Family Practice Guidelines Fifth Edition Test Bank
Chapter 1. Health Maintenance Guidelines
Multiple Choice
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Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is preparing to teach a patient of the Asian culture to perform postoperative
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dressing changes at home after discharge. Which statement made by the nurse indicates cultural
competence?
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a. Tell me how you feel about your surgery.
b. Asian people are smart, so this should be easy for you to understand.
c. American surgeons are highly qualified; Im sure you will heal quickly.
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d. Will you tell me about any traditional healing practices that you would like to use?
____ 2. An unconscious victim of a house fire is brought to the emergency department by the
action should the nurse take?
a. Tape it in place.
b. Do nothing with it.
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paramedics. Tied to the right wrist is an emblem that appears be a religious talisman. Which
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c. Remove it and lock it up for safekeeping.
d. Place it in a clothing bag with the rest of the patients belongings.
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____ 3. A 43-year-old patient of Arab descent is admitted to the hospital. To comply with the
state laws of the organization, the nurse offers the patient a Papanicolaou smear, which she
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refuses. Which action should the nurse take first?
a. Notify the physician.
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b. Report the refusal to the supervisor.
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c. Explain the rationale for and benefits of the test.
d. Tell her it is state law and that she does not have a choice.
____ 4. A patient who is a Jehovahs Witness has severe gastrointestinal bleeding and a
dangerously low hemoglobin level. The patient is fully alert and competent and refuses to accept
the blood transfusion ordered by the physician. Which action by the nurse is most appropriate?
a. Obtain a court order to give the blood.
b. Administer the blood while the patient is sleeping.
c. Have the patients spouse sign the consent to have the blood administered.
d. Ensure the patient understands possible consequences and then respect the patients wishes.
____ 5. A patient of Mexican descent sees a curandero for asthma; the curandero has prescribed
a special tea to be taken four times a day to open the airways. How should the nurse respond to
this situation?
a. Encourage the patient to continue drinking the tea.
b. Encourage the patient to drink only one cup of the tea each day.
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c. Ask the patient to bring in the tea package and have the pharmacist check the ingredients.
medications.
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d. Advise the patient to stop drinking the tea because of potential interactions with other
____ 6. The nurse is caring for a young adult male patient who refuses personal care from a
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female nursing assistant. Which approach by the nurse is best?
a. Encourage the patients family to talk with him about his care.
b. Have a registered nurse (RN) help with his personal care.
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c. Assign a male assistant to help with his personal care if one is available.
d. Explain to him that males and females take care of both genders in this hospital.
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____ 7. The nurse is providing medication instructions to a 45-year-old patient who does not
maintain eye contact. What should this patients behavior indicate to the nurse?
a. The patient is not interested.
b. The nurse threatens the patients ego.
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c. The nurse is in a hierarchical position.
d. The patient does not intend to follow the instructions.
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____ 8. The nurse is caring for a patient of Spanish descent who is experiencing pain, but does
not speak English. An interpreter is located to help with the assessment. What should the nurse
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do to facilitate communication with this patient?
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a. Use hand signals to determine the cause of the pain.
b. Ensure the interpreter is not left alone with the patient.
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c. Maintain eye contact with the patient and the interpreter.
d. Use only physical examination data; do not rely on verbal communication.
____ 9. A new mother of Guatemalan descent brings her 10-day-old infant to a clinic for a wellbaby checkup. To promote healing, she has a coin taped to the infants umbilicus. What should
the nurse do about this situation?
a. Teach the mother how to clean the coin daily and reapply it.
b. Explain to the mother that the coin is not necessary for healing.
c. Tell the mother to remove the coin, because it could cause an infection.
d. Teach the mother how to apply a dry sterile dressing in place of the coin.
____ 10. An older patient who follows the Muslim religion is approaching death. The family
says the patients bed should be turned toward the opposite wall, so it can face Mecca to ensure
an easier passage into the next life. The wall they want the bed to face has wall suction and
a. Get permission from the physician to move the bed.
b. Rearrange the furniture to accommodate the request.
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c. Tell them you will move the bed when the patient is closer to death.
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oxygen, which the patient is using. Which action by the nurse is appropriate?
d. Tell them it is impossible because of the short tubing on the oxygen and suction.
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____ 11. A patient of northern European descent recovering from surgery denies postoperative
pain; however, vital signs indicate an elevated pulse and blood pressure. The patient refuses to
a. Give the pain medicine as prescribed.
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move in bed. Which nursing action would best ensure comfort and timely discharge?
b. Ask the physician to prescribe the analgesics around the clock.
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c. Explain that the pain medicine will help prevent complications.
d. Respect the patients denial of pain, and do not encourage the pain medicine.
____ 12. A nurse who emigrated from China begins working on a medical unit. The preceptor
explains the unit routines, including the medication administration system. When the preceptor
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asks if the nurse understands, the answer is always: Yes, I understand. What should the preceptor
do to measure the nurses comprehension?
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a. Give the nurse a medication quiz.
b. Have the nurse repeat the instructions.
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c. Have the nurse demonstrate the procedures.
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d. Ask the nurse which information is hard to understand.
____ 13. A 52-year-old from Haiti is hospitalized with heart failure and wants to have a voodoo
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practitioner visit to say prayers. How should the nurse respond to this request?
a. Report the request to the physician immediately.
b. Tell the patient that this is not permitted during hospitalization.
c. Tell the patient it is okay for the voodoo practitioner to say prayers.
d. Have the patient meet with the voodoo practitioner in the hospital lobby.
____ 14. The nurse is caring for a patient from a non-English speaking culture. While providing
care, the nurse shows an appreciation for and attention to arts, music, crafts, clothing, and foods
belonging to the patients culture. What did the nurse demonstrate while caring for this patient?
a. Cultural beliefs
b. Cultural awareness
c. Cultural sensitivity
d. Cultural competence
____ 15. A female Caucasian nurse, overhead discussing a patient from another culture, asks
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why the patient wants to see a practitioner from his own culture, since everyone sees physicians
when they are ill. What characteristic is the nurse exhibiting?
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a. Stereotyping
b. Ethnocentrism
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c. Cultural sensitivity
d. Cultural generalization
____ 16. During an assessment, the nurse determines that a patient from a non-English speaking
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culture practices activities that are past-oriented. What behavior did the nurse assess in this
patient?
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a. Investing time and money
b. Enjoying each day as it comes
c. Worshipping ancestors and maintaining traditions
d. Learning from the past to avoid making the same mistakes in the future
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____ 17. The nurse notes that a patient of Arab descent is not eating anything on the meal trays.
What should the nurse do about this situation?
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a. Wait for the patient to ask for specific foods.
b. Ask if the patient has special food preferences.
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c. Consult with a physician of Arab descent on staff.
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d. Contact the dietitian to find out what patients of Arab descent patients like to eat.
____ 18. The mother of a 6-year-old Vietnamese child admitted with pneumonia is rubbing a
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coin on the childs back. The coin leaves red marks. What should the nurse do about this
observation?
a. Report the possibility of child abuse.
b. Do not allow the mother to be alone with her child.
c. Explain to the mother that she cannot do this in the hospital.
d. Add a statement to the care plan that the family practices coining.
____ 19. The family of an older Arab-American patient does not want the patient to be informed
of a diagnosis of cancer. What should the nurse do?
a. Call a religious counselor.
b. Respect the familys wishes.
c. Insist that the family tell the patient about the diagnosis.
d. Tell the patient anyway, because patients have a right to know.
____ 20. A patient with diabetes mellitus who comes to the clinic for a routine examination
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agrees to have a diagnostic test, but is concerned that her transportation will not wait for the test
a. Contact the department to have the test done now.
b. Ask the patient to schedule an appointment for the test.
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c. Refer the patient to the community health nurse practitioner.
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to be performed. What should the nurse do?
d. Schedule the test for the next time the patient comes to the clinic.
____ 21. The nurse is assessing a patient who believes in a balance of yin and yang in the body,
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has a brother with stomach cancer, and frequently uses acupuncture for headache treatment. The
nurse should validate that the patient is a member of which cultural group?
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a. Hispanic/Latino
b. Asian American
c. African American
d. American Indian/Native Alaskan
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____ 22. An older patient is observed wearing a copper bracelet to relieve the pain of arthritis.
a. Allopathy
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What type of practice should the nurse realize this patient is demonstrating?
b. Acupressure
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c. Reflexology
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d. Folk medicine
____ 23. The nurse is preparing discharge teaching for an older patient who immigrated to the
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United States a few years ago. What should the nurse remember when preparing these
instructions?
a. The patient most likely has limited financial resources.
b. The patient will prefer to follow cultural medical practices.
c. The patient will most likely live with other family members.
d. The patient will attend all follow-up appointments as needed.
____ 24. During a home visit to a family of a non-English speaking culture, the nurse observes
the male parent becoming upset when the youngest child refuses to speak the native language in
the home. What should the nurse realize is occurring within the family at this time?
a. Ethnocentrism
b. Cultural shock
c. Cultural conflict
d. Cultural assimilation
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____ 25. An older male patient is admitted to the hospital for treatment of a chronic disease. The
spouse is at the bedside for most hours of the day, and the patients children come to visit every
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day after work to discuss activities and ask for advice. What should the nurse realize about the
a. The male patient is the head of the household.
b. The spouse does not trust health care providers.
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social organization of this family?
c. The children want to learn everything before the patient dies.
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d. The children are concerned that the patient is not receiving adequate care.
Multiple Response
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Identify one or more choices that best complete the statement or answer the question.
____ 26. The nurse is planning care for a patient from a non-English speaking culture. Which
cultural factors should the nurse be aware of in order to provide culturally competent care to this
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patient? (Select all that apply.)
a. The patients nutritional habits
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b. The patients communication style
c. The patients sense of personal space
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d. Complementary therapies the patient is using
e. The prescribed medications the patient is taking
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____ 27. A female nurse is providing smoking cessation counseling and education during a
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community health fair. The nurse should avoid physical closeness, shaking hands, or touching
during instruction with which of the following? (Select all that apply.)
a. A 35-year-old man of Asian descent
b. A 45-year-old woman of Arab descent
c. A 28-year-old man of Hispanic descent
d. A 52-year-old woman of African American descent
e. A 41-year-old woman of American Indian descent
____ 28. The nurse is providing care in a clinic with a culturally diverse patient population.
Which actions should the nurse take to ensure care is culturally appropriate? (Select all that
apply.)
a. Awareness of cultural bias
b. Desire to be culturally competent
c. Educational training related to world politics
d. Awareness of personal communication patterns
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e. Number of face-to-face encounters with people from various cultural backgrounds
____ 29. The staff development instructor is planning a seminar on improving cultural sensitivity
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when providing patient care. What should the instructor include in this seminar? (Select all that
a. Information about different cultural groups
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apply.)
b. Recognition that patient are unique and not defined by their culture
c. Ways to enhance cultural assimilation in the health care environment
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d. The importance of nurses knowing information about their own cultural group
e. Strategies to incorporate patients cultural values and practices into the plan of care
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____ 30. The nurse is visiting the home of a patient who recently immigrated to the United States
from Buenos Aires. Which observations in the patients home should the nurse question to
determine the patients health beliefs? (Select all that apply.)
a. Black bracelet woven with a cross being worn on the patients left wrist
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b. A lit candle burning near a picture of a saint on a side table in the living room
c. Cup of hot black liquid that the patient is sipping from periodically during the visit
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d. A copy of a magazine printed in Spanish sitting on the coffee table in the living room
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e. A pillow placed between the patient and the nurse after the nurse sits down on the couch
Chapter 4. Cultural Influences on Nursing Care
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Answer Section
MULTIPLE CHOICE
1. ANS: D
D. Cultural sensitivity is using language and statements that do not offend another persons
cultural beliefs. Cultural competence includes the skills and knowledge required to provide
effective nursing care. The use of traditional healers and healing therapies is common for Asian
individuals, and assessing the patients desire to use such healers or therapies shows the nurse is
culturally sensitive and competent to provide care. B. This statement represents a stereotypean
opinion or belief about a group of people which is ascribed to an individual. C. This statement
exemplifies ethnocentrism or the tendency for people to think that their ways of thinking, acting,
and believing are the only right, proper, and natural ways. A. This is an assessment designed to
elicit the patients emotional reaction to the surgery. This may be an important part of adult
PTS: 1 DIF: Moderate
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KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis
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learning, but it is not the best option to represent cultural competence.
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2. ANS: A
A. Often folk practices are not harmful and can be added to the patients plan of care. Tape the
emblem in place to keep it from getting lost or damaged. C. D. Removing it could be very
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distressing to the patient. B. The item could get lost if nothing is done with it.
PTS: 1 DIF: Moderate
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KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
3. ANS: C
C. A Pap smear can provide important health information. The patient may refuse it, because she
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does not understand what it is. A. B. Teaching is a nursing action and does not need to be
approved by a physician or supervisor. D. The state law simply says the patient must be offered
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the test, not that she must accept it.
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PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
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Application
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4. ANS: D
D. Patients beliefs should be respected, even when their decisions go against medical advice. The
patient needs to understand the consequences of his decision. A. B. C. Administering the blood
without the patients knowledge or consent is unethical.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
5. ANS: C
C. Often, folk practices are not harmful and may even be helpful; they may be incorporated into
the patients plan of care. Checking with the pharmacist ensures that the tea is safe and will not
interact with other essential medications. A. B. D. As long as it is safe, there is no reason to have
the patient stop or limit tea intake.
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PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
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Level: Analysis
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6. ANS: C
C. It is important to respect differences in gender relationships when providing care. Some
people may be especially modest because of their religion, seeking out same-gender nurses and
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physicians for intimate care. Respect these patients modesty by providing privacy and assigning
a same-gender care provider when possible. A. B. D. Having a registered nurse (unless male)
provide care and talking to his family do not solve the problem or respect the patients
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preferences.
PTS: 1 DIF: Moderate
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KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
7. ANS: C
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C. Use and degree of eye contact is culturally influenced. Many cultures view health care
workers as having higher status, making it rude to maintain eye contact. A. B. D. The nurse
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ego.
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should not make assumptions about the patients level of interest, intent to follow instructions, or
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PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis
8. ANS: C
C. The use of eye contact can help the nurse interpret the information that is being exchanged
between the interpreter and patient. A. B. D. There is no reason to avoid leaving the interpreter
with the patient, to rely on hand signals, or to avoid verbal communication when an interpreter is
available.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
9. ANS: A
A. Often, folk practices are not harmful and can be added to the patients plan of care. In the case
of the coin, it should be cleaned daily to keep the area clean and free of infection. B. C. D. There
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is no reason to tell the mother to remove it or to apply a sterile dressing in place of the coin.
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PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
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Level: Application
10. ANS: B
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B. Often, folk practices are not harmful and can be added to the patients plan of care. There is no
reason not to move the patients bed. A. There is no reason to involve the physician. C. There is
no way to know the exact time the patient will die, so waiting to move the bed is not appropriate.
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D. Oxygen and suction tubing can have extensions added.
PTS: 1 DIF: Moderate
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KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis
11. ANS: C
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C. Explaining that pain control can help prevent complications allows the patient to make an
informed decision. A. B. The patients wishes must be respected, so giving the medication
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without the patients consent is not appropriate. D. Respecting the patients denial of pain and not
encouraging the pain medication may not necessarily support the patients comfort and allow for
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appropriate healing of the incision.
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PTS: 1 DIF: Difficult
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Analysis
12. ANS: C
C. The best measure of learning is observing the nurse demonstrate the procedures. A. B. D.
Having the nurse talk about the instructions or fill out a quiz may be helpful, but the only way to
know for sure if the teaching has been effective is to observe the behavior.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Application
13. ANS: C
C. Often, folk practices are not harmful and can be added to the patients plan of care. A. There is
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no reason to involve the physician in non-harmful folk practices. B. A patient should only be told
that something is not permitted if it is prohibited by policy. D. Allowing the practice to occur in
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the lobby may be unsafe for the patient and confusing to other patients and visitors.
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PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
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14. ANS: B
B. Cultural awareness focuses on history and ancestry and emphasizes an appreciation for and
attention to arts, music, crafts, celebrations, foods, and traditional clothing. A. Beliefs are
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assertions that are based on assumptions. C. Cultural sensitivity is using politically correct
language and not making statements that may offend another persons cultural beliefs. D. Cultural
PTS: 1 DIF: Moderate
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competence includes the skills and knowledge required to provide effective nursing care.
15. ANS: B
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KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis
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B. Ethnocentrism is the tendency for human beings to think that their ways of thinking, acting,
and believing are the only right ways. A. A stereotype is an opinion or belief about a group of
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people, which is ascribed to an individual from that group. C. Cultural sensitivity is using
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politically correct language and not making statements that may offend another persons cultural
beliefs. D. A generalization, or assumption, may be true for the group, but it does not necessarily
fit an individual.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis
16. ANS: C
C. Past-oriented individuals maintain traditions that were meaningful in the past, and they may
worship ancestors. A. Future-oriented people may invest time and money in the future. B.
Present-oriented people accept the day as it comes, with little regard for the past. D. Some
cultures combine all three.
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KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis
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PTS: 1 DIF: Moderate
17. ANS: B
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B. Cultural assessment must provide the basis for nursing care. This should include a review of
food preferences. A, C, and D are insensitive actions and risk stereotyping and providing
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inappropriate care to the patient.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level:
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Application
18. ANS: D
D. Individuals from Asian cultures may practice coining. This is an example of a cultural
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insensitive responses.
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practice that is harmless and may be included in the patients care. A, B, and C are culturally
PTS: 1 DIF: Moderate
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KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
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19. ANS: B
B. Initially, the familys wishes should be respected. This may be important in their culture. An
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ethics committee may be contacted for further input if the situation warrants it. A, C, and D are
culturally insensitive responses.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
20. ANS: A
A. Because it may be difficult for the patient to obtain transportation, the test should be
performed now. B, C, and D risk further delay of the test.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
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Application
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21. ANS: B
B. Asian-Americans hold these beliefs. A. C. D. Individuals from the other cultural groups do
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not believe in yin and yang and do not practice acupuncture. African Americans may have an
increased risk for stomach cancer, but they do not believe in yin and yang or acupuncture.
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PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
22. ANS: D
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C. Examples of folk medicines include covering a boil with axle grease, wearing copper
bracelets for arthritic pain, and drinking herbal teas. A. Allopathy is another name for traditional
Western medicine.
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PTS: 1 DIF: Moderate
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B. C. Acupressure and reflexology are complementary therapies.
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis
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23. ANS: A
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A. Compared with white or European American older adults, ethnic minorities are more likely to
live in poverty. The nurse needs to take the patients finances into consideration when preparing
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discharge instructions. B. The nurse needs to assess the patients preference for using cultural or
Western medicine practices. C. There is no information to support that the patient lives with
other family members. D. The patient may have difficulty accessing health care, so it is incorrect
to assume that the patient will attend all follow-up appointments.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
24. ANS: D
D. Cultural assimilation occurs when a new member takes on the dominant cultures values,
beliefs, and practices, sometimes at the cost of losing some of his or her cultural heritage. This
process is often viewed as negative as evidenced by the male parent becoming upset with the
youngest child refusing to speak the native language in the home. A. Ethnocentrism is the
tendency for humans to think that their ways of thinking, acting, and believing are the only right,
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proper, and natural ways. B. Cultural shock is when values, beliefs, and practices sanctioned by
the new culture are very different from the ones of the native culture. There is no evidence that
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cultural shock is occurring within the family. C. Cultural conflict is when one culture conflicts
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with another. There is no evidence that cultural conflict is occurring within the family.
PTS: 1 DIF: Moderate
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KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis
25. ANS: A
A. Family organization includes the perceived head of the household, gender roles, and roles of
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the elderly and extended family members. Because the spouse stays at the bedside and the
children visit every day to discuss events and ask advice, this household is most likely
patriarchal. B. There is no evidence to suggest that the spouse does not trust health care
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providers. C. Although the patient has a chronic disease, there is no evidence to suggest that
death is imminent. D. There is no evidence to support that the children are concerned that the
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patient is not receiving adequate care.
PTS: 1 DIF: Moderate
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KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis
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MULTIPLE RESPONSE
26. ANS: A, B, C, D
A, B, C, and D describe characteristics of cultural diversity of which the nurse should be aware.
E. Prescribed medications are related to physiological needs, not cultural needs.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis
27. ANS: A, E
A. E. For American Indians/Native Alaskans, touch is not acceptable from strangers. Asians and
Pacific Islanders avoid physical closeness and touching. B. Touch between persons of the same
gender is acceptable, and personal space is very close for Arab Americans. C.
Hispanics/Latinos/Spanish individuals value touching and closeness. D. African Americans have
PTS: 1 DIF: Moderate
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KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
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close personal space and touch frequently, although less with strangers.
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28. ANS: A, B, D, E
A. B. D. E. Cultural competence requires self-awareness and a desire to provide culturally
competent care. The number of encounters and experience with various groups can be helpful as
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is knowledge of your own communication patterns. C. Educational training on world politics is
not required to provide culturally competent care.
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PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
29. ANS: A, B, D, E
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A. B. D. E. The staff development instructor can help nurses improve cultural sensitivity by
using the acronym BALI or 1) be aware of your personal cultural heritage; 2) appreciate that
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each patient is unique, influenced but not defined by his or her culture; 3) learn about the patients
cultural groups; and 4) incorporate the patients cultural values, beliefs, and practices into their
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plan of care. C. Cultural assimilation is a personal endeavor, one in which the nurse may have
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little influence.
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PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
30. ANS: A, B, C
A. B. C. To determine health beliefs the nurse should ask about the practice of special rituals or
prayers to maintain health, the wearing of bracelets to ward off illnesses and the drinking of
herbs or special teas when ill. D. A copy of a magazine printed in Spanish would help indicate
the patients communication style. E. The use of a pillow between the nurse and patient could be
identifying a boundary for personal space.
31. Pertussis vaccination should begin at which age?
a. Birth
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b. 2 months
c. 6 months
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d. 12 months
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ANS: B
The acellular pertussis vaccine is recommended by the American Academy of Pediatrics
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beginning at age 6 weeks. Infants are at greater risk for complications of pertussis. The vaccine is
not given after age 7 years, when the risks of the vaccine become greater than those of pertussis.
The first dose is usually given at the 2-month well-child visit. Infants are highly susceptible to
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pertussis, which can be a life-threatening illness in this age group.
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
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32. A mother tells the nurse that she does not want her infant immunized because of the
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discomfort associated with injections. What should the nurse explain?
a. This cannot be prevented.
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b. Infants do not feel pain as adults do.
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c. This is not a good reason for refusing immunizations.
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d. A topical anesthetic can be applied before injections are given.
ANS: D
To minimize the discomfort associated with intramuscular injections, a topical anesthetic agent
can be used on the injection site. These include EMLA (eutectic mixture of local anesthetic) and
vapor coolant sprays. Pain associated with many procedures can be prevented or minimized by
using the principles of atraumatic care. Infants have neural pathways that will indicate pain.
Numerous research studies have indicated that infants perceive and react to pain in the same
manner as do children and adults. The mother should be allowed to discuss her concerns and the
alternatives available. This is part of the informed consent process.
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TOP: Integrated Process: Teaching/Learning
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MSC: Client Needs: Physiological Integrity
33. A 4-month-old infant comes to the clinic for a well-infant checkup. Immunizations she
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should receive are DTaP (diphtheria, tetanus, acellular pertussis) and IPV (inactivated poliovirus
vaccine). She is recovering from a cold but is otherwise healthy and afebrile. Her older sister has
a. DTaP and IPV can be safely given.
kt
a
cancer and is receiving chemotherapy. Nursing considerations should include which?
b. DTaP and IPV are contraindicated because she has a cold.
ba
n
c. IPV is contraindicated because her sister is immunocompromised.
d. DTaP and IPV are contraindicated because her sister is immunocompromised.
st
ANS: A
.te
These immunizations can be given safely. Serious illness is a contraindication. A mild illness
with or without fever is not a contraindication. These are not live vaccines, so they do not pose a
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risk to her sister.
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TOP: Integrated Process: Teaching/Learning
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MSC: Client Needs: Physiological Integrity
34. Which serious reaction should the nurse be alert for when administering vaccines?
a. Fever
b. Skin irritation
c. Allergic reaction
d. Pain at injection site
ANS: C
Each vaccine administration carries the risk of an allergic reaction. The nurse must be prepared
to intervene if the child demonstrates signs of a severe reaction. Mild febrile reactions do occur
m
after administration. The nurse includes management of fever in the parent teaching. Local skin
irritation may occur at the injection site after administration. Parents are informed that this is
co
expected. The injection can be painful. The nurse can minimize the discomfort with topical
nk
.
analgesics and nonpharmacologic measures.
MSC: Client Needs: Physiological Integrity
35. Which muscle is contraindicated for the administration of immunizations in infants and
kt
a
young children?
a. Deltoid
ba
n
b. Dorsogluteal
c. Ventrogluteal
st
d. Anterolateral thigh
.te
ANS: B
The dorsogluteal site is avoided in children because of the location of nerves and veins. The
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deltoid is recommended for 12 months and older. The ventrogluteal and anterolateral thigh sites
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can safely be used for the administration of vaccines to infants.
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TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
36. Which is described as an elevated, circumscribed skin lesion that is less than 1 cm in
diameter and filled with serous fluid?
a. Cyst
b. Papule
c. Pustule
d. Vesicle
ANS: D
m
A vesicle is elevated, circumscribed, superficial, smaller than 1 cm in diameter, and filled with
serous fluid. A cyst is elevated, circumscribed, palpable, encapsulated, and filled with liquid or
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semisolid material. A papule is elevated; palpable; firm; circumscribed; smaller than 1 cm in
diameter; and brown, red, pink, tan, or bluish red. A pustule is elevated, superficial, and similar
nk
.
to a vesicle but filled with purulent fluid.
kt
a
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
37. Which vitamin supplementation has been found to reduce both morbidity and mortality in
ba
n
measles?
a. A
b. B1
st
c. C
.te
d. Zinc
ANS: A
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Evidence suggests that vitamin A supplementation reduces both morbidity and mortality in
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measles.
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TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
38. What does impetigo ordinarily results in?
a. No scarring
b. Pigmented spots
c. Atrophic white scars
d. Slightly depressed scars
ANS: A
Impetigo tends to heal without scarring unless a secondary infection occurs.
m
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
co
39. What often causes cellulitis?
b. Candida albicans
c. Human papillomavirus
kt
a
d. Streptococci or staphylococci
nk
.
a. Herpes zoster
ANS: D
ba
n
Streptococci, staphylococci, and Haemophilus influenzae are the organisms usually responsible
for cellulitis. Herpes zoster is the virus associated with varicella and shingles. C. albicans is
associated with candidiasis, or thrush. Human papillomavirus is associated with various types of
st
human warts.
.te
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
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40. Lymphangitis (streaking) is frequently seen in what?
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a. Cellulitis
b. Folliculitis
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c. Impetigo contagiosa
d. Staphylococcal scalded skin
ANS: A
Lymphangitis is frequently seen in cellulitis. If it is present, hospitalization is usually required
for parenteral antibiotics. Lymphangitis is not associated with folliculitis, impetigo, or
staphylococcal scalded skin.
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
m
41. What is most important in the management of cellulitis?
co
a. Burow solution compresses
b. Oral or parenteral antibiotics
d. Incision and drainage of severe lesions
kt
a
ANS: B
nk
.
c. Topical application of an antibiotic
Oral or parenteral antibiotics are indicated depending on the extent of the cellulitis. Warm water
ba
n
compresses may be indicated for limited cellulitis. The antibiotic needs to be administered
systemically. Incision and drainage of severe lesions presents a risk of spreading infection or
making the lesion worse.
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a. A virus
.te
42. What causes warts?
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TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
b. A fungus
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c. A parasite
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d. Bacteria
ANS: A
Human warts are caused by the human papillomavirus. Infection with fungus, parasites, or
bacteria does not result in warts.
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
43. What is the primary treatment for warts?
a. Vaccination
b. Local destruction
c. Corticosteroids
m
d. Specific antibiotic therapy
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ANS: B
Local destructive therapy is individualized according to location, type, and number; surgical
nk
.
removal, electrocautery, curettage, cryotherapy, caustic solutions, x-ray treatment, and laser
therapies are used. Vaccination is prophylaxis for warts, not a treatment. Corticosteroids and
kt
a
specific antibiotic therapy are not effective in the treatment of warts.
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
a. Sympathetic nerve fibers
ba
n
44. Herpes zoster is caused by the varicella virus and has an affinity for which?
b. Parasympathetic nerve fibers
st
c. Lateral and dorsal columns of the spinal cord
.te
d. Posterior root ganglia and posterior horn of the spinal cord
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ANS: D
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The herpes zoster virus has an affinity for posterior root ganglia, the posterior horn of the spinal
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cord, and the skin. The zoster virus does not involve the nerve fibers listed.
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
45. Treatment for herpes simplex virus (type 1 or 2) includes which?
a. Corticosteroids
b. Oral griseofulvin
c. Oral antiviral agent
d. Topical or systemic antibiotic
ANS: C
Oral antiviral agents are effective for viral infections such as herpes simplex. Corticosteroids,
antibiotics, and griseofulvin (an antifungal agent) are not effective for viral infections.
m
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
co
46. What should the nurse explain about ringworm?
nk
.
a. It is not contagious.
b. It is a sign of uncleanliness.
kt
a
c. It is expected to resolve spontaneously.
d. It is spread by both direct and indirect contact.
ba
n
ANS: D
Ringworm is spread by both direct and indirect contact. Infected children should wear protective
caps at night to avoid transfer of ringworm to bedding. Ringworm is infectious. Because
st
ringworm is easily transmitted, it is not a sign of uncleanliness. It can be transmitted by seats
with head rests, gym mats, and animal-to-human transmission. The drug griseofulvin is indicated
.te
for a prolonged course, possibly several months.
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TOP: Integrated Process: Teaching/Learning
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MSC: Client Needs: Physiological Integrity
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47. When giving instructions to a parent whose child has scabies, what should the nurse include?
a. Treat all family members if symptoms develop.
b. Be prepared for symptoms to last 2 to 3 weeks.
c. Carefully treat only areas where there is a rash.
d. Notify practitioner so an antibiotic can be prescribed.
ANS: B
The mite responsible for the scabies will most likely be killed with the administration of
medications. It will take 2 to 3 weeks for the stratum corneum to heal. That is when the
symptoms will abate. Initiation of therapy does not wait for clinical symptom development. All
individuals in close contact with the affected child need to be treated. Permethrin, a scabicide, is
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the preferred treatment and is applied to all skin surfaces.
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TOP: Integrated Process: Teaching/Learning
nk
.
MSC: Client Needs: Physiological Integrity
48. Which is usually the only symptom of pediculosis capitis (head lice)?
kt
a
a. Itching
b. Vesicles
ba
n
c. Scalp rash
d. Localized inflammatory response
st
ANS: A
Itching is generally the only manifestation of pediculosis capitis (head lice). Diagnosis is made
.te
by observation of the white eggs (nits) on the hair shaft. Vesicles, scalp rash, and localized
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inflammatory response are not symptoms of head lice.
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TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
49. The school reviewed the pediculosis capitis (head lice) policy and removed the no nit
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requirement. The nurse explains that now, when a child is found to have nits, the parents must do
which before the child can return to school?
a. No treatment is necessary with the policy change.
b. Shampoo and then trim the childs hair to prevent reinfestation.
c. The child can remain in school with treatment done at home.
d. Treat the child with a shampoo to treat lice and comb with a fine-tooth comb
every day until nits are eliminated.
ANS: C
Many children have missed significant amounts of school time with no nit policies. The child
should be appropriately treated with a pediculicide and a fine-tooth comb. The environment
m
needs to be treated to prevent reinfestation. The treatment with the pediculicide will kill the lice
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and leave nit casings. Cutting the childs hair is not recommended; lice infest short hair as well as
long. With a no nit policy, treating the child with a shampoo to treat lice and combing the hair
change recognizes that most nits do not become lice.
nk
.
with a fine-tooth comb every day until nits are eliminated is the correct treatment. The policy
kt
a
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
a. Very difficult to prevent
ba
n
50. The nurse should know what about Lyme disease?
b. Easily treated with oral antibiotics in stages 1, 2, and 3
c. Caused by a spirochete that enters the skin through a tick bite
.te
st
d. Common in geographic areas where the soil contains the mycotic spores that
cause the disease
ANS: C
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Lyme disease is caused by Borrelia burgdorferi, a spirochete spread by ticks. The early
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characteristic rash is erythema migrans. Tick bites should be avoided by entering tick-infested
areas with caution. Light-colored clothing should be worn to identify ticks easily. Long-sleeve
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shirts and long pants tucked into socks should be the attire. Early treatment of erythema migrans
(stage 1) can prevent the development of Lyme disease. Lyme disease is caused by a spirochete,
not mycotic spores.
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
51. The nurse is teaching a nursing student about standard precautions. Which statement made by
the student indicates a need for further teaching?
a. I will use precautions when I give an infant oral care.
b. I will use precautions when I change an infants diaper.
c. I will use precautions when I come in contact with blood and body fluids.
m
d. I will use precautions when administering oral medications to a school-age child.
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ANS: D
nk
.
Standard precautions involve the use of barrier protection (personal protective equipment [PPE]),
such as gloves, goggles, a gown, or a mask, to prevent contamination from (1) blood; (2) all
body fluids, secretions, and excretions except sweat, regardless of whether they contain visible
kt
a
blood; (3) nonintact skin; and (4) mucous membranes. Precautions should be taken when giving
oral care, when changing diapers, and when coming in contact with blood and body fluids.
Further teaching is needed if the student indicates the need to use precautions when
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n
administering an oral medication to a school-age child.
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Chapter 2. Public Health Guidelines
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MULTIPLE CHOICE
1. Children are taught the values of their culture through observation and feedback relative to
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their own behavior. In teaching a class on cultural competence, the nurse should be aware that
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which factor may be culturally determined?
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a. Ethnicity
b. Racial variation
c. Status
d. Geographic boundaries
ANS: C
Status is culturally determined and varies according to each culture. Some cultures ascribe higher
status to age or socioeconomic position. Social roles also are influenced by the culture. Ethnicity
is an affiliation of a set of persons who share a unique cultural, social, and linguistic heritage. It
is one component of culture. Race and culture are two distinct attributes. Whereas racial
grouping describes transmissible traits, culture is determined by the pattern of assumptions,
beliefs, and practices that unconsciously frames or guides the outlook and decisions of a group of
m
people. Cultural development may be limited by geographic boundaries, but the boundaries are
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not culturally determined.
MSC: Client Needs: Psychosocial Integrity
nk
.
TOP: Integrated Process: Teaching/Learning
attitude the nurse is displaying is what?
b. Ethnocentrism
c. Cultural shock
st
d. Cultural sensitivity
ba
n
a. Acculturation
kt
a
2. The nurse is aware that if patients different cultures are implied to be inferior, the emotional
.te
ANS: B
Ethnocentrism is the belief that ones way of living and behaving is the best way. This includes
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the emotional attitude that the values, beliefs, and perceptions of ones ethnic group are superior
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to those of others. Acculturation is the gradual changes that are produced in a culture by the
influence of another culture that cause one or both cultures to become more similar. The minority
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culture is forced to learn the majority culture to survive. Cultural shock is the helpless feeling
and state of disorientation felt by an outsider attempting to adapt to a different culture group.
Cultural sensitivity, a component of culturally competent care, is an awareness of cultural
similarities and differences.
MSC: Client Needs: Psychosocial Integrity
3. Which term best describes the sharing of common characteristics that differentiates one group
from other groups in a society?
a. Race
b. Culture
c. Ethnicity
m
d. Superiority
co
ANS: C
nk
.
Ethnicity is a classification aimed at grouping individuals who consider themselves, or are
considered by others, to share common characteristics that differentiate them from the other
collectivities in a society, and from which they develop their distinctive cultural behavior. Race
kt
a
is a term that groups together people by their outward physical appearance. Culture is a pattern
of assumptions, beliefs, and practices that unconsciously frames or guides the outlook and
decisions of a group of people. A culture is composed of individuals who share a set of values,
ba
n
beliefs, and practices that serve as a frame of reference for individual perception and judgments.
Superiority is the state or quality of being superior; it does not apply to ethnicity.
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TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
generations?
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a. Race
.te
4. After the family, which has the greatest influence on providing continuity between
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b. School
c. Social class
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d. Government
ANS: B
Schools convey a tremendous amount of culture from the older members to the younger
members of society. They prepare children to carry out the traditional social roles that will be
expected of them as adults. Race is defined as a division of humankind possessing traits that are
transmissible by descent and are sufficient to characterize race as a distinct human type; although
race may have an influence on childrearing practices, its role is not as significant as that of
schools. Social class refers to the familys economic and educational levels. The social class of a
family may change between generations. The government establishes parameters for children,
including amount of schooling, but this is usually at a local level. The school culture has the
m
most significant influence on continuity besides family.
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TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
5. The nurse is planning care for a patient with a different ethnic background. Which should be
nk
.
an appropriate goal?
a. Adapt, as necessary, ethnic practices to health needs.
kt
a
b. Attempt, in a nonjudgmental way, to change ethnic beliefs.
c. Encourage continuation of ethnic practices in the hospital setting.
ba
n
d. Strive to keep ethnic background from influencing health needs.
ANS: A
Whenever possible, nurses should facilitate the integration of ethnic practices into health care
st
provision. The ethnic background is part of the individual; it should be difficult to eliminate the
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influence of ethnic background. The ethnic practices need to be evaluated within the context of
the health care setting to determine whether they are conflicting.
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MSC: Client Needs: Psychosocial Integrity
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6. The nurse discovers welts on the back of a Vietnamese child during a home health visit. The
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childs mother says she has rubbed the edge of a coin on her childs oiled skin. The nurse should
recognize this as what?
a. Child abuse
b. Cultural practice to rid the body of disease
c. Cultural practice to treat enuresis or temper tantrums
d. Child discipline measure common in the Vietnamese culture
ANS: B
This is descriptive of coining. The welts are created by repeatedly rubbing a coin on the childs
oiled skin. The mother is attempting to rid the childs body of disease. Coining is a cultural
healing practice. Coining is not specific for enuresis or temper tantrums. This is not child abuse
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or discipline.
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TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
7. A Hispanic toddler has pneumonia. The nurse notices that the parent consistently feeds the
child only the broth that comes on the clear liquid tray. Food items, such as Jell-O, Popsicles,
nk
.
and juices, are left. Which statement best explains this?
a. The parent is trying to feed the child only what the child likes most.
kt
a
b. Hispanics believe the evil eye enters when a person gets cold.
c. The parent is trying to restore normal balance through appropriate hot remedies.
ba
n
d. Hispanics believe an innate energy called chi is strengthened by eating soup.
ANS: C
st
In several cultures, including Filipino, Chinese, Arabic, and Hispanic, hot and cold describe
certain properties completely unrelated to temperature. Respiratory conditions such as
.te
pneumonia are cold conditions and are treated with hot foods. The child may like broth but is
unlikely to always prefer it to Jell-O, Popsicles, and juice. The evil eye applies to a state of
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imbalance of health, not curative actions. Chinese individuals, not Hispanic individuals, believe
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in chi as an innate energy.
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TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
8. How is family systems theory best described?
a. The family is viewed as the sum of individual members.
b. A change in one family member cannot create a change in other members.
c. Individual family members are readily identified as the source of a problem.
d. When the family system is disrupted, change can occur at any point in the system.
ANS: D
Family systems theory describes an interactional model. Any change in one member will create
change in others. Although the family is the sum of the individual members, family systems
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theory focuses on the number of dyad interactions that can occur. The interactions, not the
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individual members, are considered to be the problem.
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
a. Exchange theory
b. Developmental theory
c. Structural-functional theory
ba
n
d. Symbolic interactional theory
kt
a
nk
.
9. Which family theory is described as a series of tasks for the family throughout its life span?
ANS: B
st
In developmental systems theory, the family is described as a small group, a semiclosed system
of personalities that interact with the larger cultural system. Changes do not occur in one part of
.te
the family without changes in others. Exchange theory assumes that humans, families, and
groups seek rewarding statuses so that rewards are maximized while costs are minimized.
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Structural-functional theory states that the family performs at least one societal function while
also meeting family needs. Symbolic interactional theory describes the family as a unit of
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interacting persons with each occupying a position within the family.
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
10. Which family theory explains how families react to stressful events and suggests factors that
promote adaptation to these events?
a. Interactional theory
b. Family stress theory
c. Eriksons psychosocial theory
d. Developmental systems theory
ANS: B
Family stress theory explains the reaction of families to stressful events. In addition, the theory
m
helps suggest factors that promote adaptation to the stress. Stressors, both positive and negative,
are cumulative and affect the family. Adaptation requires a change in family structure or
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interaction. Interactional theory is not a family theory. Interactions are the basis of general
systems theory. Eriksons theory applies to individual growth and development, not families.
nk
.
Developmental systems theory is an outgrowth of Duvalls theory. The family is described as a
small group, a semiclosed system of personalities that interact with the larger cultural system.
kt
a
Changes do not occur in one part of the family without changes in others.
11. Historically, what was the justification for the victimization of women?
ba
n
a. Women were regarded as possessions.
b. Women were the weaker sex.
c. Control of women was necessary to protect them.
st
d. Women were created subordinate to men.
.te
ANS: A
Misogyny, patriarchy, devaluation of women, power imbalance, a view of women as property,
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gender-role stereotyping, and acceptance of aggressive male behaviors as appropriate contributed
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and continue to contribute to the subordinate status of women in many of the worlds societies.
Viewing women as the weaker sex is a cultural and modern stereotype that contributes to the
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victimization of women. Control of women to protect them is another cultural and modern
stereotype that contributes to the victimization of women. Yet another cultural stereotype that
contributes to the victimization of women is the idea that women were created as subordinate to
men.
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
12. What is the primary theme of the feminist perspective regarding violence against women?
a. Role of testosterone as the underlying cause of mens violent behavior
b. Basic human instinctual drive toward aggression
c. Male dominance and coercive control over women
m
d. Cultural norm of violence in Western society
co
ANS: C
The contemporary social view of violence is derived from the feminist theory. With the primary
nk
.
theme of male dominance and coercive control, this view enhances an understanding of all forms
of violence against women, including wife battering, stranger and acquaintance rape, incest, and
sexual harassment in the workplace. The role of testosterone as an underlying cause of mens
kt
a
violent behavior, the basic human instinctual drive toward aggression, and the cultural norm of
violence in Western society are not associated with the feminist perspective regarding violence
ba
n
against women.
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
(IPV)?
.te
a. Socially isolated
st
13. Which trait is least likely to be displayed by a woman experiencing intimate partner violence
b. Assertive personality
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c. Struggling with depression
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d. Dependent partner in a relationship
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ANS: B
Every segment of society is represented among women who are suffering abuse. However, traits
of assertiveness, independence, and willingness to take a stand have been documented as more
characteristic of women who are in nonviolent relationships. Women who are financially more
dependent have fewer resources and support systems, exhibit symptoms of depression, and are
more often seen as victims.
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
14. A woman who is 6 months pregnant has sought medical attention, saying she fell down the
stairs. What scenario would cause an emergency department nurse to suspect that the woman has
been a victim of IPV?
m
a. The woman and her partner are having an argument that is loud and hostile.
c. Examination reveals a fractured arm and fresh bruises.
co
b. The woman has injuries on various parts of her body that are in different stages of
healing.
nk
.
d. She avoids making eye contact and is hesitant to answer questions.
kt
a
ANS: B
The client may have multiple injuries in various stages of healing that indicates a pattern of
violence. An argument is not always an indication of battering. A fractured arm and fresh bruises
ba
n
could be caused by the reported fall and do not necessarily indicate IPV. It may be normal for the
woman to be reticent and have a dull affect.
st
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
.te
15. Which statement is most accurate regarding the reporting of IPV in the United States?
a. Asian women report more IPV than do other minority groups.
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b. Caucasian women report less IPV than do non-Caucasians.
c. Native-American women report IPV at a rate similar to other groups.
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w
d. African-American women are less likely to report IPV than Caucasian women.
ANS: B
Caucasian women report less IPV than other ethnic groups. Asian women report significantly
less IPV than do other racial groups. Native-American and Alaska Native women report
significantly more IPV than do women of any other racial background. African-American
women tend to report violence at a slightly higher rate than Caucasian women.
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
16. Intervention for the sexual abuse survivor is often not attempted by maternity and womens
health nurses because of the concern about increasing the distress of the woman and the lack of
expertise in counseling. What initial intervention is appropriate and most important in facilitating
m
the womans care?
b. Setting limits on what the client discloses
c. Listening and encouraging therapeutic communication skills
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a. Initiating a referral to an expert counselor
nk
.
d. Acknowledging the nurses discomfort to the client as an expression of empathy
kt
a
ANS: C
The survivor needs support on many different levels, and a womens health nurse may be the first
person to whom she relates her story. Therapeutic communication skills and listening are initial
ba
n
interventions. Referring this client to a counselor is an appropriate measure but not the most
important initial intervention. A client should be allowed to disclose any information she feels
the need to discuss. A nurse should provide a safe environment in which she can do so. Either
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verbal or nonverbal shock and horror reactions from the nurse are particularly devastating.
.te
Professional demeanor and professional empathy are essential.
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
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17. A young woman arrives at the emergency department and states that she thinks she has been
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raped. She is sobbing and expresses disbelief that this could happen because the perpetrator was
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a very close friend. Which statement is most appropriate at this time?
a. Rape is not limited to strangers and frequently occurs by someone who is known
to the victim.
b. I would be very upset if my best friend did that to me; that is very unusual.
c. You must feel very betrayed. In what way do you think you might have led him
on?
d. This does not sound like rape. Didnt you just change your mind about having sex
after the fact?
ANS: A
Acquaintance rape involves individuals who know one another. Sexual assault occurs when the
trust of a relationship is violated. Victims may be less prone to recognize what is happening to
them because the dynamics are different from those of stranger rape. It is not at all unusual for
the victim to know and trust the perpetrator. Stating that the woman might have led the man to
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attack her indicates that the sexual assault was somehow the victims fault. This type of mentality
is not constructive. Nurses must first reflect on their own feelings and learn to be unbiased when
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dealing with victims. A statement of this type can be very psychologically damaging to the
victim. Nurses must display compassion by first believing what the victim states. The nurse is
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.
not responsible for deciphering the facts involving the victims claim.
kt
a
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
18. Nurses are often the first health care professional with whom a woman comes into contact
after being sexually assaulted. Which statement best describes the initial care of a rape victim?
ba
n
a. All legal evidence is preserved during the physical examination.
b. The victim appreciates the legal information; however, decides not to pursue legal
proceedings.
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c. The victim states that she is going to advocate against sexual violence.
.te
d. The victim leaves the health care facility without feeling re-victimized.
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ANS: D
Nurses can assist clients through an examination that is as nontraumatic as possible with
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kindness, skill, and empathy. The initial care of the victim affects her recovery and decision to
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receive follow-up care. Preservation of all legal evidence is very important; however, this may
not be the best measure in terms of evaluating the care of a rape victim. Offering legal
information is not the best measure of evaluating the care that this victim received. The victim
may well decide not to pursue legal proceedings. Advocating against sexual violence may be
extremely therapeutic for the client after her initial recovery but not a measure of evaluating her
care.
MSC: Client Needs: Psychosocial Integrity
19. When the nurse is alone with a battered client, the client seems extremely anxious and says,
It was all my fault. The house was so messy when he got home, and I know he hates that. What
is the most suitable response by the nurse?
a. No one deserves to be hurt. Its not your fault. How can I help you?
b. What else do you do that makes him angry enough to hurt you?
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c. He will never find out what we talk about. Dont worry. Were here to help you.
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d. You have to remember that he is frustrated and angry so he takes it out on you.
nk
.
ANS: A
The nurse should stress that the client is not at fault. Asking what the client did to make her
husband angry is placing the blame on the woman and would be an inappropriate statement. The
kt
a
nurse should not provide false reassurance. To assist the woman, the nurse should be honest.
Often the batterer will find out about the conversation.
ba
n
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
20. Nurses who provide care to victims of IPV should be keenly aware of what?
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a. Relationship violence usually consists of a single episode that the couple can put
behind them.
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b. Violence often declines or ends with pregnancy.
c. Financial coercion is considered part of IPV.
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d. Battered women are generally poorly educated and come from a deprived social
background.
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ANS: C
Economic coercion may accompany physical assault and psychologic attacks. IPV almost always
follows an escalating pattern. It rarely ends with a single episode of violence. IPV often begins
with and escalates during pregnancy. It may include both psychologic attacks and economic
coercion. Race, religion, social background, age, and education level are not significant factors in
differentiating women at risk.
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
21. In 1979, Lenore Walker pioneered the cause of women as victims of violence when she
published her book The Battered Woman. While Walker conducted her research, she found a
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similar pattern of abuse among many of the women. This concept is now referred to as the cycle
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of violence. Which phase does not belong in this three-cycle pattern of violence?
a. Tension-building state
nk
.
b. Frustration, followed by violence
c. Acute battering incident
kt
a
d. Kindness and contrite, loving behavior
ANS: B
ba
n
Frustration, followed by violence, is not part of the cycle of violence. The tension-building state
is also known as phase I of the cycle. The batterer expresses dissatisfaction and hostility with
violent outbursts. The woman senses anger and anxiously tries to placate him. An acute battering
incident is phase II of the cycle. It results in the mans uncontrollable discharge of tension toward
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the woman. Outbursts can last from several hours to several days and may involve kicking,
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punching, slapping, choking, burns, broken bones, and the use of weapons. Phase III of the cycle
is sometimes referred to as the honeymoon, kindness and contrite, and loving behavior phase,
during which the batterer feels remorseful and profusely apologizes. He tries to help the woman
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and often showers her with gifts.
22. Nurses must remember that pregnancy is a time of risk for all women. Which condition is
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likely the biggest risk for the pregnant client?
a. Preeclampsia
b. IPV
c. Diabetes
d. Abnormal Pap test
ANS: B
The prevalence of IPV during pregnancy is estimated at 6% of all pregnant women. The risk for
IPV and even IPV-related homicide is more common than all of the other pregnancy-related
conditions. Although preeclampsia poses a risk to the health of the pregnant client, it is less
common than IPV. Gestational diabetes continues to be a complication of pregnancy; however, it
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screening during pregnancy, but this finding is not as common as IPV.
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is less common than IPV during pregnancy. Some women are at risk for an abnormal Pap
MSC: Client Needs: Psychosocial Integrity
nk
.
23. In the 1970s, the rape-trauma syndrome (RTS) was identified as a cluster of symptoms and
related behaviors observed in the weeks and months after an episode of rape. Researchers
RTS?
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n
a. Acute Phase: Disorganization
kt
a
identified three phases related to this condition. Which phase is not displayed in a client with
b. Outward Adjustment Phase
c. Shock/Disbelief: Disorientation Phase
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d. Long-Term Process: Reorganization Phase
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ANS: C
Shock, disbelief, or disorientation is a component of the Acute Phase. The rape survivor feels
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embarrassed, degraded, fearful, and angry. She may feel unclean and want to bathe and douche
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repeatedly, even though doing so may destroy evidence. The victim relives the scene over and
over in her mind, thinking of things she should have done. During the Outward Adjustment
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Phase, the victim may appear to have resolved her crisis and return to activities of daily living
and work. Other women may move, leave their job, and buy a weapon to protect themselves.
Disorientation is a reaction during which the victim may feel disoriented, have difficulty
concentrating, or have poor recall. The Long-Term Process is the reorganization phase. This
recovery phase may take years and may be difficult and painful.
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
24. Documentation of abuse can be useful to women later in court, should they elect to press
charges. It is of key importance for the nurse to document accurately at the time that the client is
seen. Which entry into the medical record would be the least helpful to the court?
a. Photographs of injuries
c. Summary of information (e.g., The client is a battered woman.)
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d. Accurate description of the clients demeanor
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b. Clear and legible written documentation
nk
.
ANS: C
A statement such as, The client is a battered woman lacks the supporting factual information and
will render the report inadmissible. More appropriate documentation would include exact
kt
a
statements from the woman in quotations (e.g., My husband kicked me in the stomach). The time
and date of the examination should also be included.
ba
n
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
25. Which statement regarding human trafficking is correct?
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a. Human trafficking is a multibillion-dollar business that primarily exists in the
United States.
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b. Victims often experience the Stockholm syndrome.
c. Vast majority of the victims are young boys and girls.
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d. Human trafficking primarily refers to commercial sex work.
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ANS: B
Although victims of sex trafficking can be young boys and girls, the vast majority are women
and girls. They are often lured by false promises, such as a job or marriage, sold by their parents,
or kidnapped by traffickers. These individuals are forced into sex work, hard labor, and organ
donation. This $32 billion business exists in the United States and internationally. The Stockholm
syndrome occurs when the slaves become attached to their enslavers. Health care professionals
may interact with victims who are in captivity should they require emergent health care. The
nurse is challenged to find an opportunity to speak with the client alone and assess for
victimization.
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
26. Which statement is the most comprehensive description of sexual violence?
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a. Sexual violence is limited to rape.
c. Sexual violence encompasses a number of sexual acts.
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b. Sexual violence is an act of force during which an unwanted and uncomfortable
sexual act occurs.
nk
.
d. Sexual violence includes degrading sexual comments and behaviors.
kt
a
ANS: C
Sexual violence is a broad term that includes a range of sexual victimization including sexual
ba
n
assault, sexual harassment, and rape. It may include but is not limited to rape. Sexual assault
includes unwanted or uncomfortable touches, kisses, hugs, petting, intercourse, or other sexual
acts. It is a component of sexual violence. Unwelcome or degrading e-mail messages, comments,
sexual harassment.
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contact, or behavior, such as exhibitionism, that makes any environment feel unsafe is known as
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TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
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27. Women with severe and persistent mental illness are likely to be more vulnerable to being
involved in controlling and/or violent relationships; however, many women develop mental
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health problems as a result of long-term abuse. Which condition is unlikely to be a psychologic
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consequence of continued abuse?
a. Substance abuse
b. Posttraumatic stress disorder (PTSD)
c. Eating disorders
d. Bipolar disorder
ANS: D
Bipolar disorder is a specific illness (also known as manic depressive disorder) not related to
abuse. Substance abuse is a common method of coping with long-term abuse. The abuser is also
more likely to use alcohol and other chemical substances. PTSD is the most prevalent mental
health sequela of long-term abuse. The traumatic event is persistently re-experienced through
distress recollection and dreams. Eating disorders, depression, psychologic-physiologic illness,
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and anxiety reactions are all mental health problems associated with repeated abuse.
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MSC: Client Needs: Psychosocial Integrity
MULTIPLE RESPONSE
nk
.
28. The nurse who is evaluating the client for potential abuse should be aware that IPV includes
a number of different forms of abuse, including which of the following? (Select all that apply.)
kt
a
a. Physical
b. Sexual
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n
c. Emotional
d. Psychologic
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ANS: A, B, D, E
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e. Financial
Physical, sexual, financial, and psychologic abuse can all be components in a relationship with
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IPV. Emotional abuse is a form of psychologic abuse.
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MSC: Client Needs: Psychosocial and Physiologic Integrity
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29. What are some common characteristics of a potential male batterer? (Select all that apply.)
a. High level of self-esteem
b. High frustration tolerance
c. Substance abuse problems
d. Excellent verbal skills
e. Personality disorders
ANS: C, E
Substance abuse and personality disorders are often observed in batterers. Typically, the batterer
has low self-esteem. Batterers usually have a low frustration level (i.e., they easily lose their
temper). Batterers characteristically have poor verbal skills and can especially have difficulty
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expressing their feelings.
30. Which nursing diagnoses would be most applicable for battered women? (Select all that
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apply.)
a. Loss of trust
nk
.
b. Ineffective family coping
d. Risk for self-directed violence
e. Enhanced communication
ba
n
ANS: A, B, C, D
kt
a
c. Situational low self-esteem
Loss of trust, ineffective family coping, situational low self-esteem, and risk for self-directed
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violence are potential nursing diagnoses associated with battered women. A more appropriate
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nursing diagnosis for a battered woman would be impaired communication.
MSC: Client Needs: Psychosocial Integrity
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31. A thorough abuse assessment screen should be completed on all female clients. This screen
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should include which components? (Select all that apply.)
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a. Asking the client if she has ever been slapped, kicked, punched, or physically hurt
by her partner
b. Asking the client if she is afraid of her partner
c. Asking the client if she has been forced to perform sexual acts
d. Diagramming the clients current injuries on a body map
e. Asking the client what she did wrong to elicit the abuse
ANS: A, B, C, D
Asking the client if she has been slapped, kicked, punched, or physically hurt by her partner, if
she is afraid of her partner, or if she has been forced to perform sexual acts are questions that
should be posed to all clients. If any physical injuries are present, then they should be marked on
a form that indicates their locations on the body. Implying that a client did something wrong can
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be very emotionally damaging. Many victims of violence are not aware that they are in an
words such as slap, kick, or punch to elicit information is best.
nk
.
TOP: Nursing Process: Assessment
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abusive relationship. They may not respond to questions about abuse. Using general descriptive
MSC: Client Needs: Safe and Effective Care Environment
against a woman? (Select all that apply.)
ba
n
a. Report the incident to legal authorities.
kt
a
32. What are the responsibilities of the nurse who suspects or confirms any type of violence
b. Provide resources for domestic violence shelters.
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c. Call a client advocate who can assist in the clients decision about what actions to
take.
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d. Accurately and concisely document the incident (or findings) in the clients
record.
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e. Reassure and support the client.
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ANS: B, C, D, E
Domestic violence is considered a crime in all states; however, mandatory reporting remains
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controversial. Nurses must become knowledgeable on the laws that apply in the state in which
they practice. Caring for a client who may be a victim of domestic abuse is an ideal opportunity
to provide the woman with information for safe houses or support groups for herself and her
children. The nurse may assist in reaching out to a client advocate, which often occurs when
potential legal action is taken or if the woman is seeking shelter. Documentation must be
accurate and timely to be useful to the client later in court if she chooses to press charges. The
primary functions for the nurse are to reassure the client and to provide her with emotional
support.
31. The alcoholic patient says to the nurse, I am not an alcoholic. I can quit any time I want to.
The nurse recognizes the defense mechanism of:
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a. repression.
b. denial.
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c. rationalization.
nk
.
d. intellectualization.
ANS: B
kt
a
Denial is ignoring reality in spite of hard evidence. Denial is a mechanism frequently used by
substance abusers. Repression refers to unconsciously blocking an unwanted thought or memory
from open expression. Rationalization attempts to justify a behavior or action by making an
ba
n
excuse or an explanation. Intellectualization is the excessive reasoning and logic to counter
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emotional distress.
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TOP: Alcoholism: Defense Mechanism KEY: Nursing Process Step: Assessment
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MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
34. The wife of an alcoholic tells the nurse, My husband only drinks on the weekends to relax.
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He has a very stressful job. The nurse recognizes the defense mechanism of:
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a. repression.
b. denial.
c. rationalization.
d. identification.
ANS: C
Rationalization is a justification for an unreasonable act to make it appear reasonable.
Rationalization is used by many families to allay their own anxiety about the substance abuse of
a family member. Repression refers to unconsciously blocking an unwanted thought or memory
from open expression. Denial is ignoring reality in spite of hard evidence. Denial is a mechanism
frequently used by substance abusers. Identification refers to modeling behaviors after another
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individual.
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TOP: Family Reaction to Substance Abuse: Rationalization
KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
dependent:
kt
a
a. covers up the behavior of the substance abuser.
nk
.
35. The nurse explains the difference between an enabler and a co-dependent is that a co-
b. rationalizes the behavior of the substance abuser.
ba
n
c. uses the behavior of the substance abuser to build up his or her own self-esteem.
d. is also a substance abuser.
st
ANS: A
The co-dependent fixes things by overcompensating to prevent the abuser from facing reality.
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Enabling refers to helping a person so that the persons consequences from unhealthy behavior
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are less severe; thus enabling helps the unhealthy behavior to continue.
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TOP: Co-dependent vs. Enabler KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Psychosocial Integrity
36. The nurse explains that, no matter whether you drink a 12-ounce beer, a 6-ounce glass of
wine, or 1.5 ounces of straight liquor, it takes approximately _____ minutes for the body to
metabolize it.
a. 20
b. 30
c. 40
d. 60
ANS: D
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The metabolization of any amount of alcohol takes approximately 1 hour.
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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TOP: Alcohol: Metabolization Time KEY: Nursing Process Step: Implementation
would be alert for withdrawal signs of:
kt
a
a. irritability.
nk
.
37. A person in jail for public intoxication has been without alcohol for 12 hours. The jail nurse
b. nausea and vomiting.
ba
n
c. hallucinations.
d. seizures.
st
ANS: A
.te
Marked irritability is the early sign (6 to 12 hours after last drink) of alcohol withdrawal.
TOP: Alcohol Withdrawal: Signs KEY: Nursing Process Step: Assessment
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MSC: NCLEX: Physiological Integrity: Physiological Adaptation
38. A patient who is still intoxicated has been admitted for detoxification at the treatment center.
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The nurse takes into consideration that the patient will be supported in his withdrawal with the
use of:
a. psychotherapy support only.
b. heavy doses of opioids to keep the patient sedated for 72 hours.
c. symptomatic relief until substance has cleared from his system.
d. titrated amounts of alcohol until severe withdrawal is over.
ANS: C
The alcoholic in withdrawal is supported with symptomatic relief for nausea and vomiting,
cramps, and possible seizure.
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
m
TOP: Alcoholism: Detoxification KEY: Nursing Process Step: Planning
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39. After detoxification from substance abuse, the patient says, I feel better than I have in years!
nk
.
All I needed was some rest. I am not an alcoholic. The nurse should respond to this by saying:
a. What were you doing that got you admitted to the detoxification center?
c. Admitting to alcoholism is hard.
kt
a
b. Alcoholism has many definitions. What is yours?
ba
n
d. Alcoholism has ruined your life. How can you say you are not an alcoholic?
ANS: A
Confronting denial and encouraging self-diagnosis is the point of the treatment phase after
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detoxification. Asking for the patients definition of alcoholism allows for the patient to
intellectualize the problem. Stating that alcoholism is hard is a sympathetic and unhelpful
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response. Alcoholism has ruined your life is accusatory and counterproductive.
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TOP: Alcoholism: Post-detoxification KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Psychosocial Integrity
40. The nurse explains that an alternative to disulfiram (Antabuse) is the drug naltrexone
(ReVia), which can:
a. cause severe headaches if alcohol is consumed while using the drug.
b. cause a dependence on ReVia rather than on alcohol.
c. release endorphin-like enzymes that mimic intoxication.
d. block craving and prevent relapse.
ANS: D
Naltrexone (ReVia) can be used to block the craving for alcohol and to prevent relapse in the
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MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
m
recovery phase.
a. development of improved social skills.
b. progression toward sobriety.
c. provision of a sense of belonging.
ba
n
d. increasing self-discipline.
kt
a
major and long-lasting benefit of:
nk
.
41. The nurse encourages the recovering alcoholic to participate in group therapy because of the
ANS: D
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The learning of the skill of self-discipline is the long-lasting benefit from group therapy. The
other options are also benefits, but the major one is self-discipline, a skill a drug abuser must
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acquire for successful rehabilitation.
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42. The nurse is aware that when Korsakoffs syndrome is suspected from behavioral cues, the
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syndrome can be confirmed by:
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a. liver biopsy.
b. brain scan.
c. magnetic resonance imaging.
d. spinal tap.
ANS: B
The individual with Korsakoffs syndrome has grossly impaired memory and gait disturbance.
Confabulation (making up stories) frequently is seen as an attempt to communicate. A brain scan
will show brain atrophy; currently there is no treatment to reverse the condition.
43. The nurse uses the CAGE challenge to alcoholics who persist in denial. The G in the set of
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questions from CAGE stands for:
a. Do you feel like you must get alcohol?
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b. Do you go out to drink?
d. Do you feel guilty about your drinking?
kt
a
ANS: D
nk
.
c. Is memory of drinking episodes gone?
A commonly used screening tool for alcohol abuse is the CAGE assessment. Two or more yes
answers has a 90% correlation with an alcohol abuse problem. The G stands as a reminder for the
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n
question, Do you feelguilty about your drinking?
TOP: CAGE Queries: Significance KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Psychosocial Integrity
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44. The nurse is aware that the newly admitted patient who overdosed on lorazepam (Ativan)
a. 8
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b. 24
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will show signs of withdrawal in _____ hours.
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c. 36
d. 72
ANS: D
Because of the long half-life of benzodiazepines, the withdrawal from them is delayed for up to 3
to 5 days.
45. The nurse is concerned about a coworker who exhibits a sign of amphetamine abuse, such as:
a. excited speech.
b. attention to detail.
c. sluggish, slurred speech.
m
d. eating sweets constantly.
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ANS: A
amphetamines.
kt
a
Chapter 3. Pain Management Guidelines
nk
.
Excited speech, euphoric behavior, increased alertness, and anorexia are indications of abuse of
ba
n
MULTIPLE CHOICE
1.A client tells the nurse that she rarely experiences pain, but when she does, she seeks medical
attention. The nurse realizes this client understands that pain is important because it:
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st
1.is a protective system.
2.includes the automatic withdrawal reflex.
3.creates sensitivity to pain.
4.helps with healing.
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ANS: 1
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Pain is a protective system that includes protection from unsafe behaviors by use of reflexes,
memory, and avoidance. Even though the automatic withdrawal reflex is a part of the pain
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response, it does not explain why pain is important. Pain does not create sensitivity to pain. Pain
does not help with healing.
PTS: 1 DIF: Analyze REF: Definitions and Implications of Pain
2.A client complains that the bed sheets touching his skin are extremely painful. The nurse
realizes this client is experiencing:
1.allodynia.
2.modulation.
3.kinesthesia.
4.proprioception.
ANS: 1
Allodynia or hyperalgesia is a state where a slight or nonpainful stimulus is interpreted as very
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position. Modulation is an influencing factor in the perception of pain.
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painful. Kinesthesia is the awareness of movement. Proprioception is the awareness of body
nk
.
PTS: 1 DIF: Analyze REF: Peripheral Nervous System
3.A client is complaining of severe abdomen pain. The nurse realizes this client is experiencing
kt
a
which type of pain?
ba
n
1.Neuralgia
2.Pathological
3.Somatic
4.Visceral
ANS: 4
st
Visceral pain is pain arising from the body organs or gastrointestinal tract. Somatic pain is pain
that originates from the bone, joints, muscles, skin, or connective pain. Neuralgia and
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pathological pain are both types of pain that result from injury to a nerve or malfunction of the
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neuronal transmission process or due to impaired regulation.
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PTS:1DIF:AnalyzeREF:Types of Pain
4.A client, diagnosed with acute appendicitis, is experiencing abdominal pain. The best way for
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the nurse to describe this clients pain would be:
1.chronic.
2.neuropathic.
3.referred.
4.acute.
ANS: 4
Acute pain onset is sudden and of short duration. Chronic pain is a sudden or slow onset of mild
to severe pain that lasts longer than 6 months. Referred pain is the result of the transfer of
visceral pain sensations to a body surface at a distance from the actual origin. Neuropathic pain
is paroxysmal pain that occurs along the branches of a nerve.
m
PTS:1DIF:ApplyREF:Types of Pain
5.A client is observed holding a pillow over the abdominal region with both knees flexed in a
Which of the following should the nurse say to this client?
kt
a
nk
.
1.Can I get you anything?
2.Would you like something for pain?
3.You look comfortable.
4.Your blood pressure is up.
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side-lying position. Vital signs assessment reveals an elevated blood pressure and heart rate.
ANS: 2
ba
n
Sympathetic responses to pain include elevated blood pressure and heart rate. And since the
client is hugging a pillow over the abdominal region with both knees flexed in a side-lying
position, the best thing for the nurse to say to this client is Would you like something for pain?
st
The other responses are incorrect because they do not acknowledge that the client is experiencing
.te
pain.
PTS: 1 DIF: Apply REF: Assessing the Clinical Manifestations of Pain
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6.A client experiencing chronic pain asks the nurse why she is not prescribed Demerol like she
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received when she had a total knee replacement. Which of the following should the nurse
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respond to this client?
1.You dont need something that strong.
2.That medication does not exist anymore.
3.That medication does not last very long.
4.It can cause you have high blood pressure.
ANS: 3
Meperidine is no longer a major drug for acute or chronic pain due to its short analgesic duration
of 2 to 3 hours and the potential for accumulative toxic effects of its metabolite, normeperidine.
The best response for the nurse to make to the client would be that medication does not last very
long. The other responses are inaccurate.
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PTS:1DIF:ApplyREF:Opioid Analgesics
7.A client is informed that a tricyclic antidepressant medication is going to help control his
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chronic pain. The nurse would expect the physician to prescribe:
ANS: 1
kt
a
nk
.
1.Amitriptyline.
2.Baclofen.
3.Gabapentin.
4.Diazepam.
Amitriptyline is an antidepressant. Gabapentin is an anticonvulsant. Baclofen is a muscle
ba
n
relaxant. Diazepam is a benzodiazepine.
PTS: 1 DIF: Analyze REF: Adjuvant Medications
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8.A client receiving around-the-clock medication for terminal cancer experiences additional pain
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when performing activities of daily living. The nurse realizes this client is experiencing:
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1.breakthrough pain.
2.intractable pain.
3.psychosomatic pain.
4.acute pain.
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ANS: 1
Breakthrough pain is commonly seen in the advanced stages of cancer. It is spontaneous,
unpredictable, and can be initiated by certain activities such as during activities of daily living.
Intractable pain is resistant to some or all forms of therapy. Psychosomatic pain is that which has
a psychological origin. The client is diagnosed with terminal cancer. Acute pain has a sudden
onset and resolves within 6 months.
PTS:1DIF:AnalyzeREF:Breakthrough Pain
9.A client recovering from surgery tells the nurse that she is nauseated and is experiencing an
1.The client is becoming dependent upon the pain medication.
2.The clients pain threshold is lower when experiencing nausea.
3.The client is experiencing withdrawal symptoms from pain medication.
4.The client is experiencing referred pain.
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ANS: 2
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increase in pain. Which of the following does this clients symptoms suggest to the nurse?
nk
.
Pain threshold is influenced by nausea, fatigue, and lack of sleep. The client experiencing an
increase in pain during nausea is demonstrating an alteration in the pain threshold. The client is
not becoming dependent upon the pain medication. The client is not experiencing withdrawal
kt
a
symptoms. The client is also not experiencing referred pain.
ba
n
PTS: 1 DIF: Analyze REF: Pain Threshold and Pain Tolerance
10.A client with a history of malingering pain tells the nurse that he needs a prescription for pain
medication. Which of the following should the nurse do first to assist this client?
.te
st
1.Ask the physician for a pain medication prescription for the client.
2.Remind the client that he does not have pain but just wants the medication.
3.Thoroughly assess the client for pain.
4.Suggest the client seek counseling for his pain medication-seeking behavior.
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ANS: 3
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Pain of a psychological origin is when an individual seeks treatment for pain when no actual pain
exists. This is also referred to as malingering or pretending pain. The nurse should not assume
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that the pain does not exist but rather should conduct a thorough pain assessment to rule out an
actual physiological problem. The nurse should not immediately ask the physician for pain
medication. The nurse should not remind the client that he does not have pain but just wants the
medication. The nurse should also not suggest the client seek counseling for pain medicationseeking behavior.
PTS: 1 DIF: Apply REF: Box 16-1 Pain Descriptions
11.The nurse is implementing the five Cs of pain management for a client. Which of the
following is included in this intervention?
1.Caring for the client in a holistic manner
2.Creating a calm environment
3.Comparing the degree of pain reported with previous episodes
4.Continuously assessing the clients pain
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ANS: 4
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The five Cs of pain management include comprehensive assessment, consistent use of
assessment tools, continuous reassessment, customize the plan of care, and collaborate with other
of pain management.
kt
a
PTS: 1 DIF: Apply REF: Planning and Implementation
nk
.
health care providers to plan pain management. The other choices are not included in the five Cs
12.A client, diagnosed with arthritis, should be instructed to avoid the use of NSAIDs because of
ba
n
which of the following prescribed medications?
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ANS: 2
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1.Penicillin
2.Coumadin
3.Digoxin
4.Diazide
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Persons at greatest risk for adverse reactions to NSAIDs include those who are prescribed
warfarin (Coumadin) since the NSAID can increase the effects of the Coumadin and promote
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bleeding.
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PTS: 1 DIF: Apply REF: Box 16-2 Groups of NSAID Drugs
MULTIPLE RESPONSE
1.Prior to hospitalization, a client had been ingesting high doses of oxycodone. The nurse
suspects the client is experiencing symptoms of withdrawal when which of the following are
assessed? (Select all that apply.)
1.Muscle twitching and spasms
2.Restlessness
3.Increased heart rate
4.Drop in blood pressure
5.Increase in blood pressure
6.Irritability
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ANS: 1, 2, 3, 5, 6
Withdrawal symptoms include myoclonus or muscle twitching and spasms, restlessness,
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irritability, increased heart rate, and increased blood pressure. A decrease in blood pressure is not
nk
.
a symptom of narcotic medication withdrawal.
PTS:1DIF:Analyze
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a
REF: Potential and Actual Side Effects of Opioid Analgesics
2.The nurse would be concerned that a client is at risk for developing chronic pain when which
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ANS: 1, 2, 5
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st
1.Osteoarthritis
2.Osteoporosis
3.Heart disease
4.Diabetes mellitus
5.Chronic pulmonary disease
6.Anemia
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n
of the following health problems are diagnosed? (Select all that apply.)
Common health problems associated with chronic pain include osteoarthritis, osteoporosis, and
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chronic pulmonary disease. Heart disease, diabetes mellitus, and anemia are not associated with
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chronic pain.
PTS:1DIF:AnalyzeREF:Chronic Pain
3.An 84-year-old client is experiencing severe arthritis pain. The nurse realizes that which of the
following pain management approaches would be the most beneficial for this client? (Select all
that apply.)
1.Avoid NSAIDs.
2.Utilize morphine or morphine-like medication.
3.Provide medication through the oral route.
4.Utilize diazepam.
5.Suggest Darvocet.
6.Provide medication through the intramuscular route.
ANS: 1, 2, 3
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When providing pain medication to a geriatric client, pain management approaches include the
utilization of morphine or morphine-like medication to control pain and provide medication
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using the oral route. NSAIDs should also be avoided because of the risk of gastrointestinal
bleeding. Diazepam should be avoided because of a long half-life. Darvocet should be avoided
nk
.
because of toxic effects with renal insufficiency. Medication should not be provided using the
intramuscular route because of muscle wasting and loss of fatty tissue in the elderly client.
kt
a
PTS: 1 DIF: Apply REF: Geriatric Considerations
4.A client with severe pain from spinal stenosis is prescribed Methadone. The nurse realizes that
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the advantages of this medication are what? (Select all that apply.)
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ANS: 1, 2, 4
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st
1.Decrease in the need for antidepressant adjuvant medication
2.Less frequent dosing schedule
3.Long half-life
4.Inexpensive
5.Can be used for intermittent pain
6.Does not cause respiratory depression
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The advantages of methadone include that it decreases the need for antidepressant adjuvant
medication because it increases the release of serotonin and norepinephrine, dosing is every 12
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hours, and it is inexpensive. Disadvantages of this medication include: it has a long half-life; it
cannot be used for intermittent pain management; and it does cause respiratory depression.
PTS:1DIF:AnalyzeREF:Intractable Pain
5.The nurse is using the PAINAID Scale to assess a clients level of pain. Which of the following
are assessed with this pain scale? (Select all that apply.)
1.Breathing rate
2.Assign a number to the degree of pain
3.Negative vocalizations
4.Assign a facial expression to the degree of pain
5.Facial expression
6.Body language
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ANS: 1, 3, 5, 6
The PAINAID scale assesses breathing, negative vocalizations, facial expression, body language,
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and comfort. The Numerical Rating Scale assigns a number to the degree of pain. The Wong-
nk
.
Baker FACES Scale assigns a facial expression to the degree of pain.
PTS: 1 DIF: Apply REF: Skills 360: Pain Assessment Tools
kt
a
6.A client diagnosed with severe arthritis tells the nurse that she always has some degree of pain.
Which of the following could explain this clients poor pain management? (Select all that apply.)
.te
ANS: 1, 2, 4, 5
st
ba
n
1.Client does not appear to be in pain.
2.Client does not report pain.
3.Client cannot afford pain medication.
4.Client is fearful of becoming addicted to pain medication.
5.Client believes pain medication means the condition is worse.
6.Client has a high pain tolerance.
Barriers to pain assessment and management include that the client is not demonstrating overt
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signs of pain, and therefore she does not need pain medication; the client does not report pain, so
therefore she does not need pain medication; the client is fearful of becoming addicted to pain
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medication; and the client believes pain medication means the condition is worse. The fact that
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the client is unable to afford pain medication and is having a high pain tolerance are not
identified barriers to pain assessment and management.
PTS: 1 DIF: Analyze REF: Barrier to Pain Assessment and Pain Management
7.The nurse determines that a client is experiencing chronic pain when which of the following is
assessed? (Select all that apply.)
1.Suffering
2.Fatigue
3.Sleeplessness
4.Apathy
5.Sadness
6.Anger
ANS: 1, 3, 5
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The descriptor triad for chronic pain is suffering, sleeplessness, and sadness. Fatigue, apathy, and
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anger do not describe chronic pain.
MULTIPLE CHOICE
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.
Chapter 4. Dermatology Guidelines
1.A clients wound is being debrided by letting a wet-to-dry dressing that is packed into the
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ANS: 3
ba
n
1autolytic debridement.
2enzymatic debridement.
3mechanical debridement.
4sharp debridement.
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a
wound dry. This type of debridement is called:
.te
Mechanical debridement makes use of gauze dressing to remove necrotic or devitalized tissue
from wounds. Autolytic debridement makes use of the normal phagocytic action of the
macrophages and leukocytes present in the wound. Enzymatic debridement is accomplished by
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wound.
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using a chemical debriding agent. Sharp debridement is cutting away necrotic tissue from the
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PTS:1DIF:AnalyzeREFebridement
2.A client is experiencing a circular lesion with an advancing, red, scaly border on the abdomen.
The nurse recognizes this lesion as being:
1tinea capitis.
2tinea corporis.
3tinea cruris.
4tinea pedis.
ANS: 2
Tinea corporis is a fungal infection that involves the face, trunk, and limbs. Tinea pedis is a
common infection of the feet. Tinea cruris occurs in the groin and inner thigh, and tinea capitis
involves the scalp.
m
PTS:1DIF:AnalyzeREF:Fungal Infections
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3.A client is complaining of pain and drainage coming from an area on his back. The nurse
assesses the area and finds a large erythematous, swollen mass with multiple areas of purulent
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.
drainage. The nurse suspects the client has a(n):
kt
a
1abscess.
2carbuncle.
3furuncle.
4papule.
ba
n
ANS: 2
Carbuncles are an aggregate of infected follicles originating deep in the dermis and subcutaneous
tissue. Carbuncles are many furuncles, and they form an erythematous, swollen, broad, and
slowly evolving mass that can ulcerate and drain from multiple openings. A furuncle is a single
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localized induration that is painful. An abscess is a cavity containing pus, and a papule is a small,
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raised lesion.
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PTS: 1 DIF: Analyze REF: Furuncles and Carbuncles
4.A client has what appears to be a bacterial infection or warts on her fingertips. This can be a
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sign of:
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1herpes gladiatorum.
2herpes simplex.
3herpes zoster.
4herpetic whitlow.
ANS: 4
Herpetic whitlow usually occurs on the fingertips and can resemble a bacterial infection or warts.
Herpes gladiatorum is most frequently found in athletes who participate in contact sports. The
appearance of herpes zoster is usually down a single dermatome. Herpes simplex is usually seen
orally or on the genitals.
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PTS: 1 DIF: Analyze REF: Cutaneous Herpes Simplex
5.A school-age child is experiencing pruritic vesicles around the mouth. The lesions have a
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honey-colored crust. The nurse realizes that the child is most likely experiencing:
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.
1candidiasis.
2herpes simplex.
3impetigo.
4tinea corporis.
kt
a
ANS: 3
Impetigo is a common, superficial skin infection beginning as a focal erythema and progressing
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n
to pruritic vesicles, erosions, and honey-colored crusts. Oral herpes simplex would look like a
cold sore. Tinea corporis has a circular, red, scaly border, and candidiasis is a proliferation of the
normal yeast flora.
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PTS: 1 DIF: Analyze REF: Impetigo
.te
6.A client is being treated for lice. Which of the following medications would the nurse expect to
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see prescribed for this client?
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1Acyclovir
2Diphenhydramine
3Mupirocin
4Permethrin
ANS: 4
Permethrin is applied for treatment of head lice. Diphenhydramine controls the itching but does
not treat the infestation. Mupirocin treats impetigo, and acyclovir is for herpes simplex virus.
PTS: 1 DIF: Apply REF: Pediculosis
7.A client is diagnosed with genital herpes simplex virus. The nurse know that symptoms of the
primary infection occur:
11 to 4 days after exposure.
23 to 7 days after exposure.
35 to 9 days after exposure.
47 to 11 days after exposure.
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ANS: 2
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Symptoms of the primary herpes simplex infection occur 3 to 7 days after exposure. The other
choices do not describe the length of time before symptoms of the primary herpes simplex
nk
.
infection occur.
kt
a
PTS:1DIF:AnalyzeREF:Herpes Infections
8.A client is demonstrating patches of thick, red skin with silvery scales on the elbows and
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knees. The nurse suspects that this client is experiencing:
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1psoriasis.
2rosacea.
3scabies.
4stasis dermatitis.
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ANS: 1
Psoriasis is characterized by patches of thick, red skin with silvery scales, usually on the scalp,
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elbows, knees, and lumbosacral areas. Rosacea is a chronic, inflammatory condition
characterized by erythema, papules, pustules, and telangiectasis. Scabies is a highly contagious,
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pruritic skin infection caused by a mite. Stasis dermatitis is a condition that occurs on the lower
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extremities of patients with venous insufficiency.
PTS: 1 DIF: Analyze REF: Psoriasis
9.A middle-aged construction worker has a raised lesion with a pearly border on his arm that
bleeds easily. The nurse realizes that this client most likely is experiencing a(n):
1actinic keratosis.
2basal cell carcinoma.
3malignant melanoma.
4melanoma in situ.
ANS: 2
Basal cell carcinoma in its nodular form appears as a pearly, translucent bump that bleeds easily.
Actinic keratosis is seen or palpated on the face, scalp, arms, and ears. It can have a color from
m
tan to red or have the patients normal skin tone. Malignant melanoma is a lesion that has changed
flat or raised lesions with histologic features of melanoma.
nk
.
PTS: 1 DIF: Analyze REF: Nonmelanoma Skin Cancers
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its color and shape, has gotten bigger, or has an irregular border. Melanoma in situ presents with
10.A client periodically experiences pseudofolliculitis barbae. Which of the following should the
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a
nurse instruct this client?
ba
n
1Avoid close shaving.
2Avoid washing the hair prior to shaving.
3Apply a topical antibiotic.
4Contact the physician since the client needs a prescription for an oral antibiotic.
ANS: 1
st
Pseudofolliculitis barbae is a foreign body reaction to hair in individuals with a genetic
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inclination for curly, spiral-shaped hair. Prevention requires the client to avoid close shaving.
This is what the nurse should instruct this client. This client is to wash the hair prior to shaving.
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This condition does not need an oral or topical antibiotic.
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PTS: 1 DIF: Apply REF: Folliculitis
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11.A client is diagnosed with tinea versicolor. Which of the following should the nurse instruct
this client regarding the care for this skin condition?
1Do nothing since there is no treatment.
2Utilize shampoo with selenium.
3Utilize an oral antifungal preparation as prescribed.
4Apply warm compresses to the affected areas.
ANS: 2
Treatment for tinea versicolor includes the use of selenium shampoo. The nurse should not
instruct the client to do nothing since treatment does exist for this condition. Oral antifungal
preparations are not necessary for this condition. Warm compresses will not help this condition.
PTS:1DIF:ApplyREF:Fungal Infections
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12.Which of the following should the nurse instruct a client who is prescribed a topical
medication for a skin condition?
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.
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1Apply directly to broken or irritated skin.
2Apply before bathing.
3Apply after bathing.
4Cover the area with an occlusive dressing.
kt
a
ANS: 3
The client should be instructed to apply the medication to the skin after bathing since hydration
of the area will increase absorption of the medication. The medication should not be applied
ba
n
directly to broken or irritated skin. The medication should not be applied before bathing. The
area should not be covered with an occlusive dressing.
st
PTS:1DIF:Apply
.te
REF: Table 45-2 What Every Patient Needs to Know About Topical Medications
13.A client is diagnosed with a dermatologic condition causing pruritis and inflammation. Which
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of the following should the nurse instruct this client?
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1Use regular perfumed lotion to moisturize the skin.
2Use scented soap to bathe the skin daily.
3Apply skin oil daily.
4Apply a body moisturizer to the skin within 3 to 5 minutes after bathing.
ANS: 4
Regular usage of body moisturizers, particularly within 3 to 5 minutes after bathing or
showering, will aid in the prevention of dry, flaking, and itching skin. Perfumed lotions and
scented soaps contain alcohol, which will exacerbate pruritis and inflammation. Skin oil does not
penetrate into the skin.
PTS: 1 DIF: Apply REF: Moisturizers and Lubricants
MULTIPLE RESPONSE
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14.The nurse is assessing a clients skin for signs of normal aging. Which of the following are
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.
kt
a
1Lentigo
2Loss of subcutaneous tissue
3Telangiectasias
4Thickened, wrinkled, yellowish skin
5Thin, fragile, and inelastic skin
6Seborrheic keratosis
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skin changes seen with aging? (Select all that apply.)
ANS: 2, 5
ba
n
Thin, fragile, inelastic skin that has the loss of subcutaneous tissue is the result of normal aging.
Skin that has aged as a result of sun damage exhibits a thickened, wrinkled, yellow appearance.
It may also have telangiectasias, lentigo, or seborrheic keratosis.
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PTS: 1 DIF: Analyze REF: Table 45-3 Normal Aging versus Photoaging Skin
15.A client is diagnosed with severe nodulocystic acne. The nurse should instruct the client on
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which of the following types of treatments? (Select all that apply.)
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1Oral antibiotics
2Benzoyl peroxide
3Sulfur
4Intralesional injections
5Soap and water
6Topical therapy
ANS: 1, 4, 6
Treatment for severe nodulocystic acne includes oral antibiotics, intralesional injections, and
topical therapy. Benzoyl peroxide is indicated for mild and moderate acne. Sulfur is indicated for
moderate acne. Soap and water is indicated for mild acne.
PTS: 1 DIF: Apply REF: Acne
16.A client is diagnosed with cellulitis. Which of the following will the nurse most likely assess
in this client? (Select all that apply.)
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1Heat
2Redness
3Swelling
4Pain
5Glossy, stretched skin appearance
6Thirst
nk
.
ANS: 1, 2, 3, 4, 5
Cardinal signs of cellulitis include heat, redness, swelling, pain, and a glossy, stretched
PTS: 1 DIF: Apply REF: Cellulitis
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a
appearance of the skin. Thirst is not associated with cellulitis.
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n
17.A client is diagnosed with rosacea. Which of the following should the nurse instruct the client
regarding this condition? (Select all that apply.)
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1Avoid sunlight.
2Avoid alcohol.
3Avoid spicy food.
4Wash the face five times a day.
5Wash the face with a clean washcloth.
6Apply medication to affected areas immediately after washing the face.
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ANS: 1, 2, 3
Treatment of rosacea includes avoiding sunlight, alcohol, and spicy food. The client should be
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instructed to not overwash the face. Washcloths should not be used. Medication should be
applied to the entire face, waiting 15 to 20 minutes after washing to apply.
PTS: 1 DIF: Apply REF: Rosacea
18.A client is diagnosed with a viral skin infection. The nurse realizes that which of the
following medications may be prescribed for this client? (Select all that apply.)
1Nystatin (Mycostatin)
2Docosanol (Abreva)
3Boric acid
4Penciclovir (Denavir)
5Hydrogen peroxide
6Acyclovir (Zovirax)
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ANS: 2, 4, 6
Antiviral medications include docosanol (Abreva), penciclovir (Denavir), and acyclovir
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(Zovirax). Nystatin (Mycostatin) is an antifungal medication. Boric acid is an antipruritic
solution. Hydrogen peroxide is an antiseptic solution.
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.
Chapter 7. Nasal Guidelines
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1. The primary purpose of the ciliated mucous membrane in the nose is to:
a.
Warm the inhaled air.
b.
Filter out dust and bacteria.
c.
Filter coarse particles from inhaled air.
Septum.
c.
Turbinates.
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b.
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ba
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d.
Facilitate the movement of air through the nares.
ANS: B
The nasal hairs filter the coarsest matter from inhaled air, whereas the mucous blanket filters out
dust and bacteria. The rich blood supply of the nasal mucosa warms the inhaled air.
MSC: Client Needs: General
2. The projections in the nasal cavity that increase the surface area are called the:
a.
Meatus.
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w
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d.
Kiesselbach plexus.
ANS: C
The lateral walls of each nasal cavity contain three parallel bony projections: the superior,
middle, and inferior turbinates. These increase the surface area, making more blood vessels and
mucous membrane available to warm, humidify, and filter the inhaled air.
3. The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which
statement is true in relation to a newborn infant?
a.
Sphenoid sinuses are full size at birth.
b.
Maxillary sinuses reach full size after puberty.
c.
Frontal sinuses are fairly well developed at birth.
d.
Maxillary and ethmoid sinuses are the only sinuses present at birth.
ANS: D
Only the maxillary and ethmoid sinuses are present at birth. The sphenoid sinuses are minute at
birth and develop after puberty. The frontal sinuses are absent at birth, are fairly well developed
at age 7 to 8 years, and reach full size after puberty.+
3. While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and
asks the best way to get them to stop. What would be the nurses best response?
a.
While sitting up, place a cold compress over your nose.
Sit up with your head tilted forward and pinch your nose.
c.
Just allow the bleeding to stop on its own, but dont blow your nose.
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b.
Rhinorrhea
c.
Dysphagia
kt
a
b.
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.
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d.
Lie on your back with your head tilted back and pinch your nose.
ANS: B
With a nosebleed, the person should sit up with the head tilted forward and pinch the nose
between the thumb and forefinger for 5 to 15 minutes.
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
4. A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might
also suspect which of these assessment findings?
a.
Epistaxis
ba
n
d.
Xerostomia
ANS: C
Dysphagia is difficulty with swallowing and may occur with a variety of disorders, including
stroke and other neurologic diseases. Rhinorrhea is a runny nose, epistaxis is a bloody nose, and
xerostomia is a dry mouth.
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5. The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is
correct?
a.
Inserting the speculum at least 3 cm into the vestibule
Avoiding touching the nasal septum with the speculum
c.
Gently displacing the nose to the side that is being examined
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b.
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d.
Keeping the speculum tip medial to avoid touching the floor of the nares
ANS: B
The correct technique for using an otoscope is to insert the apparatus into the nasal vestibule,
avoiding pressure on the sensitive nasal septum. The tip of the nose should be lifted up before
inserting the speculum.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
6. The nurse is performing an assessment on a 21-year-old patient and notices that his nasal
mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the
patient?
a.
Are you aware of having any allergies?
b.
Do you have an elevated temperature?
c.
Have you had any symptoms of a cold?
b.
Firm pressure
c.
Pain during palpation
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m
d.
Have you been having frequent nosebleeds?
ANS: A
With chronic allergies, the mucosa looks swollen, boggy, pale, and gray. Elevated body
temperature, colds, and nosebleeds do not cause these mucosal changes.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
7. The nurse is palpating the sinus areas. If the findings are normal, then the patient should report
which sensation?
a.
No sensation
nk
.
d.
Pain sensation behind eyes
ANS: B
The person should feel firm pressure but no pain. Sinus areas are tender to palpation in persons
with chronic allergies or an acute infection (sinusitis).
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n
kt
a
8. Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is
made to pass a catheter through both nasal cavities with no success. What should the nurse do
next?
a.
Attempt to suction again with a bulb syringe.
b.
Wait a few minutes, and try again once the infant stops crying.
c.
Recognize that this situation requires immediate intervention.
Contact the physician to schedule an appointment for the infant at his or her next
hospital visit.
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.te
st
d.
ANS: C
Determining the patency of the nares in the immediate newborn period is essential because most
newborns are obligate nose breathers. Nares blocked with amniotic fluid are gently suctioned
with a bulb syringe. If obstruction is suspected, then a small lumen (5 to 10 Fr) catheter is passed
down each naris to confirm patency. The inability to pass a catheter through the nasal cavity
indicates choanal atresia, which requires immediate intervention.
9. The nurse is assessing a 3 year old for drainage from the nose. On assessment, a purulent
drainage that has a very foul odor is noted from the left naris and no drainage is observed from
the right naris. The child is afebrile with no other symptoms. What should the nurse do next?
a.
Refer to the physician for an antibiotic order.
b.
Have the mother bring the child back in 1 week.
c.
Perform an otoscopic examination of the left nares.
d.
Tell the mother that this drainage is normal for a child of this age.
ANS: C
Children are prone to put an object up the nose, producing unilateral purulent drainage with a
foul odor. Because some risk for aspiration exists, removal should be prompt.
10. When examining the nares of a 45-year-old patient who has complaints of rhinorrhea, itching
of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of
the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause?
a.
Nasal polyps
b.
Acute sinusitis
c.
Allergic rhinitis
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.
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d.
Acute rhinitis
ANS: C
Rhinorrhea, itching of the nose and eyes, and sneezing are present with allergic rhinitis. On
physical examination, serous edema is noted, and the turbinates usually appear pale with a
smooth, glistening surface.
11. During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter
nasal spray because of her allergies. She also states that it does not work as well as it used to
when she first started using it. The best response by the nurse would be:
a.
You should never use over-the-counter nasal sprays because of the risk of addiction.
You should try switching to another brand of medication to prevent this problem.
c.
Continuing to use this spray is important to keep your allergies under control.
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a
b.
Using these nasal medications irritates the lining of the nose and may cause rebound
swelling.
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d.
ANS: D
The misuse of over-the-counter nasal medications irritates the mucosa, causing rebound
swelling, which is a common problem.
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st
12. A woman who is in the second trimester of pregnancy mentions that she has had more
nosebleeds than ever since she became pregnant. The nurse recognizes that this is a result of:
a.
A problem with the patients coagulation system.
b.
Increased vascularity in the upper respiratory tract as a result of the pregnancy.
c.
Increased susceptibility to colds and nasal irritation.
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d.
Inappropriate use of nasal sprays.
ANS: B
Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in
the upper respiratory tract.
Chapter 8. Throat and Mouth Guidelines
1. During an oral examination of a 4-year-old Native-American child, the nurse notices that her
uvula is partially split. Which of these statements is accurate?
a.
This condition is a cleft palate and is common in Native Americans.
b.
A bifid uvula may occur in some Native-American groups.
c.
This condition is due to an injury and should be reported to the authorities.
d.
A bifid uvula is palatinus, which frequently occurs in Native Americans.
ANS: B
Bifid uvula, a condition in which the uvula is split either completely or partially, occurs in some
Native-American groups.
Frontal sinusitis.
c.
Maxillary sinusitis.
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.
b.
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MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
2. A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination,
the nurse notes swollen turbinates and purulent discharge from the nose. The patient also
complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the
nurse palpates the areas. The nurse recognizes that this patient has:
a.
Posterior epistaxis.
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n
kt
a
d.
Nasal polyps.
ANS: C
Signs of maxillary sinusitis include facial pain after upper respiratory infection, red swollen nasal
mucosa, swollen turbinates, and purulent discharge. The person also has fever, chills, and
malaise. With maxillary sinusitis, dull throbbing pain occurs in the cheeks and teeth on the same
side, and pain with palpation is present. With frontal sinusitis, pain is above the supraorbital
ridge.
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3. When assessing the tongue of an adult, the nurse knows that an abnormal finding would be:
a.
Smooth glossy dorsal surface.
Thin white coating over the tongue.
c.
Raised papillae on the dorsal surface.
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b.
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d.
Visible venous patterns on the ventral surface.
ANS: A
The dorsal surface of the tongue is normally roughened from papillae. A thin white coating may
be present. The ventral surface may show veins. Smooth, glossy areas may indicate atrophic
glossitis (see Table 16-5).
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MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
4. The nurse is performing an assessment. Which of these findings would cause the greatest
concern?
a.
Painful vesicle inside the cheek for 2 days
b.
Presence of moist, nontender Stensens ducts
c.
Stippled gingival margins that snugly adhere to the teeth
d.
Ulceration on the side of the tongue with rolled edges
ANS: D
b.
Leukoplakia
c.
Rheumatic fever
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Ulceration on the side or base of the tongue or under the tongue raises the suspicion of cancer
and must be investigated. The risk of early metastasis is present because of rich lymphatic
drainage. The vesicle may be an aphthous ulcer, which is painful but not dangerous. The other
responses are normal findings.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
5. A patient has been diagnosed with strep throat. The nurse is aware that without treatment,
which complication may occur?
a.
Rubella
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.
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d.
Scarlet fever
ANS: C
Untreated strep throat may lead to rheumatic fever. When performing a health history, the patient
should be asked whether his or her sore throat has been documented as streptococcal.
kt
a
6. During an assessment of a 26 year old at the clinic for a spot on my lip I think is cancer, the
nurse notices a group of clear vesicles with an erythematous base around them located at the lipskin border. The patient mentions that she just returned from Hawaii. What would be the most
ba
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appropriate response by the nurse?
a. Tell the patient she needs to see a skin specialist.
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b. Discuss the benefits of having a biopsy performed on any unusual lesion.
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c. Tell the patient that these vesicles are indicative of herpes simplex I or cold sores
and that they will heal in 4 to 10 days.
w
ANS: C
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d. Tell the patient that these vesicles are most likely the result of a riboflavin
deficiency and discuss nutrition.
w
Cold sores are groups of clear vesicles with a surrounding erythematous base. These evolve into
pustules or crusts and heal in 4 to 10 days. The most likely site is the lip-skin junction. Infection
often recurs in the same site. Recurrent herpes infections may be precipitated by sunlight, fever,
colds, or allergy.
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
7. While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm
ulceration that is crusted with an elevated border and located on the outer third of the lower lip.
What other information would be most important for the nurse to assess?
a. Nutritional status
c. Whether the patient has had a recent cold
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d. Whether the patient has had any recent exposure to sick animals
m
b. When the patient first noticed the lesion
nk
.
ANS: B
With carcinoma, the initial lesion is round and indurated, but then it becomes crusted and
ulcerated with an elevated border. Most cancers occur between the outer and middle thirds of the
kt
a
lip. Any lesion that is still unhealed after 2 weeks should be referred.
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n
MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential
8. A pregnant woman states that she is concerned about her gums because she has noticed they
are swollen and have started bleeding. What would be an appropriate response by the nurse?
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a. Your condition is probably due to a vitamin C deficiency.
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b. Im not sure what causes swollen and bleeding gums, but let me know if its not
better in a few weeks.
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c. You need to make an appointment with your dentist as soon as possible to have
this checked.
w
w
d. Swollen and bleeding gums can be caused by the change in hormonal balance in
your system during pregnancy.
ANS: D
Gum margins are red and swollen and easily bleed with gingivitis. A changing hormonal balance
may cause this condition to occur in pregnancy and puberty.
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
9. A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that
she is concerned about her mouth. During the assessment the nurse finds areas of buccal mucosa
that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating.
The nurse recognizes that this abnormality is:
a. Aphthous ulcers.
m
b. Candidiasis.
co
c. Leukoplakia.
d. Koplik spots.
nk
.
ANS: B
Candidiasis is a white, cheesy, curdlike patch on the buccal mucosa and tongue. It scrapes off,
kt
a
leaving a raw, red surface that easily bleeds. It also occurs after the use of antibiotics or
corticosteroids and in persons who are immunosuppressed. (See Table 16-4 for descriptions of
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n
the other lesions.)
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
10. The nurse is assessing a patient in the hospital who has received numerous antibiotics and
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notices that his tongue appears to be black and hairy. In response to his concern, what would the
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nurse say?
a. We will need to get a biopsy to determine the cause.
w
b. This is an overgrowth of hair and will go away in a few days.
w
c. Black, hairy tongue is a fungal infection caused by all the antibiotics you have
received.
w
d. This is probably caused by the same bacteria you had in your lungs.
ANS: C
A black, hairy tongue is not really hair but the elongation of filiform papillae and painless
overgrowth of mycelial threads of fungus infection on the tongue. It occurs after the use of
antibiotics, which inhibit normal bacteria and allow a proliferation of fungus.
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
11. The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his
mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early
sign of:
m
a. Acquired immunodeficiency syndrome (AIDS).
b. Measles.
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c. Leukemia.
nk
.
d. Carcinoma.
ANS: A
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a
Oral Kaposis sarcoma is a bruiselike, dark red or violet, confluent macule that usually occurs on
the hard palate. It may appear on the soft palate or gingival margin. Oral lesions may be among
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n
the earliest lesions to develop with AIDS.
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
12. A mother brings her 4-month-old infant to the clinic with concerns regarding a small pad in
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the middle of the upper lip that has been there since 1 month of age. The infant has no health
problems. On physical examination, the nurse notices a 0.5-cm, fleshy, elevated area in the
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middle of the upper lip. No evidence of inflammation or drainage is observed. What would the
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nurse tell this mother?
a. This area of irritation is caused from teething and is nothing to worry about.
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b. This finding is abnormal and should be evaluated by another health care provider.
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c. This area of irritation is the result of chronic drooling and should resolve within
the next month or two.
d. This elevated area is a sucking tubercle caused from the friction of breastfeeding
or bottle-feeding and is normal.
ANS: D
A normal finding in infants is the sucking tubercle, a small pad in the middle of the upper lip
from the friction of breastfeeding or bottle-feeding. This condition is not caused by irritation,
teething, or excessive drooling, and evaluation by another health care provider is not warranted.
MSC: Client Needs: Health Promotion and Maintenance
a. How many teeth did you have at this age?
nk
.
b. All 20 deciduous teeth are expected to erupt by age 4 years.
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this is normal for a child of this age. The nurses best response would be:
m
13. A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if
c. This is a normal number of teeth for an 18 month old.
kt
a
d. Normally, by age 2 years, 16 deciduous teeth are expected.
ANS: C
ba
n
The guidelines for the number of teeth for children younger than 2 years old are as follows: the
childs age in months minus the number 6 should be equal to the expected number of deciduous
teeth. Normally, all 20 teeth are in by 2 years old. In this instance, the child is 18 months old,
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minus 6, equals 12 deciduous teeth expected.
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MSC: Client Needs: Health Promotion and Maintenance
14. When examining the mouth of an older patient, the nurse recognizes which finding is due to
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the aging process?
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a. Teeth appearing shorter
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b. Tongue that looks smoother in appearance
c. Buccal mucosa that is beefy red in appearance
d. Small, painless lump on the dorsum of the tongue
ANS: B
In the aging adult, the tongue looks smoother because of papillary atrophy. The teeth are slightly
yellowed and appear longer because of the recession of gingival margins.
15. The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite
frequently for various injuries and suspects there may be some child abuse involved. During an
inspection of his mouth, the nurse should look for:
a.
Swollen, red tonsils.
b.
Ulcerations on the hard palate.
c.
Bruising on the buccal mucosa or gums.
nk
.
co
m
d.
Small yellow papules along the hard palate.
ANS: C
The nurse should notice any bruising or laceration on the buccal mucosa or gums of an infant or
young child. Trauma may indicate child abuse from a forced feeding of a bottle or spoon.
16. During an oral assessment of a 30-year-old Black patient, the nurse notices bluish lips and a
dark line along the gingival margin. What action would the nurse perform in response to this
kt
a
finding?
a. Check the patients hemoglobin for anemia.
ba
n
b. Assess for other signs of insufficient oxygen supply.
c. Proceed with the assessment, knowing that this appearance is a normal finding.
st
d. Ask if he has been exposed to an excessive amount of carbon monoxide.
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ANS: C
Some Blacks may have bluish lips and a dark line on the gingival margin; this appearance is a
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normal finding.
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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17. During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting,
the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are
reflective of:
a. Dehydration.
b. Irritation by gastric juices.
c. A normal oral assessment.
d. Side effects from nausea medication.
ANS: A
Dry mouth occurs with dehydration or fever. The tongue has deep vertical fissures.
m
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
18. A 32-year-old woman is at the clinic for little white bumps in my mouth. During the
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assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and
nk
.
one on the mucosa of her right cheek. What would the nurse tell the patient?
a. These spots indicate an infection such as strep throat.
kt
a
b. These bumps could be indicative of a serious lesion, so I will refer you to a
specialist.
c. This condition is called leukoplakia and can be caused by chronic irritation such
as with smoking.
ba
n
d. These bumps are Fordyce granules, which are sebaceous cysts and are not a
serious condition.
st
ANS: D
Fordyce granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue,
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and lips. These little sebaceous cysts are painless and are not significant. Chalky, white raised
patches would indicate leukoplakia. In strep throat, the examiner would see tonsils that are bright
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red, swollen, and may have exudates or white spots.
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w
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
19. A 10 year old is at the clinic for a sore throat that has lasted 6 days. Which of these findings
would be consistent with an acute infection?
a. Tonsils 1+/1-4+ and pink; the same color as the oral mucosa
b. Tonsils 2+/1-4+ with small plugs of white debris
c. Tonsils 3+/1-4+ with large white spots
d. Tonsils 3+/1-4+ with pale coloring
ANS: C
With an acute infection, tonsils are bright red and swollen and may have exudate or large white
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spots. Tonsils are enlarged to 2+, 3+, or 4+ with an acute infection.
nk
.
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20. While obtaining a health history from the mother of a 1-year-old child, the nurse notices that
the baby has had a bottle in his mouth the entire time. The mother states, It makes a great
pacifier. The best response by the nurse would be:
a.
Youre right. Bottles make very good pacifiers.
b.
Using a bottle as a pacifier is better for the teeth than thumb-sucking.
c.
Its okay to use a bottle as long as it contains milk and not juice.
ba
n
kt
a
d.
Prolonged use of a bottle can increase the risk for tooth decay and ear infections.
ANS: D
Prolonged bottle use during the day or when going to sleep places the infant at risk for tooth
decay and middle ear infections.
MSC: Client Needs: Health Promotion and Maintenance
21. A 72-year-old patient has a history of hypertension and chronic lung disease. An important
question for the nurse to include in the health history would be:
a.
Do you use a fluoride supplement?
Have you had tonsillitis in the last year?
c.
At what age did you get your first tooth?
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b.
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d.
Have you noticed any dryness in your mouth?
ANS: D
Xerostomia (dry mouth) is a side effect of many drugs taken by older people, including
antidepressants, anticholinergics, antispasmodics, antihypertensives, antipsychotics, and
bronchodilators.
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22. The tissue that connects the tongue to the floor of the mouth is the:
a. Uvula.
b. Palate.
c. Papillae.
d. Frenulum.
ANS: D
The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth. The
uvula is the free projection hanging down from the middle of the soft palate. The palate is the
arching roof of the mouth. Papillae are the rough, bumpy elevations on the tongues dorsal
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surface.
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MSC: Client Needs: General
23. The salivary gland that is the largest and located in the cheek in front of the ear is the
nk
.
_________ gland.
a. Parotid
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a
b. Stensens
c. Sublingual
ba
n
d. Submandibular
ANS: A
The mouth contains three pairs of salivary glands. The largest, the parotid gland, lies within the
st
cheeks in front of the ear extending from the zygomatic arch down to the angle of the jaw. The
Stensens duct (not gland) drains the parotid gland onto the buccal mucosa opposite the second
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molar. The sublingual gland is located within the floor of the mouth under the tongue. The
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submandibular gland lies beneath the mandible at the angle of the jaw.
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MSC: Client Needs: General
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24. In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in
appearance, and appear to have deep crypts. What is correct response to these findings?
a. Refer the patient to a throat specialist.
b. No response is needed; this appearance is normal for the tonsils.
c. Continue with the assessment, looking for any other abnormal findings.
d. Obtain a throat culture on the patient for possible streptococcal (strep) infection.
ANS: B
The tonsils are the same color as the surrounding mucous membrane, although they look more
granular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until
puberty and then involutes.
m
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
co
25. The nurse is obtaining a health history on a 3-month-old infant. During the interview, the
mother states, I think she is getting her first tooth because she has started drooling a lot. The
nk
.
nurses best response would be:
a. Youre right, drooling is usually a sign of the first tooth.
kt
a
b. It would be unusual for a 3 month old to be getting her first tooth.
c. This could be the sign of a problem with the salivary glands.
ba
n
d. She is just starting to salivate and hasnt learned to swallow the saliva.
ANS: D
In the infant, salivation starts at 3 months. The baby will drool for a few months before learning
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parents think it does.
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to swallow the saliva. This drooling does not herald the eruption of the first tooth, although many
Increased production of saliva
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b.
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26. The nurse is assessing an 80-year-old patient. Which of these findings would be expected for
this patient?
a.
Hypertrophy of the gums
c.
Decreased ability to identify odors
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d.
Finer and less prominent nasal hair
ANS: C
The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibers.
Nasal hairs grow coarser and stiffer with aging. The gums may recede with aging, not
hypertrophy, and saliva production decreases.
MSC: Client Needs: Health Promotion and Maintenance
27. The nurse is performing an oral assessment on a 40-year-old Black patient and notices the
presence of a 1 cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of
these statements is true? This lesion is:
a.
Leukoedema and is common in dark-pigmented persons.
b.
The result of hyperpigmentation and is normal.
c.
Torus palatinus and would normally be found only in smokers.
co
m
d.
Indicative of cancer and should be immediately tested.
ANS: A
Leukoedema, a grayish-white benign lesion occurring on the buccal mucosa, is most often
observed in Blacks.
28. The nurse is teaching a health class to high-school boys. When discussing the topic of using
smokeless tobacco (SLT), which of these statements are accurate? Select all that apply.
One pinch of SLT in the mouth for 30 minutes delivers the equivalent of one
a.
cigarette.
Using SLT has been associated with a greater risk of oral cancer than smoking.
c.
Pain is an early sign of oral cancer.
d.
Pain is rarely an early sign of oral cancer.
e.
Tooth decay is another risk of SLT because of the use of sugar as a sweetener.
kt
a
nk
.
b.
ba
n
f.
SLT is considered a healthy alternative to smoking.
ANS: B, D, E
One pinch of SLT in the mouth for 30 minutes delivers the equivalent of three cigarettes. Pain is
rarely an early sign of oral cancer. Many brands of SLT are sweetened with sugars, which
promotes tooth decay. SLT is not considered a healthy alternative to smoking, and the use of
SLT has been associated with a greater risk of oral cancer than smoking.
c.
Frequent episodes of strep throat
Chronic allergies
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d.
Cigarette smoking
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b.
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st
MSC: Client Needs: Health Promotion and Maintenance
29. During an assessment, a patient mentions that I just cant smell like I used to. I can barely
smell the roses in my garden. Why is that? For which possible causes of changes in the sense of
smell will the nurse assess? Select all that apply.
a.
Chronic alcohol use
Aging
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e.
f.
Herpes simplex virus I
ANS: B, D, E
Sen
The sense of smell diminishes with cigarette smoking, chronic allergies, and aging. Chronic
alcohol use, a history of strep throat, and herpes simplex virus I are not associated with changes
in the sense of smell.
Chapter 9. Respiratory Guidelines
MULTIPLE CHOICE
1. Which of these statements is true regarding the vertebra prominens? The vertebra prominens
m
is:
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a. The spinous process of C7.
b. Usually nonpalpable in most individuals.
d. Located next to the manubrium of the sternum.
kt
a
ANS: A
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.
c. Opposite the interior border of the scapula.
The spinous process of C7 is the vertebra prominens and is the most prominent bony spur
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n
protruding at the base of the neck. Counting ribs and intercostal spaces on the posterior thorax is
difficult because of the muscles and soft tissue. The vertebra prominens is easier to identify and
is used as a starting point in counting thoracic processes and identifying landmarks on the
st
posterior chest.
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MSC: Client Needs: General
2. When performing a respiratory assessment on a patient, the nurse notices a costal angle of
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approximately 90 degrees. This characteristic is:
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a. Observed in patients with kyphosis.
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b. Indicative of pectus excavatum.
c. A normal finding in a healthy adult.
d. An expected finding in a patient with a barrel chest.
ANS: C
The right and left costal margins form an angle where they meet at the xiphoid process. Usually,
this angle is 90 degrees or less. The angle increases when the rib cage is chronically overinflated,
as in emphysema.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
m
3. When assessing a patients lungs, the nurse recalls that the left lung:
b. Is divided by the horizontal fissure.
nk
.
c. Primarily consists of an upper lobe on the posterior chest.
co
a. Consists of two lobes.
d. Is shorter than the right lung because of the underlying stomach.
kt
a
ANS: A
The left lung has two lobes, and the right lung has three lobes. The right lung is shorter than the
ba
n
left lung because of the underlying liver. The left lung is narrower than the right lung because the
heart bulges to the left. The posterior chest is almost all lower lobes.
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MSC: Client Needs: General
.te
4. Which statement about the apices of the lungs is true? The apices of the lungs:
a. Are at the level of the second rib anteriorly.
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b. Extend 3 to 4 cm above the inner third of the clavicles.
c. Are located at the sixth rib anteriorly and the eighth rib laterally.
w
w
d. Rest on the diaphragm at the fifth intercostal space in the midclavicular line
(MCL).
ANS: B
The apex of the lung on the anterior chest is 3 to 4 cm above the inner third of the clavicles. On
the posterior chest, the apices are at the level of C7.
MSC: Client Needs: General
5. During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates
anteriorly at the:
a. Costal angle.
b. Sternal angle.
c. Xiphoid process.
m
d. Suprasternal notch.
co
ANS: B
nk
.
The sternal angle marks the site of tracheal bifurcation into the right and left main bronchi; it
corresponds with the upper borders of the atria of the heart, and it lies above the fourth thoracic
kt
a
vertebra on the back.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
lung include the presence of:
ba
n
6. During an assessment, the nurse knows that expected assessment findings in the normal adult
a. Adventitious sounds and limited chest expansion.
st
b. Increased tactile fremitus and dull percussion tones.
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c. Muffled voice sounds and symmetric tactile fremitus.
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ANS: C
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d. Absent voice sounds and hyperresonant percussion tones.
Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular
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breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
7. The primary muscles of respiration include the:
a. Diaphragm and intercostals.
b. Sternomastoids and scaleni.
c. Trapezii and rectus abdominis.
d. External obliques and pectoralis major.
ANS: A
The major muscle of respiration is the diaphragm. The intercostal muscles lift the sternum and
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elevate the ribs during inspiration, increasing the anteroposterior diameter. Expiration is
primarily passive. Forced inspiration involves the use of other muscles, such as the accessory
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neck musclessternomastoid, scaleni, and trapezii muscles. Forced expiration involves the
nk
.
abdominal muscles.
MSC: Client Needs: General
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a
8. A 65-year-old patient with a history of heart failure comes to the clinic with complaints of
being awakened from sleep with shortness of breath. Which action by the nurse is most
appropriate?
ba
n
a. Obtaining a detailed health history of the patients allergies and a history of
asthma
b. Telling the patient to sleep on his or her right side to facilitate ease of respirations
st
c. Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea
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d. Assuring the patient that paroxysmal nocturnal dyspnea is normal and will
probably resolve within the next week
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ANS: C
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The patient is experiencing paroxysmal nocturnal dyspneabeing awakened from sleep with
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shortness of breath and the need to be upright to achieve comfort.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
9. When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most
intensely over which location?
a. Between the scapulae
b. Third intercostal space, MCL
c. Fifth intercostal space, midaxillary line (MAL)
d. Over the lower lobes, posterior side
ANS: A
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Normally, fremitus is most prominent between the scapulae and around the sternum. These sites
are where the major bronchi are closest to the chest wall. Fremitus normally decreases as one
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progresses down the chest because more tissue impedes sound transmission.
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.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
10. The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate.
Tactile fremitus:
ba
n
a. Is caused by moisture in the alveoli.
kt
a
Which statement by the graduate nurse reflects a correct understanding of tactile fremitus?
b. Indicates that air is present in the subcutaneous tissues.
c. Is caused by sounds generated from the larynx.
st
d. Reflects the blood flow through the pulmonary arteries.
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ANS: C
Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent
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bronchi and the lung parenchyma to the chest wall where they are felt as vibrations. Crepitus is
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the term for air in the subcutaneous tissues.
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
11. During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most
likely results from:
a. Shallow breathing.
b. Normal lung tissue.
c. Decreased adipose tissue.
d. Increased density of lung tissue.
ANS: D
A dull percussion note indicates an abnormal density in the lungs, as with pneumonia, pleural
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effusion, atelectasis, or a tumor. Resonance is the expected finding in normal lung tissue.
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MSC: Client Needs: General
12. The nurse is observing the auscultation technique of another nurse. The correct method to use
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.
when progressing from one auscultatory site on the thorax to another is _______ comparison.
a. Side-to-side
kt
a
b. Top-to-bottom
d. Interspace-by-interspace
ANS: A
ba
n
c. Posterior-to-anterior
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Side-to-side comparison is most important when auscultating the chest. The nurse should listen
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to at least one full respiration in each location. The other techniques are not correct.
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
13. When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath
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sounds are heard over the posterior lower lobes, with inspiration being longer than expiration.
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The nurse interprets that these sounds are:
a. Normally auscultated over the trachea.
b. Bronchial breath sounds and normal in that location.
c. Vesicular breath sounds and normal in that location.
d. Bronchovesicular breath sounds and normal in that location.
ANS: C
Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than
expiration. These breath sounds are expected over the peripheral lung fields where air flows
through smaller bronchioles and alveoli.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
m
14. The nurse is auscultating the chest in an adult. Which technique is correct?
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a. Instructing the patient to take deep, rapid breaths
b. Instructing the patient to breathe in and out through his or her nose
nk
.
c. Firmly holding the diaphragm of the stethoscope against the chest
d. Lightly holding the bell of the stethoscope against the chest to avoid friction
kt
a
ANS: C
Firmly holding the diaphragm of the stethoscope against the chest is the correct way to auscultate
ba
n
breath sounds. The patient should be instructed to breathe through his or her mouth, a little
deeper than usual, but not to hyperventilate.
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
15. The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that
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a. Dullness.
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percussion over an area of atelectasis in the lungs will reveal:
b. Tympany.
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c. Resonance.
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d. Hyperresonance.
ANS: A
A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural
effusion, atelectasis, or a tumor.
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
16. During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in
which situation?
a. When the bronchial tree is obstructed
b. When adventitious sounds are present
c. In conjunction with whispered pectoriloquy
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d. In conditions of consolidation, such as pneumonia
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ANS: A
nk
.
Decreased or absent breath sounds occur when the bronchial tree is obstructed, as in emphysema,
and when sound transmission is obstructed, as in pleurisy, pneumothorax, or pleural effusion.
kt
a
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
17. The nurse knows that a normal finding when assessing the respiratory system of an older
ba
n
adult is:
a. Increased thoracic expansion.
b. Decreased mobility of the thorax.
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c. Decreased anteroposterior diameter.
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d. Bronchovesicular breath sounds throughout the lungs.
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ANS: B
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The costal cartilages become calcified with aging, resulting in a less mobile thorax. Chest
expansion may be somewhat decreased, and the chest cage commonly shows an increased
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anteroposterior diameter.
MSC: Client Needs: Health Promotion and Maintenance
18. A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the
nurse that he has had a runny nose for a week. When performing the physical assessment, the
nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurses next
action should be to:
a. Assure the mother that these signs are normal symptoms of a cold.
b. Recognize that these are serious signs, and contact the physician.
c. Ask the mother if the infant has had trouble with feedings.
d. Perform a complete cardiac assessment because these signs are probably
indicative of early heart failure.
m
ANS: B
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The infant is an obligatory nose breather until the age of 3 months. Normally, no flaring of the
nostrils and no sternal or intercostal retraction occurs. Significant retractions of the sternum and
nk
.
intercostal muscles and nasal flaring indicate increased inspiratory effort, as in pneumonia, acute
airway obstruction, asthma, and atelectasis; therefore, immediate referral to the physician is
warranted. These signs do not indicate heart failure, and an assessment of the infants feeding is
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a
not a priority at this time.
ba
n
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
19. When assessing the respiratory system of a 4-year-old child, which of these findings would
the nurse expect?
st
a. Crepitus palpated at the costochondral junctions
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b. No diaphragmatic excursion as a result of a childs decreased inspiratory volume
c. Presence of bronchovesicular breath sounds in the peripheral lung fields
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ANS: C
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d. Irregular respiratory pattern and a respiratory rate of 40 breaths per minute at rest
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Bronchovesicular breath sounds in the peripheral lung fields of the infant and young child up to
age 5 or 6 years are normal findings. Their thin chest walls with underdeveloped musculature do
not dampen the sound, as do the thicker chest walls of adults; therefore, breath sounds are loud
and harsh.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
20. When inspecting the anterior chest of an adult, the nurse should include which assessment?
a. Diaphragmatic excursion
b. Symmetric chest expansion
c. Presence of breath sounds
d. Shape and configuration of the chest wall
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ANS: D
Inspection of the anterior chest includes shape and configuration of the chest wall; assessment of
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the patients level of consciousness and the patients skin color and condition; quality of
respirations; presence or absence of retraction and bulging of the intercostal spaces; and use of
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.
accessory muscles. Symmetric chest expansion is assessed by palpation. Diaphragmatic
excursion is assessed by percussion of the posterior chest. Breath sounds are assessed by
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a
auscultation.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
ba
n
21. The nurse knows that auscultation of fine crackles would most likely be noticed in:
a. A healthy 5-year-old child.
st
b. A pregnant woman.
c. The immediate newborn period.
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d. Association with a pneumothorax.
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ANS: C
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Fine crackles are commonly heard in the immediate newborn period as a result of the opening of
the airways and a clearing of fluid. Persistent fine crackles would be noticed with pneumonia,
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bronchiolitis, or atelectasis.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
22. During an assessment of an adult, the nurse has noted unequal chest expansion and
recognizes that this occurs in which situation?
a. In an obese patient
b. When part of the lung is obstructed or collapsed
c. When bulging of the intercostal spaces is present
d. When accessory muscles are used to augment respiratory effort
ANS: B
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pneumonia, or when guarding to avoid postoperative incisional pain.
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Unequal chest expansion occurs when part of the lung is obstructed or collapsed, as with
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.
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
23. During auscultation of the lungs of an adult patient, the nurse notices the presence of
bronchophony. The nurse should assess for signs of which condition?
kt
a
a. Airway obstruction
c. Pulmonary consolidation
d. Asthma
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ANS: C
ba
n
b. Emphysema
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Pathologic conditions that increase lung density, such as pulmonary consolidation, will enhance
the transmission of voice sounds, such as bronchophony (see Table 18-7).
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MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
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24. The nurse is reviewing the characteristics of breath sounds. Which statement about
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bronchovesicular breath sounds is true? Bronchovesicular breath sounds are:
a. Musical in quality.
b. Usually caused by a pathologic disease.
c. Expected near the major airways.
d. Similar to bronchial sounds except shorter in duration.
ANS: C
Bronchovesicular breath sounds are heard over major bronchi where fewer alveoli are located
posteriorlybetween the scapulae, especially on the right; and anteriorly, around the upper
sternum in the first and second intercostal spaces. The other responses are not correct.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
m
25. The nurse is listening to the breath sounds of a patient with severe asthma. Air passing
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through narrowed bronchioles would produce which of these adventitious sounds?
a. Wheezes
nk
.
b. Bronchial sounds
c. Bronchophony
kt
a
d. Whispered pectoriloquy
ANS: A
ba
n
Wheezes are caused by air squeezed or compressed through passageways narrowed almost to
closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic
emphysema.
st
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
.te
26. A patient has a long history of chronic obstructive pulmonary disease (COPD). During the
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assessment, the nurse will most likely observe which of these?
a. Unequal chest expansion
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b. Increased tactile fremitus
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c. Atrophied neck and trapezius muscles
d. Anteroposterior-to-transverse diameter ratio of 1:1
ANS: D
An anteroposterior-to-transverse diameter ratio of 1:1 or barrel chest is observed in individuals
with COPD because of hyperinflation of the lungs. The ribs are more horizontal, and the chest
appears as if held in continuous inspiration. Neck muscles are hypertrophied from aiding in
forced respiration. Chest expansion may be decreased but symmetric. Decreased tactile fremitus
occurs from decreased transmission of vibrations.
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
27. A teenage patient comes to the emergency department with complaints of an inability to
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breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis,
tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance
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on the left, and decreased breath sounds on the left. The nurse interprets that these assessment
findings are consistent with:
nk
.
a. Bronchitis.
b. Pneumothorax.
kt
a
c. Acute pneumonia.
d. Asthmatic attack.
ba
n
ANS: B
With a pneumothorax, free air in the pleural space causes partial or complete lung collapse. If the
pneumothorax is large, then tachypnea and cyanosis are evident. Unequal chest expansion,
st
decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest
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expansion, hyperresonant percussion tones, and decreased or absent breath sounds are found with
the presence of pneumothorax. (See Table 18-8 for descriptions of the other conditions.)
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MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
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28. An adult patient with a history of allergies comes to the clinic complaining of wheezing and
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difficulty in breathing when working in his yard. The assessment findings include tachypnea, the
use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath
sounds, and expiratory wheezes. The nurse interprets that these assessment findings are
consistent with:
a. Asthma.
b. Atelectasis.
c. Lobar pneumonia.
d. Heart failure.
ANS: A
Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a
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reaction of bronchospasm, which increases airway resistance, especially during expiration. An
increased respiratory rate, the use of accessory muscles, a retraction of the intercostal muscles,
nk
.
asthma. (See Table 18-8 for descriptions of the other conditions.)
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prolonged expiration, decreased breath sounds, and expiratory wheezing are all characteristics of
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
respiratory system of the older adult?
kt
a
29. The nurse is assessing the lungs of an older adult. Which of these changes are normal in the
ba
n
a. Severe dyspnea is experienced on exertion, resulting from changes in the lungs.
b. Respiratory muscle strength increases to compensate for a decreased vital
capacity.
c. Decrease in small airway closure occurs, leading to problems with atelectasis.
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st
d. Lungs are less elastic and distensible, which decreases their ability to collapse
and recoil.
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ANS: D
In the aging adult, the lungs are less elastic and distensible, which decreases their ability to
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collapse and recoil. Vital capacity is decreased, and a loss of intra-alveolar septa occurs, causing
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less surface area for gas exchange. The lung bases become less ventilated, and the older person is
at risk for dyspnea with exertion beyond his or her usual workload.
MSC: Client Needs: Health Promotion and Maintenance
30. A woman in her 26th week of pregnancy states that she is not really short of breath but feels
that she is aware of her breathing and the need to breathe. What is the nurses best reply?
a. The diaphragm becomes fixed during pregnancy, making it difficult to take in a
deep breath.
b. The increase in estrogen levels during pregnancy often causes a decrease in the
diameter of the rib cage and makes it difficult to breathe.
c. What you are experiencing is normal. Some women may interpret this as
shortness of breath, but it is a normal finding and nothing is wrong.
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m
d. This increased awareness of the need to breathe is normal as the fetus grows
because of the increased oxygen demand on the mothers body, which results in an
increased respiratory rate.
nk
.
ANS: C
During pregnancy, the woman may develop an increased awareness of the need to breathe. Some
women may interpret this as dyspnea, although structurally nothing is wrong. Increases in
kt
a
estrogen relax the chest cage ligaments, causing an increase in the transverse diameter. Although
the growing fetus increases the oxygen demand on the mothers body, this increased demand is
easily met by the increasing tidal volume (deeper breathing). Little change occurs in the
ba
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respiratory rate.
MSC: Client Needs: Health Promotion and Maintenance
st
31. A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is
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associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2
months. The nurses preliminary analysis, based on this history, is that this patient may be
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suffering from:
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a. Bronchitis.
b. Pneumonia.
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c. Tuberculosis.
d. Pulmonary edema.
ANS: C
Sputum is not diagnostic alone, but some conditions have characteristic sputum production.
Tuberculosis often produces rust-colored sputum in addition to other symptoms of night sweats
and low-grade afternoon fevers
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
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Which of these findings is the nurse most likely to observe in this patient?
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32. A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure.
a. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema
nk
.
b. Rasping cough, thick mucoid sputum, wheezing, and bronchitis
c. Productive cough, dyspnea, weight loss, anorexia, and tuberculosis
kt
a
d. Fever, dry nonproductive cough, and diminished breath sounds
ANS: A
ba
n
A person with heart failure often exhibits increased respiratory rate, shortness of breath on
exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, and pallor in lightskinned individuals. A patient with rasping cough, thick mucoid sputum, and wheezing may have
bronchitis. Productive cough, dyspnea, weight loss, and dyspnea indicate tuberculosis; fever, dry
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nonproductive cough, and diminished breath sounds may indicate Pneumocystis jiroveci (P.
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carinii) pneumonia (see Table 18-8).
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MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
33. A patient comes to the clinic complaining of a cough that is worse at night but not as bad
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during the day. The nurse recognizes that this cough may indicate:
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a. Pneumonia.
b. Postnasal drip or sinusitis.
c. Exposure to irritants at work.
d. Chronic bronchial irritation from smoking.
ANS: B
A cough that primarily occurs at night may indicate postnasal drip or sinusitis. Exposure to
irritants at work causes an afternoon or evening cough. Smokers experience early morning
coughing. Coughing associated with acute illnesses such as pneumonia is continuous throughout
the day.
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MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
34. During a morning assessment, the nurse notices that the patients sputum is frothy and pink.
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Which condition could this finding indicate?
a. Croup
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.
b. Tuberculosis
c. Viral infection
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a
d. Pulmonary edema
ba
n
ANS: D
Sputum, alone, is not diagnostic, but some conditions have characteristic sputum production.
Pink, frothy sputum indicates pulmonary edema or it may be a side effect of sympathomimetic
medications. Croup is associated with a barking cough, not sputum production. Tuberculosis
st
may produce rust-colored sputum. Viral infections may produce white or clear mucoid sputum.
.te
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
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35. During auscultation of breath sounds, the nurse should correctly use the stethoscope in which
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of the following ways?
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a. Listening to at least one full respiration in each location
b. Listening as the patient inhales and then going to the next site during exhalation
c. Instructing the patient to breathe in and out rapidly while listening to the breath
sounds
d. If the patient is modest, listening to sounds over his or her clothing or hospital
gown
ANS: A
During auscultation of breath sounds with a stethoscope, listening to one full respiration in each
location is important. During the examination, the nurse should monitor the breathing and offer
times for the person to breathe normally to prevent possible dizziness.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
m
36. A patient has been admitted to the emergency department with a possible medical diagnosis
of pulmonary embolism. The nurse expects to see which assessment findings related to this
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condition?
b. Productive cough with thin, frothy sputum
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.
a. Absent or decreased breath sounds
c. Chest pain that is worse on deep inspiration and dyspnea
kt
a
d. Diffuse infiltrates with areas of dullness upon percussion
ba
n
ANS: C
Findings for pulmonary embolism include chest pain that is worse on deep inspiration, dyspnea,
apprehension, anxiety, restlessness, partial arterial pressure of oxygen (PaO2) less than 80 mm
st
Hg, diaphoresis, hypotension, crackles, and wheezes.
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MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
37. During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation
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over the skin surface. On the basis of these findings, the nurse suspects:
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a. Tactile fremitus.
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b. Crepitus.
c. Friction rub.
d. Adventitious sounds.
ANS: B
Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous
emphysema when air escapes from the lung and enters the subcutaneous tissue, such as after
open thoracic injury or surgery.
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
m
38. The nurse is auscultating the lungs of a patient who had been sleeping and notices short,
popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath
b. Fine crackles and may be a sign of pneumonia.
c. Vesicular breath sounds.
kt
a
d. Fine wheezes.
nk
.
a. Atelectatic crackles that do not have a pathologic cause.
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sounds are:
ba
n
ANS: A
One type of adventitious sound, atelectatic crackles, does not have a pathologic cause. They are
short, popping, crackling sounds that sound similar to fine crackles but do not last beyond a few
breaths. When sections of alveoli are not fully aerated (as in people who are asleep or in older
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adults), they deflate slightly and accumulate secretions. Crackles are heard when these sections
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are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually
in dependent portions of the lungs, and disappear after the first few breaths or after a cough.
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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39. A patient has been admitted to the emergency department for a suspected drug overdose. His
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respirations are shallow, with an irregular pattern, with a rate of 12 respirations per minute. The
nurse interprets this respiration pattern as which of the following?
a. Bradypnea
b. Cheyne-Stokes respirations
c. Hypoventilation
d. Chronic obstructive breathing
ANS: C
Hypoventilation is characterized by an irregular, shallow pattern, and can be caused by an
overdose of narcotics or anesthetics. Bradypnea is slow breathing, with a rate less than 10
respirations per minute. (See Table 18-4 for descriptions of Cheyne-Stokes respirations and
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chronic obstructive breathing.)
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
40. A patient with pleuritis has been admitted to the hospital and complains of pain with
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.
breathing. What other key assessment finding would the nurse expect to find upon auscultation?
a. Stridor
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a
b. Friction rub
c. Crackles
ba
n
d. Wheezing
ANS: B
A patient with pleuritis will exhibit a pleural friction rub upon auscultation. This sound is made
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when the pleurae become inflamed and rub together during respiration. The sound is superficial,
coarse, and low-pitched, as if two pieces of leather are being rubbed together. Stridor is
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associated with croup, acute epiglottitis in children, and foreign body inhalation. Crackles are
associated with pneumonia, heart failure, chronic bronchitis, and other diseases (see Table 18-6).
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Wheezes are associated with diffuse airway obstruction caused by acute asthma or chronic
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emphysema.
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
MULTIPLE RESPONSE
1. The nurse is assessing voice sounds during a respiratory assessment. Which of these findings
indicates a normal assessment? Select all that apply.
a. Voice sounds are faint, muffled, and almost inaudible when the patient whispers
one, two, three in a very soft voice.
b. As the patient repeatedly says ninety-nine, the examiner clearly hears the words
ninety-nine.
c. When the patient speaks in a normal voice, the examiner can hear a sound but
cannot exactly distinguish what is being said.
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d. As the patient says a long ee-ee-ee sound, the examiner also hears a long ee-ee-ee
sound.
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e. As the patient says a long ee-ee-ee sound, the examiner hears a long aaaaaa
sound.
nk
.
ANS: A, C, D
As a patient repeatedly says ninety-nine, normally the examiner hears voice sounds but cannot
kt
a
distinguish what is being said. If a clear ninety-nine is auscultated, then it could indicate
increased lung density, which enhances the transmission of voice sounds, which is a measure of
bronchophony. When a patient says a long ee-ee-ee sound, normally the examiner also hears a
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n
long ee-ee-ee sound through auscultation, which is a measure of egophony. If the examiner hears
a long aaaaaa sound instead, this sound could indicate areas of consolidation or compression.
With whispered pectoriloquy, as when a patient whispers a phrase such as one-two-three, the
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normal response when auscultating voice sounds is to hear sounds that are faint, muffled, and
almost inaudible. If the examiner clearly hears the whispered voice, as if the patient is speaking
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through the stethoscope, then consolidation of the lung fields may exist.
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Chapter 10. Cardiovascular Guidelines
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MULTIPLE CHOICE
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1. The sac that surrounds and protects the heart is called the:
a. Pericardium.
b. Myocardium.
c. Endocardium.
d. Pleural space.
ANS: A
The pericardium is a tough, fibrous double-walled sac that surrounds and protects the heart. It
has two layers that contain a few milliliters of serous pericardial fluid.
m
MSC: Client Needs: General
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2. The direction of blood flow through the heart is best described by which of these?
nk
.
a. Vena cava right atrium right ventricle lungs pulmonary artery left atrium left
ventricle
kt
a
b. Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium
left ventricle
c. Aorta right atrium right ventricle lungs pulmonary vein left atrium left ventricle
vena cava
ba
n
d. Right atrium right ventricle pulmonary vein lungs pulmonary artery left atrium
left ventricle
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ANS: B
Returning blood from the body empties into the right atrium and flows into the right ventricle
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and then goes to the lungs through the pulmonary artery. The lungs oxygenate the blood, and it is
then returned to the left atrium through the pulmonary vein. The blood goes from there to the left
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ventricle and then out to the body through the aorta.
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MSC: Client Needs: General
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3. The nurse is reviewing the anatomy and physiologic functioning of the heart. Which statement
best describes what is meant by atrial kick?
a. The atria contract during systole and attempt to push against closed valves.
b. Contraction of the atria at the beginning of diastole can be felt as a palpitation.
c. Atrial kick is the pressure exerted against the atria as the ventricles contract
during systole.
d. The atria contract toward the end of diastole and push the remaining blood into
the ventricles.
ANS: D
Toward the end of diastole, the atria contract and push the last amount of blood (approximately
25% of stroke volume) into the ventricles. This active filling phase is called presystole, or atrial
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systole, or sometimes theatrial kick.
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MSC: Client Needs: General
nk
.
4. When listening to heart sounds, the nurse knows the valve closures that can be heard best at
the base of the heart are:
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a
a. Mitral and tricuspid.
b. Tricuspid and aortic.
d. Mitral and pulmonic.
st
ANS: C
ba
n
c. Aortic and pulmonic.
The second heart sound (S2) occurs with the closure of the semilunar (aortic and pulmonic)
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valves and signals the end of systole. Although it is heard over all the precordium, the S2 is
loudest at the base of the heart.
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MSC: Client Needs: General
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5. Which of these statements describes the closure of the valves in a normal cardiac cycle?
a. The aortic valve closes slightly before the tricuspid valve.
b. The pulmonic valve closes slightly before the aortic valve.
c. The tricuspid valve closes slightly later than the mitral valve.
d. Both the tricuspid and pulmonic valves close at the same time.
ANS: C
Events occur just slightly later in the right side of the heart because of the route of myocardial
depolarization. As a result, two distinct components to each of the heart sounds exist, and
sometimes they can be heard separately. In the first heart sound, the mitral component (M1)
closes just before the tricuspid component (T1).
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MSC: Client Needs: General
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6. The component of the conduction system referred to as the pacemaker of the heart is the:
a. Atrioventricular (AV) node.
nk
.
b. Sinoatrial (SA) node.
c. Bundle of His.
kt
a
d. Bundle branches.
ANS: B
ba
n
Specialized cells in the SA node near the superior vena cava initiate an electrical impulse.
Because the SA node has an intrinsic rhythm, it is called the pacemaker of the heart.
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MSC: Client Needs: General
.te
7. The electrical stimulus of the cardiac cycle follows which sequence?
a. AV node SA node bundle of His
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b. Bundle of His AV node SA node
c. SA node AV node bundle of His bundle branches
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d. AV node SA node bundle of His bundle branches
ANS: D
Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. The
current flows in an orderly sequence, first across the atria to the AV node low in the atrial
septum. There it is delayed slightly, allowing the atria the time to contract before the ventricles
are stimulated. Then the impulse travels to the bundle of His, the right and left bundle branches,
and then through the ventricles.
MSC: Client Needs: General
8. The findings from an assessment of a 70-year-old patient with swelling in his ankles include
jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45
degrees. The nurse knows that this finding indicates:
m
a. Decreased fluid volume.
b. Increased cardiac output.
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c. Narrowing of jugular veins.
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.
d. Elevated pressure related to heart failure.
ANS: D
kt
a
Because no cardiac valve exists to separate the superior vena cava from the right atrium, the
jugular veins give information about the activity on the right side of the heart. They reflect filling
pressures and volume changes. Normal jugular venous pulsation is 2 cm or less above the sternal
ba
n
angle. Elevated pressure is more than 3 cm above the sternal angle at 45 degrees and occurs with
heart failure.
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MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
9. When assessing a newborn infant who is 5 minutes old, the nurse knows which of these
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statements to be true?
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a. The left ventricle is larger and weighs more than the right ventricle.
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b. The circulation of a newborn is identical to that of an adult.
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c. Blood can flow into the left side of the heart through an opening in the atrial
septum.
d. The foramen ovale closes just minutes before birth, and the ductus arteriosus
closes immediately after.
ANS: C
First, approximately two thirds of the blood is shunted through an opening in the atrial septum,
the foramen ovale, into the left side of the heart, where it is pumped out through the aorta. The
foramen ovale closes within the first hour after birth because the pressure in the right side of the
heart is now lower than in the left side.
MSC: Client Needs: Health Promotion and Maintenance
10. A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm
m
Hg. In reviewing her previous examination, the nurse notes that her blood pressure in her second
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month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true?
a. This decline in blood pressure is the result of peripheral vasodilatation and is an
expected change.
nk
.
b. Because of increased cardiac output, the blood pressure should be higher at this
time.
kt
a
c. This change in blood pressure is not an expected finding because it means a
decrease in cardiac output.
ba
n
d. This decline in blood pressure means a decrease in circulating blood volume,
which is dangerous for the fetus.
ANS: A
Despite the increased cardiac output, arterial blood pressure decreases in pregnancy because of
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peripheral vasodilatation. The blood pressure drops to its lowest point during the second
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trimester and then rises after that.
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MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
11. In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm
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Hg; heart rate 104 beats per minute and slightly irregular; and the split S2 heart sound. Which of
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these findings can be explained by expected hemodynamic changes related to age?
a. Increase in resting heart rate
b. Increase in systolic blood pressure
c. Decrease in diastolic blood pressure
d. Increase in diastolic blood pressure
ANS: B
With aging, an increase in systolic blood pressure occurs. No significant change in diastolic
pressure and no change in the resting heart rate occur with aging. Cardiac output at rest is does
not changed with aging.
MSC: Client Needs: Health Promotion and Maintenance
m
12. A 45-year-old man is in the clinic for a routine physical examination. During the recording of
his health history, the patient states that he has been having difficulty sleeping. Ill be sleeping
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great, and then I wake up and feel like I cant get my breath. The nurses best response to this
a. When was your last electrocardiogram?
b. Its probably because its been so hot at night.
nk
.
would be:
kt
a
c. Do you have any history of problems with your heart?
d. Have you had a recent sinus infection or upper respiratory infection?
ba
n
ANS: C
Paroxysmal nocturnal dyspnea (shortness of breath generally occurring at night) occurs with
heart failure. Lying down increases the volume of intrathoracic blood, and the weakened heart
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cannot accommodate the increased load. Classically, the person awakens after 2 hours of sleep,
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arises, and flings open a window with the perception of needing fresh air.
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MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
13. In assessing a patients major risk factors for heart disease, which would the nurse want to
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include when taking a history?
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a. Family history, hypertension, stress, and age
b. Personality type, high cholesterol, diabetes, and smoking
c. Smoking, hypertension, obesity, diabetes, and high cholesterol
d. Alcohol consumption, obesity, diabetes, stress, and high cholesterol
ANS: C
To assess for major risk factors of coronary artery disease, the nurse should collect data
regarding elevated serum cholesterol, elevated blood pressure, blood glucose levels above 100
mg/dL or known diabetes mellitus, obesity, any length of hormone replacement therapy for post
menopausal women, cigarette smoking, and low activity level.
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MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential
14. The mother of a 3-month-old infant states that her baby has not been gaining weight. With
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further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a
a. Infants sleeping position
b. Sibling history of eating disorders
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a
c. Amount of background noise when eating
nk
.
short time, hungry again. What other information would the nurse want to have?
d. Presence of dyspnea or diaphoresis when sucking
ba
n
ANS: D
To screen for heart disease in an infant, the focus should be on feeding. Fatigue during feeding
should be noted. An infant with heart failure takes fewer ounces each feeding, becomes dyspneic
.te
time hungry again.
st
with sucking, may be diaphoretic, and then falls into exhausted sleep and awakens after a short
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MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
15. In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse
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would:
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a. Palpate the artery in the upper one third of the neck.
b. Listen with the bell of the stethoscope to assess for bruits.
c. Simultaneously palpate both arteries to compare amplitude.
d. Instruct the patient to take slow deep breaths during auscultation.
ANS: B
If cardiovascular disease is suspected, then the nurse should auscultate each carotid artery for the
presence of a bruit. The nurse should avoid compressing the artery, which could create an
artificial bruit and compromise circulation if the carotid artery is already narrowed by
atherosclerosis. Excessive pressure on the carotid sinus area high in the neck should be avoided,
and excessive vagal stimulation could slow down the heart rate, especially in older adults.
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Palpating only one carotid artery at a time will avoid compromising arterial blood to the brain.
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
16. During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the
artery. This finding would indicate:
kt
a
a. Valvular disorder.
b. Blood flow turbulence.
ANS: B
ba
n
c. Fluid volume overload.
d. Ventricular hypertrophy.
nk
.
nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid
st
A bruit is a blowing, swishing sound indicating blood flow turbulence; normally, none is present.
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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17. During an inspection of the precordium of an adult patient, the nurse notices the chest
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moving in a forceful manner along the sternal border. This finding most likely suggests a(n):
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a. Normal heart.
b. Systolic murmur.
c. Enlargement of the left ventricle.
d. Enlargement of the right ventricle.
ANS: D
Normally, the examiner may or may not see an apical impulse; when visible, it occupies the
fourth or fifth intercostal space at or inside the midclavicular line. A heave or lift is a sustained
forceful thrusting of the ventricle during systole. It occurs with ventricular hypertrophy as a
result of increased workload. A right ventricular heave is seen at the sternal border; a left
ventricular heave is seen at the apex.
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
impulse?
b. Fourth left intercostal space at the sternal border
nk
.
a. Third left intercostal space at the midclavicular line
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18. During an assessment of a healthy adult, where would the nurse expect to palpate the apical
kt
a
c. Fourth left intercostal space at the anterior axillary line
d. Fifth left intercostal space at the midclavicular line
ba
n
ANS: D
The apical impulse should occupy only one intercostal space, the fourth or fifth, and it should be
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at or medial to the midclavicular line.
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
19. The nurse is examining a patient who has possible cardiac enlargement. Which statement
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about percussion of the heart is true?
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a. Percussion is a useful tool for outlining the hearts borders.
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b. Percussion is easier in patients who are obese.
c. Studies show that percussed cardiac borders do not correlate well with the true
cardiac border.
d. Only expert health care providers should attempt percussion of the heart.
ANS: C
Numerous comparison studies have shown that the percussed cardiac border correlates only
moderately with the true cardiac border. Percussion is of limited usefulness with the female
breast tissue, in a person who is obese, or in a person with a muscular chest wall. Chest x-ray
images or echocardiographic examinations are significantly more accurate in detecting heart
enlargement.
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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20. The nurse is preparing to auscultate for heart sounds. Which technique is correct?
a. Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas
nk
.
b. Listening by inching the stethoscope in a rough Z pattern, from the base of the
heart across and down, then over to the apex
kt
a
c. Listening to the sounds only at the site where the apical pulse is felt to be the
strongest
ba
n
d. Listening for all possible sounds at a time at each specified area
ANS: B
Auscultation of breath sounds should not be limited to only four locations. Sounds produced by
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the valves may be heard all over the precordium. The stethoscope should be inched in a rough Z
pattern from the base of the heart across and down, then over to the apex; or, starting at the apex,
.te
it should be slowly worked up (see Figure 19-22). Listening selectively to one sound at a time is
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best.
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
21. While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular
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rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurses
response?
a. Talk with the patient about his intake of caffeine.
b. Perform an electrocardiogram after the examination.
c. No further response is needed because sinus arrhythmia can occur normally.
d. Refer the patient to a cardiologist for further testing.
ANS: C
The rhythm should be regular, although sinus arrhythmia occurs normally in young adults and
children. With sinus arrhythmia, the rhythm varies with the persons breathing, increasing at the
peak of inspiration and slowing with expiration.
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MSC: Client Needs: Health Promotion and Maintenance
co
22. When listening to heart sounds, the nurse knows that the S1:
b. Indicates the beginning of diastole.
c. Coincides with the carotid artery pulse.
kt
a
d. Is caused by the closure of the semilunar valves.
nk
.
a. Is louder than the S2 at the base of the heart.
ba
n
ANS: C
The S1 coincides with the carotid artery pulse, is the start of systole, and is louder than the S2 at
the apex of the heart; the S2 is louder than the S1 at the base. The nurse should gently feel the
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carotid artery pulse while auscultating at the apex; the sound heard as each pulse is felt is the S1.
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MSC: Client Needs: General
23. During the cardiac auscultation, the nurse hears a sound immediately occurring after the S2 at
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the second left intercostal space. To further assess this sound, what should the nurse do?
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a. Have the patient turn to the left side while the nurse listens with the bell of the
stethoscope.
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b. Ask the patient to hold his or her breath while the nurse listens again.
c. No further assessment is needed because the nurse knows this sound is an S3.
d. Watch the patients respirations while listening for the effect on the sound.
ANS: D
A split S2 is a normal phenomenon that occurs toward the end of inspiration in some people. A
split S2 is heard only in the pulmonic valve area, the second left interspace. When the split S2 is
first heard, the nurse should not be tempted to ask the person to hold his or her breath so that the
nurse can concentrate on the sounds. Breath holding will only equalize ejection times in the right
and left sides of the heart and cause the split to go away. Rather, the nurse should concentrate on
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the split while watching the persons chest rise up and down with breathing.
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
24. Which of these findings would the nurse expect to notice during a cardiac assessment on a 4-
a. S3 when sitting up
kt
a
b. Persistent tachycardia above 150 beats per minute
nk
.
year-old child?
c. Murmur at the second left intercostal space when supine
ba
n
d. Palpable apical impulse in the fifth left intercostal space lateral to midclavicular
line
ANS: C
st
Some murmurs are common in healthy children or adolescents and are termed innocent or
functional. The innocent murmur is heard at the second or third left intercostal space and
.te
disappears with sitting, and the young person has no associated signs of cardiac dysfunction.
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MSC: Client Needs: Health Promotion and Maintenance
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25. While auscultating heart sounds on a 7-year-old child for a routine physical examination, the
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nurse hears an S3, a soft murmur at the left midsternal border, and a venous hum when the child
is standing. What would be a correct interpretation of these findings?
a. S3 is indicative of heart disease in children.
b. These findings can all be normal in a child.
c. These findings are indicative of congenital problems.
d. The venous hum most likely indicates an aneurysm.
ANS: B
A physiologic S3 is common in children. A venous hum, caused by turbulence of blood flow in
the jugular venous system, is common in healthy children and has no pathologic significance.
Heart murmurs that are innocent (or functional) in origin are very common through childhood.
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MSC: Client Needs: Health Promotion and Maintenance
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26. During the precordial assessment on an patient who is 8 months pregnant, the nurse palpates
the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This
a. Right ventricular hypertrophy.
nk
.
finding would indicate:
kt
a
b. Increased volume and size of the heart as a result of pregnancy.
c. Displacement of the heart from elevation of the diaphragm.
ba
n
d. Increased blood flow through the internal mammary artery.
ANS: C
Palpation of the apical impulse is higher and more lateral, compared with the normal position,
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because the enlarging uterus elevates the diaphragm and displaces the heart up and to the left and
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rotates it on its long axis.
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MSC: Client Needs: Health Promotion and Maintenance
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27. In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the:
a. Bell of the stethoscope at the base with the patient leaning forward.
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b. Bell of the stethoscope at the apex with the patient in the left lateral position.
c. Diaphragm of the stethoscope in the aortic area with the patient sitting.
d. Diaphragm of the stethoscope in the pulmonic area with the patient supine.
ANS: B
The S4 is a ventricular filling sound that occurs when the atria contract late in diastole and is
heard immediately before the S1. The S4 is a very soft sound with a very low pitch. The nurse
needs a good bell and must listen for this sound. An S4 is heard best at the apex, with the person
in the left lateral position.
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
28. A 70-year-old patient with a history of hypertension has a blood pressure of 180/100 mm Hg
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and a heart rate of 90 beats per minute. The nurse hears an extra heart sound at the apex
immediately before the S1. The sound is heard only with the bell of the stethoscope while the
that this extra heart sound is most likely a(n):
kt
a
a. Split S1.
nk
.
patient is in the left lateral position. With these findings and the patients history, the nurse knows
b. Atrial gallop.
c. Diastolic murmur.
ba
n
d. Summation sound.
ANS: B
st
A pathologic S4 is termed an atrial gallop or an S4 gallop. It occurs with decreased compliance
.te
of the ventricle and with systolic overload (afterload), including outflow obstruction to the
ventricle (aortic stenosis) and systemic hypertension. A left-sided S4 occurs with these conditions
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and is heard best at the apex with the patient in the left lateral position.
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MSC: Client Needs: Health Promotion and Maintenance
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29. The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her
myocardial infarction (MI). Heart sounds are normal when she is supine, but when she is sitting
and leaning forward, the nurse hears a high-pitched, scratchy sound with the diaphragm of the
stethoscope at the apex. It disappears on inspiration. The nurse suspects:
a. Increased cardiac output.
b. Another MI.
c. Inflammation of the precordium.
d. Ventricular hypertrophy resulting from muscle damage.
ANS: C
Inflammation of the precordium gives rise to a friction rub. The sound is high pitched and
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scratchy, similar to sandpaper being rubbed. A friction rub is best heard with the diaphragm of
the stethoscope, with the person sitting up and leaning forward, and with the breath held in
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expiration. A friction rub can be heard any place on the precordium. Usually, however, the sound
comes in close contact with the chest wall.
nk
.
is best heard at the apex and left lower sternal border, which are places where the pericardium
kt
a
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
30. The mother of a 10-month-old infant tells the nurse that she has noticed that her son becomes
blue when he is crying and that the frequency of this is increasing. He is also not crawling yet.
ba
n
During the examination the nurse palpates a thrill at the left lower sternal border and auscultates
a loud systolic murmur in the same area. What would be the most likely cause of these findings?
b. Atrial septal defect
st
a. Tetralogy of Fallot
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c. Patent ductus arteriosus
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ANS: A
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d. Ventricular septal defect
The cause of these findings is tetralogy of Fallot. Its subjective findings include: (1) severe
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cyanosis, not in the first months of life but developing as the infant grows, and right ventricle
outflow (i.e., pulmonic) stenosis that gets worse; (2) cyanosis with crying and exertion at first
and then at rest; and (3) slowed development. Its objective findings include: (1) thrill palpable at
the left lower sternal border; (2) the S1 is normal, the S2 has a loud A2, and the P2 is diminished
or absent; and (3) the murmur is systolic, loud, and crescendo-decrescendo.
MSC: Client Needs: Health Promotion and Maintenance
31. A 30-year-old woman with a history of mitral valve problems states that she has been very
tired. She has started waking up at night and feels like her heart is pounding. During the
assessment, the nurse palpates a thrill and lift at the fifth left intercostal space midclavicular line.
In the same area, the nurse also auscultates a blowing, swishing sound right after the S1. These
findings would be most consistent with:
m
a. Heart failure.
b. Aortic stenosis.
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c. Pulmonary edema.
nk
.
d. Mitral regurgitation.
ANS: D
kt
a
These findings are consistent with mitral regurgitation. Its subjective findings include fatigue,
palpitation, and orthopnea, and its objective findings are: (1) a thrill in systole at the apex; (2) a
lift at the apex; (3) the apical impulse displaced down and to the left; (4) the S1 is diminished, the
ba
n
S2 is accentuated, and the S3 at the apex is often present; and (5) a pansystolic murmur that is
often loud, blowing, best heard at the apex, and radiating well to the left axilla.
st
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
.te
32. During a cardiac assessment on a 38-year-old patient in the hospital for chest pain, the nurse
finds the following: jugular vein pulsations 4 cm above the sternal angle when the patient is
elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per minute, ankle
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edema, difficulty breathing when supine, and an S3 on auscultation. Which of these conditions
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best explains the cause of these findings?
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a. Fluid overload
b. Atrial septal defect
c. MI
d. Heart failure
ANS: D
Heart failure causes decreased cardiac output when the heart fails as a pump and the circulation
becomes backed up and congested. Signs and symptoms include dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, decreased blood pressure, dependent and pitting edema; anxiety; confusion;
jugular vein distention; and fatigue. The S3 is associated with heart failure and is always
abnormal after 35 years of age. The S3 may be the earliest sign of heart failure.
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33. The nurse knows that normal splitting of the S2 is associated with:
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MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
a. Expiration.
nk
.
b. Inspiration.
c. Exercise state.
kt
a
d. Low resting heart rate.
ba
n
ANS: B
Normal or physiologic splitting of the S2 is associated with inspiration because of the increased
blood return to the right side of the heart, delaying closure of the pulmonic valve.
st
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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34. During a cardiovascular assessment, the nurse knows that a thrill is:
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a. Vibration that is palpable.
b. Palpated in the right epigastric area.
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c. Associated with ventricular hypertrophy.
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d. Murmur auscultated at the third intercostal space.
ANS: A
A thrill is a palpable vibration that signifies turbulent blood flow and accompanies loud
murmurs. The absence of a thrill does not rule out the presence of a murmur.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
35. During a cardiovascular assessment, the nurse knows that an S4 heart sound is:
a. Heard at the onset of atrial diastole.
b. Usually a normal finding in the older adult.
c. Heard at the end of ventricular diastole.
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d. Heard best over the second left intercostal space with the individual sitting
upright.
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ANS: C
nk
.
An S4 heart sound is heard at the end of diastole when the atria contract (atrial systole) and when
the ventricles are resistant to filling. The S4 occurs just before the S1.
kt
a
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
36. During an assessment, the nurse notes that the patients apical impulse is laterally displaced
a. Systemic hypertension.
b. Pulmonic hypertension.
ba
n
and is palpable over a wide area. This finding indicates:
st
c. Pressure overload, as in aortic stenosis.
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d. Volume overload, as in heart failure.
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ANS: D
With volume overload, as in heart failure and cardiomyopathy, cardiac enlargement laterally
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displaces the apical impulse and is palpable over a wider area when left ventricular hypertrophy
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and dilation are present.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
37. When the nurse is auscultating the carotid artery for bruits, which of these statements reflects
the correct technique?
a. While listening with the bell of the stethoscope, the patient is asked to take a deep
breath and hold it.
b. While auscultating one side with the bell of the stethoscope, the carotid artery is
palpated on the other side to check pulsations.
c. While lightly applying the bell of the stethoscope over the carotid artery and
listening, the patient is asked to take a breath, exhale, and briefly hold it.
co
m
d. While firmly placing the bell of the stethoscope over the carotid artery and
listening, the patient is asked to take a breath, exhale, and briefly hold it.
ANS: C
nk
.
The correct technique for auscultating the carotid artery for bruits involves the nurse lightly
applying the bell of the stethoscope over the carotid artery at three levels. While listening, the
nurse asks the patient take a breath, exhale, and briefly hold it. Holding the breath on inhalation
kt
a
will also tense the levator scapulae muscles, which makes it hard to hear the carotid arteries.
Examining only one carotid artery at a time will avoid compromising arterial blood flow to the
ba
n
brain. Pressure over the carotid sinus, which may lead to decreased heart rate, decreased blood
pressure, and cerebral ischemia with syncope, should be avoided.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
st
38. The nurse is preparing for a class on risk factors for hypertension and reviews recent
a. Blacks
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b. Whites
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statistics. Which racial group has the highest prevalence of hypertension in the world?
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c. American Indians
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d. Hispanics
ANS: A
According to the American Heart Association, the prevalence of hypertension is higher among
Blacks than in other racial groups.
MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential
39. The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular
reflux. If heart failure is present, then the nurse should recognize which finding while pushing on
the right upper quadrant of the patients abdomen, just below the rib cage?
a. The jugular veins will rise for a few seconds and then recede back to the previous
level if the heart is properly working.
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b. The jugular veins will remain elevated as long as pressure on the abdomen is
maintained.
nk
.
d. The jugular veins will not be detected during this maneuver.
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c. An impulse will be visible at the fourth or fifth intercostal space at or inside the
midclavicular line.
ANS: B
kt
a
When performing hepatojugular reflux, the jugular veins will rise for a few seconds and then
recede back to the previous level if the heart is able to pump the additional volume created by the
abdomen is maintained.
ba
n
pushing. However, with heart failure, the jugular veins remain elevated as long as pressure on the
st
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
40. The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is
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135 beats per minute. The nurse interprets this result as:
a. Normal for this age.
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b. Lower than expected.
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c. Higher than expected, probably as a result of crying.
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d. Higher than expected, reflecting persistent tachycardia.
ANS: A
The heart rate may range from 100 to 180 beats per minute immediately after birth and then
stabilize to an average of 120 to 140 beats per minute. Infants normally have wide fluctuations
with activity, from 170 beats per minute or more with crying or being active to 70 to 90 beats per
minute with sleeping. Persistent tachycardia is greater than 200 beats per minute in newborns or
greater than 150 beats per minute in infants.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
MULTIPLE RESPONSE
m
1. The nurse is presenting a class on risk factors for cardiovascular disease. Which of these are
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considered modifiable risk factors for MI? Select all that apply.
a. Ethnicity
nk
.
b. Abnormal lipids
c. Smoking
kt
a
d. Gender
e. Hypertension
f. Diabetes
ba
n
g. Family history
st
ANS: B, C, E, F
Nine modifiable risk factors for MI, as identified by a recent study, include abnormal lipids,
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smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits
and vegetables, alcohol use, and regular physical activity.
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MSC: Client Needs: Health Promotion and Maintenance
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SHORT ANSWER
1. The nurse is assessing a patients pulses and notices a difference between the patients apical
pulse and radial pulse. The apical pulse was 118 beats per minute, and the radial pulse was 105
beats per minute. What is the pulse deficit?
ANS:
13
The nurse should count a serial measurement (one after the other) of the apical pulse and then the
radial pulse. Normally, every beat heard at the apex should perfuse to the periphery and be
palpable. The two counts should be identical. If they are different, then the nurse should subtract
the radial rate from the apical pulse and record the remainder as the pulse deficit.
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Chapter 11. Gastrointestinal Guidelines
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MULTIPLE CHOICE
liver. Which sound should the nurse expect to hear?
a. Dullness
kt
a
b. Tympany
nk
.
1. The nurse is percussing the seventh right intercostal space at the midclavicular line over the
c. Resonance
ba
n
d. Hyperresonance
ANS: A
st
The liver is located in the right upper quadrant and would elicit a dull percussion note.
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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2. Which structure is located in the left lower quadrant of the abdomen?
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a. Liver
b. Duodenum
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c. Gallbladder
d. Sigmoid colon
ANS: D
The sigmoid colon is located in the left lower quadrant of the abdomen.
MSC: Client Needs: General
3. A patient is having difficulty swallowing medications and food. The nurse would document
that this patient has:
a. Aphasia.
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b. Dysphasia.
c. Dysphagia.
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d. Anorexia.
nk
.
ANS: C
Dysphagia is a condition that occurs with disorders of the throat or esophagus and results in
kt
a
difficulty swallowing. Aphasia and dysphasia are speech disorders. Anorexia is a loss of appetite.
ba
n
DIF: Cognitive Level: Applying (Application) REF: p. 542
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. The nurse suspects that a patient has a distended bladder. How should the nurse assess for this
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condition?
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a. Percuss and palpate in the lumbar region.
b. Inspect and palpate in the epigastric region.
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c. Auscultate and percuss in the inguinal region.
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d. Percuss and palpate the midline area above the suprapubic bone.
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ANS: D
Dull percussion sounds would be elicited over a distended bladder, and the hypogastric area
would seem firm to palpation.
DIF: Cognitive Level: Applying (Application) REF: p. 540
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
5. The nurse is aware that one change that may occur in the gastrointestinal system of an aging
adult is:
a. Increased salivation.
b. Increased liver size.
c. Increased esophageal emptying.
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d. Decreased gastric acid secretion.
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ANS: D
emptying is delayed, and liver size decreases.
nk
.
Gastric acid secretion decreases with aging. As one ages, salivation decreases, esophageal
kt
a
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 541
ba
n
MSC: Client Needs: Health Promotion and Maintenance
6. A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and
landing on his left side on the handle bars. The nurse suspects that he may have injured his
st
spleen. Which of these statements is trueregarding assessment of the spleen in this situation?
a. The spleen can be enlarged as a result of trauma.
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b. The spleen is normally felt on routine palpation.
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c. If an enlarged spleen is noted, then the nurse should thoroughly palpate to
determine its size.
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d. An enlarged spleen should not be palpated because it can easily rupture.
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ANS: D
If an enlarged spleen is felt, then the nurse should refer the person and should not continue to
palpate it. An enlarged spleen is friable and can easily rupture with overpalpation.
DIF: Cognitive Level: Applying (Application) REF: p. 558
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
7. A patients abdomen is bulging and stretched in appearance. The nurse should describe this
finding as:
a. Obese.
b. Herniated.
c. Scaphoid.
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d. Protuberant.
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ANS: D
nk
.
A protuberant abdomen is rounded, bulging, and stretched (see Figure 21-7). A scaphoid
abdomen caves inward.
kt
a
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 546
ba
n
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
8. The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of
the abdomen depicts a ______ profile.
st
a. Flat
c. Bulging
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ANS: D
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d. Concave
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b. Convex
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Contour describes the profile of the abdomen from the rib margin to the pubic bone; a scaphoid
contour is one that is concave from a horizontal plane (see Figure 21-7).
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 546
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
9. While examining a patient, the nurse observes abdominal pulsations between the xiphoid
process and umbilicus. The nurse would suspect that these are:
a. Pulsations of the renal arteries.
b. Pulsations of the inferior vena cava.
c. Normal abdominal aortic pulsations.
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d. Increased peristalsis from a bowel obstruction.
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ANS: C
nk
.
Normally, the pulsations from the aorta are observed beneath the skin in the epigastric area,
particularly in thin persons who have good muscle wall relaxation.
kt
a
DIF: Cognitive Level: Applying (Application) REF: p. 549
ba
n
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
10. A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive
bowel sounds is:
b. Peritonitis.
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c. Laxative use.
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a. Diarrhea.
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ANS: B
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d. Gastroenteritis.
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Diminished or absent bowel sounds signal decreased motility from inflammation as exhibited
with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 549
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
11. The nurse is watching a new graduate nurse perform auscultation of a patients abdomen.
Which statement by the new graduate shows a correct understanding of the reason auscultation
precedes percussion and palpation of the abdomen?
a. We need to determine the areas of tenderness before using percussion and
palpation.
m
b. Auscultation prevents distortion of bowel sounds that might occur after
percussion and palpation.
co
c. Auscultation allows the patient more time to relax and therefore be more
comfortable with the physical examination.
nk
.
d. Auscultation prevents distortion of vascular sounds, such as bruits and hums, that
might occur after percussion and palpation.
kt
a
ANS: B
Auscultation is performed first (after inspection) because percussion and palpation can increase
ba
n
peristalsis, which would give a false interpretation of bowel sounds.
DIF: Cognitive Level: Applying (Application) REF: p. 548
st
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
12. The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds?
.te
Bowel sounds:
w
a. Are usually loud, high-pitched, rushing, and tinkling sounds.
b. Are usually high-pitched, gurgling, and irregular sounds.
w
c. Sound like two pieces of leather being rubbed together.
w
d. Originate from the movement of air and fluid through the large intestine.
ANS: B
Bowel sounds are high-pitched, gurgling, and cascading sounds that irregularly occur from 5 to
30 times per minute. They originate from the movement of air and fluid through the small
intestine.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 549
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
13. The physician comments that a patient has abdominal borborygmi. The nurse knows that this
term refers to:
m
a. Loud continual hum.
co
b. Peritoneal friction rub.
c. Hypoactive bowel sounds.
nk
.
d. Hyperactive bowel sounds.
kt
a
ANS: D
Borborygmi is the term used for hyperperistalsis when the person actually feels his or her
ba
n
stomach growling.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 549
st
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
14. During an abdominal assessment, the nurse would consider which of these findings as
.te
normal?
a. Presence of a bruit in the femoral area
w
b. Tympanic percussion note in the umbilical region
w
c. Palpable spleen between the ninth and eleventh ribs in the left midaxillary line
w
d. Dull percussion note in the left upper quadrant at the midclavicular line
ANS: B
Tympany should predominate in all four quadrants of the abdomen because air in the intestines
rises to the surface when the person is supine. Vascular bruits are not usually present. Normally,
the spleen is not palpable. Dullness would not be found in the area of lung resonance (left upper
quadrant at the midclavicular line).
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 550
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
15. The nurse is assessing the abdomen of a pregnant woman who is complaining of having acid
indigestion all the time. The nurse knows that esophageal reflux during pregnancy can cause:
m
a. Diarrhea.
co
b. Pyrosis.
c. Dysphagia.
nk
.
d. Constipation.
kt
a
ANS: B
Pyrosis, or heartburn, is caused by esophageal reflux during pregnancy. The other options are not
ba
n
correct.
DIF: Cognitive Level: Applying (Application) REF: p. 540
st
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
16. The nurse is performing percussion during an abdominal assessment. Percussion notes heard
.te
during the abdominal assessment may include:
a. Flatness, resonance, and dullness.
w
b. Resonance, dullness, and tympany.
w
c. Tympany, hyperresonance, and dullness.
w
d. Resonance, hyperresonance, and flatness.
ANS: C
Percussion notes normally heard during the abdominal assessment may include tympany, which
should predominate because air in the intestines rises to the surface when the person is supine;
hyperresonance, which may be present with gaseous distention; and dullness, which may be
found over a distended bladder, adipose tissue, fluid, or a mass.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 550
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
17. An older patient has been diagnosed with pernicious anemia. The nurse knows that this
condition could be related to:
m
a. Increased gastric acid secretion.
co
b. Decreased gastric acid secretion.
c. Delayed gastrointestinal emptying time.
nk
.
d. Increased gastrointestinal emptying time.
kt
a
ANS: B
Gastric acid secretion decreases with aging and may cause pernicious anemia (because it
ba
n
interferes with vitamin B12 absorption), iron-deficiency anemia, and malabsorption of calcium.
DIF: Cognitive Level: Applying (Application) REF: p. 541
st
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
18. A patient is complaining of a sharp pain along the costovertebral angles. The nurse is aware
.te
that this symptom is most often indicative of:
a. Ovary infection.
w
b. Liver enlargement.
w
c. Kidney inflammation.
w
d. Spleen enlargement.
ANS: C
Sharp pain along the costovertebral angles occurs with inflammation of the kidney or
paranephric area. The other options are not correct.
DIF: Cognitive Level: Applying (Application) REF: p. 552
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
19. A nurse notices that a patient has ascites, which indicates the presence of:
a. Fluid.
b. Feces.
m
c. Flatus.
co
d. Fibroid tumors.
nk
.
ANS: A
Ascites is free fluid in the peritoneal cavity and occurs with heart failure, portal hypertension,
kt
a
cirrhosis, hepatitis, pancreatitis, and cancer.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 553
ba
n
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
20. The nurse knows that during an abdominal assessment, deep palpation is used to determine:
b. Enlarged organs.
st
a. Bowel motility.
.te
c. Superficial tenderness.
w
ANS: B
w
d. Overall impression of skin surface and superficial musculature.
w
With deep palpation, the nurse should notice the location, size, consistency, and mobility of any
palpable organs and the presence of any abnormal enlargement, tenderness, or masses.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 554
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
21. The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause
would be:
a. Gallbladder disease.
b. Overuse of laxatives.
c. Gastrointestinal bleeding.
d. Localized bleeding around the anus.
m
ANS: C
blood in stools occurs with localized bleeding around the anus.
co
Black stools may be tarry as a result of occult blood (melena) from gastrointestinal bleeding. Red
nk
.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 543
kt
a
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
22. During an abdominal assessment, the nurse elicits tenderness on light palpation in the right
lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these
ba
n
structures?
a. Spleen
c. Appendix
.te
d. Gallbladder
st
b. Sigmoid
w
ANS: C
w
The appendix is located in the right lower quadrant. When the iliopsoas muscle is inflamed,
w
which occurs with an inflamed or perforated appendix, pain is felt in the right lower quadrant.
DIF: Cognitive Level: Applying (Application) REF: p. 560
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
23. The nurse is assessing the abdomen of an older adult. Which statement regarding the older
adult and abdominal assessment is true?
a. Abdominal tone is increased.
b. Abdominal musculature is thinner.
c. Abdominal rigidity with an acute abdominal condition is more common.
d. The older adult with an acute abdominal condition complains more about pain
than the younger person.
m
ANS: B
co
In the older adult, the abdominal musculature is thinner and has less tone than that of the younger
adult, and abdominal rigidity with an acute abdominal condition is less common in the aging
nk
.
person. The older adult with an acute abdominal condition often complains less about pain than
the younger person.
kt
a
DIF: Cognitive Level: Applying (Application) REF: p. 563
ba
n
MSC: Client Needs: Health Promotion and Maintenance
24. During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be
exhibited by:
st
a. Projectile vomiting.
b. Hypoactive bowel activity.
.te
c. Palpable olive-sized mass in the right lower quadrant.
w
ANS: A
w
d. Pronounced peristaltic waves crossing from right to left.
w
Significant peristalsis, together with projectile vomiting, in the newborn suggests pyloric
stenosis. After feeding, pronounced peristaltic waves cross from left to right, leading to projectile
vomiting. One can also palpate an olive-sized mass in the right upper quadrant.
DIF: Cognitive Level: Applying (Application) REF: p. 572
MSC: Client Needs: Health Promotion and Maintenance
25. The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is
true regarding an aortic aneurysm?
a. A bruit is absent.
b. Femoral pulses are increased.
c. A pulsating mass is usually present.
m
d. Most are located below the umbilicus.
co
ANS: C
nk
.
Most aortic aneurysms are palpable during routine examination and feel like a pulsating mass. A
bruit will be audible, and femoral pulses are present but decreased. Such aneurysms are located
kt
a
in the upper abdomen just to the left of midline.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 574
ba
n
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
26. During an abdominal assessment, the nurse is unable to hear bowel sounds in a patients
abdomen. Before reporting this finding as silent bowel sounds, the nurse should listen for at
.te
a. 1 minute.
st
least:
b. 5 minutes.
w
c. 10 minutes.
w
d. 2 minutes in each quadrant.
w
ANS: B
Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding that bowel
sounds are completely absent.
DIF: Cognitive Level: Applying (Application) REF: p. 549
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
27. A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse
should conduct which of these techniques to assess for this condition?
a. Obturator test
b. Test for Murphy sign
c. Assess for rebound tenderness
m
d. Iliopsoas muscle test
co
ANS: B
nk
.
Normally, palpating the liver causes no pain. In a person with inflammation of the gallbladder, or
cholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder onto the
examining hand during inspiration (Murphy test). The person feels sharp pain and abruptly stops
kt
a
midway during inspiration.
ba
n
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 560
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
28. Just before going home, a new mother asks the nurse about the infants umbilical cord. Which
st
of these statements is correct?
.te
a. It should fall off in 10 to 14 days.
b. It will soften before it falls off.
w
c. It contains two veins and one artery.
w
d. Skin will cover the area within 1 week.
w
ANS: A
At birth, the umbilical cord is white and contains two umbilical arteries and one vein inside the
Wharton jelly. The umbilical stump dries within a week, hardens, and falls off in 10 to 14 days.
Skin will cover the area in 3 to 4 weeks.
DIF: Cognitive Level: Applying (Application) REF: p. 561
MSC: Client Needs: Health Promotion and Maintenance
29. Which of these percussion findings would the nurse expect to find in a patient with a large
amount of ascites?
a. Dullness across the abdomen
m
b. Flatness in the right upper quadrant
c. Hyperresonance in the left upper quadrant
nk
.
ANS: A
co
d. Tympany in the right and left lower quadrants
kt
a
A large amount of ascitic fluid produces a dull sound to percussion.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 553
ba
n
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
30. A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to
explain what a hernia is. Which response by the nurse is appropriate?
st
a. No need to worry. Most men your age develop hernias.
.te
b. A hernia is a loop of bowel protruding through a weak spot in the abdominal
muscles.
w
c. A hernia is the result of prenatal growth abnormalities that are just now causing
problems.
w
d. Ill have to have your physician explain this to you.
w
ANS: B
The nurse should explain that a hernia is a protrusion of the abdominal viscera through an
abnormal opening in the muscle wall.
DIF: Cognitive Level: Applying (Application) REF: p. 546
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
31. A 45-year-old man is in the clinic for a physical examination. During the abdominal
assessment, the nurse percusses the abdomen and notices an area of dullness above the right
costal margin of approximately 11 cm. The nurse should:
a. Document the presence of hepatomegaly.
b. Ask additional health history questions regarding his alcohol intake.
co
d. Consider this finding as normal, and proceed with the examination.
m
c. Describe this dullness as indicative of an enlarged liver, and refer him to a
physician.
nk
.
ANS: D
A liver span of 10.5 cm is the mean for males and 7 cm for females. Men and taller individuals
kt
a
are at the upper end of this range. Women and shorter individuals are at the lower end of this
range. A liver span of 11 cm is within normal limits for this individual.
ba
n
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 550
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
st
32. When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of
tenderness in the left upper quadrant with deep palpation. Which of these structures is most
w
a. Spleen
.te
likely to be involved?
b. Sigmoid colon
w
c. Appendix
w
d. Gallbladder
ANS: A
The spleen is located in the left upper quadrant of the abdomen. The gallbladder is in the right
upper quadrant, the sigmoid colon is in the left lower quadrant, and the appendix is in the right
lower quadrant.
DIF: Cognitive Level: Applying (Application) REF: p. 540
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
33. The nurse is reviewing statistics for lactose intolerance. In the United States, the incidence of
lactose intolerance is higher in adults of which ethnic group?
m
a. Blacks
co
b. Hispanics
c. Whites
nk
.
d. Asians
kt
a
ANS: A
A recent study found estimates of lactose-intolerance prevalence as follows: 19.5% for Blacks,
ba
n
10% for Hispanics, and 7.72% for Whites.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 541
st
MSC: Client Needs: Health Promotion and Maintenance
34. The nurse is assessing a patient for possible peptic ulcer disease. Which condition or history
.te
often causes this problem?
a. Hypertension
w
b. Streptococcal infections
w
c. Recurrent constipation with frequent laxative use
w
d. Frequent use of nonsteroidal antiinflammatory drugs
ANS: D
Peptic ulcer disease occurs with the frequent use of nonsteroidal antiinflammatory drugs, alcohol
use, smoking, and Helicobacter pylori infection.
DIF: Cognitive Level: Applying (Application) REF: p. 543
MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential
35. During reporting, the student nurse hears that a patient has hepatomegaly and recognizes that
this term refers to:
a. Enlarged liver.
m
b. Enlarged spleen.
c. Distended bowel.
ANS: A
nk
.
co
d. Excessive diarrhea.
The term hepatomegaly refers to an enlarged liver. The term splenomegaly refers to an enlarged
kt
a
spleen. The other responses are not correct.
ba
n
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 551
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
36. During an assessment, the nurse notices that a patients umbilicus is enlarged and everted. It is
.te
which condition?
st
positioned midline with no change in skin color. The nurse recognizes that the patient may have
a. Intra-abdominal bleeding
w
b. Constipation
c. Umbilical hernia
w
w
d. Abdominal tumor
ANS: C
The umbilicus is normally midline and inverted with no signs of discoloration. With an umbilical
hernia, the mass is enlarged and everted. The other responses are incorrect.
DIF: Cognitive Level: Applying (Application) REF: p. 546
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
37. During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test
occurs with:
a. Splenomegaly.
m
b. Distended bladder.
c. Constipation.
co
d. Ascites.
nk
.
ANS: D
If ascites (fluid in the abdomen) is present, then the examiner will feel a fluid wave when
kt
a
assessing the abdomen. A fluid wave is not present with splenomegaly, a distended bladder, or
constipation.
ba
n
DIF: Cognitive Level: Applying (Application) REF: p. 553
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
st
38. The nurse is preparing to examine a patient who has been complaining of right lower
.te
quadrant pain. Which technique is correct during the assessment?
The nurse should:
w
a. Examine the tender area first.
w
b. Examine the tender area last.
w
c. Avoid palpating the tender area.
d. Palpate the tender area first, and then auscultate for bowel sounds.
ANS: B
The nurse should save the examination of any identified tender areas until last. This method
avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the
examination. Auscultation is performed before percussion and palpation because percussion and
palpation can increase peristalsis, which would give a false interpretation of bowel sounds.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 555
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
m
39. During a health history, the patient tells the nurse, I have pain all the time in my stomach. Its
co
worse 2 hours after I eat, but it gets better if I eat again! Based on these symptoms, the nurse
suspects that the patient has which condition?
nk
.
a. Appendicitis
b. Gastric ulcer
kt
a
c. Duodenal ulcer
d. Cholecystitis
ba
n
ANS: C
Pain associated with duodenal ulcers occurs 2 to 3 hours after a meal; it may relieved by more
food. Chronic pain associated with gastric ulcers usually occurs on an empty stomach. Severe,
st
acute pain would occur with appendicitis and cholecystitis.
.te
DIF: Cognitive Level: Applying (Application) REF: p. 570
w
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
w
MULTIPLE RESPONSE
w
1. The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate
for use when assessing for appendicitis or a perforated appendix? Select all that apply.
a. Test for the Murphy sign
b. Test for the Blumberg sign
c. Test for shifting dullness
d. Perform the iliopsoas muscle test
e. Test for fluid wave
ANS: B, D
Testing for the Blumberg sign (rebound tenderness) and performing the iliopsoas muscle test
should be used when assessing for appendicitis. The Murphy sign is used when assessing for an
m
inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is performed
when assessing for ascites.
MULTIPLE CHOICE
kt
a
1. The external male genital structures include the:
nk
.
co
Chapter 12. Genitourinary Guidelines
a. Testis.
b. Scrotum.
ba
n
c. Epididymis.
d. Vas deferens.
st
ANS: B
.te
The external male genital structures include the penis and scrotum. The testis, epididymis, and
vas deferens are internal structures.
w
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 691
w
w
MSC: Client Needs: General
2. An accessory glandular structure for the male genital organs is the:
a. Testis.
b. Scrotum.
c. Prostate.
d. Vas deferens.
ANS: C
Glandular structures accessory to the male genital organs are the prostate, seminal vesicles, and
bulbourethral glands.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 691
co
3. Which of these statements is true regarding the penis?
m
MSC: Client Needs: General
nk
.
a. The urethral meatus is located on the ventral side of the penis.
b. The prepuce is the fold of foreskin covering the shaft of the penis.
c. The penis is made up of two cylindrical columns of erectile tissue.
kt
a
d. The corpus spongiosum expands into a cone of erectile tissue called the glans.
ba
n
ANS: D
At the distal end of the shaft, the corpus spongiosum expands into a cone of erectile tissue, the
glans. The penis is made up of three cylindrical columns of erectile tissue. The skin that covers
st
the glans of the penis is the prepuce. The urethral meatus forms at the tip of the glans.
.te
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 691
w
MSC: Client Needs: General
w
4. When performing a genital examination on a 25-year-old man, the nurse notices deeply
pigmented, wrinkled scrotal skin with large sebaceous follicles. On the basis of this information,
w
the nurse would:
a. Squeeze the glans to check for the presence of discharge.
b. Consider this finding as normal, and proceed with the examination.
c. Assess the testicles for the presence of masses or painless lumps.
d. Obtain a more detailed history, focusing on any scrotal abnormalities the patient
has noticed.
ANS: B
After adolescence, the scrotal skin is deeply pigmented and has large sebaceous follicles and
appears corrugated.
DIF: Cognitive Level: Applying (Application) REF: p. 691
co
5. Which statement concerning the testes is true?
m
MSC: Client Needs: Health Promotion and Maintenance
nk
.
a. The lymphatic vessels of the testes drain into the abdominal lymph nodes.
b. The vas deferens is located along the inferior portion of each testis.
c. The right testis is lower than the left because the right spermatic cord is longer.
kt
a
d. The cremaster muscle contracts in response to cold and draws the testicles closer
to the body.
ba
n
ANS: D
When it is cold, the cremaster muscle contracts, which raises the scrotal sac and brings the testes
st
closer to the body to absorb heat necessary for sperm viability. The lymphatic vessels of the
testes drain into the inguinal lymph nodes. The vas deferens is located along the upper portion of
.te
each testis. The left testis is lower than the right because the left spermatic cord is longer.
w
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 691
w
MSC: Client Needs: General
w
6. A male patient with possible fertility problems asks the nurse where sperm is produced. The
nurse knows that sperm production occurs in the:
a. Testes.
b. Prostate.
c. Epididymis.
d. Vas deferens.
ANS: A
Sperm production occurs in the testes, not in the other structures listed.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 692
m
MSC: Client Needs: Physiologic Integrity
7. A 62-year-old man states that his physician told him that he has an inguinal hernia. He asks
co
the nurse to explain what a hernia is. The nurse should:
nk
.
a. Tell him not to worry and that most men his age develop hernias.
b. Explain that a hernia is often the result of prenatal growth abnormalities.
kt
a
c. Refer him to his physician for additional consultation because the physician made
the initial diagnosis.
ba
n
d. Explain that a hernia is a loop of bowel protruding through a weak spot in the
abdominal muscles.
ANS: D
A hernia is a loop of bowel protruding through a weak spot in the musculature. The other options
st
are not correct responses to the patients question.
.te
DIF: Cognitive Level: Applying (Application) REF: p. 692
w
MSC: Client Needs: Physiologic Integrity
w
8. The mother of a 10-year-old boy asks the nurse to discuss the recognition of puberty. The
w
nurse should reply by saying:
a. Puberty usually begins around 15 years of age.
b. The first sign of puberty is an enlargement of the testes.
c. The penis size does not increase until about 16 years of age.
d. The development of pubic hair precedes testicular or penis enlargement.
ANS: B
Puberty begins sometime between age 9 for African Americans and age 10 for Caucasians and
Hispanics. The first sign is an enlargement of the testes. Pubic hair appears next, and then penis
size increases.
DIF: Cognitive Level: Applying (Application) REF: p. 693
m
MSC: Client Needs: Health Promotion and Maintenance
co
9. During an examination of an aging man, the nurse recognizes that normal changes to expect
would be:
nk
.
a. Enlarged scrotal sac.
b. Increased pubic hair.
d. Increased rugae over the scrotum.
ba
n
ANS: C
kt
a
c. Decreased penis size.
In the aging man, the amount of pubic hair decreases, the penis size decreases, and the rugae
st
over the scrotal sac decreases. The scrotal sac does not enlarge.
.te
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 693
MSC: Client Needs: Health Promotion and Maintenance
w
10. An older man is concerned about his sexual performance. The nurse knows that in the
w
absence of disease, a withdrawal from sexual activity later in life may be attributable to:
w
a. Side effects of medications.
b. Decreased libido with aging.
c. Decreased sperm production.
d. Decreased pleasure from sexual intercourse.
ANS: A
In the absence of disease, a withdrawal from sexual activity may be attributable to side effects of
medications such as antihypertensives, antidepressants, sedatives, psychotropics, antispasmotics,
tranquilizers or narcotics, and estrogens. The other options are not correct.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 693
m
MSC: Client Needs: Health Promotion and Maintenance
co
11. A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic for
complaints of burning and pain during urination. He is experiencing:
nk
.
a. Dysuria.
b. Nocturia.
kt
a
c. Polyuria.
d. Hematuria.
ba
n
ANS: A
Dysuria (burning with urination) is common with acute cystitis, prostatitis, and urethritis.
Nocturia is voiding during the night. Polyuria is voiding in excessive quantities. Hematuria is
st
voiding with blood in the urine.
.te
DIF: Cognitive Level: Applying (Application) REF: p. 695
w
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
w
12. A 45-year-old mother of two children is seen at the clinic for complaints of losing my urine
w
when I sneeze. The nurse documents that she is experiencing:
a. Urinary frequency.
b. Enuresis.
c. Stress incontinence.
d. Urge incontinence.
ANS: C
Stress incontinence is involuntary urine loss with physical strain, sneezing, or coughing that
occurs as a result to weakness of the pelvic floor. Urinary frequency is urinating more times than
usual (more than five to six times per day). Enuresis is involuntary passage of urine at night after
age 5 to 6 years (bed wetting). Urge incontinence is involuntary urine loss from overactive
detrusor muscle in the bladder. It contracts, causing an urgent need to void.
co
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
m
DIF: Cognitive Level: Applying (Application) REF: p. 696
13. When the nurse is conducting sexual history from a male adolescent, which statement would
nk
.
be most appropriate to use at the beginning of the interview?
b. You dont masturbate, do you?
c. Have you had sex in the last 6 months?
kt
a
a. Do you use condoms?
ba
n
d. Often adolescents your age have questions about sexual activity.
ANS: D
st
The interview should begin with a permission statement, which conveys that it is normal and
.te
acceptable to think or feel a certain way. Sounding judgmental should be avoided.
w
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 698
w
MSC: Client Needs: Health Promotion and Maintenance
14. Which of these statements is most appropriate when the nurse is obtaining a genitourinary
w
history from an older man?
a. Do you need to get up at night to urinate?
b. Do you experience nocturnal emissions, or wet dreams?
c. Do you know how to perform a testicular self-examination?
d. Has anyone ever touched your genitals when you did not want them to?
ANS: A
The older male patient should be asked about the presence of nocturia. Awaking at night to
urinate may be attributable to a diuretic medication, fluid retention from mild heart failure or
varicose veins, or fluid ingestion 3 hours before bedtime, especially coffee and alcohol. The
m
other questions are more appropriate for younger men.
MSC: Client Needs: Health Promotion and Maintenance
co
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 699
nk
.
15. When the nurse is performing a genital examination on a male patient, the patient has an
erection. The nurses most appropriate action or response is to:
kt
a
a. Ask the patient if he would like someone else to examine him.
b. Continue with the examination as though nothing has happened.
ba
n
c. Stop the examination, leave the room while stating that the examination will
resume at a later time.
st
d. Reassure the patient that this is a normal response and continue with the
examination.
.te
ANS: D
When the male patient has an erection, the nurse should reassure the patient that this is a normal
physiologic response to touch and proceed with the rest of the examination. The other responses
w
are not correct and may be perceived as judgmental.
w
w
DIF: Cognitive Level: Applying (Application) REF: p. 699
MSC: Client Needs: Psychosocial Integrity
16. The nurse is examining the glans and knows which finding is normal for this area?
a. The meatus may have a slight discharge when the glans is compressed.
b. Hair is without pest inhabitants.
c. The skin is wrinkled and without lesions.
d. Smegma may be present under the foreskin of an uncircumcised male.
ANS: D
The glans looks smooth and without lesions and does not have hair. The meatus should not have
any discharge when the glans is compressed. Some cheesy smegma may have collected under the
co
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 701
m
foreskin of an uncircumcised male.
nk
.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
17. When performing a genitourinary assessment, the nurse notices that the urethral meatus is
a. Called hypospadias.
b. A result of phimosis.
ba
n
c. Probably due to a stricture.
kt
a
ventrally positioned. This finding is:
d. Often associated with aging.
st
ANS: A
.te
Normally, the urethral meatus is positioned just about centrally. Hypospadias is the ventral
location of the urethral meatus. The position of the meatus does not change with aging. Phimosis
w
is the inability to retract the foreskin. A stricture is a narrow opening of the meatus.
w
DIF: Cognitive Level: Applying (Application) REF: p. 700
w
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
18. The nurse is performing a genital examination on a male patient and notices urethral
drainage. When collecting urethral discharge for microscopic examination and culture, the nurse
should:
a. Ask the patient to urinate into a sterile cup.
b. Ask the patient to obtain a specimen of semen.
c. Insert a cotton-tipped applicator into the urethra.
d. Compress the glans between the examiners thumb and forefinger, and collect any
discharge.
m
ANS: D
If urethral discharge is noticed, then the examiner should collect a smear for microscopic
co
examination and culture by compressing the glans anteroposteriorly between the thumb and
nk
.
forefinger. The other options are not correct actions.
DIF: Cognitive Level: Applying (Application) REF: p. 701
kt
a
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
19. When assessing the scrotum of a male patient, the nurse notices the presence of multiple
a. From urethritis.
b. Sebaceous cysts.
st
c. Subcutaneous plaques.
ba
n
firm, nontender, yellow 1-cm nodules. The nurse knows that these nodules are most likely:
.te
d. From an inflammation of the epididymis.
w
ANS: B
Sebaceous cysts are commonly found on the scrotum. These yellowish 1-cm nodules are firm,
w
nontender, and often multiple. The other options are not correct.
w
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 702
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
20. When performing a scrotal assessment, the nurse notices that the scrotal contents show a red
glow with transillumination. On the basis of this finding the nurse would:
a. Assess the patient for the presence of a hernia.
b. Suspect the presence of serous fluid in the scrotum.
c. Consider this finding normal, and proceed with the examination.
d. Refer the patient for evaluation of a mass in the scrotum.
ANS: B
m
Normal scrotal contents do not allow light to pass through the scrotum. However, serous fluid
nk
.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 703
co
does transilluminate and shows as a red glow. Neither a mass nor a hernia would transilluminate.
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
21. When the nurse is performing a genital examination on a male patient, which action is
kt
a
correct?
ba
n
a. Auscultating for the presence of a bruit over the scrotum
b. Palpating for the vertical chain of lymph nodes along the groin, inferior to the
inguinal ligament
st
c. Palpating the inguinal canal only if a bulge is present in the inguinal region
during inspection
.te
d. Having the patient shift his weight onto the left (unexamined) leg when palpating
for a hernia on the right side
w
ANS: D
w
When palpating for the presence of a hernia on the right side, the male patient is asked to shift
his weight onto the left (unexamined) leg. Auscultating for a bruit over the scrotum is not
w
appropriate. When palpating for lymph nodes, the horizontal chain is palpated. The inguinal
canal should be palpated whether a bulge is present or not.
DIF: Cognitive Level: Applying (Application) REF: p. 706
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
22. The nurse is aware of which statement to be true regarding the incidence of testicular cancer?
a. Testicular cancer is the most common cancer in men aged 30 to 50 years.
b. The early symptoms of testicular cancer are pain and induration.
c. Men with a history of cryptorchidism are at the greatest risk for the development
of testicular cancer.
d. The cure rate for testicular cancer is low.
m
ANS: C
co
Men with undescended testicles (cryptorchidism) are at the greatest risk for the development of
testicular cancer. The overall incidence of testicular cancer is rare. Although testicular cancer has
nk
.
no early symptoms, when detected early and treated before metastasizing, the cure rate is almost
100%.
kt
a
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 707
ba
n
MSC: Client Needs: Health Promotion and Maintenance
23. The nurse is describing how to perform a testicular self-examination to a patient. Which
statement is most appropriate?
st
a. A good time to examine your testicles is just before you take a shower.
.te
b. If you notice an enlarged testicle or a painless lump, call your health care
provider.
c. The testicle is egg shaped and movable. It feels firm and has a lumpy consistency.
w
w
d. Perform a testicular examination at least once a week to detect the early stages of
testicular cancer.
w
ANS: B
If the patient notices a firm painless lump, a hard area, or an overall enlarged testicle, then he
should call his health care provider for further evaluation. The testicle normally feels rubbery
with a smooth surface. A good time to examine the testicles is during the shower or bath, when
ones hands are warm and soapy and the scrotum is warm. Testicular self-examination should be
performed once a month.
DIF: Cognitive Level: Applying (Application) REF: p. 704
MSC: Client Needs: Health Promotion and Maintenance
24. A 2-month-old uncircumcised infant has been brought to the clinic for a well-baby checkup.
How would the nurse proceed with the genital examination?
m
a. Eliciting the cremasteric reflex is recommended.
co
b. The glans is assessed for redness or lesions.
c. Retracting the foreskin should be avoided until the infant is 3 months old.
nk
.
d. Any dirt or smegma that has collected under the foreskin should be noted.
kt
a
ANS: C
If uncircumcised, then the foreskin is normally tight during the first 3 months and should not be
retracted because of the risk of tearing the membrane attaching the foreskin to the shaft. The
ba
n
other options are not correct.
DIF: Cognitive Level: Applying (Application) REF: p. 706
st
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
.te
25. A 2-year-old boy has been diagnosed with physiologic cryptorchidism. Considering this
diagnosis, during assessment the nurse will most likely observe:
w
a. Testes that are hard and painful to palpation.
w
b. Atrophic scrotum and a bilateral absence of the testis.
w
c. Absence of the testis in the scrotum, but the testis can be milked down.
d. Testes that migrate into the abdomen when the child squats or sits cross-legged.
ANS: C
Migratory testes (physiologic cryptorchidism) are common because of the strength of the
cremasteric reflex and the small mass of the prepubertal testes. The affected side has a normally
developed scrotum and the testis can be milked down. The other responses are not correct.
DIF: Cognitive Level: Applying (Application) REF: p. 707
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
26. The nurse knows that a common assessment finding in a boy younger than 2 years old is:
a. Inflamed and tender spermatic cord.
m
b. Presence of a hernia in the scrotum.
co
c. Penis that looks large in relation to the scrotum.
nk
.
d. Presence of a hydrocele, or fluid in the scrotum.
ANS: D
scrotum. The other options are not correct.
kt
a
A common scrotal finding in boys younger than 2 years of age is a hydrocele, or fluid in the
ba
n
DIF: Cognitive Level: Applying (Application) REF: p. 707
MSC: Client Needs: Health Promotion and Maintenance
st
27. During an examination of an aging man, the nurse recognizes that normal changes to expect
.te
would be:
a. Change in scrotal color.
w
b. Decrease in the size of the penis.
c. Enlargement of the testes and scrotum.
w
w
d. Increase in the number of rugae over the scrotal sac.
ANS: B
When assessing the genitals of an older man, the nurse may notice thinner, graying pubic hair
and a decrease in the size of the penis. The size of the testes may be decreased, they may feel less
firm, and the scrotal sac is pendulous with less rugae. No change in scrotal color is observed.
DIF: Cognitive Level: Applying (Application) REF: p. 708
MSC: Client Needs: Health Promotion and Maintenance
28. When performing a genital assessment on a middle-aged man, the nurse notices multiple soft,
moist, painless papules in the shape of cauliflower-like patches scattered across the shaft of the
penis. These lesions are characteristic of:
m
a. Carcinoma.
b. Syphilitic chancres.
co
c. Genital herpes.
nk
.
d. Genital warts.
ANS: D
kt
a
The lesions of genital warts are soft, pointed, moist, fleshy, painless papules that may be single
or multiple in a cauliflower-like patch. They occur on the shaft of the penis, behind the corona,
or around the anus, where they may grow into large grapelike clusters. (See Table 24-4 for more
ba
n
information and for the descriptions of the other options.)
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 713
st
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
.te
29. A 15-year-old boy is seen in the clinic for complaints of dull pain and pulling in the scrotal
area. On examination, the nurse palpates a soft, irregular mass posterior to and above the testis
w
on the left. This mass collapses when the patient is supine and refills when he is upright. This
w
description is consistent with:
w
a. Epididymitis.
b. Spermatocele.
c. Testicular torsion.
d. Varicocele.
ANS: D
A varicocele consists of dilated, tortuous varicose veins in the spermatic cord caused by
incompetent valves within the vein. Symptoms include dull pain or a constant pulling or
dragging feeling, or the individual may be asymptomatic. When palpating the mass, the examiner
will feel a soft, irregular mass posterior to and above the testis that collapses when the individual
is supine and refills when the individual is upright. (See Table 24-6 for more information and for
m
the descriptions of the other options.)
co
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 717
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
nk
.
30. When performing a genitourinary assessment on a 16-year-old male adolescent, the nurse
notices a swelling in the scrotum that increases with increased intra-abdominal pressure and
kt
a
decreases when he is lying down. The patient complains of pain when straining. The nurse
knows that this description is most consistent with a(n) ______ hernia.
ba
n
a. Femoral
b. Incisional
c. Direct inguinal
st
d. Indirect inguinal
.te
ANS: D
With indirect inguinal hernias, pain occurs with straining and a soft swelling increases with
w
increased intra-abdominal pressure, which may decrease when the patient lies down. These
w
findings do not describe the other hernias. (See Table 24-7 for the descriptions of femoral, direct
w
inguinal, and indirect inguinal hernias.)
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 719
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
31. When the nurse is performing a testicular examination on a 25-year-old man, which finding
is considered normal?
a. Nontender subcutaneous plaques
b. Scrotal area that is dry, scaly, and nodular
c. Testes that feel oval and movable and are slightly sensitive to compression
d. Single, hard, circumscribed, movable mass, less than 1 cm under the surface of
the testes
m
ANS: C
co
Testes normally feel oval, firm and rubbery, smooth, and bilaterally equal and are freely movable
and slightly tender to moderate pressure. The scrotal skin should not be dry, scaly, or nodular or
nk
.
contain subcutaneous plaques. Any mass would be an abnormal finding.
kt
a
DIF: Cognitive Level: Applying (Application) REF: p. 702
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
ba
n
32. The nurse is inspecting the scrotum and testes of a 43-year-old man. Which finding would
require additional follow-up and evaluation?
a. Skin on the scrotum is taut.
st
b. Left testicle hangs lower than the right testicle.
.te
c. Scrotal skin has yellowish 1-cm nodules that are firm and nontender.
ANS: A
w
d. Testes move closer to the body in response to cold temperatures.
w
Scrotal swelling may cause the skin to be taut and to display pitting edema. Normal scrotal skin
w
is rugae, and asymmetry is normal with the left scrotal half usually lower than the right. The
testes may move closer to the body in response to cold temperatures.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 718
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
33. A 55-year-old man is experiencing severe pain of sudden onset in the scrotal area. It is
somewhat relieved by elevation. On examination the nurse notices an enlarged, red scrotum that
is very tender to palpation. Distinguishing the epididymis from the testis is difficult, and the
scrotal skin is thick and edematous. This description is consistent with which of these?
a. Varicocele
m
b. Epididymitis
co
c. Spermatocele
d. Testicular torsion
nk
.
ANS: B
Epididymitis presents as severe pain of sudden onset in the scrotum that is somewhat relieved by
kt
a
elevation. On examination, the scrotum is enlarged, reddened, and exquisitely tender. The
epididymis is enlarged and indurated and may be hard to distinguish from the testis. The
overlying scrotal skin may be thick and edematous. (See Table 24-6 for more information and for
ba
n
the descriptions of the other terms.)
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 716
st
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
.te
34. The nurse is performing a genitourinary assessment on a 50-year-old obese male laborer. On
examination, the nurse notices a painless round swelling close to the pubis in the area of the
w
internal inguinal ring that is easily reduced when the individual is supine. These findings are
w
most consistent with a(n) ______ hernia.
w
a. Scrotal
b. Femoral
c. Direct inguinal
d. Indirect inguinal
ANS: C
Direct inguinal hernias occur most often in men over the age of 40 years. It is an acquired
weakness brought on by heavy lifting, obesity, chronic cough, or ascites. The direct inguinal
hernia is usually a painless, round swelling close to the pubis in the area of the internal inguinal
ring that is easily reduced when the individual is supine. (See Table 24-6 for a description of
scrotal hernia. See Table 24-7 for the descriptions of femoral hernias and indirect inguinal
m
hernias.)
co
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 719
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
nk
.
35. The nurse is providing patient teaching about an erectile dysfunction drug. One of the drugs
potential side effects is prolonged, painful erection of the penis without sexual stimulation,
kt
a
which is known as:
a. Orchitis.
ba
n
b. Stricture.
c. Phimosis.
d. Priapism.
st
ANS: D
.te
Priapism is prolonged, painful erection of the penis without sexual desire. Orchitis is
inflammation of the testes. Stricture is a narrowing of the opening of the urethral meatus.
w
Phimosis is the inability to retract the foreskin.
w
w
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 714
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
36. During an examination, the nurse notices that a male patient has a red, round, superficial
ulcer with a yellowish serous discharge on his penis. On palpation, the nurse finds a nontender
base that feels like a small button between the thumb and fingers. At this point the nurse suspects
that this patient has:
a. Genital warts.
b. Herpes infection.
c. Syphilitic chancre.
d. Carcinoma lesion.
m
ANS: C
Table 24-4 for the descriptions of the other options.)
nk
.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 714
co
This lesion indicates syphilitic chancre, which begins within 2 to 4 weeks of infection. (See
kt
a
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
37. During a health history, a patient tells the nurse that he has trouble in starting his urine
ba
n
stream. This problem is known as:
a. Urgency.
b. Dribbling.
.te
d. Hesitancy.
st
c. Frequency.
ANS: D
w
Hesitancy is trouble in starting the urine stream. Urgency is the feeling that one cannot wait to
w
urinate. Dribbling is the last of the urine before or after the main act of urination. Frequency is
w
urinating more often than usual.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 696
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
38. During a genital examination, the nurse notices that a male patient has clusters of small
vesicles on the glans, surrounded by erythema. The nurse recognizes that these lesions are:
a. Peyronie disease.
b. Genital warts.
c. Genital herpes.
d. Syphilitic cancer.
m
ANS: C
Genital herpes, or herpes simplex virus 2 (HSV-2), infections are indicated with clusters of small
nk
.
(See Table 24-4 for the descriptions of the other options.)
co
vesicles with surrounding erythema, which are often painful and erupt on the glans or foreskin.
DIF: Cognitive Level: Applying (Application) REF: p. 713
kt
a
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
39. During a physical examination, the nurse finds that a male patients foreskin is fixed and tight
ba
n
and will not retract over the glans. The nurse recognizes that this condition is:
a. Phimosis.
c. Urethral stricture.
.te
d. Peyronie disease.
st
b. Epispadias.
w
ANS: A
w
With phimosis, the foreskin is nonretractable, forming a pointy tip of the penis with a tiny orifice
at the end of the glans. The foreskin is advanced and so tight that it is impossible to retract over
w
the glans. This condition may be congenital or acquired from adhesions related to infection. (See
Table 24-3 for information on urethral stricture. See Table 24-4 for information on epispadias
and Peyronie disease.)
DIF: Cognitive Level: Applying (Application) REF: p. 700
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
MULTIPLE RESPONSE
1. A 55-year-old man is in the clinic for a yearly checkup. He is worried because his father died
of prostate cancer. The nurse knows which tests should be performed at this time? Select all that
apply.
m
a. Blood test for prostate-specific antigen (PSA)
b. Urinalysis
co
c. Transrectal ultrasound
d. Digital rectal examination (DRE)
nk
.
e. Prostate biopsy
kt
a
ANS: A, D
Prostate cancer is typically detected by testing the blood for PSA or by a DRE. It is
recommended that both PSA and DRE be offered to men annually, beginning at age 50 years. If
ba
n
the PSA is elevated, then further laboratory work or a transrectal ultrasound (TRUS) and biopsy
may be recommended.
st
DIF: Cognitive Level: Applying (Application) REF: p. 708
.te
MSC: Client Needs: Health Promotion and Maintenance
2. A 16-year-old boy is brought to the clinic for a problem that he refused to let his mother see.
w
The nurse examines him, and finds that he has scrotal swelling on the left side. He had the
mumps the previous week, and the nurse suspects that he has orchitis. Which of the following
w
w
assessment findings support this diagnosis? Select all that apply.
a. Swollen testis
b. Mass that transilluminates
c. Mass that does not transilluminate
d. Scrotum that is nontender upon palpation
e. Scrotum that is tender upon palpation
f. Scrotal skin that is reddened
ANS: A, C, E, F
With orchitis, the testis is swollen, with a feeling of weight, and is tender or painful. The mass
does not transilluminate, and the scrotal skin is reddened. Transillumination of a mass occurs
with a hydrocele, not orchitis.
m
Chapter 13. Obstetrics Guidelines
co
MULTIPLE CHOICE
1. Which of these statements best describes the action of the hormone progesterone during
nk
.
pregnancy?
a. Progesterone produces the hormone human chorionic gonadotropin.
kt
a
b. Duct formation in the breast is stimulated by progesterone.
c. Progesterone promotes sloughing of the endometrial wall.
ba
n
d. Progesterone maintains the endometrium around the fetus.
ANS: D
st
Progesterone prevents the sloughing of the endometrial wall and maintains the endometrium
around the fetus. Progesterone increases the alveoli in the breast and keeps the uterus in a
.te
quiescent state. The other options are not correct.
w
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 807
w
MSC: Client Needs: General
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2. A female patient has nausea, breast tenderness, fatigue, and amenorrhea. Her last menstrual
period was 6 weeks ago. The nurse interprets that this patient is experiencing __________ signs
of pregnancy.
a. Positive
b. Possible
c. Probable
d. Presumptive
ANS: D
Presumptive signs of pregnancy are those that the woman experiences and include amenorrhea,
breast tenderness, fatigue, nausea, and increased urinary frequency. Probable signs are those that
m
are detected by the examiner, such as an enlarged uterus or changes in the cervix. Positive signs
positive cardiac activity on ultrasound.
nk
.
DIF: Cognitive Level: Applying (Application) REF: p. 807
co
of pregnancy are those that document direct evidence of the fetus such as fetal heart tones or
MSC: Client Needs: Health Promotion and Maintenance
kt
a
3. A woman who is 8 weeks pregnant is visiting the clinic for a checkup. Her systolic blood
pressure is 30 mm Hg higher than her prepregnancy systolic blood pressure. The nurse should:
ba
n
a. Consider this a normal finding.
b. Expect the blood pressure to decrease as the estrogen levels increase throughout
the pregnancy.
st
c. Consider this an abnormal finding because blood pressure is typically lower at
this point in the pregnancy.
w
ANS: C
.te
d. Recommend that she decrease her salt intake in an attempt to decrease her
peripheral vascular resistance.
w
During the seventh gestational week, blood pressure begins to drop as a result of falling
w
peripheral vascular resistance. Early in the first trimester, blood pressure values are similar to
those of prepregnancy measurements. In this case, the womans blood pressure is higher than it
should be.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 808
MSC: Client Needs: Health Promotion and Maintenance
4. A patient is being seen at the clinic for her 10-week prenatal visit. She asks when she will be
able to hear the babys heartbeat. The nurse should reply:
a. The babys heartbeat is not usually heard until the second trimester.
b. The babys heartbeat may be heard anywhere from the ninth to the twelfth week.
c. It is often difficult to hear the heartbeat at this point, but we can try.
m
d. It is normal to hear the heartbeat at 6 weeks. We may be able to hear it today.
co
ANS: B
nk
.
Fetal heart tones can be heard with the use of the Doppler device between 9 and 12 weeks. The
other responses are incorrect.
kt
a
DIF: Cognitive Level: Applying (Application) REF: p. 821
ba
n
MSC: Client Needs: Health Promotion and Maintenance
5. A patient who is in her first trimester of pregnancy tells the nurse that she is experiencing
significant nausea and vomiting and asks when it will improve. The nurse should reply:
st
a. Did your mother have significant nausea and vomiting?
b. Many women experience nausea and vomiting until the third trimester.
.te
c. Usually, by the beginning of the second trimester, the nausea and vomiting
improve.
w
w
d. At approximately the time you begin to feel the baby move, the nausea and
vomiting will subside.
w
ANS: C
The nausea, vomiting, and fatigue of pregnancy improve by the 12th week. Quickening, when
the mother recognizes fetal movement, occurs at approximately 18 to 20 weeks.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 808
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
6. During the examination of a woman in her second trimester of pregnancy, the nurse notices
the presence of a small amount of yellow drainage from the nipples. The nurse knows that this is:
a. An indication that the womans milk is coming in.
b. A sign of possible breast cancer in a pregnant woman.
m
c. Most likely colostrum and considered a normal finding at this stage of the
pregnancy.
co
d. Too early in the pregnancy for lactation to begin and refers the woman to a
specialist.
nk
.
ANS: C
During the second trimester, colostrum, the precursor of milk, may be expressed from the
kt
a
nipples. Colostrum is yellow and contains more minerals and protein but less sugar and fat than
mature milk. The other options are incorrect.
ba
n
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 808
MSC: Client Needs: Health Promotion and Maintenance
st
7. A woman in her second trimester of pregnancy complains of heartburn and indigestion. When
.te
discussing this with the woman, the nurse considers which explanation for these problems?
a. Tone and motility of the gastrointestinal tract increase during the second
trimester.
w
b. Sluggish emptying of the gallbladder, resulting from the effects of progesterone,
often causes heartburn.
w
w
c. Lower blood pressure at this time decreases blood flow to the stomach and
gastrointestinal tract.
d. Enlarging uterus and altered esophageal sphincter tone predispose the woman to
have heartburn.
ANS: D
Stomach displacement from the enlarging uterus plus altered esophageal sphincter and gastric
tone as a result of progesterone predispose the woman to heartburn. The tone and motility of the
gastrointestinal tract are decreased, not increased, during pregnancy. Emptying of the gallbladder
may become more sluggish during pregnancy but is not related to indigestion. Rather, some
women are predisposed to gallstone formation. A lower blood pressure may occur during the
second semester, but it does not affect digestion.
co
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
m
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 808
8. A patient who is 20 weeks pregnant tells the nurse that she feels more shortness of breath as
a. High levels of estrogen cause shortness of breath.
nk
.
her pregnancy progresses. The nurse recognizes which statement to be true?
kt
a
b. Feelings of shortness of breath are abnormal during pregnancy.
c. Hormones of pregnancy cause an increased respiratory effort.
ba
n
d. The patient should get more exercise in an attempt to increase her respiratory
reserve.
ANS: C
st
Progesterone and estrogen cause an increase in respiratory effort during pregnancy by increasing
tidal volume. Increased tidal volume causes a slight drop in partial pressure of arterial carbon
.te
dioxide (PaCO2), causing the woman to have dyspnea occasionally. The other options are not
w
correct.
w
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 809
w
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
9. The nurse auscultates a functional systolic murmur, grade II/IV, on a woman in week 30 of her
pregnancy. The remainder of her physical assessment is within normal limits. The nurse would:
a. Consider this finding abnormal, and refer her for additional consultation.
b. Ask the woman to run briefly in place and then assess for an increase in intensity
of the murmur.
c. Know that this finding is normal and is a result of the increase in blood volume
during pregnancy.
d. Ask the woman to restrict her activities and return to the clinic in 1 week for reevaluation.
ANS: C
nk
.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 809
co
be heard in 95% of pregnant women. The other actions are not appropriate.
m
Because of the increase in blood volume, a functional systolic murmur, grade II/IV or less, can
MSC: Client Needs: Health Promotion and Maintenance
kt
a
10. A woman who is 28 weeks pregnant has bilateral edema in her lower legs after working 8
hours a day as a cashier at a local grocery store. She is worried about her legs. What is the nurses
ba
n
best response?
a. You will be at risk for development of varicose veins when your legs are
edematous.
st
b. I would like to listen to your heart sounds. Edema can indicate a problem with
your heart.
.te
c. Edema is usually the result of too much salt and fluids in your diet. You may
need to cut down on salty foods.
w
ANS: D
w
d. As your baby grows, it slows blood return from your legs, causing the swelling.
This often occurs with prolonged standing.
w
Edema of the lower extremities occurs because of the enlarging fetus, which impairs venous
return. Prolonged standing worsens the edema. Typically, the bilateral, dependent edema
experienced with pregnancy is not the result of a cardiac pathologic condition.
DIF: Cognitive Level: Applying (Application) REF: p. 809
MSC: Client Needs: Health Promotion and Maintenance
11. When assessing a woman who is in her third trimester of pregnancy, the nurse looks for the
classic symptoms associated with preeclampsia, which include:
a. Edema, headaches, and seizures.
b. Elevated blood pressure and proteinuria.
c. Elevated liver enzymes and high platelet counts.
m
d. Decreased blood pressure and edema.
co
ANS: B
nk
.
The classic symptoms of preeclampsia are hypertension and proteinuria. Headaches may occur
with worsening symptoms, and seizures may occur if preeclampsia is left untreated and leads to
eclampsia. A serious variant of preeclampsia, the hemolysis, elevated liver enzymes, low platelet
kt
a
count (HELLP) syndrome, is an ominous picture. Edema is a common occurrence in pregnancy.
ba
n
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 817
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
prenatal visit is:
st
12. The nurse knows that the best time to assess a womans blood pressure during an initial
.te
a. At the end of the examination when she will be the most relaxed.
b. At the beginning of the interview as a nonthreatening method of gaining rapport.
w
c. During the middle of the physical examination when she is the most comfortable.
w
w
d. Before beginning the pelvic examination because her blood pressure will be
higher after the pelvic examination.
ANS: A
Assessing the womans blood pressure at the end of the examination, when it is hoped that she
will be most relaxed, is the best time to assess blood pressure. The other options are not correct.
DIF: Cognitive Level: Applying (Application) REF: p. 823
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
13. When examining the face of a woman who is 28 weeks pregnant, the nurse notices the
presence of a butterfly-shaped increase in pigmentation on the face. The proper term for this
finding in the documentation is:
m
a. Striae.
b. Chloasma.
co
c. Linea nigra.
nk
.
d. Mask of pregnancy.
ANS: B
kt
a
Chloasma is a butterfly-shaped increase in pigmentation on the face. It is known as the mask of
pregnancy, but when documenting, the nurse should use the correct medical term, chloasma.
Striae is the term for stretch marks. The linea nigra is a hyperpigmented line that begins at the
ba
n
sternal notch and extends down the abdomen through the umbilicus to the pubis.
DIF: Cognitive Level: Applying (Application) REF: p. 815
st
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
.te
14. Which finding is considered normal and expected when the nurse is performing a physical
w
examination on a pregnant woman?
a. Palpable, full thyroid
w
b. Edema in one lower leg
w
c. Significant diffuse enlargement of the thyroid
d. Pale mucous membranes of the mouth
ANS: A
The thyroid may be palpable during pregnancy. It should feel full, but smooth. Significant
diffuse enlargement occurs with hyperthyroidism, thyroiditis, and hypothyroidism. Pale mucous
membranes may indicate anemia. Bilateral lower extremity edema is common in pregnancy, but
edema with pain in only one leg occurs with deep vein thrombosis.
DIF: Cognitive Level: Applying (Application) REF: p. 816
MSC: Client Needs: Health Promotion and Maintenance
m
15. When auscultating the anterior thorax of a pregnant woman, the nurse notices the presence of
co
a murmur over the second, third, and fourth intercostal spaces. The murmur is continuous but can
be obliterated by pressure with the stethoscope or finger on the thorax just lateral to the murmur.
nk
.
The nurse interprets this finding to be:
a. Murmur of aortic stenosis.
c. Associated with aortic insufficiency.
ba
n
d. Indication of a patent ductus arteriosus.
kt
a
b. Most likely a mammary souffle.
ANS: B
Blood flow through the blood vessels, specifically the internal mammary artery, can often be
st
heard over the second, third, and fourth intercostal spaces. This finding is called a mammary
.te
souffle, but it may be mistaken for a cardiac murmur. The other options are incorrect.
w
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 816
w
MSC: Client Needs: Health Promotion and Maintenance
16. When the nurse is assessing the deep tendon reflexes (DTRs) on a woman who is 32 weeks
w
pregnant, which of these would be considered a normal finding on a 0 to 4+ scale?
a. Absent DTRs
b. 2+
c. 4+
d. Brisk reflexes and the presence of clonus
ANS: B
Normally during pregnancy, the DTRs are 1+ to 2+ and bilaterally equal. Brisk or greater than
2+ DTRs and the presence of clonus are abnormal and may be associated with an elevated blood
pressure and cerebral edema in the preeclamptic woman.
m
DIF: Cognitive Level: Applying (Application) REF: p. 817
co
MSC: Client Needs: Health Promotion and Maintenance
17. When performing an examination of a woman who is 34 weeks pregnant, the nurse notices a
nk
.
midline linear protrusion in the abdomen over the area of the rectus abdominis muscles as the
woman raises her head and shoulders off of the bed. Which response by the nurse is correct?
kt
a
a. The presence of diastasis recti should be documented.
b. This condition should be discussed with the physician because it will most likely
need to be surgically repaired.
ba
n
c. The possibility that the woman has a hernia attributable to the increased pressure
within the abdomen from the pregnancy should be suspected.
st
d. The woman should be told that she may have a difficult time with delivery
because of the weakness in her abdominal muscles.
.te
ANS: A
The separation of the abdominal muscles is called diastasis recti and frequently occurs during
w
pregnancy. The rectus abdominis muscles will return together after pregnancy with abdominal
w
exercise. This condition is not a true hernia.
w
DIF: Cognitive Level: Applying (Application) REF: p. 817
MSC: Client Needs: Health Promotion and Maintenance
18. The nurse is palpating the fundus of a pregnant woman. Which statement about palpation of
the fundus is true?
a. The fundus should be hard and slightly tender to palpation during the first
trimester.
b. Fetal movement may not be felt by the examiner until the end of the second
trimester.
c. After 20 weeks gestation, the number of centimeters should approximate the
number of weeks gestation.
m
d. Fundal height is usually less than the number of weeks gestation, unless an
abnormal condition such as excessive amniotic fluid is present.
ANS: C
co
After 20 weeks gestation, the number of centimeters should approximate the number of weeks
gestation. In addition, at 20 weeks gestation, the examiner may be able to feel fetal movement
nk
.
and the head can be balloted.
kt
a
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 818
MSC: Client Needs: Health Promotion and Maintenance
ba
n
19. The nurse is palpating the abdomen of a woman who is 35 weeks pregnant and notices that
the fetal head is facing downward toward the pelvis. The nurse would document this as fetal:
a. Lie.
st
b. Variety.
.te
c. Attitude.
w
ANS: D
w
d. Presentation.
Fetal presentation describes the part of the fetus that is entering the pelvis first. Fetal lie is
w
orientation of the fetal spine to the maternal spine. Fetal attitude is the position of fetal parts in
relation to each other, and fetal variety is the location of the fetal back to the maternal pelvis.
DIF: Cognitive Level: Applying (Application) REF: p. 818
MSC: Client Needs: Health Promotion and Maintenance
20. The nurse is palpating the uterus of a woman who is 8 weeks pregnant. Which finding would
be considered to be most consistent with this stage of pregnancy?
a. The uterus seems slightly enlarged and softened.
b. It reaches the pelvic brim and is approximately the size of a grapefruit.
m
c. The uterus rises above the pelvic brim and is approximately the size of a
cantaloupe.
co
d. It is about the size of an avocado, approximately 8 cm across the fundus.
nk
.
ANS: D
The 8-week pregnant uterus is approximately the size of an avocado, 7 to 8 cm across the fundus.
The 6-week pregnant uterus is slightly enlarged and softened. The 10-week pregnant uterus is
kt
a
approximately the size of a grapefruit and may reach the pelvic brim. The 12-week pregnant
uterus will fill the pelvis. At 12 weeks, the uterus is sized from the abdomen.
ba
n
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 822
MSC: Client Needs: Health Promotion and Maintenance
st
21. Which of these correctly describes the average length of pregnancy?
.te
a. 38 weeks
b. 9 lunar months
w
c. 280 days from the last day of the last menstrual period
w
d. 280 days from the first day of the last menstrual period
w
ANS: D
The average length of pregnancy is 280 days from the first day of the last menstrual period,
which is equal to 40 weeks, 10 lunar months, or roughly 9 calendar months.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 807
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
22. A patients pregnancy test is positive, and she wants to know when the baby is due. The first
day of her last menstrual period was June 14, and that period ended June 20. Using the Ngele
rule, what is her expected date of delivery?
a. March 7
b. March 14
m
c. March 21
co
d. March 27
nk
.
ANS: C
To determine the expected date of delivery using the Ngele rule, 7 days are added to the first day
of the last menstrual period; then 3 months are subtracted. Therefore, adding 7 days to June 14
kt
a
would be June 21 and subtracting 3 months would make the expected delivery date March 21.
ba
n
DIF: Cognitive Level: Analyzing (Analysis) REF: pp. 809-810
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
23. During the assessment of a woman in her 22nd week of pregnancy, the nurse is unable to
st
hear fetal heart tones with the fetoscope. The nurse should:
.te
a. Immediately notify the physician, then wait 10 minutes and try again.
b. Ask the woman if she has felt the baby move today.
w
c. Wait 10 minutes, and try again.
w
d. Use ultrasound to verify cardiac activity.
w
ANS: D
If no fetal heart tones are heard during auscultation with a fetoscope, then the nurse should verify
cardiac activity using ultrasonography. An ultrasound should be immediately done and before
notifying the physician or causing the woman distress by asking about fetal movement.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 821
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
24. A patient who is 24 weeks pregnant asks about wearing a seat belt while driving. Which
response by the nurse is correct?
a. Seat belts should not be worn during pregnancy.
m
b. Place the lap belt below the uterus and use the shoulder strap at the same time.
c. Place the lap belt below the uterus but omit the shoulder strap during pregnancy.
nk
.
co
d. Place the lap belt at your waist above the uterus and use the shoulder strap at the
same time.
ANS: B
kt
a
For maternal and fetal safety, the nurse should instruct the woman to place the lap belt below the
uterus and to use the shoulder strap. The other instructions are incorrect.
ba
n
DIF: Cognitive Level: Applying (Application) REF: p. 814
MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential
st
25. During a health history interview, a 38-year-old woman shares that she is thinking about
having another baby. The nurse knows which statement to be true regarding pregnancy after 35
.te
years of age?
a. Fertility does not start to decline until age 40 years.
w
w
b. Occurrence of Down syndrome is significantly more frequent after the age of 35
years.
c. Genetic counseling and prenatal screening are not routine until after age 40 years.
w
d. Women older than 35 years who are pregnant have the same rate of pregnancyrelated complications as those who are younger than 35 years.
ANS: B
The risk of Down syndrome increases as the woman ages, from approximately 1 in 1250 at age
25 years to 1 in 400 at age 35 years. Fertility declines with advancing maternal age. Women 35
years and older or with a history of a genetic abnormality are offered genetic counseling and the
options of prenatal diagnostic screening tests. Because the incidence of chronic diseases
increases with age, women older than 35 years who are pregnant more often have medical
complications such as diabetes, obesity, and hypertension.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 810
m
MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential
co
26. A 25-year-old woman is in the clinic for her first prenatal visit. The nurse will prepare to
b. Complete blood cell count
c. Alpha-fetoprotein
d. Carrier screening for cystic fibrosis
ba
n
ANS: B
kt
a
a. Urine toxicology
nk
.
obtain which laboratory screening test at this time?
At the onset of pregnancy, a routine prenatal panel usually includes a complete blood cell count,
serologic testing, rubella antibodies, hepatitis B screening, blood type and Rhesus factor, and
st
antibody screen. A clean-catch urine sample is collected for urinalysis to rule out cystitis. Urine
toxicology, although beneficial for women if active substance abuse is suspected or known, is
.te
not routinely performed. In the second trimester, maternal serum is analyzed for alphafetoprotein. Carrier screening for cystic fibrosis is offered to check whether a person carries the
w
abnormal gene that causes cystic fibrosis but is not part of routine testing.
w
w
DIF: Cognitive Level: Applying (Application) REF: p. 823
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
27. A woman at 25 weeks gestation comes to the clinic for her prenatal visit. The nurse notices
that her face and lower extremities are swollen, and her blood pressure is 154/94 mm Hg. The
woman states that she has had headaches and blurry vision but thought she was just tired. What
should the nurse suspect?
a. Eclampsia
b. Preeclampsia
c. Diabetes type 1
d. Preterm labor
m
ANS: B
Classic symptoms of preeclampsia include elevated blood pressure (greater than 140 mm Hg
co
systolic or 90 mm Hg diastolic in a woman with previously normal blood pressure) and
proteinuria. Onset and worsening symptoms may be sudden, and subjective signs include
nk
.
headaches and visual changes. Eclampsia is manifested by generalized tonic-clonic seizures.
These symptoms are not indicative of diabetes mellitus (type 1 or 2) or preterm labor.
kt
a
DIF: Cognitive Level: Applying (Application) REF: p. 826
ba
n
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
28. During auscultation of fetal heart tones (FHTs), the nurse determines that the heart rate is 136
beats per minute. The nurses next action should be to:
st
a. Document the results, which are within normal range.
.te
b. Take the maternal pulse to verify these findings as the uterine souffle.
c. Have the patient change positions and count the FHTs again.
w
ANS: A
w
d. Immediately notify the physician for possible fetal distress.
w
The normal fetal heart rate is between 110 and 160 beats per minute. The nurse should document
the results as within the normal range. The other options are not correct.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 821
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
29. During a womans 34th week of pregnancy, she is told that she has preeclampsia. The nurse
knows which statement concerning preeclampsia is true?
a. Preeclampsia has little effect on the fetus.
b. Edema is one of the main indications of preeclampsia.
d. Untreated preeclampsia may contribute to restriction of fetal growth.
co
ANS: D
m
c. Eclampsia only occurs before delivery of the baby.
nk
.
Untreated preeclampsia may progress to eclampsia, which is manifested by generalized tonicclonic seizures. Eclampsia may develop as late as 10 days postpartum. Before the syndrome
becomes clinically manifested, it is affecting the placenta through vasospasm and a series of
kt
a
small infarctions. The placentas capacity to deliver oxygen and nutrients may be seriously
diminished, and fetal growth may be restricted. Edema is common in pregnancy and is not an
ba
n
indicator of preeclampsia.
DIF: Cognitive Level: Applying (Application) REF: p. 826
st
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
.te
MULTIPLE RESPONSE
1. During a group prenatal teaching session, the nurse teaches Kegel exercises. Which statements
w
would be appropriate for this teaching session? Select all that apply.
w
a. Kegel exercises help keep your uterus strong during the pregnancy.
w
b. Kegel exercises should be performed twice a day.
c. Kegel exercises should be performed 50 to 100 times a day.
d. To perform Kegel exercises, slowly squeeze to a peak at the count of eight, and
then slowly release to a count of eight.
e. To perform Kegel exercises, rapidly perform alternating squeeze-release
exercises up to the count of eight.
ANS: C, D
Kegel exercises can be performed to prepare for and to recover from birth. The nurse should
direct the woman to squeeze slowly to a peak at the count of eight and then to release slowly to
the count of eight. The nurse can prescribe this exercise to be performed 50 to 100 times a day.
Chapter 14. Gynecologic Guidelines
m
MULTIPLE CHOICE
1. During a health history, a 22-year old woman asks, Can I get that vaccine for human
co
papilloma virus (HPV)? I have genital warts and Id like them to go away! What is the nurses best
nk
.
response?
a. The HPV vaccine is for girls and women ages 9 to 26 years, so we can start that
today.
kt
a
b. This vaccine is only for girls who have not yet started to become sexually active.
c. Lets check with the physician to see if you are a candidate for this vaccine.
ba
n
d. The vaccine cannot protect you if you already have an HPV infection.
ANS: D
st
The HPV vaccine is appropriate for girls and women age 9 to 26 years and is administered to
prevent cervical cancer by preventing HPV infections before girls become sexually active.
.te
However, it cannot protect the woman if an HPV infection is already present.
w
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 740
w
MSC: Client Needs: General
w
2. During an examination, the nurse observes a female patients vestibule and expects to see the:
a. Urethral meatus and vaginal orifice.
b. Vaginal orifice and vestibular (Bartholin) glands.
c. Urethral meatus and paraurethral (Skene) glands.
d. Paraurethral (Skene) and vestibular (Bartholin) glands.
ANS: A
The labial structures encircle a boat-shaped space, or cleft, termed the vestibule. Within the
vestibule are numerous openings. The urethral meatus and vaginal orifice are visible. The ducts
of the paraurethral (Skene) glands and the vestibular (Bartholin) glands are present but not
co
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 737
m
visible.
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
nk
.
3. During a speculum inspection of the vagina, the nurse would expect to see what at the end of
the vaginal canal?
kt
a
a. Cervix
b. Uterus
ba
n
c. Ovaries
d. Fallopian tubes
st
ANS: A
.te
At the end of the canal, the uterine cervix projects into the vagina.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 738
w
w
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
4. The uterus is usually positioned tilting forward and superior to the bladder. This position is
w
known as:
a. Anteverted and anteflexed.
b. Retroverted and anteflexed.
c. Retroverted and retroflexed.
d. Superiorverted and anteflexed.
ANS: A
The uterus is freely movable, not fixed, and usually tilts forward and superior to the bladder (a
position labeled as anteverted and anteflexed).
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 738
m
MSC: Client Needs: General
co
5. An 11-year-old girl is in the clinic for a sports physical examination. The nurse notices that
she has begun to develop breasts, and during the conversation the girl reveals that she is worried
nk
.
about her development. The nurse should use which of these techniques to best assist the young
girl in understanding the expected sequence for development? The nurse should:
kt
a
a. Use the Tanner scale on the five stages of sexual development.
b. Describe her development and compare it with that of other girls her age.
ba
n
c. Use the Jacobsen table on expected development on the basis of height and
weight data.
st
d. Reassure her that her development is within normal limits and tell her not to
worry about the next step.
.te
ANS: A
The Tanner scale on the five stages of pubic hair development is helpful in teaching girls the
expected sequence of sexual development (see Table 26-1). The other responses are not
w
appropriate.
w
w
DIF: Cognitive Level: Applying (Application) REF: p. 739
MSC: Client Needs: Health Promotion and Maintenance
6. A woman who is 8 weeks pregnant is in the clinic for a checkup. The nurse reads on her chart
that her cervix is softened and looks cyanotic. The nurse knows that the woman is exhibiting
__________ sign and __________ sign.
a. Tanner; Hegar
b. Hegar; Goodell
c. Chadwick; Hegar
d. Goodell; Chadwick
ANS: D
m
Shortly after the first missed menstrual period, the female genitalia show signs of the growing
fetus. The cervix softens (Goodell sign) at 4 to 6 weeks, and the vaginal mucosa and cervix look
co
cyanotic (Chadwick sign) at 8 to 12 weeks. These changes occur because of increased
vascularity and edema of the cervix and hypertrophy and hyperplasia of the cervical glands.
nk
.
Hegar sign occurs when the isthmus of the uterus softens at 6 to 8 weeks. Tanner sign is not a
correct response.
kt
a
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 739
ba
n
MSC: Client Needs: Health Promotion and Maintenance
7. Generally, the changes normally associated with menopause occur because the cells in the
reproductive tract are:
.te
b. Becoming fibrous.
st
a. Aging.
c. Estrogen dependent.
w
ANS: C
w
d. Able to respond to estrogen.
w
Because cells in the reproductive tract are estrogen dependent, decreased estrogen levels during
menopause bring dramatic physical changes. The other options are not correct.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 740
MSC: Client Needs: Health Promotion and Maintenance
8. The nurse is reviewing the changes that occur with menopause. Which changes are associated
with menopause?
a. Uterine and ovarian atrophy, along with a thinning of the vaginal epithelium
b. Ovarian atrophy, increased vaginal secretions, and increasing clitoral size
c. Cervical hypertrophy, ovarian atrophy, and increased acidity of vaginal secretions
co
m
d. Vaginal mucosa fragility, increased acidity of vaginal secretions, and uterine
hypertrophy
nk
.
ANS: A
The uterus shrinks because of its decreased myometrium. The ovaries atrophy to 1 to 2 cm and
are not palpable after menopause. The sacral ligaments relax, and the pelvic musculature
kt
a
weakens; consequently, the uterus droops. The cervix shrinks and looks paler with a thick
glistening epithelium. The vaginal epithelium atrophies, becoming thinner, drier, and itchy. The
vaginal pH becomes more alkaline, and secretions are decreased, which results in a fragile
ba
n
mucosal surface that is at risk for vaginitis.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 740
st
MSC: Client Needs: Health Promotion and Maintenance
.te
9. A 54-year-old woman who has just completed menopause is in the clinic today for a yearly
physical examination. Which of these statements should the nurse include in patient education?
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A postmenopausal woman:
w
a. Is not at any greater risk for heart disease than a younger woman.
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b. Should be aware that she is at increased risk for dyspareunia because of decreased
vaginal secretions.
c. Has only stopped menstruating; there really are no other significant changes with
which she should be concerned.
d. Is likely to have difficulty with sexual pleasure as a result of drastic changes in
the female sexual response cycle.
ANS: B
Decreased vaginal secretions leave the vagina dry and at risk for irritation and pain with
intercourse (dyspareunia). The other statements are incorrect.
DIF: Cognitive Level: Applying (Application) REF: p. 740
MSC: Client Needs: Health Promotion and Maintenance
m
10. A woman is in the clinic for an annual gynecologic examination. The nurse should plan to
a. Menstrual history, because it is generally nonthreatening.
co
begin the interview with the:
nk
.
b. Obstetric history, because it includes the most important information.
c. Urinary system history, because problems may develop in this area as well.
kt
a
d. Sexual history, because discussing it first will build rapport.
ba
n
ANS: A
Menstrual history is usually nonthreatening and therefore a good topic with which to begin the
interview. Obstetric, urinary, and sexual histories are also part of the interview but not
st
necessarily the best topics with which to start.
.te
DIF: Cognitive Level: Applying (Application) REF: p. 740
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
w
11. A patient has had three pregnancies and two live births. The nurse would record this
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information as grav _____, para _____, AB _____.
w
a. 2; 2; 1
b. 3; 2; 0
c. 3; 2; 1
d. 3; 3; 1
ANS: C
Gravida (grav) is the number of pregnancies. Para is the number of births. Abortions are
interrupted pregnancies, including elective abortions and spontaneous miscarriages.
DIF: Cognitive Level: Applying (Application) REF: p. 741
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
m
12. During the interview with a female patient, the nurse gathers data that indicate the patient is
co
perimenopausal. Which of these statements made by this patient leads to this conclusion?
a. I have noticed that my muscles ache at night when I go to bed.
nk
.
b. I will be very happy when I can stop worrying about having a period.
c. I have been noticing that I sweat a lot more than I used to, especially at night.
kt
a
d. I have only been pregnant twice, but both times I had breast tenderness as my first
symptom.
ba
n
ANS: C
Hormone shifts occur during the perimenopausal period, and associated symptoms of menopause
may occur, such as hot flashes, night sweats, numbness and tingling, headache, palpitations,
st
drenching sweats, mood swings, vaginal dryness, and itching. The other responses are not
.te
correct.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 741
w
MSC: Client Needs: Health Promotion and Maintenance
w
13. A 50-year-old woman calls the clinic because she has noticed some changes in her body and
w
breasts and wonders if these changes could be attributable to the hormone replacement therapy
(HRT) she started 3 months earlier. The nurse should tell her:
a. HRT is at such a low dose that side effects are very unusual.
b. HRT has several side effects, including fluid retention, breast tenderness, and
vaginal bleeding.
c. Vaginal bleeding with HRT is very unusual; I suggest you come into the clinic
immediately to have this evaluated.
d. It sounds as if your dose of estrogen is too high; I think you may need to decrease
the amount you are taking and then call back in a week.
ANS: B
Side effects of HRT include fluid retention, breast pain, and vaginal bleeding. The other
m
responses are not correct.
co
DIF: Cognitive Level: Applying (Application) REF: p. 741
nk
.
MSC: Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
14. A 52-year-old patient states that when she sneezes or coughs she wets herself a little. She is
kt
a
very concerned that something may be wrong with her. The nurse suspects that the problem is:
a. Dysuria.
b. Stress incontinence.
ba
n
c. Hematuria.
d. Urge incontinence.
st
ANS: B
.te
Stress incontinence is involuntary urine loss with physical strain, sneezing, or coughing. Dysuria
is pain or burning with urination. Hematuria is bleeding with urination. Urge incontinence is
involuntary urine loss that occurs as a result of an overactive detrusor muscle in the bladder that
w
w
contracts and causes an urgent need to void.
w
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 742
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
15. During the interview, a patient reveals that she has some vaginal discharge. She is worried
that it may be a sexually transmitted infection. The nurses most appropriate response to this
would be:
a. Oh, dont worry. Some cyclic vaginal discharge is normal.
b. Have you been engaging in unprotected sexual intercourse?
c. Id like some information about the discharge. What color is it?
d. Have you had any urinary incontinence associated with the discharge?
ANS: C
m
Questions that help the patient reveal more information about her symptoms should be asked in a
nonthreatening manner. Asking about the amount, color, and odor of the vaginal discharge
co
provides the opportunity for further assessment. Normal vaginal discharge is small, clear or
nk
.
cloudy, and always nonirritating.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 742
kt
a
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
16. A woman states that 2 weeks ago she had a urinary tract infection that was treated with an
ba
n
antibiotic. As a part of the interview, the nurse should ask, Have you noticed any:
a. Changes in your urination patterns?
b. Excessive vaginal bleeding?
st
c. Unusual vaginal discharge or itching?
.te
d. Changes in your desire for intercourse?
w
ANS: C
w
Several medications may increase the risk of vaginitis. Broad-spectrum antibiotics alter the
balance of normal flora, which may lead to the development of vaginitis. The other questions are
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not appropriate.
DIF: Cognitive Level: Applying (Application) REF: p. 742
MSC: Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
17. Which statement would be most appropriate when the nurse is introducing the topic of sexual
relationships during an interview?
a. Now, it is time to talk about your sexual history. When did you first have
intercourse?
b. Women often feel dissatisfied with their sexual relationships. Would it be okay to
discuss this now?
c. Women often have questions about their sexual relationship and how it affects
their health. Do you have any questions?
co
m
d. Most women your age have had more than one sexual partner. How many would
you say you have had?
ANS: C
nk
.
The nurse should begin with an open-ended question to assess individual needs. The nurse
should include appropriate questions as a routine part of the health history, because doing so
communicates that the nurse accepts the individuals sexual activity and believes it is important.
kt
a
The nurses comfort with the discussion prompts the patients interest and, possibly, relief that the
topic has been introduced. The initial discussion establishes a database for comparison with any
ba
n
future sexual activities and provides an opportunity to screen sexual problems.
DIF: Cognitive Level: Applying (Application) REF: p. 742
st
MSC: Client Needs: Psychosocial Integrity
.te
18. A 22-year-old woman has been considering using oral contraceptives. As a part of her health
history, the nurse should ask:
w
a. Do you have a history of heart murmurs?
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b. Will you be in a monogamous relationship?
c. Have you carefully thought this choice through?
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d. If you smoke, how many cigarettes do you smoke per day?
ANS: D
Oral contraceptives, together with cigarette smoking, increase the risk for cardiovascular side
effects. If cigarettes are used, then the nurse should assess the patients smoking history. The
other questions are not appropriate.
DIF: Cognitive Level: Applying (Application) REF: p. 743
MSC: Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
19. A married couple has come to the clinic seeking advice on pregnancy. They have been trying
to conceive for 4 months and have not been successful. What should the nurse do first?
m
a. Ascertain whether either of them has been using broad-spectrum antibiotics.
co
b. Explain that couples are considered infertile after 1 year of unprotected
intercourse.
nk
.
c. Immediately refer the woman to an expert in pelvic inflammatory diseasethe most
common cause of infertility.
kt
a
d. Explain that couples are considered infertile after 3 months of engaging in
unprotected intercourse and that they will need a referral to a fertility expert.
ANS: B
ba
n
Infertility is considered after 1 year of engaging in unprotected sexual intercourse without
conceiving. The other actions are not appropriate.
st
DIF: Cognitive Level: Applying (Application) REF: p. 743
.te
MSC: Client Needs: Psychosocial Integrity
20. A nurse is assessing a patients risk of contracting a sexually transmitted infection (STI). An
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appropriate question to ask would be:
w
a. You know that its important to use condoms for protection, right?
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b. Do you use a condom with each episode of sexual intercourse?
c. Do you have a sexually transmitted infection?
d. You are aware of the dangers of unprotected sex, arent you?
ANS: B
In reviewing a patients risk for STIs, the nurse should ask in a nonconfrontational manner
whether condoms are being used during each episode of sexual intercourse. Asking a person
whether he or she has an infection does not address the risk.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 743
m
MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential
co
21. When the nurse is interviewing a preadolescent girl, which opening question would be least
a. Do you have any questions about growing up?
b. What has your mother told you about growing up?
nk
.
threatening?
kt
a
c. When did you notice that your body was changing?
ba
n
d. I remember being very scared when I got my period. How do you think youll
feel?
ANS: C
Open-ended questions such as, When did you ? rather than Do you ? should be asked. Open-
.te
unexceptional.
st
ended questions are less threatening because they imply that the topic is normal and
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 743
w
MSC: Client Needs: Psychosocial Integrity
w
22. When the nurse is discussing sexuality and sexual issues with an adolescent, a permission
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statement helps convey that it is normal to think or feel a certain way. Which statement is the
best example of a permission statement?
a. It is okay that you have become sexually active.
b. Girls your age often have questions about sexual activity. Do you have any
questions?
c. If it is okay with you, Id like to ask you some questions about your sexual history.
d. Girls your age often engage in sexual activities. It is okay to tell me if you have
had intercourse.
ANS: B
The examiner should start with a permission statement such as, Girls your age often experience
implying that the topic is normal and unexceptional is important.
nk
.
MSC: Client Needs: Psychosocial Integrity
co
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 743
m
A permission statement conveys the idea that it is normal to think or feel a certain way, and
23. The nurse is preparing to interview a postmenopausal woman. Which of these statements is
kt
a
true as it applies to obtaining the health history of a postmenopausal woman?
ba
n
a. The nurse should ask a postmenopausal woman if she has ever had vaginal
bleeding.
b. Once a woman reaches menopause, the nurse does not need to ask any history
questions.
c. The nurse should screen for monthly breast tenderness.
.te
st
d. Postmenopausal women are not at risk for contracting STIs; therefore, these
questions can be omitted.
w
ANS: A
w
Postmenopausal bleeding warrants further workup and referral. The other statements are not true.
w
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 744
MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential
24. During the examination portion of a patients visit, she will be in lithotomy position. Which
statement reflects some things that the nurse can do to make this position more comfortable for
her?
a. Ask her to place her hands and arms over her head.
b. Elevate her head and shoulders to maintain eye contact.
c. Allow her to choose to have her feet in the stirrups or have them resting side by
side on the edge of the table.
d. Allow her to keep her buttocks approximately 6 inches from the edge of the table
to prevent her from feeling as if she will fall off.
m
ANS: B
co
The nurse should elevate her head and shoulders to maintain eye contact. The patients arms
should be placed at her sides or across the chest. Placing her hands and arms over her head only
nk
.
tightens the abdominal muscles. The feet should be placed into the stirrups, knees apart, and
buttocks at the edge of the examining table. The stirrups are placed so that the legs are not
abducted too far.
kt
a
DIF: Cognitive Level: Applying (Application) REF: p. 745
ba
n
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
25. An 18-year-old patient is having her first pelvic examination. Which action by the nurse is
appropriate?
st
a. Inviting her mother to be present during the examination
.te
b. Avoiding the lithotomy position for this first time because it can be
uncomfortable and embarrassing
w
c. Raising the head of the examination table and giving her a mirror so that she can
view the examination
w
w
d. Fully draping her, leaving the drape between her legs elevated to avoid
embarrassing her with eye contact
ANS: C
The techniques of the educational or mirror pelvic examination should be used. This is a routine
examination with some modifications in attitude, position, and communication. First, the woman
is considered an active participant, one who is interested in learning and in sharing decisions
about her own health care. The woman props herself up on one elbow, or the head of the table is
raised. Her other hand holds a mirror between her legs, above the examiners hands. The young
woman can see all that the examiner is doing and has a full view of her genitalia. The mirror
works well for teaching normal anatomy and its relationship to sexual behavior. The examiner
can ask her if she would like to have a family member, friend, or chaperone present for the
examination. The drape should be pushed down between the patients legs so that the nurse can
see her face.
m
DIF: Cognitive Level: Applying (Application) REF: p. 746
co
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
26. The nurse has just completed an inspection of a nulliparous womans external genitalia.
nk
.
Which of these would be a description of a finding within normal limits?
b. Multiple nontender sebaceous cysts
kt
a
a. Redness of the labia majora
c. Discharge that is foul smelling and irritating
ba
n
d. Gaping and slightly shriveled labia majora
ANS: B
st
No lesions should be noted, except for the occasional sebaceous cysts, which are yellowish 1-cm
nodules that are firm, nontender, and often multiple. The labia majora are dark pink, moist, and
.te
symmetric; redness indicates inflammation or lesions. Discharge that is foul smelling and
irritating may indicate infection. In the nulliparous woman, the labia majora meet in the midline,
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are symmetric and plump.
w
w
DIF: Cognitive Level: Applying (Application) REF: p. 747
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
27. The nurse is preparing for an internal genitalia examination of a woman. Which order of the
examination is correct?
a. Bimanual, speculum, and rectovaginal
b. Speculum, rectovaginal, and bimanual
c. Speculum, bimanual, and rectovaginal
d. Rectovaginal, bimanual, and speculum
ANS: C
The correct sequence is speculum examination, then bimanual examination after removing the
m
speculum, and then rectovaginal examination. The examiner should change gloves before
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performing the rectovaginal examination to avoid spreading any possible infection.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 748 |p. 754 |p. 758
nk
.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
proper insertion of the speculum?
kt
a
28. During an internal examination of a womans genitalia, the nurse will use which technique for
ba
n
a. The woman is instructed to bear down, the speculum blades are opened and
applied in a swift, upward movement.
b. The blades of the speculum are inserted on a horizontal plane, turning them to a
30-degree angle while continuing to insert them. The woman is asked to bear
down after the speculum is inserted.
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st
c. The woman is instructed to bear down, the width of the blades are horizontally
turned, and the speculum is inserted downward at a 45-degree angle toward the
small of the womans back.
w
w
d. The blades are locked open by turning the thumbscrew. Once the blades are open,
pressure is applied to the introitus and the blades are inserted downward at a 45degree angle to bring the cervix into view.
w
ANS: C
The examiner should instruct the woman to bear down, turn the width of the blades horizontally,
and insert the speculum at a 45-degree angle downward toward the small of the womans back.
(See the text under Speculum Examination for more detail.)
DIF: Cognitive Level: Applying (Application) REF: p. 749
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
29. The nurse is examining a 35-year-old female patient. During the health history, the nurse
notices that she has had two term pregnancies, and both babies were delivered vaginally. During
the internal examination, the nurse observes that the cervical os is a horizontal slit with some
healed lacerations and that the cervix has some nabothian cysts that are small, smooth, and
yellow. In addition, the nurse notices that the cervical surface is granular and red, especially
around the os. Finally, the nurse notices the presence of stringy, opaque, odorless secretions.
m
Which of these findings are abnormal?
co
a. Nabothian cysts are present.
c. The cervical surface is granular and red.
d. Stringy and opaque secretions are present.
kt
a
ANS: C
nk
.
b. The cervical os is a horizontal slit.
Normal findings: Nabothian cysts may be present on the cervix after childbirth. The cervical os
ba
n
is a horizontal, irregular slit in the parous woman. Secretions vary according to the day of the
menstrual cycle, and may be clear and thin or thick, opaque, and stringy. The surface is normally
smooth, but cervical eversion, or ectropion, may occur where the endocervical canal is rolled
.te
indicate a lesion.
st
out. Abnormal finding: The cervical surface should not be reddened or granular, which may
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 750
w
w
MSC: Client Needs: Health Promotion and Maintenance
30. A patient calls the clinic for instructions before having a Papanicolaou (Pap) smear. The most
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appropriate instructions from the nurse are:
a. If you are menstruating, please use pads to avoid placing anything into the
vagina.
b. Avoid intercourse, inserting anything into the vagina, or douching within 24
hours of your appointment.
c. If you suspect that you have a vaginal infection, please gather a sample of the
discharge to bring with you.
d. We would like you to use a mild saline douche before your examination. You
may pick this up in our office.
ANS: B
When instructing a patient before Pap smear is obtained, the nurse should follow these
guidelines: Do not obtain during the womans menses or if a heavy infectious discharge is
m
present. Instruct the woman not to douche, have intercourse, or put anything into the vagina
visit, not beforehand.
nk
.
DIF: Cognitive Level: Applying (Application) REF: p. 752
co
within 24 hours before collecting the specimens. Any specimens will be obtained during the
kt
a
MSC: Client Needs: Health Promotion and Maintenance
31. During an examination, which tests will the nurse collect to screen for cervical cancer?
ba
n
a. Endocervical specimen, cervical scrape, and vaginal pool
b. Endocervical specimen, vaginal pool, and acetic acid wash
c. Endocervical specimen, potassium hydroxide (KOH) preparation, and acetic acid
wash
.te
st
d. Cervical scrape, acetic acid wash, saline mount (wet prep)
ANS: A
w
Laboratories may vary in method, but usually the test consists of three specimens: endocervical
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specimen, cervical scrape, and vaginal pool. The other tests (acetic acid wash, KOH preparation,
w
and saline mount) are used to test for sexually transmitted infections.
DIF: Cognitive Level: Understanding (Comprehension) REF: pp. 752-753
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
32. When performing the bimanual examination, the nurse notices that the cervix feels smooth
and firm, is round, and is fixed in place (does not move). When cervical palpation is performed,
the patient complains of some pain. The nurses interpretation of these results should be which of
these?
a. These findings are all within normal limits.
b. Cervical consistency should be soft and velvetynot firm.
m
c. The cervix should move when palpated; an immobile cervix may indicate
malignancy.
co
d. Pain may occur during palpation of the cervix.
nk
.
ANS: C
Normally, the cervix feels smooth and firm, similar to the consistency of the tip of the nose. It
softens and feels velvety at 5 to 6 weeks of pregnancy (Goodell sign). The cervix should be
kt
a
evenly rounded. With a finger on either side, the examiner should be able to move the cervix
gently from side to side, and doing so should produce no pain for the patient. Hardness of the
cervix may occur with malignancy. Immobility may occur with malignancy, and pain may occur
ba
n
with inflammation or ectopic pregnancy.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 755
st
MSC: Client Needs: Health Promotion and Maintenance
.te
33. The nurse is palpating a female patients adnexa. The findings include a firm, smooth uterine
wall; the ovaries are palpable and feel smooth and firm. The fallopian tube is firm and pulsating.
w
The nurses most appropriate course of action would be to:
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a. Tell the patient that her examination is normal.
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b. Give her an immediate referral to a gynecologist.
c. Suggest that she return in a month for a recheck to verify the findings.
d. Tell the patient that she may have an ovarian cyst that should be evaluated
further.
ANS: B
Normally, the uterine wall feels firm and smooth, with the contour of the fundus rounded.
Ovaries are not often palpable, but when they are, they normally feel smooth, firm, and almond
shaped and are highly movable, sliding through the fingers. The fallopian tube is not normally
palpable. No other mass or pulsation should be felt. Pulsation or palpable fallopian tube suggests
ectopic pregnancy, which warrants immediate referral.
m
DIF: Cognitive Level: Applying (Application) REF: p. 757
co
MSC: Client Needs: Health Promotion and Maintenance
34. A 65-year-old woman is in the office for routine gynecologic care. She had a complete
know to be true regarding this visit?
kt
a
a. Her cervical mucosa will be red and dry looking.
nk
.
hysterectomy 3 months ago after cervical cancer was detected. Which statement does the nurse
b. She will not need to have a Pap smear performed.
ba
n
c. The nurse can expect to find that her uterus will be somewhat enlarged and her
ovaries small and hard.
st
d. The nurse should plan to lubricate the instruments and the examining hand
adequately to avoid a painful examination.
.te
ANS: D
In the aging adult woman, natural lubrication is decreased; therefore, to avoid a painful
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examination, the nurse should take care to lubricate the instruments and the examining hand
adequately. Menopause, with the resulting decrease in estrogen production, shows numerous
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physical changes. The cervix shrinks and looks pale and glistening. With the bimanual
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examination, the uterus feels smaller and firmer and the ovaries are not normally palpable.
Women should continue cervical cancer screening up to age 65 years if they have an intact
cervix and are in good health. Women who have had a total hysterectomy do not need cervical
cancer screening if they have 3 consecutive negative Pap tests or 2 or more consecutive negative
HIV and Pap tests within the last 10 years.
DIF: Cognitive Level: Applying (Application) REF: p. 760
MSC: Client Needs: Health Promotion and Maintenance
35. The nurse is preparing to examine the external genitalia of a school-age girl. Which position
would be most appropriate in this situation?
a. In the parents lap
m
b. In a frog-leg position on the examining table
d. Lying flat on the examining table with legs extended
nk
.
ANS: B
co
c. In the lithotomy position with the feet in stirrups
For school-age children, placing them on the examining table in a frog-leg position is best. With
kt
a
toddlers and preschoolers, having the child on the parents lap in a frog-leg position is best.
ba
n
DIF: Cognitive Level: Applying (Application) REF: p. 759
MSC: Client Needs: Health Promotion and Maintenance
36. When assessing a newborn infants genitalia, the nurse notices that the genitalia are somewhat
st
engorged. The labia majora are swollen, the clitoris looks large, and the hymen is thick. The
vaginal opening is difficult to visualize. The infants mother states that she is worried about the
.te
labia being swollen. The nurse should reply:
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a. This is a normal finding in newborns and should resolve within a few weeks.
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b. This finding could indicate an abnormality and may need to be evaluated by a
physician.
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c. We will need to have estrogen levels evaluated to ensure that they are within
normal limits.
d. We will need to keep close watch over the next few days to see if the genitalia
decrease in size.
ANS: A
It is normal for a newborns genitalia to be somewhat engorged. A sanguineous vaginal discharge
or leukorrhea is normal during the first few weeks because of the maternal estrogen effect.
During the early weeks, the genital engorgement resolves, and the labia minora atrophy and
remain small until puberty.
DIF: Cognitive Level: Applying (Application) REF: p. 759
MSC: Client Needs: Health Promotion and Maintenance
m
37. During a vaginal examination of a 38-year-old woman, the nurse notices that the vulva and
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vagina are erythematous and edematous with thick, white, curdlike discharge adhering to the
vaginal walls. The woman reports intense pruritus and thick white discharge from her vagina.
The nurse knows that these history and physical examination findings are most consistent with
nk
.
which condition?
a. Candidiasis
kt
a
b. Trichomoniasis
c. Atrophic vaginitis
ba
n
d. Bacterial vaginosis
ANS: A
st
The woman with candidiasis often reports intense pruritus and thick white discharge. The vulva
and vagina are erythematous and edematous. The discharge is usually thick, white, and curdlike.
.te
Infection with trichomoniasis causes a profuse, watery, gray-green, and frothy discharge.
Bacterial vaginosis causes a profuse discharge that has a foul, fishy, rotten odor. Atrophic
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option.)
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vaginitis may have a mucoid discharge. (See Table 26-5 for complete descriptions of each
w
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 768
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
38. A 22-year-old woman is being seen at the clinic for problems with vulvar pain, dysuria, and
fever. On physical examination, the nurse notices clusters of small, shallow vesicles with
surrounding erythema on the labia. Inguinal lymphadenopathy present is also present. The most
likely cause of these lesions is:
a. Pediculosis pubis.
b. Contact dermatitis.
c. HPV.
d. Herpes simplex virus type 2.
m
ANS: D
Herpes simplex virus type 2 exhibits clusters of small, shallow vesicles with surrounding
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erythema that erupt on the genital areas. Inguinal lymphadenopathy is also present. The woman
reports local pain, dysuria, and fever. (See Table 26-2 for more information and the descriptions
nk
.
of the other conditions.)
kt
a
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 764
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
ba
n
39. When performing an external genitalia examination of a 10-year-old girl, the nurse notices
that no pubic hair has grown in and the mons and the labia are covered with fine vellus hair.
These findings are consistent with stage _____ of sexual maturity, according to the Sexual
st
Maturity Rating scale.
.te
a. 1
b. 2
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d. 4
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c. 3
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ANS: A
Sexual Maturity Rating stage 1 is the preadolescent stage. There is no pubic hair, and the mons
and labia are covered with fine, vellus hair as on the abdomen (see Table 26-1).
DIF: Cognitive Level: Applying (Application) REF: p. 739
MSC: Client Needs: Health Promotion and Maintenance
40. A 46-year-old woman is in the clinic for her annual gynecologic examination. She voices a
concern about ovarian cancer because her mother and sister died of it. Which statement does the
nurse know to be correct regarding ovarian cancer?
a. Ovarian cancer rarely has any symptoms.
b. The Pap smear detects the presence of ovarian cancer.
m
c. Women at high risk for ovarian cancer should have annual transvaginal
ultrasonography for screening.
nk
.
co
d. Women over age 40 years should have a thorough pelvic examination every 3
years.
ANS: C
kt
a
With ovarian cancer, the patient may have abdominal pain, pelvic pain, increased abdominal
size, bloating, and nonspecific gastrointestinal symptoms; or she may be asymptomatic. The Pap
smear does not detect the presence of ovarian cancer. Annual transvaginal ultrasonography may
ba
n
detect ovarian cancer at an earlier stage in women who are at high risk for developing it.
DIF: Cognitive Level: Applying (Application) REF: p. 772
st
MSC: Client Needs: Health Promotion and Maintenance
.te
41. During a bimanual examination, the nurse detects a solid tumor on the ovary that is heavy
and fixed, with a poorly defined mass. This finding is suggestive of:
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a. Ovarian cyst.
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b. Endometriosis.
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c. Ovarian cancer.
d. Ectopic pregnancy.
ANS: C
Ovarian tumors that are solid, heavy, and fixed, with poorly defined mass are suggestive of
malignancy. Benign masses may feel mobile and solid. An ovarian cyst may feel smooth, round,
fluctuant, mobile, and nontender. With an ectopic pregnancy, the examiner may feel a palpable,
tender pelvic mass that is solid, mobile, and unilateral. Endometriosis may have masses (in
various locations in the pelvic area) that are small, firm, nodular, and tender to palpation, with
enlarged ovaries.
DIF: Cognitive Level: Applying (Application) REF: p. 772
m
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
co
42. A 25-year-old woman comes to the emergency department with a sudden fever of 38.3 C and
abdominal pain. Upon examination, the nurse notices that she has rigid, boardlike lower
abdominal musculature. When the nurse tries to perform a vaginal examination, the patient has
nk
.
severe pain when the uterus and cervix are moved. The nurse knows that these signs and
symptoms are suggestive of:
kt
a
a. Endometriosis.
b. Uterine fibroids.
ba
n
c. Ectopic pregnancy.
d. Pelvic inflammatory disease.
st
ANS: D
These signs and symptoms are suggestive of acute pelvic inflammatory disease, also known as
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acute salpingitis (see Table 26-7). (For the descriptions of endometriosis and uterine fibroids, see
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Table 26-6; for a description of ectopic pregnancy, see Table 26-7.)
w
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 771
w
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
43. During an external genitalia examination of a woman, the nurse notices several lesions
around the vulva. The lesions are pink, moist, soft, and pointed papules. The patient states that
she is not aware of any problems in that area. The nurse recognizes that these lesions may be:
a. Syphilitic chancre.
b. Herpes simplex virus type 2 (herpes genitalis).
c. HPV or genital warts.
d. Pediculosis pubis (crab lice).
ANS: C
HPV lesions are painless, warty growths that the woman may not notice. Lesions are pink or
m
flesh colored, soft, pointed, moist, warty papules that occur in single or multiple cauliflower-like
patches around the vulva, introitus, anus, vagina, or cervix. Herpetic lesions are painful clusters
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of small, shallow vesicles with surrounding erythema. Syphilitic chancres begin as a solitary
silvery papule that erodes into a red, round or oval superficial ulcer with a yellowish discharge.
nk
.
Pediculosis pubis causes severe perineal itching and excoriations and erythematous areas (see
Table 26-2).
kt
a
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 765
ba
n
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
44. During an examination, the nurse would expect the cervical os of a woman who has never
had children to appear:
b. Small and round.
st
a. Stellate.
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ANS: B
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d. Everted.
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c. As a horizontal irregular slit.
w
The cervical os in a nulliparous woman is small and round. In the parous woman, it is a
horizontal, irregular slit that also may show healed lacerations on the sides (see Figure 26-13).
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 750
MSC: Client Needs: Health Promotion and Maintenance
45. A woman has just been diagnosed with HPV or genital warts. The nurse should counsel her
to receive regular examinations because this virus makes her at a higher risk for _______ cancer.
a. Uterine
b. Cervical
c. Ovarian
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d. Endometrial
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ANS: B
nk
.
HPV is the virus responsible for most cases of cervical cancer, not the other options.
kt
a
DIF: Cognitive Level: Applying (Application) REF: p. 761
MSC: Client Needs: Health Promotion and Maintenance
ba
n
46. During an internal examination, the nurse notices that the cervix bulges outside the introitus
when the patient is asked to strain. The nurse will document this as:
a. Uterine prolapse, graded first degree.
st
b. Uterine prolapse, graded second degree.
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c. Uterine prolapse, graded third degree.
ANS: B
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d. A normal finding.
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The cervix should not be found to bulge into the vagina. Uterine prolapse is graded as follows:
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first degreethe cervix appears at the introitus with straining; second degreethe cervix bulges
outside the introitus with straining; and third degreethe whole uterus protrudes, even without
straining (essentially, the uterus is inside out).
DIF: Cognitive Level: Applying (Application) REF: p. 766
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
47. A 35-year-old woman is at the clinic for a gynecologic examination. During the examination,
she asks the nurse, How often do I need to have this Pap test done? Which reply by the nurse is
correct?
a. It depends. Do you smoke?
b. A Pap test needs to be performed annually until you are 65 years of age.
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c. If you have two consecutive normal Pap tests, then you can wait 5 years between
tests.
nk
.
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d. After age 30 years, if you have three consecutive normal Pap tests, then you may
be screened every 2 to 3 years.
ANS: D
kt
a
Cervical cancer screening with the Pap test continues annually until age 30 years. After age 21,
regardless of sexual history or activity, women should be screened every 3 years until age 30,
ba
n
then every 5 years until age 65.
DIF: Cognitive Level: Applying (Application) REF: p. 741
st
MSC: Client Needs: Health Promotion and Maintenance
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MULTIPLE RESPONSE
1. The nurse is palpating an ovarian mass during an internal examination of a 63-year-old
woman. Which findings of the masss characteristics would suggest the presence of an ovarian
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cyst? Select all that apply.
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a. Heavy and solid
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b. Mobile and fluctuant
c. Mobile and solid
d. Fixed
e. Smooth and round
f. Poorly defined
ANS: B, E
An ovarian cyst (fluctuant ovarian mass) is usually asymptomatic and would feel like a smooth,
round, fluctuant, mobile, nontender mass on the ovary. A mass that is heavy, solid, fixed, and
poorly defined suggests malignancy. A benign mass may feel mobile and solid.
Chapter 15. Sexually Transmitted Infections Guidelines
Multiple Choice
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Identify the choice that best completes the statement or answers the question.
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____ 1. During data collection the nurse notes the presence of a chancre on a male patients penis.
For which sexually transmitted infection should the nurse focus additional data collection?
nk
.
a. Herpes
b. Syphilis
c. Gonorrhea
kt
a
d. Chlamydia
____ 2. A patient is diagnosed with a parasitic infection caused by close contact with another
a. Phthirus pubis
b. Treponema pallidum
c. Neisseria gonorrhoeae
st
d. Chlamydia trachomatis
ba
n
persons genitals. For which infection should the nurse plan care?
____ 3. It is documented in the medical record that a patient has gummas. For which sexually
a. Syphilis
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b. Gonorrhea
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transmitted infection should the nurse plan care?
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c. Chlamydia
d. Genital herpes
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____ 4. The nurse is assisting with teaching a 22-year-old female patient who is diagnosed with a
sexually transmitted infection (STI). She says, I dont understand. My boyfriend always wears a
condom. Which understanding by the nurse should guide teaching in this situation?
a. Condoms are a reliable source of protection against STIs.
b. It is a myth that condoms provide any protection against STIs.
c. Condoms can decrease the risk of STIs, but they are not foolproof.
d. Condoms must be used with a spermicide to guarantee protection against STIs.
____ 5. The nurse is providing care for a patient with genital herpes who has vesicular lesions.
What term should the nurse use to describe these lesions to the patient?
a. Warts
b. Rashes
c. Blisters
d. Papules
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____ 6. Human papillomavirus (HPV) produces verrucous growths. What term should the nurse
use to describe these lesions to the patient?
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a. Warts
b. Rashes
nk
.
c. Blisters
d. Papules
____ 7. The nurse is collecting data on a patient with Chlamydia. Which assessment finding
kt
a
should be reported immediately to the RN or physician?
a. Painful urination
ba
n
b. Red conjunctivae
c. Vaginal discharge
d. Sharp pain at the base of the ribs
____ 8. Because Trichomonas is relatively large, unusually shaped, and diagnosed quickly, the
st
nurse is asked to assist the physician obtain which type of specimen?
b. Blood test
c. Wet mount
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a. Culture
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d. Litmus paper
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____ 9. A patient diagnosed with Trichomonas asks the nurse how the diagnosis will affect her
risk for cervical cancer. Which response by the nurse is best?
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a. Wet-mount slides should be done yearly to help detect cervical cancer.
b. Serological testing will be done to detect tumor proteins and screen for cervical cancer.
c. Papanicolaou smears should be done more frequently because results may be altered by
Trichomonas.
d. Culture and sensitivity testing is done with Papanicolaou (Pap) smears every other year to
determine if you have cervical cancer.
____ 10. A patient asks why the physician has recommended systemic interferon treatment for
genital warts. Which explanation should the nurse provide to the patient?
a. Interferon can improve liver function.
b. Interferons can increase your red blood cell count.
c. Interferon treatment does not have any side effects.
d. Interferon therapy can attack warts all over the body at the same time.
____ 11. A patient with hepatitis B virus (HBV) delivers a 6-pound 2-ounce baby boy. Which
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action should the nurse anticipate will be needed for the infant?
b. Antiviral eye medication less than 2 hours after birth
c. There is no treatment that is safe and effective for infants.
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a. Intravenous antibiotics for 12 hours
nk
.
d. HBV-immune globulin less than 12 hours after birth and then HBV vaccine series
____ 12. The nurse must bathe a patient with herpes. What is the nurses best protection against
hygiene?
a. Wearing gloves at all times
ba
n
b. Washing hands following care
kt
a
contracting sexually transmitted infections (STIs) from patients while providing perineal
c. Practicing standard precautions
d. Avoiding touching patients who have STIs
____ 13. The nurse is caring for a pregnant woman who is fearful that her unborn child will be
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born blind because of having a sexually transmitted infection (STI). For which STI should the
a. Syphilis
b. Gonorrhea
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nurse plan care to prevent ophthalmia neonatorum in the newborn?
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c. Genital warts
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d. Genital herpes
____ 14. The nurse is caring for a young woman who is newly diagnosed with genital warts. She
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states, I heard you can get cancer from STIs. Is that true? Which response by the nurse is correct?
a. No, you cannot get cancer from STIs.
b. Yes, most STIs can lead to cancerous changes if not treated promptly.
c. Yes, some STIs have been linked to cancer, so adequate treatment is very important.
d. No, that is not true, but a diagnosis of cancer does increase the risk of contracting an STI.
____ 15. The nurse is identifying ways for a young adult to reduce the risk of contracting a
sexually transmitted infection (STI). What should the nurse teach about the relationship between
consumption of alcohol and immediate risk of contracting an STI?
a. Alcohol may reduce inhibitions.
b. Alcohol increases risk for liver disease.
c. Alcohol lowers the bodys resistance to infection.
d. Alcohol impairs the integrity of the mucous membranes, providing a portal of entry for
infection.
m
____ 16. The nurse reviews the ways to prevent condom breakage with a patient. Which patient
statement indicates that more teaching is necessary?
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a. Condoms should never be reused.
b. I should use a water-soluble lubricant.
nk
.
c. Before I use a condom, I should inflate it and check it for holes and leaks.
d. I should make sure to leave a half inch extra space at the end of the condom.
____ 17. The nurse is assisting with the admission of a known intravenous drug abuser to a
kt
a
medical unit. In addition to drug abuse, which disorder in the patients history is most consistent
with a diagnosis of hepatitis?
ba
n
a. Jaundice
b. Diabetes mellitus
c. Bowel obstruction
d. Chronic headaches
st
____ 18. The nurse is teaching a patient the importance of completing treatment for gonorrhea.
On which information is the nurse basing this teaching?
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a. Gonorrhea is not treatable.
b. Only men experience symptoms; women are usually asymptomatic.
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c. Men and women may be asymptomatic and still transmit the infection.
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d. Treatment is associated with many serious side effects, so compliance is low.
____ 19. The nurse is assisting in the preparation of a teaching seminar for adolescents to
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prevent the development of a sexually transmitted infection (STI). Which nonsexual activity
should the nurse teach that may transmit a sexually transmitted infection (STI)?
a. Sharing a cigarette
b. Borrowing a hairbrush
c. Coughing and sneezing
d. Sharing intravenous drug equipment
____ 20. A patient asks for the best way to prevent contracting a sexually transmitted infection
(STI). What response should the nurse make to this patients question?
a. Abstinence
b. Oral contraceptives
c. Condom with spermicide
d. Prophylactic oral antibiotics
____ 21. A patient diagnosed with genital warts asks how they developed. Which pathogen
m
should the nurse explain as causing genital warts?
a. Sarcoptes scabiei
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b. Hepatitis A and B
c. Human papillomavirus
nk
.
d. Chlamydia trachomatis
____ 22. The nurse is caring for a 76-year-old retired man who is undergoing evaluation for
a. The patient has a history of syphilis.
b. The patient was exposed to Chlamydia.
ba
n
c. The patient has a history of hepatitis B.
kt
a
dementia. What would be an important part of the mans history to report to the physician?
d. The patient has a history of genital warts.
____ 23. A patient is undergoing treatment that involves the burning of lesions with heat or
chemical agents. The nurse recognizes that this patient most likely has which condition?
st
a. Syphilis
c. Hepatitis B
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b. Chlamydia
d. Genital warts
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____ 24. The nurse is providing care for a newborn. Which intervention should the nurse make
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to prevent development of ophthalmia neonatorum?
a. Interferon injection
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b. Antibiotic eyedrops
c. Vitamin K injection
d. Hepatitis B virus (HBV)-immune globulin
____ 25. While reviewing a medical record the nurse notes that patient has a strawberry cervix.
For which sexually transmitted infection (STI) would the nurse plan care?
a. Gonorrhea
b. Herpes simplex
c. Trichomoniasis
d. Human papillomavirus infection
____ 26. The nurse is preparing a poster presentation identifying the frequency of sexually
transmitted infections (STIs) in the United States. Which STI should the nurse highlight as being
the most commonly diagnosed?
a. Gonorrhea
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b. Chlamydia
c. Trichomoniasis
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d. Human papillomavirus
____ 27. While assisting a health care provider (HCP) conduct a pelvic examination, the patient
a. Syphilis
b. Gonorrhea
c. Pelvic inflammatory disease
ba
n
d. Human papillomavirus infection
kt
a
nurse suspect this patient is going to need care?
nk
.
complains of severe pain during the bimanual examination. For which health problem should the
____ 28. While assisting with care, the nurse counsels the patient diagnosed with a sexually
transmitted infection (STI) about notification of sexual partners. Which patient statement
indicates the need for further teaching? (Select all that apply.)
st
a. I can contact my sexual partners myself.
b. Reporting regulations are the same throughout the country.
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c. A report form will be completed in my chart that includes a list of my sexual contacts.
d. The public health authority can notify a list of sexual contacts without including my identity.
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Multiple Response
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Identify one or more choices that best complete the statement or answer the question.
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____ 29. The nurse is assisting with teaching a patient who has been exposed to hepatitis B.
Which symptoms should the nurse explain may occur before jaundice appears? (Select all that
apply.)
a. Rash
b. Nausea
c. Confusion
d. Dark-colored urine
e. Muscle or joint pain
f. Elevated blood glucose
____ 30. The nurse is reviewing prescribed laboratory tests for a patient demonstrating
manifestations of syphilis. What diagnostic tests should the nurse expect to be prescribed for this
patient? (Select all that apply.)
a. RPR
b. NAT
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c. VDRL
d. ELISA
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e. Culture
f. CD4 counts
nk
.
____ 31. A 24-year-old woman diagnosed with Chlamydia has been prescribed doxycycline.
a. Take this drug with a meal.
b. Do not take with dairy products.
c. Avoid unnecessary exposure to sunlight.
kt
a
What should be included in the nurses teaching about the drug treatment? (Select all that apply.)
ba
n
d. Abstain from alcohol for at least 48 hours after treatment.
e. Use birth control methods to ensure you do not become pregnant.
____ 32. The nurse is teaching a patient about the use of condoms to prevent sexually
Select all that apply.
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transmitted infections (STIs). Which information should the nurse include in this teaching?
a. Condoms can decrease the risk of transmitting STDs.
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b. Latex condoms are less likely to break than other types.
c. Inflating the condom prior to use allows for effective inspection.
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d. Condoms should be used no more than twice and then discarded properly.
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e. Use of a water-soluble lubricant with a condom increases its effectiveness in preventing the
spread of an STD.
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f. Use of a petroleum-based lubricant with a condom increases its effectiveness in preventing the
spread of an STD.
____ 33. The nurse is providing care for a patient recently diagnosed with Chlamydia. Which
information should the nurse recommend be included in patient teaching? (Select all that apply.)
a. Women with Chlamydia may complain of a sore throat.
b. Chlamydia is characterized by the development of chancres.
c. Ophthalmia neonatorum is seen in infants born to women with Chlamydia.
d. Chlamydia can be transmitted sexually and by blood and body fluid contact.
e. The risk of ectopic pregnancy is increased in women with a history of Chlamydia.
f. The Chlamydia virus can lie dormant in the nervous system tissues and reactivate when an
individual is under stress or has a compromised immune system.
____ 34. The nurse notes that a patient is diagnosed with vulvovaginitis. What should the nurse
expect when assessing this patient? (Select all that apply.)
m
a. Vaginal edema
b. Vaginal discharge
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c. Areas of ecchymosis
e. Complaints of vaginal itching and burning
nk
.
d. Dark brown vaginal bleeding
____ 35. A patient in labor is diagnosed with mucopurulent cervicitis. For which health problems
should the nurse anticipate providing care to the newborn? (Select all that apply.)
kt
a
a. Pneumonia
b. Conjunctivitis
ba
n
c. Irregular heart rate
d. Flaccid extremities
e. Cyanotic extremities
____ 36. A patient diagnosed with syphilis reminds the HCP of having an allergy to penicillin.
st
Which medications should the nurse expect to be prescribed for this patient? (Select all that
a. Gentamicin
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apply.)
b. Amoxicillin
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c. Tetracycline
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d. Doxycycline
e. Erythromycin
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____ 37. While providing a bath the nurse suspects that an older female patient has a
Trichomonas infection. What type of discharge did the nurse observe to come to this conclusion?
(Select all that apply.)
a. Frothy discharge
b. Foul-smelling discharge
c. Yellow-green discharge
d. Open sores on the labia majora
e. Wart-like growths on the labia minora
Answer Section
m
MULTIPLE CHOICE
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1. ANS: B
The primary stage of syphilis begins with the entry of the Treponema pallidum spirochete
through the skin or mucous membranes. Between 3 and 90 days later, a papule develops at the
nk
.
site of entry, then sloughs off, leaving a painless, red, ulcerated area called a chancre. A. Herpes
is associated with vesicular skin lesions. C. D. Gonorrhea and Chlamydia are not associated with
kt
a
skin lesions.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
ba
n
Level: Application
2. ANS: A
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Genital parasites are not a true sexually transmitted infection (STI), but they may be transmitted
during close body contact. The two most commonly seen parasites are pubic lice (Phthirus pubis,
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commonly called crabs because of the shape of the lice) and scabies (Sarcoptes scabiei). B. C. D.
Treponema pallidum, Neisseria gonorrhoeae, and Chlamydia trachomatis are not parasites.
w
PTS: 1 DIF: Moderate
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KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
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Level: Application
3. ANS: A
In the tertiary stage of syphilis, the spirochete may form gummas, which are tumors of a rubbery
consistency that can break down and ulcerate, leaving holes in body tissues. D. Herpes is
associated with vesicular skin lesions. B. C. Gonorrhea and Chlamydia are not associated with
skin lesions.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Application
4. ANS: C
Condoms can greatly decrease the risk of STIs, but condoms can have tiny channels in the rubber
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(or other elastic material) that can allow microorganisms to pass through. Condoms can break,
slip off, or be applied improperly. Petroleum-based lubricants may weaken latex condoms. A.
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Condoms do not provide a barrier for any area other than the penis and most of the vagina (or
anus). B. Some STIs may still be transmitted by contact of surrounding uncovered tissues. D.
nk
.
Spermicide helps protect against pregnancy.
PTS: 1 DIF: Moderate
kt
a
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
ba
n
5. ANS: C
Vesicles are small blisters. A. B. D. Warts, rashes, and papules do not have the same
PTS: 1 DIF: Moderate
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characteristics.
Application
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6. ANS: A
.te
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Verrucous means wart-like. B. D. D. HPV causes wart-like growths, not rashes, blisters, or
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papules.
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PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
7. ANS: D
Fitz-HughCurtis syndrome, a surface inflammation of the liver, can also be caused by C.
trachomatis. This inflammation may cause nausea, vomiting, and sharp pain at the base of the
ribs that sometimes refers to the right shoulder and arm. A. B. C. Vaginal discharge, painful
urination, and conjunctivitis are also concerns but are not as health-threatening as liver
inflammation.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
m
Analysis |
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8. ANS: C
When wet-mount slides of Trichomonas discharge are viewed under a microscope, the organisms
through a culture, blood test, or litmus paper.
kt
a
PTS: 1 DIF: Moderate
nk
.
can be identified by their motility and whip-like flagella. A. B. D. Trichomonas is not diagnosed
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
ba
n
9. ANS: C
Trichomonas may produce abnormal Pap smear readings, which require that more frequent Pap
smears be done to provide adequate surveillance of cellular changes. A. Wet mount can identify
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the organism but not cellular changes. B. D. Serological testing and culture and sensitivity
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testing are not performed to detect cervical changes caused by Trichomonas.
PTS: 1 DIF: Moderate
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KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
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Application
10. ANS: D
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Systemic interferon treatments attack warts all over the body at the same time, rather than
individually as with topical treatments. This speeds the process of treatment. A. B. C. Interferons
can produce side effects of flu-like symptoms, a drop in the number of white blood cells, and
changes in liver function.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
Level: Application
11. ANS: D
It is recommended that all babies of HBV-positive mothers receive HBV immune globulin less
m
than 12 hours after birth and then be immunized with HBV vaccine 1 week, 1 month, and 6
months after birth. A. Antibiotics are not effective against viruses. B. Eye medication may be
co
necessary for gonorrhea or chlamydia. C. The infant needs to receive the HBV vaccination.
nk
.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
kt
a
Application
12. ANS: C
A nurses best protection against catching infections from blood and body fluids of infected
ba
n
patients is the strict practice of standard precautions and maintaining his or her own healthy,
intact skin. A. Wearing gloves at all times is not appropriate. B. Washing hands is essential but is
PTS: 1 DIF: Moderate
st
not sufficient. D. Touching patients cannot and should not be avoided.
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
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13. ANS: B
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Level: Application
Newborns born to mothers who have gonorrhea can develop ophthalmia neonatorum, which
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involves inflammation of the conjunctiva and deeper parts of the eye and can, ultimately, result
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in blindness. A. C. D. Syphilis, genital warts, and genital herpes are not associated with infant
eye problems.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
14. ANS: C
Herpes, human papillomavirus (HPV), and hepatitis (not most sexually transmitted infections
[STIs]) have been associated with cancers. A. Cancer has been associated with some STIs. B
Most STIs do not cause cancer. D. Having a diagnosis of cancer does not increase the risk of
contracting an STI.
m
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
co
Application
nk
.
15. ANS: A
Consumption of alcohol or other psychoactive drugs can reduce inhibitions and may result in
unintended sexual encounters, which can transmit STIs. B. C. D. Alcohol does cause liver
kt
a
disease and may indirectly reduce resistance, but these are not the mechanisms by which
immediate STI risk increases.
ba
n
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
st
16. ANS: C
Condoms should never be inflated to test them, because this can weaken them. B. Lubrication
.te
decreases the chances of breakage during use, but only water-soluble lubricants should be used,
because substances such as petroleum jelly (Vaseline) may weaken the condom. D. Either
w
condoms with a reservoir tip or regular condoms that have been applied while holding
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approximately 1/2 inch of the closed end flat between the fingertips allow room for expansion by
the ejaculate without creating excessive pressure, which might break the condom. A. Condoms
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should not be reused.
PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Evaluation
17. ANS: A
Jaundice is a symptom of hepatitis. D. Headaches can be associated with many disorders and are
not specific to hepatitis. B. C. Diabetes and bowel obstruction are not associated with hepatitis.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation| Cognitive Level: Analysis
18. ANS: C
B. Men may be asymptomatic or may have urethritis with a yellow urethral discharge. C.
Women who have gonorrhea may have either no noticeable symptoms or have a sore throat,
m
mucopurulent cervicitis (MPC), urethritis, or abnormal menstrual symptoms such as bleeding
between periods. A. Gonorrhea is treatable with antibiotics, which have side effects, but not such
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serious side effects that compliance is affected.
nk
.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
kt
a
Application
19. ANS: D
IV drug equipment can transmit some STIs. A. B. C. Sharing a cigarette or hairbrush or coughing
ba
n
and sneezing can spread various infections, but not generally STIs.
PTS: 1 DIF: Moderate
st
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application
20. ANS: A
.te
Abstinence or lifelong monogamy of both sexual partners in a relationship are the only sure
prevention against STIs. D. Antibiotics treat but do not prevent STIs. B. Oral contraceptives do
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not prevent STIs. C. Condoms may help prevent STIs, but they are not completely effective.
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PTS: 1 DIF: Moderate
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KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application
21. ANS: C
Condylomata acuminatum (genital warts) is a common sexually transmitted viral infection, and
their incidence is increasing rapidly. Infection with human papillomavirus (HPV) produces the
condylomata. A, B, and D do not cause warts.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
22. ANS: A
Untreated syphilis can lead to neurosyphilis and neurological changes. B, C, and D do not cause
m
neurological changes.
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PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
nk
.
Application
23. ANS: D
kt
a
There is presently no known cure for papillomavirus infection. The warts may be treated by
freezing, burning, or chemically destroying them or by manipulating the patients immune system
to attack the virus. Cryotherapy (freezing) of the warts may be done by touching each wart with a
ba
n
cryoprobe or a liquid nitrogensoaked swab. Warts may also be burned or electro-coagulated with
an electrocautery or a laser. Heat causes the proteins to coagulate, resulting in death of the wart
tissue. A. B. Syphilis and Chlamydia are treated with antibiotics. C. Hepatitis B virus may be
PTS: 1 DIF: Moderate
st
treated with immune globulins as well as supportive treatment.
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KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
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Level: Analysis
24. ANS: B
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Ophthalmia neonatorum may be prevented by use of antibiotic eye preparations, which contain
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silver nitrate, erythromycin, or tetracycline. D. HBV immune globulin is given to prevent HPV.
C. Vitamin K prevents bleeding. A. Interferon is not used.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
25. ANS: C
Visualization of the cervix during pelvic examination shows a characteristic strawberry cervix
with Trichomonas infection. A, B, and D are not associated with a strawberry cervix.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
m
Application
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26. ANS: B
Chlamydia is the most commonly diagnosed STI in the United States. A. C. D. Gonorrhea,
nk
.
Trichomoniasis, and HPV are not the most commonly diagnosed STIs in the United States.
PTS: 1 DIF: Moderate
kt
a
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application
27. ANS: C
With pelvic inflammatory disease, findings during physical examination include adnexal
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tenderness upon palpation, and pain in the uterus and cervix when moved during a bimanual
examination. A. B. D. Pain during a bimanual examination is not associated with syphilis,
PTS: 1 DIF: Moderate
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gonorrhea, or human papillomavirus infection.
28. ANS: B
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KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis
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The requirements for reporting STDs may vary for different states, provinces, and countries. C.
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The report form has spaces for listing sexual contacts who should be notified of possible STD
exposure. A. Depending on the laws of the state, province, or country, HCPs may notify
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identified sexual contacts or patients may do so themselves. D. Contacts may also be notified by
a public health authority that they have been listed as a sexual contact by an anonymous person
who has tested positive for a particular STD.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Analysis
MULTIPLE RESPONSE
29. ANS: A, B, E
Early signs of hepatitis are loss of appetite, rashes, malaise, muscle and joint pain, headaches,
nausea, and vomiting. D. As the virus affects the liver, the urine may darken and the stool color
lightens, liver enzymes may rise, and jaundice may appear. C. Confusion is a late sign of liver
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disease. F. Glucose abnormalities occur with pancreatic disease.
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PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level:
nk
.
Application
30. ANS: A, C, D, E
kt
a
Several tests for syphilis exist, and a combination may be used for accurate diagnosis. Cultures
may be done but are difficult to grow. Serological (blood) tests include the Venereal Disease
Research Laboratory (VDRL) test, the rapid plasma reagin (RPR) test, and the automated reagin
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n
test (ART). Treponemal enzyme-linked immunosorbent assay (ELISA), fluorescent treponemal
antibody absorption (FTA-ABS), and polymerase chain reaction (PCR) tests for treponemal
DNA are some newer methods that reduce the risk of false results. B. F. NAT is done for
PTS: 1 DIF: Moderate
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Chlamydia. CD4 and CD8 are used to evaluate HIV/AIDS.
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Application
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KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
31. ANS: B, C, E
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Do not administer doxycycline during pregnancy due to bone/teeth effects. Do not take with
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antacids or dairy products. Avoid unnecessary exposure to sunlight. A. Administer on an empty
stomach. D. Alcohol should be avoided with metronidazole.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
Level: Application
32. ANS: A, B, E
Condoms can reduce (but not eradicate) the risk of STDs. Latex condoms are less likely to break
during intercourse than other types. Lubrication decreases the chances of breakage during use,
but only water-soluble lubricants should be used. F. Substances such as petroleum jelly
(Vaseline) may weaken the condom. C. Condoms should never be inflated to test them, because
this can weaken them. D/ Condoms should never be reused and should be discarded properly
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PTS: 1 DIF: Moderate
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after use so that others will not come in contact with the contents.
nk
.
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application
33. ANS: D, E
Chlamydia is the most commonly diagnosed sexually transmitted infection (STI) in the United
kt
a
States. It can be transmitted sexually and by blood and body fluid contact. Chlamydia is a
frequent cause of pelvic inflammatory infection (PID) and infertility, and it increases the risk of
ectopic pregnancy. A. Women who have gonorrhea may have either no noticeable symptoms or
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n
have a sore throat. C. Newborns born to mothers who have gonorrhea can develop ophthalmia
neonatorum. F. Herpes viruses have an affinity for tissues of the skin and nervous system and
can lie dormant in nervous system tissues and then reactivate periodically when the body
.te
PTS: 1 DIF: Moderate
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undergoes stress, fever, or immune system compromise/ B. Chancres can develop with syphilis.
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
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Level: Application
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34. ANS: A, B, E
Vulvovaginitis is an inflammation of the vulva and vagina and can be asymptomatic or involve
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redness, itching, burning, excoriation, pain, swelling of the vagina and labia, and discharge. C.
D. Ecchymosis and dark brown vaginal bleeding are not manifestations of this disorder.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Application
35. ANS: A, B
Mucopurulent cervicitis (MPC) is an inflammation of the cervix that may produce a
mucopurulent yellow exudate on the cervix or may have no noticeable symptoms. MPC during
pregnancy can result in conjunctivitis and pneumonia in newborn infants. C. D. E. MPC does not
cause irregular heart rate, or flaccid or cyanotic extremities in the newborn.
m
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
co
Level: Application
nk
.
36. ANS: C, D
Penicillin G is the treatment of choice for patients diagnosed with syphilis. For those who are
allergic to penicillin, doxycycline and tetracycline are treatment options. A. E Gentamicin and
penicillin and should not be given.
ba
n
PTS: 1 DIF: Moderate
kt
a
erythromycin are not antibiotics identified to treat syphilis. B. Amoxicillin is a later generation of
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
37. ANS: A, B, C
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Level: Application
Trichomoniasis is a sexually transmitted infection caused by a protozoan parasite. It can be also
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be transmitted through nonsexual contact with infected articles because it can survive for a long
time outside the body. Carriers of Trichomonas vaginalis can be asymptomatic for several years
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until changes in vaginal or urethral conditions encourage an outbreak of the infection. Symptoms
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include redness, swelling, itching, and burning of the genital area; pain with intercourse and
voiding; and a frothy, foul-smelling discharge that can be clear, white, yellowish, or greenish. D.
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Trichomoniasis is not associated with open sores or wart-like growths.
Chapter 16. Infectious Disease Guidelines
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A patient says to the nurse, what is a culture? What would be the best response by the
nurse?
a. A culture measures the level of an antibiotic.
b. A culture identifies an antibiotics effect on a pathogen.
c. A culture determines the appropriate medication dosage to be used.
d. A culture identifies the presence of disease-causing microorganisms.
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____ 2. The nurse reviews the method of transmission of Rocky Mountain spotted fever with a
patient being treated for the disease. On which mode of transmission for the disease should the
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nurse focus with the patient?
a. Droplet
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.
b. Airborne
c. Vector-borne
d. Vehicle-borne
kt
a
____ 3. There are limited amounts of influenza vaccine currently available in the clinic. Which
individual should the nurse identify as having the highest priority to receive vaccination at this
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n
time?
a. A 15-year-old who plays ice hockey
b. A 26-year-old with three young children
c. A 49-year-old who works in food services
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d. An 88-year-old who lives in an apartment for senior citizens
____ 4. The nurse is discharging a patient who has been treated for conjunctivitis. Which patient
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statement indicates that teaching was effective?
a. I will have to wear a mask for 2 weeks.
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b. I will not share towels with others in the house.
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c. I will need to have a special air filter running at all times.
d. I must stay 3 feet away from people when talking to them.
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____ 5. The nurse is reviewing patient care needs with a nursing assistant. Which intervention
should the nurse explain as being the most important means of preventing the spread of
infection?
a. Gloving
b. Gowning
c. Hand washing
d. Wearing a mask
____ 6. The nurse wants to ensure that a hospitalized patient with a healthy immune system does
not contract an infectious disease. What nursing action should the nurse identify to reduce this
patients susceptibility to an infection?
a. Planning adequate nutrition
b. Daily bathing with soap and water
c. Assessing vital signs every 4 hours
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d. Admitting the patient to a private room
____ 7. The nurse is caring for a patient with influenza. For which reason should the nurse
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encourage the patient to increase fluids?
b. Liquefies pulmonary secretions
c. Dilute bacterial serum concentration
d. Dilute bacterial urinary concentration
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.
a. Decrease metabolism
kt
a
____ 8. During data collection, a patient is experiencing warmth, redness, swelling, and minimal
drainage of the right great toe. Which health problem should the nurse recognize is occurring
a. Local infection
b. Systemic infection
c. Generalized infection
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d. Bacterial colonization
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n
with the patient?
____ 9. A patient develops a hospital-acquired surgical wound infection. Which organism should
a. Shigella
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b. Salmonella
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the nurse recognize as being the most likely cause of this infection?
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c. Campylobacter
d. Staphylococcus aureus
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____ 10. During data collection, the nurse suspects a patient is experiencing a urinary tract
infection. Which manifestation did the nurse use to come to this conclusion?
a. Diarrhea
b. Vomiting
c. Voiding frequency
d. Abdominal distention
____ 11. The nurse is providing care to a patient with a fractured femur who is in traction. Which
nursing intervention is the highest priority for the nurse to implement?
a. Increase daily fluid intake.
b. Weigh patient each morning.
c. Teach patient to cough and deep breathe.
d. Teach patient to cover mouth when coughing.
____ 12. The nurse is caring for a patient with tuberculosis (TB). What action should the nurse
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take before entering this patients room?
b. Wear a clear plastic shield over the face.
c. Wear protective plastic goggles over the eyes.
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.
d. Wear a fitted high-efficiency particulate air respirator.
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a. Wear a surgical mask with elastic straps.
____ 13. The nurse is assisting with the reorganization of the clean utility room. Which item
a. An unsealed package in a cupboard
b. Instruments on a sterile field that is moist
kt
a
should the nurse consider as being surgically aseptic?
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n
c. Sterile items untouched by nonsterile items
d. Sterile pack opened out of sight line of the nurse
____ 14. The nurse is preparing to give a newly prescribed antibiotic to a patient with an infected
surgical incision. Which action is essential for the nurse to do before giving the antibiotic?
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a. Perform ordered cultures.
b. Check the patients temperature.
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c. Give the patient something to eat.
d. Document the wounds appearance.
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____ 15. The nurse is collecting data from a patient with a systemic infection. Which finding
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should the nurse expect in this patient?
a. Warm skin
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b. Skin redness
c. General malaise
d. Purulent drainage
____ 16. The nurse is participating in planning care for a patient with mononucleosis. Which
action should the nurse recommend to promote recovery?
a. Exercise
b. Rest periods
c. Full liquid diet
d. Fluid restriction
____ 17. The nurse is reinforcing teaching provided to a patient about gastrointestinal infections.
Which symptom should the patient state which indicates that teaching has been effective?
a. Vomiting
b. Flank pain
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c. Constipation
d. Cloudy urine
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____ 18. The nurse is obtaining a health history from a patient who has a respiratory system
infection. Which finding should the nurse identify as being the most significant?
nk
.
a. Flank pain
b. Wheezing
c. Cramping
kt
a
d. Anorexia
____ 19. The nurse is preparing to provide patient care. Which item is the most important for the
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nurse to wear if the possibility of handling body secretions exists?
a. Mask
b. Gown
c. Gloves
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d. Goggles
____ 20. The nurse is preparing to care for a patient. For which action should the nurse use
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surgical asepsis to prevent infection?
a. Urinary catheter insertion
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b. Taking a rectal temperature
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c. Reinforcement of dressings
d. Irrigating a nasogastric tube
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____ 21. The nurse is caring for a patient who has influenza. In which type of transmission-based
precaution should the patient be placed?
a. Contact
b. Droplet
c. Airborne
d. Respiratory
____ 22. A patient requires care that might cause the splattering of body secretions. Which item
should the nurse wear when caring for this patient?
a. Cap
b. Gown
c. Face shield
d. Shoe covers
____ 23. A patient voids and asks to have the urinal emptied. Which action should the nurse take
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first?
a. Empty the urinal.
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b. Measure the urine.
c. Put on nonsterile gloves.
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.
d. Offer patient hand hygiene.
____ 24. The nurse has contributed to a staff education program about the principles for the first
understanding of the teaching?
a. All patients are presumed infectious.
kt
a
tier of standard precautions. Which statement by a nursing assistant indicates a correct
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b. Isolation is not required for most diseases.
c. Patients with a known infection are placed in isolation upon admission.
d. Patients are not considered infectious until confirmed so by the laboratory.
____ 25. The nurse is contributing to a staff education program about infection control. What
st
information from the following list should the nurse recommend including about methods that
are effective in destroying bacterial spores?
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a. Prolonged drying times
b. Prolonged high temperatures
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c. Cleansing with soap and water
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d. Brief exposure to room temperatures
____ 26. The nurse is contributing to a staff education program about infection control. Which
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information should the nurse recommend including as an example of a portal of exit for a
pathogen in the chain of infection?
a. Hair
b. Nails
c. Mucous membranes
d. Central nervous system
____ 27. The nurse is caring for a patient with herpes simplex. Which statement related to
disease transmission should the nurse include in the patients discharge teaching?
a. Herpes simplex is an airborne disease.
b. HEPA filtration is necessary with herpes simplex.
c. Herpes simplex is transmitted through direct transmission.
d. Vehicle transmission means that particles float through the air.
____ 28. The nurse observes a patient being transported through the hall wearing a mask. For
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which medical diagnosis should the nurse suspect the patient is receiving care?
a. Measles
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b. Cellulitis
c. Diphtheria
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.
d. Clostridium difficile
____ 29. The nurse is caring for a patient who is immunocompromised. Which action should the
a. Restrict oral fluids
b. Apply lotion to dry skin
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n
c. Provide alcohol-based mouthwash
kt
a
nurse take to ensure that the patient does not develop a hospital-acquired infection?
d. Massage back with a skin drying agent
____ 30. A patient learns that a serum antibody test is positive. What should the nurse explain to
the patient about this test result?
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a. An active infection is present.
b. It is more accurate than a blood culture.
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c. The body has been exposed to an antigen.
d. A specific antibiotic has been identified for the infection.
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____ 31. The school nurse is planning to teach a group of school-age children on cough etiquette.
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What should the nurse emphasize with these students?
a. Sneeze into hands if a tissue is not available.
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b. Place used tissues in back packs or pockets of clothing.
c. Wash hands with soap and water for 20 seconds after blowing the nose.
d. Move 1 foot away from another person when having to sneeze or cough.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 32. The nurse is collecting data from a patient with a surgical incision. Which findings
indicate to the nurse that a local infection is present? (Select all that apply.)
a. Fever
b. Redness
c. Swelling
d. Headache
e. Loss of appetite
f. General malaise
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____ 33. The nurse suspects that patient is developing sepsis. Which findings did the nurse use to
come to this conclusion? (Select all that apply.)
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a. Tachycardia
b. Hypotension
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.
c. Hypertension
d. Mental confusion
e. Increased capillary refill
kt
a
f. Hyperactive bowel sounds
____ 34. The nurse is caring for a patient with tuberculosis. What airborne precautions should
a. Private patient room
b. Semiprivate patient room
c. Closed patient room door
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n
the nurse take while caring for this patient? (Select all that apply.)
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d. Individualized respiratory mask
e. One-size-fits-all respiratory mask
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____ 35. The nurse is caring for a patient who is in droplet precautions. The nurse must wear a
mask when providing care within what distances of the patient? (Select all that apply.)
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b. 2 feet
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a. 1 foot
c. 3 feet
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d. 4 feet
e. 5 feet
f. 6 feet
____ 36. The nurse is contributing to a staff education program about infection control. What
should the nurse recommend as examples of diseases that are transmitted by direct contact?
(Select all that apply.)
a. Malaria
b. Measles
c. Impetigo
d. Influenza
e. Chickenpox
f. Lyme disease
____ 37. A patient is being admitted for treatment of a viral infection. Which diseases should the
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nurse recognize as being caused by a virus? (Select all that apply.)
a. Measles
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b. Shingles
c. Gonorrhea
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.
d. Trichomoniasis
e. Candida albicans
f. Infectious mononucleosis
kt
a
____ 38. A patient is being discharged from the hospital with a prescription for erythromycin.
What should the nurse include when teaching about this medication? (Select all that apply.)
b. Drowsiness may occur.
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n
a. Avoid sun exposure.
c. Take pills on an empty stomach.
d. Report vaginal irritation or white patches in the mouth.
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e. Take with a full glass of water but not with an acidic juice.
f. Gastric distress may occur, but unless it is severe do not discontinue the medication.
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____ 39. The nurse is providing care for a patient with a known allergy to sulfamethoxazole
(Gantanol). Which medications should the nurse question if prescribed for this patient? (Select
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all that apply.)
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a. Ciprofloxacin (Cipro)
b. Amoxicillin (Amoxil)
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c. Levofloxacin (Levaquin)
d. Sulfisoxazole (Gantrisin)
e. Doxycycline (Vibramycin)
f. Trimethoprim sulfamethoxazole (Bactrim, Septra)
____ 40. A patient is admitted for treatment of an antibody-antigen response. What should the
nurse explain to the patient about this response? (Select all that apply.)
a. Engulfs and digests the antigen
b. Initiates destruction of the antigen
c. Neutralizes toxins released by bacteria
d. Promotes antigen clumping with the antibody
e. Prevents the antigen from adhering to host cells
____ 41. The nurse is assisting with the development of an educational program to reduce the
incidence of infectious diseases in a community. What topics should the nurse suggest be
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included in this program? (Select all that apply.)
a. Use of cough etiquette
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b. Performance of hand hygiene
d. Use of safety equipment with sports
kt
a
e. Importance of receiving immunizations
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.
c. Safe food handling techniques
Answer Section
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n
MULTIPLE CHOICE
1. ANS: D
A culture is obtained and grown to identify the presence of pathogens. B. C. A sensitivity
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examination is done after a culture, which exposes any organism to many antibiotics to
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determine which antibiotic will be most effective for treatment. A. A peak and trough level
determines the level of an antibiotic present in the blood.
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PTS: 1 DIF: Moderate
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KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
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Application
2. ANS: C
Vector-borne transmission is the spread of infectious organisms through a living source other
than humans. Rocky Mountain spotted fever is transmitted to humans by tick bite. A. Droplet
transmission is a spray into the eyes or mucous membranes during sneezing, coughing, spitting,
singing, or talking. D. Vehicle-borne transmission is the spread of an infectious organism by
contact with a contaminated object. B. Airborne transmission occurs from organisms inhaled or
deposited on the mucous membrane of a susceptible host.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Application
3. ANS: D
Factors that increase susceptibility to infection are very young age, old age, malnourishment,
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being immunocompromised, chronic disease, stress, and invasive procedures. A. B. C. Although
all individuals are encouraged to receive an annual influenza vaccination the 15-year-old, 26-
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year-old, and 49-year-old have more competent immune systems. The influenza vaccination can
nk
.
be delayed for these individuals.
PTS: 1 DIF: Moderate
kt
a
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis
4. ANS: B
Vehicle-borne transmission is the spread of an infectious organism by contact with a
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n
contaminated object, such as dressings from a wound; surgical instruments; water, food, and
biological products such as blood, serum, plasma, tissues, and organs. Conjunctivitis is a vehicleborne illness. A, D. Droplet transmission is a spray into the eyes or mucous membranes and
requires the use of a mask or a 3-foot distance between individuals. C. Airborne transmission
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PTS: 1 DIF: Moderate
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occurs from organisms inhaled or deposited on the mucous membrane of a susceptible host.
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KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Evaluation
5. ANS: C
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Although using gloves, gowns, masks, goggles, and face shields help prevent the spread of
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infection, the most important action is hand washing.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Application
6. ANS: D
Factors that increase susceptibility to infection are very young age, old age, malnourishment,
immunocompromised, chronic disease, stress, and invasive procedures. Ensuring adequate
nutrition for the hospitalized patient will help prevent infection. B. Daily bathing will not reduce
the risk for contracting an infectious disease. C. Assessing vital signs every 4 hours will not
reduce the risk for contracting an infectious disease. D. Placing the patient in a private room will
not reduce the risk for contracting an infectious disease.
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PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
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Level: Application
nk
.
7. ANS: B
Fluid thins respiratory secretions to facilitate the removal through coughing. A. Fluids will not
decrease metabolism. C. D. Influenza is caused by a virus. The patient will not have bacterial
kt
a
serum or urinary concentration.
PTS: 1 DIF: Moderate
ba
n
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis
8. ANS: A
Manifestations of a local infection also include pain, redness, swelling, and warmth at the site. B.
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D. As the infection progresses, there can be an increase in fever, elevated white blood cell count,
decreased blood pressure, mental confusion, tachycardia, and shock. C. Symptoms of generalized
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infection may include headache, malaise, muscle aches, fever, and anorexia.
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PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
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Level: Analysis
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9. ANS: D
Staphylococcus aureus is the most common pathogen causing hospital-acquired surgical wound
infections. A. B. C. Hospital-acquired surgical wound infections are not commonly caused by
shigella, salmonella, or campylobacter.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Analysis
10. ANS: C
Symptoms of a urinary tract infection include urgency, frequency, burning, flank pain, change in
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color of urine, foul odor, discharge, or confusion or change in mental status. A. B. D. Diarrhea,
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vomiting, and abdominal distention are not manifestations of a urinary tract infection.
PTS: 1 DIF: Moderate
nk
.
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Analysis
kt
a
11. ANS: C
A patient who is immobile is at increased risk for atelectasis and pneumonia. Encourage
coughing and deep breathing to keep airways clear and prevent atelectasis. A. Fluid intake may
ba
n
be increased if the patient is at risk for fat emboli or renal calculi, but it is not the highest priority
over oxygenation. B. Daily weights indicate fluid and nutritional status but are not the priority
for this patient because there is no indication of an increased risk for dehydration, fluid overload,
or malnutrition. D. Teaching the patient to cover the mouth when coughing prevents the spread
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PTS: 1 DIF: Moderate
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of contagious disease and is not the priority for this patient.
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
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Level: Analysis
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12. ANS: D
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The nurse should wear a personally fit-tested high-efficiency particulate air respirator mask for
airborne protection. A. B. Do not use other masks because they do not provide adequate airborne
protection against TB. C. Eye goggles are not needed when caring for a patient with tuberculosis.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Application
13. ANS: C
Surgical asepsis refers to an item or area that is free of all microorganisms and spores. Surgical
asepsis is used in surgery and to sterilize equipment. Items can be subjected to intense heat or
chemical disinfectants to destroy all organisms. Articles can be subjected to intense heat or
chemical disinfectants. Once these articles are sterilized, they are dated, packaged, and sealed. A.
Once a package is opened or outdated, it is no longer considered sterile. B. Moist areas are not
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sterile. D. Sterile packages should be opened in view of the nurse to verify they remain sterile.
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PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
nk
.
Level: Application
14. ANS: A
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a
Cultures are a priority to obtain before giving anti-infectives so the results are not altered by the
medication. B. D. Checking the patients temperature and documenting the appearance of the
wound do not need to be done before administering medication. C. Giving the antibiotic with
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n
food depends on the specific medication.
PTS: 1 DIF: Moderate
15. ANS: C
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Level: Application
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KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
Symptoms of systemic infection may include headache, malaise, muscle aches, fever, and
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anorexia. A. B. Manifestations of a local infection also include pain, redness, swelling, and
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warmth at the site. D. Purulent drainage occurs from the local inflammatory process.
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PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Analysis
16. ANS: B
Symptoms of mononucleosis are treated as needed with supportive care. Fatigue may last for
months. Rest is important. A. Exercise should be guided by the health care provider when the
acute phase is over, based on patient tolerance. C. D. Fluids and diet are not restricted.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level:
Application
17. ANS: A
The symptoms of gastrointestinal tract infections may include nausea, vomiting, diarrhea,
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cramping, and anorexia. Patients may have frequent episodes of emesis and diarrhea and need to
be monitored for signs of dehydration resulting from the loss of fluid. B. D. Flank pain or cloudy
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urine may indicate a urinary tract or kidney infection. C. Constipation is not a manifestation of a
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.
gastrointestinal tract infection.
PTS: 1 DIF: Moderate
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a
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Evaluation
18. ANS: B
Lung sounds can include crackles, rhonchi, or wheezing in a patient with a respiratory system
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infection and can indicate potential respiratory distress. A, C, and D are not directly linked to the
respiratory system and therefore are not the most significant finding.
PTS: 1 DIF: Moderate
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19. ANS: C
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KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis
The use of gloves decreases the transmission of organisms and should be used whenever
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handling secretions. A. B. D. Gowns, masks, and protective eyewear may also be helpful in
preventing transmission of organisms and are considered based on the situation and potential for
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exposure to organisms.
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PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Application
20. ANS: A
Surgical asepsis (sterile technique) refers to an item or area that is free of all microorganisms and
spores. The urinary tract is a sterile system, and surgical asepsis must be used for urinary catheter
insertion to maintain this sterility. B, C, and D are not actions requiring sterility.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
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Level: Application
21. ANS: B
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Droplet precautions are needed for influenza. A. C. D. Influenza is transmitted through droplets.
Contact, airborne, or respiratory precautions are not appropriate for this health problem.
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.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
kt
a
Level: Application
22. ANS: C
Using a mask, eye protection, or face shield for patient care if splashes or sprays of blood or
may be worn as needed.
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PTS: 1 DIF: Moderate
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body fluids are likely is the most essential item to wear. A. B. D. A cap, gown, or shoe covers
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
23. ANS: C
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Level: Application
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The nurse would first put on gloves for protection, which do not need to be sterile to empty the
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urinal. B. A. Next, the nurse would measure the urine and then empty the urinal. D. The patient
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should be offered hand hygiene equipment to perform hand hygiene after voiding.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Application
24. ANS: A
Standard precautions are used in the care of all patients. These precautions require one to assume
that all patients are infectious regardless of their diagnosis. Using gloves, gowns, masks, goggles,
face shields, and, most important, hand washing helps prevent the spread of infection to health
care workers and other patients. B. C. D. Transmission-based precautions are only added as
needed, such as isolation.
PTS: 1 DIF: Moderate
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KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
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Level: Analysis
25. ANS: B
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.
Prolonged exposure to high temperature destroys spores. A. C. D. Prolonged drying times,
cleaning with soap and water, or exposure to room temperatures are not effective to eliminate
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a
spores.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
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n
Level: Application
26. ANS: C
The portal of exit is the route by which the infectious agent leaves the host, which has become a
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reservoir for infection: respiratory tract, skin, mucous membranes, gastrointestinal tract,
genitourinary tract, blood, open lesions, or placenta. A. B. D. Hair, nails, and the central nervous
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system are not portals of exit.
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PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
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Level: Application
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27. ANS: C
Herpes simplex is transmitted through direct transmission. Illnesses spread by direct transmission
may include influenza, impetigo, scabies, conjunctivitis, pediculosis, herpes, Clostridium
difficile, and all sexually transmitted diseases, including HIV. A. Measles, chickenpox, and
tuberculosis are transmitted by airborne transmission. B. HEPA filtration is not required, because
herpes simplex is not an airborne illness. D. Vehicle transmission refers to the spread of an
infectious organism by contact with a contaminated object.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Application
28. ANS: A
A mask must be worn for measles, tuberculosis, and varicella (chickenpox, shingles) during
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patient transport. B. C. D. A mask does not need to be worn for cellulitis, diphtheria, or
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clostridium difficile.
PTS: 1 DIF: Moderate
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.
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Analysis
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a
29. ANS: B
Intact skin and mucous membranes are the bodys first line of defense against infection.
Preventing skin dryness and cracking with lotion keeps the skin intact so organisms do not have
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an entry point. A. Restricting oral fluids could cause the oral mucous membranes to dry,
permitting the entry of microorganisms into the body. C. Alcohol-based mouth washes are
drying and could permit the entry of microorganisms into the body. D. Using a drying agent on
body.
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PTS: 1 DIF: Moderate
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the skin could encourage drying and cracking which could lead to microorganisms entering the
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
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Application
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30. ANS: C
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A serum antibody test measures the reaction to a certain antigen. A. A positive result for this test
does not always mean an active infection is present. It can simply mean there has been an
exposure to the antigen. B. This test is not as accurate as a culture. D. This test does not identify
antibiotics appropriate to treat an infection.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
31. ANS: C
The nurse should instruct the students to wash hands frequently with soap and water for 20
seconds especially after blowing the nose. A. Sneezing should be into the upper sleeve and not
the hands. B. Used tissues should be placed in the waste basket. D. For droplet precautions, the
distance is 3 feet so the students should be instructed to move at least 3 feet away from another
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person when sneezing.
PTS: 1 DIF: Moderate
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KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application
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.
MULTIPLE RESPONSE
32. ANS: B, C
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a
Manifestations of a local infection also include pain, redness, swelling, and warmth at the site. A.
D. E. F. Symptoms of generalized infection may include headache, malaise, muscle aches, fever,
and anorexia.
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PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
33. ANS: A, B, C, D
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Level: Analysis
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There can be an increase in fever, elevated white blood cell count, decreased blood pressure,
mental confusion, tachycardia, and shock with sepsis. E. F. Bowel sounds and capillary refill
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would be decreased.
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PTS: 1 DIF: Moderate
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KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis
34. ANS: A, C, D
When caring for patients with tuberculosis, wear an individually fit-tested N95 or HEPA
respirator. HEPA respirators filter the tiniest particles from the air, unlike surgical masks, which
can allow such particles to pass into the respiratory system of a host. The patient must be in a
private isolation room with the door closed. The mask must be individually fitted to ensure
adequate protection. B. A private room is required. E. A one-size-fits-all respiratory mask is not
adequate when caring for a patient with tuberculosis.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
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Level: Application
35. ANS: A, B, C
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Direct transmission occurs through droplet spray into the eyes or mucous membranes during
sneezing, coughing, spitting, singing, or talking. D. E. F. Droplet spread is usually limited to 3
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.
feet or less.
PTS: 1 DIF: Moderate
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a
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Application
36. ANS: A, C
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Illnesses spread by direct transmission may include influenza, impetigo, scabies, conjunctivitis,
pediculosis, herpes, C. difficile, and all sexually transmitted diseases, including HIV. B. E.
Measles and chickenpox are transmitted by airborne transmission. A. F. Diseases spread through
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PTS: 1 DIF: Moderate
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vectors include malaria and Lyme disease.
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
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Level: Application
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37. ANS: A, B, F
Shingles (varicella zoster), measles (rubeola), and infectious mononucleosis (Epstein-Barr) are
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caused by viruses. C. Gonorrhea (Neisseria gonorrhoeae) is caused by bacteria. D.
Trichomoniasis (Trichomonas vaginalis) is caused by protozoa. E. Candida albicans is a fungus.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Analysis
38. ANS: C, E, F
Take on an empty stomach 1 hour before or 2 hours after meals. Take with a full glass of water
and not with acidic fruit juices. Explain that gastric distress is common but not a reason to stop
the drug. B. Fluoroquinolones may cause drowsiness. D. Penicillins may cause white patches in
the mouth or vaginal irritation. A. Several other types of anti-infectives, such as sulfonamides or
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tetracycline, require avoidance of sun exposure.
PTS: 1 DIF: Moderate
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KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
nk
.
Level: Application
39. ANS: D, F
Patients with a known allergy to one antibiotic in a class should not be given other antibiotics in
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a
that same class due to potential allergy; Gantrisin, Bactrim, and Septra are sulfa antibiotics and
should not be given to a patient with a sulfa allergy. A. B. C. E. These medications are not sulfa
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antibiotics and can safely be provided to the patient.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
40. ANS: B, C, D, E
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Level: Application
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Antibodies combine with specific foreign antigens on the surface of the invading organisms,
such as bacteria or viruses, to control or destroy them. Antigens are neutralized or destroyed by
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antibodies by initiating destruction of the antigen; neutralizing toxins released by bacteria,
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promoting antigen clumping with the antibody, or preventing the antigen from adhering to host
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cells. A. Neutrophils and macrophages engulf and digest foreign antigens through phagocytosis.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
41. ANS: A, B, C, E
Educating the public about the importance of hand hygiene, the Center for Disease Control and
Preventions (CDCs) respiratory hygiene/cough etiquette measures, immunization, clean water,
safe food handling techniques, and safer sex precautions helps prevent the spread of disease in
the community. D. Use of safety equipment with sports helps prevent accidental injuries.
PTS: 1 DIF: Moderate
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Chapter 17. Systemic Disorders Guidelines
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Multiple Choice
Identify the choice that best completes the statement or answers the question.
the nurse plan care for this patient?
a. Type I
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a
b. Type II
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.
____ 1. A patient is diagnosed with urticaria. For which type of hypersensitivity reaction should
c. Type III
d. Type IV
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____ 2. A patient is diagnosed with hypogammaglobulinemia. Which of immune cell should the
nurse realize is defective in this disorder?
b. B cells
c. Mast cells
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d. Plasma cells
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a. T cells
____ 3. The nurse is contributing to a group of patients care plans. Which patient should the
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nurse identify as being at risk for developing serum sickness?
a. A patient who receives intravenous (IV) penicillin for an infection
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b. A patient who has a transfusion with packed red blood cells (RBCs)
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c. A patient who is given cryoprecipitate and factor IX after an abdominal injury
d. A patient given steroids and immunosuppressant therapy after organ transplantation
____ 4. The nurse is caring for a patient with idiopathic autoimmune hemolytic anemia. Which
action should the nurse include in the plan of care for this patient?
a. Assist with ambulation.
b. Teach good hand hygiene.
c. Avoid intramuscular injections.
d. Obtain manual blood pressures.
____ 5. The nurse is caring for a patient who has had a portion of stomach removed. Which
manifestations should the nurse expect to determine if the patient has a vitamin B12 deficiency?
a. Fever, malaise, muscle soreness, and diarrhea
b. Numbness and tingling, weakness, and glossitis
d. Frequent infections, fever, malaise, vertigo, and lymphadenopathy
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c. Urticaria, angioedema, anorexia, pruritus, and blistered lesions
nurse consider as being the cause of this patients infection risk?
a. IgA
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.
b. IgE
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____ 6. The nurse is caring for a patient at risk for infection. Which immunoglobulin should the
c. IgG
d. IgM
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a
____ 7. The nurse is caring for a patient who is stung by a wasp. Which manifestation should the
nurse expect if an allergic reaction develops?
b. Retinal hemorrhage
c. Jugular vein distention
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a. Hives
d. Pallor around the sting sites
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____ 8. The nurse is caring for a patient with a severe allergic reaction. Which medication and
route should the nurse anticipate being ordered for this patient?
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a. Intramuscular morphine
b. Subcutaneous epinephrine
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c. IV diphenhydramine
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d. Oral diphenhydramine (Benadryl)
____ 9. The nurse is caring for a patient with a severe allergic reaction. Which medication should
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the nurse anticipate being administered to control the itching?
a. Morphine
b. Epinephrine
c. Diphenhydramine (Benadryl)
d. Hydrocortisone sodium succinate (Solu-Cortef)
____ 10. A patient is stabilized after having an allergic reaction. Which preventive instructions
should the nurse reinforce with the patient?
a. Wear Medic-Alert identification.
b. Stay indoors as much as possible.
c. Wear insect repellent when outdoors.
d. Take corticosteroids before going outdoors.
____ 11. The nurse contributed to the teaching plan for a patient with a history of allergies to
a. Gardening outdoors on dry, windy days
b. Wearing a mask when mowing the lawn
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c. Driving the car with the windows open during high pollen counts
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pollen. Which patient action indicates an understanding of how to control this disease?
d. Taking frequent walks outside in spring when the weather is warm
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.
____ 12. The nurse is contributing to the teaching plan for a patient who is allergic to dust.
Which environmental modification should the nurse recommend be included in the teaching plan
a. Installing a hot air heater
b. Cover heating ducts with filters
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c. Installing wall-to-wall carpeting
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a
to help control symptoms?
d. Using heavy draperies on sunny windows
____ 13. A patient is experiencing an episode of urticaria. Which intervention should the nurse
urticaria?
a. Avoiding tub baths
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recommend to include in the teaching plan to assist the patient in controlling the symptoms of
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b. Taking one aspirin daily
c. Using relaxation techniques
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d. Drinking decaffeinated coffee
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____ 14. A patient who developed hemolytic anemia related to the administration of penicillin
asks for an explanation of this condition. What is the most appropriate response by the nurse?
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a. The red blood cells are being produced inappropriately.
b. An antigenantibody reaction is causing destruction of red blood cells.
c. An allergy to penicillin is destroying your platelets for unknown reasons.
d. Allergens are invading the bone marrow and interfering with red blood cell production.
____ 15. A patient is receiving a transfusion of packed RBCs. Ten minutes after the infusion
begins the patient reports low back pain and a headache. Which action should the nurse take
first?
a. Stop the blood infusion.
b. Notify the physician STAT.
c. Start the new 0.9% normal saline infusion.
d. Prepare a new 0.9% normal saline infusion.
____ 16. A patient is to receive a transfusion of packed RBCs. Before administering the
transfusion, which action should the nurse take?
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a. Verify the patients kidney function.
b. Verify the patients hematocrit level.
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c. Verify blood type of the patient and donor.
d. Verify the patients admitting medical diagnosis.
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.
____ 17. The nurse is reinforcing teaching provided to a patient with Hashimotos thyroiditis.
What should the nurse explain as occurring initially in this health problem?
b. Thyroid hormone production decreases.
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a
a. Thyroid hormone production increases.
c. Thyroid-stimulating hormone production increases.
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d. Thyroid-stimulating hormone production decreases.
____ 18. The nurse is collecting data from a patient with skin eruptions. What should the nurse
recall to differentiate urticaria from angioedema?
a. It is less pruritic.
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b. It lasts a shorter period of time.
c. It includes mucous membrane edema.
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d. It causes more widespread skin lesions.
____ 19. The nurse is c caring for a patient with angioedema. Which nursing action should have
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the highest priority?
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a. Monitor for restlessness.
b. Identify cause of the angioedema.
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c. Identify the presence of skin lesions.
d. Teach the patient about immunotherapy.
____ 20. The nurse is assisting in the planning of care for a patient with chronic serum sickness.
Which action should be a priority for this patient?
a. Assessing for a decrease in urine output
b. Administration of immunosuppressive medications
c. Closely monitoring the patient during the transfusion of blood products
d. Discussing with the patient and significant other the need for genetic counseling
____ 21. The nurse is caring for a patient who had a kidney transplant 5 days ago. The patient
had been very outgoing and jovial, but this morning the patient is very quiet and refusing
breakfast, and ambulation. What would be the most appropriate nursing action at this time?
a. Notify the physician for laboratory orders.
c. Inform the patient that kidney rejection signs are appearing.
d. Spend extra time with the patient, allowing verbalization of feelings.
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b. Notify the social worker for discharge follow-up care.
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____ 22. The nurse is caring for a patient with severe ankylosing spondylitis. What nursing
action would be most appropriate?
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.
a. Provide tepid tub soaks.
b. Encourage a high-fiber diet.
d. Administer narcotic analgesics.
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c. Provide activity every 2 hours.
____ 23. The mother of an infant diagnosed with hypogammaglobulinemia asks the nurse how
a. It rarely occurs in males.
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the disease process occurred. What should the nurse explain to the mother?
b. It occurs after exposure to pesticides.
c. It is because the infant was premature.
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d. There are no known causes for this disorder.
____ 24. The nurse is reinforcing teaching on chloroquine side effects for a patient with systemic
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lupus erythematosus. Which adverse effect should the nurse encourage the patient to report when
taking this medication?
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a. Tarry stools
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b. Vision changes
c. Any weight gain
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d. Changes in joint movement
____ 25. The nurse has been caring for a patient with pernicious anemia. Which finding should
indicate to the nurse that treatment has been successful?
a. Decreased folic acid level and an increase in enlarged RBCs
b. A decrease in intrinsic factor and increased vitamin B12 excreted in the urine
c. An increase in vitamin B12 levels and decrease in number of enlarged RBCs
d. A decrease in hydrochloric acid levels in gastric secretion and decrease in production of RBCs
____ 26. The nurse notes that a patient has an elevated lactate dehydrogenase, fragmented RBCs
seen on microscopic examination, and low RBC count, hematocrit (Hct), and hemoglobin (Hgb)
levels. For which health problem should the nurse consider planning care for this patient?
a. Serum sickness
b. Pernicious anemia
c. Hemolytic transfusion reaction
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d. Idiopathic autoimmune hemolytic anemia
____ 27. The nurse is reviewing data collected on several patients. Which patient should the
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nurse identify as being most likely to exhibit signs and symptoms of systemic lupus
erythematosus?
nk
.
a. A 16-year-old Caucasian man
b. A 20-year-old Hispanic woman
d. A 42-year-old Asian American man
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c. A 45-year-old Caucasian woman
____ 28. The nurse recommends the diagnosis Disturbed Body Image for a patient with systemic
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lupus erythematosus. What would be an appropriate long-term outcome for this patient?
a. Engages in diversional activities
b. Uses normal coping mechanisms
c. Returns to previous social involvement
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d. Verbalizes feelings about body changes
____ 29. A patient is suspected as having a blood transfusion reaction. Which laboratory test
a. Skin testing
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should the nurse expect to be done to confirm this diagnosis?
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b. Direct Coombs test
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c. White blood cell count
d. C-reactive protein level
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____ 30. A patient comes into the emergency department with a fear of developing poison ivy
after falling while walking through a wooded area earlier in the day. What should the nurse
instruct the patient to do if exposure to poison ivy occurs again?
a. Flood the area with cold water.
b. Wrap the area with a thick towel.
c. Cover the area with cotton gauze.
d. Wash the area with brown soap or any soap.
____ 31. The nurse is reinforcing teaching provided to a patient with pernicious anemia. Which
patient statement indicates that teaching has been effective?
a. I can miss a month or two of injections if I am feeling better.
b. I will need to take vitamin B12 injections for the rest of my life.
c. I will take the vitamin B12 injections until my strength returns.
d. I can take a vitamin B12 injection when I feel tired or fatigued.
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____ 32. A patient is being started on a blood transfusion. For how many minutes should the
nurse stay with the patient during this transfusion?
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a. 5
b. 10
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.
c. 15
d. 20
Multiple Response
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a
Identify one or more choices that best complete the statement or answer the question.
____ 33. The nurse is reinforcing teaching about potential triggers with a patient experiencing
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allergic rhinitis. What should the nurse include in the teaching? (Select all that apply.)
a. Dust
b. Penicillin
d. Pet dander
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e. Topical lotion
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c. Ragweed
f. Oral multivitamin
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____ 34. The nurse is assisting in an educational seminar on common allergens. What should the
nurse include as the most common irritant causing contact dermatitis? (Select all that apply.)
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a. Bleach
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b. Rubber
c. Fire ants
d. Poison ivy
e. Poison oak
____ 35. The nurse is participating in a teaching plan to address Risk for Impaired Skin Integrity
for a patient with contact dermatitis. Which information should the nurse recommend be
included in this plan? (Select all that apply.)
a. Keep fingernails short.
b. Take baths with an oatmeal solution.
c. Use oil-in-water lubricants for skin dryness.
d. Rub affected area roughly, but do not scratch.
e. Avoid washing affected area with brown soap.
f. Use cool washcloths over affected area to ease itching.
____ 36. The nurse is contributing to the teaching plan for a patient diagnosed with Hashimotos
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thyroiditis who has progressed to hypothyroidism with a goiter. Which self-care instructions
should the nurse recommend? (Select all that apply.)
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a. Eat a soft diet.
c. Eat more foods high in iodine.
d. Keep home at a cool temperature.
e. Eat a high-carbohydrate, high-protein diet.
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.
b. Increase activity slowly.
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a
f. During low-energy periods, use anti-embolism stockings.
____ 37. The nurse is contributing to a staff education program about nursing care for
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hypersensitivity reactions. Which should the nurse include as examples of type I hypersensitivity
reactions? (Select all that apply.)
a. Anaphylaxis
c. Serum sickness
d. Allergic rhinitis
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e. Contact dermatitis
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b. Angioedema
f. Hypogammaglobulinemia
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____ 38. A patient with lupus erythematosis is prescribed a corticosteroid. What side effects of
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this medication should the nurse review with the patient? (Select all that apply.)
a. Tinnitus
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b. Facial hair
c. Moon face
d. Mood changes
e. Increased weight
f. Rash and pruritus
____ 39. The nurse is assisting in the care of a patient with ankylosing spondylitis. What should
the nurse expect to find in the patients collaborative plan of care? (Select all that apply.)
a. Physical therapy daily
b. Sitz baths three times daily
c. Tylenol #3 every 4 hours prn pain
d. Administer Remicade as prescribed
e. Activity as tolerated; up with assistance
____ 40. The nurse is contributing to the plan of care for a patient with systemic lupus
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erythematosus (SLE). Which interventions should the nurse recommend for this patient? (Select
all that apply.)
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a. Eat a balanced diet.
c. Take cool showers or baths to relieve joint stiffness.
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.
b. Report foamy urine to physician.
d. Avoid naps and obtain a minimum of 6 hours of sleep.
e. Exercise when pain and inflammation in joints is increased.
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f. Use a daily personal schedule to plan activities to reduce fatigue.
____ 41. A patient with an autoimmune disorder asks, What might cause my body to do this to
self? (Select all that apply.)
a. Drugs
c. Vaccinations
d. Viral infections
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e. Bacterial infections
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b. Hormones
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itself? What should the nurse state as reasons for the body to have lost the ability to recognize
____ 42. The nurse is experiencing severe skin blisters after wearing latex gloves at work. Which
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treatment should the nurse expect to be prescribed by the health care provider for these skin
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lesions? (Select all that apply.)
a. Oral antibiotics
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b. Topic drying agent
c. Oral antihistamines
d. Topical corticosteroid
e. Topical immunomodulators
____ 43. The nurse applies clean white cotton socks over the hands of a patient with contact
dermatitis. What should the nurse explain to the patient about the purposes of this intervention?
(Select all that apply.)
a. Cotton allows air movement.
b. White cotton has no dye in the material.
c. White cotton prevents the wounds from spreading.
d. The cotton will absorb the drainage from the wounds.
e. Scratching is less during sleep when the area is covered.
Completion
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Complete each statement.
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44. A patient with systemic lupus erythematosis is prescribed Prednisone, 60 mg PO, in three
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.
equal doses. If using 5 mg tablets, how many tables should the nurse provide for each dose?
Other
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45. A patient is receiving a transfusion of packed RBCs. Ten minutes after the infusion begins,
the patient reports low back pain and a headache. Place the actions in order (15) of importance of
performance.
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A. ___ Stop the blood infusion.
B. ___ Notify the physician stat.
C. ___ Obtain vital signs and assess patient.
D. ___ Start the new 0.9% normal saline infusion.
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E. ___ Prepare a new 0.9% normal saline infusion.
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Answer Section
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MULTIPLE CHOICE
1. ANS: A
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Anaphylaxis, urticaria, and angioedema are the most severe forms of type I hypersensitivity
reactions. B. A type II hypersensitivity reaction involves the destruction of a cell or substance
that has an anti-gen attached to its cell membrane. C. A type III hypersensitivity reaction
involves immune complexes formed by antigens and antibodies, usually of the IgG type. D. A
type IV hypersensitivity reaction, also called a delayed reaction, occurs when a sensitized T
lymphocyte comes in contact with the particular antigen to which it is sensitized.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level:
Application
2. ANS: B
Hypogammaglobulinemia is characterized by the absence or deficiency of one or more of the
m
five classes of immunoglobulins from defective B-cell function. A. C. D.
co
Hypogammaglobulinemia is not caused by defective T, mast, or plasma cells.
PTS: 1 DIF: Moderate
nk
.
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis
3. ANS: A
kt
a
Serum sickness is seen occasionally after administration of penicillin and sulfonamide. B. C. D.
Serum sickness is not associated with blood transfusions, cryoprecipitate, factor IX, steroids, or
immunosuppressant therapy.
ba
n
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
st
Level: Analysis
4. ANS: A
.te
With anemia, the patient will be fatigued and may have activity intolerance and be a fall risk.
Assistance with ambulation should be done for safety. C. D. These actions would be appropriate
w
if the patient had thrombocytopenia. B. This action would be appropriate if the patient had
w
neutropenia.
PTS: 1 DIF: Moderate
w
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Application
5. ANS: B
Non-immune-related causes of pernicious anemia include any type of gastric or small bowel
resections coupled with no or inadequate vitamin B12 or intrinsic factor replacement. Vitamin
B12 deficiency symptoms include numbness and tingling, weakness, and glossitis. A. C. D.
These are not manifestations associated with vitamin B12 deficiency.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
m
Application
6. ANS: A
co
IgA cannot be replaced, increasing the risk for infections. B. C. D. These immunoglobulins can
be replaced.
nk
.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
7. ANS: A
kt
a
Level: Analysis
Hives is one of several symptoms of an allergic reaction. B. C. D. These manifestations are not
ba
n
associated with an allergic reaction.
PTS: 1 DIF: Moderate
st
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis
.te
8. ANS: B
Epinephrine subcutaneous (SQ) or intramuscular (IM) is given for anaphylactic reactions. It
causes vasoconstriction, bronchodilation, and cardiac stimulation. A. Morphine is not used for an
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allergic reaction. C. D. Diphenhydramine is an oral medication however will not work quickly
w
enough for the patients severe allergic reaction.
w
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
Level: Application
9. ANS: C
Benadryl blocks histamine at histamine1-receptors, therefore preventing or reversing the effects
of histamine. A. Morphine does not reduce itching. B. Epinephrine will help the overall allergic
response however will not specifically reduce itching. D. This medication might need to be
prescribed long-term if the itching continues.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
m
Level: Application
10. ANS: A
co
The nurse should teach the patient to wear medical alert identification for allergies in order for
prompt medical attention to be given if the patient is unable to give information. B. Out of doors
nk
.
might not be the reason for the patients allergic reaction. C. The patient might not be allergic to
stinging insects. D. This medication should not be taken prophylactically.
kt
a
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
ba
n
11. ANS: B
Allergen avoidance might involve wearing a mask when mowing the lawn or working outdoors
or having heating ducts cleaned or heating registers covered with filters. A. C. D. These would
.te
PTS: 1 DIF: Moderate
st
increase the patients risk of having an allergic reaction.
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis
w
12. ANS: B
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Filtering the air will reduce dust particles which the other items do not do. C. Carpeting traps
dust and is harder to clean. A. A hot air heater will not reduce the amount of dust in the patients
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environment. D. Heavy draperies will trap dust.
PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application
13. ANS: C
Stress management and relaxation techniques may be helpful with urticaria symptoms. A. B. D.
These actions are not identified to reduce the symptoms of urticaria.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level:
m
Application
co
14. ANS: B
For no known reason, autoantibodies are produced that attach to RBCs and cause them to either
hemolytic anemia in this patient.
kt
a
PTS: 1 DIF: Moderate
nk
.
lyse or agglutinate (clump). A. C. D. These choices do not correctly explain the development of
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level:
Application
ba
n
15. ANS: A
Low back pain and headache can be symptoms of a transfusion reaction. If symptoms of a
reaction are noted, the blood is immediately stopped so that no more blood is infused into the
st
patient. B. The physician should be notified after the transfusion is stopped. C. D. A new normal
saline infusion with new tubing is prepared and started to keep the vein patent should
.te
medications need to be administered as ordered. New tubing must be used so that not one more
w
drop of blood enters the patient.
PTS: 1 DIF: Moderate
w
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level:
w
Application
16. ANS: C
Prevention of hemolytic reactions is crucial. At the bedside, double-check the patients name and
identification number on the chart, unit of blood, and patients identification bracelet, as well as
check the patients blood type in the chart, on the unit of blood, and paperwork with the unit of
blood. A. B. D. These actions will not help prevent the development of a transfusion reaction.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
17. ANS: A
Autoantibodies for thyroid-stimulating hormone form, bind with the hormone receptors on the
m
thyroid gland, and initially stimulate the thyroid gland to secrete thyroid hormones. B. C. D.
co
These statements do not explain the initial action in Hashimotos thyroiditis.
PTS: 1 DIF: Moderate
nk
.
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level:
Application
kt
a
18. ANS: B
Angioedema subcutaneous eruptions last longer than with urticaria. A. C. D. These statements
describe angioedema.
ba
n
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis
st
19. ANS: A
If the angioedema reaction is severe, maintenance of a patent airway is a priority. Any symptoms
.te
of respiratory distress must be reported immediately and remain the highest priority. B. Because
the condition is already present, monitoring the patient takes priority, although the cause needs to
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be identified. C. D. These may be addressed later but are not the priority.
w
PTS: 1 DIF: Moderate
w
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis
20. ANS: A
The patient is at risk for low fluid volume which can lead to renal failure. Monitoring urine
output can help reduce the risk of renal failure from occurring. B. C. D. These actions are not
indicated in the care of this patient.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level:
Application
21. ANS: D
Psychological support is important for transplant patients. Patients need time to verbalize
m
feelings and understand that feelings of guilt are normal and diminish with time. A. B. C. These
co
actions are not appropriate for the patient at this time.
PTS: 1 DIF: Moderate
nk
.
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
22. ANS: C
kt
a
The patient should not stay in any one position for any length of time to reduce stiffness and
pain. A. B. D. These actions are not specifically identified to help the patient with severe
ankylosing spondylitis.
ba
n
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
st
Application
23. ANS: D
.te
Hypogammaglobulinemia is either a hereditary congenital disorder or acquired after childhood
from unknown causes. It is characterized by the absence or deficiency of one or more of the five
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classes of immunoglobulins (IgG, IgM, IgA, IgD, and IgE) from defective B-cell function. The
lack of normal function of these antibodies makes the patient prone to infections. A. The
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congenital form of this disorder affects males. B. It is not linked to pesticide exposure. C. It did
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not develop because the infant was premature.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level:
Application
24. ANS: B
The patient should have an ophthalmologic examination completed before starting this
medication because vision changes can occur. A.C. D. These are not identified adverse effects
for this medication.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
m
Level: Application
25. ANS: C
co
Macrocytic (enlarged RBCs) anemia, and low vitamin B12 levels are indicators of pernicious
anemia, so increased vitamin B12 levels and decreased enlarged RBCs would indicate successful
nk
.
treatment. A. B. D. These findings would not support treatment for pernicious anemia as being
successful.
kt
a
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis
26. ANS: D
ba
n
In idiopathic autoimmune hemolytic anemia, the RBC count and Hgb and Hct levels are low,
with fragmented RBCs and elevated lactate dehydrogenase because of RBC destruction and
tissue ischemia. A. B. C. These manifestations are not seen in serum sickness, pernicious anemia,
.te
PTS: 1 DIF: Moderate
st
or hemolytic transfusion reactions.
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
w
Analysis
w
27. ANS: B
Systemic lupus erythematosus tends to develop in young women of child-bearing years and
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occurs in the African American and Hispanic populations more frequently. A. C. D. These
individuals are less likely to develop manifestations of systemic lupus erythematosus.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis
28. ANS: C
The ultimate outcome is for the patient to return to previous social involvement in spite of body
image issues such as the butterfly rash. A. B. D. These outcomes would be short-term for the
patient with systemic lupus erythematosus.
PTS: 1 DIF: Moderate
m
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis
co
29. ANS: B
The direct Coombs test confirms the diagnosis of transfusion reaction. In the laboratory, a small
nk
.
amount of the patients RBCs is washed to remove any unattached antibodies. Antihuman
globulin is added to see if agglutination (clumping) of the RBCs results. If agglutination occurs,
an immune reaction such as a hemolytic transfusion reaction is taking place. A. Skin testing is
kt
a
used to determine the presence of a type I hypersensitivity reaction. C. D. These tests might be
done to determine the presence of serum sickness.
ba
n
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
st
30. ANS: D
The patient should be instructed to wash the area with a brown soap (e.g., Fels-Naptha) or, if
.te
unavailable, any soap when contact with the offending agent is suspected. This removes the
offending agent from the skin. A. Cold water is not going to remove the agent from the skin. B.
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C. Wrapping the area with a towel or gauze is going to trap the offending agent on the skin and
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make the skin reaction worse.
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PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application
31. ANS: B
If vitamin B12 injections are prescribed, the patient must understand that this is a lifelong need
to prevent the return of symptoms. A. C. Patients should not miss injections. D. Injections are not
taken as needed for fatigue.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Analysis
32. ANS: C
The nurse should stay at the bedside with a patient for the first 15 minutes of any blood
m
transfusion to detect signs of a reaction. A. B. The nurse needs to stay longer than 5 or 10
co
minutes. D. The nurse does not need to stay beyond 15 minutes.
PTS: 1 DIF: Moderate
nk
.
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
kt
a
MULTIPLE RESPONSE
33. ANS: A, C, D
Allergic rhinitis causative antigens are environmental and airborne. Frequent home vacuuming
ba
n
and dusting are recommended. B. E. F. Penicillin, topical lotion, and oral multivitamins are not
identified as being triggers for allergic rhinitis.
st
PTS: 1 DIF: Moderate
Application
.te
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
34. ANS: D, E
w
Poison ivy and poison oak are the most common irritants causing contact dermatitis. A. B. C.
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These items are not known to cause contact dermatitis.
w
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Application
35. ANS: A, B, C, F
The patient should be instructed to avoid scratching the skin to prevent the spread of dermatitis
and infection development. Ease itching with cool washcloths and oatmeal baths, and keep
fingernails short to avoid injury to skin if scratching occurs. Oil-in-water lubricants tend to be the
most effective for skin dryness. D. E. Rubbing the skin and avoiding brown soap will not help
the patient with contact dermatitis.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
m
Application
co
36. ANS: A, B, F
If the patient has a goiter, a soft diet may be necessary for comfort. Frequent rest periods may be
nk
.
necessary as well as slowly increasing patient activity. Anti-embolic stockings may help prevent
venous stasis during the low-energy, decreased-activity phase. E. During the hyperthyroidism
phase, a diet high in protein and carbohydrates encourages weight gain. D. The patient will be
kt
a
sensitive to cold, so room temperature will need to be increased for comfort. C. Foods high in
iodine should be avoided.
ba
n
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level:
37. ANS: A, B, D
st
Application
Type I hypersensitivity reactions include conditions such as allergic rhinitis and allergic asthma,
.te
atopic dermatitis, anaphylaxis, angioedema. hemolytic transfusion reactions, measles, and
transplant rejections. C. E. F. These health problems are not considered type I hypersensitivity
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reactions.
w
PTS: 1 DIF: Moderate
w
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level:
Application
38. ANS: B, C, D, E
Corticosteroids can cause weight gain, increased facial hair, acne, round moon face, mood
changes, irritability, depression, increased appetite, increased weight, poor wound healing,
headache, peptic ulcers, and osteoporosis. A. F. Tinnitus, rash, and pruritus are not adverse
effects of corticosteroid therapy.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
Level: Application
39. ANS: A, C, D, E
Nursing care focuses on patient education and administration and evaluation of prescribed
co
are provided. B. Sitz baths are not indicated for this health problem.
m
medications. Pain management, rest periods, and assistance with activities of daily living (ADLs)
PTS: 1 DIF: Moderate
nk
.
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis |
40. ANS: A, B, F
kt
a
Fatigue during activities of daily living is minimized through the use of a daily personal
schedule. Additionally, a minimum of 8 hours of sleep per night with naps as necessary are
important to combat fatigue. Because the majority of patients with SLE develop transitory
ba
n
arthralgia, maintaining fitness and joint range of motion through a regular fitness program while
decreasing activity during flares is vital. Warm baths may help with morning stiffness. Because
renal disease is a major complication of SLE, patients must learn the signs of impending
problems that need to be relayed to the physician immediately. These are such findings as facial
st
puffiness and foamy urine or coke-colored urine indicative of proteinuria and hematuria,
.te
respectively. Eating a well-balanced diet will also influence level of fatigue and weight gain
from the corticosteroids. C. Cool showers will not help relieve the pain and stiffness associated
with this disorder. D. Rest is beneficial for this disorder. E. Exercise should be reduced during
w
w
flare-ups.
PTS: 1 DIF: Moderate
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KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level:
Application
41. ANS: A, B, D
A number of factors either cause or influence this breakdown of self-recognition, including viral
infections, drugs, and cross-reactive antibodies. Hormones have also been found to influence this
breakdown of self-recognition. C. E. Vaccinations and bacterial infections have not been
identified as contributing to the development of an autoimmune disorder.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level:
Application
42. ANS: B, C, D, E
Oral or topical antihistamines and topical drying agents may be used. Topical corticosteroids
m
may be used and are most effective if sparingly applied after a bath or shower. Topical
immunomodulators also may be prescribed when other treatments fail. A. Oral antibiotics are not
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indicated in the treatment of a latex allergy.
nk
.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
kt
a
Level: Application
43. ANS: A, B, E
Cotton allows air movement. White cloth is less irritating than those with dyes. Scratching is
ba
n
decreased during sleep with the use of gloves/mittens or by covering affected area. C. D. The use
of white cotton socks over the hands of a patient with contact dermatitis is not done to prevent
PTS: 1 DIF: Moderate
st
the wounds from spreading or to absorb the drainage from the wounds.
Application
.te
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
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COMPLETION
4
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44. ANS:
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The nurse should use the equation Dosage Required/Dosage Available x 1 tablet or 20 mg/5 mg
x 1 = 4 tablets.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
Level: Application
OTHER
45. ANS:
A, C, B, E, D
Low back pain and headache can be symptoms of a transfusion reaction. If symptoms of a
reaction are noted, the blood transfusion is immediately stopped and agency policy for a
m
suspected transfusion reaction is followed. A normal saline infusion with new tubing is started to
keep the vein patent. The physician and blood bank are immediately notified. A nurse remains
co
with the patient for reassurance and monitoring of symptoms and vital signs. If a blood
incompatibility is suspected, the unused blood and blood tubing are returned to the blood bank
nk
.
for testing. A series of blood and urine specimens are collected and sent to the laboratory for
analysis. The physicians orders are followed to treat the patients symptoms.
kt
a
____ 46. The nurse is caring for a patient who has AIDS. Which outcome should receive
priority?
b. Report high self-esteem.
c. Remain free of infection.
d. Maintain baseline weight.
ba
n
a. Remain socially active.
st
____ 47. A patient with HIV asks the nurse if thinking about dying frequently is common with
HIV. What is an appropriate response by the nurse?
.te
a. HIV is a serious disease that results in death.
b. Thinking about death will not change the prognosis.
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c. HIV is now considered a chronic disease with treatment.
d. HIV has a very high mortality rate, so it is realistic to plan for death.
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____ 3. The nurse is caring for a patient with HIV. For which common opportunistic infection
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should the nurse observe when caring for this patient?
a. Toxoplasmosis
b. Cryptococcosis
c. Candida albicans
d. Cryptosporidiosis
____ 48. The nurse contributed to a staff education program about transmission precautions to
use when caring for a patient who has AIDS. Which statement by a staff member indicates a
correct understanding of the teaching?
a. Wear a mask for any patient contact.
b. Wear a waterproof gown at all times.
c. Wear clean gloves for body fluid contact.
d. Wear sterile gloves for any patient contact.
____ 49. The nurse is reinforcing teaching on transmission of HIV for a family of a patient
diagnosed with HIV. Which explanation by the nurse would be correct?
m
a. HIV can be spread by casual contact.
c. HIV is most commonly transmitted via tears and saliva.
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b. HIV lives for long periods outside the body.
d. HIV enters the body through breaks in the skin or mucous membranes.
nk
.
____ 50. The nurse is monitoring a patient with AIDS. Which manifestation should the nurse
expect to observe in this patient?
a. Diarrhea
kt
a
b. Chest pain
c. Hypertension
ba
n
d. Pustular skin lesions
____ 51. The nurse is assisting in a teaching plan for the family of a patient with HIV. Which
explanation about the transmission of HIV should the nurse include in this plan?
a. HIV is spread by casual contact with others.
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b. HIV spreads by contact with infected blood.
c. HIV can be spread by sharing eating utensils.
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d. HIV is commonly transmitted by tears or saliva.
____ 52. A patient who has AIDS expresses concern about telling others about the illness. Which
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response would be appropriate by the nurse?
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a. It would be best to tell everyone you know.
b. You should tell those who have a reason to know.
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c. Your diagnosis will be discovered anyway by those you know.
d. Secrecy is a poor idea because it will erode your self-esteem.
____ 53. The nurse is providing care to a patient who has had diagnostic testing for HIV. Which
test should the nurse review to monitor the response to antiretroviral therapy?
a. Western blot
b. Viral load testing
c. P24 antigen testing
d. Enzyme-linked immunosorbent assay
____ 54. The nurse is preparing to care for a patient who is HIV positive. Which action should
the nurse take when following standard precautions for protection from HIV exposure?
a. Put on gloves before touching body fluids.
b. Recap intramuscular needles after injection.
c. Wash own open skin lesion after providing care.
m
d. Remove one finger on a glove during venipuncture.
Which response should the nurse make to the patient?
a. B-lymphocyte levels increase if you have an acute infection.
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____ 55. A patient who has HIV asks the nurse why blood work has to be done so frequently.
nk
.
b. Phagocytes are decreased when the disease is in an active phase.
c. Neutrophil counts help the doctor titrate medication levels to keep you healthy.
d. CD4+ lymphocyte counts are monitored to determine the progression of the disease.
kt
a
____ 56. The nurse is contributing to a teaching plan. What should the nurse emphasize as being
the most effective method known to control the spread of HIV infection?
ba
n
a. Premarital serological screening
b. Prophylactic exposure treatment
c. HIV screening for pregnant women
d. Education about preventive behaviors
st
____ 57. The nurse is collecting data for a patient with suspected exposure to HIV. Which
symptoms would be most concerning in this patient?
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a. Tremors, edema, coughing
b. Fever, diarrhea, sore throat
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c. Urticaria, sneezing, pruritus
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d. Abdominal pain, anorexia, and vomiting
____ 58. The nurse is reviewing laboratory results for a patient who has HIV. Which result
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would be strongly suggestive of a diagnosis of AIDS?
a. CD4+ = 180/L
b. CD4+ percentage = 68%
c. CD8+ = 650/L
d. CD4+/CD8+ ratio = 1.5
____ 59. A patient asks, What is the main purpose of these medications I take for my HIV?
Which response should the nurse make?
a. They encapsulate the virus-infected cells.
b. They mark the virus for natural killer cells to destroy.
c. They attract macrophages to the cells making the virus.
d. They inhibit enzymes to interfere with viral production.
____ 60. The nurse is participating in the planning of care for a patient who has HIV. Which
therapeutic action should the nurse recognize as the treatment goal for HIV?
m
a. Stimulating the immune system
b. Treating opportunistic infections
co
c. Killing the virus with medication
d. Keeping the virus from replicating
nk
.
____ 61. The nurse provides teaching on nevirapine (Viramune) for a patient who is HIV
positive. Which patient statement indicates that teaching has been effective?
b. Observe urine color.
c. Report extremity pain.
ba
n
d. Monitor for flulike symptoms.
kt
a
a. Monitor for rash.
____ 62. The family of a patient with AIDS has been instructed on patient manifestations to
report to the health care provider (HCP). Which manifestation should be reported indicating that
a. Fever
b. Dry mouth
.te
c. Night sweats
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teaching has been effective?
d. Constipation
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____ 63. The nurse is reviewing the use of a condom to prevent the transmission of HIV with a
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young adult patient seeking testing for HIV. Which patient statement indicates an understanding
of how to use a condom?
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a. Use a non-latex condom.
b. Apply adequate oil-based lubricant.
c. Apply condom before penile erection occurs.
d. Withdraw from partner while the penis is erect.
____ 64. A patient with AIDS-related wasting syndrome is very weak, lies listlessly in bed, has
an intravenous (IV) drip, and receives antiretroviral medications via injection. What should be
the priority nursing diagnosis for this patient?
a. Pain related to immobility
b. Ineffective Individual Coping due to terminal stage of HIV
c. Risk for Injury due to impaired mobility, weakness, and weight loss
d. Risk for Infection due to weak immune system and parenteral therapy
____ 65. An HIV-infected patient reports being a cat lover and says, I always get my pets from a
known sanitary source. What should the nurse instruct the patient about cats and the risk of
m
infection?
b. Obtain only cats that are less than 1 year old.
c. Remove all pets from your home. Avoid all contact with cats.
co
a. Keep cats outdoors most of the time.
nk
.
d. Be sure all the cats have up-to-date immunizations, and avoid their feces.
____ 22. The nurse is caring for a patient who has AIDS. For which opportunistic lung infection
caused by a fungus should the nurse monitor in this patient?
kt
a
a. Tuberculosis
b. Cytomegalovirus
ba
n
c. Candida albicans
d. Pneumocystis jiroveci pneumonia
____ 66. The nurse is caring for the newborn of a mother who is HIV positive. What treatment
a. Bacitracin
b. Erythromycin
.te
c. Protease inhibitor
st
should the nurse expect to be prescribed for the infant?
d. Zidovudine (AZT)
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____ 67. A health care worker is exposed to blood from a patient who has HIV. What action
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should the worker take after the exposure?
a. Apply alcohol to the site.
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b. Cleanse the site with soap and water.
c. Flush the site with hot running water.
d. Apply a topical antibiotic to the site.
____ 68. The nurse notes that a patient with AIDS is prescribed trimethoprim-sulfamethoxazole
(Bactrim). For which opportunistic infection should the nurse realize that is this medication
indicated?
a. Tuberculosis
b. Cytomegalovirus retinitis
c. Mycobacterium avium complex
d. Pneumocystis jiroveci pneumonia
____ 69. The nurse is preparing to read the Mantoux tuberculin skin test placed on the forearm of
a patient with HIV. Which finding should the nurse report as a positive test for this patient?
a. 2 mm
m
b. 3 mm
c. 4 mm
co
d. 5 mm
Multiple Response
nk
.
Identify one or more choices that best complete the statement or answer the question.
____ 70. A patient who has AIDS has been instructed on foods to eat to reduce the risk of
teaching? (Select all that apply.)
a. Rare meat
ba
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b. Raw seafood
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infection. Which foods should the patient select that indicates correct understanding of this
c. Soft egg yolks
d. Pasteurized milk
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e. Well-cooked meat
____ 71. The nurse is contributing to a teaching plan. What information should the nurse include
a. Urine
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b. Sweat
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that identifies the methods in which HIV can be transmitted? (Select all that apply.)
c. Saliva
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d. Semen
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e. Breast milk
f. Vaginal secretions
____ 72. The nurse has been discussing actions to prevent AIDS-related wasting syndrome with
a patient being treated for AIDS. Which patient statements indicate an understanding of this
teaching? (Select all that apply.)
a. Eat a low-residue diet.
b. Drink liquids before meals.
c. Enjoy food odors to stimulate appetite.
d. Numb painful oral sores with ice or popsicles.
e. Eat three high-calorie, high-protein meals a day, plus snacks.
f. Increase consumption of caffeine-containing foods and fluids.
____ 73. The nurse is contributing to a nutrition and hydration teaching plan for a patient who
has AIDS. What recommendations should the nurse include in this plan? (Select all that apply.)
a. Avoid soft cheeses.
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b. Avoid Caesar salad.
c. Avoid public drinking fountains.
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d. Avoid all beers and all soft drinks.
e. Avoid leftovers or heat until steaming.
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.
f. Cook red meat until internal temperature is 165F with no trace of pink.
____ 74. The nurse is reinforcing teaching on the rising incidence of HIV in adults over the age
of 50 with a group of senior community members. Which factors should the nurse include?
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(Select all that apply.)
a. Older adults are less likely to use condoms than younger at-risk adults.
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b. At-risk individuals over the age of 50 are less likely to be tested for HIV.
c. Society continues to age with larger numbers of people entering this age group.
d. A decline in the function of the immune system increases the risk of HIV infection.
e. Decreased vaginal dryness and friability of tissues increases the risk of HIV in older women.
sexually active.
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f. Treatments for erectile dysfunction have increased the number of older individuals who are
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____ 75. The nurse is preparing to provide education related to HIV transmission at a local
community health fair. Which statements should the nurse recommend for inclusion in the
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teaching? (Select all that apply.)
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a. Use oil-based lubricants.
b. Use a new condom for each sex act.
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c. Use condoms that are not made of latex.
d. Fit condom tightly over the tip of the penis.
e. Check condom package for expiration date.
f. Apply the condom before touching partner with the penis.
____ 76. A patient with AIDS is prescribed the nucleoside reverse transcriptase inhibitor
lamivudine (Epivir). What information should the nurse ensure that the patient receives about
this medication? (Select all that apply.)
a. Report any onset of bleeding.
b. Report any yellowing of the skin.
c. Report any change in urine output.
d. Report any symptoms similar to having the flu.
e. Report any numbness or tingling of the hands or feet.
____ 77. A patient with AIDS is planning a trip to Mexico. What teaching should the nurse
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provide to this patient to prevent the development of an opportunistic infection? (Select all that
apply.)
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a. Use beach towels.
c. Do not eat raw fruits or vegetables.
d. Clean bathroom supplies with bleach.
e. Take an antimicrobial agent if diarrhea occurs.
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.
b. Do not walk barefoot.
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____ 78. While collecting admission data, the nurse suspects a patient with AIDS is experiencing
an HIV-associated neurocognitive disorder. What observations did the nurse make to come to
a. Audible bowel sounds
b. Inappropriate laughter
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this conclusion? (Select all that apply.)
c. Inability to state home address
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d. Knee buckling while walking
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e. Asking if the bugs could be removed from the walls
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Answer Section
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MULTIPLE CHOICE
1. ANS: D
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The immune system is damaged by HIV, and ability to combat infections may be severely
compromised. A minor infection for most people may kill a person who has AIDS. The priority
goal for patients with HIV is to remain free of infections. A. Remaining socially active could
lead to an infection. B. Having a high self-esteem is important although not the priority for
nursing care. D. Maintaining baseline weight is more likely to occur if the patient remains free of
infection.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Application
2. ANS: C
HIV disease is characterized as a chronic disease rather than a life-ending illness. Cocktails of
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multiple antiretroviral drugs have reduced viral loads in the bloodstream and increased CD4+ Tlymphocyte counts, resulting in prolonged survival. A. B. D. Not everyone who is HIV positive
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develops AIDS and dies. The patient should be encouraged to think about the positive treatment
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.
available and not about the possibility of dying.
PTS: 1 DIF: Moderate
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KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
3. ANS: C
Candida albicans is a fungus normally found in the gastrointestinal (GI) tract that does not infect
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a person with a healthy immune system. It is one of the common infections that can occur with
AIDS.A. Toxoplasmosis is associated with cleaning cat litter. B. Cryptococcus is transmitted
through contact with birds. D. Cryptosporidiosis can be transmitted through working with
PTS: 1 DIF: Moderate
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animals.
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Application
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KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
4. ANS: C
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Use standard precautions and wear clean gloves for body fluid contact to protect the health care
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worker. A. HIV is not an airborne disease. B. A waterproof gown is only necessary if splashes
are likely. D. Sterile gloves are not necessary for protection.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Analysis
5. ANS: D
HIV enters the body through breaks in the skin or mucous membranes. A. B. C. HIV is not
spread by casual contact, does not live outside the body for long periods, and is not most
commonly transmitted via tears and saliva. It is transmitted mainly by infected blood exposure.
PTS: 1 DIF: Moderate
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KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
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Level: Application
6. ANS: A
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.
Many factors interfere with nutrition in HIV/AIDS such as anorexia, oral lesions, nausea and
vomiting, or wasting syndrome. Diarrhea is a common manifestation in patient with AIDS. B. C.
D. Chest pain, hypertension, and pustular skin lesions are not common manifestations associated
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a
with AIDS.
PTS: 1 DIF: Moderate
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KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis
7. ANS: B
HIV is transmitted by infected blood exposure. A, C, D. HIV is not spread by casual contact,
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PTS: 1 DIF: Moderate
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such as with shared eating utensils, and is not most commonly transmitted via tears and saliva.
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
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Level: Application
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8. ANS: B
The patient should tell those who have a reason to know to prevent risk of infection and to
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provide appropriate treatment. A. C. D. Others do not need to be told confidential information.
Sharing this information will not erode the patients self-esteem.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
9. ANS: B
Viral load testing measures the amount of HIV RNA in plasma and is extremely important for
determining prognosis and monitoring the response to antiretroviral therapy. A. The Western blot
test is done to detect the presence of antibodies to four major HIV antigens C. D. These tests are
not used to measure the response to antiretroviral therapy.
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PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
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Application
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.
10. ANS: A
Gloves should be worn before touching body fluids, as all patients are considered to be infected
per standard precautions. B. Do not recap needles. C. A nurse should not provide care with open
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lesions. D. Do not remove one glove finger as it defeats the purpose of glove protection.
PTS: 1 DIF: Moderate
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KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Application
11. ANS: D
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A low ratio of CD4 cells to CD8 cells is seen as HIV/AIDS progresses. It is recommended that
CD4/CD8 T-lymphocyte counts be performed at 3-month intervals for most patients. A. B. C.
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The other responses do not appropriately explain the need for frequent blood analyses in the
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patient with HIV.
PTS: 1 DIF: Moderate
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KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
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Application
12. ANS: D
Prevention and education are the best ways to manage the HIV/AIDS epidemic. Education
should begin with older school-age children through older adults. A. B. C. Premarital screening,
prophylactic exposure treatment, and screening for pregnant women are not the best approaches
to control the spread of HIV infection.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Application
13. ANS: B
Initially after HIV infection, there may be no symptoms or mononucleosis-like symptoms such
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as extreme fatigue, headache, fever, lymphadenopathy, diarrhea, or a sore throat. A. C. D.
Tremors, edema, coughing, urticaria, sneezing, pruritis, abdominal pain, anorexia, and vomiting
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.
opportunistic infections associated with being HIV positive.
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are manifestations that might be associated with a different health problem or as a result of
PTS: 1 DIF: Moderate
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a
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis
14. ANS: A
AIDS is diagnosed when CD4+ T-lymphocyte counts are below 200 cells per microliter, or the
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CD4+ T-lymphocyte percentage is under 14 of total lymphocytes. As HIV/AIDS progresses, the
CD4+ count is decreased while the CD8+ count remains unchanged and the ratio of CD4+/CD8+
PTS: 1 DIF: Moderate
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becomes smaller.
Analysis
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15. ANS: D
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KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Antiretroviral drugs that inhibit reproduction of the virus in various ways by blocking enzyme
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action are used to treat HIV infection. A. B. C. Antiretroviral drugs do not encapsulate the virus-
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infected cells, mark the virus to be destroyed, or attract macrophages to the cells making the
virus.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
Level: Application
16. ANS: D
Keeping the virus from replicating is the treatment goal for HIV to prevent or delay development
of opportunistic diseases, as there is no cure for this disease. A. B. Treatment goals do not focus
on stimulating the immune system or treating opportunistic infections.
PTS: 1 DIF: Moderate
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KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level:
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Application
17. ANS: B
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.
When taking nevirapine (Viramune), the patient should be instructed to monitor for a rash
especially during the first month because it may be life-threatening and require stopping the
medication immediately. B. C. D. The patient does not need to monitor urine color, extremity
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pain, or flulike symptoms when taking Nevirapine (Viramune).
PTS: 1 DIF: Moderate
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KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
Level: Analysis
18. ANS: C
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Instruct family to monitor temperature daily and to report a new fever higher than 100F (38.5C)
or a change in fever pattern if low-grade fevers are commonly present to an HCP immediately.
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B. Dry mouth could be a side effect of medication or a need for more hydration. C. Night sweats
are a common manifestation of the individual who has a moved from being HIV positive to
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having AIDS. D. Constipation is not likely to occur in the patient who has AIDS.
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PTS: 1 DIF: Moderate
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KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Analysis
19. ANS: D
When using a condom, withdraw from partner by holding condom against base of erect penis to
avoid semen leakage. A. Use latex condom (or polyurethane if allergic to latex), because other
materials have large pores that allow HIV to pass. B. Use water-soluble lubricants, as oil-based
lubricants can damage latex condoms. C. Apply condom after erection for correct fit.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Analysis
20. ANS: D
In considering priority, the life-threatening risk is for infection due to weak immune system and
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parenteral therapy, so this is the priority. C. Risk for injury would be the priority after the Risk
for infection. A. Additional information is needed to determine if the patient is experiencing
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pain. B. Ineffective coping can be the focus after life-threatening risks are addressed.
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.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
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Analysis
21. ANS: D
Counsel on pet contact risks but recognize the emotional benefits of pets. Pets should have up-to-
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date immunizations, and patients should avoid pet feces. If the patient must clean the litter box,
wear mask and gloves, and wash hands well afterwards. A. B. C. Keeping the cats outdoors,
having cats less than 1 year old, or preventing all contact with cats would be extreme. The
PTS: 1 DIF: Moderate
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patient can reduce the risk of infection by avoiding pet feces and ensuring for the cats health.
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Application
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KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
22. ANS: D
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Pneumocystis jiroveci pneumonia is a common opportunistic lung infection in AIDS. It is caused
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by a fungus. A. Tuberculosis is caused by a bacterial infection. B. Cytomegalovirus is a viral
infection. C. Candida albicans is fungal infection that effects that gastrointestinal tract.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
23. ANS: D
The infant of a mother with HIV is given zidovudine (AZT) for 6 weeks. A. B. C. These
medications are not used as prophylaxis after exposure to HIV through vaginal delivery.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
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Level: Analysis
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24. ANS: B
After exposure to HIV, the site should be immediately washed with soap and water and then seek
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.
immediate medical care for assessment and treatment. A. B. D. Alcohol should not be applied to
the site. Flushing the site with hot running water is not sufficient. Soap is needed. A topical
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antibiotic should not be applied to the site.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
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Level: Application
25. ANS: D
Trimethoprim-sulfamethoxazole (Bactrim) is indicated for the treatment of Pneumocystis
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jiroveci pneumonia. A. Pyrazinamide, isoniazid (Laniazid, and ethambutol (Myambutol) are
indicated in the treatment of tuberculosis. B. Ganciclovir (Cytovene) is indicated in the treatment
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of Cytomegalovirus retinitis. C. Azithromycin, clarithromycin, ethambutol are indicated in the
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treatment of Mycobacterium avium complex.
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Chapter 18. Musculoskeletal Guidelines
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is contributing to the plan of care for a patient who has a right fractured femur.
What intervention should the nurse include in the plan of care to prevent fat emboli?
a. Decrease dietary consumption of fats.
b. Maintain immobilization of the right leg.
c. Encourage coughing and deep breathing hourly.
d. Perform passive range of motion on the right leg.
____ 2. A patient has an open reduction of a radial fracture and is casted. Several hours after the
operation, the patient reports a throbbing pain in the arm. What nursing action is essential for the
nurse to take?
a. Reposition arm.
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b. Perform neurovascular checks.
c. Administer analgesics as ordered.
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d. Notify the physician immediately.
____ 3. The nurse is monitoring a patient with a casted left tibial fracture and a contusion of the
a. Reposition the casted leg.
b. Repeat the morphine injection now.
c. Give a higher ordered dose of morphine.
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d. Ensure physician is immediately notified.
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injections. What should the nurse do?
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thigh. The patient reports increasing pain in the left foot that has not been relieved by morphine
____ 4. The nurse finds a 2-day postoperative patient who had a right total hip replacement lying
supine with crossed legs. What data should the nurse collect on this patient?
a. The right leg for shortening
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b. The right knee for crepitation
c. The left leg for internal rotation
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d. The left leg for loss of function
____ 5. The nurse is caring for a patient who had a closed reduction of the ulna with a cast
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applied. Later the patient reports left arm pain. What should the nurse do first?
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a. Pad the edges of the cast.
b. Notify the physician immediately.
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c. Administer an analgesic as ordered.
d. Perform neurovascular check on fingers.
____ 6. The nurse is reinforcing teaching provided to a patient recovering from right total hip
replacement. Which patient statement indicates a correct understanding of the teaching?
a. Keep legs apart.
b. Lie prone in bed.
c. Move right leg closer to the left leg.
d. Do not bear any weight on the left leg.
____ 7. A patient with a casted, fractured left leg asks why the leg has to be elevated. What
should the nurse respond to this patient?
a. Decreases swelling.
b. Prevents cast cracking.
c. Increases your comfort.
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d. Allows the cast to dry evenly.
____ 8. The nurse is caring for a patient who has had a right hip replacement. For which position
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is the nurse attempting to achieve when a pillow is placed between the legs during turning?
a. Flexion of the knees
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.
b. Abduction of the thighs
c. Adduction of the hip joint
d. Hyperextension of the knees
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____ 9. The nurse sees a neighbor fall and fracture a leg. What should the nurse do first for the
neighbor?
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a. Assess pain.
b. Transport to an emergency department.
c. Cover site of open fracture with clean dressing.
d. Immobilize the affected limb using minimal movement.
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____ 10. The nurse is reinforcing teaching provided to a patient with rheumatoid arthritis (RA).
a. Fatigue
b. Paralysis
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c. Crepitation
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Which patient statement indicates understanding of the symptoms of RA?
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d. Shortness of breath
____ 11. A patient with a 36-hour-old fractured femur is in traction and is prescribed morphine
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10 mg every 3 hours as needed. The patient received a dose 3 hours ago and is now reporting a
pain level of 8. The patient is stable. Which action should the nurse take?
a. Hold medication.
b. Notify the registered nurse (RN).
c. Give pain medication as ordered.
d. Give pain medication in 30 minutes.
____ 12. The nurse is caring for a patient who has a newly casted, fractured wrist. Data
collection reveals slightly puffy fingers with good capillary refill. What should the nurse do now
to prevent complications?
a. Notify the RN.
b. Apply heat to the cast.
c. Elevate the cast on pillows.
d. Remove the pillow under the cast.
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____ 13. A patient with gout has been instructed on the prescribed medication allopurinol
(Zyloprim). Which patient statement indicates understanding of the action of this medication?
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a. Excretes proteins.
c. Increases formation of purines.
d. Increases metabolism of purines.
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.
b. Blocks formation of uric acid.
____ 14. The nurse is evaluating teaching provided to a patient with gout. Which patient menu
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selection indicates that additional teaching is required?
a. Pike
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b. Bass
c. Perch
d. Sardines
____ 15. The nurse is reinforcing teaching provided to a patient with gout. Which food should
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the patient state will be avoided that indicates teaching has been effective?
b. Beets
c. Liver
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d. Bananas
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a. Rice
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____ 16. The nurse is contributing to the plan of care for a patient with Pagets disease. Which
outcome should the nurse identify as being appropriate for this patient?
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a. Gain 5 lb weekly.
b. Intake equals output.
c. Identify coping skills.
d. Pain is relieved at a satisfactory level.
____ 17. The nurse is contributing to the plan of care for a patient who has a fractured hip and is
placed in Bucks (boot) traction while awaiting surgery. What is the desired outcome for placing
the patient in Bucks traction?
a. Restrain patient.
b. Realign fracture.
c. Relieve patient pain.
d. Maintain fracture reduction.
____ 18. The nurse is reinforcing teaching for a patient who has had a total hip replacement on
correct sitting positions. Which position should the nurse teach the patient to avoid?
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a. Crossing legs
b. Elevating legs
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c. Flexing ankles
d. Extending knees
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.
____ 19. The nurse is contributing to the plan of care for a patient who has an upper extremity
amputation. Why should the nurse keep in mind that this type of amputation can be more
a. The upper extremity is more visible.
b. Prosthetic fitting is easier for the leg.
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c. The upper extremity is more specialized.
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debilitating than a lower extremity amputation when planning care?
d. There is greater blood supply to the upper extremity.
____ 20. The nurse observes a petechial rash and respiratory distress in a patient recovering from
a. Infection
b. Pneumonia
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c. Fat embolism
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a fractured femur. What should these findings suggest to the nurse?
d. Pleural effusion
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____ 21. A patient who has a displaced mid-shaft fracture of the left femur and is in balanced
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suspension skeletal traction with 35 pounds of weights is experiencing calf pain with right foot
dorsiflexion. Which action should the nurse take?
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a. Notify the RN.
b. Check the traction setup.
c. Reduce 5 pounds of weight.
d. Encourage dorsiflexion more frequently.
____ 22. The nurse is contributing to the plan of care for a patient who is scheduled for a belowthe-knee amputation. What nursing diagnosis should be recommended for the preoperative plan
of care?
a. Anxiety
b. Self-Care Deficit
c. Fluid Volume Deficit
d. Ineffective Airway Clearance
____ 23. The nurse is reinforcing teaching on positioning for a patient after a right total knee
replacement. Which patient statement indicates a correct understanding of the teaching?
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a. Prone.
b. Side lying.
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c. Supine with pillow under right knee.
d. Supine with three pillows between legs.
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.
____ 24. The nurse is reinforcing teaching provided to a patient for carpal tunnel syndrome
treatment. Which patient statement indicates a correct understanding of the teaching?
a. Bedrest.
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b. Arm sling.
c. Wrist splint.
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d. Hand exercises.
____ 25. A patient with a fractured pelvis and a left acetabular fracture is prescribed bedrest.
When the patient asks to toilet, which measure would be appropriate?
a. Help patient up on a commode very carefully.
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b. Turn patient onto right side, place the bedpan behind, and turn back.
c. Have patient sit up as high as possible and lift self up with hands pushing on the bed, then
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slide the bedpan underneath.
d. Ask patient to lift straight up using a trapeze mounted above the bed and slide a bedpan
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underneath from the right side.
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____ 26. The nurse is caring for a patient with gout. Which laboratory value should the nurse
review which indicates that the treatment plan is effective?
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a. Uric acid: 7.9 mg/dL
b. Creatinine: 0.8 mg/dL
c. Blood urea nitrogen: 15 mg/dL
d. Low-density lipoprotein (LDL): 115 mg/dL
____ 27. The nurse is reinforcing teaching provided to a patient who is postmenopausal, has lost
2 inches of height, and has osteoporosis. Which patient statement indicates correct understanding
of the purpose of calcium supplements?
a. To decrease bone loss
b. To increase energy levels
c. To decrease serum calcium
d. To increase excretion of calcium
____ 28. A patient is completing instructions about complications that can occur from
osteoporosis. Which complication should the patient state as evidence that teaching has been
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effective?
a. Hip fracture.
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b. Overgrowth of bone.
c. Bone spur formation.
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.
d. Increased bone density.
____ 29. The nurse is reviewing data collected during the health history for a patient with
osteoporosis. What should the nurse identify as a risk factor for osteoporosis development?
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a. Daily use of antacid
b. Walking 1 mile daily
d. Increased dairy food intake
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c. Increased caffeine intake
____ 30. The nurse reinforces medication teaching provided to a patient with rheumatoid
health problem?
b. Ibuprofen.
c. Morphine.
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d. Penicillin.
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a. Digoxin.
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arthritis. Which medication should the patient identify as helpful to control the symptoms of the
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____ 31. The nurse checks a patients casted right leg resting upon a pillow and finds that the cast
appears too tight. What should the nurse do?
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a. Notify the RN.
b. Administer pain medication.
c. Apply an extra blanket to the leg.
d. Remove the pillow under the cast.
____ 32. The nurse is contributing to the plan of care for a patient who has a bone fracture that is
splintered and has shattered into numerous fragments. Which term should the nurse use to
document this type of fracture?
a. Impacted
b. Avulsion
c. Greenstick
d. Comminuted
____ 33. The nurse reinforces teaching on prevention of osteomyelitis with a patient who has an
open fracture of the right leg. Which patient statement indicates that teaching has been effective?
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a. Apply ice to right leg.
b. Keep leg immobilized.
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c. Increase calcium intake in diet.
d. Wash hands prior to touching fracture area.
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.
____ 34. An 87-year-old female with a history of osteoarthritis reports an average generalized
pain score of 4 on a 0-to-10 scale while using acetaminophen prn. Which response about this
a. Do you take a daily calcium supplement?
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pain level should the nurse make to the patient?
b. Im glad the acetaminophen is working for you.
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c. Are you satisfied with this level of pain control?
d. Research shows that acetaminophen is not really effective for osteoarthritis pain.
____ 35. A patient is diagnosed with osteomyelitis of the right lower leg. What should the nurse
expect to be prescribed for this patients care?
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a. Anticoagulant therapy
b. Casting of the extremity
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c. Fasciotomy of the wound
d. Long-term antibiotic therapy
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Multiple Response
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Identify one or more choices that best complete the statement or answer the question.
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____ 36. A patient 48 hours after surgery for a fractured femoral shaft is experiencing mental
confusion, tachycardia, tachypnea, and dyspnea. The patients blood pressure is elevated and
petechiae are present on the chest. After reporting the findings to the RN what should the nurse
do while awaiting the physicians specific orders? (Select all that apply.)
a. Administer oxygen.
b. Prepare patient for arterial blood gas tests.
c. Prepare patient for chest x-ray or lung scan.
d. Maintain bedrest and keep movement to a minimum.
e. Ask patient to move affected limb to see if pain is worse.
f. Place patient in high Fowlers position or raise the head of the bed.
____ 37. A patient asks the difference between osteoarthritis and rheumatoid arthritis. What
manifestations should the nurse explain are characteristic of rheumatoid arthritis? (Select all that
apply.)
a. Low-grade fever
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b. Heberdens nodes
c. Autoimmune disease
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d. Activity increases pain
e. Early morning stiffness
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.
f. Involvement of other major organs
____ 38. The nurse is collecting data from a patient suspected of developing a fat embolus from
a fracture of the right femur. Which manifestations should the nurse expect? (Select all that
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apply.)
a. Petechiae
c. Tachycardia
d. Mental confusion
e. Numbness in the right leg
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b. A migraine
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f. Muscle spasms in the right thigh
____ 39. The nurse is caring for a patient in traction. Which actions are appropriate when caring
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for this patient? (Select all that apply.)
a. Allow weights to hang freely in place.
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b. Use assistance to reposition the patient in bed.
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c. Hold weights up if the patient is shifting position in bed.
d. Remove weights if the patient is being moved up in bed.
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e. Lighten weights for short periods if the patient reports pain.
____ 40. The nurse is contributing to the plan of care for a patient recovering from total hip
replacement. Which exercises should the nurse recommend to help prevent deep vein thrombosis
(DVT) formation? (Select all that apply.)
a. Foot circles
b. Toe touches
c. Heel pumping
d. Deep knee bends
e. Quadriceps setting
f. Straight leg raises (SLRs)
____ 41. A patient in the ambulatory clinic is diagnosed with a muscle strain. What actions
should the nurse instruct the patient to do to treat this injury? (Select all that apply.)
a. Rest the limb.
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b. Elevate the limb.
c. Apply heat for 1 hour.
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d. Apply ice to the area.
e. Wrap with an elastic bandage.
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.
____ 42. The nurse is caring for a patient with a minor rotator cuff shoulder injury. What should
the nurse emphasize when reviewing care with this patient? (Select all that apply.)
b. Rest the shoulder
c. Take NSAIDs as prescribed
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d. Begin out-patient physical therapy
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a
a. Apply ice
e. Use 2 lb hand weights for exercising
____ 43. During a health history the nurse becomes concerned that a patient is at risk for
developing osteoporosis. Which modifiable risk factors did the nurse use to come to this
a. Small boned
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b. Postmenopausal
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conclusion? (Select all that apply.)
c. Cigarette smoking
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d. Sedentary lifestyle
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e. Low calcium intake
____ 44. The nurse is assisting in the development of an educational seminar on prevention of
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osteoporosis for a group of community members. Which actions should the nurse suggest be
included in this presentation? (Select all that apply.)
a. Drink one cup of caffeinated coffee each day
b. Ensure an adequate intake of calcium each day
c. Participate in weight-bearing exercise every day
d. Wear well-supporting nonskid shoes at all times
e. Consider participating in resistance exercise training
Answer Section
MULTIPLE CHOICE
1. ANS: B
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Prevention of fat emboli includes keeping the fracture immobilized and hydrating the patient to
help dilute and excrete any fat that may escape from the fractured bone. A. Decreasing the
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consumption of fat will not help prevent fat emboli. C. D. Deep breathing and coughing and
performing passive range of motion will not prevent the development of fat emboli.
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.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
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a
Application
2. ANS: B
The nurse should begin with data collection to determine what the next action to take. For this
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patient the nurse should perform neurovascular checks. A. The arm might need to be positioned
however this should not be done until a neurovascular check is completed. C. Administering pain
medication might be indicted however should not be done until a pain assessment is completed.
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PTS: 1 DIF: Moderate
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D. The nurse needs to determine the patients neurovascular status before notifying the physician.
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
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Analysis
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3. ANS: D
The early symptom of acute compartment syndrome is the patients report of severe, increasing
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pain that is not relieved with narcotics, so the physician should be notified. A. B. C. These
actions might be done if prescribed by the physician.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
4. ANS: A
Crossing the legs puts the hip at risk for dislocation. Symptoms are pain in the affected hip,
shortening of the leg, and possibly rotation of the surgical leg. B. The patient did not have
surgery on the right knee. C. D. The patient did not have surgery to the left limb.
PTS: 1 DIF: Moderate
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KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
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Analysis
5. ANS: D
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.
The nurse should begin with data collection to determine what the next action is to take. The
nurse should perform a neurovascular check. A. The edges of the cast may need to be padded if
this is the cause of the patients pain. B. The physician should not be notified until neurovascular
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a
checks are performed. C. The nurse needs to assess the patients pain level before providing an
analgesic.
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n
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
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6. ANS: A
Prevention of dislocation is a major nursing responsibility. Correct positioning of the surgical leg
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is critical. The primary goals are to prevent hip adduction which is done by keeping the legs
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apart. B. C. D. These actions will not prevent hip adduction.
PTS: 1 DIF: Moderate
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KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
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Analysis
7. ANS: A
A casted limb is elevated for 24 to 48 hours, and ice can be applied above and below the cast to
reduce swelling. B. C. D. The limb is not elevated to prevent cast cracking, promote comfort, or
to allow the cast to dry evenly.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
8. ANS: B
A trapezoid-shaped abduction pillow (sometimes called a triangular pillow), splint, wedge, or
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regular bed pillows may be used between the legs to maintain abduction and prevent adduction.
Some research, however, indicates that these precautions may not be necessary and may slow
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recovery. A. D. The pillow is not used to support knee flexion or hyperextension. C. Adduction
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.
of the hip joint is to be prevented.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
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a
Analysis
9. ANS: D
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For emergency care of a suspected fracture, do not try to reposition the limb. Splint it as it lies
and ensure that the limb is secured above and below the break to minimize movement and bone
PTS: 1 DIF: Moderate
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grating. A. B. C. Then cover site, transport, and assess pain level.
Application
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10. ANS: A
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KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Because of the systemic nature of RA, in addition to pain and joint involvement, the patient may
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have a low-grade fever, malaise, depression, lymphadenopathy, weakness, fatigue, anorexia, and
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weight loss. B. C. D. Paralysis, crepitation, and shortness of breath are not manifestations of RA.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis
11. ANS: C
The data collection findings are normal. Since it is time for the pain medication and the patient is
in pain, the medication can be given. A. B. D. There is no need to hold the medication, notify the
RN, or wait to give the medication in 30 minutes.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
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Level: Application
12. ANS: C
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A casted limb is elevated for 24 to 48 hours, and ice can be applied above and below the cast to
reduce swelling. A. The RN does not need to be notified. B. Heat should not be applied at this
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.
time. D. The pillow should not be removed from under the cast.
PTS: 1 DIF: Moderate
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a
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
13. ANS: B
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Allopurinol decreases uric acid production. A. C. D. Allopurinol (Zyloprim) does not excrete
proteins or increase the formation or metabolism of purines.
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PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
14. ANS: D
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Level: Analysis
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The patient should avoid high-purine (protein) foods, such as organ meats, shellfish, and oily fish
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(e.g., sardines). A. B. C. These food items would be appropriate for the patient being treated for
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gout.
PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis
15. ANS: C
The patient should be instructed to avoid high-purine (protein) foods such as organ meats,
shellfish, and oily fish. A. B. D. Rice, beets, and bananas do not need to be avoided.
PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis
16. ANS: D
Pain control is a major issue with many patients with Pagets disease. The outcome stating that
pain is relieved at a satisfactory level is the most appropriate for this patient. A. B. C. Outcomes
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that address weight gain, intake and output, and coping skills are not necessarily appropriate for
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this patient.
PTS: 1 DIF: Moderate
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.
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Analysis
17. ANS: C
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a
Bucks traction does not promote bone alignment or healing but is used instead for relief of
painful muscle spasms that often accompany fractures. A. Traction is not used to restrain a
patient.
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PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Analysis
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18. ANS: A
Legs should be kept abducted (away from center of body), so legs should not be crossed. B. C.
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D. These positions do not need to be avoided for the patient with a total hip replacement.
PTS: 1 DIF: Moderate
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KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
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Application
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19. ANS: C
Upper extremity amputations are usually more significant than lower extremity amputations as
the arms and hands are necessary for performing activities of daily living. A. B. D. Upper
extremity amputations are not more debilitating because the upper extremity is more visible, the
prosthetic fitting is easier for the leg, or because of a greater blood supply to the upper
extremities.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis
20. ANS: C
The earliest manifestation of fat embolism syndrome is altered mental status from a low arterial
oxygen level. The patient then experiences tachycardia, tachypnea, fever, high blood pressure,
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severe respiratory distress, and petechiae. A. B. D. These findings are not manifestations of
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infection, pneumonia, or pleural effusion.
PTS: 1 DIF: Moderate
nk
.
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis
21. ANS: A
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a
Calf pain on dorsiflexion can indicate a thrombophlebitis (Homans sign). The RN should be
informed. B. The nurse should not take the time now to check the traction setup. C. Traction
weight cannot be reduced without a physicians order. D. The patient should not be encouraged to
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exercise the limb now since a thrombophlebitis might be present.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentManagement of Care | Cognitive Level:
.te
22. ANS: A
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Application
Patients facing surgery and especially a body image changing surgery such as amputation will
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experience anxiety. Interventions to aid with this anxiety should be planned. B. C. D. These
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would be appropriate after surgery has occurred.
PTS: 1 DIF: Moderate
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KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
23. ANS: C
The patient lies supine with pillow under right knee if a continuous passive motion (CPM)
machine is not used after a total knee replacement. A. B. D. The patient recovering from a total
knee replacement does not need to be placed in the prone, side lying, or supine position with
pillows between the legs.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Analysis
24. ANS: C
The wrist is rested to reduce inflammation, and a wrist splint may be prescribed to do this. A. B.
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D. Bedrest, an arm sling, and hand exercises are not indicated for treatment of this syndrome.
PTS: 1 DIF: Moderate
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KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Analysis
25. ANS: D
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.
The nurse should ask the patient to lift straight up using a trapeze mounted above the bed and
slide a bedpan underneath from the right side to avoid the left fracture. A. The patient is on
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a
bedrest so a bedside commode is not appropriate. B. The patient should not be turned. C. The
patient should be instructed to use the trapeze and not attempt to push self up using the bed.
PTS: 1 DIF: Moderate
ba
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KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level:
Application
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26. ANS: A
The diagnosis of gout is based on an elevated serum uric acid level which is a waste product
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resulting from the breakdown of proteins. Urate crystals, formed because of excessive uric acid
buildup, are deposited in joints and other connective tissues, causing severe inflammation. B. C.
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D. Creatinine, blood urea nitrogen, and lipoprotein levels are not used in the diagnosis or
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treatment of gout.
PTS: 1 DIF: Moderate
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KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Analysis
27. ANS: A
If serum calcium falls below normal levels, the parathyroid glands stimulate the bone to release
calcium into the bloodstream. The result is demineralized bone. Therefore, calcium supplements
are used. B. C. D. Calcium is not taken to increase energy levels, decrease serum calcium, or to
increase the excretion of calcium.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
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Level: Analysis
28. ANS: A
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Osteoporotic bone may cause a pathological fracture in which the hip breaks before the fall. For
other patients, a fall can cause a hip or other fracture. B. C. D. Bone overgrowth, spurs, or
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.
increases in bone density are not complications of osteoporosis.
PTS: 1 DIF: Moderate
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a
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis
29. ANS: C
A risk factor for osteoporosis is excessive caffeine intake or alcohol. A. B. D. Antacids, walking,
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and dairy intake are not risk factors for the development of osteoporosis.
PTS: 1 DIF: Moderate
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KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application
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30. ANS: B
Ibuprofen (an NSAID) blocks activity of the enzyme cyclooxygenase, which makes
prostaglandins that produce inflammation, fever, and pain found in rheumatoid arthritis. A.
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Digoxin is a cardiac medication. C. Morphine is an opioid which may not help reduce
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inflammation. D. Penicillin is an antibiotic, used to treat bacterial infections.
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PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
Level: Analysis
31. ANS: A
The nurse should notify the RN. A serious complication of a cast being too tight is compartment
syndrome. The physician needs to be contacted for orders to cut the cast with a cast cutter to
relieve pressure and prevent pressure necrosis of the underlying skin. B. There is no information
to support that the patient is in pain. C. There is no information to support that the limb is cool.
D. The limb should be elevated or supported with pillows.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
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Application
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32. ANS: D
A bone splintered or shattered into numerous fragments is a comminuted fracture that often
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.
occurs in crushing injuries. A. Impacted describes a bone that is forcibly pushed together,
resulting in bone being pushed into bone. B. Avulsion describes a piece of bone that is torn away
from the main bone while still attached to a ligament or tendon. C. Greenstick describes a bone
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a
that is bent and fractures on the outer arc of the bend.
PTS: 1 DIF: Moderate
ba
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KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level:
Application
33. ANS: D
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Washing hands prior to touching a fracture area is the best way to help prevent osteomyelitis. C.
Calcium is related to osteoporosis prevention. B. Keeping the leg immobilized relates to fat
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emboli reduction. A. Ice is applied to reduce swelling.
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PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
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Analysis
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34. ANS: C
Acetaminophen can be helpful in reducing pain associated with osteoarthritis, so the nurse
should assess whether the patient is satisfied with the current level of pain control. A. Calcium
supplementation is not related to pain control. B. D. These statements miss the opportunity to
assess whether the patient is both comfortable and functional with the current pain management.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level:
Application
35. ANS: D
Long-term antibiotic therapy (4-6 weeks) is the treatment of choice for patients with
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osteomyelitis. A. Anticoagulant therapy is prescribed for a thromboembolism. B. Casting is
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indicated for a fracture. C. Fasciotomy may be indicated to treat compartment syndrome.
PTS: 1 DIF: Moderate
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.
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level:
Application
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a
MULTIPLE RESPONSE
36. ANS: A, B, C, D, F
The patient is likely experiencing a fat emboli. The patient should be placed in a high Fowlers
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position to aid breathing, diagnostic tests will be done, and the patient is kept on bedrest to
reduce oxygenation needs and clot movement. Oxygen may be started per agency policy to aid in
PTS: 1 DIF: Moderate
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respiration. E. Limb should not be moved to prevent further release of fat.
Application
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KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
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37. ANS: A, C, E, F
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Rheumatoid arthritis is a systemic autoimmune disease with morning stiffness, low-grade fever,
and organ involvement. B. Heberdens nodes are seen in osteoarthritis. D. Pain increases with
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activity in osteoarthritis.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level:
Application
38. ANS: A, C, D
The earliest manifestation of fat emboli syndrome (FES) is altered mental status from a low
arterial oxygen level. The patient then experiences tachycardia, tachypnea, fever, high blood
pressure, severe respiratory distress, and petechiae. B. E. F. These are not manifestations of fat
emboli.
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PTS: 1 DIF: Moderate
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KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis
39. ANS: A, B
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.
Weights are to hang unobstructed. Assistance should be used to pull the patient up in bed to
protect the health care worker from injury. C. D. E. Weights should never touch the floor or be
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a
removed or lifted.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
ba
n
Application
40. ANS: A, C, E, F
Because most DVTs occur in the lower extremities, leg exercises are started in the immediate
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postoperative period and include heel pumping, foot circles, and SLRs. The patient also performs
quadriceps-setting exercises (quad sets). B. D. Deep knee bends and toe touches are not standard
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postoperative exercises and would be restricted in a patient with a total hip replacement due to
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restricted hip flexion.
PTS: 1 DIF: Moderate
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KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
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Application
41. ANS: A, B, D, E
RICE is an acronym for rest, ice, compression, and elevation which is the therapy for strain
injuries. Immediately after a strain, the injured area should be rested to protect it. Ice should be
applied to decrease pain, swelling, and inflammation. Applying an elastic bandage for
compression and elevating the affected area provide support and minimize swelling. C. After
inflammation subsides, heat application (15 to 30 minutes four times a day) brings increased
blood flow to the injured area for healing. Heat should not be immediately applied for 1 hour.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
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Application
42. ANS: A, B, C, D
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For minor rotator cuff injury, resting the shoulder, ice, NSAIDs, and physical therapy are
recommended. E. The use of hand weights will be determined by the physical therapist.
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.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
kt
a
Application
43. ANS: C, D, E
Modifiable risk factors for the development of osteoporosis include cigarette smoking, sedentary
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lifestyle, and low calcium intake. A. B. Bone structure and menopausal status are non-modifiable
risk factors for the health problem.
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PTS: 1 DIF: Moderate
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KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis
44. ANS: B, C, D, E
Actions to prevent the development of osteoporosis include ensuring an adequate intake of
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calcium each day, participating in weight-bearing exercise such as walking each day, wearing
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well-supporting, nonskid shoes at all times, and participating in resistance exercise such as
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weight training. A. Caffeine is a modifiable risk factor for the development of osteoporosis.
Chapter 19. Neurologic Guidelines
MULTIPLE CHOICE
1.A client is diagnosed with a headache from a secondary cause. The nurse realizes this type of
headache can be caused by:
1.a tumor.
2.tension.
3.a migraine.
4.cluster
ANS: 1
Primary headaches are identified when no organic cause can be found. A tumor headache is
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PTS: 1 DIF: Analyze REF: Headache
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caused by a tumor and is classified as a secondary headache.
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.
2.The nurse should instruct a client diagnosed with migraine headaches to be careful not to
overdose on acetaminophen (Tylenol). Which drug should the nurse tell the patient to avoid?
ba
n
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a
1.Aleve
2.Aspirin
3.Ibuprofen
4.Vicodin
ANS: 4
Vicodin, although a narcotic analgesic, also contains acetaminophen (Tylenol). It is very easy to
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overdose on the acetaminophen (Tylenol) component, which can lead to kidney damage. Aleve
(Tylenol).
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does not contain acetaminophen (Tylenol). Aspirin and ibuprofen do not contain acetaminophen
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PTS: 1 DIF: Apply REF: Headache: Pharmacology
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3.A client is diagnosed with seizures occurring because of hepatic encephalopathy. The nurse
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realizes that the cause for this clients seizures would be:
1.physiological.
2.iatrogenic.
3.idiopathic.
4.psychokinetic.
ANS: 1
The three major causes for seizures are physiological, iatrogenic, and idiopathic. Physiological
seizures include those that occur with an acquired metabolic disorder such as hepatic
encephalopathy. Iatrogenic causes include new medications or drug or alcohol use. Idiopathic
causes include fevers, fatigue, or strong emotions. Psychokinetic is not a cause for seizures.
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PTS: 1 DIF: Analyze REF: Table 37-4 Seizure Causes
4.A client tells the nurse that he sees flashing lights that occur prior to the onset of a seizure.
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Which of the following phases of a seizure is this client describing to the nurse?
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.
1.Prodromal phase
2.Aural phase
3.Ictal phase
4.Postictal phase
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a
ANS: 2
In the aural phase a sensation or warning occurs, which the patient often remembers. This
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warning can be visual, auditory, gustatory, or visceral in nature. The prodromal phase of a
seizure includes the signs or activity before the seizure such as a headache or feeling depressed.
The ictal phase of a seizure is the actual seizure. The postictal phase is the period immediately
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following the seizure.
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PTS: 1 DIF: Analyze REF: Seizures: Assessment with Clinical Manifestations
5.A client is experiencing a grand mal seizure. Which of the following should the nurse do
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during this seizure?
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1.Protect the clients head.
2.Leave the client alone.
3.Give water to the client to avoid dehydration.
4.Place a finger in the clients mouth to avoid swallowing the tongue.
ANS: 1
One of the most important interventions for a nurse to perform during a seizure is to protect the
clients head from injury. Never give a client a drink during a seizure. Placing a finger in the
clients mouth could be very dangerous to the client and the nurse. Do not leave the client
unattended during a seizure
PTS: 1 DIF: Apply REF: Seizures: Planning and Implementation
6.A client is prescribed phenytoin (Dilantin) for a seizure disorder. Which of the following
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would indicate that the client is adhering to the medication schedule?
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.
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1.The client is sleepy.
2.The client is not experiencing seizures.
3.The client no longer has headaches.
4.The client is eating more food.
ANS: 2
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a
Phenytoin (Dilantin) is a medication to control seizures. The absence of seizures indicates that
the client is adhering to the medication schedule. Sleepiness, lack of headaches, or improved
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n
appetite are not indications that the medication is being used as prescribed.
PTS: 1 DIF: Analyze REF: Seizures: Table 37-6 Medications to Treat Seizures
7.The nurse is unable to insert an intravenous access line into a client who is currently
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the client at this time?
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experiencing a seizure. Which of the following routes can the nurse use to provide medication to
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1.Oral
2.Intranasal
3.Rectal
4.Intramuscular
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ANS: 2
For a client experiencing a seizure, oral medications and sharp objects can be dangerous and
should not be used. Intranasally administered drugs are rapid and effective in treating a client
experiencing an acute seizure. Intranasal delivery is more effective than rectal.
PTS: 1 DIF: Apply REF: Red Flag: Intranasal Drug Delivery
8.One of the most important things a nurse can teach a client about seizure control is to:
1.take the medication every day as prescribed by the doctor.
2.eat a balanced diet.
3.get lots of exercise.
4.take naps during the day.
ANS: 1
Medication is effective only if it is taken as prescribed, and suddenly stopping the medication
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can trigger an increase in seizure activity. Diet and exercise are important to a healthy lifestyle
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.
PTS: 1 DIF: Apply REF: Seizures: Planning and Implementation
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but do little to control seizure activity.
9.The nurse is instructing a client newly diagnosed with multiple sclerosis (MS). To determine
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a
the effectiveness of his teaching, the nurse would expect the client to state:
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1.It is best for me to be in a cold environment.
2.I should avoid taking a hot bath.
3.I should eat foods low in salt.
4.I should be better in a week.
ANS: 2
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The clinical manifestations of MS can be exacerbated by being in a hot, humid environment or
by taking a hot bath. A cold environment and low-salt foods do not impact the symptoms of
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effective.
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multiple sclerosis. If the client states that they will improve in a week, instruction has not been
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PTS:1DIF:Analyze
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REF:Multiple Sclerosis: Assessment with Clinical Manifestations
10.An adult female in her 30s complains of numbness and tingling in the hands, fatigue, loss of
coordination, incontinence, nystagmus, and ataxia. Which of the following health problems do
these symptoms suggest to the nurse?
1.Brain tumor
2.Myasthenia gravis
3.Multiple sclerosis
4.Diabetes
ANS: 3
Multiple sclerosis is more common in women of this age. These are symptoms, along with the
age and sex of the patient, that are common to MS. These symptoms are not necessarily
associated with a brain tumor. Weakness is the primary symptom associated with myasthenia
gravis. Symptoms of diabetes include weight loss, blurred vision, excessive urination, thirst, and
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PTS: 1 DIF: Analyze REF: Table 37-8 Clinical Manifestations of MS
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hunger.
11.For a client diagnosed with Parkinsons disease, which of the following might be
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ANS: 2
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1.Performing range-of-motion exercises
2.Drinking bottled water
3.Instituting fall precautions
4.Taking naps
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.
contraindicated?
Some clients diagnosed with Parkinsons disease develop swallowing difficulties. Powders to
thicken liquids and using an upright position will help with these difficulties. Clients diagnosed
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with Parkinsons disease will benefit from range-of-motion exercises and resting. The client
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diagnosed with Parkinsons disease should be placed on fall precautions.
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PTS: 1 DIF: Apply REF: Parkinsons Disease: Planning and Implementation
12.A client diagnosed with Parkinsons disease is beginning medication therapy. The nurse
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realizes that the goal of treatment for Parkinsons disease is to:
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1.improve sleep.
2.reduce appetite.
3.control tremor and rigidity.
4.reduce the need for joint replacement surgery.
ANS: 3
The goal of pharmacologic treatment for the client diagnosed with Parkinsons disease is to
control tremor and rigidity and to improve the clients ability to carry out the activities of daily
living. Medications for Parkinsons disease are not provided to improve sleep, reduce appetite, or
reduce the need for joint replacement surgery.
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PTS: 1 DIF: Analyze REF: Parkinsons Disease: Pharmacology
13.A client presents complaining of abnormal muscle weakness and fatigability. The physician
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suspects myasthenia gravis. Which drug can be used to test for this disease?
nk
.
1.Pyridostigmine (Mestinon)
2.Neostigmine (Prostigmin)
3.Ambenonium (Mytelase)
4.Edrophonium (Tensilon)
kt
a
ANS: 4
Tensilon, a short-acting anticholinesterase agent, is the drug of choice for diagnosing myasthenia
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gravis. The clients response is a rapid improvement of manifestations within 15 to 30 seconds
that last 5 minutes. The other medications are used to treat clients diagnosed with myasthenia
PTS:1DIF:Apply
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gravis.
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REF: Myasthenia Gravis: Diagnostic Tests; Pharmacology
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MULTIPLE RESPONSE
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14.A client is diagnosed with tonic-clonic seizures. Which are the characteristics of these types
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of seizures? (Select all that apply.)
1.Progressing through all of the seizure phases
2.Beginning before age 5
3.Lasting 2 to 3 minutes
4.Causing injury to the client
5.Occurring at any time, day or night
6.Being highly variable
ANS: 1, 3, 4, 5, 6
Tonic-clonic seizures are the most common type of generalized seizure. The seizure will
progress through all of the seizure phases and last 2 to 3 minutes. Because these seizures begin
suddenly, there is an increased incidence of injury associated with them. These seizures can
occur any time of the day or night, whether the client is awake or not. Seizure frequency is
highly variable.
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15.Which of the following nursing interventions would be appropriate for a client diagnosed with
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Alzheimers disease? (Select all that apply.)
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.
1.Make changes to the room often to stimulate memory function.
2.Assign simple tasks to be completed by the client.
3.Assist the client with any needs associated with activities of daily living (ADLs).
4.Have personal/familiar items around the client.
5.Do complex games and puzzles to improve memory.
kt
a
ANS: 2, 3, 4
Alzheimers disease progressively alters the clients ability to function in the normal ways of
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living. Personal and familiar items help to keep the client oriented, and simple tasks keep the
client functioning at the highest levels as long as possible.
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PTS:1DIF:Apply
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REF: Alzheimers Disease: Planning and Implementation; Evaluation of Outcomes
16.A client has been diagnosed with Parkinsons disease. Which of the following will the nurse
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most likely assess in this client? (Select all that apply.)
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1.Tremor
2.Muscle rigidity
3.Akinesia
4.Mask-like face
5.Dysphagia
6.Reduced appetite
ANS: 1, 2, 3, 4, 5
Signs and symptoms of Parkinsons disease include tremor, muscle rigidity, akinesia, mask-like
face, and dysphagia. Reduced appetite is not a sign or symptom of Parkinsons disease.
PTS:1DIF:Analyze
REFarkinsons Disease: Assessment with Clinical Manifestations
17.The nurse is planning care for a client diagnosed with myasthenia gravis. Which of the
following should be included in this clients plan of care? (Select all that apply.)
nk
.
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1.Monitor activities frequently and assist as needed.
2.Encourage progressive increase in activities.
3.Determine the best communication method.
4.Monitor weight.
5.Restrict fluids.
6.Instruct in energy conservation measures.
ANS: 1, 3, 4, 6
kt
a
Care for the client diagnosed with myasthenia gravis includes frequent monitoring of activities
and assisting as needed, determining the best communication method, monitoring weight, and
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instructing in energy conservation methods. Encouraging a progressive increase in activities and
restricting fluids are not appropriate interventions for a client diagnosed with myasthenia gravis.
PTS: 1 DIF: Apply REF: Myasthenia Gravis: Planning and Implementation
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18.The nurse is instructing a client and family regarding the diagnosis of amyotrophic lateral
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sclerosis. Which of the following should be included in this teaching? (Select all that apply.)
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1.The length of the curative treatment
2.That exercise and physical therapy can help the patient maximize function
3.The physical, emotional, and social aspects of the disease
4.End-of-life issues
5.The use of devices to prevent aspiration pneumonia
6.The use of a speech therapist to aid with communication
ANS: 2, 3, 4, 5, 6
Currently, no cure for this disease exists. Because of the progressive, degenerative nature of the
disease, the supportive and educative role of the nurse is important. End-of-life issues need to be
discussed before an emergency situation occurs. Other topics of instruction should include the
purpose of physical therapy and speech therapy; the use of devices to prevent aspiration; and the
emotional and social aspects of the disease.
PTS:1DIF:Apply
REF:Amyotrophic Lateral Sclerosis: Planning and Implementation
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19.The nurse is caring for a client diagnosed with Huntingtons disease. Which of the following
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are considered hallmark clinical manifestations of this disorder? (Select all that apply.)
kt
a
nk
.
1.Intellectual decline
2.Weight loss
3.Decreased appetite
4.Reduced blood pressure
5.Nausea
6.Abnormal movements
ANS: 1, 6
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n
The hallmark clinical manifestations of Huntingtons disease are intellectual decline and
abnormal movements. Weight loss, decreased appetite, reduced blood pressure, and nausea are
not clinical manifestations of this disorder.
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20.For the client who is at risk for stroke, the most important guideline the nurse should teach is
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to:
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1.increase drinks with caffeine.
2.monitor blood pressure.
3.increase amounts of sodium in the diet.
4.monitor weight and activity.
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ANS: 2
Monitoring weight and activity is important, but the highest priority is monitoring the blood
pressure. This is a modifiable risk factor that, when controlled, will decrease the risk of stroke.
PTS:1DIF:Apply
REF:Box 35-1 Modifiable Risk Factors for Stroke Development
21.The family of a client diagnosed with a stroke asks the nurse if this health problem is very
common. The nurse should respond that in the United States a person has a stroke every:
1.40 seconds.
2.1 minutes.
3.2 minutes.
4.5 minutes.
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ANS: 1
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In the United States, a person has a stroke every 40 seconds, and 700,000 new or recurrent
strokes each year. Strokes are the third leading cause of death in the United States behind heart
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.
disease and cancer and are the leading cause of long-term disability.
kt
a
PTS: 1 DIF: Apply REF: Cerebrovascular Accidents or Strokes
22.A client is being evaluated for a stroke. The nurse knows that one of the easiest and most
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common diagnostic tests used to differentiate between strokes is:
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1.computed tomography (CT).
2.magnetic resonance imaging (MRI).
3.electrocardiography (EEG).
4.positron emission tomography (PET).
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ANS: 1
The CT scan is widely available in most hospitals and is an important tool to differentiate
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between ischemic strokes and hemorrhagic stroke. It is the most common tool used to diagnose a
stroke. An MRI is contraindicated in clients with metal implants or pacemakers, and it can
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exacerbate claustrophobia. An EEG will determine the presence of brain waves, and it is not a
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diagnostic test for a stroke. A PET scan determines brain tissue functioning but, it will not be
able to differentiate between the types of strokes.
PTS:1DIF:AnalyzeREFiagnostic Tests
23.While instructing a client on stroke prevention, the nurse mentions medications that are useful
in stroke prevention. The following medications are effective in preventing a stroke, EXCEPT:
1.anticoagulants.
2.antiplatelets.
3.anticholinergics.
4.neuroprotective agents.
ANS: 3
Although anticholinergic drugs have a variety of uses, stroke prevention is not one of them. All
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the other medications are used in a variety of ways to help with stroke prevention.
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PTS:1DIF:ApplyREFharmacology
24.A client is being seen in the emergency department experiencing symptoms of a stroke. The
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.
nurse realizes that the administration of a medication to break clots, such as tPA, should be
administered within how many minutes of the client presenting to the emergency department?
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n
kt
a
1.30 minutes
2.60 minutes
3.90 minutes
4.120 minutes
ANS: 2
Medications like tPA should be given within 60 minutes of the clients arrival to the emergency
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and efficiently.
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department. This is why health care teams must have a plan to deal with stroke clients quickly
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PTS: 1 DIF: Analyze REF: Emergency Management
25.The nurse, caring for a client with a traumatic brain injury, realizes that the major cause of
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these types of injuries is:
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1.guns.
2.sports.
3.falls.
4.motor vehicle crashes.
ANS: 4
Although all are major causes of traumatic brain injury, motor vehicle crashes account for 20%
of all traumatic brain injuries. Reasons for motor vehicle accidents causing the most traumatic
brain injuries include not wearing seat belts and driving while intoxicated.
PTS: 1 DIF: Analyze REF: Brain Injuries: Etiology
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26.A client is diagnosed with a mild brain injury. Which of the following is an example of a mild
injury?
nk
.
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1.Coma
2.Locked-in syndrome
3.Vegetative state
4.Concussion
kt
a
ANS: 4
A concussion is a mild form of brain trauma, and it accounts for 75% of all brain injuries. A
moderate brain injury would result in the loss of consciousness ranging from a few minutes to
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hours and days or weeks of confusion. Coma, locked-in syndrome, and a vegetative state are all
examples of severe brain injury.
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PTS: 1 DIF: Analyze REF: Brain Injuries: Pathophysiology
27.The nurse, caring for a client recovering from a traumatic brain injury, knows the client and
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the family are eligible for specific federal programs because of the:
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1.Health Brain Act.
2.Associated Brain Act.
3.Traumatic Brain Injury Act of 2008.
4.Brain Protection Act.
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ANS: 3
The Traumatic Brain Injury Act of 2008 is legislation that provides a framework for prevention
of, education about, and research on traumatic brain injuries. The act also supports community
living for people who have sustained a traumatic brain injury and their families. The other
choices are not programs to assist clients who have sustained a traumatic brain injury or their
families.
PTS:1DIF:Analyze
REF: Law in Practice: Traumatic Brain Injury Act of 2008
28.The nurse is planning care for a client diagnosed with increased intracranial pressure after a
head injury. Which of the following interventions can be used to reduce increased intracranial
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nk
.
1.Administer antibiotics as prescribed.
2.Keep the head of the bed in the flat position.
3.Administer corticosteroids and osmotic diuretics as prescribed.
4.Perform range-of-motion exercises every hour.
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pressure?
ANS: 3
kt
a
The administration of corticosteroids will decrease the swelling of the brain, and osmotic
diuretics will decrease the fluid that is building up. This intervention will decrease the
intracranial pressure. Antibiotics do not reduce intracranial pressure. Keeping the head of the bed
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in the flat position can increase intracranial pressure and not decrease it. Performing range-ofmotion exercises every hour will not reduce intracranial pressure.
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PTS: 1 DIF: Apply REF: Management of Head Injury
29.Which of the following should be avoided when caring for a client diagnosed with increased
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intracranial pressure?
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1.Starting an intravenous access line
2.Administering oxygen
3.Placing the bed in Trendelenburg
4.Placing the client on bed rest
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ANS: 3
Intravenous access and supplemental oxygen are common interventions in the treatment of
increased intracranial pressure. Placing the client on bed rest is a proper safety measure. Placing
the bed in Trendelenburg position will increase blood flow to the brain and increase ICP.
PTS: 1 DIF: Apply REF: Management of Head Injury
30.A client is being instructed on treatments available for a newly diagnosed brain tumor. The
nurse realizes that this clients treatment could include all of the following EXCEPT:
1.photo DNA therapy.
2.radiation.
3.chemotherapy.
4.surgery.
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ANS: 1
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Photo DNA therapy is not a therapy. The other answers are common treatment modalities for
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.
patients with brain tumors in addition to photodynamic and adjunctive medication therapy.
PTS: 1 DIF: Analyze REF: Brain Tumors: Planning and Implementation
kt
a
31.A client diagnosed with an embolic stroke is not a candidate for tPA. The nurse realizes that
1.Carotid stenting
2.Antiarrhythmic medication
3.Intravenous fluid therapy
4.Carotid endarterectomy
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ANS: 1
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the client might be eligible for which of the following forms of treatment?
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In clients who are ineligible for tPA therapy, catheter-based treatment such as stenting may be an
option. Carotid endarterectomy is used to prevent a stroke. Antiarrhythmic medication does not
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prevent a stroke. Intravenous fluid therapy does not prevent a stroke.
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PTS: 1 DIF: Analyze REF: Surgery
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32.A client diagnosed with a brain tumor is going to receive chemotherapy. The nurse realizes
that which of the following medications would most likely be prescribed for this clients
treatment?
1.Carmustine
2.Digoxin
3.Aminophylline
4.Acetaminophen
ANS: 1
One of the biggest obstacles for chemotherapeutic agents when treating brain tumors is selecting
a medication that will cross the blood-brain barrier. Carmustine can cross the blood-brain barrier.
The other medications are not used as chemotherapy for brain tumors.
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PTS: 1 DIF: Analyze REF: Brain Tumors: Chemotherapy
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n
ANS: 1, 3, 4, 5
kt
a
1.Minor ischemic stroke within 30 days
2.Glucose level 120 mg/dL
3.Blood pressure 190/120 mmHg
4.Lumbar puncture 2 days ago
5.Stroke onset 5 hours ago
6.INR 1.0
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.
be contraindicated for the use of tPA? (Select all that apply.)
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33.A client, being tested for a stroke, is not a candidate for tPA. Which of the following would
Contraindications of tPA to treat an embolic stroke include minor ischemic stroke within the last
30 days, blood pressure greater an 185 mmHg systolic or greater than 110 mmHg diastolic,
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lumbar puncture within the last 3 days, and onset of stroke greater than 3 hours. Glucose level of
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120 mg/dL and INR of 1.0 would not be contraindications for tPA therapy.
PTS:1DIF:Analyze
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REF: Table 35-2 Clinical Indications and Contraindications for tPA in Stroke Patients
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34.The nurse, planning care for a client recovering from a traumatic brain injury, is including
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interventions to prevent sympathetic storming. Which of the following should be included in this
clients plan of care? (Select all that apply.)
1.Medicate for pain prior to conducting a painful procedure.
2.Elevated blood pressure indicates a sympathetic storm is ending.
3.Continue suctioning until the clients heart rate is greater than 100 beats per minute.
4.Cardiac arrhythmias indicate a drop in intracranial pressure.
5.Provide beta-blockers as prescribed with symptoms of sympathetic storm.
6.If symptoms of sympathetic storm do not appear within 24 hours, the client will not develop
this health problem.
ANS: 1, 5
The nurse should medicate the client for pain prior to conducting a painful procedure and
provide beta-blockers as prescribed with symptoms of a sympathetic storm. An elevated blood
pressure is a symptom of sympathetic storm. An elevated heart rate is a symptom of sympathetic
storming. Cardiac arrhythmias are also a symptom of a sympathetic storm and do not indicate a
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drop in intracranial pressure. Symptoms of sympathetic storming can occur within 24 hours after
PTS: 1 DIF: Apply REF: Red Flag: Sympathetic Storming
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a traumatic brain injury and can reoccur periodically during the recovery process.
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.
35.The nurse is providing discharge instructions to a client recovering from a traumatic brain
injury. Which of the following should be included in these instructions? (Select all that apply.)
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kt
a
1.Return to a full schedule of work as soon as possible.
2.Acquire medical clearance prior to returning to work that uses heavy equipment.
3.Avoid the use of helmets.
4.Limit the amount of alcoholic beverages.
5.Avoid all illicit drug use.
6.Eat a well-balanced diet.
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ANS: 2, 5, 6
Discharge instructions for a client recovering from a traumatic brain injury should include:
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medical clearance is needed prior to returning to work that uses heavy equipment; avoid all illicit
drug use; and eat a well-balanced diet. The client should be cautioned to avoid returning to a full
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schedule of work as soon as possible. The client should be encouraged to use helmets or other
safety equipment to protect the head. The clients should be instructed to avoid all alcoholic
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beverages.
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PTS:1DIF:Apply
REF: Patient Playbook: Education Topics for a Patient with a Brain Injury
36.A client asks the nurse to explain symptoms that would indicate the presence of a brain tumor.
Which of the following should the nurse respond to this client? (Select all that apply.)
1.There are no symptoms specific to a brain tumor.
2.Dizziness is a common symptom.
3.Ringing or buzzing in the ears can occur.
4.Seizures may occur.
5.A headache that gets worse in the afternoon is specific to a brain tumor..
6.A headache is usually experienced by 50% of all people diagnosed with a brain tumor.
ANS: 2, 3, 4, 6
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Symptoms of a brain tumor include dizziness, ringing or buzzing in the ears, seizures, and a
headache. The headache of a brain tumor is usually worse in the morning and not the afternoon.
nk
.
PTS:1DIF:Apply
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There are symptoms associated with a brain tumor.
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a
REF: Brain Tumors: Assessment with Clinical Manifestations
37.The nurse is instructing a client diagnosed with a brain tumor on symptoms to immediately
report to her physician. Which of the following should be included in these instructions? (Select
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1.New onset of seizures
2.One-sided weakness
3.Loss of balance
4.Problems with vision
5.Inability to talk
6.Loss of appetite
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n
all that apply.)
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ANS: 1, 2, 3, 4, 5
Brain tumor symptoms that require immediate attention include new onset of seizures, slow
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progressing hemiparesis, gait or balance disturbances, visual problems, hearing loss, and aphasia.
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Loss of appetite is not a brain tumor symptom.
PTS:1DIF:Apply
REF: Red Flag: Brain Tumor Symptoms that Require Immediate Attention
38.The nurse, caring for a client diagnosed with a brain tumor, is planning interventions to assist
with swallowing and prevent aspiration. Which of the following would be appropriate for this
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1.Instruct the client to tuck the chin with each swallow.
2.Instruct the client to turn the head toward the strong side to swallow.
3.Instruct the client to turn the head toward the weak side to swallow.
4.Instruct the client to hold the breath while swallowing.
5.Instruct the client to eat in a reclining position.
6.Instruct the client to sit in an upright position when eating.
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client? (Select all that apply.)
nk
.
ANS: 1, 3, 4, 6
Interventions to assist a client with swallowing and prevent aspiration include have the client
tuck the chin with each swallow, turn the head to the weak side to swallow, hold the breath while
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a
swallowing, and sitting in an upright position to swallow. The client should not be instructed to
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turn the head toward the strong side to swallow or to eat in a reclining position.
Chapter 20. Endocrine Guidelines
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MULTIPLE CHOICE
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1.A male client is diagnosed with hyperprolactinemia. The nurse realizes that which of the
following clinical manifestations occurs less frequently in men?
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1.A decrease in testosterone
2.Erectile dysfunction
3.Gynecomastia
4.Infertility
ANS: 3
In men, hyperprolactinemia causes a decrease in testosterone secondary to an inhibition of
gonadotropin secretion, leading to decreased facial and body hair, erectile dysfunction, decreased
libido, small testicles, and infertility. Gynecomastia occurs less frequently in men.
PTS:1DIF:Analyze
REF:Hyperprolactinemia: Assessment with Clinical Manifestations
2.A female client is admitted with hyperprolactinemia. Which of the following would not be a
clinical manifestation of the disorder in this client?
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1.Excessive estrogen
2.Hirsutism
3.Osteoporosis
4.Weight gain
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ANS: 1
nk
.
Hyperprolactinemia is associated with a decrease in estrogen, resulting in symptoms of vaginal
dryness, hot flashes, osteopenia, and osteoporosis. The patient may also experience weight gain,
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a
irritability, hirsutism, anxiety, and depression.
PTS:1DIF:Analyze
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n
REF:Hyperprolactinemia: Assessment with Clinical Manifestations
3.A client has been instructed regarding a prolactin level to be drawn the next day. Which of the
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following statements indicate that the client will need further instruction?
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ANS: 1
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1.I will be on time, in the afternoon.
2.I will be relaxed.
3.I will make sure not to take my antihistamine.
4.I will practice another method of birth control rather than the pill.
Certain medications (e.g., antihistamines and oral contraceptives) and fear can increase the
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prolactin level. The prolactin level is drawn in the morning.
PTS: 1 DIF: Analyze REF: Box 56-1 Prolactin Levels
4.An adult client is complaining of vision changes and difficulty speaking because the tongue is
larger. The client also states that his shoes no longer fit. Based on these symptoms, the client is
most likely to be diagnosed with:
1.acromegaly.
2.cretinism.
3.gigantism.
4.Graves disease.
ANS: 1
Acromegaly is caused by a hypersecretion of the pituitary growth hormone over a long period.
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This hypersecretion causes a coarsening of the features, including soft tissue overgrowth such as
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the tongue. Shoes and rings may no longer fit due to tissue and bone overgrowth. In children,
hypersecretion of growth hormone causes gigantism. Cretinism and Graves disease are caused by
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.
a thyroid hormone imbalance.
PTS:1DIF:Analyze
kt
a
REF: Acromegaly (Gigantism): Assessment with Clinical Manifestations
5.A client is prescribed medication after recovering from surgery to treat acromegaly. Which of
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the following medications would the nurse expect to see prescribed?
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1.None
2.Cabergoline (Dostinex) 1 mg PO twice a week
3.Cortisone acetate (Cortone) 100 mg PO three times a day
4.Octreotide (Sandostatin) 20 mg IM every 4 weeks
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ANS: 4
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Sandostatin is used for residual growth hormone hypersecretion following surgery. Cortone is
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used to treat adrenocorticotropic dysfunction, and Dostinex is used to treat hyperprolactinemia.
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PTS: 1 DIF: Analyze REF: Acromegaly (Gigantism): Pharmacology
6.A client, complaining of weight gain, has thin extremities, a buffalo hump, and a protruding
abdomen. The nurse realizes that this client is most likely to be diagnosed with which disease
process?
1.Addisons disease
2.Cretinism
3.Cushings syndrome
4.Obesity
ANS: 3
Even though the client has gained weight (obesity), the distribution of that weight is
characteristic for the disease process of Cushings syndrome. Cretinism and Addisons disease do
not exhibit those symptoms.
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PTS:1DIF:Analyze
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REF: Cushings Disease (Hypercortisolism): Assessment with Clinical Manifestations
7.The nurse is providing instructions to a client receiving treatment for Cushings syndrome.
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a
1.Monitor glucose levels.
2.Implement safety precautions.
3.Wear medical identification.
4.Volunteer at the hospital to prevent depression.
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.
Which of the following instructions would not be appropriate for this client?
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ANS: 4
A client diagnosed with Cushings syndrome is predisposed to falls, injury, and increased glucose
levels. The client should wear an identification bracelet indicating her disease process. The client
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PTS:1DIF:Apply
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should avoid crowds and persons with infections.
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REF: Cushings Disease (Hypercortisolism): Planning and Implementation
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8.The nurse is assessing a client diagnosed with hyperaldosteronism. Which of the following
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would take the least priority during this period?
1.Assessment of breath sounds
2.Cardiac monitoring
3.Assistance with activities of daily living (ADLs)
4.Review of electrolyte levels
ANS: 3
The first priority for the nurse is to monitor cardiac and respiratory status. Cardiac status can be
impaired because of changes in potassium levels, and fluid balance can be impaired because of
sodium, affecting the respiratory status. After the client is stabilized, the nurse can assist the
client with activities of daily living.
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PTS:1DIF:Analyze
REF: Hypersecretion of the Adrenal Gland (Hyperaldosteronism): Assessment with Clinical
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Manifestations
9.A client is diagnosed with primary adrenal insufficiency. The nurse realizes that this disorder
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a
1.Adrenal cortex
2.Adrenal medulla
3.Thyroid
4.Pituitary
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.
affects which of the following glands?
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n
ANS: 1
Mineralocorticoids, glucocorticoids, and androgens are produced in the adrenal cortex. The
principal mineralocorticoid is aldosterone. The adrenal medulla secretes the catecholamines. The
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PTS:1DIF:Analyze
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thyroid and pituitary do not secrete aldosterone.
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REF: Hyposecretion of the Adrenal Gland: Pathophysiology
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10.A client tells the nurse that he is so thirsty that he has already consumed four pitchers of
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water. The clients urine output is 3500 mL in an 8-hour period. The client is recovering from
surgery on the pituitary gland. What endocrine disorder is the client most likely experiencing?
1.Diabetes insipidus
2.Diabetes mellitus
3.Myxedema
4.Syndrome of inappropriate antidiuretic hormone secretion
ANS: 1
Diabetes insipidus and diabetes mellitus both cause increased urine output, but diabetes insipidus
is related to a problem with antidiuretic hormone; diabetes mellitus is a problem with glucose.
Myxedema is caused by a thyroid hormone imbalance. Syndrome of inappropriate antidiuretic
hormone secretion causes fluid retention.
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PTS:1DIF:Analyze
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REFiabetes Insipidus: Assessment with Clinical Manifestations
11.The nurse is planning care for a client diagnosed with Graves disease. Which of the following
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.
nursing interventions would be appropriate for this clients care?
kt
a
1.Administer a stool softener.
2.Provide extra blankets.
3.Provide frequent meals.
4.Restrict the caloric intake.
ba
n
ANS: 3
Nursing interventions for Graves disease (hyperthyroidism) include offering frequent, highcalorie meals; medicating for diarrhea; providing a fan or decreasing the temperature on the air
conditioner; and taking daily weight measurements. The client does not need a stool softener.
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The client does not need extra blankets. The clients metabolic rate is increased, and she should
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not have a restriction on caloric intake.
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PTS:1DIF:Apply
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REF: Hypersecretion of the Thyroid Gland: Planning and Implementation
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12.A client is hospitalized with an ongoing fever. The nurse learns that the client has had a recent
infection. Currently the client is restless, diaphoretic, and agitated with the following vital signs:
temperature 106F, pulse 114, blood pressure 180/80 mmHg. Which of the following disorders is
the client most likely experiencing?
1.Addisonian crisis
2.Goiter
3.Myxedema
4.Thyroid crisis
ANS: 4
Thyroid crisis is a serious form of hyperthyroidism that is life threatening. It is most likely to
occur in persons who have been inadequately treated or undiagnosed. Infection, stress or
emotional trauma, pregnancy, and medications may precipitate the event. Myxedema and
addisonian crisis would not produce a severe increase in blood pressure. Goiter tends to interfere
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with swallowing and breathing.
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PTS: 1 DIF: Analyze REF: Thyroid Crisis (Thyroid Storm)
medications would the nurse expect to see?
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a
1.Levothyroxine
2.Methimazole
3.Propylthiouracil
4.Radioactive iodine
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.
13.A pregnant client is receiving treatment for hyperthyroidism. Which of the following
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n
ANS: 3
Propylthiouracil (PTU) is the drug of choice for treating hyperthyroidism in a pregnant or
breastfeeding client. Radioactive iodine and methimazole are treatments for nonpregnant clients
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PTS:1DIF:Analyze
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with hyperthyroidism. Levothyroxine is used to treat hypothyroidism.
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REF: Hypersecretion of the Thyroid Gland: Pharmacology
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14.A client is diagnosed with chronic lymphocytic thyroiditis. The nurse should instruct the
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client regarding signs and symptoms of which of the following?
1.Type 2 diabetes mellitus
2.Heart failure
3.Hypothyroidism
4.Renal failure
ANS: 3
The client diagnosed with chronic lymphocytic thyroiditis will most often progress to
hypothyroidism, which is permanent 95% of the time. The nurse should instruct the client
regarding signs and symptoms of hypothyroidism. Chronic lymphocytic thyroiditis will not cause
type 2 diabetes mellitus, heart failure, or renal failure.
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PTS: 1 DIF: Apply REF: Thyroiditis
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MULTIPLE RESPONSE
1.Which of the following symptoms would suggest to the nurse that a client is experiencing
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.
symptoms of pheochromocytoma? (Select all that apply.)
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1.Severe headache
2.Decreased urine output
3.Palpitations
4.Diarrhea
5.Profuse sweating
6.Weight gain
ANS: 1, 3, 5
Severe headache, palpitations, and profuse sweating are the most common symptoms of
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pheochromocytoma. Decreased urine output, diarrhea, and weight gain are not associated with
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this disorder.
PTS:1DIF:Analyze
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REFheochromocytoma: Assessment with Clinical Manifestations
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2.A client is receiving diagnostic tests to determine the presence of a malignant thyroid lesion.
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Which of the following are symptoms that are usually associated with a malignant thyroid?
(Select all that apply.)
1.Hoarseness
2.Onset of dysphagia
3.Age 20; male gender
4.Thyroid scan revealing a cold nodule
5.Soft nodules
6.Presence of a single firm nodule
ANS: 1, 2, 3, 4, 6
Assessment findings consistent with a malignant thyroid lesion include hoarseness, dysphagia,
young adult male; thyroid scan revealing a cold nodule; and the presence of a single firm nodule.
Multiple soft nodules are indicative of benign thyroid lesions.
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REF:Table 56-5 Comparison of Benign and Malignant Thyroid Lesions
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PTS:1DIF:Analyze
ba
n
1.Reduced level of consciousness
2.Hypothermia
3.Hypoventilation
4.Hypotension
5.Bradycardia
6.Reduced urine output
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the following is assessed? (Select all that apply.)
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.
3.The nurse suspects a client is experiencing the early signs of myxedema coma when which of
ANS: 1, 2, 3, 4, 5
Myxedema is a medical emergency. The client will present with a diminished level of
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consciousness, hypothermia, hypoventilation, hypotension, and bradycardia. Prior to the coma,
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the client may be depressed, confused, paranoid, or even manic. Reduced urine output is not
associated with this disorder.
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PTS:1DIF:AnalyzeREF:Myxedema Coma
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4.The nurse is planning care for a client diagnosed with hypercalcemia caused by
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hyperparathyroidism. Which of the following should the nurse add as interventions to this clients
care plan? (Select all that apply.)
1.Administer high volume intravenous fluids as prescribed.
2.Monitor arterial blood gases.
3.Calculate sodium chloride intake to achieve 400 mEq each day.
4.Provide low rates of intravenous fluids.
5.Provide thyroid replacement medication orally.
6.Monitor body temperature.
ANS: 1, 3
Management of fluid and electrolytes is the priority for a client diagnosed with hypercalcemia
caused by hyperparathyroidism. The client needs intensive hydration with intravenous normal
saline. The nurse also needs to ensure that the client receives greater than 400 mEq of sodium
chloride each day. The other answer choices are interventions appropriate for a client diagnosed
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with myxedema.
Chapter 21. Rheumatological Guidelines
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MULTIPLE CHOICE
1.The nurse, assessing a clients leukocyte level, determines the amount to be within normal
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ANS: 3
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1.14 to 18 g/dL
2.4.6 to 6.2 million/mm3
3.4500 to 11,000 mm3
4.50 to 60 percent
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limits. Which of the following would indicate a normal level of leukocytes in the clients blood?
The normal amount of leukocytes or white blood cells in the blood is 4500 to 11,000 mm3. The
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value of 14 to 18 g/dL is the normal hemoglobin level. The value of 4.6 to 6.2 million/mm3
represents the normal amount of red blood cells. The value of 50 to 60 percent represents a
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normal neutrophil level.
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PTS: 1 DIF: Analyze REF: Leukocytes
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2.A clients complete blood count reveals a large amount of phagocytic cells present. The nurse
realizes that this type of cell is most likely:
1.basophils.
2.eosinophils.
3.monocytes.
4.neutrophils.
ANS: 4
Monocytes are phagocytic but in a smaller amount than neutrophils. Basophils are stimulated by
allergens and eosinophils by parasites. Neutrophils are the chief phagocytic cells and are present
in larger numbers as a response to early inflammation.
PTS: 1 DIF: Analyze REF: Leukocytes
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3.According to assessment findings, the nurse determines that a client is experiencing an
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ANS: 1
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.
1.Redness, swelling, heat, and pain
2.Reduced urine output
3.Thirst
4.Elevated blood pressure and slow heart rate
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inflammatory process. Which of the following did the nurse assess in this client?
The symptoms of the inflammatory process are redness, swelling, heat, and pain. Reduced urine
output, thirst, elevated blood pressure, and slow heart rate are not symptoms of the inflammatory
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process.
PTS: 1 DIF: Analyze REF: Signs of Inflammation
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type of infection?
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4.A client is diagnosed with a bacterial infection. Which of the following is an example of this
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1.Malaria
2.Gastroenteritis
3.Urinary tract infection
4.Typhus
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ANS: 3
Urinary tract infections are caused by bacteria. Malaria and gastroenteritis are caused by
protozoa. Typhus is caused by rickettsia.
PTS: 1 DIF: Understand REF: Table 11-3 Types of Agents Causing Disease
5.A client is diagnosed with gastroenteritis. The nurse realizes that this illness occurs from which
type of disease-causing organism?
1.Bacteria
2.Fungi
3.Protozoa
4.Viruses
ANS: 3
Protozoa are single-cell parasitic organisms that form cysts or spores. Diseases caused by
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protozoa include malaria and gastroenteritis. Hepatitis A, B, and C are examples of a disease
bacteria. Ringworm is an example of a disease caused by fungi.
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caused by a virus. Pneumonia and urinary tract infections are examples of diseases caused by
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.
PTS: 1 DIF: Analyze REF: Table 11-3 Types of Agents Causing Disease
6.A client has been diagnosed with Rocky Mountain spotted fever. The causative organism for
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a
this disease process is:
ba
n
1.bacteria.
2.helminth.
3.mycoplasma.
4.rickettsia.
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ANS: 4
Rocky Mountain spotted fever is caused by the infectious organism rickettsia. Disease processes
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from bacteria, helminths, and mycoplasma include urinary tract infections, tapeworm infection,
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and pneumonia, respectively.
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PTS: 1 DIF: Understand REF: Table 11-3 Types of Agents Causing Disease
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7.Which of the following will the nurse most likely assess in a client diagnosed with asthma?
1.Wheezing and anxiety
2.Barking cough and increased blood pressure
3.Bradycardia and restlessness
4.Anemia and hypoxia
ANS: 1
Common symptoms in asthma include wheezing, anxiety, cough, shortness of breath,
tachycardia, restlessness, increased blood pressure, and hypoxia. Barking cough, bradycardia,
and anemia are not common symptoms of asthma.
PTS: 1 DIF: Analyze REF: Asthma: An Allergic Disease
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8.The nurse would expect that a client diagnosed with arthritis will be prescribed which of the
following medications?
ANS: 3
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a
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.
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1.Albuterol
2.Furosemide
3.Ibuprofen
4.Nortriptyline
Nonsteroidal anti-inflammatory drugs (NSAIDs) and cortisol drugs are common treatments for
arthritis. Albuterol relaxes bronchial smooth muscle. Furosemide is a loop diuretic, and
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nortriptyline is an antidepressant.
PTS: 1 DIF: Analyze REF: Arthritis
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1.Airborne
2.Contact
3.Droplet
4.Standard
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implement at this time?
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9.A client is being admitted to a health care facility. Which type of precautions will the nurse
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ANS: 4
Standard precautions are actions used with all clients. Transmission-based precautions such as
airborne, contact, and droplet are used when a client is known or suspected of having a
communicable disease.
PTS:1DIF:ApplyREF:Standard Precautions
10.A client diagnosed with tuberculosis is scheduled for a chest x-ray to be completed in the
radiology department. Which of the following devices should be utilized when transporting this
client?
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1.Face shield with mask and gown
2.N-95 mask
3.Surgical mask
4.Patient does not need to wear a device
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ANS: 3
For a client diagnosed with tuberculosis, transport out of the room should only be done when
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.
absolutely necessary and the client should wear a surgical mask during transport. A face shield,
PTS:1DIF:ApplyREF:Airborne Precautions
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a
gown, or N-95 mask are not needed to transport this client.
11.The nurse is preparing to administer medications to a client diagnosed with varicella. Which
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of the following personal protective equipment should the nurse use when entering the clients
room?
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1.Face shield with mask and gown
2.Gloves and gown
3.A high-efficiency particulate air filter mask
4.Surgical mask
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ANS: 3
A high-efficiency particulate air filter mask is required personal protective equipment for the
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care of a client with varicella. A mask may be worn for clients on droplet precautions, and the
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gown and gloves are for a client on contact precautions.
PTS:1DIF:ApplyREF:Airborne Precautions
12.A client is diagnosed with venous leg ulcers. The nurse would expect that these wounds will
heal by which of the following types of intention?
1.Primary
2.Secondary
3.Tertiary
4.Quaternary
ANS: 2
Primary intention type of healing occurs in wounds that are clean, and have little loss of tissue.
Secondary intention occurs when a wound heals by spread of granulation tissue from the base of
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a wound. Venous leg ulcers heal by secondary intention. In tertiary intention, the wound must be
sutured through several layers of granulation tissue in order to bring closure. Quaternary is not a
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type of wound healing.
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.
PTS: 1 DIF: Analyze REF: Types of Wound Healing
13.The nurse is using the Braden Scale to determine a clients risk for developing a pressure
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ulcer. Which of the following areas are assessed with this scale?
ba
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1.Home environment
2.Finances
3.Medications
4.Friction and shear
ANS: 4
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The Braden Scale is used to assess a clients risk for developing a pressure ulcer. This scale
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assesses the areas of sensory perception, moisture, activity, mobility, nutrition, and friction and
shear. Home environment, finances, and medications are not assessed with the use of this scale.
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PTS: 1 DIF: Apply REF: Table 11-7 Elements in Braden Pressure Scale
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14.The nurse is identifying nursing diagnoses for a client experiencing inflammation. Which of
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the following diagnoses would be appropriate for this client? (Select all that apply.)
1.Risk for infection
2.Thermoregulation: Ineffective
3.Ineffective coping
4.Pain: Acute
5.Nutrition: Imbalanced, less than body requirements
6.Anxiety
ANS: 1, 2, 4, 5
Nursing diagnoses appropriate for a client experiencing inflammation include risk for infection;
thermoregulation: ineffective; pain: acute; and nutrition: imbalanced, less than body
requirements. Ineffective coping and anxiety are not diagnoses appropriate for a client with an
inflammation.
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PTS: 1 DIF: Apply REF: Nursing Response: Inflammation
15.The nurse is determining the route of transmission for an infectious organism. Which of the
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following are types of transmission routes? (Select all that apply.)
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a
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.
1.Ingestion
2.Vector-borne
3.Common vehicle
4.Airborne
5.Droplet
6.Contact
ba
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ANS: 2, 3, 4, 5, 6
There are five types of transmission routes: 1) contact, 2) droplet, 3) airborne, 4) common
vehicle, and 5) vector-borne. Ingestion is not a type of transmission route.
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PTS: 1 DIF: Analyze REF: Infectious Disease Control
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16.The nurse is determining when gloves should be worn when providing client care. Which of
the following situations would necessitate the wearing of gloves? (Select all that apply.)
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1.In contact with blood
2.In contact with mucous membranes
3.Delivering a meal tray
4.Providing medications
5.Measuring urine output
6.Suctioning oral secretions
ANS: 1, 2, 5, 6
Gloves should be worn when in contact with blood, body fluids, secretions, excretions,
contaminated items, mucous membranes, and nonintact skin. Gloves are not needed when
delivering a meal try or providing medications.
PTS:1DIF:Analyze
REF: Table 11-4 Summary of the Updated Centers for Disease Control and Prevention Isolation
Guidelines
17.The nurse is concerned that a client will experience delayed wound healing when which of the
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ANS: 1, 2, 4, 5
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.
1.Prescribed a beta-blocker medication
2.Poor appetite
3.Ambulating in the room several times a day
4.Age 85
5.Prescribed steroids
6.Skin warm and dry
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following is assessed? (Select all that apply.)
Risk factors for delayed wound healing include ischemia, medications such as beta-blockers,
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smoking, exposure to cold, repetitive injury, altered nutrition infection, anti-inflammatory
steroids, and older age. Ambulating in the room several times a day may encourage wound
healing. Skin warm and dry will not delay wound healing.
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PTS:1DIF:Analyze
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REF: Table 11-6 Risk Factors for Delayed Wound Healing
18.The nurse is planning care for a client with a chronic wound. Which of the following
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principles should be reflected in this clients care?
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1.Debridement
2.Restrict fluids
3.Provide moist environment
4.Prevent further injury
5.Maintain on bed rest
6.Nutrition
ANS: 1, 3, 4, 6
The four principles of chronic wound management include debridement, provide moist
environment, prevent further injury, and nutrition. Restricting fluids and maintaining on bed rest
are not principles of chronic wound management.
___ 19. The nurse is reinforcing discharge instructions to a patient who has a mitral valve
prolapse. What information should be included?
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a. Begin a home aerobic exercise program.
c. Deep breathe and cough hourly when awake.
d. You may have a possible need for prophylactic anticoagulants.
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b. Perform hourly leg exercises if lying down.
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.
____ 20. The nurse is reinforcing teaching for a patient who has had a mechanical valve
replacement. What should be included regarding safety during warfarin (Coumadin) therapy?
b. Use a straight razor when shaving.
c. Keep yearly blood test appointments.
d. Increase intake of green leafy vegetables.
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a. Wear Medic-Alert identification.
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____ 21. The nurse is collecting data from a patient who has mitral stenosis. For which condition
should the nurse assess in the patients history?
a. Meningitis
c. Rheumatic fever
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d. Rheumatoid arthritis
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b. Scarlet fever
____ 22. The nurse is reinforcing teaching provided to a patient with aortic stenosis. Which
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statement indicates that the patient correctly understands what happens in aortic stenosis?
a. There is impaired emptying of the left ventricle.
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b. There is impaired emptying of the right ventricle.
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c. There is backflow of blood into the left ventricle.
d. There is backflow of blood into the right ventricle.
____ 23. A patient with mitral regurgitation asks what the health problem means. What should
the nurse explain to the patient?
a. There is impaired emptying of the left atrium.
b. There is backflow of blood into the left atrium.
c. There is impaired emptying of the right atrium.
d. There is backflow of blood into the right atrium.
____ 24. While collecting data on a patient with aortic stenosis the nurse monitors for signs of
heart failure. What is the nurse monitoring for heart failure as a complication of aortic stenosis?
a. Cardiac workload is increased from reduced cardiac output.
b. Cardiac workload is decreased from reduced cardiac output.
c. Cardiac workload is increased from increased cardiac output.
d. Cardiac workload is decreased from increased cardiac output.
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____ 7. A patient with chronic mitral regurgitation states, I am always so tired. Which factor
should the nurse identify as contributing to this patients fatigue?
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a. Coughing
b. Heart murmur
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.
c. Pulmonary congestion
d. Decreased cardiac output
____ 25. The nurse is contributing to a patients plan of care. During medication administration,
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a
which medication would the nurse understand as being prescribed to treat a patient with aortic
stenosis who has symptoms of heart failure?
b. Bumetanide (Bumex)
c. Digitalis
d. Warfarin (Coumadin)
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a. Heparin
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____ 26. The nurse is caring for a patient who has a valvular problem. The patient states the
doctor is ordering something that measures the pressures in the patients heart. Which diagnostic
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test should the nurse anticipate scheduling for the patient?
a. Echocardiogram
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b. Chest radiograph
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c. Electrocardiogram
d. Cardiac catheterization
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____ 27. The nurse is contributing to a patients plan of care. Which statement is a desired
outcome for the nursing diagnosis of Deficient Knowledge related to a new medical diagnosis of
mitral valve prolapse?
a. Exhibits less fatigue during self-care
b. Clear breathing sounds, no edema or weight gain
c. States ability to comply with therapeutic regimen
d. Verbalizes definition of disorder and manifestations
____ 28. The nurse is providing discharge teaching for a patient with mitral stenosis. What
should the nurse include in this teaching?
a. The medications you will be taking make your blood thicker, so you are at risk for small clots
to form.
b. It is important that you increase your fluid intake and take iron supplements so that your body
can make enough blood for your heart to pump around.
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c. Your blood is rushing through your heart so fast that it may not give your heart enough oxygen
and you may have something called angina, or heart pain.
tend to pool in certain areas, which might allow tiny clots to form.
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d. Because of your heart condition, the blood flow through your heart is slower and blood may
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.
____ 29. The nurse is caring for a patient who has aortic stenosis. During data collection, which
of these manifestations should indicate to the nurse that the patient is experiencing myocardial
oxygen deficiency?
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a
a. Angina
b. Sacral edema
d. Pericardial friction rub
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c. Jugular vein distention
____30. The nurse is reinforcing teaching provided to a patient with aortic regurgitation on how
a. Lie flat when in bed.
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to reduce cardiac workload. Which patient statement indicates that teaching has been effective?
b. Elevate the legs hourly.
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c. Eat three large meals daily.
d. Alternate activity with rest.
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____ 31. The nurse is evaluating care provided to a patient with the nursing diagnosis of activity
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intolerance because of aortic regurgitation. Which outcome indicates that care has been
effective?
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a. Stated maintained bedrest to reduce fatigue
b. Engaged in desired daily and social activities
c. Completed activities of daily living with assistance
d. Reported no longer participates in gardening hobby
19. ANS: D
Aspirin or anticoagulants may be ordered to help prevent formation of blood clots on the valve.
A. The patient should follow the health care providers instructions for an exercise program. B.
There is no evidence to support the need for the patient to perform leg exercises every hour. C.
There is no evidence to support that the patient needs to perform deep breathing and coughing
exercises every hour while awake.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
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20. ANS: A
If the patient is on anticoagulants for mechanical valve replacement, medical identification
should be used. D. A steady (rather than fluctuating) amount of green leafy vegetables should be
eaten so that international normalized ratio (INR) values do not fluctuate due to the vitamin K
found in these foods. C. Monthly blood tests are done. B. Avoid a straight razor to avoid cuts and
bleeding.
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.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
Level: Application
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21. ANS: C
The major cause of mitral stenosis is rheumatic fever. A. B. D. Meningitis, scarlet fever, or
rheumatoid arthritis are not associated with the development of mitral stenosis.
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PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level:
Application
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22. ANS: A
Blood flow from the left ventricle into the aorta is obstructed through the stenosed aortic valve,
and the left ventricle fails to move blood forward. B. Aortic stenosis does not impair blood flow
from the right ventricle. C. D. A backflow of blood into the left or right ventricle does not occur
with aortic stenosis.
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PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis
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5. ANS: B
Mitral regurgitation is the incomplete closure of the mitral valve leaflets, which allows backflow
of blood into the left atrium with each contraction of the left ventricle. A. C. D. Mitral
regurgitation is not characterized by impaired emptying of the left or right atrium or a backflow
of blood into the right atrium.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level:
Application
23. ANS: A
Cardiac workload is increased from reduced cardiac output. With increased narrowing of the
aortic valve opening, the compensatory mechanisms are unable to continue, and the left ventricle
fails to move blood forward. This results in decreased cardiac output and heart failure. B. The
cardiac workload in aortic stenosis is not decreased. C. In aortic stenosis, the cardiac workload is
not increased because of increased cardiac output. D. In aortic stenosis, the cardiac workload is
not decreased because of an increase in cardiac output.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis
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24. ANS: D
Decreased cardiac output causes fatigue due to less oxygen being provided to the tissues. A. B.
C. The patient is not experiencing fatigue because of coughing, a heart murmur, or pulmonary
congestion.
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PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis
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.
25. ANS: B
Diuretics reduce fluid volume returning to the heart and, subsequently, cardiac workload. A. C.
D. Medications that reduce the contractility of the heart and, subsequently, cardiac output are
avoided to prevent further heart failure.
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a
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive
Level: Comprehension | Integrated Processes: Clinical ProblemSolving Process | Question to
Guide Your Learning: 2
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ba
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26. ANS: D
Cardiac catheterization measures cardiac pressure and with dye injection shows blood flow. A.
An echocardiogram evaluates muscle activity and ejection fraction. B. Chest radiography
identifies location and size of the heart muscle. D. Electrocardiogram evaluates electrical activity
of the heart.
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PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
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27. ANS: D
The patient should be able to verbalize a definition of the disorder and its manifestations to
demonstrate understanding for promotion of health and self-care. A. B. C. These statements are
outcomes to address specific issues such as fatigue, fluid imbalance, or ineffective coping.
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PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis
28. ANS: D
Emboli form from the stasis of blood in the heart caused by valvular disorders and decreased
cardiac output. A. Patients are often placed on blood thinners, so this is a false statement. B. Iron
supplementation is provided for iron deficiency anemia, not for valvular disorders. C. Blood flow
through the heart is slowed, so this is a false statement.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level:
Application
29. ANS: A
Angina results if cardiac oxygen needs are not met. B. C. D. A lack of myocardial oxygen does
not cause sacral edema, jugular vein distention, or pericardial friction rub.
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PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis
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30. ANS: D
Cardiac workload and oxygen needs are reduced with rest. A. Lying flat may be uncomfortable
for the patient with this health problem. B. The legs do not need to be elevated every hour. C.
Large meals might be uncomfortable for this patient and should not be encouraged.
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.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Analysis
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n
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a
31. ANS: B
The desired outcome for activity intolerance would be for the patient to be able to engage in
desired daily and social activities. A. Needing bedrest to reduce fatigue indicates that
interventions to address activity intolerance have not been effective. C. Needing assistance to
complete activities of daily indicates that interventions to address activity intolerance have not
been effective. D. No longer participating in a gardening hobby indicates that interventions to
address activity intolerance have not been effective.
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Chapter 22. Psychiatric Guidelines
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MULTIPLE CHOICE
1. A nurse wants to teach alternative coping strategies to a patient experiencing severe anxiety.
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Which action should the nurse perform first?
a. Verify the patients learning style.
b. Lower the patients current anxiety.
c. Create outcomes and a teaching plan.
d. Assess how the patient uses defense mechanisms.
ANS: B
A patient experiencing severe anxiety has a markedly narrowed perceptual field and difficulty
attending to events in the environment. A patient experiencing severe anxiety will not learn
readily. Determining preferred modes of learning, devising outcomes, and constructing teaching
plans are relevant to the task but are not the priority measure. The nurse has already assessed the
patients anxiety level. Use of defense mechanisms does not apply.
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PTS: 1 DIF: Cognitive Level: Apply (Application)
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REF: DIF: 279 TOP: Nursing Process: Implementation
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.
MSC: Client Needs: Psychosocial Integrity
2. A woman is 57, 160 lbs, and wears a size 8 shoe. She says, My feet are huge. Ive asked three
orthopedists to surgically reduce my feet. This person tries to buy shoes to make her feet look
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smaller and, in social settings, conceals both feet under a table or chair. Which health problem is
a. Social anxiety disorder
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likely?
b. Body dysmorphic disorder
c. Separation anxiety disorder
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d. Obsessive-compulsive disorder due to a medical condition
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ANS: B
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Body dysmorphic disorder refers to a preoccupation with an imagined defect in appearance in a
normal-appearing person. The patients feet are proportional to the rest of the body. In obsessive-
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compulsive or related disorder due to a medical condition, the individuals symptoms of
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obsessions and compulsions are a direct physiological result of a medical condition. Social
anxiety disorder, also called social phobia, is characterized by severe anxiety or fear provoked by
exposure to a social or a performance situation that will be evaluated negatively by others.
People with separation anxiety disorder exhibit developmentally inappropriate levels of concern
over being away from a significant other.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: DIF: 287-288 TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
3. A patient experiencing moderate anxiety says, I feel undone. An appropriate response for the
nurse would be:
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a. What would you like me to do to help you?
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b. Why do you suppose you are feeling anxious?
c. Im not sure I understand. Give me an example.
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.
d. You must get your feelings under control before we can continue.
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a
ANS: C
Increased anxiety results in scattered thoughts and an inability to articulate clearly. Clarifying
helps the patient identify thoughts and feelings. Asking the patient why he or she feels anxious is
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non-therapeutic; the patient likely does not have an answer. The patient may be unable to
determine what he or she would like the nurse to do in order to help. Telling the patient to get his
or her feelings under control is a directive the patient is probably unable to accomplish.
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PTS: 1 DIF: Cognitive Level: Apply (Application)
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REF: DIF: 286 (Generic Care Plan) | DIF: 294 (Table 15-11)
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TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
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4. A patient fearfully runs from chair to chair crying, Theyre coming! Theyre coming! The
patient does not follow the staffs directions or respond to verbal interventions. The initial nursing
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intervention of highest priority is to:
a. provide for the patients safety.
b. encourage clarification of feelings.
c. respect the patients personal space.
d. offer an outlet for the patients energy.
ANS: A
Safety is of highest priority because the patient experiencing panic is at high risk for self-injury
related to increased non-goal-directed motor activity, distorted perceptions, and disordered
thoughts. Offering an outlet for the patients energy can occur when the current panic level
subsides. Respecting the patients personal space is a lower priority than safety. Clarification of
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feelings cannot take place until the level of anxiety is lowered.
co
PTS: 1 DIF: Cognitive Level: Analyze (Analysis)
MSC: Client Needs: Safe, Effective Care Environment
nk
.
REF: DIF: 293-295 (Table 15-12) TOP: Nursing Process: Planning
kt
a
5. A patient fearfully runs from chair to chair crying, Theyre coming! Theyre coming! The
patient does not follow the staffs directions or respond to verbal interventions. Which nursing
ba
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diagnosis has the highest priority?
a. Fear
c. Self-care deficit
b. Risk for injury
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st
ANS: B
d. Disturbed thought processes
A patient experiencing panic-level anxiety is at high risk for injury related to increased non-goaldirected motor activity, distorted perceptions, and disordered thoughts. Data are not present to
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support a nursing diagnosis of self-care deficit or disturbed thought processes. The patient may
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have fear, but the risk for injury has a higher priority.
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PTS: 1 DIF: Cognitive Level: Analyze (Analysis)
REF: DIF: 293-295 (Table 15-12) TOP: Nursing Process: Diagnosis/Analysis
MSC: Client Needs: Safe, Effective Care Environment
6. A patient checks and rechecks electrical cords related to an obsessive thought that the house
may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states
this event is not likely. This counseling demonstrates principles of:
c. relaxation technique.
b. desensitization.
d. cognitive restructuring.
m
a. flooding.
co
ANS: D
Cognitive restructuring involves the patient in testing automatic thoughts and drawing new
nk
.
conclusions. Desensitization involves graduated exposure to a feared object. Relaxation training
teaches the patient to produce the opposite of the stress response. Flooding exposes the patient to
kt
a
a large amount of an undesirable stimulus in an effort to extinguish the anxiety response.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
ba
n
REF: DIF: 284 (Table 15-3) | DIF: 299 TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
7. A patient undergoing diagnostic tests says, Nothing is wrong with me except a stubborn chest
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cold. The spouse reports the patient smokes, coughs daily, lost 15 pounds, and is easily fatigued.
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Which defense mechanism is the patient using?
c. Projection
b. Regression
d. Denial
w
w
a. Displacement
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ANS: D
Denial is an unconscious blocking of threatening or painful information or feelings. Regression
involves using behaviors appropriate at an earlier stage of psychosexual development.
Displacement shifts feelings to a more neutral person or object. Projection attributes ones own
unacceptable thoughts or feelings to another.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: DIF: 281-283 (Table 15-2) TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
8. A patient with an abdominal mass is scheduled for a biopsy. The patient has difficulty
understanding the nurses comments and asks, What do you mean? What are they going to do?
m
Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the patients
c. Severe
b. Moderate
d. Panic
nk
.
a. Mild
co
level of anxiety?
ANS: B
kt
a
Moderate anxiety causes the individual to grasp less information and reduces problem-solving
ability to a less-than-optimal level. Mild anxiety heightens attention and enhances problem
in disorganized behavior.
ba
n
solving. Severe anxiety causes great reduction in the perceptual field. Panic-level anxiety results
1. A person was online continuously for over 24 hours, posting rhymes on official government
st
websites and inviting politicians to join social networks. The person has not slept or eaten for 3
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days. What features of mania are evident?
c. Poor judgment and hyperactivity
b. Vegetative signs and poor grooming
d. Cognitive deficits and paranoia
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ANS: C
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a. Increased muscle tension and anxiety
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Hyperactivity (activity without sleep) and poor judgment (posting rhymes on government
websites) are characteristic of manic episodes. The distracters do not specifically apply to mania.
PTS: 1 DIF: Cognitive Level: Analyze (Analysis)
REF: DIF: 228-229 TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
2. A patient diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The
patient twirls and shadow boxes. The patient says gaily, Do you like my scarves? Here; they are
my gift to you. How should the nurse document the patients mood?
c. Suspicious
b. Irritable
d. Confident
m
a. Euphoric
co
ANS: A
The patient has demonstrated clang associations and pleasant, happy behavior. Excessive
nk
.
happiness indicates euphoria. Irritability, belligerence, excessive happiness, and confidence are
not the best terms for the patients mood. Suspiciousness is not evident.
kt
a
PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: DIF: 228-230 TOP: Nursing Process: Assessment
ba
n
MSC: Client Needs: Psychosocial Integrity
3. A person was directing traffic on a busy street, rapidly shouting, To work, you jerk, for perks
and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which
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st
assessment findings will have priority concern for this patients plan of care?
a. Insulting, aggressive behavior
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b. Pressured speech and grandiosity
c. Hyperactivity; not eating and sleeping
w
w
d. Poor concentration and decision making
ANS: C
Hyperactivity, poor nutrition, hydration, and not sleeping take priority in terms of the needs
listed above because they threaten the physical integrity of the patient. The other behaviors are
less threatening to the patients life.
PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: DIF: 234-236 (Case Study and Nursing Care Plan 13-1) TOP: Nursing Process: Planning
MSC: Client Needs: Safe, Effective Care Environment
4. A patient diagnosed with acute mania has distributed pamphlets about a new business venture
on a street corner for 2 days. Which nursing diagnosis has priority?
m
a. Risk for injury
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b. Ineffective coping
c. Impaired social interaction
nk
.
d. Ineffective therapeutic regimen management
kt
a
ANS: A
Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode,
the priority lies with the patients physiological safety. Hyperactivity and poor judgment put the
ba
n
patient at risk for injury.
PTS: 1 DIF: Cognitive Level: Apply (Application)
st
REF: DIF: 234-235 (Table 13-1) | DIF: 236 (Case Study and Nursing Care Plan 13-1)
.te
TOP: Nursing Process: Diagnosis/Analysis
w
MSC: Client Needs: Safe, Effective Care Environment
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5. A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium.
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The patient threatens to hit another patient. Which comment by the nurse is appropriate?
a. Stop that! No one did anything to provoke an attack by you.
b. If you do that one more time, you will be secluded immediately.
c. Do not hit anyone. If you are unable to control yourself, we will help you.
d. You know we will not let you hit anyone. Why do you continue this behavior?
ANS: C
When the patient is unable to control his or her behavior and violates or threatens to violate the
rights of others, limits must be set in an effort to de-escalate the situation. Limits should be set in
simple, concrete terms. The incorrect responses do not offer appropriate assistance to the patient,
threaten the patient with seclusion as punishment, and ask a rhetorical question.
PTS: 1 DIF: Cognitive Level: Apply (Application)
m
REF: DIF: 233-234 | DIF: 238-239 (Table 13-2) | DIF: 236 (Case Study and Nursing Care Plan
co
13-1)
nk
.
TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment
6. This nursing diagnosis applies to a patient with acute mania: Imbalanced nutrition: less than
body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-
kt
a
pound weight loss in 4 days.Select an appropriate outcome. The patient will:
a. ask staff for assistance with feeding within 4 days.
ba
n
b. drink six servings of a high-calorie, high-protein drink each day.
c. consistently sit with others for at least 30 minutes at meal time within 1 week.
st
d. consistently wear appropriate attire for age and sex within 1 week while on the
psychiatric unit.
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ANS: B
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High-calorie, high-protein food supplements will provide the additional calories needed to offset
the patients extreme hyperactivity. Sitting with others or asking for assistance does not mean the
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patient ate or drank. The other indicator is unrelated to the nursing diagnosis.
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PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: DIF: 238-239 (Table 13-2) | DIF: 236 (Case Study and Nursing Care Plan 13-1)
TOP: Nursing Process: Outcomes Identification
MSC: Client Needs: Physiological Integrity
7. A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium.
New orders are written to resume lithium twice daily and begin olanzapine (Zyprexa). What is
the rationale for the addition of olanzapine to the medication regimen? It will:
a. minimize the side effects of lithium.
b. bring hyperactivity under rapid control.
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c. enhance the antimanic actions of lithium.
co
d. be used for long-term control of hyperactivity.
nk
.
ANS: B
Manic symptoms are controlled by lithium only after a therapeutic serum level is attained.
Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce the
kt
a
hyperactivity initially. Antipsychotic drugs neither enhance lithiums antimanic activity nor
minimize the side effects. Lithium will be used for long-term control.
ba
n
PTS: 1 DIF: Cognitive Level: Analyze (Analysis)
REF: DIF: 239-240 | DIF: 242 TOP: Nursing Process: Planning
st
MSC: Client Needs: Physiological Integrity
.te
8. A patient diagnosed with bipolar disorder has rapidly changing mood cycles. The health care
provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug
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should the nurse anticipate will be prescribed?
c. risperidone (Risperdal)
b. clonidine (Catapres)
d. carbamazepine (Tegretol)
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w
a. phenytoin (Dilantin)
ANS: D
Some patients with bipolar disorder, especially those who have only short periods between
episodes, have a favorable response to the anticonvulsants carbamazepine and valproate.
Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid,
angry manic patients. Phenytoin is also an anticonvulsant but not used for mood stabilization.
Risperidone is not an anticonvulsant. See relationship to audience response question.
9. A patient became severely depressed when the last of the familys six children moved out of
the home 4 months ago. The patient repeatedly says, No one cares about me. Im not worth
a. Things will look brighter soon. Everyone feels down once in a while.
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anything. Which response by the nurse would be the most helpful?
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b. Our staff members care about you and want to try to help you get better.
nk
.
c. It is difficult for others to care about you when you repeatedly say the same
negative things.
kt
a
d. Ill sit with you for 10 minutes now and 10 minutes after lunch to help you feel
that I care about you.
ANS: D
ba
n
Spending time with the patient at intervals throughout the day shows acceptance by the nurse and
will help the patient establish a relationship with the nurse. The therapeutic technique is offering
self. Setting definite times for the therapeutic contacts and keeping the appointments show
predictability on the part of the nurse, an element that fosters trust building. The incorrect
st
responses would be difficult for a person with profound depression to believe, provide false
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reassurance, and are counterproductive. The patient is unable to say positive things at this point.
PTS: 1 DIF: Cognitive Level: Apply (Application)
w
w
REF: DIF: 263 (Table 14-4) | DIF: 256 (Case Study and Nursing Care Plan 14-1)
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TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
10. A patient became depressed after the last of the familys six children moved out of the home 4
months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem
related to feelings of abandonment. The patient will:
a. verbalize realistic positive characteristics about self by (date).
b. agree to take an antidepressant medication regularly by (date).
c. initiate social interaction with another person daily by (date).
d. identify two personal behaviors that alienate others by (date).
ANS: A
Low self-esteem is reflected by making consistently negative statements about self and self-
m
worth. Replacing negative cognitions with more realistic appraisals of self is an appropriate
intermediate outcome. The incorrect options are not as clearly related to the nursing diagnosis.
co
Outcomes are best when framed positively; identifying two personal behaviors that might
PTS: 1 DIF: Cognitive Level: Apply (Application)
nk
.
alienate others is a negative concept.
REF: DIF: 259 | DIF: 261 (Table 14-2) | DIF: 256 (Case Study and Nursing Care Plan 14-1) |
ba
n
MSC: Client Needs: Psychosocial Integrity
kt
a
DIF: 274 TOP: Nursing Process: Outcomes Identification
11. A patient diagnosed with major depression says, No one cares about me anymore. Im not
worth anything. Today the patient is wearing a new shirt and has neat, clean hair. Which remark
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by the nurse supports building a positive self-esteem for this patient?
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a. You look nice this morning.
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ANS: B
d. You must be feeling better today.
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b. Youre wearing a new shirt.
c. I like the shirt you are wearing.
Patients with depression usually see the negative side of things. The meaning of compliments
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may be altered to I didnt look nice yesterday or They didnt like my other shirt. Neutral comments
such as making an observation avoid negative interpretations. Saying, You look nice or I like
your shirt gives approval (non-therapeutic techniques). Saying You must be feeling better today
is an assumption, which is non-therapeutic.
PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: DIF: 259 | DIF: 261 (Table 14-2) | DIF: 256 (Case Study and Nursing Care Plan 14-1) |
DIF: 274 TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
12. An adult diagnosed with major depression was treated with medication and cognitive
m
behavioral therapy. The patient now recognizes how passivity contributed to the depression.
co
Which intervention should the nurse suggest?
c. Desensitization techniques
b. Relaxation training classes
d. Use of complementary therapy
nk
.
a. Social skills training
ANS: A
kt
a
Social skill training is helpful in treating and preventing the recurrence of depression. Training
focuses on assertiveness and coping skills that lead to positive reinforcement from others and
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n
development of a patients support system. Use of complementary therapy refers to adjunctive
therapies such as herbals, which would be less helpful than social skill training. Assertiveness
would be of greater value than relaxation training because passivity was a concern.
st
Desensitization is used in treatment of phobias.
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PTS: 1 DIF: Cognitive Level: Analyze (Analysis)
REF: DIF: 256 (Case Study and Nursing Care Plan 14-1) | DIF: 259
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TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
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13. Priority interventions for a patient diagnosed with major depression and feelings of
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worthlessness should include:
a. distracting the patient from self-absorption.
b. careful unobtrusive observation around the clock.
c. allowing the patient to spend long periods alone in meditation.
d. opportunities to assume a leadership role in the therapeutic milieu.
ANS: B
Approximately two-thirds of people with depression contemplate suicide. Patients with
depression who exhibit feelings of worthlessness are at higher risk. Regular planned observations
of the patient diagnosed with depression may prevent a suicide attempt on the unit.
m
PTS: 1 DIF: Cognitive Level: Apply (Application)
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REF: DIF: 263 (Table 14-3) | DIF: 256 (Case Study and Nursing Care Plan 14-1)
nk
.
TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment
14. When counseling patients diagnosed with major depression, an advanced practice nurse will
a. psychoanalytic therapy.
b. desensitization therapy.
ba
n
c. cognitive behavioral therapy.
kt
a
address the negative thought patterns by using:
d. alternative and complementary therapies.
st
ANS: C
.te
Cognitive behavioral therapy attempts to alter the patients dysfunctional beliefs by focusing on
positive outcomes rather than negative attributions. The patient is also taught the connection
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between thoughts and resultant feelings. Research shows that cognitive behavioral therapy
involves the formation of new connections between nerve cells in the brain and that it is at least
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as effective as medication. Evidence is not present to support superior outcomes for the other
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psychotherapeutic modalities mentioned.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: DIF: 274 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
15. A patient says to the nurse, My life doesnt have any happiness in it anymore. I once enjoyed
holidays, but now theyre just another day. The nurse documents this report as an example of:
a. dysthymia.
c. euphoria.
b. anhedonia.
d. anergia.
m
ANS: B
co
Anhedonia is a common finding in many types of depression. It refers to feelings of a loss of
pleasure in formerly pleasurable activities. Dysthymia is a diagnosis. Euphoria refers to an elated
nk
.
mood. Anergia means without energy.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
ba
n
MSC: Client Needs: Psychosocial Integrity
kt
a
REF: DIF: 250 | DIF: 264 TOP: Nursing Process: Assessment
16. A patient diagnosed with major depression began taking a tricyclic antidepressant 1 week
ago. Today the patient says, I dont think I can keep taking these pills. They make me so dizzy,
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especially when I stand up. The nurse will:
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a. limit the patients activities to those that can be performed in a sitting position.
b. withhold the drug, force oral fluids, and notify the health care provider.
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c. teach the patient strategies to manage postural hypotension.
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d. update the patients mental status examination.
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ANS: C
Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of
therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the
patient to stay well hydrated and rise slowly. Knowing this information may convince the patient
to continue the medication. Activity is an important aspect of the patients treatment plan and
should not be limited to activities that can be done in a sitting position. Withholding the drug,
forcing oral fluids, and notifying the health care provider are unnecessary actions. Independent
nursing action is called for. Updating a mental status examination is unnecessary.
17. A kindergartener is disruptive in class. This child is unable to sit for expected lengths of time,
inattentive to the teacher, screams while the teacher is talking, and is aggressive toward other
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children. The nurse plans interventions designed to:
a. promote integration of self-concept.
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b. provide inpatient treatment for the child.
d. improve language and communication skills.
kt
a
ANS: C
nk
.
c. reduce loneliness and increase self-esteem.
Because of their disruptive behaviors, children with ADHD often receive negative feedback from
parents, teachers, and peers, leading to self-esteem disturbance. These behaviors also cause peers
ba
n
to avoid the child with ADHD, leaving the child with ADHD vulnerable to loneliness. The child
does not need inpatient treatment at this time. The incorrect options might or might not be
relevant.
st
PTS: 1 DIF: Cognitive Level: Analyze (Analysis)
.te
REF: DIF: 189 | DIF: 193-194 TOP: Nursing Process: Planning
w
MSC: Client Needs: Psychosocial Integrity
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18. A nurse will prepare teaching materials for the parents of a child newly diagnosed with
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attention deficit hyperactivity disorder (ADHD). Which medication will the information focus
on?
a. Paroxetine (Paxil)
c. Methyphenidate (Ritalin)
b. Imipramine (Tofranil)
d. Carbamazepine (Tegretol)
ANS: C
CNS stimulants are the drugs of choice for treating children with ADHD: Ritalin and dexedrine
are commonly used. None of the other drugs are psychostimulants used to treat ADHD.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: DIF: 193 TOP: Nursing Process: Planning
m
MSC: Client Needs: Physiological Integrity
co
19. What is the nurses priority focused assessment for side effects in a child taking
a. Dystonia, akinesia, and extrapyramidal symptoms
c. Sleep disturbances and weight loss
ba
n
d. Neuroleptic malignant syndrome
kt
a
b. Bradycardia and hypotensive episodes
nk
.
methylphenidate (Ritalin) for attention deficit hyperactivity disorder (ADHD)?
ANS: C
The most common side effects are gastrointestinal disturbances, reduced appetite, weight loss,
st
urinary retention, dizziness, fatigue, and insomnia. Weight loss has the potential to interfere with
the childs growth and development. The distracters relate to side effects of conventional
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antipsychotic medications.
w
PTS: 1 DIF: Cognitive Level: Apply (Application)
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REF: DIF: 193-194 TOP: Nursing Process: Assessment
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MSC: Client Needs: Physiological Integrity
20. A desired outcome for a 12-year-old diagnosed with attention deficit hyperactivity disorder
(ADHD) is to improve relationships with other children. Which treatment modality should the
nurse suggest for the plan of care?
a. Reality therapy
c. Social skills group
b. Simple restitution
d. Insight-oriented group therapy
ANS: C
Social skills training teaches the child to recognize the impact of his or her behavior on others. It
uses instruction, role-playing, and positive reinforcement to enhance social outcomes. The other
therapies would have lesser or no impact on peer relationships.
m
21. An adult outpatient diagnosed with major depression has a history of several suicide attempts
by overdose. Given this patients history and diagnosis, which antidepressant medication would
a. Amitriptyline (Elavil), a sedating tricyclic medication
nk
.
b. Fluoxetine (Prozac), a selective serotonin reuptake inhibitor
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the nurse expect to be prescribed?
c. Desipramine (Norpramin), a stimulating tricyclic medication
kt
a
d. Tranylcypromine sulfate (Parnate), a monoamine oxidase inhibitor
ba
n
ANS: B
Selective serotonin reuptake inhibitor antidepressants are very safe in overdosage situations,
which is not true of the other medications listed. Given this patients history of overdosing, it is
prescribed medication.
st
important that the medication be as safe as possible in case she takes an overdose of her
.te
PTS: 1 DIF: Cognitive Level: Analyze (Analysis)
w
REF: DIF: 492 TOP: Nursing Process: Planning
w
MSC: Client Needs: Physiological Integrity
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22. Four individuals have given information about their suicide plans. Which plan evidences the
highest suicide risk?
a. Turning on the oven and letting gas escape into the apartment during the night
b. Cutting the wrists in the bathroom while the spouse reads in the next room
c. Overdosing on aspirin with codeine while the spouse is out with friends
d. Jumping from a railroad bridge located in a deserted area late at night
ANS: D
This is a highly lethal method with little opportunity for rescue. The other options are lower
lethality methods with higher rescue potential. See relationship to audience response question.
PTS: 1 DIF: Cognitive Level: Analyze (Analysis)
m
REF: DIF: 486-487 TOP: Nursing Process: Assessment
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MSC: Client Needs: Psychosocial Integrity
a. Psychiatric hospitalization of a suicidal patient
nk
.
23. Which measure would be considered a form of primary prevention for suicide?
kt
a
b. Referral of a formerly suicidal patient to a support group
c. Suicide precautions for 24 hours for newly admitted patients
ba
n
d. Helping school children learn to manage stress and be resilient
ANS: D
st
This measure promotes effective coping and reduces the likelihood that such children will
become suicidal later in life. Admissions and suicide precautions are secondary prevention
1
DIF:
Cognitive
Level:
Understand
(Comprehension)
w
PTS:
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measures. Support group referral is a tertiary prevention measure.
w
REF: DIF: 487-488 TOP: Nursing Process: Implementation
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MSC: Client Needs: Safe, Effective Care Environment
24. Which change in the brains biochemical function is most associated with suicidal behavior?
a. Dopamine excess
c. Acetylcholine excess
b. Serotonin deficiency
d. Gamma-aminobutyric acid deficiency
ANS: B
Research suggests that low levels of serotonin may play a role in the decision to commit suicide.
The other neurotransmitter alterations have not been implicated in suicidality.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: DIF: 484-485 TOP: Nursing Process: Assessment
m
MSC: Client Needs: Physiological Integrity
co
25. A college student who failed two tests cried for hours and then tried to telephone a parent but
got no answer. The student then gave several expensive sweaters to a roommate and asked to be
nk
.
left alone for a few hours. Which behavior provides the strongest clue of an impending suicide
attempt?
c. Giving away sweaters
kt
a
a. Calling parents
b. Excessive crying
d. Staying alone in dorm room
ba
n
ANS: C
Giving away prized possessions may signal that the individual thinks he or she will have no
further need for the item, such as when a suicide plan has been formulated. Calling parents,
.te
st
remaining in a dorm, and crying do not provide direct clues to suicide.
PTS: 1 DIF: Cognitive Level: Apply (Application)
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REF: DIF: 486-487 TOP: Nursing Process: Assessment
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MSC: Client Needs: Psychosocial Integrity
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26. A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data
relevant to:
a. current stress level.
c. suicide potential.
b. mood disturbance.
d. level of anxiety.
ANS: C
The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age,
depression, previous attempt, ethanol use, rational thinking loss, social supports lacking,
organized plan, no spouse, and sickness. The tool does not have categories to provide
information on the other options listed.
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REF: DIF: 486-487 (Table 25-2) TOP: Nursing Process: Assessment
m
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
MSC: Client Needs: Psychosocial Integrity
nk
.
27. A person intentionally overdosed on antidepressants. Which nursing diagnosis has the
highest priority?
c. Risk for suicide
kt
a
a. Powerlessness
b. Social isolation
d. Compromised family coping
ba
n
ANS: C
This diagnosis is the only one with life-or-death ramifications and is therefore of higher priority
st
than the other options.
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PTS: 1 DIF: Cognitive Level: Apply (Application)
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REF: DIF: 487-490 (Table 25-3) TOP: Nursing Process: Diagnosis/Analysis
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MSC: Client Needs: Psychosocial Integrity
28. A person who attempted suicide by overdose was treated in the emergency department and
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then hospitalized. The initial outcome is that the patient will:
a. verbalize a will to live by the end of the second hospital day.
b. describe two new coping mechanisms by the end of the third hospital day.
c. accurately delineate personal strengths by the end of first week of hospitalization.
d. exercise suicide self-restraint by refraining from attempts to harm self for 24
hours.
ANS: D
Suicide self-restraint relates most directly to the priority problem of risk for self-directed
violence. The other outcomes are related to hope, coping, and self-esteem.
PTS: 1 DIF: Cognitive Level: Apply (Application)
m
REF: DIF: 487 | DIF: 492 (Table 25-4) TOP: Nursing Process: Outcomes Identification
co
MSC: Client Needs: Psychosocial Integrity
nk
.
29. A college student who attempted suicide by overdose was hospitalized. When the parents
were contacted, they responded, We should have seen this coming. We did not do enough. The
kt
a
parents reaction reflects:
a. guilt.
c. shame.
d. rescue feelings.
ba
n
b. denial.
ANS: A
The parents statements indicate guilt. Guilt is evident from the parents self-chastisement. The
st
feelings suggested in the distracters are not clearly described in the scenario.
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PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
w
REF: DIF: 493-494 TOP: Nursing Process: Assessment
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MSC: Client Needs: Psychosocial Integrity
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30. Select the most critical question for the nurse to ask an adolescent who has threatened to take
an overdose of pills.
a. Why do you want to kill yourself?
b. Do you have access to medications?
c. Have you been taking drugs and alcohol?
d. Did something happen with your parents?
ANS: B
The nurse must assess the patients access to means to carry out the plan and, if there is access,
alert the parents to remove from the home and take additional actions to assure the patients
safety. The information in the other questions may be important to ask but are not the most
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critical.
PTS: 1 DIF: Cognitive Level: Apply (Application)
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REF: DIF: 483 (Box 25-2) | DIF: 486-487
nk
.
TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment
31. It has been 5 days since a suicidal patient was hospitalized and prescribed an antidepressant
priority nursing intervention.
ba
n
a. Supervise the patient 24 hours a day.
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medication. The patient is now more talkative and shows increased energy. Select the highest
b. Begin discharge planning for the patient.
c. Refer the patient to art and music therapists.
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d. Consider discontinuation of suicide precautions.
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ANS: A
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The patient now has more energy and may have decided on suicide, especially given the prior
suicide attempt history. The patient must be supervised 24 hours per day. The patient is still a
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suicide risk.
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PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: DIF: 486-487 TOP: Nursing Process: Assessment
MSC: Client Needs: Safe, Effective Care Environment
32. A nurse and patient construct a no-suicide contract. Select the preferable wording.
a. I will not try to harm myself during the next 24 hours.
b. I will not make a suicide attempt while I am hospitalized.
c. For the next 24 hours, I will not in any way attempt to harm or kill myself.
d. I will not kill myself until I call my primary nurse or a member of the staff.
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ANS: C
The correct answer leaves no loopholes. The wording about not harming oneself and not making
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an attempt leaves loopholes or can be ignored by the patient who thinks I am not going to harm
myself, I am going to kill myself or I am not going to attempt suicide, I am going to commit
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PTS: 1 DIF: Cognitive Level: Apply (Application)
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.
suicide. A patient may call a therapist and leave the telephone to carry out the suicidal plan.
REF: DIF: 491-492 (Table 26-5) TOP: Nursing Process: Implementation
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MSC: Client Needs: Safe, Effective Care Environment
33. A tearful, anxious patient at the outpatient clinic reports, I should be dead. The initial task of
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the nurse conducting the assessment interview is to:
c. establish rapport with the patient.
b. encourage expression of anger.
d. determine risk factors for suicide.
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a. assess lethality of suicide plan.
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ANS: C
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This scenario presents a potential crisis. Establishing rapport facilitates a therapeutic alliance that
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will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan,
lethality of plan, and presence of risk factors for suicide.
PTS: 1 DIF: Cognitive Level: Analyze (Analysis)
REF: DIF: 488-491 (Nursing Care Plan 25-1)
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
34. A nurse interacts with an outpatient who has a history of multiple suicide attempts. Select the
most helpful response for a nurse to make when the patient states, I am considering committing
suicide.
a. Im glad you shared this. Please do not worry. We will handle it together.
c. Bringing up these feelings is a very positive action on your part.
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d. We need to talk about the good things you have to live for.
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b. I think you should admit yourself to the hospital to keep you safe.
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.
ANS: C
The correct response gives the patient reinforcement, recognition, and validation for making a
positive response rather than acting out the suicidal impulse. It gives neither advice nor false
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reassurance, and it does not imply stereotypes such as You have a lot to live for. It uses the
patients ambivalence and sets the stage for more realistic problem solving.
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PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: DIF: 484 | DIF: 488-491 (Nursing Care Plan 25-1)
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TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
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35. Which intervention will the nurse recommend for the distressed family and friends of
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someone who has committed suicide?
a. Participating in reminiscence therapy
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b. Psychological postmortem assessment
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c. Attending a self-help group for survivors
d. Contracting for at least two sessions of group therapy
ANS: C
Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups
provide peer support while survivors work through feelings of loss, anger, and guilt.
Psychological postmortem assessment would not provide the support necessary to work through
feelings of loss associated with the suicide. Reminiscence therapy is not geared to loss
resolution. Contracting for two sessions of group therapy would not provide sufficient time to
work through the issues associated with a death by suicide.
PTS: 1 DIF: Cognitive Level: Apply (Application)
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REF: DIF: 493-494 TOP: Nursing Process: Implementation
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MSC: Client Needs: Psychosocial Integrity
patient during antidepressant medication therapy?
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36. Which statement provides the best rationale for closely monitoring a severely depressed
a. As depression lifts, physical energy becomes available to carry out suicide.
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b. Patients who previously had suicidal thoughts need to discuss their feelings.
c. For most patients, antidepressant medication results in increased suicidal
thinking.
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d. Suicide is an impulsive act. Antidepressant medication does not alter impulsivity.
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ANS: A
Antidepressant medication has the objective of relieving depression. Risk for suicide is greater as
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the depression lifts, primarily because the patient has more physical energy at a time when he or
she may still have suicidal ideation. The other options have little to do with nursing interventions
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relating to antidepressant medication therapy.
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PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
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REF: DIF: 486-487 TOP: Nursing Process: Planning
MSC: Client Needs: Safe, Effective Care Environment
37. A nurse assesses a patient who reports a 3-week history of depression and periods of
uncontrolled crying. The patient says, My business is bankrupt, and I was served with divorce
papers. Which subsequent statement by the patient alerts the nurse to a concealed suicidal
message?
a. I wish I were dead.
b. Life is not worth living.
c. I have a plan that will fix everything.
d. My family will be better off without me.
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ANS: C
Verbal clues to suicide may be overt or covert. The incorrect options are overt references to
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suicide. The correct option is more veiled. It alludes to the patients suicide as being a way to fix
REF: DIF: 485-486 | DIF: 490 (Table 25-3)
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a
PTS: 1 DIF: Cognitive Level: Apply (Application)
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.
everything but does not say it outright.
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
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38. A depressed patient says, Nothing matters anymore. What is the most appropriate response
by the nurse?
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a. Are you having thoughts of suicide?
b. I am not sure I understand what you are trying to say.
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c. Try to stay hopeful. Things have a way of working out.
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ANS: A
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d. Tell me more about what interested you before you became depressed.
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The nurse must make overt what is covert; that is, the possibility of suicide must be openly
addressed. The patient often feels relieved to be able to talk about suicidal ideation.
PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: DIF: 486-487 | DIF: 488-490 (Nursing Care Plan 25-1) and (Table 25-3)
TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment
39. A nurse counsels a patient with recent suicidal ideation. Which is the nurses most therapeutic
comment?
a. Lets make a list of all your problems and think of solutions for each one.
b. Im happy youre taking control of your problems and trying to find solutions.
c. When you have bad feelings, try to focus on positive experiences from your life.
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d. Lets consider which problems are very important and which are less important.
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ANS: D
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.
The nurse helps the patient develop effective coping skills. Assist the patient to reduce the
overwhelming effects of problems by prioritizing them. The incorrect options continue to present
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overwhelming approaches to problem solving.
PTS: 1 DIF: Cognitive Level: Apply (Application)
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REF: DIF: 484 | DIF: 488-489 (Nursing Care Plan 25-1) | DIF: 491-492
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
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40. When assessing a patients plan for suicide, what aspect has priority?
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a. Patients financial and educational status
b. Patients insight into suicidal motivation
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c. Availability of means and lethality of method
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d. Quality and availability of patients social support
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ANS: C
If a person has plans that include choosing a method of suicide readily available and if the
method is one that is lethal (i.e., will cause the person to die with little probability for
intervention), the suicide risk is high. These areas provide a better indication of risk than the
areas mentioned in the other options. See relationship to audience response question.
PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: DIF: 486-487 TOP: Nursing Process: Assessment
MSC: Client Needs: Safe, Effective Care Environment
41. The feeling experienced by a patient that should be assessed by the nurse as most predictive
c. elation.
b. sadness.
d. anger.
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a. hopelessness.
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of elevated suicide risk is
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.
ANS: A
Of the feelings listed, hopelessness is most closely associated with increased suicide risk.
Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for
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suicide.
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PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: DIF: 487-490 (Table 25-3) and (Nursing Care Plan 25-1)
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TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
42. Which statement by a depressed patient will alert the nurse to the patients need for
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immediate, active intervention?
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a. I am mixed up, but I know I need help.
b. I have no one to turn to for help or support.
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c. It is worse when you are a person of color.
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d. I tried to get attention before I cut myself last time.
ANS: B
Hopelessness is evident. Lack of social support and social isolation increases the suicide risk.
Willingness to seek help lowers risk. Being a person of color does not suggest higher risk
because more whites commit suicide than do individuals of other racial groups. Attention
seeking is not correlated with higher suicide risk.
PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: DIF: 487-490 (Table 25-3) and (Nursing Care Plan 25-1) TOP: Nursing Process: Planning
MSC: Client Needs: Safe, Effective Care Environment
43. A patient hospitalized for 2 weeks committed suicide during the night. Which initial nursing
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measure will be most important regarding this event?
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a. Ask the information technology manager to verify the hospital information
system is secure.
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b. Hold a staff meeting to express feelings and plan care for the other patients.
c. Ask the patients roommate not to discuss the event with other patients.
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d. Prepare a report of a sentinel event.
ANS: B
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Interventions should help the staff and patients come to terms with the loss and grow because of
the incident. Then, a community meeting should occur to allow other patients to express their
feelings and request help. Staff should be prepared to provide additional support and reassurance
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to patients and should seek opportunities for peer support. A sentinel event report can be
prepared later. The other incorrect options will not control information or would result in unsafe
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care.
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Chapter 23. Assessment Guide for Sport Participation
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Question 1
Type: MCMA
The student nurse is reviewing the cranial nerves. The student recognizes some of the nerves are
exclusively sensory nerves. Which of the following cranial nerves belong to this group?
Standard Text: Select all that apply.
1. Olfactory nerve (cranial nerve I)
2. Optic nerve (cranial nerve II)
3. Trochlear nerve (cranial nerve IV)
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4. Trigeminal nerve (cranial nerve V)
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5. Facial nerve (cranial nerve VII)
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.
Correct Answer: 1,2
Rationale 1: Olfactory nerve (cranial cerve I). The cranial nerves may be classified by
function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for
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receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves
are able to receive sensory information and perform physical activities. The olfactory nerve is a
sensory nerve and is responsible for the sense of smell. The optic nerve is a sensory nerve
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responsible for vision.
Rationale 2: Optic nerve (cranial nerve II). The cranial nerves may be classified by function.
The nerves may be sensory, motor or mixed. Sensory nerves are responsible for receiving
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sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to
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receive sensory information and perform physical activities. The olfactory nerve is a sensory
nerve and is responsible for the sense of smell. The optic nerve is a sensory nerve responsible for
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vision.
Rationale 3: Trochlear nerve (cranial nerve IV). The cranial nerves may be classified by
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function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for
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receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves
are able to receive sensory information and perform physical activities. The trochlear nerve is a
motor nerve responsible for eye movement.
Rationale 4: Trigeminal nerve (cranial nerve V). The cranial nerves may be classified by
function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for
receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves
are able to receive sensory information and perform physical activities. The trigeminal nerve is a
mixed nerve is responsible for sensory impulses from the lower eyelid, nasal cavity and palate.
Motor actions of the trigeminal nerve involve teeth clenching and movement of the mandible.
Rationale 5: Facial nerve (cranial nerve VI). The cranial nerves may be classified by function.
The nerves may be sensory, motor or mixed. Sensory nerves are responsible for receiving
sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to
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receive sensory information and perform physical activities. The facial nerve is a mixed nerve
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responsible for taste, facial movements, and the production of tears and salivary stimulation.
Global Rationale: The cranial nerves may be classified by function. The nerves may be sensory,
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.
motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves
allow the body to perform an action. Mixed nerves are able to receive sensory information and
perform physical activities. The olfactory nerve is a sensory nerve and is responsible for the
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sense of smell. The optic nerve is a sensory nerve responsible for vision. The trochlear nerve is a
motor nerve responsible for eye movement. The trigeminal nerve is a mixed nerve is responsible
for sensory impulses from the lower eyelid, nasal cavity, and palate. Motor actions of the
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trigeminal nerve involve teeth clenching and movement of the mandible. The facial nerve is a
mixed nerve responsible for taste, facial movements, and the production of tears and salivary
stimulation.
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Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system.
Question 2
Type: HOTSPOT
The nurse is caring for a client having problems with emotional appropriateness as a result of a
brain injury. Mark the area that has most likely been damaged.
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.
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Standard Text: Select the correct area on the image.
Correct Answer:
Global Rationale:
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Cognitive Level: Applying
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Rationale : The frontal lobe of the cerebrum is responsible for the control of emotions.
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system.
Question 3
Type: HOTSPOT
The nurse is caring for a client with a traumatic brain injury. The client has begun to experience
bradycardia. What area of the brain is likely responsible for the changes in heart rate?
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.
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Standard Text: Select the correct area on the image.
Correct Answer:
Global Rationale:
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Cognitive Level: Applying
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Rationale : The brain stem is responsible for control of the vital signs.
Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system.
Question 4
Type: MCSA
The nurse is assessing a client to determine tremors associated with Parkinsons disease. The
nurse would correctly observe for which of the following movements?
1. Fasciculations
2. Chorea
3. Rhythmic shaking
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4. Athetoid movements
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Correct Answer: 3
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Rationale 1: Fasciculations are muscle twitches.
Rationale 2: Chores refer to controllable jerking movements as are associated with Huntingtons
disease.
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Rationale 3: Rhythmic shaking of the hands is a manifestations associated with Parkinsons
disease.
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Rationale 4: Athetoid moements are repetitive and slow and are seen with cerebral palsy.
Global Rationale: The tremors noted with Parkinsons disease produce rhythmic shaking of the
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hands. Fasciculations are muscle twitches; chorea is the uncontrollable jerking associated with
Huntingtons disease; athetoid movements are repetitive and slow and are seen with cerebral
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palsy.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system.
Question 5
Type: MCSA
The nurse is performing a neurological assessment on a client experiencing anosmia. The nurse
would suspect cranial nerve involvement in which of the following?
1. Trochlear (cranial nerve IV)
2. Trigeminal (cranial nerve V)
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3. Olfactory (cranial nerve I)
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4. Oculomotor (cranial nerve III)
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Correct Answer: 3
Rationale 1: The trochlear nerve (cranial nerve IV) is related to vision. Dysfunction of the
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trochlear nerve nerve may include diplopia or strabismus.
Rationale 2: The trigeminal nerve (cranial nerve V) is responsible for sensory impulses from
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scalp, upper eyelid, nose, cornea, and lacrimal gland. Dysfunction of the trigeminal nerve may be
associated with a loss of facial sensation.
Rationale 3: Anosmia is the absence of the sense of smell and can be indicative of problems
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with the olfactory nerve (cranial nerve I).
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Rationale 4: The oculomotor nerve (cranial nerve III) is associated with vision.
Global Rationale: Anosmia is the absence of the sense of smell and can be indicative of
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problems with the olfactory nerve (cranial nerve I). The trochlear nerve (cranial nerve IV) is
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responsible for eye muscle movements. Dysfunction of the trochlear nerve nerve may include
diplopia or strabismus. The trigeminal nerve (cranial nerve V) has three branches. The
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ophthalmic branch is responsible for sensory impulses from scalp, upper eyelid, nose, cornea,
and lacrimal gland. The maxillary branch is responsible for sensory impulses from lower eyelid,
nasal cavity, upper teeth, upper lip, and palate. The mandibular branch controls sensory impulses
from the tongue, lower teeth, skin of chin, and lower lip. Motor action function includes teeth
clenching, movements. Dysfunction of the trigeminal nerve may be associated with a loss of
facial sensation, sensation deficits in the tongue, lower teeth, skin of the chin and lower lip, and
an inability to clench the teeth. The oculomotor nerve (cranial nerve III) is associated with
papillary reflexes and extrinsic muscle movements of the eyes.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need Sub:
nk
.
Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system.
Question 6
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Type: MCSA
The nurse is assessing the patellar reflex on a client and obtains no reflexive activity. The client
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is alert and oriented. The nurse should do which of the following in this situation?
1. Document the findings as normal.
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2. Notify the healthcare provider immediately.
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3. Look at the medication records for central nervous system depressants.
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4. Retest the reflex after having the client use distraction during the exam.
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Correct Answer: 4
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Rationale 1: Reflexes are stimulus-response activities of the body. They are fast, predictable,
unlearned, innate, and involuntary reactions to stimuli. The individual is aware of the results of
the reflex activity and not the activity itself. The reflex activity may be simple and take place at
the level of the spinal cord, with interpretation at the cerebral level. Reflex activity is recorded
using a 4-point scale. Normal reflexes are listed as a 2+. The absence of the patellar reflex is not
normal. Before concluding that a reflex is absent or diminished the test should be repeated. The
client should be encouraged to relax. It may be necessary to distract the client to achieve
relaxation of the muscle before striking the tendon. Reflexes are stimulus-response activities of
the body. They are fast, predictable, unlearned, innate, and involuntary reactions to stimuli. The
individual is aware of the results of the reflex activity and not the activity itself. The reflex
activity may be simple and take place at the level of the spinal cord, with interpretation at the
cerebral level. Reflex activity is recorded using a 4-point scale. Normal reflexes are listed as a
diminished the test should be repeated.
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Rationale 2: There is no immediate need to notify the healthcare provider.
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2+. The absence of the patellar reflex is not normal. Before concluding that a reflex is absent or
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.
Rationale 3: Reflexes are stimulus-response activities of the body. They are fast, predictable,
unlearned, innate, and involuntary reactions to stimuli. The individual is aware of the results of
the reflex activity and not the activity itself. The reflex activity may be simple and take place at
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the level of the spinal cord, with interpretation at the cerebral level. Reflex activity is recorded
using a 4-point scale. Normal reflexes are listed as a 2+. The absence of the patellar reflex is not
normal. Before concluding that a reflex is absent or diminished the test should be repeated.
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Medications should eventually be reviewed to determine any impact on the nervous system but
this action does not precede attempting to reassess the reflexes.
Rationale 4: Reflexes are stimulus-response activities of the body. They are fast, predictable,
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unlearned, innate, and involuntary reactions to stimuli. The individual is aware of the results of
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the reflex activity and not the activity itself. The reflex activity may be simple and take place at
the level of the spinal cord, with interpretation at the cerebral level. Reflex activity is recorded
using a 4-point scale. Normal reflexes are listed as a 2+. The absence of the patellar reflex is not
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normal. Before concluding that a reflex is absent or diminished the test should be repeated. The
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client should be encouraged to relax.
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Global Rationale: Reflexes are stimulus-response activities of the body. They are fast,
predictable, unlearned, innate, and involuntary reactions to stimuli. The individual is aware of
the results of the reflex activity and not the activity itself. The reflex activity may be simple and
take place at the level of the spinal cord, with interpretation at the cerebral level. Reflex activity
is recorded using a 4-point scale. Normal reflexes are listed as a 2+. The absence of the patellar
reflex is not normal. Before concluding that a reflex is absent or diminished the test should be
repeated. The client should be encouraged to relax. It may be necessary to distract the client to
achieve relaxation of the muscle before striking the tendon. Documentation of the reflexes as
normal is not appropriate, as a score of 0 is not normal. There is no immediate need to notify the
healthcare provider. Medications should eventually be reviewed to determine any impact on the
nervous system but this action does not precede attempting to reassess the reflexes.
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Cognitive Level: Applying
Client Need Sub:
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.
Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need: Physiological Integrity
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Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system.
Question 7
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Type: MCSA
The nurse is interviewing a client with suspected Lyme disease. Which of the following
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questions would be a priority in this situation?
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1. When was your last seizure?
2. Have you been hiking or camping lately?
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3. What has your temperature been running?
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4. Do you have an appetite?
Correct Answer: 2
Rationale 1: Lyme disease is an infection caused by a spirochete transmitted by a bite from an
infected tick that lives on deer. This tick exposure may have come from hiking or camping.
Lyme disease if not treated may result in neurological disorders. There is not, however, any
indication that the client has long-term Lyme disease or neurological changes.
Rationale 2: Lyme disease is an infection caused by a spirochete transmitted by a bite from an
infected tick that lives on deer. This tick exposure may have come from hiking or camping.
Rationale 3: Lyme disease is an infection caused by a spirochete transmitted by a bite from an
infected tick that lives on deer. This tick exposure may have come from hiking or camping.
During the initial period after becoming infected the client may experience flu-like illnesses but
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there is no indication that this is the primary concern for the client.
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Rationale 4: Lyme disease is an infection caused by a spirochete transmitted by a bite from an
infected tick that lives on deer. This tick exposure may have come from hiking or camping. An
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.
infectious process may result in changes in the clients appetite or dietary but this is not the
priority area of concern for investigation.
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Global Rationale: Lyme disease is an infection caused by a spirochete transmitted by a bite
from an infected tick that lives on deer. This tick exposure may have come from hiking or
camping. Lyme disease if not treated may result in neurological disorders. There is not, however,
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any indication that the client has long-term Lyme disease or neurological changes. During the
initial period after becoming infected the client may experience flu-like illnesses but there is no
indication that this is the primary concern for the client. While appetite changes may result
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during an infection this is not the priority for the nurses questions.
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Cognitive Level: Applying
Client Need: Physiological Integrity
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Client Need Sub: Physiological Adaptation
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.2: Develop questions to be used when completing the focused interview.
Question 8
Type: MCSA
The nurse is performing the Romberg test and asks the client to stand with the feet together and
eyes closed. The nurse notes the findings are normal. Which of the following client responses
occurred in this situation? The client:
1. Swayed from side to side.
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2. Had minimal swaying.
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3. Felt moderately dizzy.
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4. Had complete loss of balance.
Correct Answer: 2
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Rationale 1: The Romberg test is used to test coordination and equilibrium. A minimal amount
of swaying is normal. Swaying from side to side is not a normal finding.
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Rationale 2: The Romberg test is used to test coordination and equilibrium. A minimal amount
of swaying is normal.
Rationale 3: The Romberg test is used to test coordination and equilibrium. During the test, the
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client is asked to stand with feet together and arms at the sides. A minimal amount of swaying is
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normal. The onset of dizziness is not a normal finding.
Rationale 4: The Romberg test is used to test coordination and equilibrium. A minimal amount
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of swaying is normal. A complete loss of balance is not a normal finding.
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Global Rationale: The Romberg test is used to test coordination and equilibrium. During the
test, the client is asked to stand with feet together and arms at the sides. The clients eyes are
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initially open. Then, the examiner will ask the client to close his eyes. The examiner will need to
observe for swaying. A minimal amount of swaying is normal. Dizziness during the test is not a
normal finding. Significant swaying from side to side and loss of balance are not normal findings
and may indicate a cerebellar dysfunction.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
system.
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Question 9
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Type: MCMA
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The nurse is assessing a client that experienced a head injury and assigns a Glascow Coma Scale
Standard Text: Select all that apply.
2. No verbal response
4. No motor movement
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3. Pupil response sluggish
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1. No response with eyes with commands
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rating of 3. The nurse would correctly note which of the following for this client?
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5. Pupils fixed and dilated
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Correct Answer: 1,2,4
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Rationale 1: No response with eyes with commands. The Glascow Coma Scale assesses level
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of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and
motor response. The client may score between 3 and 15 points with the tool. The lack of eye
response, verbal response, and motor response indicate a score of 3 points.
Rationale 2: No verbal response. The Glascow Coma Scale assesses level of consciousness on
a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response.
The client may score between 3 and 15 points with the tool. The lack of eye response, verbal
response, and motor response indicate a score of 3 points.
Rationale 3: Pupil response sluggish. The Glascow Coma Scale assesses level of consciousness
on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response.
The client may score between 3 and 15 points with the tool. The lack of eye response, verbal
response, and motor response indicate a score of 3 points. The lower the score, the more critical
the clients condition. A score of 3 indicates the clients condition is grave. Pupil activity is not
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evaluated using the Glascow Coma Scale.
Rationale 4: No motor movement. The Glascow Coma Scale assesses level of consciousness on
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a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response.
The client may score between 3 and 15 points with the tool. The lack of eye response, verbal
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response, and motor response indicate a score of 3 points. The lower the score, the more critical
the clients condition. A score of 3 indicates the clients condition is grave.
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Rationale 5: Pupils fixed and dilated. The Glascow Coma Scale assesses level of
consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and
motor response. The client may score between 3 and 15 points with the tool. The lack of eye
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response, verbal response, and motor response indicate a score of 3 points. The lower the score,
the more critical the clients condition. A score of 3 indicates the clients condition is grave. Pupil
activity is not evaluated using the Glascow Coma Scale.
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Global Rationale: The Glascow Coma Scale assesses level of consciousness on a continuum
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from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may
score between 3 and 15 points with the tool. The lack of eye response, verbal response and motor
response indicate a score of 3 points. Lower scores indicate more critical conditions. A score of 3
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Scale.
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indicates the clients condition is grave. Pupil activity is not evaluated using the Glascow Coma
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
system.
Question 10
Type: MCSA
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The nurse is performing a neurological assessment and needs to test cranial nerves. The nurse
is assessing the function of which of the following cranial nerves?
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.
1. Trigeminal nerve (cranial nerve V)
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4. Optic nerve (cranial nerve II)
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2. Abducens nerve (cranial nerve VI)
3. Facial nerve (cranial nerve VII)
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asks the client to close both eyes and report when a touch with a wisp of cotton is felt. The nurse
Correct Answer: 1
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Rationale 1: The cranial nerve V is responsible for facial sensations and may be assessed by a
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wisp of cotton on the face.
Rationale 2: The cranial nerve VI is related to vision.
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Rationale 3: The cranial nerve VII is related to facial movements and the sensation of taste.
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Rationale 4: The cranial nerve II is related to vision.
Global Rationale: The trigeminal nerve, cranial nerve V, is responsible for the facial sensations,
sensory impulses from the tongue, lower teeth, skin of chin, and lower lip. The nerve also has
motor functions including teeth clenching and movement of the mandible. The abducens nerve,
cranial nerve VI, is related to vision. The facial nerve, cranial nerve VII, has responsibilities
including facial expressions, the production of tears and salivary stimulation and is also
associated with taste. The optic nerve, cranial nerve II, has the sensory function of vision.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
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system.
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.
Question 11
Type: MCSA
nerves?
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1. Olfactory nerve (cranial nerve I)
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The nurse in the photograph is performing an assessment on which of the following cranial
2. Optic nerve (cranial nerve II)
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3. Oculomotor nerve (cranial nerve III)
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4. Trochlear nerve (cranial nerve IV)
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Correct Answer: 1
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Rationale 1: The sense of smell assessment is being demonstrated in the photograph. The
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olfactory nerve (cranial nerve I) is being evaluated.
Rationale 2: Cranial nerve II is the optic nerve. Assessment of cranial nerve II (optic nerve)
would involve assessment of vision.
Rationale 3: Cranial nerve III (oculomotor nerve) involves the assessment of vision-related
parameters.
Rationale 4: Cranial nerve IV (trochlear nerve) involves the assessment of vision related
parameters.
Global Rationale: The sense of smell assessment is being demonstrated in the photograph. The
olfactory nerve (cranial nerve I), which is responsible for the sense of smell, is being evaluated.
Cranial nerve II is the optic nerve. Assessment of cranial nerve II (optic nerve) would involve
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assessment of vision. Cranial nerve III (oculomotor nerve) involves the assessment of papillary
reactivity and the extrinsic muscles of the eyes. Cranial nerve IV (trochlear nerve) assessment
Cognitive Level: Understanding
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Client Need: Health Promotion and Maintenance
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follow an object such as the examiners finger with the eyes.
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would require assessing the movements of the eyes. This would include instructing the client to
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
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system.
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Type: MCSA
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Question 12
Review the 2 photographs below. Which of the following cranial nerves is being evaluated by
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this activity being demonstrated?
1. Trigeminal nerve (cranial nerve V)
2. Facial nerve (cranial nerve VII)
3. Vagus nerve (cranial nerve X)
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4. Hypoglossal nerve (cranial nerve XII)
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Correct Answer: 4
Rationale 1: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the
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tongue for swallowing, movement of food during eating, chewing and speech. The trigeminal
nerve (cranial nerve V) is responsible for sensory impulses from the tongue, lower teeth, skin of
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the teeth and lower lip.
Rationale 2: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the
tongue for swallowing, movement of food during eating, chewing and speech. The facial nerve
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(cranial nerve VII) is responsible for the sense of taste.
Rationale 3: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the
tongue for swallowing, movement of food during eating, chewing and speech. The vagus nerve
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(cranial nerve X) innervates the muscles of the throat and mouth for swallowing and talking.
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Rationale 4: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the
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tongue for swallowing, movement of food during eating, chewing, and speech.
Global Rationale: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of
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the tongue for swallowing, movement of food during eating, chewing and speech. The trigeminal
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nerve (cranial nerve V) is responsible for facial sensation and temporal and massetter strength.
The facial nerve (cranial nerve VII) is responsible for the sense of taste and facial expressions.
The vagus nerve (cranial nerve X) innervates the muscles of the throat and mouth for swallowing
and talking.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
system.
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Question 13
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Type: MCSA
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The nurse is examining a client experiencing vertigo and wants to perform the Romberg test. The
nurse would correctly provide which set of instructions to the client?
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1. Touch your finger to your nose, alternating hands.
2. Walk across the room by placing one foot in front of the other, heel to toes.
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3. Walk on your toes, then on your heels, then on your toes again.
Correct Answer: 4
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4. Stand with your feet together, arms at sides, and eyes open.
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Rationale 1: The Romberg test is used to assess coordination and equilibrium. During the test
the client is asked to stand with feet together, arms at sides, and eyes open. As the test progresses
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the client is asked to close her eyes. The amount of swaying done by the client once the eyes are
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closed is observed. Touching the finger to the nose with alternating hands is referred to as the
finger-to-nose test and is used to assess coordination and equilibrium but is not the same as the
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Romberg test.
Rationale 2: Walking across the room in this manner describes tandem walking. This technique
is used to observe gait.
Rationale 3: Walking in this manner enables the examiner to assess posture. The examiner
should note the clients stance and the degree of stiffness or relaxation.
Rationale 4: The Romberg test is used to assess coordination and equilibrium. During the test
the client is asked to close her eyes. The degree of swaying demonstrated is evaluated.
Global Rationale: The Romberg test is used to assess coordination and equilibrium. During the
test the client is asked to stand with feet together, arms at sides, and eyes open. As the test
progresses the client is asked to close her eyes. The amount of swaying done by the client once
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the eyes are closed is observed. Walking across the room by placing one foot in front of the
other, heel to toes, describes tandem walking, which is used to observe gait. Posture is assessed
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by asking the client to walk on the toes, then on the heels. Touching the finger to the nose with
alternating hands is referred to as the finger-to-nose test and is used to assess coordination and
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equilibrium but is not the same as the Romberg test.
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Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
Question 14
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Type: MCSA
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system.
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The nurse is performing a neurological assessment on a client and needs to use stereognosis[0]
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Which of the following instructions would the nurse provide for the client?
1. Tell me if you feel one or two objects touching you with your eyes closed.
2. Identify the object in your hand with your eyes closed.
3. Identify the number being traced in your hand with your eyes closed.
4. Open and close your hand each time I tell you to.
Correct Answer: 2
Rationale 1: Stereognosis is the ability to identify an object without seeing it. It is illustrated by
asking the client to identify objects placed in the hands with the eyes closed. Asking the client to
identify the presence of objects touching them is not an example of the technique.
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Rationale 2: Stereognosis is the ability to identify an object without seeing it. It is illustrated by
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asking the client to identify objects placed in the hands with the eyes closed.
Rationale 3: Stereognosis is the ability to identify an object without seeing it. It is illustrated by
asking the client to identify objects placed in the hands with the eyes closed. Asking the client to
is the ability to perceive writing on the skin.
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identify the presence of objects touching them is not an example of the technique. Graphesthesia
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Rationale 4: Sterognosis is the ability to identify an object without seeing it. It is illustrated by
asking the client to identify objects placed in the hands with the eyes closed. Asking the client to
open and close the hand may be used to assess the ability to follow commands to assess hand
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strength.
Global Rationale: Stereognosis [0]is the ability to identify an object without seeing it. It is
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illustrated by asking the client to identify objects placed in the hands with the eyes closed.
Asking the client to identify the presence of objects touching them is not an example of the
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technique. Graphesthesia is the ability to perceive writing on the skin. Asking the client to open
and close the hand may be used to assess the ability to follow commands to assess hand strength.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
system.
Question 15
Type: MCSA
The nurse performing reflex testing on a client uses the reflex hammer to gently strike the
forearm about two inches above the wrist. The nurse is assessing which of the following
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reflexes?
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1. Brachioradialis
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2. Biceps
3. Triceps
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4. Achilles
Correct Answer: 1
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Rationale 1: The brachioradialis reflex is initiated by striking the forearm just above the wrist.
The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is initiated by
striking just above the olecranon process. The Achilles reflex is initiated by dorsiflexion of the
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foot and striking the Achilles tendon.
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Rationale 2: The brachioradialis reflex is initiated by striking the forearm just above the wrist.
The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is initiated by
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striking just above the olecranon process. The Achilles reflex is initiated by dorsiflexion of the
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foot and striking the Achilles tendon.
Rationale 3: The brachioradialis reflex is initiated by striking the forearm just above the wrist.
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The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is initiated by
striking just above the olecranon process. The Achilles reflex is initiated by dorsiflexion of the
foot and striking the Achilles tendon.
Rationale 4: The brachioradialis reflex is initiated by striking the forearm just above the wrist.
The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is initiated by
striking just above the olecranon process. The Achilles reflex is initiated by dorsiflexion of the
foot and striking the Achilles tendon.
Global Rationale: The brachioradialis reflex is initiated by striking the forearm just above the
wrist. The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is
initiated by striking just above the olecranon process. The Achilles reflex is initiated by
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dorsiflexion of the foot and striking the Achilles tendon.
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Cognitive Level: Applying
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.
Client Need: Physiological Integrity
Client Need Sub:
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a
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
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system.
Question 16
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Type: MCSA
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The nurse is admitting a client with suspected meningitis and notes a positive Brudzinskis sign
has been noted in the history and physical. To validate this assessment finding, the nurse would
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note which of the following?
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1. Seizure activity
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2. Neck pain and stiffness
3. Flexion of the legs and thighs
4. Neck extension
Correct Answer: 3
Rationale 1: Brudzinskis sign is assessed in clients suspected of having meningitis. To assess for
this sign the client is placed in a supine position and assisted to flex the neck. In a positive test
the legs and thighs will also flex. Seizure activity may be seen in meningitis but seizure activity
does not constitute a positive Brudzinskis sign.
Rationale 2: Brudzinskis sign is assessed in clients suspected of having meningitis. To assess for
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this sign the client is placed in a supine position and assisted to flex the neck. In a positive test
the legs and thighs will also flex. Neck pain and stiffness may be noted with meningitis but this
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is referred to as nuchal rigidity.
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.
Rationale 3: Brudzinskis sign is assessed in clients suspected of having meningitis. To assess for
this sign the client is placed in a supine position and assisted to flex the neck. In a positive test
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the legs and thighs will also flex.
Rationale 4: Neck extension is not associated with Brudzinskis sign.
Global Rationale: Brudzinskis sign is assessed in clients suspected of having meningitis. To
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assess for this sign the client is placed in a supine position and assisted to flex the neck. In a
positive test the legs and thighs will also flex. Seizure activity may be seen in meningitis but
seizure activity does not constitute a positive Brudzinskis sign. Neck pain and stiffness may be
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noted with meningitis but this is referred to as nuchal rigidity. It does not constitute a positive
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Brudzinskis sign. Neck extension is not associated with a positive Brudzinskis sign.
Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
system.
Question 17
Type: MCSA
The nurse is assessing cranial nerve XI (spinal accessory). Which of the following statements
would the nurse say to the client?
1. Shrug your shoulders and turn your head against my hand.
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4. Smell these items and identify what they are.
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3. Taste these foods and decide which is sweet and which is sour.
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2. Stick out your tongue and move it from side to side.
Correct Answer: 1
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Rationale 1: The spinal accessory nerve (cranial nerve XI) controls shoulder and neck
movements. The examiner planning to test this nerve should ask the client to shrug the shoulders
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and turn the head.
Rationale 2: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the
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tongue.
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Rationale 3: The facial nerve (cranial nerve VII) is responsible for the sense of taste.
Rationale 4: Smell is controlled by the olfactory nerve (cranial nerve I).
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Global Rationale: The spinal accessory nerve (cranial nerve XI) controls shoulder and neck
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movements. The examiner planning to test this nerve should ask the client to shrug the shoulders
and turn the head. The hypoglossal nerve (cranial nerve XII) is responsible for the movement of
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the tongue. The facial nerve (cranial nerve VII) is responsible for the sense of taste and
symmetrical facial movements. Smell is controlled by the olfactory nerve (cranial nerve I).
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
system.
Question 18
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Type: MCMA
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The nurse is performing a neurological assessment and needs to assess for vibration, as well as
information?
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Standard Text: Select all that apply.
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sharp and dull sensation. The nurse would use which of the following objects to obtain this
1. Tuning fork
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2. Paper clip
3. Safety pin
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5. Tongue blade
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4. Cotton ball
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Correct Answer: 1,3
Rationale 1: Tuning fork. To test for sharp and dull sensation, areas of the clients skin are
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touched with the sharp and blunt ends of a safety pin. The client then verbalizes if the sensation
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is dull or sharp. Vibration is tested by striking a tuning fork and placing it on bony parts of the
clients body.
Rationale 2: Paper clip. To test for sharp and dull sensation, areas of the clients skin are
touched with the sharp and blunt ends of a safety pin. The client then verbalizes if the sensation
is dull or sharp. Vibration is tested by striking a tuning fork and placing it on bony parts of the
clients body.
Rationale 3: Safety pin. To test for sharp and dull sensation, areas of the clients skin are
touched with the sharp and blunt ends of a safety pin. The client then verbalizes if the sensation
is dull or sharp. Vibration is tested by striking a tuning fork and placing it on bony parts of the
clients body.
Rationale 4: Cotton ball. The trigeminal nerve (cranial nerve V) may be evaluated by using a
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wisp of cotton to touch the face.
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Rationale 5: Tongue blade. The gag reflex may be evaluated by using a tongue blade.
Global Rationale: To test for sharp and dull sensation, areas of the clients skin are touched with
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the sharp and blunt ends of a safety pin. The client then verbalizes if the sensation is dull or
sharp. Vibration is tested by striking a tuning fork and placing it on bony parts of the clients
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body. The paper clip may be used to assess for the ability to determine the identity of an object
unseen. A cotton ball may be used to assess sensation when evaluating the facial nerve. A tongue
Cognitive Level: Applying
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blade would be used to assess the gag reflex and the movements of the tongue.
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Client Need Sub:
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Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Assessment
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system.
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Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous
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Question 19
Type: MCSA
The nurse has assessed a client and notes diminished reflexes. The nurse would correctly
document which of the following?
1. 4+/0-4+
2. 3+/0-4+
3. 2+/0-4+
4. 1+/0-4+
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Correct Answer: 1
Rationale 1: 4+ Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ =
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diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive.
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Rationale 2: 3+ Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ =
diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive.
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Rationale 3: 2+ Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ =
diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive.
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Rationale 4: 1+ Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ =
diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive.
Global Rationale: Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+
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= diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment
of the neurologic system.
Question 20
Type: MCSA
The nurse is interviewing a client and notes that the left eyelid is drooping. The nurse would
correctly chart which of the following conditions?
1. Ptosis
2. Nystagmus
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3. Strabismus
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4. Myopia
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Correct Answer: 1
Rationale 1: Ptosis, or a dropped lid, is usually related to weakness of the muscles.
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Rationale 2: Nystagmus is an involuntary movement of the eyeball.
Rationale 3: Strabismus causes deviation of one or both eyes and is due to lack of muscular
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coordination.
Rationale 4: Myopia is a visual disturbance in which the individual is unable to see objects that
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are at a distance.
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Global Rationale: Ptosis, or a dropped lid, is usually related to weakness of the muscles.
Nystagmus is an involuntary movement of the eyeball. Strabismus causes deviation of one or
both eyes and is due to lack of muscular coordination. Myopia is a visual disturbance in which
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the individual is unable to see objects that are at a distance.
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment
of the neurologic system.
Question 21
Type: MCSA
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The nurse observes drainage from a clients ears after a head injury, and suspects a cerebral spinal
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fluid (CSF) leak. Which of the following descriptions would best support this finding?
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1. Yellow without sediment
2. Blood-tinged without sediment
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3. Clear, colorless
4. Pink without sediment
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Correct Answer: 3
Rationale 1: It is important to recognize CSF as clear and colorless. Due to its appearance, it can
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cerebral spinal fluid.
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be mistaken for normal drainage such as rhinorrhea. Yellow drainage is not consistent with
Rationale 2: It is important to recognize CSF as clear and colorless. Due to its appearance, it can
be mistaken for normal drainage such as rhinorrhea. Blood-tinged fluid is not consistent with
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cerebral spinal fluid.
Rationale 3: It is important to recognize CSF as clear and colorless. Due to its appearance, it can
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be mistaken for normal drainage such as rhinorrhea.
Rationale 4: It is important to recognize CSF as clear and colorless. Pink drainage without
sediment is not consistent with cerebral spinal fluid.
Global Rationale: It is important to recognize CSF as clear and colorless. Due to its appearance,
it can be mistaken for normal drainage such as rhinorrhea. Yellow drainage is not consistent with
normal cerebral spinal fluid. Blood-tinged fluid is not consistent with normal cerebral spinal
fluid. Pink drainage without sediment is not consistent with cerebral spinal fluid.
Cognitive Level: Applying
Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need Sub:
nk
.
Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment
of the neurologic system.
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Question 22
Type: MCSA
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The nurse notes that a client has difficulty with ambulation due to an unsteady gait. The nurse
would correctly document this finding as which of the following?
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1. Flaccidity
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2. Paralysis
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3. Hemiparesis
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4. Ataxia
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Correct Answer: 4
Rationale 1: Flaccidity refers to muscle tone. The flaccid body part is not toned but is limp.
Rationale 2: Paralysis refers to the inability to move parts of the body.
Rationale 3: Hemiparesis refers to a weakness on one side of the body.
Rationale 4: Ataxia refers to the loss of balance or coordination.
Global Rationale: Ataxia refers to loss of balance and/or coordination. Flaccidity refers to
muscle tone. Paralysis refers to the inability to move parts of the body. Hemiparesis refers to a
weakness on one side of the body.
Cognitive Level: Understanding
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Client Need: Physiological Integrity
nk
.
Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment
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of the neurologic system.
Question 23
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Type: HOTSPOT
A teenaged client has been brought to the clinic with complaints of pain. After an examination it
was determined that the client has an inflamed Bartholins cyst. After the examination the client
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and her mother ask the nurse to show them the location of the gland involved. Mark an X on the
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location of the Bartholins gland.
Standard Text: Select the correct area on the image.
Correct Answer:
Rationale : The Bartholins glands, or greater vestibular glands, are located posteriorly at the
base of the vestibule and produce mucus, which is released into the vestibule.
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Global Rationale:
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Cognitive Level: Remembering
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.
Client Need: Physiological Integrity
Client Need Sub:
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a
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 22.1: Describe the anatomy and physiology of the female reproductive
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system.
Type: HOTSPOT
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Question 24
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The nurse is caring for a pregnant client. The nurse notes the healthcare provider has documented
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the client has a positive Goodells sign. Mark an X on the area to which this refers.
Standard Text: Select the correct area on the image.
Correct Answer:
Rationale : Goodells sign refers to the softening of the cervix during pregnancy.
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Global Rationale:
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Cognitive Level: Understanding
nk
.
Client Need: Physiological Integrity
Client Need Sub:
kt
a
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 22.1: Describe the anatomy and physiology of the female reproductive
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system.
Question 25
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Type: MCMA
The nurse is preparing to assess a female clients external genitalia. The structures included in this
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assessment would be:
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Standard Text: Select all that apply.
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1. Vagina
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2. Cervix
3. Clitoris
4. Labia majora
5. Labia minora
Correct Answer: 3,4,5
Rationale 1: Vagina. The internal female reproductive organs are the vagina, uterus, cervix,
fallopian tubes, and ovaries.
Rationale 2: Cervix. The internal female reproductive organs are the vagina, uterus, cervix,
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fallopian tubes, and ovaries.
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Rationale 3: Clitoris. Female external genitalia include the mons pubis, labia, glands, clitoris,
and perianal area.
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Rationale 4: Labia minora. Female external genitalia include the mons pubis, labia, glands,
clitoris, and perianal area.
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Rationale 5: Labia majora. Female external genitalia include the mons pubis, labia, glands,
clitoris, and perianal area.
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Global Rationale: The female external genitalia include the clitoris, labia majora, and the labia
minora. The vagina and cervix are considered to be internal genitalia.
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Cognitive Level: Understanding
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Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 22.1: Describe the anatomy and physiology of the female reproductive
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system.
Question 26
Type: MCSA
The nurse notes a forward-tilted uterus with a downward-tilted cervix when examining a female
client. The nurse would correctly document which of the following findings in this situation?
1. Anteflexion
2. Retroflexion
3. Anteversion
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4. Midposition
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Correct Answer: 3
Rationale 1: The uterus in anteflexion is folded forward at a 90-degree angle with the cervix is
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tilted downward.
Rationale 2: The retroverted uterus is tilted backward with the cervix tilted upward.
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Rationale 3: Normal variations of uterine position include anteversion in which the uterus is
tilted forward, the cervix is tilted downward.
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Rationale 4: The uterus in midposition lies parallel to the tailbone with the cervix pointed
straight.
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Global Rationale: Normal variations of uterine position include anteversion (the uterus is tilted
forward, the cervix is tilted downward), midposition (the uterus lies parallel to the tailbone, the
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cervix is pointed straight), and retroversion (the uterus is tilted backward, the cervix is tilted
upward). Abnormal variations of uterine position include anteflexion (the uterus is folded
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forward at a 90-degree angle, the cervix is tilted downward), and retroflexion (the uterus is
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folded backward at a 90-degree angle, the cervix is tilted upward).
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 22.1: Describe the anatomy and physiology of the female reproductive
system.
Question 27
Type: MCSA
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The nurse notes that the uterus is folded backward with the cervix tilted upward when examining
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a female client. The nurse would correctly document which of the following findings in this
situation.
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1. Retroversion
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2. Retroflexion
3. Midposition
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4. Anteflexion
Correct Answer: 2
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Rationale 1: The retroversion positioned uterus is tilted backward with the cervix tilted upward.
tilted upward.
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Rationale 2: The retroflexion uterus is folded backward at a 90-degree angle with the cervix
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Rationale 3: The midposition uterus lies parallel to the tailbone, the cervix is pointed straight.
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Rationale 4: The anteversion uterus is tilted forward with the cervix tilted downward.
Global Rationale: Normal variations of uterine position include anteversion (the uterus is tilted
forward, the cervix is tilted downward), midposition (the uterus lies parallel to the tailbone, the
cervix is pointed straight), and retroversion (the uterus is tilted backward, the cervix is tilted
upward). Abnormal variations of uterine position include anteflexion (the uterus is folded
forward at a 90-degree angle, the cervix is tilted downward), and retroflexion (the uterus is
folded backward at a 90-degree angle, the cervix is tilted upward). Fibroids are benign tumors
located within the uterine walls.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 22.1: Describe the anatomy and physiology of the female reproductive
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system.
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Question 28
Type: HOTSPOT
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The nurse is reviewing the technique utilized to obtain an endocervical specimen on a client.
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Mark with an X the location from which the specimen will be obtained.
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Standard Text: Select the correct area on the image.
Correct Answer:
Rationale : The comprehensive pap smear will include swabbed specimens from the
endocervical region.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 21.2: Explain client preparation for the assessment of the reproductive
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system.
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Question 29
Type: MCMA
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The nurse is preparing to examine the female reproductive system of a client. The nurse would
anticipate using which of the following assessment techniques?
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Standard Text: Select all that apply.
1. Inspection
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3. Percussion
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2. Palpation
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4. Auscultation
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5. Aspiration
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Correct Answer: 1,2
Rationale 1: Inspection. When completing the assessment of the female reproductive system the
examiner will inspect the external genitalia.
Rationale 2: Palpation. Palpation will be used in the examination of the female reproductive
system. The abdomen will be palpated to assess for the size and shape of the internal organs.
Rationale 3: Percussion. Percussion will not be employed in the assessment of the female
reproductive system. Percussion will be used to assess the gastrointestinal and pulmonary
systems.
Rationale 4: Auscultation. Auscultation will not be used to assess the female reproductive
system. Auscultation will be used to assess the cardiovascular, pulmonary, and gastrointestinal
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systems.
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Rationale 5: Aspiration. Aspiration will not be used to assess the female reproductive system.
Aspiration may be performed to obtain a sample.
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Global Rationale: The physical assessment techniques of inspection and palpation are used in
the examination of the female reproductive system. When completing the assessment of the
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female reproductive system the examiner will inspect the external genitalia. Palpation will be
used in the examination of the female reproductive system. The abdomen will be palpated to
assess for the size and shape of the internal organs. Percussion will not be employed in the
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assessment of the female reproductive system. Percussion will be used to assess the
gastrointestinal and pulmonary systems. Auscultation will not be used to assess the female
reproductive system. Auscultation will be used to assess the cardiovascular, pulmonary, and
gastrointestinal systems. Aspiration will not be used to assess the female reproductive system.
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Aspiration may be performed to obtain a sample.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 21.2: Explain client preparation for the assessment of the reproductive
system.
Question 30
Type: MCSA
The nurse is examining a 65 year old and palpates a mobile, smooth, round-shaped mass in the
left lower abdominal quadrant. The nurse would correctly choose which of the following actions
next?
1. Ask the client if she is menstruating.
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2. Report the findings to the healthcare provider.
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3. Re-examine the area using a vaginal speculum.
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4. Ask the client if she could be pregnant.
Correct Answer: 2
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Rationale 1: The client in this scenario is elderly. Menstruation is not a viable option.
Rationale 2: In women who have been postmenopausal for more than 2.5 years, palpable ovaries
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are considered abnormal as the ovaries would normally atrophy with the decrease in estrogen.
Rationale 3: The ovary cannot be viewed with a vaginal speculum.
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Rationale 4: The age of the client would not support a likely pregnancy for the client in the
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scenario. In addition, the pregnant uterus would not be palpated in the area described.
Global Rationale: In women who have been postmenopausal for more than 2.5 years, palpable
ovaries are considered abnormal as the ovaries would normally atrophy with the decrease in
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estrogen. The ovary cannot be viewed with a vaginal speculum, and a pregnant uterus would not
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be palpated in this area. Menstruation is not relevant to this situation.
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Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 22.3: Develop questions to be used when conducting the focused interview.
Question 31
Type: MCSA
The nurse is performing a gynecological examination and is ready to insert the speculum. The
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nurse would correctly insert the speculum at which of the following angles with the client in the
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lithotomy position?
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1. 90 degrees
2. 45 degrees
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3. Straight down
4. Straight up
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Correct Answer: 2
Rationale 1: The speculum should be inserted at a 45-degree downward angle. This angle
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matches the downward slope of the vagina when the client is in the lithotomy position.
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Rationale 2: The speculum should be inserted at a 45-degree downward angle. This angle
matches the downward slope of the vagina when the client is in the lithotomy position.
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Rationale 3: The speculum should be inserted at a 45-degree downward angle. This angle
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matches the downward slope of the vagina when the client is in the lithotomy position.
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Rationale 4: The speculum should be inserted at a 45-degree downward angle. This angle
matches the downward slope of the vagina when the client is in the lithotomy position.
Global Rationale: The speculum should be inserted at a 45-degree downward angle. This angle
matches the downward slope of the vagina when the client is in the lithotomy position.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 22.4: Describe techniques required for assessment of the female
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reproductive system.
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Question 32
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Type: MCMA
The nurse is preparing to perform an endocervical swab and needs to choose the most effective
procedure?
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Standard Text: Select all that apply.
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equipment to collect this specimen. The nurse would have which of the following ready for this
1. Microscopic slides
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2. Saline
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3. Cytobrush
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4. Cotton applicator
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5. Fixative
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Correct Answer: 1,3,5
Rationale 1: Microscopic slides. The slides will be used to place the specimen on.
Rationale 2: Saline. Saline is used to moisten a cotton tipped applicator but is not needed with
the cytobrush.
Rationale 3: Cytobrush. The cytobrush is preferred to obtain the endocervical cells.
Rationale 4: Cotton applicator. The use of the cotton application is not as highly recommended
as the cytobrush. The endocervical cells will not adhere as well to the cotton-tipped applicator.
Rationale 5: Fixative. A fixative is a solution used to secure the specimen.
Global Rationale: When preparing to obtain an endocervical swam specimen the nurse will
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need to have microscopic slides, cytobrush, and a fixative. The slides will be used to place the
specimen on. The cell specimens are obtained using a cytobrush. The cotton applicator will not
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be used in place of the cytobrush as it is not as effective in obtaining cells. Saline is used to
Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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moisten a cotton-tipped applicator but not used with the cytobrush.
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 22.4: Describe techniques required for assessment of the female
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reproductive system.
Type: MCSA
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Question 33
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The nurse is performing a vaginal examination on a client who has had a hysterectomy. Which of
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the following would the nurse choose to do in this situation?
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1. Defer the cervical scrape.
2. Use the vaginal wall for the cervical scrape.
3. Tell the client an examination is not needed.
4. Use the surgical stump for the cervical scrape.
Correct Answer: 4
Rationale 1: Clients who have had hysterectomies should have the surgical stump scraped as
part of the examination. Deferring the cervical assessment could result in the omission of
important information for the comprehensive care of the client.
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Rationale 2: Specimens from the vaginal walls are indicated but do not replace the need to have
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cells obtained from the cervical stump.
Rationale 3: Clients that have had hysterectomies should have the surgical stump scraped as part
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of the examination.
Rationale 4: Clients that have had hysterectomies should have the surgical stump scraped as part
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of the examination.
Global Rationale: Clients who have had hysterectomies should have the surgical stump scraped
as part of the examination. Deferring the scrape, using the walls of the vagina, or telling the
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client the examination is not needed would reduce the clients ability to have a comprehensive
pelvic examination. Important cellular specimens must be obtained from the cervical stump.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 22.4: Describe techniques required for assessment of the female
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reproductive system.
Question 34
Type: MCSA
The nurse assisting the healthcare provider who is performing a bimanual examination on an
extremely obese client. The healthcare provider is unable to palpate the uterus. Which of the
following actions would most likely be selected in this situation?
1. Defer the examination.
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2. Schedule an X-ray.
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3. Schedule an ultrasound.
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4. Ask the client if she has had recent problems.
Correct Answer: 3
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Rationale 1: Forgoing an examination as a result of difficulties encountered is not a responsible
action. The nurse has a responsibility to utilize other methods available as indicated.
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Rationale 2: The use of an X-ray is not the best diagnostic test to review the condition of soft
tissue organs and surrounding tissue.
Rationale 3: In an obese female palpation of the uterus may be difficult. An ultrasound would
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allow for examination of the female reproductive organs.
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Rationale 4: The size of the client is the most likely cause of the inability to palpate the uterus.
A discussion of recent problems is a part of the assessment but it does not reduce the need to
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discuss obtaining the ultrasound.
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Global Rationale: In the obese female, it may be difficult to clearly differentiate the uterine
structures and an ultrasound may be needed. Obtaining an ultrasound can only be done after
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consulting with the healthcare provider about the findings. The remaining choices are incorrect
for this situation. An X-ray is not the best diagnostic test to review the condition of soft tissue
organs and surrounding tissue. Deferring the examination does not meet the needs of the client.
Determining the clients recent health history does not meet the needs of the client in having the
uterus evaluated.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 22.4: Describe techniques required for assessment of the female
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reproductive system.
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Question 35
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Type: MCSA
The nurse is examining a pregnant client and notes the cervix is soft in texture and nontender.
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The nurse would correctly document which of the following conditions in this situation?
1. Nabothian cyst
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2. Chadwicks sign
4. Goodells sign
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Correct Answer: 4
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3. Hegars sign
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Rationale 1: Nabothian cysts are yellow and nodular and are benign areas that may appear after
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childbirth.
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Rationale 2: Chadwicks sign, also occurring during pregnancy, is the appearance of a bluishpurple coloration of the cervix due to vascular congestion.
Rationale 3: Hegars sign refers to the softening of the lower uterine segemt during pregnancy.
Rationale 4: During pregnancy, the vascularity of the cervix increases and contributes to the
softening of the cervix. This is a normal finding called Goodells sign.
Global Rationale: During pregnancy, the vascularity of the cervix increases and contributes to
the softening of the cervix. This is a normal finding called Goodells sign. Chadwicks sign, also
occurring during pregnancy, is the appearance of a bluish-purple coloration of the cervix due to
vascular congestion. Hegars sign refers to a softening of the lower uterine segment during
pregnancy. Nabothian cysts are yellow and nodular and are benign areas that may appear after
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childbirth.
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Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment
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of the female reproductive system.
Question 36
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Type: MCSA
The nurse is examining a pregnant client and notes the cervix has a bluish-purple change in
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situation?
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coloration. The nurse would correctly document which of the following conditions in this
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1. Nabothian cyst
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2. Goodells sign
3. Chadwicks sign
4. Bloody show
Correct Answer: 3
Rationale 1: Nabothian cysts are yellow and nodular and are benign areas that may appear after
childbirth.
Rationale 2: Vascularity of the cervix also contributes to the softening of the cervix, and is
called Goodells sign.
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Rationale 3: Chadwicks sign appears during pregnancy and is the appearance of a bluish-purple
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coloration of the cervix due to vascular congestion.
Rationale 4: Expulsion of the mucous plug at the endocervical canal produces a bloody show at
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the initiation of labor.
Global Rationale: Chadwicks sign appears during pregnancy and is the appearance of a bluishpurple coloration of the cervix due to vascular congestion. Nabothian cysts are yellow and
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nodular and are benign areas that may appear after childbirth. Vascularity of the cervix also
contributes to the softening of the cervix, and is called Goodells sign. Nabothian cysts are yellow
and nodular and are benign areas that may appear after childbirth. Expulsion of the mucous plug
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at the endocervical canal produces a bloody show at the initiation of labor.
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Type: MCMA
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Question 37
A pregnant client reports concern about the development of reddish marks on her abdomen and
breasts. The client asks about having a cream prescribed to help them disappear. What
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information should be included in the teaching provided to the client regarding this inquiry?
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Standard Text: Select all that apply.
1. The stretch marks will fade but not disappear.
2. Cream will help the skin stay supple.
3. Cocoa butter lotions and creams will clear the marks completely.
4. The marks will lighten to a silvery tone after pregnancy.
5. Wearing supportive undergarments will help to support the skin and reduce the appearance of
the marks.
Correct Answer: 1,2,4
Rationale 1: The stretch marks will fade but not disappear. Striae gravidarum are known as
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stretch marks. They commonly occur during pregnancy. They result from the stretching of the
skin to accommodate fetal growth. These marks will not disappear but will fade and lighten after
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the pregnancy ends.
Rationale 2: Cream will help the skin stay supple. There is no need for a prescription cream.
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Over-the-counter preparations can be used to keep the skin soft and supple.
Rationale 3: Cocoa butter lotions and creams will clear the marks completely. These marks
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will not disappear but will fade and lighten after the pregnancy ends. There is no need for a
prescription cream. Over-the-counter preparations can be used to keep the skin soft and supple.
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Rationale 4: The marks will lighten to a silvery tone after pregnancy. These marks will not
disappear but will fade and lighten after the pregnancy ends.
Rationale 5: Wearing supportive undergarments will help to support the skin and reduce
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the appearance of the marks. Wearing supportive undergarments will help promote comfort to
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the growing abdomen but will not prevent the development of stretch marks.
Global Rationale: Striae gravidarum are known as stretch marks. They commonly occur during
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pregnancy. They result from the stretching of the skin to accommodate fetal growth. These
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marks will not disappear but will fade and lighten after the pregnancy ends. There is no need for
a prescription cream. Over-the-counter preparations can be used to keep the skin soft and supple.
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Wearing supportive undergarments will help promote comfort to the growing abdomen but will
not prevent the development of stretch marks.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 26.1: Recall the anatomy and physiology specific to assessment of the
pregnant and postpartum female.
Question 38
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Type: MCSA
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A client who is 38 weeks pregnant reports she has been experiencing urinary frequency. Which
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response by the nurse is indicated?
1. Your reports are consistent with a urinary tract infection.
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2. I will need to check your blood sugar as excessive urination is associated with gestational
diabetes.
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3. Reducing your fluid intake will be helpful to manage this problem.
4. This is normal occurrence in the later stages of pregnancy.
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Correct Answer: 4
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Rationale 1: During the last few weeks prior to delivery, the client will experience lightening.
The pressure caused by this event results in frequent urination. It is a normal occurrence. In the
absence of other information, this is the most correct response. There are no indications the client
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has a urinary tract infection.
Rationale 2: During the last few weeks prior to delivery, the client will experience lightening.
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The pressure caused by this event results in frequent urination. It is a normal occurrence. In the
absence of other information, this is the most correct response. There are no indications the client
has an elevation in blood glucose levels.
Rationale 3: The health of the pregnancy requires adequate fluid intake. Reduction of fluid
intake is problematic as it will reduce fluids available to the fetus. In addition, the condition is
not being caused by an increased oral fluid intake.
Rationale 4: During the last few weeks prior to delivery, the client will experience lightening.
The pressure caused by this event results in frequent urination. It is a normal occurrence.
Global Rationale: During the last few weeks prior to delivery, the client will experience
lightening. The pressure caused by this event results in frequent urination. It is a normal
occurrence. In the absence of other information, this is the most correct response. There are no
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indications the client has an elevation in blood glucose levels or a urinary tract infection. The
health of the pregnancy requires adequate fluid intake. Reduction of fluid intake is problematic
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as it will reduce fluids available to the fetus. In addition, the condition is not being caused by an
Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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increased oral fluid intake.
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 26.1: Recall the anatomy and physiology specific to assessment of the
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pregnant and postpartum female.
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Type: MCSA
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Question 39
The nurse is reading the history and physical on a pregnant client and reads that the cervix was
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noted as soft in texture and nontender during the pelvic examination. The nurse would correctly
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identify this as which of the following?
1. Piscaceks sign
2. Goodells sign
3. Chadwicks sign
4. Hegars sign
Correct Answer: 2
Rationale 1: Piscaceks sign is when the shape of the uterus becomes irregular due to the
implantation of the ovum.
Rationale 2: During pregnancy, the vascularity of the cervix increases and contributes to the
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softening of the cervix. This is a normal finding called Goodells sign.
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Rationale 3: Chadwicks sign is the appearance of a bluish-purple coloration of the cervix due to
vascular congestion.
connects the body of the uterus and the cervix.
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Rationale 4: Hegars sign occurs throughout pregnancy and is the softening of the region that
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Global Rationale: During pregnancy, the vascularity of the cervix increases and contributes to
the softening of the cervix. This is a normal finding called Goodells sign. Chadwicks sign, also
occurring during pregnancy, is the appearance of a bluish-purple coloration of the cervix due to
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vascular congestion. Piscaceks sign is when the shape of the uterus becomes irregular due to the
implantation of the ovum. Hegars sign occurs throughout pregnancy and is the softening of the
region that connects the body of the uterus and the cervix.
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Cognitive Level: Applying
Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 26.1: Recall the anatomy and physiology specific to assessment of the
pregnant and postpartum female.
Question 40
Type: MCSA
The nurse is assessing the fundal height of a pregnant client and notes the fundus is halfway
between the symphysis pubis and the umbilicus. The nurse would correctly estimate the weeks in
pregnancy as which of the following?
1. 1012
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2. 16
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3. 2022
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4. 38
Correct Answer: 2
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Rationale 1: At 10 to 12 weeks the fundus is slightly above the symphysis pubis.
Rationale 2: At 16 weeks, the fundus is halfway between the symphysis pubis and the
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umbilicus.
Rationale 3: Between 20 and 22 weeks the fundus reaches the umbilicus.
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Rationale 4: At 38 weeks the fundus is above the umbilicus.
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Global Rationale: At 16 weeks, the fundus is halfway between the symphysis pubis and the
umbilicus. At 10 to 12 weeks the fundus is slightly above the symphysis pubis, and between 20
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and 22 weeks the fundus reaches the umbilicus and increases above this until 38 weeks.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 26.1: Recall the anatomy and physiology specific to assessment of the
pregnant and postpartum female.
Question 41
Type: HOTSPOT
The nurse is assessing the abdomen of a client who is 20 weeks gestation. Indicate the
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anticipated height of the fundus.
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Correct Answer:
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Standard Text: Select the correct area on the image.
Rationale : The fundal height can be anticipated passed upon gestational age. At 20 weeks
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gestation, the fundal height will be at the level of the umbilicus.
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Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 26.1: Recall the anatomy and physiology specific to assessment of the
pregnant and postpartum female.
Question 42
Type: MCSA
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The nurse is interviewing a female client who reports no menstrual periods for 2 months and
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breast soreness. The nurse would document this data as which classification of signs of
pregnancy?
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1. Objective
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2. Probable
3. Presumptive
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4. Positive
Correct Answer: 3
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Rationale 1: Objective findings are those things that are measurable as opposed to subjective
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findings that are condition reports by an individual that cannot directly be validated.
Rationale 2: Probable signs are those that may be documented by an examiner and include
positive pregnancy test, abdominal enlargement, Piskaceks sign, Hegars sign, Goodells sign,
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Chadwicks sign, and Braxton Hicks contractions.
Rationale 3: Presumptive signs of pregnancy are symptoms the client reports that may have
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multiple causes other than pregnancy. These include amenorrhea, breast tenderness, nausea and
vomiting, frequent urination, perceived quickening, skin changes, and fatigue.
Rationale 4: Positive signs of pregnancy have no possible explanation other than pregnancy and
include hearing the fetal heart tone and visualization of the fetus with ultrasound or radiology.
Global Rationale: Presumptive signs of pregnancy are symptoms the client reports that may
have multiple causes other than pregnancy. These include amenorrhea, breast tenderness, nausea
and vomiting, frequent urination, perceived quickening, skin changes, and fatigue. Probable
signs are those that may be documented by an examiner and include positive pregnancy test,
abdominal enlargement, Piskaceks sign, Hegars sign, Goodells sign, Chadwicks sign, and
Braxton Hicks contractions. Positive signs of pregnancy have no possible explanation other than
pregnancy and include hearing the fetal heart tone and visualization of the fetus with ultrasound
or radiology. Objective findings are those things that are measurable as opposed to subjective
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findings that are condition reports by an individual that cannot directly be validated. Many of the
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presumptive and all of the probable and positive signs of pregnancy are objectives findings.
Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Cognitive Level: Applying
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 26.1: Recall the anatomy and physiology specific to assessment of the
pregnant and postpartum female.
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Question 43
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Type: MCSA
The healthcare provider is performing an assessment on a pregnant client. The examiner notes a
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softening in the area being assessed. Review the photograph below and identify the probable sign
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of pregnancy being assessed.
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1. Goodells sign
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2. Hegars sign
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3. Chadwicks sign
4. Ladins sign
Correct Answer: 1
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Rationale 1: Goodells sign refers to the softening of the cervix.
Rationale 2: Hegars sign refers to the softening of the lower uterine segment.
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Rationale 3: Chadwicks sign refers to the change in coloration of the mucous membranes of the
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female genitalia during pregnancy
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Rationale 4: Ladins sign refers to the softening of the mid uterus during pregnancy.
Global Rationale: Goodells sign refers to the softening of the cervix. Hegars sign refers to the
softening of the lower uterine segment. Chadwicks sign refers to the change in coloration of the
mucous membranes of the female genitalia during pregnancy. Ladins sign refers to the softening
of the mid uterus during pregnancy.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 26.2: Identify anatomical and physiologic variations in body systems that
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guide assessment in pregnancy and postpartum.
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Question 44
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Type: MCSA
The nurse is performing a pelvic examination on a client who is 20 weeks pregnant and notes a
following actions?
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1. Ask the client about vaginal discomfort.
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white, odorless discharge from the vagina. The nurse would correctly choose which of the
2. Inquire about recent sexual intercourse.
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3. Obtain a culture of the discharge.
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4. Document the findings as normal.
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Correct Answer: 4
Rationale 1: During pregnancy it is normal for vaginal secretions to be increased, white, and
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odorless, also called leukorrhea. The presence of leukorrhea is normal and does not require a
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culture or additional subjective information. It is appropriate to document the findings of the
nursing assessment.
Rationale 2: During pregnancy it is normal for vaginal secretions to be increased, white, and
odorless, also called leukorrhea. The presence of leukorrhea is normal and does not require a
culture or additional subjective information. It is appropriate to document the findings of the
nursing assessment.
Rationale 3: During pregnancy it is normal for vaginal secretions to be increased, white, and
odorless, also called leukorrhea. The presence of leukorrhea is normal and does not require a
culture or additional subjective information. It is appropriate to document the findings of the
nursing assessment.
Rationale 4: During pregnancy it is normal for vaginal secretions to be increased, white, and
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odorless, also called leukorrhea. The presence of leukorrhea is normal and does not require a
culture or additional subjective information. It is appropriate to document the findings of the
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nursing assessment.
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Global Rationale: During pregnancy it is normal for vaginal secretions to be increased, white,
and odorless, also called leukorrhea. The presence of leucorrhea is normal and does not require a
culture or additional subjective information. It is appropriate to document the findings of the
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nursing assessment.
Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 26.2: Identify anatomical and physiologic variations in body systems that
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guide assessment in pregnancy and postpartum.
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Question 45
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Type: MCSA
The nurse is assessing a postpartum client and notes the peri-pad has whitish-yellow discharge.
The nurse would correctly document this vaginal discharge as which of the following?
1. Postpartal bleeding
2. Lochia rubra
3. Lochia serosa
4. Lochia alba
Correct Answer: 4
Rationale 1: To refer to the discharge simply as postpartal bleeding does not provide an
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adequate description.
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Rationale 2: The uterine lining, or endometrium, returns to the nonpregnant state through the
process of a postpartum vaginal discharge called lochia. The initial lochia rubra contains blood
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from the placental site, amniotic membrane, cells from the decidua basalis, vernix and lanugo
from the infants skin, and meconium. It is dark red and has a fleshy odor, and lasts anywhere
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from 2 days to 18 days.
Rationale 3: The uterine lining, or endometrium, returns to the nonpregnant state through the
process of a postpartum vaginal discharge called lochia. Once the lochia rubra has subsided the
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discharge becomes pinkish and is called lochia serosa. It is composed of blood, placental site
exudates, erythrocytes, leukocytes, cervical mucus, microorganisms, and decidua, and lasts
approximately a week.
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Rationale 4: The uterine lining, or endometrium, returns to the nonpregnant state through the
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process of a postpartum vaginal discharge called lochia. In the final stages the discharge
becomes whitish-yellow, lochia alba, and is composed of leukocytes, mucus, bacteria, epithelial
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cells, and decidua.
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Global Rationale: The uterine lining, or endometrium, returns to the nonpregnant state through
the process of a postpartum vaginal discharge called lochia. The initial lochia rubra contains
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blood from the placental site, amniotic membrane, cells from the decidua basalis, vernix and
lanugo from the infants skin, and meconium. It is dark red and has a fleshy odor, and lasts
anywhere from 2 days to 18 days. Next the discharge becomes pinkish and is called lochia
serosa. It is composed of blood, placental site exudates, erythrocytes, leukocytes, cervical
mucus, microorganisms, and decidua, and lasts approximately a week. Finally, the discharge
becomes whitish-yellow, lochia alba, and is composed of leukocytes, mucus, bacteria, epithelial
cells, and decidua. Most females will have vaginal discharge from 10 days to 5 or 6 weeks. To
refer to the discharge simply as postpartal bleeding does not provide an adequate description.
Cognitive Level: Understanding
Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Client Need Sub:
guide assessment in pregnancy and postpartum.
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Question 46
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Learning Outcome: 26.2: Identify anatomical and physiologic variations in body systems that
Type: MCSA
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The nurse is assessing a client in the third trimester of pregnancy and notes a yellowish discharge
from both breasts. The nurse would correctly choose which of the following actions?
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1. Ask the client if she is preparing for breastfeeding.
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2. Notify the healthcare provider.
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3. Document the findings as normal.
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4. Obtain a culture of the discharge immediately.
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Correct Answer: 3
Rationale 1: Colostrum, a yellowish, specialized form of early breast milk, is produced starting
in the second trimester and is replaced by mature milk during the early days of lactation after
birth. This substance is produced regardless of whether the woman is planning to breastfeed,
making this inquiry unnecessary.
Rationale 2: Colostrum, a yellowish, specialized form of early breast milk, is produced starting
in the second trimester and is replaced by mature milk during the early days of lactation after
birth. This substance is produced regardless of whether the woman is planning to breastfeed,
making this inquiry unnecessary. This is a normal finding and does not require a culture,
additional subjective information, or notification of the healthcare provider.
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Rationale 3: Colostrum, a yellowish, specialized form of early breast milk, is produced starting
in the second trimester and is replaced by mature milk during the early days of lactation after
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birth. This substance is produced regardless of whether the woman is planning to breastfeed,
making this inquiry unnecessary. This is a normal finding and does not require a culture,
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.
additional subjective information, or notification of the healthcare provider.
Rationale 4: Colostrum, a yellowish, specialized form of early breast milk, is produced starting
kt
a
in the second trimester and is replaced by mature milk during the early days of lactation after
birth. This substance is produced regardless of whether the woman is planning to breastfeed,
making this inquiry unnecessary. This is a normal finding and does not require a culture,
ba
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additional subjective information, or notification of the healthcare provider.
Global Rationale: Colostrum, a yellowish, specialized form of early breast milk, is produced
starting in the second trimester and is replaced by mature milk during the early days of lactation
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after birth. This substance is produced regardless of whether the woman is planning to
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breastfeed, making this inquiry unnecessary. This is a normal finding and does not require a
culture, additional subjective information, or notification of the healthcare provider.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 26.2: Identify anatomical and physiologic variations in body systems that
guide assessment in pregnancy and postpartum.
Question 47
Type: MCSA
The nurse is assisting the healthcare provider during a vaginal examination. The healthcare
provider notes the cervix has a bluish-purple change in coloration. The nurse would recognize
this condition is known as:
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1. Goodells sign
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2. Leukorrhea
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3. Chadwicks sign
4. Mucous plug
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Correct Answer: 3
Rationale 1: Hormonal changes in pregnancy cause a series of changes to the female genitalia.
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The vascularity of the cervix increases contributing to the softening of the cervix, and is called
Goodells sign.
Rationale 2: Hormonal changes in pregnancy cause a series of changes to the female genitalia.
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Leukorrhea is a profuse, nonodorous, nonpainful, vaginal discharge, which is a normal finding.
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Rationale 3: Hormonal changes in pregnancy cause a series of changes to the female genitalia.
Chadwicks sign appears during pregnancy and is the appearance of a bluish-purple coloration of
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the cervix due to vascular congestion.
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Rationale 4: The endocervical canal is closed by a plug of mucus. This mucus remains in place
until the final days of the pregnancy. At that time it is expelled, producing a discharge referred to
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as bloody show.
Global Rationale: Hormonal changes in pregnancy cause a series of changes to the female
genitalia. Chadwicks sign appears during pregnancy and is the appearance of a bluish-purple
coloration of the cervix due to vascular congestion. This vascularity of the cervix also
contributes to the softening of the cervix, and is called Goodells sign. The endocervical canal is
closed by a plug of mucus. This mucus remains in place until the final days of the pregnancy. At
that time it is expelled, producing a discharge referred to as bloody show. Leukorrhea is a
profuse, nonodorous, nonpainful, vaginal discharge.
Cognitive Level: Understanding
Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
guide assessment in pregnancy and postpartum.
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Question 48
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Learning Outcome: 26.2: Identify anatomical and physiologic variations in body systems that
Type: MCSA
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The nurse is discussing dietary recommendations with a client who has been experiencing a
larger than recommended weight gain during her pregnancy. The client reports reducing the
amount of empty calories and of red meat consumed while significantly increasing intake of fish,
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poultry, and fresh fruits and vegetables. What response is indicated by the nurse?
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1. It looks like you have things under control. Do you have any other questions?
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2. Have you considered seeing a dietitian for nutritional counseling?
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3. Tell me more about the meat and fish you are eating each day.
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4. I think we should discuss the risky dietary choices you are making with the healthcare
provider.
Correct Answer: 3
Rationale 1: Questions should be sought from the client; however, there are areas for potential
problems such as the reduction in protein sources and intake of still-undetermined varieties of
fish.
Rationale 2: Nutritional counseling is within the scope of practice for the nurse and a dietary
consult is still premature.
Rationale 3: Some of the clients actions are positive changes. The reduction of empty calories is
a good change. Red meat is a good source of protein and should not be entirely eliminated.
Mercury levels can be problematic in some types of fish. The nurse will need to evaluate the
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types of fish being eaten. Swordfish, shark, king mackerel, and tilefish should be avoided. Intake
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of white tuna and game fish should also be restricted.
Rationale 4: The client is making some positive changes and notification of the healthcare
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provider is premature.
Global Rationale: Some of the clients actions are positive changes. The reduction of empty
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calories is a good change. Red meat is a good source of protein and should not be entirely
eliminated. Mercury levels can be problematic in some types of fish. The nurse will need to
evaluate the types of fish being eaten. Swordfish, shark, king mackerel, and tilefish should be
ba
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avoided. Intake of white tuna and game fish should also be restricted. It is premature to consult
with the dietitian. Dietary education is within the scope of nursing practice and the clients
behaviors do not warrant further action at this time. It is premature to notify the healthcare
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provider of the nutritional status without additional information.
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Cognitive Level: Applying
Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 26.3: Identify questions used when completing the focused interview.
Question 49
Type: MCSA
A client at 33 weeks gestation calls the healthcare providers office and reports she was
attempting to nap when she became dizzy and felt faint. What assessment data should be
collected by the nurse first?
1. The position the client was in during the nap period
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2. Dietary intake prior to the episode
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4. No additional data as this appears to be an isolated incident
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3. History of hyperemesis
Correct Answer: 1
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Rationale 1: The client has most likely experienced an episode of supine hypotension. This is
caused by compression on the aorta and the inferior vena cava by the pregnant uterus. This is a
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common occurrence when the client is in the supine position.
Rationale 2: The client has most likely experienced an episode of supine hypotension. This is
caused by compression on the aorta and the inferior vena cava by the pregnant uterus. This is a
common occurrence when the client is in the supine position. Dietary factors and the presence of
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hyperemesis are not implicated in this clients scenario.
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Rationale 3: The client has most likely experienced an episode of supine hypotension. This is
caused by compression on the aorta and the inferior vena cava by the pregnant uterus. This is a
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common occurrence when the client is in the supine position. Dietary factors and the presence of
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hyperemesis are not implicated in this clients scenario.
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Rationale 4: The client has most likely experienced an episode of supine hypotension. This is
caused by compression on the aorta and the inferior vena cava by the pregnant uterus. This is a
common occurrence when the client is in the supine position. The nurse must investigate the
complaints to ensure client safety.
Global Rationale: The client has most likely experienced an episode of supine hypotension.
This is caused by compression on the aorta and the inferior vena cava by the pregnant uterus.
This is a common occurrence when the client is in the supine position. Dietary factors and the
presence of hyperemesis are not implicated in this clients scenario. The nurse must investigate
the complaints to ensure client safety.
Question 50
Type: HOTSPOT
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The nurse is preparing to perform an abdominal assessment. The client states, Can you point to
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where my appendix is located? Draw an arrow to the location of the clients appendix.
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Select the correct area on the image.
Correct Answer:
Global Rationale:
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Cognitive Level: Remembering
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Rationale : The vermiform appendix is attached to the large intestines at the cecum.
Client Need Sub:
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Client Need: Health Promotion and Maintenance
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen.
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Question 51
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Type: HOTSPOT
The nurse is speaking with the client during the focused interview. The client states, My doctor
said that my spleen was enlarged. Where is my spleen? Draw an arrow to the location of the
spleen.
Standard Text: Select the correct area on the image.
Correct Answer:
Rationale : The spleen, the largest of the lymphoid organs, is located in the left upper portion of
the abdomen directly inferior to the diaphragm.
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Global Rationale:
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Cognitive Level: Remembering
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Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen.
Question 52
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Type: MCMA
A client asks the nurse, Whats the purpose of the liver? Which of the following statements would
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be beneficial for the nurse to share with the client?
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Standard Text: Select all that apply.
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1. It helps you digest fats.
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2. It is an endocrine and exocrine gland.
3. It filters waste from the blood and makes urine.
4. It makes some blood clotting substances.
5. It can help you store certain vitamins.
Correct Answer: 1,4,5
Rationale 1: It helps you digest fats. The liver helps the body digest fats by producing bile.
Rationale 2: It is an endocrine and exocrine gland. The pancreas is an example of an exocrine
and endocrine gland.
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Rationale 3: It filters waste from the blood and makes urine. The kidneys filter nitrogen
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waste from the blood and make urine.
Rationale 4: It makes some blood clotting substances. The liver makes blood clotting
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substances.
Rationale 5: It can help you store certain vitamins. The liver can store certain types of
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vitamins.
Global Rationale: The liver produces and secretes bile for fat breakdown, but also aids in the
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metabolism of proteins and carbohydrates. It stores some vitamins, helps with blood coagulation,
produces antibodies, and detoxifies some harmful substances. The pancreas is an example of an
exocrine and endocrine gland. The kidneys filter nitrogen waste from the blood and make urine.
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Cognitive Level: Understanding
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen.
Question 53
Type: MCMA
The nurse is palpating the right upper quadrant of a clients abdomen. Which of the following
organs may be assessed during this portion of the assessment?
Standard Text: Select all that apply.
1. Liver
2. Gallbladder
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3. Appendix
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4. Spleen
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5. Stomach
Correct Answer: 1,2
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Rationale 1: Liver. The liver is located in the right upper quadrant.
Rationale 2: Gallbladder. The gallbladder is located in the right upper quadrant.
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Rationale 3: Appendix. The appendix is located in the right lower quadrant.
Rationale 4: Spleen. The spleen is located in the left upper quadrant.
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Rationale 5: Stomach. The stomach is located in the left upper quadrant.
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Global Rationale: The liver is located in the right upper quadrant. The gallbladder is located in
the right upper quadrant. The appendix is located in the right lower quadrant. The spleen is
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located in the left upper quadrant. The stomach is located in the left upper quadrant.
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Cognitive Level: Remembering
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen.
Question 54
Type: MCSA
A client asks the nurse, Whats the purpose of a gall bladder anyway? My mom lived for many
years without her gallbladder after she had to have it taken out. Which of the following
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1. You are right. We still dont know the function of the gallbladder.
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information would be beneficial for the nurse to share with this client?
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2. It stores bile until it is needed for digestion of fats.
3. It destroys old red blood cells.
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4. It helps you digest carbohydrates by producing enzymes.
Correct Answer: 2
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Rationale 1: The gallbladder does have an important function within the body.
Rationale 2: The gallbladder is used to store bile that is produced in the liver, until the bile is
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needed to help digest fats.
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Rationale 3: The spleen destroys red blood cells.
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Rationale 4: The pancreas helps the body digest carbohydrates.
Global Rationale: The gallbladder is used to store bile. It is a thin-walled sac that is nestled in a
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shallow depression on the ventral surface of the liver. The gallbladder releases stored bile into
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the duodenum when stimulated and thus promotes the emulsification of fats. The main functions
of the gallbladder are storing of bile and assisting in the digestion of fats. The spleen destroys red
blood cells. The pancreas helps the body digest carbohydrates.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen
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Question 55
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Type: MCMA
The nurse is palpating the left upper quadrant of a clients abdomen. Which of the following
Standard Text: Select all that apply.
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1. Liver
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.
organs may be assessed during this portion of the assessment?
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2. Gallbladder
3. Appendix
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4. Spleen
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5. Stomach
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Correct Answer: 4,5
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Rationale 1: Liver. The liver is located in the right upper quadrant.
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Rationale 2: Gallbladder. The gallbladder is located in the right upper quadrant.
Rationale 3: Appendix. The appendix is located in the right lower quadrant.
Rationale 4: Spleen. The spleen is located in the left upper quadrant.
Rationale 5: Stomach. The stomach is located in the left upper quadrant.
Global Rationale: The spleen is located in the left upper quadrant. The stomach is located in the
left upper quadrant. The liver is located in the right upper quadrant. The gallbladder is located in
the right upper quadrant. The appendix is located in the right lower quadrant.
Cognitive Level: Remembering
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Client Need: Physiological Integrity
nk
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen.
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Question 56
Type: MCMA
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The nurse is mapping the clients abdomen into four quadrants. Which of the following
landmarks would the nurse use to perform this assessment?
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Standard Text: Select all that apply.
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1. Umbilicus
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2. Midclavicular lines
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3. Xiphoid process
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4. Lower border of the right ribs
5. Iliac crests
Correct Answer: 1,3
Rationale 1: Umbilicus. To obtain four quadrants when mapping the abdomen, extend the
midsternal line from the xiphoid process through the umbilicus to the pubic bone, then draw a
horizontal line perpendicular to the first line.
Rationale 2: Midclavicular lines. The midclavicular lines are not used to map the clients
abdomen into four quadrants.
Rationale 3: Xiphoid process. To obtain four quadrants when mapping the abdomen, extend the
midsternal line from the xiphoid process through the umbilicus to the pubic bone, then draw a
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horizontal line perpendicular to the first line.
Rationale 4: Lower border of the right ribs. The lower border of the right ribs is not used to
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map the clients abdomen into four quadrants.
Rationale 5: Iliac crests. The iliac crests are not used to map the clients abdomen into four
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quadrants.
Global Rationale: To obtain four quadrants when mapping the abdomen, extend the midsternal
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line from the xiphoid process through the umbilicus to the pubic bone, then draw a horizontal
line perpendicular to the first line. The midclavicular lines are not used to map the clients
abdomen into four quadrants. The lower border of the right ribs is not used to map the clients
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abdomen into four quadrants. The iliac crests are not used to map the clients abdomen into four
quadrants.
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Cognitive Level: Remembering
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 19.2: Identify landmarks that guide assessment of the abdomen.
Question 57
Type: MCSA
The nurse is performing a focused interview with a 79-year-old client. Which of the following
statements by the client is unexpected?
1. I have been having loose stools every day for the last 3 years.
2. I know I just dont drink as much water as I should.
3. My belly seems softer and flabbier as I get older.
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4. My mouth is always dry.
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Correct Answer: 1
Rationale 1: Older clients tend to experience constipation as a result of changes in their
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digestive tracts. Loose stools are an unexpected finding in the older client.
Rationale 2: Older clients do not tend to drink as much water as they should to avoid frequent
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urination.
Rationale 3: The older clients abdomen tends to be softer and more relaxed than in the younger
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adult.
Rationale 4: The older clients saliva production is decreased resulting in a dry mouth.
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Global Rationale: Older clients tend to experience constipation as a result of changes in their
digestive tracts. Loose stools are an unexpected finding in the older client. Older clients do not
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tend to drink as much water as they should to avoid frequent urination. The older clients
abdomen tends to be softer and more relaxed than in the younger adult. The older clients saliva
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production is decreased resulting in a dry mouth.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 19.3: Develop questions to be used when completing the focused interview.
Question 58
Type: MCMA
The student nurse is preparing to examine a client who is complaining of left lower quadrant
abdominal pain. The experienced nurse is observing the student nurses abdominal assessment.
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Which of the following statements by the student nurse would indicate that the student nurse
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requires further education?
Standard Text: Select all that apply.
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1. It is a little cool in our examination room; may I turn up the thermostat?
2. Ive been told you are experiencing some pain in the lower left area of your abdomen. I will
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examine that area first.
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3. I am going to stand on your left side so I can feel your liver better.
4. Im going to place this drape over you so you dont feel too exposed during this examination.
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Correct Answer: 2,3
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5. I am going to place this pillow behind your head and this pillow under your knees.
Rationale 1: It is a little cool in our examination room; may I turn up the thermostat? The
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nurse should provide an environment that is warm and comfortable.
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Rationale 2: Ive been told you are experiencing some pain in the lower left area of your
abdomen. I will examine that area first. When a client is experiencing abdominal pain, the
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nurse should examine that area last.
Rationale 3: I am going to stand on your left side so I can feel your liver better. Stand on the
right side of the client, because the liver and the right kidney are in the right side of the abdomen.
Rationale 4: Im going to place this drape over you so you dont feel too exposed during this
examination. Maintain the dignity of the client through appropriate draping techniques.
Rationale 5: I am going to place this pillow behind your head and this pillow under your
knees. The client should be in a supine position with a small pillow placed beneath the head and
knees.
Global Rationale: When a client is experiencing abdominal pain, the nurse should examine that
area last. Stand on the right side of the client, because the liver and the right kidney are in the
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right side of the abdomen. The nurse should provide an environment that is warm and
comfortable. Maintain the dignity of the client through appropriate draping techniques. The
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client should be in a supine position with a small pillow placed beneath the head and knees.
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.
Cognitive Level: Applying
Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 19.4: Explain client preparation for assessment of the abdomen.
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Type: MCMA
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Question 59
The nurse is performing an abdominal assessment on a client. During the focused interview, the
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client stated that he had been experiencing some abdominal pain. As the nurse assesses the
client, which of the following behaviors indicates that the client may be experiencing pain or
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anxiety during the examination?
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Standard Text: Select all that apply.
1. The clients respiratory rate is 26 per minute.
2. The client moves away from the nurses hands.
3. The client grimaces.
4. The client pulls his knees toward his stomach.
5. The client coughs loudly.
Correct Answer: 1,2,3,4
Rationale 1: The clients respiratory rate is 26 per minute. If the clients respiratory rate
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increases during the examination, it can indicate that the client is experiencing pain or anxiety.
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the nurse during the examination if the client is experiencing pain.
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Rationale 2: The client moves away from the nurses hands. The client may move away from
Rationale 3: The client grimaces. Grimacing is a facial expression that can indicate that the
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client is experiencing pain during the assessment.
Rationale 4: The client pulls his knees toward his stomach. The client who exhibits guarding
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behavior is most likely experiencing pain.
Rationale 5: The client coughs loudly. The client who coughs loudly is not necessarily
experiencing pain. This is not a typical expression of pain or anxiety.
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Global Rationale: If the clients respiratory rate increases during the examination, it may
indicate that the client is experiencing pain or anxiety. The client may move away from the nurse
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during the examination if the client is experiencing pain. Grimacing is a facial expression that
can indicate that the client is experiencing pain during the assessment. The client who exhibits
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guarding behavior is most likely experiencing pain. The client who coughs loudly is not
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necessarily experiencing pain. This is not a typical expression of pain or anxiety.
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Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 19.4: Explain client preparation for assessment of the abdomen.
Question 60
Type: MCSA
The client was recently admitted to the hospital with left lower quadrant pain. The client states, It
feels like my belly is cramping. Guarding is noted during the abdominal examination. During the
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focused interview, the client admitted to experiencing a significant amount of occupational
stress. The nurse reviews the information included in the chart above and determines that the
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client has developed a specific condition. Which of the following statements by the client is most
consistent with this condition?
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2. I drink a whole pot of coffee every day.
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1. I get home so late at night, but Ive got to stop lying down right after dinner.
3. I drink 912 beers after I get home from work, every day.
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4. We have been growing green beans in our garden and I think I ate too many the other day.
Correct Answer: 4
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Rationale 1: Lying down after meals is often associated with gastroesophageal reflux disorder.
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Rationale 2: Caffeine intake is associated with irritable bowel syndrome.
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Rationale 3: Drinking alcohol is associated with irritable bowel syndrome and pancreatitis.
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Rationale 4: This client is most likely experiencing diverticulitis. The clients white blood cell
count, temperature, and blood pressure are elevated as a result of the infection. High-fiber food
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intake can be a precipitating factor.
Global Rationale: This client most likely is experiencing diverticulitis. The clients white blood
cell count, temperature, and blood pressure are elevated as a result of the infection. High-fiber
food intake can be a precipitating factor. Lying down after meals is often associated with
gastroesophageal reflux disorder. Caffeine intake is associated with irritable bowel syndrome.
Drinking alcohol is associated with irritable bowel syndrome and pancreatitis.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment
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of the abdomen.
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Question 61
Type: MCSA
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The nurse is performing an abdominal assessment on a client. While the nurse is palpating the
lower border of the liver, the nurse asks the client to take a deep breath and hold it. The client
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complains of a sharp pain located in the right upper quadrant. In which of the following ways
would the nurse accurately document this finding?
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1. Positive Blumbergs sign
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2. Presence of pain at McBurneys point
3. Positive Murphys sign
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4. Positive Psoas sign
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Correct Answer: 3
Rationale 1: Blumbergs sign can be elicited when the nurse presses on an area of the abdomen.
If the client complains of pain as the nurse pulls back and releases the compressed area, the client
has a positive Blumbergs sign.
Rationale 2: Pain at McBurneys point is associated with appendicitis. This area is located in the
right lower quadrant of the clients abdomen.
Rationale 3: Murphys sign can be elicited when the client takes a deep breath and holds it while
the nurse presses into the right upper quadrant. The nurse is pressing against the gallbladder.
Normally, the client will not complain of pain.
Rationale 4: With the client in a supine position, the nurse places her left hand just above the
level of the clients right knee. The client is requested to raise the leg to meet the nurses hand.
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Flexion of the hip causes contraction of the psoas muscle and indicates that the client is
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experiencing peritoneal inflammation, or appendicitis.
Global Rationale: Pain with palpation of the liver is indicative of cholecystitis and is noted as a
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positive Murphys sign. The examination should be halted. Blumbergs sign is sharp pain
occurring with the release of a compressed area and is present when the client has peritoneal
irritation. Pain at McBurneys point in the right lower quadrant is associated with appendicitis.
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Pain that is elicited while flexing the hip is indicative of psoas muscle irritation and is associated
with peritoneal inflammation or appendicitis.
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Cognitive Level: Understanding
Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment
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of the abdomen.
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Question 62
Type: MCSA
The nurse is assessing the clients abdomen and notes dullness when percussing over the left
lower quadrant. Which of the following questions is most appropriate for the nurse to ask the
client at this time?
1. How much alcohol do you drink?
2. Do you have pain after eating?
3. When was your last bowel movement?
4. Have you ever had splenomegaly?
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Correct Answer: 3
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Rationale 1: Alcohol can place the client at risk for hepatomegaly and inflammation of the liver.
Rationale 2: Pain after eating may indicate that some sort of upper gastrointestinal problem has
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developed.
Rationale 3: Stool in the distal portion of the clients colon can produce dullness upon percussion
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of the left lower quadrant.
Rationale 4: Splenomegaly would produce dullness while percussing the left upper quadrant.
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Global Rationale: Percussion over the abdomen produces tympany, and dullness is heard over
the solid organs such as the liver and spleen. Dullness may also indicate an enlarged uterus,
distended urinary bladder or ascites. Dullness in the left lower quadrant may also indicate the
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presence of stool in the colon. Significant alcohol consumption may be associated with possible
liver enlargement. The nurse would be able to percuss the liver in the right upper quadrant. Pain
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after eating is more likely to be associated with an upper gastrointestinal problem. Splenomegaly
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is associated with dullness while percussing the clients left upper quadrant.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment
of the abdomen.
Question 63
Type: MCMA
The nurse is completing discharge instructions for a client admitted with esophagitis. Which of
the following statements by the client indicate that the client requires further education?
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Standard Text: Select all that apply.
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1. Im going to talk to my doctor about a nicotine patch.
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2. I can do all of this stuff youre talking about as long as I dont have to give up my beer.
3. I have been eating foods and drinks that were either too hot or too cold for my esophagus to
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handle.
4. The root of this problem is that I just sleep too much.
Correct Answer: 2,4,5
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5. I told my wife to stop making serving me all of those vegetables.
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Rationale 1: Im going to talk to my doctor about a nicotine patch. Smoking cigarettes is
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associated with an increased risk for developing esophagitis.
Rationale 2: I can do all of this stuff youre talking about as long as I dont have to give up
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my beer. Alcohol can increase the clients risk for developing esophagitis.
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Rationale 3: I have been eating foods and drinks that were either too hot or too cold for my
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esophagus to handle. Eating foods that are either too hot or too cold can be irritating to the
tissue and can result in esophagitis.
Rationale 4: The root of this problem is that I just sleep too much. Sleeping too much is not
associated with the development of esophagitis.
Rationale 5: I told my wife to stop making serving me all of those vegetables. Eating
vegetables is not associated with the development of esophagitis.
Global Rationale: Alcohol can exacerbate and is an established risk factor for the development
of esophagitis. Sleeping too much is not associated with the development of esohagitis. Eating
vegetables is not associated with the development of esophagitis. Smoking cigarettes is
associated with an increased risk for developing esophagitis. Eating foods that are either too hot
or too cold can be irritating to the tissue and can result in esophagitis.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment
of the abdomen.
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Question 64
Type: MCSA
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The nurse is assessing a client with reports of right upper quadrant pain that radiates toward the
right upper portion of the back. The client states, This has been happening more often after I eat
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rich, high-fat foods. The nurse would suspect which of the following?
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1. Cholecystitis
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2. Duodenal ulcer
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3. Gastritis
4. Pancreatitis
Correct Answer: 1
Rationale 1: Right upper quadrant pain that radiates to the right scapula is characteristic of
cholecystitis. The pain usually occurs after the client eats a fatty meal.
Rationale 2: Duodenal ulcers cause aching, gnawing, epigastric pain. This is associated with
stress and NSAID use.
Rationale 3: Gastritis causes epigastric pain. It is associated with NSAID use, alcohol abuse,
stress, infection, H. pylori infection, and/ or autoimmune responses.
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Rationale 4: Pancreatitis produces upper abdominal, knifelike, deep epigastric or umbilical area
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pain. It is associated with alcohol abuse, use of acetaminophen, and infection.
Global Rationale: Right upper quadrant pain that radiates to the right scapula is characteristic of
cholecystitis. The pain usually occurs after the client eats a fatty meal. Duodenal ulcers cause
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aching, gnawing, epigastric pain. It is associated with stress and NSAID use. Gastritis causes
epigastric pain. It is associated with NSAID use, alcohol abuse, stress, infection, H. pylori
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infection, and autoimmune responses. Pancreatitis produces upper abdominal, knifelike, deep
epigastric or umbilical area pain. It is associated with alcohol abuse, use of acetaminophen, and
infection.
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Cognitive Level: Understanding
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Client Need Sub:
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Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment
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of the abdomen.
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Question 65
Type: MCSA
The nurse is performing an abdominal assessment. After percussing the abdomen, the nurse
notes that the liver span is approximately 9 centimeters. Which of the following ways is an
appropriate way to document this finding?
1. Hepatomegaly
2. A normal finding
3. Related to recent diagnosis of chronic bronchitis
4. Presence of ascites
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Correct Answer: 2
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Rationale 1: Hepatomegaly would be associated with a liver span greater than 10 centimeters.
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Rationale 2: This is a normal finding.
Rationale 3: The client with chronic bronchitis may have a liver that is displaced downward
within the abdomen.
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Rationale 4: The client with ascites may have a liver that is displaced upward within the
abdomen.
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Global Rationale: The liver span is the distance between the lower and upper border of the
liver. It should be approximately 5 to 10 centimeters (2 to 4 inches). The liver in this situation is
not enlarged, and it would be inappropriate for the nurse to determine that client has an enlarged
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liver (hepatomegaly). The client with chronic bronchitis may have a liver that is displaced
downward within the abdomen. The client with ascites may have a liver that is displaced upward
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within the abdomen.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment
of the abdomen.
Question 66
Type: MCSA
The client is experiencing the effects of a recent cerebrovascular accident. The client is unable to
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hear out of the left ear. Which of the following cranial nerves was most likely affected?
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1. Cranial nerve I
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2. Cranial nerve XII
3. Cranial nerve VIII
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4. Cranial nerve VII
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Correct Answer: 3
Rationale 1: The sense of smell is controlled by cranial nerve I.
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Rationale 2: Tongue movement is controlled by cranial nerve XII.
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Rationale 3: Hearing and balance is controlled by cranial nerve VII.
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Rationale 4: The sense of taste is controlled by cranial nerves VII and IX.
Global Rationale: Hearing and balance is controlled by cranial nerve VII. The sense of smell is
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controlled by cranial nerve I. Tongue movement is controlled by cranial nerve XII. The sense of
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taste is controlled by cranial nerves VII and IX.
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 14.1: Identify the anatomy and physiology of the ear, nose, mouth, and
throat.
Question 67
Type: MCHS
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The nurse is assessing the clients vestibule of the oral cavity. The student nurse requests
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information regarding the vestibule and the mouth. Draw an arrow to the structure that separates
the vestibule from the mouth.
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Correct Answer:
Rationale : The vestibule is made up of the lips, buccal mucosa, outer surface of the gums and
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the teeth and cheeks. The mouth is separated from the vestibule by the teeth. The mouth is made
Global Rationale:
Cognitive Level: Analyzing
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up of the tongue, hard and soft palate, uvula, mandibular arch, and axillary arch.
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Client Need Sub:
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Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 14.1: Identify the anatomy and physiology of the ear, nose, mouth, and
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throat.
Question 68
Type: MCSA
The nurse educates the client about the major functions of the nose and sinuses. Which of the
following structures is specifically responsible for filtering, moistening, and warming air that
enters the lower portion of the respiratory tract?
1. Olfactory cells
2. Columella
3. Turbinates
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4. Nares
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Rationale 1: The olfactory cells assist the client to smell.
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Correct Answer: 3
Rationale 2: The columella is located at the base of the nose and helps form the nares.
Rationale 3: The superior, middle, and inferior turbinates are specifically responsible for
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warming, moistening, and filtering the air before it enters the trachea and lungs.
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Rationale 4: The nares are structures that lead into the internal vestibule and nasal cavity.
Global Rationale: The superior, middle, and inferior turbinates are specifically responsible for
warming, moistening, and filtering the air before it enters the trachea and lungs. The olfactory
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cells assist the client to smell. The columella is located at the base of the nose and helps form the
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nares. The nares are structures that lead into the internal vestibule and nasal cavity.
Cognitive Level: Understanding
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 14.1: Identify the anatomy and physiology of the ear, nose, mouth, and
throat.
Question 69
Type: MCSA
Which of the following structures attaches the tongue to the floor of the mouth?
1. Hard palate
2. Papillae
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3. Frenulum
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4. Alveoli sockets
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Correct Answer: 3
Rationale 1: The hard palate is the anterior portion of the roof of the mouth.
Rationale 2: The papillae contain the taste buds and assist with moving food within the mouth.
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The papillae are located on the dorsal surface of the tongue.
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Rationale 3: The frenulum connects the anterior portion of the tongue to the floor of the mouth.
Rationale 4: The alveoli sockets contain the teeth within the mandible and maxilla.
Global Rationale: The frenulum connects the anterior portion of the tongue to the floor of the
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mouth. The hard palate is the anterior portion of the roof of the mouth. The papillae contain the
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taste buds and assist with moving food within the mouth. The papillae are located on the dorsal
surface of the tongue. The alveoli sockets contain the teeth within the mandible and maxilla.
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Cognitive Level: Remembering
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 14.1: Identify the anatomy and physiology of the ear, nose, mouth, and
throat.
Question 70
Type: MCMA
The nurse is performing a focused interview with a client who has been cleaning the ears with a
cotton-tipped applicator. The nurse should educate the client about which of the following
complications that can occur as a result of this practice?
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Standard Text: Select all that apply.
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1. The client has a higher risk of developing otitis externa.
3. The client could perforate the tympanic membrane.
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4. The client could require tympanostomy tubes.
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2. The client has a higher risk of developing tophi along the outer rim of the ears.
5. The clients cerumen might become impacted.
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Correct Answer: 3,5
Rationale 1: The client has a higher risk of developing otitis externa. Otitis externa is an
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infection of the clients outer ear. This client does not have an increased risk of developing otitis
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externa.
Rationale 2: The client has a higher risk of developing tophi along the outer rim of the ears.
Tophi are small white nodules that are found on the helix or antihelix. These nodules are a sign
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of gout and contain uric acid crystals.
Rationale 3: The client could perforate the tympanic membrane. This client is at risk for
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perforating the tympanic membrane with the cotton-tipped applicator. The inside of the ear
should not be cleaned. Cerumen moves to the outside of the ear canal naturally.
Rationale 4: The client could require tympanostomy tubes. Tympanostomy tubes are placed
when clients develop repeated otitis media infections. These tubes help relieve middle ear
pressure and allow drainage that occurs as a result of the infection. This client does not require
tympanostomy tubes.
Rationale 5: The clients cerumen might become impacted. This client is at risk for impacting
the cerumen within the ears with the cotton-tipped applicator. The inside of the ear should not be
cleaned. Cerumen moves to the outside of the ear canal naturally.
Global Rationale: Otitis externa is an infection of the clients outer ear. This client does not have
an increased risk of developing otitis externa. Tophi are small white nodules that are found on
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the helix or antihelix. These nodules are a sign of gout and contain uric acid crystals. This client
is at risk for perforating the tympanic membrane with the cotton-tipped applicator. The inside of
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the ear should not be cleaned. Cerumen moves to the outside of the ear canal naturally.
Tympanostomy tubes are placed when clients develop repeated otitis media infections. These
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tubes help relieve middle ear pressure and allow drainage that occurs as a result of the infection.
This client does not require tympanostomy tubes. This client is at risk for impacting the cerumen
within the ears with the cotton-tipped applicator. The inside of the ear should not be cleaned.
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Cerumen moves to the outside of the ear canal naturally.
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Question 71
Type: MCSA
The client has been brought via ambulance to the emergency room following a motor vehicle
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nursing action?
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accident. The nurse notes that the clients ear is draining clear fluid. What is the nurses priority
1. Request information from the client regarding any chronic allergies.
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2. Test the drainage for glucose.
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3. Ask the patient if she has experienced a recent middle ear infection.
4. Irrigate the ear with warm mineral oil, peroxide, and flush with warm water.
Correct Answer: 2
Rationale 1: Chronic allergies would not result in clear fluid draining from the clients ear.
However, an acute allergic reaction may result in serous fluid that drains from the clients ear.
Rationale 2: When a clients ear is draining clear fluid, this might indicate the client has a
cerebrospinal fluid leak. The fluid should be tested for glucose. Glucose is present in
cerebrospinal fluid.
Rationale 3: A recent middle ear infection may result in purulent or bloody drainage from the
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clients ear.
Rationale 4: The ear should not be irrigated at this time. Irrigation with warm mineral oil,
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peroxide, and flushing with warm water is often used to remove cerumen. There is nothing to
suggest that the client has impacted cerumen.
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Global Rationale: When a clients ear is draining clear fluid, this might indicate the client has a
cerebrospinal fluid leak. The fluid should be tested for glucose. Glucose is present in
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cerebrospinal fluid. Chronic allergies would not result in clear fluid draining from the clients ear.
However, an acute allergic reaction may result in serous fluid that drains from the clients ear. A
recent middle ear infection may result in purulent or bloody drainage from the clients ear. The
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ear should not be irrigated at this time. Irrigation with warm mineral oil, peroxide, and flushing
with warm water is often used to remove cerumen. There is nothing to suggest that the client has
impacted cerumen.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 14.3: Describe the techniques required for assessment of the structures of
the ear, nose, mouth, and throat.
Question 72
Type: MCSA
The nurse is assessing the tympanic membrane of a client and notes the presence of a bluish
color. The nurse would suspect which of the following?
1. Acute otitis media
2. Recent head trauma
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3. Blocked eustachian tubes
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4. History of frequent middle ear infections
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Correct Answer: 2
Rationale 1: Acute otitis media is associated with a reddish or yellowish tinge on the tympanic
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membrane.
Rationale 2: The presence of a bluish tinge on the tympanic membrane is most likely due to
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blood in the middle ear and may be indicative of recent head trauma.
Rationale 3: A blocked eustachian tube will cause the tympanic membrane to retract.
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Rationale 4: Previous middle ear infections will result in white patches noted on the tympanic
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membrane that indicate scarring.
Global Rationale: The presence of a bluish tinge on the tympanic membrane is most likely due
to blood in the middle ear and may be indicative of recent head trauma. Acute otitis media is
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associated with a reddish or yellowish tinge on the tympanic membrane. A blocked eustachian
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tube will cause the tympanic membrane to retract. Previous middle ear infections will result in
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white patches noted on the tympanic membrane that indicate scarring.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 14.4: Explain the use of otoscope.
Question 73
Type: MCSA
The nursing is performing an otoscopic examination on an adult client and is unable to visualize
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the tympanic membrane. The nurse should perform which of the following steps to better
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1. Pull the pinna up and back, then reinsert the otoscope
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visualize this structure?
2. Tell the client to move away from the speculum if they experience any pain as the otoscope is
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advanced.
3. Reinsert the otoscope quickly and press against both sides of the inner auditory canal.
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4. Pull the pinna down and back, then reinsert the otoscope.
Correct Answer: 1
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Rationale 1: To avoid trauma to the ear, the otoscope is to be removed and the pinna should be
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pulled up and back for better visualization.
Rationale 2: The client should be instructed to state any feelings of discomfort or pain but not to
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pull away because this may result in injury during this examination.
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Rationale 3: The otoscope should not be inserted quickly and should not be pressed against
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either side of the inner auditory canal because it would be painful for the client.
Rationale 4: Pulling down and back is recommended in children because of the shape of their
auditory canal.
Global Rationale: To avoid trauma to the ear, the otoscope is to be removed and the pinna
should be pulled up and back for better visualization. The client should be instructed to state any
feelings of discomfort or pain but not to pull away because this may result in injury during this
examination. The otoscope should not be inserted quickly and should not be pressed against
either side of the inner auditory canal because it would be painful for the client. Pulling down
and back is recommended in children because of the shape of their auditory canal.
Cognitive Level: Applying
Client Need: Physiological Integrity
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Learning Outcome: 14.4: Explain the use of otoscope.
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
Question 74
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Type: MCMA
The nurse is examining a clients ears and notes that right ear is occluded with wax. The nurse
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would choose which of the following to remove the earwax?
Standard Text: Select all that apply.
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1. Irrigation with warm mineral oil, peroxide, followed by warm water
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2. A sharp instrument to break up the ear wax
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3. Irrigation with a cold solution
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4. A cerumen spoon to remove the wax
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5. Irrigation with warm sudsy water
Correct Answer: 1,4
Rationale 1: Irrigate the ear canal with warm mineral oil, peroxide, followed by warm
water. Care must be taken when removing cerumen. Warmed mineral oil and peroxide soften the
earwax and the ear can be irrigated with warm water afterwards.
Rationale 2: A sharp instrument to break up the ear wax within the ear canal. Sharp
instruments should not be placed within the ear canal because it may injure the tympanic
membrane.
Rationale 3: Irrigate the ear canal with a cold solution. Cold solutions may harden the ear
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wax, making it more difficult to remove.
Rationale 4: A cerumen spoon can be placed in the ear canal to remove the wax. The
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cerumen can also be safely removed with a cerumen spoon. The cerumen spoon is designed to
remove the wax safely without risking injury or perforation of the eardrum.
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Rationale 5: Irrigate the ear canal with warm sudsy water. Warm, sudsy solutions may
irritate the ear canal.
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Global Rationale: Care must be taken when removing cerumen. Warmed mineral oil and
peroxide soften the earwax and the ear can be irrigated with warm water afterwards. Sharp
instruments should not be placed within the ear canal because it may injure the tympanic
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membrane. Cold solutions may harden the ear wax, making it more difficult to remove. The
cerumen can also be safely removed with a cerumen spoon. The cerumen spoon is designed to
remove the wax safely without risking injury or perforation of the eardrum. Warm, sudsy
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solutions may irritate the ear canal.
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Cognitive Level: Applying
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Client Need: Safe Effective Care Environment
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 14.4: Explain the use of otoscope.
Question 75
Type: MCMA
During the focused interview, the client admits to regularly abusing cocaine. Which of the
following findings does the nurse expect to discover during the physical assessment of the clients
nose?
Standard Text: Select all that apply.
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1. The nurse notes that the nasal septum has perforated.
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2. Temporomandibular joint pain when the client opens and closes the mouth
4. Yeast infection of nasal mucosa and in mouth
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5. Difficulty swallowing water
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3. The septum is noted to be very pale in color.
Correct Answer: 1,3
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Rationale 1: The nurse notes that the nasal septum has perforated. When a client is abusing
cocaine, the nurse may note that the nasal septum has broken down and has even perforated.
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Rationale 2: Temporomandibular joint pain when the client opens and closes the mouth.
Temporomandibular joint pain could be the result of otitis externa or might indicate
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temporomandibular joint dysfunction. It is unrelated to cocaine use.
Rationale 3: The septum is noted to be very pale in color. When a client is abusing cocaine,
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the nasal mucosa might appear vasoconstricted and very pale in color.
Rationale 4: Yeast infection of nasal mucosa and in mouth. Steroid inhalers can cause growth of
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Candida in the nose, mouth, or throat. It is unrelated to cocaine use.
Rationale 5: Difficulty swallowing water. If the client experiences difficulty in swallowing, this
may be due to a neurological or gastrointestinal problem, or it may be related to ill-fitting
dentures or malocclusion.
Global Rationale: When a client is abusing cocaine, the nurse may note that the nasal septum
has broken down and has even perforated. Temporomandibular joint pain could be the result of
otitis externa or might indicate temporomandibular joint dysfunction. It is unrelated to cocaine
use. When a client is abusing cocaine, the nasal mucosa might appear vasoconstricted and very
pale in color. Steroid inhalers can cause growth of Candida in the nose, mouth, or throat. It is
unrelated to cocaine use. If the client experiences difficulty in swallowing, this may be due to a
neurological or gastrointestinal problem, or it may be related to ill-fitting dentures or
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malocclusion.
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Question 76
Type: MCMA
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The nurse is discharging an 11-month-old child who was brought to the emergency room for the
treatment of an ear infection and fever. The nurse would include which of the following
Standard Text: Select all that apply.
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statements in the discharge teaching to the parents?
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1. The babys last bottle before bedtime should only contain water.
2. It is important not to prop the babys bottle during feeding.
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3. You must rinse the babys mouth right after the baby falls asleep.
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4. You must perform oral hygiene more frequently throughout the day.
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5. The last bottle of the evening should not be given just before the baby goes to sleep.
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Correct Answer: 2,5
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Rationale 1: The babys last bottle before bedtime should only contain water. Milk should
not be replaced with water because the baby may not receive enough nutrition. Bottles should not
be given just before bedtime.
Rationale 2: It is important not to prop the babys bottle during feeding. A primary source of
ear infection in infants and small children is the practice of propping the bottle with milk or
juice. The sugar in these liquids remains in the mouth and contributes to the potential for
infection in the throat, which travels through the shorter, narrower, and more horizontal auditory
tube.
Rationale 3: You must rinse the babys mouth right after the baby falls asleep. This would
not be appropriate and might be dangerous for the baby. Providing oral hygiene for children
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immediately before bedtime might be helpful to help reduce the risk of ear infections.
Rationale 4: You must perform oral hygiene more frequently throughout the day.
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Increasing the oral hygiene frequency throughout the day will not improve this situation if bottle
propping is occurring or if the baby is given a bottle immediately prior to bedtime.
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Rationale 5: The last bottle of the evening should not be given just before the baby goes to
sleep. A major source of ear infection in infants and small children is the practice of giving the
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baby a bottle at bedtime. The sugar in these liquids remains in the mouth and contributes to the
potential for infection in the throat, which travels through the shorter, narrower, and more
horizontal auditory tube.
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Global Rationale: Milk should not be replaced with water because the baby may not receive
enough nutrition. Bottles should not be given just before bedtime. A primary source of ear
infection in infants and small children is the practice of propping the bottle with milk or juice.
st
The sugar in these liquids remains in the mouth and contributes to the potential for infection in
the throat, which travels through the shorter, narrower, and more horizontal auditory tube. This
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would not be appropriate and might be dangerous for the baby. Providing oral hygiene for
children immediately before bedtime might be helpful to help reduce the risk of ear infections.
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Increasing the oral hygiene frequency throughout the day will not improve this situation if bottle
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propping is occurring or if the baby is given a bottle immediately prior to bedtime. A major
source of ear infection in infants and small children is the practice of giving the baby a bottle at
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bedtime. The sugar in these liquids remains in the mouth and contributes to the potential for
infection in the throat, which travels through the shorter, narrower, and more horizontal auditory
tube.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 14.6: Describe developmental, psychosocial, cultural, and environmental
variations in assessment techniques and findings.
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Question 77
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Type: MCSA
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The nurse is assessing the ears, nose and mouth of an Asian client with a student nurse. Which of
the following statements made by the nurse to the student nurse about cultural differences is
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accurate?
1. Asians are more likely to experience greater difficulty with otitis media than people from other
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cultures.
2. Sometimes in Asians and Native Americans, their ear wax looks dry and dark.
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3. Asians have a higher risk of having issues associated with cleft lips and cleft palates.
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4. Asians have a high incidence of tooth decay.
Correct Answer: 2
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Rationale 1: Asians do not have a tendency to develop otitis media more than other cultures.
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Rationale 2: Cerumen appears dry and gray to brown in Asians and Native Americans. Cerumen
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found in Caucasians and African Americans looks moist and yellow-orange in color.
Rationale 3: Cleft lip and palate occur with greatest frequency in Asians and least often in
African Americans.
Rationale 4: Caucasians have the highest incidence of tooth decay.
Global Rationale: Cerumen appears dry and gray to brown in Asians and Native Americans.
Cerumen found in Caucasians and African Americans looks moist and yellow-orange in color.
Asians do not have a tendency to develop otitis media more than other cultures. Cleft lip and
palate occur with greatest frequency in Asians and least often in African Americans. Caucasians
have the highest incidence of tooth decay.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 14.6: Describe developmental, psychosocial, cultural, and environmental
variations in assessment techniques and findings.
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Question 78
Type: MCSA
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The nurse is assessing several children in a pediatric clinic. Which of the following children
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might be experiencing delayed development?
1. The 6-year-old child has lost 2 deciduous teeth.
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2. The 26-month-old child has one baby tooth.
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3. The 4-month-old infant is drooling.
4. The 2-month-old infants salivary glands are not producing saliva.
Correct Answer: 2
Rationale 1: Eruption of permanent teeth begins at around age 6 and continues through
adolescence.
Rationale 2: Deciduous (baby) teeth begin to erupt between 6 months and 2 years of age. A 26month-old child might be expected to have more than one deciduous tooth.
Rationale 3: Drooling of saliva occurs for several months after saliva is produced (3 months old)
until swallowing saliva is learned.
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Rationale 4: Salivation begins at 3 months of age.
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Global Rationale: Eruption of permanent teeth begins at around age 6 and continues through
adolescence. Deciduous (baby) teeth begin to erupt between 6 months and 2 years of age. A 26month-old child might be expected to have more than one deciduous tooth. Drooling of saliva
Cognitive Level: Understanding
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Client Need: Physiological Integrity
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learned. Salivation begins at 3 months of age.
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occurs for several months after saliva is produced (3 months old) until swallowing saliva is
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 14.6: Describe developmental, psychosocial, cultural, and environmental
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Question 79
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variations in assessment techniques and findings.
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Type: MCMA
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During the focused interview, the client provides information to the nurse regarding her
daughters recent diagnosis with cancer. The client is exhibiting clinical manifestations associated
with anxiety. During the physical assessment, which of the following findings might be
expected?
Standard Text: Select all that apply.
1. The client complains of pain when the tragus is gently manipulated.
2. The client has several small ulcers on her lip.
3. Pale nasal mucosa
4. Small sores are noted within the mouth.
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5. Perforated nasal septum
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Correct Answer: 1,2,4
Rationale 1: The client complains of pain when the tragus is gently manipulated. Pain that
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occurs with manipulation of the tragus may accompany temporomandibular joint dysfunction
that may be associated with jaw clenching. Jaw clenching can accompany psychological stress.
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Rationale 2: The client has several small ulcers on her lip. Clients who are under a great deal
of stress might bite their lips.
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Rationale 3: Pale nasal mucosa. Pale nasal mucosa is associated with cocaine use, infection,
hypoxia, and allergies.
Rationale 4: Small sores are noted within the mouth. Clients who are under a great deal of
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stress might present with ulcers in their mouth.
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Rationale 5: Perforated nasal septum. A perforated nasal septum is associated with cocaine
use.
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Global Rationale: Pain that occurs with manipulation of the tragus may accompany
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temporomandibular joint dysfunction that may be associated with jaw clenching. Jaw clenching
can accompany psychological stress. Clients who are under a great deal of stress might bite their
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lips. Pale nasal mucosa is associated with cocaine use, infection, hypoxia, and allergies. Clients
who are under a great deal of stress might present with ulcers in their mouth. A perforated nasal
septum is associated with cocaine use.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 14.6: Describe developmental, psychosocial, cultural, and environmental
variations in assessment techniques and findings.
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Question 80
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Type: MCMA
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The nurse is conducting a hearing assessment on an older adult client with impacted cerumen
noted in the right ear canal. When performing the Weber test, the nurse would expect to learn
Standard Text: Select all that apply.
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which of the following?
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1. Air conduction is longer than bone conduction.
2. Bone conduction is longer than air conduction.
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3. Sound lateralized to the right ear.
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4. The client is unable to maintain balance while standing.
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5. The 4 year old placed a pea into his nose during lunch.
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Correct Answer: 3
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Rationale 1: The Rinne test, not the Weber test, compares air and bone conduction.
Rationale 2: The Rinne test, not the Weber test, compares air and bone conduction.
Rationale 3: The Weber test uses bone conduction to evaluate hearing in a person who hears
better in one ear than in the other. With impacted cerumen, an ear infection, or a perforated
tympanic membrane, the sound will lateralize to the affected ear during the Weber test.
Rationale 4: The Romberg test is used to determine equilibrium and the clients ability to
maintain balance while standing.
Rationale 5: The 4 year old placed a pea into his nose during lunch. Children are more likely
to introduce foreign objects into their mouth and nose. This behavior is not associated with gum
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or oral mucosa problems.
Global Rationale: The Rinne test compares air and bone conduction. Normally, the sound is
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heard twice as long by air conduction than by bone conduction after bone conduction stops. The
Weber test uses bone conduction to evaluate hearing in a person who hears better in one ear than
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in the other. With impacted cerumen, an ear infection, or a perforated tympanic membrane, the
sound will lateralize to the affected ear during the Weber test. The Romberg test is used to
Cognitive Level: Applying
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Client Need: Physiological Integrity
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determine equilibrium and the clients ability to maintain balance while standing.
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Diagnosis
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Learning Outcome: 14.8: Apply critical thinking in selected simulations related to physical
assessment of the structures of the ear, nose, mouth, and throat.
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Question 81
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Type: MCSA
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The nurse wants to assess the apex of a clients right lung. Which of the following locations
should the nurse place the stethoscope to assess this area on the client?
1. Intercostal space 6th rib near the sternum
2. Intercostal space 4th rib near the axillary line
3. Below the scapula
4. Near the right clavicle
Correct Answer: 4
Rationale 1: The apex of each lung is slightly superior to the inner third of the clavicle.
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Rationale 2: The apex of each lung is slightly superior to the inner third of the clavicle.
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Rationale 3: The apex of each lung is slightly superior to the inner third of the clavicle.
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Rationale 4: The apex of each lung is slightly superior to the inner third of the clavicle.
Global Rationale: The apex of each lung is slightly superior to the inner third of the clavicle
Cognitive Level: Remembering
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Client Need: Physiological Integrity
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whereas the base of each lung rests on the diaphragm.
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
system.
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Question 82
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Learning Outcome: 15.2: Distinguish landmarks that guide assessment of the respiratory
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Type: MCSA
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During the respiratory assessment of a client the nurse wishes to locate the angle of Louis. This
structure can be identified by using which of the following landmarks?
1. Clavicle
2. Sternum
3. First rib
4. Vertebral column
Correct Answer: 2
Rationale 1: The angle of Louis is the horizontal ridge formed by the intersection of the
manubrium and the body of the sternum.
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Rationale 2: The angle of Louis is the horizontal ridge formed by the intersection of the
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manubrium and the body of the sternum.
manubrium and the body of the sternum.
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Rationale 3: The angle of Louis is the horizontal ridge formed by the intersection of the
manubrium and the body of the sternum.
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Rationale 4: The angle of Louis is the horizontal ridge formed by the intersection of the
Global Rationale: The angle of Louis is the horizontal ridge formed by the intersection of the
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manubrium and the body of the sternum.
Cognitive Level: Understanding
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Client Need Sub:
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Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 15.2: Distinguish landmarks that guide assessment of the respiratory
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system.
Question 6
Type: MCSA
While assessing the client, the nurse notes that the client has a moist cough. The nurse would
include which of the following questions in the focused interview?
1. Have you been losing weight?
2. How long have you been sick?
3. Are you wheezing?
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4. Are you coughing up any mucus or phlegm?
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Correct Answer: 4
Rationale 2: The client may not necessarily be sick.
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Rationale 1: At this point, the client should not be questioned about weight loss.
Rationale 3: The client should be questioned about the cough during the focused interview and
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not about wheezing.
Rationale 4: The nurse must determine if the cough is productive or nonproductive. A moist
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cough is often associated with lung infections. The color and odor of any mucus or phlegm
(sputum) is associated with specific diseases or problems
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Global Rationale: The nurse must determine if the cough is productive or nonproductive. A
moist cough is often associated with lung infections. The color and odor of any mucus or phlegm
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(sputum) is associated with specific diseases or problems. At this point, the client should not be
questioned about weight loss. The client may not necessarily be sick. The client should be
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questioned about the cough during the focused interview and not about wheezing.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.3: Develop questions to be used when completing the focused interview.
Question 83
Type: MCSA
The nurse is assessing the clients respiratory system. Which of the following methods will result
in the most accurate assessment of the clients respiratory rate?
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1. The nurse should place a hand on the clients chest to count respirations accurately.
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3. The nurse should count only the respirations that are audible.
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2. The nurse should inform the client that the nurse is counting the clients respirations.
4. The nurse should count the respirations in an unobtrusive manner without informing the client.
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Correct Answer: 4
Rationale 1: Though laying a hand on the clients chest allows the nurse to feel the rise and fall
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of the chest, this may be considered an intrusive move and might increase the clients level of
anxiety, which may affect the respiratory rate.
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Rationale 2: The nurse should not inform the client about this portion of the assessment.
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Rationale 3: Not all clients have audible respiratory cycles, and this would not be an effective
method for accuracy.
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Rationale 4: If a client knows his respirations are being counted, it may alter the normal
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breathing pattern.
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Global Rationale: If a client knows his respirations are being counted, it may alter the normal
breathing pattern. Though laying a hand on the clients chest allows the nurse to feel the rise and
fall of the chest, this may be considered an intrusive move and might increase the clients level of
anxiety, which may affect the respiratory rate. The nurse should not inform the client about this
portion of the assessment. Not all clients have audible respiratory cycles, and this would not be
an effective method for accuracy.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 15.4: Explain client preparation for assessment of the respiratory system.
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Question 84
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Type: SEQ
The nurse is preparing to assess the clients respiratory system. Rank in order according to how
the nurse should proceed.
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Standard Text: Click and drag the options below to move them up or down.
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Choice 1. Auscultation
Choice 2. Inspection
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Choice 3. Percussion
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Choice 4. Client survey
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Choice 5. Palpation
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Correct Answer: 4,2,5,3,1
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Rationale 1: The fifth step in physical assessment of the respiratory system is auscultation.
Rationale 2: The second step of respiratory assessment is inspection of the anterior and posterior
thorax.
Rationale 3: The fourth step in physical assessment of the respiratory system is percussion of the
anterior and posterior thorax.
Rationale 4: The first step in any physical assessment is the client survey.
Rationale 5: The third step in respiratory assessment is palpation of the structures of the anterior
and posterior thorax.
Global Rationale: The physical assessment of the respiratory system follows an organized
pattern. It begins with the client survey, then inspection of the anterior and posterior thorax. The
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assessment ends with palpation, percussion, and auscultation of the anterior thorax.
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Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.5: Describe the techniques required for assessment of the respiratory
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system.
Question 86
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Type: MCSA
During the examination of an elderly male the nurse notes thin, gray pubic hairs and a scrotal sac
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that hangs significantly lower than the penis. The nurse would correctly choose which of the
following actions?
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1. Document the findings as normal.
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2. Inform the client that he is no longer fertile.
3. Notify the healthcare provider of the findings.
4. Ask the client about his sexual practices.
Correct Answer: 1
Rationale 1: The older adult male begins to demonstrate thinning and graying of the pubic hair.
The penis and testicles begin to diminish in size and the scrotum hangs lower.
Rationale 2: Sperm production in the middle aged and older man is reduced but there is still
adequate sperm production to father children.
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Rationale 3: The findings are normal and do now warrant notification of the healthcare provider.
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Rationale 4: The sexual practices of the client are not impacted by the findings. Inquiry into
them is not indicated at this time.
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Global Rationale: According to Tanners Maturation Stages in the male, the findings in this
situation are appropriate for the elderly male client. Although sperm production does decline
during middle age, the presence of viable sperm in the elderly male contradicts infertility. No
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further subjective information is required by the nurse, and the healthcare provider does not need
Cognitive Level: Analyzing
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notification.
Client Need Sub:
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Client Need: Health Promotion and Maintenance
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Nursing/Integrated Concepts: Nursing Process: Assessment
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system.
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Learning Outcome: 21-1: Identify the anatomy and physiology of the male reproductive
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Question 87
Type: MCSA
During the examination of a male client who has not been circumcised, the nurse is attempts to
retract the foreskin of the penis, but skin is very tight and cannot be pulled back. The nurse
would correctly anticipate which of the following conditions?
1. Urethral stricture
2. Paraphimosis
3. Urethritis
4. Phimosis
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Correct Answer: 4
Rationale 1: Urethral strictures would be suspected in the event of voiding problems or a
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pinpoint size meatus opening was noted not an inability to retract the foreskin over the glans
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penis.
Rationale 2: Paraphimosis is a condition in which the foreskin cannot be moved back over the
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glans penis once it has been retracted
Rationale 3: Urethritis manifests with symptoms including redness and edema around the glans
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and foreskin, eversion of the urethral mucosa, and drainage.
Rationale 4: Phimosis refers to a condition in which the foreskin cannot be moved back over the
glans penis.
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Global Rationale: Phimosis is a condition in which the foreskin is too tight to retract over the
glans penis. Paraphimosis is a condition in which the foreskin cannot be moved back over the
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glans penis once retracted. Urethritis is a condition in which the urethra is infected or inflamed.
Signs of urethritis include redness and edema around the glans and foreskin, eversion of urethral
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mucosa, and drainage. A urethral stricture is suspected if the urinary meatus is pinpoint size.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 21-1: Identify the anatomy and physiology of the male reproductive
system.
Question 88
Type: MCSA
The nurse is interviewing a male client who states I feel like I have a bag of worms in my
scrotum. The nurse would correctly suspect which of the following conditions?
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1. Orchitis
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2. Varicocele
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3. Epididymitis
4. Hernia
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Correct Answer: 2
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Rationale 1: Orchitis refers to a swelling and inflammation of the testicles.
Rationale 2: A varicocele is a distention of the spermatic cord and may be described as a bag of
worms.
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Rationale 3: Epididymitis is an inflammatory condition of the epididymis.
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Rationale 4: An inguinal hernia feels like a bulge or mass upon palpation of the inguinal canal,
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which indicates a protrusion of the intestine into the groin region.
Global Rationale: Swelling or inflammation of the testicles is referred to as orchitis. A
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varicocele is a distention of the spermatic cord and often is described as a bag of worms.
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Epididymitis is an inflammatory condition of the epididymis. An inguinal hernia feels like a
bulge or mass upon palpation of the inguinal canal, which indicates a protrusion of the intestine
into the groin region.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 21-1: Identify the anatomy and physiology of the male reproductive
system.
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Question 89
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Type: MCMA
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When caring for a male client scheduled for a prostatectomy due to cancer, the nurse would
expect which of the following assessment findings to be present?
1. Enlargement of the scrotal sac
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2. Pyuria
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Standard Text: Select all that apply.
4. Dribbling of urine
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3. Increase in prostatic specific antigen (PSA)
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5. Difficulty in initiating urine stream
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Correct Answer: 3,4,5
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Rationale 1: Enlargement of the scrotal sac. The scrotal sac will not be enlarged with a
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diagnosis for prostate cancer. Scrotal sac enlargement may be noted in the presence of
inflammation of the testicles or the epididymis.
Rationale 2: Pyruia. Pyruia refers to pus in the urine. Pus in the urine is not consistent with the
presence of prostate cancer.
Rationale 3: Increase in prostatic specific antigen (PSA). Low levels of prostatic specific
antigen are present in normal, healthy men. Laboratory values for the PSA will be elevated in the
presence of prostate cancer.
Rationale 4: Dribbling of urine. The dribbling of urine may be seen with prostate cancer.
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Dribbling will occur in the presence of prostate enlargement.
Rationale 5: Difficulty in initiating urine stream. Prostate enlargement as seen in malignant
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conditions may result in the client experiencing difficulty in initiating the urine stream.
Global Rationale: The scrotal sac of the client diagnosed with prostate cancer would not be
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enlarged. The prostate is located on each side of the male urethra just below the bladder. It is not
anatomically near the scrotal sac. Pyruia refers to pus in the urine. Pus in the urine is not
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consistent with a diagnosis of prostate cancer. Low levels of prostatic specific antigen (PAS) are
present in normal, healthy men. PSA levels are used to assess for the presence of prostate cancer.
Laboratory values for the PSA will be elevated in the presence of prostate cancer. Conditions of
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the prostate gland may result in urinary changes. The dribbling of urine may be seen with
prostate cancer. Dribbling or difficulty starting the urine stream may be seen in the presence of
prostate enlargement.
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Cognitive Level: Analyzing
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Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 21-1: Identify the anatomy and physiology of the male reproductive
system.
Question 90
Type: MCSA
While performing prostate palpation, the nurse notes that the client expresses severe tenderness
and discomfort during the procedure. The nurse should suspect which of the following conditions
in the client?
1. Prostate cancer
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2. Prostatitis
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3. Enlargement of the prostate
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4. Urinary tract infection
Correct Answer: 2
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Rationale 1: The presence of extreme hardness or nodules is characteristic of prostate cancer.
Rationale 2: The prostate should feel smooth, firm, or rubbery, and extend no larger than 1
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centimeter into the rectal area. This exam should not cause tenderness, which is an indication of
inflammation.
Rationale 3: Enlargement of the prostate will cause urinary tract symptoms such as difficulty in
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starting a stream, or dribbling of urine.
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Rationale 4: Urinary tract infections will cause painful and frequent urination.
Global Rationale: Upon examination, the prostate should feel smooth, firm, or rubbery, and
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extend no larger than 1 centimeter into the rectal area. This exam should not cause tenderness,
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which is an indication of inflammation. The presence of extreme hardness or nodules is
characteristic of prostate cancer. Enlargement of the prostate will cause urinary tract symptoms
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such as difficulty in starting a stream, or dribbling of urine. Urinary tract infections will cause
painful and frequent urination.
Question 91
Type: MCMA
The nurse is preparing to assess the female clients cardiovascular system during the clients visit
to the healthcare providers office. Which of the following items should the nurse have available
in the room in order to complete the examination?
Standard Text: Select all that apply.
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1. Ruler (metric)
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2. Stethoscope
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3. Lamp
4. Client gown and a drape
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5. Doppler
Correct Answer: 1,2,3,4,5
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Rationale 1: Ruler (metric). The nurse will require a metric ruler to determine distention of
blood vessels.
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Rationale 2: Stethoscope. The nurse will require a stethoscope to auscultate the clients heart and
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arteries.
Rationale 3: Lamp. The nurse will require a lamp or adequate lighting in the room for the
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inspection process of the assessment.
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Rationale 4: Client gown and a drape. Female clients should be provided with a gown and a
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drape for this examination in order to maintain privacy and avoid overexposure.
Rationale 5: Doppler. A Doppler device can be used to determine the presence of a pulse if the
nurse is unable to adequately palpate the pulse.
Global Rationale: The nurse will require a metric ruler to determine distention of blood vessels.
The nurse will require a stethoscope to auscultate the clients heart and arteries. The nurse will
require a lamp or adequate lighting in the room for the inspection process of the assessment.
Female clients should be provided with a gown and a drape for this examination in order to
maintain privacy and avoid overexposure. A Doppler device can be used to determine the
presence of a pulse if the nurse is unable to adequately palpate the pulse.
Cognitive Level: Remembering
Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
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Learning Outcome: 17.4: Explain client preparation for assessment of the cardiovascular
system.
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Question 92
Type: MCMA
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The nurse is preparing to assess the clients cardiovascular system. Which of the following
positions will the nurse need to place the client in during the assessment?
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1. Dorsal recumbent
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Standard Text: Select all that apply.
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2. Leaning forward
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3. Right lateral position
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4. Left lateral position
5. Sitting upright
Correct Answer: 1,2,4,5
Rationale 1: Dorsal recumbent. The client will be asked to remain in a supine position or
dorsal recumbent position for part of the examination. The nurse may be able to auscultate
murmurs better while the client is in this position.
Rationale 2: Leaning forward. The client will be asked to lean forward during auscultation of
the heart. The nurse should listen to the clients heart while the client is leaning forward.
Rationale 3: Right lateral position. This is not a common position to place the client in during
this type of examination.
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Rationale 4: Left lateral position. The client will be asked to lie on the left side during part of
this examination. In obese clients, heart sounds are best heard at the apical area with the client in
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the left lateral position.
Rationale 5: Sitting upright. The nurse will most likely begin this examination while the client
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is in this position. This is the position the nurse should ask the client to assume when beginning
chest auscultation.
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Global Rationale: The nurse will most likely begin this examination with the client sitting
upright. This is the position the nurse should ask the client to assume when beginning chest
auscultation. The client will be asked to remain in a supine position or dorsal recumbent position
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for part of the examination. The nurse may be able to auscultate murmurs better while the client
is in this position. The client will be asked to lean forward during auscultation of the heart. The
nurse should listen to the clients heart while the client is leaning forward. The client will be
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asked to lie on the left side during part of this examination. In obese clients, heart sounds are best
heard at the apical area with the client in the left lateral position. Right lateral position is not a
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Question 93
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common position to place the client in during this type of examination.
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Type: MCMA
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The nurse is preparing to perform an interview to obtain information about the client. Which of
the following are classified as secondary sources of information?
Standard Text: Select all that apply.
1. The clients wife
2. The clients medical record from his last hospital admission
3. The client
4. The clients daughter
5. The clients physical therapist
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Correct Answer: 1,2,4,5
Rationale 1: The clients wife: The clients wife is an example of a secondary source of
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information.
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Rationale 2: The clients medical record from his last hospital admission: The clients medical
record is an example of a secondary source of information.
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Rationale 3: The client: The client is the primary source of information.
Rationale 4: The clients daughter: The clients daughter is an example of a secondary source of
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information.
Rationale 5: The clients physical therapist: The clients physical therapist is another member of
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the clients health team and is a secondary source of information.
Global Rationale: The clients wife is an example of a secondary source of information. The
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clients medical record is an example of a secondary source of information. The clients daughter
is an example of a secondary source of information. The clients physical therapist is another
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member of the clients health team and is a secondary source of information. The client is the
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primary source of information.
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Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 28.1: Use professional communication skills to gather subjective data in a
health history.
Question 94
Type: MCMA
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The nurse is interviewing the client. Which of the following may lead to communication
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breakdown between the nurse and client?
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Standard Text: Select all that apply.
1. The client is a Native American and the nurse is of Northern European descent.
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2. During the interview, the nurse is trying to remember what the healthcare provider asked her
to do earlier in the day.
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3. The young nurse creates an informal atmosphere to discuss safe sexual practices with a
teenaged client.
4. The young nurse uses a serious and respectful tone to discuss erectile dysfunction with an
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older client.
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5. The nurse states, So, you experience pain with micturation.
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Correct Answer: 1,2,5
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Rationale 1: The client is a Native American and the nurse is of Northern European
descent. Communication has an increased chance of breaking down when the nurse and the
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client are from different cultures. Some Native Americans believe that direct eye contact is an
invasion of privacy and a firm handshake can be an aggressive action. A person of Northern
European descent may feel that a person who avoids direct eye contact is untrustworthy and a
weak handshake indicates the client has a weak demeanor.
Rationale 2: During the interview, the nurse is trying to remember what the healthcare
provider asked her to do earlier in the day. Communication can break down when the nurse
fails to decode the messages by not actively listening to the client.
Rationale 3: The young nurse creates an informal atmosphere to discuss safe sexual
practices with a teenaged client. It is appropriate for the nurse to create an informal atmosphere
when discussing a sensitive topic with a younger client.
Rationale 4: The young nurse uses a serious and respectful tone to discuss erectile
dysfunction with an older client. It is appropriate for the young nurse to use a serious and
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respectful when discussing a sensitive topic with an older client.
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Rationale 5: The nurse states, So, you experience pain with micturation. Communication can
break down easily when nurses use words that clients do not understand. The nurse should avoid
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medical jargon.
Global Rationale: Communication has an increased chance of breaking down when the nurse
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and the client are from different cultures. Some Native Americans believe that direct eye contact
is an invasion of privacy and a firm handshake can be an aggressive action. A person of Northern
European descent may feel that a person who avoids direct eye contact is untrustworthy and a
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weak handshake indicates the client has a weak demeanor. Communication can break down
when the nurse fails to decode the messages by not actively listening to the client.
Communication can break down easily when nurses use words that clients do not understand.
The nurse should avoid medical jargon. It is appropriate for the nurse to create an informal
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atmosphere when discussing a sensitive topic with a younger client. It is appropriate for the
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young nurse to use a serious and respectful when discussing a sensitive topic with an older client.
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Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 28.1: Use professional communication skills to gather subjective data in a
health history.
Question 95
Type: FIB
The client weighs 224 pounds. How many kilograms does the client weigh? Round to the nearest
tenth.
_____ kilograms
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Standard Text:
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Correct Answer: 101.8 kilograms
Rationale: There are 2.2 pounds in 1 kilogram. The client weighs 224 pounds. The nurse can
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divide the clients weight in pounds by 2.2 and determine that the client weighs 101.8181
Global Rationale:
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Cognitive Level: Remembering
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kilograms. When rounded to the nearest tenth, the client weighs 101.8 kilograms.
Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general
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survey and physical assessment of a client.
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Question 96
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Type: FIB
The client weighs 145 kilograms. The client is 1.75 meters. What is this clients body mass index
(BMI) using the following formula: BMI = weight (kg)/height2 (meters)? Round to the nearest
whole number. ____
Standard Text:
Correct Answer: 47
Rationale: Body mass index (BMI) is widely used to assess appropriate weight for height using
the following formula: BMI = weight (kg)/ height2 (meters). 145 divided by 1.752 = 47.3469.
When rounded to the nearest whole number, the clients BMI is 47.
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Global Rationale:
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Cognitive Level: Remembering
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Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general
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survey and physical assessment of a client.
Question 97
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Type: MCSA
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The nurse is interviewing the client and learns that the client has an open leg wound that has
been draining a moderate amount of yellowish drainage over the last 3 days. Prior to assessing
the clients wound, which of the following pieces of personal protective equipment is most
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important for the nurse to wear based on the principles of standard precautions?
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1. Fluid-resistant gown
2. Shoe covers
3. Mask
4. Gloves
Correct Answer: 4
Rationale 1: A fluid-resistant gown should be worn if the clients leg drainage cannot be
contained adequately and the drainage has the potential to contaminate the nurses clothing.
Rationale 2: Shoe covers are important to wear if the clients drainage cannot be contained
adequately and has the potential to contaminate the nurses shoes. Along with the shoe covers, the
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Rationale 3: A mask should be worn if the client has a productive cough.
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nurse should also wear a fluid-resistant gown and gloves if the drainage cannot be contained.
Rationale 4: The nurse should always follow standard precautions while assessing the client.
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The most important personal protective equipment for the nurse to wear is a pair of gloves.
Global Rationale: The nurse should always follow standard precautions while assessing the
client. The most important personal protective equipment for the nurse to wear is a pair of
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gloves. A fluid-resistant gown should be worn if the clients leg drainage cannot be contained
adequately and the drainage has the potential to contaminate the nurses clothing. Shoe covers are
important to wear if the clients drainage cannot be contained adequately and has the potential to
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contaminate the nurses shoes. Along with the shoe covers, the nurse should also wear a fluidresistant gown and gloves if the drainage cannot be contained. A mask should be worn if the
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client has a productive cough.
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Cognitive Level: Applying
Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general
survey and physical assessment of a client.
Question 98
Type: MCMA
The nurse is performing a physical assessment of the client. Which of the following pieces of
information are examples of objective data?
Standard Text: Select all that apply.
1. Apical pulse is 94 beats per minute.
3. The client has a nonproductive cough.
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4. The client reports that his pain is severe and throbbing.
5. Respiratory rate is 18 breaths per minute.
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Correct Answer: 1,2,3,5
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2. Blood pressure in right arm is 118/74.
Rationale 1: Apical pulse 94 beats per minute. Objective data can be observed or measured by
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any professional nurse. These are signs and can be measured, seen, felt, or auscultated by the
professional nurse. An apical pulse is objective data because it can be auscultated. A blood
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pressure can be auscultated by any professional nurse.
Rationale 2: Blood pressure in right arm 118/74. Objective data can be observed or measured
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by any professional nurse. These are signs and can be measured, seen, felt, or auscultated by the
professional nurse. A blood pressure can be auscultated by any professional nurse.
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Rationale 3: The client has a nonproductive cough. Objective data can be observed or
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measured by any professional nurse. These are signs and can be measured, seen, felt, or
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auscultated by the professional nurse. A clients cough can be heard by any professional nurse.
Rationale 4: The client reports that his pain is severe and throbbing. The clients description
of his pain is subjective data because the nurse must rely on the client to provide this
information.
Rationale 5: Respiratory rate 18 breaths per minute. Objective data can be observed or
measured by any professional nurse. These are signs and can be measured, seen, felt, or
auscultated by the professional nurse. The clients respiratory rate can be measured by any
professional nurse.
Global Rationale: Objective data can be observed or measured by any professional nurse. These
are signs and can be measured, seen, felt, or auscultated by the professional nurse. An apical
pulse is objective data because it can be auscultated. A blood pressure can be auscultated by any
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professional nurse. A clients cough can be heard by any professional nurse. The clients
respiratory rate can be measured by any professional nurse. The clients description of his pain is
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subjective data because the nurse must rely on the client to provide this information.
Client Need: Health Promotion and Maintenance
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Client Need Sub:
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Cognitive Level: Applying
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general
survey and physical assessment of a client.
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Type: MCSA
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Question 99
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The student nurse is preparing to assess the client while the more experienced nurse assists. Prior
to the physical assessment, the client indicates that he has been experiencing severe left lower
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quadrant pain. Which of the following statements by the student nurse indicates that the student
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nurse requires further education prior to performing this part of the assessment?
1. Im going to start by percussing and palpating the clients left lower quadrant first.
2. I will start the abdominal assessment by inspecting the clients abdomen.
3. Im going to auscultate the abdomen prior to percussing the abdomen.
4. I need to ask the client about the characteristics of his pain.
Correct Answer: 1
Rationale 1: Beginning the assessment with the nontender areas permits the nurse to establish
the borders of the affected area. Examination of the painful area can exacerbate symptoms,
increase the pain, and force termination of the assessment process. The nurse should delay this
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part of the assessment until the last portion of the examination.
Rationale 2: The nurse should begin the assessment of the clients abdomen with inspection of
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the abdomen.
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Rationale 3: The nurse should auscultate the clients abdomen, and then percuss the abdomen.
Rationale 4: The nurse should inquire about the characteristics of the clients pain.
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Global Rationale: Beginning the assessment with the nontender areas permits the nurse to
establish the borders of the affected area. Examination of the painful area can exacerbate
symptoms, increase the pain, and force termination of the assessment process. The nurse should
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begin the assessment of the clients abdomen with inspection of the abdomen. The nurse should
auscultate the clients abdomen, and then percuss the abdomen. The nurse should inquire about
the characteristics of the clients pain.
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Cognitive Level: Applying
Client Need: Physiological Integrity
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Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general
survey and physical assessment of a client.
Question 100
Type: MCMA
The nurse is performing a physical assessment on a client in an outpatient clinic. The nurse is
inspecting and palpating the clients face, skin folds, axillae, palms, and soles of the feet. The
nurse determines the client is diaphoretic. Which of the following statements by the client are
expected?
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Standard Text: Select all that apply.
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1. Your elevator is out and I had to climb three flights of stairs.
3. I think I have hypothyroidism.
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4. Im in a lot of pain today.
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2. Ive been running a fever for the last few days.
5. I heard a rumor at work yesterday that layoffs were inevitable.
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Correct Answer: 1,2,4,5
Rationale 1: Your elevator is out and I had to climb three flights of stairs. Diaphoresis can
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occur with exertion, such as climbing stairs.
Rationale 2: Ive been running a fever for the last few days. Clients who have a fever may
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become diaphoretic.
Rationale 3: I think I have hypothyroidism. It is not typically associated with hypothyroidism.
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More commonly, it is associated with hyperthyroidism.
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Rationale 4: Im in a lot of pain today. Clients who are in pain may become diaphoretic.
Rationale 5: I heard a rumor at work yesterday that layoffs were inevitable. Clients who are
experiencing emotional stress may become diaphoretic.
Global Rationale: Diaphoresis can occur with exertion, such as climbing stairs. Clients who
have a fever may develop diaphoresis. Clients who are in pain may become diaphoretic. Clients
who are experiencing emotional stress may become diaphoretic. It is not typically associated
with hypothyroidism. More commonly, it is associated with hyperthyroidism.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general
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survey and physical assessment of a client.
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Question 101
Type: MCSA
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The student nurse is preparing to insert the otoscope into the adult clients ear. Which of the
following statements indicates that the student nurse requires further education?
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1. Im going to use the largest speculum that will fit easily into the ear canal.
2. Im going to prepare to insert the otoscope by pulling the pinna down and back.
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3. The tympanic membrane should look gray and translucent.
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4. I will ask the client to perform the valsalva maneuver so that I can see how well the tympanic
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membrane moves.
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Correct Answer: 2
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Rationale 1: For the best visualization, use the largest speculum that will fit into the auditory
canal.
Rationale 2: In infants, the pinna is pulled down and back due to the shorter, straight external
ear canal. In the adult client, pull the pinna up, back, and out to straighten the canal.
Rationale 3: The membrane should be flat, gray, and translucent with no scars.
Rationale 4: The valsalva maneuver lets the nurse assess the mobility of the tympanic
membrane.
Global Rationale: In infants, the pinna is pulled down and back due to the shorter, straight
external ear canal. In the adult client, pull the pinna up, back, and out to straighten the canal. For
the best visualization, use the largest speculum that will fit into the auditory canal. The
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membrane should be flat, gray, and translucent with no scars. The valsalva maneuver lets the
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nurse assess the mobility of the tympanic membrane.
Client Need: Physiological Integrity
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Client Need Sub:
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Cognitive Level: Applying
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general
survey and physical assessment of a client.
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Question 102
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Type: MCSA
The nurse holds the tuning fork by the handle and gently strikes the fork on the palm of his hand.
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Then, the nurse places the base of the fork on the clients mastoid process. The nurse requests that
the client indicate when the sound can no longer be heard. Which of the following tests is the
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nurse performing?
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1. Weber
2. Whisper
3. Rinne
4. Romberg
Correct Answer: 3
Rationale 1: The Weber test uses bone conduction to evaluate hearing in a person who hears
better in one ear than in the other. The nurse holds the tuning fork by the handle and strikes the
fork on the palm of the hand. The nurse places the base of the vibrating fork against the clients
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skull. The midline of the anterior portion of the frontal bone is used.
Rationale 2: The whisper test is performed by standing to the side of the client at a distance of
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12 feet and whispering information to the client. The client then repeats the information back to
the nurse.
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Rationale 3: The Rinne test is used to compare air and bone conduction of sound and is
performed in this manner.
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Rationale 4: The Romberg test is used to assess equilibrium. The client stands with feet together
and arms at sides, first with eyes opened and then with eyes closed. The clients ability to
maintain balance for 20 seconds with only mild swaying is documented as a negative Romberg
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test.
Global Rationale: The Rinne test is used to compare air and bone conduction of sound and is
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performed in this manner. The Weber test uses bone conduction to evaluate hearing in a person
who hears better in one ear than in the other. The nurse holds the tuning fork by the handle and
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strikes the fork on the palm of the hand. The nurse places the base of the vibrating fork against
the clients skull. The midline of the anterior portion of the frontal bone is used. The whisper test
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is performed by standing to the side of the client at a distance of 12 feet and whispering
information to the client. The client then repeats the information back to the nurse. The Romberg
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test is used to assess equilibrium. The client stands with feet together and arms at sides, first with
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eyes opened and then with eyes closed. The clients ability to maintain balance for 20 seconds
with only mild swaying is documented as a negative Romberg test.
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general
survey and physical assessment of a client.
Question 103
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Type: MCSA
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During the physical assessment of the client, the nurse notes that the client is able to shrug her
1. Cranial nerve I (olfactory)
2. Cranial nerve II (optic)
3. Cranial nerve VII (facial)
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4. Cranial nerve XI (spinal accessory)
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shoulders bilaterally. The function of which of the following cranial nerves is intact?
Correct Answer: 4
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Rationale 1: Cranial nerve I (olfactory) is also referred to the olfactory nerve. The client with an
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intact cranial nerve I will be able to identify familiar odors.
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Rationale 2: Cranial nerve II (optic) is responsible for the client being able to see.
Rationale 3: The client who has a functioning cranial nerve VII (facial) will be able to use her
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facial muscles symmetrically.
Rationale 4: An intact cranial nerve XI (spinal accessory) is responsible for allowing the client
to shrug her shoulders.
Global Rationale: An intact cranial nerve XI is responsible for allowing the client to shrug her
shoulders. Cranial nerve I is also referred to as the olfactory nerve. The client with an intact
cranial nerve I will be able to identify familiar odors. Cranial nerve II is responsible for the client
being able to see. The client who has a functioning cranial nerve VII will be able to use her facial
muscles symmetrically.
Cognitive Level: Understanding
Client Need: Physiological Integrity
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Nursing/Integrated Concepts: Nursing Process: Assessment
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Client Need Sub:
survey and physical assessment of a client.
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Question 104
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Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general
Type: MCSA
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The function of the clients cranial nerve XII (hypoglossal) is intact. The nurse is able to assess
this nerve by asking the client to perform which of the following activities?
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1. Can you stick out your tongue?
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2. Im going to ask you to taste something and tell me what you think it is.
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3. Close your eyes and tell me when you feel me touch your face with this wisp of cotton.
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4. Im going to lightly touch the back of your throat with this tongue depressor.
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Correct Answer: 1
Rationale 1: An intact cranial nerve XII (hypoglossal) allows the client to stick out the tongue.
Rationale 2: An intact cranial nerve VII (facial) allows the client to taste.
Rationale 3: An intact cranial nerve V (trigeminal) allows the client to identify sensations on the
face.
Rationale 4: Cranial nerve X (vagus) is responsible for producing the gag reflex when the back
of the clients throat is lightly touched.
Global Rationale: An intact cranial nerve XII (hypoglossal) allows the client to stick out the
tongue. An intact cranial nerve VII (facial) allows the client to taste. An intact cranial nerve V
(trigeminal) allows the client to identify sensations on the face. Cranial nerve X (vagus) is
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responsible for producing the gag reflex when the back of the clients throat is lightly touched.
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Cognitive Level: Applying
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Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general
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survey and physical assessment of a client.
Question 105
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Type: HOTSPOT
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The nurse is performing a physical assessment of the client. Identify the location of the right
costovertebral angle on the following figure by drawing an arrow to the site.
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Standard Text: Select the correct area on the image.
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Correct Answer:
Rationale : The costovertebral angle is formed as the ribs articulate with the vertebra.
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 28.2: Apply knowledge and skill in gathering objective data in a general
survey and physical assessment of a client.
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Question 106
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Type: SEQ
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The nurse is documenting information about the client using Problem-Oriented Charting and the
acronym SOAP. Rank the following pieces of information in the order that they should be
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documented.
Standard Text: Click and drag the options below to move them up or down.
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Choice 1. The clients skin is cool and dusky. Poor capillary refill noted. Oxygen saturation level
is 90% on room air. The client was diagnosed with COPD in 1993.
Choice 2. The nurse will apply oxygen at 2 liters per minute, per healthcare providers orders
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when the clients oxygen saturation level is below 92%.
my lungs.
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Choice 3. The client states, I am so tired all of the time. I feel like Im not getting enough air into
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Choice 4. The client is most likely experiencing an exacerbation of a chronic lung disease.
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Correct Answer: 3,1,4,2
Rationale 1: S refers to subjective data that are provided by the client regarding the symptoms
that the client is experiencing.
Rationale 2: O refers to objective data. The nurse documents information about the signs that the
client is exhibiting.
Rationale 3: A refers to assessment. The nurse draws conclusions regarding the subjective and
objective data that the nurse has collected about the client.
Rationale 4: P refers to planning. Planning indicates that interventions that the nurse can use to
help resolve the clients problems or address the clients needs.
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Global Rationale: S refers to subjective data that are provided by the client regarding the
symptoms that the client is experiencing. O refers to objective data. The nurse documents
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information about the signs that the client is exhibiting. A refers to assessment. The nurse draws
conclusions regarding the subjective and objective data that the nurse has collected about the
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client. P refers to planning. Planning indicates that interventions that the nurse can use to help
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resolve the clients problems or address the clients needs.