twice as likely to have surgical complications. If chronic conditions are under
control, drug therapy is evaluated, and the patient is well hydrated and nourished before surgery,
then surgical risks are greatly reduced. Modern surgical techniques can restore many lost
functions and can often improve the patient’s quality of life.
2. ANS: 2
Informed consent requires that the patient is fully awake and aware of what the consent form
contains when signing it. Explaining the procedure, whether the patient has alternative options,
and the risks to the patient is the physician’s responsibility. If the patient wants to explore other
options or has questions about the procedure, then the physician should be contacted.
3. ANS: 3
Right after surgery, the spinal anesthesia patient has potential for injury because movement
returns before sensation because of the decreased level of consciousness associated with general
anesthesia or other sedatives. The effects of regional anesthesia are brief and the blood flow to
the extremities is not affected. With regional anesthesia, sensation and movement are blocked for
a brief time, so the affected body part may have potential for injury. It does not last for several
weeks. Patients can move the affected body part even though feelings of pain or pressure are
present.
4. ANS: 3, 4
Immediate postoperative complications include shock and hypoxia. Wound infection generally
doesn’t appear until several days after surgery. Pneumonia and thrombophlebitis are surgical
risks for older adult patients, but both conditions would not appear until a few days after surgery.
5. ANS: 4
Since these vital signs seem to be within normal limits, the nurse must compare them to the
patient’s preoperative vital signs to determine if there is a great difference. Then the nurse can
assess what medications the patient had during surgery, length of time under general anesthesia,
and whether the patient is having pain.
6. ANS: 4
Dehiscence is the reopening and separation of the surgical wound. If organs protrude (called
evisceration), then saturate the dressing with normal saline; cover the wet dressing with a dry,
sterile dressing; and notify the surgeon. Don’t have the patient lie flat in bed because that could
open the wound more. Also, reapplying the same dressing may contaminate the open wound.
7. ANS: 1
If a patient voids 20 to 30 mL of urine at frequent intervals, then the patient could be suffering
from urinary retention with overflow. This can be caused by the effects of anesthesia or opioids,
trauma to the urinary tract, or anxiety about voiding. Bladder damage during surgery would
prevent the patient from being able to void and may reveal fluid pooling in the abdomen and
pelvis. Fluid volume excess can overload the heart and aggravate the stress of surgery. This
would result in clear, pale urine as the body attempts to excrete excess volume. With kidney
failure, the kidneys are unable to produce enough urine to remove wastes from the body and
urine output would fall dangerously low. Normal urine output needs to be at least 30 mL/hour.
8. ANS: 2, 3
During a hand-off report on a patient with a paralytic ileus, information about the patient’s
nasogastric tube and suction used and bowel sounds should be passed along to the oncoming
nurse. Information about a patient with a paralytic ileus need not include the patient’s ability to
walk or the need for a blood transfusion. Also, a patient with a paralytic ileus is kept NPO and
does not take any liquids by mouth.
9. ANS: 1, 2, 3, 4
Preoperative medications include sedative/hypnotics, opioid analgesics, antiemetics, and
anticholinergics. They do not include nonsteroidal anti-inflammatory drugs.
10. ANS: 1, 2, 3, 4, 5
Guidelines to prevent wrong site surgery include confirming that the operative site is marked
before giving any sedating drugs, verifying that the appropriate equipment is available for the
procedure, confirming that the consent form has been signed and witnessed, verifying with the
patient the procedure that is to be performed, and conducting a time-out before the first incision
to resolve any concerns.
Chapter 18: The Patient with an Ostomy
1. ANS: 1, 2
Colostomies and ileostomies are surgically created to remove fecal matter from the intestines.
Ileal conduits, vesicostomies, and ureterosigmoidostomies are ostomies of the urinary tract that
drain urine from the kidney, ureters, or bladder.
2. ANS: 4
A colostomy will produce the most formed stool because the closer to the rectum, the more
formed the stool. A jejunostomy has the most liquid type of stool, followed by a duodenostomy,
and then an ileostomy with a semiliquid stool.
3. ANS: beefy red
A new intestinal stoma on the first postoperative day should be beefy red in color. When healed,
it should be rose red and somewhat darker than the color of the oral mucosa. A very pale, bluish,
or black stoma has impaired circulation and must be reported to the RN and the physician
immediately.
4. ANS: 3
After ileostomy surgery, the patient is at risk for fluid volume deficit because fluid normally
reabsorbed in the colon is lost through the ileostomy. Normally, there is minimal blood loss
during the surgical procedure. Postoperatively, the presence of some blood and mucus in the
drainage is normal at first. Postoperatively, the patient has a nasogastric tube attached to low
suction to prevent vomiting. Intravenous fluids are given for several days, after which oral intake
is gradually increased. The stoma does not have to be healed completely before oral fluid intake
is begun.
5. ANS: 4
The nurse should reinforce to the patient to cut the opening on the wafer no more than ¼ inch
larger than the stoma. Every 3 to 7 days, and not daily, the patient should remove the appliance
to cleanse around the stoma. After removing the adhesive, the patient should wash the stoma and
the area around it with water and not with moisturizing soap. If soap is used, it should be nonoily
and rinsed off thoroughly. To prevent skin irritation, gently pat dry the skin around the stoma and
never vigorously rub the skin.
6. ANS: 1
The most appropriate reply to a patient about foods to eat that do not encourage the passing of
gas is to gradually try them 1 day at a time to see how you tolerate them. It does not mean that
the patient will never again be able to eat those foods. Different foods can be tolerated better by
different patients. Some patients can have problems with flatus with some foods and other
patients can tolerate those same food. Vitamins do not replace fruits and vegetables, so the
patient needs to try different fruits and vegetables to see which ones the patient can tolerate.
Fibrous vegetables should be avoided.
7. ANS: 3
To help the 3-day postoperative patient adjust to his stoma and learn to do self-care, encourage
him to participate in care once he begins looking at the stoma. Do not shield the stoma until the
patient asks to see it because patients should be able to watch stoma care from the beginning.
Don’t threaten the patient that, if he doesn’t do the stoma care, then no one will do it. If the
patient does not begin to show some interest in learning self-care, then seek supportive help from
the wound care nurse. Family members can be included in the instructions for the care if they
and the patient so desire.
8. ANS: obstruction
If a patient with a new continent ileostomy has abdominal distention and hypoactive bowel
sounds, then the patient could be suffering from a bowel obstruction.
9. ANS: 3
An Indiana pouch is a continent internal reservoir that allows for the storage and controlled
drainage of urine. A cutaneous ureterostomy, ileal conduit, and ureteroileostomy are all
incontinent types of urinary diversions.
10. ANS: 1
The main advantage of an ileum neobladder is that the patient does not have a stoma for urine
drainage. This orthotopic bladder is a new bladder constructed from a segment of bowel that is
placed in the normal bladder location and attached to the urethra so urine drains into the reservoir
and is eliminated through the urethra instead of a stoma. Continence is not always maintained, so
an artificial urinary sphincter is sometimes implanted. Urine is not eliminated through the
rectum, and there is no need for the neobladder to be drained daily.
Chapter 19: Palliative and Hospice Care
1. ANS: 1, 2, 3, 4. 5
A loss is separation from something that is valued. It can be an object, a person, a job, a
developmental milestone such as a child leaving home, a change in appearance, etc.
2. ANS: 2
The focus of palliative care is to provide comfort, rather than to achieve a cure. Providing
supportive care while allowing natural death in a pain- and symptom-controlled environment is a
part of palliative care. Finding alternative methods of treatment of a disease may be appropriate
when there is still some hope for a cure, but this patient has advanced cancer and has decided to
discontinue treatment. Delaying death for as long as possible by any means is not following the
patient’s decision to discontinue treatment. Hastening death when no hope exists for a cure is not
consistent or ethical within the role of a health care provider.
3. ANS: 2
Uncomplicated grief is a normal, healthy response to a loss. It assists the person in accepting the
reality of death. When grief begins before a death occurs, or when the reality that death is
inevitable is known, that uncomplicated grief is called anticipatory grief. Dysfunctional grief is
not uncomplicated and may be prolonged, unresolved, or disruptive. Reactive grief is not a
defined type of grief. Exaggerated grief may be defined as dysfunctional.
4. ANS: 3
According to Kubler-Ross, bargaining is a stage of grief in which a person, recognizing the
terminal nature of the illness, seeks to “buy” more time.
5. ANS: 1
The hospice approach to pain management is that prevention of pain and relief from discomfort
should be a priority and handled with compassion. Hospice care embraces palliative care with a
focus on quality of life, comfort, and dignity near the end of life. There is no need to use caution
to avoid addiction with a dying patient. The patient should not be kept heavily sedated. Most
patients want their pain relieved without excessive grogginess or sleepiness. Terminally ill
patients who do experience physical pain should have medication available and provided
whenever needed. Pain relief is best achieved by scheduled administration rather than
administration only when pain returns.
6. ANS: 2, 4
Life review is thought to help confirm a person’s worth and help that person find meaning in his
or her life. It also helps to resolve old regrets and mistakes.
7. ANS: 3
Hearing is thought to be perceived longer than other senses as death nears. The husband may
find some peace in supporting his wife through the dying experience.
8. ANS: 3
Many nurses deal with death much more often than other people. The only option that recognizes
and accepts the assistant’s response with compassion is 3. None of the other options are
therapeutic. They deny the assistant the opportunity to learn and grow from this experience.
9. ANS: 4
Of the options presented, only the power of attorney identifies a person who can make health
care decisions when the patient is unable to. The other documents described address organ
donation, naming an executor, and advance directives.
10. ANS: 2, 3, 4, 5
Five Wishes communicates how the patient wishes to be treated in their final days. Distribution
of property is not a component of this document.
Chapter 20: Complementary and Alternative Therapies
1. ANS: 3
The use of herbal remedies instead of receiving chemotherapy and radiotherapy by a cancer
client is an example of alternative or nontraditional therapy. Complementary therapy is
nontraditional therapy used along with conventional therapy. Conventional therapy focuses on
conditions that are treated by correcting the underlying physiologic processes with drugs,
surgery, diet, and physical manipulation. Allopathic therapy refers to medical therapy that is
sometimes involved with Western medicine, biomedicine, evidence-based medicine, or modern
medicine.
2. ANS: 2
Guided imagery uses mind and body interventions and focuses on interactions among the brain,
mind, body, and behavior. Chiropractic is a form of manipulative and body-based practices and
refers to manipulation or movement of one or more parts of the body. Ginkgo biloba is an herbal
remedy drug and is used to control seizures. Homeopathy is a form of the whole medicine
system and is built on complete systems of theory and practice that have come from different
cultures separate from conventional medicine.
3. ANS: 1, 2, 4
Herbs, minerals, and vitamins are all consumed with an intended health outcome in mind. Tai chi
and Pilates are physical activities that do not involve any consumable products.
4. ANS: 4
All of these therapies may be used to alleviate pain and improve function; however, the unique
feature of chiropractic is the use of spinal manipulation.
5. ANS: 2
The safety and efficacy of nonmainstream practices and therapies often is not known because
they are not regulated like conventional therapies. Because nonmainstream products may interact
with conventional drugs, health care providers need to be aware if patients are using them.
6. ANS: 2
Some Ayurvedic medicine products have been found to contain toxic chemicals, such as lead,
mercury, and arsenic. They are marketed as dietary supplements so do not have to provide
evidence of safety and efficacy. Although they may interact with conventional medications, that
is not the most serious concern.
7. ANS: 1, 2, 3, 4
All statements are true except option 5. Most states have some requirement such as a license or
registration to practice acupuncture.
8. ANS: 4
Mind–body techniques are widely used in many other countries, but are relatively new in the
United States. Research has found that the use of natural products is more common than the
other therapies listed.
9. ANS: 1, 4, 5
The patient has a right to choose nonmainstream therapies. The primary nurse responsibilities are
to document use of these therapies and to direct the patient to sources of information about them.
It is not the nurse’s role to prescribe treatments.
10. ANS: 3
Magnet therapy, light therapy, and healing touch all focus on the manipulation of energy fields to
affect health.
Chapter 21: Neurologic System Introduction
1. ANS: 1, 2, 3, 4
Neurotransmitters include acetylcholine, norepinephrine, epinephrine, and dopamine.
Monoamine oxidase (MAO) inhibitor is not a neurotransmitter, but an enzyme that degrades
dopamine and increases available dopamine.
2. ANS: 1, 2, 3, 5
Normal aging of the neurologic system includes a decrease in the number of neurons, deposits of
lipofuscin and amyloid in nerve cells, retention of normal cognition despite loss of neurons, and
decrease in brain size and enlargement of ventricles. Reflexes are usually intact, except the
Achilles tendon jerk is often absent.
3. ANS: 3
A stuporous altered level of consciousness response is defined as decreased responsiveness
accompanied by lack of spontaneous motor activity. Somnolent is unnatural drowsiness or
sleepiness. Lethargy describes excessive drowsiness. Semicomatose is defined as a stuporous
patient who can be aroused.
4. ANS: 90 degrees
A patient with normal strength should be able to lift each leg at least 90 degrees while lying
supine.
5. ANS: 3
To help decrease intracranial pressure (ICP), the nurse should avoid flexing the patient’s neck
and hips. Suctioning the patient frequently, encouraging isometric exercises, and providing
continuous stimulation to the patient increase ICP.
6. ANS: 2
The earliest sign of increased intracranial pressure (ICP) is a change in the patient’s level of
consciousness. Pupillary and blood pressure changes are a late sign of increased ICP. Motor and
sensory functions may change but are not the earliest signs of increased ICP.
Chapter 22: Neurologic Disorders
1. ANS: 1, 2, 5
Factors that trigger migraines headaches include alcohol, menstruation, and certain foods.
Exposure to light can aggravate a migraine after it has started. Changes in environmental
temperature do not trigger migraines.
2. ANS: 3, 4, 5
Nursing measures for a patient having a generalized seizure include turning the patient to one
side to maintain a patent airway, moving objects away from the patient to prevent injury, and
noting the time the seizure began. The patient should not be restrained, so any type of restraints
should not be applied. Inserting a tongue blade between the teeth can result in injury to the
mouth.
3. ANS: 2, 3
Proper management of an external ventricular drainage system includes strict aseptic technique
when cleansing the insertion site and keeping the zero point of the drip chamber at the level of
the external auditory canal. The drainage tube can be clamped when the patient is repositioned
and then the drainage tube is restored to the correct level and unclamped. The drainage tube
should not be irrigated.
4. ANS: 3
To help decrease intracranial pressure (ICP), the nurse should avoid flexing the patient’s neck
and hips. Suctioning the patient frequently, encouraging isometric exercises, and providing
continuous stimulation to the patient increase ICP.
5. ANS: dopamine
A deficit of the neurotransmitter dopamine is associated with Parkinson disease and can
contribute to the loss of motor function.
Chapter 23: Cerebrovascular Accident
1. ANS: brainstem
The brainstem is the area where the structures that control respirations and heart rate are located.
2. ANS: 3
Recognizing symptoms of a transient ischemic attack (TIA) is important because it is a warning
sign of a future stroke. TIA is not a symptom of a brain tumor because the neurologic signs and
symptoms resolve with no permanent effects and no permanent disability. TIAs are related to
embolic strokes and not hemorrhagic strokes.
3. ANS: 1, 2, 3, 4, 5
Signs and symptoms present in both transient ischemic attack (TIA) and stroke include visual
disturbances, dysphagia, drooping mouth, confusion, and weakness.
4. ANS: 4
Transient ischemic attacks (TIAs) and stroke are different because an infarction occurs with
stroke but not with a TIA. Weakness and impaired balance are symptoms of both stroke and TIA,
and anticoagulants are often used with both conditions. Brain imaging studies can show
circulatory changes with both TIAs and stroke.
5. ANS: 4
The nurse needs to notify the physician if a patient taking an anticoagulant has an international
normalized ratio (INR) greater than 3 because of the risk of bleeding. An INR of 2 to 3 is within
normal limits. The physician does not have to be called for an INR of 1.5.
6. ANS: 1
Ischemic strokes occur in 80% of strokes. An incomplete stroke could be thought of as a
transient ischemic attack (TIA). Hemorrhagic strokes account for 20% of all strokes. A
subarachnoid hemorrhage is a type of hemorrhagic stroke that occurs between the arachnoid and
pia mater layers of the brain covering.
7. ANS: dysarthria
Dysarthria is present when an alert stroke patient speaks slowly with great effort and with
prolonged words that are hard to understand.
8. ANS: 2, 4, 5
Modifiable risk factors for stroke include those factors that can be changed, such as obesity,
hypertension, and cigarette smoking. Nonmodifiable risk factors that cannot be changed include
age and gender.
9. ANS: 1, 2, 3
Factors that are necessary for the most successful use of recombinant tissue plasminogen
activator (rt-PA) in the stroke patient include that the patient is not taking warfarin (Coumadin),
that the medication is only given after the ischemic stroke, and that the intravenous (IV)
administration of the drug is given within 3 hours of the onset of symptoms. In some select
patients, it can be given between 3 and 4.5 hours after the onset of symptoms. The drug is not
given concurrently with heparin and the drug is not given deep, intramuscularly into a large
muscle mass but always given IV.
10. ANS: 2, 3, 5
The interventions that are appropriate for a long-term care stroke patient with aphasia are helping
the patient find the right word if the patient becomes frustrated while attempting to find the
word, give praise to the patient when attempting to verbalize, and establish a system such as
patient blinks for the nonverbal patient to communicate. The nurse should not insist that the
patient express needs verbally and should also not encourage families to speak for the patient
rather than expecting the patient to speak.
Chapter 24: Spinal Cord Injury
1. ANS: 2
A patient with a complete transection of the spinal cord at T8 has paraplegia. A patient with a
high cervical injury at or above C5 will always be dependent on a ventilator. A patient who
cannot be aroused even by a powerful stimulus is said to be in a coma or comatose. Tetraplegia
is used to be called quadriplegia and refers to a patient with a high cervical injury who has loss
of motor and sensory function in all four extremities.
2. ANS: 1
Spinal shock is resolving when there are spastic, involuntary movements of the extremities.
Blood pressure and the patient sensing light touch and pressure have no relationship to the
resolving of spinal shock. During the period of spinal shock, and not with the resolution of spinal
shock, paralysis is described as flaccid and the involved extremity or muscle group has no tone.
3. ANS: autonomic dysreflexia
Autonomic dysreflexia is a potentially dangerous problem and is an exaggerated response of the
autonomic system to some noxious (painful) stimuli. It occurs in patients whose spinal injury is
at or above the level of T6.
4. ANS: 3
A patient’s bladder begins to empty spontaneously after spinal shock has resolved because intact
reflex activity is causing the bladder to empty. The bladder becomes spastic and may
spontaneously empty. Generally, in 1 to 2 years, a gradual reduction in spastic episodes occurs. It
does not mean that the patient has regained normal bladder control, or that the spinal cord is
beginning to heal. The patient may be a good candidate for bladder retraining.
5. ANS: 1, 2, 4, 5
Patient teaching for women with spinal cord injuries includes that pregnancy is still possible and
that, if pregnancy occurs, cesarean section will be necessary if the lesion is high. Also, menstrual
cycles will resume in women with spinal cord injuries. Although there may be a lack of vaginal
sensation, some women with spinal cord injuries do experience orgasm even if it is not vaginally
triggered.
6. ANS: 3, 4, 5
Interventions for a suspected spinal cord injury (SCI) patient should include opening the airway
using the jaw-thrust method instead of the head tilt–chin lift method to prevent further damage to
the spinal cord. Once the airway has been opened, 100% O2 may be administered by mask and
manual resuscitator (e.g., an Ambu bag). The risk of additional damage is especially high with
cervical injury. It is also important to maintain alignment and immobilization of the spinal
column and avoid any flexion of the neck, even that caused by propping the patient’s head on a
pillow or other support.
7. ANS: 1
The purpose of a skeletal traction device after a spinal cord injury (SCI) is to align and
immobilize the vertebrae to prevent further cord damage. Skeletal traction devices do not apply
tension to the spinal cord to keep it straight, nor do they have any relationship to healing of the
spinal cord. The SCI traction device does not ensure an open airway because the neck should
already be in appropriate alignment to keep the airway open.
8. ANS: 3
Methylprednisolone needs to be given within the first 8 hours of injury to spinal cord injury
(SCI) patients to reduce damage to the cellular membrane of the cord and limit the neurologic
effects of the injury. This drug is not used to prevent allergic reactions to diagnostic dyes, nor
does it have any effect on boosting patients’ immune system. This drug does not promote
regeneration of neurons.
9. ANS: 3
Nursing care during the acute phase of spinal cord injury (SCI) should include avoiding grasping
muscles when performing range-of-motion exercises and instead supporting the joints above and
below the affected muscle groups with the caregiver’s palms of the hands. Injectable drugs
should be administered above the level of paralysis for better absorption of the medication and to
avoid injury. Patients in cervical traction should never turn themselves to maintain muscle
strength. Passive range-of-motion exercises need to be performed by the health care provider.
Teaching catheter care is not performed during the acute phase of an SCI but is addressed during
the rehabilitation phase of the injury. Halo vests allow the paralyzed patient to be moved out of
bed and allow the patient who is not paralyzed to be ambulatory.
10. ANS: 1, 3, 5
Postoperative care for the laminectomy patient includes inspecting the skin under the back brace
for signs of pressure, irritation, or skin breakdown; administering analgesics and muscle
relaxants as ordered to manage pain; and comparing neurologic findings with preoperative
assessments and reporting any decrease in sensory or motor responses to the physician. To
reduce strain on the operative site, the bed needs to be kept flat or only slightly elevated and not
in a high Fowler position. Inform the physician if clear, not bloody, drainage is observed coming
from the incision. Clear drainage could indicate a cerebrospinal fluid (CSF) leak.
Chapter 25: Respiratory System Introduction
1. ANS: 3
Turbinates are folds of tissue on the side walls of the internal nose. They increase the surface
area that inspired air crosses, and that air is quickly warmed to body temperature. They also
contain openings through which secretions drain from the sinuses. Turbinates do not trap
inspired particles or have any effect on inspired microorganisms. They also have no odor
detection properties.
2. ANS: 1, 2, 3, 4
The anatomic and physiologic changes in the nose, sinuses, and throat in older people include
thinning of the mucous membrane, more frequent nasal obstruction because of the softening of
the cartilage of the external nose, decreased mucous production, and decreased sense of smell.
Older people have a greater risk of epistaxis, especially those taking anticoagulants to slow blood
clotting.
3. ANS: 1
When performing tracheal suctioning, no more than 10 to 15 seconds should be taken to remove
the catheter and apply suction because the process removes oxygen as well as secretions and can
cause the patient to become hypoxic.
4. ANS: 1, 4, 5
Nasal hairs and mucus trap particles that enter the airway. Tonsils and adenoids are lymphoid
tissue that protects against pathogens that enter the pharynx. The Eustachian tubes equalize
pressure between the middle ear and the environment. The pleura surrounds the lungs.
5. ANS: 4
Orthopnea specifically refers to difficulty breathing in a flat position. Dyspnea is difficulty
breathing, bradypnea means slow respirations, and tachypnea is rapid respirations.
6. ANS: 1
Pack-years is a term used to quantify a smoking history. It is obtained by multiplying the packs
smoked each day times the numbers of years that the person smoked.
7. ANS: 2
A wheeze is a sound made when air is forced through narrowed airways. It is commonly heard in
patients with asthma and COPD. It may be high pitched or low pitched.
8. ANS: 3
An iodine radioisotope is used in contrast media during imaging procedures. Iodine is also found
in seafood. Patients who are allergic to seafood may also be allergic to iodine-based contrast
media. Therefore, a medium that does not contain iodine may be used or the patient may be
pretreated with antihistamines to prevent an allergic reaction.
9. ANS: 1
Readings below 90% should be reported to a supervisor. The patient’s oxygenation status is less
than normal and the oxygen available to the tissues is inadequate.
10. ANS: 3
Both first- and second-generation antihistamines have similar effects. The main difference is that
first-generation drugs cause more drowsiness than second generation.
Chapter 26: Upper Respiratory Disorders
1. ANS: 4
After nasal surgery, if the mustache dressing used to absorb drainage becomes saturated, then the
nurse needs to change it. The nurse also needs to document the number of dressings saturated
and the frequency of changes. Only the surgeon should remove the packing. Just removing the
dressing and not applying a new one would not absorb drainage but may cause it to drip onto the
patient. Just reinforcing the dressing would make the dressing too bulky and could prevent
absorption of drainage from the nose.
2. ANS: 3
When a postoperative patient is restless with an increased heart rate from 70 to 90 bpm and a
respiratory rate of 20/minute, and no fresh bleeding is evident on the nasal dressing, then the
nurse needs to inspect the back of the throat. Also, the nurse needs to check for frequent
swallowing and inspect any vomitus and stool for signs of blood or red, maroon, or black stools.
The physician needs to be notified if there are any indications of excessive bleeding; frequent
saturation of the dressing with blood; increased pulse and respirations; restlessness; decreased
blood pressure; frequent swallowing; and hematemesis. Blood would be ordered based upon the
patient’s diagnostic laboratory results. Vital signs do not need to be taken again. Inspecting the
back of the throat would be a faster intervention and alert the nurse more quickly. If there is
blood in the back of the throat, then giving the patient fluids could cause vomiting and possible
aspiration.
3. ANS: 1, 2, 3
A patient who has asthma, nasal polyps, and an aspirin allergy is said to have triad disease.
Laryngeal nodules and sinusitis are not considered part of triad disease.
4. ANS: 1
Immediate treatment of epistaxis includes having the patient sit down and lean forward and then
pinch and apply direct pressure to the nostrils. Placing the patient in semi-Fowler position with
head tilted back or lying supine with a cold pack to the nose would only promote blood to flow
down the back of the throat, causing nausea and vomiting and not stopping the bleeding. Sitting
up and leaning forward with the head between the knees and no pressure on the nostrils would
not control or stop the bleeding.
5. ANS: 3
The priority patient problem for a patient who had a total laryngectomy 24 hours ago is potential
airway obstruction. The patient’s oxygen status must be monitored frequently so that factors such
as positioning, fluids, and humidification can be adjusted as needed. Anxiety, pain, and impaired
communication are important patient problems, but potential airway obstruction takes priority
over them.
6. ANS: 1, 3, 4
The differences in needs for a postoperative supraglottic laryngectomy patient and a
postoperative total laryngectomy patient are that the total laryngectomy patient will be able to
swallow more easily. Also, the supraglottic laryngectomy patient will have a temporary
tracheostomy and be at greater risk for aspiration, while the total laryngectomy patient’s
tracheostomy will be permanent. The voice on the total laryngectomy patient will be lost and that
patient is more likely to have a radical neck dissection. The voice on the supraglottic
laryngectomy patient will be preserved and that patient will not need a radical neck dissection.
Chapter 27: Acute Lower Respiratory Tract Disorders
1. ANS: 1
Common complaints related to respiratory disorders include cough, dyspnea, and pain. When
assessing a cough, it is important to include the onset, duration, frequency, type (wet or dry),
severity, and related symptoms, such as sputum production and characteristics (color,
consistency, odor, amount) and pain. Just documenting “coughing up a lot” is too subjective and
not objective enough. Documenting “physical activity seeming to cause coughing spells” is also
not complete enough. The word “seem” should not be used when documenting unless it is a
direct quote from the patient. And “coughing up less sputum than yesterday” does not relay all of
the characteristics of the sputum.
2. ANS: 4
Both influenza (flu) and the common cold are equally likely to have serious complications such
as viral and bacterial pneumonitis. The diagnosis of each is usually based upon the patient’s
history and physical findings. Influenza is not just a severe cold but an acute viral respiratory
infection accompanied by a fever, although patients with severe cases of the common cold can
also develop fever. The common cold is also a viral infection that invades the upper respiratory
tract and is spread similar to the flu via airborne droplets. The common cold does not require
antimicrobial therapy.
3. ANS: hypoxemia
Edema and secretions that occur with pneumonia interfere with the exchange of gases in the
lungs. Hypoxemia means that the level of O2 in the blood is low. Patients with hypoxemia are
restless and tachycardic, and are tachypneic. Because normal oxygenation is essential for all
body tissues, efforts must be made to improve the patient’s gas exchange.
4. ANS: 4
In trauma cases, a chest wound may be present. If air can be heard or felt moving in and out of
the wound, then it is called a sucking chest wound. Always cover any open chest wound with an
airtight dressing taped on three sides. This is called a vented dressing because it lets air escape
through the chest wound but prevents additional air from entering the chest through the wound.
If the dressing completely sealed an open chest wound, then air could continue to leak from the
lung into the pleural space and accumulate in the space, causing a tension pneumothorax. The
vented dressing allows air to escape and not drainage from the pleural space. Sealing the wound
has nothing to do with preventing bacterial contamination. The vented dressing allows air to
escape from the injured lung and does not prevent it from escaping.
5. ANS: 1
The term flail chest refers to an injury in which two adjacent ribs on the same side of the chest
are each broken into two or more segments. The affected section of the rib cage is detached from
the rest of the rib cage and moves independently, so that the segment moves in with inspiration
and out with expiration. The pattern of movement is exactly the opposite of the movement of an
intact chest wall and is called paradoxical movement. Ventilation is impaired, and the patient
becomes hypoxemic. With a tension pneumothorax, air repeatedly enters the pleural space with
inspiration, causing the pressure to rise. Because air is not escaping from the wound, the
accumulating pressure causes the affected lung to collapse. The heart, trachea, esophagus, and
great blood vessels shift toward the unaffected side. This is called a mediastinal shift, a condition
that interferes with blood return to the heart. This is a medical emergency because both the
respiratory and circulatory systems are affected. If not corrected, then cardiac output falls and the
patient dies. The main cause of respiratory alkalosis is hyperventilation, a compensatory
breathing mechanism resulting in a loss of carbon dioxide. Cheyne-Stokes respirations are
related to severe brain pathology. The breaths become progressively deeper and then become
more shallow, followed by a period of apnea.
6. ANS: 1, 2, 5
Interventions to decrease the risk of further emboli include antiembolism and pneumatic
compression stockings, active and passive range-of-motion exercises for immobilized patients,
and early ambulation after surgery. Do not wait for wound healing to being ambulation. Also,
avoid constricting clothing such as garters or tight girdles and avoid prolonged pressure on the
back of the knee. Cushions and pillows should not be placed under the legs where circulation
might be impaired.
Chapter 28: Chronic Lower Respiratory Tract Disorders
1. ANS: 4
During the late phase, which lasts several hours or days, the airways are hyperresponsive. The
patient is at risk for another acute episode until the late phase subsides. During the early phase of
an acute episode, the airways constrict (bronchoconstriction or bronchospasm) and become
edematous. Mucus secretion increases (not decreases) and the patient becomes hypoxemic with
compensatory hyperventilation.
2. ANS: 1, 3
Appropriate drugs to relieve acute asthma symptoms include beta2-receptor agonists and
anticholinergics. Anticholinergics enhance the bronchodilating action of beta2-receptor agonists.
Drugs used to treat asthma are classified as those that provide long-term control (“controllers”)
and those that relieve acute symptoms (“relievers”). Controllers are drugs that provide long-term
control such as systemic corticosteroids (used for asthma that does not respond to other
controllers) and leukotriene modifiers. A decongestant or nasal decongestant is a type of
pharmaceutical drug that is used to relieve nasal congestion in the upper respiratory tract. The
active ingredient in most decongestants is either pseudoephedrine or phenylephrine.
3. ANS: 2
Many chronic asthma patients are taught to use peak expiratory flow rate (PEFR) meters
routinely. Initially, the patient uses the meter twice daily to establish a baseline (personal best)
PEFR and then daily to monitor level of control. When a daily PEFR reading is 80% to 100% of
the patient’s personal best, the patient should continue current medications.
4. ANS: 3
Chronic bronchitis is bronchial inflammation characterized by increased production of mucus
and chronic cough that persist for at least 3 months of the year for 2 consecutive years, as well as
by impaired ciliary action. The inflammation, which is caused by inhaled irritants (including
cigarette smoke), causes blood vessels to dilate and the mucosa to become edematous.
Centriacinar emphysema is associated primarily with cigarette smoking and affects mainly the
respiratory bronchioles. The walls of respiratory bronchioles enlarge and break down, whereas
the alveoli remain intact. Elastic recoil diminishes, and the airways partially collapse. Acute
asthma attacks can be triggered by allergic reactions to substances in the environment, by
exercise, and by infection; stress can aggravated them. Mycobacterium tuberculosis, an acid-fast
aerobic bacterium, causes tuberculosis. The disease is spread through droplets emitted during
coughing, laughing, sneezing, and singing. Drug-resistant strains include multidrug-resistant
tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB).
5. ANS: 2
Hypoxic drive is what tells the chronic obstructive pulmonary disease (COPD) patient to breathe.
When a COPD patient has a hypoxic drive, the nurse needs to make sure that the patient’s O2
therapy does not exceed 3 L/minute. High levels of O2 are not administered because patients with
COPD may rely on hypoxic drive to breathe. A healthy person’s respirations are stimulated by
rising PaCO2 levels. The patient with COPD who retains CO2, however, has adapted to high
blood CO2 and relies on low PaO2 to stimulate breathing. A high concentration of O2 may raise
the PaO2 level so that the patient’s stimulus to breathe is lost and respiratory depression may
result. The patient needs pursed-lip breathing and not deep-breathing exercise to improve
oxygenation. The nurse should instruct the patient to breathe in through the nose and exhale
slowly through the mouth, with the lips almost closed. Pursed-lip breathing reduces the collapse
of airways with exhalation and reduces dyspnea. The patient should not remain inactive and in
bed. Pulmonary rehabilitation programs are individualized and use progressive exercise with the
patient walking 10 to 15 minutes every day or every other day. The goal is to exercise
comfortably for 45 minutes to 1 hour daily or every other day. Many COPD patients live with
constantly high levels of CO2. Respiratory acidosis or retention of CO2 must be confirmed by
blood gas analysis.
6. ANS: 4
The nurse needs to contact the nursing supervisor to report signs of possible heart failure. Signs
of failure include increasing dyspnea, decreasing urine output, tachycardia, and dependent
edema. Patients with chronic bronchitis and emphysema are at risk for right-sided heart failure
that eventually affects the left side of the heart as well. The patient’s O2 flow rate should not be
higher than 3 L/minute except in a code. Increased walking should not be done because it would
increase dyspnea and heart rate. Place the patient in a high Fowler position or seat the patient on
the bedside with the arms folded on the overbed table to promote full expansion of the lungs. The
findings need to be documented but only after the patient has been treated and the supervisor
notified.
7. ANS: 1
The first priority for a patient with cystic fibrosis is airway obstruction. Airway and breathing are
always the top priorities when caring for patients. Cystic fibrosis is a hereditary disorder
characterized by dysfunction of the exocrine glands and the production of thick, tenacious
mucus. Cough is the first pulmonary symptom. Over time, but not initially, symptoms progress
with increasing dyspnea, decreasing exercise tolerance, potential for infection, and weight loss.
Potential for fluid volume deficit is not one of the top priorities for cystic fibrosis.
8. ANS: 1, 2, 3, 4
Patient teaching for active tuberculosis includes a balanced diet to help the body recover from an
infectious disease, covering the mouth when coughing to prevent spreading the infection,
completing the entire course of therapy to prevent a recurrence of the disease, and taking
antitubercular drugs at bedtime to reduce nausea and vomiting. People with tuberculosis are
usually hospitalized for just a short time, if at all, so that efficient patient teaching and written
material can be generated. Just taking the antitubercular drugs does not prevent transmission of
the disease. The patient’s sputum cultures need to show low counts of acid-fast bacilli before the
patient can be discharged.
9. ANS: isoniazid (INH)
Isoniazid (INH) is the primary drug for the prevention and treatment of tuberculosis. An example
of an initial regimen for a person with culture-positive pulmonary tuberculosis caused by
drug-sensitive organisms is as follows: INH, rifampin, pyrazinamide, and ethambutol given
every day for 56 doses. The patient would then continue therapy with only INH and rifampin
daily for 126 doses.
10. ANS: smoking
Lung cancer, the leading cause of cancer death in the United States, is usually caused by
cigarette smoking and is most treatable if detected while still localized.
Chapter 29: Hematologic System Introduction
1. ANS: type O
People with type O blood have neither the A nor the B antigen. Those with type A blood have
the A antigen, those with type B blood have the B antigen, those with type AB blood have both
the A and B antigens.
2. ANS: platelets
Petechiae are small (1 to 3 mm), red or reddish purple pinpoint spots on the skin due to blood
capillaries breaking and leaking small amounts of blood into the surrounding tissues. Petechiae
can be confused with a skin rash. Petechiae generally signal that the patient has a very low
platelet count.
3. ANS: type O
People with type O− blood are considered universal donors because their blood does not contain
any of the A, B, or Rh antigens and can safely be given to anyone. Those with AB+ blood are
considered universal recipients because their blood contains the A, B, and Rh antigens, so they
can safely receive any type of blood.
4. ANS: 4
While receiving a blood transfusion, if the patient experiences back or chest pain, fever, or chills,
then stop the transfusion immediately and keep the intravenous line open with normal saline.
Other emergency reactions include decreased blood pressure, urticaria, wheezing, dyspnea,
coughing, or blood in the urine. Then take the vital signs and notify the physician, nursing
supervisor, and blood bank immediately. Acetaminophen should not be administered unless
ordered by the physician. Anticipate administering O2, epinephrine, Solu-Cortef, furosemide
(Lasix), and antipyretics as prescribed by the physician. There are four main types of transfusion
reactions with blood or any of the blood components: (1) hemolytic, (2) anaphylactic, (3) febrile,
and (4) circulatory overload. Save the unused portion of the blood bag for the blood bank and
anticipate collecting blood and urine samples from the patient for evaluation.
5. ANS: 4
When a patient with orthostasis suddenly moves from a sitting or lying to a standing posture, the
blood pressure falls putting the patient at risk for fainting and falling. Someone should be present
for support and the patient should be instructed to move slowly.
6. ANS: 3
Petechiae are tiny red spots on the skin. In contrast, ecchymoses (also called bruises) are larger
purple discolorations. When bleeding occurs under the skin, the lesion is called purpura. As they
heal, purpura lesions go through the same color changes as bruises.
7. ANS: 1, 2, 3
The first three options are correct. Fasting is not necessary. The specimen is usually taken from
the iliac bone, specifically the posterior superior spine of the pelvis.
8. ANS: 2
Platelets play a critical role in blood clotting. A patient with a low platelet count is at risk for
bleeding.
9. ANS: 1, 3, 4
To minimize trauma and possible bleeding, he should shave with an electric razor and use a soft
toothbrush. He must not engage in contact sports while on this treatment because of the potential
for injury. Aspirin and NSAIDs like ibuprofen are contraindicated because they impair the
clotting process. The amount of fluid consumed in a day is not relevant to his risk for bleeding.
10. ANS: 3
Erythropoietin stimulates the production of red blood cells.
11. ANS: 1
The first few minutes of a platelet infusion is the critical time when a reaction might occur. Signs
of a reaction include back pain, fever, chills, and/or decreased blood pressure. Headache would
not require discontinuing the infusion. Vital signs should be monitored, not urine output. The
CNA cannot take responsibility for monitoring the patient.
Chapter 30: Hematologic Disorders
1. ANS: 1, 2, 5
Blood is redistributed from the skin and intestinal tract to the heart and brain to maintain critical
function. The heart and respiratory rates increase to provide additional oxygen to the cells.
Erythropoietin production increases to stimulate production of RBCs.
2. ANS: 3
Platelets aid the body in clotting. Ecchymosis and petechiae are signs of bleeding. Patients with
low platelets will be a high risk for bleeding. Other choices have nothing to do with clotting.
3. ANS: 2
Pernicious anemia is caused by the inability to absorb adequate vitamin B12 due to lack of
intrinsic factor in the stomach. It is treated by prescribing vitamin B12. If the patient has
neurological symptoms, a monthly intramuscular injection of vitamin B12 (cyanocobalamin) is
needed. Other patients may be prescribed large doses of oral vitamin B12.
4. ANS: 2, 5
For patients with a low red blood cell (RBC) count, it is appropriate to allow rest between
periods of activity and provide extra blankets as needed to maintain warmth. Symptoms of a low
RBC count that would prompt an RBC transfusion include shortness of breath, tachycardia,
decreased blood pressure, chest pain, lightheadedness, and extreme fatigue. Patients may
experience orthostatic vital sign changes in pulse and blood pressure when they rise. These
patients are dyspneic because they do not have enough RBCs to carry O2 to all their tissues, yet
the lungs will sound clear to auscultation without wheezing, crackles, or rhonchi. Rectal
temperatures and suppositories do not need to be avoided unless a bleeding disorder is also
noted. Fluids and fiber do not need to be increased, and fresh flowers may remain in the room.
5. ANS: 1
Aplastic anemia results from the complete failure of the bone marrow. Signs and symptoms of
aplastic anemia can include pallor, extreme fatigue, tachycardia, shortness of breath,
hypotension, unusually prolonged or spontaneous bleeding, and frequent infections that do not
resolve. In addition to abnormally low red blood cell (RBC), white blood cell (WBC), and
platelet counts on blood tests, patients with aplastic anemia have abnormally low numbers of
blood-making cells in their bone marrow. With aplastic anemia, the bone marrow does not make
adequate amounts of the blood cells; with autoimmune hemolytic anemia, the bone marrow
makes adequate amounts of the blood cells, but they are destroyed once they are released into the
circulation. Causes of autoimmune hemolytic anemia can include certain infections, drug
reactions, and certain cancers. As with aplastic anemia, many times the cause of the hemolytic
anemia is never identified. Patients with hemolytic anemia usually have high bilirubin levels in
their blood from all the RBCs being lysed (broken down) and a positive result on a direct
Coombs antiglobulin blood test. Sickle cell anemia is a genetic disease occurring almost
exclusively in African Americans where normally disk-shaped RBCs become sickle shaped.
These misshapen blood cells are much more fragile than normal RBCs, so the sickled cells easily
rupture as they pass through small capillaries. This leads to a chronic anemia. Iron deficiency
anemia is caused by inadequate dietary intake of iron or inadequate absorption of dietary iron.
6. ANS: 3
Symptoms of sickle cell anemia include persistently low red blood cell (RBC) counts, fatigue,
and jaundice. Sickle cell crisis occurs when blood flow is obstructed due to abnormally shaped,
sickled cells getting stuck in the small capillaries of the body, obstructing blood flow. With
circulation obstructed, tissue hypoxia occurs, causing severe pain. Patients in a sickle cell crisis
often have a fever, either because infection precipitated the crisis or as part of the inflammatory
response to tissue hypoxia. The cells do not lack hemoglobin, nor are the cells unable to transport
adequate O2. The lack of O2 is due to the blocked circulation to the tissues. Although O2 therapy
is often prescribed, it is of little benefit in reversing the crisis. Sickle cell anemia and crisis are
not related to a bone marrow disease.
7. ANS: 1, 2, 4, 5
Factors that can trigger a sickle cell crisis include dehydration, infection, smoking, and cold
weather changes. Other factors include excessive alcohol consumption and overexertion.
Symptoms vary depending on where the circulation is blocked by the sickled red blood cells
(RBCs). Low iron intake is related to iron deficiency anemia and to sickle cell crisis.
8. ANS: 4
The pain with sickle cell crisis can be very severe. The patient needs adequate pain relief during
these episodes even if they last for several days. Usually, intravenous morphine is prescribed.
Initially, it is not unusual for patients to need large amounts of medication to control their pain.
Sometimes patient-controlled analgesia is used. Addiction to opioids can be a problem, so
physicians try to quickly transition the patient from intravenous opioids to oral opioids to
nonopioid pain relievers such as nonsteroidal anti-inflammatory drugs (NSAIDs) as the crisis
resolves. Physical therapy and nerve blocks would not be helpful during a sickle cell crisis. Red
blood cell (RBC) transfusions may be prescribed to correct the anemia and help the body
oxygenate tissues.
9. ANS: 1
Disseminated intravascular coagulation (DIC) is a hypercoagulable state, meaning that blood
clotting is abnormally increased. DIC occurs when overstimulation of the normal coagulation
cascade results in simultaneous thrombosis and hemorrhage. DIC is always secondary to another
pathologic process, such as overwhelming sepsis, shock, major trauma, crush injuries, burns,
cancer, acute tumor lysis syndrome, or obstetric complications such as abruptio placentae or fetal
death. Coagulation occurs at so many sites in the body that eventually all available platelets and
clotting factors are depleted and uncontrolled hemorrhage results. Both idiopathic
thrombocytopenic purpura (ITP) and thrombotic thrombocytopenic purpura (TTP) are examples
of thrombocytopenia resulting from too many platelets being either destroyed or consumed. Both
of these disorders are abnormal immunologic processes that result in thrombocytopenia.
Hemophilia is a genetic disease wherein the affected person lacks some of the blood-clotting
factors normally found in plasma.
10. ANS: VIII
Patients with hemophilia A need factor VIII, which is found in fresh frozen plasma (FFP) and
cryoprecipitate. These patients also need adequate pain relief during these episodes even if they
last several days.
Chapter 31: Immunologic System Introduction
1. ANS: bacteria
Neutrophils fight bacterial infections. They are the most numerous of the white blood cells
(WBCs), comprising approximately 60% of all the WBCs. The bone marrow is capable of
producing huge numbers of neutrophils to fight infection.
2. ANS: active
Acquired antibody immunity can be active or passive. Active acquired immunity occurs when a
person synthesizes his or her own antibodies in response to a pathogen. A person develops active
acquired immunity when he or she manufactures antibodies in response to an infection or a
vaccination. Active acquired immunity is permanent.
3. ANS: 1, 2, 3, 5
With advancing age, the bone marrow becomes less productive and the immune system function
is generally not affected under normal circumstances. The lymphatic tissue shrinks, resulting in
fewer and smaller lymph nodes. Even if a higher production of blood cells is needed, the bone
marrow usually can respond to the increased demand, given more time. However, as with the
bone marrow, this does not generally affect the overall health of an individual.
4. ANS: 2
For approximately 2 weeks after transplantation, when the new bone marrow is engrafting,
patients are severely neutropenic and at very high risk for infection.
5. ANS: 1
Immunodeficiency occurs when the body is unable to launch an adequate immune response,
resulting in an increased risk for infection. Assessing for signs and symptoms of infection is a
priority when collecting data on a patient with an immune disorder. Unexplained weight loss,
increased blood pressure, and characteristics of urine are important to assess, but signs and
symptoms of infection are the most important to determine.
6. ANS: 3
Normal white blood cell (WBC) counts range between 5000 and 10,000 WBCs per cubic
millimeter (mm3) of blood. A person’s WBCs can vary by 2000/mm3 of blood on a given day, so
a WBC count of 20,000/mm3 is interpreted as the patient having a severe infection. It is too high
to interpret as a mild infection or that the infection is resolving. If a person has a low and not
high or excessive neutrophil count (as tested in a complete blood count), then it is interpreted as
the patient being at increased risk for infection.
7. ANS: 1, 2
Compromised host precautions are needed when a patient’s absolute neutrophil count (ANC)
falls below 1000 cells/mm3. Thorough hand washing by visitors and staff caring for these
patients is of extreme importance. Because patients with low white blood cell (WBC) counts can
become infected with their own microorganisms through their gastrointestinal tract, consider
discouraging patients from eating fresh fruits or vegetables and from drinking milk products.
Once the patient’s ANC climbs above 1000 cells/mm3, compromised host precautions can be
discontinued and a regular diet resumed without restrictions. Staff does not need to wear masks
when in the patient’s room, and an isolation room is not needed. Complete vital signs need to be
taken every 4, and not 8, hours.
8. ANS: 2
Antigens are foreign substances that stimulate a response from the immune system whereas
antibodies are proteins that are produced by the immune system to help eradicate antigens. A
phagocyte is a cell that engulfs foreign substances, and a pathogen is an organism that can cause
infection.
9. ANS: 3, 4
For an autologous transplant, the patient’s own bone marrow is harvested. The patient is then
given chemotherapy and radiation to destroy the diseased tissue. Afterward, the patient’s bone
marrow is given back to the patient. Until the patient’s immune system is adequate, he or she
will remain hospitalized in a specialized care setting.
10. ANS: 2
An autologous procedure uses the patient’s own stem cells. An allogeneic transplant used stem
cells from a matched donor. An syngeneic transplant uses cells from an identical match (identical
twin).
Chapter 32: Immunologic Disorders
1. ANS: 3
Neutrophils are white blood cells that play a critical role in protecting the body from pathogens.
When neutrophils are low (neutropenia), the patient is at greatest risk for infection.
2. ANS: 1, 3, 4, 5
Examples of autoimmune diseases are idiopathic thrombocytopenic purpura (ITP), thrombotic
thrombocytopenic purpura (TTP), acute rheumatic fever, type 1 diabetes mellitus, systemic lupus
erythematosus, multiple sclerosis, rheumatoid arthritis, Graves disease, and Hashimoto
thyroiditis. Hodgkin disease is not an autoimmune disorder.
3. ANS: 2
Because platelets are essential for normal blood coagulation, the patient is at risk for excessive
bleeding. The nurse should examine the skin to detect bruising and bleeding.
4. ANS: 1
Epinephrine should be on hand because it reverses the effects of anaphylaxis, raising the blood
pressure and relaxing the bronchi.
5. ANS: 3
The most important finding is an elevation in body temperature which suggests an infection. The
other findings are typical of a leukemia patient having chemotherapy.
6. ANS: 1
Type I immediate hypersensitivity reactions are mediated by immunoglobulin (Ig) E reacting to
common allergens such as dust, pollen, animal dander, insect stings, or various drugs.
7. ANS: 1
During the latent stage, the virus is inactive, resting CD4 host cells. When the resting CD4 host
cells are activated for an immune response, the virus begins to replicate.
8. ANS: 2
HIV enters the body by exposure to bodily fluids (e.g., blood, semen, breast milk, vaginal
secretions) that contain the virus, not by lifestyle or sexual preference. It is not transmitted by the
respiratory tract, contaminated foods, or skin contact.
9. ANS: 2
Infection is the leading cause of death among persons with AIDS because of the reduced CD4
and CD8 cell that would normally allow a person to resist infection.
10. ANS: 4
At this time, no drugs directly destroy HIV. Available drugs primarily work by suppressing the
replication of the virus.
11. ANS: 3
A patient with HIV becomes confused. The best comment to give to the patient’s partner is, “The
patient’s mental status may improve with drug therapy.” Many patients with HIV-induced
encephalopathy improve with zidovudine therapy. Patients with HIV encephalopathy may also
have cognitive and motor impairment or withdraw from social activities because of
embarrassment. It is important to make sure that the patient is safe. Confusion is not rare and
irreversible with HIV and is generally related to HIV. Encephalopathy can occur during the
infection and does not necessarily occur just before death.
Chapter 33: Cardiovascular System Introduction
1. ANS: 4
African Americans have the highest prevalence of hypertension of all ethnic groups, and
African-American women have a higher incidence of hypertension than African-American men.
2. ANS: 2
Transfer of O2 and nutrients between the blood and the tissue cells occurs in the capillaries.
Capillaries consist of a single layer of endothelial cells that allow the efficient delivery of
nutrients and O2 into the tissues and the removal of metabolic wastes from the tissues.
3. ANS: 3
Older adults are at risk for emboli when the intima layer of blood vessels thickens, hardens, and
roughens with age. Anemia is a decrease in number of red blood cells (RBCs) or less than the
normal quantity of hemoglobin in the blood and is the most common disorder of the blood.
Bradycardia is defined as a heart rate below 60 beats/minute. Hypotension is low blood pressure,
especially in the arteries of the systemic circulation, and is generally considered when the
systolic blood pressure is less than 90 millimeters of mercury (mm Hg) or diastolic less than 60
mm Hg.
4. ANS: intermittent claudication
Intermittent claudication is the term used to describe a patient’s complaint of pain and cramping
in the legs that occurs when walking and is relieved by rest. It is associated with decreased
perfusion and can affect any major muscle group distal to (beyond) the point of arterial
occlusion. When the exercise is stopped, the metabolic demands of the muscle tissue decrease,
wastes are removed from the tissues, and the pain is relieved.
5. ANS: 4
Dependent edema develops as a result of systemic disorders, lymphatic dysfunction, deep vein
thrombosis (DVT), or chronic venous insufficiency. The severity of edema is determined by the
nurse pressing the thumb into the edematous area for approximately 5 seconds. The severity is
graded from 1 to 4, depending on the depth of depression: less than ¼ inch (2 mm) = 1; ¼ to ½
inch (4 mm) = 2; ½ to 1 inch (6 mm) = 3; and more than 1 inch (8 mm) = 4. So this patient’s
edema is rated as 2+. 1+ edema is less than ¼ inch (2 mm). Pitting edema is defined as when the
depression of the thumb remains in the edematous area. Mild edema is too subjective, and the
status of the edema needs to be graded objectively. The same area on both extremities should be
compared.
6. ANS: 3
Angiography is an invasive procedure that requires the injection of dye into the vascular system,
which makes the vessels visible on radiographs. The two types of angiography are (1)
arteriography, which examines arteries and (2) venography, which examines veins.
Abnormalities can be visualized and assessed during the procedure. Ultrasonography is when
Doppler ultrasound is used to help diagnose peripheral vascular disease (PVD) and monitor the
changes in blood flow associated with vascular diseases. It is a noninvasive, inexpensive, highly
reliable diagnostic tool. Plethysmography is a noninvasive study used to measure blood flow in
the extremities. Multiple blood pressure cuffs are applied to different parts of the extremities and
variations in pressure from one site to another can show vascular occlusions or obstructions. An
exercise treadmill test is also called a stress test. This noninvasive procedure helps evaluate the
patient’s tolerance for physical activity. Signed consent is required. The patient is asked to walk
for approximately 5 minutes at a rate of 1.5 mph on a treadmill. Continuous electrocardiogram
(ECG) and blood pressure monitoring is done.
7. ANS: 1, 2, 4, 5
A specific type of exercise program that is effective in the management of peripheral vascular
disease (PVD) is the use of Buerger-Allen exercises or active postural exercises. These exercises
allow gravity to fill and empty the blood vessels. Elevating the lower extremities above the level
of the heart promotes venous return and reduces venous stasis. Smoking cessation is critical to
effective management of PVD because smoking causes vasoconstriction. Elastic stockings or
antiembolism hose are useful in the management of PVD. These stockings provide sustained,
evenly distributed pressure over the entire surface of the calves and thighs. Thermotherapy (hot
or cold) should be used cautiously for patients with PVD. If heat is used, they may suffer burns
because their tissues have impaired sensation as a result of tissue ischemia. If cold is used, blood
vessels constrict in response to cold. Clothing can replace thermotherapy effectively by
promoting warmth and preventing chilling and vasoconstriction.
8. ANS: 1, 2, 3, 4
Dabigatran etexilate (Pradaxa, Pradax) is a direct thrombin inhibitor. It is used to prevent stroke
with atrial fibrillation, and in Canada to prevent venous thromboembolism after knee or hip
replacement surgery. It does not require regular blood testing and the same dose can be taken
every day. It needs to be taken with food to reduce gastrointestinal (GI) distress and is safer than
warfarin but can still cause serious bleeding and GI disturbances (nausea and vomiting,
abdominal pain, gastroesophageal reflux disease [GERD], gastritis, ulcer). An overdose cannot
be reversed because no specific antidote exists.
9. ANS: 3
In patients with peripheral artery disease, prompt reporting of any injury to the feet and legs is
very important. The patient also needs to report pain, numbness, coolness, or pale or bluish skin
color. Discharge teaching should also include protecting affected limbs from pressure, trauma,
and temperature extremes. Elevation of the extremities usually is not recommended with arterial
disease. Exercise is encouraged according to the individualized exercise plan, and vasodilator,
not vasoconstrictor, drugs are prescribed.
10. ANS: SA node
For the heart to pump blood through the chambers, nerves must stimulate muscle contractions.
The pattern of conduction follows an orderly and particular route. The SA node initiates the
impulse, and is called the pacemaker.
11. ANS: 1
The three factors that affect stroke volume are preload, contractility, and afterload. Contractility
is the ability of cardiac muscle fibers to shorten and produce a muscle contraction. Preload is the
amount of blood remaining in a ventricle at the end of diastole or the pressure generated at the
end of diastole, not the amount of blood remaining in the atria at the end of diastole. Cardiac
output is not one of the three factors that affect stroke volume. Afterload is the amount of
pressure the ventricles must overcome to eject the blood volume, not the amount of blood
remaining in the ventricles at the end of systole.
12. ANS: 3
If the valves thicken and stiffen, they may not close properly. If this happens, the patient may
have a murmur. Decreased elasticity of connective tissue in the heart muscle, arterial stiffening,
and stretching and dilation of veins do not cause murmurs, nor does an aging heart responding
more slowly to increased demands.
13. ANS: yes
The normal heart rate is 60 to 100 beats per minute (bpm). A rate of 62 bpm is within normal
range.
14. ANS: 4
All antidysrhythmics have the potential to cause additional dysrhythmias. Fluid and electrolyte
imbalance, drowsiness, and diarrhea are not adverse effects common to antidysrhythmic drugs.
15. ANS: 3, 5
Cardiac patients should use unsaturated fats (vegetable oil or olive oil) instead of saturated fats
(butter or lard). Cardiac patients should include foods containing omega-3 fatty acids (salmon,
walnuts, soybeans) and limit sodium intake to 1500 mg/day. They should eat fruits and
vegetables and eat no more than 5 to 7 ounces of meat per day.
16. ANS: 2, 4, 5
Vasoconstriction in the extremities raises the blood pressure by increasing peripheral resistance
to blood flow. Compensation also occurs through sympathetic nervous system stimulation, which
causes catecholamines to be released that increase heart rate; regulation of blood volume by the
kidneys (renal compensation); and enlargement of the ventricular myocardium, which results
from strain and initially increases contractility. Compensation occurs through the sympathetic
nervous system, not the parasympathetic system. When cardiac output falls, so does renal
perfusion, so the kidneys do not eliminate excess fluid. As a result of the renal compensatory
process, aldosterone causes the kidneys to retain sodium and water, which increases blood
volume.
Chapter 34: Cardiac Disorders
1. ANS: 1, 2, 4, 5
Risk factors that can be modified include increased serum lipids (serum cholesterol),
hypertension (high blood pressure), physical inactivity, and stress. Heredity is a risk factor that
cannot be modified.
2. ANS: stable angina
Chest pain that radiates to either arm, the jaw, the neck, or the epigastrium is called stable angina
(also called chronic angina or exertional angina).
3. ANS: 2
Thrombolytics are administered after a myocardial infarction (MI) to destroy clots that have
already formed. Tissue plasminogen activator (t-PA) is an example of a thrombolytic drug.
Heparin is an anticoagulant drug, used to prevent formation of new clots. Aspirin is an
antiplatelet drug used to decrease platelet aggregation. It prolongs bleeding time, and is used to
prevent thromboembolic disorders such as stroke and MI. Lidocaine is an antidysrhythmic drug
used for rapid control of ventricular dysrhythmias during MI, cardiac surgery, cardiac
catheterization, and digitalis intoxication. Neither heparin, aspirin, nor lidocaine destroys
existing clots.
4. ANS: 2
The nurse is correct in telling the patient to inform the physician if there is a weight gain of 3 to
5 pounds in 1 week. The nurse should not advise an immediate vigorous exercise program.
Activity should be gradual and should not cause shortness of breath or severe fatigue. The nurse
should not advise weighing oneself before going to bed. The patient should weigh himself or
herself each morning before breakfast, on the same scale and with the same amount of clothing.
The nurse should not advise the patient to expect to continue having shortness of breath, chest
pain, and cough. Any of these should be reported to the physician.
5. ANS: rejection of the transplanted heart
A heart transplantation patient with symptoms that include elevated temperature, fatigue,
shortness of breath, and irregular heartbeat may be rejecting the donated heart because the body
recognizes it as foreign tissue. The steroid dose usually is increased to help prevent the body
from rejecting the organ.
6. ANS: 1
Mitral stenosis is a narrowing of the opening of the mitral valve, which impedes blood flow from
the left atrium to the left ventricle. As the blood flow decreases, the left atrium dilates to
accommodate the amount of blood not ejected and left atrial pressure increases. Pulmonary
pressure increases, not decreases, as the blood volume backs up into the pulmonary system.
Cardiac output decreases, not increases, because less blood is delivered to the left ventricle.
Right ventricular pressure increases, not decreases, because the workload on the right side of the
heart is increased.
Chapter 35: Vascular Disorders
1. ANS: 2
In a postoperative abdominal aneurysm repair patient, it is most important to monitor the
patient’s intake and output. During repair of an abdominal aneurysm, the aorta is clamped for a
period of time and this can put the patient at risk for renal damage and subsequent renal failure.
Fluid intake and urine output are measured hourly at first, then less often if output is satisfactory.
Declining urine output must be promptly reported to the physician. Neurologic and cardiac issues
are not as important as potential renal damage, so reflexes in the lower extremities, mental status,
and electrocardiograms (ECGs) are not as important to monitor as intake and output.
2. ANS: 1
The most serious complication of venous thrombosis is pulmonary embolism, which can be fatal.
The possibility of a pulmonary embolus developing during the treatment of venous thrombosis is
an ever-present threat. When an embolus lodges in the lung, the affected blood vessels can no
longer exchange gases, so pressure builds in vessels behind the embolus. Symptoms of
pulmonary embolism depend on the amount of tissue affected. Small emboli may produce no
symptoms, but larger emboli can cause dyspnea, chest pain, tachycardia, cough, fever, anxiety,
and a change in mental status. A massive embolus can cause heart failure and shock. Sixty
percent of people do not survive massive emboli. The goals of treatment are to prevent thrombus
extension and pulmonary emboli, to reduce the risk of further thrombus formation, and to reduce
discomfort. Stasis dermatitis is a common inflammatory skin disease that occurs on the lower
extremities. It is usually the earliest cutaneous sequela of chronic venous insufficiency and may
be a precursor to more problematic conditions, such as venous leg ulceration and
lipodermatosclerosis, ankle ulceration, and pitting edema. These are not considered serious
complications.
Chapter 36: Hypertension
1. ANS: 3
Stage 1 hypertension is a blood pressure (BP) reading of 140 to 159 mm Hg systolic or 90 to 99
mm Hg diastolic. Normal BP is less than 120 to 139 mm Hg systolic and less than 80 mm Hg
diastolic. High normal is a BP of 120 to 139 mm Hg systolic or 80 to 89 mm Hg diastolic. Stage
2 hypertension is 160 mm Hg systolic or 100 mm Hg diastolic.
2. ANS: unknown
Hypertension is classified as primary (essential) or secondary. Primary hypertension accounts for
90% to 95% of all cases of hypertension. The cause for primary hypertension is unknown,
although several contributing factors, including increased sodium intake, greater than ideal body
weight, diabetes mellitus, and excessive alcohol consumption, have been identified. Secondary
hypertension is caused by underlying factors such as kidney disease, certain arterial conditions,
some drugs, and, occasionally, pregnancy.
3. ANS: 3, 4, 5
Complications of hypertension, including damage to the heart, blood vessels, kidneys, brain, and
eyes, increase after age 50. As blood pressure (BP) rises, so does the risk of heart attack, heart
failure (HF), stroke, kidney disease, and blindness. Men, especially African Americans, suffer
serious complications more often than women. Cardiac disease is the leading cause of death in
hypertensive people. Improved management of hypertension has significantly reduced the death
rate from stroke in women age 50 and older. Prolonged hypertension does not increase a person’s
risk for glaucoma and damage to heart valves.
4. ANS: 2, 3, 4, 5
The nurse should monitor for hypokalemia in a patient taking hydrochlorothiazide. Side effects
of that drug include confusion, irritability, muscle weakness, cardiac dysrhythmias, anorexia, and
diminished bowel sounds. Edema is not a side effect of the drug; an action of the drug is to help
reduce edema.
5. ANS: 2
Beta-blockers inhibit cardiac stimulation, resulting in decreased heart rate, decreased strength of
cardiac contraction, and bronchial constriction. They do not by themselves have any diuretic
effects. Calcium antagonists are called calcium channel blockers because they block the
movement of calcium into cardiac and vascular smooth muscle cells. This action reduces the
heart rate, decreases the force of cardiac contraction, and dilates peripheral blood vessels.
Angiotensin-converting enzyme (ACE) inhibitors prevent the conversion of angiotensin I to
angiotensin II, a potent vasoconstrictor. Blocking the production of angiotensin II decreases
peripheral resistance. ACE inhibitors also decrease fluid retention by decreasing the production
of aldosterone.
6. ANS: 4
The patient should be seated comfortably in a chair with his or her feet on the floor. Determine
the systolic pressure first by palpating the radial or brachial pulse while inflating the cuff. The
pressure when the last pulse is felt is the palpated systolic pressure. Then deflate the cuff and
take the pressure by auscultation, being careful to reinflate the cuff above the palpated systolic
pressure. The bladder of the cuff should encircle at least 80%, and not 50%, of the circumference
of the patient’s arm. A cuff that is too small may give a false high reading, whereas a cuff that is
too large may give a false low reading. Position the arm on a surface at the level of and not
above the heart.
7. ANS: 1
If a patient taking an antihypertensive drug complains of feeling dizzy when first rising from a
supine position, then tell the patient to change positions slowly and exercise the legs before
standing. Orthostatic or postural hypotension is a sudden drop in systolic blood pressure (SBP),
usually of 20 mm Hg, when going from a lying or sitting position to a standing position. These
patients need to exercise their legs and then rise slowly from a lying or sitting position. They
should avoid activities that cause blood pressure (BP) to fall, such as prolonged standing in one
place and taking very hot baths or showers. They should also be told not to stop taking their
medications unless instructed by their physician because suddenly stopping antihypertensive
drugs may produce adverse effects, including rebound hypertension (sudden return of elevated
BP), myocardial infarction, and cerebrovascular accident (CVA). Feeling dizzy when getting up
quickly is a common side effect of antihypertensive drugs, so it is not necessary to tell the patient
to go back to bed and call the physician. Increasing salt intake can increase fluid retention and
cause an increase in BP. A diet low in saturated fats and sodium may help lower BP.
8. ANS: 1
The most appropriate reply is “BP tends to increase with age, but treatment reduces the risk of
complication regardless of your age.” In the past, elevated blood pressure (BP) was considered
normal in the older person and was often untreated. With aging, atherosclerotic changes reduce
the elasticity of the arteries, causing a decrease in cardiac output (CO) and an increase in
peripheral vascular resistance (PVR). A change in dosage or in the medication itself may reduce
undesirable effects, but the patient should not make changes unless advised to do so by the
physician. Research has shown that older people do benefit from controlling hypertension and
that age is no longer considered a barrier to aggressive treatment. The nurse should not lecture to
the patient that the physician will be upset if orders are not followed. It is best to explain to the
patient the risks of not following the medication schedule and checking with the physician before
any changes are made.
9. ANS: 1, 4
The DASH (Dietary Approaches to Stop Hypertension) eating plan is low in fat and red meat. It
includes components of lifestyle modifications such as weight reduction, dietary sodium
reduction, aerobic physical activity, and moderation of alcohol consumption. Lean meats,
poultry, and fish; foods low in saturated fat, total fat, and cholesterol; and fruits, vegetables, and
low-fat dairy foods are included. To prevent hypokalemia, the DASH diet has foods rich in
potassium, including bananas and orange juice.
Chapter 37: Digestive System Introduction
1. ANS: 2
The small intestine is the main area of the gastrointestinal tract for absorption. The small
intestine has three separate sections: (1) the duodenum, (2) the jejunum, and (3) the ileum. The
majority of nutrient absorption occurs in the duodenum and jejunum. The duodenum absorbs
carbohydrates, proteins, and minerals, including calcium, magnesium, iron, chloride, sodium,
and zinc. Remaining starches in the form of glucose or proteins passed from the duodenum are
absorbed in the jejunum in addition to vitamin C, thiamine, vitamins B2 and B6, and folic acid.
The last section of the small intestine, known as the ileum, absorbs amino acids, fat, cholesterol,
and fat-soluble vitamins such as vitamins A, D, E, and K. The stomach is the widest section of
the digestive tract. The stomach is not very large when empty, but it expands considerably when
food is present. It consists of three sections: (1) the fundus, (2) the body, and (3) the pylorus. A
unique arrangement of muscle layers allows the stomach to churn the food, mixing it with gastric
secretions until it becomes a semiliquid mass called chyme. The major function of the large
intestine is to absorb water from the remaining indigestible food matter and transmit the useless
waste material from the body. Once contents get to the colon and rectum, there aren’t any
nutrients left to be absorbed. Basically, all that’s left to shift (either into or out of the system) is
water.
2. ANS: 1, 2, 4
The teeth are mechanically worn down with age. They appear darker and somewhat transparent.
The gingiva (gum) tends to recede. Although tooth loss is not a normal effect of aging, about
40% of all Americans ages 65 years and older are edentulous (toothless). The main reasons for
tooth loss are caries and periodontal disease. Many older people have complete or partial
dentures. The jaw may be affected by osteoarthritis. A significant loss of taste buds occurs with
age. The older person may be able to detect sweet better than other tastes. Xerostomia (dry
mouth) is common but may be caused more by poor hydration and drug side effects than by
aging.
3. ANS: 2
Placement of the tube in the stomach or the duodenum has to be confirmed before administering
feedings. Radiographic confirmation is the most reliable method. Various other methods of
checking placement have been used. Currently, observation of aspirated material and assessment
of pH are thought to be the most reliable. Stomach contents are grassy green, clear and colorless,
or brown; they normally have a pH of 5 or less. The intestinal pH is normally 6 or higher. Other
measures that are being evaluated are checking the aspirated fluid for enzymes and for bilirubin.
Methods that lack scientific support are listening over the stomach area with a stethoscope while
injecting air through the tube, placing the end of the tube in water to see if bubbles appear,
testing the patient’s ability to speak, and observing for respiratory symptoms. When a patient has
continuous feedings, placement is usually checked at least once each shift.
4. ANS: 3
Because the patient has had oral surgery, the nurse must check the health care provider’s orders
for mouth care instructions before proceeding. Good nutrition and appropriate mouth care are
essential for oral health and wound healing. Just telling the patient that this is normal after oral
surgery is not enough. Giving the patient a commercial mouthwash to rinse the mouth is
definitely contraindicated. It may contain certain properties that the surgeon does not want the
patient exposed to. Suctioning the patient’s mouth after giving sips of water can be damaging to
oral tissue that is in the process of healing.
5. ANS: 2, 4, 5
Antisecretory drugs decrease gastric acid secretion, which relieves symptoms and allows the
ulcer to begin healing. H2 receptor blockers, proton pump inhibitors, and prostaglandins are
examples of antisecretory drugs. H2 receptor blockers, which are the most commonly used
antiulcer drugs, include cimetidine (Tagamet), famotidine (Pepcid), ranitidine (Zantac), and
nizatidine (Axid). Antacids are not antisecretory drugs and can have serious side effects, and
may impair the absorption of many other drugs if taken at the same time. Sucralfate (Carafate) is
a mucosal barrier and not an antisecretory drug. Mucosal barriers are used less often now. They
work by clinging to the surface of the ulcer and protecting it so that healing can take place.
6. ANS: 3, 2, 4, 1
The assessment should begin with inspection of the abdomen followed by auscultation.
Percussion and palpation are done afterwards because they can alter normal bowel sounds.
7. ANS: 2
The portal vein carries blood with absorbed nutrients and other substances from the small
intestine to the liver where bacteria and toxins can be removed.
8. ANS: 1, 2, 3, 4
Older adults commonly consume less fluids and fiber than is ideal. In addition, many are
somewhat inactive. Last, older persons typically take more drugs than younger adults and many
of them can contribute to constipation. Hyperthyroidism is not common among older adults;
when present, it is more likely to stimulate bowel activity rather than to slow it down.
9. ANS: 1, 4, 5
Respiratory distress suggests a pneumothorax resulting from accidental puncture of a lung. The
supervisor should be notified and vital signs monitored. Reinforcing the dressing would not be
helpful.
10. ANS: 2
These symptoms are typical of dumping syndrome which can occur when a feeding is given too
quickly. The symptoms occur then hypertonic fluid enters the duodenum drawing fluid into the
intestine and causing diarrhea. The loss of fluid from the circulation causes blood pressure to fall
resulting in dizziness and weakness.
Chapter 38: Upper Digestive Tract Disorders
1. ANS: 2
The small intestine is the main area of the gastrointestinal tract for absorption. The small
intestine has three separate sections: (1) the duodenum, (2) the jejunum, and (3) the ileum. The
majority of nutrient absorption occurs in the duodenum and jejunum. The duodenum absorbs
carbohydrates, proteins, and minerals, including calcium, magnesium, iron, chloride, sodium,
and zinc. Remaining starches in the form of glucose or proteins passed from the duodenum are
absorbed in the jejunum in addition to vitamin C, thiamine, vitamins B2 and B6, and folic acid.
The last section of the small intestine, known as the ileum, absorbs amino acids, fat, cholesterol,
and fat-soluble vitamins such as vitamins A, D, E, and K. The stomach is the widest section of
the digestive tract. The stomach is not very large when empty, but it expands considerably when
food is present. It consists of three sections: (1) the fundus, (2) the body, and (3) the pylorus. A
unique arrangement of muscle layers allows the stomach to churn the food, mixing it with gastric
secretions until it becomes a semiliquid mass called chyme. The major function of the large
intestine is to absorb water from the remaining indigestible food matter and transmit the useless
waste material from the body. Once contents get to the colon and rectum, there aren’t any
nutrients left to be absorbed. Basically, all that’s left to shift (either into or out of the system) is
water.
2. ANS: 1, 2, 4
The teeth are mechanically worn down with age. They appear darker and somewhat transparent.
The gingiva (gum) tends to recede. Although tooth loss is not a normal effect of aging, about
40% of all Americans ages 65 years and older are edentulous (toothless). The main reasons for
tooth loss are caries and periodontal disease. Many older people have complete or partial
dentures. The jaw may be affected by osteoarthritis. A significant loss of taste buds occurs with
age. The older person may be able to detect sweet better than other tastes. Xerostomia (dry
mouth) is common but may be caused more by poor hydration and drug side effects than by
aging.
3. ANS: 2
Placement of the tube in the stomach or the duodenum has to be confirmed before administering
feedings. Radiographic confirmation is the most reliable method. Various other methods of
checking placement have been used. Currently, observation of aspirated material and assessment
of pH are thought to be the most reliable. Stomach contents are grassy green, clear and colorless,
or brown; they normally have a pH of 5 or less. The intestinal pH is normally 6 or higher. Other
measures that are being evaluated are checking the aspirated fluid for enzymes and for bilirubin.
Methods that lack scientific support are listening over the stomach area with a stethoscope while
injecting air through the tube, placing the end of the tube in water to see if bubbles appear,
testing the patient’s ability to speak, and observing for respiratory symptoms. When a patient has
continuous feedings, placement is usually checked at least once each shift.
4. ANS: 3
Because the patient has had oral surgery, the nurse must check the health care provider’s orders
for mouth care instructions before proceeding. Good nutrition and appropriate mouth care are
essential for oral health and wound healing. Just telling the patient that this is normal after oral
surgery is not enough. Giving the patient a commercial mouthwash to rinse the mouth is
definitely contraindicated. It may contain certain properties that the surgeon does not want the
patient exposed to. Suctioning the patient’s mouth after giving sips of water can be damaging to
oral tissue that is in the process of healing.
5. ANS: 1, 2
Included in the care plan for a patient with achalasia is deciding what is the best position for the
patient during meals and making sure that clothing is not too restrictive. Also included is
elimination of specific foods that could be difficult to swallow. Achalasia is a progressively
worsening dysphagia (difficulty swallowing) and is generally caused by failure of the lower
esophageal muscles and sphincter to relax during swallowing. The patient does not have to be
kept NPO, or bowel sounds specifically auscultated, or strict intake and output maintained.
However, the patient’s level of consciousness and alertness needs to be determined so that he or
she is able to understand and follow directions regarding swallowing and when to notify the
nurse if a problem arises.
6. ANS: 2, 4, 5
Antisecretory drugs decrease gastric acid secretion, which relieves symptoms and allows the
ulcer to begin healing. H2 receptor blockers, proton pump inhibitors, and prostaglandins are
examples of antisecretory drugs. H2 receptor blockers, which are the most commonly used
antiulcer drugs, include cimetidine (Tagamet), famotidine (Pepcid), ranitidine (Zantac), and
nizatidine (Axid). Antacids are not antisecretory drugs and can have serious side effects, and
may impair the absorption of many other drugs if taken at the same time. Sucralfate (Carafate) is
a mucosal barrier and not an antisecretory drug. Mucosal barriers are used less often now. They
work by clinging to the surface of the ulcer and protecting it so that healing can take place.
7. ANS: 1
Patients with hiatal hernia should avoid lying flat after eating a meal because this can cause
excessive intraabdominal pressure. They should also sleep with their heads elevated 6 to 12
inches. Wooden blocks can be placed under the legs of the head of the bed if a mechanical or
electrical bed is not available. Advise the patient to eat small, frequent meals, because large
meals increase pressure in the stomach and delay gastric emptying. The patient needs to be
encouraged to take the prescribed histamine receptor antagonist medications.
8. ANS: 1
To help prevent dumping syndrome, the patient needs to eat a diet low in carbohydrates and
refined sugar, moderate in fat, and moderate to high in protein and eat smaller, more frequent
meals rather than three large meals. To avoid dehydration, the patient also needs to drink fluids
between meals and not with them, and lie down for about 30 minutes after meals.
9. ANS: 2
Chronic gastritis results in decreased production of acid and intrinsic factor. Intrinsic factor is
needed for the absorption of vitamin B12, which is essential for the maturation of red blood cells
(RBCs). Without intrinsic factor, a serious condition called pernicious anemia develops.
Deficiencies of vitamins A, C, and E are not related to this condition.
10. ANS: true
This statement is true. Nursing care of patients being treated for oral cancer should focus on pain,
impaired oral communication, and altered body image. Also, inadequate nutrition, potential for
infection, and inadequate tissue perfusion are included in the care of a patient with oral cancer.
Chapter 39: Lower Digestive Tract Disorders
1. ANS: all correct
A diagnosis of appendicitis is based on classic signs and symptoms and a white blood cell
(WBC) count of 10,000 to 15,000/mm3. The classic symptom of appendicitis is pain at the
McBurney point, which is located midway between the umbilicus and the iliac crest. The patient
may also assume a position of hip flexion and be unable to straighten the right leg without pain.
The abdomen may be rigid, although this sign is often absent with peritonitis in older patients.
2. ANS: 1
Recurrence is so common that surgery is not usually done unless necessitated by serious
complications. Postoperatively, the disease typically reappears at the site of anastomosis within 1
year. Newly affected areas also may appear in other sections of the intestine. Crohn disease can
affect any area of the gastrointestinal tract. It is most often treated with a combination of drug
therapy. There is no increased risk of surgical complications for Crohn disease. Patients with
Crohn disease also are thought to have an increased risk of colon cancer.
3. ANS: 1, 3, 4, 5
Content that needs to be included in a presentation to an ulcerative colitis support group includes
stress reduction measures to help control symptoms, avoidance of caffeine and other irritating
fluids and foods, regular colon screening because of an increased risk of cancer, and drugs to
treat acute attacks and preventing future attacks. After an acute attack has subsided, the drug
dosage is gradually reduced. There may also be periods of remission lasting several weeks to
several years. The exact cause of ulcerative colitis is unknown.
4. ANS: 3
The initial symptom of appendicitis is usually pain in the epigastric region or around the
umbilicus, which then shifts to the right lower quadrant. Signs and symptoms of colorectal
cancer depend on the location of the disease. If the cancer is located on the right side of the
abdomen, then the patient may have only vague cramping until the disease is advanced.
Unexplained anemia, weakness, and fatigue related to blood loss may be the only early
symptoms of right-sided colon cancer. The pancreas is a large gland located behind the stomach
and next to the duodenum (the first section of the small intestine). Pancreatitis is where the
pancreas becomes inflamed and damage occurs when the digestive enzymes are activated before
they are secreted into the duodenum and begin attacking the pancreas. Ascites is an accumulation
of fluid in the peritoneal cavity most commonly due to cirrhosis, severe liver disease, or
metastatic cancer. Diagnosis of the cause is usually with blood tests, an ultrasound scan of the
abdomen, and direct removal of the fluid by needle or paracentesis (which may also be
therapeutic). Treatment may be with medication (diuretics), paracentesis, or other treatments
directed at the cause.
5. ANS: 4
Colorectal cancer, or cancer of the large intestine, is the third most common cancer. People at
greater risk for colorectal cancer are those with histories of inflammatory bowel disease (IBD) or
family histories of colorectal cancer or multiple intestinal polyps. Cancer of the esophagus is not
common, but when it does occur, it has a very poor prognosis. Most esophageal cancers are
located in the middle or lower portion of the esophagus. No known cause exists, but predisposing
factors are cigarette smoking, excessive alcohol intake, chronic trauma, poor oral hygiene, and
eating spicy foods. Cancer of the stomach is diagnosed in more than 21,000 people in the United
States each year. The incidence is highest among men, people older than 70 years, and people of
lower socioeconomic status. Cancer of the pancreas is very serious. Pancreatic cancer quickly
spreads to the duodenum, stomach, spleen, and left adrenal gland. About 42,000 new cases are
diagnosed each year in the United States. Only 24% of these people will survive for 1 year; 4%
will be alive after 5 years.
6. ANS: 1
With Crohn disease, an inflamed colon typically causes abdominal pain, cramping, rectal
bleeding, and diarrhea. Many factors can contribute to constipation. When stool is present in the
rectum, the urge to defecate occurs. If the urge is ignored, then stool remains in the rectum
longer than usual and becomes dry. It is then more difficult, and sometimes painful, to have a
bowel movement. People who frequently ignore the urge to defecate may become chronically
constipated. The frequent use of laxatives or enemas also may contribute to chronic constipation.
These medications keep the lower digestive tract empty and eventually interfere with the normal
pattern of elimination. Constipation alternating with diarrhea may be a symptom of bowel
obstruction. Stool consistently oozing from the rectum may a symptom of fecal impaction.
7. ANS: 3
Additional teaching about celiac disease is needed when a patient says, “I really don’t need to
restrict my diet of gluten-containing foods as I am not having diarrhea.” Celiac disease is treated
by avoiding products that contain gluten (i.e., wheat, barley, oats, rye). In the case of celiac
sprue, it is helpful to teach the patient how to eliminate gluten from the diet. Genetic testing
cannot diagnose celiac disease, but it can tell you whether celiac disease is a possibility. Testing
is recommended for anyone who has a parent, sibling, or child with celiac disease. Lymphoma of
the small intestine is a rare type of cancer but may be 30 times more common in people with
celiac disease. Today, there are many products that are free of gluten that can be purchased from
specialty food stores and supermarkets.
8. ANS: 1, 2, 3
Anticholinergic drugs may be given to decrease spasms in the colon. Patients with diverticulosis
need to get an annual colonoscopy to detect any possible changes that may be cancerous. Stool
softeners or bulk-forming laxatives are used to treat constipation, and antidiarrheals are
prescribed for those who have diarrhea. Other high-fiber foods are dried beans, most vegetables,
and fruits. Diverticulosis is currently being treated with a high-residue, high-fiber diet without
spicy foods. Whole-grain breads, brown rice, and whole-grain cereals are recommended.
9. ANS: 2
Patients taking immunosuppressants need to avoid contact with people with active infection.
Corticosteroids are used in inflammatory bowel disease (IBD) for their ability to reduce
inflammation. Unfortunately, this action also decreases the ability of the body to resist infection.
Patients on steroids must be monitored for any signs and symptoms of infections. A
low-roughage diet without milk products is prescribed for mild to moderate IBD. A
low-maintenance dose of the immunosuppressant may be given for as long as 1 year, so
discontinuing the drug early may result in another acute attack. Frequently, patients have
diarrhea with frequent bloody stools and abdominal cramping. Medications should not be
stopped if diarrhea occurs. The patient needs to report this to the physician.
10. ANS: 1, 2, 4, 5
The diet should include high-fiber foods such as fruits, raw vegetables, greens, whole grains, and
lean proteins in the diet. Animal proteins and fats should be avoided, along with irritating foods
and alcohol.
Chapter 40: Liver, Gallbladder, and Pancreatic Disorders
1. ANS: icteric phase
The icteric phase is characterized by jaundice, light- or clay-colored stools, and dark urine
typical of impaired bile production and secretion. Bile salts accumulate under the skin and can
cause pruritus. Gastrointestinal symptoms from the preicteric phase often persist. The icteric
phase lasts 2 to 4 weeks. Hepatitis patients who do not develop jaundice are said to have
anicteric hepatitis.
2. ANS: 1, 2, 3
Moisturizing lotions protect the skin and can help relieve itching associated with jaundice. The
patient should bathe in tepid water, and pat dry. Mild soap is used unless it seems to increase
symptoms. Lubricating lotions or topical antipruritics can be applied. Use light strokes in the
direction of the heart. Select older, soft sheets. Gently pat the skin instead of scratching to reduce
the itching sensation. Vigorous massage can further irritate the skin. If a patient is confused, trim
the fingernails as agency policy permits. Mittens may be needed to prevent skin injury. If
conservative measures are not effective, consult the physician about ordering an antihistamine. If
the event that the patient is having an allergic reaction to antibiotics, contact the physician before
continuing the medications.
3. ANS: 2
Health care providers should be vaccinated against hepatitis B because it can be spread through
contact with body fluids. Hepatitis A is also called infectious hepatitis and epidemic hepatitis. It
is caused by the hepatitis A virus (HAV), which is transmitted from one person to another by
way of water, food, or medical equipment that has been contaminated with infected fecal matter.
Hepatitis A is the most common type of viral hepatitis. Fortunately, it is rarely fatal and infected
persons do not become asymptomatic carriers. Hepatitis C is transmitted by contact with
contaminated blood or medical equipment or by contact with infected body fluids. Like hepatitis
B, it can be transmitted from an infected mother to her baby during birth; however, that is rare.
Whereas some individuals recover completely from acute hepatitis C, a significant proportion of
people with hepatitis C develop chronic infections and become carriers. Many of these will
develop cirrhosis or cancer of the liver. Hepatitis D is caused by a virus known as the delta
agent, which is a defective ribonucleic acid (RNA) virus that can survive only in the company of
hepatitis B virus (HBV). Hepatitis D is transmitted percutaneously (through the skin or mucous
membranes) with or following HBV infection. The presence of hepatitis D greatly increases the
risk that the patient will progress to chronic hepatitis and possible liver failure.
4. ANS: 3
Distended, engorged vessels in the esophagus are called esophageal varices. They are fragile and
bleed easily, with the potential for fatal hemorrhage. Circumstances that may trigger bleeding in
the esophageal varices and hemorrhoids include irritation and increased intraabdominal pressure.
5. ANS: 4
The most concerning transplant rejection finding is fever. Fever is sometimes the only sign of
rejection. Other assessment findings that would alert the nurse are anorexia, depression, vague
abdominal pain, muscle aches, and joint pain. Rejection may be treated with corticosteroids or
other immunosuppressant medications. If this treatment is unsuccessful, then retransplantation
may be needed. Heartburn, constipation, and pale urine are not complaints or signs that might
signal transplant rejection.
6. ANS: 2, 3
The common hepatic bile duct joins the cystic duct to form the common bile duct. The cystic
duct leads to the gallbladder, a saclike organ beneath the liver. Bile flows from the liver to the
gallbladder, where it is stored and concentrated. The duodenum, main pancreatic duct, and
ductus arteriosus are not components of the common bile duct.
7. ANS: 1
A T-tube is placed in the common bile duct to maintain bile flow until swelling in the duct
subsides. One part of the tubing is brought through the patient’s skin and connected to a
closed-gravity drainage receptacle. A T-tube does not relieve pressure on the liver, or divert
intestinal contents, or prevent bile from leaking on the abdomen.
8. ANS: 1, 2
The endocrine function of the pancreas is carried out by clusters of specialized cells scattered
throughout the pancreas. These cells are called islets of Langerhans. The islets contain alpha,
beta, delta, and PP cells. Alpha cells produce and secrete glucagon. Beta cells produce and
secrete insulin. Insulin is secreted when the blood glucose rises, as after a meal. It stimulates the
use of glucose by the cells so that a normal blood glucose level is maintained. Glucagon is
secreted when the blood glucose level falls. It stimulates the liver to convert glycogen into
glucose. Pancreatic fluid is part of the exocrine function of the pancreas. This fluid contains
enzymes needed for the digestion of proteins, fats, and carbohydrates. It is secreted into the
duodenum through the pancreatic duct. The manufacture and storage of bile is not an endocrine
function of the pancreas. Bile is produced in the liver, stored in the gallbladder, and delivered to
the intestine, where it is essential for emulsification and digestion of fats. When fats enter the
duodenum, the gallbladder contracts and delivers bile to the intestine through the common bile
duct.
9. ANS: 2
The patient with chronic pancreatitis is likely to need to take pancreatic enzymes to digest food.
The enzymes can be taken with meals or snacks. The effect of the enzymes can be determined by
examining the stools for steatorrhea: a high-fat content caused by inadequate enzymes.
Monitoring daily weights, recording intake and output, and checking for pain relief are not
assessments related to pancreatic enzyme tablets.
10. ANS: 1, 4
Among the risk factors for pancreatic cancer are chronic pancreatitis and smoking. Other
probable risk factors are a high-fat diet and exposure to certain toxic chemicals. Tumors may
develop in the head, body, or tail of the pancreas. Chronic pancreatitis is often related to alcohol
abuse, so stress reduction exercises are needed. Nursing care of the patient with pancreatitis
addresses anxiety along with pain; fluid volume deficit; potential for infection; inadequate
oxygenation; inadequate nutrition; and lack of knowledge. Increased dietary protein is not an
intervention needed to reduce one’s risk of pancreatic cancer. Regular exercise is not as
important as interventions to relieve stress.
Chapter 41: Urologic System Introduction
1. ANS: 1, 4
With aging, bladder muscles weaken and connective tissue increases. The effect is decreased
capacity and incomplete emptying. The mechanism that prevents the reflux of urine from the
bladder into the ureters is less effective, and this can contribute to kidney infections. Older
people often have nocturia and awaken from sleep to void. Decreased renal blood flow,
decreased creatinine clearance, and decreased bladder capacity are not age-related factors that
contribute to frequent kidney infections.
2. ANS: 4
Dysuria is painful urination. Polyuria refers to a large volume of urine, anuria is the absence of
urine output, and hematuria refers to blood in the urine.
3. ANS: 3
Pink-tinged urine is normal the first time a patient voids after a cystoscopy. Because it is an
anticipated event, the physician does not have to be notified, additional fluids do not have to be
encouraged, nor does blood pressure (BP) have to be taken.
4. ANS: 3
The most common cause of health care–associated infection is catheterization.
5. ANS: 2, 3, 5
Adverse effects of sulfonamides include crystal formation in the urine, sensitivity to sunlight,
and risk for Stevens-Johnson syndrome which is characterized by widespread skin lesions.
6. ANS: 1
The capacity of the renal pelvis is only 3 to 5 mL.
Chapter 42: Urologic Disorders
1. ANS: 4
Ms. P. is experiencing fluid volume overload as evidenced by shortness of breath, and an
increased pulse which is bounding. Other symptoms may include a rising blood pressure and
edema. In older adults, a sudden increase in fluid volume may result in heart failure.
2. ANS: 2
Although the pathophysiology associated with urinary tract infection frequency in clients with
polycystic kidney disease is not fully understood, it is thought to occur because cysts inside the
kidneys may interfere with urine flow, which increases the potential for infection.
3. ANS: 1, 3, 4, 5
Risk factors that have been identified as contributing to renal calculi include having concentrated
urine; taking excess amounts of vitamins C or D, animal protein, oxalates, sodium, sucrose, or
calcium-based antacids; having a low dietary calcium intake; having a familial history of renal
calculi; being sedentary or immobile; having an altered urine pH; and/or a history of
hyperparathyroidism, gout, diabetes, obesity, gastric bypass surgery, Crohn disease, or renal
tubular acidosis.
4. ANS: 3
Passage of renal calculi can be incredibly painful. The nurse will administer medication to
address the pain. Once the pain is under control, the nurse can accomplish other actions such as
encouraging fluids, teaching to breathe deeply, and assisting the client to ambulate to facilitate
passage.
5. ANS: 2
Hydronephrosis can be caused by an obstruction in urine flow. Renal calculi can block urine
flow, creating this condition.
6. ANS: 1
Prevention of thrombi is of key importance following any surgery. Thrombi can cause a
pulmonary embolism, which can be fatal. Teaching breathing exercises, encouraging fluid
intake, and helping to calm anxiety can take place after thrombi prevention has been
accomplished.
7. ANS: 1, 3, 4
Women are more susceptible than men to cystitis, because the female urethra is shorter and
closer to the vagina and rectum. They should avoid coffee, tea, and carbonated beverages with
caffeine, as well as apple, grapefruit, orange, and tomato juices, because these irritate the
bladder. They should drink a glass of water after swimming and before and after intercourse to
“flush” the urethra. Women should also wipe from front to back after bowel movements or
voiding. Showers instead of tub baths should be taken. Cotton undergarments instead of
synthetic should be worn because they keep the perineum drier. Moisture encourages bacterial
growth. Tight-fitting clothing in the perineal area should be avoided.
8. ANS: 4
Glomerulonephritis is an immunologic disease characterized by inflammation of the capillary
loops in the glomeruli. Several immunologic mechanisms can cause acute glomerulonephritis.
For example, the patient may develop antibodies against antigens in the glomeruli. A common
type of glomerulonephritis follows an infection of the respiratory tract caused by group
A-negative hemolytic streptococcus. Glomerulonephritis is not caused by bacteria, viruses, or
urinary obstruction.
9. ANS: 1
Lithotripsy is shattering of renal calculus and is performed by extracorporeal shock wave
lithotripsy (ESWL), which uses sound, laser, or dry shock wave energy (electrohydraulic,
electromagnetic, piezoelectric) to shatter the stones. The incision of an organ or a duct to remove
a calculus is a lithotomy. A nephrolithotomy is the surgical procedure used if a calculus is in the
kidney. An ureterolithotomy is removal of a calculus from a ureter.
10. ANS: 5 mL
When irrigating a nephrostomy tube, not more than 5 mL of warm, sterile normal saline at a time
can be used.
11: ANS: 4
After a nephrectomy, to prevent the risk of renal failure, it is most important to notify the
physician if the patient’s urine output is less than 30 mL in an hour. When the patient is able to
be weighed, daily weights are an even better measure of fluid balance than intake and output.
Blood urea nitrogen (BUN), serum creatinine, serum electrolytes, and urine specific gravity are
assessed and compared with preoperative values. Having the patient change position, or drink an
8-ounce glass of water every 2 hours, or increasing the patient’s intravenous flow rate are not as
important as contacting the physician.
12: ANS: 2
Elevated serum potassium interferes with normal cardiac function, causing cardiac dysrhythmias.
Dysrhythmias are potentially fatal. The patient becomes apathetic and confused and may have
nausea, abdominal cramps, muscle weakness, and numbness of the extremities. Many physicians
treat the development of peripheral neuropathy as a signal to begin dialysis. The blood urea
nitrogen (BUN) test is a general indicator of the kidneys’ ability to excrete urea, an end product
of protein metabolism. Signs of metabolic acidosis are headache, lethargy, and delirium. Patients
with hypocalcemia experience tingling sensations, muscle twitches, irritability, and tetany, but
not confusion.
Chapter 43: Musculoskeletal System Introduction
1. ANS: synarthroses
Classified on the basis of the extent of movement, joints include synarthroses (fixed joints),
amphiarthroses (slightly moveable joints), and diarthroses (freely moveable joints).
Synarthrodial joints, such as those in the skull, allow no movement at all.
2. ANS: 2, 3, 4, 5
Age-related changes in connective tissue can significantly affect function, and joint changes are
related primarily to the changes in cartilage. Water content decreases and cartilage gradually
loses elasticity and then becomes soft and frayed. Friction between unprotected bony joint
surfaces promotes the growth of osteophytes (bony spurs). A loss of bone mass and bone
strength occurs. Bone tissue softens, it does not harden.
Chapter 44: Connective Tissue Disorders
1. ANS: 1
If a patient who has gout reports having flank pain and blood in her urine, the nurse needs to
immediately report these signs and symptoms of urinary stones to the physician. This action is
taken so that severe attacks can be averted and treatment is begun soon after symptoms develop.
When the serum uric acid level is elevated, the excess acid is excreted in the urine, where it may
form uric acid stones. Urinary stones can obstruct urine flow from the kidney, leading to renal
damage. These complaints are not normal in gout patients, and treatment cannot wait a day or a
week to begin.
2. ANS: 1, 2
A continuous passive motion (CPM) machine is a device used after some types of joint
replacement surgery. It moves the joints through a set range of motion at a set rate of movements
per minute, prevents formation of scar tissue, and promotes flexibility of the new joint. The CPM
machine does not lubricate the prosthesis, or restore muscle strength, nor does it test the
prosthetic joint. Physical therapy can help to improve range of motion and to maintain muscle
mass and strength.
3. ANS: 4
Subluxation (dislocation) of a hip joint prosthesis can occur due to improper position, movement,
or activity. Signs of prosthesis dislocation include sudden, severe pain and abnormal position
with inability to bear weight on the affected leg. Rejection occurs with transplanted organs and
not with prosthesis implants. Wound dehiscence is a surgical complication in which a wound
ruptures along a surgical suture. Symptoms of dehiscence can include bleeding, pain,
inflammation, fever, or the wound opening spontaneously. The wound is generally located on a
highly mobile or high-tension area such as the back, shoulders, or legs. A new hip fracture would
not occur on the hip prosthesis side.
4. ANS: 1, 2, 4
A care plan for a patient with rheumatoid arthritis (RA) needs to include impaired mobility
related to fatigue; decreased socialization related to physical impairment and poor body image;
and pain related to swelling and tenderness. Other pertinent patient problems include inadequate
coping related to frustration, embarrassment, and inability to do activities independently; and
inability to manage treatment program related to lack of understanding of RA, its treatment, and
self-care. Inadequate circulation related to vasoconstriction is related to a cardiovascular
problem, and potential for trauma related to loss of bone strength is not related to a patient with
RA.
5. ANS: 4
After age 50, women need 1200 mg of calcium daily. Before menopause and while on hormone
replacements, women need 1000 mg of calcium daily. Men require 1000 mg every day up to age
71, when it should be increased to 1200 mg per day. Doses of 200 mg and 500 mg of calcium are
too low.
6. ANS: 2, 3
Patients taking antigout drugs need to maintain urine output of at least 2000 mL/day to reduce
the risk of urinary calculi formation. Also, tell the patient it takes several weeks for the
medication to achieve full therapeutic effect. The nurse also needs to assess for allergies and not
give the drug with penicillin. Caution is advised with renal impairment. This drug does not have
any immunosuppressant effect on patients and has no cardiovascular effect on blood pressure.
This drug has no gastrointestinal effects, so patients do not need to remain in an upright position
for 30 minutes after taking the medication.
7. ANS: 2
The teaching plan for a patient with systemic scleroderma (SSc) includes remaining upright for 1
to 2 hours after meals. Esophageal reflux with this disease can also be managed with drug
therapy; relaxing meals; and avoiding spicy foods, caffeine, and alcohol. When a patient has SSc,
the health history should document pain and stiffness in the fingers and intolerance for cold. The
home temperature should not be kept below 70 degrees but warmer. To prevent vasospasm,
hands need to be kept warm and attempts made to reduce stress and exhaustion. SSc is a chronic
(not acute) autoimmune disease of unknown origin that takes its name from the characteristic
hardening of the skin and can affect the gastrointestinal tract, lungs, heart, kidneys, muscles,
joints, and blood vessels. Death may occur because of infection or cardiac or renal failure.
8. ANS: 2
Sjögren syndrome is an autoimmune inflammatory disease that obstructs secretory ducts in the
eyes, mouth, and vagina. An oral moisturizer should be used when caring for a postoperative
patient. This syndrome is often seen with rheumatoid arthritis (RA), polymyositis, scleroderma,
or systemic lupus erythematosus (SLE). Some classic signs and symptoms include dry eyes,
mouth, and vagina. It can affect joints, lungs, liver, nervous system, blood, and kidneys. Other
treatments include artificial tears and lubricant ointments; artificial saliva, pilocarpine
hydrochloride to stimulate salivary flow, and dental care; vaginal lubricants and perineal
hygiene; and glucocorticoids. Lighting does not have to be dim for this patient. This is not a
musculoskeletal disorder, so assistance with meals is not needed and hand splints are not used.
Chapter 45: Fractures
1. ANS: 4
The patient has a grade II complete open fracture, which is a moderately severe injury with skin
and muscle contusions (bruises). A closed or simple fracture is one in which the broken bone
does not break through the skin. A grade III incomplete open fracture is the most severe injury
(wound larger than 6 to 8 cm), with skin, muscle, blood vessel, and nerve damage. A grade I
complete open fracture is the least severe injury, with minimal skin damage.
2. ANS: stage IV
The ends of a broken bone begin to knit during stage 4 of healing. There are 5 stages of bone
healing. Stage 4 is the ossification stage that occurs 3 weeks to 6 months after the break. A
permanent bone callus, known as woven bone, forms, and it is during this stage that the ends of
the broken bone begin to knit.
3. ANS: 2
Fat embolism syndrome is suspected. This is most commonly associated with fractures of the
long bones, multiple fractures, and severe trauma and occurs 24 to 72 hours after injury. It
happens most often in young men ages 20 to 40 years and in older adults ages 70 to 80 years.
Older patients with a hip fracture are at highest risk. Respiratory distress is the first sign of a fat
embolism, followed by tachycardia, tachypnea, fever, confusion, and decreased level of
consciousness. Petechiae, a measles-like rash over the neck, upper arms, chest, or abdomen, can
also appear. Shock can occur after a fracture with a large loss of blood. Tissue trauma may
rupture local blood vessels, and vascular internal organs may be punctured, with resultant
internal bleeding. Besides blood loss, signs of shock include tachycardia, anxiety, pallor, and
cool, clammy skin. Avascular necrosis can result when a fracture or bone infection interferes
with the blood supply to the bone. Bone cells are deprived of O2 and nutrients, and they die and
their cell walls collapse. Signs and symptoms include increasing pain, instability, and decreased
function in the affected area. Treatment includes relief of weight bearing and removal of part of
the bone to decrease pressure. Some surgical procedures may be needed, and sometimes
amputation is necessary. Compartment syndrome is a serious complication that results from
internal or external pressure on the affected area. A cast or tight dressing creates external
pressure, leading to decreased blood flow to the area. Internal pressure can be caused by edema
or bleeding into a compartment. Fluid gets trapped in the compartment and puts pressure on the
tissues, nerves, and blood vessels, decreasing blood flow and leading to pain and tissue damage.
Compartment syndrome is relatively rare, but a serious condition leading to an emergency
situation. Within 4 to 6 hours after the onset of compartment syndrome, irreversible muscle and
nerve damage can occur. Paresis (i.e., partial paralysis) can result if the condition is not treated
within 24 hours, and within 24 to 48 hours the limb can become useless. Pain is the primary
symptom of compartment syndrome, especially pain with touch or movement that cannot be
relieved with opioid analgesia. Other signs and symptoms are edema, pallor, weak or unequal
pulses, cyanosis, tingling, numbness, and paresthesia.
4. ANS: 2, 3, 5
Methods that can be used to stimulate fracture healing include devices that deliver electrical
stimulation and pulsed electromagnetic fields (PEMFs). Electrical stimulation promotes bone
healing by promoting bone growth. An electrical current is delivered through a surgically
implanted device, a device applied to the skin, or a device that uses pins inserted through the
skin. Electrical bone stimulators are successful in approximately 80% of cases, with an average
healing time of 16 weeks. PEMFs are noninvasive devices that include a control box and a pad
that induces electrical changes around and within the cell. In theory, the electrical changes
activate and regenerate a cell, which promotes healing and reduces pain. The implantation of
bone grafts (osteogenic methods) is also used to stimulate fracture healing when nonunion of a
fracture exists. Traction and fixation do not stimulate fracture healing, but help keep an extremity
immobile and in proper alignment.
5. ANS: 1, 2
Patient teaching about a plaster of Paris cast includes not inserting any foreign object inside the
cast and reporting to a health care provider any swelling, discoloration of toes or fingers, pain
during motion, and burning or tingling under the cast. Other teaching issues include not bearing
weight on a new plaster cast for 48 hours (with synthetics, may be less than 1 hour) and not
covering the cast with plastic for prolonged periods. A plaster of Paris cast consists of anhydrous
calcium sulfate embedded in gauze. It is the least expensive type of cast to use. A well-fitting
stockinette is applied and the gauze is immersed in water and wrapped around the affected part.
The cast must remain dry, and showers are not allowed. Loss of sensation is not normal and must
be reported immediately to the health care provider. The cast dries completely in 48, and not 8,
hours.
6. ANS: 4
A crutch is properly fitted when the pad reaches three to four fingerbreadths below the axilla to
avoid pressure on the axilla and nerves when walking. Axillary pressure could result in
temporary or permanent numbness in the hands. The patient’s statement about being
“comfortable” is not accurate for crutch measurement. Hand grips are adjusted so that the elbow
is bent no more than 30, and not 45, degrees when the patient is standing in the tripod position.
Crutch measurement is not based upon the crutch being 75% of the patient’s height.
7. ANS: 2
The main advantage of surgery over traction for older patients with hip fractures is that surgical
repair allows them to move around sooner and results in fewer complications related to
immobility. Traction may require 12 to 16 weeks of immobilization for healing. The focus of
nursing care for a patient with a fracture is on prevention of complications, pain relief, and
restoration to independent function. After total hip replacement, weight bearing can begin almost
immediately. Surgery may be more expensive than traction, but the risk of complications is much
lower. After a few postoperative days, pain may be less after surgery than traction; it is still not
the main advantage of surgery over traction. Bones may heal better with traction, but the
prolonged immobility associated with traction puts the patient at greater risk for complications.
8. ANS: 1
Colles fracture is a break in the distal radius (wrist area) that often occurs in older adults,
particularly older women, when an outstretched hand is used to break a fall. The major signs and
symptoms are pain and swelling in the area of the injury and a characteristic displacement of the
bone in which the wrist has the appearance of a dinner fork. The most common complication is
impaired circulation in the area resulting from edema. It does not result from jumping from a
high place onto a hard surface or from landing in a sitting position after falling. Falling with the
leg in a position of outward rotation is not related to Colles fractures.
9. ANS: 3, 4
The best diet for a patient discharged after treatment for a pelvic fracture includes increased
protein and calcium to build bone, and supplementary doses of vitamins B, C, and D. Prolonged
immobilization, which often is required after multiple fractures, contributes to the loss of
calcium and protein. Reduced fat and calories and high-calorie meal supplements would not
promote healing. High-calorie meal supplements alone are not recommended, but supplemental
feedings that are high in calories, protein, and calcium, such as milkshakes, may be served
between meals to promote healing. Because of periods of immobilization, a daily fluid intake of
2000 to 3000 mL is recommended (unless contraindicated) to promote bowel and bladder
function. Decreased fluid intake is contraindicated.
10. ANS: crepitus
Crepitus is a grating sound heard over an injured arm after a fall. It results from broken bone
ends rubbing together. Grating sensations or sounds are felt or heard if the injured part is moved.
Chapter 46: Amputations
1. ANS: 2
Vascular disease accounts for the majority of the estimated 185,000 lower extremity amputations
performed in the United States each year. In these cases, blood supply to the tissues is inadequate
and the tissues become deprived of oxygen (O2) and other important nutrients. Necrosis, or death
of the tissue, occurs. Vascular disease can be complicated by infection, because wounds
sustained by limbs without a good blood supply do not heal well and gangrene can set in quickly.
Trauma tends to be the most common reason for upper extremity amputations. Because these
accidents are typically occupational hazards, the victims are usually young men. Amputations
also may be performed for bone tumors that are very large and invasive. Treatment may require
amputation and disarticulation of an entire limb. Primary bone tumors occur mostly in
adolescents but can occur at any age. About one-third of these individuals are 11 to 20 years of
age. Congenital defects occur when a limb or part of a limb may be absent or deformed at birth.
Congenital amputations may result when the infant is born with a missing, deficient, or abnormal
limb. Sometimes surgery is performed to convert a deformed limb into a more functional one
that can be fitted with a prosthetic device.
2. ANS: vasoconstriction
Smoking is contraindicated after a finger replantation because nicotine causes vasoconstriction.
Patients with peripheral vascular disease already have vasoconstricted vessels, so smoking is
definitely discouraged.
3. ANS: 4
An accident victim with a crushing injury would most likely have an open amputation. In open
amputations, the severed bone or joint is left uncovered by a skin flap. This is required when an
actual or potential infection exists from gangrene or trauma. The wound is left open for 5 to 10
days, sometimes longer, and is closed surgically when infection no longer poses a problem.
Another term for this procedure is a staged amputation or guillotine amputation. Closed
amputations may be performed for bone tumors that are very large and invasive. Treatment may
require amputation and disarticulation of an entire limb. Primary bone tumors occur most
frequently in adolescents but can occur at any age. Vascular diseases, such as with diabetes,
account for the majority of the estimated 185,000 lower extremity closed amputations performed
in the United States each year. In these cases, blood supply to the tissues is inadequate and the
tissues become deprived of oxygen (O2) and other important nutrients. A child with a congenital
deformity may have a limb or part of a limb absent or deformed at birth. These are sometimes
called congenital amputations. They result from factors that affect the developing fetus in such a
way that the infant is born with a missing, deficient, or abnormal limb.
4. ANS: 2
Complications associated with amputations include hemorrhage and hematoma, necrosis, wound
dehiscence, gangrene, edema, contracture, pain, infection, phantom limb sensation, and phantom
limb pain. Phantom limb sensation is when a patient experiences sensations (tingling, numbness,
itching, warmth/cold) as if the limb were still present. This is caused by stimulation along a
nerve pathway in which sensory endings were in the amputated part. Phantom limb pain is when
the patient experiences pain as if the limb were still present. It is more common when the patient
had pain in the limb before amputation. Poor psychologic adjustment is generally due to
inadequate coping skills caused by the overwhelming injury. These patients do not have phantom
pain but may be unable to cope due to a lack of education and knowledge about the amputation.
Early signs of infection may include fever, foul drainage on the dressing, and excessive redness,
warmth, or edema on the residual limb. Denial of the amputation may occur when the patient
refuses to look at or talk about the amputation.
5. ANS: 3
Hemorrhage is the greatest danger in the early postoperative period. It can be detected by
observations of excessive bleeding or changes in vital signs and behavior. Bleeding into tissue in
and around the residual limb because of inadequate hemostasis can be fatal if not corrected
immediately. Restlessness and increasing pulse and respiratory rates may be early signs of
hemorrhage. Hypotension and cyanosis are late signs. If an immediate prosthesis had been
applied, the nurse cannot see the dressing well, so monitoring vital signs is even more critical.
Other postoperative complications associated with amputations include hematoma, necrosis,
wound dehiscence, gangrene, edema, contracture, pain, infection, phantom limb sensation, and
phantom limb pain. Pneumonia would not develop in the early postoperative period. Pain is an
important complication but not as life threatening as hemorrhage. Anxiety is generally related to
anticipated changes in body image and in function and is normal.
6. ANS: 2
In a closed amputation, a compression dressing with elastic bandages is used, as well as a cast to
promote healing and to shrink and shape the residual limb to a tapered, round, smooth end that
will fit the prosthesis. This casting is not done to reduce pain or prevent stimulation of nerve
endings. It is also not done to prevent contamination. In fact, sometimes the heavy cast or
pressure dressing is applied in the operating room to help prevent infection. The nurse needs to
inspect the residual limb frequently for irritation and edema. Edema in the residual limb is most
common during the first 24 hours postoperatively.
7. ANS: 2, 3
In a patient with an above-the-knee amputation, interventions to prevent contractures of the
residual limb include active and passive range-of-motion exercises, which are important to
maintain mobility and prevent debilitation, and also having the patient lie supine (if tolerable),
with the head turned away from the affected side, for 30 minutes three or four times a day. Avoid
prolonged sitting, which can lead to hip and knee contractures, and do not use pillows with lower
extremity amputations because they can cause contractures of the hip. Position the patient in a
low Fowler rather than high Fowler position and not on the side of the amputation.
8. ANS: 1, 2, 3, 5
Patient teaching related to care of a residual limb and prosthesis includes wearing a clean
residual limb sock every day and hand washing, rinsing well, and drying the sock flat. It is also
advised to have several socks so the socks can dry between washings. Wash, rinse, and dry the
prosthetic socket every day. Wash the residual limb with soap and water every night and dry the
skin thoroughly. Lotions, ointments, or powders are used only if prescribed by the physician.
Teach the patient to use a mirror each day to inspect the entire residual limb, especially the
incision, for irritation, redness, and edema. If redness or irritation is seen, discontinue use of the
prosthesis until the area is checked by the health care provider.
9. ANS: 4
When a finger is completely amputated in an out-of-hospital incident, the finger needs to be
sealed in a plastic bag and put in ice water. Direct contact between the amputated part and the ice
can lead to further tissue damage and cell death. It should not be wrapped in a clean dry, cloth, or
especially washed, dried, and wrapped in plastic because those interventions could destroy the
integrity of the finger and prevent any chance of replantation.
10. ANS: 3
Signs of venous congestion are cyanosis, rapid capillary refill, edema, and warmth. The limb
needs to be assessed for edema, because massive edema often accompanies replantation. Signs of
arterial occlusion are pale or blue color, slow capillary refill, shriveled appearance, and coolness.
If evidence of inadequate arterial circulation exists (i.e., no pulse, pallor or cyanosis, cool skin),
immediately notify the surgeon and prepare the patient for a return to the operating suite. Signs
of venous congestion do not necessarily mean rejection of the reimplanted hand. These signs also
do not mean that the replantation was successful. In a severely injured hand in which two or
more fingers are detached, an attempt is made by the surgeon to restore as many fingers as
possible. In general, the greater the muscle mass injury, the less likely that replantation will be
successful, or even possible.
Chapter 47: Endocrine System Introduction
1. ANS: 3
The overall mission of the endocrine system is to maintain homeostasis. Homeostasis is the
maintenance of physiologic stability despite the constant changes that occur in the environment.
Hormones are responsible for important functions related to reproduction, fluid and electrolyte
balance, host defenses, responses to stress and injury, energy metabolism, and growth and
development. Pituitary hormones affect growth, fluid and electrolyte balance, metabolism,
ovulation, milk production, uterine contractions, and skin pigmentation. The endocrine system is
not primarily involved in the body’s effort to resist infection.
2. ANS: 2, 3, 4, 5
ACTH, GH, LH, and TSH are hormones secreted by the anterior pituitary. Adrenocorticotropic
hormone (ACTH) controls the growth, development, and function of the cortex of the adrenal
glands; controls release of glucocorticoids and adrenal androgens, necessary for secretion of
aldosterone; but does not control rate of aldosterone secretion. Growth hormone (GH), or
somatotropic hormone, stimulates the growth and development of bones, muscles, and organs
and stimulates the release of insulin-like growth factor 1 (IGF-1) by the liver and other tissues.
IGF-1 promotes tissue growth. Luteinizing hormone (LH) controls progesterone production and
ovulation or egg release in women and controls testicular growth and testosterone production in
men. Thyroid-stimulating hormone (TSH), or thyrotropic hormone, controls the secretory
activities of the thyroid gland. Other hormones include follicle-stimulating hormone (FSH),
which stimulates the development of the eggs in the ovary and estrogen production in the
woman, and sperm production in the man; prolactin, or lactogenic hormone, which stimulates
breast milk production in the woman; and melanocyte-stimulating hormone (MSH), which
promotes pigmentation. Antidiuretic hormone (ADH) is not a hormone secreted by the anterior
pituitary.
3. ANS: 1
ADH stimulates the kidneys to retain water when fluid volume is reduced. If the kidneys do not
respond well to ADH, as occurs in older persons, the person is at risk for dehydration.
4. ANS: 2, 3
Only FSH and LH are involved in reproduction.
5. ANS: 2
Catecholamines have multiple physiologic effects, all directed toward adapting to stress.
6. ANS: They bind with adrenergic receptors on the cell membranes of target organs
In order to cause responses in specific tissues, these neurotransmitters only interact with
adrenergic receptors.
7. ANS: 1, 2, 3, 5
All are correct except option 4. Glucocorticoids cause retention of sodium, not potassium.
8. ANS: radioactive iodine
Thyroid tissue takes up iodine. A low dose of radioactive iodine is useful for imaging the thyroid
gland. A therapeutic dose of radioactive iodine actually destroys thyroid tissue.
9. ANS: 3
Excessive thyroid hormone replacement will increase the heart rate. Symptoms of inadequate
hormone replacement include fatigue and weight gain. A respiratory rate of 14 is normal.
10. ANS: metabolic rate
The thyroid gland plays a major role in regulating the body’s rate of metabolism and growth and
development. When the metabolic rate falls, the hypothalamus stimulates the pituitary gland to
secrete thyroid-stimulating hormone (TSH). This hormone in turn stimulates the thyroid gland to
secrete hormones that affect the production and use of energy.
Chapter 48: Pituitary and Adrenal Disorders
1. ANS: 3
Responding to a patient with acromegaly who says, “I will be glad to look like myself again,” the
nurse should say, “Treatment will keep your symptoms from getting worse but will not reverse
them.” Drugs used to treat gigantism and acromegaly decrease hormone secretion but do not
reverse the existing skeletal effects of the condition. The statements, “I know you are looking
forward to that,” “The process of reversing the effects of acromegaly is very slow,” and “These
drugs can slow down the progression of acromegaly, but you will have additional bone
enlargement” are all untrue.
2. ANS: 4
When a patient complains of neck stiffness after removal of a pituitary adenoma, the nurse
should look for other signs of infection. Minor symptoms, such as a low-grade fever (99.5 F or
higher), sore throat, or aches, can indicate the onset of a potentially serious infection. Any
symptoms indicative of a cold or other infectious problem should be brought to the attention of
the physician. The most common factor in hyperpituitarism is the presence of a pituitary
adenoma. An adenoma is a benign tumor composed of epithelial tissue. It may vary in size and
invasiveness. Those that are larger than 10 mm are called macroadenomas; those that are smaller
than 10 mm are called microadenomas. A neck massage, giving a prescribed analgesic, and
lowering the head of the bed are not appropriate interventions.
3. ANS: 1, 3
In hypopituitarism patients for whom childbearing is desirable, follicle-stimulating hormone
(FSH) and luteinizing hormone (LH) are the two hormones administered to both men and
women. Prolactin and adrenocorticotropic hormone (ACTH) are not needed hormonal
replacements for couples with hypopituitarism who desire children. In hypothyroidism,
insufficient thyroid hormone is available for normal metabolism and thermogenesis, or heat
production. Excess prolactin can cause prolactinemia, characterized by abnormal lactation
(galactorrhea), amenorrhea, decreased vaginal lubrication, impotence and decreased libido in
men, depression, anxiety, and visual loss. An absence of ACTH affects the person’s ability to
cope effectively with stress, which in turn affects the person’s ability to metabolize glucose, and
results in hypoglycemia.
4. ANS: 2
The main symptom of syndrome of inappropriate antidiuretic hormone (SIADH) is characterized
by a water imbalance related to an increase in antidiuretic hormone (ADH) synthesis, ADH
secretion, or both. When ADH is elevated despite normal or low serum osmolality, the kidneys
retain excessive water; plasma volume expands and causes the blood pressure to rise. Body
sodium is diluted (hyponatremia), and water intoxication develops. The blood glucose level is
not increased and there is fluid volume excess without edema. Hypertension, and not
hypotension, occurs.
5. ANS: 3
Urine specific gravity has to be measured to regulate drug dosage for a patient with diabetes
insipidus (DI). Drug doses for DI do not depend upon daily diet, sodium intake, or blood
pressure and pulse, although all of those factors are important to document.
6. ANS: 1, 2
Fluid and electrolyte imbalances associated with Addison disease include hyperkalemia and
hyponatremia. Dehydration and not hypervolemia occurs. Metabolic alkalosis is a metabolic
condition in which the pH of tissue is elevated beyond the normal range (7.35 to 7.45) due to
decreased hydrogen ion concentration. This can lead to increased bicarbonate, or alternatively
can be a direct result of increased bicarbonate concentrations. Addison disease is frequently the
result of a destructive disease process affecting the adrenal glands that causes deficiencies of
cortisol and aldosterone. The most common cause of Addison disease is idiopathic atrophy, an
autoimmune disease in which adrenal tissue is destroyed by antibodies formed by the patient’s
own immune system. If left untreated, fluid and electrolyte imbalances can lead to circulatory
collapse, cardiac dysrhythmias, cardiac arrest, coma, and death. Hypercalcemia is an
overabundance of calcium in the blood. Calcium is not an electrolyte.
7. ANS: 1
A confused emergency department patient on drugs for Addison disease with a blood pressure of
88/40 mm Hg; pulse 108 bpm, thready; and dry skin and mucous membranes is diagnosed as
having an acute adrenal crisis or addisonian crisis. This usually results from a sudden marked
decrease in available adrenal hormones. Precipitating factors are adrenal surgery, pituitary
destruction, abrupt withdrawal of steroid therapy (often a result of a patient unwittingly stopping
medications), and stress. Examples of stressors include infection, illness, trauma, and emotional
or psychiatric disturbances. Other manifestations of an addisonian crisis include more severe
symptoms of mineralocorticoid and glucocorticoid deficiency: hyponatremia, hyperkalemia,
hypercalcemia, and hypoglycemia. If left untreated, then fluid and electrolyte imbalances can
lead to circulatory collapse, cardiac dysrhythmias, cardiac arrest, coma, and death. Cushing
syndrome is caused by excessive cortisol levels. Hallmark findings of Cushing syndrome include
truncal obesity (excess adipose in body trunk); protein wasting (slender extremities and very thin
and friable skin); facial fullness, often called a moon face; purple striae on the abdomen, breasts,
buttocks, or thighs; osteoporosis (a significant finding in premenopausal women); and
hypokalemia of uncertain cause. Diabetic ketoacidosis (DKA) is a potentially life-threatening
complication in patients with diabetes mellitus. It happens mostly in those with type 1 diabetes,
but it can occur in those with type 2 diabetes under certain circumstances. DKA results from a
shortage of insulin; in response the body switches to burning fatty acids and producing acidic
ketone bodies that cause most of the symptoms and complications. Vomiting, dehydration, deep
gasping breathing, confusion and, occasionally, coma are typical symptoms. DKA is diagnosed
with blood and urine tests. Excessive production of adrenocorticotropic hormone (ACTH)
because of a pituitary tumor is called Cushing disease.
8. ANS: 2, 3
Nursing care of the patient with Cushing syndrome includes telling the patient that mood swings
and changes in appearance are usually corrected with treatment and to avoid exposure to people
with infections because of a decreased resistance to infection. Moisturizers are not specifically
ordered to apply to dark, toughened areas of the patient’s skin. Salt should not be used liberally
because reducing sodium intake can decrease edema and related weight gain with Cushing
syndrome.
Chapter 49: Thyroid and Parathyroid Disorders
1. ANS: 1, 2, 4
Levothyroxine should be taken every day, preferably around the same time each day. Patients
usually require lifelong treatment. Shortness of breath is not indicative of a thyroid imbalance.
2. ANS: 3
Hypothyroidism usually does not require hospitalization, but it may be detected when patients
are hospitalized for other reasons. Because the onset of symptoms is often subtle, the nurse in the
community or long-term care setting must be alert for signs and symptoms of hypothyroidism.
Cold intolerance is a very uncomfortable effect of hypothyroidism. Provide extra clothing and
blankets as needed. An emergency tracheostomy tray or padded side rails are not needed. Also,
hyperthyroidism patients are sensitive to light. Hypothyroidism patients are not, so blinds do not
have to be closed. Maintain the room temperature at a level comfortable to the patient. A room
temperature of 68 F is not mandatory. This is easier to manage if the patient has a private room.
Once thyroid replacement is initiated, the cold intolerance gradually improves.
3. ANS: 2, 3, 4
Severe hyperthyroidism includes tachycardia, dysrhythmias, fine tremor of fingers, tongue
palpitations, and systolic hypertension. Other symptoms include angina, nervousness and
irritability, insomnia, personality change, agitation, inability to concentrate, and hyperreflexia.
There is an increased respiratory rate (not a rate of 12 breaths/minute) and dyspnea. Also, body
temperature is increased and not decreased (e.g., an oral temp of 96 F). In hypothyroidism,
bradycardia is present, the respiratory rate is decreased, and body temperature is decreased.
4. ANS: exophthalmos
Exophthalmos is a classic sign of Graves disease. Exophthalmos is caused by fat accumulation,
edema, and inflammation of the orbital contents. Tearing, light sensitivity, decreased visual
acuity, and swelling around the orbit of the eye occur as well. Graves disease is thought to be an
autoimmune disorder triggered by genetic and environmental factors. Antibodies activate
thyroid-stimulating hormone (TSH) receptors, which in turn stimulate thyroid enlargement and
hormone secretion. Graves disease develops most often in women and, whether treated or not,
the condition tends to have periods of remission and exacerbation. Some patients with Graves
disease eventually develop hypothyroidism.
5. ANS: 2
The best response to a patient who is taking propylthiouracil (PTU) before a scheduled
thyroidectomy is “It reduces your thyroid activity, which makes surgery safer for you.” PTU
treats hyperthyroidism by interfering with the synthesis of thyroid hormones. It does not
eliminate excess thyroid hormones or replace thyroid hormones after the thyroid gland is
removed. It also does not shrink the thyroid gland or reduce pressure on the airway.
6. ANS: 1
The first priority in the immediate postoperative thyroidectomy period is to maintain a patent A
(airway), B (breathing), and C (circulation) and the basic emergency interventions for a patient
recovering from surgery. Checking for hemorrhage would be the second most important
intervention. Monitoring for hypocalcemia and preventing strain on the suture line are important
interventions, but not the initial priorities in the postoperative thyroidectomy patient.
7. ANS: 2
It is important to measure serum thyroglobulin in a patient with thyroid cancer because it rises if
thyroid cancer recurs. Thyroid replacement therapy is based on the thyroid-stimulating hormone
(TSH) level and not the serum thyroglobulin level. Diagnostic studies of the thyroid gland
include laboratory blood tests and studies employing radioactive iodine (RAI). Scans using RAI
are sometimes ordered at intervals to detect the presence of any remaining cancerous tissue in the
thyroid gland. RAI is just another diagnostic test to determine the presence of thyroid cancer.
Serum thyroglobulin does not measure parathyroid function.
8. ANS: 1, 2, 5
When the serum calcium level falls, parathyroid hormone (PTH) is secreted. PTH increases the
absorption of calcium from the intestines, transfers calcium from the bones to the blood, and
signals the kidneys to conserve calcium. In general, calcium retention by the kidney is balanced
by phosphate loss. Without PTH, the serum calcium level falls, thus causing tetany. Muscle
contractions begin as twitches around the mouth and eyes. The face, fingers, and toes begin to
tingle. The patient may have painful “cramps.” The most serious effect of hypocalcemia is spasm
of the larynx. As the larynx closes, the patient has difficulty breathing and can suffocate. Cardiac
dysrhythmias and seizures also can occur. Tetany is treated with calcium salts given
intravenously or orally. The condition usually improves as the injured parathyroid glands
recover. Rarely is hypoparathyroidism permanent, so it is not a chronic condition. Increased, and
not decreased, serum PTH causes calcium to shift from the bones to the blood.
9. ANS: 3
Muscle cramp in hands and feet 2 days after a parathyroid adenoma has been removed is
generally caused by hypocalcemia. Two potential complications specific to parathyroidectomy
are (1) airway obstruction and (2) hypocalcemia. A second possible cause of airway obstruction
is related to severe hypocalcemia. Poor circulation is not an issue after a parathyroidectomy.
Thyrotoxicosis (thyroid storm or crisis) is caused by hyperthyroidism. It is not related to a
parathyroidectomy. It is a medical emergency, but modern treatment of hyperthyroidism makes
this complication rare. Metabolic acidosis is not related to a parathyroidectomy.
10. ANS: 1
When administering iodide solution to a patient, first dilute it in milk or juice, and then have the
patient drink it with a straw. Iodine solutions can cause discoloration of the teeth and gastric
upset, so they must be diluted with milk, fruit juice, or some other beverage and sipped through a
straw. Iodide solutions inhibit the synthesis of thyroid hormones and are used most often after a
course of propylthiouracil to suppress hormone secretion before thyroidectomy. These drugs
have no cardiovascular effects, so the patient’s blood pressure and pulse are not required to be
taken before each dose. Signs of iodine toxicity include swelling and irritation of the mucous
membranes and increased salivation; iodine toxicity has no effect on a patient’s hearing.
Although the patient’s intake and output may be recorded, careful monitoring is not necessary.
Chapter 50: Diabetes and Hypoglycemia
1. ANS: 2, 4
Insulin is considered a critical hormone for glucose metabolism. Insulin also is needed for the
synthesis of fatty acids and proteins. Insulin stimulates the active transport of glucose into the
cells. When insulin is absent, glucose cannot enter most cells, so it remains in the bloodstream.
Glucose is the source of energy, not insulin. Insulin is the stimulant to bring the energy source to
the cells. Insulin transports, but does not metabolize, the glucose for energy. Insulin does not
stimulate excretion of excess glucose. It stimulates the transport of glucose to the cells.
2. ANS: 1
The risk of diabetes among Latino Americans is approximately 300% that of Caucasian
Americans. Other ethnicities at greater risk of diabetic incidence include those with Alaska
Native, Native American, African American, Asian American, and Pacific Islander ethnicity.
3. ANS: 3, 4, 5
Macrovascular complications of diabetes include coronary heart disease (CHD), cerebrovascular
accidents (CVAs) or stroke, and peripheral vascular disease (PVD). Retinopathy and end-stage
renal disease are microvascular complications.
4. ANS: 3
Autonomic neuropathy related to diabetes affects the sympathetic and parasympathetic nervous
systems. Microvascular complications result from changes in small blood vessels that are unique
to diabetes and occur in both type 1 and type 2 diabetes. The basement membrane of capillaries
thickens, which impairs the exchange of nutrients, gases, and wastes. Tissues that are most
vulnerable to microvascular complications are the eyes (retinopathy) and the kidneys
(nephropathy). Neuropathy is sometimes classified with microvascular complications. It can
affect the pupillary response and functions of the cardiovascular, gastrointestinal, and
genitourinary systems. Cardiovascular involvement may be manifested by postural hypotension,
resting tachycardia, exercise intolerance, and failure of the heart rate to increase with vigorous
exercise. These symptoms are consistent with the data regarding this patient. Macrovascular
changes are associated with coronary heart disease (CHD) and chronic hyperglycemia.
5. ANS: 2
Tremors, sweating, nervousness, tingling or numbness of the lips or tongue, tachycardia, and
palpitations are all signs and symptoms of low blood pressure, or hypoglycemia. They are not
“common symptoms of diabetes,” nor are they “very unusual.” Low levels of glucose in the
blood may be corrected, at least temporarily, by ingestion of 4 to 6 ounces of fruit juice, 8 ounces
of skim milk, a tablespoon of sugar or honey, or even some Life Saver candies. Medication may
need adjustment at some point, but this is not the best response. Treatment needs to be given as
soon as possible.
6. ANS: 4
High protein intake indirectly contributes to the development of nephropathy. Nephropathy
(kidney disease) can lead to end-stage renal disease (ESRD). An increased level of protein in the
urine is an indication that the condition is progressing to ESRD. Limiting protein intake will help
to slow or terminate this condition. Ketoacidosis is a deficiency or a complete lack of insulin and
can lead to disorders in the metabolism of fats, carbohydrates, and proteins. It is a problem
primarily with type 1 diabetes mellitus and occurs when ketone bodies accumulate as the result
of the breakdown of fats for energy associated with inadequate insulin. Protein needs are not
decreased because excess glucose is meeting metabolic needs, and high protein intake has
nothing to do with the absorption of other nutrients.
7. ANS: 2
Insulin was, and still is, obtained from beef and pork; however, most hospitals have switched to
human insulin as the standard. A drawback of using beef and pork as the source is that humans
may form antibodies against them. Humans do not, however, form antibodies against human
insulin. Human insulin is not less expensive. Human insulin does not have a longer duration. Its
duration is shorter, but has less risk associated with its use. All types of insulin can cause
hypoglycemia if the dose is too much for the patient needs. Intentional or accidental overdose of
insulin, a combination of insulin with inadequate food intake, usually increased exercise,
decrease in insulin requirement, or potentiating medications are factors that cause hypoglycemia.
8. ANS: 1
Alpha-glucosidase inhibitors are the least likely type of oral diabetes mellitus (DM) medication
to cause hypoglycemia. Examples of alpha-glucosidase inhibitors are acarbose (Precose) and
miglitol (Glyset). Acarbose and miglitol do not cause hypoglycemia when used alone. If patients
with type 2 DM are unable to control their blood glucose with a nutrition program and exercise,
the physician may prescribe one or more oral hypoglycemic agents. Other oral hypoglycemic
agents include sulfonylureas, biguanides, thiazolidinediones, meglitinides, and d-phenylalanines,
dipeptidyl peptidase-4 (DPP-4) inhibitors, and sodium-glucose co-transporter-2 inhibitors.
Conversely, a significant adverse effect of the sulfonylureas is the risk of hypoglycemia. With
meglitinide and d-phenylalanine drugs, hypoglycemia may occur with strenuous exercise or
alcohol consumption.
9. ANS: 1, 3, 4
Polyphagia, polydipsia, and polyuria, known as the three Ps, are classic signs of diabetes
mellitus (DM). Polyhidrosis (excessive or profuse sweating) and polycythemia (a blood disease)
are not signs and symptoms of DM.
10. ANS: 4
People with diabetes are at increased risk for heart disease, renal disease, blindness, amputation,
and complications during pregnancy. Fortunately, with early diagnosis and better management, it
is possible to reduce the risk of serious complications. Reassuring the patient that there are ways
to help prevent serious complications is the most appropriate reply. Telling the patient not to
think about it can increase anxiety and does not provide the patient with needed education about
the disease. To indicate that most people with diabetes have to have amputations is inaccurate
information, and will also increase the patient’s anxiety level. To attempt to intimidate the
patient into following the physician’s order blindly is cruel and incorrect, and will also increase
the patient’s anxiety.
Chapter 51: Female Reproductive System Introduction
1. ANS: 3
Fertilization, the union of sperm and ovum, takes place in the fallopian tubes. There are two
fallopian tubes. They are thin, hollow, cilia-lined, tubular structures that extend from the uterine
fundus. The fallopian tubes have funnel-shaped ends that partially surround the ovaries and that
receive the ovum from the ovary. The fallopian tubes serve as passages for ova from the ovaries
and for sperm that travel through the vagina and into the tubes. Fertilization does not occur in the
uterus, ovary, or vagina.
2. ANS: 1
When collecting data about a patient’s menarche, the question to ask is “At what age did you
begin menstruating?” Menarche is the first menstrual cycle, or first menstrual bleeding, in female
humans. Age at menarche, if 11 years or younger, is an established risk factor for breast cancer.
Age at menarche is not related to the patient’s menstrual flow, age when first experienced a “hot
flush,” or mood changes before menstrual periods.
3. ANS: 1, 4
Appropriate statements before a culdoscopy include “You will need to be in a knee-chest or
lithotomy position.” This position can be physically uncomfortable, embarrassing, and
humiliating, so assure the patient that she will be draped throughout the procedure. When
completed, help the patient get out of the knee-chest position without exposure. Another
appropriate statement is, “You may have shoulder pain caused by air entering the pelvic cavity.”
Shoulder pain with this procedure is a common complaint. After the procedure, restrictions
include nothing inserted in the vagina (e.g., no vaginal intercourse, douching, or tampons) for the
period of time the physician specifies. There are not sutures to remove. A small incision in the
posterior vagina is made but will close and heal without sutures. General anesthesia is not given.
The procedure is usually performed with light sedation and local anesthetic on an outpatient
basis.
4. ANS: 1, 2, 5
When teaching a class on breast self-examination (BSE), the primary role of the nurse is to
instruct the class in BSE and to encourage scheduled professional examinations. BSE is not a
substitute for periodic professional breast examinations. The BSE should be done at the same
time each month and at the end of the menstrual period for menstruating women or on the same
date each month for women who have ceased menstruating. Bilateral axillae need to be palpated
with each arm only slightly (not fully) raised. Older women should do a BSE on the same date
each month and not every day. The American Cancer Society recommends that mammograms be
obtained in women at the age of 40 years and subsequent testing should be done annually
thereafter and continued as long as they are otherwise in good health (ACS, 2013). In 2009, the
U.S. Preventive Services Task Force issued new recommendations that mammography should
begin at age 50. Mammograms are not done only if a lump has been discovered.
5. ANS: 1
The nurse’s best advice to a patient about douching is “Your body has normal processes to
cleanse the vagina, so douching is not necessary.” It does not need to be done unless ordered by a
physician or nurse practitioner. Douching is not harmless but potentially dangerous, because it
may force tissue and microorganisms up into the uterus. In addition, cleansing and perfumed
agents may cause allergic or irritant reactions. Contrary to common belief, douching is not an
effective contraceptive practice. The vagina is not a sterile area, so sterile solution is not used.
6. ANS: 2
The Papanicolaou test uses scrapings from the cervix to assess for abnormal cells including
cancer.
7. ANS: 1, 2, 3, 5
The collection of vaginal specimens is done by the physician or nurse practitioner. The other
activities are appropriate for the LVN/LPN.
8. ANS: 2
By definition, gravidity is the total number of pregnancies, regardless of the outcome.
9. ANS: 1
Both Plan B and ella are emergency contraceptives that are taken after unprotected intercourse
when pregnancy is not desired.
10. ANS: 3
Recommendations made by the American Cancer Society and by the U.S. Task Force on
Prevention vary somewhat. Decisions are based on the individual patient situation, so the patient
should discuss the mammogram schedule with her primary care provider.
Chapter 52: Female Reproductive Disorders
1. ANS: 3
New vaccines, Gardasil, Gardasil 9, and Cervarix, are available to protect against HPV infection
and therefore dramatically reduce cervical cancer.
2. ANS: 2, 3, 4, 5
All are correct except option 1 as it is important to encourage frequent and progressive exercise
of the arm on the affected side.
3. ANS: 4
Breast cancer is the most prevalent form of cancer in American women; the current prediction is
that 1 in every 8 or 9 women will develop breast cancer at some point in her life.
4. ANS: 3
Infertility may be a sign of endometriosis when adhesions affect uterine position or fallopian
tube patency, movement, or both because bleeding by endometrial tissue causes local
inflammation and pain wherever the site of implantation may be located. The number of implants
gradually increases, creating multiple sites of inflammation and pain. In response to the
inflammation, fibrous tissue that results in scarring and adhesions forms.
5. ANS: 2
Yeast infections often are associated with disruption of the normal vaginal flora by antibiotic
therapy.
6. ANS: 4
Escherichia coli is not associated with pelvic inflammatory disease (PID). Neisseria
gonorrhoeae, Chlamydia trachomatis, and Mycoplasma hominis are recognized as the organisms
most associated with PID. Chlamydia infection is thought to be the most commonly occurring
sexually transmitted infection and the one most often responsible for PID. As such, it is often
implicated in infection of the fallopian tubes (salpingitis) and is considered to be the primary
cause of ectopic pregnancy and infertility associated with tubal obstruction.
7. ANS: 3
If a patient has been taking danazol (Danocrine) for 6 months and wants to get pregnant, she
needs to wait 1 month because danazol can cause birth defects. Danazol is a synthetic androgenic
steroid that inhibits gonadotropin excretion, resulting in amenorrhea and atrophy of intrauterine
and ectopic endometrial tissue. It is also contraindicated during pregnancy, so the patient should
know to use a barrier contraceptive during and for 1 to 3 months after the first normal menstrual
period after therapy. The patient will not begin menstrual bleeding within 1 week after stopping
the drug. She should not get pregnant in the first month after stopping the drug because of the
risk of birth defects. She may try to get pregnant after 3 months of stopping the drug; she does
not have to wait 1 year.
8. ANS: 4
After placement of a pessary, advise the patient to return within 24 hours for the physician to
assess placement, effectiveness, and problems related to pressure on surrounding structures. A
pessary is a device that is inserted into the vagina to apply pressure on the vaginal wall, thereby
supporting the uterus in the pelvis. For women who are poor surgical risks or who refuse surgical
treatment, pessaries are an option but they do not correct the uterine prolapse. Pessaries must be
removed, cleaned, and replaced periodically. Although some primary health care providers prefer
to remove, clean, and replace pessaries, capable patients can be taught to do this themselves. If
they are not maintained or are fitted improperly, then they may act as irritants and cause tissue
erosion, malignant tissue changes, or both. The patient’s pessary must be documented so that it
will not be forgotten and neglected.
9. ANS: 1
Characteristic breast cancer lumps are usually singular and unilateral (affecting only one breast),
and they can be found in any part of the breast. However, nearly one-half of all malignant breast
tumors are located in the upper outer quadrant, and nearly one-fourth are located in the
nipple-areolar complex. Most malignant lumps are painless and are palpated as firm, irregularly
shaped, and fixed to underlying structures or skin. Fibrocystic breast changes are an exaggerated
response to hormonal influences. Excess fibrous tissue develops, accompanied by overgrowth of
the lining of the mammary ducts, proliferation of mammary ducts, and the formation of cysts.
Fibrocystic nodules do not “become cancerous,” but their presence may make it more difficult to
detect malignant tumors by palpation. They are firm, painful lumps that usually affect both
breasts. Smooth round lumps that are freely moveable may be felt. Sometimes milky yellow or
green discharge from the nipple is seen. Symptoms commonly are most apparent during the
premenstrual phase of the menstrual cycle and typically improve after the menstrual period.
10. ANS: 3
The risk for cervical cancer is increased in women who had their initial sexual intercourse in
early adolescence, or have been infected with the human papillomavirus (HPV), or human
immunodeficiency virus (HIV). Additional factors associated with cervical cancer are cigarette
smoking, a compromised immune system, and multiple sexual partners. Cervical cancer was
formerly thought to be linked to sexual intercourse with uncircumcised males, but current
research does not support this speculation. Age at menarche, if 11 years or younger, is an
established risk factor for breast cancer. Uterine prolapse and fibroid tumors are not related to the
risk factors for cervical cancer.
Chapter 53: Male Reproductive System Introduction
1. ANS: 2
Testosterone is the hormone responsible for male sexual development. Secretion of this male
hormone results in the development of other male reproductive organs and causes the testes to
descend into the scrotum during the last 2 months of gestation. Luteinizing hormone (LH) is
secreted by the anterior pituitary gland and causes stimulation of special cells (i.e., Leydig cells)
in the testes to produce testosterone. Gonadotropins are hormones secreted by the endocrine
system directly into the blood that regulate reproduction. Progesterone is one of the female
hormones secreted by the ovaries along with estrogens, androgens, and relaxin.
2. ANS: 1, 2, 4
Normal aging in the healthy male includes rapidly decreased testosterone production after the
age of 50, slower to arousal, and a longer refractory period between erections. This phenomenon
has been called the male climacteric and may be associated with symptoms of hot flushes,
feelings of suffocation, and psychologic disorders similar to those of menopause. These
symptoms may be relieved by the administration of testosterone and other androgens. In a
healthy man, there is no lack of interest in sexual activity, and spermatogenesis and the ability to
have erections can last a lifetime.
3. ANS: 4
Normally, the testes descend into the scrotum within the last 2 months of gestation. Part of the
male newborn assessment is palpation to determine whether the testes have descended.
4. ANS: 2
Cryptorchidism refers to testes that have not descended into the scrotum. Failure to descend may
result in sterility, even if corrected surgically.
5. ANS: 1
Hot flashes may occur as a result of blocking androgen receptors.
6. ANS: 4
With aging, the normal decline in testosterone production may result in hot flashes and feelings
of suffocation, much like that experienced in the female menopause.
7. ANS: 1
Many blood pressure medications can affect the sexual response. Men on antihypertensive drugs
who experience ED should discuss other options for BP management with their primary care
provider. In a healthy man, the ability to have erections last a lifetime.
8. ANS: 2
The patient should abstain from sexual activity for 2 to 3 days before collecting the specimen in
a clean container. Rubber condoms should not be used because they often have powder or
lubricants that may kill the sperm. The specimen should be kept a room temperature and
delivered to the lab within an hour.
9. ANS: 4
The risks of testosterone use when not medically indicated are contraindicated because of the
potential for serious adverse effects including stroke and myocardial infarction.
10. ANS: 4
Thrombosis resulting in stroke, myocardial infarction, and death is the most serious adverse
effect of testosterone therapy.
11. ANS: 1, 2, 3
Nitroglycerin in combination with sildenafil can cause hypotension that may be fatal. There is no
evidence of benefit to females. Headache, dizziness, and flushing may occur. Sexual stimulation
is required to achieve an erection. Sildenafil should be taken about an hour before anticipated
sexual activity.
Chapter 54: Male Reproductive Disorders
1. ANS: 4
Many older adults are taking drug for hypertension. These drugs may interact with sildenafil to
cause hypotension. The patient should be advised to discuss the use of sildenafil with his health
care provider to see if the combination is safe.
2. ANS: 1, 2, 4, 5
Some drugs can cause ED. The patient should discuss his options with his health care provider.
Measures that may improve sexual function include physical conditioning, management of stress
and anxiety, and ideal weight. Alcohol may contribute to hypotension so is not recommended.
3. ANS: 2, 4
Patient teaching about benign prostatic hypertrophy (BPH) includes having the patient void
promptly when he gets the urge and explaining that medications that have antihistamines can
cause urinary retention. Other obstructive symptoms include decreasing the size and force of the
urinary stream and postvoid dribbling. Irritative symptoms include urgency, frequency, dysuria,
nocturia, hematuria, and sometimes urge incontinence. Other factors that may trigger retention
are alcohol, infections, delayed voiding, bed rest, opioids, and chilling. Avoiding caffeine and
alcohol, maintaining fluid intake of 1500 to 2000 mL/day, and restricting fluids for 2 hours
before bedtime can help prevent urinary retention. Fluid restriction is not recommended because
it increases the risk of urinary tract infection (UTI). Prolonged exposure to warm temperatures
does not promote bladder spasms.
4. ANS: 3
Urine characteristics must be assessed after a transurethral prostatectomy (TURP) to detect any
evidence of bleeding. During a TURP, an instrument is inserted into the urethra and an electrode
or laser is used to cut away or destroy obstructing portions of the prostate gland. There is no
external incision and so no abdominal dressing or perineal drainage. There is not a suprapubic
drain because this is a transurethral and not a suprapubic prostatectomy. With a TURP, a
triple-lumen urinary catheter is used to maintain continuous irrigation and bladder drainage.
Continuous irrigation is intended to clear the bladder of blood and debris. If the catheter output is
less than the irrigating fluid delivered, then the catheter may be obstructed and so manual
irrigation may be needed as ordered to clear the clots and restore drainage.
5. ANS: 4
Finasteride (Proscar) reduces prostate size, which decreases urethral obstruction. The effects are
not evident for several months. Tamsulosin (Flomax) relaxes smooth muscle in bladder neck,
prostate capsule, and prostatic urethra, which reduces urethral obstruction. Flutamide (Eulexin)
decreases testosterone levels and is used with luteinizing hormone–releasing hormone (LHRH)
to treat prostate cancer. Oxybutynin chloride (Ditropan) is an antispasmodic drug often used for
pain after prostatectomy and is used to relieve bladder spasms.
6. ANS: 1
Sterile normal saline is isotonic and not hypotonic like water. Hypotonic solutions can cause cell
damage when you irrigate a body cavity (or wound). It is not less expensive but will not cause
tissue damage. Isotonic solutions are not absorbed into the bloodstream because their tonicity or
pH is the same as the blood. Sterile water has no irritating properties that would make the skin
sting.
7. ANS: 3
Mumps may result in male infertility. Mumps can cause acute orchitis and epididymitis,
accompanied by fever and debilitating pain, bilateral swelling, and redness of the testicles. If
damage to seminiferous epithelium occurs, then the size of the testes will be reduced. Measles,
chickenpox, and diphtheria are not related to male infertility. Other infections such as
tuberculosis, pneumonia, and syphilis may affect the testes, but less dramatically than mumps.
8. ANS: 4
Cryptorchidism, or failure of the testicles to descend from the abdomen into the cooler scrotum,
may result in sterility. Cryptorchidism must be corrected within the first 18 months of life to give
the best chance for fertility. Men with undescended testes have a 10 to 30 times higher incidence
of testicular cancer than men whose testes descended normally. Incomplete or partial descent of
the testicles may be resolved by surgical assistance before maturity, but if fetal testes are
abnormally formed and do not secrete enough testosterone to cause the testicles to descend into
the scrotum, then surgical intervention is unlikely to be successful. Testicular torsion occurs
when the spermatic cord twists, cutting off the blood supply to a testicle, and most commonly
occurs in adolescents. A varicocele is a lengthening and enlargement of the scrotal portion of the
venous system that drains the testicle and is caused by incompetent or absent valves in the
spermatic venous system. Most often, only the left testicle is affected. They are most frequently
diagnosed when a patient is 15 to 30 years of age, and rarely develop after the age of 40. They
occur in 15% to 20% of all males. Untreated bilateral cryptorchidism results in sterility but not
chronic infections.
9. ANS: 4
Patient teaching related to vasectomy includes an analysis of the semen to determine if a
complete absence of sperm exists. Vasectomy is the surgical removal or tying of a portion of the
vasa deferentia for sterilization purposes. The patient is not sterile immediately after the
procedure. Intercourse can be resumed as soon as he feels comfortable, but it is important that
the patient use other methods of birth control until a determination that sperm no longer exist is
made. The patient can expect the analysis to be done after about 15 ejaculations after the
vasectomy. Although a vasectomy can sometimes be successfully reversed, it should be
considered permanent. The reversal procedure, in which the severed ends of the vas deferens are
anastomosed (surgically joined), is called a vasovasectomy. Erection, ejaculation, and intercourse
are unaffected.
10. ANS: 1
Serum prostate specific antigen (PSA) increases with prostate cancer, but also with a variety of
other conditions. PSA is the most useful tool for the follow-up of patients who have undergone
treatment for prostate cancer. Persistent or rising PSA levels indicate advancing or recurrent
tumor growth. Periodic biopsies of perineal tissue are not necessary, and studies of urine flow
would not lend any reliable data about the status of the cancer. The diagnosis of prostate cancer
may be based on rectal examination, transrectal ultrasound, PSA level, and needle aspiration and
biopsy. Additional procedures may be done to identify the stage of the disease but not the
effectiveness of treatment. These include radiographs, radionuclide imaging, bone scans,
excretory urography, transurethral ultrasound, computed tomography, and magnetic resonance
imaging.
Chapter 55: Sexually Transmitted Infections
1. ANS: 3
The purpose of reporting sexually transmitted infections (STIs) is to reduce transmission of the
infection by treating all infected persons. STIs include a number of conditions that can be
transmitted from one person to another during intimate contact. The term sexually transmitted
disease (STD) is commonly used to describe these same conditions as well. The difference in the
two terms is that a disease, by definition, has recognizable signs and symptoms, whereas
infections may or may not manifest specific signs and symptoms. Worldwide, the incidence of
STIs increases every year. Some states only report the incidence but not individual people’s
names. Other states confirm cases of STDs and a current list is posted yearly at
www.cdc.gov/ncphi/disss/nndss/casedef/. An investigator asks the patient to name sexual
contacts. Sexual contacts are notified and advised that they have been exposed to the disease and
are encouraged to seek medical evaluation. The purpose of this process is to identify and treat
infected individuals so that transmission of the infection can be slowed. Another approach is to
provide the patient with a prescription or additional drugs for his or her sexual partner without
examination of the partner. This approach, which is legal in some but not all states, is called
expedited partner therapy (EPT). Individuals are not prosecuted for transmitting the disease to
others. Reporting STIs is not related to emphasizing to infected persons the importance of
practicing safe sex. That intervention is done by health care providers. Reporting does not reduce
transmission of the infection by treating all infected persons nor teach the general public about
measures to prevent STIs.
2. ANS: 2, 3
Newborns of women with gonorrhea or chlamydial infection may acquire eye infections during
birth. Erythromycin ophthalmic ointment is ordered for the newborn of a mother who has
chlamydia or gonorrhea. Chlamydial infection is thought to be the most common bacterial
sexually transmitted infection (STI) in the United States, and symptoms are similar to those of
gonorrhea. Chlamydia is an intracellular bacterium that comprises multiple genera and species.
This infection is transmitted by contact with the mucous membranes in the mouth, eyes, urethra,
vagina, or rectum. Newborns of infected women may have eye infections (infant inclusion
conjunctivitis) or infant pneumonia. Gonorrhea is transmitted most often through direct sexual
contact, but some cases have been reported of transmission to newborn infants by infected
mothers and to medical personnel with skin lacerations who have come in contact with infected
fluids. Syphilis is passed through the placenta, thus causing an infant to be born with the disease
(i.e., congenital syphilis). Condylomata acuminata, or genital warts, are caused by the human
papillomavirus (HPV) and have a high rate of recurrence despite drug therapy, cryotherapy,
cautery, and surgical or laser excision. For unknown reasons, pregnancy can stimulate venereal
warts to grow very large. Transmission of the virus is by vaginal, anal, or genital contact with an
infected person. If a woman has genital warts, which are caused by HPV, the warts may appear
on the outside of the vagina and/or on the inner walls of the vagina and on the cervix. Genital
warts don’t interfere with a woman’s ability to get pregnant. However, during pregnancy, warts
may get larger and/or may bleed, possibly due to increasing levels of estrogen. Warts along the
vaginal wall might make the vagina less flexible and elastic during delivery. It may not be
advisable to have the warts removed at this point because of the unknown possibility of birth
defects caused by the substances used to remove them. Instead, cesarean delivery might
sometimes be recommended when there is a possibility of warts being present toward the end of
a woman’s pregnancy. It is believed to be unlikely for a child to be born with HPV. There have
been some cases where women with HPV in their vaginal canals during birth have passed the
virus on to their babies in the form of laryngeal papilloma, which affects their throat, but this is
quite rare. In cases in which this occurs, surgery on the infant is sometimes necessary to remove
airway blockages, but again, this is rare. Transmission of hepatitis B virus results from exposure
to infectious blood or body fluids containing blood. It can be vertically transmitted from mother
to child (MTCT) during childbirth. Without intervention with antiviral drugs, a mother who is
positive for hepatitis B surface antigen (HBsAg) confers a 20% risk of passing the infection to
her offspring at the time of birth. This risk is as high as 90% if the mother is also positive for
hepatitis B e antigen (HBeAg). Only 5% of newborns that acquire the infection from their
mother at birth will clear the infection. Nucleoside reverse transcriptase inhibitors (NRTIs) are
given to treat this infection. An infected woman who becomes pregnant has a greatly increased
risk of fetal infection, deformities, or death. Syphilis can be passed through the placenta, thus
causing an infant to be born with the disease (i.e., congenital syphilis). The treatment of choice
for syphilis is parenteral penicillin G unless contraindicated. For an infection of less than 1 year’s
duration, a single dose is usually sufficient. For infections of 1 year’s duration or longer, a longer
course of therapy is indicated. Newborns with congenital syphilis are not treated with
erythromycin ophthalmic ointment.
3. ANS: 1
The nurse should respond, “Without treatment, the bacteria remain in your body and you remain
highly infectious.” It is essential for the patient to complete the prescribed course of antibiotics
and return so that the physician can determine whether the treatment was effective. Telling the
patient, “As long as your symptoms have cleared up, no reason exists to treat you now,” is
incorrect. Symptoms generally disappear after a few weeks, but if the infection is untreated, then
the bacteria remain in the body and the person remains highly infectious. Also, responding to the
patient, “If you have symptoms in the future, then come to the clinic immediately,” does not
emphasize that the patient has to be cleared of this course of the disease. The response,
“Fortunately, gonorrhea has no serious complications, but I must advise you to seek treatment
anyway,” is also incorrect. If untreated, gonorrhea can cause sterility in both genders and
infections that may lead to damage to heart tissue and joints. Men may develop epididymitis and
prostatitis. Women may develop pelvic inflammatory disease (PID). People with gonorrhea are
at increased risk for human immunodeficiency virus (HIV); people with HIV and gonorrhea are
more likely to transmit HIV to another person.
4. ANS: 2
The primary stage of syphilis involves a typical lesion, called a chancre, that is the first sign of
syphilis. The chancre is a reddish papule-like lesion that appears where the organism entered the
body, usually on the genitals, anus, or mouth. Within 1 week, the papule becomes a painless red
ulcer. Lymph nodes in the area of the chancre may be enlarged but are not tender. The chancre is
generally first noticed 1 to 12 weeks after contact. During the primary stage, the chancre may last
from 1 to 5 weeks. When it disappears, patients may assume they are cured when, in fact, the
infecting organism has moved into the blood. Signs and symptoms change throughout the course
of the disease. If untreated, syphilis progresses through four stages: (1) primary, (2) secondary,
(3) latent, and (4) late. The secondary stage involves a rash on the extremities, chest or back,
palms of the hands, and soles of the feet. Pustules that contain highly contagious material often
develop. The patient is contagious during the first and second stages. Lymph nodes in the area of
the skin lesion can be enlarged but they are not tender. Fever, sore throat, and generalized aching
are also seen in the secondary stage.
5. ANS: 1, 2, 3, 4
The patient with untreated syphilis may develop severe, potentially fatal complications,
including neurosyphilis (meningitis, blindness, paralysis), and cardiovascular disease.
Osteoporosis is not related to patients with untreated syphilis.
6. ANS: 1, 2, 3
The modes of transmission of both types 1 and 2 herpes simplex virus (HSV) are the same, and
both types can be treated with antiviral drugs. Type 1 (HSV-1) is transmitted through contact
with open lesions, usually on the lips or inside the mouth. Type 2 (HSV-2) is most often
transmitted by genital contact, and vaginal or anal intercourse and oral-genital contact are the
primary transmission modes. But HSV-2 can be transferred by hand contact as well. There are no
vaccines available and no cure for HSV infection exists. Oral antiviral drugs acyclovir (Zovirax),
valacyclovir (Valtrex), and famciclovir (Famvir) help by partially controlling the signs and
symptoms during initial and recurrent episodes.
7. ANS: 1, 4, 5
The teaching plan for a woman with genital herpes simplex virus type 2 (HSV-2) infection
should include encouraging the women to have yearly Papanicolaou tests because she is at
increased risk for cervical cancer and telling the patient that her partner must use a condom for
intercourse even when lesions are not present. The woman also needs to be advised that
medications can reduce the frequency and severity of her symptoms. She can become pregnant,
but a physician should supervise her closely. Various guidelines are used to determine whether
the patient should have a vaginal delivery or cesarean section. The goal is to decrease the risk of
transmission to the baby. New diagnostic procedures allow the physician to detect active disease
more accurately than in the past. No cure for HSV infection exists, but the oral antiviral drugs
acyclovir (Zovirax), valacyclovir (Valtrex), and famciclovir (Famvir) help by partially
controlling the signs and symptoms during initial and recurrent episodes. She needs to know to
start the drug when preliminary (prodromal) symptoms of recurrence are experienced or within 1
day of the outbreak of lesions. Some patients with especially disabling recurrences can take one
of these drugs continuously to reduce the frequency of outbreaks.
8. ANS: 3
The teaching plan for a patient with genital warts should include information that a topical
medication can remove the warts but is not curative. Genital warts can be transmitted to a sexual
partner and are not caused by poor personal hygiene. There is no cure for these warts but
removal of visible warts provides symptomatic relief. Some treatments such as the application of
podofilox, imiquimod, or kunecatechins can be managed by the patient. Other treatments must be
administered by the physician (i.e., cryotherapy, which uses liquid nitrogen or solid carbon
dioxide [CO2] to freeze the warts; topical trichloroacetic acid, bichloroacetic acid, or podophyllin
resin; surgical removal; injection of interferon into the lesions).
9. ANS: 2, 4, 5
Effective use of condoms should include information that latex condoms are preferred over
natural-membrane condoms because some pathogens can pass through natural-membrane
condoms. Also, to put a condom on, hold it by the tip and unroll it onto the penis and leave a
space of about 1 inch at the tip for semen. Make sure to withdraw the penis carefully after
ejaculation to keep the condom from slipping off and spilling the contents and to avoid
unprotected contact. Condoms do not provide 100% protection against disease transmission. Use
only water-based lubricants because oil-based and other lubricants can cause the condom to
break. Spermicidal drugs may be used. Protect condoms from heat and sunlight to keep them
from deteriorating, and do not use condoms that are brittle, discolored, or in damaged packages.
10. ANS: 1, 3, 4, 5
Gonorrhea, syphilis, trichomoniasis, and chlamydia can usually be cured with antimicrobial
drugs. There is no cure for herpes simplex virus infection, but the oral antiviral drugs acyclovir
(Zovirax), valacyclovir (Valtrex), and famciclovir (Famvir) can help by partially controlling the
signs and symptoms during initial and recurrent episodes.
Chapter 56: Integumentary System Introduction
1. ANS: 2
The functions of the skin are protection, body temperature regulation, secretion, sensation, and
synthesis of vitamin D. In addition, the blood vessels of the skin can serve as a blood reservoir.
To regulate body temperature, the skin participates by altering the diameter of surface blood
vessels and through sweating. To dissipate heat, the blood vessels dilate. As the blood flows
close to the body surface, heat is lost through the surface. To retain heat, blood vessels constrict
and heat loss is minimized. Sweating helps cool the body because heat is lost as sweat evaporates
from the skin. The skin’s protective function is shielding underlying tissues from trauma and
pathogens and preventing excess loss of fluids from those tissues. A second type of protective
function is fulfilled by Langerhans cells, which initiate an immune response when foreign
substances invade the epidermis. Sebum is another secretion function that coats the skin, creating
an oily barrier that holds in water. The skin does not react to sunlight by producing vitamin C,
but vitamin D.
2. ANS: lentigines
These pigmented spots on sun-exposed areas are commonly called liver spots, although they
have nothing to do with the liver.
Chapter 57: Skin Disorders
1. ANS: 1, 3, 5
To help prevent scratching and skin injury for a client who is experiencing severe itching
secondary to atopic dermatitis, the nurse should maintain room temperature around 70 F, have
the client wash new clothing before wearing it, and encourage the client to wear loose clothing.
The sensation of itching is not completely understood, but it may be triggered by touch,
temperature changes, and emotional stress, as well as chemical, mechanical, and electrical
stimuli. The severity of the response to stimulation is enhanced by emotional stress, anxiety, and
fear. Pruritus is a prominent symptom with psoriasis, dermatitis, eczema, and insect bites. It may
also be seen with the following systemic conditions: urticaria, some cancers, renal failure,
diabetes mellitus, thyroid disorders, liver disease, and anemia. Hot baths are avoided as well as
other factors that aggravate itching, such as temperature extremes, extremely dry air, irritating
fabrics, chemicals, sweating, and stress. Keratolytics are used for the treatment of scales on a
patient with psoriasis.
2. ANS: 4
Contact dermatitis is an inflammatory condition caused by contact with a substance that triggers
an allergic response. Topical use of some herbal products and aloe can cause allergic dermatitis
in susceptible persons. Angelica can cause a skin rash if a patient is exposed to sunlight. It is not
related to infestations of parasites. Contact dermatitis is contact with the skin and not an oral or
parenteral drug allergic reaction. However, some patients develop contact dermatitis to some
ointments such as Bacitracin. It is not excessive dryness but an inflammatory condition triggered
by an allergic response.
3. ANS: 4, 5
Psoriasis can be aggravated by stress as well as by streptococcal infections, overuse of alcohol,
and drugs such as lithium, antimalarials, angiotensin-converting enzyme inhibitors, and
beta-blockers. Moderate to severe psoriasis may be treated with PUVA, a combination of
methoxsalen and ultraviolet A (UVA) light, but this is contraindicated during pregnancy because
of the risk of fetal harm. No cure for psoriasis exists, but it can be treated topically or
systemically. Psoriasis is an autoimmune disorder and cannot be transmitted by direct contact.
Anthralin (Anthra-Derm) may be used to remove heavy scales but, after a specified period of
time, it is removed with tissues.
4. ANS: 1
To reduce the risk of recurrence of intertrigo in an obese patient in a long-term care facility, the
patient needs to keep body folds clean and dry. If she has pendulous breasts, she needs to wear a
soft, supportive bra, and if incontinence has contributed to perineal intertrigo, then positioning
the patient with the legs apart allows moisture to evaporate. Intertrigo is inflammation of the skin
where two skin surfaces touch: axillae, abdominal skinfolds and the area under the breasts. The
affected area is usually red and “weeping,” with clear margins. If the skin is not broken, then it
needs to be washed with water twice daily and not just 3 times a week. Cornstarch is
contraindicated because it supports the growth of Candida albicans. The area is then rinsed and
patted dry. Affected areas are not scrubbed with topical antiseptics. Scrubbing can increase the
irritation to the skin. For severe inflammation or fungal infection, treatment may include a
topical corticosteroid or antifungal drug.
5. ANS: 4
The most important statement to give to a patient taking isotretinoin (Accutane) is that she needs
to be aware that the drug is teratogenic (harmful to a developing fetus) and can cause severe fetal
deformities. Therefore, women who take the drug must prevent pregnancy until at least 1 month
after therapy has been completed. Two forms of effective contraception must be used if the
patient is sexually active while taking the drug. Accutane is an oral medication that has a drying
effect on the skin. Tell the patient to expect the condition to worsen initially and then begin to
improve. Improvement of the acne can take several months. Sensitivity to the sun occurs when
Accutane is taken.
6. ANS: 3
Herpes simplex virus (HSV) infections are treated with acyclovir (Zovirax) or (for cold sores)
docosanol (Abreva). Acyclovir (Zovirax) does not cure HSV infections. Patients still can
transmit the infection to others despite antiviral therapy and the absence of lesions. Antiviral
drugs may reduce the severity and frequency of outbreaks. Oral acyclovir is more effective than
the topical preparation for initial and recurrent infections. Analgesics and topical anesthetics may
be prescribed for pain. Hydrocortisone (Cortizone) is used to reduce inflammation in various
skin disorders. Isotretinoin (Accutane) is used to treat acne and may decrease risk of skin cancer.
Methoxsalen (Oxsoralen) and ultraviolet A light (PUVA) decreases proliferation of epidermal
cells in psoriasis.
7. ANS: avoid excessive sun exposure
The best way to prevent skin cancer is to avoid sun exposure. Other risk factors for skin cancer
are fair skin with freckling, light-colored hair and eyes, male gender, cigarette smoking, tanning
beds, and a tendency to sunburn easily.
8. ANS: 2
Typical melanomas have irregular borders and uneven coloration. A malignant melanoma arises
from the pigment-producing cells in the skin. It is the most serious form of skin cancer because it
can be fatal if it metastasizes. Basal cell carcinomas usually begin as painless, nodular lesions
that have a pearly appearance. They are thought to be related to sun exposure. Squamous cell
carcinomas may appear as scaly ulcers or raised lesions with usually no clear lesion margins.
Kaposi sarcoma is a malignancy of the blood vessels and is manifested by red, blue, or purple
macules accompanied by pain, itching, and swelling. The lesions appear first on the legs and then
on the upper body, face, and mouth.
Chapter 58: Special Senses Introduction
1. ANS: 1
Aqueous humor is a clear, watery fluid that fills the anterior chamber of the eyeball and is
located between the iris and the cornea. Aqueous humor is produced in the ciliary body. The
function of aqueous humor is to moisturize and nourish the lens and cornea. The production and
drainage of the fluid from the eye must be balanced to maintain normal pressure within the eye.
Ciliary fluid is produced by the ciliary muscle and is the same fluid as aqueous humor. The
larger posterior chamber behind the lens is filled with vitreous humor. Vitreous humor is a clear,
gelatinous material that helps hold the retina in place. Refractive fluid pertains to refraction.
2. ANS: 1, 2, 4, 5
As people age, typical changes occur in the structures and functions of the eye. The skin around
the eye becomes wrinkled and looser. The amount of fat around the eye decreases, permitting the
eyeball to sink deeper into the orbit. A grayish ring may be seen around the outer margin of the
iris. This ring is called the arcus senilis and may be related to elevated serum lipid levels; it does
not affect vision. Tear secretion diminishes and the eyes may feel dry sometimes. The pupil is
usually smaller but still responds, although more slowly, to light.
3. ANS: 4
This means that the person could read at 20 feet what a person with normal vision could read at
40 feet. The Snellen chart may be used for vision screening in clinic and office settings. In the
hospital, it may be more practical simply to ask the patient to read available print. From a
distance of 20 feet, the patient is instructed to read down the chart until more than two mistakes
are made on a single line. Each eye is tested separately and then together. The lines are
numbered 20 over 200, 100, 70, 50, 40, 30, 25, 20, and 15. The findings are reported as the last
line the person could read with no more than two errors. That is, if the person read the 20/30 line
with one error but made three errors on the 20/25 line, then the vision would be recorded as
20/30 in the eye tested. It does not mean that people can see best at 20 to 40 feet from objects or
that they cannot see more than 40 feet. It is also not reversed where at 40 feet people can read
what most people can read at 20 feet.
4. ANS: 2
Phenylephrine ophthalmic preparation instilled in the eye is used to dilate the pupil. This permits
a better view of the inner eye. Degenerative changes of the retina may be observed. A darkened
room also causes the pupil to dilate. Fluorescein is used to detect abrasions or scratches of the
cornea. Fluorescein is applied to the surface of the eye, followed by a saline rinse. The cornea
can be anesthetized with eye drops such as proparacaine 0.5% (Ophthaine). Phenylephrine
ophthalmic preparation is not used to dilate retinal blood vessels. The blood vasculature of the
retina includes the branches and tributaries of the central retinal artery and vein, respectively, and
the vascular circle of the optic nerve. The retina is the inner lining of the eyeball and is
composed of two layers. The pigmented layer is between the choroid and the sensory layer; it
receives nutrients and O2 from the choroid and supplies the sensory layer.
5. ANS: 2
The best way to help a visually impaired resident walk is to let the person hold your upper arm.
Standing side by side would not prevent the patient from falling to the opposite side. Walking
behind the patient and advising the patient of obstacles definitely put the patient at risk for falling
forward. Having the patient walk behind you with hands on your shoulders prevents you from
seeing what is happening to the patient and is very risky for the patient to fall and could be
physically harmful to the nurse or assistant.
6. ANS: 3
The position of the auricles is significant. For adult patients, pull the auricle up and back to
straighten the canal; then guide the speculum gently into the canal. For a child, the auricle is
pulled down and back. Normally, the top of the auricle is at approximately the level of the eye.
The ears should be positioned symmetrically. The auricles should be examined for shape,
lesions, and nodules. The auricle must not only be pulled straight up but also back. Pulling the
earlobe down or pulling the auricle back does not visualize the external auditory canal and
tympanic membrane.
7. ANS: 3
A normal response to the Rinne test is when the patient reports hearing the tuning fork when it is
placed on the mastoid bone and when the tines are then positioned near the ear canal. Normally,
air conduction is better than bone conduction. Therefore, the patient should be able to hear the
sound transmitted through air even after it can no longer be heard through bone. This normal
finding is recorded as “AC > BC” (air conduction is greater than bone conduction). If bone
conduction is greater than air conduction, then the patient has a conductive hearing loss. Some
factors that may cause conductive hearing loss include obstruction of the external canal or
eustachian tube and otosclerosis. Sensorineural hearing loss is sometimes called nerve deafness
and is a disturbance of the neural structures in the inner ear or the nerve pathways to the brain.
Patients with sensorineural hearing loss can hear sounds but have difficulty understanding
speech.
8. ANS: 2, 3
One of the changes in the ears of the older adult is that hairs in the canal become coarser and
longer, especially in men. Cerumen production declines and the protective wax is drier. The
eardrum thickens rather than thinning, and the bony joints in the middle ear degenerate
somewhat. Changes occur in the external, middle, and inner ear with aging. Some changes have
no functional significance, but others can lead to serious problems with hearing or balance.
These changes are not thought to impair hearing significantly. Changes in the inner ear, however,
affect sensitivity to sound, understanding of speech, and balance. Degenerative changes include
atrophy of the cochlea, the cochlear nerve cells, and the organ of Corti. The result is that many
older people have some degree of hearing loss and some have problems with balance. The type
of hearing loss most often associated with age is called presbycusis.
9. ANS: 4
If the hearing aid is not working, first check to be sure it is turned to the on position. If it is on,
then check the ear mold to see if it needs cleaning. The next step is to check battery placement. If
the battery is not inserted correctly, then the hearing aid will not work. If the hearing aid has a
cord, then check it to see if it is broken or unplugged. If these checks fail to locate the problem,
then change the battery. If a new battery does not correct the problem, then the cord can be
changed. Should the hearing aid still not work, return it to the dealer for service. Turning up the
volume needs to be done by the patient.
10. ANS: 1
When the nurse is receiving a shift report about a newly admitted patient who is very hard of
hearing, it is most important for the nurse to ask how the patient communicates. Being able to
communicate with the patient is essential to nursing practice. Asking if the patient knows about
latest hearing technology or if has ever been hospitalized before is not that important. Also,
asking about a family member staying to interpret is not that important and may not be
necessary.
11. ANS: 2
Medication placed on the external portion of the ear wick soaks the gauze and distributes the
medication in the canal. The nurse should not remove the packing or trim the gauze to prevent
the packing from being accidentally pulled out. The RN does not need to be notified that the
drops cannot be given. However, if not familiar with the ear gauze, then it is important to ask the
RN for information. An ear wick is a long piece of gauze that extends out of the ear canal. The
physician may insert an ear wick through the blocked canal if the external canal is obstructed by
edema. Any drainage from the ear should be treated as infected material and handled carefully.
Chapter 59: Eye and Vision Disorders
1. ANS: 1, 2
The only curative treatment for cataract is removal of the lens, although mydriatic drugs may be
helpful in the early stages. Cataract extraction is the most frequently performed eye operation in
the United States. After cataract surgery, the most important thing is to prevent strain on the
operative eye. To decrease strain on the eye, tell the patient to sleep on the unaffected side, and
not to rub the eye. Also, tell the patient not to lift more than 5 lbs, and avoid bending forward.
Postoperative patients with cataract surgery should not have severe pain. A mild analgesic is
usually ordered as needed. If a patient complains of severe pain, then tell the patient to notify the
physician, because severe pain may indicate hemorrhage or rising pressure within the eye. There
should be no bleeding after the procedure, and usual activities cannot be immediately resumed
because of the risk of injury to the eye. The surgeon will tell the patient when to resume daily
activities.
2. ANS: 2
The best way to help a visually impaired resident walk is to let the person hold your upper arm.
Standing side by side would not prevent the patient from falling to the opposite side. Walking
behind the patient and advising the patient of obstacles definitely put the patient at risk for falling
forward. Having the patient walk behind you with hands on your shoulders prevents you from
seeing what is happening to the patient and is very risky for the patient to fall and could be
physically harmful to the nurse or assistant.
3. ANS: 3
Corneal opacity is treated by removal of the scarred cornea and replacement with a healthy
cornea. The surgical procedure is called a keratoplasty. Rejection of corneal grafts is not
common, but it can happen. When rejection occurs, blood vessels appear in the cornea and the
cornea becomes cloudy. Other symptoms of rejection include redness, swelling, decreased
vision, and pain. Cloudiness in the affected eye is not normal. Elevating the patient’s head and
encouraging increased fluid intake is not the action to take for rejection of the graft. It is the
surgeon’s decision to prepare the patient for emergency surgery.
4. ANS: 1, 4
Open-angle glaucoma is more common than angle closure glaucoma. Chronic open-angle
glaucoma results from some alteration that prevents the normal passage of aqueous humor
through the trabecular meshwork. Carbonic anhydrase inhibitors reduce intraocular pressure by
decreasing the formation and production of aqueous humor. Hyperosmotic drugs, including oral
glycerin and intravenous mannitol, increase aqueous outflow and promote movement of fluid
from the intraocular structures. These medications do not dilate the canal of Schlemm.
Trabeculoplasty is done using a laser to create multiple holes and relax the trabecular meshwork
to improve drainage of aqueous humor from the anterior chamber. Open-angle glaucoma
medications do not reduce systemic blood pressure. Beta-blockers reduce heart rate but are not
intended to reduce systemic blood pressure.
5. ANS: 2
The most serious complication of acute angle closure glaucoma is permanent blindness. Angle
closure glaucoma is also called acute glaucoma. It accounts for only approximately 10% of all
glaucomas. Because open-angle glaucoma is painless, the patient may not appreciate the need for
ongoing treatment. There is no rupture of the eyeball. Other signs and symptoms are blurred
vision, halos around lights, nausea and vomiting, and headache on the affected side. There is a
rapid rise in intraocular pressure, which is often greater than 50 mm Hg. There is no rise in
intracranial pressure.
6. ANS: 3, 4
Positioning orders may be very specific for these patients and are dependent upon the location of
the repaired tear and the use of air or saline to support the repair. If an air bubble has been
injected, then it will rise to the top of the eye. If the patient’s detachment is in the back of the
eye, then a face-down position is necessary to keep the bubble in the right place. Saline travels
down rather than up, so the same patient would need to stay face up if saline had been injected.
The surgeon prescribes any activity limitations. A scleral buckle is not related to postoperative
patient positioning. Sometimes it is used with laser treatment or cryotherapy. This is a Silastic
band that is secured around the eyeball under the sclera. Small silicone implants are sutured
under the band opposite the area of detachment. This procedure brings the layers of tissue back
together by pressing from the outside. The band is left in place permanently. Positioning is not
related to the patient’s preference or intraocular pressure.
Chapter 60: Ear and Hearing Disorders
1. ANS: 2
Medication placed on the external portion of the ear wick soaks the gauze and distributes the
medication in the canal. The nurse should not remove the packing or trim the gauze to prevent
the packing from being accidentally pulled out. The RN does not need to be notified that the
drops cannot be given. However, if not familiar with the ear gauze, then it is important to ask the
RN for information. An ear wick is a long piece of gauze that extends out of the ear canal. The
physician may insert an ear wick through the blocked canal if the external canal is obstructed by
edema. Any drainage from the ear should be treated as infected material and handled carefully.
2. ANS: 1, 3
Appropriate nursing measures for the patient who is having an acute attack of Ménière disease
include keeping the room quiet and dark and delaying routine care until the patient no longer
complains of being dizzy. During an acute attack in the hospitalized patient, let the patient
remain still because movement may trigger vomiting. Giving medications for nausea and
vomiting and keeping an emesis basin close to the patient are very important. An intravenous
infusion probably will be ordered to provide fluids, medications, or both. Advising the patient to
drink additional fluid can stimulate vomiting and is not appropriate during an acute attack.
Monitoring hourly vital signs is not necessary unless initially abnormal, and assisting the patient
to sit in the chair for an hour twice a day is contraindicated during an acute attack. Once the
symptoms subside, assist the patient when getting up until dizziness goes away.
3. ANS: 1
Instructions about “ringing in the ears” are important to tell a patient who is taking an
aminoglycoside antibiotic. Aminoglycosides can cause permanent hearing loss. Ototoxicity can
range from reversible tinnitus to permanent hearing loss. The extent depends on the drug dosage
and how long it was given. Ototoxicity is damage to the ear or eighth cranial nerve caused by
specific chemicals and some drugs, such as salicylates (i.e., aspirin) and aminoglycoside
antibiotics. Checking the white part of the eye for a color change is not needed because
ototoxicity has no relationship to the liver. Restricting fluid intake has no effect on the toxicity of
these drugs. Orthostatic hypotension is not related to the ototoxicity of these drugs. Hearing,
balance, or both may be affected. Patients who have poor renal function are at special risk for
ototoxicity.
4. ANS: 3
Otosclerosis can be treated surgically with a procedure called a stapedectomy. Otosclerosis is a
hereditary condition in which an abnormal growth causes the footplate of the stapes to become
fixed so it cannot vibrate and sound waves cannot be transmitted to the inner ear. The effect of
this abnormality is a conductive hearing loss. Sensorineural hearing loss and Ménière disease
cannot be treated with a stapedectomy. Otitis media is an acute or chronic infection of the middle
ear, and sometimes called suppurative or purulent otitis media because of the presence of
purulent material.
5. ANS: 3
Patients considering a cochlear implant need to know that results vary from minimal to excellent
improvement in hearing. Some patients can hear well enough to understand speech on a
telephone; others can hear only environmental sounds, such as sirens, doorbells, and ringing
telephones. This procedure does not restore hearing 99%, and the complications are not
disabling. Cochlear implants allow people to discriminate speech. Several months of training are
needed to learn to tell sounds apart, so candidates for the implants must be highly motivated and
carefully screened.
Chapter 61: Psychobiologic Disorders
1. ANS: 1
Nursing interventions are diverse and geared toward helping patients and families cope with the
mental illness, manage their lives, and enhance quality of life. The focus is not just limited to
tasks such as administering medications, protecting other people from the patient, or controlling
a patient’s behavior.
2. ANS: 2, 4
A therapeutic relationship is one that focuses on the needs of the patient as to purpose, place, and
time. It has a clear purpose and an ending. A social relationship focuses on needs of both
participants, does not require a defined purpose, has less formal boundaries, and is not
time-limited.
3. ANS: 4
Clarifying is one way of validating that you understand what the patient is saying. Asking
questions may help patients clarify their thoughts. Telling the patient that he looks sad does not
clarify but instead makes a statement, and asking the patient a question to obtain information is
not focused on the patient’s feelings. Also, asking the patient why she “gets quiet when I ask
about your husband” is not focusing on the patient’s feelings but trying to get personal
information. Better to say, “You seem to get quiet when I ask you about your husband.”
4. ANS: 1, 2, 3, 5
Data collected on a mental status examination needs to include thought content, mood and affect,
appearance, and memory and attention. Other components for this examination include activity,
speech and language, perceptual disturbances, insight and judgment, sensorium, and general
intellectual level. Reaction time is not evaluated in a mental status examination but included with
teaching for patients taking antipsychotic or antianxiety drugs.
5. ANS: 3
This patient is exhibiting symptoms of conversion disorder. This disorder is also called
functional neurologic symptom disorder. Symptoms may include blindness, deafness, or
paralysis of the legs without a physiologic cause. Usually, the symptoms are neurologic and
occur in response to some threatening or traumatic event. The symptoms are real and not created
and can cause significant distress or impairment in social, occupational, or other important areas
of functioning. In some cases, a true physiologic cause for the symptoms has been discovered
years later, so a diagnosis of conversion disorder is usually tentative and provisional. Illness
anxiety disorder (hypochondriasis) involves individuals who are preoccupied with having or
acquiring a serious, undiagnosed illness. They are convinced that they have a serious medical
problem in spite of the absence of any concrete medical findings and will seek other opinions if
one physician does not validate their concerns. They often take multiple prescription medications
from various health care providers. The feared illness often becomes a central part of the
individual’s life and may impair social, occupational, or other important areas of functioning.
Posttraumatic stress disorder (PTSD) is a cluster of symptoms experienced after a distressing
event that is outside the range of normal events, and one in which the person experienced intense
fear, helplessness, or horror (or a combination of these feelings). Examples of symptoms include
reexperiencing the trauma through repeated and intrusive recall of the event (flashback);
avoiding situations that in some way remind the person of the event; feeling detached from other
people; and having a heightened sense of arousal, which is experienced as difficulty falling
asleep, hypervigilance, an exaggerated startle response, or a combination of these. In panic
disorder, a patient experiences recurrent panic attacks, which are intense episodes of
apprehension, at times to the point of terror. Often these attacks are accompanied by feelings of
impending doom.
6. ANS: 1
The best response is that schizophrenia is a mental illness that affects a person’s thinking and
distorts a person’s view of reality. It refers to a group of very serious, usually chronic thought
disorders in which psychotic symptoms primarily impair the affected person’s ability to interpret
the world accurately. It is characterized by disturbances in thinking, mood, and behavior. Many
schizophrenic patients have functioned normally in early life and are often very intelligent and
well educated before the onset of the first symptoms. With effective drug and psychiatric
therapy, most people with schizophrenia do not require permanent care in a psychiatric facility.
Medications and treatments are available; the most commonly administered medications for
people with schizophrenia are antipsychotic (neuroleptic) and antiparkinsonism medications,
which are at times administered to prevent or relieve some of the side effects of the
antipsychotics. Newer medications have been very successful in helping people return to their
previous activities. The cause of schizophrenia disorder is not certain. The episodes do not
resolve in 1 to 2 weeks, but the timing varies. The patient’s ability to function in the areas of
work, interpersonal relationships, or self-care deteriorates significantly during acute episodes and
may not return to baseline after the first psychotic episode. With each subsequent episode, the
ability to function independently continues to deteriorate, intelligence quotient (IQ) levels drop,
and thinking becomes very concrete.
7. ANS: 1, 2, 4
Nursing interventions to promote communication include letting the patient know that you do not
share his or her delusions, encouraging the patient to attend to activities in the environment, and
informing the patient that hallucinations are part of the disease. Pointing out flaws in the
patient’s illogical statements is argumentative and criticizing and is not therapeutic. Also, asking
the patient to explain why he behaves as he does would probably not be effective. Patients with
schizophrenia usually have little insight into their illness. Some communication interventions
include seeking clarification and verbalizing the implied, speaking in a gentle and
nonconfrontational manner, decreasing unwanted environmental stimuli, focusing on reality (i.e.,
real events, real people), letting the patient know that you do not share the delusion without
directly confronting the delusion, encouraging the patient to express feelings and anxiety, and
connecting delusions with anxiety-provoking situations.
8. ANS: 1, 2, 3, 4, 5
Data the LVN/LPN should collect from each resident include dry mouth, shuffling gait, muscle
rigidity, abnormal movements, and faintness upon changing from a sitting to standing position.
These drugs can cause drowsiness and sedation, postural hypotension, dry mouth, and blurred
vision (especially in frail and older people). Watch for extrapyramidal side effects (EPS), such as
Parkinson syndrome–like involuntary movements, muscle rigidity, dystonia, akathisia, and
oculogyric crisis. Long-term administration may result in tardive dyskinesia, which is usually an
irreversible syndrome that occurs after prolonged use of antipsychotic drug therapy. It involves
persistent involuntary movements of the face, jaw, and tongue that lead to grimacing, jerky
movements of the upper extremities, and tonic contractions of the neck and back.
9. ANS: narcissistic
Narcissistic personality disorder involves a pattern of grandiosity, a need for admiration, and a
lack of empathy. The individual has an exaggerated sense of self-importance; requires excessive
admiration; takes advantage of others to achieve his or her own ends; is often envious of others;
and exhibits arrogant, haughty behaviors or attitudes. Many often appear dramatic, highly
emotional, or erratic.
10. ANS: 1
Divalproex sodium (Depakote) is one of the key medications for people with manic episodes.
Relief from symptoms can take up to 3 weeks. Divalproex is metabolized by the liver, so patients
with liver disorders should receive lower dosages. A valproic acid level is done at intervals to
assess blood levels. The therapeutic level of divalproex sodium in the blood is 50 to 100 µg/mL,
and the patient can develop toxicity if the blood level exceeds the therapeutic range. Acute
dystonic reactions are one of the extrapyramidal side effects (EPS). These stem from the effects
of the antipsychotics on the extrapyramidal tracts of the central nervous system and can occur
after one dose of medication or during the first few days of treatment. They consist of severe
muscle contractions involving the tongue, face, neck (i.e., torticollis), and back (i.e.,
opisthotonos). The larynx also may be constricted (i.e., laryngospasm), which compromises the
patient’s airway. Acute dystonia is a medical emergency and must be treated immediately. Also,
certain antiemetics such as promethazine (Phenergan) and prochlorperazine (Compazine) can
cause dystonic reactions. Extrapyramidal syndromes are related to EPS and include parkinsonian
syndrome, tardive dyskinesia, and neuroleptic malignant syndrome. They are related to people
taking antipsychotic (neuroleptic) drugs and certain antiemetics such as prochlorperazine
(Compazine).
Chapter 62: Substance Abuse
1. ANS: biologic
The majority of experts in substance-related disorders subscribe to the biologic theory that
proposes that faulty physiologic processes contribute to addiction to a specific substance and that
addiction is a physical illness. Most believe that it most likely involves a combination of
biologic, cultural, and behavioral factors.
2. ANS: denial
Defense mechanisms used by addicts include denial, rationalization, intellectualization, and
projection. Denial is apparent when patients state that they do not have a problem with alcohol or
drug use despite evidence to the contrary.
3. ANS: 2
Hair analysis is a recent addition to the methods for the detection of substance use. It requires
sensitive technology but may be very helpful in monitoring patients for relapse. Depending on
the length of the hair, a substance can be detected for up to 1 year after only 2 or 3 days of use.
However, the presence of addiction or whether the person is currently under the influence of the
substance cannot be inferred from a positive finding. The evidence this test provides regarding
long-term substance use may be a valuable tool in the diagnosis and follow-up of substance use
disorders. After collection, the sample is kept under chain of custody (i.e., each person handling
the sample signs a special document that accompanies the sample until it can be analyzed). Any
temporary storage of the sample is maintained under secure conditions.
4. ANS: 72 hours
The second stage, major withdrawal, begins with the onset of seizures and hallucinations and can
advance to life-threatening delirium tremens. This stage usually occurs after approximately 3
days (72 hours) and sometimes less without alcohol or treatment, and can be predicted from
extreme elevations in temperature, pulse, and blood pressure. The patient typically becomes
disoriented and confused. Hallucinations are often visual and “animal” in nature.
5. ANS: 2
Enabling behaviors are any behaviors that “cover up” or protect alcoholics from the
consequences of their drinking behaviors. Those who enable are sometimes considered
co-dependent, in that their behavior is highly structured around managing and adapting to the
alcoholic’s dysfunctional behavior. Support is to give moral or psychological support, aid, or
courage to someone. Rationalization is a defense mechanism in which people attempt to justify
the reasons for substance use and make an “excuse” for addiction. Compensation is to give
money or something else of value to (someone) in return for something (such as work) or as
payment for something lost, damaged, etc.
6. ANS: 1, 2, 3, 4
The treatment team may recommend the use of disulfiram (Antabuse) to assist the alcoholic who
is highly motivated to remain sober but who recognizes that poor impulse control may increase
the odds of relapse. Signs and symptoms of a disulfiram-alcohol reaction include hypotension,
rapid heart rate, confusion, nausea, and vomiting. Flushing and not pallor also occur. Other
symptoms include headache, dizziness, difficulty breathing, sweating, coma, convulsions, and
death. The severity of the symptoms varies from person to person, and symptoms can last for 30
to 60 minutes or more.
7. ANS: 1
Inhalants can cause central nervous system, progressive brain, and cardiac damage. Inhalants do
not cause sexual dysfunction or schizophrenia. Euphoria and giddiness and not aggressive
behavior may occur. Other symptoms, including headache, fatigue, drowsiness, and objective
signs such as dysrhythmias, damage to kidneys, and liver abnormalities, can occur.
8. ANS: 3
Naloxone hydrochloride (Narcan) is given to reverse the effects of opioids and prevent
respiratory depression. Narcan and nalmefene (Revex) are opioid antagonists that counteract the
dangerous respiratory depressant effects of heroin or other opiate overdose. When Narcan is
given to a person who is addicted and under the influence of an opiate, the person may
experience acute withdrawal symptoms. Narcan does not raise the blood pressure or stimulate the
heart. One of the side effects of Narcan is fast or irregular pulse and seizures. Other possible side
effects of Narcan include change in mood, increased sweating, nausea, nervousness, restlessness,
trembling, vomiting, allergic reactions such as rash or swelling, dizziness, fainting, flushing,
headache, heart rhythm changes, sudden chest pain, and pulmonary edema.
9. ANS: 2, 3
Older adults are more likely to abuse over-the-counter (OTC) and prescription sleeping pills,
pain medications, or tranquilizers than illegal drugs such as cocaine and marijuana. Although
older adults use approximately 25% of the medications used in the United States, only about 2%
to 5% of men and less than 1% of women older than 65 years abuse alcohol. Most of the older
adults who abuse alcohol have maintained a regular pattern of use over many years without
obvious problems, so alcohol is not one of the most commonly abused drugs.
10. ANS: 2
Average adolescents view themselves as omnipotent and deny the likelihood of negative
consequences of drug use and their behaviors. Breaking through adolescents’ denial is the most
difficult aspect of treatment, especially because they seldom want to be in treatment and do not
see the potential negative consequences of their behaviors. It is estimated that 1 in 4 adolescents,
and not 1 in 10, become involved in substance abuse. Entry into treatment usually occurs as a
result of a crisis situation and not the abuser seeking treatment on his or her own. It is
controversial to mix adolescents with adults in treatment programs because of adolescents’
vulnerability to being influenced by the more experienced and usually charismatic adult
substance user. Successful rehabilitation usually involves regular involvement in an Alcoholics
Anonymous (AA) group made up of younger people to whom the adolescent can relate;
successful development of a new, non–drug-using peer group; and reentry into school with the
support of other recovering classmates. AA group meetings may be held at high schools in some
cities.
Chapter 63: First Aid, Emergency Care, and Disaster Management
1. ANS: 2
If the patient is bleeding the nurse would want to apply pressure. By applying pressure this
would decrease the amount of bleeding until further treatment can be rendered.
2. ANS: 4
If circulation is not restored within 4 minutes after a cardiac arrest, brain cells are the first cells
to begin to die. Irreversible kidney failure and coagulation of blood begins after a prolonged
episode of cardiac arrest. The lungs do not fill with fluid during cardiac arrest because there is no
blood flow to the lungs.
3. ANS: 3
In this situation, the Poison Control Center needs to be called immediately, and the caregiver
should follow their directions. Do not give the client anything to drink or any syrup of ipecac,
but follow the Poison Control Center’s directions for intervention. Then drive the client to the
emergency department (ED).
4. ANS: 3
The force of abdominal thrusts can safely dislodge a foreign body from the airway by causing the
object to be expelled from the airway.
5. ANS: 1
When suspecting a leg fracture, the first-aid provider should immobilize the leg in the same
position in which it was found. The injured parts need to be immobilized, including the joints
above and below the injury. Trying to straighten a broken bone could cause further trauma to the
bone and surrounding soft tissue. If there is severe bleeding, direct pressure to the artery above
the injury, and not a tourniquet, needs to be applied. Do not elevate the injured part above the
level of the victim’s heart but instead splint the bone in the same position in which it was found
and use as little movement as possible.
6. ANS: 1, 4, 5
Signs of increased intracranial pressure include headache, unequal pupils, and confusion as well
as decreasing level of consciousness, impaired sensory or motor function, and projectile
vomiting. Blood pressure is increased, not decreased, with a widening pulse pressure.
Respiratory rate is decreased, not increased, along with a decreased pulse.
7. ANS: 3
The immediate concern is to stop the burning process. If a victim’s clothing is burning, have him
drop to the ground and roll to extinguish the flames. Then try to smother the flames with a coat
or blanket or extinguish with water if flames are not due to chemicals or flammable liquids.
Telling him to run and jump in the lake would aggravate the burning process and increase the
client’s injuries. Trying to extinguish the flames with your hands would be ineffective and only
cause severe hand burns to the bystander. Running to the phone to call for help would take too
much time and would increase the victim’s injuries and could lead to death.
8. ANS: 1, 2, 5
If the football player collapses on a hot, humid day and is breathing and not responding, then he
is probably suffering from hyperthermia. The first intervention is to move the player to a cool
location and then activate the Emergency Medical Services (EMS). Then apply wet, cool towels
to the trunk and the extremities, and place ice packs on the forehead and axillae. Since he is not
verbally responding, do not give him anything orally. Also, EMS should be called before the
parents are notified, and EMS will transport him to the hospital.
9. ANS: cardiac dysrhythmias
Excessive rewarming of hypothermic victims sends lactic acid and cold blood from the
extremities to the heart, leading to a risk for cardiac dysrhythmias.
10. ANS: 1
A tick bite that 1 week later appears as a ring-shaped, reddened area at the bite site could be a
sign of early Lyme disease. This finding would call for a referral for medical treatment.
Application of antibiotic ointment would not treat the Lyme disease. Neurotoxic reactions to
black widow spider bites include pain, nausea, vomiting, fever, weakness, muscle cramps, and
headache occurring right after the bite. Constricting bands are not recommended. The swelling
from brown recluse spider bites usually occurs within a few hours after the bite and there is no
specific antivenin available for treatment.