Ray A. Hargrove-Huttel
RN, PhD
West Coast University
Los Angeles, California
Kathryn Cadenhead Colgrove
RN, MS, CNS, OCN
Trinity Valley Community College
Kaufman, Texas
F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright © 2010 by F. A. Davis Company
All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means,
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As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and
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and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the
contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique
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dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs.
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This is our fourth project in writing NCLEX-RN questions for F.A. Davis. We have been in the nursing and teaching
profession for over 30 years, with our goal being to help nursing students successfully pass the nursing program and
become registered nurses. But we also want nurses to care for clients by applying both the art and science of nursing. We
hope you will enjoy your nursing career as much as we have over the last three decades. This book would not be possible
without the unbelievable computer skills of Glada Norris and input from Kathryn McAfee. We would also like to extend
our appreciation to the gang at West Coast University for their invaluable assistance in piloting these questions.
I dedicate this book to the memory of my mother, Mary Cadenhead, and grandmother, Elsie Rogers. They always
said that I could accomplish anything I wanted to accomplish. I also dedicate this book to my husband, Larry; children,
Laurie, Todd, Larry Jr, and Mai; and grandchildren, Chris, Ashley, Justin C., Justin A. Connor, Sawyer, and Carson.
Without their support and patience, the book would not have been possible.
Kathryn Cadenhead Colgrove
I thank my nursing students for always keeping me on my toes and making sure I learn something new every day.
I thank my nursing peers and teaching colleagues for helping me to be the best nurse and teacher I can be. I thank all
my friends for providing me with wonderful experiences and memories. I thank my family for always loving me just the
way I am. I thank my sisters, Gail and Debbie; my nephew, Ben; and Paula for always supporting the choices I make in
life, especially my move to Los Angeles to become the Associate Dean of Nursing at West Coast University. I thank my
children, Teresa and Aaron, being wonderful young people of whom I am so proud and who are always there for me.
I dedicate this book to my parents and to my husband, Bill, who supported me and allowed me to travel a wonderful
journey in my life.
Ray A. Hargrove-Huttel
REVIEWERS
Tammy Blatnick, RN, MS
Nursing Instructor
Southwestern Oklahoma State University
Weatherford, Oklahoma
Ruth Gladen, MSN
ASN-RN Program Director
North Dakota State College of Science
Wahpeton, North Dakota
Wonda Brown, RN
Nurse Instructor
Connors State College of Nursing
Warner, Oklahoma
Cheri Goit, MSN
Assistant Professor
Northwest University
Kirkland, Washington
Cheryl DeGraw, RN, MSN, CNE, CRNP
Nursing Instructor
Florence Darlington Technical College
Florence, South Carolina
Susan Golden, MSN, RN
Nursing Faculty
ENMU-Roswell
Roswell, New Mexico
Valerie Edwards, RN, MSN
Associate Professor
Passaic County Community College
Paterson, New Jersey
Annie Ruth Grant, BSN, MSN
Medical Surgical Instructor
Florence Darlington Technical College
Florence, South Carolina
Joyce Arlene Ennis, RN, MSN, ANP, BC
Assistant Professor
Carroll University Nursing Program
Waukesha, Wisconsin
Rhonda Renea Hendricks, RN, MSN, BA
Assistant Professor
Nova Southeastern University
Fort Myers, Florida
Julia Hooley, RN, BSN
Director of the Center for Study and Testing
Malone College
Canton, Ohio
Linda Ann Kucher, MSN, RN, CMSRN
Instructor
St. Joseph School of Nursing
North Providence, Rhode Island
Martha Horst, MSN, RN
Associate Professor of Nursing
Malone College
Canton, Ohio
Christy Madore, FNP-C, MSN
Assistant Professor of Nursing
University of Maine at Fort Kent
Fort Kent, Maine
Cheryl Jackson, RN, BSN
Clinical Specialists
Southeast Kentucky Community and Technical
College
Pineville, Kentucky
Donna Maheady, ARNP, EdD
Adjunct Assistant Professor
Florida Atlantic University and DeVry (Chamberlain
College of Nursing)
Palm Beach Gardens, Florida
Peggy Kelly, RN, BSN
PN Instructor
University of Arkansas—Fort Smith
Fort Smith, Arkansas
Nadine Mason, CEN, MSN, CRNP
Assistant Professor
Cedar Crest College
Allentown, Pennsylvania
Kim Kocur, MSN, RNC
Assistant Professor
Saint Xavier University
Chicago, Illinois
Susan A. Moore, RN, PhD
Assistant Professor
University of Memphis
Memphis, Tennessee
Kathy O’Connor, MSN, APRN-BC, FNP,
MBA, PLNC
Associate Dean and Assistant Professor
Union University School of Nursing
Jackson, Tennessee
Tricia Brown–O’Hara, RN, MSN
Assistant Professor
Gwynedd-Mercy College
Gwynedd Valley, Pennsylvania
Paula A. Olesen, RN, MSN
Program Director
South Texas College
McAllen, Texas
Martha Olson, RN, BSN, MS
Assistant Professor
Iowa Lakes Community College
Emmetsburg, Iowa
Christine Ouellette, MSN, NP
Adjunct Clinical Faculty
Quincy College
Quincy, Massachusetts
Diane Peters, RN, MSN
Director, ADN Program
Northwestern Technical College
Rock Spring, Georgia
Kathleen Poindexter, PhD, RN
MSN, Nursing Education Program Coordinator
Michigan State University
East Lansing, Michigan
Pauline Powell, MSN, RN
Nursing Instructor
Northwest Florida State College
Niceville, Florida
Pam Rhodes, MSN
Assistant Professor
University of Arkansas Fort Smith
Fort Smith, Arkansas
Elizabeth Robinson, MSN, RN-BC, CNE
Associate Professor
Northwest Florida State College
Niceville, Florida
Kowanda O. Robinson, RN, BSN
Program Director
Gwinnett Technical College
Lawrenceville, Georgia
Brigitte Thiele, RN, BSN
Coordinator of Practical Nursing Education
Kennett Career and Technology Center
Kennett, Missouri
Jean Rodgers, RN, MSN
Nursing Faculty
Hesston College
Hesston, Kansas
Kathy Thornton, RN, PhD
Assistant Professor
Georgia Southern University
Statesboro, Georgia
Nancy Rogers, RN, BSN, MA
Associate Professor of Nursing
Carroll Community College
Westminster, Maryland
Joan Ulloth, RN, PhD
Professor of Nursing
Kettering College of Medical Arts
Kettering, Ohio
Patsy M. Spratling, RN, MSN
ADN Faculty
Holmes Community College
Ridgeland, Mississippi
CONTENTS
Introduction _______________________ X
10. Maternal Child Health ____________ 469
1
11. Pediatric Disorders _______________ 497
2. Cardiovascular Disorders __________ 55
12. Emergency Nursing ______________ 551
3. Respiratory Disorders _____________ 121
13. Immune Inflammatory
Disorders ________________________ 585
1. Neurological Disorders ____________
4. Gastrointestinal Disorders _________ 177
5. Endocrine Disorders ______________ 235
6. Musculoskeletal Disorders ________ 277
7. Genitourinary Disorders __________ 319
8. Mental Health Disorders __________ 371
9. Women’s Health __________________ 429
14. Integumentary ___________________ 637
15. Operative Care ___________________ 671
16. Pharmacology ____________________ 695
Index ____________________________ 759
Introduction to F.A. Davis Card Questions Features the Latest
Content in the New 2010 Test Plan
These questions are designed to assist nursing students in preparing for various courses across the
curriculum and, of course, that all-important examination, the NCLEX-RN.
This card deck includes 1535 critical thinking questions on flash cards and is organized according
to systems and disease processes. Each card has two to four questions on the front, with answers and
rationales on the back. Approximately half the questions cover medical-surgical content, with the
remaining questions divided equally among pediatric, pharmacology, psychiatric, maternity, women’s
health, and management content. All questions are written at the application and analysis level—just
like the NCLEX.
Users will have access to a unique 265-question final exam on a CD-ROM and included in the
box. The CD also includes all the questions from the card deck, for a total of 1535 questions. All
questions are coded according to the client need category, nursing process step, cognitive level
category of health alteration, and content area, resulting in a diagnostic workup available to the
student for both the final exam and all the questions in the card deck.
The box contains 16 raised tabs to help the user easily find various subjects to review. Included are
key questions on major drug classes, medication administration, plus delegation and management
content integrated within the various tabs. Alternate-format questions are included in the various
systems and diseases/disorders.
For convenience, the box includes a plastic card pouch for easy portability of the flash cards.
The National Council of State Boards of Nursing (NCSBN) provides a blueprint that assists
nursing faculty when developing test questions in preparation for student success on the NCLEX-RN.
Content included in management of care covers nursing care delivery to protect patients, family/
significant others, and health-care personnel. Related content includes but is not limited to questions
on advance directives, advocacy, case management, patient rights, collaboration with the interdisciplinary
team, delegation, establishing priorities, ethical practice, informed consent, information technology,
and performance improvement. The topics also include legal rights and responsibilities, referrals,
resource management, staff education, supervision, confidentiality/information security, and continuity
of care. The questions in these cards follow this blueprint.
Management, prioritizing, and delegation questions are some of the most difficult questions for the
student and new graduate to answer because there is no reference book in which to find the correct
answer. Answers to these types of questions require a knowledge of basic scientific principles, leadership,
standards of care, pathophysiology, psychosocial behaviors, and the ability to think critically.
Using a Nursing Standard to Make a Decision
The Nursing Process
Nurses base their decisions on many different bodies of information in order to arrive at a course
of action. One of the basic guidelines for nursing practice is to use the nursing process. The nursing
process consists of five steps; the steps are usually completed in a systematic order. The first step
in the nursing process is assessment. Many questions can be answered based on assessment. If a
priority-setting question asks the test taker which step to implement first, then the test taker should
look for an answer that would assess for the problem discussed in the stem.
For Example:
The nurse is caring for a patient diagnosed with congestive heart failure when the patient complains
of dyspnea. Which intervention should the nurse implement first?
1. Administer furosemide (Lasix), a loop diuretic, IVP.
2. Check the patient for adventitious lung sounds.
3. Ask Respiratory Therapy to administer a treatment.
4. Notify the health-care provider of the problem.
Answer 2, check the patient for adventitious lung sounds, would be assessing the patient to determine
the extent of the breathing difficulties. There are numerous words that can be used to indicate assessment.
The test taker should not discard an option because the word “assessment” is not used.
The test taker must be aware that the assessment data must match the problem stated in the
stem. Do not jump to a conclusion that an option is correct just because the word “assess” is used.
The nurse must assess for the correct information. If option 2 in the above example said to assess
the patient’s urinary output for the last shift, this would be an incorrect option. The exception to
utilizing assessment to guide the test taker is “If in stress, DO NOT assess.”
Suppose the above question had listed option 3 as:
3. Apply oxygen via nasal cannula at 2 LPM.
Then the nurse would first attempt to intervene to relieve the patient’s distress before assessing.
These types of questions are designed to determine if the test taker can set priorities in patient care.
To further utilize the nursing process, the test taker must remember the steps of the nursing
process: Assessment, Diagnosis, Planning, Intervention, Evaluation. A question might ask which
the nurse would do next. In this case, the test taker would need to decide which step of the using
process has been completed and then choose an option that matches the next step.
Maslow’s Hierarchy of Needs
If the test taker has looked at the question and the nursing process does not assist in determining
the correct answer option, then using a tool such as Maslow’s Hierarchy of Needs can assist in
choosing the correct answer. Basic physiological needs are the most important in the hierarchy,
followed by safety and security needs, then belongingness and affection, esteem and self respect,
and finally self-actualization. So if a question asks the test taker to determine which is the priority
intervention, and a physiological need is not listed, then a safety-and-security need takes priority.
Prioritizing Questions/Setting Priorities
In a test question that asks for which intervention the nurse would implement first, two or more
of the options will appropriate nursing interventions for the situation. The test taker must decide
which intervention occurs first in a sequence of events or which intervention directly impacts the
situation in order to choose the correct answer.
When the test taker is reading a question that asks which patient the nurse should assess first,
the test taker should look at each option and determine if the signs/symptoms the patient is
exhibiting are normal for the disease process. If they are, the nurse does not need to assess this
patient first. Second, if two or more of the options state signs/symptoms are not normal for the
disease process, then the test taker should select the option that has the greatest potential for a
poor outcome. Each option should be examined carefully to determine the priority by asking these
questions:
1. Is the situation life-threatening or life-altering? If yes, this patient is the highest priority.
2. Is the situation unexpected for the disease process? If yes, then this patient may be priority.
3. Are the lab data abnormal? If yes, then this patient may be priority.
4. Is the situation expected for the disease process? If yes, then this patient may be but probably is
not priority.
5. Is the situation/presentation normal? If yes, this patient can be seen last because this is the least
priority.
The test taker should try to make a decision pertaining to each option. It is helpful to write out
the decision by the option on pencil-and-paper examinations. This will prevent the test taker from
“second guessing.” When taking a computerized test, the test taker should make the decision and
move on to the next question.
Delegating and Assigning Care
Although Nursing Practice Acts are individualized by state and province, there are some general
guidelines that apply to all professional nurses.
When delegating to unlicensed assistive personnel (UAP), the nurse may not delegate any activity
that requires nursing judgment. This includes assessing, teaching, evaluating, and medicating and
unstable patients.
When assigning care to a licensed practical nurse, the nurse can assign some medications but
cannot assign assessments, teaching, evaluation, or unstable patients.
Nursing Practice Decisions
The nurse is frequently called upon to make decisions about staffing, movement of patients from
one unit to another, and handling conflicts as they arise. Some general guidelines for answering
questions in this area are:
1. The most experienced nurse gets the most critical patient.
2. A graduate nurse can take care of any patient who is receiving care that a student can give
with supervision.
3. The most stable patient can move or be discharged. The most unstable patient must move to
or stay in the ICU.
When the nurse must make a decision regarding a conflict in the nursing station, a good rule to
follow is to use the chain of command. The primary nurse should confront a peer (another primary
nurse) or a subordinate, unless the situation is illegal (such as stealing drugs). The primary nurse
should use the chain of command in situations that address superiors (a manager or director of
nursing); then the nurse should discuss the situation with the next in command above the superior.
Nursing Judgment
The nurse is required to acquire information, analyze the data, and make inferences based on
the available information. Sometimes this process is relatively easy; at other times the pieces of
information do not seem to fit. This is when critical thinking and nursing judgment must guide in
making the decision.
SECTION ONE
Neurological Disorders
1
SECTION ONE
Neurological Disorders
3
Head Injury
1. The client has sustained a traumatic brain injury
3. The rehabilitation nurse is caring for the client with a
(TBI) secondary to a motor vehicle accident. Which
signs/symptoms would the emergency department (ED)
nurse expect the client to exhibit?
l 1. Blurred vision, nausea, and right-sided hemiparesis.
l 2. Increased urinary output, negative Babinski, and
ptosis.
l 3. Autonomic dysreflexia, positive Brudzinski, and
hyperpyrexia.
l 4. Negative dextrostik, nuchal rigidity, and nystagmus.
closed head injury. Which cognitive goal would be most
appropriate for this client?
l 1. The client will be able to feed himself/herself
independently.
l 2. The client will attend therapy sessions 3 hours a day.
l 3. The client will interact appropriately with staff
members.
l 4. The client will be able to stay on task for 15 minutes.
2. The intensive care nurse is caring for a client
diagnosed with a closed head injury. Which data would
warrant immediate intervention?
l 1. The client refuses to cough and deep-breathe.
l 2. The client’s Glasgow Coma Scale goes from
13 to 7.
l 3. The client complains of a frontal headache.
l 4. The client’s Mini-Mental Status Exam
(MMSE) is 30.
ANSWERS
1. Correct answer 1: Signs/symptoms of TBI include
neurological deficits, among them blurred vision,
nausea, and right-sided hemiparesis. A positive
Babinski sign would also occur with head trauma.
Autonomic dysreflexia would be found in a client with
a spinal cord injury; a positive dextrostik for glucose
would be found in someone with a cerebrospinal fluid
leak; and a positive Brudzinski and nuchal rigidity are
signs of meningitis. Content–Medical; Category of
Health Alteration–Neurological; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
2. Correct answer 2: A 15 on the Glasgow Coma Scale
indicates the client is neurologically intact; a decrease
to 7 indicates an increase in the intracranial pressure,
which warrants immediate intervention. A 30 on
the MMSE indicates the client is cognitively intact.
Content–Medical; Category of Health Alteration–
Neurological; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
4
3. Correct answer 4: Cognitive is mental functioning;
therefore, the ability to stay on task would be the
client’s most appropriate cognitive goal. Content–
Medical; Category of Health Alteration–Neurological;
Integrated Process–Planning; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive Level–
Synthesis.
SECTION ONE
Neurological Disorders
4. The intensive care nurse is caring for a client diagnosed
6. The nurse is preparing the client diagnosed with a
with a TBI who is exhibiting decorticate posturing. Three
hours later the client has flaccid posturing. Which action
should the nurse implement first?
l 1. Notify the client’s health-care provider (HCP)
immediately.
l 2. Prepare to administer mannitol (Osmitrol), an
osmotic diuretic.
l 3. Complete a thorough neurological assessment on
the client.
l 4. Reassess the client in 1 hour, including calculating
the Glasgow Coma Scale.
head injury for a magnetic resonance imaging (MRI).
Which interventions should the nurse implement? Select
all that apply.
l 1. Ask the client if he/she is claustrophobic.
l 2. Have the client sign a procedural permit.
l 3. Determine if the client is allergic to shellfish.
l 4. Check if the client has any prosthetic devices.
l 5. Ask the client to empty his/her bladder.
5. The emergency department nurse is entering the room
of a client who was at a baseball game and was hit in the
head with a bat. Which intervention should the nurse
implement first?
l 1. Assess the client’s orientation to date, time, and
place.
l 2. Ask the client to squeeze the nurse’s fingers.
l 3. Determine the client’s reaction to the door opening.
l 4. Request the client to move his lower legs.
5
ANSWERS
4. Correct answer 1: Flaccid posturing is the worst-case
scenario for a client with a TBI; therefore, the nurse
should notify the HCP. Completing a neurological
assessment, administering an osmotic diuretic, and
reassessing the client are all plausible interventions,
but they are not the first to be implemented. Content–
Medical; Category of Health Alteration–Neurological;
Integrated Process–Assessment; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
5. Correct answer 3: The nurse should first determine
how alert the client is by noticing the reaction when
the door opens. The best reaction is spontaneous
opening of the eyes without verbal or noxious stimuli.
The other three options are appropriate but should
not be the nurse’s first intervention when entering
the client’s room. Content–Medical; Category of
Health Alteration–Neurological; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
6
6. Correct answer 1, 4, 5: The client is enclosed in an
MRI tube for an extended period so the client cannot
be claustrophobic or want to stop the procedure. An
MRI cannot be completed on a client with a metal
prosthesis unless it is made with titanium because
the MRI may dislodge the prosthesis. The hospital
admission permit covers the MRI, and because no
contrast dye is now used in most MRIs, an allergy to
shellfish is not pertinent. Content–Medical; Category
of Health Alteration–Neurological; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Application.
SECTION ONE
7. The client with increased intracranial pressure is
Neurological Disorders
7
9. The nurse is discussing the TBI Act at a support
receiving mannitol (Osmitrol), an osmotic diuretic.
Which intervention should the nurse implement?
l 1. Monitor the client’s complete blood cell (CBC)
count.
l 2. Do not administer the drug if the client’s apical
pulse is less than 60.
l 3. Ensure that the client’s cardiac status is monitored
by telemetry.
l 4. Use a filter needle when administering the
medication.
group meeting. Which statement best explains the act?
l 1. It is a federal act that provides public policy
regarding community living for clients with a TBI.
l 2. It ensures that all public buildings must have access
for physically challenged clients.
l 3. This act ensures that all clients with a TBI have
access to rehabilitation services.
l 4. It is a national policy that establishes guidelines for
neurological rehabilitation centers.
8. The male client is being discharged from the ED after
a closed head injury 8 days ago due to a motor vehicle
accident. Which signs/symptoms would alert the nurse
to a complication of the head injury?
l 1. The client reports having trouble sleeping due to
having nightmares about the wreck.
l 2. The client tells the nurse she has a stuffy nose and
green nasal drainage.
l 3. The client complains of extreme thirst and has an
increased urine output.
l 4. The client informs the nurse that she has started
her menstrual period.
sustaining a minor head injury. Which statement
indicates the wife understands the discharge teaching?
l 1. “My husband will be hard to wake up for a couple
of days.”
l 2. “He doesn’t need any pain medication because
I have some at home.”
l 3. “I should not give my husband anything to eat or
drink for 12 hours.”
l 4. “I will bring my husband back to the emergency
room if he starts vomiting.”
10. The nurse is caring for a female client who sustained
ANSWERS
7. Correct answer 4: The nurse must use a filter needle
when administering mannitol because crystals may
form in the solution and syringe and be inadvertently
injected into the client. The CBC and apical pulse
are not affected by the medication. Mannitol is
administered cautiously in clients with heart failure,
but telemetry is not required routinely. Content–
Medical; Category of Health Alteration–Neurological;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Pharmacological and Parenteral
Therapies; Cognitive Level–Application.
8. Correct answer 4: Vomiting indicates an increase in
intracranial pressure, which is a complication of a
head injury. The client should arouse easily, may eat
and drink (not alcohol), and should not take any type
of pain medication that would mask mental status.
Content–Medical; Category of Health Alteration–
Neurological; Integrated Process–Evaluation; Client
Needs–Health Promotion and Maintenance; Cognitive
Level: Evaluation.
Copyright © 2010 F.A. Davis Company
8
9. Correct answer 1: The TBI Act is part of the
Children’s Act of 2000 and is the only federal
legislation designed for clients with a TBI. The Act
provides for a balanced public policy for prevention,
education, research, and community living for clients
with a TBI and their families. Content–Medical;
Category of Health Alteration–Neurological; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Knowledge.
10. Correct answer 3: For 7–10 days post head injury,
the client is at risk for developing diabetes insipidus,
which is a lack of the antidiuretic hormone, resulting
in increased urine output and increased thirst.
Content–Medical; Category of Health Alteration–
Neurological; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
SECTION ONE
Neurological Disorders
9
Spinal Cord Injury
11. Which clinical manifestation would the nurse assess
13. The rehabilitation nurse caring for the young client
in the client with a T-12 spinal cord injury (SCI) who is
experiencing spinal shock?
l 1. Flaccid paralysis below the waist.
l 2. Lower extremity muscle spasticity.
l 3. Complaints of a pounding headache.
l 4. Hypertension and bradycardia.
with a T-12 SCI is developing the nursing care plan.
Which priority intervention should the nurse implement?
l 1. Monitor the client’s indwelling urinary catheter.
l 2. Insert a rectal stimulant at the same time every
morning.
l 3. Encourage active lower extremity range of motion
(ROM) exercises.
l 4. Refer the client to a vocational training assistance
program.
12. The nurse is caring for a client who has a C-6 vertebral
fracture and is using Crutchfield tongs with 2-pound
weights. Which data would the nurse expect the client to
exhibit?
l 1. The client is on controlled mechanical ventilation
at 12 respirations a minute.
l 2. The client has no movement of the lower extremities.
l 3. The client has 2+ deep tendon reflexes in the lower
extremities.
l 4. The client has loss of sensation below the C-6
vertebral fracture.
14. The nurse is caring for a client with a C-6 SCI in the
neurological intensive care unit. Which nursing intervention
should be implemented?
l 1. Monitor the client’s heparin drip.
l 2. Assess the neurological status every shift.
l 3. Maintain the client’s ice saline infusion.
l 4. Administer corticosteroids intrathecally.
ANSWERS
11. Correct answer 1: Spinal shock is associated with an
SCI. It is a sudden depression of reflex activity, a loss
of sensation, and flaccid paralysis below the level of
the injury. T-12 is just above the waist. Content–
Medical; Category of Health Alteration–Neurological;
Integrated Process–Assessment; Client Needs–
Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
12. Correct answer 3: The spinal cord has not been
injured; therefore, normal body movement,
responses, and reflexes should be intact. The
Crutchfield tongs ensure that the cervical spine
remains in alignment. Content–Medical; Category of
Health Alteration–Neurological; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
10
13. Correct answer 2: The client’s bowel and bladder
functions must be addressed; therefore, administering
a daily rectal stimulant will ensure a daily bowel
movement. Indwelling urinary catheters are
discouraged due to the increased risk of infection
associated with their use. Content–Medical; Category
of Health Alteration–Neurological; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Basic Care and Comfort; Cognitive Level–Application.
14. Correct answer 3: Current treatment options that
have proven efficacy in treating SCI is to decrease
inflammation and edema by lowering the body
temperature with ice saline solutions. Intravenous
corticosteroid therapy is a standard of care but not
intrathecal, into the spinal cord. Content–Medical;
Category of Health Alteration–Neurological; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Pharmacological and Parenteral Therapies;
Cognitive Level–Application
SECTION ONE
Neurological Disorders
11
15. The male client with a C-6 SCI tells the home health
17. The nurse caring for a client with a C-6 SCI
nurse he has had a severe pounding headache for the last
2 hours. Which intervention should the clinic nurse
implement?
l 1. Determine when and how much the client last
urinated.
l 2. Ask the client if he has taken any medication for
the headache.
l 3. Inquire when the client had his last bowel
movement.
l 4. Check the client’s respiratory rate reading
immediately.
determines the client has no plantar reflexes. Which area
on the stick figure should the nurse document this
finding?
16. The client with a T-1 SCI complains of
lightheadedness and dizziness when the head of the
bed is elevated. The client’s B/P is 84/40. Which
action should the nurse implement first?
l 1. Increase the client’s intravenous (IV) rate by
50 mL/hr.
l 2. Administer dopamine, a vasopressor, via an IV pump.
l 3. Notify the HCP immediately.
l 4. Lower the client’s head of bed immediately.
ANSWERS
15. Correct answer 1: The cause of the pounding
headache is most likely autonomic dysreflexia, a
result of exaggerated autonomic responses to stimuli.
An elevated blood pressure would confirm this.
The most common cause of autonomic dysreflexia
is a full bladder. All the other options could be
implemented, but confirming the autonomic
dysreflexia is priority. Content–Medical; Category
of Health Alteration–Neurological; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Analysis.
16. Correct answer 4: The blood pressure tends to be
very unstable and low for clients with an SCI of T-6
or above, and slight elevations of the head of the bed
can cause profound drops in the client’s vital signs.
Content–Medical; Category of Health Alteration–
Neurological; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
12
17. Correct answer: Content–Medical; Category of Health
Alteration–Neurological; Integrated Process–Assessment;
Client Needs–Safe Effective Care, Management of Care;
Cognitive Level–Analysis.
Neurological Disorders
SECTION ONE
18. The nurse on the rehabilitation unit is caring for the
following clients with SCIs. Which client should the
nurse assess first after receiving the change-of-shift report?
l 1. The client with a C-6 SCI who has a warm,
reddened edematous gastrocnemius muscle.
l 2. The client with an L-4 SCI who is concerned
about being able to live independently.
l 3. The client with an L-2 SCI who is complaining of
a headache and nausea.
l 4. The client with a T-4 SCI who is unable to move
the lower extremities.
19. The nurse is caring for clients on a rehabilitation
unit. Which nursing task would be most appropriate
for the nurse to delegate to the unlicensed assistive
personnel (UAP)?
l 1. Ask the UAP to hold the urinal while the client
performs the Credé maneuver.
l 2. Discuss the proper method of administering tube
feedings to the family member.
l
l
13
3. Assist with bowel training by inserting a suppository
into the client’s rectum.
4. Observe the client demonstrating self-catheterization
technique.
20. The 25-year-old client with an SCI is sharing with
the nurse that he is worried about how his family will be
able to survive financially until he can go back to work.
Which intervention should the nurse implement?
l 1. Refer the client to the American Spinal Injury
Association.
l 2. Refer the client to the state rehabilitation
commission.
l 3. Refer the client to the social worker about applying
for disability.
l 4. Refer the client to an occupational therapist for life
skills training.
ANSWERS
18. Correct answer 1: The gastrocnemius muscle is the
calf muscle, and warmth, redness, and swelling in
the muscles indicate the client has a deep vein
thrombosis (DVT), which requires immediate
intervention. A client with an L-2 SCI (option 3)
would not experience autonomic dysreflexia. A client
with a T-4 SCI (option 4) would not be expected to
be able to move the lower extremities. Content–
Medical; Category of Health Alteration–Neurological;
Integrated Process–Assessment; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
19. Correct answer 1: The UAP can hold a urinal for
the client. The UAP cannot assess, teach, evaluate,
administer medications, or care for an unstable client.
Content–Medical; Category of Health Alteration–
Neurological: Integrated Process–Planning; Client
Needs–Effective Care Management, Management of
Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
14
20. Correct answer 3: The social worker is responsible
for assisting the client with financial concerns. The
ASIA assists clients to live with their SCI, and the
rehabilitation commission can assist with employment.
Content–Medical; Category of Health Alteration–
Neurological; Integrated Process–Implementation;
Client Needs–Psychosocial Integrity; Cognitive
Level–Application.
SECTION ONE
Neurological Disorders
15
Seizures
21. The nurse walks into the room and notes the male
23. The nurse observes a client having a tonic-clonic
client is lying supine, and the entire body is rigid with his
arms and legs contracting and relaxing. The client is not
aware of what is going on and is making guttural sounds.
Which action should the nurse implement first?
l 1. Loosen constrictive clothing.
l 2. Place padding on the side rails.
l 3. Assess the client’s vital signs.
l 4. Turn the client on his side.
seizure. Which information should the nurse document
in the client’s chart? Select all that apply.
l 1. Determine if the client is incontinent of urine or
stool.
l 2. Document the client had privacy during the
seizure.
l 3. Note the time and where the movement or stiffness
began.
l 4. Note the circumstances before the client’s seizure
activity began.
l 5. Note the results of a complete neurological
assessment.
22. The client newly diagnosed with epilepsy who works in
an office asks the nurse, “What can I do to prevent having
seizures?” Which statement is the nurse’s best response?
l 1. “I recommend getting about 4 hours of sleep a
night.”
l 2. “Ask your supervisor to have someone else make
copies.”
l 3. “Request your employer to provide a work area
with dim lighting.”
l 4. “You should get your serum blood level checked
every month.”
ANSWERS
21. Correct answer 4: Placing the client on his side
helps keep the airway patent; therefore, it is the first
intervention. All the other interventions may be
done, but airway is priority. Content–Medical;
Category of Health Alteration–Neurological; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Analysis.
22. Correct answer 2: Flashing lights, such as occur
with a copying machine, can evoke a seizure and
should be avoided; other causes of seizures include
stress, fatigue, and alcohol intake. Serum blood levels
will not help prevent seizures, but they do indicate
the serum drug level. Content–Medical; Category of
Health Alteration–Neurological; Integrated Process–
Planning; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
16
23. Correct answer 1, 3, 4: The nurse should assess
the client before, during, and after seizure activity.
Providing privacy is expected and would not be
documented in the chart. The client in the postictal
state needs rest; therefore, a complete neurological
assessment would not be appropriate. Content–Medical;
Category of Health Alteration–Neurological; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
SECTION ONE
Neurological Disorders
17
24. The UAP is holding the arms of a client who is having
26. The client is admitted to the intensive care unit
a tonic-clonic seizure. Which action should the nurse
implement?
l 1. Help the UAP restrain the client’s upper extremities.
l 2. Instruct the UAP to release the client’s arms
immediately.
l 3. Take no action because the assistant is handling the
situation.
l 4. Notify the charge nurse of the situation
immediately.
(ICU) experiencing status epilepiticus. Which intervention
should the nurse anticipate implementing first?
l 1. Assess the client’s neurological status frequently.
l 2. Monitor the client’s heart rhythm via telemetry.
l 3. Administer diazepam (Valium), a benzodiazepine.
l 4. Prepare to administer anticonvulsant medication.
25. The client diagnosed with a seizure disorder is
prescribed phenytoin (Dilantin), an anticonvulsant.
Which statement indicates the client needs more
teaching concerning this medication?
l 1. “I will brush my teeth after every meal.”
l 2. “I will get my Dilantin level checked regularly.”
l 3. “My urine will turn orange while on Dilantin.”
l 4. “This medication will help prevent my seizures.”
27. The client is admitted to the ED after experiencing a
partial seizure. Which question would be most appropriate
for the nurse to ask the client?
l 1. “Do you know if you lost consciousness during the
seizure?”
l 2. “Are you feeling sleepy or very tired at this time?”
l 3. “When did you last take your seizure medication?”
l 4. “Were you feeling jittery or irritable prior to the
seizure?”
ANSWERS
24. Correct answer 2: The client should be protected
from injury but be allowed to move freely. Restraining
the client’s extremities could result in orthopedic
injury to the client. Content–Medical; Category of
Health Alteration–Neurological; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
25. Correct answer 3: Dilantin does not turn the urine
orange; therefore this statement indicates the client
needs more teaching. Content–Medical; Category of
Health Alteration–Drug Administration; Integrated
Process–Evaluation; Client Needs–Physiological
Integrity, Pharmacological and Parenteral Therapies;
Cognitive Level–Synthesis.
18
26. Correct answer 3: The client is in distress; therefore,
assessment is not priority. The nurse should first
administer Valium to halt the seizure immediately
to ensure adequate oxygen supply to the brain.
Anticonvulsant medications are administered later
to maintain a seizure-free state. Content–Medical;
Category of Health Alteration–Neurological; Integrated
Process–Planning; Client Needs–Safe Effective Care,
Management of Care; Cognitive Level–Analysis.
27. Correct answer 3: The nurse must determine if the
client has been compliant with medication; therefore,
this question is appropriate. The client does not
lose consciousness in a partial seizure and does not
experience a postictal state. Hypoglycemia (feeling
jittery or irritable) causes tonic-clonic seizures, not
partial seizures. Content–Medical; Category of Health
Alteration–Neurological; Integrated Process–Assessment;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
SECTION ONE
Neurological Disorders
19
28. Which statement by the female client indicates that
30. The mother of a child who had a febrile seizure tells
the client understands factors that may precipitate seizure
activity?
l 1. “I should not take birth control pills to prevent
pregnancy.”
l 2. “I need to limit my intake of dairy products.”
l 3. “I should not participate in any contact sports.”
l 4. “My menstrual cycle may affect my seizure
disorder.”
the pediatric clinic nurse, “I am so upset because now my
child has epilepsy.” Which statement is the clinic nurse’s
best response?
l 1. “Your child had a seizure due to a high fever, not
due to epilepsy.”
l 2. “You are upset about your child having epilepsy.
Let’s talk.”
l 3. “The Epilepsy Foundation of America provides
good information.”
l 4. “I would recommend you attend the local epilepsy
support group.”
29. The clinic nurse is checking diagnostic test results.
Which diagnostic test result would warrant notifying the
client immediately?
l 1. The female client who is taking an anticonvulsant
who has a low bone density scan.
l 2. The client who is diagnosed with epilepsy who has
a phenytoin (Dilantin) level of 28 mcg/dL.
l 3. The client with a seizure disorder who has a
carbamazepine (Tegretol) of 10 mcg/mL.
l 4. The client who has partial seizures who has a
serum sodium level of 143 mEq/L.
ANSWERS
28. Correct answer 4: Because of the fluctuations in
hormones that alter the excitability of neurons in
the cerebral cortex, an increase in seizure frequency
may occur during menses. Content–Medical; Category
of Health Alteration–Neurological; Integrated Process–
Evaluation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Evaluation.
29. Correct answer 2: The therapeutic Dilantin level is
10–20 mcg/dL; a level of 28 mcg/dL requires
notifying the client. Content–Medical; Category of
Health Alteration–Neurological; Integrated
Process–Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
20
30. Correct answer 1: A high fever in a child can cause
a seizure, but it does not indicate the child has a
seizure disorder. The nurse should provide
information if at all possible instead of a therapeutic
response that encourages the client to ventilate
feelings. Content–Medical; Category of Health
Alteration–Neurological; Integrated Process–Evaluation;
Client Needs–Health Promotion and Maintenance;
Cognitive Level–Synthesis.
SECTION ONE
Neurological Disorders
21
Cerebrovascular Accident
(Stroke, Brain Attack)
31. The 88-year-old client is admitted to the ED with
33. The HCP has discussed a carotid endarterectomy
numbness and weakness of the left arm and slurred
speech. The computed tomography (CT) scan was negative
for bleeding. Which nursing intervention is priority?
l 1. Prepare to administer tissue plasminogen activator
(TPA).
l 2. Discuss the precipitating factors that caused the
symptoms.
l 3. Determine the exact time the symptoms occurred.
l 4. Notify the speech pathologist for an emergency
consult.
with the client who has experienced two transient ischemic
attacks (TIAs). The client tells the nurse, “I really don’t
understand why I need this procedure, and I don’t want
to have it.” Which scientific rationale would support the
nurse’s response?
l 1. This surgery is indicated for clients with symptoms
of a TIA due to carotid artery stenosis.
l 2. This surgical procedure will ensure the client does
not have a cerebrovascular accident.
l 3. This surgery will remove all atherosclerotic plaque
from the carotid arteries.
l 4. This surgical procedure will increase the elasticity
of the carotid arterial wall.
32. The nurse is assessing the client experiencing a
left-sided cerebrovascular accident (CVA). Which clinical
manifestations would the nurse expect the client to
exhibit?
l 1. Hemiparesis of the left arm and apraxia.
l 2. Paralysis of the right side of the body and aphasia.
l 3. Inability to recognize and use familiar objects.
l 4. Impulsive behavior and hostility toward family.
ANSWERS
31. Correct answer 3: The nurse must first determine
when the symptoms started before administering
TPA, a standard of care. TPA must be initiated
within 3 hours of the start of symptoms because,
after that time, revascularization of necrotic tissue,
which occurs with the administration of TPA,
increases the risk for cerebral edema and hemorrhage.
Content–Medical; Category of Health Alteration–
Neurological; Integrated Process–Assessment; Client
Needs–Reduction of Risk Potential; Cognitive
Level–Analysis.
32. Correct answer 2: A left-sided CVA results in rightsided paralysis, right visual field deficit, aphasia
(inability to speak), and altered intellectual ability.
All other options are results of right-sided CVA.
Content–Medical; Category of Health Alteration–
Neurological; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
22
33. Correct answer 1: This is the rationale the nurse
would utilize to encourage the client to have this
surgical procedure. An endartectomy does not ensure
the client will not have a CVA nor does it ensure
that all atherosclerotic plaque will be removed or
that the carotid artery wall will become more elastic.
Content–Medical; Category of Health Alteration–
Neurological; Integrated Process–Planning; Client
Needs–Physiological Adaptation, Reduction of Risk
Potential; Cognitive Level–Synthesis.
SECTION ONE
Neurological Disorders
23
34. Which client would the nurse identify as being least
36. The nurse is planning care for the client experiencing
at risk for experiencing a CVA?
l 1. A 55-year-old African-American male who is obese.
l 2. A 73-year-old Japanese female who has essential
hypertension.
l 3. A 67-year-old Caucasian male whose cholesterol
level is below 200 mg/dL.
l 4. A 39-year-old female who is taking oral
contraceptives.
dysphagia secondary to a CVA. Which intervention
should be included in the plan of care?
l 1. Evaluate the client during mealtime.
l 2. Position the client in a semi-Fowler position.
l 3. Administer oxygen during meals.
l 4. Refer the client to a physical therapist.
35. The client diagnosed with a right-sided CVA is
admitted to the rehabilitation unit. Which intervention
should be included in the nursing care plan?
l 1. Turn and reposition the client every shift.
l 2. Place a small pillow under the client’s left shoulder.
l 3. Have the client perform quadriceps exercises three
times a day.
l 4. Instruct the client to hold fingers in a fist.
37. The nurse and a UAP are caring for a client with
right-sided paralysis. Which action by the UAP requires
the nurse to intervene?
l 1. The UAP places the gait belt under the client’s
axilla prior to ambulating.
l 2. The UAP places the client on the abdomen with
the client’s head to the side.
l 3. The UAP uses a lift sheet when moving the client
up in the bed.
l 4. The UAP praises the client for attempting to
perform activities of daily life (ADLs) independently.
ANSWERS
34. Correct answer 3: Caucasians have a lower risk of
CVA than African Americans, Hispanics, and Native
Pacific Islanders. A high cholesterol level, being African
American, hypertension, and oral contraceptive use are
risk factors for developing a CVA. Content–Medical;
Category of Health Alteration–Neurological; Integrated
Process–Diagnosis; Client Needs–Health Promotion and
Maintenance; Cognitive Level–Analysis.
35. Correct answer 2: Placing a small pillow under the
left shoulder will prevent the shoulder from adducting
toward the chest and developing a contracture. The
client should be repositioned at least every 2 hours;
quadricep exercises should be done for 10 minutes at
least five times a day; and the fingers are positioned so
that they are barely flexed. Content–Medical; Category
of Health Alteration–Neurological; Integrated Process–
Planning; Client Needs–Physiological Integrity, Basic
Care and Comfort; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
24
36. Correct answer 1: Dysphagia (swallowing difficulty)
puts the client at risk for aspiration, pneumonia,
dehydration, and malnutrition; therefore, the nurse
should evaluate the client during mealtime. The client
should be in a high Fowler position or, preferably, in a
chair. Content–Medical; Category of Health Alteration–
Neurological; Integrated Process–Planning; Client Needs–
Physiological Integrity, Physiological Adaptation;
Cognitive Level–Synthesis.
37. Correct answer 1: The gait belt should be around
the waist because this is the client’s center of gravity.
All other options are appropriate interventions for
the UAP and would not require intervention.
Content–Medical; Category of Health Alteration–
Neurological; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Immobility; Cognitive Level–Synthesis.
SECTION ONE
Neurological Disorders
25
38. The client diagnosed with chronic atrial fibrillation has
40. The nurse has received the morning shift report.
experienced a transient TIA. Which discharge instruction
should the nurse implement?
l 1. Keep nitroglycerin tablets in a dark-colored bottle.
l 2. Check the radial pulse prior to all medications.
l 3. Obtain International Normalized Ratio (INR)
routinely.
l 4. Take over-the-counter vitamin K tablets daily.
Which client should the nurse assess first?
l 1. The client who is complaining of a headache at
a 3 on a scale of 1–10.
l 2. The client who has an apical pulse of 56 and a
blood pressure of 210/116.
l 3. The client who is reporting not having a bowel
movement in 3 days.
l 4. The client who is angry because the call light was
not answered for 1 hour.
39. The client diagnosed with a CVA has hemiparesis.
Which problem would be priority for the client?
l 1. Impaired skin integrity.
l 2. Fluid volume overload.
l 3. High risk for aspiration.
l 4. High risk for injury.
Brain Tumors
41. The client is being admitted with rule-out (R/O)
brain tumor. Which signs/symptoms support the
diagnosis of a brain tumor?
l 1. Widening pulse pressure, hypertension, and
bradycardia.
l 2. Headache, vomiting, and diplopia.
l 3. Hypotension, tachycardia, and tachypnea.
l 4. Abrupt loss of motor function, diarrhea, and
changes in taste.
ANSWERS
38. Correct answer 3: An oral anticoagulant, warfarin
(Coumadin), will be prescribed to help prevent the
formation of thrombi in the atrium secondary to atrial
fibrillation. The thrombi can become embolic, which
may cause a TIA. The INR is the laboratory value
used to determine therapeutic oral anticoagulant
levels. Content–Medical; Category of Health Alteration–
Neurological; Integrated Process–Planning; Client
Needs–Health Promotion and Maintenance; Cognitive
Level–Synthesis
39. Correct answer 4: Hemiparesis is a weakness on one
side of the body that may lead to falls; this makes
high risk for injury the priority problem for this
client. Content–Medical; Category of Health Alteration–
Neurological; Integrated Process–Diagnosis; Client Needs–
Physiological Integrity, Reduction of Risk Potential;
Cognitive Level–Analysis.
26
40. Correct answer 2: This blood pressure is extremely
high, and the pulse rate is decreased; therefore, this
client should be assessed first. A 3 headache, no
bowel movement, and an upset client would not be
priority over a client who may be having a CVA.
Content–Medical; Category of Health Alteration–
Neurological; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
41. Correct answer 2: The classic triad of symptoms of
a brain tumor includes a headache that is dull and
unrelenting and worse in the morning, vomiting
unrelated to food intake, and edema of the optic
nerve (papilledema) causing diplopia. Option 1 is the
Cushing triad, which indicates increased intracranial
pressure that would not be seen initially on diagnosis;
option 3 is signs/symptoms of hypovolemic shock.
Content–Medical; Category of Health Alteration–
Neurological; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
SECTION ONE
Neurological Disorders
27
42. The client is diagnosed with a frontal lobe brain
44. The client diagnosed with lung cancer has developed
tumor. Which sign/symptom would the nurse expect
the client to exhibit?
l 1. Ataxia.
l 2. Decreased visual acuity.
l 3. Scanning speech.
l 4. Personality changes.
metastasis to the brain. Which problem would be priority
for this client?
l 1. Anticipatory grieving.
l 2. Impaired gas exchange.
l 3. Altered nutritional status.
l 4. Alteration in comfort.
43. The male client diagnosed with a brain tumor is
45. The client diagnosed with a brain tumor was
having a closed magnetic resonance imaging (MRI) scan
in 1 hour. The client tells the radiology nurse, “I don’t
like small enclosed spaces.” Which action should the
nurse implement?
l 1. Allow the client to express his feelings.
l 2. Discuss the procedure with the client.
l 3. Obtain an order for an anti-anxiety medication.
l 4. Reschedule the procedure for another day.
admitted to the ICU with decorticate posturing. Which
indicates that the client’s condition is improving?
l 1. The client has purposeful movement with painful
stimuli.
l 2. The client assumes adduction of the upper
extremities.
l 3. The client assumes the decerebrate posture upon
painful stimuli.
l 4. The client has become flaccid and does not respond
to stimuli.
ANSWERS
42. Correct answer 4: Personality changes occur in a
client with a frontal lobe tumor. Ataxia or gait
problems indicate a temporal lobe tumor. Decreased
visual acuity is a symptom indicating papilledema, a
general symptom of the majority of all brain tumors,
not specifically a frontal lobe tumor. Scanning
speech is symptomatic of multiple sclerosis. Content–
Medical; Category of Health Alteration–Neurologic;
Integrated Process–Assessment; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive Level–
Analysis.
43. Correct answer 3: The client is claustrophobic and
will need medications to help decrease the anxiety
associated with small enclosed spaces. Ventilating
feelings and discussing the procedure will not help
claustrophobia. Reschedule for an open MRI, not
another closed MRI. Content–Medical; Category of
Health Alteration–Neurological; Integrated Process–
Planning; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
28
44. Correct answer 1: Anticipatory grieving is priority
because brain metastasis is a terminal diagnosis,
indicating death within 6 months or less. With the
development of brain metastasis, the nurse must
address death and dying issues, which is why this is
priority over all the other client problems. Content–
Medical; Category of Health Alteration–Neurological;
Integrated Process–Diagnosis; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
45. Correct answer 1: Purposeful movement following
painful stimuli would indicate an improvement in the
client’s condition. Adducting the upper extremities
while internally rotating the lower extremities is
decorticate positioning; this would indicate the
client’s condition had not changed. Decerebrate
posturing and flaccid movement indicate a worsening
of the condition. Content–Medical; Category of Health
Alteration–Neurological; Integrated Process–Evaluation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Evaluation.
SECTION ONE
Neurological Disorders
29
46. The intensive care nurse is caring for a client following
48. The client has undergone a craniotomy for a brain
an infratentorial craniotomy. Which interventions should
the nurse implement? Select all that apply.
l 1. Keep the head of the bed elevated at 30 degrees.
l 2. Keep a humidifier in the client’s room.
l 3. Do not put anything in the client’s mouth.
l 4. Provide the client with a clear liquid diet.
l 5. Assess the client’s respiratory status every hour.
tumor. Which data indicate a complication of this surgery?
l 1. The client complains of a headache at a 3–4 on a
1–10 scale.
l 2. The client has a urinary output of 250 mL over the
last 24 hours.
l 3. The client has a serum sodium level of 137 mEq/L.
l 4. The client experiences dizziness when trying to get
up too quickly.
47. The client is diagnosed with a pituitary tumor and is
scheduled for a transsphenoidal hypophysectomy. Which
postoperative instruction is important to discuss with the
client?
l 1. Demonstrate to a family member how to change a
turban dressing.
l 2. Explain to the client how to monitor urine output
at home.
l 3. Tell the client not to blow his nose for 2 weeks
after surgery.
l 4. Tell the client he will have to lie flat for 24 hours
following the surgery.
ANSWERS
46. Correct answer 2, 4, 5: Humidified air would be
provided; the client’s diet is started slowly; and the
respiratory status is assessed because the centers that
control respiration and vomiting are in the area of
the brain affected by the surgery. The head of the
bed would be flat, and caution with oral care is
appropriate for a client with a transsphenoidal
hypophysectomy, not with an infratentorial
craniotomy. Content–Surgical; Category of Health
Alteration–Neurological; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Analysis.
47. Correct answer 3: Blowing the nose creates
increased intracranial pressure and could result in a
leak of cerebral spinal fluid. A transsphenoidal
hypophysectomy is done by an incision above the
gum line, and there is no turban dressing. The head
of the bed is elevated to 30 degrees to allow for
gravity to assist in draining the cerebrospinal fluid.
Content–Surgical; Category of Health Alteration–
Neurological; Integrated Process–Planning; Client
Copyright © 2010 F.A. Davis Company
30
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Synthesis.
48. Correct answer 2: The decreased urinary output
may indicate syndrome of inappropriate antidiuretic
hormone (SIADH), which is a complication of a
craniotomy. A headache after this surgery would be
an expected occurrence. The sodium level is normal
(135–145 mEq/L). Dizziness upon arising quickly
would not be a complication of this surgery. Content–
Surgical; Category of Health Alteration–Neurological;
Integrated Process–Assessment; Client Needs–Physiological
Adaptation, Reduction of Risk Potential; Cognitive
Level–Analysis.
SECTION ONE
Neurological Disorders
31
Meningitis
49. The client diagnosed with a brain tumor is prescribed
51. The nurse is assessing the client diagnosed with
intravenous dexamethasone (Decadron), a steroid.
Which intervention should the nurse implement when
administering this medication?
l 1. Administer medication with normal saline only.
l 2. Check the client’s white blood cell (WBC) count.
l 3. Determine if the client has oral candidiasis.
l 4. Monitor the client’s glucose level.
bacterial meningitis. In addition to nuchal rigidity, which
clinical manifestations would the nurse assess?
l 1. Positive Cushing sign and ascending paralysis.
l 2. Negative Kernig sign and facial tingling.
l 3. Positive Brudzinski sign and photophobia.
l 4. Negative Trousseau sign and descending paralysis.
50. The male client is scheduled for gamma knife
meningococcal meningitis and notes lesions over the face
and extremities. Which priority intervention should the
nurse implement?
l 1. Initiate the intravenous antibiotics stat.
l 2. Obtain a skin biopsy for culture and sensitivity.
l 3. Perform a complete neurological assessment.
l 4. Close all the curtains in the room and turn off
lights.
stereotactic surgery for a brain tumor. Which preoperative
instruction should the nurse discuss with the client?
l 1. Instruct the client to avoid bright lights and wear
sunscreen.
l 2. Tell the client he must sleep with the head of the
bed elevated.
l 3. Explain there are no activity limitations after this
procedure.
l 4. Encourage the client to take off at least 2 weeks
from work.
52. The nurse is admitting a client diagnosed with
ANSWERS
49. Correct answer 4: Decadron, a glucocorticosteroid,
will increase insulin resistance, which increases
glucose levels; therefore, glucose levels should be
monitored. Decadron is compatible with dextrose,
so normal saline does not need to be used, and the
WBC count and oral candidiasis would not be
interventions pertinent to administering this
medication. Content–Medical; Category of Health
Alteration–Drug Administration; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Application.
50. Correct answer 3: This is a day-surgery procedure,
and the client is usually discharged home 3–4 hours
after the surgery and can resume normal activities.
Content–Medical; Category of Health Alteration–
Surgical; Integrated Process–Planning; Client Needs–
Safe Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
32
51. Correct answer 3: A positive Brudzinski sign (raise
the client’s head, and the knees will come up) and
photophobia due to meningeal irritation are key
signs of meningitis. A positive Kernig sign (client is
unable to extend leg when lying flat) would also be
expected. Content–Medical; Category of Health
Alteration–Neurological; Integrated Process–Diagnosis;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Analysis.
52. Correct answer 1: Purpuric lesions over the face and
extremities are the signs of a fulminating infection in
clients with meningococcal meningitis. The infection
can lead to death within a few hours. The nurse
should start the antibiotics immediately. Content–
Medical; Category of Health Alteration–Neurological;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
SECTION ONE
Neurological Disorders
33
53. Which type of precautions should the nurse implement
55. The nurse is preparing for a lumbar puncture for the
for the client diagnosed with aseptic meningitis?
l 1. Standard precautions.
l 2. Airborne precautions.
l 3. Contact precautions.
l 4. Droplet precautions.
client diagnosed with R/O meningitis. Which interventions
should the nurse implement? Select all that apply.
l 1. Determine if the client has any allergies to iodine.
l 2. Do not let the client urinate 2 hours before the
procedure.
l 3. Place the client in a prone position with the face
turned to the side.
l 4. Instruct the client to take slow deep breaths during
the procedure.
l 5. Label the specimen and send to the laboratory for
cultures.
54. A college student came to the university health clinic
and was diagnosed with bacterial meningitis and admitted
to a local hospital. Which intervention should the university
health clinic nurse implement?
l 1. Place the client’s dormitory under strict respiratory
isolation.
l 2. Notify the parents of all students about the
meningitis outbreak.
l 3. Arrange for students to receive the meningococcal
vaccination.
l 4. Ensure dormitory roommates receive
chemoprophylaxis using rifampin.
56. The client diagnosed with septic meningitis is admitted
to the medical floor at 1200. Which HCP’s order would
the nurse implement first?
l 1. Administer intravenous antibiotic.
l 2. Start the client’s intravenous line.
l 3. Provide a quiet, calm dark room.
l 4. Initiate seizure precautions.
ANSWERS
34
53. Correct answer 1: Aseptic meningitis is caused by a
55. Correct answer 1, 4, 5: The lumbar area is cleansed
noninfectious agent or a virus and is not likely to be
transmitted to other people; therefore, standard
precautions would be expected. Septic meningitis
would require droplet precautions for 24-48 hours
after initiation of antibiotics. Content–Medical;
with Betadine; therefore, iodine allergies should be
noted. The client’s bladder should be empty for
comfort during the procedure, and the client should
be in a side-lying position with back arched for
access to intravertebral space. Taking slow deep
breaths will help calm the client, and specimens are
sent to the laboratory. Content–Medical; Category of
Category of Health Alteration–Neurological; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
54. Correct answer 4: People in close contact with
clients diagnosed with meningococcal meningitis,
the most common type of infectious agent in group
settings, should receive chemoprophylaxis for
prevention of meningitis. The public health nurse or
college administration would notify parents. It is too
late for the vaccine. Content–Medical; Category of
Health Alteration–Infectious Disease; Integrated
Process–Planning; Client Needs–Safe Effective Care
Environment, Safety and Infection Control; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
Health Alteration–Neurological; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Application.
56. Correct answer 2: Intravenous antibiotics are of
paramount importance, so the nurse must start an
intravenous line first. Content–Medical; Category of
Health Alteration–Infectious Diseases; Integrated
Process–Planning; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Synthesis.
SECTION ONE
Neurological Disorders
35
57. The nurse asks the UAP to help admit the client
59. The nurse is developing a plan of care for a client
diagnosed with bacterial meningitis. Which nursing task
is priority?
l 1. Take the client’s vital signs.
l 2. Obtain the client’s height and weight.
l 3. Prepare the room for respiratory isolation.
l 4. Pull the drapes and make sure the room is dim.
diagnosed with septic meningitis. Which client goal
would be most appropriate for the client problem of
“altered thermoregulation”?
l 1. The client will have no injury from using the
hypothermia blanket.
l 2. The client will be protected from injury if seizure
activity occurs.
l 3. The client will be afebrile for 48 hours prior to
discharge.
l 4. The client will have serum electrolytes within
normal limits.
58. The 18-year-old client is admitted to the medical
floor with a diagnosis of meningitis. Which priority
intervention should the nurse assess?
l 1. Assess the client’s neurovascular status.
l 2. Assess the client’s cranial nerve IX function.
l 3. Assess the client’s brachioradialis reflex.
l 4. Assess the client’s neurological status.
60. The nurse is admitting a client diagnosed with
meningitis who has AIDS. Which signs/symptoms would
the nurse expect the client to exhibit?
l 1. A positive Babinski sign.
l 2. Diplopia and blurred vision.
l 3. Auditory deficits.
l 4. The client may be asymptomatic.
ANSWERS
57. Correct answer 3: Equipment needed for the staff
to enter the client’s room safely is the priority
nursing task that can be delegated. All other tasks
could be safely delegated to the UAP, but they are
not priority. Content–Medical; Category–Infectious
Diseases; Integrated Process–Planning; Client Needs–
Safe Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
58. Correct answer 4: Meningitis directly affects
the client’s brain; therefore, assessing the
neurological status would have priority for this
client. Neurovascular assessment involves peripheral
nerves and changes such as paralysis and skin
temperature. Content–Medical; Category of Health
Alteration–Infectious Diseases; Integrated Process–
Assessment; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Analysis.
Copyright © 2010 F.A. Davis Company
36
59. Correct answer 3: The client with septic meningitis
has a high fever; therefore, being afebrile for 48 hours
would be an appropriate goal. Content–Medical; Category of Health Alteration–Infectious Diseases; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Synthesis.
60. Correct answer 4: The client with AIDS may be
asymptomatic or may exhibit atypical symptoms
because of blunted inflammatory responses. Content–
Medical; Category of Health Alteration–Infectious
Diseases; Integrated Process–Assessment; Client Needs–
Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
SECTION ONE
Neurological Disorders
37
Parkinson Disease
61. Which clinical manifestations would the nurse
63. The nurse and the UAP are caring for clients on
expect to assess in the client diagnosed with Parkinson
disease (PD)?
l 1. Nausea, vomiting, and diarrhea.
l 2. Polyuria, polydipsia, and polyphagia.
l 3. Dysphonia, dysphagia, and scanning speech.
l 4. Tremors, rigidity, and bradykinesia.
a medical surgical unit. Which task would be most
appropriate to assign to the UAP?
l 1. Feed the client with Parkinson disease who has
intention tremors of the hand.
l 2. Change the sterile pressure ulcer dressing for a
client who is on bedrest.
l 3. Give the client who is having heartburn 30 mL of
the antacid Maalox.
l 4. Obtain vital signs on a client with Parkinson
disease who is hallucinating.
62. The nurse caring for a client diagnosed with Parkinson
disease writes a problem of “Impaired Nutrition.” Which
nursing intervention would be included in the plan of care?
l 1. Give the client a pureed diet.
l 2. Request a low-residue heart-healthy diet.
l 3. Provide an 1800-calorie American Diabetic
Association diet.
l 4. Offer bite-sized foods on a plate warmer.
ANSWERS
61. Correct answer 4: Tremors, rigidity, and bradykinesia
are the classic manifestations of PD. They are known
as the triad of PD. Content–Medical; Category of
Health Alteration–Neurological; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
62. Correct answer 4: Bite-sized foods require less
energy from the client for chewing, and a plate
warmer preserves the appeal of the food. Nothing in
the stem of the question indicates that the client has
diabetes, so the ADA diet would not be necessary.
The client should have a high-residue (fiber) diet to
prevent constipation. A pureed diet has baby-food
consistency and should not be given to a client
who can chew. Content–Medical; Category of Health
Alteration–Neurological; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
38
63. Correct answer 1: The client with intention tremors
is stable but cannot keep the food on the eating
utensil to get it to the mouth; this task could be
safely delegated to the UAP. UAP cannot assess,
teach, evaluate, administer medications, or care for
an unstable client. The client hallucinating is having
a reaction to the Parkinson disease medications and
is unstable. Content–Medical; Category of Health
Alteration–Neurological; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
SECTION ONE
Neurological Disorders
39
64. The charge nurse is making assignments on a medical
66. The client diagnosed with Parkinson disease is
surgical unit. Which client should be assigned to the
licensed practical nurse (LPN)?
l 1. The client with Parkinson disease who became
disoriented throughout the night.
l 2. The client with aseptic meningitis who is
complaining the light is bothersome.
l 3. The client newly diagnosed with Parkinson disease
who is being discharged.
l 4. The client diagnosed with a brain tumor who had
a seizure at the change of shift.
being discharged. Which statement made by the client’s
significant other indicates a need for more teaching?
l 1. “I know that my husband may have some
emotional mood swings.”
l 2. “My spouse may experience hallucinations until the
medication starts working.”
l 3. “I will schedule appointments late in the morning
after his morning bath.”
l 4. “My spouse must take his medication at the same
time every day.”
65. The nurse is planning the care for a client diagnosed
67. The client with Parkinson disease is admitted to the
with Parkinson disease. Which goal would be appropriate
for the client problem of “impaired mobility”?
l 1. The client will experience periods of akinesia
throughout the day.
l 2. The client will be able to turn from side to
side in bed.
l 3. The client will be able to ambulate in the hall three
times a day.
l 4. The client will be able to carry out ADLs.
medical unit diagnosed with pneumonia. The nurse needs
to administer ceftriaxone (Rocephin) 100 mg in 100 mL
of normal saline to infuse over 30 minutes. Which rate
should the nurse set the intravenous pump?
Answer: ____________________
ANSWERS
64. Correct answer 2: Photophobia is an expected clinical
manifestation of aseptic meningitis, so the LPN could
be assigned to this client. New-onset disorientation
indicates the client is unstable and would require the
registered nurse (RN) to assess the client. The newly
diagnosed client with PD requires extensive teaching.
Seizure activity may indicate increasing intracranial
pressure. Content–Medical; Category of Health
Alteration–Neurological; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
65. Correct answer 3: The goal of a client with impaired
mobility would be to be mobile; walking in the hall
would be an appropriate goal. Akinesia is lack of
movement, and the client should not be allowed to
stay in bed due to immobility complications. Ability
to do ADLs would be appropriate for self-care deficit
problem. Content–Medical; Category of Health
Alteration–Neurological; Integrated Process–Planning;
Client Needs–Physiological Integrity, Basic Care and
Comfort; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
40
66. Correct answer 2: Hallucinations are a sign that the
client is experiencing drug toxicity; therefore, this
statement indicates that the significant other needs
more teaching. The other statements indicate the
client’s significant other understands the discharge
teaching. Content–Medical; Category of Health
Alteration–Neurological; Integrated Process–Planning;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Synthesis.
67. Correct answer 200 mL/hour: Intravenous pumps
are set at an hourly rate; if 100 mL is infused in
1 hour, the nurse should double the rate so that
100 mL would infuse in 30 minutes. Content–Medical;
Category of Health Alteration–Drug Administration;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
SECTION ONE
Neurological Disorders
41
68. The home health nurse is caring for a client diagnosed
69. The nurse is conducting a support group for clients
with Parkinson disease. Which comment by the client’s
significant other would suggest a common cognitive
problem associated with Parkinson disease?
l 1. “My wife is never happy about anything
I do for her.”
l 2. “All my wife does is sit on the porch and look at
her garden.”
l 3. “My wife is becoming more forgetful about routine
things.”
l 4. “My wife thinks the medication I give her is poison.”
diagnosed with PD and their significant others. Which
information regarding physiological needs should be
included in the discussion?
l 1. Remove all throw rugs and tack down all loose
carpet.
l 2. Recommend the client completes an advance
directive.
l 3. Explain the reason why the client has “pill rolling”
tremors.
l 4. Give simple, short, concise directions to their
loved one.
70. The client has been diagnosed with Parkinson disease
for 12 years and has been taking levodopa (L-dopa) for
the last 8 years. Which symptom would alert the nurse to
a possible medication complication?
l 1. The client is unable to initiate voluntary movement.
l 2. The client has recently developed dyskinesia.
l 3. The client has masklike facies and cogwheel
movements.
l 4. The client has excessive saliva production.
ANSWERS
68. Correct answer 3: Memory deficits are cognitive
42
70. Correct answer 2: Dyskinesia is abnormal involun-
impairments; the client may also develop a dementia.
Emotional liability, depression, and paranoia are
psychosocial problems, not cognitive ones. Content–
tary movement, including facial grimacing, rhythmic
jerking movements, and head-bobbing. These movements indicate a complication of the L-dopa.
Medical; Category of Health Alteration–Neurological;
Integrated Process–Evaluation; Client Needs–Psychosocial
Integrity; Cognitive Level–Evaluation.
Content–Medical; Category of Health Alteration–
Neurological; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Analysis.
69. Correct answer 1: The client’s safety is priority due to
the physiological shuffling gait that makes the client
high risk for injuries due to falls. Content–Medical;
Category of Health Alteration–Neurological; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
SECTION ONE
Neurological Disorders
43
Sensory Deficits
71. The client is diagnosed with acute otitis media.
73. The nurse is preparing to administer otic drops into
Which statement would cause the nurse to suspect the
client had a ruptured tympanic membrane?
l 1. “I always have a lot of earwax buildup.”
l 2. “I have been running a fever with my ear pain.”
l 3. “I had ear pain but then it went away on its own.”
l 4. “I had a sinus infection prior to getting the ear pain.”
the adult client’s right ear. Which action should the nurse
implement?
l 1. Grasp the ear lobe and pull up and out when
putting drops in the ear.
l 2. Insert the eardrops without touching the outside of
the ear.
l 3. Place the applicator 1⁄4 inch into the outer ear canal.
l 4. Pull the auricle down and back prior to instilling
drops.
72. The client is diagnosed with Ménière disease. Which
statement by the client supports that the client needs
more teaching concerning the management for this
disease?
l 1. “Surgery is the only cure for Ménière, but I may
be deaf.”
l 2. “I will have to use a hearing aid for the rest of
my life.”
l 3. “I must adhere to a low-sodium diet, 2000 mg/day.”
l 4. “When I get dizzy I need to lie down on my bed.”
ANSWERS
71. Correct answer 3: The pain associated with otitis
media is relieved after spontaneous perforation or
therapeutic incision of the tympanic membrane.
Ear pain and fever are expected with otitis media.
Content–Medical; Category of Health Alteration–
Neurosensory; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Analysis.
72. Correct answer 2: Ménière disease does not lead to
deafness unless surgery is done, which may result in
permanent deafness in the affected ear. Sodium regulates the balance of fluid within the body; therefore, a
low-sodium diet is prescribed to help control the
symptoms of Ménière disease. Content–Medical;
Category of Health Alteration–Neurosensory; Integrated
Process–Evaluation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Evaluation.
Copyright © 2010 F.A. Davis Company
44
73. Correct answer 4: Pulling the auricle down and back
prior to instilling drops will straighten the ear canal
so that the ear drops will enter the ear canal and
drain toward the tympanic membrane (eardrum).
Nothing should be placed in the outer ear canal.
Content–Medical; Category of Health Alteration–Drug
Administration; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Application.
SECTION ONE
Neurological Disorders
74. The client is scheduled for right tympanoplasty.
76. The client is diagnosed with cataracts. Which
Which statement indicates the client understands the
preoperative teaching concerning the surgery?
l 1. “If I have to sneeze or blow my nose, I will do it
with my mouth open.”
l 2. “If I have any dizzy spells, I will contact my doctor
immediately.”
l 3. “I will probably have permanent hearing loss in my
right ear.”
l 4. “I can shampoo my hair the day after surgery as
long as I am careful.”
symptom would the nurse expect the client to report?
l 1. Halos around lights.
l 2. Floating spots in the eye.
l 3. Everything has a yellow haze.
l 4. Painless, blurry vision.
75. The client diagnosed with osteoarthritis has been
self-medicating with high doses of aspirin for the pain.
Which comment by the client would warrant further
evaluation by the nurse?
l 1. “I always take my medication with food.”
l 2. “I have noticed a buzzing sound in my ears.”
l 3. “I soak in a hot tub bath in the morning.”
l 4. “I will call my doctor if my gums bleed.”
45
77. The 65-year-old client is diagnosed with macular
degeneration. Which statement indicates the client
understands the discharge teaching concerning this
diagnosis?
l 1. “I should use artificial tears three times a day.”
l 2. “I will look at my Amsler grid at least twice a week.”
l 3. “I am going to use low-watt lightbulbs in my house.”
l 4. “I will wear dark sunglasses when I go outside.”
ANSWERS
74. Correct answer 1: Leaving the mouth open when
coughing or sneezing will minimize the pressure
changes in the middle ear. Dizziness is expected after
ear surgery. Tympanoplasty is a repair of the inner ear
structure and will not cause permanent hearing loss.
Shampooing is avoided to prevent contamination of
the ear canal. Content–Surgical: Category of Health
Alteration–Neurosensory; Integrated Process–Evaluation;
Client Needs–Physiological Integrity, Reduction of Risk
Potential: Cognitive Level–Evaluation.
75. Correct answer 2: The “buzzing” should alert the
nurse to possible tinnitus, which is a sign of aspirin
toxicity and warrants further evaluation by the nurse.
Content–Medical; Category of Health Alteration–Drug
Administration; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
46
76. Correct answer 4: A cataract is a lens opacity or
cloudiness resulting in painless, blurry vision. The
symptom in option 1 is characteristic of glaucoma;
that in option 2 of retinal detachment; and that in
option 3 of digoxin toxicity. Content–Medical;
Category of Health Alteration–Neurosensory; Integrated
Process–Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
77. Correct answer 2: Amsler grids provide the earliest
sign of worsening of the client’s macular degeneration.
If the lines of the grid become distorted or faded,
the client should call the ophthalmologist. Content–
Medical; Category of Health Alteration–Neurosensory;
Integrated Process–Evaluation; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive
Level–Evaluation.
Neurological Disorders
SECTION ONE
47
78. The nurse is preparing to administer eyedrops to a
79. A male client is brought to the employee health
client. To which area should the nurse apply pressure to
prevent systemic absorption of the medication?
l 1. A
l 2. B
l 3. C
l 4. D
clinic reporting some type of chemical was splashed in his
eyes. Which action should the nurse implement first?
l 1. Arrange for transportation to the ophthalmologist.
l 2. Perform a vision screening test on the client.
l 3. Flush the eye continuously with water.
l 4. Complete an occurrence report for the situation.
80. The client with glaucoma is prescribed a miotic
A
D
B
C
cholinergic medication. Which data support the teaching
for this medication has been effective?
l 1. The client reports taking the medication on
vacations.
l 2. The client reports taking a stool softener every day.
l 3. The client places the medication in the inner
canthus.
l 4. The client wears gloves when instilling the
medication.
ANSWERS
78. Correct answer 4: The area marked A is known as
the inner canthus; gentle pressure to this area will
prevent systemic absorption of the medication.
Content–Medical; Category of Health Alteration–Drug
Administration; Integrated Process–Implementation;
Client Needs–Physiological Adaptation, Pharmacological
and Parenteral Therapies; Cognitive Level–Synthesis.
79. Correct answer 3: The first and most important
intervention is to flush the agent out of the eye.
Then the nurse should refer the client to an
ophthalmologist, maybe check vision, and then
complete an occurrence report because the client was
not wearing goggles. Content–Medical; Category of
Health Alteration–Neurosensory; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
48
80. Correct answer 1: The client realizes that medication
compliance is priority for glaucoma and consequently
takes the medication while on vacation. The client
should prevent constipation, but it has nothing to do
with miotic medications. Medication should be placed
in the conjunctiva. The client needs to wash the hands
but not wear gloves. Content–Medical; Category of
Health Alteration–Drug Administration; Integrated
Process–Evaluation; Client Needs–Health Promotion and
Maintenance; Cognitive Level–Evaluation.
SECTION ONE
Neurological Disorders
49
Management Issues
81. The nurse is caring for clients on a medical surgical
82. The charge nurse in the medical/surgical department
floor. Which client should be assessed first?
l 1. The client diagnosed with epilepsy who reports
over the intercom having an aura.
l 2. The client with an L-1 SCI who is complaining of
shortness of breath while exercising.
l 3. The client diagnosed with Parkinson disease who is
being discharged today.
l 4. The client diagnosed with a CVA who has
resolving left hemiparesis.
is making rounds at 0700. Which client should the nurse
see first?
l 1. The client diagnosed with a brain tumor who is
complaining of a headache.
l 2. The client diagnosed with meningitis who is
complaining of a stiff neck.
l 3. The client diagnosed with diabetes who is
reporting seeing spots in the eyes.
l 4. The client diagnosed with low back pain who has
radiating pain down the left leg.
83. The registered nurse (RN), an LPN, and a UAP are
caring for clients on a neurological unit. Which task would
be most appropriate for the nurse to assign/delegate?
l 1. Instruct the LPN to complete the client’s admission
assessment.
l 2. Request the UAP to change the central line
dressing.
l 3. Assign the LPN to administer routine medications.
l 4. Tell the UAP to complete the Glasgow Coma Scale.
ANSWERS
81. Correct answer 1: The client with an aura is getting
ready to have a seizure. This client should be seen
first. Content–Medical; Category of Health Alteration–
Neurological; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
82. Correct answer 3: Seeing spots could indicate a
retinal detachment, and this requires the nurse to
assess this client first. If the signs/symptoms are
expected for the disease process—such as headache
with a brain tumor, a stiff neck with meningitis, and
pain radiating down the leg in a client with low back
pain—then the nurse should not assess that client
first unless the symptom is life-threatening. Content–
Medical; Category of Health Alteration–Neurological;
Integrated Process–Assessment; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
50
83. Correct answer 3: The LPN can administer routine
medications. The RN should not delegate/assign
assessment to an LPN or a UAP (options 1 and 4).
The central line dressing change is a sterile dressing
that should not be delegated to a UAP. Content–
Medical; Category of Health Alteration–Drug
Administration; Integrated Process–Planning; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
SECTION ONE
Neurological Disorders
51
84. The nurse is caring for a client diagnosed with septic
86. The 22-year-old client with a severe head injury is
meningitis. The UAP reports T 101.6°F, P 128, R 32,
B/P 96/46. Which action should the nurse implement
first?
l 1. Notify the HCP.
l 2. Assess the client immediately.
l 3. Prepare to administer acetaminophen (Tylenol).
l 4. Check the chart for the culture and sensitivity
report.
admitted to the critical care unit. Some of the client’s
friends come to the nurse’s station requesting information.
Which action would be most appropriate by the nurse?
l 1. Tell the friends to talk to the parents.
l 2. Discuss the client’s situation with the friends.
l 3. Allow the friends to visit the client for 10 minutes.
l 4. Explain that no information can be shared with the
friends.
85. The nurse is preparing to administer dexamethasone
87. The male client diagnosed with a brain tumor who is
(Decadron) intravenous push (IVP) to a client with an
acute spinal cord injury. Which interventions should the
nurse implement? Rank in order.
l 1. Administer the medication over 2 minutes.
l 2. Dilute the medication with normal saline.
l 3. Check the client’s medication administration
record (MAR).
l 4. Check the client’s identification band.
l 5. Clamp the primary tubing distal to the port.
receiving hospice care is admitted to the hospital and
provides the nurse with a copy of his living will, stating
he does not want any heroic measures. Which action
should the nurse implement first?
l 1. Check the chart to make sure there is a do not
resuscitate (DNR) order.
l 2. Inform the HCP that the client has a living will.
l 3. Place a copy of the living will in the front of the
client’s chart.
l 4. Request the hospital chaplain to come and talk to
the client.
ANSWERS
84. Correct answer 2: Whenever another health-care team
member reports information to the nurse, assessment
should be completed to confirm the data. Then the
nurse should notify the HCP, administer Tylenol to
decrease the fever, and check the chart, but the nurse
must first realize this is potential septic shock, and the
client should be assessed. Content–Medical; Category of
Health Alteration–Infectious Diseases; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
85. Correct answer 3, 2, 4, 5, 1: First check the MAR
to ensure the right medication, the right dose, at the
right time. Diluting the medication saves the vein
and decreases the client’s pain during administration.
Check for the right client by checking the client’s
identification band. Clamping the tubing will ensure
the medication goes into the vein, and 2 minutes is
the recommended administration time. Content–
Medical; Category of Health Alteration–Drug
Administration; Integrated Process–Implementation;
Copyright © 2010 F.A. Davis Company
52
Cognitive Level–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
86. Correct answer 4: The nurse cannot violate the
client’s confidentiality according to the Health
Information Privacy and Portability Act (HIPPA).
Content–Fundamentals; Category of Health Alteration–
Neurological; Integrated Process–Planning; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Application.
87. Correct answer 1: This action should be implemented
first to ensure the client’s wishes will be honored in
case the client codes. All other actions could be taken,
but the client’s wishes are priority. Content–Medical;
Category of Health Alteration–Neurological; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
SECTION ONE
Neurological Disorders
53
88. The charge nurse has received laboratory data for
90. The nurse and a UAP are caring for a client with
clients. Which situation requires the charge nurse’s
intervention first?
l 1. The client with a brain tumor who has ABGs:
ph 7.36, PaO2 95, PaCO2 38, HCO3 24.
l 2. The postoperative craniotomy client who has a
serum sodium level of 153 mEq/L.
l 3. The client with septic meningitis who has a white
blood cell count of 12,000 mm.
l 4. The client with epilepsy who has a serum
phenytoin (Dilantin) level 15 mcg/mL.
right-sided paralysis secondary to a CVA. Which action
by the UAP requires the nurse to intervene?
l 1. The UAP encourages the client to perform ROM
exercises.
l 2. The UAP places the client on a side with a pillow
between the legs.
l 3. The UAP leaves a urinal full of urine at the client’s
bedside.
l 4. The UAP praises the client for attempting to get
dressed alone.
89. The primary nurse in the neurological critical
care unit is very busy. Which nursing task must be
implemented first?
l 1. Assist the HCP with a sterile dressing change for a
client who has a turban dressing.
l 2. Obtain a tracheostomy tray for a client with a
C-4 SCI who is exhibiting air hunger.
l 3. Transcribe orders for a client who was transferred
from the emergency department.
l 4. Administer the antibiotic therapy to the client
diagnosed with meningitis.
ANSWERS
88. Correct answer 2: An elevated serum sodium level
(normal is 135–145 mEq/L) indicates possible
diabetes insipidus, which is a complication of brain
surgery. The ABGs are within normal limits, the
WBC count would be elevated in a client with
meningitis, and the therapeutic Dilantin level is
10–20 mcg/mL. Content–Medical; Category of Health
Alteration–Surgical; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
89. Correct answer 2: The client with a C-4 SCI may
have ascending edema that could cause respiratory
compromise; therefore, the nurse should have a
tracheostomy tray at the bedside. Content–Medical;
Category of Health Alteration–Neurological; Integrated
Process–Planning; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Evaluation.
Copyright © 2010 F.A. Davis Company
54
90. Correct answer 3: The UAP should be instructed to
keep all urinals and bedpans clean when at the bedside.
Content–Medical; Category of Health Alteration–
Neurological; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management of
Care; Cognitive Level–Application.
SECTION TWO
Cardiovascular Disorders
55
SECTION TWO
Cardiovascular Disorders
57
Angina/Myocardial Infarction
1. The nurse is caring for a client who was diagnosed
3. Which statement indicates the client diagnosed with
with a myocardial infarction 24 hours ago. The client has
developed an audible S3 heart sound. Which action
should the nurse implement first?
l 1. Notify the health-care provider (HCP)
immediately.
l 2. Document the finding in the client's chart.
l 3. Assess the client's blood pressure.
l 4. Check the client's telemetry reading.
angina needs more discharge teaching?
l 1. “I will keep my nitroglycerin in a dark bottle at all
times.”
l 2. “I should stay on a low-fat, low-cholesterol diet.”
l 3. “I will not walk outside if it is colder than 40ºF.”
l 4. “I should perform isometric exercises three times
a week.”
2. While the nurse is ambulating the client diagnosed
complaining of chest pain. Which comment by the client
would indicate to the nurse the client is experiencing
angina instead of a myocardial infarction?
l 1. “I was resting in my recliner when my chest started
hurting.”
l 2. “I was mowing my lawn when I started having
chest pain.”
l 3. “I started having chest pain when I took a deep
breath.”
l 4. “My heart started pounding in my chest and then
I felt pain.”
with angina to the bathroom, the client begins to
complain of chest pain radiating to the left arm. Which
intervention should the nurse implement first?
l 1. Administer a nitroglycerin tablet sublingually.
l 2. Return the client to bed and tell client to lie in
the bed.
l 3. Place oxygen on the client via nasal cannula.
l 4. Request a stat electrocardiogram (ECG).
4. The client comes to the emergency department
ANSWERS
1. Correct answer 1: An audible S3 heart sound indicates
heart failure, which is a complication of a myocardial
infarction. Therefore, the nurse should notify the
HCP first. Assessing the blood pressure, checking
the telemetry, and documenting findings in the
patient's chart are interventions that should be implemented, but the nurse should notify the HCP first.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
2. Correct answer 2: The nurse should first have the
client lie down to help decrease the need for oxygen to
the myocardium. Then the nurse should administer
sublingual nitroglycerin and place oxygen on the
client. After these interventions, the nurse should
request a stat ECG. Content Area–Medical; Category
of Health Alteration–Cardiovascular; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
Copyright © 2010 F.A. Davis Company
58
3. Correct answer 4: Isometric exercises are musclebuilding exercises such as weightlifting. The client
should perform isotonic exercises such as walking
and swimming. This indicates the client needs more
discharge teaching. All other statements indicate the
client understands the teaching.Content Area–Medical;
Category of Health Alteration–Cardiovascular; Integrated
Process–Evaluation; Client Needs–Health Promotion and
Maintenance; Cognitive Level–Evaluation
4. Correct answer 2: Angina is usually brought on by
activity such as exercising, cold weather (constriction),
stress, or sexual intercourse. Content Area–Medical;
Category of Health Alteration–Cardiovascular; Integrated
Process–Evaluation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
Cardiovascular Disorders
SECTION TWO
5. The nurse is discussing modifiable risk factors with the
client diagnosed with angina. Which instructions should
be included in the instructions? Select all that apply.
l 1. Discuss the importance of eating a diet low in fiber.
l 2. Explain the need to keep the cholesterol level under
200 mg/dL.
l 3. Instruct the client to walk for 30 minutes three
times a week.
l 4. Tell the client to decrease the amount of cigarettes
smoked daily.
l 5. Inform the client the blood glucose level should be
70–120 mg/dL.
6. The nurse is caring for a client diagnosed with a
myocardial infarction. Which assessment data would
warrant immediate attention by the nurse?
l 1. The client has a urinary output of 120 mL in
2 hours.
l 2. The client's telemetry shows multifocal premature
ventricular contractions (PVCs).
l
l
59
3. The client's bilateral anterior and posterior breath
sounds are clear.
4. The client's cardiac enzymes and white blood cells
are elevated.
7. The HCP has prescribed thrombolytic therapy for the
client diagnosed with a myocardial infarction. Which data
indicate the medication is effective?
l 1. The client's cardiac enzymes decrease.
l 2. The client's chest pain is relieved.
l 3. The client exhibits reperfusion dysrhythmias.
l 4. The client's blood pressure is within normal limits.
ANSWERS
5. Correct answer 2, 3, 5: Risk factors include a high
cholesterol level, sedentary lifestyle, cigarette smoking,
and diabetes. The client must quit smoking, not just
decrease smoking. The client should eat a low-fat, lowcholesterol, and high-fiber diet. Content Area–Medical;
Category of Health Alteration–Cardiovascular; Integrated
Process–Implementation; Client Needs–Health Promotion
and Maintenance; Cognitive Level–Application.
6. Correct answer 2: Cardiac dysrhythmias occur in
about 90% of clients experiencing a myocardial
infarction. Multifocal PVCs are life-threatening
and require immediate intervention by the nurse.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Evaluation.
Copyright © 2010 F.A. Davis Company
60
7. Correct answer 3: Reperfusion dysrhythmias
(premature ventricular contractions) indicate the
tissue is viable, which indicates the medication is
effective. Content Area–Medical; Category of Health
Alteration–Cardiovascular; Integrated Process–
Evaluation; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Evaluation.
SECTION TWO
Cardiovascular Disorders
61
8. The charge nurse is making assignments for clients on
10. The charge nurse is observing a licensed practical
a medical unit. Which client should the charge nurse
assign to the recent graduate nurse?
l 1. The client diagnosed with angina whose pain is
unrelieved with nitroglycerin.
l 2. The client who is scheduled for a left-sided cardiac
catheterization.
l 3. The client with a myocardial infarction whose
pulse oximeter reading is 90%.
l 4. The client diagnosed with heart disease who needs
discharge teaching.
nurse (LPN) applying a nitroglycerin patch to the client
diagnosed with angina. Which action warrants immediate
intervention from the charge nurse?
l 1. The LPN places the nitroglycerin patch on a
non-hairy area.
l 2. The LPN dates and times the nitroglycerin patch.
l 3. The LPN wears gloves when applying the
nitroglycerin patch.
l 4. The LPN applies the new patch while leaving the
old patch in place.
9. The intensive care nurse is caring for a client
Atherosclerosis
diagnosed with a myocardial infarction. Which
intervention should the nurse implement?
l 1. Monitor the client's urine output every shift.
l 2. Keep the head of the client's bed flat.
l 3. Assess the client's breath sounds every 2 hours.
l 4. Discourage the client from deep breathing.
11. Which statement indicates to the nurse the client
understands a modifiable risk factor for atherosclerosis?
l 1. “As I get older my chance of having a heart attack
increases.”
l 2. “My father and grandfather both died of heart disease.”
l 3. “I listen to relaxation tapes to help decrease my
high stress level.”
l 4. “I will take saw palmetto every day to help decrease
my blood pressure.”
ANSWERS
8. Correct answer 2: A newly graduated nurse would be
able to care for a stable client scheduled for a cardiac
catheterization. The client with angina not relieved
by nitroglycerin is not stable, and a client with
hypoxemia (a pulse oximeter reading less than 93%)
should be assigned to a more experienced nurse, as
should discharge teaching. Content Area–Medical;
Category of Health Alteration–Cardiovascular; Integrated
Process–Planning; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Analysis.
9. Correct answer 3: The client is at risk for cardiac
failure; therefore, the nurse should assess the breath
sounds for crackles. The urine output should be
checked more frequently than every shift, the head of
the bed should be in semi-Fowler position, and deep
breathing should be encouraged to decrease the chance
of pneumonia. Content Area–Medical; Category of
Health Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
62
10. Correct answer 4: The LPN should remove
the old patch prior to administering the new
patch. Content Area–Medical; Category of Health
Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
11. Correct answer 3: A modifiable risk factor is a risk
factor that can possibly be altered by modifying or
changing behavior, such as developing new ways to
deal with stress. Age and family history are nonmodifiable risk factors. Saw palmetto helps treat benign
prostatic hypertrophy, not high blood pressure.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Evaluation; Client
Needs–Health Promotion and Maintenance; Cognitive
Level–Evaluation.
SECTION TWO
Cardiovascular Disorders
63
12. The client asks the nurse, “My doctor just told me
14. The female client tells the nurse that her cholesterol
that atherosclerosis is why my chest hurts when I walk
real fast. What does that mean?” Which statement is the
nurse's best response?
l 1. “The muscle fibers and endothelial lining of your
arteries have become thickened.”
l 2. “You sound concerned because your chest hurts
when you walk real fast.”
l 3. “The valves in your heart are incompetent, which
is why your chest hurts with activity.”
l 4. “You have a hardening of your arteries with fatty
buildup that decreases the oxygen to your heart.”
level was 189 mg/dL. Which action should the nurse
implement?
l 1. Praise the client for having an acceptable cholesterol
level.
l 2. Explain that the client needs to lower the cholesterol
level.
l 3. Discuss dietary changes that could help increase the
level.
l 4. Allow the client to ventilate feelings about the
blood result.
13. The client diagnosed with peripheral vascular disease
is overweight, has smoked two packs of cigarettes a day
for 20 years, and sits behind a desk all day. Which
statement by the client refers to the strongest factor in
the development of atherosclerotic lesions?
l 1. “I am going to try and lose at least 20 pounds.”
l 2. “I have to get out from behind the desk more often.”
l 3. “I am going to eat foods that are high in fiber.”
l 4. “I have to quit smoking cigarettes but it will be hard.”
ANSWERS
12. Correct answer 4: This response explains in plain
terms why the client has chest pain with increased
activity. The client needs information, not a therapeutic response (option 2). The nurse should assume
the client is a layperson and should not explain
disease processes using medical terminology such as
in option 1. Content Area–Medical; Category of
Health Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Physiological, Physiological Adaptation; Cognitive Level–Application.
13. Correct answer 4: Tobacco use is the strongest factor in the development of atherosclerosis. Nicotine
decreases blood flow to the extremities and increases
heart rate and blood pressure. In addition it increases
the risk of clot formation by increasing the aggregation of platelets. Content Area–Medical; Category of
Health Alteration–Cardiovascular; Integrated Process–
Evaluation; Client Needs–Health Promotion and
Maintenance; Cognitive Level–Evaluation.
Copyright © 2010 F.A. Davis Company
64
14. Correct answer 1: The American Heart Association
recommends the cholesterol level should be less than
200 mg/dL; therefore the nurse should praise the
client. Content Area–Medical; Category of Health
Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Health Promotion and
Maintenance; Cognitive Level–Application.
Cardiovascular Disorders
SECTION TWO
15. The nurse is discussing the pathophysiology of
atherosclerosis with a client who has a high low-density
lipoprotein (LDL) level. Which information should
the nurse discuss with the clients concerning the
pathophysiology of LDL?
l 1. A high LDL is good because it has a protective
action in the body.
l 2. This test result measures the free fatty acids and
glycerol in the blood.
l 3. LDLs are the primary transporters of cholesterol
into the cell.
l 4. The client needs to decrease the amount of
cholesterol and fat in the diet.
16. Which assessment data would cause the nurse to
suspect the client has atherosclerosis?
l 1. The client complains of her legs swelling when she
stands for long periods.
l 2. The client has episodes of jitteriness and headache
when feeling hungry.
l
l
65
3. The client has bilateral calf pain when walking for
short periods.
4. The client complains of mid-epigastric pain after
eating spicy foods.
17. The HCP prescribed atorvastatin, (Lipitor), an
HMG-CoA reductase inhibitor. Which teaching
intervention should the nurse include when discussing
this medication?
l 1. Tell the client to take the medication with
food only.
l 2. Instruct the client to take the medication in the
evening.
l 3. Explain that muscle pain is a common side effect
of this medication.
l 4. Demonstrate how to use the machine to check the
cholesterol level daily.
ANSWERS
15. Correct answer 3: LDLs have the harmful effect of
66
17. Correct answer 2: These medications should be taken
depositing cholesterol into the walls of the arterial
vessels, which is the pathophysiology of LDL. Highdensity lipoprotein transports cholesterol away from
the tissue and cells of the arterial wall to the liver for
excretion, which helps decrease the development
of atherosclerosis. Content Area–Medical; Category
in the evening for best results, because the enzyme
that destroys cholesterol works best in the evening,
and the medication enhances this process. Muscle
pain is an adverse effect and should be reported to
the HCP immediately. Cholesterol levels cannot be
checked daily. Content Area–Medical; Category of
of Health Alteration–Cardiovascular; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive Level–
Application.
Health Alteration–Cardiovascular; Integrated Process–
Intervention; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Application.
16. Correct answer 3: The client is describing intermittent claudication, which should make the nurse
suspect the client has generalized atherosclerosis, a
marker of coronary artery disease. Option 1 could be
heart failure, option 2 hypoglycemia, and option 4
peptic ulcer disease. Content Area–Medical; Category
of Health Alteration–Cardiovascular; Integrated
Process–Assessment; Client Needs–Physiological
Integrity, Reduction of Risk Potential; Cognitive
Level–Application.
Copyright © 2010 F.A. Davis Company
SECTION TWO
Cardiovascular Disorders
67
18. Which menu selection indicates to the nurse the
20. The nurse is caring for clients on a telemetry floor.
client diagnosed with atherosclerosis understands the
teaching concerning a low-fat, low-cholesterol diet?
l 1. Fried chicken, garlic mashed potatoes, and
skim milk.
l 2. Ham and cheese on white bread and whole milk.
l 3. Baked fish, brown rice, lettuce salad, and iced tea.
l 4. A hamburger, potato chips, and carbonated
beverage.
Which nursing task would be most appropriate to
delegate to unlicensed assistive personnel (UAP)?
l 1. Teach the client how to take their radial pulse for
1 minute.
l 2. Escort the discharged client in a wheelchair to the
client's car.
l 3. Check the triglyceride level for the client diagnosed
with atherosclerosis.
l 4. Assist the client who just returned from a cardiac
catheterization to ambulate.
19. Which interventions should the nurse implement
when teaching the 54-year-old client diagnosed with
atherosclerosis? Select all that apply.
l 1. Include significant other when teaching the client.
l 2. Provide the client with written handouts and
pamphlets.
l 3. Refer the client to the American Heart Association
(AHA).
l 4. Help the client to identify ways to deal with
stressful situations.
l 5. Discuss the importance of isometric exercises daily.
ANSWERS
18. Correct answer 3: Baked, broiled, or grilled meats
68
20. Correct answer 2: The UAP can escort a stable
or fish, high-fiber brown rice, and ice tea would be
an appropriate meal. Fried foods are high in fat and
cholesterol; white bread is low in fiber; and whole
milk is high in fat. Hamburger meat is high in fat,
and carbonated beverages are high in calories.
client to the car. The nurse cannot delegate assessment (option 3), teaching (option 1), evaluation,
administering medications, or care of an unstable
client. A client returning from cardiac catheterization
cannot ambulate for 6 hours. Content Area–Medical;
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Evaluation; Client
Needs–Health Promotion and Maintenance; Cognitive
Level–Evaluation.
Category of Health Alteration–Cardiovascular;
Integrated Process–Intervention; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
19. Correct answer 1, 2, 3, 4: Including the significant
other increases adherence to lifestyle modifications;
written information helps the client review information after the teaching session; the AHA is an appropriate referral; and decreasing stress is appropriate for
teaching about atherosclerosis. Isotonic exercises,
not isometric exercises, should be recommended.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Intervention; Client
Needs–Health Promotion and Maintenance; Cognitive
Level–Application.
Copyright © 2010 F.A. Davis Company
SECTION TWO
Cardiovascular Disorders
69
Valve Disorders
21. The nurse is discharging a 65-year-old client diagnosed
23. The nurse is admitting a client diagnosed with a
with aortic stenosis who had undergone mechanical valve
replacement surgery. Which information should the nurse
teach the client?
l 1. Splint the incision when turning, coughing, and
deep breathing.
l 2. Sleep in a recliner or with the head on two pillows
at night.
l 3. Avoid being around children or people who have
had an immunization.
l 4. Take antibiotics prior to any dental or other
invasive procedures.
mitral valve murmur. Which information supports this
finding?
l 1. The client has a history of rheumatic fever as a
child.
l 2. The client takes an oral anticoagulant daily.
l 3. The client has elevated troponin levels.
l 4. The client recently took a vacation to Central
America.
22. The nurse caring for clients on a medical unit thinks
she hears a murmur while assessing the client. After
determining that no other HCP have documented a
murmur, which action should the nurse implement next?
l 1. Do nothing because the nurse was probably mistaken.
l 2. Document the finding in the client's chart.
l 3. Notify the HCP.
l 4. Ask the client if there is a history of a murmur.
24. The nurse is preparing the 52-year-old male client diagnosed with mitral valve regurgitation for surgery. Which
statement by the client warrants immediate intervention?
l 1. “I have been told that I will be on medication for
the rest of my life.”
l 2. “I get short of breath walking to the bathroom to
bathe myself.”
l 3. “I made out an advance directive to make sure my
wishes are known.”
l 4. “I will be in the intensive care unit for a day or two
after surgery.”
ANSWERS
21. Correct answer 4: Clients with a mechanical valve
are at risk for developing bacterial endocarditis after
dental cleaning or other invasive procedures, such as
genitourinary or gastrointestinal procedures. Prophylactic antibiotics prevent this. Content Area–Surgical;
Category of Health Alteration–Cardiovascular; Integrated
Process–Intervention; Client Needs–Health Promotion
and Maintenance; Cognitive Level–Application.
22. Correct answer 4: Part of assessing the client is to
conduct a client interview about abnormal data.
The nurse can reassess the client to gather more data
before notifying the HCP and documenting the
finding in the chart. The nurse should never ignore
abnormal data. Content Area–Medical; Category of
Health Alteration–Cardiovascular; Integrated Process–
Intervention; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
Copyright © 2010 F.A. Davis Company
70
23. Correct answer 1: Rheumatic fever is caused by a
streptococcal infection that can result in vegetative
growth on the cardiac valves, resulting in valvular
disease later in life. Oral anticoagulants are prescribed after mechanical valve surgery, and troponin
levels are elevated after a myocardial infarction.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Application.
24. Correct answer 2: This statement indicates heart
failure, and the nurse should investigate this further
and notify the HCP. The other statements convey
correct information or indicate appropriate preparation. Content Area–Surgical; Category of Health
Alteration–Cardiovascular; Integrated Process–
Intervention; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
SECTION TWO
Cardiovascular Disorders
71
25. The 24-year-old female client has had surgery to
27. The client diagnosed with aortic stenosis scheduled
replace a diseased mitral graft. Which information should
the nurse teach the client prior to discharge?
l 1. Take your temperature four times a day and notify
the HCP of the results.
l 2. Have routine International Normalized Ratio
(INR) lab tests performed.
l 3. Limit lifting to less than 5 pounds until you are
seen by the surgeon.
l 4. Your menses will be heavier because of the
anticoagulant medications.
for an echocardiogram tells the nurse, “I am scared. What
will they do during the test?” Which statement is the
nurse's best response?
l 1. “You're scared? We should discuss how you are
feeling.”
l 2. “The doctor will insert a catheter into the artery in
your groin.”
l 3. “I think you should talk with the doctor about you
fears.”
l 4. “Sound waves will be used to determine how your
heart is working.”
26. The nurse is assisting the client diagnosed with
cardiac valve disease to choose a menu for the next day.
Which menu is most appropriate for this client?
l 1. A ham and cheese sandwich, potato chips, and
2% milk.
l 2. Roast beef, lettuce salad with low-fat dressing, and
water.
l 3. Eggs, bacon, whole wheat toast, jelly, and black
coffee.
l 4. Chicken-fried steak, mashed potatoes and gravy,
and iced tea.
ANSWERS
25. Correct answer 3: Postoperative instructions for
any surgery that involves the abdomen or trunk area
require a lifting restriction to prevent pulling on the
surgical site. Female clients of childbearing age are
given living-tissue valves so that anticoagulant therapy is not needed during a pregnancy, if one should
occur, and therefore routine INR lab tests are not
necessary. Content Area–Surgical; Category of
Health Alteration–Cardiovascular; Integrated Process–
Intervention; Client Needs–Health Promotion and
Maintenance; Cognitive Level–Application.
26. Correct answer 2: The client should be on a hearthealthy diet, limiting caffeine (black coffee) and
alcohol, salt, and fat- and cholesterol-containing
foods (ham, cheese, potato chips, eggs, bacon,
fried steak, etc.). Content Area–Medical; Category
of Health Alteration–Cardiovascular; Integrated
Process–Intervention; Client Needs–Health Promotion
and Maintenance; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
72
27. Correct answer 4: An echocardiogram uses sound
waves to determine the functioning of the heart.
It is not invasive. The nurse should provide factual
answers, not refer the client to a health-care provider.
Nor should the nurse in a situation in which the
client is asking for information provide a therapeutic
response (option 1). Content Area–Medical; Category
of Health Alteration–Cardiovascular; Integrated
Process–Intervention; Client Needs–Physiological
Integrity, Reduction of Risk Potential; Cognitive
Level–Application.
Cardiovascular Disorders
SECTION TWO
28. The client diagnosed with mitral valve stenosis
complains of shortness of breath and chest pain while
ambulating in the hall with a UAP. Which action should
the nurse implement first?
l 1. Tell the UAP to take the client's vital signs.
l 2. Determine if this has happened to the client before.
l 3. Get a wheelchair for the client to sit down.
l 4. Have a stat electrocardiogram (ECG) done.
29. The client is admitted to the intensive care unit post
aortic valve replacement. Which interventions should the
nurse implement? Select all that apply.
l 1. Monitor the client's telemetry readings.
l 2. Monitor vital signs every 4 hours.
l 3. Assess for S3 or S4 heart sounds.
l 4. Auscultate for a heart click.
l 5. Maintain intravenous lines.
l
l
l
2. A murmur heard with a stethoscope at the right
sternal notch.
3. Shortness of breath on exertion and weakness.
4. Palpitations, fatigue, and pink frothy sputum.
Dysrhythmia
31. Which medication should the nurse prepare to
administer for the client exhibiting the following
telemetry strip?
30. The client diagnosed with a grade II aortic murmur
l
is admitted to the telemetry unit. Which symptoms
should the nurse expect to assess?
l 1. Peripheral edema, jugular vein distention, and a
productive cough.
l
l
l
1. The miscellaneous antidysrhythmic adenosine
(Adenocard).
2. The antidysrhythmic lidocaine (Xylocaine).
3. The cardiac glycoside digoxin (Lanoxin).
4. The inotropic medication dopamine (Intropin).
73
ANSWERS
28. Correct answer 3: The nurse should first stop the
activity that is causing the client's distress by providing a place for the client to sit. Assessment can be
made after interventions for the client's comfort or
safety. Content Area–Medical; Category of Health
Alteration–Cardiovascular; Integrated Process–
Intervention; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
29. Correct answer 1, 3, 5: The nurse should monitor
the client's telemetry for dysrhythmias, assess for
symptoms of heart failure such as S3 or S4 heart
sounds, and maintain IV lines. Vital signs should be
monitored every 5–15 minutes initially and then
every 1–2 hours when the patient is stable. A heart
click is a symptom of a mitral valve problem.
Content Area–Surgical; Category of Health Alteration–
Cardiovascular; Integrated Process–Intervention; Client
Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
74
30. Correct answer 2: A stage 2 murmur can be heard
over the area of the chest closest to the diseased
valve. Many valve disorders are present long before
any other symptoms occur. Answers 1, 3, and 4 are
symptoms of heart failure and would not be present
with a stage 2 aortic murmur. Content Area–Medical;
Category of Health Alteration–Cardiovascular; Integrated Process–Assessment; Client Needs–Physiological
Integrity, Reduction of Risk Potential; Cognitive
Level–Application.
31. Correct answer 2: Lidocaine is an antidysrhythmic
medication that suppresses ventricular ectopy and is
the drug of choice for multifocal premature ventricular contractions, which is a potentially life-threatening
dysrhythmia. Content Area–Medical; Category of
Health Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Application.
SECTION TWO
Cardiovascular Disorders
75
32. The client is exhibiting the following telemetry strip.
34. The telemetry nurse is unable to read the telemetry
Which interventions should the nurse implement? Rank
in order of performance.
monitor at the nurse's station. Which intervention should
the telemetry nurse implement?
l 1. Go to the client's room to check the client.
l 2. Instruct the primary nurse to assess the client.
l 3. Notify the charge nurse of the emergency situation.
l 4. Request the UAP to take the crash cart to the
client's room.
l
l
l
l
l
35. Which intervention should the nurse implement
1. Administer the antidysrhythmic atropine.
2. Determine if the telemetry strip is artifact.
3. Administer epinephrine, a sympathomimetic.
4. Perform 30 hard and fast cardiac compressions.
5. Administer two breaths with the nose pinched.
33. The client is exhibiting sinus bradycardia on the
telemetry monitor. Which intervention should the nurse
implement first?
l 1. Administer the antidysrhythmic atropine.
l 2. Determine if the client is symptomatic.
l 3. Prepare for an insertion of a pacemaker.
l 4. Notify the client's HCP.
first when defibrillating a client who is in ventricular
fibrillation?
l 1. Defibrillate the client at 360 joules.
l 2. Remove the client's oxygen source.
l 3. Energize the defibrillator source.
l 4. Shout “all clear” prior to defibrillation.
ANSWERS
32. Correct answer in order 2, 5, 4, 3, 1: The nurse
should first determine if the client is in asystole
(it could be an artifact). Then the nurse should
start cardiopulmonary resuscitation by giving two
breaths and cardiac compressions. This is followed
by administering intravenous epinephrine to vasoconstrict the peripheral circulation and shunt the
blood to the central circulation (brain, heart, lungs)
in clients who do not have a heartbeat. Atropine is
then administered; it decreases vagal stimulation and
increases the heart rate and is the drug of choice for
a client exhibiting asystole. Content Area–Medical;
Category of Health Alteration–Cardiovascular;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Pharmacological and Parenteral
Therapies; Cognitive Level–Application.
33. Correct answer 2: The nurse must first determine if
the client is weak, lightheaded, or experiencing other
symptoms of syncope and hypotension. If the client is
symptomatic, atropine is the drug of choice, along
with insertion of a pacemaker, which must be done by
Copyright © 2010 F.A. Davis Company
76
the HCP. Content Area–Medical; Category of Health
Alteration–Cardiovascular; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Application.
34. Correct answer 2: The telemetry nurse cannot leave
the monitors; therefore, the primary nurse should be
instructed to go and assess the client immediately. The
primary nurse must assess the client before contacting
the charge nurse and taking the crash cart to the room.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
35. Correct answer 2: The oxygen source should be
removed to prevent any type of spark during defibrillation. Then the nurse should shout “all clear,”
energize the source, and defibrillate at 360 joules.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Application.
Cardiovascular Disorders
SECTION TWO
36. The client who has been exhibiting the following
37. The client is in complete heart block. Which
telemetry reading for the last 6 months is being
discharged from the hospital. Which statement indicates
the discharge teaching by the nurse has been effective?
intervention should the nurse implement first?
l 1. Prepare to insert a pacemaker.
l 2. Administer atropine, an antidysrhythmic.
l 3. Obtain a stat ECG.
l 4. Assess the client's peripheral pulses.
77
38. The client is 1 day postoperative open heart surgery
l
l
l
l
1. “I will take my blood pressure prior to taking my
medication.”
2. “I need to eat a low-fat, low-cholesterol, and
low-salt diet.”
3. “I must have an INR frequently while I am taking
warfarin (Coumadin).”
4. “I should use a straight razor instead of an electric
razor.”
and has a temperature (T) of 99ºF, a pulse (P) of 96,
a respiration rate (R) of 22, and B/P 128/92 and is
complaining of incisional pain of 8 on a 1–10 pain scale.
Which intervention should the nurse implement?
l
l
l
l
1. Continue to monitor the client and take no action.
2. Administer the antipyretic acetaminophen (Tylenol).
3. Administer a narcotic analgesic to the client.
4. Assess the client's pulse oximeter reading.
ANSWERS
36. Correct answer 3: Atrial fibrillation could cause a
blood clot; therefore, the client is placed on the anticoagulant warfarin (Coumadin), which is monitored
for effectiveness by the INR (2–3). Atrial fibrillation
does not cause hypertension; therefore, the client
does not need to monitor the blood pressure or be
on a low-salt diet. An electric razor is appropriate
to prevent cuts, which lead to bleeding. Content
Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Evaluation; Client
Needs–Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Evaluation.
37. Correct answer 2: Atropine decreases vagal stimulation and increases the heart rate; therefore, it is the
first intervention. Remember, the client is in distress;
therefore, do not assess the peripheral pulses first.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
78
38. Correct answer 3: Pain, elevated temperature, exercise, anxiety, hypoxemia, hypovolemia, and cardiac
failure may all cause sinus tachycardia. The nurse
should administer pain medication to the client. The
pulse oximeter reading will not help the client's pain.
Content Area–Surgical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Application.
SECTION TWO
Cardiovascular Disorders
79
Cardiac Inflammatory Diseases
39. The client is exhibiting the following telemetry
41. The client is diagnosed with pericarditis. Which
reading. Which intervention should the nurse implement?
signs/symptoms should the nurse expect in this client?
l 1. The client has pulsus paradoxus and night sweats.
l 2. Complaints of fatigue and arthralgias.
l 3. Constant chest pain and friction rub.
l 4. Increased chest pain when ambulating but not
at rest.
42. The client is diagnosed with acute pericarditis.
l
l
l
l
1. Document this as normal sinus rhythm.
2. Request a 12-lead electrocardiogram.
3. Prepare to administer the cardiotonic digoxin by
mouth (PO).
4. Assess the client's cardiac enzymes.
40. Which client problem is priority for the client with a
cardiac dysrhythmia?
l 1. Knowledge deficit.
l 2. Altered cardiac output.
l 3. Impaired gas exchange.
l 4. Activity intolerance.
During the shift assessment, the nurse notes muffled
heart sounds. Which intervention should the nurse
implement?
l 1. Notify the HCP.
l 2. Continue to monitor the client.
l 3. Get an order to place the client on telemetry.
l 4. Recheck the client in 4 hours.
ANSWERS
39. Correct answer 1: The P-wave represents atrial
contraction, and the QRS complex represents
ventricular contraction. This electrocardiogram strip
indicates a normal telemetry reading. In addition, a
rate 60–100 indicates normal sinus rhythm. The
nurse should document these findings and not take
any action. Content Area–Medical; Category of
80
41. Correct answer 3: In pericarditis, chest pain is
usually constant but can be aggravated by respiratory
movements (deep inspiration, coughing), changes in
body position, or swallowing. The most characteristic symptom is a friction rub. Pulsus paradoxus is
associated with cardiac tamponade, not pericarditis.
Health Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Application.
40. Correct answer 2: Any abnormal electrical activity of
42. Correct answer 1: Muffled heart sounds require the
the heart causes an altered or decreased cardiac output.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Diagnosis; Client
Needs–Safe Effective Care Environment, Management of
Care; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
nurse to notify the HCP. Acute pericardial effusion
interferes with normal cardiac filling and pumping,
causing venous congestion and decreased cardiac
output, resulting in muffled heart sounds. Content
Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Application.
SECTION TWO
Cardiovascular Disorders
81
43. The nurse is assessing the client diagnosed with
45. The client diagnosed with endocarditis is complaining
subacute bacterial endocarditis. Which question should
the nurse ask the client during the admission interview to
support this diagnosis?
l 1. “Have you had a sore throat in the last month?”
l 2. “Did you have frequent strep throats as a child or
young adult?”
l 3. “Do you have a family history of heart disease?”
l 4. “What prescription medications do you take?”
of increased dyspnea and nausea. Which intervention
should the nurse implement first?
l 1. Ask Respiratory Therapy to evaluate the client's
dyspnea.
l 2. Obtain an order for an indwelling urinary catheter.
l 3. Auscultate the client's lung sounds and assess the
periphery.
l 4. Give the client a specimen cup to collect sputum.
44. The client with pericarditis is prescribed a
46. The client diagnosed with pericarditis complains
nonsteroidal anti-inflammatory drug (NSAID). Which
teaching instruction should the nurse discuss with the
client?
l 1. Explain the importance of keeping a pain diary to
show the HCP.
l 2. Discuss not driving or operating machinery while
taking the medication.
l 3. Instruct the client not to take the medication on an
empty stomach.
l 4. Alternate the medication with acetaminophen
(Tylenol) every 8 hours.
of pressure in the chest and shortness of breath. The
intensive care nurse assesses a decreasing systolic blood
pressure and jugular vein distention. Which collaborative
intervention should the nurse anticipate for this client?
l 1. Prepare for a pericardiocentesis.
l 2. Send the client for a cardiac catheterization.
l 3. Have Respiratory Therapy draw arterial blood
gases.
l 4. Refer the client to the chaplain for anticipatory
grief counseling.
ANSWERS
43. Correct answer 2: Rheumatic fever, a systemic
inflammatory disease caused by an abnormal immune
response to pharyngeal infection by group A betahemolytic streptococci, causes carditis in about 50%
of the people. Frequent strep throats can lead to rheumatic fever; therefore, this would be the most appropriate question. Content Area–Medical; Category of
Health Alteration–Cardiovascular; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Application.
44. Correct answer 3: The medication must be taken
with food, milk, or antacids to help decrease gastric
distress. NSAIDs reduce fever, inflammation, and
pericardial pain. Steroids are tapered; NSAIDs do
not make the client drowsy; and NSAIDs should be
taken routinely to decrease inflammation, not alternated with Tylenol. Content Area–Medical; Category
of Health Alteration–Cardiovascular; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Pharmacological and Parenteral Therapies;
Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
82
45. Correct answer 3: The nurse should assess the client
for heart failure and then plan interventions based on
the data collected. Some clients develop intractable
heart failure as a result of endocarditis. Content
Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
46. Correct answer 1: These are symptoms of cardiac
tamponade, and the treatment is an emergency pericardiocentesis. A pericardiocentesis removes fluid
from the pericardial sac, which requires collaboration
with the health-care provider. The other options are
collaborative but not appropriate for the client's
condition. Content Area–Medical; Category of
Health Alteration–Cardiovascular; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
SECTION TWO
Cardiovascular Disorders
83
47. The female client is diagnosed with rheumatic fever
49. The client has just had a pericardiocentesis. Which
and prescribed penicillin, an antibiotic. Which statement
indicates the client understands the discharge teaching?
l 1. “I must take the prescribed antibiotics for 7 days
only.”
l 2. “I may get a vaginal yeast infection with penicillin.”
l 3. “I will have no problems as long as I take my
medication.”
l 4. “My throat culture was positive for a staph
infection.”
interventions should the nurse implement? Select all that
apply.
l 1. Monitor vital signs every 2 hours for 24 hours.
l 2. Assess the client for a fluid wave.
l 3. Record the amount of fluid removed as output.
l 4. Evaluate the client's cardiac rhythm.
l 5. Keep the client in a semi-Fowler position.
48. The nurse is planning the care of a client diagnosed
with acute bacterial endocarditis who has been admitted
for intravenous therapy. Which intervention should the
nurse include in the plan of care?
l 1. Limit interruptions to allow for uninterrupted rest
and sleep.
l 2. Refer the client to inpatient cardiac rehabilitation.
l 3. Maintain oxygen via nasal cannula at 2 L/min.
l 4. Discuss the need for valve replacement surgery.
50. The client with infective endocarditis is admitted to
the medical department. Which HCP's order should be
implemented first?
l 1. Administer the intravenous antibiotic.
l 2. Schedule an echocardiogram.
l 3. Insert a 20-gauge intravenous catheter.
l 4. Bedrest with bathroom privileges.
ANSWERS
47. Correct answer 2: Female clients may experience
vaginal yeast infections when taking antibiotics
because the antibiotics kill the good bacteria and
well as the bad. The client should take all the antibiotics, not for just 7 days. Rheumatic fever is caused
by a group A beta-hemolytic streptococcus infection.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Evaluation; Client
Needs–Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Evaluation.
48. Correct answer 1: This helps decrease the workload
of the heart and helps ensure the restoration of physical and emotional health. The client is placed on
bedrest to decrease the workload of the heart.
Endocarditis may lead to valve damage and the need
for valve replacement, but not in the acute phase.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Planning; Client
Needs–Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
84
49. Correct answer 3, 4, 5: This fluid is output and
should be documented on the client's daily intake
and output record. The nurse must assess for cardiac
failure. The client should be in the semi-Fowler
position, not flat, which increases the workload
of the heart. Vital signs should be assessed more
frequently initially, and a fluid wave is for assessing
the abdomen. Content Area–Medical; Category of
Health Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
50. Correct answer 3: Initiation of antibiotics is priority, so the nurse must start the intravenous line for
the antibiotics. Obtaining cultures would be done
before starting the antibiotics.Content Area–Medical;
Category of Health Alteration–Cardiovascular;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
SECTION TWO
Cardiovascular Disorders
85
Essential Hypertension
51. The male client diagnosed with hypertension has
53. The nurse is caring for the client diagnosed with
epistaxis and a flushed face. Which action should the
nurse implement first?
l 1. Notify the client's HCP.
l 2. Assess the client's blood pressure lying, standing,
and sitting.
l 3. Elevate the client's head of the bed.
l 4. Prepare to administer an intravenous
antihypertensive medication.
essential hypertension who is prescribed hydrochlorothiazide
(HTCZ), a thiazide diuretic. Which intervention should
the nurse implement when administering this medication?
l 1. Check the client's apical pulse for 1 minute.
l 2. Question administering if the client's potassium
level is less than 5.5 mEq/L.
l 3. Instruct the client to rise slowly from a lying to a
sitting position.
l 4. Tell the client to drink 1000 mL of fluid daily.
52. The nurse is completing discharge teaching for a
client diagnosed with essential hypertension. Which
statement indicates the client understands the discharge
teaching?
l 1. “I can eat bacon, eggs, and wheat toast for breakfast.”
l 2. “I will walk for 30 minutes a day at least once
a week.”
l 3. “I am going to lose 2–3 pounds a week until I lose
30 pounds.”
l 4. “When I feel all right I do not need to take my
medication.”
54. The charge nurse is checking laboratory results for
clients on a medical unit. Which laboratory data would
warrant notifying the HCP?
l 1. The client who has an arterial blood gases (ABGs)
of pH 7.38, PaO2 90, PaCO2 38, and HCO3 34.
l 2. The client who has a serum potassium level of
3.8 mEq/L.
l 3. The client who has a serum sodium level of
138 mEq/L.
l 4. The client who has an INR of 4.2.
ANSWERS
51. Correct answer 2: The client is exhibiting signs of
a hypertensive crisis; therefore; the nurse should
check the client's blood pressure. Epistaxis is a
nosebleed. Elevating the head of the bed (option 3),
administering antihypertensive medication
(option 4), and notifying the HCP (option 1)
should be done in this order. Content Area–Medical;
Category of Health Alteration–Cardiovascular; Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
52. Correct answer 3: Being overweight is a risk factor
for essential hypertension; therefore; losing weight
indicates the client understands the discharge
teaching. Bacon is high in salt, and eggs are high
in cholesterol. The client should walk at least
three times a week, and medication should be
taken every day, no matter how the client feels.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Evaluation; Client
Copyright © 2010 F.A. Davis Company
86
Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Evaluation.
53. Correct answer 3: The nurse must teach the client
about orthostatic hypotension. The blood pressure,
not the apical pulse, should be checked. The normal
potassium level is 3.5–5.5 mEq/L, and the client
should not be on fluid restriction. Content Area–
Medical; Category of Health Alteration–Cardiovascular;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Pharmacological and Parenteral
Therapies; Cognitive Level–Application.
54. Correct answer 4: The therapeutic INR is 2–3;
therefore, this laboratory information should be
reported to the HCP. All other laboratory data are
within normal limits. Content Area–Medical; Category
of Health Alteration–Cardiovascular; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Reduction of Risk Potential; Cognitive
Level–Application.
SECTION TWO
Cardiovascular Disorders
55. The client newly diagnosed with essential hypertension
57. The nurse is preparing to administer a calcium
tells the nurse, “I don't feel bad, so why do I have to take
medication every day?” Which statement is the nurse's
best response?
l 1. “Even if you feel all right, your blood pressure
could still be high.”
l 2. “Your doctor would not have prescribed them if
you didn't need them.”
l 3. “People have strokes and heart attacks with high
blood pressure.”
l 4. “If you don't feel bad, then you don't have to take
your medication.”
channel blocker to a client diagnosed with arterial
hypertension. Which data would cause the nurse to
question administering this medication?
l 1. The client's blood pressure is 110/70.
l 2. The client has a calcium level of 10.5 mg/dL.
l 3. The client reports having a dry mouth.
l 4. The client complains of being dizzy.
56. The nurse is caring for clients on a medical unit.
Which task would be appropriate for the nurse to
delegate to a UAP?
l 1. Vital signs of a client who is having chest pain.
l 2. Take the client downstairs to smoke a cigarette.
l 3. Remove the telemetry leads from the client who is
being discharged.
l 4. Help the client who is scheduled for a cardiac
catheterization to eat.
87
58. The nurse is discussing essential hypertension with a
group of clients. Which interventions should be included
in the discussion? Select all that apply.
l 1. Discuss the importance of a low-cholesterol,
low-fat, low-salt diet.
l 2. Encourage isotonic exercises at least three times a
week.
l 3. Explain that uncontrolled diabetes increases blood
pressure.
l 4. Recommend relaxation classes to help decrease
stress.
l 5. Tell them to elevate the head of the bed to sleep.
ANSWERS
55. Correct answer 1: Essential hypertension is the
“silent killer,” and the blood pressure could be elevated when the client is asymptomatic. Clients with
hypertension may have stokes and heart attacks, but
the nurse should address the client's comment.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Application.
56. Correct answer 3: The UAP can remove the
telemetry leads from a client's chest. A client with
chest pains is unstable so cannot be assigned to the
UAP. The UAP also needs to be on the unit, not
downstairs with a client smoking, and the client
scheduled for a cardiac catheterization should have
nothing by mouth. Content Area–Medical; Category
of Health Alteration–Cardiovascular; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
Copyright © 2010 F.A. Davis Company
88
57. Correct answer 4: Dizziness may indicate the client is
experiencing hypotension; therefore, the nurse should
question administering an antihypertensive medication. The blood pressure is within normal limits,
but if the client had elevated blood pressure, then the
client could be experiencing hypotension; the calcium
level is not monitored when administering this medication, and dry mouth will not affect the medication
administration. Content Area–Medical; Category of
Health Alteration–Cardiovascular; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Application.
58. Correct answer 1, 2, 3, 4: Diet, isotonic exercises,
diabetes, and stress are modifiable risk factors for
essential hypertension. Elevating the head of the bed
will not help clients with essential hypertension.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Health Promotion and Maintenance;
Cognitive Level–Application.
SECTION TWO
Cardiovascular Disorders
89
Congestive Heart Failure
59. The nurse is taking blood pressure readings at a com-
61. The nurse is caring for a client diagnosed with
munity health fair. The 68-year-old client's blood pressure is
168/98. Which action should the nurse implement?
l 1. Recommend the client see a HCP within 2 days.
l 2. Tell the client to go to the nearest emergency
department.
l 3. Explain the blood pressure is all right for an elderly
person.
l 4. Instruct the client to go home and rest for the
remainder of the day.
congestive heart failure (CHF) who is complaining of
shortness of breath and dyspnea. Which intervention
should the nurse implement first?
l 1. Assess the client's lung sounds.
l 2. Elevate the client's head of the bed.
l 3. Administer oxygen via nasal cannula.
l 4. Check the client's pulse oximeter reading.
60. The UAP tells the nurse the client whose T is 98.9ºF,
P 92, R 18, and B/P 164/92 is complaining of a
headache. Which action should the nurse implement?
l 1. Assess the client as soon as possible.
l 2. Administer acetaminophen (Tylenol), a non-narcotic
analgesic.
l 3. Tell the UAP to check on the client in 1 hour.
l 4. Request the charge nurse to check on the client.
62. The client is preparing to administer the initial dose
of digoxin (Lanoxin), a cardiac glycoside, to the client
diagnosed with CHF. Which intervention should the
nurse implement?
l 1. Check the client's serum potassium level.
l 2. Assess the client's blood pressure.
l 3. Monitor the client's digoxin level.
l 4. Take the client's apical pulse.
ANSWERS
59. Correct answer 1: The client should be seen by an
90
61. Correct answer 2: The nurse should first elevate
HCP because the diastolic blood pressure is greater
than 85, but the client does not need to go to the
emergency department. Content Area–Medical;
the head of the bed to help the client breathe more
easily, then apply oxygen, and then the nurse can
assess the client. Content Area–Medical; Category of
Category of Health Alteration–Cardiovascular;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Physiological Adaptation;
Cognitive Level–Application.
Health Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
60. Correct answer 1: The nurse should assess the client
62. Correct answer 4: The nurse should check the
because the blood pressure is elevated along with
the complaint of a headache. The nurse should not
administer medication without assessing the client;
the UAP cannot assess the client; and this client is
not in a life-threatening situation so the charge
nurse does not need to check the client. Content
client's apical pulse, and if it is less than 60, the
nurse should question administering the digoxin.
The client's potassium level and digoxin level would
not be affected by the first dose of the medication.
The blood pressure does not have to be assessed
prior to administering digoxin. Content Area–Medical;
Area–Medical: Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Application.
Category of Health Alteration–Cardiovascular; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Pharmacological and Parenteral Therapies;
Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
SECTION TWO
Cardiovascular Disorders
91
63. The home health-care nurse is visiting a client
65. The nurse, along with a UAP, is caring for a client
diagnosed with CHF. Which comment by the client
would warrant intervention by the nurse?
l 1. “I take my water pill every morning.”
l 2. “I have to sleep on two pillows at night”
l 3. “I have some leg cramps every now and then.”
l 4. “I must rest after I walk around the block.”
diagnosed with an acute exacerbation of congestive heart
failure. Which task could the nurse delegate to the UAP?
l 1. Request the UAP to evaluate client's intake and
output.
l 2. Ask the UAP to assist the client to ambulate in
the hall.
l 3. Tell the UAP to increase the oxygen rate from
4 to 6 L.
l 4. Instruct the UAP to assist the client with taking a
bed bath.
64. The clinic nurse is checking laboratory data for
clients seen yesterday. Which laboratory data would
warrant contacting the client at home?
l 1. The client whose serum digoxin level is 2.4 mg/dL.
l 2. The client whose serum potassium level is
4.2 mEq/L.
l 3. The client whose serum brain or beta natriuretic
peptide (BNP) level is 92 mg/mL.
l 4. The client whose glycosylated hemoglobin is 5.3%.
66. The nurse is preparing to administer digoxin (Lanoxin),
a cardiac glycoside intravenous push (IVP). The digoxin vial
has 5 mg/2 mL. The HCP has ordered 0.25 mg. How
much medication would the nurse administer?
Answer: ______________________
ANSWERS
63. Correct answer 3: Leg cramps could indicate
92
65. Correct answer 4: The UAP could assist the client
hypokalemia, which would warrant intervention by
the nurse. Taking the diuretic every morning, sleeping with two pillows, and resting after extended
walks would not warrant intervention by the nurse.
to take a bath. The UAP cannot assess, teach, evaluate, administer medications, or care for a client who
is unstable. The client in an acute exacerbation of
congestive heart failure is unstable. Content Area–
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Application.
Medical; Category of Health Alteration–Cardiovascular;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
64. Correct answer 1: The therapeutic level for digoxin
66. Correct answer 0.1 mL: 5 is to 2 = 0.25 mg is
is 0.8–2.0 mg/dL; therefore, the nurse should notify
this client concerning the potential for digoxin
toxicity. All other data are within normal limits.
to x. Cross-multiply to get 5x = 0.50. Divide both
sides of the equation by 5 to solve for x and get the
answer = 0.1 mL. Content Area–Medical; Category of
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Application.
Health Alteration–Cardiovascular; Integrated Process–
Planning; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Application.
Copyright © 2010 F.A. Davis Company
Cardiovascular Disorders
SECTION TWO
67. The nurse is caring for a client diagnosed with CHF
l
93
3. The medication will help prevent vasoconstriction of
the periphery and prevents the release of aldosterone.
4. The medication blocks calcium from entering the cell
membrane, resulting in vasodilation of the vessels.
who is receiving 40 mg furosemide (Lasix) intravenous
push (IVP) daily. Which data indicate the medication is
effective?
l 1. The client's urine output for the last 8 hours is
300 mL.
l 2. The client's lungs are clear bilaterally anterior and
posterior.
l 3. The client has lost 1 kg of weight in 2 days.
l 4. The client's arterial blood pressure is
138/90 mm Hg.
Which HCP's admission order would the nurse question?
l 1. Oxygen 2 L via nasal cannula.
l 2. Fursosemide (Lasix) 40 mg IVP daily.
l 3. Low-cholesterol, low-fat, low-salt diet.
l 4. Activity as tolerated.
68. The nurse is preparing to administer an ACE-inhibitor
70. The nurse is completing discharge teaching for a
to a client diagnosed with congestive heart failure. Which
statement best describes the scientific rationale for
administering this medication?
l 1. The medication will help increase the urine output,
thereby decreasing the volume of blood in the
intravascular system.
l 2. The medication will decrease the sympathetic
stimulation to the beta cells in the heart muscle.
l
69. The nurse is admitting a client diagnosed with CHF.
client diagnosed with end-stage congestive heart failure.
Which statement indicates the client understands the
discharge teaching?
l 1. “I will notify my HCP if I lose more than 2 lb in
a week.”
l 2. “I will check my digoxin level daily and write down
the results.”
l 3. “I will increase my intake of foods that are high in
potassium.”
l 4. “I will drink at least 3000 mL of fluid every day.”
ANSWERS
67. Correct answer 2: Clear lung sounds indicate that the
client's CHF is responding to diuretic therapy. The
output should be much greater than 30 mL/hr for a
diuretic to be effective, and a 2.2-lb weight loss does
not indicate effective therapy. The blood pressure does
indicate the effectiveness of a diuretic for the client
with CHF. Content Area–Medical; Category of Health
Alteration–Cardiovascular; Integrated Process–Evaluation;
Client Needs–Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Evaluation.
68. Correct answer 3: ACE inhibitors prevent
angiotensin-1 from converting to angiotensin-2,
which is a potent vasoconstrictor and prevents the
release of aldosterone, which, in turn, prevents
the reabsorption of sodium. The medication that
increases urine output (option 1) is a diuretic. The
medication that decreases sympathetic stimulation to
the beta cells in the heart muscle (option 2) is a
beta blocker. The medication that blocks calcium
from entering the cell membrane (option 4) is a
calcium-channel blocker. Content Area–Medical;
Copyright © 2010 F.A. Davis Company
94
Category of Health Alteration–Cardiovascular; Integrated
Process–Evaluation; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Evaluation.
69. Correct answer 1: The client does not have chronic
obstructive pulmonary disease; therefore; the client
does not need a low oxygen rate. This order should
be questioned. Content Area–Medical; Category of
Health Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
70. Correct answer 3: The client with congestive heart
failure will be on digoxin and a diuretic; therefore,
the client should increase foods high in potassium.
Weight loss would not warrant notifying the HCP;
the digoxin level is not done daily; and the client
should drink about 2000 mL a day unless on a fluid
restriction. Content Area–Medical; Category of Health
Alteration–Cardiovascular; Integrated Process–Evaluation;
Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Evaluation.
SECTION TWO
Cardiovascular Disorders
95
Peripheral Vascular Disease
71. The client is diagnosed with arterial occlusive disease.
73. The clinic nurse is caring for the female client
Which data would the nurse expect the client to exhibit?
l 1. Intermittent claudication and cool extremities.
l 2. Capillary refill <3 seconds and 4+ pedal pulses.
l 3. Dry scaly skin and 3+ pitting edema.
l 4. Piloerection and “alligator” skin.
diagnosed with venous insufficiency. Which intervention
should the nurse implement?
l 1. Instruct the client to elevate her feet frequently.
l 2. Encourage the client to eat a low-sodium diet.
l 3. Tell the client to wear open-toed shoes.
l 4. Recommend going to the podiatrist for nail cutting.
72. The client is diagnosed with peripheral vascular
disease. Which statement indicates the client understands
the discharge teaching?
l 1. “I will buy my new shoes first thing in the
morning.”
l 2. “I use a heating pad when my feet are really cold.”
l 3. “I need to wear knee-high socks when wearing
shoes.”
l 4. “I should not cross my legs when I am sitting down.”
74. The client diagnosed with arterial occlusive disease is
1 day postoperative right femoral popliteal bypass. Which
intervention should the nurse implement?
l 1. Keep the right leg in the dependent position.
l 2. Maintain the leg in alignment with abductor pillow.
l 3. Monitor the client's continuous passive motion
(CPM) machine.
l 4. Assess the client's right leg for paralysis and
paresthesia.
ANSWERS
96
71. Correct answer 1: Intermittent claudication, calf
73. Correct answer 1: The client should elevate her feet to
pain with walking, and cool extremities would be
expected because the client has decreased arterial
blood flow to the lower extremities. Content Area–
help decrease edema. A low-sodium diet will not help
decrease the lower extremity edema; wearing open-toed
shoes will not help; and as the client does not have
decreased vision, the client can cut her own toenails.
Medical; Category of Health Alteration–Cardiovascular;
Integrated Process–Assessment; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive Level–
Application.
72. Correct answer 4: The client should not perform
activity that will impede blood flow to the lower
extremities; therefore, the client should not cross
the legs. New shoes should be bought in the afternoon when the feet are swollen. The legs may have
decreased feeling; therefore, a heating pad should
not be applied to the lower extremities. Content
Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Evaluation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Evaluation.
Copyright © 2010 F.A. Davis Company
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Application.
74. Correct answer 4: The nurse should assess the 6 Ps:
paralysis, paresthesia, poikilothermia (temperature),
pain, pulses, and pallor. The leg should be elevated to
decrease postoperative edema; the abductor pillow is
used for total hip replacement, not for femoral popliteal
bypass; and the CPM machine is used with total
knee replacement. Content Area–Surgical; Category of
Health Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Reduction for Risk Potential; Cognitive Level–Application.
SECTION TWO
Cardiovascular Disorders
97
75. The UAP and a nurse are caring for clients in a
77. The client is diagnosed with arterial occlusive disease.
long-term facility. Which action by the UAP would
require intervention by the nurse?
l 1. The UAP elevated the legs of a client diagnosed
with arterial occlusive disease.
l 2. The UAP is ambulating the client using a gait belt
around the waist.
l 3. The UAP placed the client in the chair while
assisting the client to eat.
l 4. The UAP assisted the client with venous
insufficiency to put on antiembolic hose.
Which information should the nurse discuss with the
client?
l 1. Encourage the client to walk three times a day.
l 2. Discuss the need to increase fluid intake.
l 3. Explain how to prevent orthostatic hypotension.
l 4. Tell the client to take acetaminophen four times
a day.
76. Which data would require the nurse to notify the HCP
for the client diagnosed with arterial occlusive disease?
l 1. The client has 1+ bilateral dorsalis pedis pulses.
l 2. The client has bilateral leg pain while resting.
l 3. The client has numbness and tingling of the legs.
l 4. The client has cool, pale extremities.
78. The client is diagnosed with venous insufficiency.
Which discharge teaching should the nurse discuss with
the client?
l 1. Take one baby aspirin every day with food.
l 2. Check the feet daily for cuts and blisters.
l 3. Monitor the popliteal and pedal pulses daily.
l 4. Perform passive range-of-motion exercise daily.
ANSWERS
75. Correct answer 1: The client with arterial occlusive
98
77. Correct answer 1: Walking will help increase collat-
disease should have the legs in the dependent, not
elevated, position, because elevating the feet further
impedes the arterial blood supply to the legs. The
nurse would need to intervene. Using a gait belt, sitting the client up to eat, and putting on antiembolic
hose are all appropriate interventions. Content Area–
eral circulation, which will, in turn, increase the blood
supply to the lower extremities. Increasing fluid intake
will not help; the client does not experience orthostatic hypotension or take medications that would cause
it; and acetaminophen is not prescribed to treat arterial occlusive disease. Content Area–Medical; Category
Medical; Category of Health Alteration–Cardiovascular;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
of Health Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
76. Correct answer 2: Resting pain indicates the client
is not receiving any blood supply to the calf muscles,
and this would require notifying the HCP. Weak
pedal pulses, paresthesia, and cool extremities are
expected in the client diagnosed with arterial
occlusive disease. Content Area–Medical; Category of
Health Alteration–Cardiovascular; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
78. Correct answer 2: In a client with venous insufficiency, the feet are edematous; the skin is fragile;
and the sensation is decreased. Cuts will not heal
effectively; therefore, the client should check the feet
daily. Baby aspirin is for arterial insufficiency, not
venous insufficiency. The client does not check
pulses. The client should perform active range-ofmotion exercises. Content Area–Medical; Category of
Health Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
SECTION TWO
Cardiovascular Disorders
99
Abdominal Aortic Aneurysm
79. The nurse is unable to palpate the dorsalis pedis
81. The nurse is assessing the client's abdomen. Which
pulse for the client diagnosed with arterial occlusive
disease. Which action should the nurse implement first?
l 1. Notify the client's HCP.
l 2. Place the feet in the dependent position.
l 3. Use a Doppler to assess for pedal pulse.
l 4. Assess for proximal pulses bilaterally.
assessment data would support the diagnosis of abdominal
aortic aneurysm (AAA)?
l 1. Visible peristalsis and hyper bowel sounds.
l 2. A palpable mass and an abdominal bruit.
l 3. Rebound tenderness and protruding umbilicus.
l 4. Hard rigid abdomen and low-grade fever.
80. The client diagnosed with arterial occlusive disease
82. The client diagnosed with a 3-cm AAA asks the
asks the nurse, “What caused me to have this problem?”
Which statement is the nurse's best response?
l 1. “Being overweight can lead to incompetent valves,
which caused your problem.”
l 2. “Sometimes people who stand all the time can have
arterial occlusive disease.”
l 3. “There is not a definite cause for developing
arterial occlusive disease.”
l 4. “Increased plaque in your arteries is the cause of
peripheral vascular disease.”
nurse, “What will the doctors do for my abdominal aortic
aneurysm?” Which statement is the nurse's best response?
l 1. “You will probably have an ultrasound every
6 months to check on the size.”
l 2. “Usually an endoscopy is done once a year to make
sure it doesn't get too big.”
l 3. “You will have to check your abdominal girth once
a week and keep a record.”
l 4. “You will need to have an abdominal aortic
aneurysm repair within 2 weeks.”
ANSWERS
79. Correct answer 3: The nurse should first attempt to
assess the pedal pulse with a Doppler and place an X
when the pulse is heard. Placing the feet in dependent position will increase blood supply, which is not
desirable. The nurse can assess proximal pulses and
notify the HCP if total occlusion is determined.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Application.
80. Correct answer 4: Arterial occlusive disease is due to
atherosclerosis, which is a buildup of plaque in the arteries. Incompetent valves cause venous insufficiency.
Occupations where clients stand all the time lead to
varicose veins. Content Area–Medical; Category of
Health Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
100
81. Correct answer 2: A systolic bruit over the abdomen
and a palpable mass are indicative of an AAA. The
nurse should palpate the area very lightly to prevent
rupture of the AAA. Content Area–Medical; Category
of Health Alteration–Cardiovascular; Integrated Process–
Assessment; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Application.
82. Correct answer 1: When the aneurysm is small
(<5–6 cm), an abdominal sonogram will be done
every 6 months until the aneurysm reaches a size
at which surgery to prevent rupture is of more
benefit than possible complications of the surgery.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Application.
SECTION TWO
83. Which client would be most likely to develop an AAA?
l 1. A 45-year-old African-American female with type 1
l
l
l
diabetes mellitus.
2. A 75-year-old Oriental female with COPD.
3. A 54-year-old Caucasian male diagnosed with
essential hypertension.
4. A 30-year-old Hispanic male with a genetic
predisposition to AAA.
84. The nurse is caring for a client diagnosed with an
AAA who is scheduled for surgery in the morning. Which
statement would require immediate intervention by the
nurse?
l 1. “I just started having pain in my lower back.”
l 2. “When I urinate I can't quit dribbling.”
l 3. “I am having loose runny stools.”
l 4. “I feel my heart beating when I lie down.”
Cardiovascular Disorders
101
85. The client is 2 days postoperative AAA repair. Which
assessment data would require immediate intervention
from the nurse?
l 1. The client refuses to perform range-of-motion
exercises.
l 2. The client urinary output is 300 mL in 8 hours.
l 3. The client's dorsalis pedis pulse is not palpable.
l 4. The client's vital signs are T 98ºF, P 90, R 18,
B/P 130/70.
86. The nurse is assessing the client who had an AAA
repair 2 days ago. Which intervention should the nurse
implement first?
l 1. Assess the client's bowel sounds.
l 2. Administer an IV prophylactic antibiotic.
l 3. Encourage the client to splint the incision.
l 4. Ambulate the client in the room with assistance.
ANSWERS
83. Correct answer 3: The most common cause of AAA
is atherosclerosis (which is the cause of essential hypertension and peripheral vascular disease). AAA occurs
in men four times more often than in women, and
primarily in Caucasians. Content Area–Medical; Category of Health Alteration–Cardiovascular; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
84. Correct answer 1: Low back pain is present because
of the pressure of the aneurysm on the lumbar
nerves; this is a serious symptom usually indicating
that the aneurysm is expanding rapidly and about to
rupture. A sign/symptom of AAA is “heart beating in
the abdomen.” Content Area–Surgical; Category of
Health Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
85. Correct answer 3: Any neurovascular abnormality,
such as nonpalpable dorsalis pedis pulse in the
client's lower extremities, indicates the graft is
Copyright © 2010 F.A. Davis Company
102
occluded or there is possibly internal bleeding and
requires immediate intervention by the nurse. The
client should be ambulating on the second postoperative day; urine output should be greater than
30 mL/hr—which it is; and the vital signs are stable.
Content Area–Surgical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Application.
86. Correct answer 1: Assessment is the first part of the
nursing process and is the first intervention the nurse
should implement. Antibiotic therapy, splinting the
incision when coughing, and ambulating are appropriate interventions but not prior to assessment.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Application.
SECTION TWO
87. The client is being admitted for repair of an AAA.
Which HCP's order should the nurse question?
l 1. Complete blood cell count.
l 2. Tap water enema until clear fecal return.
l 3. Bedrest with bathroom privileges.
l 4. Start intravenous line with normal saline.
88. The client is diagnosed with a 2-cm AAA. Which
interventions should be included in the client's teaching?
Select all that apply.
l 1. Perform isometric exercises for 30 minutes three
times a week.
l 2. Encourage a low-fat, low-cholesterol, low-salt diet.
l 3. Use an abdominal binder when amputating.
l 4. Discuss with the client the importance of losing
weight.
l 5. Demonstrate the correct way to apply a truss.
Cardiovascular Disorders
103
89. Which assessment data would require immediate
intervention by the nurse for the client who is 6 hours
postoperative AAA repair?
l 1. A blood pressure of 92/68 and apical pulse 114.
l 2. Complaints of incisional pain of 7 on a scale of
1–10.
l 3. A soft nondistended, tender abdominal area.
l 4. Green bile draining from the nasogastric tube.
90. The nurse is discussing discharge teaching with the
client who is 3 days postoperative AAA repair. Which
statement indicates the client needs more discharge
teaching?
l 1. “I will notify my doctor if there is any redness or
irritation of my incision.”
l 2. “I will not lift any objects that weigh more than
5 pounds for 4–6 weeks.”
l 3. “I will have abdominal pain that will not be
relieved by my pain medication.”
l 4. “I should increase my fluid intake and make sure
I do not get constipated."
ANSWERS
87. Correct answer 2: Increasing pressure in the
104
89. Correct answer 1: These vital signs indicate hypo-
abdomen secondary to a tap water enema could
cause the AAA to rupture. Blood work, bathroom
privileges, and intravenous line would be expected
HCP orders. Content Area–Surgical; Category of
volemia, which is a medical emergency and requires
immediate intervention. Incisional pain, a soft nondistended abdomen, and green bile would be expected
assessment data. Content Area–Surgical; Category of
Health Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
Health Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Application.
88. Correct answer: 2, 4: The most common cause of
90. Correct answer 3: Pain medication should keep the
AAA is atherosclerosis and essential hypertension;
therefore, a low-fat, low-cholesterol diet will help
decrease development of atherosclerosis. Losing
weight will help decrease the pressure on the AAA
and will help address decreasing cholesterol level.
A truss is worn for a client with a hernia, not an
AAA, and an abdominal binder should not be
worn because it will increase abdominal pressure.
client comfortable, and if it does not help, the client
should call the HCP; this statement indicates the
client needs more teaching. Redness or irritation of
the incision indicates infection; lifting more than
5 pounds may cause dehiscence; and constipation
will increase pressure on the incision. Content Area–
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
Surgical; Category of Health Alteration–Cardiovascular;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Physiological Adaptation;
Cognitive Level–Application.
SECTION TWO
Cardiovascular Disorders
105
Deep Vein Thrombosis
91. The nurse is discharging a client diagnosed with deep
93. The male client is diagnosed with Guillain-Barré
vein thrombosis (DVT). Which discharge instructions
should be provided to the client?
l 1. Have the PTT levels checked routinely to maintain
a therapeutic level.
l 2. When traveling, the client should plan rest stops to
exercise the legs.
l 3. Eat a diet high in green leafy vegetables and expect
the urine to be red-tinted.
l 4. Wear knee stockings with an elastic band around
the top.
(GB) syndrome and is in the intensive care unit on a
ventilator. Which intervention should the nurse
implement to prevent complications?
l 1. Percutaneous tube feedings once a day.
l 2. Encouraging the client to verbalize feelings.
l 3. Administer a narcotic pain medication PRN.
l 4. Frequent passive range-of-motion to the legs.
92. The nurse is caring for clients on a surgical floor.
Which client should be assessed first?
l 1. The postoperative abdominal surgery client who
has a red swollen left calf.
l 2. The postoperative hernia client who just voided
350 mL of clear amber urine.
l 3. The postoperative cholecystectomy client who is
refusing to turn and cough.
l 4. The postabdominal hysterectomy client who is
complaining of gas pains.
94. The nurse and a UAP are bathing an immobile
client. Which instruction should the nurse provide
the UAP?
l 1. Place a clean gown on the client before beginning
the bath.
l 2. Wash the calves, but do not massage the muscles.
l 3. Use lots of soap and water to get the client clean.
l 4. Dispose of the linens in a red container in the room.
ANSWERS
91. Correct answer 2: The client should perform frequent active and passive leg exercises. In an airplane
the client should be instructed to drink plenty of
fluids and move the legs up and down and flex the
muscles. In an automobile the client should take
frequent breaks to walk around. PT/INR should
be monitored. Content Area–Medical; Category of
Health Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
106
93. Correct answer 4: Passive range of motion will help
prevent deep vein thrombosis as well as contractures
of the limbs. Venous blood returns to the heart in
part because of the action of the muscles against the
walls of the veins. Content Area–Medical; Category of
Health Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
94. Correct answer 2: Massaging the calves can dislodge
after surgery is developing a deep vein thrombosis
(DVT). This client should be assessed for a DVT.
The other clients are exhibiting expected findings
that are not life-threatening. Content Area–Medical;
a thrombus and create an embolus. The calves can
be washed and lotion applied gently, but they should
not be massaged. Clean gowns are put on the client
after the bath. Minimal soap and water are used to
prevent drying of the client's skin. Linens are not
thrown away in the biohazard trash. Content Area–
Category of Health Alteration–Cardiovascular; Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
Medical; Category of Health Alteration–Cardiovascular;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
92. Correct answer 1: A complication of immobility
Copyright © 2010 F.A. Davis Company
SECTION TWO
Cardiovascular Disorders
107
95. The client diagnosed with a DVT in the right leg is
97. Which client should the nurse assess first after
admitted to the medical unit. Which nursing interventions
should be implemented? Select all that apply.
l 1. Place an antiembolism hose on the unaffected calf.
l 2. Instruct the client to ambulate in the hallway
frequently.
l 3. Encourage fluids and a diet high in roughage.
l 4. Monitor the intravenous site every 24 hours
l 5. Assess for calf tenderness in the left leg.
receiving the shift report?
l 1. The client diagnosed with DVT who complains of
chest pain on inspiration.
l 2. The immobile client who has not been turned
from the left side for 3 hours.
l 3. The client who had a partial pancreatectomy and
who is refusing a blood glucose test.
l 4. The client who has had an inguinal hernia repair
and must void before discharge.
96. The nurse is caring for a client receiving heparin
sodium via constant infusion. The heparin protocol reads
to decrease the IV rate by 50 units/hour if the PTT is
greater than 85 seconds. The current PTT level is
92 seconds. The heparin comes in 500 mL of D5W with
25,000 units of heparin added. The current rate on the
IV pump is 24 mL/hr. At what rate should the pump
be set?
Answer: ____________________
98. The client diagnosed with a DVT is on a heparin
(anticoagulant) drip at 1200 units per hour, and the HCP
has ordered Coumadin (warfarin sodium), an anticoagulant,
5 mg daily. Which should be the nurse's first action?
l 1. Check the client's laboratory values for PTT and
PT/INR.
l 2. Call the HCP to see which drug should be
discontinued.
l 3. Administer both medications as prescribed.
l 4. Discontinue the heparin when the client receives
the first dose of Coumadin.
ANSWERS
95. Correct answer 1, 3, 5: An antiembolism hose
should be put on to prevent a thrombosis from
forming in the other calf. The client is on bedrest for
5–7 days. Drinking lots of fluids and a diet high in
roughage will help prevent constipation and provide
adequate fluid volume. The intravenous site should
be monitored more frequently than every 24 hours,
and the nurse should assess for signs of DVT in the
unaffected calf. Content Area–Medical; Category of
Health Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
96. Correct answer 23 mL/hr: The nurse must first
determine the number of units of heparin in each mL
of solution. Divide 25,000 by 500 to equal 50 units
per mL of solution. If the current rate is 24 mL/hr,
then decreasing by 50 units results in 23 mL an hour.
24 mL–1 mL = 23 mL/hr. Content Area–Medical;
Category of Health Alteration–Cardiovascular;
Integrated Process–Implementation; Client
Copyright © 2010 F.A. Davis Company
108
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Application.
97. Correct answer 1: A potentially life-threatening
complication of DVT is pulmonary embolus, which
causes chest pain. The nurse should determine if
the client has “thrown” a pulmonary embolus.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
98. Correct answer 3: It will take several days for the
client to reach a therapeutic level of anticoagulation
with the Coumadin. The client should not be
removed from the heparin until appropriate levels of
oral anticoagulant can be achieved. Content Area–
Medical; Category of Health Alteration–Cardiovascular;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Pharmacological and Parenteral
Therapies; Cognitive Level–Application.
SECTION TWO
Cardiovascular Disorders
109
Anemia
99. The client is being admitted with Coumadin
101. The nurse is admitting a client with a diagnosis of
(anticoagulant) toxicity. Which medication should the
nurse prepare to administer?
l 1. Protamine sulfate intravenously.
l 2. Warfarin sodium orally.
l 3. Aquamephyton (vitamin K) intravenously.
l 4. Sodium heparin subcutaneously.
rule out (R/O) anemia. The client has a history of gastric
bypass surgery for obesity 3 years ago. Current assessment
findings include height 5'9", weight 75 kg, P 120, R 27,
BP 100/70, pale mucous membranes, and dyspnea on
exertion. Which type of anemia would the nurse suspect
the client has developed?
l 1. Sickle cell anemia.
l 2. Folic acid deficiency.
l 3. Iron deficiency.
l 4. Vitamin B12 deficiency.
100. The charge nurse observes the primary nurse
assessing the client diagnosed with DVT. Which action
by the nurse warrants immediate intervention by the
charge nurse?
l 1. The nurse assesses for the Homan sign in the
affected leg.
l 2. The nurse instructs the client to stay in bed as
much as possible.
l 3. The nurse tells the client to notify the nurse if
developing chest discomfort.
l 4. The nurse reminds the client not to pull on the
intravenous tubing.
102. The client who has menorrhagia complains to
the nurse of feeling listless and tired all the time. Which
laboratory data should the nurse monitor?
l 1. Blood urea nitrogen (BUN).
l 2. White blood cell (WBC) count.
l 3. Hemoglobin and hematocrit (H&H).
l 4. Urinalysis (UA).
ANSWERS
99. Correct answer 3: AquaMephyton (vitamin K), is
the antidote for Coumadin. Warfarin is the generic
form of Coumadin. Protamine sulfate is the antidote for heparin. Content Area–Medical; Category of
Health Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Application.
100. Correct answer 1: Assessing for the Homan sign
used to be standard practice, but current research
indicates that there is a possibility of dislodging
the clot from the vein wall. The charge nurse
should intervene to prevent this from occurring.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
101. Correct answer 4: Gastric bypass surgery drastically reduces the amount of rugae in the stomach.
Rugae produce intrinsic factor, which allows the
Copyright © 2010 F.A. Davis Company
110
body to utilize vitamin B12 from the foods eaten.
With a reduced number of rugae, clients who have
had gastric bypass surgery often develop pernicious
anemia (vitamin B12 deficiency). Other symptoms
of anemia include dizziness, tachycardia, and
dyspnea. Content Area–Medical; Category of Health
Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
102. Correct answer 3: Menorrhagia means excessive
blood loss during menses. The nurse should
monitor the client's H & H. The symptoms are
the direct result of the excessive blood loss. Content
Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Reduction of
Risk Potential; Cognitive Level–Application.
SECTION TWO
Cardiovascular Disorders
111
103. The nurse writes a diagnosis of altered tissue
105. The nurse and UAP are caring for clients on a
perfusion for a client diagnosed with folic acid deficiency
anemia. Which interventions should be included in the
plan of care? Select all that apply.
l 1. Administer iron supplements.
l 2. Move to room near the nurse's desk.
l 3. Encourage the client to eat green vegetables.
l 4. Assess for history of alcohol consumption.
l 5. Allow for rest periods during the day.
medical unit. Which task is inappropriate for the nurse to
delegate to the UAP?
l 1. Checking on the bowel movements of a client
diagnosed with melena.
l 2. Taking the vital signs of a client who received
blood the day before.
l 3. Documenting the amount of food a client
consumed from the lunch tray.
l 4. Setting up the food tray for a client with an
intravenous line in the hand.
104. The client diagnosed with iron deficiency anemia is
prescribed iron dextran intravenously. Which intervention
should the nurse implement when administering this
medication?
l 1. Administer epinephrine intravenously prior to
beginning the infusion.
l 2. Start the infusion with a test dose, and monitor the
client for 15 minutes.
l 3. Place the client on bedrest with bathroom
privileges.
l 4. Teach the client the stools may be very dark, and
this can mask blood.
106. The client is diagnosed with anemia. The HCP
ordered a transfusion of 2 units of packed red blood cells.
The unit has 250 mL of red blood cells plus 45 mL of
additive. The blood transfusion set delivers 10 gtt/mL.
At what rate should the nurse set the IV tubing to infuse
each unit of packed red blood cells in 4 hours?
Answer: ____________________
ANSWERS
103. Correct answer 2, 3, 4, 5: A room near the nurse's
desk is important because decreased oxygenation
levels to the brain, resulting from the anemia, can
cause the client to become confused, and a history
of alcohol consumption can require observation for
delirium tremens. The client should include leafy
green vegetables in the diet. These are high in folate.
Folic acid deficiency is common among heavy
drinkers. Fatigue is the primary presenting symptom
of anemia. Content Area–Medical; Category of Health
Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
104. Correct answer 2: Because iron dextran can cause
anaphylactic reactions in the client to the dextran,
the nurse should start with a test dose and monitor
the client for 15 minutes before initiating the full
dose. Epinephrine is administered if the client has
an allergic reaction to the medication, but not
before. Activity is not restricted, and the stools
become dark with oral iron. Content Area–Medical;
Copyright © 2010 F.A. Davis Company
112
Category of Health Alteration–Cardiovascular;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Application.
105. Correct answer 1: The nurse must assess the stools
for blood (melena); the nurse should not delegate
this task. The UAP can take vital signs on a stable
client, document the amount of food consumed
from a tray, and set up the tray for a client. Content
Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
106. Correct answer 12 gtt/min: 250 + 45 = 295 mL
to infuse in 4 hours. 295 divided by 4 = 73.75 mL to
infuse in 1 hour, divided by 60 minutes = 12.2 mL
per minute to infuse. Multiplied by 10 gtt per mL =
12 gtt per minute. Content Area–Medical; Category of
Health Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Application.
SECTION TWO
Cardiovascular Disorders
113
107. The charge nurse is making assignments on a
109. The nurse is discharging a client prescribed oral
medical floor. Which client should be assigned to the
new graduate nurse?
l 1. The client diagnosed with iron-deficiency anemia
who is prescribed iron tablets.
l 2. The client diagnosed with pernicious anemia who
is receiving intravenous iron.
l 3. The client diagnosed with aplastic anemia who has
developed pancytopenia.
l 4. The client diagnosed with renal disease on an
experimental medication protocol.
iron supplements. Which instructions should the nurse
teach?
l 1. Sit upright after taking the medication for
30–60 minutes.
l 2. Perform a daily stool test for occult blood.
l 3. Eat a full meal and then take the iron supplement.
l 4. Take the iron about 2 hours after you eat breakfast
each day.
108. The client diagnosed with folic acid anemia is
admitted to the medical unit. Which HCP order would
the nurse question?
l 1. Chlordiazepoxide (Librium), a benzodiazepine,
every 8 hours.
l 2. Serum vitamin B12 laboratory studies.
l 3. Administer 3 units of packed red blood cells over
2 hours each.
l 4. Assist the client with activities of daily living
(ADLs).
110. The nurse is admitting a client diagnosed with
anemia. Which nursing intervention should the nurse
implement first?
l 1. Teach the client to pace activities.
l 2. Refer the client to the dietitian.
l 3. Assess the client's activity tolerance.
l 4. Obtain an order for daily hemoglobin.
ANSWERS
107. Correct answer 1: The new graduate can administer and teach about oral medications. Clients
receiving parenteral iron are at risk for anaphylactic
reactions. Pancytopenia requires an experienced
nurse as does administering an experimental
medication protocol. Content Area–Medical; Category of Health Alteration–Cardiovascular; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
108. Correct answer 3: Blood transfusions are given
cautiously for clients diagnosed with anemia because the client's body has compensated for the
anemia. If given, the blood is administered slowly
to prevent pulmonary edema. Vitamin B12 studies
are done to help differentiate between B12 anemia
and folic acid deficiency. Antianxiety medications
would not be questioned because folic acid anemia
is usually secondary to alcoholism. Content Area–
Medical; Category of Health Alteration–Cardiovascular;
Integrated Process–Implementation; Client
Copyright © 2010 F.A. Davis Company
114
Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Application.
109. Correct answer 4: Approximately 2 hours after
breakfast is the correct dosing time for iron to
achieve the best effects. Iron preparations should be
administered 1 hour before a meal or 2 hours after
the meal. Iron can cause gastrointestinal upset if
administered with a meal, and absorption can be
diminished by as much as 50%. Content Area–
Medical; Category of Health Alteration–Cardiovascular;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Physiological Adaptation;
Cognitive Level–Application.
110. Correct answer 3: The nurse should assess for the
symptoms associated with anemia first and then plan
other interventions based on the assessment data.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
SECTION TWO
Cardiovascular Disorders
115
Management Issues
111. The nurse is discharging a client diagnosed with
113. The nurse is preparing to administer digoxin
coronary artery disease. Which discharge instructions
should the nurse teach the client?
l 1. Instruct the client to decrease the amount of
cigarettes smoked.
l 2. Encourage to perform weight-lifting exercises
3 days a week.
l 3. Teach the client how to take coronary vasodilators.
l 4. Explain the need to prepare an advance directive
and living will.
to a client diagnosed with heart failure. Which nursing
intervention should the nurse implement?
l 1. Check the client's potassium level.
l 2. Assess the client's radial pulse.
l 3. Monitor the client's respirations.
l 4. Ask if the client has eaten today.
112. The nurse is caring for a client diagnosed with
congestive heart failure. Which diagnostic test indicates
the client's condition is getting better?
l 1. The client's chest x-ray (CXR) shows a large
cardiac silhouette.
l 2. The client's LDH and SGOT levels have decreased.
l 3. The client's blood urea nitrogen (BUN) is 10 points
higher.
l 4. The client's B-type natriuretic peptide (BNP) has
decreased.
114. Which client should the nurse on a cardiac unit
assess first after receiving the shift report?
l 1. The client diagnosed with a myocardial infarction
with four unifocal PVCs in a minute.
l 2. The client diagnosed with mitral valve prolapse
(MVP) who has an audible S3 and dyspnea.
l 3. The client diagnosed with coronary artery disease
who wants to ambulate in the hallway.
l 4. The client diagnosed with pericarditis whose third
dose of intravenous antibiotic is late.
ANSWERS
111. Correct answer 3: The client diagnosed with
coronary artery disease will have angina at times.
The nurse should discuss how to use the medication, storage, and when to know the medication is
still potent. The nurse should also discuss when to
call the emergency medical response system. Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Application.
112. Correct answer 4: BNP is secreted from the
ventricles and directly relates to the amount of fluid
volume overload. A decreased BNP indicates the
therapy is effective. LDH and SGOT measure liver
function; BUN measures kidney function; and a
large cardiac silhouette indicates heart failure and
does not indicate the client is getting better.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
116
113. Correct answer 1: Digoxin can potentiate dysrhythmias if the potassium level is low. The nurse
should check the apical pulse and the digoxin level.
The medication does not have to be given with
food. Content Area–Medical; Category of Health
Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Application.
114. Correct answer 2: The development of an S3
heart sound indicates heart failure, a complication
of MVP. The nurse should assess this client first.
The client may have up to 6 unifocal PVCs in a
minute and be considered within normal limits.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Planning; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Application.
SECTION TWO
Cardiovascular Disorders
117
115. The nurse is told in report that the client has mitral
117. The nurse is reviewing HCP orders on a client
valve regurgitation. Which anatomical position should the
nurse auscultate to assess the murmur?
l 1. Second intercostal space, right sternal notch.
l 2. Erb point.
l 3. Fourth intercostal space, left axillary line.
l 4. Fifth intercostal space, midclavicular line.
diagnosed with an AAA who is scheduled for surgery in
the morning. Which orders should the nurse question?
l 1. Administer biscodyl (Dulcolax), a cathartic laxative,
on admission to the unit.
l 2. Send an intravenous piggyback (IVPB) antibiotic
to surgery with the client.
l 3. Have the client bathe using an iodine preparation
at night and in the morning.
l 4. Elevate the head of the bed at 45º.
116. The nurse is assisting with a synchronized
cardioversion on a client in atrial fibrillation. Which
statement by the client indicates the client understands
the pre-procedure teaching?
l 1. “This procedure will cure my atrial fibrillation
problems for good.”
l 2. “I should be able to eat breakfast before the
procedure.”
l 3. “I will be given some medication to relax me before
the procedure.”
l 4. “I won't need to be hooked up to telemetry after
the procedure.”
118. The nurse is admitting a client with a suspected
myocardial infarction who was brought in by ambulance.
Which nursing intervention has priority?
l 1. Ask if the client is allergic to aspirin.
l 2. Place the client on the telemetry monitor.
l 3. Notify the cardiac catheterization lab.
l 4. Have the client sign for permission to treat.
ANSWERS
115. Correct answer 4: The fifth intercostal space, midclavicular line is directly over the mitral valve and is
the best place to hear a mitral murmur. Option 1 is
the aortic area; option 2 is the pulmonic area; and
option 3 is in between areas. Content Area–Medical;
Category of Health Alteration–Cardiovascular;
Integrated Process–Assessment; Client Needs–Health
Promotion and Maintenance; Cognitive Level–
Application.
116. Correct answer 3: The client is given sedating
medications prior to the procedure. The other
options are false statements. Content Area–Medical;
Category of Health Alteration–Cardiovascular;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Reduction of Risk Potential;
Cognitive Level–Application.
117. Correct answer 1: Administering a stimulant
laxative will increase intra-abdominal pressure and
could cause the aneurysm to rupture. Sending an
IVPB antibiotic to surgery for administration is
Copyright © 2010 F.A. Davis Company
118
appropriate. Research indicates that administering
antibiotics within an hour of the first incision is
the best practice for prophylaxis of infection.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Application.
118. Correct answer 1: The nurse must immediately
begin morphine, oxygen, nitroglycerin, and
aspirin (MONA is an acronym to help the
students remember the initial treatment ). Aspirin
decreases platelet aggregation and may prevent
worsening of the damage to the cardiac muscle.
Content Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
SECTION TWO
Cardiovascular Disorders
119
119. The nurse is preparing to administer daily
120. The client admitted with deep vein thrombosis is
medications. Which medication would the nurse
question?
l 1. The ACE inhibitor to the client who tells the nurse
his cough has gone away.
l 2. The calcium channel blocker to the client who
states an allergy to calcium.
l 3. The beta blocker to the client who has a BP of
156/94 and a pulse of 58.
l 4. The antidysrhythmic medication to the client in
normal sinus rhythm.
prescribed heparin by constant infusion after an initial
dose of 5000 units intravenous push. The heparin comes
prepared 20,000 units in 500 mL of D5W. The bolus
heparin was administered at 0800 and the infusion
initiated per protocol at 25 mL/hr. At the 1900 shift
change, how much heparin had been administered?
Answer: ____________
ANSWERS
119. Correct answer 3: Beta blockers decrease the blood
120
120. Correct answer 5440: The nurse must determine
pressure and the pulse. The nurse should question
administering this medication because of the pulse.
Calcium channel blockers do not contain calcium.
The body must have calcium in order to live. Con-
the number of units in each mL; 20,000 divided by
500 = 40 units per mL; 40 units times 11 hours
= 440 units administered via constant infusion +
5000 = 5440 units administered this shift. Content
tent Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Planning; Client
Needs–Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Application.
Area–Medical; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
SECTION THREE
Respiratory Disorders
121
SECTION THREE
Respiratory Disorders
123
Chronic Obstructive Pulmonary
Disease (COPD)
1. The nurse is teaching a class at a local community
2. The nurse is admitting the client diagnosed with an
center. Which information is the most important fact
to discuss with the clients regarding the prevention of
chronic obstructive pulmonary disease (COPD)?
l 1. Explain the importance of quitting smoking
cigarettes, which will help repair lungs.
l 2. Inform the participants that people who have never
smoked can get COPD.
l 3. Tell the participants there is no reason to quit
smoking if they have smoked for years.
l 4. Discuss that secondhand smoke is not as harmful
as actually smoking the cigarette.
acute exacerbation of end-stage COPD. The client has a
dusky color, is dyspneic, and has a respiration rate of 36.
Which intervention should the nurse implement first?
l 1. Apply O2 at 10 liters per minute (LPM) via nasal
cannula.
l 2. Assist the client into the high Fowler position.
l 3. Monitor the client’s telemetry reading.
l 4. Notify the client’s health-care provider (HCP)
3. The nurse is caring for a client diagnosed with COPD.
Which assessment data requires the nurse to intervene?
l 1. Use of accessory muscles during inspiration.
l 2. Oxygen flow meter set on 3 L while the client is
ambulating.
l 3. Presence of a barrel chest and dyspnea.
l 4. Rust-colored sputum in the sputum collection
container.
ANSWERS
1. Correct answer 1: When the client stops smoking,
the lungs will begin to repair themselves. Some clients
who do not smoke but have familial asthma or occupational exposure to irritants can still have forms of
COPD. Many medications will be more effective
without the presence of the chemicals in cigarette
smoke. Content–Medical; Category of Health Alteration–
Respiratory; Integrated Process–Planning; Client Needs–
Health Promotion and Maintenance; Cognitive
Level–Synthesis.
2. Correct answer 2: The client should be assisted into a
high sitting position, which helps increase lung expansion. Some clients find it easier sitting on the side of
the bed leaning over the bed table in a three-point
stance. Oxygen will be applied as soon as possible but
at 2 LPM, not 10 LPM, because of the client’s
hypoxic drive. Because the client with COPD has
become adapted to a low oxygen level, the client will
be supplied oxygen at a lower level—2 LPM—than
what would be expected based on the amount of
Copyright © 2010 F.A. Davis Company
124
carbon dioxide in the blood. Content–Medical; Category
of Health Alteration–Respiratory; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Analysis.
3. Correct answer 4: Rusty-colored sputum indicates the
presence of an infection and the nurse should intervene by notifying the HCP and obtaining cultures.
Oxygen at 3 LPM during ambulation is appropriate; it
is decreased when the client is at rest. Use of accessory
muscles and barrel chest and dyspnea are characteristic
of COPD. Content–Medical; Category of Health Alteration–Respiratory; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management of
Care; Cognitive Level–Analysis.
SECTION THREE
4. The nurse is evaluating the care provided to a client
diagnosed with COPD. Which client outcome indicates
the plan of care is effective?
l 1. The client’s sputum culture indicates Klebsiella.
l 2. The client’s circumoral mucosa is pale gray.
l 3. The client ambulates in the hallway without
dyspnea.
l 4. The client participates in establishing goals.
5. The nurse and an unlicensed assistant personnel
(UAP) are caring for clients on a medical unit. Which
nursing task should the nurse delegate to the UAP?
l 1. Instruct the UAP to increase the oxygen level for a
client who is dyspneic.
l 2. Document the amount, color, and consistency of a
sputum collection specimen.
l 3. Bag the sputum specimen in a plastic bag and take
it to the laboratory.
l 4. Refer the client to the respiratory therapist to
collect a sputum specimen.
Respiratory Disorders
125
6. The home health-care nurse is providing care for a
client diagnosed with COPD. Which instruction should
the nurse teach the client?
l 1. Instruct the client to call the HCP if the sputum is
white in the mornings.
l 2. Tell the client to practice blowing into the
incentive spirometer every 2 hours.
l 3. Encourage the client to sleep on one pillow with
the head of the bed (HOB) flat.
l 4. Recommend the client maintain a fluid intake of
1500 mL per 24 hours.
7. Which statement made by the client diagnosed with
COPD indicates to the clinic nurse that teaching has
been effective?
l 1. “I should take the pneumonia vaccine annually.”
l 2. “I need to get the flu shot every year in the fall.”
l 3. “I must reduce how many cigarettes I smoke a day.”
l 4. “I will make an appointment to see an
endocrinologist.”
ANSWERS
4. Correct answer 3: Ambulating without dyspnea
indicates the plan of care is effective. Klebsiella is a
bacterium that causes some types of pneumonia.
Cyanosis (option 2) does not indicate effective
care. Establishing goals does not indicate the care
is effective. Content–Medical; Category of Health
Alteration–Respiratory; Integrated Process–Evaluation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Evaluation.
126
6. Correct answer 2: An incentive spirometer will assist
the client to expand the lungs and improve breathing.
White sputum is normal for a client with COPD. The
client should elevate the HOB or may need to use two
or more pillows. Fluid intake is not limited. Content–
Medical; Category of Health Alteration–Respiration;
Integrated Process–Planning; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
5. Correct answer 3: The UAP can obtain the specimen
7. Correct answer 2: The client should receive the flu vac-
and take it to the lab for analysis. The UAP cannot
care for a client who is unstable. The UAP cannot
teach or evaluate the specimen. Referrals are made by
the nurse. Content–Medical; Category of Health Alter-
cine annually prior to the winter flu season. Pneumonia
vaccines are recommended every 5–6 years. The client
should stop smoking. A pulmonologist, not an
endocrinologist, cares for a client with COPD. Content–
ation–Respiratory; Integrated Process–Planning; Client
Needs–Safe Effective Care Environment, Management of
Care; Cognitive Level–Synthesis.
Medical; Category of Health Alteration–Respiratory;
Integrated Process–Evaluation; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive
Level–Evaluation.
Copyright © 2010 F.A. Davis Company
SECTION THREE
Respiratory Disorders
127
8. The nurse is assessing the client diagnosed with “black
10. The client diagnosed with end-stage COPD has a
lung.” Which intervention should the nurse delegate to
the UAP?
l 1. Ask the UAP to take all liquids off the client’s meal
trays.
l 2. Tell the UAP to give the client a sputum cup for a
sputum culture.
l 3. Have the UAP measure the client’s chest expansion
with each breath.
l 4. Instruct the UAP to suction the client for a sputum
specimen.
pulse oximeter reading of 91%. Which intervention
should the nurse implement?
l 1. Document the findings in the client’s chart.
l 2. Request a stat arterial blood gas reading.
l 3. Notify the respiratory therapist immediately.
l 4. Encourage the client to cough and deep-breathe.
9. The elderly client with COPD is admitted to the
medical unit. The client’s level of consciousness is altered
and the vital signs are P 118, R 28, BP 176/96. Which
arterial blood gases (ABGs) results would the nurse
expect?
l 1. pH 7.28, PaCO2 56, HCO3 29, PaO2 76.
l 2. pH 7.48, PaCO2 33, HCO3 25, PaO2 98.
l 3. pH 7.35, PaCO2 56, HCO3 18, PaO2 100.
l 4. pH 7.40, PaCO2 38, HCO3 24, PaO2 80.
Reactive Airway Disease (Asthma)
11. The nurse is caring for the client diagnosed with
reactive airway disease who is prescribed montelukast
(Singulair), a leukotriene modifier. Which information
should the nurse teach the client?
l 1. Instruct the client to take the Singulair when there
is a tightening in the chest.
l 2. Tell the client it will take up to 2 weeks for the
medication to become effective.
l 3. Explain that a fast-acting medication is needed for
an asthma attack, not Singulair.
l 4. Recommend the client take the breathing
medication three times a day with meals.
ANSWERS
8. Correct answer 2: Black-streaked sputum is a classic
sign of coal workers’ pneumoconiosis (black lung). All
clients’ sputum should be assessed for color and
amount. The UAP can deliver a specimen cup to the
client; the nurse must instruct the client and evaluate
the specimen. Content–Medical; Category of Health
Alteration–Management; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
9. Correct answer 1: The client would be in respiratory
acidosis with a low oxygen level. Normal pH is
7.35–7.45; a pH of 7.28 indicates acidosis. A PaCO2
of 56 (normal is 35–45) indicates a respiratory problem,
and a low oxygen level—PaO2 of 76 (normal is
80–100)—is associated with confusion. The HCO3 of
29 (normal is 22–26) indicates the body’s attempt to
compensate. Content–Medical; Category of Health
Alteration–Respiratory; Integrated Process–Assessment;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
128
10. Correct answer 1: The client with end-stage COPD
would be expected to have a low oxygen level—less
than 93% indicates a low oxygen level—even as low as
80%. The nurse should document the oxygen level in
the client’s chart. Content–Medical; Category of Health
Alteration–Respiratory; Integrated Process– Implementation; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
11. Correct answer 3: Singulair prevents the
excitability of leukotrienes and maintains medication
blood levels, but it is not useful in an acute attack.
The medication will begin to work in 24 hours and
is taken once a day. Content–Medical; Category of
Health Alteration–Respiratory; Integrated Process–
Planning; Client Needs–Physiological Integrity,
Physiological Adaptation: Cognitive Level–Synthesis.
SECTION THREE
Respiratory Disorders
129
12. The client presents to the emergency department (ED)
14. The nurse on the medical unit is caring for a client
diagnosed with status asthmaticus. Which intervention
should the nurse implement first?
l 1. Administer Solu-Medrol, a glucocorticoid,
intravenously.
l 2. Give the client a short-acting beta adrenergic agonist.
l 3. Hang an intravenous infusion of the
bronchodilator theophylline.
l 4. Assess the client’s breath sounds every 5 minutes.
experiencing an asthma attack. Which nursing intervention
should be implemented first?
l 1. Obtain the client’s short-acting beta agonist
medication.
l 2. Notify the HCP.
l 3. Have Respiratory Therapy administer a breathing
treatment.
l 4. Elevate the head of the bed.
13. The nurse is completing the admission assessment on
15. The nurse is planning the care of a 65-year-old client
a client diagnosed with reactive airway disease. Which
signs and symptoms would indicate an acute exacerbation
of reactive airway disease?
l 1. The client complains of tightness in the chest and
difficulty breathing.
l 2. The client has a temperature of 100ºF and nausea.
l 3. The nurse hears crackles in all lung fields and
notices red raised areas on the chest.
l 4. The client is able to expand the thoracic cavity
symmetrically during inhalation.
diagnosed with adult onset of reactive airway disease.
Which interventions should the nurse include? Select all
that apply.
l 1. Assess the client for gastroesophageal reflux symptoms.
l 2. Teach the client about rescue and maintenance
medications.
l 3. Ambulate the client with a gait belt when short of
breath.
l 4. Do not allow the client to perform activities of
daily living.
l 5. Encourage the client to drink 6–8 glasses of
water a day.
ANSWERS
12. Correct answer 2: The client should first be given a
130
14. Correct answer 4: The nurse should elevate the
short-acting beta-adrenergic medication to treat the
symptoms. The nurse can then administer the steroid
Solu-Medrol and the bronchodilator theophylline.
Remember, “If in stress, do not assess.”
head of the client’s bed to assist in lung expansion.
The nurse can send another nurse to obtain the
client’s medication; the nurse should not leave
the client. Content–Medical; Category of Health
Content–Medical; Category of Health Alteration–
Respiratory; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
Alteration–Respiratory; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Synthesis.
13. Correct answer 1: During an asthma attack, the
15. Correct answer: 1, 2, 5: Up to 85% of the time,
muscles surrounding the bronchioles constrict, causing a narrowing of the bronchioles. The lungs then
respond with production of secretions that further
narrow the lumen. The resulting symptoms include
wheezing from air passing through narrow clogged
spaces and dyspnea. Content–Medical; Category of
adult-onset asthma is caused by gastric reflux. The
client should be knowledgeable of the medication
regimen and drink the recommended amount of
water daily. The client should not be ambulated when
having difficulty breathing, and the nurse should
encourage the client’s independence. Content–
Health Alteration–Respiratory; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.
Medical; Category of Health Alteration–Respiratory;
Integrated Process–Planning; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
SECTION THREE
Respiratory Disorders
131
16. The client is diagnosed with reactive airway disease.
18. The client diagnosed with reactive airway disease is
Which information should the nurse teach when discussing
zone classifications?
l 1. The green zone means the client has mild symptoms.
l 2. The yellow zone means the client is at 50%–80%
of peak inspiratory effort.
l 3. The red zone means the client has improved since
the last HCP visit.
l 4. The black zone means the client should go to the
emergency department.
admitted to the ED with difficulty breathing and a bluish
tint around the mouth. Which intervention should the
ED nurse implement first?
l 1. Draw blood for a complete blood count.
l 2. Apply oxygen via nasal cannula.
l 3. Request arterial blood gases (ABGs).
l 4. Take the client’s vital signs.
17. Which statement by the client indicates to the
nurse the client understands the teaching regarding the
inhaled steroid medication fluticasone (Flovent) by
metered dose inhaler (MDI)?
l 1. “I should take two puffs of the medications within
30 seconds of one another.”
l 2. “I should eat before I use the inhaler to prevent
stomach upset.”
l 3. “I should rinse my mouth before using the inhaler.”
l 4. “I should not take these drugs when I am having
an asthma attack.”
19. The clinic nurse is discussing the client’s frequent
asthma attacks. Which intervention should the nurse
implement?
l 1. Discuss the client moving to a different climate.
l 2. Ask the client when and where the attacks occur.
l 3. Tell the client to buy cotton linens for the home.
l 4. Teach the client to attempt to avoid all stress.
ANSWERS
16. Correct answer 2: Health-care providers rank asthma
symptoms by zones. Green means everything is going
well, and yellow indicates the client is not at top performance and is beginning to show distress. The
client with 50%–80% of normal lung capacity is in
the yellow zone. The red zone indicates more severe
distress and the need for immediate medical intervention. There is no black zone. Content–Medical; Category of Health Alteration–Respiratory; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
17. Correct answer 4: Inhaled steroids are used for prophylaxis and are not effective during an acute asthma
attack. The puffs should be spaced apart to allow for
increased absorption of the medication. The mouth is
rinsed after the medication to prevent oral candidiasis;
the client does not need to eat before using the medication. Content–Medical; Category of Health Alteration–
Drug Administration: Integrated Process–Evaluation;
Client Needs–Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Evaluation.
Copyright © 2010 F.A. Davis Company
132
18. Correct answer 2: The nurse should first take care
of the client by applying oxygen, which is the only
option that will directly affect the client’s cyanosis.
Drawing blood, requesting ABGs, and taking vital
signs are appropriate interventions, but they will not
help the client’s cyanosis. Content–Medical; Category
of Health Alteration–Respiratory; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Analysis.
19. Correct answer 2: The nurse should assess for possible causes of the frequent asthma attacks by asking
when and where they occur. Moving to a different
climate may not help and could even be worse for
the client. The client may not be reacting to the bed
linens. Avoiding all stress is not realistic. Content–
Medical; Category of Health Alteration–Respiratory;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
SECTION THREE
Respiratory Disorders
133
20. The charge nurse on a medical unit is making
22. The nurse planning the care of a client diagnosed
rounds. Which client should the charge nurse see first?
l 1. The client diagnosed with reactive airway disease
whose pulse oximeter reading is 90%.
l 2. The client diagnosed with heart failure who
has 2+ edema of the lower extremities.
l 3. The client diagnosed with type 2 diabetes whose
blood glucose reading is 243 mg/dL.
l 4. The client diagnosed with COPD who states he
cannot breathe without his oxygen.
with pneumonia writes a problem of “impaired gas
exchange.” Which nursing interventions should be
included in the plan of care? Select all that apply.
l 1. Respiratory therapy to perform chest physiotherapy.
l 2. Complete activities of daily living at the same time.
l 3. Ambulate in the hall and back several times each
shift.
l 4. Assess the client neurological status frequently.
l 5. Keep the client’s HOB elevated at all times.
Lower Respiratory Infections
23. The nurse is planning the care for a client with
21. The nurse is assessing an 89-year-old client
diagnosed with pneumonia. Which signs and symptoms
would the nurse expect the client to exhibit?
l 1. Pink frothy sputum and edema.
l 2. Confusion and lethargy.
l 3. High fever and chills.
l 4. Bradypnea and jugular vein distention.
continuous percutaneous gastrostomy (PEG) feedings.
Which intervention should the nurse include in the plan
of care?
l 1. Inspect the insertion line at the nares daily.
l 2. Elevate the HOB only after feeding the client.
l 3. Auscultate the lungs each shift and as needed.
l 4. Change the dressing on the feeding tube every
72 hours.
ANSWERS
20. Correct answer 1: A pulse oximeter reading of 90%
is the equivalent of an arterial blood gas oxygen level
of 60. This client should be evaluated first. The other
clients have expected clinical manifestations of their
conditions and are not in life-threatening situations.
Content–Medical; Category of Health Alteration–
Respiratory; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
21. Correct answer 2: The elderly client diagnosed with
pneumonia may present with weakness, fatigue,
lethargy, confusion, and poor appetite but may not
have any of the classic signs and symptoms of
pneumonia. Fever and chills are classic symptoms of
pneumonia but are usually absent in the elderly
client. Content–Medical; Category of Health Alteration–
Respiratory; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
134
22. Correct answers: 1, 4, 5: Respiratory therapy
should perform chest physiotherapy. A decrease in
oxygenation will cause the client to become confused
and disoriented; therefore, the nurse should assess
the client’s neurological status. Keeping the HOB
elevated will increase lung expansion. Activities
should be spaced out, and the client should not
ambulate. Content–Medical; Category of Health
Alteration–Respiratory; Integrated Process–Diagnosis;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Analysis.
23. Correct answer 3: PEG tube feedings are placed
directly into the stomach, resulting in a risk of regurgitation into the lungs; therefore, the nurse should
assess for aspiration pneumonia. The insertion site is
through the abdominal wall, not the nares; the
feedings are continuous, not bolus; and the dressing
should be changed daily. Content–Medical; Category
of Health Alteration–Respiratory; Integrated Process–
Diagnosis; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Analysis.
SECTION THREE
Respiratory Disorders
135
24. The client diagnosed with community-acquired
26. The employee health nurse is administering tuberculin
pneumonia is being admitted to a medical unit. Which
nursing intervention should the nurse implement first?
l 1. Administer the intravenous antibiotic stat.
l 2. Order the meal tray to be delivered as soon as
possible.
l 3. Obtain a sputum specimen for culture and
sensitivity.
l 4. Notify the pharmacy to prepare the antibiotic.
skin testing to the employees who have possibly been
exposed to a client with active tuberculosis. Which finding
indicates the need for radiological evaluation?
l 1. The employee’s skin test indicates a purple flat area
at the site of injection.
l 2. The employee’s skin test indicates a red area
measuring 6 mm.
l 3. The employee whose previous skin test was read as
12 mm.
l 4. The employee who has never been outside the
country.
25. The client diagnosed with tuberculosis (TB) is being
discharged on rifampin, an antitubercular antibiotic.
Which statement made by the client indicates an
understanding of the discharge instructions?
l 1. “I will take my medication for the full 3 weeks
prescribed.”
l 2. “My urine may turn a red-orange but I still should
take my medication.”
l 3. “I can be around my friends since I have started
taking antibiotics.”
l 4. “I should get a tuberculin skin test every 3 months
to determine if I still have TB.”
27. The nurse is feeding the client diagnosed with
aspiration pneumonia, and the client begins to cough and
is having difficulty breathing. Which intervention should
the nurse implement first?
l 1. Suction the client’s mouth.
l 2. Change the client to tube feedings.
l 3. Apply oxygen via nasal cannula.
l 4. Turn the client to the side.
ANSWERS
24. Correct answer 3: In order to determine which
antibiotic will effectively treat an infection, a sputum
culture must be obtained prior to initiating antibiotic therapy. Administering antibiotics prior to
cultures may make it impossible to determine the
actual agent causing the disease. Content–Medical;
Category of Health Alteration–Respiratory; Integrated
Process– Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
25. Correct answer 2: Rifampin may turn body fluids a
red-orange, but it will not cause permanent damage,
and the client must take the medication. Clients will
need to take the medications for 9–12 months, not
3 weeks. Clients are contagious until three morning
sputum specimens are cultured negative; and the
client should have chest x-rays, not TB skin tests.
Content–Medical; Category of Health Alteration–Drug
Administration; Integrated Process–Evaluation; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Evaluation.
Copyright © 2010 F.A. Davis Company
136
26. Correct answer 3: Induration of 10 mm or greater
is considered a positive skin test. Once the skin test
result is positive, it will always be positive. This
employee requires a chest x-ray to determine if
tuberculosis is present. Content–Medical; Category of
Health Alteration–Respiratory; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.
27. Correct answer 4: Turning the client to the side will
allow for the food to be coughed up and come out
of the mouth. The nurse could suction the client’s
mouth next, but the nurse should first assist the
client to cough the food up and out of the mouth.
Content–Medical; Category of Health Alteration–
Respiratory; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
SECTION THREE
Respiratory Disorders
137
28. The charge nurse on a medical unit is making
30. The female client is admitted to a medical unit with
rounds after report. Which client should be seen first?
l 1. The client diagnosed with tuberculosis who has a
sputum specimen to send to the lab.
l 2. The client diagnosed with aspiration pneumonia
who has a clogged feeding tube.
l 3. The client diagnosed with pneumonia who has a
pulse oximeter reading of 98%.
l 4. The client diagnosed with bronchitis who has an
arterial oxygenation level of 78 mm Hg.
a diagnosis of pneumonia. Which nursing task should the
nurse delegate to the UAP?
l 1. Ask the client if he/she is having chest discomfort
and anxiety.
l 2. Draw a blood specimen for admitting lab work.
l 3. Assist the radiology technician to take a stat
portable x-ray.
l 4. Show the client the call light and bathroom.
29. The client is admitted with a diagnosis of rule-out
(R/O) tuberculosis. Which type of isolation precautions
should the nurse implement?
l 1. Standard.
l 2. Contact.
l 3. Droplet.
l 4. Airborne.
Upper Respiratory Infections
31. The male client calls the clinic nurse to ask, “Which
over-the-counter (OTC) remedy should I take for my
cold and runny nose?” Which question is the most
important for the nurse to ask the client?
l 1. “Which medications do you have in your house?”
l 2. “What chronic conditions do you have?”
l 3. “Do you have any allergies to decongestants?”
l 4. “Did you take the flu shot this year?”
ANSWERS
28. Correct answer 4: The normal arterial oxygenation
138
30. Correct answer 4: The UAP can orient the client to
level is 80–100 mm Hg; therefore, this client should
be seen first. A sputum culture, a clogged feeding
tube, and a normal pulse oximeter reading would
not be priority over a client who is in respiratory
distress. Content–Medical; Category of Health
the room. The UAP cannot assess for chest discomfort,
and the lab is responsible for drawing blood for lab
work. The nurse must make sure a female UAP is
not pregnant before asking her to assist with radiological procedures.Content–Medical; Category of
Alteration–Respiratory; Integrated Process–Assessment;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Analysis.
Health Alteration–Respiratory; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
29. Correct answer 4: Tuberculosis bacteria are capable
of disseminating over distances on air currents.
Airborne precautions are needed. The client should
be placed in a negative air pressure room where the
air is not allowed to cross-contaminate the air in
the hallway. Content–Medical; Category of Health
Alteration–Respiratory; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
Copyright © 2010 F.A. Davis Company
31. Correct answer 2: The nurse should determine
what, if any, medical conditions the client has
because many OTC cold and flu medications work
by vasoconstriction and are contraindicated in clients
diagnosed with hypertension and diabetes. Content–
Medical; Category of Health Alteration–Respiratory;
Integrated Process–Assessment; Client Needs–Physiological
Integrity, Physiological Adaptation: Cognitive Level–
Analysis.
Respiratory Disorders
SECTION THREE
32. The school nurse is preparing a class to present to
staff members who teach the primary grades. Which
information is most important to teach regarding the
prevention of the transmission of the common cold?
l 1. The teacher should keep tissues available for the
students to use.
l 2. The teacher should encourage the children to share
their food at lunch.
l 3. The teacher should remind the children to cough
into their sleeve.
l 4. The teacher should disinfect the classroom at the
end of the day.
33. Which statement made by the female client indicates
to the nurse that the client understands the teaching
about the new diagnosis of acute sinusitis?
l 1. “I will get a bulb syringe to irrigate my sinuses
twice each day.”
l 2. “If I need to blow my nose, I will use a disposable
Kleenex.”
l
l
139
3. “I should eat a container of yogurt every day while
I am on the antibiotic.”
4. “I must take all the prescribed medication before
I feel better.”
34. The client diagnosed with chronic sinusitis calls the
clinic nurse and reports a severe headache and a stiff
neck. Which intervention should the nurse implement?
l 1. Have the HCP call in a different antibiotic
prescription.
l 2. Make an appointment for the client to see the
HCP next week.
l 3. Instruct the client to sleep with the head elevated
on several pillows.
l 4. Tell the client to go to the hospital’s ED.
ANSWERS
32. Correct answer 3: Current recommendations are to
encourage good hand washing and teach children to
cough into their sleeves. These activities prevent
bacteria and viruses from reaching the child’s hands.
Tissues are not always disposed correctly; children
should not share their foods; and disinfectant will
not kill the cold virus. Content–Medical; Category of
Health Alteration–Respiratory; Integrated Process–
Planning; Client Needs–Health Promotion and
Maintenance; Cognitive Level–Synthesis.
33. Correct answer 3: Female clients on antibiotics
frequently get vaginal yeast infections. Eating yogurt
will replace the good bacteria in the vagina that are
destroyed by the antibiotic. The client may feel
better before the prescription is completed, but she
still needs to take all of the medication to prevent
resistant strains of bacteria from developing. A bulb
syringe will not help client. Content–Medical;
Category of Health Alteration–Respiratory; Integrated
Copyright © 2010 F.A. Davis Company
140
Process–Evaluatiol; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Evaluation.
34. Correct answer 4: Neck stiffness (nuchal rigidity)
and headache are symptoms of meningitis, a potential fatal complication of sinusitis. Survival depends
on the appropriate antibiotic being administered in a
timely manner. The client should go to the hospital’s
ED. Content–Medical; Category of Health Alteration–
Respiratory; Integrated Process–Implementation; Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
SECTION THREE
Respiratory Disorders
141
35. The client diagnosed with tonsillitis is scheduled to
37. The charge nurse on a surgical floor is making shift
have a tonsillectomy in the morning. Which statement
made by the client would warrant immediate intervention
by the nurse?
l 1. “I have been told that I will not feel anything during
the operation.”
l 2. “My tonsils have been giving me problems for over
a year now.”
l 3. “The doctor said that I will hear better once I have
the tube put in my ears.”
l 4. “My spouse bought gelatin and ice cream for me to
eat when I go home.”
assignments. Which client should be assigned to the least
experienced registered nurse (RN)?
l 1. The client who has undergone an antral irrigation
for sinusitis who has a severe headache.
l 2. The pediatric client scheduled for a tonsillectomy
who will not swallow medication.
l 3. The client who had a Caldwell-Luc procedure and
has purulent drainage on the drip pad.
l 4. The elderly client with a peritonsillar abscess who
has a feeling of tightness in the throat.
36. The client diagnosed with sinusitis who has undergone
a Caldwell-Luc procedure is complaining of pain. Which
intervention should the nurse implement first?
l 1. Assess the client’s pain level on a 1–10 scale.
l 2. Administer the narcotic analgesic by intravenous
push (IVP).
l 3. Perform gentle oral hygiene with an antiseptic
mouthwash.
l 4. Place the client in a semi-Fowler position.
ANSWERS
35. Correct answer 3: This statement indicates that
another procedure may be done. The nurse should
investigate to determine if a myringotomy (placing a
tube in the tympanic membrane) is also planned to
be done so the appropriate permits can be obtained.
All the other statements indicate the client understands the surgical procedure. Content–Surgical;
Category of Health Alteration–Respiratory; Integrated
Process–Evaluation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Synthesis.
36. Correct answer 1: The nurse should assess the level
of pain first to determine if the client is experiencing
a postoperative complication or having routine
postoperative pain. If it is routine postoperative pain,
then the nurse should administer the pain medication. A semi-Fowler position may help to reduce
edema, but oral hygiene will not help the pain.
Copyright © 2010 F.A. Davis Company
142
Content–Surgical; Category of Health Alteration–
Respiratory; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
37. Correct answer 2: An inexperienced nurse can care
for a child who is not cooperative and is NPO for
surgery. A severe headache after an antral irrigation
procedure could indicate meningitis. Purulent
drainage and feelings of tightness in the throat
indicate possible complications and should be
assigned to a more experienced nurse. Content–
Surgical; Category of Health Alteration–Management;
Integrated Process–Planning; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
SECTION THREE
Respiratory Disorders
143
38. The clinic nurse is discharging a client diagnosed
40. The female client tells the clinic nurse that she prefers
with influenza type A. Which statement best describes the
scientific rationale for the HCP prescribing antibiotics?
l 1. The antibiotics will vasoconstrict the sinuses.
l 2. The antibiotics will kill the influenza bacteria.
l 3. The medication may help the client get better
faster.
l 4. The medication may prevent pneumonia from
developing.
to treat her cold symptoms with “natural” medications.
Which complimentary alternative medicine (CAM) is an
example of this type of therapy?
l 1. Echinacea.
l 2. A sulfa antibiotic.
l 3. Over-the-counter (OTC) antihistamines.
l 4. Amantadine, an anti-Parkinson preparation.
39. The nurse is delegating tasks to the UAP. Which
nursing task should not be delegated to the UAP?
l 1. Feed a postoperative tonsillectomy client the third
meal of clear liquids.
l 2. Encourage the client diagnosed with a cold to
drink an 8-ounce glass of juice.
l 3. Obtain a throat swab on a client diagnosed with
bacterial pharyngitis.
l 4. Take the client diagnosed with laryngitis to the
radiology department for a chest x-ray.
Lung Cancer
41. The nurse is taking the social history from a client
diagnosed with small-cell carcinoma of the lung. Which
information is significant for this disease?
l 1. The client worked with asbestos for a short time
many years ago.
l 2. The client has no family history for this type of
lung cancer.
l 3. The client has numerous tattoos covering upper
and lower arms.
l 4. The client has smoked two packs of cigarettes a day
for 20 years.
ANSWERS
38. Correct answer 4: Antibiotics are prescribed as prophylaxis to prevent a secondary bacterial pneumonia.
Antibiotics will not vasoconstrict sinuses, will not
kill a virus, and will not help the client feel better
because influenza is a viral, not a bacterial, infection.
Content–Medical; Category of Health Alteration–
Respiratory; Integrated Process–Diagnosis; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
39. Correct answer 3: Throat swabs for culture must be
done correctly, or false negatives can result; the nurse
should obtain the throat culture. The UAP can feed
a stable client, can encourage the client to drink juice,
and can escort clients to the radiology department.
Content–Medical; Category of Health Alteration–
Management; Integrated Process–Planning; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
144
40. Correct answer 1: Echinacea is an herb used to
stimulate the immune system. Research on echinacea
has not shown efficacy against cold viruses. All other
options are medications. Content–Medical; Category
of Health Alteration–Complimentary Alternative
Medicine; Integrated Process–Evaluation; Client
Needs–Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Evaluation.
41. Correct answer 4: Smoking is the primary risk
factor for developing cancer of the lung, with risk
increasing with the amount of use and length of
time the client smoked. Asbestos is significant for
mesothelioma, not small-cell carcinoma. Family
history and tattoos are not risk factors for lung
cancer. Content–Medical; Category of Health
Alteration–Respiratory; Integrated Process–Assessment;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Analysis.
SECTION THREE
Respiratory Disorders
145
42. The nurse writes a problem of “anticipatory grieving”
44. The nurse and a UAP are caring for a group of
for a client diagnosed with metastatic cancer of the lung.
Which interventions should be included in the plan of
care for this problem? Select all that apply.
l 1. Apply O2 via nasal cannula.
l 2. Spend time with the client and family.
l 3. Place the client in respiratory isolation.
l 4. Assist the client to prepare an advance directive.
l 5. Listen to lung sounds every shift.
clients on a medical unit. Which information provided by
the UAP warrants immediate intervention by the nurse?
l 1. The client diagnosed with cancer of the lung has a
small amount of blood in a tissue.
l 2. The client diagnosed with emphysema is sitting on
the side of the bed, leaning on a table.
l 3. The client receiving intravenous (IV)
chemotherapy for lung cancer has a T 100.2°F and
BP of 148/92.
l 4. The client receiving prednisone, a steroid, is
requesting an antacid for indigestion.
43. The nurse is discussing lung cancer with a group of
individuals in the community. Which information should
the nurse teach the group?
l 1. Explain lung cancer is the second leading cause of
cancer deaths in women.
l 2. Tell the individuals most cases of lung cancer can
be prevented.
l 3. Explain that young people are not at risk for
developing lung cancer.
l 4. Tell the individuals lung cancer deaths have begun
to decline.
45. The client diagnosed with lung cancer has been
placed on experimental IV antineoplastic medication.
Which priority intervention should the nurse implement
when administering the medication?
l 1. Discuss the need to implement the advance directive.
l 2. Make sure the client understands the possible
reactions.
l 3. Obtain an IV pump to infuse the medication.
l 4. Include the significant other in the discussion
about the treatment.
ANSWERS
42. Correct answer 2, 4: The nurse should take time
with the client and family to help them cope with
the grieving process. Preparing an advance directive
helps the family and HCP know the client’s wishes.
Oxygen administration and assessing lung sounds
are not appropriate for grieving. The client is not in
respiratory isolation. Content–Medical; Category of
Health Alteration–Respiratory; Integrated Process–
Diagnosis; Client Needs–Psychosocial Integrity;
Cognitive Level–Analysis.
43. Correct answer 2: Most lung cancers are directly
related to the incidence of cigarette smoking. The
longer the time and the greater the number of
cigarette smoked, the greater the risk for developing
lung cancer. Young people are at risk if they choose
to smoke. Lung cancer is the primary cause of cancer
deaths of both sexes in the United States. Content–
Medical; Category of Health Alteration–Respiratory;
Integrated Process–Planning; Client Needs–Health
Promotion and Maintenance; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
146
44. Correct answer 3: This client is receiving medications that can decrease the ability to fight infection;
therefore, the low-grade fever should be investigated
by the nurse. A small amount of blood on the tissue
of a client with lung cancer, the orthopneic position
in a client with emphysema, and indigestion in a
client receiving steroids would not warrant immediate
intervention by the nurse. Content–Medical; Category
of Health Alteration–Respiratory; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.
45. Correct answer 2: In order to receive experimental
medication, the client must sign an informed consent
document stating an understanding of the possible
reactions to the medication. Discussing an advance
directive, obtaining an IV pump, and including
significant others are plausible interventions, but not
priority interventions. Content–Medical; Category of
Health Alteration–Drug Administration; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Pharmacological and Parenteral Therapies;
Cognitive Level–Application.
SECTION THREE
Respiratory Disorders
147
46. The client diagnosed with lung cancer is being
48. The client is 4 hours post right pneumonectomy
discharged. Which statement made by the client
indicates that discharge teaching is effective?
l 1. “I should quit smoking even though I have cancer.”
l 2. “My primary care provider can answer all my
questions.”
l 3. “A low-grade fever is expected after chemotherapy.”
l 4. “I should plan to visit my children before it is
too late.”
for cancer of the lung. Which assessment data warrant
immediate intervention by the nurse?
l 1. The client has an intake of 1500 mL IV and an
output of 1000 mL.
l 2. The client has absent lung sounds on the right side.
l 3. The client is complaining of pain of 10 on a
1–10 scale.
l 4. The client has turned onto the right side.
47. The nurse in a clinic is completing a client admission
49. The client is admitted to the outpatient surgery
interview. Which statement by the client warrants further
investigation?
l 1. “I have been using the nicotine patch for 2 weeks.”
l 2. “I know I should stop dipping snuff, but I really
like the taste.”
l 3. “I have two siblings who have smoked for
30 years.”
l 4. “I coughed up blood the past several mornings.”
center for a bronchoscopy to rule out cancer of the lung.
Which information should the nurse provide to the
client?
l 1. Instruct the client to eat breakfast before the
0900 procedure.
l 2. Explain that a catheter will be inserted in the groin
and dye instilled.
l 3. Inform the client there is discomfort associated
with this procedure.
l 4. Tell the client the HCP can do a biopsy of the
tumor through the scope.
ANSWERS
46. Correct answer 1: Research indicates the smoking
will interfere with the client’s response to treatment.
The oncologist should be asked questions regarding
cancer treatment and prognosis. The client should
report any fever, not expect it. There is no indication
that death is imminent. Content–Medical; Category of
Health Alteration–Respiratory; Integrated Process–
Evaluation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
47. Correct answer 4: Coughing up blood, especially in
the mornings, should be investigated because it is a
sign of lung cancer. Using the nicotine patch, liking
the taste of tobacco, and having siblings who smoke
would not warrant further investigation. Content–
Medical; Category of Health Alteration–Respiratory;
Integrated Process–Evaluation; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive Level
Synthesis.
Copyright © 2010 F.A. Davis Company
148
48. Correct answer 3: This is a very high pain level;
therefore, the nurse should rule out complications
and then administer pain medication. Option 1 is an
adequate output because of the fluid shift occurring
as a result of trauma to the body. The nurse should
encourage the client to turn, and the right side has
no lung to have lung sounds. Content–Surgical;
Category of Health Alteration–Respiratory; Integrated
Process–Assessment; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Synthesis.
49. Correct answer 4: The HCP will insert a fiber-optic
tube through the mouth (not the groin) into the client’s
lungs to obtain a biopsy of suspicious tissue. Clients
have nothing by mouth prior to the procedure and
are sedated throughout the procedure so there is no
discomfort. Content–Surgical; Category of Health
Alteration–Respiratory; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment, Reduction
of Risk Potential; Cognitive Level–Synthesis.
SECTION THREE
Respiratory Disorders
149
50. The client diagnosed with oat cell carcinoma of the
52. The male client diagnosed with cancer of the larynx
lung tells the nurse, “I am so tired of all this. I might as
well just end it all.” Which therapeutic response would be
most appropriate by the nurse?
l 1. “This must be hard for you. Would you like to talk
about your feelings?”
l 2. “Are you planning to do something that will end
your life?”
l 3. “Have you discussed your feelings with your
significant other?”
l 4. “I think you should tell your HCP how you are
feeling.”
is scheduled to have radiation therapy to the area. Which
information should the nurse teach the client?
l 1. Explain to the client that his teeth will be extracted
and he will be fitted for dentures.
l 2. Tell the client the therapy will be administered for
4 days and then again in 4 weeks.
l 3. Instruct the client to scrub his throat area with an
antibacterial soap nightly.
l 4. Inform the client to expect mild throat irritation
that will resolve quickly.
Cancer of the Larynx
action is the nurse’s best method to communicate with
the client?
l 1. The nurse provides the client with a tablet for
writing.
l 2. The nurse and client have a verbal conversation.
l 3. The nurse attempts to use sign language to talk to
the client.
l 4. The nurse requests the speech therapist to provide
an electric larynx.
51. The nurse is admitting a client diagnosed with
cancer of the larynx. Which intervention should the nurse
implement first?
l 1. Allow the client to verbalize feelings of having
cancer.
l 2. Request a diet with a mechanical soft consistency.
l 3. Assess the client’s ability to swallow.
l 4. Elevate the head of the bed during meals.
53. The client is 3 days post partial laryngectomy. Which
ANSWERS
50. Correct answer 1: A therapeutic response encourages
the client to verbalize feelings. Option 2 and 3 requires
yes/no answers, which do not encourage verbalizations.
Option 4 is advising the client. Content–Medical;
Category of Health Alteration–Respiratory; Integrated
Process–Implementation; Client Needs–Psychosocial
Integrity; Cognitive Level–Application.
51. Correct answer 3: The nurse should assess the client’s
ability to swallow before implementing a change in
the consistency of the food served. All other interventions are appropriate but not before assessment,
which is the first step of the nursing process.
Content–Medical; Category of Health Alteration–
Respiratory; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
150
52. Correct answer 1: The teeth will be in the area of
radiation; the roots of teeth are highly sensitive to
radiation. Exposure to radiation results in abscesses of
the teeth roots; therefore, the teeth are removed, and
the client is fitted for dentures. Radiation therapy is
administered daily for 4–6 weeks; no soap is used in
the area; and the client can develop esophagitis, which
is extremely painful. Content–Medical; Category of
Health Alteration–Respiratory; Integrated Process–
Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
53. Correct answer 2: A partial laryngectomy leaves the
client with some vocal cords. The voice quality may
change, but the ability to speak does not. Content–
Surgical; Category of Health Alteration–Respiratory;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
SECTION THREE
Respiratory Disorders
151
54. The nurse is preparing the client diagnosed with
56. The nurse and a UAP are caring for a group of
laryngeal cancer for a total laryngectomy in the morning.
Which interventions should the nurse implement? Select
all that apply.
l 1. Take the client to the intensive care unit (ICU) for
a visit.
l 2. Explain that the client will need to request pain
medication.
l 3. Demonstrate how to apply anti-embolism hose.
l 4. Determine if the client has the ability to read and
write.
l 5. Refer the client to the occupational therapist.
clients on a surgery floor. Which information provided by
the UAP requires immediate intervention by the nurse?
l 1. The client who had a radical neck dissection who
has a small amount of dark dried blood on the
dressing.
l 2. The client who had a right upper lobectomy and is
complaining that the patient-controlled anesthesia
(PCA) pump is not giving any relief.
l 3. The client diagnosed with cancer of the lung who
is complaining of being tired and short of breath.
l 4. The client admitted with COPD who whistles with
every breath.
55. The nurse is discharging a client who had a total
laryngectomy. Which referral should the nurse make for
this client?
l 1. CanSurmount.
l 2. Dialogue.
l 3. Lost Chords.
l 4. The hospital chaplain.
ANSWERS
54. Correct answer 1, 2, 4: A visit to the ICU will
152
56. Correct answer 2: The client is in pain, and the
familiarize the client with the machines and rules; the
client needs to know pain control methods; and the
nurse needs to know if the client can read and write.
The client will not have antiembolism hose, and a
referral to a speech therapist, not an occupational
therapist, would be appropriate. Content–Surgical;
nurse should assess the situation. Dark dried blood
on the dressing of a client who had a radical neck
dissection and dyspnea and fatigue in a client with
cancer of the lung are expected findings. Whistling
with every breath in a client with COPD indicates
the client is purse-lip breathing. Content–Surgical;
Category of Health Alteration–Respiratory; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
Category of Health Alteration–Respiratory; Integrated
Process–Assessment; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Synthesis.
55. Correct answer 3: The Lost Chords Club is an
American Cancer Society–sponsored group for
survivors of laryngeal cancer. These clients are able
to discuss their feelings and needs concerning the
laryngectomies because the volunteers have also had
this surgery. Content–Surgical; Category of Health
Alteration–Respiratory; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
SECTION THREE
Respiratory Disorders
153
57. The charge nurse is assigning clients for the shift. Which
59. The male client has had a radial neck dissection for
client should be assigned to the most experienced nurse?
l 1. The client diagnosed with cancer of the lung who
has chest tubes.
l 2. The client diagnosed with laryngeal spasms who
has a respiratory rate of 16.
l 3. The client diagnosed with laryngeal cancer who has
multiple fistulas.
l 4. The client who is 1 week post partial laryngectomy.
cancer of the larynx. Which action by the client could
indicate a disturbance in body image?
l 1. The client refuses to allow visitors in the room.
l 2. The client asks for a hand-held mirror.
l 3. The client is trying to learn esophageal speech.
l 4. The client practices neck and shoulder exercises.
58. The nurse is developing a care plan for a client
diagnosed with cancer of the larynx who has had a radical
neck dissection. Which problem would have the highest
priority?
l 1. Risk for wound infection.
l 2. Risk for hemorrhage.
l 3. Altered nutrition.
l 4. Knowledge deficit.
60. The HCP has recommended a total laryngectomy for
a male client diagnosed with cancer of the larynx, but the
client refuses. Which intervention by the nurse illustrates
the ethical principle of beneficence?
l 1. The nurse listens to the client explain why he is
refusing surgery.
l 2. The nurse and client’s wife insist the client have the
surgical procedure.
l 3. The nurse tells the client he may die if he does not
have the surgery.
l 4. The nurse asks a cancer visitor to come and discuss
the surgery with the client.
ANSWERS
57. Correct answer 3: A client with multiple fistulas in
154
59. Correct answer 1: Refusing to allow friends and
the neck area is at high risk for airway compromise
and should be assigned to a more experienced nurse.
Clients with chest tubes, a respiratory rate of 16, or
being 1 week postoperative could be cared for by a
less experienced nurse. Content–Medical; Category of
family to visit could indicate that the client has a
disturbance in body image. Looking at the incision
in a mirror, attempting to speak, and performing
postoperative exercises indicate the client is accepting
the surgery. Content–Surgical; Category of Health
Health Alteration–Management; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
Alteration–Respiratory; Integrated Process–Evaluation;
Client Needs–Psychosocial Integrity; Cognitive
Level–Evaluation.
58. Correct answer 2: The client who has had a radical
neck dissection is at risk for carotid hemorrhage.
Prophylactic antibiotics can be prescribed to prevent
wound infections. Content–Surgical; Category of
Health Alteration–Respiratory; Integrated Process–
Diagnosis; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
60. Correct answer 4: The nurse is attempting “to do
good” for the client. This is beneficence. Listening is
non-malfeasance, insisting the client have the surgery
is paternalism, and telling the client what may
happen is veracity. Content–Fundamentals; Category
of Health Alteration–Respiratory; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Synthesis.
Respiratory Disorders
SECTION THREE
Adult Respiratory Distress
Syndrome (ARDS)
61. The UAP is bathing the client diagnosed with adult
respiratory distress syndrome (ARDS). The bed is in a
high position with the opposite side rail in the up
position. Which action should the nurse implement?
l 1. Demonstrate the correct technique when giving a
bed bath.
l 2. Encourage the UAP to put the bed in the lowest
position.
l 3. Instruct the UAP to get another person to help
with the bath.
l 4. Provide praise for performing the bath safely for
the client and the UAP.
62. The client diagnosed with ARDS is transferred to the
intensive care department and placed on a ventilator.
Which intervention should the intensive care unit nurse
implement first?
l 1. Confirm that the ventilator settings are correct.
l 2. Verify that ventilator alarms are functioning
properly.
l
l
155
3. Assess the client’s upper extremity restraints.
4. Monitor the client’s ABG results.
63. The nurse suspects the client may be developing
ARDS. Which assessment data confirm the diagnosis
of ARDS?
l 1. The client has dyspnea and tachycardia and is feeling
anxious.
l 2. The client respiratory rate is 26, and he has cyanotic
buccal mucosa.
l 3. The client’s arterial blood gases are pH 7.38,
PaO2 90, PaCO2 44, HCO3 24.
l 4. The client’s pulse oximeter is 90% after 15 minutes
of 10 L of oxygen.
ANSWERS
61. Correct answer 4: The opposite side rail should be
elevated so the client will not fall out of the bed.
Because the UAP is ensuring the client’s safety, the
nurse should acknowledge the UAP’s performance
with praise. Content–Medical; Category of Health
Alteration–Respiratory; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
62. Correct answer 1: Maintaining ventilator settings
and checking to ensure they are specifically set as
prescribed is the nurse’s first intervention; this
machine is now functioning as the client’s lungs.
Verifying alarms, assessing the client’s hands, and
monitoring ABGs are appropriate but not before
confirming the ventilator settings. Content–Medical;
Category of Health Alteration–Respiratory; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
156
63. Correct answer 4: The classic sign of ARDS is
decreased arterial oxygen level (PaO2) while high
levels of oxygen are being administered; the oxygen
is unable to cross the alveolar membrane. Dyspnea,
tachycardia, anxiety, tachypnea, and cyanosis are also
signs of ARDS. The ABGs are within normal limits.
Content–Medical; Category of Health Alteration–
Respiratory; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
SECTION THREE
Respiratory Disorders
157
64. The client whose husband has ARDS asks the nurse,
66. The HCP ordered stat ABGs for the client suspected
“What is happening to my husband? Why did he get
this?” Which statement by the nurse is most appropriate?
l 1. “No one really knows why your husband developed
ARDS.”
l 2. “Platelets and fluid enter the alveoli due to
permeability instability.”
l 3. “Your husband’s lungs are filling up with fluid,
causing breathing problems.”
l 4. “You are concerned about what is happening to
your husband.”
of having ARDS. The ABG results are pH 7.42, PaO2 84,
PaCO2 41, HCO3 23. Which action should
the nurse implement?
l 1. Administer oxygen via nasal cannula to the client.
l 2. Encourage the client to take deep breaths and
cough.
l 3. Administer 1 amp of intravenous sodium
bicarbonate.
l 4. Notify the respiratory therapist of the ABG results.
65. Which assessment data would indicate the client
diagnosed with ARDS is experiencing a complication
secondary to the ventilator?
l 1. The client’s urine output is 210 mL in 8 hours.
l 2. The pulse oximeter reading is greater than 95%.
l 3. The client has asymmetrical chest expansion.
l 4. The telemetry reading shows sinus tachycardia.
ANSWERS
64. Correct answer 3: This is a very basic explanation of
ARDS and explains why the client is having trouble
breathing. It is the nurse’s best response. The nurse
should provide information in simple terms. The
layperson may not know terms such as platelets,
alveoli, and permeability. The cause of ARDS is
unknown, but the wife does not need to know this.
The spouse is asking for information, so a therapeutic
response (option 4) is not appropriate. Content–
Medical; Category of Health Alteration–Respiratory;
Integrated Process–Implementation; Client Needs–
Psychosocial Integrity; Cognitive Level–Application.
65. Correct answer 3: Asymmetrical chest expansion
indicates the client has had a pneumothorax, which
is a complication of ventilation. A urine output less
than 30 mL/hr indicates renal failure, but it is not
secondary to the ventilator. Sinus tachycardia is not
secondary to the ventilator. Content–Medical;
Category of Health Alteration–Respiratory; Integrated
Copyright © 2010 F.A. Davis Company
158
Process–Assessment; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive Level–
Analysis.
66. Correct answer 1: These ABGs are within normal
limits, but the oxygen level is low, possibly secondary
to ARDS. Because the client is suspected of having
ARDS, administering oxygen will either increase the
oxygen level or help confirm ARDS. If the oxygen
level continues to decrease even with supplemental
oxygen, the client is developing ARDS. Content–
Medical; Category of Health Alteration–Respiratory;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Reduction of Risk Potential;
Cognitive Level–Application.
SECTION THREE
Respiratory Disorders
159
67. The client with ARDS is on a mechanical ventilator.
69. The client diagnosed with ARDS is on a ventilator,
Which intervention addressing endotracheal tube (ET)
care should be included in the nursing care plan?
l 1. Alternate the ET from side to side in the mouth.
l 2. Replace the ET daily.
l 3. Ensure the ET is deflated.
l 4. Check the lip line of the ET daily.
and the high alarm is going off. The client is having
respiratory difficulty, and the nurse cannot determine the
cause of the problem. Which intervention should the
nurse implement first?
l 1. Notify the respiratory therapist immediately.
l 2. Auscultate the client’s lung sounds.
l 3. Ventilate with a manual resuscitation bag.
l 4. Check the client’s pulse oximeter reading.
68. Which medication should the nurse anticipate the
HCP prescribing for the client diagnosed with ARDS?
l 1. An intravenous Tridil (nitroglycerin) drip.
l 2. A synthetic surfactant.
l 3. An intravenous loop-diuretic.
l 4. A nonsteroidal anti-inflammatory drug (NSAID).
ANSWERS
160
67. Correct answer 1: Alternating the ET tube will help
69. Correct answer 3: If the ventilator system malfunc-
prevent a pressure ulcer on the client’s tongue and
mouth. The ET tube is not replaced daily; the cuff
should be inflated no more than 25 cm H2O to ensure
there is no air leakage; and the lip line should be
checked more often than daily. Content–Medical;
tions, the nurse must ventilate the client with a
manual resuscitation bag (Ambu) until the problem
is resolved. Remember “when in distress, do not
assess.” Assessing the lungs and pulse oximeter
reading will not help the client’s respiratory distress.
Category of Health Alteration–Respiratory; Integrated
Process–Diagnosis; Client Needs–Physiological Integrity,
Basic Care and Comfort; Cognitive Level–Analysis.
Content–Medical; Category of Health Alteration–
Respiratory; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
68. Correct answer 2: Surfactant therapy may be prescribed to reduce the surface tension of the alveoli.
This medication helps maintain open alveoli,
decreases the work of breathing, improves compliance,
and helps prevent atelectasis. Tridil is a coronary
vasodilator. Diuretics and NSAIDs are not routine
medications for ARDS. Content–Medical; Category of
Health Alteration–Drug Administration; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
SECTION THREE
Respiratory Disorders
70. The nurse is caring for the client diagnosed with
72. The client is suspected of having a PE. Which
ARDS who is on a ventilator. Which interventions should
the nurse implement? Select all that apply.
l 1. Assess the client’s level of consciousness.
l 2. Monitor the client’s urine output.
l 3. Perform passive range-of-motion (ROM) exercises.
l 4. Maintain intravenous fluids as ordered.
l 5. Place the client with the HOB flat.
diagnostic laboratory test confirms the diagnosis?
l 1. Plasma D-dimer test.
l 2. Arterial blood gases (ABGs).
l 3. Chest x-ray (CXR).
l 4. Pulmonary/ventilation perfusion scan.
Pulmonary Embolus
71. The client is diagnosed with a pulmonary embolus
(PE) and is on a heparin drip. The bag hanging is
20,000 units/500 D5W infusing at 20 mL/hr.
How many units of heparin is the client receiving
an hour?
Answer: ___________________
161
73. Which statement by the client would make the nurse
suspect the client has experienced a PE?
l 1. “I have pain in my calf muscle when I move
my foot.”
l 2. “My chest hurts and I feel like something bad is
going to happen.”
l 3. “I have chest pain that is radiating down my left arm.”
l 4. “I hear myself wheezing and I have a low-grade
fever.”
ANSWERS
70. Correct answer 1, 2, 3, 4: Altered level of conscious-
162
72. Correct answer 1: The plasma D-dimer test is highly
ness is the earliest sign of hypoxemia; urine output less
than 30 mL/hr indicates decreased cardiac output; the
client is at risk for complications of immobility and
fluid volume overload. The semi-Fowler position, not
the supine position, facilitates lung expansion and
reduces the workload of breathing. Content–Medical;
specific to the presence of a thrombus; an elevated
D dimer indicates a thrombus formation and lysis.
ABGs evaluate oxygenation level; a CXR shows
pulmonary infiltration; and a pulmonary/ventilation
scan is a radiological diagnostic test, not a laboratory
test. Content–Medical; Category of Health Alteration–
Category of Health Alteration–Respiratory; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
Respiratory; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Analysis.
71. Correct answer 800 units:
20,000 units !
L
"
500 mL ! 20 mL
400,000
Cross multiply and divide =
= 800
500
Content–Medical; Category of Health Alteration–Drug
Administration; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
73. Correct answer 2: The most common signs of a PE
are sudden onset of chest pain when taking a deep
breath, shortness of breath, and a feeling of impending
doom. Calf pain is a sign of a deep vein thrombosis,
which is a precursor to a PE, not a sign of one. Chest
pain radiating down the left arm is a sign of a
myocardial infarction, and wheezing and low-grade
fever may indicate pneumonia. Content–Medical;
Category of Health Alteration–Respiratory; Integrated
Process–Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level– Analysis.
SECTION THREE
Respiratory Disorders
163
74. The client diagnosed with a PE is in the intensive
76. The nurse is preparing to administer the oral
care department. Which assessment data would warrant
immediate intervention from the nurse?
l 1. The client’s ABGs are pH 7.36, PaO2 95, PaCO2 38,
HCO3 24.
l 2. The client’s telemetry exhibits multifocal premature
ventricular contractions (PVCs).
l 3. The client’s pulse oximeter reading is 96%.
l 4. The client’s urinary output for the 12-hour shift is
800 mL.
anticoagulant warfarin (Coumadin) to a client who has a
prothrombin time/partial thromboplastin time (PT/PTT)
of 32/39 and an International Normalized Ratio (INR)
of 3.8. What action should the nurse implement first?
l 1. Assess the client for abnormal bleeding.
l 2. Prepare to administer vitamin K (AquaMephyton).
l 3. Administer the medication as ordered.
l 4. Notify the HCP to obtain an order to decrease
the dose.
75. The client has just been diagnosed with a PE. Which
77. The nurse is completing the discharge teaching for a
intervention should the nurse implement?
l 1. Administer parenteral anticoagulants.
l 2. Assess the client’s bilateral popliteal pulses.
l 3. Prepare the client for a thoracentesis.
l 4. Bedrest with bathroom privileges.
client diagnosed with a PE. Which statement indicates
the client needs more teaching?
l 1. “I am going to use a soft-bristle toothbrush.”
l 2. “I will not go barefooted while taking my
medication.”
l 3. “I can take enteric-coated aspirin for my
headache.”
l 4. “I will wear a medic alert band at all times.”
ANSWERS
74. Correct answer 2: Multifocal PVCs are a potentially
life-threatening dysrhythmia; therefore, the nurse
should assess this client immediately. The ABGs and
pulse oximater reading are within normal limits,
and urine output more than 30 mL/hr would not
warrant immediate intervention by the nurse.
Content–Medical; Category of Health Alteration–
Respiratory; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
75. Correct answer 1: The intravenous anticoagulant
heparin should be administered immediately after
diagnosis of a PE. The pulses behind the knees
(popliteal pulses) would not need to be assessed by
the nurse. A thoracentesis is used to aspirate fluid
from the pleural space and is not a treatment of
choice for a PE. Strict bedrest reduces metabolic
demands and tissue needs for oxygen; therefore,
bathroom privileges would be denied. Content–
Medical; Category of Health Alteration–Respiratory;
Integrated Process–Implementation; Client Needs–Safe
Copyright © 2010 F.A. Davis Company
164
Effective Care Environment, Management of Care;
Cognitive Level–Application.
76. Correct answer 1: The normal INR is 2–3; the
client’s level is too high. The nurse should first assess
for abnormal bleeding and then obtain an order
from an HCP to either decrease the dose of warfarin
or to administer vitamin K, which is the antidote for
warfarin overdose. Content–Medical; Category of
Health Alteration–Respiratory; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.
77. Correct answer 3: Aspirin, enteric-coated or not, is
an antiplatelet, which may increase bleeding tendencies and should be avoided. The client needs more
teaching. Using a soft-bristle toothbrush, preventing
possible cuts or injuries, and wearing a medic alert
band indicate the client understands the discharge
teaching. Content–Medical; Category of Health
Alteration–Respiratory; Integrated Process–Evaluation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Synthesis.
SECTION THREE
Respiratory Disorders
165
78. The client diagnosed with a PE is being discharged.
80. The client is getting out of bed and becomes very
Which intervention should the nurse discuss with the
client?
l 1. Decrease fluid intake to 1 L a day.
l 2. Do not eat foods high in vitamin K.
l 3. Avoid being around large crowds.
l 4. Take pneumonia and flu vaccines.
anxious and has a feeling of impending doom. The nurse
thinks the client may be experiencing a PE. Which action
should the nurse implement first?
l 1. Administer oxygen 10 L via nasal cannula.
l 2. Place the client in high Fowler position.
l 3. Notify the client’s HCP.
l 4. Assess the client for a positive Homan sign.
79. The nurse is preparing to administer medications to
the following clients. Which medication would the nurse
question administering?
l 1. The oral coagulant warfarin (Coumadin) to the
client with an INR of 1.9.
l 2. A coronary vasodilator to the client with a digoxin
level of 1.3.
l 3. Hanging the heparin bag of a client with a
PT/PTT of 12.9/98.
l 4. The anticonvulsant medication to a client with a
dilantin level of 22.
Chest Trauma
81. The client is admitted to the ED with chest trauma.
Which signs/symptoms would the nurse expect to assess
that supports the diagnosis of pneumothorax?
l 1. Bronchovesicular lung sounds and friction rub.
l 2. Absent breath sounds and tachypnea.
l 3. Nasal flaring and lung consolidation.
l 4. Symmetrical chest expansion and bradypnea.
ANSWERS
78. Correct answer 2: The client will be discharged on
warfarin (Coumadin); the antidote for Coumadin is
vitamin K; therefore, the client should not eat foods
high in vitamin K. Increasing fluids will help prevent
the development of a deep vein thrombosis (DVT),
which is the most common cause of PE. The client
can have another DVT. Content–Medical; Category of
Health Alteration–Respiratory; Integrated Process–Planning; Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Synthesis.
79. Correct answer 3: A PTT of 98 is greater than
1.5–2 times the normal value, which puts the client at
risk for abnormal bleeding; therefore, the medication
should be questioned. Therapeutic PTT is 68–88, so
a value of 98 means the client is not clotting, and the
medication should be held. An INR of 2–3 is therapeutic; digoxin therapeutic level is 0.8–20, and therapeutic
dilantin level is 10–20. Content–Medical; Category of
Health Administration–Drug Administration; Integrated
Process–Assessment; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
166
80. Correct answer 2: Placing the client in high Fowler
position facilitates maximal lung expansion and
reduces venous return to the right side of the heart,
thus lowering pressures in the pulmonary vascular
system. Administering oxygen and notifying the
HCP would be appropriate but not prior to placing
the client in a high Fowler position. The client is
in distress; therefore do not assess for a positive
Homan sign first. Content–Medical; Category of
Health Alteration–Respiratory; Integrated Process–Implementation; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
81. Correct answer 2: Absent breath sounds, tachypnea,
and asymmetrical chest expansion would indicate a
pneumothorax. Lung consolidation occurs when
there is no air moving through the alveoli and occurs
in pneumonia; friction rub occurs with pericarditis.
Content–Medical; Category of Health Alteration–
Respiratory; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
SECTION THREE
Respiratory Disorders
167
82. The client had a right-sided chest tube inserted for a
84. The client has a right-sided chest tube. As the client
pneumothorax 3 days ago. Which action should the nurse
take first if there is no fluctuation (tidaling) in the water-seal
compartment?
l 1. Obtain an order for a chest x-ray.
l 2. Prepare for the removal of the chest tube.
l 3. Pre-medicate the client with an analgesic.
l 4. Assess the client’s right-sided lung sounds.
is getting out of the bed, the tube is accidentally pulled
out of the pleural space. Which action should the nurse
implement first?
l 1. Notify the HCP.
l 2. Request a new chest tube.
l 3. Place a vaseline gauze over the insertion site.
l 4. Tell the client to exhale forcefully.
83. The male client who has right-sided chest tubes asks
85. The client with a flail chest asks the nurse, “What is a
the UAP to help him go to the bathroom. Which situation
warrants immediate intervention from the nurse?
l 1. The UAP keeps the chest tube below the level of
the chest.
l 2. The UAP removes the Pleuravac from the wall
suction.
l 3. The UAP stands to the side and behind the client
when the client is ambulating.
l 4. The UAP clamps the chest tube closest to the
client’s chest.
tension pneumothorax? My doctor is worried about my
getting one.” Which statement is the nurse’s best response?
l 1. “It is an air-filled bleb on the lung that ruptures
spontaneously.”
l 2. “Air moves freely between your lungs and the
atmosphere.”
l 3. “There is air between your lung and chest lining
that can’t escape.”
l 4. “The air in your pleural space causes the trachea to
shift.”
ANSWERS
82. Correct answer 4: No fluctuation in the water seal
3 days after tube insertion may indicate the client’s
pneumothorax has resolved. Breath sounds over the
area would indicate re-expansion of the lung. Then
the nurse should contact the health-care provider for
a chest x-ray, medicate the client prior to removal of
the tube, and prepare for the removal of the tube.
Content–Medical; Category of Health Alteration–
Respiratory; Integrated Process–Implementation; Client
Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Application.
83. Correct answer 4: The chest tubes should never be
clamped because it may lead to a tension pneumothorax. Ambulating the client safely facilitates lung
ventilation. Drainage systems are portable and
should be kept lower than the chest to promote
drainage and prevent reflux. The chest tube system
can function due to gravity; it does not have to be
attached to suction. Content–Medical; Category of
Copyright © 2010 F.A. Davis Company
168
Health Alteration–Respiratory; Integrated Process–
Evaluation; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
84. Correct answer 4: The client should first exhale
forcefully to push air out of the pleural space. Then
the nurse can apply a Vaseline gauze, request a new
chest tube, and notify the HCP. Content–Medical;
Category of Health Alteration–Respiratory; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Reduction of Risk Potential; Cognitive
Level–Application.
85. Correct answer 3: This describes a tension pneumothorax; this is a medical emergency requiring
immediate intervention to preserve life. Option 4 is
called a mediastinal shift. Content–Medical; Category
of Health Alteration–Respiratory; Integrated Process–
Implementation; Client Needs–Health Promotion and
Maintenance; Cognitive Level–Application.
SECTION THREE
Respiratory Disorders
169
86. Which action should the nurse implement for the
88. The charge nurse is making client assignments on a
client with a hemothorax and a right-sided chest tube who
has excessive bubbling in the water seal compartment?
l 1. Pinch the chest tubing nearest the client.
l 2. Assess the tubing for any blood clots.
l 3. Milk the tubing proximal to distal.
l 4. Encourage the client to cough forcefully.
medical floor. Which client should the charge nurse assign
to the LPN?
l 1. The client with a pneumothorax who has a pulse
oximeter reading of 91%.
l 2. The client with a hemothorax who has hemoglobin
of 12 and hematocrit of 40%.
l 3. The client with chest tubes who has jugular vein
distention and B/P of 96/60.
l 4. The client with a flail chest who is having chest
tubes inserted.
87. The nurse is caring for a client with a right-sided
chest tube secondary to a hemothorax. Which interventions
should the nurse implement when caring for this client?
Select all that apply.
l 1. Place the client in a high Fowler position.
l 2. Document the amount of bloody drainage.
l 3. Empty the blood from the drainage compartment.
l 4. Secure a loop of drainage tubing to the sheet.
l 5. Observe the site for subcutaneous emphysema.
89. The alert and oriented client is diagnosed with a
spontaneous pneumothorax, and the HCP is scheduled to
insert a left-sided chest tube. Which intervention should
the nurse implement first?
l 1. Teach the client how to deep-breathe.
l 2. Obtain a signed informed consent form.
l 3. Assist the client into a side-lying position.
l 4. Open the chest tube insertion equipment.
ANSWERS
86. Correct answer 1: The nurse should pinch the chest
tube nearest the client to determine if the bubbling
stops. If the bubbling stops, the air leak is within the
client, which is an emergency. If the bubbling continues, the air leak is in the system, which is not an
emergency. Content–Medical; Category of Health
Alteration–Respiratory; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Application.
87. Correct answer 1, 2, 4, 5: The client should be in
a high-Fowler position to facilitate lung expansion.
The nurse should document the amount of drainage
every shift and loop the draining tubing to prevent
direct pressure on the chest tube. The nurse should
also observe the site for subcutaneous emphysema,
which is air under the skin, a common occurrence
after chest tube insertion. The PLEURAvac is a
closed system, and the blood should not be emptied
from the drainage compartment. Content–Medical;
Category of Health Alteration–Respiratory; Integrated
Copyright © 2010 F.A. Davis Company
170
Process–Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
88. Correct answer 2: This client is the most stable
because the hemoglobin and hematocrit levels are
within normal limits. A client with a low pulse
oximeter reading (91%), a jugular vein distention, or
a flail chest is unstable and should not be assigned to
an LPN. Content–Medical; Category of Health
Alteration–Management; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
89. Correct answer 2: Inserting a chest tube is an invasive procedure and requires informed consent; without a consent form this procedure cannot be done
on an alert and oriented client. Then the nurse could
also teach the client how to deep-breathe, assist the
client into the side-lying position, and open up the
equipment. Content–Medical; Category of Health
Alteration–Respiratory; Integrated Process–Planning;
Client Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Synthesis.
SECTION THREE
Respiratory Disorders
171
90. The client who is 2 days postoperative left
92. The nurse is administering medications to clients
pneumonectomy has an apical pulse (AP) of 128 and
B/P 92/60. Which intervention should the nurse implement?
l 1. Elevate the client’s head of the bed (HOB).
l 2. Assess the client’s incisional wound.
l 3. Administer a narcotic analgesic.
l 4. Decrease the client’s intravenous rate.
on a surgical unit. Which medication should the nurse
administer first?
l 1. The narcotic analgesic morphine IV to the client
with a hemothorax and pain of 8.
l 2. The aminoglycoside antibiotic vancomycin
intravenous piggyback (IVPB) to the client with a
gunshot wound to the chest.
l 3. The proton pump inhibitor pantoprazole
(Protonix) IVPB to the client who is NPO after
chest surgery.
l 4. The loop diuretic furosemide (Lasix) PO to the
client who is diagnosed with congestive heart
failure.
Management
91. The charge nurse is reviewing the morning laboratory
results. Which data should the charge nurse report to the
HCP via telephone?
l 1. The client who is 4 hours postoperative
pneumonectomy who has a white blood cell
(WBC) count of 9000 mm.
l 2. The client who has chest tubes secondary to a
hemothorax who has H&H of 9/20.
l 3. The client diagnosed with fractured ribs who has a
pulse oximeter reading of 98%.
l 4. The client with a flail chest who has ABGs of
pH 7.43, PaO2 90, PaCO2 43, HCO3 24.
ANSWERS
90. Correct answer 2: The client is exhibiting signs of
hypovolemia, and the nurse should determine the
cause and assess the incisional wound. Elevating the
HOB, administering narcotic analgesics, and
decreasing the intravenous rate would not help
identify the source or stop the bleeding. Content–
Medical; Category of Health Alteration–Respiratory;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Reduction of Risk Potential;
Cognitive Level–Analysis.
91. Correct answer 2: The client has a low H&H, and
the nurse should notify the HCP of this client’s
situation. All the other data are within normal
limits and would not require notifying the HCP.
Content–Medical; Category of Health Alteration–
Management: Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level: Analysis.
Copyright © 2010 F.A. Davis Company
172
92. Correct answer 1: The client who is in pain is priority
because pain is considered the fifth vital sign; none
of the other clients have life-threatening conditions
nor are their medications priority medications.
Content–Medical; Category of Health Alteration–Drug
Administration; Integrated Process–Planning; Client
Needs–Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Synthesis.
SECTION THREE
Respiratory Disorders
173
93. The charge nurse is making shift assignments to the
95. The client is diagnosed with laryngeal cancer and is
surgical staff, which consists of 2 RNs, 2 LPNs, and
2 UAPs. Which assignment would be most appropriate
by the charge nurse?
l 1. Instruct the RN to transcribe all the new HCP orders.
l 2. Delegate the UAP to assist the client who has been
discharged.
l 3. Assign the LPN to administer a unit of packed red
blood cells.
l 4. Request the LPN to complete the admission for a
new client.
scheduled for a laryngectomy. Which intervention would
be priority for the clinic nurse?
l 1. Recommend contacting the American Cancer
Society.
l 2. Refer the client to a speech therapist.
l 3. Order the client’s preoperative lab work.
l 4. Determine if the client has an advance directive
(AD).
94. The charge nurse is making assignments for the
surgical unit. Which client should be assigned to the new
graduate nurse?
l 1. The client who has a chest tube for a hemothorax
that is draining bright red blood.
l 2. The client who is 1 day postoperative
pneumonectomy with a temperature of 102.2°F.
l 3. The client with pneumonia who has bilateral
crackles and a productive cough.
l 4. The client who has a deep vein thrombosis and is
complaining of chest pain.
96. The HCP is angry and yelling in the nurse’s station
because the client diagnosed with reactive airway disease
has not had the stat chest x-ray ordered yesterday. Which
action should the female charge nurse implement first?
l 1. Contact the radiology department immediately.
l 2. Tell the HCP she will find out what has happened.
l 3. Tell the HCP to discuss the issue with x-ray
department.
l 4. Report the HCP’s behavior to the chief nursing
officer.
ANSWERS
93. Correct answer 2: The UAP can discharge a client
home. A unit secretary/ward clerk and an LPN can
transcribe orders; the RN should be assessing and caring for clients. An LPN cannot initiate a blood transfusion or assess the client. Content–Medical; Category of
Health Alteration–Management; Integrated Process–Planning; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
94. Correct answer 3: The client diagnosed with pneumonia would be expected to have bilateral crackles
and a productive cough; therefore this client should
be assigned to the new graduate nurse. Bleeding may
lead to hypovolemia; elevated temperature indicates
infection; and chest pain may be pulmonary embolus;
clients with these problems should be assigned to a
more experienced nurse. Content–Medical; Category
of Health Alteration–Management; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
174
95. Correct answer 2: The client will not be able to
speak after the removal of the larynx; therefore,
discussing an alternate communication technique
and eventual communication ability are the priorities. Referral to the American Cancer Society and
discussion about an AD may be appropriate, but
they are not priority over communication. Content–
Surgical; Category of Health Alteration–Respiratory;
Integrated Process–Planning; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
96. Correct answer 2: The charge nurse should immediately investigate why the chest x-ray was not done.
This may include contacting the radiology department
or having the HCP contact the radiology department.
If the HCP’s behavior continues to be inappropriate,
the chief nursing officer could be notified. Content–
Medical; Category of Health Alteration–Respiratory;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Reduction of Risk Potential;
Cognitive Level–Application.
SECTION THREE
97. The client diagnosed with terminal lung cancer who
Respiratory Disorders
175
99. The female nurse tells the male nurse, “I really think
is upset and crying tells the nurse, “I think they are
keeping something from me. I just want to know the
truth.” Which response by the nurse is an example of
the ethical principle of veracity?
l 1. “You are concerned because you think they are not
telling you the truth.”
l 2. “I know this is hard, but the truth is you have lung
cancer.”
l 3. “You should ask your doctor for the truth. You
have a right to know.”
l 4. “Who do you think is keeping something from you?”
you look sexy when you wear that white scrub suit.” The
male nurse thinks this comment is sexual harassment.
Which action should the male nurse implement first?
l 1. Document the comment in writing and file a
formal grievance.
l 2. Tell the female nurse this makes him feel very
uncomfortable.
l 3. Notify the clinical manager of the sexual
harassment.
l 4. Discuss the female nurse’s behavior with the
hospital lawyer.
98. Which client should the nurse on the medical unit
100. The nurse is caring for a male client diagnosed with
assess first after receiving the morning shift report?
l 1. The client diagnosed with reactive airway disease
who is short of breath and wheezing.
l 2. The client diagnosed with COPD who is in the
orthopneic position.
l 3. The client diagnosed with pneumonia whose pulse
oximeter reading is 95%.
l 4. The client diagnosed with DVT whose calf is
edematous and reddened.
lung cancer who has a Do Not Resuscitate (DNR) order
and has Cheyne-Stokes respirations. The client’s wife is
at the bedside. Which intervention should the nurse
implement first?
l 1. Notify the nurse’s desk of the impending death.
l 2. Remain quietly at the client’s bedside.
l 3. Make the client as comfortable as possible.
l 4. Ask the wife if she would like to stay at the
bedside.
ANSWERS
97. Correct answer 2: The ethical principle of veracity is
the duty to tell the truth; telling the client about the
diagnosis of cancer is telling the truth. A therapeutic
response (option 1), passing the buck (option 3),
and attempting to obtain more information about
the situation (option 4) is not telling the truth.
Content–Fundamentals; Category of Health Alteration–
Respiratory; Integrated Process–Implementation; Client
Needs–Psychosocial Integrity; Cognitive Level–Application.
98. Correct answer 1: The client with reactive airway
disease is having an acute exacerbation and requires
immediate attention; therefore, this client should be
seen first. The orthopneic position is expected in a
client with COPD; a pulse oximeter reading greater
than 93% is normal; and a client with a DVT would
be expected to have an edematous and reddened calf.
Content–Medical; Category of Health Alteration–
Management; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
176
99. Correct answer 2: The first action when an employee thinks he/she is being sexually harassed is
to directly confront the harasser with the allegation
of sexual harassment. If it happens again, the male
nurse should notify the clinical manager and then
file a formal grievance. Then, if necessary, it may
need to be reported to an attorney. Content–
Fundamentals; Category of Health Alteration–
Management; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
100. Correct answer 4: The nurse should first determine
if the wife wants to be at her husband’s bedside
when he dies. Then the nurse should make the
client comfortable, remain at the bedside, and
notify the nurse’s desk so that another nurse can
care for the nurse’s clients until the client dies.
Content–Medical; Category of Health Alteration–
Respiratory; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
SECTION FOUR
Gastrointestinal Disorders
177
SECTION FOUR
Gastrointestinal Disorders
179
Inflammatory Bowel Disease
1. The nurse is admitting a client diagnosed with regional
3. The client diagnosed with ulcerative colitis is 3 days
enteritis (Crohn disease). Which data would the nurse
expect the client to exhibit?
l 1. The client has 10–20 loose stools a day.
l 2. The client has left lower quadrant pain and
low-grade fever.
l 3. The client complains of abdominal pain when
eating.
l 4. The client has an increased abdominal girth.
postoperative creation of an ileostomy. Which information
should the nurse discuss with the client?
l 1. Demonstrate how to perform colostomy irrigations.
l 2. Explain that the stoma site should be pink and moist.
l 3. Refer the client to the dietitian to discuss foods on
a high-fiber diet.
l 4. Tell the client that with time an ostomy appliance
may not be needed.
2. The client diagnosed with an acute exacerbation of
4. The client is diagnosed with an acute exacerbation of
regional enteritis (Crohn disease) is prescribed total
parenteral nutrition (TPN). Which intervention should
the nurse implement?
l 1. Insert an 18-gauge needle in the client’s forearm.
l 2. Monitor the client’s urine for ketones.
l 3. Check the TPN bag with the prescription.
l 4. Encourage the client to eat a low-residue diet.
inflammatory bowel disease (IBD). Which statement
indicates the client needs more discharge teaching?
l 1. “When I quit taking my prednisone I will taper it
off slowly.”
l 2. “I will not drink any caffeinated or alcoholic
beverages.”
l 3. “I am going to call the Ileitis and Colitis
Foundation.”
l 4. “I am so glad I can eat anything I want because
I am not NPO.”
ANSWERS
1. Correct answer 3: Peristalsis causes the ulcerated,
inflamed area to contract, causing pain. If the client
does not eat, then there is no pain. The abdomen does
not increase in size with Crohn disease. Content–Medical;
Category of Health Alteration–Gastrointestinal; Integrated Process–Assessment; Client Needs–Physiological
Adaptation, Physiological Integrity; Cognitive Level–
Analysis.
2. Correct answer 3: The TPN bag should be checked
to make sure the prescribed nutrients are included.
The TPN must be administered via a central line, and
glucometer checks are necessary because of the high
glucose level of the TPN. The client on TPN is nothing by mouth (NPO). Content–Medical; Category of
Health Alteration–Gastrointestinal; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive Level–
Synthesis.
Copyright © 2010 F.A. Davis Company
180
3. Correct answer 2: The stoma site should be pink and
moist. A purple stoma site indicates necrosis and the
health-care provider should be notified. An ileostomy
will have continuous drainage and will need an ostomy
appliance at all times. An ileostomy is not irrigated.
A high-fiber diet is not prescribed for a client with
an ileostomy. Content–Medical; Category of Health
Alteration–Gastrointestinal; Integrated Process–Planning;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Synthesis.
4. Correct answer 4: The client should eat a lowresidue, low-fat, high-protein, and high-calorie diet
and avoid foods that cause diarrhea. The client should
avoid caffeinated beverages, pepper, alcohol, and
milk products. Content–Medical; Category of Health
Alteration–Gastrointestinal; Integrated Process–Planning;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Synthesis.
SECTION FOUR
Gastrointestinal Disorders
181
5. The nurse is caring for a client diagnosed with an
7. The male client diagnosed with regional enteritis
acute exacerbation of ulcerative colitis. Which priority
intervention should the nurse implement?
l 1. Ensure privacy when the client is having a bowel
movement.
l 2. Provide perianal care to help excoriation of the
client’s buttocks.
l 3. Allow the client to ventilate feelings of powerless
over disease process.
l 4. Instruct the unlicensed assistive personnel (UAP)
to obtain the client’s weight daily.
(Crohn disease) calls the clinic nurse and tells the nurse,
“I have been having abdominal pain and some diarrhea.”
Which intervention should the nurse implement first?
l 1. Make an appointment for the client to be seen in
the clinic today.
l 2. Tell the client to rest the bowel by not eating or
drinking anything.
l 3. Encourage the client to write down all the foods he
ate during the last 24 hours.
l 4. Ask the client if he has experienced any type of leg
cramps in the last 8 hours.
6. The nurse is caring for a client diagnosed with an
acute exacerbation of ulcerative colitis. Which data would
warrant immediate intervention by the nurse?
l 1. The client’s serum potassium level is 4.2 mEq/L.
l 2. The client’s serum sodium level is 138 mEq/L.
l 3. The client’s arterial blood gases (ABGs) are
pH 7.33, PaO2 95, PaCO2 38, HCO3 20.
l 4. The client’s hemoglobin/hematocrit is 12/40%.
8. The nurse and the UAP are caring for clients on a
medical/surgical unit. Which task would be most
appropriate for the nurse to delegate to the UAP?
l 1. Transfer the client to the intensive care unit via the
stretcher.
l 2. Assist the client who is receiving TPN to eat.
l 3. Empty the bedside commode of the client who has
loose runny stools.
l 4. Check the client who is complaining of abdominal
cramping.
ANSWERS
5. Correct answer 2: The client may have up to
10–20 stools a day; therefore, impaired skin integrity
of the perianal care is priority for the client. Daily
weights, privacy, and ventilating feelings are not
priority over a physiological problem. Content–
Medical; Category of Health Alteration–Gastrointestinal;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Evaluation.
6. Correct answer 3: These ABGs indicate metabolic
182
7. Correct answer 2: The nurse should first instruct the
client to rest the bowel. Making an appointment and a
24-hour food diary should be implemented but not
prior to resting the bowel. Leg cramps may indicate
hypokalemia, but “some diarrhea” would not cause
hypokalemia. Content–Medical; Category of Health
Alteration–Gastrointestinal; Integrated Process–Evaluation;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Evaluation.
8. Correct answer 3: The UAP can empty the client’s
acidosis, which is caused by excessive diarrhea; this
client requires immediate intervention. The potassium,
sodium, hemoglobin, and hematocrit levels are within
normal limits (WNLs). Content–Medical; Category of
bedside commode. A client being transferred to the
intensive care unit is not stable; the client on TPN
should have nothing by mouth; and the UAP cannot
assess a client who has abdominal cramping. Content–
Health Alteration–Gastrointestinal; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
Medical; Category of Health Alteration–Gastrointestinal;
Integrated Process–Planning; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
SECTION FOUR
Gastrointestinal Disorders
183
Gastroesophageal Reflux
Disease (GERD)
9. The nurse is preparing to hang the third bag of TPN
for the client diagnosed with an acute exacerbation of
regional enteritis (Crohn disease). The third bag is not
ready, and the second bag is empty. Which action should
the nurse implement?
l 1. Hang dextrose 10% at the same rate as the TPN.
l 2. Administer normal saline at keep open vein rate.
l 3. Stop the TPN and wait for the third bag to come
to the unit.
l 4. Notify the HCP of the situation.
10. The client diagnosed with an acute exacerbation of
ulcerative colitis is admitted to the medical unit. Which
HCP’s order would the nurse question?
l 1. Prepare the client for a colonoscopy in the morning.
l 2. Administer Lomotil, an antidiarrheal, once after
each loose stool up to 8 in 24 hours.
l 3. Total parenteral nutrition (TPN) at 83 mL/hr via a
subclavian line.
l 4. Administer the steroid SoluCortef intravenous
piggyback (IVPB) every 12 hours.
11. The client in the clinic tells the nurse that he has
been experiencing “heartburn.” Which intervention
should the nurse implement first?
l 1. Measure the client’s abdominal girth.
l 2. Schedule the client for gastrointestinal x-rays.
l 3. Determine alleviating and aggravating factors.
l 4. Perform an electrocardiogram.
12. The nurse caring for a client diagnosed with GERD
writes the client problem of “behavior modification.”
Which intervention should be included for this problem?
l 1. Instruct the client to bend with knees and not to
stoop over.
l 2. Encourage the client to decrease the amount of
smoking.
l 3. Instruct the client to take OTC medication,
specifically proton pump inhibitors.
l 4. Discuss the need to attend Al-Anon to learn to quit
drinking.
ANSWERS
9. Correct answer 1: The nurse should hang dextrose
10% (D10) at the same rate to prevent the client
from developing hypoglycemia. Content–Medical;
Category of Health Alteration Drug–Administration;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Pharmacological and Parenteral
Therapies; Cognitive Level–Application.
10. Correct answer 1: The client should not have invasive
procedures in the colon during an acute exacerbation.
Antidiarrheals, steroids, and resting the bowel are
orders the nurse would expect for the client with an
acute exacerbation of ulcerative colitis. Content–
Medical; Category of Health Alteration–Gastrointestinal;
Integrated Process–Planning; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
11. Correct answer 3: Determining alleviating and
aggravating factors is part of assessing the client.
Most clients with “heartburn” have gastroesophageal
Copyright © 2010 F.A. Davis Company
184
reflux disease and have been self-medicating with
over-the-counter medications prior to seeking advice
from health-care provider. It is important to know
what the client has been using to treat the problem.
Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
12. Correct answer 1: The client should bend with the
knee to prevent intra-abdominal pressure. Behavior
modification is changing one’s behavior. The client
should be encouraged to quit smoking completely.
Drinking alcohol is not a cause of GERD. Content–
Medical; Category of Health Alteration–Gastrointestinal;
Integrated Process–Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive
Level–Synthesis.
Gastrointestinal Disorders
SECTION FOUR
13. The nurse is preparing a client diagnosed with GERD
l
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185
3. A large pepperoni pizza, green salad, and coffee.
4. One piece of baked fish, buttered carrots, and a
for discharge following an esophagogastroduodenoscopy.
Which statement indicates the client needs further teaching
concerning the discharge instructions?
l 1. “I should not eat until I can swallow water without
gagging.”
l 2. “After I eat, I should sit up for several hours before
I go to bed.”
l 3. “Stomach contents can cause my esophagus to have
an ulcer.”
l 4. “I can drink orange juice and tomatoes whenever
I feel like it.”
Which interventions should the nurse implement?
l 1. Have the client lie prone in bed when sleeping.
l 2. Administer nonsteroidal anti-inflammatory drugs
(NSAIDs) for pain.
l 3. Encourage the client to drink 8–10 glasses of water
each day.
l 4. Place the head of the bed (HOB) on 6-inch blocks.
14. The nurse is discussing dietary modifications with
16. The nurse is administering morning medications at
a client diagnosed with lower esophageal sphincter
dysfunction. Which menu indicates the client understands
the nurse’s instructions?
l 1. Tortillas with hot sauce, three-bean-and-cheese
enchiladas, and tea.
l 2. Four pieces of fried chicken, mashed potatoes with
gravy, and water.
cup of pudding for a snack.
15. The nurse is caring for a client diagnosed with GERD.
0730. Which medication should the nurse administer first?
l 1. The mucosal barrier agent to a client who is going
home this morning.
l 2. The proton pump inhibitor to a client diagnosed
with peptic ulcer disease.
l 3. The non-narcotic analgesic to a client complaining
of a mild headache.
l 4. The histamine receptor antagonist to a client
scheduled for an endoscopy.
ANSWERS
13. Correct answer 4: Orange and tomato juices are
acidic; the client diagnosed with GERD should avoid
acidic foods until the esophagus has had a chance to
heal. Content–Surgical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Evaluation; Client
Needs–Physiological Integrity, Reduction of Risk Potential;
Cognitive Level–Evaluation.
14. Correct answer 4: Clients with lower esophageal
sphincter dysfunction should eat small frequent
meals and limit fluids with the meals to prevent
reflux from a distended stomach. The client should
avoid spicy or acidic or fried foods and foods or
drinks that contain caffeine. Content–Medical; Category of Health Alteration–Gastrointestinal; Integrated
Process–Evaluation; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive Level–
Evaluation.
Copyright © 2010 F.A. Davis Company
186
15. Correct answer 4: Elevating the HOB allows
gravity to work to prevent reflux. NSAIDs inhibit
prostaglandin synthesis in the stomach, and this, in
turn, puts the client at increased risk for developing
gastric ulcers. The client is already experiencing
gastric acid difficulty. Water increases the amount
of substances in the stomach and increases GERD.
Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
16. Correct answer 1: Mucosal barrier agents (Carafate)
must be administered on an empty stomach if the
medication is going to coat the mucosa and not the
food the client has eaten. Content–Medical; Category
of Health Alteration–Drug Administration; Integrated
Process–Planning; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive Level–
Evaluation.
Gastrointestinal Disorders
SECTION FOUR
17. The nurse in the operating suite is preparing a male
client diagnosed with GERD for surgery. Which data
would require the nurse to call a time out?
l 1. The client marked the right upper quadrant as the
operative site.
l 2. The client’s abdominal x-ray indicates the client has
a hiatal hernia.
l 3. The client’s WBC count is 7000 mg/dL.
l 4. The client’s hemoglobin is 13.8 mg/dL.
18. The charge nurse is making assignments. Staffing
includes a registered nurse (RN) with 5 years of
medical-surgical experience, a newly graduated RN,
and two UAPs. Which client should be assigned to the
new graduate nurse?
l 1. The client diagnosed with lower esophageal
dysfunction who has changes noted on an
electrocardiogram (ECG).
l 2. The client diagnosed with Barrett esophagitis
who is scheduled to have an endoscopy this
morning.
l
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187
3. The client diagnosed with GERD who has wheezes
in all lobes.
4. The client who is 3-days postoperative hiatal hernia
who has a temperature of 101.2°F.
19. The home health nurse is caring for an obese adult
client. Which statement made by the client would indicate
to the nurse that the client may be experiencing GERD?
l 1. “My abdomen hurts if I bend over too much.”
l 2. “My spouse won’t sleep with me because I snore.”
l 3. “I take Prilosec over-the-counter every day.”
l 4. “I drink several soft drinks every day.”
20. The nurse is performing an admission assessment
on a client diagnosed with GERD. Which signs and
symptoms would indicate GERD?
l 1. Pyrosis, water brash, and flatulence.
l 2. Weight loss, dysrthymias, hernia, and diarrhea.
l 3. Decreased abdominal fat, proteinuria, and
constipation.
l 4. Midepigastric positive H. pylori test and melena.
ANSWERS
17. Correct answer 1: A hiatal hernia is a problem
between the esophagus and the stomach in the left
upper quadrant of the abdomen, not the right upper
quadrant. Time out procedures are called when what
the client understands he/she consented to and what
the health-care team understands are not the same.
Content–Surgical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
18. Correct answer 2: Barrett esophagitis is a complication of GERD. A new graduate should be capable of
preparing a client for an endoscopy procedure. The
signs/symptoms in the other clients could indicate
an undiagnosed problem. Content–Medical; Category
of Health Alteration–Gastrointestinal; Integrated
Process–Planning; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive Level–
Synthesis.
Copyright © 2010 F.A. Davis Company
188
19. Correct answer 3: Clients self-medicate for problems such as GERD. If the Prilosec relieves the
client’s symptoms, then the client probably does have
some amount of reflux occurring. Content–Medical;
Category of Health Alteration–Gastrointestinal; Integrated Process–Assessment; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive
Level–Analysis.
20. Correct answer 1: Pyrosis is heartburn; water brash
is the feeling of saliva secretion as a result of reflux;
and flatulence is gas. All are symptoms of GERD.
Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
SECTION FOUR
Gastrointestinal Disorders
189
Peptic Ulcer Disease
21. The nurse is admitting a client diagnosed with rule
23. The nurse in the intensive care unit (ICU) is preparing
out (R/O) peptic ulcer disease. Which statement by the
client supports the diagnosis of a gastric ulcer?
l 1. “I have bright red rectal bleeding after a bowel
movement.”
l 2. “If I lie down after eating a meal, I get a burning in
my chest.”
l 3. “After I eat a big meal, I get pain in my right side
so bad I double over.”
l 4. “I get pain in my stomach about 30 minutes after
I eat, so I don’t eat much.”
to hang a daily continuous infusion of the histamine-2
blocker ranitidine (Zantac) for a client on a ventilator. The
medication is mixed in 100 mL of normal saline. At which
rate should the nurse set the pump?
22. The client has been seen by an HCP in an outpatient
clinic, and a presumptive diagnosis of peptic ulcer disease
was made. Which diagnostic test confirms this diagnosis?
l 1. Esophagogastroduodenoscopy (EGD).
l 2. Magnetic resonance imaging (MRI).
l 3. Fecal occult blood test.
l 4. Gastric acid stimulation.
Answer: ____________________
24. The charge nurse observes the primary nurse assessing
a client diagnosed with peptic ulcer disease. Which action
by the primary nurse warrants immediate intervention by
the charge nurse?
l 1. The nurse auscultates the client’s bowel sounds in
all four quadrants.
l 2. The nurse begins by palpating the abdominal area
for tenderness.
l 3. The nurse percusses the abdominal borders to
identify organs.
l 4. The nurse assesses the non-tender area progressing
to the tender area.
ANSWERS
21. Correct answer 4: The pain associated with a gastric
ulcer usually occurs 30–60 minutes after eating, and
the client experiences no pain at night. A duodenal
ulcer has pain during the night that is often relieved
by eating food. Bright red blood would indicate
hemorrhoids; burning in the chest would indicate
GERD; and right-sided pain would indicate gallbladder problems. Content–Medical; Category of
Health Alteration–Gastrointestinal; Integrated Process–
Evaluation; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Evaluation.
22. Correct answer 1: The EGD is an invasive diagnostic test that visualizes the esophagus and stomach.
This test accurately diagnoses an ulcer and evaluates
the effectiveness of the client’s treatment. Cultures
and biopsies of suspicious tissue can be made at the
time of the procedure. Content–Medical; Category of
Health Alteration–Gastrointestinal; Integrated Process–
Planning; Client Needs–Physiological Integrity, Reduction of Risk Potential; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
190
23. Correct answer 4 mL/hr: The medication cannot be
allowed to hang for more than 24 hours. 100 mL
divided by 24 = 4.16 mL/hr, rounded to 4 mL/hr.
Content–Medical; Category of Health Alteration–Drug
Administration; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Application.
24. Correct answer 2: Auscultation should be used
prior to palpation or percussion when assessing the
abdomen. If the nurse manipulates the abdomen,
the bowel sounds can be altered, giving false information. Palpation gives good information that the
nurse needs to collect but if done prior to auscultation, the sounds will be altered. Content–Medical;
Category of Health Alteration–Gastrointestinal; Integrated Process–Assessment; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Analysis.
SECTION FOUR
Gastrointestinal Disorders
191
25. The nurse is planning the care of a client diagnosed
27. The clinic nurse is planning the care of a client
with peptic ulcer disease admitted into the hospital. The
client is complaining of midepigastric pain and has a
hemoglobin of 9.2 mg/dL. Which client problem is
priority?
l 1. Alteration in bowel elimination.
l 2. Knowledge deficit.
l 3. Inability to cope.
l 4. Risk for hemorrhage.
diagnosed with peptic ulcer disease. Which is an expected
short-term outcome for the client?
l 1. The client’s pain decreases by 3–4 points 30 minutes
after the NSAID is given.
l 2. The client will maintain lifestyle changes of
decreasing stress for 1 month.
l 3. The client will not have signs and symptoms of
hemoptysis within 1 week.
l 4. The client will take antacids before each meal and
at bedtime.
26. The client has been admitted to the emergency
department vomiting coffee-ground emesis. The client is
pale and clammy. Which intervention should the nurse
implement first?
l 1. Perform a complete head-to-toe assessment.
l 2. Take the client’s pulse and blood pressure.
l 3. Start an intravenous (IV) line with an 18-gauge
catheter.
l 4. Request a stat type-and-crossmatch.
28. The nurse has been assigned to care for a client
diagnosed with peptic ulcer disease. Which assessment
data require further intervention?
l 1. Bowel sounds auscultated 15 times in 1 minute.
l 2. A positive H. pylori laboratory report.
l 3. Pulse 96, respirations 22, and blood pressure 104/79.
l 4. The nurse notes red drainage on a tissue at the
bedside.
ANSWERS
25. Correct answer 4: Physiological problems are priority, and hemorrhage is a greater priority than bowel
elimination. Content–Medical; Category of Health
Alteration–Gastrointestinal; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
26. Correct answer 3: This client is in hypovolemic
shock, and the nurse must intervene to support the
client’s cardiovascular status by starting an IV line.
Vital signs, assessment, and ordering lab work can
be done after starting an IV line. Remember, “If in
distress, do not assess.” Content–Medical; Category
of Health Alteration–Gastrointestinal; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Evaluation.
Copyright © 2010 F.A. Davis Company
192
27. Correct answer 2: Maintaining lifestyle changes
such as diet and stress reduction indicate that the
client is complying with the medical modalities.
Many clients with bleeding ulcers have recurrence of
the bleeding. The goal of treatment is to prevent this
and other complications. The client is taught not
to take NSAIDs. Content–Medical; Category of Health
Alteration–Gastrointestinal; Integrated Process–
Diagnosis; Client Needs–Health Promotion and
Maintenance; Cognitive Level–Analysis.
28. Correct answer 4: The most common “red drainage”
is blood. The nurse should assess the client for bleeding. Normal bowel sounds are 5–35 in a minute. The
client’s pulse and blood pressure are still within normal
range. Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management of
Care; Cognitive Level–Analysis.
SECTION FOUR
Gastrointestinal Disorders
193
Colorectal Disease
29. Which medication should the nurse question
31. The nurse is discussing information about colon
administering to the 28-year-old female client diagnosed
with peptic ulcer disease?
l 1. Misoprostol, (Cytotec), a prostaglandin E analog.
l 2. Prilosec, a proton pump inhibitor.
l 3. Flagyl, an antimicrobial.
l 4. Bismuth (Pepto Bismol), an antibiotic.
cancer to a 23-year-old client with a family history of
colorectal cancer. Which statement indicates the client
needs more teaching concerning the colorectal cancer?
l 1. “I should drink at least 3 L of water a day.”
l 2. “I need to eat a diet that is high in fiber and
low in fat.”
l 3. “I will take a multiple vitamin with iron every day.”
l 4. “I should try and have a least one bowel
movement a day.”
30. The nurse is assessing a client diagnosed with peptic
ulcer disease and notes a painful hard rigid abdomen.
Which intervention should the nurse implement first?
l 1. Administer a narcotic analgesic intravenously.
l 2. Rule out complications and check the client’s
armband.
l 3. Notify the HCP immediately.
l 4. Reassess the client in 1–2 hours.
32. The nurse is caring for a client who is 1 day
postoperative abdominal perineal resection for cancer
of the colon. Which intervention(s) should the nurse
implement? Select all that apply.
l 1. Irrigate the sigmoid colostomy in the morning.
l 2. Assess the client’s rectal dressing.
l 3. Maintain the suprapubic catheter.
l 4. Check the client’s vital signs every 4 hours.
l 5. Place the client in semi-Fowler position.
ANSWERS
29. Correct answer 1: Cytotec is listed as category X.
This client is of childbearing age. The nurse must
determine if the client is or could become pregnant.
Content–Medical; Category of Health Alteration–Drug
Administration; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Application.
30. Correct answer 3: A hard, rigid abdomen indicates
an inflammation of the peritoneum, a complication
of a perforated ulcer. The nurse must notify the HCP
and not mask symptoms by medicating the client.
Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Reduction for Risk
Potential; Cognitive Level–Application.
31. Correct answer 3: Taking a multivitamin with iron
will not affect the chances of developing colon
cancer. The longer the transit time (the time from
ingestion of the food to the elimination of the waste
Copyright © 2010 F.A. Davis Company
194
products), the greater the chance of developing
cancer of the colon. Therefore, the client should
prevent constipation by increasing fluids, by eating a
high-fiber diet, and by having a daily bowel movement.
Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Evaluation; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Evaluation.
32. Correct answer 2, 4, 5: Assessing the rectal dressing,
checking vital signs, and placing the client in a semiFowler position (upright position causes pressure on
the perineum) are all interventions the nurse should
implement. The client would have an indwelling
catheter, not a suprapubic catheter, and the
colostomy would not be irrigated for several days
after the surgery. Content–Surgical; Category of Health
Alteration–Gastrointestinal; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
SECTION FOUR
Gastrointestinal Disorders
195
33. The client who has had an abdominal perineal
35. The nurse is preparing to hang a new bag of total
resection with a creation of a sigmoid colostomy is being
discharged. Which discharge information should the
nurse discuss with the client?
l 1. Instruct the client to notify the HCP if the stoma
is pink.
l 2. Tell the client to irrigate the colostomy with a Fleet
enema.
l 3. Encourage the client to look at the stoma site in a
mirror.
l 4. Recommend the client empty the pouch when it is
75% full.
parental nutrition for a client who has had an abdominal
perineal resection. The bag has 1000 mL of 50% dextrose,
500 mL of amino acids, 200 mL of lipids, 10 mL of
trace elements, 20 mL of multivitamins, and 20 mL of
potassium chloride. The bag is to infuse at a 24 hour rate.
At what rate should the nurse set the pump?
34. The client with a new colostomy is being discharged.
Which statement made by the client indicates the client
understands the teaching?
l 1. “I should use spirit of peppermint to help with the
fecal odor.”
l 2. “I should drink only liquids until the colostomy
starts to work.”
l 3. “I should take a tub bath for at least 4–6 weeks.”
l 4. “I should eat a low-residue diet because I have a
colostomy.”
Answer ____________________
36. The nurse is caring for clients in an outpatient clinic.
Which information should the nurse teach regarding the
American Cancer Society’s recommendations for the early
detection of colon cancer?
l 1. A carcinoembryonic antigen (CEA) serum level
every 2 years.
l 2. A rectal digital examination every year after age 40.
l 3. A colonoscopy every year after age 50.
l 4. A stool blood test every year at physical examinations
after age 21.
ANSWERS
33. Correct answer 3: Looking in the mirror allows the
client to be sure there is no irritation or redness
around the site and that the stoma is pink. The
colostomy should be irrigated with 500–750 mL tap
water, not with a Fleet enema, and the pouch should
be emptied when it is 1⁄3–1⁄2 full to prevent the contents from becoming too heavy for the seal to hold
and leakage occurring. Content–Surgical; Category
of Health Alteration–Gastrointestinal; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
34. Correct answer 1: The client can use spirit of peppermint or commercially prepared deodorants to
help with the odor, which can be very embarrassing
to the client. The client should be on a regular diet,
and until the incision is completely healed the client
should not sit in bath water because of the potential
contamination of the wound by the bath water.
Content–Surgical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Planning; Client
Copyright © 2010 F.A. Davis Company
196
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Synthesis.
35. Correct answer 73 mL/hr: 1000 + 500 + 200 +
10 + 20 + 20 = 1750 mL per 24 hours; 1750
divided by 24 = 72.9 = 73 mL/hr. This should be
rounded to the nearest whole number to set the
pump. Content–Medical; Category of Health Alter-
ation–Drug Administration; Integrated Process–Implementation; Client Needs–Physiological Integrity, Pharmacological and Parenteral Therapies; Cognitive
Level–Application.
36. Correct answer 2: The American Cancer Society
recommends a rectal digital exam every year after
age 40, a colonoscopy every 5 years after age 50, and
a stool blood test every year after age 50. A CEA is a
tumor marker used to evaluate the effectiveness of
chemotherapy, not diagnosis. Content–Medical;
Category of Health Alteration–Oncology; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
SECTION FOUR
Gastrointestinal Disorders
197
37. The nurse writes a psychosocial problem of “risk for
39. The nurse is preparing the client for a colonoscopy.
ineffective coping related to a new colostomy.” Which
intervention should the nurse implement?
l 1. Recommend the client complete a durable power
of attorney for health care.
l 2. Ensure that the client and significant other are able
to change the ostomy pouch.
l 3. Discuss the importance of eating a high-fiber diet
to prevent constipation.
l 4. Refer the client to the American Cancer Society
ostomate support group.
Which statement indicates the client understands the
nurse’s teaching?
l 1. “I do not have to sign a permit for this procedure.”
l 2. “I cannot eat or drink anything after midnight.”
l 3. “I need to eat a low-residue diet 24 hours before
the test.”
l 4. “I should drink a clear liquid diet the morning of
the test.”
38. Which sign/symptom would make the nurse suspect
the client may have colon cancer?
l 1. The client has one soft brown stool every morning.
l 2. The client reports having clay-colored stools.
l 3. The client saw blood in the commode after a bowel
movement.
l 4. The client reported the stool was fatty-looking.
40. The nurse is demonstrating how to irrigate a sigmoid
colostomy to the client who was diagnosed with colon
cancer. Which interventions should the nurse implement?
Rank in order of performance.
l 1. Cleanse the stomal site with mild soap and water.
l 2. Wait 30–45 minutes for the stool to evacuate the
bowel.
l 3. Remove the ostomy drainage bag from the abdomen.
l 4. Insert the enema cone into the stoma site.
l 5. Allow 500–750 mL tap water to enter stoma.
ANSWERS
37. Correct answer 4: A support group provides the
client with help after discharge from the hospital.
The group can support the client emotionally and
provide information on how to live with an ostomy.
A durable power of attorney, changing the pouch,
and high-fiber diet do not address psychosocial issues.
Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Implementation;
Client Needs–Psychosocial Integrity; Cognitive
Level–Application.
38. Correct answer 3: Rectal bleeding and change of
bowel habits are signs of colon cancer. One brown
soft stool is normal for most individuals; clay-colored
stool indicates liver failure; and fatty-looking stool
is steatorrhea. Content–Medical; Category of Health
Alteration–Gastrointestinal; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
198
39. Correct answer 2: Along with a bowel preparation,
the client must have nothing by mouth prior to the
procedure to ensure the colon is empty of stool. A
permit must be signed for an invasive procedure, and
the client is on a liquid diet 24 hours prior to test.
Content–Surgical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Evaluation;
Client Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Evaluation.
40. Correct answer 3, 4, 5, 2, 1: The client should first
remove the drainage bag, insert the enema cone, and
allow water to enter the stoma; there will be an
initial gush of water because the stoma does not
have a sphincter. Then the client should wait for
30–45 minutes for all stool to be evacuated. Then,
the stoma site should be cleansed and a new ostomy
bag placed in position. Content–Medical; Category of
Health Alteration–Gastrointestinal; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
SECTION FOUR
Gastrointestinal Disorders
199
Diverticulosis/Diverticulitis
41. The nurse is caring for a client diagnosed with
43. The client is diagnosed with acute diverticulitis.
diverticulosis. Which instruction should the nurse discuss
with the client?
l 1. Discuss the need to eat a low-residue diet.
l 2. Tell the client to drink at least 3000 mL water a day.
l 3. Encourage the client to walk at least once a week.
l 4. Explain the importance of sitting up after meals.
Which data would warrant immediate intervention by
the nurse?
l 1. The client is having left lower quadrant pain.
l 2. The client has an elevated temperature.
l 3. The client has hypoactive bowel sounds.
l 4. The client’s abdomen is soft and tender.
42. The client diagnosed with acute diverticulitis is
44. The client diagnosed with acute diverticulitis has
admitted to the medical unit. Which intervention should
the nurse implement first?
l 1. Administer an intravenous narcotic analgesic.
l 2. Insert a 20-gauge angiocath in the distal forearm.
l 3. Ensure the client is maintained on NPO status.
l 4. Administer intravenous antibiotic therapy.
green bile draining from the nasogastric (N/G) tube.
Which intervention should the nurse implement?
l 1. Document the finding in the client’s chart.
l 2. Irrigate the N/G tube with sterile normal saline.
l 3. Notify the client’s HCP.
l 4. Increase the client’s intravenous rate.
ANSWERS
41. Correct answer 2: The priority for the client with
diverticulosis is to prevent constipation; therefore,
increasing fluids, eating a high-fiber diet, and daily
exercise would be appropriate teaching for this
client. Content–Medical; Category of Health
Alteration–Gastrointestinal; Integrated Process–
Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
42. Correct answer 3: The first intervention for an acute
exacerbation of a gastrointestinal problem is to put the
bowel on rest, which is to keep the client NPO. All
other interventions are implemented after placing
client on NPO status. Content–Medical; Category of
Health Alteration–Gastrointestinal; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
200
43. Correct answer 3: Hypoactive bowel sounds indicate
a possible obstruction, which would warrant further
intervention by the nurse. All the other data would be
expected for a client diagnosed with acute diverticulitis.
Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
44. Correct answer 1: Green bile is the normal color
output for the nasogastric output; therefore, the
nurse should document the finding in the client’s
chart. Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
SECTION FOUR
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201
45. The client diagnosed with acute diverticulitis is
47. The nurse is caring for a client diagnosed with acute
scheduled for a gastric resection. Which intervention
should the nurse implement?
l 1. Provide written instructions on how to perform
colostomy irrigations.
l 2. Demonstrate how to splint the abdomen when
coughing and deep-breathing.
l 3. Explain that the client will be receiving TPN
postoperatively.
l 4. Discuss the importance of maintaining bedrest for
72 hours after surgery.
diverticulitis who is receiving antibiotic therapy. Which
data would warrant intervention by the nurse?
l 1. The client has thrush in the mouth.
l 2. The client has a temperature of 100.2°F.
l 3. The client had a soft brown stool.
l 4. The client has moist buccal mucosa.
46. Which statement indicates the client with diverticulosis
needs more teaching concerning how to prevent
diverticulitis?
l 1. “I shoFuld not eat any foods that have seeds such
as tomatoes.”
l 2. “I will do low-impact weightlifting exercises every
day for 30 minutes.”
l 3. “I must cook all my vegetables and not eat any
foods that have peels.”
l 4. “I need to have at least one soft bowel
movement a day.”
48. The client diagnosed with diverticulosis asks the
nurse, “What did I do to make myself get this disease?”
Which statement is the nurse’s best response?
l 1. “There is no exact cause for developing
diverticulosis.”
l 2. “Chronic constipation over time caused the
diverticulosis.”
l 3. “Eating a high-fiber diet over time causes
diverticulosis.”
l 4. “You are wondering why you have diverticulitis?”
ANSWERS
45. Correct answer 2: The nurse should discuss the
importance of coughing and deep-breathing to help
prevent postoperative pneumonia, and splinting the
incision will help decrease pain. Content–Surgical;
Category of Health Alteration–Gastrointestinal;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Physiological Adaptation;
Cognitive Level–Application.
46. Correct answer 3: The client should be on a highfiber diet, which includes raw vegetables and leaving
the peels on foods such as apples and potatoes. This
statement indicates the client needs more teaching.
Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Evaluation; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Evaluation.
Copyright © 2010 F.A. Davis Company
202
47. Correct answer 1: Thrush indicates the client has a
suprainfection secondary to the antibiotic therapy
and warrants notifying health-care provider to
obtain an order for an oral Nystatin swish and
swallow. A moist buccal mucosa, soft brown stool,
and a low-grade fever do not require the nurse’s
immediate intervention. Content–Medical; Category
of Health Alteration–Drug Administration; Integrated
Process–Assessment; Client Needs–Physiological
Integrity, Pharmacological and Parenteral Therapies;
Cognitive Level–Analysis.
48. Correct answer 2: Chronic constipation causes
increased gastrointestinal intraluminal pressure,
which is the precipitating factor for diverticulosis.
Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Diagnosis; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
SECTION FOUR
Gastrointestinal Disorders
203
Gallbladder Disease
49. The client diagnosed with diverticulosis has just had
51. The client is 8 hours postoperative open
a colonoscopy. Which discharge teaching should the
nurse discuss with the client?
l 1. Notify the HCP if any rectal bleeding.
l 2. Do not eat or drink anything for at least 8 hours.
l 3. Expect the stool to be clay-colored for a few days.
l 4. Drink 30 mL of an antacid every 4 hours for 2 days
cholecystectomy. Which data would warrant
immediate intervention by the nurse?
l 1. The client has hypoactive bowel sounds in all four
quadrants.
l 2. The client’s T-tube has 40 mL of green drainage.
l 3. The client’s surgical dressing is dry and intact.
l 4. The client refuses to use the incentive spirometer.
50. Which client should the nurse assess first after
receiving the change-of-shift report?
l 1. The client who is scheduled for a colonoscopy.
l 2. The client who has a hard, rigid abdomen.
l 3. The client who has abdominal pain of 4 on a
1–10 scale.
l 4. The client who is complaining of jitteriness and
headache.
52. The client who is 2 hours postoperative laparoscopic
cholecystectomy is complaining of pain in the right
shoulder. Which nursing intervention should the nurse
implement?
l 1. Perform active range-of-motion (ROM) exercises to
the right arm.
l 2. Administer Tylenol #3 by mouth (PO) to the client
for the shoulder pain.
l 3. Request an order to have an x-ray of the client’s
right shoulder.
l 4. Apply a heating pad to the abdomen for
15–20 minutes.
ANSWERS
49. Correct answer 1: The client should notify the
HCP if any rectal bleeding occurs because this
could indicate a possible perforation of the intestines, which is a potential complication. Clay-colored
stools occur with a barium enema or barium swallow.
Content–Surgical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Planning; Client
Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Synthesis.
50. Correct answer 2: The client with a hard, rigid
abdomen may have peritonitis, which is a medical
emergency; therefore, this client should be seen first.
The client in pain and the client who is jittery need
to be seen, but peritonitis is life-threatening and
takes priority. Content–Medical; Category of Health
Alteration–Gastrointestinal; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
204
51. Correct answer 4: Refusal to use the incentive
spirometer may result in the client developing pneumonia, which is a complication, especially due to the
location of the cholecystectomy incision. Hypoactive
bowel sounds, green drainage, and a dry dressing
would be expected. Content–Surgical; Category of
Health Alteration–Gastrointestinal; Integrated
Process–Assessment; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
52. Correct answer 4: A heating pad should be applied
for 15–20 minutes to assist the migration of the carbon dioxide that was used to insufflate the abdomen
for surgery. Pain medication, ROM exercises, and
an x-ray will not help alleviate the pain, due to the
reason for the pain. Content–Surgical; Category
of Health Alteration–Gastrointestinal; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
SECTION FOUR
Gastrointestinal Disorders
205
53. The nurse is teaching a client recovering from a
55. The nurse is caring for the immediate postoperative
laparoscopic cholecystectomy. Which statement indicates
the client needs more discharge teaching?
l 1. “I will take my lipid-lowering medicine at the
same time each night.”
l 2. “I may experience some discomfort when I eat
a high-fat meal.”
l 3. “I will be able to go back to work in a couple
of days.”
l 4. “I should splint my incision when I take deep
breaths and cough.”
client who had a laparoscopic cholecystectomy. Which
task would be most appropriate for the nurse to delegate
to the UAP?
l 1. Assist the client to take a bed bath.
l 2. Empty the client’s indwelling catheter.
l 3. Bring a pitcher of ice water to the client.
l 4. Discuss care of the “band-aid” incisions.
54. When assessing the client recovering from an open
cholecystectomy, which signs and symptoms should the
nurse report to the HCP? Select all that apply.
l 1. Clay-colored stools.
l 2. Yellow-tinted sclera.
l 3. Dark yellow urine.
l 4. T 99°F, P 90, R 20, B/P 112/80.
l 5. Hypoactive bowel sounds.
56. Which statement by the client scheduled for an
upper gastrointestinal series (UGI) indicates the client
teaching has been effective?
l 1. “I will have soft brown stools after this procedure.”
l 2. “I need to check my stool for any bright red
bleeding.”
l 3. “I should increase my fluid intake for at least
1 week.”
l 4. “If I am allergic to shellfish, I cannot have this
procedure.”
ANSWERS
53. Correct answer 1: This surgery does not require lipid-
206
55. Correct answer 3: Laparoscopic surgery is per-
lowering medications, but high fatty meals may cause
discomfort. Laparoscopic surgeries are performed in
day surgery, and the client can return to work within a
few days of surgery. Using a pillow to splint the
abdomen provides support for the incision and should
be continued after discharge. Content–Surgical;
formed in ambulatory care centers, and clients take
fluids/food and ambulate immediately after surgery.
A bed bath and an indwelling catheter would not be
nursing interventions for a client with a laparoscopic
cholecystectomy. The nurse cannot delegate teaching
to the UAP. Content–Surgical; Category of Health
Category of Health Alteration–Gastrointestinal; Integrated Process–Evaluation; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive Level–
Evaluation.
Alteration–Gastrointestinal; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
54. Correct answer 1, 2, 3: Clay-colored stools,
jaundice, and dark yellow urine are signs of postcholecystectomy syndrome, which should be
reported to the surgeon. The vital signs and hypoactive bowel sounds would be expected. Content–
Surgical; Category of Health Alteration–Gastrointestinal;
Integrated Process–Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive
Level–Analysis.
Copyright © 2010 F.A. Davis Company
56. Correct answer 3: The barium used in the UGI
can cause constipation; therefore, the client should
increase fluid intake to help prevent constipation. The
client stools will be chalky, not brown. This procedure
does not cause bright red bleeding, and iodine is not
used for this procedure. Content–Surgical; Category of
Health Alteration–Gastrointestinal; Integrated Process–
Evaluation; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Evaluation.
SECTION FOUR
Gastrointestinal Disorders
207
57. The client is immediate post-procedure endoscopic
59. The client in the ambulatory care unit scheduled for
retrograde cholangiopancreatography (ERCP). Which
intervention should the nurse implement first?
l 1. Monitor the client’s stool for bleeding.
l 2. Provide the client with a regular diet.
l 3. Assess for return of the client’s gag reflex.
l 4. Administer the client’s held medications.
a laparoscopic cholecystectomy tells the nurse, “I think
I may be allergic to latex.” Which intervention should
the nurse implement first?
l 1. Notify the operating room personnel.
l 2. Label the client’s chart with the allergy.
l 3. Place a red allergy band on the client.
l 4. Check the chart to see if the allergy is documented.
58. The nurse is preparing the female client for an open
cholecystectomy. Which information would alert the
nurse that the client may be at risk for a postoperative
complication?
l 1. The client is 20 lb over the desired weight.
l 2. The client has delivered two children by
cesarean-section.
l 3. The client has a 10-year history of essential
hypertension.
l 4. The client has smoked two packs of cigarettes for
the last 20 years.
60. Which signs/symptoms would the nurse expect the
client diagnosed with cholelithiasis to exhibit?
l 1. Fever and elevated white blood cell count.
l 2. Jaundice and clay-colored stools.
l 3. Rigid, board-like abdomen.
l 4. Elevated amylase and lipase.
ANSWERS
57. Correct answer 3: The ERCP requires that an anes-
208
59. Correct answer 4: The nurse must first see if this
thetic spray be used prior to insertion of the endoscope. If medication, food, or fluid is given orally
prior to the return of the gag reflex, the client may
aspirate, causing pneumonia that could be fatal. If
there is any blood in the stool, it will not occur until
after the gag reflex returns. Content–Surgical; Cate-
information is documented in the client’s chart prior to
taking any other action. If it is documented, then the
nurse should check the allergy band. If it is not in the
chart, the nurse should label the chart and notify the
operating room so that no latex glove or equipment
comes into contact with the client. Content–Surgical;
gory of Health Alteration–Gastrointestinal; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
Category of Health Alteration–Gastrointestinal; Integrated
Process–Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive Level–Synthesis.
58. Correct answer 4: The location of the incision, the
general anesthesia, and smoking makes this client
high risk for pulmonary complications. Obesity,
hypertension, or history of cesarean section would
not put this client at risk for any postoperative
complication more than any other type of surgery.
Content–Surgery; Category–Gastrointestinal; Integrated
Process–Assessment; Client Needs–Physiological
Integrity, Reduction of Risk Potential; Cognitive
Level–Analysis.
Copyright © 2010 F.A. Davis Company
60. Correct answer 2: Cholelithiasis (gallstones) may
block the gallbladder duct, leading to signs of liver
dysfunction such as jaundice and clay-colored stools.
Fever and elevated white blood cell count may indicate cholecystitis (inflammation of the gall bladder).
A board-like abdomen would indicate peritonitis,
and elevated amylase/lipase levels would indicate
pancreatitis. Content–Medical; Category of Health
Alteration–Gastrointestinal; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
SECTION FOUR
Gastrointestinal Disorders
209
Liver Failure
61. The nurse is caring for the client diagnosed with
63. The client diagnosed with end-stage liver disease has
end-stage liver failure. Which data indicates the laxative
lactulose (Chronulac) is effective?
l 1. The client no longer complains of pruritus.
l 2. The client’s skin is no longer jaundiced.
l 3. The client is alert and oriented times three.
l 4. The client’s abdominal girth has decreased in size.
bleeding esophageal varices. Which HCP order would the
nurse question?
l 1. Insert a Sengstaken-Blakemore tube.
l 2. Administer salt-poor albumin intravenously.
l 3. Type and cross for 4 units of blood.
l 4. Administer AquaMephyton subcutaneously.
62. The HCP schedules a paracentesis for the client
64. The nurse is caring for a client diagnosed with
diagnosed with end-stage liver failure who has ascites.
Which priority intervention should the nurse implement
post procedure?
l 1. Assess the client’s abdominal girth.
l 2. Monitor the client’s blood pressure and pulse.
l 3. Label the specimen and send to the laboratory.
l 4. Place the client on the right side.
end-stage liver failure. Which data would warrant
immediate intervention by the nurse?
l 1. The client is complaining of clay-colored stools.
l 2. The client’s abdominal girth increased 1 inch.
l 3. The client’s urine output is 180 mL in 8 hours.
l 4. The client’s ammonia level is elevated.
ANSWERS
61. Correct answer 3: Lactulose is administered to help
decrease the ammonia level in a client with end-stage
liver failure. Increased ammonia level causes neurological deficits. The fact that the client is alert and
oriented indicates a lessening of any neurological
deficits and that the medication lactulose is effective.
Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Evaluation; Client
Needs–Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Evaluation.
62. Correct answer 2: The client is at risk for hypovolemic
shock; therefore, the priority intervention is assessing
the client’s vital signs. The client should be placed on
the right side for a liver biopsy. Content–Medical;
Category of Health Alteration–Gastrointestinal; Integrated Process–Planning; Client Needs–Physiological
Integrity, Reduction of Risk Potential; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
210
63. Correct answer 2: Salt-poor albumin is administered to help treat ascites, not bleeding esophageal
varices. All the other orders would be expected for a
client who is bleeding. Content–Medical; Category of
Health Alteration–Gastrointestinal; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
64. Correct answer 3: The client may be going into renal
failure as the urine output is less than 30 mL/hr. All
the other data would be expected in a client with
end-stage liver failure. Content–Medical; Category of
Health Alteration–Gastrointestinal; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.
SECTION FOUR
Gastrointestinal Disorders
211
65. The home health nurse is caring for a client
67. The client diagnosed with end-stage liver failure who
diagnosed with end-stage liver failure who has ascites.
Which intervention should the nurse implement?
l 1. Instruct the client to decrease drinking alcohol.
l 2. Tell the client to increase the intake of protein.
l 3. Encourage the client to eat canned soup daily.
l 4. Explain the need to limit fluid intake.
has ascites is complaining of trouble breathing. Which
intervention should the nurse implement?
l 1. Elevate the client’s head of the bed.
l 2. Administer the loop-diuretic furosemide (Lasix)
intravenous push (IVP).
l 3. Encourage the client to take slow, deep breaths.
l 4. Measure the client’s abdominal girth.
66. The client diagnosed with end-stage liver failure is
being discharged home. Which statement indicates the
client needs more teaching?
l 1. “If I gain 2 pounds in 1 day, I will notify my HCP.”
l 2. “If my handwriting gets worse, it means my
ammonia level is increasing.”
l 3. “If I start itching, it is all right to scratch as long as
I do it very carefully.”
l 4. “I will not use any sharp utensils or go barefoot in
my house or yard.”
68. The nurse and a UAP are caring for clients on a
medical unit. Which task could the nurse delegate to
the UAP?
l 1. Take the client’s urine specimen to the laboratory.
l 2. Evaluate the client’s intake and output for the shift.
l 3. Give an antacid to the client complaining of
heartburn.
l 4. Clean the room of a client who has been discharged.
ANSWERS
65. Correct answer 4: The client with ascites should
limit fluid intake. Alcohol will further damage the
liver; therefore, the client should not decrease alcohol
intake but rather should stop alcohol intake completely. The client should decrease protein intake and
maintain a low-salt (canned soup usually has a large
amount of salt) diet. Content–Medical; Category
of Health Alteration–Gastrointestinal; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive Level–
Application.
66. Correct answer 3: Even if the client starts itching
secondary to pruritus, the client should not scratch
because it could cause a break in the skin with
bleeding and possible infection. The client needs
more teaching. Content–Medical; Category of Health
Alteration–Gastrointestinal; Integrated Process–
Evaluation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Evaluation.
Copyright © 2010 F.A. Davis Company
212
67. Correct answer 1: Elevating the head of the bed
will help the client breathe easier. A loop-diuretic
will not work for at least 15–30 minutes. Content–
Medical; Category of Health Alteration–Gastrointestinal;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
68. Correct answer 1: The UAP can take specimens to
the laboratory. The UAP cannot assess, teach, evaluate, administer medications, or care for a client who
is unstable. The housekeeping department cleans the
room, not the UAP. Content–Medical; Category of
Health Alteration–Gastrointestinal; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
SECTION FOUR
Gastrointestinal Disorders
213
Hepatitis
69. The nurse is preparing to administer medications to
71. The clinic nurse is teaching the client just diagnosed
clients on a medical unit. Which medication should the
nurse question administering?
l 1. Acetaminophen (Tylenol), an analgesic, to a client
diagnosed with liver failure.
l 2. The potassium supplement to the client who has a
potassium level of 4.2 mEq/L.
l 3. The laxative lactulose to the client whose ammonia
level is WNL.
l 4. The antihistamine Benadryl to the client who is
complaining of pruritus.
with hepatitis C. Which intervention should the nurse
discuss with the client?
l 1. Explain the need to decrease alcohol intake.
l 2. Discuss the importance of resting the liver.
l 3. Recommend getting the hepatitis C vaccine.
l 4. Tell the client to wash the hands for 20 seconds.
70. Which client should the nurse assess first after receiving
the shift report?
l 1. The client diagnosed with liver failure whose liver
enzymes are elevated.
l 2. The client diagnosed with pancreatitis whose
amylase is elevated.
l 3. The client diagnosed with type 2 diabetes whose
glucose level is 160 mg/dL.
l 4. The client diagnosed with end-stage liver failure
whose platelet count is 25,000.
72. Which signs/symptoms would the nurse expect the
client diagnosed in the pre-icteric stage of hepatitis to
exhibit?
l 1. Mild, flu-like symptoms and anorexia.
l 2. Jaundiced sclera and skin pigmentation.
l 3. Dark-colored urine and clay-colored stool.
l 4. Right epigastric pain and flatulence.
ANSWERS
69. Correct answer 1: Tylenol is detoxified by the liver
and should not be administered to clients in liver failure.
Content–Medical; Category of Health Alteration–Drug
Administration; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Application.
70. Correct answer 4: The normal platelet level is
greater than 150,000; this client is at risk for bleeding and should be seen first. All other laboratory
data would not warrant the nurse seeing those clients
first. Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
214
71. Correct answer 2: The liver will regenerate and
recover from the acute inflammation if the client does
not drink alcohol at all (not decrease intake), takes
medications, and rests the body. Hepatitis C is transmitted via blood and body fluid so washing hands will
not help prevent transfer. There is no hepatitis C vaccine.
Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Planning; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Synthesis.
72. Correct answer 1: Most clients are asymptomatic,
are anicteric (without jaundice) at first, and anorexic
due to the release of a toxin by the damaged liver.
The other signs/symptoms will appear as the hepatitis advances to the icteric (yellow) phase. Content–
Medical; Category of Health Alteration–Gastrointestinal;
Integrated Process–Assessment; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive Level–
Analysis.
Copyright © 2010 F.A. Davis Company
SECTION FOUR
Gastrointestinal Disorders
215
73. The nurse is discussing how to prevent hepatitis with
75. Which intervention is most important when preventing
a group of clients. Which intervention is important in
preventing hepatitis B?
l 1. Wash hands after having bowel movements.
l 2. Do not share any type of eating utensils.
l 3. Obtain three doses of the hepatitis B vaccine.
l 4. Use caution when eating fresh fish.
the transmission of hepatitis A?
l 1. Careful hand washing before eating.
l 2. Environmental sanitation of food.
l 3. Effective sewage disposal.
l 4. Good personal hygiene.
74. The home health nurse is caring for a client with
the nurse, “I am afraid to get the blood because I don’t
want to get hepatitis.” Which statement is the nurse’s best
response?
l 1. “I can see you are frightened about receiving a
blood transfusion.”
l 2. “Would you like me to have your doctor talk to
you about the transfusion?”
l 3. “The blood is screened, and there is very little
chance of you getting hepatitis.”
l 4. “Hepatitis is a possibility with a transfusion, but
you must have the blood.”
viral hepatitis. Which intervention should the nurse
discuss with the client?
l 1. Do not drink more than 1000 mL of water a day.
l 2. Eat a diet low in protein and high in fat.
l 3. Take acetaminophen (Tylenol) for fever.
l 4. Recommend small, frequent meals.
76. The client scheduled to receive a unit of blood tells
ANSWERS
73. Correct answer 3: The hepatitis B vaccine will prevent
the client from getting hepatitis B. The virus is transmitted via blood and body fluids. Content–Medical;
Category of Health Alteration–Gastrointestinal; Integrated Process–Implementation; Client Needs–Health
Promotion and Maintenance; Cognitive Level–Synthesis.
74. Correct answer 4: Small, frequent meals will help
decrease the nausea/vomiting associated with viral
hepatitis. The client should increase fluid intake
2000–3000 mL a day and eat a high-protein, highcalorie, low-fat diet. The client should refrain from
taking medications, especially Tylenol, which is
hepatotoxic. Content–Medical; Category of Health
Alteration–Gastrointestinal; Integrated Process–Planning;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Synthesis.
216
75. Correct answer 1: Careful hand washing after bowel
movements and before meals is the most important
intervention to prevent transmission of hepatitis A.
Good personal hygiene, sanitation of foods, and
proper sewage disposal are appropriate but not more
important than good hand washing. Content–Medical;
Category of Health Alteration–Gastrointestinal; Integrated Process–Implementation; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive
Level–Application.
76. Correct answer 3: Screening of blood has reduced
the incidence of hepatitis associated with blood
transfusions; therefore, this is the best response. The
nurse cannot tell the client to take blood; it is the
client’s decision. The client is expressing a concern
and needs information so a therapeutic response
(option 1) is not the best answer. Content–Medical;
Category of Health Alteration–Gastrointestinal; Integrated Process–Planning; Client Needs–Physiological
Integrity, Reduction of Risk Potential; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
SECTION FOUR
Gastrointestinal Disorders
217
77. The clinic nurse is caring for a client with hepatitis C.
79. The nurse is caring for a male client diagnosed with
Which statement by the client requires teaching by the
nurse?
l 1. “I enjoy having one glass of wine with my evening
meal.”
l 2. “I check with my pharmacist before I take any
medication.”
l 3. “I was asked to donate blood but I knew that
I could not.”
l 4. “I get at least 6–8 hours of sleep a night.”
hepatitis A who asks, “What about my family? Can
anything be done to help them from getting this?” Which
statement is the nurse’s best response?
l 1. “No; once someone is exposed to the hepatitis A
virus, they will get it.”
l 2. “Yes; globulin can be given within 2 weeks of
exposure to prevent hepatitis A.”
l 3. “Doses of interferon and ribavirin will help prevent
the spread of hepatitis A.”
l 4. “You should not have sexual intercourse with your
wife or kiss your children.”
78. The nurse and UAP are caring for a client with an
acute exacerbation of hepatitis C. Which action by the
UAP warrants immediate intervention by the nurse?
l 1. The UAP assists the client to the semi-private
bathroom.
l 2. The UAP takes a food tray to the client without
wearing gloves.
l 3. The UAP wears gloves when helping the client
with a bath.
l 4. The UAP does not wash the hands after caring for
the client.
80. The nurse is caring for clients on a medical unit.
Which client should the nurse see first?
l 1. The client with hepatitis C who has dark-colored
urine.
l 2. The client with hepatitis B who has jaundiced sclera.
l 3. The client with hepatitis A who is nauseated and
vomiting.
l 4. The client with hepatitis B who needs to have
blood drawn.
ANSWERS
77. Correct answer 1: The client should abstain from
drinking any type of alcohol, including wine, beer,
or foods or medications that contain alcohol.
Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Evaluation; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Evaluation.
78. Correct answer 4: The UAP must wash the hands
thoroughly after caring for the client and prior to
caring for the next client. This is a part of standard
precautions. Content–Medical; Category of Health
Alteration–Gastrointestinal; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
218
79. Correct answer 2: Globulin bolsters the person’s
antibody production and provides 6–8 weeks of
passive immunity. Hepatitis A is transmitted via
fecal/oral route. Interferon and ribavirin are used in
clients with hepatitis C. Content–Medical; Category
of Health Alteration–Gastrointestinal; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
80. Correct answer 3: The client who is nauseated and
vomiting needs an antiemetic; therefore, this client
should be seen first. Dark-colored urine and jaundice
are expected with a client who has hepatitis. The
laboratory technician is responsible for adhering to
standard precautions when drawing blood. Content–
Medical; Category of Health Alteration–Gastrointestinal;
Integrated Process–Evaluation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Evaluation.
SECTION FOUR
Gastrointestinal Disorders
219
Gastroenteritis
81. The female client called the clinic complaining of
83. The emergency department nurse is assessing the
abdominal cramping and has had several episodes of
diarrhea for 2 days. The client reported that she had
been in Mexico on a trip and just returned. Which
intervention should the nurse implement?
l 1. Instruct the client to take an over-the-counter antacid.
l 2. Encourage the client to drink sports drinks, such as
Gatorade, frequently.
l 3. Discuss the need to decrease the amount of protein
in the diet.
l 4. Explain to the client that she should watch for
fluid buildup in the extremities.
client diagnosed with salmonellosis. Which question is
the most appropriate for the nurse to ask the client?
l 1. “Did the food you ate have an unusual odor or
taste?”
l 2. “Do you eat rare or medium-rare hamburgers?”
l 3. “Do you have insurance to cover the cost of the
visit?”
l 4. “What made you decide to come to the emergency
department?”
82. The public health nurse is discussing with a group
of peers some ways to help prevent potential episodes
of gastroenteritis due to Clostridium botulism. Which
information should the nurse teach?
l 1. Make sure that all hamburger meat is well cooked.
l 2. Ensure that all dairy products are refrigerated.
l 3. Teach that campers should drink only bottled water.
l 4. Discard all canned goods that are damaged.
84. The client is diagnosed with gastroenteritis. Which
laboratory data would warrant immediate intervention by
the nurse?
l 1. ABGs of pH 7.37, PaO2 95, PaCO2 43, HCO3 24.
l 2. A serum potassium level of 3.5 mEq/L.
l 3. A stool sample that is positive for fecal leukocytes.
l 4. A serum sodium level of 154 mEq/L.
ANSWERS
81. Correct answer 2: The client probably has traveler’s
diarrhea, and oral rehydration is the preferred choice
for replacing fluids lost due to diarrhea. Oral glucose
electrolyte solutions, such as Gatorade, All-Sport,
and Pedialyte, are recommended. Content–Medical;
Category of Health Alteration–Gastrointestinal;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Physiological Adaptation;
Cognitive Level–Application.
82. Correct answer 4: Any food that is discolored or
comes from a can or jar that has been damaged or
does not have a tight seal should be destroyed without
tasting or touching. Cooking beef well prevents
Salmonella and avoiding unrefrigerated dairy products
prevents Staphylococcus food poisoning. Avoiding
contaminated water prevents E. coli infections.
Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Planning; Client
Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
220
83. Correct answer 2: Salmonella is frequently transmitted through undercooked beef. This is the most
appropriate question. Most foods causing bacterial
poisoning do not have an unusual odor or taste.
Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
84. Correct answer 4: The normal serum sodium level
is 135–145 mEq/L; this elevated sodium level indicates dehydration, and the nurse should intervene.
The potassium level and ABGs are within normal
limits, and the stool sample would be expected to
have leukocytes. Content–Medical; Category of
Health Alteration–Gastrointestinal; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Synthesis.
SECTION FOUR
Gastrointestinal Disorders
221
85. The client diagnosed with gastroenteritis is being
87. Which data would the nurse assess in the client
discharged from the emergency department. Which
statement by the client indicates an understanding of the
discharge teaching?
l 1. “I should wash my hands before I eat or cook
any food.”
l 2. “I will call the doctor if I have diarrhea for more
than 4 days.”
l 3. “I will have to taper off the steroids and not just
quit taking them.”
l 4. “I will bring all my stools into the laboratory for
analysis in 24 hours.”
diagnosed with acute gastroenteritis?
l 1. Bowel assessment reveals loud, rushing bowel
sounds.
l 2. Decreased gurgling sounds upon auscultation of
abdominal wall.
l 3. A soft, firm edematous abdomen upon palpation.
l 4. Frequent, small melena-type liquid bowel
movements.
86. The nurse is caring for an elderly client diagnosed
with staphylococcal food poisoning. Which client
problem has the highest priority?
l 1. Altered comfort.
l 2. Risk for aspiration.
l 3. Risk for spread of the bacteria.
l 4. Fluid volume deficit.
88. The elderly client diagnosed with acute gastroenteritis
is admitted to the medical unit. Which nursing task
would be most appropriate for the registered nurse (RN)
to delegate to the UAP?
l 1. Record the client’s intake and output.
l 2. Discuss the purpose of collecting a stool sample.
l 3. Insert an indwelling urinary catheter.
l 4. Assess the client’s skin turgor.
ANSWERS
85. Correct answer 1: This should be done by a client
at all times but especially one with gastroenteritis. If
hands are not washed properly, the bacteria in feces
that cause the illness may be transferred to other
people via food. The client should contact healthcare provider if diarrhea persists for 48 hours. A onetime stool specimen may be required but not a 24hour specimen. Content–Medical; Category of Health
Alteration–Gastrointestinal; Integrated Process–
Evaluation; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Evaluation.
86. Correct answer 4: Fluid volume deficit secondary
to the diarrhea associated with staphylococcal food
poisoning is priority due to the potential for metabolic acidosis and hypokalemia, which are both
life-threatening, especially in the elderly. Content–
Medical; Category of Health Alteration–Gastrointestinal;
Integrated Process–Diagnosis; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
222
87. Correct answer 1: Borborygmi, loud, rushing bowel
sounds, indicate increased peristalsis, which occurs in
clients with diarrhea. Diarrhea is the primary clinical
manifestation in a client diagnosed with acute gastroenteritis. Content–Medical; Category of Health
Alteration–Gastrointestinal; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
88. Correct answer 1: The UAP can record the client’s
intake and output. The nurse must evaluate the
findings. The UAP cannot teach (discuss the purpose
of a stool sample), assess a client’s condition, or
perform a sterile procedure (inserting an indwelling
urinary catheter). Content–Medical; Category of Health
Alteration–Gastrointestinal; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
SECTION FOUR
Gastrointestinal Disorders
223
Constipation and Diarrhea
89. The nurse is caring for a male client diagnosed with
91. The client in the long-term care facility has a
gastritis on a medical unit. Which action by the client
warrants immediate intervention?
l 1. The client tells the nurse that his legs have stopped
cramping.
l 2. The client writes down his intake and output on
the record by the bed.
l 3. The client chooses a large meal of fried foods from
the hospital menu.
l 4. The client takes frequent drinks from the bedside
water container.
fecal impaction. Which intervention should the nurse
implement first?
l 1. Administer a stool softener.
l 2. Remove the fecal impaction manually.
l 3. Administer an oil retention enema.
l 4. Increase the client’s fluid intake.
90. Which nursing intervention(s) should the nurse
include in the care plan of an elderly client diagnosed
with acute gastroenteritis? Select all that apply.
l 1. Assess the skin turgor on the upper abdomen.
l 2. Monitor the client for hypertension.
l 3. Record the frequency and characteristic of stools.
l 4. Use contact precautions when caring for the client.
l 5. Assist the client when getting out of bed.
92. The clinic nurse is caring for a 78-year-old client
who takes cathartics daily to have a bowel improvement.
Which statement indicates the client needs more teaching
concerning cathartic abuse?
l 1. “I will take a bulk laxative every morning with my
breakfast meal.”
l 2. “I do not have to have a bowel movement every day.”
l 3. “I should try and walk about 30 minutes every day
to help prevent constipation.”
l 4. “If I feel sluggish and not had a BM, I will eat a lot
of cheese and dairy products.”
ANSWERS
89. Correct answer 3: Solid foods are reintroduced
slowly in small amounts, and fried foods are limited.
This allows the bowel to rest and the mucosa to
return normal. Content–Medical; Category of Health
Alteration–Gastrointestinal; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
90. Correct answer 1, 3, 5: The abdomen is an approved place for assessing tissue turgor. The frequency and characteristics of the stools should be
documented. The elderly client is at risk for orthostatic hypotension; therefore, safety precautions
should be instituted to ensure that the client does
not fall due to drop in a blood pressure. Content–
Medical; Category of Health Alteration–Gastrointestinal;
Integrated Process–Diagnosis; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive
Level–Analysis.
Copyright © 2010 F.A. Davis Company
224
91. Correct answer 3: Oil retention enemas help to
soften the feces and evacuate the stool, but if necessary the nurse could remove the fecal impaction
manually. A stool softener would help soften the
stool, and increasing fluid may prevent constipation
but would not help evacuate the fecal impaction.
Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
92. Correct answer 4: Cheese and dairy products are
low in residue and are constipating; therefore, the
client needs more teaching. A BM is not needed
daily, and exercising helps decrease constipation.
A bulk laxative does not cause the client to become
cathartic- (laxative- ) dependent. Content–Medical;
Category of Health Alteration–Gastrointestinal;
Integrated Process–Evaluation; Client Needs–
Physiological Integrity, Physiological Adaptation;
Cognitive Level–Evaluation.
SECTION FOUR
Gastrointestinal Disorders
225
93. The client has been experiencing difficulty and
95. The client diagnosed with gastroenteritis is
straining when expelling feces. Which statement indicates
the client understands the teaching?
l 1. “I should expect to have some bright red blood
when I have a bowel movement (BM).”
l 2. “I will perform the Crede´ maneuver whenever
I need to have a BM.”
l 3. “I will sit in a sitz bath at night to help me
have a BM.”
l 4. “I will eat foods high in fiber such as wheat bread,
salads, and apples.”
experiencing voluminous diarrhea. Which intervention(s)
should the nurse implement? Select all that apply.
l 1. Monitor stools for character and consistency.
l 2. Assess the client’s serum potassium level.
l 3. Provide the client with carbonated soft drinks.
l 4. Administer anti-diarrheal medication.
l 5. Cleanse the perianal area with warm water.
94. The client in the long-term facility has had a stool
that is dark, watery, and shiny in appearance. Which
action should the nurse implement first?
l 1. Check the client for a fecal impaction.
l 2. Document the findings in the client’s chart.
l 3. Send the client to the emergency department.
l 4. Place the client on a warmed bedpan.
96. The nurse, a licensed practical nurse (LPN), and a
UAP are caring for clients on a medical floor. Which task
would be best to assign to the LPN?
l 1. Assist the UAP to learn how to insert an indwelling
catheter.
l 2. Clean the client who is incontinent and has diarrhea.
l 3. Administer an antidiarrheal medication to the
client.
l 4. Check the abdomen of a client who is constipated.
ANSWERS
93. Correct answer 4: A high-fiber diet will help prevent constipations; therefore, this statement indicates
the client understands the teaching. Blood may indicate a hemorrhoid; it is not normal to expel blood
when having a BM. The Credé maneuver is used to
help expel urine from the bladder. Sitz baths will not
help the client have a BM. Content–Medical; Category
of Health Alteration–Gastrointestinal; Integrated Process–
Evaluation; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Evaluation.
94. Correct answer 1: Dark, watery, shiny stools are
symptoms of diarrhea moving around an impaction
higher up in the colon; therefore, the nurse should
assess for an impaction and then place the client on
a warmed bedpan if needed. The nurse should document the finding and may need to send the client to
the emergency department, but this is not the first
action. Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
226
95. Correct answer 1, 2, 4, 5: The nurse should monitor
the amount, color, and characteristics of all body fluids
lost. Diarrhea causes potassium loss, so the potassium
level should be monitored. Antidiarrheal medication is
appropriate, and the perianal area should be cleansed
with warm water. Carbonated soft drinks increase flatus in the gastrointestinal tract, and the increased sugar
will act as an osmotic laxative and increase the diarrhea. Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Application.
96. Correct answer 3: The LPN can administer medications such as an antidiarrheal medication to the clients.
The LPN should not be teaching a UAP how to insert
an indwelling catheter; the UAP should be asked to
clean the client; and the nurse should not delegate
assessment. Content–Medical; Category of Health
Alteration–Gastrointestinal; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
SECTION FOUR
97. The client is placed on percutaneous gastrostomy
Gastrointestinal Disorders
227
99. The nurse is planning the care of a client diagnosed
(PEG) tube feedings. Which data would warrant
immediate intervention by the nurse?
l 1. The client tolerates 50 mL/hr feedings.
l 2. The client has no gastric residual.
l 3. The client’s HOB is elevated.
l 4. The client has a green watery stool.
with infectious diarrhea. Which client problem would be
priority?
l 1. Risk for impaired skin integrity.
l 2. Potential for transmission of infection.
l 3. Fluid and electrolyte imbalance.
l 4. Knowledge deficit of prevention.
98. The client is complaining of frequent watery bloody
100. The nurse is caring for clients on a medical unit.
stools after eating some undercooked meat at a fast-food
restaurant. Which intervention should the nurse implement
first?
l 1. Obtain a stool sample to send to the laboratory.
l 2. Teach the client about the antibiotic therapy.
l 3. Request a serum sodium and potassium level.
l 4. Administer Lomotil, an anti-diarrheal medication.
Which client information should be brought to the
attention of the HCP immediately?
l 1. A serum sodium of 142 mEq/L on a client
diagnosed with obstipation.
l 2. The client’s telemetry reading shows occasional
premature ventricular contractions (PVCs).
l 3. A serum potassium level of 3.2 mEq/L on a client
diagnosed with diarrhea.
l 4. The client diagnosed with diarrhea who has had
two semi-liquid stools totaling 300 mL.
ANSWERS
228
97. Correct answer 4: A green watery stool could be a
99. Correct answer 3: Fluid and electrolyte imbalance
complication of the tube feedings, and the client
needs to be assessed for dehydration and anal excoriation. Tolerating tube feedings, no gastric residual, and an elevated HOB are normal for a client
with tube feedings. Content–Medical; Category
is the client’s priority problem. Remember to apply
Maslow’s hierarchy, in which a physiological problem takes priority over other problems. Impaired
skin integrity, transmission of infection, and
knowledge deficit are appropriate client problems,
but they are not priority over fluid and electrolyte
imbalance. Content–Medical; Category of Health
of Health Alteration–Gastrointestinal; Integrated
Process–Assessment; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
98. Correct answer 1: The client may have developed
an infection from the undercooked meat, and a stool
specimen should be sent to the laboratory for tests.
Antibiotic therapy is initiated for serious cases of
infectious diarrhea, but the diarrhea must be assessed
first. Sodium and potassium imbalances can occur
from diarrhea, and medication should be given.
Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
Alteration–Gastrointestinal; Integrated Process–
Diagnosis; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.
100. Correct answer 3: The client’s potassium level is low
(normal is 3.5–5.5 mEq/L), which could lead to cardiac dysrhythmias; therefore, the nurse should contact the HCP. The sodium level is within normal
limits (135–145 mEq/L); occasional PVCs are not
life-threatening; and 300 mL of semi-liquid stool
is expected with a client diagnosed with diarrhea.
Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
Gastrointestinal Disorders
SECTION FOUR
Management
101. The nurse has received the morning shift report.
Which client should the nurse assess first?
l 1. The client diagnosed with peptic ulcer disease who
is complaining of acute epigastric pain.
l 2. The client diagnosed with acute gastroenteritis who
had four diarrhea stools during the night.
l 3. The client diagnosed with inflammatory bowel
disease who has a hard, rigid abdomen.
l 4. The client diagnosed with food poisoning who has
vomited several times during the night shift.
102. The nurse and the UAP are caring for clients on a
medical-surgical unit. Which task should be assigned to
the UAP?
l 1. Instruct the UAP to feed the 69-year-old client
who has dysphagia.
l 2. Request the UAP to turn and position the
89-year-old client who has a pressure ulcer.
l
l
229
3. Tell the UAP to monitor the 54-year-old client
while performing occupational therapy.
4. Ask the UAP to perform chest physiotherapy on a
72-year-old client with pneumonia.
103. The nurse on a medical unit is discussing a male
client with the case manager. Which information is most
appropriate for the nurse to share with the case manager?
l 1. Tell the case manager that the client is threatening
to sue a nurse who forgot his pain medication.
l 2. Provide the case manager with any information
about the client’s required home care and financial
status.
l 3. Explain that the client does not want any
information given out to the public about his being
admitted to the hospital.
l 4. Have the case manager sign a confidentiality
agreement to not discuss the client in public.
ANSWERS
230
101. Correct answer 3: A hard, rigid abdomen is abnor-
103. Correct answer 2: The case manager is part of the
mal in any circumstance and is a clinical manifestation of peritonitis, a potential life-threatening
condition. The nurse should assess this patient first
and should also assess for an elevated temperature.
health-care team and should be provided with the
information needed to perform the job. The case
manager should have already signed a confidentiality agreement with the facility. Content–Medical;
Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
Category of Health Alteration–Gastrointestinal; Integrated Process–Planning; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
102. Correct answer 2: The UAP can turn the client.
The UAP should not feed a client with difficulty
swallowing, monitor a client during therapy, or
perform chest physiotherapy. Content–Medical;
Category of Health Alteration–Gastrointestinal; Integrated Process–Planning; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
SECTION FOUR
Gastrointestinal Disorders
231
104. The nurse and LPN are caring for a client diagnosed
106. The female client diagnosed with viral hepatitis C
with a bleeding peptic ulcer. Which intervention should
the nurse assign to the LPN?
l 1. Perform the pre-blood assessment.
l 2. Teach the client to stop smoking.
l 3. Administer the proton pump inhibitor PO.
l 4. Return the used blood bag to the laboratory.
is being discharged. Which instructions should the nurse
teach the client?
l 1. Discuss limiting alcohol consumption to two to
three beers or glasses of wine a day.
l 2. Teach the client to remain on strict bedrest for at
least 1 month.
l 3. Instruct the client to use a condom during sexual
intercourse.
l 4. Explain that the client is no longer contagious and
can resume normal activities.
105. The nurse on the GI unit is administering the
client’s scheduled intravenous antibiotic when the client
shows the nurse a white, cheesy plaque on the tongue
that bleeds when removed. Which statement is the nurse’s
best response?
l 1. “These white plaques happen sometimes with
antibiotics. I will tell your HCP.”
l 2. “Those white patches usually go away without
treatment within 2 weeks.”
l 3. “You need to rinse your mouth with a solution of
diluted hydrogen peroxide and water.”
l 4. “I can tell these plaques bother you. Would you
like to talk?”
107. The adolescent male client who has begun to use
tobacco tells this information to the clinic nurse. Which
statement is an example of the ethical principle of fidelity?
l 1. The nurse tells the client’s parents that he uses
chewing tobacco.
l 2. The nurse tells the client that he is at risk for
developing oral cancer.
l 3. The nurse gives the client information on oral
cancers and the risks involved.
l 4. The nurse keeps confidential the information that
the client shared.
ANSWERS
104. Correct answer 3: The LPN should be capable of
administering a proton pump inhibitor. Assessing
and teaching cannot be delegated or assigned to the
LPN. The UAP can return an empty blood bag
to the lab. Content–Medical; Category of Health
Alteration–Gastrointestinal; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
105. Correct answer 1: Oral candidiasis or thrush is a
fungal infection that presents as white, cheesy
plaques that bleed if rubbed. They can occur as a
side effect of antibiotic treatment. Clients with diabetes or immunosuppression have a high risk for
developing it. The HCP should be contacted to
obtain an antifungal solution. Content–Medical;
Category of Health Alteration–Drug Administration;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
232
106. Correct answer 3: The client can spread the virus
through blood and body fluids. The sexual contacts
of the client should be protected. Clients should
not drink any alcoholic beverages; strict bedrest
is not necessary; and the client is still contagious
until she seroconverts. Content–Medical; Category
of Health Alteration–Gastrointestinal; Integrated
Process–Planning; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive
Level–Synthesis.
107. Correct answer 4: Fidelity is being faithful to the
relationship with the client. Telling the parents is
paternalism. Giving the client information is beneficence. Content–Fundamentals; Category of Health
Alteration–Gastrointestinal; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
SECTION FOUR
Gastrointestinal Disorders
233
108. The elderly client in the long-term care facility
110. The nurse is caring for clients on a medical unit.
insists on receiving a cathartic laxative daily. Which
action by the nurse is the most appropriate?
l 1. The nurse administers the as-needed (PRN)
laxative per the client’s request.
l 2. The nurse obtains an order for a bulk-forming
laxative daily.
l 3. The nurse refuses to administer the cathartic
laxative to the client.
l 4. The nurse discusses the problem with the chief
nursing officer.
Which client should the nurse assess first?
l 1. The 45-year-old client diagnosed with peptic ulcer
disease whose Hgb is 10.2 mg/dL.
l 2. The 50-year-old client diagnosed with a hiatal
hernia who is complaining of severe indigestion.
l 3. The 67-year-old client diagnosed with
gastroenteritis who has dry mucous membranes.
l 4. The 78-year-old client diagnosed with obstipation
who had three hard dry stools on the last shift.
109. The client presents to the emergency department
complaining of right upper quadrant pain after eating
supper. Which intervention should the nurse implement
first?
l 1. Schedule a gallbladder sonogram.
l 2. Draw a complete blood count.
l 3. Run a 12-lead electrocardiogram.
l 4. Send the client to radiology for a chest x-ray.
ANSWERS
108. Correct answer 2: The client is fixated on the need
for a medication daily. A bulk laxative will provide
more fiber for the client to aid in a more normal
bowel movement. Cathartic laxatives stimulate
peristalsis and can cause laxative dependence.
Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
109. Correct answer 3: Cardiac pain may mimic gallbladder pain. The nurse should make sure that the
client is having gallbladder problems and not cardiac problems. Content–Medical; Category of Health
Alteration–Gastrointestinal; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
Copyright © 2010 F.A. Davis Company
234
110. Correct answer 3: This client is exhibiting symptoms of dehydration and should be assessed first. A
Hgb of 10.2 mg/dL is not life-threatening, and the
client with a hiatal hernia is expected to have “indigestion.” The client with obstipation is passing
stools, which means the problem is resolving.
Content–Medical; Category of Health Administration–
Gastrointestinal; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
SECTION FIVE
Endocrine Disorders
235
SECTION FIVE
Endocrine Disorders
237
Type 1 Diabetes
1. Which statement by the client would make the nurse
3. The nurse administered 20 units of NPH intermediate-
suspect the client may have type 1 diabetes?
l 1. “I have gained about 30 pounds in the last few
years.”
l 2. “I have to go to the bathroom and urinate all
the time.”
l 3. “I have a sore on my big toe that is not healing.”
l 4. “I have a granddaughter who had gestational
diabetes.”
acting insulin to a client diagnosed with type 1 diabetes at
1630. Which intervention should the nurse implement?
l 1. Give the client the bedtime snack.
l 2. Ensure the client eats the evening meal.
l 3. Perform a glucometer check at 1800.
l 4. Check the client's urine for ketones.
2. The client diagnosed with type 1 diabetes is complaining
of being jittery and nervous and has a headache. Which
action should the nurse implement first?
l 1. Check the client's serum glucose level.
l 2. Determine the last time the client received insulin.
l 3. Give the client one glass of orange juice.
l 4. Assess the client's vital signs.
4. The nurse is caring for a client diagnosed with diabetic
ketoacidosis (DKA) who has a blood glucose level of
510 mg/dL. Which priority intervention should the
intensive care nurse implement?
l 1. Administer intravenous regular insulin.
l 2. Monitor the client's intake and output.
l 3. Check the client's glucose level frequently.
l 4. Turn the client every 2 hours.
ANSWERS
238
1. Correct answer 2: Polyuria, polyphagia, and polydip-
3. Correct answer 1: The intermediate-acting insulin
sia are the three classic symptoms of type 1 diabetes.
Being overweight and a non-healing wound are signs
of type 2 diabetes. Content–Medical; Category of Health
peaks in 6–8 hours, and the client needs glucose to
prevent hypoglycemia; therefore, the client needs to
eat a bedtime snack. Content–Medical; Category of
Alteration–Endocrine; Integrated Process–Assessment;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Analysis.
Health Alteration–Drug Administration; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Pharmacological and Parenteral Therapies;
Cognitive Level–Application.
2. Correct answer 3: The client is having signs/symptoms
of hypoglycemia; therefore, the nurse should provide
the client with a simple carbohydrate. A serum glucose
level requires a venipuncture, and then the laboratory
must perform the test, which will take too long. The
nurse can check the last insulin administration and
assess vital signs after treating the client. Content–
Medical; Category of Health Alteration–Endocrine;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
4. Correct answer 1: Administering intravenous regular
insulin is priority because the blood glucose must be
lowered to help reverse the client's metabolic acidosis.
Assessing the glucose level, urine output, and turning
the client are appropriate interventions, but they are
not priority over decreasing the glucose level. Content–
Medical; Category of Health Alteration–Endocrine;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Pharmacological and Parenteral
Therapies Adaptation; Cognitive Level–Application.
Endocrine Disorders
SECTION FIVE
5. The nurse is teaching the client newly diagnosed with
type 1 diabetes. Which information should the nurse
include in the teaching plan? Select all that apply.
l 1. Discuss the importance of checking the feet weekly.
l 2. Encourage the client to walk for at least 30 minutes
a day.
l 3. Recommend the client to the American Diabetic
Association (ADA).
l 4. Explain the need to wear SPF 30 sunscreen when
in the sun.
l 5. Tell the client to get an ophthalmology check-up
yearly.
6. The client diagnosed with DKA asks the nurse, “Why
are you checking my urine with that stick?” Which
statement is the nurse's best response?
l 1. “I am checking your urine to see if glucose is
spilling into the urine.”
l 2. “This test determines if ketones from fat
breakdown are in your urine.”
l
l
239
3. “Your doctor needs to know the specific gravity of
your urine.”
4. “I need to find out if there is any protein in your
urine output.”
7. The nurse is discussing exercise with the client
diagnosed with type 1 diabetes. Which intervention
should the nurse discuss with the client?
l 1. Instruct the client to eat a simple source of
carbohydrate before walking.
l 2. Tell the client to wear open-toed supportive shoes
when walking.
l 3. Explain that the client should carry hard candies
when exercising.
l 4. Recommend the client perform isometric exercises
three times a week.
ANSWERS
5. Correct answer 2, 3, 5: The treatment for type
1 diabetes is insulin, exercise, and diet. The ADA is an
excellent resource for clients. Diabetic retinopathy is a
long-term complication; therefore, regular eye checkups are needed. The client should check the feet daily,
not weekly. Sunscreen is not a part of diabetic teaching. Content–Medical; Category of Health Alteration–
Endocrine; Integrated Process–Planning; Client Needs–
Physiological Integrity, Physiological Adaptation;
Cognitive Level–Synthesis.
6. Correct answer 2: Fat breakdown results in ketone
production, and the urine is checked for ketonuria.
The glucose level is checked by glucometer readings,
not in urine output. Content–Medical; Category
of Health Alteration–Endocrine; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
240
7. Correct answer 3: The client should carry a simple
carbohydrate, such as hard candies, while exercising in
case the client becomes hypoglycemic. The client
should eat a complex carbohydrate prior to walking,
wear closed toes tennis shoes, and perform isotonic
exercises. Isometric is weight-lifting. Content–Medical;
Category of Health Alteration–Endocrine; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
SECTION FIVE
Endocrine Disorders
241
8. The intensive care nurse is caring for the client
10. The client newly diagnosed with type 1 diabetes
diagnosed with DKA. Which data indicate the client
is responding to the medical regime?
l 1. The client is exhibiting Kussmaul breathing.
l 2. The client's serum glucose level is 220 mg/dL.
l 3. The client buccal mucosa is pink and moist.
l 4. The client's arterial blood gases (ABGs) are
pH 7.34, PaO2 90, PaCO2 44, HCO3 20.
asks the nurse, “Why am I hungry all the time?” Which
statement is the nurse's best response?
l 1. “You do not have enough insulin to allow sugar
into the cells.”
l 2. “The insulin you have circulating is not effective
for glucose metabolism.”
l 3. “The high sugar level in your blood causes the
brain to think you are hungry.”
l 4. “The high glucose level prevents carbohydrates
from being broken down.”
9. The client diagnosed with type 1 diabetes called the
clinic and told the nurse, “I am nauseated and vomiting.
I think I have a bug.” Which statement should be the
nurse's best response?
l 1. “I will make an appointment for you to come to
the clinic today.”
l 2. “Do not take your routine insulin dosage if you
cannot eat.”
l 3. “Is anyone else in your home nauseated and
vomiting?”
l 4. “Take your insulin and drink foods high in
carbohydrates such as Jello.”
Type 2 Diabetes
11. The nurse is caring for a client newly diagnosed with
type 2 diabetes. Which intervention should the nurse
implement?
l 1. Administer pancreatic enzymes.
l 2. Monitor the client's arterial blood gases.
l 3. Assess the client for ketonuria.
l 4. Administer oral hypoglycemic medications.
ANSWERS
8. Correct answer 3: A pink and moist buccal mucosa
indicates the client is well hydrated, which means the
client is responding to the medical regime. Kussmaul
breathing, an elevated glucose level, and metabolic
acidosis indicate the medical regime is not effective.
Content–Medical; Category of Health Alteration–
Endocrine; Integrated Process–Evaluation; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Evaluation.
9. Correct answer 4: The client must continue to take
the routine insulin dosage because illness increases
the glucose level. The client should consume foods
high in carbohydrates, such as Jello, orange juice,
puddings, and regular Coke, to prevent hypoglycemia.
Content–Medical; Category of Health Alteration–
Endocrine; Integrated Process–Implementation; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
242
10. Correct answer 1: Polyphagia occurs because there
is not enough insulin to allow glucose to enter the
cell; therefore, the cell is starved for glucose, which
makes the client feel hungry. Content–Medical;
Category of Health Alteration–Endocrine: Integrated
Process–Assessment; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive
Level–Analysis.
11. Correct answer 4: The client diagnosed with type 2
diabetes is treated with oral hypoglycemics. Changes
in arterial blood gases and diabetic ketoacidosis
occur in a client diagnosed with type 1 diabetes.
Pancreatic enzymes are not administered to clients
with diabetes. Content–Medical; Category of Health
Alteration–Endocrine; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Application.
Endocrine Disorders
SECTION FIVE
12. The nurse is teaching a client newly diagnosed with
type 2 diabetes. Which statement indicates the client
needs more teaching?
l 1. “If I lose weight, it may help decrease my blood
glucose level.”
l 2. “I must start counting my carbohydrates to help
my diabetes.”
l 3. “I am so glad my children won't have to worry
about getting diabetes.”
l 4. “If I get any types of cuts on my feet, I need to
watch them closely.”
13. The client newly diagnosed with type 2 diabetes tells
the nurse, "I don't understand why I need to keep my
sugar down. I don't feel bad.” Which statement is the
nurse's best response?
l 1. “You are concerned you don't feel bad because
your sugar level is high.”
l 2. “With time your high sugar level can cause
blindness or kidney failure.”
l
l
243
3. “If you don't keep your sugar down you may start
feeling bad.”
4. “A high sugar level can cause you to gain weight
over time.”
14. The nurse is caring for the client diagnosed with
hyperglycemic, hyperosmolar nonketotic (HHNK) coma.
Which intervention warrants immediate intervention by
the nurse?
l 1. The client's arterial blood gas reveals metabolic
acidosis.
l 2. The client's urine has 4+ ketones.
l 3. The client's skin turgor is tented.
l 4. The client has bilateral crackles in the lungs.
ANSWERS
12. Correct answer 3: A risk factor for developing type
2 diabetes is a family history; therefore, this statement indicates the client needs more teaching.
Obesity, carbohydrate counting, and delayed wound
healing indicate the client understands the client
teaching. Content–Medical; Category of Health
Alteration–Endocrine; Integrated Process–Evaluation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Evaluation.
13. Correct answer 2: Type 2 diabetes can lead
to long-term complications such as blindness,
diabetic nephropathy, peripheral neuropathy, and
heart disease. Content–Medical; Category of Health
Alteration–Endocrine; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
244
14. Correct answer 4: Bilateral crackles indicate
the client is in fluid volume overload from fluid
replacement. This requires immediate intervention.
Metabolic acidosis and ketonuria occur in type
1 diabetes, not type 2 diabetes. The client in HHNK
would be dehydrated; therefore, tented skin turgor
would not warrant immediate intervention. Content–
Medical; Category of Health Alteration–Endocrine;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Reduction of Risk Potential;
Cognitive Level–Application.
SECTION FIVE
Endocrine Disorders
245
15. The nurse is administering metformin (Glucophage) to
17. The charge nurse noted that the primary nurse
the client diagnosed with type 2 diabetes. Which statement
best describes the scientific rationale for administering this
medication?
l 1. Glucophage prevents the breakdown of glucose in
the liver.
l 2. The medication increases the production of insulin
in the beta cells.
l 3. Metformin causes the muscle cells to be more
receptive to circulating insulin.
l 4. This medication slows the absorption of
carbohydrates in the intestines.
administered metformin (Glucophage) to a client
diagnosed with type 2 diabetes who is scheduled for a
CT scan with contrast. Which action should the charge
nurse implement first?
l 1. Complete an adverse occurrence report.
l 2. Notify the client's health-care provider (HCP).
l 3. Call radiology and cancel the CT scan.
l 4. Do not take any action at this time.
16. The nurse in the diabetes clinic is triaging phone
calls from clients. Which client should the nurse call first?
l 1. The client who needs to reschedule an
appointment as soon as possible.
l 2. The client who needs a prescription refill for oral
hypoglycemics.
l 3. The client who has a wound on the left foot that
looks infected.
l 4. The client who has had loose runny stools for the
last 2 days.
18. The nurse is checking laboratory data for clients.
Which laboratory data warrant notifying the HCP?
l 1. The client with type 2 diabetes whose fasting blood
glucose is 185 mg/dL.
l 2. The client with type 2 diabetes who has negative
ketones in the urine.
l 3. The client with type 2 diabetes who has a serum
creatinine level of 1.8 mg/dL.
l 4. The client with type 2 diabetes who has a serum
potassium level of 3.3 mEq/L.
ANSWERS
15. Correct answer 1: This is the scientific rationale for
administering metformin (Glucophage) to a client
with type 2 diabetes. Content–Medical; Category of
Health Alteration–Drug Administration; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive
Level–Analysis.
16. Correct answer 4: Acute illness leads to an increase
in the client's glucose level and may lead to dehydration; therefore, the nurse should return this client's
call first. Then, call the client who has an infected
foot. Content–Medical; Category of Health Alteration–
Endocrine; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
246
17. Correct answer 3: Glucophage must be held 2 days
before and 2 days after the contrast dye is administered to the client. The charge nurse should first cancel the CT scan, then notify the HCP, and complete
an adverse occurrence report. Content–Medical;
Category of Health Alteration–Endocrine; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Evaluation.
18. Correct answer 4: The client who has a low potassium
level (3.5–5.5 mEq is normal) is at risk for dysrhythmias; therefore, the nurse should contact the client's
HCP. A blood glucose level of 185 mg/dL is not
life-threatening. Content–Medical; Category of Health
Alteration–Endocrine; Integrated Process–Assessment;
Client Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Synthesis.
SECTION FIVE
Endocrine Disorders
247
Thyroid Disorders
19. The unlicensed assistive personnel (UAP) tells the
21. Which signs/symptoms should the nurse assess for
nurse the client has a glucometer reading of 40. Which
action should the nurse implement?
l 1. Assess the client immediately.
l 2. Tell the UAP to give the client orange juice.
l 3. Prepare to administer an oral hypoglycemic
medication.
l 4. Contact the laboratory to confirm the client's
blood glucose level.
the client diagnosed with Graves disease?
l 1. Fatigue and bradycardia.
l 2. Polyuria and polyphagia.
l 3. Diarrhea and heat intolerance.
l 4. Weight gain and thick brittle nails.
20. The clinic nurse is caring for a client newly diagnosed
with type 2 diabetes. Which referral would be most
appropriate for the nurse to discuss with the client?
l 1. Refer the client to an endocrinologist.
l 2. Refer the client to a registered dietitian.
l 3. Refer the client to the home health nurse.
l 4. Refer the client to a social worker.
22. The client is postoperative bilateral thyroidectomy.
Which intervention should the nurse implement?
l 1. Place a tracheostomy tray at the bedside.
l 2. Have potassium chloride easily accessible.
l 3. Administer propylthiouracil (PTU), an antithyroid
medication.
l 4. Monitor the client's thyroid hormone levels,
T3 and T4.
ANSWERS
19. Correct answer 1: The client's blood glucose level is
low (70–100 mg/dL); therefore, the nurse should
assess the client immediately. The nurse cannot delegate an unstable client to the UAP. Content–Medical;
Category of Health Alteration–Endocrine; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
20. Correct answer 2: The client with type 2 diabetes
needs to be on a carbohydrate counting diet; therefore, a referral to the registered dietitian would be
most appropriate. The nurse does not refer a client
to an endocrinologist. A home health nurse or social
worker would not be appropriate referrals for a
newly diagnosed type 2 diabetic client. Content–
Medical; Category of Health Alteration–Endocrine;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care,
Physiological Adaptation; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
248
21. Correct answer 3: Graves disease, a type of hyperthyroidism, results in an increase in metabolism
that results in symptoms that include weight loss,
increased appetite, diarrhea, heat intolerance, and
nervousness. Content–Medical; Category of Health
Alteration–Endocrine; Integrated Process–Assessment;
Client Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Application.
22. Correct answer 1: A postoperative complication
of a bilateral thyroidectomy is laryngeal edema;
therefore, a tracheostomy tray, oxygen, and a suction
machine should be placed at the bedside. PTU may
be administered preoperatively; the T3 and T4 levels
are not monitored after surgery. Content–Medical;
Category of Health Alteration–Endocrine; Integrated
Process–Planning; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Evaluation.
SECTION FIVE
Endocrine Disorders
249
23. The nurse is caring for the client who is immediate
25. The client diagnosed with Graves disease received
postoperative thyroidectomy. Which data would warrant
immediate intervention by the nurse?
l 1. The client's hemoglobin/hematocrit is 12/36.
l 2. The client's vital signs are T 99.4, AP 98, R 20,
B/P 142/88.
l 3. The client is agitated and extremely anxious.
l 4. The client's surgical dressing is dry and intact.
iodine 131, radioactive iodine. Which statement indicates
the client needs more teaching?
l 1. “I should not be around young children and
pregnant women.”
l 2. “It is important for me to flush my commode twice
after I urinate.”
l 3. “It is not uncommon to vomit after taking the
radioactive iodine.”
l 4. “I will have to wear a radioactive badge during the
treatment.”
24. The clinic nurse is caring for a client diagnosed with
hyperthyroidism. Which information should the nurse
discuss with the client?
l 1. Maintain a calm, restful environment.
l 2. Eat a low-calorie, low-protein diet.
l 3. Take the thyroid hormone with food.
l 4. Wear thick-weaved clothes in the sun.
26. The client diagnosed with hypothyroidism is
prescribed levothyroxine (Synthroid), a hormone
replacement. Which data indicate the medication is
effective?
l 1. The client has lost 4 lb in 1 week.
l 2. The client's radial pulse is 88.
l 3. The client complains of being cold.
l 4. The client's temperature is 97.0ºF.
ANSWERS
23. Correct answer 3: Thyroid storm is a life-threatening
event caused by an oversecretion of thyroid hormone.
It results in agitation, anxiety, fever, tachycardia, and
hypertension. Content–Surgical; Category of Health
Alteration–Endocrine; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Application.
24. Correct answer 1: The client is nervous and anxious;
250
twice after urinating. Iodine 131 is very irritating to
the gastrointestinal tract and the client may vomit.
Content–Medical; Category of Health Alteration–
Endocrine; Integrated Process–Evaluation; Client
Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Evaluation.
26. Correct answer 2: A radial pulse between 60 and
therefore, maintaining a calm, restful environment
is an appropriate intervention. The client should
eat a high-calorie, high-protein, low-caffeine diet.
100 indicates the medication is effective. Weight loss
indicates taking too much medication. Being cold
and having a subnormal temperature indicate not
enough medication. Content–Medical; Category of
Content–Medical; Category of Health Alteration–
Endocrine; Integrated Process–Planning; Client Needs–
Physiological Integrity, Physiological Adaptation;
Cognitive Level–Synthesis.
Health Alteration–Drug Administration; Integrated
Process–Evaluation; Client Needs–Physiological
Integrity, Reduction of Risk Potential; Cognitive
Level–Evaluation.
25. Correct answer 4: The client is not radioactive and
does not have to wear a radioactive badge. The
client's body fluids are, however, radioactive; therefore, the client should not be around young children
or pregnant women and should flush the commode
Copyright © 2010 F.A. Davis Company
SECTION FIVE
Endocrine Disorders
251
27. Which statement by the client would make the nurse
29. The client is diagnosed with myxedema coma.
suspect the client has hypothyroidism?
l 1. “I wake up at night feeling hot all over.”
l 2. “I have a bowel movement once a day.”
l 3. “I keep putting lotion on my dry skin.”
l 4. “I have trouble going to sleep at night.”
Which signs/symptoms would the nurse expect the client
to exhibit?
l 1. The client's blood pressure is 110/70.
l 2. The client's serum sodium level is 138 mEq/L.
l 3. The client's respirations are 16 beats per minute.
l 4. The client's serum glucose level is 60 mg/dL.
28. The clinic nurse is teaching the client diagnosed with
hypothyroidism. Which intervention should the nurse
discuss with the client?
l 1. Tell the client to decrease fluid intake to 1000 mL
a day.
l 2. Encourage the client to eat foods high in fiber.
l 3. Recommend the client take a daily laxative.
l 4. Discourage the client from eating fresh fruits and
vegetables.
30. Which medication teaching should the nurse discuss
with the client diagnosed with hypothyroidism who is
prescribed levothyroxine (Synthroid)?
l 1. Explain the need to monitor thyroid levels daily.
l 2. Inform the client to avoid foods high in iodine.
l 3. Instruct the client to monitor weight monthly.
l 4. Tell the client chest pain may occur while taking
medication.
ANSWERS
27. Correct answer 3: The client with hypothyroidism
has dry skin; thin, dry hair; cold intolerance, constipation, dull emotions, and fatigue. Content–Medical;
Category of Health Alteration–Endocrine; Integrated
Process–Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
28. Correct answer 2: The client with hypothyroidism
experiences constipation; therefore, the client should
have a diet high in fiber. The client should also increase
fluid intake to 3000 mL a day. The nurse should discourage daily laxatives or enemas. Content–Medical;
Category of Health Alteration–Endocrine; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
29. Correct answer 4: The client diagnosed with
myxedema coma experiences hypotension, hypothermia, hypoglycemia, hyponatremia, and respiratory
failure. A serum glucose level of 60 mg/dL indicates
hypoglycemia. The blood pressure, sodium level, and
Copyright © 2010 F.A. Davis Company
252
respirations are within normal limits and would not
indicate myxedema coma. Content–Medical; Category
of Health Alteration–Endocrine; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
30. Correct answer 2: Foods high in iodine will cause
the levothyroxine not to be effective. Thyroid level is
monitored monthly, not daily. Weights should be
daily, not monthly. Synthroid should be administered cautiously in clients with cardiovascular disease.
Content–Medical; Category of Health Alteration–Drug
Administration; Integrated Process–Planning; Client
Needs–Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Synthesis.
SECTION FIVE
Endocrine Disorders
253
Adrenal Disorders
31. The nurse is admitting a client who has been
33. The nurse is caring for a client diagnosed with
diagnosed with primary adrenal cortex insufficiency
(Addison disease). Which signs and symptoms support
the diagnosis of Addison disease?
l 1. Bronze pigmentation, hypotension, and anorexia.
l 2. Moon face, buffalo hump, and hyperglycemia.
l 3. Hirsutism, fever, and irritability.
l 4. Tachycardia, bulging eyes, and goiter.
Addison disease. Which nursing interventions should be
implemented?
l 1. Place the client in contact isolation.
l 2. Administer intravenous and oral steroid
medications.
l 3. Provide a brightly lit room and recreational
activities.
l 4. Consult occupational therapy for work retraining.
32. The nurse is caring for a client diagnosed with acquired
immune deficiency syndrome (AIDS) who has developed
an infection in the adrenal gland. Which client problem has
the highest priority?
l 1. Altered body image.
l 2. Activity intolerance.
l 3. Impaired coping.
l 4. Fluid volume deficit.
34. The nurse is admitting the client diagnosed with
rule-out Cushing syndrome. Which laboratory tests
would confirm the diagnosis of Cushing syndrome?
l 1. Complete blood count (CBC) and erythrocyte
sedimentation rate (ESR).
l 2. Plasma levels of adrenocorticotropic hormone
(ACTH) and cortisol.
l 3. 24-hour urine for metanephrine and catecholamine.
l 4. Early morning spot urine specimen for protein and
glucose.
ANSWERS
31. Correct answer 1: Bronze pigmentation of the skin,
particularly of the knuckles and other areas of skin
creases, occurs in Addison disease. Hypotension
and anorexia also occur. Moon face, buffalo hump,
and hyperglycemia are due to Cushing syndrome,
which is hyperfunction of the adrenal gland. Content–
Medical; Category of Health Alteration–Endocrine; Integrated Process–Assessment; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive Level–
Analysis.
32. Correct answer 4: Fluid volume deficit (dehydration)
can lead to circulatory impairment and hyperkalemia.
Fluid volume deficit is the only physiological problem and should be chosen for this reason. Content–
Medical; Category of Health Alteration–Endocrine;
Integrated Process–Diagnosis; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
254
33. Correct answer 2: Clients diagnosed with Addison
disease have adrenal gland hypofunction. The client
will require glucocorticosteroids, mineral steroids,
and androgens. Content–Medical; Category of
Health Alteration–Endocrine; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
34. Correct answer 2: The adrenal gland secretes cortisol;
the pituitary gland secretes adrenocorticotropic
hormone (ACTH), a hormone used by the body to
stimulate the production of cortisol. Twenty-four-hour
urine specimens for 17-hydroxycorticosteroids and
17-ketosteroids may be collected to determine the
client's urine cortisol level. Content–Medical; Category
of Health Alteration–Endocrine; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Analysis.
Endocrine Disorders
SECTION FIVE
35. The client admitted for chronic obstructive pulmonary
disease (COPD) has developed iatrogenic Cushing disease.
Which is a scientific rationale for the development of this
problem?
l 1. The client's chronic lack of oxygen has destroyed
the adrenal glands.
l 2. The client has a pituitary tumor that causes an
overproduction of cortisol.
l 3. The client has been taking steroid medications for
an extended time.
l 4. The HCP cannot explain why the client has this
problem.
36. The nurse is performing discharge teaching for a
client diagnosed with Cushing disease. Which statement
made by the client indicates the client needs further
discharge instructions?
l 1. “I will be sure to notify my HCP if I start to run a
fever.”
l 2. “Before I stop taking the prednisone, I will be
taught how to taper it off.”
l
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255
3. “If I get thirsty and urinate a lot, I should let my
doctor know.”
4. “I should be sure and take safety precautions to
prevent an injury.”
37. The charge nurse of an intensive care unit (ICU) is
making assignments for the night shift. Which client
should be assigned to the least experienced ICU nurse?
l 1. The client with respiratory failure who is on a
ventilator who has a tension pneumothorax.
l 2. The client with iatrogenic Cushing disease with a
pH 7.35, O2 88, PCO2 44, and HCO3 22.
l 3. The client with Addison disease who is lethargic
and has BP 80/45, P 124, R 28.
l 4. The client who has undergone a thyroidectomy
and has a positive Trousseau sign.
ANSWERS
35. Correct answer 3: Iatrogenic means that a problem
has been caused by the medical treatment or procedure
used to treat another problem. Clients taking exogenous steroids over a period of time, such as those with
COPD, develop the clinical manifestations of Cushing
disease. Disease processes for which long-term steroids
are prescribed include COPD, cancer, and arthritis.
Content–Medical; Category of Health Alteration–Drug
Administration; Integrated Process–Evaluation; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Synthesis.
36. Correct answer 2: The client has too much cortisol
and would not be on prednisone, a steroid medication. The nurse should clarify the instructions
with the client. Content–Medical; Category of Health
Alteration–Endocrine; Integrated Process–Evaluation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Evaluation.
Copyright © 2010 F.A. Davis Company
256
37. Correct answer 2: This client has normal arterial
blood gases. The nurse with the least experience
should be able to care for this client. A tension
pneumothorax is an emergency; the client diagnosed
with Addison disease may be in crisis; and a positive
Trousseau sign indicates hypocalcemia. Content–
Medical; Category of Health Alteration–Endocrine;
Integrated Process–Planning; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
SECTION FIVE
Endocrine Disorders
257
38. The nurse writes a problem of “altered glucose
40. The client diagnosed with Cushing disease has
metabolism” for a client diagnosed with Cushing disease.
Which interventions should the nurse implement?
l 1. Monitor blood glucose levels before meals and at
bedtime.
l 2. Perform a head-to-toe assessment every shift.
l 3. Use therapeutic communication to allow the client
to discuss feelings.
l 4. Assess bowel sounds and temperature every 4 hours.
developed 2+ peripheral edema in the last 24 hours. The
primary intravenous rate is 100 mL per hour, and he is
receiving an intravenous piggyback (IVPB) medication in
50 mL of fluid every 6 hours. He has an oral intake of
2450 mL and a recorded output of 3000 mL. Which
intervention should the nurse implement first?
l 1. Convert the intravenous fluids to a saline lock.
l 2. Notify the HCP.
l 3. Teach the client to measure all output.
l 4. Assess the lung fields and jugular vein.
39. The client diagnosed with possible Addison disease is
admitted to the emergency department. The client is
lethargic, confused, and weak. Which intervention should
the emergency department implement first?
l 1. Have the lab draw serum cortisol levels stat.
l 2. Check the client's medic alert bracelet to confirm
Addison disease.
l 3. Administer replacement steroids intravenously.
l 4. Start an intravenous line and administer normal
saline rapidly.
Pituitary Disorders
41. The client diagnosed with a pituitary tumor has
developed syndrome of inappropriate antidiuretic hormone
(SIADH). Which intervention should the nurse implement?
l 1. Assess the client for tented skin turgor.
l 2. Weigh the client daily at the same time.
l 3. Monitor the client's serum potassium level.
l 4. Perform a fluid deprivation test on the client.
ANSWERS
38. Correct answer 1: Blood glucose levels should be
obtained to monitor for the effects of insulin resistance caused by Cushing disease. Content–Medical;
258
+ 2450 mL oral intake = 5050 total intake, and total
output is 3000 mL. Content–Medical; Category of
Category of Health Alteration–Endocrine; Integrated
Process–Diagnosis; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
Health Alteration–Endocrine; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Application.
39. Correct answer 2: The nurse should look for an iden-
41. Correct answer 2: The client with SIADH is pro-
tification band alerting the health-care professional of
a chronic disease and then start the intravenous line
and administer steroids. Content–Medical; Category
of Health Alteration–Endocrine; Integrated Process–
Implementation; Client Needs–Safe Effect Care Environment, Management of Care; Cognitive Level–Analysis.
40. Correct answer 4: The nurse should first perform a
complete assessment to determine further evidence
of heart failure and make sure that all urine output is
measured before slowing the IV and notifying the
HCP. The 24-hour intake is 2600 mL of IV fluid
Copyright © 2010 F.A. Davis Company
ducing a hormone that will not allow the client to
urinate; therefore, weighing the client daily would
be appropriate. The client experiences fluid volume
overload, not dehydration, so assessment for skin
turgor is not needed. Dilutional hyponatremia is
assessed to detect the level of sodium, not potassium,
in the blood, and a water challenge test is performed,
not a fluid deprivation test. Content–Medical;
Category of Health Alteration–Endocrine; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive
Level–Application.
Endocrine Disorders
SECTION FIVE
42. The nurse is caring for a client who is 8 hours post
transphenoidal hyposphysectomy for a pituitary tumor.
Which data would warrant immediate intervention by
the nurse?
l 1. The client has clear straw-colored fluid draining
from the nose.
l 2. The client has an 8-hour urine output of 330 mL
and an input of 280 mL.
l 3. The client's vital signs are T 97.6ºF, P 88, R 20,
BP 130/80.
l 4. The client has a 3-cm amount of dark red drainage
on the turban dressing.
43. The nurse is discharging the client newly diagnosed
with diabetes insipidus (DI). Which statement made by
the client indicates the client understands the discharge
teaching?
l 1. “I will keep a list of my medications with me and
wear a Medic-Alert bracelet.”
l 2. “I should take my medication in the morning and
leave it refrigerated at home.”
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259
3. “I should weigh myself once a week and keep a
journal of my weight.”
4. “It is not uncommon to develop a tightness in my
chest early in the morning.”
44. The client is admitted to the medical unit with a
diagnosis of rule-out diabetes insipidus (DI). Which
intervention should the nurse implement when
conducting a fluid deprivation test?
l 1. Have the client drink 500 mL of hyperosmolar
fluid and obtain a serum sodium level hourly.
l 2. Inject an antidiuretic hormone and measure the
client's urine output for 8–10 hours.
l 3. Keep the client NPO and check vital signs and
weight hourly until the end of the test.
l 4. Initiate an IV line with normal saline and do not
allow the client to urinate until the sonogram is
completed.
ANSWERS
42. Correct answer 1: A transphenoidal hypophysectomy
is performed by surgical access above the gum line;
therefore, the nurse should test the drainage from
the nose to determine if it is cerebrospinal fluid. The
input and output is within normal limits; the vital
signs are stable; and the client does not have a
turban (head) dressing. Content–Surgical; Category
of Health Alteration–Endocrine; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
43. Correct answer 1: DI is a chronic illness that requires
daily medication; therefore, the client should keep a
list of medication being taken and wear a Medic-Alert
bracelet. DI medication is taken every 8–12 hours
and should be kept close at hand. The client should
weigh daily, and it is not common to have chest
tightness. Content–Medical; Category of Health
Alteration–Endocrine; Integrated Process–Evaluation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Evaluation.
Copyright © 2010 F.A. Davis Company
260
44. Correct answer 3: The client is deprived of all fluids;
if the client has DI, the urine production will not
diminish. Vital signs and weights are taken every
hour to determine circulatory status. If a marked
decrease in weight or vital signs occurs, the test is
immediately terminated. Content–Medical; Category
of Health Alteration–Endocrine; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Application.
SECTION FIVE
Endocrine Disorders
261
45. The nurse is caring for clients in a medical department.
47. The nurse is caring for a client diagnosed with
Which client should the nurse assess first?
l 1. The client diagnosed with SIADH who is lethargic
and confused.
l 2. The client diagnosed with diabetes insipidus (DI)
who has urinated 10,450 mL of urine in the last
24 hours.
l 3. The client diagnosed with SIADH who is
complaining of being thirsty.
l 4. The client diagnosed with DI who is complaining
of urinating every hour during the night.
diabetes insipidus (DI). Which interventions should be
implemented? Select all that apply.
l 1. Restrict fluid intake to no more than 1000 mL/day.
l 2. Administer DDAVP, an anti-diuretic hormone.
l 3. Assess the client for signs of water intoxication.
l 4. Place the client on seizure precautions.
l 5. Check the client's urine specific gravity.
46. The HCP has ordered 60 g/24 hours of intranasal
vasopressin for a client diagnosed with diabetes insipidus.
Each metered spray delivers 10 g. The client takes the
medication every 12 hours. How many sprays are
delivered at each dosing time?
Answer: ____________________
48. The nurse is caring for a client diagnosed with
diabetes insipidus (DI). Which nursing intervention
should be implemented?
l 1. Monitor blood glucose before meals and at
bedtime.
l 2. Restrict caffeinated coffee and colas.
l 3. Check the client's urine for ketonuria.
l 4. Assess the client's oral mucosa every 4 hours.
ANSWERS
45. Correct answer 1: If the client with SIADH develops lethargy and confusion, it could lead to seizures
and coma. Therefore, this client needs to be assessed
first. The other options include signs/symptoms
associated with the disease process. Content–Medical;
Category of Health Alteration–Endocrine; Integrated
Process–Assessment; Client Needs–Safe Effective Care
Management, Management of Care; Cognitive
Level–Synthesis.
46. Correct answer 3 sprays per dose: 60 g of
medication every 24 hours to be given every
12 hours. Twelve hours into 24 hours = 2, so there
will be 2 dosing times. Sixty divided by 2 = 30 g of
medication per dose. 30 g divided by 10 g per spray
= 3 sprays per dose. Content–Medical; Category of
Health Alteration–Drug Administration; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Pharmacological and Parenteral Therapies;
Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
262
47. Correct answer: 2, 3, 5. The treatment for DI is
hormone replacement with DDAVP and assessment
for signs of hyponatremia, water intoxication, weight
gain, and headache, which indicate the medication is
not effective. Interventions for syndrome of inappropriate antidiuretic hormone include restricting fluids
and seizure precautions. Content–Medical; Category
of Health Alteration–Endocrine; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
48. Correct answer 4: The client is excreting large
amounts of dilute urine. If the client is unable to
take in enough fluids, the client will quickly become
dehydrated. DI is not diabetes mellitus, so glucose
levels and ketones are not checked. There is no caffeine restriction for DI. Content–Medical; Category
of Health Alteration–Endocrine; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
SECTION FIVE
Endocrine Disorders
263
Pancreatitis
49. The UAP complains to the nurse that the client keeps
51. The nurse is admitting a client diagnosed with
asking for cold water to drink. The client is diagnosed
with a closed head injury. Which intervention should the
nurse implement first?
l 1. Tell the UAP to give the client cold water.
l 2. Evaluate the client's intake and output.
l 3. Ask the UAP to check the client's weight.
l 4. Check the client's BUN and creatinine levels.
rule-out (R/O) acute pancreatitis. Which laboratory
value should the nurse monitor?
l 1. Serum SGOT and serum SGPT.
l 2. Hemoglobin and hematocrit.
l 3. Serum amylase and lipase.
l 4. Serum bilirubin and calcium.
50. The nurse is admitting a client diagnosed with
pancreatitis on a medical unit. Which client problems
should be included in the client's plan of care? Select all
that apply.
l 1. Risk for hemorrhage.
l 2. Alteration in comfort.
l 3. Imbalanced nutrition: less the body requirements.
l 4. Knowledge deficit.
l 5. Impaired gas exchange.
syndrome of inappropriate antidiuretic hormone (SIADH).
Which laboratory data would warrant intervention by the
nurse?
l 1. The client has a serum sodium of 120 mEq/L.
l 2. The client has a serum potassium of 5.0 mEq/L.
l 3. The client has serum creatinine of 1.8 g/day.
l 4. The client has negative glucose in the urine.
52. The nurse is caring for a client diagnosed with acute
ANSWERS
49. Correct answer 2: Diabetes insipidus is a complication of head trauma; therefore, the nurse should
evaluate the client's intake and output to determine
if the client has increased urinary output. Then, the
nurse could document the client's weight, check
renal function (BUN and creatinine levels), and
give the client cold water. Content–Medical; Category
of Health Alteration–Endocrine; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive Level–
Application.
50. Correct answer 1: A serum sodium level of
120 mEq/L is dangerously low, and the client is at
risk for seizures; therefore, the nurse should intervene. All the other laboratory data are normal.
Content–Medical; Category of Health Alteration–
Endocrine; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
264
51. Correct answer 3: Serum amylase rises within
2–12 hours of onset of acute pancreatitis to two
to three times normal and returns to normal in
3–4 days; lipase elevates and remains elevated for
7–14 days. Amylase and lipase are produced by
the pancreas. Content–Medical; Category of Health
Alteration–Endocrine; Integrated Process–Assessment;
Client Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Application.
52. Correct answer 1, 2, 3, 4: Clients diagnosed with
pancreatitis are at risk for hemorrhage if the digestive
juices erode a blood vessel. Autodigestion of the
pancreas results in severe epigastric pain accompanied by nausea and vomiting. The client will have
nothing by mouth, so nutrition is a problem, and
acute problems usually have some knowledge deficit.
Content–Medical; Category of Health Alteration–
Endocrine; Integrated Process–Diagnosis; Client Needs–
Physiological Integrity, Physiological Adaptation;
Cognitive Level–Synthesis.
SECTION FIVE
Endocrine Disorders
265
53. The nurse is preparing to administer morning
55. The charge nurse is transcribing orders for a client
medications to the following clients. Which medication
should the nurse question before administering?
l 1. The pancreatic enzymes to the client who is no
longer NPO.
l 2. The pain medication morphine to the client
diagnosed with pancreatitis.
l 3. The loop diuretic to the client diagnosed with
heart failure.
l 4. The beta-blocker to the client who has an apical
pulse of 78 beats per minute (bpm).
diagnosed with chronic pancreatitis. The HCP ordered
Librium intravenously every 8 hours. Which action by
the charge nurse would be most appropriate?
l 1. Move the client to a room near the nurse's station.
l 2. Question the HCP about the medication.
l 3. Do nothing except transcribe the order as is.
l 4. Have the lab draw a serum Librium level.
54. The nurse assessing the client diagnosed with
pancreatitis notes the client has a bluish discoloration
around the umbilicus. Which intervention should the
nurse implement next?
l 1. Assess the left flank for bruising.
l 2. Check the chart for the latest hemoglobin.
l 3. Note the finding in the chart.
l 4. Notify the HCP.
56. The nurse is completing discharge teaching to
the client diagnosed with acute pancreatitis. Which
instruction should the nurse discuss with the client?
l 1. Instruct the client to decrease the amount of
smoking.
l 2. Explain the need to avoid all stress.
l 3. Discuss the importance of avoiding alcohol.
l 4. Teach the correct way to take pancreatic enzymes.
ANSWERS
53. Correct answer 2: Morphine causes spasms of the
sphincter of Oddi; the pain medication of choice for
clients diagnosed with pancreatitis is meperidine.
Content–Medical; Category of Health Alteration–Drug
Administration; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Synthesis.
54. Correct answer 1: Bluish discoloration around the
umbilicus (Cullen sign) is an indicator of intraperitoneal hemorrhage. Grey-Turner sign is bluish
discoloration in the left flank area. The nurse should
complete the assessment of the client before notifying
the HCP, documenting the finding, or looking at
lab values. Content–Medical; Category of Health
Alteration–Endocrine; Integrated Process–Assessment;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
266
55. Correct answer 1: Chronic pancreatitis is frequently
caused by alcoholism. Librium is prescribed to limit
the neurological effect of alcohol withdrawal. The
client should be moved close to the nurse's station
for observation. Content–Medical; Category of Health
Alteration–Endocrine; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment, Safety
and Infection Control; Cognitive Level–Synthesis.
56. Correct answer 3: Alcohol must be avoided entirely
because it can cause stones to form, blocking pancreatic ducts and the outflow of pancreatic juice, which,
in turn, causes further inflammation and destruction
of the pancreas. The client should stop smoking.
Pancreatic enzymes are prescribed for chronic
pancreatitis. Content–Medical; Category of Health
Alteration–Endocrine; Integrated Process–Planning;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Synthesis.
SECTION FIVE
Endocrine Disorders
267
57. The male client diagnosed with chronic pancreatitis
59. The nurse is caring for a client diagnosed with acute
reports to the clinic nurse that he has been having a lot of
“gas” and frothy, foul-smelling stools. Which statement is
the nurse's best response?
l 1. “How often and when do you take your pancreatic
enzymes?”
l 2. “Can you bring a stool specimen to the clinic for
analysis?”
l 3. “You must come into the clinic and see the HCP.”
l 4. “You should stay on low-fat diet or this will
continue to happen.”
pancreatitis. The client is complaining of mid-epigastric
pain unrelieved by narcotic pain medication administered
45 minutes ago. The narcotic medication is prescribed
every 4 hours prn. Which intervention should the nurse
implement next?
l 1. Tell the client to lie in the prone position with legs
extended.
l 2. Call the HCP for an increase in the pain
medication.
l 3. Place the client in side-lying position with knees
flexed.
l 4. Explain that the nurse cannot administer more
medication for 3 hours.
58. The nurse is caring for a client who has just returned
from an endoscopic retrograde cholangiopancreatogram
(ERCP). Which post-procedure intervention should the
nurse implement?
l 1. Have the client swallow some water.
l 2. Place the bed in a semi-Fowler position.
l 3. Assess for the gag reflex.
l 4. Prop the client in a side-lying position.
ANSWERS
57. Correct answer 1: Clients diagnosed with chronic
pancreatitis are prescribed replacement enzymes
that should be taken with every meal and snack.
The nurse should assess if the client is compliant
with the medication regimen before telling the
client to come in to see the HCP. Content–Medical;
Category of Health Alteration–Endocrine; Integrated
Process–Assessment; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive
Level–Analysis.
58. Correct answer 4: The client returning from this
procedure will have had twilight sleep, and the
throat will have been numbed. The client should be
allowed to sleep until the medication wears off.
Placing the client on the side will prevent aspiration
if the client should vomit. After client wakes up, the
nurse should check for the gag reflex prior to allowing the client to swallow water. Content–Medical;
Copyright © 2010 F.A. Davis Company
268
Category of Health Alteration–Endocrine; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Reduction of Risk Potential; Cognitive
Level–Application.
59. Correct answer 3: The fetal position decreases
pain caused by stretching of the peritoneum due to
edema. If nonpharmacological methods fail to relieve
the client's pain, then the nurse should discuss the
client's pain level with the HCP. Content–Medical;
Category of Health Alteration–Drug Administration;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Pharmacological and Parenteral
Therapies; Cognitive Level–Application.
Endocrine Disorders
SECTION FIVE
60. The client diagnosed with an acute exacerbation of
chronic pancreatitis has a nasogastric tube and is NPO.
Which interventions should the nurse implement? Select
all that apply.
l 1. Monitor serum amylase and lipase.
l 2. Weigh the client weekly.
l 3. Assess the intravenous site.
l 4. Provide perineal care.
l 5. Monitor blood glucose levels.
Management Questions
61. The nurse is teaching a class to teachers in an
elementary school about children diagnosed with
hyperinsulinemia. Which would explain the development
of hyperinsulinemia in children?
l 1. The islet cells in the pancreas stop producing any
insulin, leading to type 2 diabetes.
l 2. The child has an excessive intake of calories related
to the amount of energy the child uses.
l
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269
3. The pituitary gland signals the pancreas to increase
the amount of insulin produced.
4. Hyperinsulinemia is a precursor to developing type
1 diabetes mellitus in children.
62. The charge nurse is reviewing laboratory data.
Which data require immediate intervention?
l 1. A creatinine level of 2.8 mg/dL in a client
diagnosed with primary hyperparathyroidism.
l 2. A serum calcium level of 9.2 mg/dL in a client
diagnosed with Addison disease.
l 3. A serum triglyceride level of 130 mg/dL in a client
diagnosed with diabetes mellitus type 2.
l 4. A sodium level of 135 mEq/L in a client diagnosed
with an acute exacerbation of diabetes insipidus.
ANSWERS
60. Correct answer 1, 3, 5: Amylase and lipase are pancreatic enzymes and are monitored to assess the status of the problem. The nurse should assess the
IV for signs of infection or infiltration. Blood glucose levels are monitored because clients with
chronic pancreatitis can develop diabetes mellitus.
Content–Medical; Category of Health Alteration–
Endocrine; Integrated Process–Implementation; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Application.
61. Correct answer 2: The pancreas responds to excessive caloric intake by secreting more insulin to maintain a normal blood glucose level. Hyperinsulinemia
can be identified by markers known as acanthosis
nigricans. This is a precursor to type 2 diabetes.
Clients with type 1 diabetes have no insulin production, and the pituitary gland does not stimulate
insulin production. Content–Medical; Category of
Health Alteration–Endocrine; Integrated Process–
Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
270
62. Correct answer 1: This would indicate the client
is in renal failure, which is a complication of hyperparathyroidism. Stones related to the increased
urinary excretion of calcium and phosphorus form
in the kidneys. This occurs in about 55% of clients
with primary hyperparathyroidism and can lead
to renal failure. All other values are within normal
limits. Content–Medical; Category of Health Alteration–
Endocrine; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Application.
Endocrine Disorders
SECTION FIVE
63. The nurse and UAP are caring for a client diagnosed
with a pheochromocytoma. Which nursing task should
the nurse delegate to the UAP?
l 1. Instruct the UAP to show the client how to work
the call light system.
l 2. Inspect the client's skin for signs of lesions or
discoloration.
l 3. Talk to the client about providing a family history
of adrenal tumors.
l 4. Ask how the high blood pressure has made the
client feel in the past.
64. The nurse is caring for a client 3 days postoperative
unilateral adrenalectomy. Which statement by the client
indicates the client understands the discharge teaching?
l 1. “I will need to taper off my steroid medications
when I no longer need them.”
l 2. “I will use my intranasal vasopressin when I start to
go to the bathroom a lot.”
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271
3. “My urinary catheter will have to stay in until I can
develop bladder control.”
4. “I should call my surgeon if I start running a
temperature over 101ºF.”
65. The female client diagnosed with Cushing disease
asks the nurse. “How long will I look like this? I feel like
a freak.” Which response by the nurse best illustrates the
ethical principal of fidelity?
l 1. “You feel like you look abnormal? We should
discuss how you are feeling about your body.”
l 2. “Some of the changes to your body may improve
with treatment, but there is no guarantee.”
l 3. “Your body will return to the way it looked before
after your adrenalectomy surgery.”
l 4. “I am not sure what you mean by 'freak.' Tell why
you are bothered about your body.”
ANSWERS
63. Correct answer 1: The UAP can orient a new
client to the room and make sure the client is able
to work the call light system. The other options
include obtaining assessment data, and the nurse
must perform these tasks. A family history of adrenal
tumors is a risk factor for a pheochromocytoma.
Content–Medical; Category of Health Alteration–
Endocrine; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Application.
64. Correct answer 4: Any temperature greater than
101ºF would indicate an infection, and the client
will need to be on antibiotics; therefore, the healthcare provider must be notified. The client still has
one adrenal gland and will not be on steroid medications. The client does not have diabetes insipidus
and will not be on vasopression. The client will
not go home with an indwelling catheter. Content–
Surgical; Category of Health Alteration–Endocrine;
Integrated Process–Evaluation; Client Needs–Physiological
Copyright © 2010 F.A. Davis Company
272
Integrity, Physiological Adaptation; Cognitive
Level–Evaluation.
65. Correct answer 2: The ethical principal of fidelity
means to treat all clients the same and how the nurse
would like to be treated. It is the principle on which
the nurse-client relationship is built. This option tells
the client the truth and provides the client with the
opportunity to ask for more clarification. Content–
Medical; Category of Health Alteration–Endocrine;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
Endocrine Disorders
SECTION FIVE
66. The charge nurse on a medical unit is making
rounds after the shift report. Which client should the
charge nurse assess first?
l 1. The adolescent male client who uses anabolic
steroids to increase his muscle size for football.
l 2. The elderly client diagnosed with COPD who
expectorated rusty-colored sputum during the
night.
l 3. The female client who refuses to remove her gown
because of the striae from taking steroids.
l 4. The client whose blood glucose reading averages
140 mg/dL since being placed on steroids.
67. Which client should the charge nurse in the ICU
assign to the most experienced nurse?
l 1. The client diagnosed with thyroid storm who is
1 hour postoperative thyroidectomy.
l 2. The client diagnosed with end-stage renal failure
(ESRD) who had 30 mL of urine output on the
last shift.
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3. The client diagnosed with diabetic ketoacidosis
whose last serum glucose was 220 mg/dL.
4. The client diagnosed with pheochromocytoma
whose blood pressure is 146/92.
68. The home health nurse is caring for a client recently
placed on thyroid hormone replacement medication.
Which signs/symptoms would indicate to the nurse the
client is taking too much medication?
l 1. Complaints of weight loss and fine tremors.
l 2. Complaints of excessive thirst and urination.
l 3. Complaints of constipation and being cold.
l 4. Complaints of delayed wound healing and
belching.
ANSWERS
66. Correct answer 2: Clients diagnosed with COPD
are placed on long-term steroids because of the
inflammation in their lungs. This can mask
infection. Frequently the only sign of an infection
in these clients is a change in the character of the
sputum or a rusty color. The charge nurse should see
this client first. Content–Medical; Category of Health
Alteration–Endocrine; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
67. Correct answer 1: This client has the greatest
potential for being unstable and requires an experienced ICU nurse. The nurse should assess for
signs/symptoms of complications. Any output in a
client with ESRD is good. A serum glucose under
240 mg/dL means the client is no longer in diabetic
ketoacidosis. A pheochromocytoma causes extremely
high blood pressure readings. This client is stable.
Copyright © 2010 F.A. Davis Company
274
Content–Medical; Category of Health Alteration–
Endocrine; Integrated Process–Planning; Client Needs–
Safe Effective Care Environment, Management of Care;
Cognitive Level–Application.
68. Correct answer 1: This would make the nurse suspect the client is taking too much thyroid hormone
because these are symptoms of hyperthyroidism.
Excessive thirst and urination are symptoms of
diabetes. Constipation and feeling cold indicate that
the client is not taking enough thyroid hormone.
Delayed wound healing and belching would indicate
Cushing disease. Content–Medical; Category of Health
Alteration–Drug Administration; Integrated Process–
Evaluation; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Analysis.
SECTION FIVE
Endocrine Disorders
275
69. The nurse is planning the care of the client diagnosed
70. Which laboratory data indicate the client's pancreatitis
with acute pancreatitis. Which client problem is the
priority concern for the client?
l 1. Impaired nutrition.
l 2. Altered skin integrity.
l 3. Ineffective coping.
l 4. Alteration in comfort.
is deteriorating?
l 1. The amylase and lipase serum levels are decreased.
l 2. The white blood cell count (WBC) is decreased.
l 3. The hematocrit has decreased by 5% in a 24-hour
period.
l 4. The blood urea nitrogen (BUN) serum level is
decreased.
ANSWERS
69. Correct answer 4: The client with pancreatitis is in
excruciating pain because the enzymes are autodigesting the pancreas; severe abdominal pain is the
hallmark symptom of pancreatitis. Content–Medical;
Category of Health Alteration–Endocrine; Integrated
Process–Diagnosis; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
276
70. Correct answer 3: A 5% decrease in the hematocrit
level indicates the client is bleeding, probably from
the pancreatic enzymes eating into a blood vessel.
Hemorrhage indicates the client's condition is
deteriorating. Decreased amylase and lipase would
mean the client is improving. Content–Medical;
Category of Health Alteration–Endocrine; Integrated
Process–Assessment; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Application.
SECTION SIX
Musculoskeletal Disorders
277
SECTION SIX
Musculoskeletal Disorders
279
Osteoarthritis
1. The nurse is teaching clients at a community center
3. The client diagnosed with OA is a resident in a
about the risk factors for developing osteoarthritis (OA).
Which is not a modifiable risk factor for developing OA?
l 1. Obesity.
l 2. Age.
l 3. Repetitive recreational use.
l 4. Joint pain.
long-term care facility. Which action by the unlicensed
assistive personnel (UAP) working with the client
warrants immediate intervention by the nurse?
l 1. The UAP allows the client to stay in bed and not
get up.
l 2. The UAP encourages the client to take a warm
shower.
l 3. The UAP performs passive range of motion on the
client’s ankles.
l 4. The UAP assists the client to sit in the chair for
breakfast.
2. Which signs and symptoms would the nurse assess in
the client diagnosed with osteoarthritis (OA)?
l 1. Severe bone deformity in the lower extremities.
l 2. Joint stiffness in the morning.
l 3. Enlarged joint space on x-rays.
l 4. Elevated temperature in the evening hours.
ANSWERS
1. Correct answer 2: Obesity is a well-recognized risk
factor for the development of OA, and it is modifiable
in that the client can lose weight. The client can also
change the level of recreational activity. However, the
client cannot modify age. Pain is a symptom, not a
risk factor. Content–Medical; Category of Health
Alteration–Musculoskeletal; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
2. Correct answer 2: The classic symptoms of OA
include joint stiffness in the morning, pain, and
functional impairment. Severe bone deformity is seen
in clients diagnosed with rheumatoid arthritis (RA).
The joint space is narrowed on x-rays, but clients do
not have a temperature. Content–Medical; Category of
Health Alteration–Musculoskeletal; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
280
3. Correct answer 1: Clients with OA should be
encouraged to move, which will decrease the pain.
Encouraging movement gets the client’s joints in
motion and will limit deformity and pain. The other
actions by the UAP are appropriate. Content–Medical;
Category of Health Alteration–Musculoskeletal; Integrated
Process–Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive Level–
Application.
Musculoskeletal Disorders
SECTION SIX
4. The client who has been diagnosed with OA for 7 years
frequently uses over-the-counter (OTC) nonsteroidal
anti-inflammatory drugs (NSAIDs) for the pain. The
client is pale and short of breath. Which assessment
question should the nurse ask the client?
l 1. “How long does the pain relief last after you take
the medicine?”
l 2. “Do you eat before taking the NSAID pain
medication?”
l 3. “Have you seen a rheumatologist for your
continuing pain?”
l 4. “Would you consider having someone to come in
and help around the house?”
5. The nurse administered ibuprofen, an NSAID,
40 minutes ago to the client diagnosed with osteoarthritis.
Which interventions should the nurse implement at
this time?
l 1. Apply hot moist packs to the client’s affected joints.
l 2. Encourage the client to ambulate in the hallway.
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3. Teach the client how to take the NSAID
medications safely.
4. Assess the amount of relief achieved using a pain
scale.
6. The nurse is caring for clients diagnosed with OA in
a long-term care facility. Which equipment should the
nurse instruct the UAP to utilize when performing
activities of daily living (ADLs)?
l 1. The client’s walking stick for ambulation.
l 2. Splint devices for feeding.
l 3. A shower chair for bathing the client.
l 4. A lap board over the client’s wheelchair.
ANSWERS
4. Correct answer 2: The client is experiencing
symptoms of anemia. NSAIDs can interfere with
prostaglandin production in the stomach and
predispose the client to ulcers, which can lead to
bleeding. Taking the medications with food helps to
prevent this. The nurse should assess how the client
takes the NSAIDs. Content–Medical; Category of
Health Alteration–Musculoskeletal; Integrated
Process–Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
5. Correct answer 4: The nurse should evaluate any pain
as needed (PRN) medication administered within a reasonable time frame. Depending on the evaluation of the
effectiveness of the medication, the nurse might try hot
packs on the affected joints. Clients with osteoarthritis
should ambulate, but this is not evaluating the medication. Content–Medical; Category of Health Alteration–
Musculoskeletal; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Implementation.
Copyright © 2010 F.A. Davis Company
282
6. Correct answer 3: The UAP should use a shower chair
for the safety of the client and UAP. The client should
use a walker or quad cane if needed, not a walking stick.
Lap boards are considered restraints. Content–Medical;
Category of Health Alteration–Musculoskeletal; Integrated
Process–Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
SECTION SIX
Musculoskeletal Disorders
283
7. The nurse is discussing the importance of an exercise
9. The nurse is admitting the client with osteoarthritis to
program for pain control with the client diagnosed with
OA. Which information should the nurse include in the
teaching plan? Select all that apply.
l 1. Wear supportive walking shoes with white socks
when walking.
l 2. Carry a complex carbohydrate while exercising.
l 3. Alternate walking briskly and jogging when
exercising.
l 4. Walk at least 20–30 minutes every day.
l 5. Use a walker to ambulate if unsteady or weak.
the medical floor. Which statement by the client indicates
the client is using a complementary and alternative
medicine (CAM) form of treatment for OA?
l 1. “I take ibuprofen every 4–6 hours for my pain.”
l 2. “I use a heating pad when my joints are stiff.”
l 3. “I wear my copper bracelet to help with my OA.”
l 4. “I always wear my ankle splints when I sleep.”
8. The client diagnosed with OA asks the clinic nurse
“Is there anything I can take to help treat my disease?”
Which is the nurse’s best response?
l 1. “No; nothing helps the disease once it has started.”
l 2. “Some clients use glucosamine and chondroitin.”
l 3. “You can take over-the-counter pain medications.”
l 4. “Daily exercise helps to decrease the pain and
stiffness.”
10. The nurse is caring for the following clients. After
receiving the shift report, which client should the nurse
assess first?
l 1. The client who had a total knee replacement and is
complaining of pain.
l 2. The client who has a prophylactic antibiotic on call to
surgery.
l 3. The client diagnosed with back pain who is scheduled
for a laminectomy.
l 4. The client diagnosed with osteoarthritis who fell and
cannot move the leg.
ANSWERS
7. Correct answer 1, 4, 5: Safety should always be
discussed when teaching about exercises; using a
walker and supportive shoes will prevent shin splints.
Colored socks have dye that may cause athlete’s feet;
that is why white socks are recommended. For
exercising to help control pain, the client must walk
daily. Content–Medical; Category of Health Alteration–
Musculoskeletal; Integrated Process–Planning; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
8. Correct answer 2: Glucosamine and chondroitin
improve tissue function and retard the breakdown of
cartilage. The client asked if there was something that
could be taken, not if there was something that could
be done to improve the disease. Over-the-counter
(OTC) pain medications do not treat the disease; they
simply alleviate the pain. Content–Medical; Category of
Health Alteration–Musculoskeletal; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
284
9. Correct answer 3: Alternative forms of treatment,
including wearing a copper bracelet, have no proven
efficacy in the treatment of a disease. The nurse
should be nonjudgmental and open to discussions
about alternative treatment unless it interferes with
the medical regimen. Medications and heating pads are
standard medical treatment. Ankle splints will not help
OA. Content–Medical; Category of Health Alteration–
Musculoskeletal; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
10. Correct answer 4: Inability to move the leg after a
fall indicates a possible fracture. The nurse should
assess this client first. Pain after surgery is expected.
Scheduled activities are not priority over a client
with an injury. Content–Medical; Category of Health
Alteration–Musculoskeletal; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
SECTION SIX
Musculoskeletal Disorders
285
Osteoporosis
11. The nurse is discussing osteoporosis with a group
13. The nurse is caring for clients in a long-term care
of women. Which factor will the nurse identify as a
modifiable risk factor?
l 1. History of Crohn disease.
l 2. Tobacco use.
l 3. Being of childbearing age.
l 4. Lack of alcohol intake.
facility. Which signs/symptoms would make the nurse
suspect that a client has developed osteoporosis?
l 1. The elderly female client walks stooped over.
l 2. The elderly female client has lost 12 pounds in the
last year.
l 3. The elderly male client’s hands are painful when
touched.
l 4. The elderly male client’s serum uric acid level is
elevated.
12. The client diagnosed with osteoporosis asks the nurse,
“Why does lack of sun exposure cause my bones to be
brittle?” Which response by the nurse would be most
appropriate?
l 1. “Your body requires vitamin D from sunlight to use
the calcium you eat.”
l 2. “You can substitute vitamin C over-the-counter for
being out in the sun.”
l 3. “Calcium is produced by the sun when you are
exposed to sunlight.”
l 4. “Your bones need sunlight to become strong and
healthy.”
14. The client is being evaluated for osteoporosis. Which
diagnostic test is the most accurate?
l 1. X-ray of the chest.
l 2. Serum alkaline phosphatase.
l 3. Dual-energy x-ray absorptiometry (DEXA).
l 4. Serum bone Gla-protein test.
ANSWERS
11. Correct answer 2: Smoking is a modifiable risk factor
for developing osteoporosis, as is not participating
in weight-bearing exercises, alcohol consumption,
and lack of exposure to sunlight. Nicotine slows the
production of osteoblasts and impairs the absorption
of calcium, contributing to decreased bone density.
Malabsorption syndrome is a non-modifiable risk
factor, as is being of childbearing age. Content–Medical;
Category of Health Alteration–Musculoskeletal; Integrated
Process–Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
12. Correct answer 1: Vitamin D is required for the body
to be able to absorb calcium from foods consumed,
and an adequate intake of calcium is essential for bone
health. Vitamin C is not a substitute for vitamin D.
Content–Medical; Category of Health Alteration–
Musculoskeletal; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
286
13. Correct answer 1: Osteoporosis is most common
in postmenopausal women. As the vertebrae lose
calcium, the client loses height and begins to walk
stooped over. A loss of height occurs as vertebral
bodies collapse. Content–Medical; Category of Health
Alteration–Musculoskeletal; Integrated Process–
Assessment; Client Needs–Safe Effective Care
Environment, Health Promotion and Maintenance;
Cognitive Level–Analysis.
14. Correct answer 3: The DEXA test measures bone
density in the lumbar spine or hip and is considered to
be highly accurate. Chest x-rays are most useful in
diagnosing lung problems. Serum alkaline phosphatase
serum blood studies are elevated after a fracture. The
serum bone Gla-protein test is most useful to evaluate
the effects of treatment of osteoporosis rather than as
an indicator of the severity of bone disease. Content–
Medical; Category of Health Alteration–Musculoskeletal;
Integrated Process–Assessment; Client Needs–Physiological
Integrity, Reduction of Risk Potential; Cognitive
Level–Analysis.
SECTION SIX
Musculoskeletal Disorders
287
15. The nurse knows the client diagnosed with osteoporosis
17. The female client diagnosed with osteoporosis tells
understands the dietary teaching when the client makes
which menu selection?
l 1. Oatmeal with brown sugar, bacon, and orange
juice.
l 2. French toast with maple syrup, sausage, and coffee.
l 3. Whole wheat toast, poached eggs, and a diet cola.
l 4. Cold cereal with milk, yogurt, and decaffeinated
coffee.
the nurse that she is going to try to exercise regularly.
Which exercise should the nurse recommend?
l 1. Walk 30 minutes a day.
l 2. Swim several laps every day.
l 3. Perform isometric exercise every other day.
l 4. Passive range-of-motion exercises weekly.
16. The gynecological clinic nurse is caring for
postmenopausal clients. Which intervention is an
example of a primary nursing intervention when
discussing osteoporosis?
l 1. Obtain a bone density evaluation test.
l 2. Perform non-weight-bearing exercises regularly.
l 3. Increase the intake of dietary calcium.
l 4. Tell the client to limit smoking to one pack
per day.
18. The nurse is teaching a class to pregnant teenagers.
Which information is most important when discussing
ways to prevent osteoporosis later in life?
l 1. Perform pelvic stretching exercises twice a day.
l 2. Eat foods low in calcium and high in phosphorus.
l 3. Take at least 1200 mg of calcium supplements a day.
l 4. Remain as active as possible until the baby is born.
ANSWERS
15. Correct answer 4: The best dietary sources of calcium,
which is needed for those with osteoporosis, are
milk, other daily products, yogurt, oysters, canned
sardines or salmon, beans, cauliflower, and dark
green leafy vegetables. Content–Medical; Category
of Health Alteration–Musculoskeletal; Integrated
Process–Evaluation; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive
Level–Synthesis.
16. Correct answer 3: Primary nursing interventions are
aimed at prevention of the problem. Increasing
dietary calcium is a primary intervention to help
prevent osteoporosis or tertiary intervention that
helps treat osteoporosis. The client should perform
weight-bearing exercises and stop smoking
completely. Content–Medical; Category of Health
Alteration–Musculoskeletal; Integrated Process–
Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
288
17. Correct answer 1: Weight-bearing activity, such as
walking, is beneficial in preventing or slowing
bone loss; the mechanical force of weight-bearing
exercises promotes bone growth. Swimming is not
as beneficial in maintaining bone density because of
the lack of weight-bearing activity. Isometric exercises
are for body building, and passive exercise requires
no effort by the client. Content–Medical; Category
of Health Alteration–Musculoskeletal; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
18. Correct answer 3: The National Institutes of Health
recommend a daily calcium intake of 1200–1500 mg
per day for adolescents and young adults as well as
for pregnant and lactating women. Taking calcium
throughout the life span will help prevent osteoporosis.
Activity will not help prevent osteoporosis in the
teenager. Content–Medical; Category of Health
Alteration–Musculoskeletal; Integrated Process–Planning;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Synthesis.
SECTION SIX
Musculoskeletal Disorders
Herniated Disc Disease/Low
Back Pain
19. The 84-year-old client is a resident in a long-term
21. The clinic nurse is caring for an elderly client
care facility. Which interventions should the nurse
implement to prevent complications secondary to
osteoporosis?
l 1. Administer 1 oz. of Maalox daily.
l 2. Perform passive range-of-motion exercises.
l 3. Turn the client every 2 hours.
l 4. Use a gait belt when ambulating the client.
diagnosed with lower back pain and possible ruptured
disc. Which discharge instructions should the nurse
teach the client?
l 1. When lifting heavy objects, hold them near
the body.
l 2. Perform lower-back strengthening exercises.
l 3. Use an antidiarrheal medication when taking
narcotics.
l 4. Return to the office to demonstrate the Credé
maneuver for voiding.
20. The client is prescribed 3 g of calcium supplement a
day. The medication comes in 600 mg/tablet with added
vitamin D. How many tablets should the client take
daily?
Answer: ____________________
289
ANSWERS
19. Correct answer 4: Gait belts will help prevent
the client from falling; fractures are the primary
complication of osteoporosis. Maalox does not treat
osteoporosis. Content–Medical; Category of Health
Alteration–Musculoskeletal; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
20. Correct answer 5 tablets: 1000 mg = 1 g; therefore,
3 g = 3000 mg; 1 tablet is 600 mg, so the client
will need 5 tablets to get the total amount of
calcium needed daily; 3000 mg ! 600 mg = 5 tablets.
Content–Fundamentals; Category of Health Alteration–
Drug Administration; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
290
21. Correct answer 2: The client should be taught
exercises to strengthen the lower back muscles.
Clients with a possible ruptured disc should not be
lifting heavy objects. The Credé maneuver is for
clients with a neurogenic bladder; the client voids
because a rolling pressure is applied to the lower
abdomen. The client taking codeine is at risk for
developing constipation; antidiarrheals should not be
taken prophylactically. Content–Medical; Category of
Health Alteration–Musculoskeletal; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive
Level–Application.
Musculoskeletal Disorders
SECTION SIX
22. The 34-year-old male client presents to the
outpatient clinic complaining of numbness and pain
radiating down his left leg. Which intervention should
the nurse implement first?
l 1. Ask the client to stand up and walk away from the
nurse.
l 2. Tell the client to bend over at the waist and stoop
to pick up a pencil.
l 3. Have the client lie down and lift his legs one at a
time into the air.
l 4. Request the client to twist from the waist and neck
to assess for mobility.
23. The employee health nurse in a hospital is preparing
an in-service for a group of nursing staff members. Which
statement provides information the nurse should teach
the staff members?
l 1. “Back pain is caused when the discs between the
vertebrae dry out.”
l 2. “Always get assistance when lifting or turning a
large client.”
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3. “Try not to use lifting devices because they can
weaken your back muscles.”
4. “Workers’ compensation will cover your living
expenses for on-the-job injuries.”
24. The occupational health nurse is planning health
promotion activities for a group of factory workers.
Which activity is an example of primary prevention of
low back pain?
l 1. Provide instructions on how to complete incident
reports.
l 2. Arrange a pot-luck lunch program for the staff.
l 3. Administer a non-narcotic analgesic to a worker
complaining of back pain.
l 4. Teach proper use of body mechanics to all workers.
ANSWERS
22. Correct answer 1: Posture and gait will be affected
if the client is experiencing sciatica, pain radiating
down a leg resulting from pressure on the sciatic
nerve. The client with pain and numbness would not
be able to bend or stoop and should not be asked to
do so. Content–Medical; Category of Health Alteration–
Musculoskeletal; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Synthesis.
23. Correct answer 2: This is a case of “always” being the
correct answer. The nurse should protect both the
staff’s and the client’s safety by getting lift assistance
before attempting to lift a heavy client. A back injury
can result in a permanent disability. Workers’ compensation covers part of the lost wages. There is no guarantee that it will cover all the nurse’s living expenses.
Content–Medical; Category of Health Alteration–
Musculoskeletal; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Safety and
Infection Control; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
292
24. Correct answer 4: Primary interventions are
concentrated on preventing an illness or injury.
Teaching proper body mechanics will help prevent
low back pain. None of the other options will
prevent back pain. Content–Medical; Category of
Health Alteration–Musculoskeletal; Integrated
Process–Planning; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Synthesis.
Musculoskeletal Disorders
SECTION SIX
25. The nurse is caring for a client diagnosed with a
cervical neck injury. The client complained of pain of a
3 on a 1-to-10 pain scale, and the nurse positioned the
client and turned on the radio. After 25 minutes, the
client states the pain is still at a 3. Which intervention
should the nurse implement next?
l 1. Tell the client to wait a while to see if positioning
will work.
l 2. Obtain a heating pad for the client to use on
the neck.
l 3. Administer acetaminophen (Tylenol) ES, a
non-narcotic analgesic.
l 4. Prepare to administer morphine sulfate, a narcotic
analgesic.
26. The client diagnosed with cervical neck disc
degeneration has undergone a laminectomy. Which
interventions should the nurse implement? Select all that
apply.
l 1. Position the client supine with the head on a small
pillow.
l 2. Assess the client for difficulty speaking or breathing.
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3. Measure the drainage in the Jackson-Pratt bulb
every 8 hours.
4. Encourage the family to give patient-controlled
analgesia (PCA) when needed.
5. Log-roll the client every 4–6 hours and prn.
27. The client is 12-hours post lumbar disc and fusion.
Which interventions should the nurse implement?
l 1. Place the client on a regular bedpan for voiding.
l 2. Keep the bed in the Trendelenburg position.
l 3. Place sand bags on each side of the head.
l 4. Administer subcutaneous anticoagulants.
28. The nurse is working with a UAP. Which nursing
task should the nurse not delegate to the UAP?
l 1. Feed a client 2 days postoperative for a cervical
laminectomy a regular diet.
l 2. Help a client who is 12-hours post lumbar
laminectomy sit on the side of the bed.
l 3. Assist the obese client diagnosed with back pain to
the bedside commode.
l 4. Place the call light within reach of the client who
has had surgery.
ANSWERS
25. Correct answer 3: The client’s pain is at a level 3,
indicating mild pain. The nurse should administer
Tylenol. Content–Medical; Category of Health
Alteration–Musculoskeletal; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
26. Correct answer 1, 2, 3: The client should be positioned supine with a very small pillow. Difficulty
speaking or breathing would indicate a potentially
life-threatening problem. The surgical position of the
wound places the client at risk for edema in the neck.
The drainage should be measured every shift. Only
the client pushes the PCA button. Turning is every
2 hours, not every 4–6 hours. Content–Surgical;
Category of Health Alteration–Musculoskeletal; Integrated
Process–Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
294
27. Correct answer 4: Prophylactic anticoagulants
are prescribed to prevent deep vein thrombosis.
The client should use a fracture pan for voiding. The
bed in not kept “head down” in the Trendelenburg
position. The client had a lumbar procedure, not a
cervical procedure, so sand bags on each side of the
head are not required. Content–Surgical; Category of
Health Alteration–Musculoskeletal; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
28. Correct answer 2: This client should not be up until
the surgeon writes the order. At 12 hours the client
is still being log-rolled. The other options can be
delegated to a UAP. Content–Medical; Category of
Health Alteration–Musculoskeletal; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
Musculoskeletal Disorders
SECTION SIX
29. The charge nurse is caring for clients on an orthopedic
floor. Which client should be assigned to the most
experienced nurse?
l 1. The client diagnosed with back pain who is
complaining of a 4 on a 1–10 pain scale.
l 2. The client who has undergone a myelogram and
who is complaining of a slight headache.
l 3. The client who is 2 days postoperative disc and
fusion who has a T 100.4ºF, P 96, R 24, and
BP 138/78.
l 4. The client with back pain who is angry that he has
not gotten his pain medication.
30. The nurse is administering medications at 0730 to
clients on a medical orthopedic unit. Which medication
should be administered first?
l 1. The ACE inhibitor to a client diagnosed with
back pain and hypertension.
l 2. The heparin bag on a client diagnosed with
pulmonary embolus.
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3. The oral proton pump inhibitor to a client
scheduled for a laminectomy this morning.
4. The IV antibiotic for a client diagnosed with a
postsurgical infection.
Fractures
31. The client is admitted to the emergency department
with an injury to the left leg. Which action should the
nurse implement first?
l 1. Assess the client’s left dorsalis pedis pulse.
l 2. Elevate the left extremity on two pillows.
l 3. Call Radiology for a stat x-ray of the extremity.
l 4. Ask the client how the injury occurred.
32. Which intervention should the nurse perform for the
client diagnosed with a closed fracture of the left ankle?
l 1. Apply an immobilizer snuggly to prevent edema.
l 2. Apply a covered ice pack to the left ankle.
l 3. Place the extremity in the dependent position.
l 4. Administer tetanus 0.5 mL intramuscular (IM) in
the client’s upper arm.
ANSWERS
29. Correct answer 3: This client is postoperative and
now has a fever, possibly indicating an infection,
and should be assigned to the most experienced
nurse. The patient with pain rated as 4 has mild-tomoderate pain, and an angry patient can be assigned
to a less experienced nurse. The patient with a
headache following a myelogram can also be cared
for by a less experienced nurse. Content–Medical;
Category of Health Alteration–Musculoskeletal;
Integrated Process–Planning; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
30. Correct answer 2: Heparin has a short half-life, and
the infusion must be maintained at a continuous rate
to remain therapeutic. Content–Medical; Category of
Health Alteration–Drug Administration; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Application.
Copyright © 2010 F.A. Davis Company
296
31. Correct answer 1: The nurse should first assess
the foot for any neurovascular compromise before
taking any further action. Elevating the extremity
to decrease edema, obtaining an x-ray, and asking
how the injury occurred should be implemented but
not before assessing the extremity. Content–Medical;
Category of Health Alteration–Musculoskeletal;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
32. Correct answer 2: Ice packs should be applied to
cause vasoconstriction to help decrease edema; ice
is a nonpharmacological pain management technique.
An immobilizer should not be applied snuggly because
it will impair circulation to the extremity; the leg
should be elevated; and tetanus is administered with
open fractures or wounds, not with closed fractures.
Content–Medical; Category of Alteration–Musculoskeletal;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Basic Care and Comfort;
Cognitive Level–Synthesis.
SECTION SIX
Musculoskeletal Disorders
297
33. The nurse is caring for a client with a fractured left
35. The 85-year-old client admitted with a diagnosis of a
tibia and fibula. Which data should the nurse report to
the health-care provider (HCP) immediately?
l 1. Ecchymosis of the left lower extremity.
l 2. Deep unrelenting pain of the left leg.
l 3. Capillary refill time of 2 seconds of the toes.
l 4. The left foot has a 2+ dorsalis pedal pulse.
right fractured hip is in Buck traction and is complaining
of pain of 8 on a 1–10 pain scale. Which action should
the nurse take first?
l 1. Check the client’s medication administration
record (MAR) to determine the last time pain
medication was administered.
l 2. Ensure that the weights of the Buck traction are off
the floor and hanging freely.
l 3. Administer the prn intravenous narcotic analgesic
diluted over 5 minutes.
l 4. Insert an abductor pillow securely between the
client’s legs with two leg straps.
34. The client with a fractured right femur is exhibiting
dyspnea, has adventitious breath sounds, and has
petechiae over the chest area. Which intervention
should the nurse implement?
l 1. Assess the client’s right leg for movement.
l 2. Obtain the client’s arterial blood gases.
l 3. Notify the client’s HCP immediately.
l 4. Encourage the client to cough and deep breathe.
36. The nurse is discussing cast care with the parents of a
12-year-old male client with a fractured humerus. Which
statement indicates the mother understands the teaching?
l 1. “I will keep my son’s arm level with his chest.”
l 2. “There may be some hot areas on his cast.”
l 3. “If he complains of itching I will apply ice
to the cast.”
l 4. “After time the cast will probably start smelling.”
ANSWERS
33. Correct answer 2: Deep unrelenting pain may
indicate compartment syndrome, which is a
complication of a fracture and requires immediate
attention. Ecchymosis (bruising), capillary refill time
less than 3 seconds, and 2+ pedal pulse are all
normal data. Content–Medical; Category of Health
Alteration–Musculoskeletal; Integrated Process–
Evaluation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Synthesis.
34. Correct answer 3: These symptoms indicate a fat
embolism, which is a life-threatening emergency;
therefore, the HCP should be notified. The other
interventions will not treat a fat embolism. Content–
Medical; Category of Health Alteration–Musculoskeletal;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
298
35. Correct answer 2: Weights from traction should be
off the floor and hanging freely. Buck traction is
used to reduce muscle spasms preoperatively in
clients who have fractured hips; therefore, this
intervention should be implemented first to see
if the weights need adjustment. If the weights
are adjusted, determine if this relieves the pain,
before medicating an elderly client with a narcotic
analgesic. Content–Medical; Category of Alteration–
Musculoskeletal; Integrated Process–Evaluation; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
36. Correct answer 3: Applying ice packs to the cast
will help relieve itching. Nothing should be placed
down a cast to scratch because the skin may be torn
easily, resulting in an infection. The arm should be
elevated above the chest. Hot areas and an odor may
indicate an infection. Content–Medical; Category of
Health Alteration–Musculoskeletal; Integrated Process–
Evaluation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Evaluation.
Copyright © 2010 F.A. Davis Company
SECTION SIX
Musculoskeletal Disorders
299
37. The nurse is caring for a client diagnosed with a
39. The orthopedic nurse is admitting a female client
fracture of the distal right humerus. Which data should
the nurse assess? Select all that apply.
l 1. Ask the client if there is any tingling in the extremity.
l 2. Assess the client’s brachial and radial pulses.
l 3. Check the client’s pulse oximeter reading bilaterally.
l 4. Evaluate for point tenderness and crepitus.
l 5. Determine if the client can move the fingers of the
right hand.
with a compound fracture of the right fibula. Which
intervention should the nurse implement?
l 1. Prepare the client for insertion of skeletal traction.
l 2. Complete the client’s preoperative checklist.
l 3. Discuss purchasing a wheelchair for mobility.
l 4. Place the client in a continuous passive motion
(CPM) machine.
38. An 88-year-old-client is admitted to the orthopedic
client should the nurse assess first after receiving the
morning shift report?
l 1. The client with a compound fracture of the fibula
who will not use the incentive spirometer.
l 2. The client with a fractured left humerus who
denies tingling and numbness of the fingers.
l 3. The client with a fractured right ankle that is
edematous and has ecchymotic areas.
l 4. The client with a fractured left femur who is
having chest pain and shortness of breath.
floor with the diagnosis of fractured pelvis. Which
assessment data would warrant immediate intervention?
l 1. The client has clear-colored, amber urine in the
indwelling catheter.
l 2. The client is complaining of pain in the lower
abdominal area.
l 3. The client’s bowel sounds in all four quadrants are
hypoactive.
l 4. The client’s lower extremities are warm and pink
bilaterally.
40. The nurse is working on an orthopedic unit. Which
ANSWERS
37. Correct answer 1, 2, 4, 5: The nurse should assess
for paresthesia, paralysis, pulses, point tenderness,
and crepitus, with the arm handled gently. The
client’s peripheral oxygen level does not need to be
assessed. The client’s capillary refill could be assessed.
Content–Medical; Category of Health Alteration–
Musculoskeletal; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Analysis.
38. Correct answer 3: Decreasing bowel sounds
could indicate a possible ileus, which is a common
complication of a fractured pelvis. Clear-colored urine,
pain, and warm extremities would be expected.
Content–Medical; Category of Health Alteration–
Musculoskeletal; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
300
39. Correct answer 2: The client will be scheduled for
surgery; therefore, completing the preoperative check
list would be appropriate. The client would not have
skeletal traction or a CPM machine, which is used
for knee replacement, and a client with a fracture of
the arm would not need a wheelchair.
Content–Medical; Category of Health Alteration–
Musculoskeletal; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
40. Correct answer 4: Chest pain and shortness of
breath may indicate a fat embolus, which is a lifethreatening emergency; therefore, this client should
be assessed first. Not using the incentive spirometer,
edema, and ecchymosis are not life-threatening. No
paresthesia is a normal finding. Content–Medical;
Category of Health Alteration–Musculoskeletal;
Integrated Process–Planning; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
SECTION SIX
Musculoskeletal Disorders
301
Amputation
41. The nurse is caring for a client who had a right
43. The 62-year-old client diagnosed with type 2
below-the-knee amputation (BKA) 2 days ago. Which
intervention should the nurse implement?
l 1. Keep the residual limb elevated on two pillows.
l 2. Place the client in the prone position frequently.
l 3. Put the prosthetic limb on when ambulating the
client.
l 4. Maintain the client’s right leg in Buck traction.
angiocatheter who has a gangrenous right toe is being admitted for a BKA amputation. Which intervention
should the nurse implement?
l 1. Refer the client to the certified diabetic educator
(CDE).
l 2. Check the client’s right pedal pulse.
l 3. Determine if the client is allergic to intravenous
(IV) dye.
l 4. Start an 18-gauge angiocatheter in the upper
extremity.
42. The recovery room nurse is caring for a client who
has just had a left BKA. The client’s surgical dressing is
saturated with blood, the apical pulse is elevated, and the
blood pressure is decreased. Which intervention should
the nurse implement first?
l 1. Notify the client’s surgeon immediately.
l 2. Place the client in the Trendelenburg position.
l 3. Place a large tourniquet proximal to the surgical
dressing.
l 4. Reinforce the surgical dressing with 4 × 4 gauze.
44. The male nurse is helping his friend Joe cut wood
with an electric saw. Joe accidently cut two fingers off his
right hand with the electric saw. Which action should the
nurse take first?
l 1. Wrap the right hand with towels and apply
pressure.
l 2. Instruct Joe to hold the right hand above his head.
l 3. Recover Joe’s two fingers if at all possible.
l 4. Drive Joe to the nearest emergency room.
ANSWERS
41. Correct answer 2: The prone position will help
302
43. Correct answer 4: The nurse should start an 18-gauge
stretch the hamstring muscle, which will help prevent
flexion contractures that may lead to problems when
fitting the client for a prosthetic limb. The residual
limb should be elevated for 24 hours only, and the
client will not be fitted for a prosthetic limb until
4–6 weeks after surgery. Content–Surgical; Category of
angiocatheter because the client is having surgery and
may need to have blood products. This is not the appropriate time to refer the client to the CDE. The
client’s right foot is being amputated, so there is no
reason to assess the right pedal pulse. Intravenous dye
is not used during this surgical procedure. Content–
Health Alteration–Musculoskeletal; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive Level–
Application.
Surgical; Category of Health Alteration–Musculoskeletal;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care; Cognitive Level–Application.
42. Correct answer 3: The client is hemorrhaging, and the
bleeding must be stopped first; placing a tourniquet
above the dressing will stop the arterial bleeding. Then
the nurse should notify the surgeon, reinforce the surgical dressing, and place the client in the Trendelenburg position. Content–Surgical; Category of Health
Alteration–Musculoskeletal; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
44. Correct answer 1: Applying pressure will help
decrease the bleeding, which is the first intervention.
Then have Joe elevate his right hand to further
decrease the bleeding, recover the amputated parts,
and get Joe to the emergency department. Content–
Medical; Category of Health Alteration–Musculoskeletal;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
SECTION SIX
Musculoskeletal Disorders
303
45. A man accidentally cut off his right big toe with
47. The female client is 3 hours postoperative left AKA.
an axe. The man’s wife is a nurse. Which action should
the nurse implement to preserve the big toe so that it
could possibly be reattached in surgery?
l 1. Place the right toe in a bowl with crushed ice cubes.
l 2. Take no action because the toe cannot be reattached.
l 3. Secure the toe in a plastic bag and bring it to the
hospital.
l 4. Put the toe in a clean piece of material and place
on ice.
The client tells the nurse, “My left foot is killing me.
Please do something.” Which action by the licensed
practical nurse (LPN) would require intervention by
the RN?
l 1. The LPN tells the client that her left leg has been
amputated and that she cannot be in pain.
l 2. The LPN checks the MAR and medicates the
client with a narcotic analgesic.
l 3. The LPN checks the client’s vital signs and the
surgical dressing for bleeding.
l 4. The LPN readjusts the residual limb and ensures it
is elevated on two pillows.
46. The Jewish client with peripheral vascular disease is
scheduled for a left above the knee amputation (AKA).
Which information should the nurse obtain during the
admission interview?
l 1. Ask the client if the local rabbi has blessed the
left leg.
l 2. Determine if the client will accept any blood
products.
l 3. Ask if the client has seen the occupational
therapist (OT).
l 4. Determine if the client has arrangements for the
amputated limb.
ANSWERS
304
45. Correct answer 4: Placing the big toe in material and
47. Correct answer 1: Phantom pain is caused by severing
placing it on ice will help preserve it so that it may be
reconnected in surgery. The toe should not be placed
directly on ice because this will cause necrosis of
viable tissue. A surgeon will attempt to reattach a toe,
but not an entire leg. Content–Surgical; Category of
the peripheral nerves, and the pain is real to the client.
The RN must intervene when the LPN makes this
statement to the client. The nurse needs to medicate
the client immediately. Checking for complications,
medicating the client, and elevating the residual limb
are appropriate interventions. Content–Surgical;
Health Alteration–Musculoskeletal; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive Level–
Analysis.
46. Correct answer 4: Judaism believes that all body parts
must be buried together; therefore, many synagogues
will keep amputated limbs until death occurs. Rabbis
do not bless legs; blood product administration is
addressed on the operative permit; and OTs address
upper extremity amputation, not lower extremity
amputations. Content–Surgical; Category of Health
Alteration–Musculoskeletal; Integrated Process–Planning;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
Category of Health Alteration–Musculoskeletal; Integrated
Process–Assessment; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive Level–
Analysis.
Musculoskeletal Disorders
SECTION SIX
48. The nurse is caring for clients on a surgical unit.
Which nursing task would be appropriate for the nurse
to delegate to the UAP?
l 1. Tell the UAP to assist the lower-extremity amputee
to ambulate down the hall.
l 2. Ask the UAP to take vital signs on a client who is
exhibiting signs of hypovolemia.
l 3. Request the UAP to change the dressing on the
client with a Syme amputation.
l 4. Instruct the UAP to obtain the height and weight
on a newly admitted client.
49. The client in the rehabilitation unit who is 1 week
postoperative right AKA is being taught how to prepare
the residual limb for a prosthetic device. Which
intervention should the nurse implement? Select all
that apply.
l 1. Instruct the client to push the residual limb against
a pillow.
l 2. Demonstrate how to apply an Ace bandage around
the residual limb.
l
l
l
305
3. Encourage the client to apply vitamin B12 to the
surgical incision.
4. Tell the client to press the residual limb against a
hard surface.
5. Explain the importance of wearing a limb sock
under the prosthesis.
50. The 27-year-old client has a right above the elbow
amputation secondary to a motor vehicle accident. Which
statement by the client indicates to the nurse the client
has accepted the amputation?
l 1. “I am going to the vocational therapist to get
assistance with job retraining.”
l 2. “I know I will never be able to use my left arm to
write, eat, or brush my teeth.”
l 3. “I keep waking up at night and thinking this could
not have happened to me.”
l 4. “If I could just get my arm back I would be the
best person I could be.”
ANSWERS
48. Correct answer 4: The UAP can obtain height and
weight on a client who is stable. The amputee client
should ambulate with the nurse or physical therapist
only. The UAP cannot care for clients who are
unstable, such as one exhibiting signs of hypovolemia,
and cannot change surgical dressings. Content–Surgical;
Category of Health Alteration–Musculoskeletal; Integrated
Process–Planning; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive Level–
Synthesis.
49. Correct answer 1, 2, 4, 5: Applying pressure against
a pillow will help toughen the limb, and then pushing
gradually against a harder surface will help prepare it
for a prosthesis. An Ace bandage applied distal to
proximal will help decrease edema and help shape the
residual limb into a conical shape for the prosthesis. A
limb sock should be worn to help prevent irritation to
the residual limb. Vitamin B12 will help decrease the
angriness of the scar, but it will not help with residual
limb toughening. Content–Surgical; Category of Health
Copyright © 2010 F.A. Davis Company
306
Alteration–Musculoskeletal; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
50. Correct answer 1: Looking toward the future and
problem solving indicate that the client is accepting
the loss. Negative thinking, depression, denial, and
bargaining indicate the client is not accepting the
loss. Content–Surgical; Category of Health Alteration–
Musculoskeletal; Integrated Process–Evaluation; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Evaluation.
SECTION SIX
Musculoskeletal Disorders
307
Joint Replacements
51. The nurse is caring for a client 3 days postoperative
53. The nurse is preparing the client who received a
total knee replacement (TKR) of the left knee. Which
intervention should the nurse implement?
l 1. Keep abduction pillow in place between the legs at
all times.
l 2. Place knee-high hose on the client to keep the
feet warm.
l 3. Feed the client in a semi-Fowler position.
l 4. Obtain a high-seated bedside commode for the
client to use.
THR for discharge. Which statement indicates the client
understands the discharge teaching?
l 1. “I should not cross my legs to prevent the hip from
coming out of the socket.”
l 2. “I may expect a sudden increase in pain when I try
new activities.”
l 3. “I can sit in my soft, cushiony recliner when
I get home.”
l 4. “After 3 weeks, I don’t have to worry about
infection.”
52. The male client 4 days postoperative right total hip
replacement (THR) tells the nurse he heard a
“popping sound” when he was turned by the UAP.
Which question should the nurse ask the client?
l 1. “Did the UAP keep you covered while turning you?”
l 2. “When did you notice the popping sound?”
l 3. “Do you have any groin pain on the right side?”
l 4. “Is the swelling at the incision site larger than
before?”
54. When assessing the wound of a client who had a
THR, the nurse finds small, fluid-filled lesions along the
side of the dressing. Which intervention should the nurse
implement?
l 1. Notify the surgeon immediately.
l 2. Place the client in contact isolation.
l 3. Obtain a nonallergenic tape to use.
l 4. Use nonlatex gloves to change the dressing.
ANSWERS
51. Correct answer 4: Using a high-seated bedside
commode and chair will help the client to be able to
sit down and rise up without placing pressure on the
knee. The abduction pillow is used for hip surgery.
The client may sit upright as tolerated. Nonskid
booties may be used. Content–Surgical; Category of
Health Alteration–Musculoskeletal; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive Level–
Application.
52. Correct answer 3: Groin pain or increasing discomfort in the affected leg and the “popping sound”
indicate that the leg is dislocated and should be
reported immediately to the physician. Protecting
the client’s modesty is good but not important at
this time. The client told the nurse when he heard
the popping sound. The nurse should not ask the
client to assess himself. Content–Surgical; Category
of Health Alteration–Musculoskeletal; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
308
53. Correct answer 1: Clients should not cross their legs
because that position increases the risk for dislocation.
If the client experiences a sudden increase in pain in
the joint or surrounding area, the client should notify
the HCP. Clients should sit in chairs with firm seats
and high arms. These will decrease the risk of
dislocating the hip joint. Infections are possible
months after surgery. Content–Surgical; Category of
Health Alteration–Musculoskeletal; Integrated Process–
Evaluation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Evaluation.
54. Correct answer 3: The small fluid-filled lesions are
mostly likely due to the tape used to adhere the
dressing. The nurse should change the type of tape
being applied to the client’s skin. Content–Surgical;
Category of Health Alteration–Musculoskeletal; Integrated
Process–Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive Level–
Synthesis.
SECTION SIX
Musculoskeletal Disorders
309
55. Which interventions should the nurse include in the
57. The female client postoperative TKR asks the nurse
discharge teaching for the client after having a THR?
Select all that apply.
l 1. Inform the client not to bear weight on the
affected side.
l 2. Demonstrate how to use a walker.
l 3. Attempt to resume normal activity on returning
home.
l 4. Instruct the client to use the pain medication when
the pain is at an 8 on a 1–10 scale.
l 5. Discuss planning for periods of rest.
“They did surgery on my knee, so why do I have tiny
bruises on my upper abdomen?” Which intervention
should the nurse implement first?
l 1. Inform the client that the small bruises are from a
medication.
l 2. Check the MAR for parenteral anticoagulant
medication orders.
l 3. Report the data to the HCP on rounds.
l 4. Assess the client’s abdomen and document the
finding in the chart.
56. The nurse is caring for a client 6 hours post right
58. The nurse is caring for a client who had a TKR
TKR. Which data warrant immediate intervention
by the nurse?
l 1. 100 mL of red drainage in the auto-transfusion
drainage system.
l 2. The client falls asleep after using the patient-control
analgesia (PCA) pump.
l 3. Cool toes, absent pulses, and pale nailbeds on the
operative side.
l 4. Urinary output of 120 mL of clear yellow urine in
3 hours.
2 days ago. Which is an expected client goal?
l 1. The client will ask for pain medication every
4 hours.
l 2. The client will attend a smoking cessation support
group.
l 3. The client will be turned every 2 hours.
l 4. The client will be able to ambulate with a walker.
ANSWERS
55. Correct answer 2, 5: Clients are allowed to bear
weight but need to understand the level of weight
bearing they can tolerate without causing injury.
Teaching the safe use of assistive devices, such as a
walker, is necessary prior to discharge. The client
should be encouraged to rest periodically to promote
healing and energy. Increases in activity should occur
slowly to prevent complications. The client should not
wait to take pain medication until the pain is at 8.
Content–Surgical; Category of Health Alteration–
Musculoskeletal; Integrated Process–Planning; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Synthesis.
56. Correct answer 3: The absence of pulses and a cool
extremity with pale nailbeds indicate circulatory compromise. The nurse must intervene. Drainage in the
first 24 hours can be expected to be 200–400 mL,
so 100 mL in 6 hours is not abnormal. Sleeping after
using PCA is common. The urinary output is adequate. Content–Surgical; Category of Health Alteration–
Musculoskeletal; Integrated Process–Assessment; Client
Copyright © 2010 F.A. Davis Company
310
Needs–Safe Effective Care Environment, Management of
Care; Cognitive Level–Synthesis.
57. Correct answer 2: Many clients receive subcutaneous
anticoagulant medications, such as Lovenox, after
orthopedic surgery. The nurse should first determine
if the client is receiving this medication. This medication
could cause the tiny bruises on the upper abdomen.
Content–Surgical; Category of Health Alteration–
Musculoskeletal; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management of
Care; Cognitive Level–Analysis.
58. Correct answer 4: The client should be ambulating
with assistance for short distances by 2 days post surgery. The client should ask for pain medication when
needed, not on a regimented time schedule. The client
being turned is a nursing goal, not a client goal. Smoking cessation is a good goal, but it is not specific to a
client who has had a TKR 2 days ago. Content–Surgical;
Category of Health Alteration–Musculoskeletal; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
SECTION SIX
Musculoskeletal Disorders
311
Management
59. The nurse is caring for a client postoperative right
61. The nurse is working in an orthopedic department.
THR. Which assessment data warrant immediate
intervention by the nurse?
l 1. Temp 99ºF, HR 80, RR 20, and B/P 128/76.
l 2. Pain in the left leg during dorsiflexion of the ankle.
l 3. Bowel sounds heard intermittently in four
quadrants.
l 4. Pain in the right hip when turning.
Which client should the nurse assess first?
l 1. The client with an open reduction and internal
fixation (ORIF) of the right hip who needs to be
removed from Buck traction.
l 2. The client with a total knee repair who is using a
CPM machine when lying in the bed.
l 3. The client with an L3–L4 laminectomy who will
not allow the UAP to turn the client using the
log-rolling method.
l 4. The client who is being admitted to the orthopedic
department from the emergency department (ED).
60. The nurse is working on an orthopedic floor. Which
client should the nurse assess first after change of shift
report?
l 1. The 84-year-old female in Buck traction for a
fractured femur.
l 2. The 64-year-old female postoperative TKR who is
now confused.
l 3. The 88-year-old male who had a right THR who
has an abduction pillow.
l 4. The 50-year-old post TKR who has a CPM device.
ANSWERS
59. Correct answer 2: Pain with dorsiflexion of the
ankle indicates deep vein thrombosis. The vital signs
are within normal limits. Bowel sounds are normally
intermittent. Pain at the operative site with movement is normal. Content–Surgical; Category of Health
Alteration–Musculoskeletal; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
60. Correct answer 2: This is an abnormal occurrence
from the information given. This client should
be seen first because confusion is a symptom of
hypoxia. Buck traction is expected for a fractured
femur. An abduction pillow is expected for a THR.
Continuous passive motion is an expected treatment
on an orthopedic unit. Content–Medical; Category
of Health Alteration–Musculoskeletal; Integrated
Process–Assessment; Client Needs–Physiological
Integrity, Reduction of Risk Potential; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
312
61. Correct answer 4: The client from the ED needs to
be assessed first to determine the needs of the client.
The client with a laminectomy needs to be log-rolled
to prevent injury to the surgical incision but not
before a new admission is assessed. The postoperative
ORIF client would not have Buck traction, and the
client with TKR should be on the CPM machine.
Content–Medical; Category of Health Alteration–
Musculoskeletal; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
SECTION SIX
Musculoskeletal Disorders
313
62. The nurse is unable to assess the pedal pulse on a
64. Which client should the charge nurse on the
client who had a right THR. The client’s foot is cool, but
the client is able to move the toes. Which intervention
should the nurse implement first?
l 1. Place the abductor pillow between the client’s legs.
l 2. Utilize the Doppler to auscultate the right pedal
pulse.
l 3. Elevate the client’s right leg on two pillows.
l 4. Wrap the client’s right leg in a warm blanket.
orthopedic unit assess first after receiving the morning
shift report?
l 1. The client with a right BKA who has a hemoglobin
and hematocrit (H&H) of 12/42.
l 2. The client with rheumatoid arthritis who has a
positive rheumatoid factor (RF).
l 3. The client with compound fracture of the right
ulna who has a white blood cell (WBC) count of
14,000.
l 4. The client with osteoarthritis who has an
erythrocyte sedimentation rate (ESR) of 18 mm/hr.
63. The nurse is preparing to administer medications to
clients on the orthopedic unit. Which medication should
the nurse administer first?
l 1. The NSAID to the client diagnosed with
osteoarthritis.
l 2. The narcotic analgesic to the client with a BKA.
l 3. The intravenous antibiotic to the client with a TKR.
l 4. The biphosphonate to the client diagnosed with
osteoporosis.
65. The UAP tells the nurse the client with a right AKA
has a large amount of bright red blood on the right leg
residual limb. Which action should the nurse take first?
l 1. Assess the client’s residual limb dressing.
l 2. Document the findings in the client’s chart.
l 3. Place a large tourniquet proximal to the dressing.
l 4. Notify the client’s HCP.
ANSWERS
62. Correct answer 2: To identify the location of the
pulse, the nurse should use a Doppler device to
amplify the sound first as the client is able to move
the toes. Using an abductor pillow and elevating or
wrapping the leg will not help the nurse assess the
pedal pulse. The nurse should place an X when the
pulse is heard. Content–Medical; Category of Health
Alteration–Musculoskeletal; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
63. Correct answer 2: The client in postoperative pain
314
64. Correct answer 3: The client with a compound fracture should not have an infection, which a WBC
of 14,000 indicates; this client requires immediate
intervention. The H&H and ESR are within normal
limits, and a client with rheumatoid arthritis would
have a positive RF. Content–Medical; Category of
Health Alteration–Musculoskeletal; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
65. Correct answer 1: Because the UAP is informing
should receive the prn narcotic analgesic first. Pain is
priority over routine medications such as NSAIDs,
antibiotics, or a monthly medication for osteoporosis.
the nurse of pertinent information, the nurse should
assess the client to determine which action to take.
All the other interventions could be implemented
after the nurse assesses the client. Content–Surgical;
Content–Medical; Category of Health Alteration–
Musculoskeletal; Integrated Process–Planning; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
Category of Health Alteration–Musculoskeletal; Integrated Process–Assessment; Client Needs–Physiological
Integrity, Reduction of Risk Potential; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
Musculoskeletal Disorders
SECTION SIX
66. The nurse and a UAP are caring for clients in the
rehabilitation unit. Which action by the UAP warrants
immediate intervention?
l 1. The UAP calls for assistance when taking a client
to the shower.
l 2. The UAP is assisting the client who weighs 70 kg
to the bedside commode.
l 3. The UAP places the call light within reach of the
client who is sitting in the chair.
l 4. The UAP ties a sheet around the client who keeps
slipping out of the chair.
67. The charge nurse on the busy 36-bed orthopedic
unit must send one staff member to the ED. Which
staff member would be the most appropriate staff member
to send?
l 1. The RN who has worked on the orthopedic unit
for 5 years.
l 2. The RN who has worked on many medical units
over the last 8 years.
l
l
315
3. The graduate nurse who is completing the hospital
orientation.
4. The RN who transferred from the surgical unit to
the orthopedic unit.
68. The client who is scheduled for a L3–L4 laminectomy
tells the orthopedic nurse, “I do not trust my doctor.
I don’t think he knows what he is doing. What do you
think about my doctor?” Which statement is the nurse’s
best response?
l 1. “I really can’t give you an opinion on your doctor
since I work for the hospital.”
l 2. “What has your doctor done to make you not
trust him?”
l 3. “You have a right to a second opinion. Would you
like me to help you?”
l 4. “Since your surgery is scheduled you must keep
this surgeon.”
ANSWERS
66. Correct answer 4: The UAP is restraining the client
without an order; this is a violation of the client’s
rights. The nurse needs to release the client immediately and discuss the behavior with the UAP. Assisting with a shower, assisting a client to a bedside
commode, and placing a call light within reach of
the client are all appropriate actions of the UAP.
Content–Medical; Category of Health Alteration–
Musculoskeletal; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
67. Correct answer 4: The charge nurse must send a
qualified nurse but not at the detriment of the
orthopedic unit. The RN with surgical unit and
orthopedic experience should be able to work in the
ED. The RN with 5 years’ experience on the orthopedic unit and the RN who has experience on many
units should be kept on a busy 36-bed unit. The
new graduate should not be transferred to the ED.
Content–Medical; Category of Health Alteration–
Musculoskeletal; Integrated Process–Planning; Client
Copyright © 2010 F.A. Davis Company
316
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
68. Correct answer 3: The nurse must be a client advocate. If the client does not trust the HCP, the client
has a right to a second opinion; therefore, the nurse
should help resolve this dilemma for the client. The
nurse cannot discuss personnel opinions of the HCP
and does not have to know what the HCP has done.
Many clients do not feel comfortable confronting
their HCP. Content–Medical; Category of Health
Alteration–Musculoskeletal; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
SECTION SIX
Musculoskeletal Disorders
317
69. The overhead page has issued a code black indicating
70. The primary nurse overhears the UAP telling a
a tornado in the area. Which intervention should the
charge nurse of the orthopedic unit implement?
l 1. Instruct the staff to assist the clients and visitors to
the cafeteria.
l 2. Request the clients and visitors to go into the
bathroom in each client’s room.
l 3. Move all clients and visitors into the hallways and
close all doors.
l 4. Request all clients and visitors stay in the rooms
and leave all doors open.
family member of another client, “A client was admitted
today who murdered his wife and tried to kill himself.”
Which action should the primary nurse take first?
l 1. Notify the charge nurse of the UAP’s comments.
l 2. Tell the UAP the comment is a violation of the
HIPAA.
l 3. Ask the family to please not repeat what the
UAP said.
l 4. Request the UAP to go to the nurse’s station
immediately.
ANSWERS
69. Correct answer 3: The procedure for tornadoes is
having all clients, staff, and visitors stay in the hallway and close the doors to all the rooms. This will
help prevent any flying debris or glass from hurting
anyone. Content–Medical; Category of Health
Alteration–Musculoskeletal; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
Copyright © 2010 F.A. Davis Company
318
70. Correct answer 4: The primary nurse needs to stop
the conversation immediately without embarrassing
the UAP; therefore, asking the UAP to go to the
nurse’s station is the nurse’s first action. Then the
primary nurse should tell the UAP that the UAP
committed a HIPAA violation, report the incident to
the charge nurse, and if necessary talk to the family
member who heard the gossip. Content–Medical;
Category of Health Alteration–Musculoskeletal;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
SECTION SEVEN
Genitourinary Disorders
319
SECTION SEVEN
Genitourinary Disorders
321
Fluid and Electrolytes
1. The nurse is caring for a client with a serum sodium
3. The client has a serum potassium level of 2.9 mEq/L.
level of 152 mEq/L. Which signs/symptoms should the
nurse expect the client to exhibit?
l 1. Sticky mucous membranes and thirst.
l 2. Anorexia, nausea, and muscle cramps.
l 3. Tingling of extremities and numbness.
l 4. Paresthesias, dysrhythmias, and fatigue.
Which intervention should the nurse implement first?
l 1. Administer intravenous potassium.
l 2. Encourage foods high in potassium.
l 3. Place the client on cardiac telemetry.
l 4. Monitor the client’s intake and output.
2. The client is diagnosed with acute renal failure. The
has a nasogastric tube (NGT) in place and an intravenous
(IV) line running at 150 mL/hr via an IV pump. Which
data would warrant intervention by the nurse?
l 1. The alarm on the IV pump keeps going off,
possibly indicating high pressure.
l 2. The client has an IV intake 1200 mL, output
700 mL, and NGT 350 mL.
l 3. The client’s lungs are clear in all lobes on
auscultation.
l 4. The client has non-pitting edema and 1 kg
weight loss.
nurse assesses peripheral edema, increased bounding
pulses, and jugular vein distention. Which interventions
should the nurse implement? Select all that apply.
l 1. Administer intravenous diuretics.
l 2. Provide the client with a regular diet.
l 3. Place the client on strict intake and output (I&O).
l 4. Put the client on fluid restriction.
l 5. Weigh the client weekly in the same clothes.
4. The client who has undergone an exploratory laparotomy
ANSWERS
1. Correct answer 1: Hypernatremia, a serum sodium
322
3. Correct answer 3: The client has an extremely
level above 145 mEq/L, will cause the client to be thirsty,
to have a dry mouth and sticky mucous membranes,
to be irritable, and to have seizures. Option 2 could be
signs/symptoms of hyponatremia, option 3 of hypocalcemia, and option 4 of hypokalemia. Content–Medical;
low potassium level (3.5–5.5 mEq/L is normal); therefore, the client is at risk for life-threatening cardiac
dysrhythmias and should be placed on telemetry.
Replacing the potassium is important but not priority
over life-threatening dysrhythmias. Content–Medical;
Category of Health Alteration–Genitourinary; Integrated
Process–Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
Category of Health Alteration–Genitourinary; Integrated
Process–Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive Level–
Synthesis.
2. Correct answer 1, 3, 4: The client is exhibiting fluid
volume overload; therefore, administering diuretics,
strict I & O, and fluid restriction are appropriate interventions. The client should be on a sodium-restricted
diet, not a regular diet, and the client should be weighed
daily, not weekly. Content–Medical; Category of Health
Alteration–Genitourinary; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive Level–
Application.
Copyright © 2010 F.A. Davis Company
4. Correct answer 1: The nurse should assess the client’s
IV pump because the alarm indicates a possible infiltrated
IV. The other data would not warrant intervention as
the intake and output are equal, considering insensible
loss; the lungs are clear; and non-pitting edema and
weight loss are not life-threatening. Content–Surgical;
Category of Health Alteration–Drug Administration;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Pharmacological and Parenteral
Therapies; Cognitive Level–Synthesis.
SECTION SEVEN
Genitourinary Disorders
323
5. The client has a calcium level less than 7 mg/dL.
7. The client is receiving total parental nutrition (TPN)
Which assessment data would the nurse expect the
client to exhibit?
l 1. Flushing of the face and hypoactive reflexes.
l 2. Constipation, polyuria, and polydipsia.
l 3. Dysrthymias with peaked T-waves.
l 4. Positive Trousseau sign and diarrhea.
into a subclavian line at 73 mL/hr. Which intervention
should the nurse implement?
l 1. Infuse the solution via gravity at 73 mL/hr.
l 2. Monitor the serum blood glucose daily.
l 3. Change the IV tubing every 3 days.
l 4. Check intake and output (I&O) every shift.
6. The client with gastroenteritis has tented skin turgor,
8. The client who is 1 day postoperative bilateral
lightheadedness, and dizziness. Which intervention
should the nurse implement?
l 1. Monitor the client for respiratory alkalosis.
l 2. Administer intravenous calcium supplements.
l 3. Infuse intravenous normal saline.
l 4. Provide a sodium-restricted diet.
thyroidectomy complains of numbness and tingling
around the mouth and the tips of the fingers. Which
intervention should the nurse implement?
l 1. Notify the client’s health-care provider (HCP)
immediately.
l 2. Check the B/P and see if the hand makes a claw
shape.
l 3. Check the serum calcium and magnesium levels.
l 4. Prepare to administer calcium gluconate by
intravenous push (IVP).
ANSWERS
5. Correct answer 4: The calcium level is low (9–11 mg/dL
is normal). Signs/symptoms of hypocalcemia include
diarrhea, numbness, tingling of extremities, and positive Trousseau and Chvostek signs. Option 1 could be
signs of hypermagnesemia; option 2 could be signs of
diabetes; and option 3 could be signs of hypokalemia.
Content–Medical; Category of Health Alteration–
Genitourinary; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management of
Care; Cognitive Level–Analysis.
6. Correct answer 3: The client is dehydrated, and
isotonic fluids must be administered to a client who is
dehydrated so the fluid will remain in the vessels and
increase blood volume. The client would exhibit a
metabolic problem, not a respiratory one. Calcium is
not administered for dehydration, and sodium is
restricted for fluid volume overload, not for fluid
deficit. Content–Medical; Category of Health Alteration–
Gastrointestinal; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management of
Care; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
324
7. Correct answer 4: I&O is monitored to observe for
fluid balance. TPN should be administered via an
IV pump only. The glucose is checked every 6 hours,
and the IV tubing is changed with every bag of TPN.
Content–Medical; Category of Health Alteration–Drug
Administration; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Application.
8. Correct answer 2: Checking for the Trousseau sign is
the nurse’s first intervention because the client is
exhibiting signs of hypocalcemia. Then the nurse
can check electrolyte levels, administer appropriate
medication, and notify the HCP. Content–Surgical;
Category of Health Alteration–Endocrine; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
SECTION SEVEN
Genitourinary Disorders
325
Benign Prostatic Hypertrophy (BPH)
9. The client has a serum potassium level of 6.9 mEq/L.
11. The UAP emptied 4000 mL from the drainage
Which HCP prescription should the nurse question?
l 1. Administer 50% glucose and intravenous regular
insulin.
l 2. Administer kayexalate, a cation exchange resin.
l 3. Administer intravenous loop diuretics.
l 4. Administer intravenous potassium over 8 hours.
bag of a continuous irrigation of a client who had a
transurethral resection of the prostate (TURP). The
amount of irrigation in the bag hanging was 3000 mL at
the beginning of shift. A second bag of 3000 mL was
hung midway through the shift, with 2500 mL left in the
bag at the end of the shift. Which is the corrected urine
output the nurse would document for the 12-hour shift?
10. The nurse and an unlicensed assistive personnel
(UAP) are caring for a group of clients. Which task
would be inappropriate to delegate to the UAP?
l 1. Measure the urine in the client’s urinal.
l 2. Obtain the client’s daily weight.
l 3. Discuss fluid restrictions with client.
l 4. Maintain the client’s nothing by mouth (NPO)
status.
Answer: _______________________
12. The nurse is caring for the client who had a TURP.
Which assessment data require immediate intervention by
the nurse?
l 1. The client is snoring after receiving a belladonna
and opiate (B&O) suppository.
l 2. The client has dark red drainage and large clots in
the urinary drainage system.
l 3. The client complains of backache from being in
the bed and wants to ambulate.
l 4. The client complains of a “caffeine” headache from
lack of coffee and colas.
ANSWERS
9. Correct answer 4: The client is hyperkalemic;
326
11. Correct answer 500 mL: A total of 6000 mL of
therefore, the nurse should question administering
potassium supplements. Kayexalate removes potassium
from the bowel, and diuretics remove potassium
via the urine. Intravenous regular insulin transports
potassium in the bloodstream to the intracellular space.
irrigation solution was hung. That, minus the
2500 mL left in the bag, equals 3500 mL of irrigation solution in the drainage system. Subtract
3500 mL from 4000 mL equals the urine output
of 500 mL for the shift. Content–Surgical; Category
Content–Medical; Category of Health Alteration–Drug
Administration; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Analysis.
of Health Alteration–Genitourinary; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
10. Correct answer 3: The nurse cannot delegate teaching;
therefore, the nurse must discuss fluid restrictions
with the client. The UAP can measure urine from a
urinal, take daily weights, and make sure the client
does not drink any fluids. Content–Medical; Category
of Health Alteration–Management; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
12. Correct answer 2: Dark red drainage indicates the
continuous bladder irrigation (CBI) rate needs to be
increased to decrease the chance of hemorrhaging. A
B&O suppository is a narcotic pain medication that
treats bladder spasms and causes drowsiness. The
client with a backache and the client with a headache
are not priority over a client who may be at risk of
hemorrhaging. Content–Surgical; Category of Health
Alteration–Genitourinary; Integrated Process–Assessment;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
Genitourinary Disorders
SECTION SEVEN
13. Which data would indicate to the nurse the male
client has acute bacterial prostatitis?
l 1. Terminal dribbling.
l 2. Urinary frequency.
l 3. Stress incontinence.
l 4. Sudden fever and chills.
14. Which client problem is priority for the client who
had a TURP for benign prostatic hypertrophy (BPH)
1 week ago?
l 1. Altered sexual functioning.
l 2. Altered body image.
l 3. Chronic infection.
l 4. Hemorrhage.
15. The nurse is discharging a client who is postoperative
TURP. Which statement by the client indicates discharge
teaching is effective?
l 1. “I will call the surgeon if I experience any difficulty
urinating.”
l 2. “I will take my saw palmetto the same as before my
surgery.”
l
l
327
3. “I should restrict my oral intake to keep from
urinating so much”
4. “I can mow my yard and do the rest of my yard
work when I get home.”
16. The nurse and UAP are caring for clients on a
urology floor. Which nursing task should the nurse
delegate to the UAP?
l 1. Increase the continuous bladder irrigation fluid.
l 2. Elevate the client’s scrotum on a towel roll for
support.
l 3. Change the surgical dressing for the client 1 day
postoperative.
l 4. Teach the client to care for the continuous
irrigation catheter.
ANSWERS
13. Correct answer 4: Clients with acute bacterial
prostatitis will frequently experience a sudden onset
of fever and chills. Options 1 and 2 are symptoms of
benign prostatic hypertrophy (BPH). Stress incontinence occurs when the bladder experiences the stress
of coughing, running, or jumping. Content–Medical;
Category of Health Alteration–Genitourinary; Integrated
Process–Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
14. Correct answer 1: The client may experience erectile
dysfunction after the surgery, and the nurse should
address the issue with the client. Chronic infections
occur prior to surgery, and hemorrhage occurs
immediately postoperatively, not 1 week after
the surgery. Content–Surgical; Category of Health
Alteration–Genitourinary; Integrated Process–Diagnosis;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
328
15. Correct answer 1: The client should notify the
surgeon if he has difficulty urinating; this statement
indicates that the teaching was effective. Saw palmetto
is taken to shrink the prostate and the surgery has
removed prostatic tissue. The client should increase
fluid intake, and yard work is too strenuous immediately following surgery. Content–Surgical; Category of
Health Alteration–Genitourinary; Integrated Process–
Evaluation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Evaluation.
16. Correct answer 2: The UAP can position a client.
The nurse cannot delegate teaching nor give medication to a UAP; the continuous irrigation should be
considered a medication. The surgeon changes the
first dressing. Content–Medical; Category of Health
Alteration–Management; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
SECTION SEVEN
Genitourinary Disorders
329
17. The client who had a TURP and has a CBI complains
19. The client diagnosed with BPH tells the nurse,
he feels the need to urinate. Which intervention should the
nurse implement first?
l 1. Call the surgeon to report the client’s complaint.
l 2. Administer a narcotic analgesic to help the client
urinate.
l 3. Tell the client the sensation is expected.
l 4. Assess the continuous irrigation catheter to
determine if it is patent.
“I started taking saw palmetto 2 weeks ago, but I have
not noticed any difference when I urinate.” Which
statement is the nurse’s best response?
l 1. “Saw palmetto must not be working. You should
take a prescription medication.”
l 2. “Why did you start taking saw palmetto? Herbs
can be very dangerous.”
l 3. “It may take weeks to see the results from herbs
that shrink prostate tissue.”
l 4. “Are you currently taking any other medications
with the saw palmetto?”
18. The client asks the clinic nurse, “What does an
elevated prostate-specific antigen (PSA) test mean?” Which
statement is the nurse’s best response?
l 1. “An elevated PSA can be for different reasons.
You need to talk to your HCP.”
l 2. “An elevated PSA indicates prostate cancer only.
You should see an oncologist.”
l 3. “An elevated PSA is diagnostic for testicular cancer
and other male problems.”
l 4. “An elevated PSA is the only test used to diagnose
benign prostatic hypertrophy.”
ANSWERS
17. Correct answer 4: The nurse should always assess
330
19. Correct answer 3: Saw palmetto works similarly to
any complaint before dismissing it as a commonly
occurring problem. The nurse should not call a
health-care provider until all assessment is complete.
Pain medication will not help the client urinate.
Telling a client that what he is experiencing is
normal without checking is unsafe. Content–Surgical;
finasteride (Proscar) to reduce the size of prostate
tissue, but it takes several weeks to months to see the
optimal effects. Saw palmetto has been proved to be
as effective as prescription medications to treat BPH.
Saw palmetto is well tolerated with few drug interactions. Content–Medical; Category of Health Alteration–
Category of Health Alteration–Genitourinary; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care;
Cognitive Level–Analysis.
Genitourinary; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Application.
18. Correct answer 1: An elevated PSA can result from
urinary retention, benign prostatic hypertrophy,
prostate cancer, or prostate infarct. An elevated
PSA test result indicates the need for further tests.
Content–Medical; Category of Health Alteration–
Genitourinary; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Reduction of
Risk Potential; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
Genitourinary Disorders
SECTION SEVEN
20. The male client tells the clinic nurse he has to get up
to go to the bathroom frequently at night but when he
does, it takes a long time to get started. Which intervention
should the nurse implement first?
l 1. Prepare the client for a digital rectal exam (DRE)
by the HCP.
l 2. Have the laboratory draw a prostate-specific
antigen (PSA).
l 3. Encourage the client to not drink any fluids 2 hours
before bedtime.
l 4. Instruct the client to provide a clean-catch urine
specimen.
Urinary Tract Infection
21. The client from a long-term care facility is admitted
with a fever, hot flushed skin, and clumps of white
sediment in the indwelling catheter drainage bag. Which
intervention should the nurse implement first?
l 1. Start an intravenous line with a 20-gauge catheter.
l 2. Initiate the antibiotic therapy intravenous
piggyback (IVPB).
l
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331
3. Clamp the drainage tubing to obtain a culture.
4. Change the indwelling catheter.
22. The nurse is inserting an indwelling urinary catheter
into a female client. Which interventions should be
implemented? Rank in order of performance.
l 1. Explain the procedure to the client.
l 2. Set up the sterile field.
l 3. Test the catheter balloon.
l 4. Place absorbent pads under the client.
l 5. Ask the client if she is allergic to iodine.
23. The nurse performed a bladder irrigation through an
indwelling catheter. The nurse instilled 100 mL of sterile
normal saline. The catheter drained 1010 mL. What is
the client’s output?
Answer: ________________________
ANSWERS
332
20. Correct answer 2: The PSA must be done prior to
22. Correct answer 1, 5, 4, 2, 3: The nurse should first
the DRE or the results will be skewed. Then, the
client should have a DRE performed. A clean catch
urine specimen would be done because BPH causes
urinary stasis and predisposes the client to a urinary
tract infection (UTI). Decreasing fluid intake will
not help an enlarged prostate gland. Content–
explain the procedure to the client and then ask the
client if she is allergic to iodine as that is the medium
used to cleanse the area. Then the nurse should place
absorbent pads under the client, set up the sterile
field, and test the catheter balloon before inserting the
catheter into the client. Content–Medical; Category of
Medical; Category of Health Alteration–Genitourinary;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
Health Alteration–Genitourinary; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
21. Correct answer 4: The nurse should first replace the
23. Correct answer 910 mL of urine: The amount of
catheter and obtain a urine specimen that will be
most accurate for an analysis. Then the nurse should
start an IV and antibiotic therapy. The nurse should
not get a urine specimen from the catheter bag.
Content–Medical; Category of Health Alteration–
Genitourinary; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
sterile normal saline is subtracted from the total volume
removed from the catheter: 1010 − 100 = 910 mL.
Content–Medical; Category of Health Alteration–
Genitourinary; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level-Application.
SECTION SEVEN
Genitourinary Disorders
333
24. The nurse is assessing a 16-year-old female who is
26. The male client diagnosed with chronic pyelonephritis
complaining of pain, frequency, and urgency when
urinating. The nurse asked the mother to leave the
room. Which question should the nurse ask the client?
l 1. “When was your last menstrual cycle?”
l 2. “Has there been a change in the color of the
urine?”
l 3. “Are you sexually active?”
l 4. “What have you done for the pain?”
is being admitted to a medical unit for intensive intravenous
therapy. Which statement made by the client indicates
a diagnosis of chronic pyelonephritis?
l 1. “I woke up with fever, chills, pain in my side, and
burning when I urinated.”
l 2. “I am tired all the time, I have a headache, and
I have to urinate every hour.”
l 3. “I had a group B strep infection last week and my
doctor gave me antibiotics.”
l 4. “The doctor told me I had an acute case of viral
pneumonia infection.”
25. The client calls the clinic nurse reporting chills, fever,
and left costovertebral pain. Which diagnostic test should
be implemented first?
l 1. A midstream urine for culture.
l 2. A sonogram of the kidney.
l 3. An intravenous pyelogram.
l 4. An MRI of the kidneys.
27. The female client is diagnosed with a urinary tract
infection (UTI). Which instruction should the clinic
nurse teach the client to prevent a recurrence of a UTI?
l 1. Clean the perineum from back to front after a
bowel movement.
l 2. Take warm tub baths, instead of hot showers, daily.
l 3. Void immediately preceding sexual intercourse.
l 4. Avoid coffee, tea, colas, and alcoholic beverages.
ANSWERS
24. Correct answer 3: The client is exhibiting signs of
334
26. Correct answer 2: Fatigue, headache, polyuria, weight
cystitis, a bladder infection, which is often caused by
sexual intercourse due to the introduction of bacteria
into the urethra during intercourse. A teenager may
not want to divulge this information in front of a
parent. The other questions could be asked in front
of the parent. Content–Medical; Category of Health
loss, anorexia, and excessive thirst are symptoms of
chronic pyelonephritis. Fever, chills, flank pain, and
dysuria are symptoms of acute pyelonephritis, not
chronic pyelonephritis. Group B beta-hemolytic
streptococcal infections and acute viral pneumonia
cause acute glomerulonephritis, not pyelonephritis.
Alteration–Genitourinary; Integrated Process–Assessment;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Analysis.
Content–Medical; Category of Health Alteration–
Genitourinary; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
25. Correct answer 1: Fever, chills, and costovertebral
pain are symptoms of a urinary tract infection (UTI)
and of acute pyelonephritis. A urine culture will
determine if the client has a UTI. The other tests are
more invasive and expensive. Intravenous pyelogram
studies are done to rule out renal calculi. Content–
Medical; Category of Health Alteration–Genitourinary;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Reduction of Risk Potential;
Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
27. Correct answer 4: Coffee, tea, cola, and alcoholic
beverages are urinary tract irritants. The perineum
should be cleaned from front to back after a bowel
movement. The client should take showers instead
of baths to prevent bacteria in the bath water from
entering the urethra. The client should void after
sexual intercourse. Content–Medical; Category of
Health Alteration–Genitourinary; Integrated Process–
Planning: Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
SECTION SEVEN
Genitourinary Disorders
335
28. The nurse is discharging a client with a nosocomial-
30. The elderly client is diagnosed with chronic
acquired urinary tract infection. Which information
should the nurse include in the discharge teaching?
l 1. Explain the hospital will pay for the antibiotics
because it is a nosocomial infection.
l 2. Tell the client to bring a urine specimen to the lab
for analysis in 1 week.
l 3. Instruct the client to take all the antibiotics as
prescribed.
l 4. Tell the client to urinate every 5–6 hours.
glomerulonephritis. Which lab value indicates the
condition is improving?
l 1. The blood urea nitrogen (BUN) is 15 mg/dL.
l 2. The creatinine level is 3.0 mg/dL.
l 3. The glomerular filtration rate is 40 mL/min.
l 4. The 24-hour creatinine clearance is 60 mL/min.
29. The nurse is preparing a plan of care for the
calculus in a client diagnosed with renal calculi. Which
statement indicates the client understands the discharge
teaching?
l 1. “I am going to eat liver and organ meats only once
a week.”
l 2. “I should drink at least two glasses of cranberry
juice a day.”
l 3. “I must limit how much milk and dairy products
I consume.”
l 4. “I will urinate at least every 2 hours so I won’t
develop a stone.”
client diagnosed with acute glomerulonephritis. Which
outcome would be a long-term goal for the client?
l 1. The client will maintain a BP of less than 160/90.
l 2. The client will maintain adequate renal
functioning.
l 3. The client will have no white blood cells in the urine.
l 4. The client will have a urinary output of >30 mL/hr.
Renal Calculi
31. Laboratory data reveal a calcium phosphate renal
ANSWERS
28. Correct answer 3: The client should be taught to
336
30. Correct answer 1: For a client over age 60, the
take all the prescribed medication any time a prescription is written for antibiotics. The hospital will
not assume responsibility for payment. The client will
not bring in a specimen; the client usually provides
the specimen on site. The client should be taught to
void every 2–3 hours. Content–Medical; Category of
normal BUN is 8–20 mg/dL. Therefore, a BUN of
15 mg/dL indicates an improvement in the client’s
condition. The other lab values are abnormal; normal
creatinine level is 0.6–1.2 mg/dL; normal glomerular
filtration level is approximately 120 mL/min; and
normal creatinine clearance is 75–125 mL/min.
Health Alteration–Genitourinary; Integrated Process–
Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
Content–Medical; Category of Health Alteration–
Genitourinary; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Analysis.
29. Correct answer 2: A long-term complication of acute
glomerulonephritis is chronic glomerulonephritis. If
acute glomerulonephritis is unresponsive to treatment,
it can lead to end-stage renal disease. Therefore,
maintaining renal function would be an appropriate
long-term goal. An elevated BP is an inappropriate
goal. Options 3 and 4 are short-term goals. Content–
Medical; Category of Health Alteration–Genitourinary;
Integrated Process–Diagnosis; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive Level–
Analysis.
Copyright © 2010 F.A. Davis Company
31. Correct answer 3: Dietary changes for preventing
calcium phosphate renal calculi include limiting
vitamin D, which will, in turn, inhibit the absorption
of calcium from the gastrointestinal tract. Organ
meats should be limited in a client with uric acid
stones. Cranberry juice and urinating frequently will
not prevent the development of renal calculi. Content–
Medical; Category of Health Alteration–Genitourinary;
Integrated Process–Evaluation; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive Level–
Evaluation.
SECTION SEVEN
Genitourinary Disorders
337
32. The male client diagnosed with renal calculi is
34. The client is being admitted to the hospital. Which
admitted to the medical unit from the emergency
department. Which nursing intervention should the
nurse implement first?
l 1. Strain the client’s urine.
l 2. Give the client a urinal.
l 3. Encourage oral fluids.
l 4. Monitor the intake and output.
clinical manifestations would the nurse expect to assess
for the client diagnosed with renal calculi in the kidney?
l 1. Dull, aching flank pain and microscopic hematuria.
l 2. Increased hunger and thirst and abdominal pain.
l 3. Gross hematuria and dull suprapubic pain with
voiding.
l 4. Severe pain of 10 on a 1–10 pain scale when
urinating.
33. The client with rule-out renal calculi is scheduled for
an intravenous pyelogram. Which intervention should the
nurse implement for this procedure?
l 1. Ask if the client is allergic to shellfish or iodine.
l 2. Keep the client nothing by mouth (NPO) 8 hours
prior to the procedure.
l 3. Insert an indwelling catheter 1 hour before the
procedure.
l 4. Explain that the client will have to drink a
special dye.
35. The male client diagnosed with renal calculi is
scheduled for a 24-hour urine specimen collection. Which
interventions should the nurse implement? Select all that
apply.
l 1. Keep the client NPO during the 24-hour urine
collection time.
l 2. Instruct the client to urinate and then discard this
urine when starting collection.
l 3. Tell the client to urinate into the urinal at the
bedside.
l 4. Insert an indwelling catheter in the client after
having client empty bladder.
l 5. Place all the urine in the specific urine containers.
ANSWERS
32. Correct answer 2: The nurse should give the client
338
34. Correct answer 1: A client with renal calculi in the
a urinal and instruct him to put all urine into the
urinal. Then the nurse should strain the urine,
encourage oral fluids, and monitor the client’s intake
and output but first ensure that all urine output
is strained. Content–Medical; Category of Health
kidney will have dull aching pain in the region of the
kidney (flank) and hematuria showing on urinanalysis.
Option 2 is hyperglycemia; option 3 is calculi in the
ureter; and option 4 is a calculus in the urethra
trying to pass. Content–Medical; Category of Health
Alteration–Genitourinary; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
Alteration–Genitourinary; Integrated Process–Assessment;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Analysis.
33. Correct answer 1: Iodine-based dye is used for an
intravenous pyelogram; therefore, determining if the
client is allergic to iodine is an appropriate intervention. The client is not NPO; there is no indwelling
catheter; and the client must have an intravenous
line for administering the dye. Content–Medical;
Category of Health Alteration–Genitourinary; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Reduction of Risk Potential; Cognitive
Level–Application.
Copyright © 2010 F.A. Davis Company
35. Correct answer 2, 3, 5: When the collection
begins, the client should urinate and discard the
urine. All urine for 24 hours should be saved and
put in a container with a preservative, be refrigerated,
or be put on ice (if indicated). Not following specific
instructions will result in an inaccurate test result.
The client does not have an indwelling catheter.
Content–Medical; Category of Health Alteration–
Genitourinary; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
SECTION SEVEN
Genitourinary Disorders
339
36. Which priority client problem should the nurse address
38. The client diagnosed with renal calculi has undergone
when caring for a client diagnosed with an acute episode of
ureteral calculi?
l 1. Fluid volume excess.
l 2. Knowledge deficit.
l 3. Impaired urinary elimination.
l 4. Alteration in comfort.
lithotripsy. Which post-procedure nursing task would be
most appropriate to delegate to the UAP?
l 1. Tell the UAP to monitor the client’s urine output.
l 2. Ask the UAP to discuss post-procedure care.
l 3. Instruct the UAP to encourage oral fluids.
l 4. Request the UAP to check the client’s vital signs.
37. The client is diagnosed with uric acid calculi. Which
39. The client had surgery to remove a kidney stone.
foods should the client eliminate from the diet to help
prevent reoccurrence?
l 1. Red wine and colas.
l 2. Asparagus and cabbage.
l 3. Sweetbreads and ham.
l 4. Cheese and eggs.
Which laboratory assessment data would warrant
immediate intervention by the nurse?
l 1. A serum sodium level of 144 mEq/L.
l 2. A urinalysis that shows microscopic hematuria.
l 3. A creatinine level of 0.8 mg/100 mL.
l 4. A white blood cell count of 12,000 mm.
ANSWERS
36. Correct answer 4: Pain is priority; the pain can be
so severe that a sympathetic response, which causes
nausea, vomiting, pallor, and cool and clammy skin,
may occur. All the other client problems are pertinent,
but the priority is pain. Content–Medical; Category of
Health Alteration–Genitourinary; Integrated Process–
Diagnosis; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Analysis.
37. Correct answer 3: Sweetbreads (yeast), ham, venison,
sardines, goose, organ meats, and herrings are highpurine foods that should be eliminated from the diet
to help prevent uric acid stones. All the other foods
should be limited in clients with calcium oxalate stones.
Content–Medical; Category of Health Alteration–
Genitourinary; Integrated Process–Planning; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Synthesis.
340
38. Correct answer 3: The UAP could encourage the
client to drink oral fluids. The urine must be assessed
by the nurse for bleeding and cloudiness, and the
nurse cannot delegate teaching. Because the kidney is
highly vascular, hemorrhaging and resulting shock
are potential complications of lithotripsy; therefore,
the nurse cannot delegate checking vital signs post
procedure to the UAP. Content–Medical; Category of
Health Alteration–Genitourinary; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
39. Correct answer 4: This white blood cell count is
elevated (normal is 5000–10,000 mm); this could
possibly indicate an infection. The serum sodium
level is normal (135–145 mEq/L) as is the creatinine
level (0.8–1.2 mg/100 mL). Hematuria is not
uncommon after removal of a kidney stone. Content–
Medical; Category of Health Alteration–Genitourinary;
Integrated Process–Assessment; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
SECTION SEVEN
Genitourinary Disorders
341
40. The client diagnosed with calculi in the ureter is
42. The nurse is teaching clients at a community center
complaining of severe pain of 10 on a pain scale of 1–10.
Which intervention should the nurse implement first?
l 1. Administer the intravenous narcotic analgesic.
l 2. Assess the client to rule out any complications.
l 3. Check the MAR to determine when the client was
last medicated.
l 4. Ensure the client’s side rails are up and the call
light is within reach.
about the risks of developing bladder cancer. Which
modifiable risk factor could lead to the development of
cancer of the bladder?
l 1. Previous exposure to chemicals.
l 2. Pelvic radiation therapy.
l 3. High cholesterol intake.
l 4. Previous cancer of the prostate.
Cancer of the Bladder
is scheduled to have a cutaneous urinary diversion
procedure. Which preoperative teaching should be
included? Select all that apply.
l 1. Demonstrate turn-and-cough and deep breathing.
l 2. Explain that a bag will drain the urine from now on.
l 3. Instruct the client about pain control after surgery.
l 4. Take the client to tour the intensive care unit
(ICU).
l 5. Show the client the deodorants that are used inside
the pouch.
41. The nurse is working on a renal surgery unit. After
receiving the change of shift report, which client should
be assessed first?
l 1. The client who left glasses in the x-ray department
and cannot see without them.
l 2. The client 1 day postoperative who has a large
amount of serosanguineous drainage on the dressing.
l 3. The client scheduled for surgery in the morning
who needs an explanation of the surgery.
l 4. The client who had ileal conduit surgery who has
sediment and urine in the drainage bag.
43. The client diagnosed with cancer of the bladder
ANSWERS
342
40. Correct answer 2: The client in severe pain must be
42. Correct answer 3: High cholesterol and tobacco use
assessed to determine if the pain is a complication
that requires medical intervention or is expected
pain. If it is expected pain, the nurse should check
the MAR for the last pain medication administered
and, if appropriate, administer the narcotic analgesic
and ensure the safety of the client. Content–Medical;
are modifiable risk factors. Previous exposure to chemicals or previous cancer cannot be undone. Pelvic
radiation is done for cancer in the abdomen; it is a
life-saving procedure, but one of the risks of radiation
therapy is the development of a secondary cancer.
Category of Health Alteration–Genitourinary; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
41. Correct answer 2: This client may be bleeding, and
the nurse should assess this client first. An ileal conduit drains urine, but mucus will also be present
because the tissue used to create the conduit normally produces mucus. Content–Surgical; Category
of Health Alteration–Genitourinary; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
Content–Medical; Category of Health Alteration–
Genitourinary; Integrated Process–Planning; Client
Needs–Health Promotion and Maintenance; Cognitive
Level–Synthesis.
43. Correct answer 1, 2, 3, 4: Any client undergoing
general anesthesia should be taught to turn, cough,
and deep-breathe. A urinary diversion procedure
involves the removal of the bladder. The nurse should
always explain pain control, and if the client is going
to the ICU, it is helpful for the client to become
familiar with it prior to surgery. Deodorants used to
counteract the odor are not included in preoperative
teaching. Content–Surgical; Category of Health
Alteration– Genitourinary; Integrated Process–Planning;
Client Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Synthesis.
SECTION SEVEN
Genitourinary Disorders
343
44. The client diagnosed with cancer of the bladder is
46. The nurse and a licensed practical nurse (LPN) are
receiving intravesical chemotherapy. Which instruction
should the nurse provide the client about pre-therapy
routine?
l 1. Instruct the client to increase fluids just prior to
the therapy.
l 2. Encourage the client to attend a support group for
bladder cancer.
l 3. Teach the client how to perform Kegel exercises.
l 4. Indicate that the client will be turned every
15 minutes.
caring for a group of clients. Which nursing task should
be assigned to the LPN?
l 1. Assess the client who has had a Koch pouch
procedure.
l 2. Monitor the client who is 2 days postoperative who
has a white blood cell (WBC) count of 7000 mm.
l 3. Administer the prescribed antineoplastic
medications.
l 4. Discharge the client with a new ileal conduit.
45. The nurse is planning the care of a postoperative
the bladder is angry and states, “I am going to kill
myself.” Which statement is the nurse’s best response?
l 1. “I can see you are upset. We should talk about it.”
l 2. “Did you tell your oncologist how you feel?”
l 3. “Do you have a plan on how you are going to kill
yourself?”
l 4. “Your treatments are going well. Don’t talk about
suicide.”
client who had a urinary diversion with a creation of an
ileal conduit. Which assessment data warrant immediate
intervention by the nurse?
l 1. The client’s stoma is purple.
l 2. The client’s pouch has a strong odor to it.
l 3. The client’s urine pH is acidic.
l 4. The client’s drainage is amber-colored.
47. The male client diagnosed with metastatic cancer of
ANSWERS
44. Correct answer 4: The client will be turned every
15 minutes to have the medication reach the entire
bladder surface. The chemotherapy is instilled in the
bladder and should remain in the bladder for a
prescribed time. The client receives nothing by mouth
prior to the procedure. Kegel exercises help prevent
stress incontinence, and referring to a support group
is not pertinent to pre-procedure teaching. Content–
Medical; Category of Health Alteration–Drug
Administration; Integrated Process–Planning; Client
Needs–Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Synthesis.
45. Correct answer 1: A purple stoma indicates a lack
of circulation to the stoma. This requires immediate
intervention. A strong odor and acidic and ambercolored urine would not warrant immediate intervention by the nurse. Content–Medical; Category of
Health Alteration–Drug Administration; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
344
46. Correct answer 2: This client is 2 days postoperative
with a normal WBC count; therefore the LPN could
care for this client. Assessment, administering antineoplastic medications, and discharge teaching for an
ileal conduit are the responsibility of the registered
nurse. Content–Medical; Category of Health Alteration–
Management; Integrated Process–Planning; Client Needs–
Safe Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
47. Correct answer 3: Anytime a client threatens
suicide, the nurse must determine how lethal the
client’s threat is. A therapeutic response (option 1),
determining if the client discussed the thought with
the oncologist, and negating the client’s comments
are not the best responses. Content–Medical; Category
of Health Alteration–Genitourinary; Integrated Process–
Implementation; Client Needs–Safety and Infection
Control; Cognitive Level–Application.
SECTION SEVEN
Genitourinary Disorders
345
48. The married client with a continent urinary diversion
50. The female client with a cutaneous urinary diversion
is being discharged. Which instruction should the nurse
include in the discharge teaching?
l 1. Have the client return and demonstrate
catheterizing the stoma.
l 2. Tell the client to wear adult diapers to prevent
accidents.
l 3. Teach the client to irrigate the stoma once a day.
l 4. Encourage the client and spouse to see a marriage
counselor.
for cancer of the bladder states, “Will I be able to have
children?” Which statement is the nurse’s best response?
l 1. “Cancer does not make you sterile, but sometimes
chemotherapy can.”
l 2. “You are concerned that you cannot have children
since you have cancer.”
l 3. “No, you will no longer be able to have children
because of the surgery.”
l 4. “I will let your HCP know about your concerns.”
49. The nurse is preparing to discharge a client diagnosed
with a cutaneous ileal conduit. Which information
should the nurse teach the client?
l 1. To measure the amount of urine in the pouch every
8 hours.
l 2. To change the pouch when it is three-quarters full.
l 3. To expect the skin around the stoma to be red at
times.
l 4. To instill a few drops of vinegar into the pouch.
ANSWERS
48. Correct answer 1: A continent urinary diversion is a
346
50. Correct answer 1: This client is asking for information
surgical procedure in which a reservoir holds urine
(acts as the bladder) until the client can self-catheterize.
There is no need for a diaper. Sigmoid colostomies are
irrigated, not urinary, diversions. A marriage counselor
may be needed, but the physiological need is priority.
and should be given facts, which is that the procedure
will not cause sterility, but chemotherapy can induce
menopause, and radiation therapy to the pelvis can
render a client sterile. Option 2 is a therapeutic
response, and option 3 is a false statement. Content–
Content–Surgical; Category of Health Alteration–
Genitourinary; Integrated Process–Planning; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
Medical; Category of Health Alteration–Genitourinary;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
49. Correct answer 4: Vinegar will act as a deodorizing
agent in the pouch and help prevent a strong urine
smell. The pouch is emptied when it is half to
two-thirds full, but the pouch is only changed every
couple of days to prevent skin breakdown. The client
should notify the ostomy nurse if the skin around
the stoma becomes red. Content–Surgical; Category
of Health Alteration–Genitourinary; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
SECTION SEVEN
Genitourinary Disorders
347
Male Cancers
51. Which statement is the American Cancer Society’s
53. The 80-year-old male client has been diagnosed with
recommendation for the early detection of cancer of the
prostate?
l 1. A yearly prostate-specific antigen (PSA) level followed
by a digital rectal exam beginning at age 50.
l 2. A biannual urinalysis beginning at age 40 to check
for the presence of seminal fluid.
l 3. An annual alkaline phosphatase level beginning at
age 45.
l 4. A yearly blood urea nitrogen (BUN) to determine
the damage to the kidneys.
cancer of the prostate. Which treatment would the nurse
discuss with the client?
l 1. Radiation therapy every day for 4 weeks.
l 2. Radical prostatectomy with lymph node dissection.
l 3. The client may choose not to take any treatment.
l 4. Penile implants to maintain sexual functioning.
52. The nurse is caring for a client diagnosed with early
cancer of the prostate. Which statement made by the
client supports the diagnosis?
l 1. “I have urinary urgency and have to go all the time.”
l 2. “I do not have semen production during
intercourse.”
l 3. “I take a lot of ibuprofen for my lower back and
hip pain.”
l 4. “I haven’t had any problems going to the bathroom.”
54. The nurse writes a client problem of urinary retention
for a client diagnosed with stage IV cancer of the prostate.
Which intervention should the nurse implement?
l 1. Prepare the client for a suprapubic catheter.
l 2. Obtain an order for a prophylactic antibiotic.
l 3. Teach the client to use the Credé maneuver.
l 4. Determine the client’s normal voiding pattern.
ANSWERS
51. Correct answer 1: The American Cancer Society
recommends that all men have a yearly PSA blood
level, followed by a digital rectal examination, beginning at age 50. Content–Medical; Category of Health
Alteration–Genitourinary; Integrated Process–Planning;
Client Needs–Health Promotion and Maintenance;
Cognitive Level–Synthesis.
52. Correct answer 4: In early-stage prostate cancer, the
man will not be aware of the disease. Early detection
is achieved by screening for the cancer. The other
statements indicate late disease. Content–Medical;
Category of Health Alteration–Genitourinary; Integrated
Process–Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
53. Correct answer 3: Some men with a life expectancy
of less than 10 years choose not to treat the cancer at
all and will die from causes other than prostate cancer.
If the client treats the cancer, then diethylstilbesterol
(DES), a hormone preparation that suppresses the
male hormones and slows the growth of the tumor,
Copyright © 2010 F.A. Davis Company
348
may be prescribed. Content–Medical; Category of
Health Alteration–Genitourinary: Integrated Process–
Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
54. Correct answer 4: Determining the client’s normal
voiding pattern provides a baseline for the nurse and
client to use when setting goals. The client does not
need a suprapubic catheter or an antibiotic. Clients
with a neurogenic bladder use the Credé maneuver
to void. Content–Medical; Category of Health Alteration–
Genitourinary; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
SECTION SEVEN
Genitourinary Disorders
349
55. The 45-year-old client has undergone a bilateral
57. The nurse enters the room of a 26-year-old client
orchiectomy for cancer of the prostate. Which intervention
should the nurse implement?
l 1. Teach the client how to use the patient-controlled
analgesia (PCA) pump.
l 2. Administer testosterone replacement hormone
orally.
l 3. Apply a heating pad to the client’s scrotum.
l 4. Have the client talk to another man with ejaculation
dysfunction (ED).
diagnosed with testicular cancer. The client asks the nurse
“Will I be able to have children?” Which is the nurse’s
best response?
l 1. “I can see you are concerned. Would you like to
talk about your concerns?”
l 2. “You may need to consider adopting children
because you will be sterile.”
l 3. “Sperm banking prior to treatment is an option so
that you can father children.”
l 4. “You should ask your HCP that question. It
depends on many things.”
56. The school nurse is preparing a class for male high
school seniors on testicular cancer. Which information
regarding testicular self-examination (TSE) should the
nurse include?
l 1. Perform the examination after a cool shower.
l 2. Feeling a cord-like structure is normal.
l 3. Expect to find a small hard mass on one side.
l 4. TSE should be performed once a year.
ANSWERS
55. Correct answer 1: The nurse should make sure the
client knows how to use the PCA pump. The testes
have been removed to decrease the production of
male hormones, so replacing the hormones negates
the purpose of the surgery. The client would use ice,
not heat, and he does have ED. Content–Surgical;
Category of Health Alteration–Genitourinary;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
56. Correct answer 2: The client may note a cord-like
structure, which is the spermatic cord, and is normal.
Any lump or mass felt is abnormal and should be
checked by a health-care provider as soon as possible.
The client should perform TSE monthly after or
during a warm shower. Content–Medical; Category of
Health Alteration–Genitourinary; Integrated Process–
Planning; Client Needs–Health Promotion and
Maintenance; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
350
57. Correct answer 3: Sperm banking will allow the client
to father children through artificial insemination
with the client’s sperm. The client needs information,
not a therapeutic conversation (option 1). The client
may or may not be sterile. Content–Medical; Category
of Health Alteration–Genitourinary; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
SECTION SEVEN
Genitourinary Disorders
351
58. The client diagnosed with testicular cancer is scheduled
60. The nurse is assessing a client to rule out testicular
for a unilateral orchiectomy. Which information should
the nurse discuss with the client regarding his sexual
functioning?
l 1. “You may have ejaculation difficulties and dribbling
after the surgery.”
l 2. “You will need to take testosterone, a male hormone,
following the surgery.”
l 3. “You may need to have penile implant surgery to
be able to have intercourse.”
l 4. “Your libido and orgasms are usually not affected
by this surgery.”
cancer. Which statement by the client supports the
finding of testicular cancer?
l 1. “It hurts and burns when I try to urinate.”
l 2. “I have a small ulceration on my penis.”
l 3. “My scrotum feels full and heavy.”
l 4. “My scrotum has a rash that itches.”
59. The nurse and a UAP are caring for clients on a
genitourinary floor. Which intervention is inappropriate
for the nurse to delegate to the UAP?
l 1. Increase the drip rate on the Murphy drip
irrigation set.
l 2. Empty the drainage bag of the suprapubic catheter.
l 3. Encourage the client who is 1 day postoperative to
turn and cough.
l 4. Record the amount of drainage in the catheter on
the bedside record.
Renal Failure
61. The client diagnosed with chronic kidney disease
(CKD) received the initial dose of the biological response
modifier, erythropoietin-1, week ago. Which statement by
the client would indicate the need to notify the HCP?
l 1. “I think I may have the flu. I don’t feel well.”
l 2. “I just don’t have any energy. I am tired all
the time.”
l 3. “I took my blood pressure, and it is higher than
normal.”
l 4. “I have been having pain in both my legs
and back.”
ANSWERS
58. Correct answer 4: Sex drive (libido) and orgasm are
usually unimpaired because the client still has one
functioning testicle. Content–Surgical; Category of
Health Alteration–Genitourinary; Integrated Process–
Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
59. Correct answer 1: Increasing the drip rate on a
Murphy irrigation requires nursing judgment and
cannot be delegated. The UAP can empty a drainage
bag, turn a client, and record the amount of drainage
on the bedside record. Content–Medical; Category of
Health Alteration–Management; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
60. Correct answer 3: Classic signs of cancer of the
testes are a mass on the testicle, painless enlargement
of the testes, and heaviness of the scrotum or lower
abdomen. Burning on urination indicates a urinary
tract infection; an ulceration indicates a sexually
Copyright © 2010 F.A. Davis Company
352
transmitted disease; and there is no rash associated
with cancer of the testes. Content–Medical; Category
of Health Alteration–Genitourinary; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
61. Correct answer 3: Hypertension after the initial
administration of erythropoietin may require an
adjustment to initiate or increase antihypertensive
medications. Flu-like symptoms are expected; the
medication takes up to 2–6 weeks to become effective; and long-bone and vertebral pain is an expected
occurrence. Content–Medical; Category of Health
Alteration–Genitourinary; Integrated Process–Evaluation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
SECTION SEVEN
Genitourinary Disorders
353
62. The nurse is developing a nursing care plan for the
64. The client diagnosed with end-stage renal disease is
client diagnosed with chronic kidney disease (CKD).
Which client problem would have priority for the client?
l 1. Impaired skin integrity.
l 2. Knowledge deficit.
l 3. Activity intolerance.
l 4. Excess fluid volume.
receiving peritoneal dialysis. Which assessment data
warrant immediate intervention by the nurse?
l 1. Inability to palpate a thrill over the fistula.
l 2. Abdomen is soft, nontender, and has bowel sounds.
l 3. The dialysate being removed from the abdomen is
cloudy.
l 4. The dialysate instilled was 1500 mL and removed
was 2100 mL.
63. The client diagnosed with chronic kidney disease
(CKD) is placed on a fluid restriction of 1200 mL per day.
On the 7 a.m.–7 p.m. shift, the client drank 6 ounces of
coffee, 6 ounces of juice, 8 ounces of tea, and 6 ounces
of water with medications. What amount of fluid can the
7 p.m. –7 a.m. nurse give to the client?
Answer: ________________________
ANSWERS
62. Correct answer 4: Excess fluid volume is priority
because of the stress placed on the heart and vessels,
and this could lead to heart failure, pulmonary edema,
and death. Fistulas or grafts that are surgically
implanted to treat CKD (formally known as end-stage
renal disease [ESRD]) cause impaired skin integrity,
but that is not life-threatening nor is activity intolerance. Teaching is important but not priority over a
physiological problem. Content–Medical; Category of
Health Alteration–Genitourinary; Integrated Process–
Diagnosis; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
63. Correct answer 420 mL: The nurse must add up
how many milliliters of fluid the client drank on the
7 a.m.–7 p.m. shift and then subtract that amount
from 1200 mL to determine how much fluid the
client can receive on the 7 p.m.–7 a.m. shift: 1 ounce
is equal to 30 mL; therefore, the client drank 780 mL
(180 mL + 180 mL + 240 mL + 180 mL = 780 mL)
of fluid on the 7 a.m.–7 p.m. shift and can have
420 mL on the 7 p.m.–7 a.m. shift (1200 - 780 = 420.
Copyright © 2010 F.A. Davis Company
354
Content–Medical; Category of Health Alteration–
Genitourinary; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
64. Correct answer 3: The dialysate return is normally
colorless or straw-colored but should never be cloudy,
which indicates an infection. The client does not
have a fistula; a soft non-tender abdomen would be
normal; and an output greater than intake indicates
the dialysis is effective. Content–Medical; Category of
Health Alteration–Genitourinary; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
SECTION SEVEN
Genitourinary Disorders
355
65. The client is diagnosed with acute renal failure.
67. The client diagnosed with acute renal failure has a
Which laboratory value is most significant?
l 1. A creatinine level of 3.8 mg/dL.
l 2. A blood urea nitrogen (BUN) level of 22 mg/dL.
l 3. A potassium level of 5.5 mEq/L.
l 4. A sodium level of 144 mEq/L.
serum potassium level of 6.5 mEq/L. Which collaborative
intervention should the nurse implement?
l 1. Administer a phosphate binder.
l 2. Type and cross-match for whole blood.
l 3. Administer a cation-exchange resin enema.
l 4. Prepare the client for dialysis.
66. The client is admitted to the emergency department
after multiple knife wounds to the abdomen. Which
intervention should the nurse implement first to help
prevent acute renal failure?
l 1. Monitor the client’s urine output.
l 2. Assess the client’s blood pressure.
l 3. Insert an indwelling catheter.
l 4. Initiate intravenous fluids.
68. The client diagnosed with chronic kidney disease
(CKD) has a new arteriovenous fistula in the left forearm.
Which statement indicates the client needs more discharge
teaching?
l 1. “I cannot carry any heavy packages on my left arm.”
l 2. “I should have my blood tests drawn from my
fistula.”
l 3. “I will lie on my back or right arm when I sleep.”
l 4. “I need to perform hand exercises on my left arm.”
ANSWERS
65. Correct answer 1: Creatinine is the laboratory
value most significant in diagnosing renal failure
(0.5–2.0 mg/dL is normal). Normal BUN is
10–30 mg/dL but may be elevated in renal failure. The
potassium level is WNL (normal is 3.5–5.5 mEq/L),
but this does not diagnose renal failure. The sodium
level is normal (135–145 mEq/L). Content–Medical;
Category of Health Alteration–Genitourinary; Integrated
Process–Assessment; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Analysis.
66. Correct answer 4: Preventing and treating shock
with blood and fluid replacement will prevent acute
renal failure due to hypoperfusion of the kidneys.
Monitoring intake and output, assessing blood
pressure, and inserting a catheter would be appropriate
interventions, but maintaining circulatory status
is the nurse’s first intervention. Content–Medical;
Category of Health Alteration–Genitourinary; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
356
67. Correct answer 3: A 6.5-mEq/L level is high and
life threatening, and kayexalate, a cation-exchange
resin, can be administered orally or rectally to decrease the potassium level. Phosphate binders are
used for elevated phosphorous levels; blood transfusions will not decrease the potassium level; and dialysis would not be prescribed for an elevated potassium
level. Content–Medical; Category of Health Alteration–
Genitourinary; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
68. Correct answer 2: The fistula should be used only
for dialysis access, not for routine blood draws.
Carrying heavy objects in the left arm could cause
the fistula to clot, and lying on the left arm may
cause clotting by putting pressure on the site. Hand
exercises are recommended to help mature the
fistula. Content–Medical; Category of Health Alteration–
Genitourinary; Integrated Process–Evaluation; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Synthesis.
SECTION SEVEN
Genitourinary Disorders
357
Sexually Transmitted
Diseases (STDs)
69. The male client diagnosed with chronic kidney
71. The high school nurse is preparing a class for
disease (CKD) on hemodialysis has a blood pressure of
88/60. Which action should the nurse implement first?
l 1. Place the client in the Trendelenburg position.
l 2. Turn off the dialysis machine immediately.
l 3. Bolus the client with 500 mL of normal saline.
l 4. Ask the client if he feels lightheaded or dizzy.
junior- and senior-level students regarding sexually
transmitted diseases (STDs). Which high-risk behavior
information should be included in the class information?
l 1. Engaging in oral or anal sex decreases the risk of
getting an STD.
l 2. Use of a sterile latex barrier device ensures that the
client will not get an STD.
l 3. The more sexual partners, the less the chance of
contracting an STD.
l 4. A condom will not guarantee the student will not
get an STD.
70. The client diagnosed with chronic kidney disease
(CKD) is on hemodialysis three times a week. Which
information should the nurse discuss with the client?
l 1. Notify the HCP when oral temperature is 103°F
or greater.
l 2. Apply ice to the fistula if it starts bleeding at home.
l 3. Recommend a low-fat and low-cholesterol diet.
l 4. Discuss the importance of an advance directive.
ANSWERS
69. Correct answer 4: Because the client’s blood pressure
is low, the first intervention is for the nurse is to
determine if the client is symptomatic. Then, the
nurse should place the client in the Trendelenburg
position, bolus the client with normal saline, and
turn off the dialysis machine. Content–Medical;
Category of Health Alteration–Genitourinary; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Analysis.
70. Correct answer 4: End-stage renal disease is a chronic
illness. An advance directive with a durable power of
attorney for health care will ensure that the client’s
end-of-life wishes will be honored by the client’s
designate. The temperature should be no greater than
100°F; a low-fat/low-cholesterol diet is for a cardiac
disease; and ice may cause clotting. Content–Medical;
Category of Health Alteration–Genitourinary; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
358
71. Correct answer 4: Condom use provides a barrier to
contracting an STD, but it is not a guarantee. The
condom can break or come off during intercourse.
Engaging in oral and anal sex increases the risk of
contracting an STD. Condoms are not packaged to
be sterile. The more sexual partners, the greater the
risk for contracting an STD. Content–Medical;
Category of Health Alteration–Genitourinary; Integrated
Process–Planning; Client Needs–Health Promotion and
Maintenance; Cognitive Level–Synthesis.
Genitourinary Disorders
SECTION SEVEN
72. The female client diagnosed with human
papillomavirus (HPV) asks the nurse, “What
problems can HPV cause?” Which statement is the
most appropriate response by the nurse?
l 1. “Your partner can develop chancre sores on his
penis.”
l 2. “HPV infection can lead to cancer of the cervix.”
l 3. “You will become sterile and not be able to have
children.”
l 4. “You can take oral antibiotics to cure the HPV
infection.”
73. The public health nurse (PHN) notes a rash on the
trunk, palms of the hands, and soles of the feet of a male
client. Which assessment question should the nurse ask
the client?
l 1. “Have you noticed a sore on your penis within the
last 2 months?”
l 2. “How many sexual partners have you had in the
past year?”
l
l
359
3. “Do you urinate immediately after intercourse and
wash your penis?”
4. “Can you start and stop your stream without pain
or difficulty?”
74. The nurse is caring for a young adult client who
has been diagnosed with gonorrhea. Which statement
reflects an understanding of the transmission of sexually
transmitted diseases?
l 1. Only people of lower socioeconomic level are at risk
for gonorrhea and syphilis.
l 2. The longer a client waits to become sexually active,
the greater the risk for an STD.
l 3. Females can transmit infectious diseases more
rapidly than males.
l 4. If a client is diagnosed with an STD, the client
should be evaluated for other STDs.
ANSWERS
72. Correct answer 2: Untreated HPV infection is a
cause of cancer of the cervix. Chancre sores indicate
syphilis. HPV does not cause sterility, and there is no
cure for HPV infections. Content–Medical; Category
of Health Alteration–Genitourinary; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
73. Correct answer 1: A rash on the trunk, palms, and
soles suggests early-stage syphilis, so asking about
another sign of syphilis—a sore on the penis—is an
appropriate assessment question. A sore on the penis
is a sign of the second stage of syphilis. The PHN
may need to know the number of sexual partners the
client has had to be able to notify the partners of
their risk for infection. Urinating and washing after
intercourse and starting and stopping the urine
stream would not assess for syphilis. Content–Medical;
Category of Health Alteration–Genitourinary; Integrated
Process–Assessment; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Analysis.
Copyright © 2010 F.A. Davis Company
360
74. Correct answer 4: If a client is diagnosed with
one STD, there is a great likelihood the client has
another STD. Clients of all socioeconomic levels
contract STDs. The longer the client abstains from
sexual activity and the fewer partners the client has
usually lessen the risk of an STD. Both females and
males spread STDs. Content–Medical; Category of
Health Alteration–Genitourinary; Integrated Process–
Evaluation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Evaluation.
SECTION SEVEN
Genitourinary Disorders
361
75. The young female client is admitted with pelvic
77. The nurse is planning the care of a client who has
inflammatory disease (PID) secondary to a Chlamydia
infection. Which discharge instructions should the nurse
teach the client?
l 1. The client will develop antibodies to protect her
against a future infection.
l 2. This infection will not have any long-term effect
for the client.
l 3. Both the client and the sexual partner must be
treated simultaneously.
l 4. Once the infection subsides the pain will also go
away and not be a problem.
post-PID secondary to a gonorrhea infection. Which
collaborative diagnosis is appropriate for this client?
l 1. Risk for infertility.
l 2. Knowledge deficit about the transmission of STDs.
l 3. Anxiety related to stigma of having an STD.
l 4. Noncompliance of recommended abstinence.
76. The nurse is assessing a male client for symptoms of
gonorrhea. Which assessment data support the diagnosis
of gonorrhea?
l 1. Presence of a chancre sore on the shaft of the penis.
l 2. The client may be asymptomatic.
l 3. A CD4 count of greater than 3500.
l 4. A urethral discharge and pain in the testes.
78. The nurse is caring for a female client diagnosed
with rule-out syphilis. Which intervention should the
nurse implement first?
l 1. Place the client in the lithotomy position.
l 2. Have the lab draw a blood sample for a serum
rapid plasma reagin (RPR).
l 3. Obtain a Gram stain specimen of the urethral
meatus.
l 4. Teach the client to abstain from intercourse.
ANSWERS
362
75. Correct answer 3: If both the client and sexual partner
77. Correct answer 1: The diagnosis of risk for infertility
are not treated simultaneously, the sexual partner
can re-infect the client. Chlamydia does not cause an
antigen/antibody reaction, and it may have the longterm effects of chronic pain. There is an increased
risk for ectopic pregnancy, postpartum endometritis,
and infertility associated with PID. Content–Medical;
problems requires collaboration between the nurse
and the health-care provider. Knowledge deficit,
anxiety, and noncompliance are independent nursing
problems. Content–Medical; Category of Health
Category of Health Alteration–Genitourinary; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
76. Correct answer 4: A urethral discharge, pain in the
testes, and scrotal edema can indicate epididymitis,
an inflammatory process of the epididymis frequently
associated with gonorrhea. A chancre sore is a symptom
of syphilis. Gonorrhea is more likely to be asymptomatic in females than in males. Option 3 is a normal
CD4 count. Content–Medical; Category of Health
Alteration–Genitourinary; Integrated Process–Assessment;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
Alteration–Genitourinary; Integrated Process–Diagnosis;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Analysis.
78. Correct answer 1: The conclusive diagnosis for
syphilis is made by direct identification of a spirochete
obtained from a lesion. Obtaining a specimen from
such a lesion requires that the client be in the lithotomy position. The RPR test and Venereal Disease
Research Laboratory (VDRL) test are diagnostic
for staging syphilis. Content–Medical; Category of
Health Alteration–Genitourinary; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level– Analysis.
SECTION SEVEN
Genitourinary Disorders
363
Management
79. The client is diagnosed with primary syphilis.
81. The charge nurse has received laboratory data on
Which signs and symptoms would the nurse observe?
l 1. Lymphadenopathy and hair loss.
l 2. Multiple chancre sores in the genital area.
l 3. Dementia and psychosis.
l 4. No signs or symptoms are present.
clients in the critical care unit. Which situation requires
the charge nurse’s intervention first?
l 1. The client with an indwelling urinary catheter who
has bacteria in the urine specimen.
l 2. The client with ESRD who has a creatinine level of
3.8 mg/dL.
l 3. The client who is 1 day postoperative thyroidectomy
with a 9.4 mg/dL calcium level.
l 4. The client who is receiving loop diuretics who has
a potassium level of 3.5 mEq/L.
80. The nurse is admitting a pregnant client diagnosed
with Chlamydia trichomatis to the labor and delivery
department. Which intervention should the nurse
implement?
l 1. Prepare the client for an emergency cesarean
section.
l 2. Administer an antibiotic ophthalmic ointment to
the neonate.
l 3. Ask the mother when she became infected with
Chlamydia.
l 4. Notify the postpartum unit of the mother’s
infection.
ANSWERS
79. Correct answer 2: Chancre sores occur in the
primary stage of syphilis infection. Lymphadenopathy
and hair loss are symptoms of secondary syphilis.
Aortitis and neurosyphilis (dementia, psychosis,
stroke, meningitis) are common manifestations of
tertiary syphilis. Absence of symptoms is latent
syphilis and occurs after 4–5 months. Content–
Medical; Category of Health Alteration–Genitourinary;
Integrated Process–Assessment; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive Level–
Analysis.
80. Correct answer 2: Transmission of a Chlamydia
infection during delivery is common, and the neonate
should be given antibiotic ophthalmic ointment.
About 20%–50% of neonates develop Chlamydia
conjunctivitis, and 20% develop pneumonia. The
client can deliver vaginally. The postpartum staff
should use standard precautions and would not be at
risk. Content–Medical; Category of Health Alteration–
Genitourinary; Integrated Process–Implementation;
Copyright © 2010 F.A. Davis Company
364
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
81. Correct answer 1: The client with the indwelling
urinary catheter who has bacteria in the urine
specimen may have developed a urinary tract
infection; therefore, this client should be seen first.
A client with ESRD would have an elevated creatinine
level. The calcium and potassium levels are within
normal limits (WNL). Content–Management; Category
of Health Alteration–Genitourinary; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Analysis.
Genitourinary Disorders
SECTION SEVEN
82. The nurse and UAP are caring for clients on a medical
unit. Which task would be most appropriate for the nurse
to delegate to the UAP?
l 1. Provide indwelling catheter care to a client who is
third spacing.
l 2. Evaluate the 8-hour I&O of a client who is receiving
a loop diuretic.
l 3. Collect urine for a client who is having a 24-hour
urine creatinine test.
l 4. Administer a cation-exchange resin enema to a
client in end-stage renal disease.
83. The charge nurse of a medical/surgical unit is making
assignments for the night shift. Which client should be
assigned to the graduate nurse who has just completed an
internship?
l 1. The client who is 1 day postoperative transurethral
resection of the prostate (TURP) who has light
pink urine in the catheter bag.
l 2. The client diagnosed with ureteral renal calculi who
is in pain and has bright red blood in the urine.
l
l
365
3. The client diagnosed with acute gastroenteritis who
is dehydrated and has arterial blood gases (ABGs)
of pH 7.48, PaCO2 44, HCO3 20, PaO2 95.
4. The client diagnosed with heatstroke who has a
serum sodium level of 150 mEq/L and is
hallucinating.
84. The nurse notices that the sharps container in the
client’s room is above the fill line. Which action should
the nurse implement?
l 1. Complete an adverse occurrence report.
l 2. Discuss the situation with the charge nurse.
l 3. Change the sharps container immediately.
l 4. Notify the housekeeping department.
ANSWERS
82. Correct answer 3: The UAP can collect the client’s
366
84. Correct answer 3: The nurse should change the
urine and place in a special container for the 24-hour
urine test. The client who is third spacing (option 1)
is unstable. The UAP cannot evaluate the effectiveness of a medication (option 2), and the enema is a
medication, the administration of which cannot be
delegated to a UAP (option 4). Content–Management;
sharps container because the container being filled
above the fill line is a violation of Occupational
Safety Health Administration (OSHA) rules and
can result in a financial fine. An adverse occurrence
report is completed for incidents occurring to clients.
No other person or department needs to be notified.
Category of Health Alteration–Genitourinary; Integrated
Process–Planning; Client Needs–Safe Effective Environment, Management of Care; Cognitive Level–Synthesis.
Content–Management; Category of Health Alteration–
Management; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
83. Correct answer 1: The client with a TURP would
be expected to have light pink urine; therefore, this
client is stable and should be assigned to the new
graduate nurse. The clients with bright red blood,
metabolic alkalosis, and an elevated sodium level
are not stable and should be assigned to a more
experienced nurse. Content–Management; Category
of Health Alteration–Genitourinary; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
SECTION SEVEN
Genitourinary Disorders
367
85. The husband of a client diagnosed with chronic
87. The client diagnosed with chronic kidney disease
kidney disease (CKD) tells the nurse, “I have no idea how
I am going to take care of my wife.” Which statement
would be the nurse’s best response?
l 1. “I can contact the hospital social worker to talk
to you.”
l 2. “I will contact the hospital chaplain to talk to you.”
l 3. “Have you talked to your wife’s doctor about your
concern?”
l 4. “Do you think your children could help take care
of your wife?”
(CKD) is receiving oral kayexalate, a cation exchange
resin. Which assessment data indicate the medication is
effective?
l 1. The client’s serum potassium level is 6.8 mEq/L.
l 2. The client’s serum sodium level is 133 mEq/L.
l 3. The client’s serum potassium level is 3.8 mEq/L.
l 4. The client’s serum sodium level is 145 mEq/L.
86. The nurse is caring for clients on a medical unit. For
which client should the health-care team utilize the client’s
advance directive when needing to make decisions for the
client?
l 1. The client with bladder cancer who refuses to have
an ileal conduit.
l 2. The client with tertiary syphilis who has developed
dementia.
l 3. The client with CKD who is being placed on dialysis.
l 4. The client with terminal prostate cancer who is on
a ventilator.
88. The nurse and UAP are caring for clients on a
genitourinary unit. Which nursing task would be most
appropriate to delegate to the UAP?
l 1. Insert a 20-gauge angiocatheter in a client.
l 2. Empty the client’s nephrostomy urine output.
l 3. Assist the client to ambulate with a gait belt.
l 4. Discuss safe sex practices with a client being
discharged.
ANSWERS
85. Correct answer 1: A social worker is qualified to
assist the client with referrals to any agency or personnel that may be needed to care for the wife at home.
The chaplain addresses spiritual guidance; the nurse
does not need to refer this to the health-care provider;
and the nurse should not depend on the client’s
children to care for the wife. Content–Management;
Category of Health Alteration–Management; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
86. Correct answer 2: The client must have lost decisionmaking capacity due to a condition that is not
reversible; dementia is not reversible. Refusing
surgery, being on dialysis, and being on a ventilator
does not mean the client has lost decision-making
capacity. Content–Management; Category of Health
Alteration–Genitourinary; Integrated Process–
Implementation; Client Needs–Psychosocial Integrity;
Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
368
87. Correct answer 3: Kayexalate is a medication that is
administered to decrease an elevated serum potassium
level; therefore, a potassium level within the normal
range of 3.5–5.5 mEq/L indicates the medication
is effective. Content–Medical; Category of Health
Alteration–Drug Administration; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Analysis.
88. Correct answer 3: The UAP can use a gait belt to
ambulate the client. The UAP scope of practice
does not include starting IVs. A nephrostomy tube
is in the ureter, so emptying it cannot be delegated
to the UAP. Teaching also cannot be delegated.
Content–Management; Category of Health Alteration–
Genitourinary; Integrated Process–Planning; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
SECTION SEVEN
Genitourinary Disorders
369
89. The primary nurse on the genitourinary unit tells
90. The female UAP on the genitourinary unit
the clinical manager, “Nurses are upset and arguing over
how the clients are being assigned by the charge nurse.”
Which statement indicates the clinical manager has a
democratic leadership style?
l 1. “The charge nurse makes the assignments and I will
not interfere.”
l 2. “Have you discussed your concerns with the charge
nurse?”
l 3. “All the nurses need to come and tell me how
they feel.”
l 4. “I will schedule a meeting so that the situation can
be discussed.”
reports low back pain after transferring a client from
the bed to the wheelchair. Which priority action should
the charge nurse implement first?
l 1. Reassign the UAP’s unit assignment.
l 2. Send the UAP to the emergency department (ED).
l 3. Complete an employee occurrence report.
l 4. Notify the employee health nurse.
ANSWERS
89. Correct answer 4: Democratic managers are peopleoriented and emphasize efficient group functioning.
The environment is open, and communication
flows both ways, which includes having meetings
to discuss concerns. Content–Management; Category
of Health Alteration–Genitourinary; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
370
90. Correct answer 4: The charge nurse should first
notify the employee health nurse as this is the chain
of command. Then the charge nurse should send
the UAP to the ED for evaluation by a health-care
provider. After that, the charge nurse can complete
the employee occurrence report and reassign
the UAP’s clients to someone else if necessary.
Content–Management; Category of Health Alteration–
Genitourinary; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment, Safety
and Infection Control; Cognitive Level–Synthesis.
SECTION EIGHT
Mental Health Disorders
371
SECTION EIGHT
Mental Health Disorders
373
Major Depression
1. Which statement indicates that the client diagnosed
3. The psychiatric nurse is caring for clients on an inpatient
with major depression and prescribed a tricyclic
antidepressant understands the nurse's medication
teaching?
l 1. “I will take the medication in the morning with my
breakfast.”
l 2. “I should not eat any type of aged cheese or
chocolates.”
l 3. “If I don't start feeling better in a week I will call
my doctor.”
l 4. “I should not drink any type of beer, red wine, or
alcohol.”
psychiatric unit. Which task would be most appropriate to
delegate to the unlicensed assistive personnel (UAP)?
l 1. Instruct the UAP to watch the client on a
one-to-one suicide watch.
l 2. Identify alternate coping strategies with the client
who is depressed.
l 3. Discuss the side effects of the client's antidepressant
medications.
l 4. Make the client diagnosed with major depression
eat a meal.
2. The client diagnosed with major depression is admitted
to the inpatient psychiatric unit. Which priority intervention
should the nurse implement?
l 1. Monitor the client's nutritional status.
l 2. Assess the client for suicidal thoughts.
l 3. Assist the client with activities of daily living
(ADLs).
l 4. Allow the client to ventilate feelings.
ANSWERS
1. Correct answer 4: The client on an antidepressant
medication should avoid any type of alcohol. The
antidepressant should be taken at night. Foods high in
tyramine should be avoided when taking monoamine
oxidase inhibitors (MAO), not a tricyclic antidepressant.
It takes 2–3 weeks for the therapeutic effect to be
achieved. Content–Mental Health; Category of Health
Alteration–Psychiatric; Integrated Process–Evaluation;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Evaluation.
2. Correct answer 2: The priority for the nurse is to
assess if the client is suicidal. All the other interventions are appropriate and pertinent, but the priority
intervention is the client's safety. Content–Mental
Health; Category of Health Alteration–Psychiatric;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
374
3. Correct answer 1: The UAP could watch the client
who is suicidal and maintain an appropriate distance
from the client at all times. The UAP cannot teach,
and the client cannot be forced to eat without a
court order. Content–Mental Health; Category of Health
Alteration–Psychiatric; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
Mental Health Disorders
SECTION EIGHT
4. The client diagnosed with major depression tells the
nurse, “I just don't feel like living anymore. I am so
unhappy.” Which response would be most appropriate
for the nurse?
l 1. “You are feeling depressed. I will sit down and we
can talk.”
l 2. “You shouldn't be unhappy. You have a lot to be
grateful for.”
l 3. “Have you thought about hurting or killing
yourself?”
l 4. “I will need to tell the treatment team about your
comment.”
5. The client diagnosed with major depression who is
taking paroxetine (Paxil), a selective serotonin uptake
inhibitor (SSRI), calls the clinic nurse and tells the nurse,
“I have a high fever, my muscles are tight, and I am
sweating.” Which statement is the nurse's best response?
l 1. “You must notify your internal medicine doctor
about your symptoms.”
l 2. “You should take some Tylenol and go to bed and
call me tomorrow.”
l
l
375
3. “You need to have someone take you to the
emergency department.”
4. “When did you take your last antidepressant
medication?”
6. The client diagnosed with major depression is crying
and tells the clinic nurse, “I just don't find any pleasure
in life.” Which priority intervention should the nurse
implement?
l 1. Administer the client's antidepressant medication.
l 2. Offer support by sitting quietly with the client.
l 3. Recommend the client join a support group.
l 4. Encourage the client to exercise daily.
7. The client diagnosed with major depression has put on
makeup for the first time since admission to the inpatient
psychiatric unit. Which statement would be the nurse's
best response?
l 1. “You look very pretty today.”
l 2. “I noticed you put on makeup today.”
l 3. “Makeup can't be worn on the unit.”
l 4. “What made you decide to put on makeup?”
ANSWERS
4. Correct answer 3: If a client with major depression
376
6. Correct answer 2: Sitting quietly with the client offers
makes any comment that insinuates the client may
harm self, the nurse must ask directly if the client has
thought about suicide. That is the most important and
appropriate response. Content–Mental Health; Category
the client support. Antidepressant medications take
2–3 weeks to become therapeutic. A support group and
exercise are appropriate interventions, but the priority is
to support the client. Content–Mental Health; Category
of Health Alteration–Psychiatric; Integrated Process–
Implementation; Client Needs–Psychosocial Integrity;
Cognitive Level–Synthesis.
of Health Alteration–Psychiatric; Integrated Process–
Implementation; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
5. Correct answer 3: The client is exhibiting signs/
7. Correct answer 2: Clients who are depressed have
symptoms of serotonin syndrome, which is a medical
emergency. The client should not take any more
medication and should be seen immediately in the
emergency department. Content–Mental Health;
difficulty accepting compliments because of their low
self-esteem; therefore, commenting on a change in
behavior that suggests an improvement in the depression is the most appropriate intervention. Content–
Category of Health Alteration–Psychiatric; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive Level–
Synthesis.
Mental Health; Category of Health Alteration–Psychiatric;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
Mental Health Disorders
SECTION EIGHT
8. Which sign/symptom is most important when
assessing the client diagnosed with major depression?
l 1. The client does not find pleasure in life.
l 2. The client is unable to concentrate.
l 3. The client does not have any energy.
l 4. The client does not want to eat.
9. The nurse is caring for a client admitted to a medical
unit who is taking an antidepressant medication. Which
intervention is most appropriate when evaluating the
effectiveness of the antidepressant medication?
l 1. Assess the client's food intake for all meals.
l 2. Ask the client to rate the depression on a scale
of 1–10.
l 3. Notice what type of clothes the client is wearing.
l 4. Monitor the client's laboratory results.
10. The psychiatric clinic nurse is returning phone calls.
Which client should the nurse call first?
l 1. The client who needs a refill on the antidepressant
medications.
l 2. The client who reported having a runny nose and
puffy eyes.
l
l
377
3. The client who was crying because her husband
left her.
4. The client who was threatening to take the entire
bottle of sleeping pills.
Bipolar Disorder—Mania
11. The client diagnosed with bipolar disorder, manic
episode, is being admitted to the psychiatric unit.
Which signs/symptoms would the nurse expect the client
to exhibit?
l 1. Flight of ideas, extreme hyperactivity, and sleep
disturbances.
l 2. Feeling of well-being, feeling on a high, and
talkativeness.
l 3. Aggressive acting out without remorse and callous
behavior.
l 4. Overly dependent on others, makes suicidal
gestures, and argumentative.
ANSWERS
8. Correct answer 1: The most important sign of depression is the client has a loss of pleasure in life. All the
other signs/symptoms are experienced by the client,
but the most important is loss of pleasure in life.
Content–Mental Health; Category of Health Alteration–
Psychiatric; Integrated Process–Assessment; Client Needs–
Safe Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
9. Correct answer 2: Because the nurse does not know
this client, the best way to make subjective data
objective is to put information on a 1–10 scale.
In an inpatient psychiatric unit, the nurse can notice
a change in appetite, dress, or activity level. Antidepressant medications do not have therapeutic serum
blood levels. Content–Mental Health; Category of
Health Alteration–Psychiatric; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Application.
Copyright © 2010 F.A. Davis Company
378
10. Correct answer 4: The client threatening suicide is a
danger to self; therefore the nurse should call this
client first. Content–Mental Health; Category of Health
Alteration–Psychiatric; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Application.
11. Correct answer 1: To be admitted to the psychiatric
unit, the signs/symptoms must be severe, such as
extreme hyperactivity. Mild mania with symptoms
described in option 2 would not require a psychiatric
unit admission; in fact, many clients like this
pleasurable feeling. Option 3 may indicate antisocial
personality, and option 4 is borderline personality.
Content–Mental Health; Category of Health Alteration–
Psychiatric; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
SECTION EIGHT
Mental Health Disorders
379
12. Which statement indicates the client diagnosed with
14. The nurse is preparing to administer lithium
bipolar disorder and prescribed lithium (Eskalith), an
antimania medication, needs more medication teaching?
l 1. “My doctor will monitor my lithium level
frequently.”
l 2. “I need to drink at least 2000 mL of water a day.”
l 3. “I will have episodes of diarrhea while taking this
medication.”
l 4. “I should take my antimanic medication with
food.”
(Eskalith), an antimania medication, to a client
diagnosed with bipolar disorder. The lithium level is
0.9 mEq/L. Which action should the nurse implement?
l 1. Administer the medication.
l 2. Hold the medication.
l 3. Notify the HCP.
l 4. Verify the lithium level.
13. The psychiatric nurse is caring for a client diagnosed
with bipolar disorder who is experiencing an acute manic
attack. Which priority intervention should the nurse
implement?
l 1. Decrease the client's environmental stimuli.
l 2. Provide finger foods that can be carried.
l 3. Use a consistent approach with caring for the
client.
l 4. Set limits for the client's intrusive behavior.
15. The psychiatric nurse is caring for a client diagnosed
with bipolar disorder who is in a manic state. The client
is wearing bizarre clothes, swearing at other clients, and
running around the dayroom. Which intervention should
the nurse implement?
l 1. Avoid giving attention to the client's behavior and
clothing.
l 2. Instruct the clients in the dayroom to go to their
bedrooms.
l 3. Administer an oral PRN antimania medication to
the client.
l 4. Provide a safe environment for the client away
from the dayroom.
ANSWERS
12. Correct answer 3: Diarrhea is a sign of lithium
toxicity, and the client should notify the health-care
provider (HCP) so that a serum lithium level can
be evaluated; the client needs more medication
teaching. Monitoring the lithium level, preventing
dehydration, and taking medication with food
indicate the client understands the medication
teaching. Content–Mental Health; Category of Health
Alteration–Psychiatric; Integrated Process–Evaluation;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Synthesis.
13. Correct answer 2: The priority intervention is
meeting the client's physiological need, one of which
is nutrition. The other interventions are pertinent
but not priority over addressing the client's nutritional needs. Remember Maslow's Hierarchy of
Needs. Content–Mental Health; Category of
Health Alteration–Psychiatric; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
380
14. Correct answer 1: The therapeutic serum level for
Eskalith is 0.6–1.5 mEq/L; therefore, the nurse
should administer the medication. Content–Mental
Health; Category of Health Alteration–Psychiatric;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Physiological Adaptation;
Cognitive Level–Application.
15. Correct answer 4: Swearing at other clients and
running around the dayroom may result in a danger
to self or other clients; therefore, removing the client
and providing a safe environment is an appropriate
intervention. Avoidance, removing the other clients,
and an oral medication will not immediately help
the client. Content–Mental Health; Category of Health
Alteration–Psychiatric; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment, Safety and
Infection Control; Cognitive Level–Synthesis.
SECTION EIGHT
Mental Health Disorders
381
16. The client with bipolar disorder who is taking
18. The client with bipolar disorder is prescribed
lithium (Eskalith), an antimania medication, has a
lithium level of 3.1 mEq/L. Which treatment would
the nurse expect the HCP to prescribe?
l 1. Keep the client nothing by mouth (NPO) and
obtain arterial blood gases (ABGs).
l 2. Initiate intravenous therapy with a 20-gauge
angiocatheter.
l 3. Prepare the client for a subclavian line insertion.
l 4. Administer the antidote for lithium toxicity.
carbamazepine (Tegretol), an anticonvulsant. Which data
indicate the medication is effective?
l 1. The client is able to work daily and meet family
responsibilities.
l 2. The client takes the medication daily and has a
Tegretol level of 10 g/mL.
l 3. The client reports a 1 on a depression scale of
1–10 (10 severely depressed).
l 4. The client denies hearing voices and has no delusional
thoughts.
17. The client diagnosed with bipolar disorder with
acute mania is being admitted to the psychiatric unit.
Which room should the charge nurse assign to the client?
l 1. The semiprivate room with a client who is
depressed.
l 2. The private room that is near the unit's dayroom.
l 3. The semiprivate room with the client who is
hallucinating.
l 4. The private room that is away from the nurse's
station.
19. The client diagnosed with bipolar disorder is being
discharged home. Which intervention should the nurse
discuss with the client's significant other?
l 1. Ensure the client takes the prescribed medication
daily.
l 2. Explain the need to protect access to credit cards by
the client.
l 3. Encourage the client's significant other to take the
client to a support group.
l 4. Tell family members to act normally when around
the client.
ANSWERS
16. Correct answer 3: Extremely high toxic levels of
382
18. Correct answer 1: Tegretol is prescribed as a mood
lithium require hemodialysis, which must be administered via a subclavian line. The therapeutic range of
Eskalith is 0.6–1.5 mEq/L. ABGs are not affected by
lithium, and intravenous fluids will not help this
toxic level. There is no known antidote for lithium
toxicity. Content–Mental Health; Category of Health
stabilizer. Meeting family and employment responsibilities indicates the medication is effective. A therapeutic
level (for Tegretol, it is 8–12 g/mL) does not indicate
effectiveness. Tegretol is not an antidepressant medication, and the client does not have delusions and
hallucinations. Content–Mental Health; Category of
Alteration–Psychiatric; Integrated Process–Planning;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Synthesis.
Health Alteration–Drug Administration; Integrated
Process–Evaluation; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Evaluation.
17. Correct answer 4: The charge nurse should assign
the client to a quiet part of the psychiatric unit. The
client should not be assigned to a room with another
client or a room near the dayroom because it will be
too loud and busy. Content–Mental Health; Category
of Health Alteration–Psychiatric; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
19. Correct answer 2: If the client takes money, runs
up credit card bills, or sells community property
during the manic state, the significant other would
be responsible. The client should be responsible for
taking medication and attending support groups,
and the family members should act normally when
around the client. Content–Mental Health; Category
of Health Alteration–Psychiatric; Integrated Process–
Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
SECTION EIGHT
Mental Health Disorders
383
20. The male client is running and pacing in the
22. The client diagnosed with schizophrenia frantically
dayroom, is agitated with explosive behavior, and has
not slept for 2 days. Which intervention should the
nurse implement?
l 1. Take the client to the seclusion room.
l 2. Have the client throw balls in a hoop.
l 3. Talk therapeutically to the client.
l 4. Encourage the client to lie down.
tells the inpatient psychiatric nurse, “The FBI is out to
get me. They are everywhere.” Which statement is the
nurse's best response?
l 1. “Why do you think the FBI is out to get you?”
l 2. “Let's sit down and play a game of cards.”
l 3. “I will get your medication and the FBI will
go away.”
l 4. “The FBI is not everywhere you're in the hospital.”
Schizophrenia
21. The client is diagnosed with schizophrenia. Which
behavior would the nurse expect the client to exhibit?
l 1. Decreased energy and flat affect.
l 2. Manipulative behavior and overly dramatic.
l 3. Thought disturbances and difficulty with
communication.
l 4. Grandiosity and bizarre dress and grooming.
23. The nurse is administering chlorpromazine (Thorazine),
a traditional antipsychotic medication, to the client
diagnosed with schizophrenia. Which intervention
should the nurse implement when administering this
medication?
l 1. Assess the client for akathisia and dystonia.
l 2. Administer the medication with cranberry juice.
l 3. Do not administer with foods high in tyramine.
l 4. Monitor the client's red blood cell count.
ANSWERS
20. Correct answer 2: The client should be engaged in
noncompetitive physical activities that will help tire
the client. Secluding the client will further agitate
the client. The client is unable to talk rationally at
this time and is unable to lie down. Content–Mental
Health; Category of Health Alteration–Psychiatric;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Safety and Infection
Control; Cognitive Level–Synthesis.
21. Correct answer 3: The client with schizophrenia has
delusions, hallucinations, and bizarre speech. Option
1 is depression; option 2 is personality disorder; and
option 4 is mania. Content–Mental Health; Category
of Health Alteration–Psychiatric; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
384
22. Correct answer 2: The nurse should not agree or
support the delusion. Distracting the client allows
the client to focus on something else. Content–Mental
Health; Category of Health Alteration–Psychiatric;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Safety and Infection
Control; Cognitive Level–Application.
23. Correct answer 1: Extrapyramidal side effects, such
as akathisia and dystonia, are a major concern for
clients receiving antipsychotic medications. The
client's white blood cell (WBC) count, not the red
blood cell count, should be monitored for agranulocytosis. Content–Mental Health; Category of Health
Alteration–Drug Administration; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Application.
SECTION EIGHT
Mental Health Disorders
385
24. The male client diagnosed with schizophrenia is
26. The nurse is caring for a client in an inpatient
talking to the wall. Which action should the nurse
implement first?
l 1. Continue to monitor the client's behavior.
l 2. Document the finding in the client's chart.
l 3. Ask the client if he is talking to someone.
l 4. Discuss the behavior with the treatment team.
psychiatric unit. Which client warrants intervention
from the nurse?
l 1. The client with schizophrenia who is complaining
of hard-feeling muscles.
l 2. The client with schizophrenia who reports hearing
voices of his mother.
l 3. The client with schizophrenia who is refusing to
eat the breakfast meal.
l 4. The client with schizophrenia who is constantly
repeating words.
25. The nurse is teaching the wife and the client
newly diagnosed with schizophrenia concerning the
antipsychotic medication. Which statement indicates
the client's significant other needs more teaching?
l 1. “If my husband gets any flulike symptoms, I will
call his doctor.”
l 2. “My husband should not drink any alcohol when
taking this medication.”
l 3. “If my husband becomes drowsy or sleepy, I will
call his doctor.”
l 4. “It will take 2–3 weeks for the medication to work
properly.”
27. The nurse is caring for clients in an inpatient
psychiatric unit. Which intervention is the nurse's
priority intervention?
l 1. Establish a trusting relationship with the clients.
l 2. Set limits on the clients' behavior.
l 3. Praise a clients' socially acceptable behavior.
l 4. Provide a safe and secure environment.
ANSWERS
24. Correct answer 3: If the nurse sees the client possibly
386
26. Correct answer 1: Hard rigid muscles and high
hallucinating, the nurse should discuss the observation
with the client first. Then the nurse can continue to
observe the client, document the findings, and share
the observation with the treatment team. Content–
fever may indicate neuroleptic malignant syndrome,
which requires immediate intervention by the nurse.
Hallucinations and echolalia, or repeating words, are
expected behaviors of the client with schizophrenia.
Mental Health; Category of Health Alteration–Psychiatric;
Client Needs–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
Content–Mental Health; Category of Health Alteration–
Psychiatric; Integrated Process–Assessment; Client Needs–
Safe Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
25. Correct answer 3: The client will experience drowsiness initially when taking the medication; the client's
wife does not understand the teaching. Flu-like
symptoms indicate agranulocytosis. Content–Mental
Health; Category of Health Alteration–Drug Administration; Integrated Process–Evaluation; Client Needs–
Safe Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
27. Correct answer 4: The nurse's priority is to provide
a safe and secure environment for all clients in the
inpatient psychiatric setting. Establishing trust, setting
limits, and praising good behavior are pertinent interventions but not priority over safety of the clients.
Content–Mental Health; Category of Health Alteration–
Psychiatric; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Safety and
Infection Control; Cognitive Level–Synthesis.
Mental Health Disorders
SECTION EIGHT
28. The psychiatric nurse is monitoring laboratory data
for clients. Which laboratory data require intervention by
the nurse?
l 1. The client taking valproic acid (Depakote) whose
serum drug level is 80 mcg/mL.
l 2. The client taking risperidone (Risperdal) whose
potassium level is 4.9 mEq/L.
l 3. The client taking haloperidol (Haldol) whose
platelet count is 150,000.
l 4. The client taking clozapine (Clozaril) whose
WBC count is 3000 mm3.
29. The psychiatric nurse and unlicensed assistive
personnel (UAP) are caring for clients on an inpatient
psychiatric unit. Which task would be most appropriate
for the nurse to delegate to the UAP?
l 1. Discuss the side effects of medication with a newly
admitted client.
l 2. Take vital signs on the client experiencing a high
fever and tachycardia.
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387
3. Escort the client who has shuffling gait and tremors
to the dining room.
4. Assist the client with physical hygiene and activities
of daily living (ADLs).
30. The client is experiencing anticholinergic side effects
of the antipsychotic medication. Which intervention
should the nurse discuss with the client?
l 1. Instruct the client to wear SPF 30 or higher when
outside.
l 2. Tell the client to chew sugarless gum and suck on
hard candy.
l 3. Encourage the client to eat a low-residue diet.
l 4. Recommend the client report this to the HCP.
ANSWERS
28. Correct answer 4: The client with a decreased WBC
count is experiencing agranulocytosis, which requires
intervention by the nurse. All the other laboratory
data are within normal limits (WNL). Content–Mental
Health; Category of Health Alteration–Psychiatric;
Integrated Process–Assessment; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Analysis.
29. Correct answer 4: The UAP can assist the client with
personal hygiene and ADLs. The client in option 2 is
exhibiting signs of neuroleptic malignant syndrome,
and the client in option 3 is exhibiting extrapyramidal
side effects. Content–Mental Health; Category of Health
Alteration–Management; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
388
30. Correct answer 2: One anticholinergic side effect,
which is common, is a dry mouth; therefore, taking
sips of water, chewing sugarless gum, and sucking on
hard candy would be appropriate to discuss with the
client. Content–Mental Health; Category of Health
Alteration–Drug Administration; Integrated Process–
Planning; Client Needs–Physiological Integrity, Pharmacological and Parenteral Therapies; Cognitive
Level–Synthesis.
SECTION EIGHT
Mental Health Disorders
389
Personality Disorders
31. The male client mistrusts others, is suspicious, and
33. Which individual would the nurse suspect has a
blames others for his problems. Which type of personality
disorder is the client exhibiting?
l 1. Antisocial personality.
l 2. Paranoid personality.
l 3. Dependent personality.
l 4. Narcissistic personality.
borderline personality?
l 1. The male college student who blames his parents
because he does not have enough money to live on.
l 2. The homeless woman who wears layers of clothing,
two or three knit hats, and unmatched shoes and
socks.
l 3. The high school student who suspects everyone in
the class is cheating because everyone makes a
better grade on the tests.
l 4. The woman who threatens killing herself when her
husband leaves but is out dating within the month.
32. The client diagnosed with an avoidant personality is
socially inhibited, feels inadequate, and is hypersensitive
to negative criticisms. Which priority intervention should
the clinic psychiatric nurse implement when caring for
this client?
l 1. Encourage the client to attend a weekly support
group.
l 2. Tell the client to socialize with others for 15 minutes
a day.
l 3. Talk to the client honestly and in a straightforward
manner to establish trust.
l 4. Identify the client's strengths and accomplishments.
ANSWERS
390
31. Correct answer 2: A paranoid personality is charac-
33. Correct answer 4: This is an example of borderline
terized by pervasive, long-standing suspiciousness, a
mistrust of others, and fearfulness. Content–Mental
personality. A person with a borderline personality
has impulsive behavior and makes suicidal gestures.
Option 1 is an example of a dependent personality;
option 2 is an example of schizotypal personality;
and option 3 is an example of paranoid personality.
Health; Category of Health Alteration–Psychiatric;
Integrated Process–Diagnosis; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive Level–
Analysis.
32. Correct answer 3: Establishing trust with the client is
the priority nursing intervention because without
trust the client will not be able to work with the
nurse. Encouraging weekly support groups, socialization, and identifying the client's strengths are appropriate interventions but not priority over establishing
trust. Content–Mental Health; Category of Health
Alteration–Psychiatric; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
Content–Mental Health; Category of Health Alteration–
Psychiatric; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
Mental Health Disorders
SECTION EIGHT
34. The female client diagnosed with an antisocial
personality has an appointment in 30 minutes. She is
loud and obnoxious, will not sit down, and demands to
be seen immediately. Which intervention should the
clinic nurse implement when caring for this client?
l 1. Tell the client to sit down or she will not be seen at
her appointment time.
l 2. Escort the client back to the psychiatrist office so
that she can be seen next.
l 3. Ask the client to leave the waiting room and cancel
the appointment.
l 4. Request one of the staff to sit with the client in the
waiting room.
35. The wife of a client diagnosed with narcissistic
personality says to the clinic psychiatric nurse, “I just
can't live with my husband anymore. Can anything be
done to help him?” Which statement is the nurse's best
response?
l 1. “If he would take his medication daily, this would
control his behavior.”
l 2. “You don't think you can live with your husband
anymore?”
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3. “Individual and weekly group therapy may help
your husband.”
4. “There is no definitive treatment to help a client
with a personality disorder.”
36. The female client has low self-esteem, is unable to
make decisions, and sees herself as stupid. Which type of
personality disorder would the nurse suspect the client as
having?
l 1. Dependent.
l 2. Histrionic.
l 3. Schizoid.
l 4. Obsessive-compulsive.
ANSWERS
34. Correct answer 1: The nurse cannot allow the client
to manipulate the staff to be seen earlier. Setting and
maintaining limits is the most important intervention for the nurse. Allowing the client to see the
health-care provider allows the client to “win.”
Asking the client to leave and sitting with the client
are not appropriate interventions. Content–Mental
Health; Category of Health Alteration–Psychiatric;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
35. Correct answer 4: There is no medication or specific
treatment to help control the symptoms for the client
with a personality disorder. A therapeutic response
(option 2) is not appropriate at this time; the wife
needs factual information. Therapy cannot help the
client with a narcissistic personality. Content–Mental
Health; Category of Health Alteration–Psychiatric;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Physiological Adaptation;
Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
392
36. Correct answer 1: The client is exhibiting the Cluster
C dependent personality. Content–Mental Health;
Category of Health Alteration–Psychiatric; Integrated
Process–Diagnosis; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
Mental Health Disorders
SECTION EIGHT
37. The client who is 3 days postoperative total knee
replacement is diagnosed with a borderline personality.
The client is demanding, yelling for the nurses, and
argumentative with the staff. The nursing staff does not
want to be assigned the client. Which intervention
should the charge nurse implement?
l 1. Request that the client be transferred to the
psychiatric unit.
l 2. Schedule a meeting to discuss the client's behavior.
l 3. Tell the staff members they have to take care of the
client.
l 4. Explain to the client to stop this behavior
immediately.
38. The husband of a client asks the nurse, “Someone
told me my wife had a histrionic personality disorder.
What does that mean?” Which statement is the nurse's
best response?
l 1. “The person is flamboyant and always needs to be
the center of attention.”
l 2. “Histrionic personality means the person is very
orderly and very rigid.”
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393
3. “Does your wife keep isolated to herself and have
no close friends?”
4. “This type of person is unable to conform to social
norms.”
39. Which axis of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV-TR) identifies if the client
has a personality disorder?
l 1. Axis I.
l 2. Axis II.
l 3. Axis III.
l 4. Axis IV.
ANSWERS
37. Correct answer 2: The staff needs to be consistent
with the client and plan interventions to address the
manipulative behavior. The client cannot be transferred to the psychiatric unit, and the client cannot
help this behavior. Helping the staff deal with the
client's behavior will help the staff care for the
client. Content–Mental Health; Category of Health
Alteration–Psychiatric; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
38. Correct answer 1: Flamboyant and a need to be the
center of attention are expressions often used to
describe a person with a histrionic personality.
Option 2 describes an obsessive-compulsive personality; option 3 describes a schizoid personality disorder; and option 4 describes an antisocial personality
disorder. Content–Mental Health; Category of
Health Alteration–Psychiatric; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
394
39. Correct answer 2: Axis II contains the personality
disorders in adults. Axis I contains clinical disorders;
Axis III contains clients' general medical conditions;
and Axis IV contains psychosocial and environments
disorders. Axis V is the Global Functioning Assessment (GAF). Content–Mental Health; Category of
Health Alteration–Psychiatric; Integrated Process–
Diagnosis; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.
Mental Health Disorders
SECTION EIGHT
40. The Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV-TR) identifies three types of personality
disorders. Which statement best describes the clusters for
clients diagnosed with personality disorders?
l 1. Clients with Cluster A disorders are odd and
eccentric.
l 2. Clients with Cluster B disorders are fearful and
anxious.
l 3. Clients with Cluster C disorders are dramatic and
emotional.
l 4. Clients with Cluster D disorders are delusional and
hallucinate.
Anxiety Disorders
41. Which signs/symptoms would the nurse expect to
assess in the client diagnosed with a generalized anxiety
disorder?
l 1. The client has repetitive behaviors that interfere
with normal functioning.
l 2. The client reports an abnormal fear of crowds or
open spaces.
l
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395
3. The client is restless and tense and has difficulty
concentrating and sleeping.
4. The client complains of having flashbacks and
nightmares of a war.
42. The client diagnosed with a general anxiety disorder
is prescribed alprazolam (Xanax), a benzodiazepine.
Which statement indicates the client understands the
medication teaching?
l 1. “This medication can cause dependency so I will
only use it a short time.”
l 2. “I may experience some heightened excitement
while taking this medication.”
l 3. “I should not eat grapefruit or drink grapefruit
juice while taking this medication.”
l 4. “I need to take this medication four times a day
whether I am anxious or not.”
ANSWERS
40. Correct answer 1: Odd and eccentric are words
used to describe clients in Cluster A. Words that
describe Cluster B personality disorders are dramatic
and emotional. Cluster C personality disorders are
described as fearful and anxious. There are no
Cluster D personality disorders. Content–Mental
Health; Category of Health Alteration–Psychiatric;
Integrated Process–Diagnosis; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
41. Correct answer 3: The client with a generalized anxiety disorder has unrealistic, excessive, and persistent
(6 months or longer) anxiety and worry. Option 1
is obsessive-compulsive disorder; option 2 is claustrophobia; and option 4 is post-traumatic stress disorder.
Content–Mental Health; Category of Health Alteration–
Psychiatric; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
396
42. Correct answer 1: Xanax has the potential for dependency, but this potential can be minimized by using
the lowest effective dosage for the shortest time necessary. It should not be taken routinely. Heightened excitement is a paradoxical reaction, which leads to discontinuing the medication. Grapefruit does not affect
this medication. Content–Mental Health; Category of
Health Alteration–Psychiatric; Integrated Process–Evaluation; Client Needs–Physiological Integrity, Pharmacological and Parenteral Therapies; Cognitive Level–Evaluation.
SECTION EIGHT
Mental Health Disorders
397
43. The client diagnosed with a panic attack disorder
45. The male client with an obsessive-compulsive
who is sitting in the waiting room of a psychiatric
clinic appears anxious, is starting to hyperventilate, is
trembling, and is sweating. Which intervention should
the nurse implement first?
l 1. Encourage the client to take slow deep breaths.
l 2. Assess the client's vital signs.
l 3. Remove the client from the waiting room.
l 4. Administer alprazolam (Xanax), a benzodiazepine.
disorder is washing his hands. The nurse calls the client
back to the office for his appointment, but he cannot
stop washing his hands. Which action should the nurse
implement?
l 1. Tell the client he must stop washing his hands.
l 2. Cancel the client's appointment and reschedule.
l 3. Notify the client's health-care provider (HCP) of
the situation.
l 4. Wait for the client to finish washing his hands.
44. The female client who was viciously raped 1 year
ago is diagnosed with post-traumatic stress disorder
(PTSD). Which intervention should the psychiatric
nurse implement?
l 1. Encourage the client to go through a desensitization
process.
l 2. Recommend the client attend a support group for
rape victims.
l 3. Encourage the client to not talk about the
traumatic rape.
l 4. Tell the client to write her feelings in a journal and
keep it locked.
ANSWERS
43. Correct answer 1: The nurse should first tell the
client to take slow, deep breaths and then remove
the client from the waiting room. Then the nurse
can administer medication (will take 20–30 minutes
to work) and assess the client's vital signs. Content–
Mental Health; Category of Health Alteration–
Psychiatric; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
44. Correct answer 2: Support groups allow clients to
share their experience with other individuals who
have experienced similar traumatic events. Desensitization is recommended for the client with phobias.
The nurse should encourage the client to verbalize
the events, but journaling is not helpful for clients
with PTSD. Content–Mental Health; Category of
Health Alteration–Psychiatric; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
Copyright © 2010 F.A. Davis Company
398
45. Correct answer 4: This behavior is due to anxiety.
The nurse should allow the client to finish the ritual
because stopping it will increase the behavior and
may lead to violence by the client. The only time the
nurse should make the client stop the behavior is if
the client is a danger to self—for example, washing
the hands until they are raw. Content–Mental Health;
Category of Health Alteration–Psychiatric; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
Mental Health Disorders
SECTION EIGHT
46. The client who was in a near-fatal car accident
3 weeks ago is diagnosed with post-traumatic stress
syndrome (PTSD) and prescribed paroxetine (Paxil), an
SSRI. The client asks the nurse, “Will this medication really
help me? I don't like feeling this way.” Which statement is
the nurse's best response?
l 1. “Since the accident was within 1 month the Paxil
should be helpful.”
l 2. “The medication will make you feel better within a
couple of days.”
l 3. “You're worried the medication will not help
prevent the nightmares.”
l 4. “Individual and group therapy are the only
treatments for PTSD.”
47. The client diagnosed with claustrophobia is undergoing
a desensitization process. Which intervention should the
nurse implement?
l 1. Progressively expose the client to closed-in places
along with support.
l 2. Provide negative reinforcement when there is an
increase in phobic reaction.
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399
3. Discuss the desensitization process with members
of the support group.
4. Complete the admission assessment to the
psychiatric unit.
48. The client with an obsessive-compulsive disorder
must check to see if the windows are locked every
night for at least 2 hours before going to bed. Which
intervention would be most appropriate for the nurse to
discuss with the client?
l 1. Recommend the client's significant other check the
windows instead of the client doing so.
l 2. Ask why the client feels the need to check the
windows more than once.
l 3. Discuss the need to have an alarm system installed
in the client's home.
l 4. Tell the client to gradually decrease the amount of
time checking the windows.
ANSWERS
46. Correct response 1: SSRIs reduce the three core
400
48. Correct answer 4: Gradually limiting the amount of
symptoms of PTSD: re-experiencing, avoidance/
emotional numbing, and hyperarousal. The medication is most effective when started within 3 months of
the traumatic event and may take up to 2–3 months
for maximal response. Content–Mental Health;
time for the ritual helps the client with an obsessivecompulsive disorder. The compulsive act is due to
anxiety; therefore, the significant other checking the
windows or putting in an alarm system will not stop
the compulsive act. Content–Mental Health; Category
Category of Health Alteration–Drug Administration;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Physiological Adaptation;
Cognitive Level–Synthesis.
of Health Alteration–Psychiatric; Integrated Process–
Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
47. Correct response 1: The treatment for phobias is
desensitization, which is gradually exposing the
client to the situation that triggers the irrational fear
while providing support. Positive reinforcement is
given when there is a decrease in the phobic reaction;
desensitization is not implemented in a group
setting; and inpatient treatment is not required.
Content–Mental Health; Category of Health Alteration–
Psychiatric; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management of
Care; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
SECTION EIGHT
Mental Health Disorders
401
Cognitive Disorders
49. The client is having an acute anxiety attack. Which
51. The 78-year-old female client who is 1 day
priority intervention should the nurse implement?
l 1. Help the client recognize signs of an anxiety attack.
l 2. Provide the client with a safe environment.
l 3. Discuss alternate coping strategies with the client.
l 4. Determine if the client has had any caffeine or
nicotine.
postoperative right hip repair is confused and does not
recognize her family members. The client's son asks the
nurse, “What is going on? She was fine before she fell.”
Which statement is the nurse's best response?
l 1. “Sometimes the anesthesia can cause the client to
become confused.”
l 2. “She may be experiencing delirium, which is
reversible with time.”
l 3. “Your mother may have developed dementia since
the accident.”
l 4. “You are concerned because you don't know what
is going on.”
50. The psychiatric nurse is working with clients
diagnosed with generalized anxiety disorders, phobias,
obsessive-compulsive disorders, and post-traumatic stress
syndrome. Which intervention is most important when
working with these clients?
l 1. Teach the client about the prescribed medications.
l 2. Allow the client to ventilate feelings about anxiety.
l 3. Avoid being judgmental when talking to the client.
l 4. Provide positive reinforcements when the client
makes progress.
ANSWERS
49. Correct answer 2: Safety for the client is the priority
intervention. During an acute attack the client is
unable to learn new information. Caffeine and
nicotine should be decreased, but it is not appropriate
to determine if the client had any caffeine or nicotine during an acute anxiety attack. Content–Mental
Health; Category of Health Alteration–Psychiatric;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
50. Correct answer 3: The nurse must establish a trusting relationship with the client. This includes being
nonjudgmental, listening to the client, and providing
a calm environment. Teaching about medications,
verbalizing feelings, and providing positive reinforcements are appropriate interventions, but the most
important is to establish trust. Content–Mental
Health; Category of Health Alteration–Psychiatric;
Integrated Process–Planning; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive Level–
Synthesis.
Copyright © 2010 F.A. Davis Company
402
51. Correct answer 2: Delirium is caused by an acute
stressor (the fall and surgery) and is usually reversible.
The acute onset of confusion makes this delirium,
instead of dementia, which has a gradual onset of
confusion. Option 4 is a therapeutic response, but
the nurse should provide factual information to
the son. Content–Mental Health; Category of Health
Alteration–Psychiatric; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Application.
Mental Health Disorders
SECTION EIGHT
52. The wife of an 81-year-old client newly diagnosed
with Alzheimer disease tells the nurse, “My husband has
been getting more forgetful and lies to me so I won't
know he is forgetting things.” Which statement is the
nurse's best response?
l 1. “Your husband lies to you so that you won't realize
his is getting more confused.”
l 2. “Why do you think your husband is lying to you
after being married for 50 years?”
l 3. “Your husband is getting older and maybe he
should start writing down information.”
l 4. “He is using confabulation, which is not lying
but is making excuses to protect his ego.”
53. The nurse is teaching the husband of a woman
diagnosed with Alzheimer disease about home care.
Which intervention should the nurse discuss with the
client's husband?
l 1. Provide a variety of activities to keep the client
occupied.
l 2. Tell him to help his wife dress in the morning.
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403
3. Discuss the importance of providing a consistent
environment.
4. Tell the husband to have different people take care
of his wife.
54. The daughter of an 85-year-old woman calls the
clinic and tells the nurse, “My mother is acting strangely.
She is not dressed, hasn't bathed in a few days, and is
acting like she is hearing and seeing things.” Which
intervention should the nurse implement first?
l 1. Instruct the daughter to take her mother to the
emergency department.
l 2. Schedule an appointment for the mother to be seen
in the clinic today.
l 3. Ask the daughter if the mother has any type of
substance abuse problem.
l 4. Determine when was the last time someone visited
the mother.
ANSWERS
52. Correct answer 4: Confabulation is not lying, and it
is used by the client with dementia to help protect
the ego and decrease anxiety related to being confused and forgetful. The nurse should provide the
wife with facts. Content–Mental Health; Category of
Health Alteration–Psychiatric; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
53. Correct answer 3: The client needs a consistent,
safe environment and a consistent caregiver. Change
increases anxiety and confusion. The client should
have simple tasks and activities with limited variety
because the client has difficulty making decisions.
The husband should encourage self-care as much as
possible. Content–Mental Health; Category of Health
Alteration–Psychiatric; Integrated Process–Planning;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
404
54. Correct answer 4: The first intervention is to try
and determine the onset of this behavior. The client
should be seen by a health-care provider either at
the clinic or the emergency department. Substance
intoxication or withdrawal could cause this behavior,
but the first intervention is to get an accurate history.
Content–Mental Health; Category of Health Alteration–
Psychiatric; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management of
Care; Cognitive Level–Synthesis.
SECTION EIGHT
Mental Health Disorders
405
55. The nurse is teaching the family and client who is
57. The client with Alzheimer disease is prescribed
diagnosed with vascular dementia. Which statement best
describes this cognitive disorder?
l 1. This disorder has an abrupt, episodic onset with
multiple remissions.
l 2. It is a genetic, progressive, degenerative disorder
with motor and cognitive changes.
l 3. This dementia is caused by eating contaminating
beef and is called “mad cow disease.”
l 4. The client has extrapyramidal signs, visual
hallucinations, and fluctuating cognition.
tacrine (Cognex), an acetylcholinesterase inhibitor.
Which intervention should the nurse discuss with the
client's family member who will be responsible for giving
the medication?
l 1. Instruct the family member to give the medication
with food.
l 2. Explain that this medication will prevent further
deterioration.
l 3. Recommend an increase in the client's fluid intake
to 3000 mL a day.
l 4. Administer the medication at night only to help
the client sleep.
56. The nurse and UAP are caring for clients in a locked
Alzheimer unit. Which action by the UAP would require
immediate intervention by the nurse?
l 1. The UAP is calling the client “honey” and “sweetie.”
l 2. The UAP is assisting the client to take a shower.
l 3. The UAP is preparing the client's lunch tray.
l 4. The UAP did not lock the door after leaving
the unit.
58. The son of a 68-year-old client tells the clinic nurse
his mother has been becoming more confused lately.
Which action should the nurse implement first?
l 1. Explain that confusion is common as people get
older.
l 2. Complete a Mini-Mental Status Examination
(MMSE).
l 3. Request the HCP to order a CT scan.
l 4. Assess the client's cranial nerve function.
ANSWERS
55. Correct answer 1: In vascular dementia, brain tissue
is destroyed by intermittent emboli, which can range
from a few to more than a dozen. The emboli cause
focal neurological signs such as one-sided weakness
and emotional disturbances. Option 2 is Huntington
disease; option 3 is Creutzfeldt-Jakob disease; and
option 4 is dementia with Lewy bodies. Content–
Mental Health; Category of Health Alteration–
Psychiatric; Integrated Process–Diagnosis; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
56. Correct answer 4: This is a safety issue for the clients;
406
57. Correct answer 1: Administering the medication
with food will help decrease gastrointestinal upset.
The medication may help delay Alzheimer symptoms,
but it will not prevent further deterioration. Increasing fluids is not needed for this medication, and the
medication does not help the client sleep. Content–
Mental Health; Category of Health Alteration–Drug
Administration; Integrated Process–Planning; Client
Needs–Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Synthesis.
58. Correct answer 2: Confusion in the elderly is often
therefore, this requires immediate intervention.
The UAP should call the clients by their names, not
“honey,” but this does not require immediate intervention. Assisting the client with a shower and preparing
a lunch tray are appropriate actions by the UAP.
accepted as normal, but it is not. The client who is
becoming confused should be evaluated for cognitive
functioning through use of the MMSE. Confusion
can have a physiological etiology, which may require
further testing, including a CT scan or complete
neurological examination. Content–Mental Health;
Content–Mental Health; Category of Health Alteration–
Management; Integrated Process–Planning; Client
Needs–Safe Effective Care Environment, Safety and
Infection Control; Cognitive Level–Synthesis.
Category of Health Alteration–Psychiatric; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Safety and Infection Control;
Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
Mental Health Disorders
SECTION EIGHT
59. The wife of a client with stage 3 Alzheimer disease
tells the nurse, “I am physically and mentally exhausted.
I don't know what else to do.” Which recommendation
would be most important for the nurse to discuss with
the wife?
l 1. Consider admitting the client to a long-term care
facility (LTCF).
l 2. Arrange for respite care to come to the home at
least 2 days a week.
l 3. Encourage the wife to attend an Alzheimer support
group.
l 4. Make an appointment with the HCP to have a
physical examination.
60. The nurse and UAP are caring for clients in a locked
Alzheimer unit. Which task would be most appropriate
for the nurse to delegate to the UAP?
l 1. Instruct the UAP to reorient a client to the
orientation board.
l 2. Ask the UAP to play a game of monopoly with
several clients.
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3. Tell the UAP to give a client an antacid for
indigestion.
4. Ask the UAP to escort a client outside to smoke
a cigarette.
Eating Disorders
61. The 16-year-old female client in the clinic weighs
42 kg and is 67 inches tall. Which assessment data are
most important for the nurse to obtain?
l 1. Determine if the client participates in sports.
l 2. Have the client keep a 3-day food diary.
l 3. Talk with the parents about the client's weight.
l 4. Ask the client how she is doing in school.
ANSWERS
59. Correct answer 2: Respite care arranges for someone
to come to the client's home so that the significant
other can have a “break” from caring for the loved
one. Admitting the client to an LTCF, attending a
support group, and having a physical examination
may be implemented but arranging for relief is
most important. Content–Mental Health; Category
of Health Alteration–Psychiatric; Integrated Process–
Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
60. Correct answer 1: All staff should reorient the
clients to the orientation board, which has the
date, type of weather outside, and other pertinent
information. The client with Alzheimer should
participate in simple activities; the UAP cannot
administer any medications; and the UAP needs to
stay on the unit, not take a client outside to smoke.
Content–Mental Health; Category of Health Alteration–
Management; Integrated Process–Planning; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
408
61. Correct answer 2: The nurse should first determine
what the client is eating and how much. A young
female who is 5'7" tall and weighs 92.4 pounds
should be evaluated for anorexia. Content–Mental
Health; Category of Health Alteration–Psychiatric;
Integrated Process–Assessment; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
SECTION EIGHT
Mental Health Disorders
409
62. The 10-year-old overweight client complains of
64. The mother of an adolescent girl tells the nurse she
being thirsty and tired all the time. Which assessment
data should the nurse evaluate?
l 1. Determine the amount of soft drinks and candy
bars the client consumes.
l 2. Check to see if the child's parents are overweight.
l 3. Obtain liver function studies and an
electrocardiogram.
l 4. Assess the client's blood pressure and the skin on
the client's neck.
found several boxes of stimulant laxatives in the girl's room.
The adolescent is a normal body size for her height. Which
question should the nurse ask the mother?
l 1. “How long has your daughter had problems with
her bowels?”
l 2. “How often does your daughter participate in
school activities?”
l 3. “Does your daughter spend a long time in the
bathroom after meals?”
l 4. “Has your daughter been feeling depressed about
how she looks?”
63. The 40-year-old male client tells the nurse, “I have
been overweight all of my life and have tried every diet
around, but I can't lose weight.” Which intervention
should the nurse implement first?
l 1. Tell the client to ask the HCP for a diet drug
prescription.
l 2. Determine what specific diets the client has tried
and the results.
l 3. Refer the client to a bariatric clinic for surgery.
l 4. Assess the client's body mass index (BMI).
ANSWERS
62. Correct answer 4: The client should be checked for
signs of hyperinsulinemia, signs of which include
dark, “dirty”-looking skin on the neck and elevated
blood pressure. These are acanthosis nigricans (AN)
markers and indicate the client is at risk for type 2
diabetes mellitus. The amount of junk food the
client eats will not directly give the nurse information about AN. Content–Mental Health; Category
of Health Alteration–Psychiatric; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Analysis.
63. Correct answer 2: The nurse should first assess what
the client has tried in order to determine where to
refer him. Then the nurse should assess the BMI and
possibly have the client discuss medications with his
HCP or consider surgery. Content–Mental Health;
Category of Health Alteration–Psychiatric; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
410
64. Correct answer 3: Use of laxatives and inducing
vomiting after a meal are signs of bulimia. The nurse
should assess for this disease. Clients with bulimia
are usually of a normal weight but go to extremes
to maintain their weight. Content–Mental Health;
Category of Health Alteration–Psychiatric; Integrated
Process–Assessment; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Analysis.
SECTION EIGHT
Mental Health Disorders
411
65. The client diagnosed with anorexia-bulimia is admitted
67. The female client tells the nurse that she is considering
to the medical unit for cardiac complications. Which task
should the nurse delegate to the UAP?
l 1. Instruct the UAP to show the client a high-calorie
meal plan.
l 2. Have the UAP sit with the client for 45–60 minutes
after the meal.
l 3. Request the UAP to talk with the client about the
dangers of malnutrition.
l 4. Tell the UAP to work with the client to set
weight goals.
using the over-the-counter medication orlistat (Xenical), a
lipase inhibitor. Which information is most important for
the nurse to teach the client?
l 1. Tell the client to adhere to a strict fat-free diet.
l 2. Teach the client to refrain from vitamins while
taking orlistat.
l 3. Remind the client of the importance of tapering off
the medication.
l 4. Discuss how much weight the client wants to lose.
66. The nurse is working with obese clients. Which
(AIDS) is diagnosed with protein calorie malnutrition and
prescribed megestrol (Megacel), a progestin. Which data
indicate the medication is effective?
l 1. The client has no nausea and vomiting.
l 2. The client eats at least 50% of the meals.
l 3. The client gained 2 pounds in 1 week.
l 4. The client will drink Ensure at night.
information should the nurse include in the teaching?
l 1. Tell the client that to maintain weight there must
be a change in eating behaviors.
l 2. Recommend that the client lose at least 4–5 pounds
every week.
l 3. Encourage the client to exercise 1 hour on the same
day each week.
l 4. Instruct the client to weigh and measure foods
consumed at mealtimes only.
68. The client with acquired immune deficiency syndrome
ANSWERS
65. Correct answer 2: The UAP can sit with the
client to make sure that the client does not induce
vomiting after a meal. The dietitian or nurse should
plan meals, discuss malnutrition, and set goals.
Content–Mental Health; Category of Health Alteration–
Management; Integrated Process–Planning; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
66. Correct answer 1: Behavior modification is necessary
if the client is to maintain weight loss. A 1–2 pound
weight loss every week is the appropriate goal.
Exercise should be for 30 minutes at least 3 days a
week. If the client is weighing and measuring food,
then all food, not just that eaten at mealtimes, must
be weighed and measured. Content–Mental Health;
Category of Health Alteration–Psychiatric; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
412
67. Correct answer 1: Orlistat works by interfering with
the absorption of fats in the gastrointestinal (GI) tract.
This can cause oily spotting, flatulence with discharge,
fecal urgency, and fecal incontinence when the client
eats fats. The client should take vitamins and does not
need to taper off the medication. Content–Mental
Health; Category of Health Alteration–Psychiatric;
Integrated Process–Planning; Client Needs–Physiological
Integrity, Pharmacological and Parenteral Therapies;
Cognitive Level–Synthesis.
68. Correct answer 3: Megestrol is a progestin that has
the side effect of appetite stimulation. A weight gain
indicates the medication is effective. Eating 50% of
meals, no nausea and vomiting, and drinking supplemental calories do not indicate the medication is
effective. Content–Mental Health; Category of Health
Alteration–Drug Administration; Integrated Process–
Evaluation; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Evaluation.
Mental Health Disorders
SECTION EIGHT
69. The nurse is counseling a female client diagnosed
with anorexia. Which psychosocial client goal should the
nurse and client set?
l 1. The client will state one positive physical attribute
about herself.
l 2. The client will not induce vomiting after meals for
1 week.
l 3. The client will exercise for 30 minutes three times
a week.
l 4. The client will gain 1 pound every 7–10 days.
70. After the holiday season the clinic nurse weighed
the client who is overweight, and the client had gained
2 pounds. Which statement is the nurse's best response?
l 1. “You know that you should not overeat during the
holiday season.”
l 2. “Why would you get off your diet just because it
was a holiday?”
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413
3. “Two pounds is not bad. Don't get discouraged;
just start back eating properly.”
4. “I must document your 2-pound weight gain in
your chart.”
Substance Abuse Disorder
71. The client who has chronic alcoholism is admitted to
the hospital for a medical problem. Which medication
will the nurse administer to prevent neurological
complications from alcohol withdrawal?
l 1. Chlordiazepoxide (Librium), a benzodiazepine.
l 2. Clonidine (Catapres), an alpha-adrenergic blocker.
l 3. Disulfiram (Antabuse), an abstinence medication.
l 4. Thiamine (vitamin B1), a vitamin.
ANSWERS
69. Correct answer 1: This is a psychosocial goal.
Inducing vomiting is done by clients with bulimia.
Weight gain is a physiological goal. The client
usually over-exercises to prevent weight gain.
Content–Mental Health; Category of Health Alteration–
Psychiatric; Integrated Process–Diagnosis; Client Needs–
Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
70. Correct answer 3: The nurse should not discourage
the client. The nurse should encourage the client to
continue to lose weight. The client does not owe the
nurse an explanation as to “why.” Options 1 and 4
are judgmental and condescending. Content–Mental
Health; Category of Health Alteration–Psychiatric;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
414
71. Correct answer 4: Thiamine is a vitamin prescribed
for clients with chronic alcoholism to prevent the
neurological complication of Wernicke encephalopathy. Librium prevents delirium tremens; Catapres
lessens withdrawal symptoms; and Antabuse is
administered to keep the client from consuming
alcohol. Content–Mental Health; Category of Health
Alteration–Drug Administration; Integrated Process–
Planning; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Synthesis.
Mental Health Disorders
SECTION EIGHT
72. The nurse is working in an inpatient drug and
alcohol rehabilitation program. Which referral is most
appropriate to help the client with a substance abuse
problem remain drug-free after discharge?
l 1. Obtaining employment in a drug-related field.
l 2. Having a supportive significant other to assist the
client.
l 3. Attending Narcotics Anonymous (NA) self-help
support meetings.
l 4. Counseling by a psychologist who specializes in
drug-abuse clients.
73. The female client who has smoked cigarettes since
she was an adolescent asks the clinic nurse “Is there
anything I can take to help me stop smoking?” Which
statement is the nurse's best response?
l 1. “You should attend a smoking cessation support
group.”
l 2. “Reduce the number of cigarettes you smoke each
day by one.”
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415
3. “You should try a nicotine patch to help with the
craving.”
4. “The drugs used to help alcoholics quit are helpful
with all addictions.”
74. The male client is prescribed methadone, an opiate
agonist. Which intervention is most important for the
nurse to teach the client?
l 1. Take the medication with an antacid to prevent
nausea.
l 2. Teach the client to increase the fiber in the diet.
l 3. Discuss taking the methadone only if respirations
are greater than 16.
l 4. Instruct to rise slowly when changing positions
from lying to standing.
ANSWERS
72. Correct answer 3: Attending regular NA meetings
416
74. Correct answer 4: Methadone causes lightheadedness,
will keep the client focused on remaining abstinent
from drugs. Significant others may or may not be
helpful. The client should not obtain a job in a
drug-related field, such as bartending. Counseling is
once a week at best, but the client must face the
problem daily. Content–Mental Health; Category of
dizziness, and a transient fall in blood pressure; therefore, the nurse should discuss ways to prevent
orthostatic hypotension. Methadone also causes
gastrointestinal distress and constipation, but the
most important teaching is safety. The client does not
need to check respirations. Content–Mental Health;
Health Alteration–Psychiatric; Integrated Process–
Planning; Client Needs–Psychosocial Integrity;
Cognitive Level–Synthesis.
Category of Health Alteration–Psychiatric; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Synthesis.
73. Correct answer 3: The client wants something to
take to help her stop. A nicotine patch or nicotine
gum will help with withdrawal from this drug.
Smoking cessation groups may help psychologically,
but not physically. Reducing the number of cigarettes will not help the physiological withdrawal, and
option 4 is a false statement. Content–Mental Health;
Category of Health Alteration–Psychiatric; Integrated
Process–Implementation; Client Needs–Psychosocial
Integrity; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
SECTION EIGHT
Mental Health Disorders
417
75. The client has been using crack cocaine daily for the
77. The female client found wandering at the side of the
last 2 years and repeated outpatient interventions have
been unsuccessful. Which intervention should the clinic
nurse recommend at this time?
l 1. Use of daily acupuncture treatments.
l 2. Placement in an inpatient facility.
l 3. Intensive aversion therapy.
l 4. Persuasion and psychotherapy.
road is brought to the emergency department (ED) by
paramedics with complaints of being weak and sleepy.
The client cannot remember her name or where she was
prior to being brought to the ED. Which intervention
should the nurse prepare to implement first?
l 1. Prepare for a rape examination.
l 2. Institute a psychiatric consult.
l 3. Allow the client to sleep.
l 4. Schedule a CT scan of the head.
76. The client admitted to the intensive care unit from
the emergency department who was diagnosed with a
myocardial infarction (MI) is emaciated and appears
malnourished. Which assessment data are most important
for the nurse to obtain?
l 1. Ask the client to do a nutritional food recall diary.
l 2. Determine if the client drinks alcohol and
how much.
l 3. Obtain a current troponin level.
l 4. Request a STAT electrocardiogram (ECG).
ANSWERS
75. Correct answer 2: Treatment of crack cocaine is
extremely difficult. If outpatient treatments have
failed, then admission to an inpatient facility where
access to the drug is limited may be beneficial.
Acupuncture, persuasion, and psychotherapy can
be done on an outpatient basis. Aversion therapy is
useful with alcohol. Content–Mental Health; Category
of Health Alteration–Psychiatric; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
76. Correct answer 2: The emaciated client should be
assessed for chronic alcoholism to determine if the
client is at risk for withdrawal. A nutrition recall
diary would be inappropriate for a client newly diagnosed with an MI, requiring too much energy at this
time. The troponin level and ECG from the ED will
be sufficient at this time. Content–Mental Health;
Category of Health Alteration–Psychiatric; Integrated
Copyright © 2010 F.A. Davis Company
418
Process–Assessment; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Analysis.
77. Correct answer 1: This client is exhibiting symptoms of the date rape drug Rohypnol and should
be given a rape examination. A psychiatric consult is
not needed at this time. The nurse should intervene,
not just allow the client to sleep. A CT scan may
or may not need to be done, but it is not the first
intervention. Content–Mental Health; Category of
Health Alteration–Psychiatric; Integrated Process–
Planning; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Synthesis.
SECTION EIGHT
Mental Health Disorders
419
78. The female student at a high school presents to the
80. The adolescent client is brought to the emergency
school nurse complaining she has chest pain and feels
like her heart is racing. The nurse suspects the client has
taken amphetamines. Which intervention should the
nurse implement first?
l 1. Call 911 and have the paramedics transport the
client to the hospital.
l 2. Notify the parents that the student is taking
amphetamines.
l 3. Check the client's pulse, respirations, and blood
pressure.
l 4. Assess the client's mood elevation, appetite, and
progress in classes.
department from a party where it was determined the
participants were “sniffing” a chemical solvent with
chloroform as the main ingredient. Which intervention
should the nurse implement first?
l 1. Place the client on oxygen via nasal cannula.
l 2. Monitor the client's heart rhythm.
l 3. Obtain cardiac enzymes and an ECG.
l 4. Have the lab draw a STAT creatinine level.
79. Which assessment data indicate to the nurse the
client is using marijuana?
l 1. Agitation, dizziness, and tremors.
l 2. Increased self-confidence and paranoid ideation.
l 3. Kaleidoscopic images and emotional mood swings.
l 4. Euphoria, sedation, and hallucinations.
ANSWERS
78. Correct answer 3: Assessing for the cardiovascular
effects of amphetamines is priority. Notifying the
emergency medical services system should be done if
the nurse determines an irregular cardiac rhythm and
hypertension. Mood elevation, loss of appetite, and
class work could indicate taking amphetamines but
are not most important to assess. Content–Mental
Health; Category of Health Alteration–Psychiatric;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
79. Correct answer 4: Euphoria, sedation, and hallucinations are the three principal subjective effects of
marijuana. Agitation, dizziness, and tremors are signs
of cocaine overdose. Increased self-confidence and
paranoid ideation are associated with amphetamines.
Kaleidoscopic images and mood swings are caused
by LSD. Content–Mental Health; Category of Health
Alteration–Psychiatric; Integrated Process–Assessment;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
420
80. Correct answer 1: The nurse would perform all
of the activities listed, but because respiratory
depression leading to death can occur after sniffing a
chemical solvent, placing the client on oxygen is the
first intervention. Content–Mental Health; Category
of Health Alteration–Psychiatric; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Synthesis.
Mental Health Disorders
SECTION EIGHT
Management
81. The nurse in the outpatient psychiatric unit is
returning phone calls. Which client should the
psychiatric nurse call first?
l 1. The female client diagnosed with depression whose
significant other called to state the client is sleeping
20 hours a day.
l 2. The male client diagnosed with schizophrenia who
is hearing voices telling him he is Jesus Christ.
l 3. The male client diagnosed with major depression
whose wife left him and states he has nothing to
live for.
l 4. The client diagnosed with bipolar disorder whose
mania is now becoming depressive and the client
wants the mania back.
82. The nurse and a UAP are caring for children in
a psychiatric unit. Which client requires immediate
intervention by the psychiatric nurse?
l 1. The 10-year-old child diagnosed with oppositional
defiant disorder who is complaining the UAP does
not like him.
l
l
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421
2. The 7-year-old child diagnosed with pervasive
developmental disorder who is practicing her
spelling words with the UAP.
3. The 9-year-old child diagnosed with conduct
disorder who is sitting and watching television
when he should be in class.
4. The 12-year-old mentally retarded girl who is
banging her head against the concrete floor and
has a nosebleed.
83. The female client diagnosed with major depression is
returning to the psychiatric unit after attending a music
therapy class. Which intervention should the nurse
implement first?
l 1. Request the client to sing a song in the dayroom.
l 2. Determine if the client took her medication.
l 3. Ask the client to share how the class went.
l 4. Check the client for sharps or dangerous objects.
ANSWERS
81. Correct answer 3: The nurse should determine if
the client has a plan for suicide. This is the first
client the nurse should contact. Options 1, 2, and 3
are expected for the disease process. Content–Mental
Health; Category of Health Alteration–Management;
Integrated Process–Assessment; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
82. Correct answer 4: This child has injured herself,
and the nurse should attend to this injury first.
Complaining that someone does not like them and
not attending class are expected with the disorders
the clients have. Interacting with a UAP is progress
for a client with pervasive developmental disorder
(autism). Content–Mental Health; Category of Health
Alteration–Psychiatric; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
422
83. Correct answer 3: Asking the client to share her
thoughts about the therapy is supporting the therapy
and helps the nurse determine if the client is participating in therapy. The client may not want to sing a
song; the nurse is responsible for administering
medications; and the client is checked for sharps
returning from day/week-end passes. Content–Mental
Health; Category of Health Alteration–Psychiatric;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
Mental Health Disorders
SECTION EIGHT
84. The psychiatric nurse is working in an outpatient
mental health clinic. Which client should the nurse
intervene with first?
l 1. The client with postpartum depression who had a
baby 2 months ago and tells the nurse her baby is
at the day-care center.
l 2. The client with schizophrenia whose wife tells the
nurse that he is hearing voices telling him he
should be dead.
l 3. The client with antisocial personality disorder who
tells the nurse he should be the new vice president
of his company.
l 4. The client with obsessive-compulsive disorder
(OCD) who is rocking compulsively back and
forth in a chair by the window.
85. The charge nurse received laboratory data for clients
in the psychiatric unit. Which client data warrant
notifying the psychiatric HCP?
l 1. The client on lithium (Eskalith) whose serum
lithium level is 2.0 mEq/L.
l 2. The client on clozapine (Clozaril) whose white
blood cell count is 8000 mm3.
l
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423
3. The client on methadone whose potassium level is
4.0 mEq/L.
4. The client on donepezil (Aricept) whose glucose
level is 128 mg/dL.
86. The clinical manager assigned the psychiatric nurse
a male client diagnosed with major depression who
attempted suicide by tying sheets together to hang
himself. Which intervention by the psychiatric nurse
would warrant intervention by the clinical manager?
l 1. The nurse places the client in the seclusion room
to sleep.
l 2. The nurse encourages the client to discuss his
feeling of despair.
l 3. The nurse allows the client to watch television in
the dayroom.
l 4. The nurse tells the client he is not allowed to have
sleeping medications.
ANSWERS
84. Correct answer 2: This client should be assessed
for suicidal risk. The baby in day care is safe at the
moment. Clients with antisocial disorders think
they deserve the best, and rocking by the window
compulsively is a sign of OCD. Content–Mental
Health; Category of Health Alteration–Psychiatric;
Integrated Process–Assessment; Client Needs–Safe
Effective Care Environment, Safety and Infection
Control; Cognitive Level–Analysis.
85. Correct answer 1: The therapeutic serum level of
lithium is 0.6–1.5 mEq/L. This information should
be immediately relayed to the HCP. The white blood
cells and potassium are within normal limits, and the
glucose is only slightly elevated. Content–Mental
Health; Category of Health Alteration–Psychiatric;
Integrated Process–Assessment; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
424
86. Correct answer 1: The client who has attempted
suicide should be on one-on-one observation.
Placing the client in a room alone allows the client
to make another attempt at suicide. Encouraging
verbalization of feelings, watching television where
he is observed, and refusing to give the client
sleeping medications are appropriate activities.
Content–Mental Health; Category of Health Alteration–
Psychiatric; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Safety and
Infection Control; Cognitive Level–Synthesis.
SECTION EIGHT
Mental Health Disorders
425
87. The charge nurse is caring for clients in an acute care
88. Which task would be appropriate for the psychiatric
psychiatric unit. Which client would be most appropriate
for the charge nurse to assign to a licensed practical nurse
(LPN)?
l 1. The client diagnosed with Alzheimer disease who
has begun to seize.
l 2. The client diagnosed with schizophrenia who is
experiencing tardive dyskinesia.
l 3. The client diagnosed with bipolar disorder who has
a lithium level of 1.0 mEq/L.
l 4. The client diagnosed with alcoholism who is
experiencing Wernicke encephalopathy.
charge nurse to delegate to the UAP?
l 1. Instruct the UAP to escort the client to the
multidisciplinary team meeting.
l 2. Ask the UAP to conduct a class on psychiatric
medications for the clients.
l 3. Tell the UAP to take care of the client who is
hallucinating and angry.
l 4. Request the UAP to draw the morning blood
studies on all the clients.
ANSWERS
87. Correct answer 3: Because this client has a normal
level of lithium (0.6–1.5), the LPN can care for this
client. Clients with seizures; clients with tardive
dyskinesia, a potentially life-threatening complication; and clients with Wernicke encephalopathy, a
severe complication of chronic alcoholism, should be
assigned to an experienced registered nurse (RN).
Content–Mental Health; Category of Health Alteration–
Psychiatric; Integrated Process–Planning; Client Needs–
Safe Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
426
88. Correct answer 1: The UAP can escort clients to
meetings. The UAP should not be delegated teaching, unstable clients, or work that is appropriate for
lab personnel. Content–Mental Health; Category of
Health Alteration–Management; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
SECTION EIGHT
Mental Health Disorders
427
89. The female client in the psychiatric unit requests the
90. The UAP on the psychiatric unit has tried to calm
male UAP to take her to the gift shop for a soda. Which
action would warrant intervention by the psychiatric
nurse?
l 1. The UAP checks to see what privileges the client is
allowed to have.
l 2. The UAP stops what he is doing and takes the
client to the gift shop.
l 3. The UAP tells the client that she can go when the
UAP takes all the clients.
l 4. The UAP reports the client's request to the charge
nurse of the unit.
the client who is angry and attempting to fight another
client. The nurse observes the UAP allowing the client to
continue the argument. Which intervention should the
nurse implement first?
l 1. Inform the UAP to perform a “take down” of the
client.
l 2. Discuss why the UAP did not intervene to stop a
fight.
l 3. Document the UAP's behavior in the personnel file.
l 4. Review procedures for dealing with out-of-control
clients.
ANSWERS
89. Correct answer 2: Clients on a psychiatric ward
have to learn boundaries. The UAP should not interrupt work being done to immediately comply with a
social request. The UAP should check to make sure
the client has privileges and can take the client when
it is time for the outing, and the charge nurse should
be notified of the request. Content–Mental Health;
Category of Health Alteration–Psychiatric; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Safety and Infection Control;
Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
428
90. Correct answer 1: Client safety is priority. The
first intervention is to perform a “take down” and
stop the aggressive behavior. Then the nurse should
review procedures, discuss the behavior, and
document the behavior for the file. Content–Mental
Health; Category of Health Alteration–Psychiatric;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
SECTION NINE
Women’s Health
429
SECTION NINE
Women’s Health
431
Pelvic Floor Dysfunction
1. The nurse is instructing the female client experiencing
3. A 56-year-old female client tells the clinic nurse,
urinary incontinence. Which data should the nurse assess
when teaching Kegel exercises to the client?
l 1. Determine if the client can stop and hold her
stream of urine.
l 2. Ask the client if she uses tampons during her menses.
l 3. Palpate the client’s lower abdomen for bladder
distention.
l 4. Request the client to keep a 24-hour log of voiding
times.
“I have low back pain and feel like something is falling
out between my legs.” Which statement is the nurse’s best
response?
l 1. “How often do you have sexual intercourse?”
l 2. “Are you experiencing vaginal dryness?”
l 3. “Your doctor should check for uterine prolapse.”
l 4. “It sounds like you may have a cystocele or
rectocele.”
2. The nurse is caring for a 65-year-old female client who
the client is experiencing stress incontinence. Which
statement should the nurse make when discussing this
concern?
l 1. “Do you have a bowel movement every day?”
l 2. “Do you ever unexpectedly lose urine?”
l 3. “Do you have to wear tampons all the time?”
l 4. “Do you experience anxiety when urinating?”
requests a peri-pad. Which question would be most
appropriate for the nurse to ask the client?
l 1. “How long have you been having your period?”
l 2. “I need to obtain a doctor’s order so it will be
paid for.”
l 3. “Are you experiencing any abdominal cramping?”
l 4. “Do you have stress incontinence when you cough?”
4. The nurse caring for an elderly female client suspects
ANSWERS
1. Correct answer 1: The client will not be able to
perform Kegel exercises correctly if she is unable to
stop and hold her stream of urine. Tampon use,
assessing for bladder distention, and voiding times
are not pertinent assessment data when teaching
Kegel exercises. Content–Medical; Category of Health
Alteration–Gynecology; Integrated Process–Planning;
Client Needs–Psychological Integrity, Psychological
Adaptation; Cognitive Level–Synthesis.
2. Correct answer 4: A 65-year-old female client would
not be having a period and the peri-pad would be
for urine incontinence; therefore, asking about stress
incontinence would be the most appropriate question.
Content–Medical; Category of Health Alteration–
Gynecology; Integrated Process–Assessment; Client Needs–
Psychological Integrity, Psychological Adaptation;
Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
432
3. Correct answer 3: Symptoms of uterine prolapse
include feeling of pelvic fullness and pressure with low
back pain. The client may express these symptoms as
a feeling everything is falling out. Content–Medical;
Category of Health Alteration–Gynecology; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Analysis.
4. Correct answer 2: Clients may be reluctant to discuss
problems with urinary incontinence; therefore, the nurse
must ask the client direct questions to encourage the
client to discuss problems or concerns. Content–Medical;
Category of Health Alteration–Gynecology; Integrated
Process–Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.
SECTION NINE
Women’s Health
433
5. The nurse is discussing stress incontinence with the
7. The client diagnosed with uterine prolapse is 6 hours
female client. Which intervention should the nurse
discuss with the client?
l 1. Instruct the client to decrease fluid intake to
1000 mL/day.
l 2. Encourage the client to walk at least 30 minutes
every day.
l 3. Tell the client to refrain from consuming caffeinated
drinks.
l 4. Discuss the importance of increasing daily fiber
intake.
postoperative vaginal hysterectomy. Which intervention
should the nurse include in the discharge teaching?
l 1. Instruct the client not to insert anything into the
vagina for 4–6 weeks.
l 2. Notify the health-care provider (HCP) if the
incision is reddened or swollen.
l 3. Tell the client to expect a period-like blood flow for
2 weeks after surgery.
l 4. Discuss the need to take estrogen replacement
medication for life.
6. The elderly female client diagnosed with overactive
8. The client diagnosed with a rectocele is 8 hours
bladder is prescribed tolterodine (Detrol), a nonselective
muscarinic antagonist. Which statement by the client
would cause immediate intervention by the nurse?
l 1. “I am so glad that I don’t have to urinate every hour.”
l 2. “I suck on sugar-free hard candy because my
mouth is dry.”
l 3. “I get my blood pressure checked every time I go
to my pharmacy.”
l 4. “I have to use eyedrops every day for my glaucoma.”
postoperative posterior colporrhaphy and has not
urinated since surgery. Which intervention should the
nurse implement first?
l 1. Perform an in-and-out urinary catheterization.
l 2. Assess urinary volume with a bladder scan.
l 3. Assist the client to ambulate to the bathroom.
l 4. Increase the client’s oral fluid intake.
ANSWERS
5. Correct answer 3: Alcohol and caffeine can irritate the
bladder and increase urinary incontinence. Decreasing
fluid intake may worsen the incontinence because the
bladder does not fill to its normal capacity. Walking and
increasing fiber intake would help decrease constipation.
Normal bladder capacity is individualized per client;
it is how much the client normally can contain in the
bladder, and not filling to capacity routinely will
decrease bladder size. Content–Medical; Category of
Health Alteration–Gynecology; Integrated Process–
Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
6. Correct answer 4: Detrol is an anticholinergic medication, which is contraindicated in clients diagnosed with
glaucoma because it causes a midratic reaction and can
further exacerbate glaucoma. Decreased urination is
the rationale for administering Detrol, and dry mouth
is an expected side effect. Content–Medical; Category
of Health Alteration–Gynecology; Integrated Process–
Evaluation; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
434
7. Correct answer 1: The uterus is removed through the
vagina; therefore, nothing, including a tampon, a finger,
or a penis, should be inserted into the orifice until
healing has occurred. There is no incision the client
can see; there should be very little blood; and the
client’s ovaries were not removed, so there is no need
for estrogen replacement. Content–Surgical; Category
of Health Alteration–Gynecology; Integrated Process–
Planning; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Synthesis.
8. Correct answer 2: By using the bladder scan, the nurse
can determine how much urine is in the bladder. The
nurse should implement a noninvasive procedure first,
not catheterization. Ambulating or increasing fluid
intake will not help the client urinate. Content–Surgical;
Category of Health Alteration–Gynecology; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Analysis.
Women’s Health
SECTION NINE
9. The client diagnosed with pelvic floor dysfunction
asks the nurse, “What did I do to cause this problem?”
Which statement is the nurse’s best response?
l 1. “No one really knows what causes pelvic floor
dysfunction.”
l 2. “I can see you are upset. Would you like to sit and
talk about it?”
l 3. “Many times it is due to multiple or traumatic
childbirths.”
l 4. “One cause may be having multiple sexual partners
over time.”
10. The nurse is caring for a female client diagnosed with
uterine prolapse who has been prescribed a pessary. Which
intervention should the nurse discuss with the client?
l 1. Tell the client to use a spermicidal gel when using
the pessary.
l 2. Recommend lubricating the pessary with Vaseline
prior to insertion.
l
l
435
3. Discourage the client from using topical or systemic
estrogen treatment.
4. Instruct the client to remove the pessary every
night to reduce discharge.
Ovarian/Uterine Disorders
11. Which secondary intervention should the nurse
recommend to the female client who has had multiple
sexual partners?
l 1. Recommend the client schedule a routine Pap smear.
l 2. Teach the client to use a latex condom.
l 3. Tell the client to have a CA-125 tumor mark test.
l 4. Instruct the client to douche after sexual intercourse.
12. Which client should the clinic nurse recommend to
receive the vaccine Gardasil?
l 1. The 11-year-old client who is not sexually active.
l 2. The 21-year-old client who has genital warts.
l 3. The 35-year-old client who is diagnosed with
cervical cancer.
l 4. The 52-year-old client who is going through
menopause.
ANSWERS
9. Correct answer 3: Pelvic floor dysfunction usually
occurs in the perimenopausal period. Multiple births,
traumatic births, having children within 1 year of each
other, and being overweight may exacerbate the condition. Content–Medical; Category of Health Alteration–
Gynecology; Integrated Process–Implementation; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Application.
10. Correct answer 4: A pessary is a device used to
support pelvic structures. It is inserted into the vagina
without using any gels or Vaseline. Removing the
pessary every night helps prevent vaginal discharge,
ulceration, and infection. Estrogen treatment will
not affect the pessary. Content –Medical; Category of
Health Alteration–Gynecology; Integrated Process–
Planning; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
436
11. Correct answer 1: A routine Pap smear will detect
early changes in the cervical mucosa associated with
cancer or a sexually transmitted disease (STD).
A primary intervention is teaching, and a secondary
intervention is screenings. CA-125 is used to monitor
ovarian cancer. Content–Medical; Category of Health
Alteration–Gynecology; Integrated Process–Planning;
Client Needs–Health Promotion and Maintenance;
Cognitive Level–Synthesis.
12. Correct answer 1: Gardasil is an immunization that
prevents up to 70% of cervical cancer. The vaccine is
recommended for young women 9–14 years of age
prior to sexual activity. Content–Medical; Category
of Health Alteration–Gynecology; Integrated Process–
Planning; Client Needs–Health Promotion and Maintenance; Cognitive Level–Synthesis.
SECTION NINE
Women’s Health
437
13. The client asks the clinic nurse, “How would I know
15. Which statement by the client would indicate to the
that I had fibroid tumors in my uterus?” Which response
would be most appropriate for the nurse?
l 1. “You would probably have a feeling of something
falling out between your legs.”
l 2. “Many times fibroid tumors in the uterus do not
produce any symptoms.”
l 3. “Why do you ask this question? Are you having
any problems with your period?”
l 4. “Fibroid tumors of the uterus will block menses
and you will not have a period.”
nurse the client is at risk for developing ovarian cancer?
l 1. “I started having a period when I was 15 years old.”
l 2. “I quit smoking cigarettes about 2 years ago.”
l 3. “I have never been able to have my own child.”
l 4. “I am glad I went through the change in my 40s.”
14. The nurse and the unlicensed assistive personnel (UAP)
are caring for clients on a gynecological unit. Which task
would be inappropriate for the nurse to delegate to the UAP?
l 1. Request the UAP to take the vital signs on a newly
admitted client.
l 2. Tell the UAP to obtain an intravenous pump and
pole for the client.
l 3. Ask the UAP to escort the client who had a vaginal
hysterectomy to the car.
l 4. Ask the UAP to document the number of peri-pads
used by the client.
16. The client diagnosed with ovarian cancer is crying
and tells the nurse, “I have always had regular female
check-ups. Why didn’t my doctor find my cancer earlier?”
Which statement by the nurse is the best response?
l 1. “A test was not available until recently to detect
ovarian cancer early.”
l 2. “Because the ovaries are deep in the pelvis, the
symptoms are vague.”
l 3. “Did you tell your doctor about having sharp pain
in the pelvic area?”
l 4. “It is only found if the person has menstrual
irregularities.”
ANSWERS
13. Correct answer 2: Uterine leiomyomas (fibroid
tumors) usually do not produce symptoms, but
increased uterine size, pelvic pain, and excessive
menstrual bleeding may occur. Content–Medical;
Category of Health Alteration–Gynecology; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
14. Correct answer 4: The nurse must assess the peri-pads
for amount and type of drainage; documenting the
number of peri-pads is not sufficient; therefore, this
task would not be delegated to a UAP. Taking vital
signs, discharging the client, and obtaining equipment
can be delegated to a UAP. Content–Medical; Category
of Health Alteration–Gynecology; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
438
15. Correct answer 3: Risk factors for ovarian cancer
include no child or first child after 30 years of age,
starting menses before 12 years old, and menopause
after 55 years old. Smoking is a risk factor for cervical
cancer, not for ovarian cancer. Content–Medical;
Category of Health Alteration–Gynecology; Integrated
Process–Assessment; Client Needs–Health Promotion
and Maintenance; Cognitive Level–Analysis.
16. Correct answer 2: Ovarian cancer is the number
one cause of gynecological death due to the fact that
ovarian cancer does not have early signs/symptoms
and there is no screening available. Content–Medical;
Category of Health Alteration–Gynecology; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
SECTION NINE
Women’s Health
439
17. The client diagnosed with an ovarian cyst is being
19. The married client diagnosed with uterine cancer
discharged from the ambulatory surgery center after having
a laparoscopy. Which discharge instruction should the
nurse discuss with the client?
l 1. Tell the client to maintain pelvic rest for 4–6 weeks.
l 2. Instruct the client to perform Kegel exercises daily.
l 3. Demonstrate to the client how to splint the
abdominal incision when coughing.
l 4. Recommend the client take acetaminophen (Tylenol)
for pain.
who has had a total abdominal hysterectomy is crying and
tells the nurse, “I always wanted children. Now it is too
late.” Which statement would be the nurse’s best response?
l 1. “You are sad because you can’t have children.
Would you like to talk?”
l 2. “Have you ever thought about adopting a child?
So many children need parents.”
l 3. “You should be thankful because your cancer has
not metastasized.”
l 4. “I think you need to discuss your feelings with your
husband.”
18. The client diagnosed with ovarian cancer is receiving
chemotherapy in an outpatient clinic. Which data would
warrant the client not receiving chemotherapy?
l 1. The client’s CA-125 has doubled.
l 2. The client’s platelet count is 150,000.
l 3. The client’s white blood cell (WBC) count is 1800.
l 4. The client’s hemoglobin is 10 mg/dL.
20. The client comes to the outpatient clinic for her
well-woman check-up. Which statement by the client
would warrant further investigation by the nurse?
l 1. “I always know when I am going to start my period.”
l 2. “I take Tylenol to help my cramping during my
period.”
l 3. “I use a peri-pad because I don’t like wearing
tampons.”
l 4. “I am having pain when my husband and
I make love.”
ANSWERS
17. Correct answer 4: This procedure produces only
mild discomfort because an incision less than 2 cm is
made into the abdominal wall; therefore, splinting is
not taught. The client is able to resume normal activities when awake and alert and may take Tylenol for
any discomfort. Content–Surgical; Category of Health
Alteration–Gynecology; Integrated Process–Planning;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Synthesis.
18. Correct answer 3: The client’s WBC count of 1800 is
very low, and administration of chemotherapy would
increase the risk of infection; therefore, the client
would not receive chemotherapy. The CA-125 is a
tumor marker that is not used to determine if
chemotherapy is administered; the platelet count is
within normal limits (WNL), and the hemoglobin
is not critically low. Content–Medical; Category of
Health Alteration–Gynecology; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
440
19. Correct answer 1: The nurse cannot teach or
problem-solve for the client’s concern; therefore, the
nurse should help the client ventilate her feelings by
responding in a therapeutic manner. Content–
Surgical; Category of Health Alteration–Gynecology;
Integrated Process–Implementation; Client Needs–
Psychosocial Integrity, Cognitive Level–Application.
20. Correct answer 4: Dyspareunia, or painful intercourse,
is a symptom that should cause the nurse to further
assess the client. Content–Medical; Category of Health
Alteration–Gynecology; Integrated Process–Assessment;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Analysis.
Women’s Health
SECTION NINE
Infertility Disorders
21. The female client experiencing fertility problems tells
the clinic nurse that she is taking St. John’s wort for her
depression. Which statement would be the nurse’s best
response?
l 1. “This herb is useful for depression. I hope it
will help.”
l 2. “Did you discuss taking this herb with your
fertility specialist?”
l 3. “This herb may cause more infertility problems.”
l 4. “Taking herbs is dangerous and you should not
take them.”
22. The female client is taking clomiphene (Clomid),
an estrogen antagonist. Which statement indicates the
teaching has been effective?
l 1. “The medication may cause my child to be deaf at
birth.”
l 2. “There are very few risks associated with taking this
medication.”
l
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441
3. “I should stagger the times that I take this
medication.”
4. “I will have to have many sonograms during my
pregnancy.”
23. The nurse is counseling parents who have undergone
successful in vitro fertilization and have embryos remaining
from the first attempt. Which moral issue should the
nurse discuss with the parents?
l 1. Discuss the cost of the yearly storage fee for the
embryos.
l 2. Recommend donating the embryos to another
infertile couple.
l 3. Talk to the parents about destroying the embryos.
l 4. Tell the parents all embryos must be implanted
within 2 years.
ANSWERS
21. Correct answer 2: The client should discuss taking
herbs with all health-care providers; therefore, recommending the client talk to the fertility specialist is the
nurse’s best response. St. John’s wort may affect sperm
cells, causing decreased sperm motility and viability;
therefore, the male client should not take this herb.
The herb is not known to affect a woman’s fertility.
Content–Medical; Category of Health Alteration–
Complementary Alternative Medicine; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Pharmacological and Parenteral Therapies;
Cognitive Level–Application.
22. Correct answer 4: Clomid is an ovarian stimulant
that promotes follicle maturation and ovulation.
Many follicles can mature simultaneously, resulting in
an increased possibility of multiple births; therefore,
the client will have serial sonograms. Content–Medical;
Category of Health Alteration–Obstetrics; Integrated
Process–Evaluation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Evaluation.
Copyright © 2010 F.A. Davis Company
442
23. Correct answer 3: The moral issue is “Does life occur
at conception?” If so, then destroying the embryos
would be the same as having an elective abortion.
The cost is a financial issue, donating the embryos is
a personal preference, and the embryos can be frozen
for many years. Content–Medical; Category of Health
Alteration–Obstetrics; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
SECTION NINE
Women’s Health
443
24. The infertile client diagnosed with endometriosis has
26. The nurse administers human chorionic gonadotropin
been taking leuprolide (Lupron), a gonadotropin-releasing
hormone (GnRH) medication, for 2 months. She tells the
clinic nurse, “I don’t think the medication is working.”
Which statement is the nurse’s most appropriate response?
l 1. “This medication may take 3–6 months to work
effectively.”
l 2. “You need to relax and let the medication work so
that you can get pregnant.”
l 3. “Please tell me what makes you think the medication
is not working?”
l 4. “Has your husband been checked for any type of
infertility problems?”
(hCG) intramuscularly (IM) to the infertile female client.
Which statement indicates the client and significant other
understand the teaching?
l 1. “We should not have sexual intercourse for 14 days
after receiving the medication.”
l 2. “My husband should not wear boxer shorts and
wear tight-fitting jockey shorts.”
l 3. “I will test my cervical mucosa the day after I start
my menstrual cycle.”
l 4. “We should have intercourse on the eve and 3 days
after receiving the medication.”
25. The female client has been taking infertility
indicates the couple is knowledgeable of fertility issues?
l 1. “Most insurance companies do not cover the cost
of the medications completely.”
l 2. “A multi-fetal pregnancy does not result in preterm
labor and birth.”
l 3. “There is an excellent probability we will get
pregnant the first time.”
l 4. “Most of the implanted zygotes will result in a live
birth.”
medications. Which signs/symptoms would indicate
ovarian overstimulation syndrome?
l 1. Vague gastrointestinal discomfort.
l 2. Bright red vaginal bleeding.
l 3. A positive fluid wave.
l 4. An increase frequency in urinating.
27. The nurse is discussing fertility issues. Which statement
ANSWERS
24. Correct answer 1: The client should be aware it
444
may take up to 3–6 months for leuprolide therapy
to achieve maximum benefits; therefore, the nurse
should discuss the long-term possibility with the client.
promote ovulation; therefore, the couple should not
wait to have sexual intercourse. Wearing tight-fitting
underwear causes the scrotum to be close to the body,
and the heat reduces the sperm count. Content–
Content–Medical; Category of Health Alteration–
Obstetrics; Integrated Process–Implementation; Client
Needs–Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Application.
Medical; Category of Health Alteration–Obstetrics;
Integrated Process–Evaluation; Client Needs–Physiological
Integrity, Pharmacological and Parenteral Therapies;
Cognitive Level–Evaluation.
25. Correct answer 3: Ovarian hyperstimulation syndrome involves marked ovarian enlargement with
exudation of fluid into the woman’s peritoneal and
pleural cavities. This syndrome can result in an ovarian
cyst that may rupture, causing pain. Content–Medical;
Category of Health Alteration–Obstetrics; Integrated
Process–Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
26. Correct answer 4: The couple should have sexual
intercourse during this time because this is the probable period of ovulation; hCG acts immediately to
Copyright © 2010 F.A. Davis Company
27. Correct answer 1: Infertility therapy is extremely
expensive and most insurance companies do not
cover it at all or cover only a small portion. Multifetal pregnancies can result in preterm labor; there is
no guarantee of pregnancy on the first attempt; and
most of the implanted zygotes do not result in a live
birth. Content–Medical; Category of Health Alteration–
Obstetrics; Integrated Process–Evaluation; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Evaluation.
SECTION NINE
Women’s Health
445
28. The male infertile client asks the clinic nurse “Is there
30. Which modifiable risk factor should the nurse discuss
anything I can do to increase my chances of fathering a
child?” Which statement is the nurse’s best response?
l 1. “Improving your overall health by exercising may
help you father a child.”
l 2. “You are concerned about not being able to father
a child?”
l 3. “There is medication that may help increase your
sperm count.”
l 4. “Massaging your testicles prior to intercourse may
help with sperm release.”
with the female client who is infertile?
l 1. History of pelvic inflammatory disease (PID).
l 2. Smoking two packs of cigarettes a day.
l 3. Chronic urinary tract infections (UTIs).
l 4. Dysfunction of the pituitary gland.
29. The nurse is counseling a couple that is visiting the
infertility clinic for the first time. Which question would
be most important for the nurse to ask the couple?
l 1. “Have you discussed your infertility with any
friends and family?”
l 2. “Has your relationship changed since you have not
been able to conceive?”
l 3. “Do you have any cultural or religious concerns
about not being able to get pregnant?”
l 4. “If you cannot conceive a baby, would you consider
adopting a child?”
Birth Control Issues
31. The nurse is counseling the female adolescent client
who confides in the nurse she is sexually active. Which
information is most important to discuss with the client?
l 1. Tell the client to discuss this important issue with
her parents.
l 2. Discuss using the female condom when having
sexual intercourse.
l 3. Recommend the client talk to her HCP about
taking birth control pills.
l 4. Encourage the client to make her sexual partner
wear protection.
ANSWERS
28. Correct answer 3: Administration of testosterone
will improve hormonal levels, resulting in a potential
for increased production of sperm. Content–Medical;
446
they act on the ovaries. This can be modified by
administering supplemental medications. Cigarette
smoking, chronic UTIs, and PID are not risk factors
for infertility. Content–Medical; Category of Health
Category of Health Alteration–Obstetrics; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
Alteration–Obstetrics; Integrated Process–Planning;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Synthesis.
29. Correct answer 2: The most important question is
31. Correct answer 2: The female condom (vaginal
one that evaluates how infertility has affected the couple’s relationship with each other. This issue may cause
tension, fear, and guilt between the couple. Content–
Medical; Category of Health Alteration–Obstetrics;
Integrated Process–Assessment; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Analysis.
30. Correct answer 4: Dysfunction of the pituitary
gland may alter the secretion of the reproductive
hormones—GnRH, follicle-stimulating hormone
(FSH), and leutenizing hormone (LH)—and how
Copyright © 2010 F.A. Davis Company
pouch) can protect the client from pregnancy and
sexually transmitted diseases and does not rely on
the male for protection. Empowering the client to be
responsible for safe sex is the most important information to discuss with the client. Content–Medical;
Category of Health Alteration–Obstetrics; Integrated
Process–Planning; Client Needs–Health Promotion and
Maintenance; Cognitive Level–Synthesis.
SECTION NINE
Women’s Health
447
32. The couple has decided to use spermicide for birth
34. Which statement indicates the client that is prescribed
control. Which statement indicates the female partner
understands the teaching?
l 1. “I must insert the foam prior to having sexual
intercourse.”
l 2. “I will douche with vinegar and water immediately
after having sex.”
l 3. “I should put the spermicidal foam on my partner’s
penis.”
l 4. “I must use the spermicide immediately after
having intercourse.”
oral contraceptives for birth control understands the
medication teaching?
l 1. “I need to get a Pap smear every 3 months because
I am on the pill.”
l 2. “If I have breakthrough bleeding, I will quit taking
my pill.”
l 3. “If I miss taking a pill, I will take it as soon as
I remember.”
l 4. “I should not drink alcohol because my birth
control pill will not work.”
33. Which female client would the nurse not
35. The client tells the nurse, “I am going to breastfeed
recommend taking oral contraceptive pills for birth
control?
l 1. The 21-year-old client who has had irregular
periods for 3 years.
l 2. The 29-year-old client who is 65" tall and weighs
68 kilograms.
l 3. The 35-year-old client who smokes two packs of
cigarettes a day.
l 4. The 38-year-old client who has lymphoma and
taking chemotherapy.
so I don’t have to worry about getting pregnant.” Which
statement is the nurse’s best response?
l 1. “Breastfeeding can be used as an effective form of
birth control.”
l 2. “I think you should talk to your HCP about other
forms of birth control.”
l 3. “Do you and your husband want to have more
children?”
l 4. “Breastfeeding is the least reliable form of birth
control.”
ANSWERS
448
32. Correct answer 1: Spermicide must be in place prior
34. Correct answer 3: The client should be instructed to
to intercourse because the foam is immediately active.
If a suppository or tablet is used, it must be inserted
10–15 minutes before intercourse to allow time for
it to dissolve. Content–Medical; Category of Health
take any missed pill as soon as she remembers; therefore, the client could and should take more than one
pill in a day. To maintain ovulation suppression, the
client must take the medication routinely. Content–
Alteration–Obstetrics; Integrated Process–Evaluation;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Evaluation.
Medical; Category of Health Alteration–Obstetrics;
Integrated Process–Evaluation; Client Needs–Physiological
Integrity, Pharmacological and Parenteral Therapies;
Cognitive Level–Evaluation.
33. Correct answer 3: A client who is older and smokes
cigarettes is at greater risk for cardiovascular complications of the pill. Clients with irregular periods are
prescribed birth control pills as are clients taking
chemotherapy who should not get pregnant. Content–
35. Correct answer 2: A woman must breastfeed a mini-
Medical; Category of Health Alteration–Obstetrics;
Integrated Process–Assessment; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Analysis.
gory of Health Alteration–Obstetrics; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
mum of 10 times in 24 hours with no supplementary
feedings to possibly avoid ovulation, but it is the least
reliable form of birth control. Content–Medical; Cate-
SECTION NINE
Women’s Health
36. The male adolescent client tells the clinic nurse,
38. The client received an intrauterine device (IUD)
“Last night when I used a condom with my girlfriend
I got a red itchy rash around my penis.” Which question
would be the nurse’s best response?
l 1. “How long have you had the condom?”
l 2. “Do you have any type of latex allergy?”
l 3. “Do you need to be tested for an STD?”
l 4. “Was the condom exposed to sunlight?”
5 weeks ago. Which statement by the client would
warrant intervention by the clinic nurse?
l 1. “My breasts get tender around my period.”
l 2. “I have not had a period since I had the IUD
inserted.”
l 3. “I am so hurt. My boyfriend is being treated for
syphilis.”
l 4. “I feel a thickening underneath my breast when
I examine them.”
37. Which statement indicates to the nurse that the
client just prescribed a vaginal contraceptive ring needs
more teaching concerning this type of birth control?
l 1. “I must change the ring every month.”
l 2. “I should insert the ring within 30 minutes of having
intercourse.”
l 3. “I will remove the ring 3 weeks after I have
inserted it.”
l 4. “I will continue to have my periods when using
the ring.”
449
39. The client is prescribed the 21-day oral contraceptive
pack. Which statement best describes the scientific rationale
for this birth control product?
l 1. This ensures that the client will take a pill every day.
l 2. It has fewer side effects than other forms of birth
control.
l 3. This medication will limit the symptoms of
premenstrual syndrome.
l 4. This prescription allows for the client to have a
period.
ANSWERS
36. Correct answer 2: The adolescent’s comments should
450
make the nurse consider an allergic reaction to the
condom, most of which are made of latex. Suggesting
a type of condom made of lamb’s intestines would
prevent an allergic reaction. Content–Medical; Category
indicates the client is at risk or may have an STD;
therefore, the nurse should intervene. The IUD
does not alter the woman’s body function, and the
thickening of the breasts would be the inframammary
ridge, which is normal. Content–Medical; Category
of Health Alteration–Obstetrics; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Analysis.
of Health Alteration–Obstetrics; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
37. Correct answer 2: This statement is appropriate for
39. Correct answer 4: The lack of hormone medication
a client using a diaphragm; therefore, the client
needs more teaching. The ring works on the same
principle that oral contraceptives work. The method
provides 21 days of hormone suppression and then
7 days to allow for menses. Content–Medical; Cate-
during the 7 days off will cause the uterus to slough
off the built-up tissue resulting in menses. The
21-day pack makes the client have to remember to
restart the pill 7 days after completing the pack.
A 28-day pack contains 21 days of the hormone and
7 days of placebos, which ensures the client takes a
pill every day. Content–Medical; Category–Obstetrics;
gory of Health Alteration–Obstetrics; Integrated
Process–Evaluation; Client Needs–Pharmacological and
Parenteral Therapies; Cognitive Level–Evaluation.
38. Correct answer 3: Women who have or are at risk
for a sexually transmitted disease (STD) should
not use an IUD for birth control. The comment
Copyright © 2010 F.A. Davis Company
Integrated Process–Planning; Client Needs–Physiological
Integrity, Pharmacological and Parenteral Therapies;
Cognitive Level–Knowledge.
Women’s Health
SECTION NINE
40. The adolescent client is prescribed the birth control
medication depot medroxyprogesterone (Depo-Provera).
Which interventions should the clinic nurse implement?
Select all that apply.
l 1. Instruct the client to schedule an appointment
every 6 months.
l 2. Explain that the client may not be able to conceive
for at least 1 year after discontinuing the Depo-Provera.
l 3. Administer the medication intramuscularly in the
deltoid area.
l 4. Discuss how to care for the intrauterine device
(IUD) inserted in her vagina.
l 5. Tell the client that she will not have to take a pill
every day.
Breast Disorders
41. The 54-year-old female client tells the nurse, “My
doctor told me the lump in my breast is nothing and not
to worry, but I am scared.” Which statement is the nurse’s
best response?
l 1. “You should get a second opinion about the lump
in your breast.”
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2. “I can see you are scared. Would you like to talk
about your fears?”
3. “Do monthly breast self-examinations and come
back if it changes.”
4. “This is probably breast cancer and you need to
have surgery.”
42. The client is diagnosed with breast cancer and opted
for a modified radical mastectomy. Which intervention
should the nurse include in the discharge teaching?
l 1. Discuss care of the skin after radiation therapy.
l 2. Teach the client how to care for the surgical site.
l 3. Tell the client she is not a candidate for
reconstruction surgery.
l 4. Instruct the client to have a tumor marker study
done yearly.
ANSWERS
40. Correct answers 2, 3, 5: When injections are discontinued, an average of 12 months is required for
fertility to return. The medication is administered
intramuscularly every 3 months, no pill is taken,
and no IUD is used. Content–Medical; Category
of Health Alteration–Obstetrics; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Application.
41. Correct answer 1: The client is entitled to a second
opinion, and a breast lump should be thoroughly
investigated, especially if the client is scared. Content–
Medical; Category of Health Alteration–Gynecology;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
452
42. Correct answer 2: The client needs to know how
to care for the surgical wound. Follow-up can differ,
and the nurse should not assume which therapy is
planned. She can have reconstruction surgery, and
tumor markers are checked depending on the followup therapy, not yearly. Content–Surgical; Category of
Health Alteration–Cancer; Integrated Process–Planning;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Synthesis.
SECTION NINE
Women’s Health
453
43. The client has undergone a wedge resection for
45. The client has had a mastectomy for cancer of the
cancer of the left breast. Which discharge instruction
should the nurse teach?
l 1. Do not lift more than 20 pounds with the left hand
until released by the HCP.
l 2. Instruct the client not to have any blood drawn from
the left arm.
l 3. Explain the importance of follow-up radiation therapy
after the procedure.
l 4. The client should arrange an appointment with a
plastic surgeon for reconstruction.
breast and asks the nurse about reconstructive surgery
options. Which information should the nurse discuss
with the client?
l 1. The only option after a mastectomy is a saline breast
implant.
l 2. It is recommended to postpone reconstruction for
5 years after surgery.
l 3. Refer the client to the American Cancer Society for
information.
l 4. One option is for the surgeon to perform the
TRAM-flap procedure.
44. Which is the American Cancer Society (ACS)
guideline for the early detection of breast cancer?
l 1. Beginning at age 20 have a mammogram every
5 years.
l 2. Beginning at age 30 perform monthly self breast
exams.
l 3. Beginning at age 40 get a yearly mammogram.
l 4. Beginning at age 50 have a breast sonogram yearly.
ANSWERS
43. Correct answer 3: Clients with wedge resections
must have follow-up radiation therapy to the area to
make sure all cancer cells have been destroyed. The
client should not lift more than 5 pounds, and she
can have blood drawn. There is no need for reconstruction surgery. Content–Surgical; Category of
Health Alteration–Cancer; Integrated Process–Planning;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Synthesis.
44. Correct answer 3: The ACS recommends a yearly
mammogram beginning at age 40 years for the early
detection of breast cancer. A mammogram can detect
a lump that will not be large enough to be felt.
Content–Medical; Category of Health Alteration–
Oncology; Integrated Process–Planning; Client Needs–
Health Promotion and Maintenance; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
454
45. Correct answer 4: The TRAM-flap procedure is one
in which the client’s own tissue is utilized to form
the new breast. Tissue and fat are pulled under the
skin, with one end left attached to the body providing circulation until the body builds collateral circulation in the area. There are multiple options for
reconstruction surgery. Content–Surgical; Category of
Health Alteration–Oncology; Integrated Process–Planning;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Synthesis.
Women’s Health
SECTION NINE
46. The nurse is teaching a class on breast health to a
group of senior citizens. Which information should the
nurse discuss with the group of men and women?
l 1. Eight out of 10 women who develop breast cancer
have a family history.
l 2. Men can have breast cancer and should report any
breast lumps.
l 3. Monthly breast self-examination is the main
method of early detection.
l 4. The older a woman is, the least likely she is to
develop breast cancer.
47. The client is scheduled to have a sentinel node breast
biopsy. The client tells the nurse “I don’t understand.
What does a sentinel node biopsy do?” Which statement
is the nurse’s best response?
l 1. “A dye is injected into the tumor and traced,
determining the spread of the cancer.”
l 2. “The surgeon will palpate nodes that drain the
diseased portion of the breast.”
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3. “A portion of your breast, along with the nodes,
will be removed with a syringe.”
4. “Nodes will be frozen, and the surgeon will be
notified if more should be removed.”
48. The client who had a right modified radical
mastectomy 4 years before is being admitted for a
cardiac workup for complaints of chest pain. Which task
would be most appropriate for the nurse to delegate to
the unlicensed assistive personnel (UAP)?
l 1. Request the UAP to complete the client’s
admission assessment.
l 2. Ask the UAP to prepare the client for a cardiac
catheterization in the morning.
l 3. Tell the UAP to put a sign at the bedside to not use
the right arm for blood pressure.
l 4. Instruct the UAP to draw the client’s cardiac
enzymes and take them to the laboratory.
ANSWERS
46. Correct answer 2: Men are diagnosed every year
with breast cancer, and it frequently goes undetected
because men consider this a women’s disease. Most
women who develop breast cancer do not have a
family history of the disease; mammograms can detect
breast cancer earlier than breast self-examinations;
and the second greatest risk factor for breast cancer is
being elderly. Content–Medical; Category of Health
Alteration–Gynecology; Integrated Process–Planning;
Client Needs–Health Promotion and Maintenance;
Cognitive Level–Synthesis.
47. Correct answer 1: A sentinel node biopsy is a procedure in which a radioactive dye is injected into the
tumor and then traced by instrumentation and color
to try to identify the exact lymph nodes that the
tumor could have shed into. Content–Surgical;
Category of Health Alteration–Surgical; Integrated
Process–Implementation; Cognitive Level–Physiological
Integrity, Reduction of Risk Potential; Cognitive
Level–Application.
Copyright © 2010 F.A. Davis Company
456
48. Correct answer 3: The right arm should not be used
for blood pressures or lab draws because the client is
at risk for lymphedema. The UAP cannot assess,
teach the client, or draw blood. Content–Surgical;
Category of Health Alteration–Management; Integrated
Process–Planning; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive Level–
Synthesis.
Women’s Health
SECTION NINE
457
Abuse
49. The client with a modified radical mastectomy has
51. A woman comes to the emergency department (ED)
a Hemovac. The Hemovac output for the 7 a.m.–3 p.m.
shift is 78 mL, for the 3 p.m.–11 p.m. shift 45 mL, and
for the 11 p.m.–7 a.m shift 15 mL. Which amount
should the nurse document in the client’s chart for the
24-hour total?
and tells the triage nurse she was raped by her date. The
woman is crying, disheveled, and has bruises on her face.
Which action should the nurse implement first?
l 1. Ask the client if she wants the police department
notified.
l 2. Notify a Sexual Assault Nurse Examiner (SANE)
to see the client.
l 3. Ask the client if she has any pain or discomfort at
this time.
l 4. Determine if the client has any support person to
notify.
Answer: ____________________
50. The client is being discharged after a left modified
radical mastectomy. Which discharge instructions should
the nurse include? Select all that apply.
l 1. Explain an elevated temperature is expected after
this surgery.
l 2. Do not carry large purses and bundles with the
right arm.
l 3. Encourage the client to participate in group
activities.
l 4. Tell the client to elevate the left arm on two
pillows.
l 5. Recommend the client to Reach to Recovery.
ANSWERS
49. Correct answer 138 mL: This is a simple addition
problem. The nurse should add the three shift
amounts to obtain the total 24-hour total. Content–
Surgical: Category of Health Alteration–Oncology;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
50. Correct answer 3, 4, 5: The client should be
encouraged to participate in activities, and elevating
the arm will decrease edema. Reach to Recovery is
a support group for clients with breast cancer. An
elevated temperature should be reported, and purses
should be carried in the right arm. Content–Surgical;
Category of Health Alteration–Cancer; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
458
51. Correct answer 3: The nurse’s first intervention is
to assess the client for any physical injuries, which
includes asking if the client is in pain. The nurse can
then notify the SANE nurse and after that contact a
support person. The SANE nurse will notify the police
department. Content–Medical; Category of Health
Alteration–Pain; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
SECTION NINE
Women’s Health
459
52. The emergency department nurse is assessing a
54. The nurse is teaching a class about rape prevention
female client who has abdominal bruising and small,
round burns on her trunk. The nurse asks the man who
is with the client to please leave the room. The man
refuses to leave the room. Which action should the nurse
implement?
l 1. Escort the client to the bathroom to collect a urine
specimen.
l 2. Request the emergency department physician to
complete the assessment.
l 3. Ask the client if it is all right if the man stays in
the room.
l 4. Give the client a slip of paper with the phone
number of a shelter.
to a group of women at a community center. Which
information is a myth about rape?
l 1. Rape can occur at any age, including infants and
elderly.
l 2. If a woman says “no,” it means no, and the woman
has this right.
l 3. Rape is an attempt to exert power and control over
the client.
l 4. All victims of sexual assault are women; men cannot
be raped.
53. The adolescent female tells the school nurse, “I hate
to go home because my stepfather does ‘stuff ’ to me.”
Which action should the nurse implement next?
l 1. Tell the mother about the child’s allegations.
l 2. Contact Child Protective Services immediately.
l 3. Request the stepfather to come to the school.
l 4. Arrange for the client to be examined by an HCP.
55. The nurse working in the emergency department is
admitting a female client who reported her husband beat
her up, but she does not want the police notified. Which
action should the nurse implement?
l 1. Notify the police department because it is the law.
l 2. Treat the client’s wounds and take no further
action.
l 3. Try to talk the client into reporting her husband.
l 4. Give the client the number of a woman’s shelter.
ANSWERS
52. Correct answer 1: The nurse needs to remove the
client from the room so that the nurse can talk to the
client and discuss probable abuse. The nurse should
not attempt to give information about a shelter to
the client in front of the potential abuser. Content–
Medical; Category of Health Alteration–Psychosocial;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
53. Correct answer 2: Legally the nurse must notify
child protective services to protect the child from
further abuse. The nurse should not contact either
parent and does not have the authority to send the
child to an HCP. Content–Fundamentals; Category
of Health Alteration–Psychosocial; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
460
54. Correct answer 4: Men and children can be victims
of rape. Sexual arousal and orgasm do not imply
consent but may be a pathological response to
stimulation. Content–Medical; Category of Health
Alteration–Psychosocial; Integrated Process–Planning;
Client Needs–Psychosocial Integrity; Cognitive
Level–Synthesis.
55. Correct answer 4: The nurse should help the client
to devise a plan for safety, including giving the client
the number of a safe house or a woman’s shelter. The
nurse does not legally have to report spousal abuse,
and it is a Health Insurance Portability and Accountability Act (HIPAA) violation if reported. The nurse
cannot coerce the client into reporting her husband.
Content–Fundamentals; Category of Health Alteration–
Psychosocial; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment; Cognitive
Level–Application.
Women’s Health
SECTION NINE
56. The 84-year-old female client who lives with her son
is admitted with multiple burn marks on the torso and
under the breasts, along with contusions in various stages
of healing. The client denies anyone abusing her. Which is
the most probable reason the client denies being abused?
l 1. The client may have accidently burned herself
smoking a cigarette.
l 2. The client may be afraid of being moved into a
long-term care facility.
l 3. The client’s son may have been abused as a child
by the client.
l 4. The client may not be able to feel the burns due to
neuropathy.
57. Which is an appropriate interview question for the
nurse to use with clients involved in abuse?
l 1. “I know you are being abused. Can you tell me
about it?”
l 2. “Did you allow your children to watch you being
abused?”
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3. “What did you do that caused your spouse to
get mad?”
4. “Do you have a safe place to go when the abuse
starts?”
58. The emergency department nurse writes the problem
of “fear of pregnancy” for a client who has been raped.
Which intervention should the nurse implement?
l 1. Discuss the possibility of the client taking the
“morning after” pill.
l 2. Refer the client to the social worker for a list of
adoption agencies.
l 3. Explain that one-time intercourse usually does not
result in a pregnancy.
l 4. Determine when the client last had her period to
determine if she may get pregnant.
ANSWERS
56. Correct answer 2: Many times the elderly are
ashamed to report abuse because they raised the
abuser and feel responsible for their abusive actions.
The elder parent may feel financially dependent on
the child or be afraid of being placed in a long-term
care facility. Content–Medical; Category of Health
Alteration–Integumentary; Integrated Process–Evaluation;
Client Needs–Safe Effective Care Environment; Cognitive
Level–Knowledge.
57. Correct answer 4: This statement assesses the abused
client’s safety (or a plan for safety). These other questions do not assess for the client’s safety in the home
and/or place blame for the abuse on the client.
Content–Medical; Category of Health Alteration–
Psychosocial; Integrated Process–Assessment; Client
Needs–Psychosocial Integrity; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
462
58. Correct answer 1: The RU 486, or the morningafter pill, prevents pregnancy from occurring. The
client should have the opportunity to prevent the
pregnancy. Content–Medical; Category of Health
Alteration–Obstetrics; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.
Women’s Health
SECTION NINE
463
Management
59. The nurse writes a nursing diagnosis “risk for injury
61. The client diagnosed with breast cancer has a
related to physical abuse by spouse” for a client. Which
goal would be the most appropriate for this client?
l 1. The client will report the abuse to the police.
l 2. The client will confront her abuser.
l 3. The client will identify a plan for safety.
l 4. The client will attend a self-defense class.
hemoglobin/hematocrit (H/H) of 12.8 mg/dL and 38%,
a WBC of 6800/mm3, and a neutrophil count of 80%.
Which action should the nurse implement?
l 1. Place the client in reverse isolation.
l 2. Notify the HCP.
l 3. Make sure no flowers are taken into the room.
l 4. Continue to monitor the client.
60. The client who was raped 3 months ago tells the
clinic nurse, “I just can’t seem to quit thinking about the
rape. I cry all of the time.” Which priority action should
the nurse implement?
l 1. Allow the client to ventilate her feelings of
helplessness.
l 2. Encourage the client to make an appointment with
a psychiatrist.
l 3. Refer the client to a rape crisis center for group
support.
l 4. Recommend the client seek pastoral support from
her church.
62. The clinic nurse has been named in a lawsuit by a
client who alleges professional negligence while being
seen for infertility issues. Which action should the nurse
take first?
l 1. Consult with the nurse’s malpractice insurance
attorney.
l 2. Review the client’s clinic medical record.
l 3. Contact the client to try and resolve the issue.
l 4. Discuss the case with the HCP.
ANSWERS
59. Correct answer 3: Ensuring the client’s safety is the
most appropriate goal for the “risk for injury” problem.
Content–Medical; Category of Health Alteration–
Psychosocial; Integrated Process–Diagnosis; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
60. Correct answer 3: A rape support group will help
the client to discuss her feelings with people who are
trained to deal with crisis, and the client can talk to
other women who have been raped. After 3 months,
the client can ventilate feelings, see a psychiatrist, and
seek pastoral support, but the priority action is to
refer the client to a support group. Content–Medical;
Category of Health Alteration–Psychosocial; Integrated
Process–Implementation; Client Needs–Psychosocial
Integrity; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
464
61. Correct answer 4: The client’s lab work is within
normal limits; therefore, the nurse should continue to
monitor the client. Reverse isolation and no flowers
would be appropriate if the client was neutropenic.
Content–Management; Category of Health Alteration–
Hematology; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Application.
62. Correct answer 1: The nurse should first contact her
attorney and then familiarize herself with the client’s
medical record in preparation for the deposition.
The nurse should not discuss the case with anyone,
especially not the client. Content–Management;
Category of Health Alteration–Obstetrics; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
SECTION NINE
Women’s Health
465
63. The nurse has accepted the position of clinic manager
65. The charge nurse observes a nurse and HCP talking
for a women’s health clinic. Which role is an important
aspect of the management position?
l 1. Ensure the clinic is appropriately staffed.
l 2. Be the sole decision maker for the unit.
l 3. Take responsibility for the nurses’ actions.
l 4. Complete insurance billing by end of the month.
loudly about a client at the nurse’s station. Which action
should the charge nurse take first?
l 1. Notify the HIPAA officer of the breech in
confidentiality.
l 2. Take no action because it involves an HCP.
l 3. Have the individuals go to a private room to talk.
l 4. Tell the individuals their conversation can be
overheard.
64. The manager on the gynecological unit notices that
the charge nurse takes frequent smoke breaks and is not
available to clients, staff, and HCPs. Which priority action
should the manager implement regarding this employee?
l 1. Discuss the nurse’s actions with the chief nursing
officer.
l 2. Talk with the nurses at the next scheduled staff
meeting.
l 3. Informally talk to the charge nurse about the
behavior.
l 4. Complete a formal counseling record and place in
employee’s file.
66. The nurse on the gynecological unit has received the
shift report. Which client should the nurse assess first?
l 1. The client scheduled for a hysterectomy who
saturated four peri-pads during the last shift.
l 2. The client who had a mastectomy and refuses to
look at the site.
l 3. The client who is scheduled for an endometrial
biopsy for infertility issues.
l 4. The client who has just been given the diagnosis of
ovarian cancer.
ANSWERS
63. Correct answer 1: One of the many jobs of a manager is to make sure the clinic operates efficiently,
which includes evaluating staff members to ensure
they are qualified for the position. A good manager
should be democratic and not the sole decision maker.
The manager does not take responsibility for nurses’
action, and the financial department is responsible
for billing. Content–Management; Category of Health
Alteration–Gynecology; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
64. Correct answer 3: The first step in employee discipline is to confront the employee with the inappropriate behavior with objective data and give the
employee a chance to correct the behavior. Content–
Management; Category of Health Alteration–Gynecology;
Integrated Process–Planning; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
466
65. Correct answer 4: The first action is to address
the individuals with the inappropriate behavior so
confidential information is not being discussed in
public. Then the individuals could go to a private
room if needed. It does not matter who is violating
confidentiality. The charge nurse must intervene.
Content–Management; Category of Health Alteration–
Gynecology; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Application.
66. Correct answer 1: The client who is bleeding should be
assessed first. Remember Maslow’s Hierarchy of Needs:
physiological needs are first. Content–Management; Category of Health Alteration–Gynecology; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Analysis.
SECTION NINE
Women’s Health
467
67. The female client tells the ambulatory surgery clinic
69. The clinic nurse is discussing upcoming surgery
nurse that she had a reaction when her husband used a
latex condom. Which intervention should the nurse
implement first?
l 1. Notify the clinic supervisor of the allergy.
l 2. Label the client’s chart with the allergy.
l 3. Place a red allergy band on the client.
l 4. Inform the client to tell all HCPs of the allergy.
with the elderly female client diagnosed with a uterine
prolapse. The client is worried about what will happen
if something goes wrong with the surgery. Which
intervention should the nurse implement first?
l 1. Encourage the client to ventilate her feelings.
l 2. Determine if the client has an advance directive.
l 3. Assure the client that everything will be all right.
l 4. Ask the client if her family knows how she feels.
68. Which task would be most appropriate for the nurse to
delegate/assign when caring for clients on a surgical unit?
l 1. Instruct the LPN to feed the client who is 1 day
postoperative vaginal hysterectomy.
l 2. Tell another LPN to administer an intravenous
push (IVP) pain medication for a client in
severe pain.
l 3. Request the UAP to check on a client whose last
AP was 112, R was 6, and B/P was 92/58.
l 4. Assign the RN to administer a unit of blood to the
4-hour postoperative client.
70. The nurse is triaging phone calls in a women’s health
clinic. Which client should the nurse call first?
l 1. The client who reported her husband beat her up
and has gone to buy a gun.
l 2. The client whose uterus has prolapsed out of the
vagina and she does not know what to do.
l 3. The client with infertility issues who just started
her period and is crying.
l 4. The client whose vaginal ring fell out and she is
afraid she may be pregnant.
ANSWERS
67. Correct answer 3: The nurse should first place the
allergy band on the client and then label the client’s
chart. The nurse should also notify the operating
room director. Content–Management; Category of
Health Alteration–Gynecology; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive Level–
Synthesis.
68. Correct answer 4: An RN must administer blood
and blood products and assess the client for the first
15 minutes of the infusion for a possible reaction.
The UAP could feed a stable client; the LPN should
not administer an IVP medication; and the nurse
cannot delegate an unstable client. Content–Surgical;
Category of Health Alteration–Gynecology; Integrated
Process–Planning; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive Level–
Synthesis.
Copyright © 2010 F.A. Davis Company
468
69. Correct answer 2: The nurse should determine if
the client’s wishes are stated in an advance directive,
which includes a living will and durable power of
attorney for health care. The nurse should empower
the client to make her own decisions and then tell
the family of her wishes. Content–Surgical; Category
of Health Alteration–Gynecology; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive Level–
Analysis.
70. Correct answer 1: The client is in danger, and
her safety should be priority; therefore, the nurse
should contact this client by phone first. The nurse
should attempt to get her to a safe place. Content–
Management; Category of Health Alteration–
Gynecology; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Analysis.
SECTION TEN
Maternal Child Health
469
Maternal Child Health
SECTION TEN
Antepartum
1. The nurse working in a women’s health clinic is
returning telephone calls. Which client should the nurse
contact first?
l 1. The 16-year-old client who wants to know the
results of her pregnancy test.
l 2. The 27-year-old primigravida client who is
complaining of severe headache.
l 3. The 32-year-old pregnant client who is concerned
because she has gained 2 pounds.
l 4. The 41-year-old client who wants a referral to an
infertility clinic as soon as possible.
2. The nurse is completing the admission assessment on a
client who is 12 weeks pregnant and is visiting the
women’s health clinic. The client tells the nurse, “I am a
vegan and will not drink any milk or eat any meat.”
Which intervention should the nurse implement?
l 1. Recommend the client eat grains, legumes, and
nuts daily during the pregnancy.
l 2. Tell the client it is safe to adhere to the vegan diet
during her pregnancy.
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3. Discuss the importance of eating meat and dairy
products during pregnancy.
4. Inform the client that iron supplements should not
be taken during pregnancy.
3. A client 36 weeks pregnant comes to the clinic and has
a blood pressure 160/102, 4+ proteinuria, and edematous
hands and feet. Which data should the nurse assess next?
l 1. The client’s apical heart rate.
l 2. The client’s urine-specific gravity.
l 3. The client’s deep tendon reflexes.
l 4. The client’s activity tolerance.
ANSWERS
472
1. Correct answer 2: A severe headache is a symptom of
3. Correct answer 3: The client’s signs/symptoms suggest
pre-eclampsia; because this is the client’s first pregnancy,
she requires further evaluation. The other clients are
not priority over a client who has an acute complaint.
pregnancy-induced hypertension (PIH), which if
worsening would cause hyperreflexia. Therefore, the
nurse should assess the client’s deep tendon reflexes
(range 0–4+, with 2+ being normal). The heart rate,
urine specific gravity, and activity tolerance would not
yield information pertinent to possible PIH. Content–
Content–Obstetrics; Category of Health Alteration–
Antepartum; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
2. Correct answer 1: The vegan diet does not include
any animal protein, which is needed for fetal development and growth. Vegetable proteins lack one or more
of the essential amino acids; therefore the vegan must
combine different plant proteins, grains, legumes, and
nuts to allow for intake of all essential amino acids.
Content–Obstetrics; Category of Health Alteration–
Antepartum; Integrated Process–Implementation; Client
Needs–Health Promotion and Maintenance; Cognitive
Level–Analysis.
Copyright © 2010 F.A. Davis Company
Obstetrics; Category of Health Alteration–Antepartum;
Integrated Process–Assessment; Client Needs–Physiological
Integrity, Reduction of Risk Potential; Cognitive
Level–Analysis.
SECTION TEN
Maternal Child Health
473
4. The client at 28 weeks gestation tells the clinic nurse,
6. The client in her second trimester tells the clinic nurse
“I do not want to have a sonogram because I am afraid it
will harm my baby.” Which statement is the nurse’s best
response?
l 1. “You are afraid the test will harm your baby.”
l 2. “The doctor would not order anything that would
hurt your baby.”
l 3. “What makes you think that this test will harm
your baby?”
l 4. “This test uses sound waves to check your baby,
not x-rays.”
she is thirsty all the time and urinates every hour. Which
intervention should the nurse implement?
l 1. Check the client’s urine protein.
l 2. Check the client’s glucose level.
l 3. Check the client’s blood pressure.
l 4. Check the client’s oral mucosa.
5. The client who is 2 weeks past her menses calls the
clinic and reports left upper quadrant pain. Which
assessment finding would cause the nurse to suspect an
ectopic pregnancy?
l 1. The client is 18 years old, and this is her first
pregnancy.
l 2. The client has taken oral contraceptives for 10 years.
l 3. The client is Rh-negative, and the father is
Rh-positive.
l 4. The client has a history of pelvic inflammatory
disease (PID).
7. The client in her first trimester of pregnancy asks the
clinic nurse, “My husband wants to know if it is safe for
us to make love.” Which statement is the nurse’s best
response?
l 1. “During the first trimester, it is all right for you to
make love.”
l 2. “It is not recommended, but if your husband
insists then you should.”
l 3. “You can have sexual intercourse up until the time
you deliver.”
l 4. “As long as your husband uses a condom it will be
just fine.”
ANSWERS
4. Correct answer 4: The client needs factual information
to allay her fears; therefore, explaining the procedure
would be the nurse’s most appropriate response.
Content–Obstetrics; Category of Health Alteration–
Antepartum; Integrated Process–Implementation; Client
Needs–Health Promotion and Maintenance; Cognitive
Level–Synthesis.
5. Correct answer 4: Scarring of the fallopian tubes can
prevent a fertilized ovum from progressing down the
tube to the uterus for implementation and is a risk
factor for ectopic pregnancy. PID causes scarring;
therefore, this assessment finding is pertinent. Content–
Medical; Category of Health Alteration–Antepartum;
Integrated Process–Assessment; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
474
6. Correct answer 2: The client is exhibiting polyuria
and polydipsia, which are signs of diabetes. The client’s
glucose level should be checked to rule out gestational
diabetes. Protein in the urine and blood pressure are
used to evaluate for PIH. Content–Obstetrics; Category
of Health Alteration–Antepartum; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive Level–
Analysis.
7. Correct answer 1: During the first trimester, the
pregnant woman can continue any activities that were
done prior to getting pregnant. During the second and
third trimesters, as the client’s center of gravity shifts
and the baby’s head engages, activities must be curtailed.
The condom is used to prevent pregnancy. Content–
Obstetrics; Category of Health Alteration–Antepartum;
Integrated Process–Implementation; Health Promotion
and Maintenance; Cognitive Level–Application.
SECTION TEN
Maternal Child Health
475
8. The 18-week gestational multigravida client asks the
10. The client at 38 weeks gestation tells the clinic nurse,
nurse, “Why would a doctor want to do an amniocentesis
on someone who is pregnant?” Which situation would
indicate the need for an amniocentesis? Select all that
apply.
l 1. The pregnant mother is over the age of 35.
l 2. It is done to determine the gender of the fetus.
l 3. The client has a history of two elective abortions.
l 4. An elevated level of maternal serum alphafetoprotein (AFP).
l 5. The Rh-negative woman who did not receive
Rhogam after the first pregnancy with an Rh+ baby.
“My baby was really moving a lot yesterday, but I haven’t
felt any movements today.” Which action should the
nurse implement?
l 1. Explain that this is normal before delivery.
l 2. Arrange for the client to have a non-stress test.
l 3. Have the client go home and call back in the
morning.
l 4. Perform Leopold maneuvers on the client’s
abdomen.
9. The client at 14 weeks gestation calls the clinic and
11. The client is admitted to the labor and delivery unit
tells the nurse, “I am nauseated and vomit almost every
morning.” Which instructions should the nurse provide
the client?
l 1. Make an appointment to be seen today.
l 2. Drink lukewarm coffee in the morning.
l 3. Eat crackers before getting out of bed.
l 4. Take an antiemetic ordered by the HCP.
Intrapartum
diagnosed with PIH and has pre-eclampsia. Which
intervention should the nurse implement first?
l 1. Administer intravenous magnesium sulfate.
l 2. Check the client’s blood pressure (BP) in both arms.
l 3. Perform the Snellen eye examination.
l 4. Notify the nursery of the impending delivery.
ANSWERS
8. Correct answer 1, 4, 5: An amniocentesis is performed when the maternal age is over 35 years, when
the woman has had three or more spontaneous abortions, when the serum AFP level remains elevated, and
when the woman has become sensitized to the Rh+
factor from exposure to the blood of the first baby. It is
performed to detect chromosomal abnormalities. It is
not used to determine the gender. Content–Obstetrics;
Category of Health Alteration–Antepartum; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Synthesis.
9. Correct answer 3: Eating crackers tends to settle
the stomach, and crackers are easily digested. Being
nauseated and vomiting early in pregnancy are not
uncommon; therefore, the client does not need to be
seen. Caffeine beverages should be avoided. Medication
should be the last resort if the client becomes dehydrated.
Content–Obstetrics; Category of Health Alteration–
Antepartum; Integrated Process–Planning; Client Needs–
Physiological Integrity, Physiological Adaptation;
Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
476
10. Correct answer 2: Vigorous movement by the
fetus followed by no movement may indicate fetal
demise and is cause for further assessment. Leopold
maneuvers are used to assess the fetus’s position
in utero. Content–Obstetrics; Category of Health
Alteration–Antepartum; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
11. Correct answer 1: The nurse’s first intervention is to
prevent the client from having a seizure during the
delivery of her baby; therefore, starting magnesium
sulfate intravenously is priority. Then, the nurse
should check the client’s BP and notify the nursery.
The client’s vision is not assessed (Snellen chart)
during labor and delivery. Content–Obstetrics;
Category of Health Alteration–Intrapartum; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
SECTION TEN
Maternal Child Health
477
12. The client at 40 weeks gestation has just delivered a
14. The nurse in the labor and delivery department is
stillborn infant. Which intervention should the nurse
implement first?
l 1. Discuss the importance of attending a grief support
group.
l 2. Arrange for the client to have a room in the
medical unit.
l 3. Notify the hospital chaplain of the fetal demise.
l 4. Offer the mother the chance to hold her baby.
caring for a client who is having bright red painless
bleeding, and the fetal heart rate is 100. Which client
problem is priority?
l 1. Alteration in comfort.
l 2. Altered cardiac output.
l 3. Risk for fetal demise.
l 4. Risk for hemorrhaging.
13. The client in labor is showing late decelerations on
examination and has assessed a prolapsed cord. Which
intervention should the nurse implement?
l 1. Place the client in the left lateral position.
l 2. Force the prolapsed cord back into the uterus.
l 3. Tell the client not to push during contractions.
l 4. Prepare the client for a vaginal delivery.
the fetal monitor. Which intervention should the nurse
implement first?
l 1. Notify the HCP immediately.
l 2. Instruct the mother to take slow deep breaths.
l 3. Place the client in the left lateral position.
l 4. Prepare for an emergency cesarian section
(C-section).
15. The labor and delivery nurse is performing a vaginal
ANSWERS
12. Correct answer 4: The mother should be allowed to
478
14. Correct answer 3: The client is exhibiting signs of
hold her infant in order to facilitate the grieving
process and to say good-bye. This is the nurse’s first
intervention. The client should not be placed on the
postpartum floor, where babies are crying and happy
people are reminders of her loss. Content–Obstetrics;
placenta previa, and a decreased fetal heart rate
indicates a compromised fetus. These problems will
quickly lead to death of the fetus; therefore, this is
the priority problem. The mother is hemorrhaging;
it is an actual problem, not a risk problem. Content–
Category of Health Alteration–Intrapartum; Integrated
Process–Implementation; Client Needs–Psychosocial
Integrity; Cognitive Level–Application.
Obstetrics; Category of Health Alteration–Intrapartum;
Integrated Process–Diagnosis; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
13. Correct answer 3: The left lateral position will improve placental blood flow and oxygen supply to the
fetus; therefore, this is the nurse’s first intervention.
Then, the nurse should calm the mother, notify the
HCP, and prepare for an emergency C-section.
Content–Obstetrics; Category of Health Alteration–
Intrapartum; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
15. Correct answer 3: The nurse does not want the
fetus to be delivered if the cord is compressed between
the baby’s head and the cervical os. Therefore, the
nurse must attempt to stop the delivery by telling the
client not to push. The client should be placed in
the Trendelenburg position and be prepared for an
emergency C-section. Content–Obstetrics; Category
of Health Alteration–Intrapartum; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
SECTION TEN
16. Which client should the labor and delivery charge
nurse assess first after receiving report?
l 1. The client receiving oxytocin (Pitocin) who is
having contractions every 4 minutes.
l 2. The client who is 10 centimeters dilated and 100%
effaced who is pushing.
l 3. The client whose husband is irate and threatening
to hurt his wife.
l 4. The adolescent client who may want to give her
baby up for adoption.
17. The nurse is caring for a client who is 38 weeks
gestation in the first stage of labor who is 2 cm dilated
and 30% effaced. Which intervention should the nurse
implement?
l 1. Check the client’s progress every 10 minutes.
l 2. Assess the fetal heart rate every 30 minutes.
l 3. Prepare the client for epidural anesthesia.
l 4. Place the client in the left lateral position.
Maternal Child Health
479
18. The client at 38 weeks gestation is 10 cm dilated and
100% effaced and has begun pushing. Which intervention
should the nurse implement?
l 1. Notify the client’s HCP.
l 2. Administer 6 L of oxygen via nasal cannula.
l 3. Encourage the father to change into scrubs.
l 4. Place the client in the supine position.
19. The mother has just delivered the newborn. The
newborn has a pulse of 120, a lusty cry, a flexed body,
and spontaneous movements and responds promptly to
suctioning. Which APGAR score should this newborn
receive?
l 1. 0.
l 2. 4.
l 3. 8.
l 4. 10.
ANSWERS
16. Correct answer 3: The charge nurse should address
safety and management issues, which include talking
with clients and family members who are upset and
may be a danger to the client. The client on Pitocin
and the client ready to deliver will have primary
nurses assigned to them. The social worker could
talk to the client who wants to put the child up for
adoption. Content–Obstetrics; Category of Health
Alteration–Intrapartum; Integrated Process–Assessment;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Analysis.
17. Correct answer 2: At the beginning of the first stage
of labor, the mother and fetus should be monitored
every 30 minutes to assess for complications. The
client is checked every 10 minutes initially;
anesthesia is administered when the client is 7–8 cm
dilated; and the client can lie in any position of comfort. Content–Obstetrics; Category of Health Alteration–
Intrapartum; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
480
18. Correct answer 1: This mother is going to deliver
this infant; therefore, the HCP (obstetrician or
midwife) should be notified immediately. The
mother should be in a high Fowler position. It is
too late for the father to be changing into scrubs
because the delivery is imminent. Content–Obstetrics;
Category of Health Alteration–Intrapartum; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
19. Correct answer 4: This infant meets the criteria for
an APGAR of 10, which indicates the infant was
born healthy. Content–Obstetrics; Category of Health
Alteration–Intrapartum; Integrated Process–Assessment;
Client Needs–Health Promotion and Maintenance;
Cognitive Level–Analysis.
SECTION TEN
Maternal Child Health
481
20. The client at 38 weeks gestation has had a 6-hour
22. The nurse is administering medications to clients on
uncomplicated labor and has delivered a healthy baby
boy. Which intervention should the nurse implement?
l 1. Administer terbutaline (Brethine), a uterine
relaxant.
l 2. Ensure the placenta has been expelled intact.
l 3. Place the client in the lithotomy position.
l 4. Teach the client about pain control.
a postpartum floor. Which medication should the nurse
question administering?
l 1. The rubella vaccine to the postpartum client who
has a negative titer.
l 2. The yearly flu vaccine to a client who reports an
allergy to tomatoes.
l 3. The magnesium sulfate to the client with eclampsia
who is 4 hours post delivery.
l 4. The temazepam (Restoril), a sleeping medication,
to the client who is breastfeeding her infant.
Postpartum
21. The nurse is caring for a postpartum client who is a
Jehovah’s Witness and needs a Rhogam injection. Which
intervention should the nurse implement first?
l 1. Inform the client that Rhogam is a blood product.
l 2. Determine if the client has signed the permit.
l 3. Obtain the Rhogam injection from the laboratory.
l 4. Document the lot number in the client’s chart.
23. Which client should the postpartum nurse assess first
after receiving the morning shift report?
l 1. The client who is complaining of cramps when
breastfeeding.
l 2. The client who used one peri-pad during the night.
l 3. The client who has an edematous and warm
right calf.
l 4. The client who is crying because her husband went
to work.
ANSWERS
20. Correct answer 2: If the placenta is not expelled
intact, the client could develop complications.
Brethine is administered to stop preterm labor; the
lithotomy position is used during delivery, not after
the infant is delivered; and teaching about pain control is not appropriate at this time. Content–Obstetrics;
Category of Health Alteration–Intrapartum; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
21. Correct answer 1: Jehovah’s Witnesses do not believe
in accepting blood products, but the nurse should
make sure the client is aware that, without the
injection, her next pregnancy could result in an
infant with erythroblastosis fetalis. However, with the
injection her religious belief might be compromised:
Rhogam is a blood product. Content–Obstetrics;
Category of Health Alteration–Postpartum; Integrated
Process–Implementation; Client Needs–Health Promotion
and Maintenance; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
482
22. Correct answer 4: Restoril is a pregnancy category X
drug, which means it is teratogenic. Any medication
the client takes can be excreted in the breast milk,
affecting the infant. The client with a negative titer
needs the rubella vaccine; the flu vaccine is contraindicated in someone with an allergy to eggs, not tomatoes;
and magnesium sulfate is given up to 24 hours after
delivery. Content–Obstetrics; Category of Health
Alteration–Drug Administration; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Analysis.
23. Correct answer 3: A warm, edematous calf is a sign
of a possible deep vein thrombosis (DVT); therefore,
this client should be assessed first. Cramps when
breastfeeding are normal; using one peri-pad indicates
no abnormal bleeding; and the client crying can be
assessed after the nurse checks the other clients.
Content–Medical; Category of Health Alteration–
Postpartum; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
SECTION TEN
Maternal Child Health
483
24. The charge nurse has received laboratory results for
26. The client is 1 day postpartum, and the nurse notes
clients on the postpartum unit. Which client would
warrant intervention by the nurse?
l 1. The client whose white blood cell (WBC) count
is 18,000/mm3.
l 2. The client whose platelet count is 32,000 mm.
l 3. The client whose serum creatinine level is
0.8 mg/dL.
l 4. The client whose serum glucose level is 145 mg/dL.
the fundus is displaced laterally to the right. Which
nursing intervention should be implemented first?
l 1. Prepare to insert an indwelling urinary catheter.
l 2. Assess the bladder using the bladder scanner.
l 3. Massage the client’s fundus for 2 minutes.
l 4. Assist the client to the bathroom to urinate.
25. The nurse on the postpartum unit is administering
morning medications. Which medication should the
nurse administer first?
l 1. The narcotic analgesic to the client complaining of
incisional pain of 8 on a 0–10 pain scale.
l 2. The oral hypoglycemic medication to the client
diagnosed with gestational diabetes.
l 3. The pain medication to the client complaining of
headache of 3 on a 0–10 pain scale.
l 4. The antacid to the client who is complaining of
“heartburn” and passing gas.
27. The charge nurse is making assignments on the
postpartum unit. Which client should be assigned to the
licensed practical nurse (LPN)?
l 1. The client diagnosed with type 1 diabetes who has
erratic blood glucose levels.
l 2. The client who had a C-section yesterday and who
is on an oxytocin (Pitocin) drip.
l 3. The client who had a vaginal delivery this morning
who is complaining of perineal pain.
l 4. The client being discharged whose infant will be
on an apnea monitor at home.
ANSWERS
24. Correct answer 2: Normal platelet count is
150,000–450,000/mm3. This client’s platelet count
is critically low and could indicate disseminated
intravascular coagulation (DIC). The WBC count
normally rises (up to 25,000) during labor and
postpartum; therefore, this does not warrant intervention. The creatinine and glucose levels are within
normal limits. Content–Obstetrics; Category of Health
Alteration–Postpartum; Integrated Process–Assessment;
Client Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Analysis.
25. Correct answer 1: The client in pain is priority for
the nurse when administering medication. An 8 for
incisional pain is priority over a 3 for a headache.
Content–Obstetrics; Category of Health Alteration–
Drug Administration; Integrated Process–Planning;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
484
26. Correct answer 4: The primary reason for a displaced
fundus is a full bladder. The nurse should implement
the least invasive procedure, which is to ask the client
to attempt to void. The emptying of the bladder should
allow the fundus to return to the midline position.
Content–Obstetrics; Category of Health Alteration–
Postpartum; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management of
Care; Cognitive Level–Analysis.
27. Correct answer 3: Perineal pain is expected after
a vaginal delivery; therefore, this client could be
assigned to the LPN. The other clients require more
nursing judgment and should not be assigned to an
LPN. The client taking home a child on the apnea
monitor requires extensive teaching. Content–
Obstetrics; Category of Health Alteration–Postpartum;
Integrated Process–Planning; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
Maternal Child Health
SECTION TEN
28. The unlicensed assistive personnel (UAP) tells the
98.2ºF,
485
30.The postpartum nurse is assessing the client who is
P 124, R 30,
nurse the postpartum client has T
and BP 88/60. Which action should the nurse implement
first?
l 1. Ask the UAP when the last vital signs were obtained.
l 2. Go to the room and check the client immediately.
l 3. Notify the client’s health-care provider (HCP).
l 4. Check the client’s hemoglobin and hematocrit.
1 day post vaginal delivery and notes that the fundus is at
umbilicus, and the client has moderate lochia on her
peri-pad. Which intervention should the nurse implement?
l 1. Continue to monitor the client.
l 2. Notify the HCP.
l 3. Assess the client’s vital signs.
l 4. Place the client on intake and output.
29. The postpartum client who is being discharged home
Newborn
has not bathed or brushed her hair and does not hold
or cuddle her infant. Which action should the nurse
implement prior to discharging the client?
l 1. Ask the chaplain to come talk to the client.
l 2. Insist the client dress and feed the infant.
l 3. Notify the hospital social worker.
l 4. Encourage the client to ventilate her feelings.
31. Which newborn infant would warrant immediate
intervention by the nurse?
l 1. The 1-hour-old newborn whose heart rate is 128.
l 2. The 6-hour-old newborn who is jittery and
irritable.
l 3. The 12-hour-old newborn who took 2 ounces of
formula.
l 4. The 24-hour-old newborn who has passed
meconium.
ANSWERS
28. Correct answer 2: Whenever anyone else reports
information to the nurse, the nurse must assess the
client in person; this client’s vital signs indicate
hypovolemic shock. Content–Obstetrics; Category of
Health Alteration–Postpartum; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Synthesis.
29. Correct answer 3: Because the client is being
discharged and is exhibiting signs of postpartum
depression, the nurse must ensure there will be
follow-up visits with the mother and infant. The
social worker is responsible for arranging the
follow-up. Helping the client ventilate feelings will
not ensure the infant is safe. Content–Obstetrics;
Category of Health Alteration–Postpartum; Integrated
Process– Implementation; Client Needs–Psychosocial
Integrity; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
486
30. Correct answer 1: These data are normal and
expected for a client who is 1 day post vaginal delivery;
therefore, the nurse should continue to monitor the
client. There is no need to take the vital signs more
frequently than usual, monitor intake and output, or
notify the HCP. Content–Obstetrics; Category of
Health Alteration–Postpartum; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.
31. Correct answer 2: The infant who is jittery and irritable may have hypoglycemia and should be assessed
immediately by the nurse. The normal heart rate for
a newborn is 120–160 beats per minute (bpm);
2 ounces of formula is an adequate feeding for a
12-hour-old newborn; and the newborn should pass
meconium. Content–Obstetrics; Category of Health
Alteration–Newborn; Integrated Process–Assessment;
Client Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Synthesis.
SECTION TEN
32. The nurse is assessing normal reflexes for a newborn.
Maternal Child Health
487
34. The unlicensed assistive personnel (UAP) is assisting
Which finding should be documented in the chart as an
abnormal reflex?
l 1. The infant who extends one arm and curls the
opposite when supine.
l 2. The infant’s toes flare out when the lateral heel is
stroked.
l 3. The infant whose head does not turn toward the
cheek being stroked.
l 4. The infant who extends the arms when hearing a
loud noise.
the nurse in the newborn nursery. Which action by the
UAP would warrant intervention?
l 1. The UAP does not wipe down the crib with a
disinfectant.
l 2. The UAP protects the umbilical cord when
changing the diaper.
l 3. The UAP leaves the identity band on when giving
a bath.
l 4. The UAP does not use soap when bathing the
newborn.
33. The 16-year-old client with a 1-day-old infant wants
35. Which action by the nurse would warrant immediate
her son circumcised, but the client’s mother does not
want the newborn to be circumcised. Which intervention
should the nurse implement?
l 1. Determine if the client’s mother must sign the
permit.
l 2. Request the chaplain to come and talk to the client
and mother.
l 3. Find out if the circumcision is covered by insurance.
l 4. Obtain informed consent for the procedure from
the client.
intervention by the charge nurse?
l 1. The nurse allows the mother to place the infant
skin to skin.
l 2. The nurse enlarges the hole in the nipple to feed
the infant with a cleft palate.
l 3. The nurse is performing the Barlowe maneuver on
the newborn.
l 4. The nurse notifies the HCP about an abnormal
laboratory value.
ANSWERS
32. Correct answer 3: When the cheek is stroked, the
488
34. Correct answer 1: Not wiping down the crib increases
infant should turn toward the cheek being stroked;
this is the rooting reflex. Option 1 is the tonic-neck
reflex; option 2 is the Babinski reflex; and option 4 is
the Moro reflex, all of which are normal reflexes in a
newborn. Content–Obstetrics; Category of Health
the infant’s risk for infection; therefore, this warrants
intervention from the nurse. Protecting the umbilical
cord, not removing the identity band, and not using
soap when bathing a newborn are all acceptable
actions by the UAP. Content–Obstetrics; Category
Alteration–Newborn; Integrated Process–Assessment;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Analysis.
of Health Alteration–Newborn; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
33. Correct answer 4: The 16-year-old client has the
legal right to decide if her son will be circumcised.
The client’s mother does not have the legal right to
make any decisions for the infant. Content–Obstetrics;
Category of Health Alteration–Newborn; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
Copyright © 2010 F.A. Davis Company
35. Correct answer 3: The Barlowe and Ortoloni
maneuvers are performed to assess developmental
hip dysplasia, and a pediatrician or a nurse practitioner must perform these maneuvers because they
can cause further damage if done incorrectly.
Kangaroo pouching is encouraged, and special
feeding is required for a child with a cleft palate.
Content–Obstetrics; Category of Health Alteration–
Newborn; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
SECTION TEN
Maternal Child Health
489
36. Which intervention should the nurse implement
38. The client, whose child is 4 hours old and has a cleft
when administering an intramuscular vitamin K injection
to the newborn?
l 1. Dilute the vitamin K with 1 mL normal saline.
l 2. Use a tuberculin syringe with a 5/8-inch needle.
l 3. Administer the injection in the dorsal gluteus.
l 4. Check the mother for any type of allergies.
lip and cleft palate, is crying while holding her child. Which
intervention would be most appropriate for the nurse?
l 1. Stand quietly and support the client.
l 2. Refer the client to a parent support group.
l 3. Tell the client with surgery her child will look just fine.
l 4. Ask the client how her husband is dealing
with this.
37. The nurse is preparing to administer a 20-mL
intravenous piggyback (IVPB) to a 2-week-old infant.
The medication is to be infused over 1 hour. Which rate
should the nurse infuse the medication?
Answer: ______________________
39. The nurse is caring for a newborn who was just
brought from the labor and delivery area. Which
intervention should the nurse implement first?
l 1. Take the neonate’s vital signs.
l 2. Bathe the neonate to remove the lanugo.
l 3. Complete the newborn assessment.
l 4. Place the infant under a radiant warmer.
ANSWERS
36. Correct answer 2: The smallest amount of medication should be administered in the newborn’s vastus
lateralis, using a tuberculin syringe with a small,
short needle. Content–Obstetrics; Category of Health
Alteration–Drug Administration; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Analysis.
37. Correct answer 20 mL/hr: IV medication is always
administered on an IV pump to ensure safety for the
newborn. Fluid volume overload can be detrimental
to the newborn. Content–Obstetrics; Category of
Health Alteration–Drug Administration; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Pharmacological and Parenteral Therapies;
Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
490
38. Correct answer 1: The mother is distraught, and
there is nothing the nurse can do but be supportive
of the client. At 4-hour post-delivery referral to a
support group is not appropriate. Telling the client
everything will be all right is false reassurance. The
nurse should support the client, not the client’s
husband. Content–Obstetrics; Category of Health
Alteration–Newborn; Integrated Process–Implementation;
Client Needs–Psychosocial Integrity; Cognitive Level–
Application.
39. Correct answer 4: The neonate’s thermoregulatory
mechanism is immature; therefore, the nurse must
support the neonate’s body temperature. All the
other options should be implemented but not before
placing the infant in a warmer. Content–Obstetrics;
Category of Health Alteration–Newborn; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
SECTION TEN
40. Which newborn infant would the nursery nurse
assess first?
l 1. The 2-hour-old newborn whose APGAR scores
were 9 and 10.
l 2. The 4-hour-old newborn who has a respiratory rate
of 70.
l 3. The 6-hour-old newborn whose skin is jaundiced.
l 4. The 8-hour-old newborn who was born at
40 weeks gestation.
Management
41. The client being seen in the OB clinic tells the nurse,
“My husband thinks this is his baby, but I am not sure who
the father is. What do you think I should do?” Which response by the nurse supports the ethical principle of veracity?
l 1. “I think you should talk to your husband about
your concern.”
l 2. “You could wait until the baby is born and have
DNA testing”.
l 3. “I would not tell your husband about your suspicions.”
l 4. “Do you have any idea who the father might be if
it is not your husband?”
Maternal Child Health
491
42. The mother of a newborn infant tells the nurse
excitedly, “Someone just tried to take my baby and they
didn’t know the code word.” Which action should the
nurse implement first?
l 1. Notify hospital security of the situation.
l 2. Interview the mother about the appearance of the
person.
l 3. Page a code pink, an infant abduction, overhead.
l 4. Notify the nurse’s station to account for all the
mothers and babies.
43. The estranged husband comes to the postpartum
unit requesting his wife’s room number. The nurse can
smell alcohol on the man’s breath. Which action should
the nurse implement?
l 1. Give the husband the client’s room number.
l 2. Ask the client if she would like to see her husband.
l 3. Contact hospital security to come to the unit and
to talk to the husband.
l 4. Tell the husband that he cannot be here if he has
been drinking.
ANSWERS
40. Correct answer 2: The normal respiratory rate for a
newborn is 30–60; therefore, this infant should be
assessed first. Jaundice should be assessed but not
before an airway problem. A 9–10 APGAR is
normal, and a 40-week gestation is not post-mature.
Content–Obstetrics; Category of Health Alteration–
Newborn; Integrated Process–Assessment; Client Needs–
Safe Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
41. Correct answer 1: Veracity is the ethical principle of
telling the truth. This response is encouraging the client
to tell the husband the truth. Content–Management;
Category of Health Alteration–Obstetrics; Integrated
Process–Implementation; Client Needs–Psychosocial
Integrity; Cognitive Level–Application.
42. Correct answer 4: Ensuring the safety of the mothers
and babies on the unit is the nurse’s first priority.
Then, the nurse should notify security and interview
the mother for more specific information. A code
Copyright © 2010 F.A. Davis Company
492
pink is not called until an abduction has occurred.
Content–Management; Category of Health Alteration–
Obstetrics; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Application.
43. Correct answer 2: The nurse should ask the client if
she would like to see her husband because, even if
they are estranged, she may want to see him. The
nurse should not let the husband go into the room
unannounced. Hospital security should be notified if
the husband is causing problems. The nurse cannot
refuse the husband’s wish to visit his wife. Content–
Management; Category of Health Alteration–Obstetrics;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Safety and Infection
Control; Cognitive Level–Application.
SECTION TEN
Maternal Child Health
493
44. The charge nurse is making assignments in the labor
46. A nurse from the medical/surgical unit is assigned to
and delivery department. Which client should be assigned
to the most experienced nurse?
l 1. The 36-week gestational client who is 9 cm dilated
and 90% effaced.
l 2. The 32-week gestational client who is having twins
and is on bed rest.
l 3. The 38-week gestational client who has contractions
3 minutes apart.
l 4. The 39-week gestational client who has non-reassuring
patterns on the monitor.
the postpartum unit. Which client should the charge
nurse assign to the medical/surgical (M/S) nurse?
l 1. The client trying to breastfeed her first-born child
who has developed mastitis.
l 2. The client with an abdominal hysterectomy who
has a hemoglobin of 10 mg/dL.
l 3. The client who is P6 G8 who has just delivered
twins who are healthy.
l 4. The unmarried client who is considering giving her
child up for adoption.
45. Which task would be most appropriate for the nurse
on the postpartum unit to delegate to the unlicensed
assistive personnel (UAP)?
l 1. Bring an infant back to the nursery.
l 2. Call the laboratory for a stat complete blood count
(CBC) results.
l 3. Show the mother how to bottle-feed the infant.
l 4. Check the 1-day postpartum client’s fundus.
ANSWERS
44. Correct answer 4: Nonreassuring patterns are a sign
of complications in the fetus; therefore, this client
should be assigned to the most experienced
labor and delivery nurse. The other three clients are
stable and could be assigned to any nurse. Content–
Management; Category of Health Alteration–Obstetrics;
Integrated Process–Planning; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
45. Correct answer 1: The UAP can transport an infant
to and from the nursery as long as the UAP knows
the security protocol. The UAP is not knowledgeable
about laboratory results, and the UAP cannot teach
or assess. Content–Management; Category of Health
Alteration–Obstetrics; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
494
46. Correct answer 2: A hysterectomy is a routine
surgical procedure; even though this client has a low
hemoglobin level, an M/S nurse should be able to
care for this client. Mastitis is a complication requiring
an experienced nurse; the client who has had six
deliveries may experience postpartum complications;
and giving up a child for adoption is a complicated
situation. Content–Management; Category of Health
Alteration–Obstetrics; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
SECTION TEN
Maternal Child Health
495
47. While making rounds the charge nurse notices that a
49. The client who is 16 weeks pregnant calls and tells the
cup with medication in it was left at the client’s bedside.
Which action should the charge nurse implement first?
l 1. Counsel the primary nurse about medication
delivery protocol.
l 2. Mandate the nurse to take a pharmacology course.
l 3. Take the cup of medications back to the nurse’s
station.
l 4. Ask the client who left the medication at the
bedside.
office nurse, “My husband’s insurance has changed. What
should I do?” Which statement is the nurse’s best response?
l 1. “This doctor takes all types of insurance so don’t
worry.”
l 2. “Would you like the number of a free clinic in
our city?”
l 3. “I will transfer you to the clerk to check your new
insurance coverage.”
l 4. “You can keep your old insurance if you pay
COBRA payments.”
48. The day nurse has documented three medication
errors made by the night nurse in the last week and is
concerned that client safety is at risk. Which action
should the day nurse implement?
l 1. Discuss the numerous medication errors with the
unit manager.
l 2. Initiate the formal counseling procedure for
multiple medication errors.
l 3. Discuss the errors with the nurse to determine if
there is a systems problem.
l 4. Do not take any action because it is the night
charge nurse’s responsibility.
50. Which client should the newborn nurse refer to the
hospital ethics committee?
l 1. The 24-week-old infant whose mother does not
have any insurance to pay for the infant’s care.
l 2. The 27-week-old infant who has multisystem
organ failure whose parents want everything done.
l 3. The 36-week-old infant who needs to be placed on
the extracorporeal membrane oxygenation pump
(ECMO).
l 4. The 40-week-old infant with Down syndrome whose
parents want to put the infant up for adoption.
ANSWERS
47. Correct answer 3: The charge nurse should first
remove the medications from the bedside for the
safety of the client and visitors. The nurse may need
to be counseled, but the charge nurse must investigate
before assuming. Content–Management; Category of
Health Alteration–Drug Administration; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
48. Correct answer 1: The day nurse should follow the
chain of command and share her concerns with the
unit manager. The day nurse has no authority to discuss the errors or initiate formal counseling with the
night nurse. The day nurse must voice her concerns
concerning safe client care to the unit manager.
Content–Management; Category of Health Alteration–
Obstetrics; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Safety and
Infection Control; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
496
49. Correct answer 3: The nurse should determine if the
client’s new insurance will be valid at the office at
which the client works. The nurse should delegate
this task to the clerk. COBRA is available at a cost
to the individual who no longer works for the
employer where the person had insurance coverage.
Content–Management; Category of Health Alteration–
Obstetrics; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Application.
50. Correct answer 2: A premature infant with multisystem organ failure has a poor prognosis. The infant
should be spared from painful invasive procedures
and provided with comfort. This situation could be
referred to the ethics committee. No insurance, an
infant needing to be placed on an ECMO, and an
adoption are not situations for the ethics committee.
Content–Management; Category of Health Alteration–
Obstetrics; Integrated Process–Planning; Client Needs–
Safe Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
SECTION ELEVEN
Pediatric Disorders
497
Pediatric Disorders
SECTION ELEVEN
Health Promotion
1. The unlicensed assistive personnel (UAP) is transporting
a new mother and her infant to the automobile for discharge
home. Which statement by the UAP warrants immediate
intervention by the nurse?
l 1. “The client is taking all the diapers in the hospital
crib when she goes home.”
l 2. “The mother is going to buy a car seat when her
husband gets paid.”
l 3. “The mother said she likes to put lotion on her
beautiful daughter.”
l 4. “The client says she always keeps the side rails up
on the baby's crib.”
2. The new mother brings her 4-month old son to the
pediatric clinic for the well-baby check-up. Which
statement by the mother indicates the child is
developmentally on target for growth and development?
l 1. “My baby babbles all the time and smiles at me.”
l 2. “My baby has difficulty holding his head up.”
l
l
499
3. “My baby eats four 6-ounce bottles of formula
a day.”
4. “My baby sleeps about 20 hours every day.”
3. The nurse is caring for clients on a pediatric unit.
Which client should the nurse assess first?
l 1. The 2-year-old child whose axillary temperature
is 99ºF.
l 2. The 4-year-old child whose apical pulse is 119 beats
per minute.
l 3. The 10-year-old child whose respirations are
22 breaths per minute.
l 4. The 16-year-old child whose blood pressure is
160/92 in the right arm.
ANSWERS
1. Correct answer 2: Federal law mandates that all
infants be securely and correctly placed in a car seat
in the back seat of the automobile; therefore, this
statement would warrant intervention by the nurse.
All the other options are appropriate statements for
the client to make. Content–Pediatrics; Category of
Health Alteration–Growth and Development; Integrated
Process–Implementation; Client Needs–Health Promotion
and Maintenance; Cognitive Level–Synthesis.
2. Correct answer 1: A language developmental milestone for a 4-month-old is babbling, and the infant's
cry becomes more differentiated. The infant should be
holding the head up at 2 months, and at 4 months
the baby should be eating 6 ounces of formula five to
six times a day and sleeping 15 or 16 hours. Content–
Pediatrics; Category of Health Alteration–Growth and
Development; Integrated Process–Assessment; Client
Needs–Health Promotion and Maintenance; Cognitive
Level–Analysis.
Copyright © 2010 F.A. Davis Company
500
3. Correct answer 4: A normal blood pressure for a
16-year-old child is systolic 93–131 and diastolic
49–85. This client's blood pressure is elevated. All
other vital signs are within normal limits (WNLs) for
the age of the child. Content–Pediatrics; Category of
Health Alteration–Growth and Development; Integrated
Process–Assessment; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Analysis.
Pediatric Disorders
SECTION ELEVEN
4. The pediatric clinic nurse is administering immunizations
to a 2-month-old infant. Which instructions should the
nurse discuss with the mother? Select all that apply.
l 1. Tell the mother slight redness at the injection site is
expected.
l 2. Instruct the mother to give the infant a baby
aspirin for comfort.
l 3. Inform the mother to notify the health-care
provider (HCP) of a temperature greater than
101ºF.
l 4. Explain the importance of keeping a record of her
child's immunization.
l 5. Discuss that the Haemophilus inflenzae type B (HIB)
vaccine will cause your baby to get a mild flu.
5. The pediatric clinic nurse notes some discoloration
and decay on the 9-month old male infant's teeth. Which
question would be most appropriate for the nurse ask the
mother concerning the child's teeth?
l 1. “When is the last time your child saw a dentist?”
l 2. “At what age did your child begin to cut teeth?”
l
l
501
3. “Does your baby fall asleep with a bottle in his
mouth?”
4. “Has your baby had many infections requiring
antibiotics?”
6. The pediatric clinic nurse is discussing poison control
awareness with the parents of a 10-month-old baby.
Which priority intervention should the nurse discuss
with the parents?
l 1. Instruct the parents to place the poison control
number by the phone.
l 2. Tell the parents to keep all household cleaners in a
locked cabinet.
l 3. Explain that some painted surfaces in older homes
have lead content.
l 4. Discuss the need to discard poisonous containers in
a special trashcan.
ANSWERS
4. Correct answer 1, 3, 4: Common reactions to
immunizations include soreness, redness, and edema
at the injection site. A low-grade fever is also common, but a temperature greater than 101ºF could
indicate an adverse reaction to the vaccine and should
be reported to the HCP. A record of immunizations
should be kept because it must be shown when the
child starts school. Aspirin can cause Reye syndrome
and should be avoided. The HIB vaccine does not
cause the flu. Content–Pediatrics; Category of Health
Alteration–Growth and Development; Integrated
Process–Planning; Client Needs–Health Promotion and
Maintenance; Cognitive Level–Synthesis.
5. Correct answer 3: The nurse should investigate
possible bottle/mouth caries caused by allowing
the infant to fall asleep with formula or juice in the
mouth. The other questions may be asked by the
nurse, but determining the cause of the discoloration
and decay is priority. Tetracyline, an antibiotic, may
cause discoloration of the teeth of a child, which is
Copyright © 2010 F.A. Davis Company
502
why it is not prescribed for children. Content–
Pediatrics; Category of Health Alteration–Growth and
Development; Integrated Process–Assessment; Client
Needs–Health Promotion and Maintenance; Cognitive
Level–Analysis.
6. Correct answer 2: The most important intervention is
to prevent the child from gaining access to potentially
poisonous chemicals and substances. Having the
poison control number is appropriate, but prevention
is the initial priority. Content–Pediatrics; Category of
Health Alteration–Growth and Development; Integrated
Process–Planning; Client Needs–Health Promotion and
Maintenance; Cognitive Level–Synthesis.
SECTION ELEVEN
Pediatric Disorders
503
7. Which information should the school nurse discuss
9. The mother of 7-year-old child calls the clinic and tells
with the parents at a Parent-Teacher Association meeting
at an elementary school?
l 1. Explain the importance of keeping all electrical
wires hidden or out of reach.
l 2. Tell the parents the child must be appropriately
restrained while riding in the car.
l 3. Encourage the parents to discuss sexuality issues
with their children.
l 4. Recommend the parents use a gait belt when
teaching the child to skate
the nurse, “My daughter has a red rash on her face and
neck that is spreading down her body. She does not
have a fever, is not itching, and is not having trouble
breathing.” Which intervention should the nurse
implement?
l 1. Instruct the mother to keep her daughter at home
isolated from other children.
l 2. Tell the mother the HCP will telephone a
prescription for antibiotics.
l 3. Encourage the mother to bathe the child in a
tepid-water oatmeal bath.
l 4. Discuss the need to administer Tylenol elixir every
8 hours around the clock.
8. The pediatric clinic nurse is interviewing a 17-year-old
female client during a yearly physical examination. The
client's mother is in the room. Which action should the
nurse implement?
l 1. Ask the mother how she gets along with her
daughter.
l 2. Discuss the client's relationships with her parents.
l 3. Determine if the client wants her mother in
the room.
l 4. Request the client's mother to leave the room.
ANSWERS
7. Correct answer 3: Even children as young as 9 or
504
9. Correct answer 1: These are manifestations of rubella,
10 years old may engage in some type of sexual
activity with other children or adults. It is not too
early to discuss age-appropriate sexual issues with
children. Household and car safety issues should have
already been implemented. A gait belt is used when
ambulating a client. Content–Pediatrics; Category of
which is a self-limiting viral infection that is contagious and usually mild in children of this age. Keeping
the child isolated is appropriate. Antibiotics are not
prescribed for a virus, oatmeal baths help decrease
itching, and Tylenol is only needed if the child is
uncomfortable. Content–Pediatrics; Category of Health
Health Alteration–Growth and Development; Integrated
Process–Planning; Client Needs–Health Promotion and
Maintenance; Cognitive Level–Synthesis.
Alteration–Infectious Diseases; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
8. Correct answer 4: A 17-year-old client may not feel
comfortable discussing personal issues in front of the
parent. Asking the 17-year-old if her mother can stay
in the room places the client at a disadvantage.
Content–Pediatrics; Category of Health Alteration–
Growth and Development; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
Copyright © 2010 F.A. Davis Company
SECTION ELEVEN
Pediatric Disorders
505
10. The elementary school nurse is teaching a class on
12. The charge nurse on a pediatric cardiovascular unit is
health promotion to third-grade students. Which activity
should the nurse implement when teaching this age
group?
l 1. Show the students a video on the importance of
bicycle safety.
l 2. Have the students divide into groups and make
safety posters.
l 3. Provide a written handout discussing safety in
the home.
l 4. Give the students a pre- and post-test on the
information taught.
checking laboratory values. Which laboratory result
would require intervention by the charge nurse?
l 1. The 1-year-old child's potassium level is 3.8 mmol/L.
l 2. The 2-year-old child's digoxin level is 2.5 mcg/L.
l 3. The 4-year-old child's sodium level is 140 mmol/L.
l 4. The 10-year-old child's lead level is 8 mg/dL.
Cardiovascular System
11. Which intervention should the nurse implement
to calm the 3-year-old child for an electrocardiogram
(ECG)?
l 1. Allow the child to play with the ECG leads.
l 2. Ask the parents to leave the child's room.
l 3. Encourage the mother to stroke the child's head
during the ECG.
l 4. Give the child a sucker if the child behaves.
13. The 2-year-old child diagnosed with tetralogy of
Fallot is playing in the room and suddenly squats. Which
action should the nurse implement?
l 1. Allow the child to stay in that position.
l 2. Pick the child up and place in the bed.
l 3. Place oxygen on the child immediately.
l 4. Ask the child if something is wrong.
ANSWERS
10. Correct answer 2: Children of this age master skills
506
12. Correct answer 2: The therapeutic serum digoxin
by playing and working with their peers; therefore,
requiring group work covering the topic is most
appropriate when teaching this age group. Videos,
writing handouts, and tests are not the best
teaching/learning activities for 8–9-year-old children.
level ranges 0.8–2.0 mcg/L; therefore, this child's
level is elevated, and this requires intervention. The
normal potassium is 3.5–5.0 mmol/L; the normal
sodium level is 138–145 mmol/L; and the lead level
should be less than 10 mg/dL. Content–Pediatrics;
Content–Pediatrics; Category of Health Alteration–
Growth and Development; Integrated Process–Planning;
Client Needs–Health Promotion and Maintenance;
Cognitive Level–Synthesis.
Category of Health Alteration–Cardiovascular; Integrated
Process–Assessment; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Analysis.
11. Correct answer 3: The child must be kept quiet
and cooperative during an ECG to ensure accurate
results, and the mother would have the most calming
influence on the child. Suckers could lead to choking
and/or dental caries and are not appropriate for
children in the hospital. The child should be able to
see and touch the leads but not play with the leads.
Content–Pediatrics; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
13. Correct answer 1: The squatting position allows
blood to stay in the lower extremities, which
decreases the work load of the heart. The nurse
should stay with the child but leave the child in
the squatting position. Content–Pediatrics; Category
of Health Alteration–Cardiovascular; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
SECTION ELEVEN
Pediatric Disorders
507
14. Which signs and symptoms would the nurse expect
16. The 4-year-old child is brought to the pediatric clinic
in the 1-year-old child diagnosed with an acyanotic
cardiovascular defect?
l 1. Buccal and peripheral cyanosis.
l 2. Clubbing of the fingers and barrel chest.
l 3. Increased urine output and tented tissue turgor.
l 4. Periorbital/facial edema and jugular vein distention
(JVD).
with complaints of a sore throat. Which priority action
should the nurse implement?
l 1. Have the child gargle with salt water.
l 2. Obtain a throat culture for strep.
l 3. Give the child a throat lozenge.
l 4. Do not open the child's mouth.
15. The 18-month-old child diagnosed with Kawasaki
hyperlipidemia about dietary food choices. Which school
cafeteria menu selection indicates the child understands
the teaching?
l 1. Chicken nuggets, mashed potatoes and gravy, and
whole milk.
l 2. Roast beef sandwich, potato chips, and 2% milk.
l 3. Baked fish, vegetable medley, and bottled water.
l 4. Pepperoni pizza, fruit cocktail, and juice.
disease, mucocutaneous lymph node syndrome, is
prescribed salicylate (aspirin) therapy. Which action
should the nurse implement?
l 1. Contact the HCP to verify the order.
l 2. Administer the medication as prescribed by HCP.
l 3. Give an antacid when administering the medication.
l 4. Do not administer the aspirin because of Reye
syndrome.
17. The nurse is teaching the 10-year-old diagnosed with
ANSWERS
14. Correct answer 4: Acyanotic cardiovascular defects
lead to congestive heart failure; if the defect is not
surgically corrected, the child will have edema and
JVD. Acynotic defects do not lead to cyanosis.
Clubbing and barrel chest are secondary to longterm hypoxia, and the child would have decreased
cardiac output. Content–Pediatrics; Category of
Health Alteration–Cardiovascular; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
15. Correct answer 2: An anti-inflammatory medication, such as aspirin (acetylsalicylic acid) and intravenous gamma globulin are the treatments of choice
for Kawasaki disease. Even though there is a risk for
Reye syndrome associated with aspirin therapy in
children, the risk is greater for the child if the aspirin
is not administered. An antacid will neutralize the
acid and prevent breakdown of the medication.
Content–Pediatrics; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
508
16. Correct answer 2: An untreated or partially treated
group A beta-hemolytic streptococcal infection can lead
to rheumatic fever. The nurse should culture the throat
to determine if it is a strep infection. If the child is
drooling, the nurse should not open the child's mouth
because of possible epiglottitis. A 4-year-old child may
choke while gargling. Content–Pediatrics; Category of
Health Alteration–Cardiovascular; Integrated Process–
Implementation; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Application.
17. Correct answer 3: The child with hyperlipidemia
should adhere to a low-fat, low-cholesterol diet.
Children with a family history of hyperlipidemia are
now being screened at an early age, and the treatment
is primarily diet, but some children may be on medication. Content–Pediatrics; Category of Health Alteration–
Cardiovascular; Integrated Process–Evaluation; Client
Needs–Health Promotion and Maintenance; Cognitive
Level–Evaluation.
SECTION ELEVEN
Pediatric Disorders
509
18. The nurse is caring for children on a pediatric unit.
20. The nurse is teaching the parents of a 1-year-old
Which client should the nurse assess first after receiving
change-of-shift report?
l 1. The 1-year-old child with ventral septal defect who
has 1+ pitting edema.
l 2. The 2-year-old child with bacterial endocarditis
who has a low-grade fever.
l 3. The 3-year-old child with rheumatic fever whose
white blood cell count is 8000 mm.
l 4. The 4-year-old child with heart disease whose pulse
is 138 and blood pressure is 70/38.
child diagnosed with congestive heart failure. Which
interventions should the nurse discuss with the parents?
Select all that apply.
l 1. Encourage the parents to limit the child's activities.
l 2. Teach the parents how to take child's pulse.
l 3. Discuss the signs/symptoms of digoxin toxicity.
l 4. Measure the child's daily intake and the output of
urine.
l 5. Tell the parents to feed the child a daily serving of
bananas.
19. The 5-year-old is 1 hour post right femoral cardiac
catheterization. Which data would warrant immediate
intervention by the nurse?
l 1. The child's right foot capillary refill is greater than
3 seconds.
l 2. The child is very groggy and refuses to drink any
liquids.
l 3. The child's right foot is warm to touch and is pink.
l 4. The child is lying very still with the right leg
extended.
ANSWERS
18. Correct answer 4: The child is exhibiting signs
of shock: an increased pulse and decreased blood
pressure; therefore, this child should be evaluated
first. All other children are exhibiting signs/symptoms
expected for the disease process they have. Content–
Pediatrics; Category of Health Alteration–Cardiovascular;
Integrated Process–Assessment; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Analysis.
19. Correct answer 1: A capillary refill greater than
3 seconds indicates a possible obstruction of the
artery, which would require further evaluation by
the nurse. The right foot should be warm and pink;
the child is sedated during the procedure, so grogginess is expected; and the leg should be extended.
Content–Pediatrics; Category of Health Alteration–
Cardiovascular; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
510
20. Correct answer 2, 3, 5: Digoxin administration is
held if the pulse is below normal limits; therefore,
teaching the parents how to take the child's pulse
and the signs/symptoms of digoxin toxicity are
appropriate interventions. Bananas are high in
potassium, which can be lost with diuretic therapy,
that the child is probably receiving. The parents
should not limit the child's activities, and daily
intake and output is not implemented at home, but
the parents may be asked to count the number
of diapers used. Content–Pediatrics; Category of
Health Alteration–Cardiovascular; Integrated Process–
Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
SECTION ELEVEN
Pediatric Disorders
511
Respiratory System
21. Which intervention would be most appropriate for
23. The mother of a 2-year-old diagnosed with pertussis,
the nurse to implement when caring for a 3-year-old
child diagnosed with cystic fibrosis?
l 1. Schedule the child's chest physiotherapy (CPT)
1 hour prior to meals.
l 2. Elevate the child's head of the bed on 6-inch
blocks when sleeping.
l 3. Apply continuous positive airway pressure (CPAP)
during the day.
l 4. Administer oxygen via nasal cannula at 6 L/min.
or whooping cough, who is in the convalescent stage tells
the nurse her child is still coughing at night. Which
statement is the nurse's best response?
l 1. “I will make an appointment for your child to see
the doctor today.”
l 2. “You should give your child an over-the-counter
cough suppressant.”
l 3. “Your child may have a cough for several months
after having pertussis.”
l 4. “Take your child into the bathroom and turn on
the hot shower.”
22. The 6-year-old child is brought to the emergency
department wheezing and short of breath. Which
intervention should the nurse implement first?
l 1. Start an intravenous line.
l 2. Elevate the head of the bed.
l 3. Administer aminophylline, a bronchodilator.
l 4. Perform a peak flow meter test.
ANSWERS
21. Correct answer 1: CPT helps to remove the thick
tenacious secretions from the child's lungs. Parents
are taught to perform CPT at home prior to meals;
too close to a meal will spoil the child's appetite
due to the taste of secretions. The child has chronic
hypoxia and should have low-level oxygen. Content–
Pediatrics; Category of Health Alteration–Respiratory;
Integrated Process–Planning: Client Needs–Physiological
Integrity, Physiological Adaptation: Cognitive
Level–Synthesis.
22. Correct answer 2: The priority intervention is to
ensure lung expansion; therefore, elevating the head
of bed is the first intervention. Then the nurse
should start an IV line, administer aminophylline
intravenously, and use a peak flow meter to assess
the extent of respiratory compromise. Remember,
if in distress, do not assess. Content–Pediatrics;
Category of Health Alteration–Respiratory; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
512
23. Correct answer 3: Episodes of coughing, whooping,
and vomiting decrease in frequency and severity but
may persist for several months. The shower would be
appropriate during an acute asthma attack or croup.
Content–Pediatrics; Category of Health Alteration–
Respiratory; Integrated Process–Implementation; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Application.
Pediatric Disorders
SECTION ELEVEN
24. The nurse is counseling parents of an infant who
died from sudden infant death syndrome (SIDS)
2 months ago. The parents have an older child at home.
Which intervention would be most appropriate for the
nurse to implement?
l 1. Recommend the older child to be evaluated as soon
as possible for SIDS.
l 2. Tell the parents to have genetic testing before
having another child.
l 3. Make an appointment for the family to receive
psychiatric counseling.
l 4. Provide the parents with information, including the
date and time of a SIDS support group.
25. The mother of a male child diagnosed with an upper
respiratory infection, a cold, asks the nurse, “Why didn't
the doctor give my son antibiotics so he will be better?”
Which statement is then nurse's best response?
l 1. “You are worried your child will not get well
without antibiotics.”
l 2. “A cold is a virus that does not require antibiotic
therapy.”
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513
3. “Antibiotic therapy causes diarrhea in most children
who take it.”
4. “Antibiotics are very expensive and your insurance
won't cover it.”
26. The 8-year-old client is 2 hours post tonsillectomy.
Which intervention should the ambulatory care nurse
implement for the client?
l 1. Notify the dietary department to bring a soft
regular diet.
l 2. Keep the child in the supine position with head of
the bed elevated.
l 3. Encourage the client to drink clear liquids every
30 minutes.
l 4. Tell the child to cough and deep-breathe every
2 hours.
ANSWERS
24. Correct answer 4: The nurse should recommend a
support group for the grieving process so the parents
can share feelings with others who have experienced
a loss of a child due to SIDS and receive information
concerning SIDS. SIDS is not known to be genetic,
and there is no test for the older child. Content–
Pediatrics; Category of Health Alteration–Respiratory;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
25. Correct answer 2: A virus does not respond
to antibiotic therapy; antibiotics kill bacteria.
Overprescribing antibiotics leads to resistant strains
of bacteria. Antibiotics may cause diarrhea, but
this is not the reason for not prescribing antibiotics
for a cold. The mother needs information, not a
therapeutic response. Content–Pediatrics; Category
of Health Alteration–Respiratory; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies: Cognitive
Level–Application.
Copyright © 2010 F.A. Davis Company
514
26. Correct answer 3: Fluids are encouraged because
the throat is normally a wet environment, and
allowing the throat to dry out causes spasms of the
tissues, increasing the child's pain. A soft, regular
diet is provided the second day; the child should
be on the abdomen or side to facilitate drainage of
secretions; and coughing is discouraged because it
may aggravate the operative site. Content–Pediatrics;
Category of Health Alteration–Respiratory; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Reduction of Risk Potential; Cognitive
Level–Application.
SECTION ELEVEN
27. The nurse is caring for children on a pediatric unit.
Which child should the nurse assess first?
l 1. The 1-month-old child exhibiting substernal
retractions and nasal flaring.
l 2. The 3-month-old child whose mother reports a
salty taste on the skin.
l 3. The 6-month-old child whose respiratory rate is
42 breaths a minute.
l 4. The 8-month-old child who has a “whooping”
throaty cough.
28. Which clinical manifestations would the nurse expect
to assess in a child who has acute epiglottitis?
l 1. Snoring respirations and mouth breathing during
sleep.
l 2. Otalgia and purulent, foul-smelling otorrhea.
l 3. Bilateral crackles and grayish, green sputum.
l 4. Drooling, dyspnea, and high fever.
Pediatric Disorders
515
29. The child diagnosed with pneumonia is being
discharged home. Which intervention should the nurse
discuss with the child's parents?
l 1. Instruct the parents to assess the child's lungs every
2 hours.
l 2. Tell the parents not to allow anyone to smoke in
the child's room.
l 3. Encourage the parents to use a cool-mist
humidifier.
l 4. Recommend the parents limit the child's fluid
intake.
ANSWERS
27. Correct answer 1: This child is in respiratory distress
and requires immediate intervention; therefore, the
nurse should assess this client first. Salty skin indicates cystic fibrosis. Normal respiratory rate for a
6-month-old is 30–60 breaths per minute, and the
child with a cough is moving air and would not
be priority over a child in respiratory distress.
Content–Pediatrics; Category of Health Alteration–
Respiratory; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
28. Correct answer 4: Drooling, because it hurts the
child to swallow, is the hallmark sign of acute
epiglottitis. Drooling results from difficulty or pain
from swallowing. Option 1 may be enlarged adenoids; option 2 could be otitis media; and option 3
could be pneumonia. Content–Pediatrics; Category
of Health Alteration–Respiratory; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
516
29. Correct answer 3: Cool mist will help liquefy the
pulmonary secretions, which will help the child to
expectorate. Parents cannot assess lungs. No one who
smokes should be near the child; smoking in the
house should be prohibited; and smoke smell can be
on clothes when smoking outside. The child's fluid
intake should be increased to help liquefy the
secretions. Content–Pediatrics; Category of Health
Alteration–Respiratory; Integrated Process–Planning;
Client Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Synthesis.
SECTION ELEVEN
Pediatric Disorders
517
30. The mother yells for the nurse, stating, “I think my
32. The day shift nurse who has just come on duty
child swallowed one of the little toys.” The child is lying
in the bed. Which actions should the nurse implement?
Rank in order of performance.
l 1. Look in the mouth for any foreign object.
l 2. Perform a head-tilt/chin-lift maneuver.
l 3. Listen and assess for breath sounds.
l 4. Attempt to administer a rescue breath.
l 5. Shake the child and call the child's name.
is assigned to care for a 3-year-old child who has a
ventriculoperitoneal shunt. After waking up, the child
complains of a headache. Which action should the nurse
implement?
l 1. Complete a neurological assessment.
l 2. Pump the hydrocephalic shunt.
l 3. Measure the child's head circumference.
l 4. Administer a non-narcotic analgesic.
Neurological Disorders
33. The 7-year-old child diagnosed with a
31. Which signs/symptoms would the nurse expect to
assess in a 9-year-old child diagnosed with absence seizure
(petit mal)?
l 1. Generalized stiffness of the muscles.
l 2. Blank facial expression for 5–10 seconds.
l 3. Unexplained feeling of fear or dread.
l 4. Teeth grinding, lip smacking, or chewing.
myelomeningocele is attending the local elementary
school. Which intervention should the school nurse
anticipate implementing for this child?
l 1. Perform sterile wound dressing changes.
l 2. Assist the child with eating in the cafeteria.
l 3. Routine intermittent urinary catheterization.
l 4. Use a gait belt when assisting the child to
ambulate.
ANSWERS
30. Correct answer in order 5, 2, 1, 3, 4: The nurse
must first establish responsiveness (5) and an open
airway (2) and then determine if anything is visible in
the mouth (1) before assessing for respirations (3) and
administering breaths (4). The nurse does not want to
blow any foreign object further into the airway; therefore, the nurse must look in the mouth. Content–
518
32. Correct answer 1: A headache upon awakening is a
sign of hydrocephalus; therefore, this complaint could
indicate a shunt malfunction and requires further
assessment. The nurse does not shunt pumps; head
circumference is assessed in children younger than
12–18 months; and children do not commonly
complain of headaches, so the nurse should assess
before giving medications. Content–Pediatrics; Category
Pediatrics; Category of Health Alteration–Respiratory;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
of Health Alteration–Neurological; Integrated Process–
Implementation; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Application.
31. Correct answer 2: Absence seizures have no muscle
33. Correct answer 3: The child with a myelomeningo-
activity except for eye fluttering or head bobbing
with blank facial expressions for a short time. These
seizures may go undiagnosed because there is little
change in the child's behavior. Option 1 is the tonic
phase of a generalized seizure; option 3 is a simple
partial seizure; and option 4 is a complex partial
seizure. Content–Pediatrics; Category of Health
Alteration–Neurological; Integrated Process–Assessment;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
cele will be paralyzed below the level of the defect,
which usually causes the child to be a paraplegic,
requiring assistance with bowel and bladder function.
Content–Pediatrics; Category of Health Alteration–
Neurological; Integrated Process–Planning; Client Needs–
Safe Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
SECTION ELEVEN
Pediatric Disorders
519
34. The nurse is caring for a 6-month-old infant who
36. The nurse caring for a 7-year-old child diagnosed
was brought to the emergency department after a possible
seizure. The CT scan indicates a coup/contracoup head
injury. Which intervention should the nurse implement?
l 1. Ask the parents how the injury occurred.
l 2. Place the child in Trendelenburg position.
l 3. Close all the curtains in the child's room.
l 4. Notify child protective services (CPS).
with a head injury assesses purposeless movement with
painful stimuli. Two hours later the child assumes
decorticate posturing with painful stimuli. Which action
should the nurse implement first?
l 1. Reassess the client in another 2 hours.
l 2. Document the findings in the chart.
l 3. Notify the client's health-care provider (HCP).
l 4. Turn and position the client on the side.
35. The nurse is admitting a 12-year-old client diagnosed
with bacterial meningitis to the pediatric department.
Which priority intervention should the nurse implement?
l 1. Prepare the client for a CT scan of the brain.
l 2. Place an isolation cart outside the client's room.
l 3. Administer as-needed (prn) narcotic analgesic.
l 4. Initiate intravenous antibiotic therapy.
ANSWERS
34. Correct answer 4: A coup/contracoup head injury
indicates “shaken baby syndrome,” which is an incident where the child is shaken violently, leading to a
head injury. This is child abuse, which must legally
be reported to CPS. The parents brought the child
in for seizure activity, not for an injury. Content–
Pediatrics; Category of Health Alteration–Neurological;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
35. Correct answer 4: The first priority of nursing care
of a client suspected of having meningitis is to
administer the antibiotic ordered as soon as possible.
Failure to do this can result in the death of the
client. The nurse can use a mask when entering
the room before the isolation cart is at the door. All
other interventions can be implemented but not
before starting the antibiotics. Content–Pediatrics;
Category of Health Alteration–Neurological; Integrated
Process–Implementation; Client Needs–Safe Effective
Copyright © 2010 F.A. Davis Company
520
Care Environment, Safety and Infection Control;
Cognitive Level–Application.
36. Correct answer 3: Decorticate posturing indicates a
worsening of the client's condition due to increased
intracranial pressure (ICP); therefore, the nurse
should notify the HCP. The nurse should document
the findings and continue to assess the client but not
before notifying the HCP. Positioning the client
helps prevent pressure ulcers. Content–Pediatrics;
Category of Health Alteration–Neurological; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Reduction of Risk Potential; Cognitive
Level–Synthesis.
SECTION ELEVEN
Pediatric Disorders
521
37. The 13-year-old adolescent diagnosed with epilepsy
39. The pediatric clinic nurse is discussing the care of
is prescribed phenytoin (Dilantin). Which instruction
should the nurse discuss with the adolescent and parents?
l 1. Perform daily self-monitoring of Dilantin levels.
l 2. Explain the importance of flossing and dental care.
l 3. Do not drive or operate heavy machinery.
l 4. Be sure to eat prior to taking medication.
the 6-week-old infant diagnosed with trisomy-21, Down
syndrome. Which interventions should the nurse discuss
with the client's parents? Select all that apply.
l 1. Refer the parents to the Down syndrome support
group.
l 2. Ask the parents about their feelings of attachment
with their child.
l 3. Encourage the parents to use a cool-mist vaporizer.
l 4. Do not re-feed the child the baby food if thrust out
of the mouth.
l 5. Schedule the occupational therapist to visit the
child's home.
38. The 4-year-old child is being discharged home
following supratentorial brain surgery. Which discharge
instructions should the nurse discuss with the parents?
l 1. Discuss the importance of wearing a helmet.
l 2. Teach the parents about follow-up chemotherapy.
l 3. Tell the parents to keep the child in the prone
position.
l 4. Demonstrate how to feed the child through the
percutaneous endoscopic gastrostomy (PEG) tube.
ANSWERS
522
37. Correct answer 2: Dilantin causes gingival hyperpla-
39. Correct answer 1, 2, 3: A support group is helpful
sia; therefore, the client must floss regularly, brush
the teeth often, and see the dentist regularly.
Dilantin levels are not obtained daily, but monthly.
The client is 13-years-old and is not of age to drive.
There is no reason to take the medication with food.
to parents with special-needs children; the nurse
must ensure the parents are bonding with the
infant; and a cool-mist vaporizer keeps the mucous
membranes moist and the secretions liquefied. The
parents should re-feed the food spit out of the
mouth, and the child should be referred to early
childhood intervention, not occupational therapy.
Content–Pediatrics; Category of Health Alteration–
Neurological; Integrated Process–Planning; Client
Needs–Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Synthesis.
38. Correct answer 1: A helmet is mandatory to
protect the surgical site and is worn when the child
is ambulatory. Most chemotherapy agents do not
cross the blood brain barrier and so are not usually
administered for brain tumors. There is no reason to
keep the child in the prone position, and the child
will not have a PEG tube. Content–Pediatrics;
Category of Health Alteration–Neurological; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
Content–Pediatrics; Category of Health Alteration–
Neurological; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
Pediatric Disorders
SECTION ELEVEN
40. The mother of a child calls the clinic and tells the
nurse, “I accidentally gave my child an aspirin for her
fever. How would I know if she gets Reye syndrome?”
Which statement is the nurse's best response?
l 1. “Your child may have a productive cough and
low-grade fever with Reye syndrome.”
l 2. “If your child is listless and doesn't want to play,
that could be Reye syndrome.”
l 3. “The child with Reye syndrome usually vomits
and becomes dehydrated.”
l 4. “Reye syndrome can cause swelling of the
extremities due to increased fluid volume.”
Gastrointestinal Disorders
41. The nurse observes the UAP taking an oral
temperature on a 1-year-old child who is 1 day
postoperative cleft palate repair. Which action should
the nurse implement first?
l 1. Ensure the UAP documents the child's temperature
in the chart.
l 2. Instruct the UAP to take the child's temperature by
the axillary method.
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523
3. Tell the UAP to remove the thermometer from the
child's mouth immediately.
4. Explain the correct way to take the temperature for
a client with a cleft palate repair.
42. The labor and delivery nurse is assisting with
the delivery of an infant diagnosed with congenital
diaphragmatic hernia (CDH). Which interventions
should the nurse implement? Select all that apply.
l 1. Notify the respiratory therapy to prepare a
ventilator.
l 2. Prime the extracorporeal membrane oxygenation
(ECMO) machine.
l 3. Prepare a crib for the newborn in the nursery.
l 4. Request the laboratory to type the infant's blood.
l 5. Do not allow the parents to visit the baby until
after the surgery.
ANSWERS
40. Correct answer 2: Stage 1 of Reye syndrome is
characterized by lethargy followed by profound
unconsciousness and hepatic dysfunction. Content–
Pediatrics; Category of Health Alteration–Neurological;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Reduction of Risk Potential;
Cognitive Level–Application.
41. Correct answer 3: The nurse should avoid the use
of suction or other objects in the mouth, such as a
tongue depressor, thermometer, spoons, or straws, of
a child who is 1 day postoperative cleft palate repair
because the object or suction may irritate or destroy
the incision line. Content–Pediatrics; Category of
Health Alteration–Gastrointestinal; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
524
42. Correct answer 1, 2, 4: The infant will be placed
on a ventilator to manage acidosis, bicarbonate level,
and ventilation. The infant will be on ECMO until
surgical reduction of the hernia, and the infant will
be in the neonatal intensive care unit under a radiant
warmer, not in a regular crib in the nursery. The
ECMO requires multiple units of blood, so the
infant's blood should be typed. The parents should
be encouraged to visit the client before and after
the surgery. Content–Pediatrics; Category of Health
Alteration–Gastrointestinal; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
SECTION ELEVEN
Pediatric Disorders
525
43. Which sign/symptom would the nurse assess for an
45. The nurse overhears the UAP telling the mother of
8-year-old child who is admitted with the diagnosis of
congenital aganglionic megacolon, or Hirschsprung
disease?
l 1. Stools that look like currant jelly.
l 2. Ribbon-like, foul-smelling stools.
l 3. Loose, runny stools with undigested particles.
l 4. Nausea, vomiting, and abdominal pain.
a child diagnosed with gastroenteritis not to use the
bathroom in the child's room. Which action should the
nurse implement?
l 1. Tell the UAP not to discuss infection control with
the mother.
l 2. Notify the infection control nurse of the UAP's
statement.
l 3. Ask the UAP why the mother was told not to use
the bathroom.
l 4. Praise the UAP for reinforcing infection control
measures.
44. The mother of an infant calls the pediatric clinic
reporting her child is having diarrhea. Which instructions
should the nurse discuss with the mother concerning the
child's diet?
l 1. Encourage the mother to give her child fruit juices.
l 2. Instruct the mother to feed the infant beef broth.
l 3. Recommend the mother give the infant a
regular cola.
l 4. Tell the mother to feed the infant Pedialyte.
46. The 5-year-old child is 1 day postoperative emergency
appendectomy. Which intervention should the nurse
implement?
l 1. Remove the incisional staples carefully.
l 2. Assess the child's surgical dressing.
l 3. Keep the child on strict bedrest.
l 4. Maintain the child's nothing by mouth (NPO)
status.
ANSWERS
43. Correct answer 2: The area of colon without ganglion does not have peristalsis; therefore, the stool
is narrow and foul-smelling due to the increased
time in the colon. Option 1 is intussusception,
and options 3 and 4 may be gastroenteritis. Content–
Pediatrics; Category of Health Alteration–Gastrointestinal;
Integrated Process–Assessment; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive
Level–Analysis.
44. Correct answer 4: Pedialyte has electrolytes to
help replace those being lost through the diarrhea.
Fruit juices are high in carbohydrate content and
osmolality; beef broth is avoided because it has
increased sodium and is inadequate in carbohydrates;
and carbonated beverages are avoided because they
are a mild diuretic and may increase dehydration.
Content–Pediatrics; Category of Health Alteration–
Gastrointestinal; Integrated Process–Planning; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
526
45. Correct answer 4: The nurse should encourage and
support the UAP's attempt to prevent the spread
of infectious disease. The UAP is part of the healthcare team. Content–Pediatrics; Category of Health
Alteration–Gastrointestinal; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
46. Correct answer 2: Postoperative interventions
include assessing the surgical incision, turning the
client, asking the client to cough, ambulating the
client in the room, and increasing the diet as
tolerated. The staples are removed 7–10 days after
surgery. Content–Pediatrics; Category of Health
Alteration–Gastrointestinal; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
Pediatric Disorders
SECTION ELEVEN
47. Which statement by the mother of a 14-day-old
daughter would make the nurse suspect the infant had
pyloric stenosis?
l 1. “My child has projectile vomiting after I feed her.”
l 2. “My daughter has not had a bowel movement in
2 days.”
l 3. “My child's abdomen is board-like and rigid.”
l 4. “My daughter has gained 6 ounces since last week.”
48. The nurse is preparing to administer an antibiotic by
intravenous piggy back (IVPB) to an 8-year-old client.
The medication is prepared in a 50-mL bag, and the
child's IV is infusing at 50 mL/hr. At what rate should
the nurse set the intravenous pump?
Answer: ____________________
49. The child is diagnosed with extrahepatic biliary
atresia (EHBA). The parents are crying and ask the nurse,
“What will happen to our baby?” Which statement is
most appropriate by the nurse?
l 1. “Your baby will have to have surgery to correct this
problem.”
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527
2. “There is nothing you can do for this type of birth
defect.”
3. “Your baby will have to be on dialysis at least three
times a week.”
4. “Medications are available to help cure this
disease.”
50. The 7-year-old child diagnosed with inflammatory
bowel disease (IBD) is scheduled for a temporary
colostomy surgical procedure. Which intervention should
the nurse implement preoperatively?
l 1. Take the child and parents to the operating room.
l 2. Give the child a doll with a colostomy appliance.
l 3. Discuss the numeric 1–10 pain scale with the
child.
l 4. Measure the child's legs for anti-thrombolism
stockings.
ANSWERS
47. Correct answer 1: Projectile vomiting is the major
symptom of pyloric stenosis, because the pyloric
sphincter does not open, and the food is forcibly
ejected. Content–Pediatrics; Category of Health
Alteration–Gastrointestinal; Integrated Process–
Evaluation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Evaluation.
48. Correct answer 50 mL/hr: The antibiotic IVPB
should be infused over 1 hour via the IV pump and
volume control chamber. Content–Pediatrics; Category of Health Alteration–Drug Administration;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Pharmacological and Parenteral
Therapies; Cognitive Level–Application.
49. Correct answer 1: The infant must have a hepatoportoenterostomy (Kasai procedure) as soon as
possible to help prevent liver damage, which will
occur over time even with the procedure. The
child will eventually require a liver transplant.
Copyright © 2010 F.A. Davis Company
528
Content–Pediatrics; Category of Health Alteration–
Gastrointestinal; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Application.
50. Correct answer 2: Demonstrating the postoperative
equipment with the child using a doll is an agespecific teaching strategy. The child and parents
can be shown the intensive care unit (ICU) or
post-anesthesia care unit (PACU), but only operating
room personnel in appropriate clothing are allowed
in the sterile operating room area. The 7-year-old
child would use the faces pain scale, not the numeric
scale. Children do not need to wear antithrombolism
stockings after surgery. Content–Pediatrics; Category
of Health Alteration–Gastrointestinal; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Reduction of Risk Potential; Cognitive
Level–Application.
SECTION ELEVEN
Pediatric Disorders
529
Musculoskeletal Disorders
51. The middle school nurse observes an 11-year-old
53. The 4-year-old client with a cast right below the
female student has a noticeable difference in the space
between the arms and the trunk. Which intervention
should the nurse implement first?
l 1. Notify the parents to have the child evaluated.
l 2. Perform a spinal screening check on the student.
l 3. Recommend the child have a spinal x-ray.
l 4. Discuss the possibility of spinal fusion surgery.
knee after having surgery for a compound fracture is
crying. The nurse determines the right toes are colder
than the left. Which interventions should the nurse
implement? Rank in order of performance.
l 1. Elevate the child's right leg on two pillows.
l 2. Explain to the mother what is happening.
l 3. Bifurcate the cast to relieve pressure.
l 4. Attempt to insert two fingers in the distal portion
of cast.
l 5. Notify the child's HCP.
52. The mother of the infant born with bilateral clubfeet
is crying and tells the nurse, “I am so scared my baby is
going to have to have surgery.” Which statement is the
nurse's best therapeutic response?
l 1. “Don't worry; your baby will not have to have
surgery.”
l 2. “Have you discussed your concerns with your
baby's doctor?”
l 3. “You sound frightened. Would you like to talk
about your baby?”
l 4. “You should not be worried. Clubfeet can be easily
corrected.”
54. The pediatric clinic nurse suspects a 6-week-old
baby may have developmental dysplasia of the hip. Which
intervention should the nurse implement to further assess
for hip dysplasia?
l 1. Perform the Ortolani maneuver.
l 2. Check for the Barlow response.
l 3. Measure the length of each leg.
l 4. Assess for asymmetrical gluteal folds.
ANSWERS
51. Correct answer 2: A noticeable difference in the
space between the arms and the trunk indicates spinal
curvature, which should be further assessed by a spinal
screening check. Then, based on the findings of the
screening check, the parents should be notified,
further diagnostic tests completed, and then possible
treatments implemented, which may include bracing
or surgery. Content–Pediatrics; Category of Health
Alteration–Musculoskeletal; Integrated Process–
Implementation; Client Needs–Health Promotion and
Maintenance; Cognitive Level–Application.
52. Correct answer 3: A therapeutic response should
encourage the client to ventilate feelings and acknowledges the mother's feelings. Asking if she would like to
talk would encourage verbalization of feelings. Option
1 is providing factual information; option 2 is passing
the buck; and option 4 is denying the mother the
right to having feelings. Content–Pediatrics; Category of
Health Alteration–Musculoskeletal; Integrated Process–
Implementation; Client Needs–Psychosocial Integrity;
Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
530
53. Correct answer in order 4, 1, 2, 3, 5: The nurse
should first determine if the cast is too tight and
then elevate the leg to help decrease the edema.
Then, the nurse should elicit the mother's support
while bifurcating the cast and, finally, notify the
orthopedist. Content–Pediatrics; Category of Health
Alteration–Musculoskeletal; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–
Application.
54. Correct answer 4: Infants beyond the newborn
period exhibit asymmetry of the gluteal skin folds
when the infant is held upright with the feet
dangling. Measuring the length of the legs is not
pertinent assessment information. The Ortolani and
Barlow maneuvers can be done only by the HCP
or trained advanced nurse practitioner. Content–
Pediatrics; Category of Health Alteration–Musculoskeletal;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
SECTION ELEVEN
Pediatric Disorders
531
55. The 5-year-old child in the emergency department is
57. The 9-year-old client diagnosed with juvenile arthritis
diagnosed with a spiral fracture of the right ulna. Which
intervention should the nurse implement?
l 1. Place the right arm in a dependent position.
l 2. Apply a heating pad to the right arm.
l 3. Contact child protective services.
l 4. Notify the hospital's physical therapist.
is prescribed naproxen sodium (Naproxyn), a nonsteroidal
anti-inflammatory drug (NSAID). Which intervention
should the nurse implement?
l 1. Tell the client to take the medication with an
antacid.
l 2. Instruct the client to take the medication with food.
l 3. Encourage the client to take the medication at
night.
l 4. Explain the medication will turn the stools black.
56. The child diagnosed with osteomyelitis of the
right leg is being discharged home. Which statement
by the mother indicates the discharge teaching has been
effective?
l 1. “I will need to check my child's IV site for redness
and swelling.”
l 2. “The antibiotic therapy will make my child feel
nauseated.”
l 3. “I should encourage my child to ambulate around
the house.”
l 4. “I can throw the soiled dressings in my kitchen
trash can.”
ANSWERS
55. Correct answer 3: A spiral fracture, a twisted or
circular break, is frequently seen in child abuse;
therefore, this would be an appropriate intervention.
The fractured arm should be elevated, and ice
should be applied to it. Content–Pediatrics; Category
of Health Alteration–Musculoskeletal; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
56. Correct answer 1: The parents must be able to care
for the child's IV site as long-term antibiotic therapy
is the treatment of choice for osteomyelitis. IV
antibiotics will not make the child nauseated; the
child should be on bedrest; and the soiled dressings
must be removed in a biohazard bag and not in the
regular trash. Content–Pediatrics; Category of Health
Alteration–Musculoskeletal; Integrated Process–
Evaluation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Evaluation.
Copyright © 2010 F.A. Davis Company
532
57. Correct answer 2: NSAIDs are very irritating to
the stomach lining and decrease the production of
prostaglandin, the protective barrier of the stomach;
they should be taken with food to minimize the
irritation. Antacids decrease the absorption of
medications, so they should not be used. The
medication is administered 4 times a day or around
the clock, not just at night. NSAIDs may cause
gastrointestinal bleeding, so if the stools are black,
the mother must call the health-care provider.
Content–Pediatrics; Category of Health Drug
Administration; Integrated Process–Implementation;
Implementation; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Synthesis.
Pediatric Disorders
SECTION ELEVEN
58. The pediatric nurse notices the 6-year-old male child
puts his hands on his knees and moves the hands up the
legs so that he can stand up. Which question should the
nurse ask the mother?
l 1. “Do you have a history of Duchenne muscular
dystrophy?”
l 2. “Why does your son need to rise by using his
hands?”
l 3. “Do you have any other children who get up
this way?”
l 4. “Have you noticed your son getting weak after
walking?”
59. The 5-year-old child diagnosed with developmental
dysplasia of the right hip has surgery to correct the
deformity. Which discharge teaching should the nurse
discuss with the client?
l 1. Show the parents how to apply and remove the
Pavlik harness.
l 2. Explain the care of the client with skeletal traction.
l
l
533
3. Demonstrate toileting procedures for the child in a
spica cast.
4. Teach the parents how to place the child on the
Stryker frame.
60. The 16-year-old child with a fractured left ankle is
ambulating on crutches and tells the nurse, “My hands
feel like they are going to sleep.” Which intervention
should the nurse implement?
l 1. Observe the child ambulating on the crutches.
l 2. Ask the child to squeeze the nurse's fingers.
l 3. Evaluate the child's handwriting quality.
l 4. Tell the client to flex and extend the fingers.
ANSWERS
58. Correct answer 4: The Gowers maneuver (walking
up the legs) is a hallmark sign of Duchenne muscular
dystrophy (MD). Muscle wasting and weakness occur
with MD; therefore, this is an appropriate question.
Duchenne is genetically linked, with the mother
passing it on to a son, but she does not have it
herself and may be unaware of a familial link.
Content–Pediatrics; Category of Health Alteration–
Musculoskeletal; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
59. Correct answer 3: After surgery, long-term
immobilization in a spica cast is necessary until
healing of the hip is achieved and specific toileting
procedures are needed. The Pavlik harness is used
for infants with congenital hip dysplasia; skeletal
traction is used for cervical or femur fractures; and
the Stryker frame is used for paralyzed clients.
Content–Pediatrics; Category of Health Alteration–
Musculoskeletal; Integrated Process–Planning; Client
Copyright © 2010 F.A. Davis Company
534
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Synthesis.
60. Correct answer 1: The numbness may be due to
pressure on the axillary area and nerve compression,
which occurs when the axillary crutch pads are not
properly placed when ambulating. Observing ambulation can determine if the child is crutch-walking
properly. Squeezing fingers, evaluating handwriting,
and moving fingers will not determine if axillary
nerves are being compressed. Content–Pediatrics;
Category of Health Alteration–Musculoskeletal;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Application.
SECTION ELEVEN
Pediatric Disorders
535
Hematological Disorders
61. The nurse is caring for clients on a pediatric
63. The 8-year-old child diagnosed with leukemia has
oncology unit. Which neutropenia precaution should
be implemented for the 6-year-old child diagnosed with
leukemia?
l 1. Perform all painful procedures in the treatment
room.
l 2. Limit the number of children visiting the client.
l 3. Use a tympanic thermometer to take the
temperature.
l 4. Have the client use a soft-bristle toothbrush.
central nervous system involvement. Which instructions
should the nurse discuss with the parents?
l 1. Explain the need to keep the child away from other
children.
l 2. Give the child an analgesic medication for pain
only when the pain becomes severe.
l 3. Discuss the potential for possible learning
disabilities in the future.
l 4. Reassure the parents the child's hair will grow back
after treatment.
62. The nurse is assessing a client diagnosed with acute
myeloid leukemia. Which assessment data support this
diagnosis?
l 1. Petechiae on the trunk.
l 2. Red raised rash on the legs.
l 3. Nausea, vomiting, diarrhea.
l 4. Inguinal lymph-node enlargement.
64. The 7-year-old child diagnosed with anemia is
prescribed one unit of packed red blood cells. The unit
has 125 mL of blood plus 15 mL of additives to be
infused over 3.5 hours. At what rate should the nurse set
the IV pump?
Answer: ____________________
ANSWERS
61. Correct answer 2: Children are more prone to
536
63. Correct answer 3: Radiation therapy to the head
carry viruses and bacteria because of their immature
immune systems, and visiting children might expose
the client to these infections. All the other interventions are appropriate but do not address neutropenia
precautions. Content–Pediatrics; Category of Health
and scalp area is the treatment of choice for central
nervous system involvement of any cancer. Chronic
illness and subsequent treatment in children can
impact the child's learning ability and social
interaction. Content–Pediatrics; Category of Health
Alteration–Oncology; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment, Safety
and Infection Control; Cognitive Level–Synthesis.
Alteration–Oncology; Integrated Process–Planning;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Synthesis.
62. Correct answer 1: Petechiae, fever, bruising,
intermittent stomachache, and infections are hallmark symptoms of leukemia. All other data would
not support the diagnosis of acute myeloid leukemia.
Content–Pediatrics; Category of Health Alteration–
Oncology; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
64. Correct answer 40 mL/hr: Pumps are set at an
hourly rate. The nurse must do the following:
125 + 15 = 140. Divide 140 by 3.5 = 40 mL/hr.
Content–Pediatrics; Category of Health Alteration–
Drug Administration; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Application.
SECTION ELEVEN
Pediatric Disorders
537
65. The adolescent who is diagnosed with anemia has the
67. The 8-year-old child diagnosed with sickle cell
following lab values: red blood cell (RBC) count: 3 mm
(106); white blood cell (WBC) count of 8.9 mm(103);
and platelets 150 mm(103). Which intervention should
the nurse implement?
l 1. Place the client in reverse isolation.
l 2. Continue to monitor the client's lab results.
l 3. Administer erythropoietin (Epogen), a biological
response modifier.
l 4. Institute bleeding precautions for the client.
anemia tells the nurse that her family is planning a skiing
trip. Which action should the nurse take?
l 1. Take no action because this sounds like an
enjoyable trip.
l 2. Talk to the parents about taking the child to the
mountains.
l 3. Tell the child she cannot go skiing because of her
disease.
l 4. Suggest the child talk to the parents about going
on this trip.
66. The child diagnosed with sickle cell anemia comes
to the emergency department complaining of joint pain
after playing a game of soccer in 100ºF weather. Which
intervention should the emergency department nurse
implement first?
l 1. Check the pulse oximeter reading.
l 2. Document why the client came to the ED.
l 3. Administer intravenous pain medication.
l 4. Infuse intravenous fluids via pump.
68. The nurse is caring for a 10-year-old child in a sickle
cell crisis. Which regimen should the nurse implement to
relieve the child's pain?
l 1. Frequent acetylsalicylic acid (aspirin) and a
non-narcotic analgesic.
l 2. Ibuprofen (Motrin), an NSAID, prn.
l 3. Meperidine (Demerol), a narcotic analgesic, every
4 hours.
l 4. A morphine via a patient-controlled analgesia
(PCA) pump.
ANSWERS
65. Correct answer 3: The client's RBC count is low.
Therefore, the nurse should administer Epogen, a
biological response modifier that stimulates the
production of red blood cells. The WBC count
and the platelet count are within normal limits.
Content–Pediatrics; Category of Health Alteration–
Hematology; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Reduction of
Risk Potential; Cognitive Level–Synthesis.
66. Correct answer 4: The client is obviously dehydrated, which will cause the cells to sickle, resulting
in pain. The nurse should first administer fluids to
correct the dehydration. Then, the nurse should
administer pain medication and check the client's
oxygen level. After the client is treated, the nurse
can document what was done. Content–Pediatrics;
Category of Health Alteration–Hematology; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
538
67. Correct answer 2: High altitudes have decreased
oxygen, which could lead to a sickle cell crisis;
therefore, the nurse should discuss this with the
parents. The nurse should not directly talk to an
8-year-old child about where the child is going on
vacation. Content–Pediatrics; Category of Health
Alteration–Hematology; Integrated Process–Planning;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Synthesis.
68. Correct answer 4: A 10-year-old child who is in
severe pain can be allowed to administer pain
medication as needed; this is the best pain relief
regimen. The PCA pump has prescribed lock-out
mechanisms to prevent an overdose. Children's pain
is frequently undertreated, and this type of pain is
severe. Demerol is contraindicated because of the
metabolite normeperidine. Content–Pediatrics;
Category of Health Alteration–Hematology; Integrated
Process–Planning; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Synthesis.
SECTION ELEVEN
Pediatric Disorders
539
Psychiatric Disorders
69. Which nursing intervention should the nurse
71. The 10-year-old child is diagnosed with attention
implement when caring for a child diagnosed with
hemophilia A?
l 1. Encourage participation in noncontact sports.
l 2. Teach the mother how to insert rectal
suppositories.
l 3. Apply a Band-Aid when bleeding occurs.
l 4. Explain the importance of not flossing gums.
deficit–hyperactivity disorder (ADHD) and is taking the
central nervous stimulant methylphenidate (Ritalin).
Which assessment data would warrant intervention from
the pediatric clinic nurse?
l 1. The child has lost 3 kg in the last month.
l 2. The child's pulse is 96 and BP is 108/78.
l 3. The child has grown 2 inches in the last year.
l 4. The child sits quietly in the waiting room.
70. The 5-year child with hemophilia fell on the
playground and is experiencing hemarthros of the right
knee. Which intervention should the school nurse
implement?
l 1. Administer aspirin to the child.
l 2. Apply cold packs to the right knee.
l 3. Call 911 for emergency treatment.
l 4. Elevate the right child's right leg.
72. The 7-year-old child newly diagnosed with ADHD
is prescribed Adderall, an amphetamine mixture. Which
information should the nurse discuss with the parents?
l 1. Take the medication on an empty stomach.
l 2. Provide multiple activities for the child.
l 3. Administer the medication in the morning.
l 4. Allow the child to drink regular colas.
ANSWERS
69. Correct answer 1: Even minor trauma can lead
540
71. Correct answer 1: ADHD medications are notorious
to serious bleeding episodes; safer activities such
as swimming or golf should be recommended.
Suppositories cause tissue damage and vascular
trauma, which can precipitate bleeding. Teach the
child and/or parents to apply direct pressure if
bleeding occurs. The child should floss the teeth.
for causing weight loss and stunting the child's growth.
A 6.6-pound weight loss in 1 month is significant. The
vital signs are within normal limits for a 10-year-old
child. Sitting quietly in the waiting room would indicate the medication is effective and would not warrant
intervention by the nurse. Content–Pediatrics; Category
Content–Pediatrics; Category of Health Alteration–
Hematology; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
of Health Alteration–Psychiatric; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Synthesis.
70. Correct answer 2: Hemarthros is bleeding into the
72. Correct answer 3: The medication should be ad-
joint; applying ice to the area can cause vasoconstriction, which can help decrease bleeding. Aspirin will
destroy platelet aggregation and may cause Reye syndrome. The nurse cannot call 911 every time the child
with hemophilia injures himself. Elevating the leg will
not stop the bleeding. Content–Pediatrics; Category
ministered in the morning and again, if prescribed,
no later than 5 hours after the first dose so that the
child can sleep at night. The medication should be
taken with food to help decrease gastrointestinal
upset and counteract anorexia. The child should try
to focus on one activity at a time. The child should
avoid caffeine. Content–Pediatrics; Category of Health
of Health Alteration–Hematology; Integrated Process–
Implementation; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Application.
Alteration–Psychiatric; Integrated Process–Planning;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
SECTION ELEVEN
Pediatric Disorders
541
73. The nurse is discussing ADHD with a parent of a
75. The 6-year-old male child is diagnosed with conduct
newly diagnosed male child. Which statement by the
mother would support this diagnosis?
l 1. “My child is always engaging in repetitive-type
behavior.”
l 2. “My child use to hug and kiss me, but now he
doesn't.”
l 3. “My child insists on collecting all toys in a series
of toys.”
l 4. “My child is easily distracted and fidgets all the time.”
disorder. The mother asks the nurse, “What will happen
to my child because they cannot cure him?” Which
statement supports the ethical principle of veracity?
l 1. “He will probably develop an antisocial personality
disorder.”
l 2. “With continued treatment your child will have a
normal life.”
l 3. “Sometimes the child will outgrow it even if it
can't be cured.”
l 4. “There are medications that can control it but not
cure it.”
74. The parents of a child newly diagnosed with
oppositional defiant disorder (ODD) tell the nurse,
“We don't know what to do to help our child.” Which
intervention should the nurse discuss with the parents?
l 1. Discuss administering antidepressant medication to
the child daily.
l 2. Recommend the parents attend a parent training
program.
l 3. Allow the parents to ventilate their feelings of
frustration.
l 4. Talk to the parents about placing their child in a
protective environment.
ANSWERS
73. Correct answer 4: The DSM IV-TR diagnostic
criteria for ADHD state that six or more symptoms
of inattention and hyperactivity-impulsivity must be
present for at least 6 months; one of these symptoms
is being easily distracted and fidgety. The other
comments do not address inattention, hyperactivity,
or impulsivity. Content–Pediatrics; Category of Health
Alteration–Psychiatric; Integrated Process–Evaluation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Evaluation.
74. Correct answer 2: The American Psychiatric Association recommends parent training programs to help
parents develop consistent parenting skills. There are
no medications for children with ODD. The parents
need help to figure out what to do, not to ventilate
their frustration. Placing a child in another environment is the last resort. Content–Pediatrics; Category
of Health Alteration–Psychiatric; Integrated Process–
Planning; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
542
75. Correct answer 1: Veracity is telling the truth. The
nurse must give facts, which include the fact that
after the age of 18, a conduct disorder may develop
into an antisocial personality disorder. There are no
medications for conduct disorders, and the child will
not outgrow it, nor will the child have a normal life.
Content–Pediatrics; Category of Health Alteration–
Psychiatric; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Application.
SECTION ELEVEN
Pediatric Disorders
543
76. The 13-year-old female child diagnosed with
78. The father of a 13-year-old daughter tells the
bipolar disorder is admitted to the child psychiatric unit
diagnosed with mania. Which activity would be most
appropriate for the client?
l 1. Encourage the child to play checkers with a staff
member.
l 2. Recommend the child throw basketballs into a
hoop by herself.
l 3. Tell the client to sit in her room and read a book
quietly.
l 4. Ask the client to write her feelings in a journal.
pediatric nurse, “My daughter has really changed. She
doesn't go to school, she wears black all the time, and
she won't talk to me.” Which priority intervention
should the nurse implement?
l 1. Tell the father this is normal adolescent behavior.
l 2. Determine if the father has talked to the school
counselor.
l 3. Suggest the father obtain a urine drug screen on his
daughter.
l 4. Discuss the possibility of his daughter being
depressed.
77. The mother asks the nurse, “What behavior would
my child have if the child were autistic?” Which
statement is the nurse's best response?
l 1. “Your child will not allow you to hold him when
he is angry.”
l 2. “Your child will have problems with authority
figures.”
l 3. “Your child may repeat the same word over and
over again.”
l 4. “You child will not be able to feed himself
independently.”
79. The mother of the 14-year-old child diagnosed with
autism tells the nurse, “My child does not have any
friends.” Which recommendation should the nurse
discuss with the mother?
l 1. Encourage the child to join a club at the school.
l 2. Recommend the child join an online autism
support group.
l 3. Tell the mother to take the child to church
activities.
l 4. Instruct the mother not to try to change her child.
ANSWERS
76. Correct answer 2: The client should engage in
activities that will exhaust her physically, such as
continuously throwing and chasing a basketball, but
the nurse should discourage competitive and sedate
activities. Content–Pediatrics; Category of Health
Alteration–Psychiatric; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
77. Correct answer 3: Autism is exhibited by age 3 and
includes a lack of emotional and social reciprocity,
repetitive use of language, and persistent preoccupation with parts of objects. Most children will not let
themselves be hugged when they are angry. Children
with conduct disorders have problems with authority
figures, and children with autism can feed themselves.
Content–Pediatrics; Category of Health Alteration–
Psychiatric; Integrated Process–Implementation; Client
Needs–Health Promotion and Maintenance;
Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
544
78. Correct answer 4: These are typical symptoms of
depression, and the nurse should discuss this with
the father so the father will be informed. This is not
normal adolescent behavior. The father could talk to
the school counselor and get a drug screen, but the
father should understand the signs/symptoms of
depression. Content–Pediatrics; Category of Health
Alteration–Psychiatric; Integrated Process–Implementation;
Client Needs–Health Promotion and Maintenance;
Cognitive Level–Analysis.
79. Correct answer 2: Autistic individuals have
difficulty expressing themselves directly to people.
The Internet provides an avenue for the child to
interact with other people. The mother should
supervise the sites the child accesses. Content–
Pediatrics; Category of Health Alteration–Psychiatric;
Integrated Process–Planning; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive Level–
Synthesis.
Pediatric Disorders
SECTION ELEVEN
80. The male child who is “out of control” is admitted to
a psychiatric unit because he is a danger to himself.
Which priority intervention should the nurse implement?
l 1. Contact the client's family to come to the unit.
l 2. Place the client on a one-to-one observation.
l 3. Develop a plan for a therapeutic milieu.
l 4. Notify the client's school for assignments.
Management
81. The nurse is caring for children in a psychiatric unit.
Which client requires immediate intervention by the
psychiatric nurse?
l 1. The 10-year-old child diagnosed with oppositional
defiant disorder who refuses to eat what is on the
lunch tray.
l 2. The 5-year-old child diagnosed with pervasive
developmental disorder who refuses to talk and
will not make eye contact.
l
l
545
3. The 7-year-old child diagnosed with conduct
disorder who is standing in front of the television
in the dayroom.
4. The 8-year-old mentally retarded child who is
sitting on the playground and eating dirt and sand.
82. The male child diagnosed with conduct disorder on
the psychiatric unit is yelling at other children, throwing
furniture, and threatening the staff members. The
charge nurse determines the child is at imminent risk
for harming the other children or himself. Which
intervention should the charge nurse implement first?
l 1. Document the client's behavior in the nurse's
notes.
l 2. Place the client in the seclusion room with direct
observation.
l 3. Obtain a restraint/seclusion order from the
physician.
l 4. Ensure that none of the other clients are injured.
ANSWERS
80. Correct answer 2: Safety is priority for the psychiatric
546
82. Correct answer 2: The nurse should first ensure the
client; therefore, placing the client on a one-to-one
observation until he is stabilized is the priority
intervention. Contacting the family and the client's
school and providing a therapeutic milieu are
appropriate interventions but not priority over safety.
safety of the child and then the other clients. Then,
the nurse should obtain an order for seclusion from
the physician immediately and document the reason
why the child had to be secluded, which must be
because the child is a danger to self or others.
Content–Pediatrics; Category of Health Alteration–
Psychiatric; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Safety and
Infection Control; Cognitive Level–Synthesis.
Content–Pediatrics; Category of Health Alteration–
Psychiatric; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Safety and
Infection Control; Cognitive Level–Synthesis.
81. Correct answer 3: The child with conduct disorder
is aggressive to people and animals. The child bullies,
threatens others, destroys property, and sets fires.
Because the child is in front of the television
antagonizing other children by blocking the television, the nurse should intervene with this client
first. Content–Management; Category of Health
Alteration–Psychiatric; Integrated Process–Assessment;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Analysis
Copyright © 2010 F.A. Davis Company
SECTION ELEVEN
Pediatric Disorders
547
83. The pediatric nurse is preparing to administer
85. The charge nurse is making assignments for clients
digoxin elixir, a cardiac glycoside, to a 2-year-old client
with congenital heart disease who has an apical pulse rate
of 74. Which intervention should the nurse implement?
l 1. Administer the medication via a syringe.
l 2. Check the medication dose with another RN.
l 3. Ask the mother if the child is having any leg
discomfort.
l 4. Hold the medication and document it on the
medication administration record (MAR).
on a pediatric unit. Which client should the charge nurse
assign to a new graduate nurse?
l 1. The 2-year-old child diagnosed with tetralogy of
Fallot who is having surgery.
l 2. The 4-year-old child who has been newly diagnosed
with cystic fibrosis (CF).
l 3. The 6-year-old child who has a fractured tibia and
is in a long leg cast.
l 4. The 8-year-old child diagnosed with an acute
exacerbation of ulcerative colitis.
84. The nurse and the UAP are caring for clients on a
pediatric unit. Which nursing task should be assigned to
the UAP?
l 1. Instruct the UAP to feed the 3-year-old child who
has a gastrostomy tube.
l 2. Request the UAP to turn and position the 4-year-old
with a spica cast.
l 3. Tell the UAP to assist the mother who is changing
a wet diaper.
l 4. Ask the UAP to obtain vital signs on the child
diagnosed with sickle cell disease.
86. The charge nurse is making assignments on a 30-bed
pediatric unit which is staffed with two registered nurses
(RNs), two licensed practical nurses (LPNs), and three
UAPs. Which assignment is most appropriate?
l 1. Assign the RN to pass out the breakfast trays.
l 2. Assign the UAP to orient a new nurse to the unit.
l 3. Assign the UAP to complete the morning care
l 4. Assign the LPN to write the care plans.
ANSWERS
83. Correct answer 4: The normal pulse rate for a
2-year-old is 80–125; because the client's heart rate
is below normal, the dose should be held. Content–
Pediatrics; Category of Health Alteration–Drug
Administration; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Analysis.
84. Correct answer 2: The UAP can turn and position
a child who is stable, and a child in a spica cast
(from mid-abdomen to both knees) needs to be
turned. The UAP cannot feed through feeding tubes.
Content–Pediatrics; Category of Health Alteration–
Management; Integrated Process–Planning; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
85. Correct answer 3: The new graduate should be
able to safely care for a child who has a fractured
extremity. The child going to surgery, the child
newly diagnosed with CF, and a child with an acute
exacerbation of ulcerative colitis should be assigned
Copyright © 2010 F.A. Davis Company
548
to a more experienced nurse for the care of the child
and the comfort of the parents. Content–Pediatrics;
Category of Health Alteration–Management; Integrated
Process–Planning; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Synthesis.
86. Correct answer 3: The UAP is qualified and
expected to perform activities of daily living for the
clients. The UAP cannot assess, teach, evaluate, or
care for a client who is unstable. The UAP should
not be orienting nurses to the unit. The RN should
not be passing out meal trays, and the LPN does not
write care plans; the RN does. Content–Pediatrics;
Category of Health Alteration–Management; Integrated
Process–Planning; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Synthesis.
SECTION ELEVEN
Pediatric Disorders
549
87. The nurse is working the emergency department of a
89. The nurse is caring for clients on the pediatric medical
children's medical center. Which client should the nurse
assess first?
l 1. The 1-month-old infant who has angry-looking red
diaper rash.
l 2. The 2-year-old toddler whose father is demanding
his child be seen now.
l 3. The 6-year-old school-age child who was bitten by
a dog yesterday.
l 4. The 14-year-old adolescent whose mother suspects
has been raped.
unit. Which client should the nurse assess first?
l 1. The child diagnosed with type 2 diabetes who has
a blood glucose of 60 mg/dL.
l 2. The child diagnosed with pneumonia who has a
pulse oximeter reading of 98%.
l 3. The child diagnosed with gastroenteritis who has a
sodium level of 135 mEq/L.
l 4. The child diagnosed with cystic fibrosis who has
clubbing of the extremities.
88. The 8-year-old client diagnosed with a vaso-occlusive
clients on a pediatric unit. Which medication should the
nurse administer first?
l 1. The third dose of the aminoglycoside antibiotic to
the child diagnosed with methicillin-resistant
Staphylococcus aureus (MRSA).
l 2. The IVP steroid methylprednisolone (Solumedrol)
to a child diagnosed with asthma.
l 3. The scheduled morning insulin to the child
diagnosed with type 1 diabetes mellitus.
l 4. The narcotic pain medication to the child who had
a postoperative spinal fusion.
sickle cell crisis is complaining of a severe headache.
Which intervention should the nurse implement first?
l 1. Administer 6 L of oxygen via nasal cannula.
l 2. Assess the client's pupillary reaction.
l 3. Administer a narcotic analgesic intravenous push
(IVP).
l 4. Increase the client's IV rate.
90. The nurse has received morning shift report for
ANSWERS
87. Correct answer 4: The adolescent who has possibly
been raped must be assessed for physical injury,
and her emotional trauma must be addressed. In
addition, evidence must be obtained and preserved
for legal purposes. A diaper rash and a dog bite are
not life-threatening. The father must wait until the
child who was raped is assessed. Content–Pediatrics;
Category of Health Alteration–Emergency; Integrated
Process–Assessment; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Analysis.
88. Correct answer 2: Because the client is complaining
of a headache, the nurse should first rule out a cerebral vascular accident (CVA) and determine if it is
a headache that can be treated with medication.
Administering oxygen, fluids, and pain medication
will help prevent the sickling, but the first intervention is to assess. Content–Pediatrics; Category of Health
Alteration–Hematology; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
550
89. Correct answer 1: The client's blood glucose is low,
and the client is at risk for hypoglycemia; therefore,
this child should be assessed first. The pulse oximeter
reading and the sodium level are within normal
limits. Clubbing of the extremities occurs in children
with cystic fibrosis due to chronic hypoxemia.
Content–Pediatrics; Category of Health Alteration–
Endocrine; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
90. Correct answer 4: The child who has postoperative
pain should be medicated prior to being given an
antibiotic, a steroid, or a routine dose of insulin.
Content–Pediatrics; Category of Health Alteration–
Drug Administration; Integrated Process–Planning;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Synthesis.
S E C T I O N T W E LV E
Emergency Nursing
551
S E C T I O N T W E LV E
Emergency Nursing
553
Cardiac Arrest/Codes
1. The nurse working on a medical unit finds the client
3. Which is the primary responsibility of the supervising
unresponsive in the bed. After establishing the client is
not breathing and giving two rescue breaths with a mask,
which action should the nurse implement next?
l 1. Check the client for airway obstruction.
l 2. Assess the carotid artery for a pulse.
l 3. Begin chest compressions.
l 4. Call a code via the call light.
nurse during a code?
l 1. Escort family members from the room.
l 2. Ensure that all roles are being performed.
l 3. Notify the client’s health-care provider (HCP) of
the event.
l 4. Document what happened in the code.
2. Which behavior by the unlicensed assistant personnel
Which client is most likely to experience sudden cardiac
death?
l 1. The client exhibiting uncontrolled atrial fibrillation
at a rate of 136 bpm.
l 2. The client exhibiting symptomatic sinus
bradycardia who received a pacemaker.
l 3. The client exhibiting multifocal premature
ventricular contractions.
l 4. The client exhibiting supraventricular tachycardia
at a rate of 110 bpm.
(UAP) who is performing cardiac compressions during a
code warrants immediate intervention by the nurse?
l 1. The UAP has two hands on the upper half of the
sternum.
l 2. The UAP notifies the team when getting tired of
performing compressions.
l 3. The UAP depresses the sternum 1.5–2 inches during
compressions.
l 4. The UAP counts out loud to keep the rhythm of
compressions.
4. The nurse is caring for clients on a telemetry floor.
ANSWERS
1. Correct answer 4: The nurse should notify the code
team to come to the room so that a defibrillator is
brought to the bedside. The earlier the client is defibrillated, the better the chance of success. Then, the
nurse should assess for a carotid pulse and then start
compressions. The nurse has already checked for airway obstruction before giving the two rescue breaths.
Content–Emergency; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
2. Correct answer 1: The correct hand placement is the
lower half of the sternum just above the xiphoid process.
The nurse should have the UAP reposition the hands.
The other actions by the UAP are appropriate. Content–
Management; Category of Health Alteration–Cardiovascular;
Integrated Process–Evaluation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
554
3. Correct answer 2: The supervisor should make sure
that all the roles in a code are being performed: compression, ventilation, medication, equipment, and
documentation. Then, if needed, the supervisor
nurse can worry about crowd control. The HCP
will be notified by the staff at the nursing station.
Content–Management; Category of Health Alteration–
Cardiovascular; Integrated Process–Planning; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
4. Correct answer 3: Premature ventricular contractions
occur when the ventricle initiates a beat; when there
are several areas of the ventricles competing to initiate
a beat, then the client is at risk for cardiac arrest. The
client with bradycardia may have been symptomatic
but now has a pacemaker. Atrial problems are not lifethreatening as in options 1 and 4. Content–Emergency;
Category of Health Alteration–Cardiovascular; Integrated
Process–Assessment; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Analysis.
S E C T I O N T W E LV E
Emergency Nursing
555
5. The male client is experiencing a cardiac arrest, and
7. The nurse is teaching cardiopulmonary resuscitation
his wife is distraught. Which intervention should the
nurse implement at this time?
l 1. Notify hospital security to keep an eye on the wife.
l 2. Stay with the significant other until the client’s
minister arrives.
l 3. Ask the UAP to talk to the wife.
l 4. Request the hospital chaplain to come to the
station and support the wife.
(CPR) to a UAP class. Which statement best explains the
definition of sudden cardiac death?
l 1. Death that occurs after being removed from a
mechanical ventilator.
l 2. Cardiac death is the time that the physician declares
the heart has stopped.
l 3. Unexpected death occurring within 1 hour of onset
of cardiovascular symptoms.
l 4. The client is found unresponsive without a pulse or
respirations.
6. Which medication intervention is the most important
for the nurse to implement when functioning as the
medication nurse in a code?
l 1. Check the armband against the medication
administration record (MAR).
l 2. Administer the medications rapidly and then raise
the client’s arm.
l 3. Feel for a pulse to make sure the medications are
being delivered.
l 4. Document the amount of medication administered
and the route.
8. Which statement explains the scientific rationale for
administering epinephrine, a catecholamine, to a client
during a code?
l 1. It will prevent gastric distention resulting from
overventilation with the ambu-bag.
l 2. Epinephrine will treat any potential anaphylactic
reaction to the medications administered.
l 3. Epinephrine dries secretions and makes it easier for
the HCP to intubate the client.
l 4. It vasoconstricts the peripheral circulation and
shunts the blood to the central circulation.
ANSWERS
5. Correct answer 4: The chaplain should be called to
help address the concerns of the client’s family and/or
significant others. A small community hospital would
not have a 24-hour pastoral service but may have a
chaplain on call. The nurse and UAP must see that the
other clients on the unit are cared for. Hospital security is called when there is a danger to self or others,
and this is not the case. Content–Emergency; Category
of Health Alteration–Cardiovascular; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
6. Correct answer 2: The medication nurse administers
the medications and then raises the client’s arm to
help the medications reach the central circulation. The
MAR will not have the emergency medications, and
the nurse works from standard protocols and verbal
orders in a code. Another nurse will document the
medications in the record. This is an emergency.
Copyright © 2010 F.A. Davis Company
556
Content–Emergency; Category of Health Alteration–Drug
Administration; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Application.
7. Correct answer 3: This is the definition of sudden
cardiac death. Removal from a ventilator is not sudden.
Content–Emergency; Category of Health Alteration–
Cardiovascular; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Application.
8. Correct answer 4: Epinephrine is a potent vasoconstrictor that keeps the blood in the central circulation
of the heart, lungs, and brain. It is given in allergic reactions, but this client has no pulse or respirations and is
not having an allergic reaction. Content–Emergency;
Category of Health Alteration–Drug Administration; Integrated Process–Planning; Client Needs–Physiological
Integrity, Pharmacological and Parenteral Therapies;
Cognitive Level–Analysis.
Emergency Nursing
S E C T I O N T W E LV E
557
Shock
9. The charge nurse is responding to a code on a surgical
unit. Which personal protective equipment should the
nurse utilize?
l 1. The nurse should glove and gown before entering
the room.
l 2. The nurse should use a bag/mask to ventilate the
client.
l 3. The nurse may not need any personal protective
equipment.
l 4. The nurse should don a face shield and mask when
in a code.
10. The client in a code is now in ventricular bigimeny.
The HCP orders a lidocaine drip at 4 mg/min. The
lidocaine comes prepackaged 2 g of lidocaine in 500-mL
D5W. At what rate will the nurse set the infusion pump?
Answer: ____________________
11. The client who is 1 day postoperative abdominal
surgery has a blood pressure (BP) of 88/60 and an apical
pulse of 122; is diaphoretic; and has pale, cold, and
clammy skin. Which intervention would the nurse
implement first?
l 1. Increase the client’s intravenous fluid rate.
l 2. Administer an intravenous dopamine drip.
l 3. Obtain arterial blood gases (ABGs).
l 4. Assess the client’s abdominal dressing.
ANSWERS
9. Correct answer 3: The charge nurse is responsible
for ensuring that all the roles of the code team are
being performed. The charge nurse does not personally perform the roles. Content–Emergency; Category
of Heath Alteration–Cardiovascular; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
10. Correct answer 60 mL/hr: The test taker could
remember the pneumonic which is: 1 mg, 2 mg,
3 mg, 4 mg is 15 mL, 30 mL, 45 mL, 60 mL. If the
test taker has not memorized the sequence, it is too
late to figure it out in an emergency situation. The
math follows:
2 g × 1000 mg = 2000 mg per 500 mL
2000 mg ÷ 500 mL = 4 mg/mL
In algebraic terms:
4 mg : 1 mL = 4 mg : X mL
By cross multiplying: 4 mg = 4X
Copyright © 2010 F.A. Davis Company
558
Divide each side by 4 to arrive at X = 4/4 = 1
Then, to set the pump at an hour rate, multiply
4
/4 x 60 = 60
Content–Emergency; Category of Health Alteration–Drug
Administration; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Application.
11. Correct answer 1: The client is exhibiting symptoms
of hypovolemic shock; therefore, the nurse should
maintain the client’s circulatory volume by increasing
the fluid rate. Remember: do not assess when in distress. Assessing the abdominal dressing, obtaining the
ABGs, and administering dopamine are appropriate,
but the first intervention is to maintain fluid volume.
Content–Emergency; Category of Health Alteration–
Shock; Integrated Process–Implementation; Client Needs–
Physiological Integrity, Reduction of Risk Potential;
Cognitive Level–Synthesis.
S E C T I O N T W E LV E
Emergency Nursing
559
12. Which assessment data indicates the client diagnosed
14. Which data would the nurse expect to assess in a
with septic shock is responding to the medical regime?
l 1. Vital signs: T 100.4°F, P 104, R 26, and BP 102/60.
l 2. A white blood cell count of 18,000 mm3.
l 3. A urinary output of 200 mL in the last 4 hours.
l 4. Dry, mucous membranes and tented skin turgor.
client diagnosed with neurogenic shock?
l 1. The client has cool, clammy skin.
l 2. The client’s apical pulse is 56.
l 3. The client has bilateral wheezing.
l 4. The client urine will be diluted.
13. The client diagnosed with septicemia is admitted to
15. The nurse is preparing to administer dopamine, a beta
the emergency department. Which intervention should
the nurse implement first?
l 1. Insert an indwelling urinary catheter.
l 2. Administer the intravenous (IV) antibiotic therapy.
l 3. Obtain a stat basic metabolic profile (BMP).
l 4. Place the client in the Trendelenburg position.
and alpha agonist, to a client in cardiogenic shock. has an
output of intervention should the nurse implement?
l 1. Request the respiratory therapist to perform a
12-lead ECG.
l 2. Assess the client’s blood pressure (BP) every 2 hours.
l 3. Use an urimeter to evaluate the intake and output
every hour.
l 4. Cover the intravenous bag and tubing with foil.
ANSWERS
12. Correct answer 3: The client must have a urinary
output of at least 30 mL an hour; therefore, an output
of 200 mL in 4 hours indicates the client’s kidneys are
functioning normally, which, in turn, indicates the
client is responding to the medical regime. The vital
signs, white blood cell count, and dehydration
indicate the client is not responding to the medical
regime. Content–Emergency; Category of Health
Alteration–Shock; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Analysis.
13. Correct answer 2: The IV antibiotic is the priority
medication for the client with septicemia, a systemic
bacterial infection of the blood. Inserting an indwelling
catheter, obtaining a BMP, and placing the patient in
the Trendelenburg position are interventions used for
clients in hypovolemic shock, not septic shock.
Content–Emergency; Category of Health Alteration–
Shock; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
560
14. Correct answer 2: The client diagnosed with neurogenic shock will have bradycardia, instead of the
tachycardia seen in other forms of shock. The client’s
skin will be dry and warm, rather than the cool moist
skin seen in hypovolemic shock. Wheezing would be
associated with anaphylactic shock, and the client
would not have dilute urine. Content–Emergency;
Category of Health Alteration–Shock; Integrated
Process–Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
15. Correct answer 3: The urinary output should be
monitored via a urometer hourly to ensure the client
has an output of at least 30 mL/hr. Dopamine
is administered to increase the BP, so it should be assessed every 5–15 minutes, not every 2 hours. The
client should be on a cardiac monitor, not a one-time
12-lead ECG. The medication is not sensitive to light,
so the intravenous bag and tubing need not be covered with foil. Content–Emergency; Category of Health
Alteration–Shock; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Application.
S E C T I O N T W E LV E
Emergency Nursing
561
16. The client in hypovolemic shock is receiving dextran,
18. The client diagnosed with septic shock has an
a non-blood colloid. Which assessment data would
warrant immediate intervention by the nurse?
l 1. The client has a negative Chvostek sign.
l 2. The client’s pulse oximeter reading is 95%.
l 3. The client refuses to cough and deep-breathe.
l 4. The client has bilateral jugular vein distention (JVD).
elevated temperature, a BP of 110/70, and a high cardiac
output with systemic vasodilation. Which phase of septic
shock is the client experiencing?
l 1. Hypodynamic phase.
l 2. Compensatory phase.
l 3. Hyperdynamic phase.
l 4. Progressive phase.
17. The nurse caring for a client with sepsis writes the
client diagnosis of “alteration in comfort related to chills
and hyperpyrexia.” Which independent intervention
should be included in the plan of care?
l 1. Place a hyperthermia blanket on the client.
l 2. Assess the client’s vital signs every 2 hours.
l 3. Obtain blood sputum cultures.
l 4. Administer an antipyretic medication every
4 hours.
19. Which assessment data would indicate to the nurse
the client is experiencing hypovolemic shock?
l 1. The client’s BP is 80/40 and apical pulse 128.
l 2. The client’s cardiac output is 5 L/min.
l 3. The client’s central venous pressure (CVP) is 8 cm
H2O pressure.
l 4. The client is hypertensive and bradycardic.
ANSWERS
16. Correct answer 4: Because of the ability of all colloids
to pull fluid into the vascular space, circulatory overload is a serious adverse outcome; JVD is a sign of
circulatory overload. The Chvostek sign indicates
hypocalcemia; a pulse oximeter reading of greater than
93% is within normal limits (WNLs); and refusing to
cough and deep-breathe is a concern but does not warrant immediate intervention. Content–Emergency; Category of Health Alteration–Shock; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
17. Correct answer 2: The client has an elevated temperature; therefore, taking the client’s vital signs would be
an appropriate independent intervention. The client
would need a hypothermia blanket, not a hyperthermia
blanket, for a fever (hyperpyrexia). Administering medication and obtaining a blood culture are collaborative
interventions. Content–Emergency; Category of Health
Alteration–Shock; Integrated Process–Diagnosis; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
562
18. Correct answer 3: The hyperdynamic phase, the
first phase of septic shock, is characterized by high
cardiac output with systemic vasodilation. The BP
may remain within normal limits, but the heart rate
increases to tachycardia, and the client becomes
febrile. Content–Emergency; Category of Health
Alteration–Shock; Integrated Process–Diagnosis; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
19. Correct answer 1: The hallmark signs of hypovolemic shock are decreased blood pressure and
tachycardia. Normal cardiac output is 4–6 L/min,
and normal CVP pressure is 4–10 cm H2O pressure.
Content–Emergency; Category of Health Alteration–
Shock; Integrated Process–Assessment; Client Needs–
Physiological Integrity, Reduction of Risk Potential;
Cognitive Level–Analysis.
S E C T I O N T W E LV E
Emergency Nursing
563
20. The nurse and a female unlicensed assistive personnel
22. The school nurse has had five students in the last
(UAP) are caring for a group of clients on the medical
floor. Which action by the UAP would warrant immediate
intervention by the nurse?
l 1. The UAP places a urine specimen in a biohazard bag.
l 2. The UAP washes her hands with alcohol foam
hand cleanser.
l 3. The UAP puts soiled linen in a plastic bag in the
hallway.
l 4. The UAP uses a disposable stethoscope for a client
in the isolation room.
3 hours present to the school health clinic with complaints
of severe abdominal cramping, nausea, vomiting, and
diarrhea. Which intervention should the nurse implement
first?
l 1. Notify the public health department of the situation.
l 2. Administer an antiemetic medication to the students.
l 3. Determine if the students ate the same food in the
cafeteria.
l 4. Contact the parents or legal guardians of the
students.
Bioterrorism
23. The nurse is caring for three clients who have botulism.
21. The Homeland Security Office has issued a warning
of suspected biological warfare using the Franciscella
tularensis (tularemia) bacteria. Which signs and symptoms
would support the initial diagnosis of tularemia?
l 1. Fever, chills, headache, and malaise.
l 2. Vomiting, diarrhea, and fatigue.
l 3. The nurse smells the odor of bitter almonds.
l 4. Visual and gastrointestinal disturbances.
Which category of personal protective equipment (PPE)
should the nurse wear?
l 1. Level A
l 2. Level B
l 3. Level C
l 4. Level D
ANSWERS
20. Correct answer 3: Soiled linen should be put in a
564
22. Correct answer 3: These could be signs of botulism,
plastic bag in the client’s room, not in the hallway.
Specimens should be put in biohazard bags; the UAP
should wash her hands with alcohol foam hand
cleanser; and using a disposable stethoscope is an
appropriate intervention. Content–Management; Cate-
but the nurse should first assess to determine if all
the students ate the same food. The parents should
be notified, and the public health department may
need to be notified. The school nurse would not
have antiemetic medications in the nurse’s office.
gory of Health Alteration–Shock; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Synthesis.
Content–Emergency; Category of Health Alteration–
Bioterrorism; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment, Safety
and Infection Control; Cognitive Level–Synthesis.
21. Correct answer 1: Tularemia is extremely contagious
23. Correct answer 4: Standard precautions are used
and is contracted by exposure to infected animals or
an aerosolized or biological weapon. Symptoms are
a sudden onset of fever, fatigue, chills, headache,
lower backache, malaise, rigor, and coryza. Option 2
lists signs/symptoms of radiation exposure, option 3
of cyanide poisoning, and option 4 of malathion
exposure. Content–Emergency; Category of Health
when caring for clients with botulism; therefore,
the nurse should wear the work uniform, which
is Level D. Level A protection is worn for the
highest-level protection, Level B protection when a
lesser level of protection is needed, and Level C
protection requires an air-purified respirator
(APR). Content–Emergency; Category of Health
Alteration–Bioterrorism; Integrated Process–Assessment;
Client Needs–Safe Effective Care Environment, Safety
and Infection Control; Cognitive Level–Analysis.
Alteration–Bioterrorism; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment, Safety
and Infection Control; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
S E C T I O N T W E LV E
Emergency Nursing
565
24. The emergency department (ED) has been notified
26. The employee health nurse working in an industrial
of an explosion in a chemical manufacturing plant.
Which intervention should be implemented first as the
clients arrive at the ED?
l 1. Triage the explosion victims in the ambulances.
l 2. Find out if family members have been notified.
l 3. Prepare charts for the clients as they come into
the ED.
l 4. Remove the client’s clothes before entering the ED.
plant has been informed employees smell the odor of
bitter almonds. Which intervention should the nurse
implement?
l 1. Notify security to evacuate all employees.
l 2. Tell the employees to continue working.
l 3. Instruct employees to wear face shields.
l 4. Assess the employees for respiratory distress.
25. The Muslim client who was exposed to anthrax has
Which statement indicates one of the students needs
more teaching concerning the information presented?
l 1. “Anthrax, smallpox, and plagues are examples of
biological agents.”
l 2. “Chemical agents are more apparent and problems
occur more quickly than with biological agents.”
l 3. “Biological weapons are less of a threat than
chemical agents.”
l 4. “Biological agents can be released in one city and
affect cities thousands of miles away.”
died. Which statement indicates the family understands
the information discussed concerning anthrax exposure?
l 1. “We should cremate our loved one as soon as
possible.”
l 2. “We will take our loved one back to our homeland.”
l 3. “We need to be vaccinated against polio within
3 days.”
l 4. “We shall have an open casket ceremony for our
loved one.”
27. The nurse is teaching a class on biological warfare.
ANSWERS
24. Correct answer 4: Removing the clothing is the first
step. Depending on the type of exposure, this step
alone can remove a large portion of exposure. Triage
is usually the first step, but preventing potential
chemical exposure to staff and clients in the ED is
the first step (safety of the hospital); therefore, the
clients must be decontaminated. Content–Emergency;
Category of Health Alteration–Bioterrorism; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Safety and Infection Control;
Cognitive Level–Application.
25. Correct answer 1: Cremation is recommended
because the anthrax spores can survive for decades
and represent a threat to morticians and forensic
medicine personnel. There is no vaccination for
anthrax. Content–Emergency; Category of Health
Alteration–Bioterrorism; Integrated Process–Evaluation;
Client Needs–Safe Effective Care Environment, Safety
and Infection Control; Cognitive Level–Evaluation.
Copyright © 2010 F.A. Davis Company
566
26. Correct answer 1: The smell of bitter almonds is
associated with cyanide gas, a deadly poison. The
nurse should evacuate the area. Face shields will not
protect against cyanide poisoning. Cyanide poisoning includes respiratory muscle failure, but assessment will not save the employees’ lives. Content–
Emergency; Category of Health Alteration–Bioterrorism;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Safety and Infection
Control; Cognitive Level–Synthesis.
27. Correct answer 3: Because of the variety of biological agents (anthrax, smallpox, plague), the means of
transmission, and the lethality of agents, they are
more of a threat and more dangerous than chemical
agents. Chemical agents (nerve agents, cyanide, vesicant agents, pulmonary agents) are more apparent.
Content–Emergency; Category of Health Alteration–
Bioterrorism; Integrated Process–Evaluation; Client
Needs–Health Promotion and Maintenance; Cognitive
Level–Synthesis.
S E C T I O N T W E LV E
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567
28. The medical unit staff admitted seven clients who
30. Which intervention should the nurse implement for
were exposed to anthrax. Which type of precaution should
the infection control nurse implement on the unit?
l 1. Airborne precautions.
l 2. Standard precautions.
l 3. Contact precautions.
l 4. Droplet precautions.
clients who have been exposed to a liquid form of the
chemical nerve agent sarin?
l 1. Prepare to administer sodium nitrate intravenously.
l 2. Wash the skin with copious amounts of soap and
water.
l 3. Instruct the clients not to burst any blister formation.
l 4. Administer the antibiotic penicillin intravenously.
29. The emergency department (ED) has been notified
of an accident at a chlorine chemical plant and to expect
10–12 casualties. Which priority intervention should the
ED department implement?
l 1. Prepare to decontaminate the clients in a
decontamination room.
l 2. Discharge clients from the ED to make room for
victims.
l 3. Notify the respiratory therapy department of the
disaster.
l 4. Prepare to place clients on ventilatory support.
Disaster/Triage Nursing
31. According to the North Atlantic Treaty Organization
(NATO) triage system, which situation would be considered
priority 4, color black?
l 1. Injuries are extensive, and chances of survival are
unlikely.
l 2. Injuries are life-threatening but survivable with
minimal interventions.
l 3. Injuries are significant but can wait hours without
threat to life or limb.
l 4. Injuries are minor, and treatment can be delayed
hours to days.
ANSWERS
28. Correct answer 2: Standard precautions are all that
is necessary because the client is not contagious
and the disease cannot be spread from person to
person. Equipment should be cleaned using standard
hospital disinfectant. Content–Medical; Category of
Health Alteration–Bioterrorism; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Safety and Infection Control; Cognitive
Level–Application.
29. Correct answer 3: Chlorine is a gas that, when inhaled, separates the alveoli from the capillary bed.
The respiratory therapy department is responsible for
oxygen therapy and setting up/maintaining ventilators; therefore, this would be the priority intervention. Clearing out the ED should be done but not
before preparing for clients. Clients would not need
to be decontaminated. Content–Emergency; Category
of Health Alteration–Bioterrorism; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Safety and Infection Control; Cognitive
Level–Application.
Copyright © 2010 F.A. Davis Company
568
30. Correct answer 2: Liquid forms of nerve agents evaporate into colorless, odorless vapors that can be inhaled
or absorbed through the skin; therefore, washing the
skin with soap and water is an appropriate treatment.
Sodium nitrate is used to treat cyanide exposure.
Vesicants cause blistering. Oral penicillin is the treatment for anthrax exposure. Content–Emergency; Category of Health Alteration–Bioterrorism; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive Level–
Application.
31. Correct answer 1: A client tagged Priority 4, color
black, is considered expectant, which means the client
will probably die. Option 2 is color red, Priority 1;
option 3 is color yellow, Priority 2; option 3 is green,
Priority 3. Content–Emergency; Category of Health
Alteration–Disaster/Triage; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
S E C T I O N T W E LV E
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569
32. Which situation would warrant the charge nurse in
34. The nurse in a disaster is triaging clients. Which
a long-term care facility to obtain information from a
material safety data sheet (MSDS)?
l 1. The nurse was accidently stuck with a used insulin
syringe.
l 2. The custodian spilled bleach water on the floor of
the lobby.
l 3. The family member brought the resident’s dog into
the building.
l 4. The resident had a mercury thermometer that broke
in the bathroom.
client should be triaged as a Minimal category, Priority 3,
and color green?
l 1. The client with a sucking chest wound who is alert.
l 2. The client with a head injury who is unresponsive.
l 3. The client with an abdominal wound and stable
vital signs.
l 4. The client with a sprained ankle that may be
fractured.
33. The triage nurse is working in the emergency
department. Which client should be assessed first?
l 1. The 10-year-old child who has a compound fracture
of the right arm.
l 2. The 17-year-old adolescent who has a pencil sticking
out of his eye.
l 3. The 38-year-old female who accidently spilled hot
grease on her leg.
l 4. The 55-year-old man with hypertension who has
an occipital headache.
35. The triage nurse has coded a client as priority 2,
color yellow. Which action would warrant immediate
intervention by the nurse?
l 1. The American Red Cross (ARC) volunteer
documents the tag number in the disaster log.
l 2. The licensed practical nurse (LPN) documents the
client’s vital signs on the tag.
l 3. The HCP removes the tag to examine the client’s
injured right leg.
l 4. The UAP attaches the tag to the client’s foot.
ANSWERS
32. Correct answer 4: The MSDS provides chemical
information regarding specific agents, health information, and spill information for a variety of chemicals.
Mercury thermometers have been removed from
health-care facilities because of the risk of inhaling
the mercury. Content–Emergency; Category of Health
Alteration–Disaster/Triage; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
33. Correct answer 2: This nurse should see this client
first because the pencil needs to be stabilized in the
eye, the operating room needs to be notified, and
more than likely the eye will be enucleated. The
compound fracture, the burned leg, and an occipital
headache are not potentially life-threatening.
Content–Emergency; Category of Health Alteration–
Disaster/Triage; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
570
34. Correct answer 4: Minimal Category, Priority 3,
and color green are clients who could wait for days
until treated. An ankle, even if it is fractured, could
wait. Remember the traffic light—red needs to be
seen immediately, yellow should be seen within a
few hours, and green a few days. Black has a very
low survival rate. Content–Emergency; Category of
Health Alteration–Disaster/Triage; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
35. Correct answer 3: The tag should never be removed
until the client is admitted, and the tag becomes a
part of the client’s record. The HCP needs to be
informed immediately of the action. The ARC
volunteer, the LPN, and UAP actions would not
warrant intervention. Content–Emergency; Category
of Health Alteration–Disaster/Triage; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
S E C T I O N T W E LV E
Emergency Nursing
571
36. Which situation would require the emergency
38. The nurse is triaging phone calls in an outpatient
department manager to schedule and conduct a Critical
Incident Stress Management (CISM) session?
l 1. A policeman received a gunshot wound to the
abdomen in the line of duty.
l 2. A 4-year-old who had an accidental poisoning and
was admitted to the ICU.
l 3. A 22-year-old client who died after taking an
overdose of sleeping pills.
l 4. A school bus accident that resulted in 14 hospital
admissions and 11 deaths.
clinic. Which client should the nurse inform to come to
the emergency clinic today?
l 1. The client who reports burning and pain upon
urination.
l 2. The client who calls complaining of severe
chest pain.
l 3. The client who has had a stuffy nose and cough for
2 days.
l 4. The client who needs a physical examination for
football.
37. The nurse in a disaster is triaging clients. Which client
39. Which activity is most important for the hospital staff
would be triaged as an Expectant Category, Priority 4, and
color black?
l 1. The client who has a hard, distended abdomen.
l 2. The client who is exhibiting decerebrate posturing.
l 3. The client who has a possible L1–L2 spinal cord
injury.
l 4. The client who has paresthesia in the left lower leg.
when planning disaster preparedness and implementing
the hospital’s emergency operations plan (EOP)?
l 1. Evaluate how other hospitals implement disaster
drills.
l 2. Discuss the disaster plan with small groups of
employees.
l 3. Instruct all staff to read the EOP disaster procedure.
l 4. Have community and hospital practice disaster
drills.
ANSWERS
36. Correct answer 4: CISM is an approach to preventing and treating the emotional trauma that can affect
emergency responders as a consequence of their job;
a major accident is a traumatic experience. The ED
staff often care for gunshot wounds, survivors in
accidental poisonings, and clients who overdose.
Content–Emergency; Category of Health Alteration–
Disaster/Triage; Integrated Process–Planning; Client
Needs–Psychosocial Integrity; Cognitive Level–Synthesis.
37. Correct answer 2: The client who is decerebrate
posturing has severe increased intracranial pressure
secondary to a head injury and has a very poor
prognosis; even with treatment, survival is unlikely.
A hard distended abdomen, a possible spinal cord
injury, and paresthesia in the lower leg are injuries
that could be treated. Content–Emergency; Category of
Health Alteration–Disaster/Triage; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
572
38. Correct answer 1: The client needs to come to the
clinic for a midstream urinalysis because the problem
sounds like a urinary tract infection and the client
will need antibiotics. The client with chest pain
should call 911 immediately; the client with a possible cold does not need to be seen today; and a physical examination does not need to be performed today.
Content–Emergency; Category of Health Alteration–
Disaster/Triage; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Analysis.
39. Correct answer 4: The most important activity is
to implement practice drills, which allow for troubleshooting any issues before a real incident occurs.
Reading the procedure, discussing the procedure,
and evaluating other facilities are not as important as
having a practice drill. Content–Emergency; Category
of Health Alteration–Disaster/Triage; Integrated
Process–Planning; Client Needs–Safe Effective Care
Environment, Safety and Infection Control; Cognitive
Level–Synthesis.
S E C T I O N T W E LV E
Emergency Nursing
573
40. The emergency department (ED) has received a
42. The client has ingested a corrosive solution containing
phone call reporting an implosion of a building with
multiple injuries. Which action should the charge nurse
implement first?
l 1. Contact the local blood bank to report the
incident.
l 2. Call nurses off-duty to come into work.
l 3. Notify the house supervisor of the incident.
l 4. Instruct staff to check the supplies in the ED.
lye. Which intervention should the nurse implement first?
l 1. Monitor the client’s neurological status.
l 2. Insert a nasogastric (NG) tube in the client’s nares.
l 3. Assess for the client’s ability to breathe.
l 4. Administer milk to dilute the corrosive solution.
Poisoning
41. Which statement is the primary goal of the emergency department (ED) nurse in caring for a client who
has ingested a poison?
l 1. To stop the action of the poison and maintain
organ functioning.
l 2. To determine why the client ingested the poisonous
substance.
l 3. To document the interventions taken to treat the
client’s condition.
l 4. To implement treatment that increases the
elimination of the poison.
ANSWERS
40. Correct answer 3: The house supervisor should be
notified so that staff can be mobilized, client census
evaluated, and plans made for multiple admissions to
the ED. The blood bank may need to be notified,
off-duty nurses may need to be called in, and supplies should be checked, but the first intervention is
to notify the house supervisor. Content–Emergency;
Category of Health Alteration–Disaster/Triage; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
41. Correct answer 1: The primary goal is to inactivate
the poison before it is absorbed and causes permanent
organ damage or death. The nurse should attempt to
determine why the client ingested the poison, but this
is not priority. Documentation is vital, but the nurse
must first take care of the client. Eliminating the poison is not always priority; neutralizing the poison is
sometimes priority. Content–Emergency; Category of
Copyright © 2010 F.A. Davis Company
574
Health Alteration–Poisoning; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
42. Correct answer 3: Airway edema or obstruction can
occur as a result of the burning action of corrosive
substances. Neurological assessment is important but
not priority over airway. Inserting an NG tube and
administering milk are appropriate interventions, but
they are not prior to airway management. Content–
Emergency; Category of Health Alteration–Poisoning;
Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
S E C T I O N T W E LV E
Emergency Nursing
575
43. The nurse hiking on a trail is providing first aid to a
45. Which statement indicates the client understands the
victim of a poisonous snakebite on the right lower leg.
Which action should the nurse implement first?
l 1. Remove the client’s right shoe.
l 2. Instruct the client to lie very still.
l 3. Immobilize the client’s right leg.
l 4. Keep the client warm as possible.
teaching concerning carbon monoxide poisoning?
l 1. “I should install smoke detectors in my home.”
l 2. “Carbon monoxide will make you sick but it is not
lethal.”
l 3. “You can smell carbon monoxide, so it easy to detect.”
l 4. “I should have my furnace checked for leaks before
turning it on.”
44. A gastric lavage has been ordered for a comatose
client who ingested a full bottle of sleeping pills in an
attempt to commit suicide. Which interventions should
the nurse implement? Select all that apply.
l 1. Place the client supine with the head of the bed flat.
l 2. Insert a large-bore gastric tube into the client’s
mouth.
l 3. Make sure there is standby suction at the bedside.
l 4. Withdraw all stomach contents and then instill
irritating solution.
l 5. Use gloves to dispose all stomach contents into the
commode.
46. The client overdosed by taking too much narcotic
cough syrup. The nurse administers naloxone (Narcan).
Which priority intervention should the nurse implement?
l 1. Assess for signs of respiratory depression.
l 2. Monitor the client’s pulse oximeter reading.
l 3. Place a tracheostomy tray at the client’s bedside.
l 4. Determine if the overdose was accidental.
ANSWERS
43. Correct answer 2: The client should lie down and
remove all restrictive items. Then, the wound should
be cleaned and covered with a sterile dressing. The affected body part should be immobilized, and the client
should be kept warm. Content–Emergency; Category
of Health Alteration–Poisoning; Integrated Process–
Implementation; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.
44. Correct answer 2, 3, 4: A large-bore tube is used
with a comatose client; suction is to prevent aspiration;
and removing stomach contents before the lavage
helps to prevent overdistention of the stomach. The
client should be placed on the left side to allow the
gastric contents to pool in the stomach, decreasing
passage of fluid into the duodenum during lavage.
Samples are sent to the lab to be analyzed for chemical
compounds. Content–Emergency; Category of Health
Alteration–Poisoning; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
576
45. Correct answer 4: One of the major causes of accidental carbon monoxide poisoning is faulty furnaces; the
client understands the teaching. A smoke detector will
not detect carbon monoxide; the client should install
a carbon monoxide detector. Carbon monoxide is
colorless and odorless, and it can be lethal. Content–
Emergency; Category of Health Alteration–Poisoning;
Integrated Process–Evaluation; Client Needs–Health
Promotion and Maintenance; Cognitive Level–Evaluation.
46. Correct answer 1: Narcan has a short half-life and
may wear off before the effects of the cough syrup
wear off; this could result in the return of respiratory
depression. Monitoring oximeter readings is not priority over the client. An intubation tray may be needed
if the client does not respond to Narcan, and determining the cause of overdose is not priority. Content–
Emergency; Category of Health Alteration–Drug
Administration; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Application.
S E C T I O N T W E LV E
Emergency Nursing
577
47. The toddler was brought to the emergency room
49. The health-care provider has prescribed edetate
after taking her mother’s prenatal vitamins. Which
interventions should the nurse implement? Select all
that apply.
l 1. Determine if the prenatal vitamins had iron.
l 2. Administer activated charcoal to the toddler.
l 3. Assess the toddler’s vital signs frequently.
l 4. Notify child protective services of the situation.
l 5. Ask the parents if they have the vitamin bottle.
calcium disodium (calcium EDTA), a chelating agent, for
a client diagnosed with lead poisoning. Which laboratory
data would warrant immediate intervention?
l 1. The client’s ALT/GPT is 30 IU/mL.
l 2. The client’s calcium level is 9.5 mg/dL.
l 3. The client’s blood urea nitrogen (BUN) is 15 mg/dL.
l 4. The client’s creatinine level is 2.4 mg/dL.
48. A 23-year-old male was brought to the emergency
sedative hyponotic, and is admitted to the intensive care
unit (ICU). Which priority intervention should the ICU
nurse implement?
l 1. Refer the client to a psychiatric nurse practitioner.
l 2. Allow the client to ventilate her feelings.
l 3. Administer 1.5 L of Go-Lytely, a whole bowel
irrigation.
l 4. Ensure the client turns, coughs, and deep-breathes
every 2 hours.
department after trying to kill himself by drinking motor
oil. Which HCP order should the nurse question?
l 1. Initiate intravenous fluids with a 20-gauge
angiocatheter.
l 2. Insert an indwelling urinary catheter with a
urometer.
l 3. Place a nasogastric tube and perform gastric lavage.
l 4. Monitor the client’s cardiac status on telemetry.
50. The female client took an overdose of Ambien CR, a
ANSWERS
47. Correct answer 1, 3, 5: Iron can destroy a toddler’s
liver; vital signs must be assessed; and by looking at
the vitamin bottle the nurse can see how many
vitamins were in the bottle when it was purchased
and if the vitamins have iron. Activated charcoal is
administered for poisons, and at this time there is no
evidence to support that the parents are negligent or
unfit to care for their child. Content–Emergency;
Category of Health Alteration–Poisoning; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Reduction for Risk Potential; Cognitive
Level–Application.
48. Correct answer 3: Gastric lavage should not be
attempted with ingestion of caustic agents such as
high-viscosity petroleum products. Intravenous
fluids, monitoring intake and output, and monitoring
the cardiac status are appropriate interventions.
Content–Emergency; Category of Health Alteration–
Poisoning; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
578
49. Correct answer 4: The creatinine level indicates renal
failure, and adequate renal function is required before
administering the drug as both the drug and the lead
will be excreted through glomerular filtration. The
client’s liver, calcium, and BUN levels are all within
normal limits. Content–Emergency; Category of Health
Alteration–Poisoning; Integrated Process–Assessment;
Client Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Synthesis.
50. Correct answer 3: Whole bowel irrigation is effective following ingestion of sustained-released medication, such as Ambien CR, lead, lithium, and iron.
Therapeutic communication, referrals, and preventing complications of immobility are all appropriate
interventions, but the most important intervention is
to rid the body of the sustained-release medication.
Content–Emergency; Category of Health Alteration–
Poisoning; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
S E C T I O N T W E LV E
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579
Management
51. A potential chemical spill has occurred on the
53. The charge nurse is making assignments in the
medical floor. Which intervention should the charge
nurse implement first?
l 1. Instruct the staff to evacuate the immediate area.
l 2. Contain the area where the chemical spill occurred.
l 3. Notify the hazard management team.
l 4. Contact the hospital shift supervisor.
medical department and has one RN, one recent graduate
nurse, two licensed practical nurses (LPN), and an
unlicensed assistive personnel (UAP). Which client
should be assigned to the graduate nurse who has just
completed orientation?
l 1. The client diagnosed with a snakebite who is
receiving antivenin.
l 2. The client who swallowed poison and is on a
one-to-one suicide watch.
l 3. The client who was exposed to the powder form of
anthrax.
l 4. The elderly client with septicemia who is receiving
IV antibiotic therapy.
52. The nurse and unlicensed assistive personnel (UAP)
are caring for clients in the ED. Which task would be
most appropriate to delegate to the UAP?
l 1. Tell the UAP to take the vital signs of a client with
a gunshot wound to the chest.
l 2. Instruct the UAP to flush the eyes of a client who
splashed bleach in the eyes.
l 3. Ask the UAP to use the Rule of Nines to determine
the percentage body surface burned.
l 4. Request the UAP complete the discharge teaching
for the client diagnosed with scabies.
ANSWERS
51. Correct answer 2: The first intervention is to contain
the spill area and make sure no clients, staff, or visitors come near the area. The nurse should then notify
the shift supervisor (following chain of command)
and then the hazardous materials team. Evacuation is
done only if that team instructs that it be done.
Content–Management; Category of Health Alteration–
Management; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
52. Correct answer 2: The UAP could flush the eyes
continuously with normal saline because this take a
long time, and the nurse will not have to be tied up
with the client for an extended period. A client with
a gunshot wound would require assessment; the
Rule of Nines is assessment; and the UAP cannot
teach. Content–Management; Category of Health
Alteration–Management; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
580
53. Correct answer 4: The newly graduated nurse has
the knowledge to care for a client receiving antibiotic
therapy. Antivenin administration requires specific
assessment, infusion rates, and has many complications, and anthrax is a biological agent; therefore, a
more experienced nurse should care for these clients.
The UAP could sit with a client on a one-to-one
suicide watch. Content–Medical; Category of Health
Alteration–Management; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
S E C T I O N T W E LV E
Emergency Nursing
581
54. The emergency department (ED) nurse is caring for
56. The charge nurse is making client assignments in the
a client with a head injury secondary to a motorcycle
accident who in response to painful stimuli assumes
decerebrate posturing. Which data would indicate the
client’s condition is improving?
l 1. The client has purposeful movement when the
nurse rubs the sternum.
l 2. The client extends the upper and lower extremities
in response to painful stimuli.
l 3. The client is flaccid when the nurse applies painful
pressure to the sternum.
l 4. The client has a Glasgow Coma Scale Rating of
4 on a 1–15 scale.
critical care unit. Which client should be assigned to the
most experienced nurse?
l 1. The client with diabetic ketoacidosis (DKA) with
arterial blood gases (ABGs) of pH 7.29, PaO2 98,
PaCO2 30, HCO3 15.
l 2. The client with chronic obstructive pulmonary
disease (COPD) with ABGs of pH 7.35, PaO2 78,
PaCO2 54, and HCO3 20.
l 3. The client with a myocardial infarction (MI) with
ABGs of pH 7.4, PaO2 91, PaCO2 43, and
HCO3 25.
l 4. The client with a pulmonary embolism (PE) with
ABGs of pH 7.35, PaO2 88, PaCO2 44.
55. The nurse is preparing to administer morphine sulfate
2 mg intravenous push (IVP) to a client complaining of
chest pain who has a saline lock in the left forearm. Which
interventions should the nurse implement? Rank in order.
l 1. Administer the medication over 5 minutes.
l 2. Sign out the medication from the narcotics cabinet.
l 3. Flush the saline lock with 2 mL of normal saline.
l 4. Ask the client about allergies to medications.
l 5. Draw up the medication in 10 mL syringe.
ANSWERS
54. Correct answer 1: Purposeful movement following
painful stimuli would indicate an improvement in the
client’s condition. Extending the upper and lower
extremities is assuming a decerebrate posture. Flaccidity
and a Glasgow Coma Scale of 4 indicate a worsening
of the client’s condition. Content–Management;
Category of Health Alteration–Neurological; Integrated
Process–Assessment; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Analysis.
55. Correct answer in order 2, 5, 4, 3, 1: The nurse
should first sign out the appropriate medication from
the narcotics cabinet. Morphine should be administered over 5 minutes, so diluting the medication to
10 mL will allow for a controlled administration
time. Then, the nurse should make sure the client is
not allergic to morphine. After that, the nurse should
flush the saline lock and administer the medication
over 5 minutes. Content–Management; Category of
Health Alteration–Drug Administration; Integrated
Copyright © 2010 F.A. Davis Company
582
Process–Implementation; Client Needs–Physiological
Integrity, Pharmacological and Parenteral Therapies;
Cognitive Level–Application.
56. Correct answer 1: This client’s ABGs reflect that
the DKA has not resolved, and the most experienced nurse should care for the most unstable
client. The client with COPD has good ABGs for
the diagnosis, and the other ABGs are normal.
Content–Management; Category of Health Alteration–
Endocrine; Integrated Process–Planning; Client Needs–
Safe Effective Care Environment, Management of
Care; Cognitive Level–Synthesis.
S E C T I O N T W E LV E
Emergency Nursing
583
57. The client has an advance directive for health care.
59. The nurse and an unlicensed assistive personnel
Which situation would require the nurse to consult the
surrogate decision maker?
l 1. The client with a head injury who has Glasgow
Coma Scale of 13.
l 2. The client with COPD who is having difficulty
being weaned from the ventilator.
l 3. The client in a hyperglycemic hyperosmolar
nonketotic coma.
l 4. The client in a hyperbaric chamber for nonhealing
wounds on the legs.
(UAP) are working in an ED. Which nursing task should
the nurse delegate to the UAP?
l 1. Instruct the UAP to take the client with a fractured
arm to the car.
l 2. Ask the UAP to escort the battered woman to the
restroom.
l 3. Tell the UAP to give the medication prescription to
the client.
l 4. Discuss having the UAP relay discharge
instructions to a client.
58. The nurse is triaging clients in the emergency
60. The charge nurse of an emergency department (ED)
department (ED). Which client can wait to be seen by
the ED staff?
l 1. The 57-year-old client complaining of right-sided
chest pain and diaphoresis.
l 2. The 13-year-old client with a headache and a purple
spotted rash.
l 3. The 78-year-old client who became disoriented and
has slurred speech.
l 4. The 35-year-old client who has a possible fracture
of the right tibia.
must send one nurse to the intensive care unit (ICU) for
the shift. Which nurse should be assigned to the ICU for
the day?
l 1. The RN who is orienting to the emergency
department from a medical unit.
l 2. The RN who frequently functions as charge nurse
of the emergency department.
l 3. The RN who has floated between the ED and ICU.
l 4. The RN who is interested in training for the ICU.
ANSWERS
57. Correct answer 3: The client in a coma cannot
make decisions. A Glasgow Coma Scale of 13
indicates a cognizant functioning individual. A client
on the ventilator can relate wishes to the nurse, and
a client in a hyperbaric chamber can make decisions.
Content–Management; Category of Health Alteration–
Neurological; Integrated Process–Planning; Client Needs–
Safe Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
58. Correct answer 4: A fracture, although painful, is not
life-threatening. Chest pain, right- or left-sided, must
be assessed to make sure it is not cardiac pain. A client
with a headache and purple spotted rash is exhibiting
symptoms of meningitis, and if antibiotics are not initiated immediately, the meningitis could be deadly.
Disorientation and slurred speech are symptoms of a
cerebrovascular accident (CVA), or stroke. Content–
Emergency; Category of Health Alteration–Disaster/
Triage; Integrated Process–Assessment; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
584
59. Correct answer 1: The UAP can take a client to a car
for discharge after the nurse provides instructions. The
nurse should escort the battered woman to the restroom so that assessment of the client’s situation can
be achieved when the client is alone. The nurse should
give the prescriptions to the client and answer questions about the medications. Content–Management;
Category of Health Alteration–Management; Integrated
Process–Planning; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Synthesis.
60. Correct answer 3: This RN will provide the most help
to the ICU for the shift. The RN in orientation should
stay and continue orientation. The relief charge nurse
is the strength of the ED, and the nurse who would
like to cross-train should be given a chance to orient to
the unit first before being assigned to take a client load
in the ICU. Content–Management; Category of Health
Alteration–Management; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
SECTION THIRTEEN
Immune Inflammatory Disorders
585
SECTION THIRTEEN
Immune Inflammatory Disorders
Acquired Immune Deficiency
Syndrome
1. The nurse is admitting a client diagnosed with protein
calorie malnutrition secondary to acquired immune
deficiency syndrome (AIDS). Which intervention should
the nurse implement?
l 1. Assess the client's body weight, and ask what the
client has been able to eat.
l 2. Place in contact isolation, and don a mask and
gown before entering the room.
l 3. Have the client collect a clean voided urine
specimen for culture.
l 4. Teach the client about the importance of
consuming adequate calories.
2. The nurse assesses white patchy lesions covering the
hard and soft palates and on the right inner cheek in a
male client diagnosed with AIDS. Which intervention
should the nurse implement?
l 1. Provide a soft-bristle toothbrush for the client to use.
l 2. Obtain an order for an antifungal swish-and-swallow
medication.
l
l
587
3. Teach the client to gargle with an antiseptic
mouthwash several times a day.
4. Ask the client if he has been eating a lot of yogurt
recently.
3. The nurse is describing the human immunodeficiency
virus (HIV) infection to a female client who has been
told that she is HIV-positive. Which information
regarding the virus is important to teach?
l 1. The HIV virus is a retrovirus, which means it may
go dormant but remain in the body.
l 2. HIV is a virus that, with the correct treatment, can
be eradicated from the host body.
l 3. It is difficult for the HIV virus to replicate in
humans because it is a monkey virus.
l 4. The HIV virus uses the client's own red blood cells
to reproduce itself.
ANSWERS
1. Correct answer 1: The client has a malnutrition
syndrome. The nurse should assess the body and what
the client has been able to eat. Standard precautions
are used for clients diagnosed with AIDS, the same as
for every other client. A urinary tract infection would
not cause malnutrition. The client does not need
teaching; there is a physiological reason for the
malnutrition. Content–Medical; Category of Health
Alteration–Infectious Diseases; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
2. Correct answer 2: This is most likely a fungal
infection known as oral candidiasis, commonly called
thrush. An antifungal medication is needed to treat
this condition. Brushing the teeth and patchy areas
will not remove the lesions and will cause considerable
pain. Antiseptic-based mouthwashes usually contain
Copyright © 2010 F.A. Davis Company
588
alcohol, which would be painful for the client. Yogurt
did not cause this condition. Content–Medical; Category of Health Alteration–Infectious Diseases; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
3. Correct answer 1: Retroviruses never completely
leave the body. They may become dormant, only to be
reactivated at a later time. “Eradicated” means to be
completely cured or done away with; the HIV cannot
be completely eradicated. HIV originated in the
green monkey where it is not life-threatening. HIV
in humans replicates readily using the CD4 cells
as reservoirs. Content–Medical; Category of Health
Alteration–Infectious Diseases; Integrated Process–
Planning; Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Synthesis.
SECTION THIRTEEN
Immune Inflammatory Disorders
4. The male client who engaged in needle-sharing drug
l
3. Follow up with the employee health nurse to have
abuse activities has developed a flu-like infection. Which
intervention should the nurse implement?
l 1. Teach the client he did not contract HIV from an
infected needle this time.
l 2. Report the client to the public health department
for a diagnosis of AIDS.
l 3. Encourage the client to have an HIV antibody
test performed in a few weeks.
l 4. Have the family admit the client to a drug
rehabilitation center.
encephalopathy. Which client problem is priority?
l 1. Altered role performance.
l 2. Anticipatory grieving.
l 3. Knowledge deficit, procedures, and prognosis.
l 4. Risk for injury.
5. The female nurse caring for a client who is known to
7. The client diagnosed with Pneumocystis carnii
be HIV-positive accidentally stuck herself with the stylet
used to start an intravenous line. Which action should
the nurse take first?
l 1. Notify the charge nurse, and fill out an incident
report.
l 2. Go to the employee health nurse to start on
prophylactic medication.
l
589
lab work drawn.
4. Flush the skin with water, and try to get the area to
bleed.
6. The client on a medical floor is diagnosed with HIV
pneumonia (PCP) is being admitted to the intensive
care unit. Which health-care provider (HCP) order
should the nurse question?
l 1. Have the client sign a permit for a bronchoscopy.
l 2. Oxygen therapy via nasal cannula at 5–6 L/min.
l 3. Administer trimethoprim sulfa, a sulfa antibiotic,
via intravenous piggyback (IVPB).
l 4. Place the client in respiratory isolation.
ANSWERS
4. Correct answer 3: The primary phase of HIV infection ranges from being totally asymptomatic to severe
flu-like symptoms, but during this time the client may
test negative even though infected with HIV. The
nurse should encourage the client to be tested in a few
weeks, by which time antibodies have formed against
the virus and can be detected. The nurse cannot
know if the client has or has not developed an HIV
infection. The adult client must self-admit to a rehabilitation center. Content–Medical; Category of Health
Alteration–Infectious Diseases; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Analysis.
5. Correct answer 4: The nurse should immediately attempt to get the area to bleed and to remove contaminated blood from the body before the HIV infects the
nurse. Flushing the area attempts to accomplish this.
Then, the nurse should notify the charge nurse, start
prophylactic medication, and follow up to have lab
work done. Content–Medical; Category of Health
Copyright © 2010 F.A. Davis Company
590
Alteration–Infectious Diseases; Integrated Process–
Implementation; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
6. Correct answer 4: Safety is always an issue with
a client with diminished mental capacity. After physiological needs, safety is highest on Maslow's Hierarchy
of Needs. Content–Medical; Category of Health
Alteration–Infectious Diseases; Integrated Process–
Diagnosis; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
7. Correct answer 4: The client diagnosed with PCP
should be placed on standard precautions. PCP is a
common fungus that is found in the lungs of most
adults. The infection is only a problem with a client
who is immunocompromised, such as one who is
HIV-positive. The other options are expected
orders. Content–Medical; Category of Health Alteration–
Infectious Diseases; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.
SECTION THIRTEEN
Immune Inflammatory Disorders
591
8. The hospice nurse is caring for a client diagnosed with
10. The nurse is caring for a female client diagnosed
AIDS. Which intervention should the nurse implement?
l 1. Perform a thorough head-to-toe assessment.
l 2. Encourage the client to drink nutritional
supplements.
l 3. Talk with the client about the funeral arrangements.
l 4. Request physical therapy to assist with strength
training.
with AIDS who has not told her significant other that she
is HIV-positive. Which interventions should the nurse
implement?
l 1. Tell the significant other to be tested for HIV
antibodies.
l 2. Notify the HCP to make the client tell her
significant other.
l 3. Call a meeting of the ethics committee to discuss
the situation.
l 4. Encourage the client to tell the significant other of
the infection.
9. Which client diagnosed with AIDS should the nurse
on a medical unit assess first after end-of-shift report?
l 1. The client who has flushed warm skin with tented
turgor.
l 2. The client who states that the staff ignores the call
light.
l 3. The client who has T 99.9ºF, P 101, R 26, and
BP 110/68.
l 4. The client who is unable to provide a sputum
specimen.
ANSWERS
8. Correct answer 3: The client on hospice should
prepare for death. The client should have an advance
directive in place and discuss funeral plans. Physical
assessment is not a priority at this time. Strength
training and nutrition are physiological needs which
are priority for a client expected to recover. A client on
hospice is encouraged to do and eat whatever he/she
desires. Content–Medical; Category of Health Alteration–
Infectious Diseases; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Application.
9. Correct answer 1: Flushed warm skin with tented turgor indicates dehydration. The HCP should be notified
immediately so fluid orders or other orders to correct
the reason for the dehydration can be given. Clients
diagnosed with AIDS frequently have massive diarrhea,
which can cause dehydration, to the point where it
can be life-threatening. Content–Medical; Category of
Health Alteration–Infectious Diseases; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
592
10. Correct answer 4: The nurse should appeal to the
client to tell the significant other. The HCP, the
nurse, and ethics committee are all bound by Health
Insurance Portability and Accountability Act
(HIPAA) regulations and cannot force the client to
disclose her HIV status. Content–Medical; Category
of Health Alteration–Infectious Diseases; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive
Level–Application.
SECTION THIRTEEN
Immune Inflammatory Disorders
593
Rheumatoid Arthritis
11. Which primary nursing intervention should the
13. The nurse is caring for the female client diagnosed
nurse implement with the client diagnosed with
rheumatoid arthritis (RA)?
l 1. Perform joint x-rays to determine progression of
the disease.
l 2. Recommend the client knit as a recreational
activity.
l 3. Encourage the client to obtain flu and pneumonia
vaccines.
l 4. Assess the client's pain medication protocol.
with RA who is prescribed methotrexate, a diseasemodifying antirheumatic drug (DMARD). Which
statement indicates the client needs more medication
teaching?
l 1. “I need to use an electric razor when I shave my legs.”
l 2. “I should get a wig to wear when my hair falls out.”
l 3. “I will rinse my mouth with water after every meal.”
l 4. “I must use sunscreen with an SPF 30 or above.”
12. Which assessment data would the nurse expect in
swan-neck fingers. Which intervention should the nurse
implement?
l 1. Instruct the client to soak the hands in cool water.
l 2. Refer the client to the occupational therapist.
l 3. Encourage the client to keep hands elevated.
l 4. Tell the client to wear arm braces daily.
the client diagnosed with RA?
l 1. The client has symmetrical joint stiffness.
l 2. The client has bilateral ascending paralysis.
l 3. The client has reddened inflamed joints.
l 4. The client has a flat facial affect.
14. The client diagnosed with RA has developed
ANSWERS
11. Correct answer 3: A primary nursing intervention is
prevention. RA is a disease with many immunological
abnormalities, and there is an increased susceptibility
to infectious disease such as the flu or pneumonia.
Administering vaccines is prevention. Radiological
procedures, activity, and assessment are not preventive interventions. Content–Medical; Category of
Health Alteration–Immune/Inflammatory Disorders;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Reduction of Risk Potential;
Cognitive Level–Analysis.
12. Correct answer 1: Clients diagnosed with RA have
bilateral and symmetrical stiffness, edema, tenderness, and temperature changes in the joints. Other
symptoms include sensory changes, lymph-node
enlargement, weight loss, fatigue, and pain. A 1-kg
weight loss and fatigue are expected. Content–Medical;
Category of Health Alteration–Immune/Inflammatory
Disorders; Integrated Process–Assessment; Client Needs–
Safe Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
594
13. Correct answer 2: Methotrexate does not cause
hair loss; the client needs more medication teaching.
Methotrexate can cause abnormal bleeding, mouth
ulcers, and photosensitivity. The client's other statements indicate that she understands the medication
teaching. Content–Medical; Category of Health
Alteration–Immune/Inflammatory Disorders; Integrated
Process–Evaluation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Evaluation.
14. Correct answer 2: Swan-neck fingers will cause the
client to have difficulty with activities of daily living
(ADLs). The occupational therapist assists the client
with fine-motor skills and ADLs. Warm water may
help the pain, but keeping the hands elevated and
bracing will not help the client with RA. Content–
Medical; Category of Health Alteration–Immune/
Inflammatory Disorders; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
SECTION THIRTEEN
Immune Inflammatory Disorders
595
15. The client with RA is taking phenylbutazone
17. The female client with RA has been taking
(Butazolidin), a pyrazoline nonsteroidal anti-inflammatory
drug (NSAID). Which statement would make the nurse
question administering this medication?
l 1. “I think I may have gotten the flu. I don't
feel well.”
l 2. “My hands have been very painful the last
day or so.”
l 3. “I am having burning and pain when I urinate.”
l 4. “I have been having trouble sleeping at night.”
methotrexate, a DMARD. Which laboratory would
warrant intervention by the nurse?
l 1. A platelet count of 250,000 mm3.
l 2. A red blood cell (RBC) count of 3.2 million/mm3.
l 3. A white blood cell (WBC) count of 7000 mm3.
l 4. A sedimentation rate of 13 mm/hr.
16. The home health nurse is caring for a client diagnosed
with RA. Which question would be most appropriate to
ask the client?
l 1. “Are you walking at least 30 minutes a day?”
l 2. “Did you enjoy going to the coast last week?”
l 3. “Have you had any choking episodes when eating?”
l 4. “Are you having any trouble sleeping at night?”
ANSWERS
15. Correct answer 1: The most dangerous adverse
reaction to this classification of medication is blood
dyscrasias, which may be manifested by flu-like
symptoms. NSAIDs are administered for pain.
Urinary tract infections and insomnia are not side
effects; therefore, the nurse would not question
administering the medication. Content–Medical;
Category of Health Alteration–Immune/Inflammatory
Disorders; Integrated Process–Evaluation; Client
Needs–Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Evaluation.
16. Correct answer 4: Sleep deprivation due to pain is
common; therefore, this would be an appropriate
question. Strenuous exercise would place increased
pressure on the joints and increase pain. RA does not
put the client at risk for choking. The client receiving home health must be homebound, so a question
about a vacation is not an appropriate question.
Content–Medical; Category of Health Alteration–
Immune/Inflammatory Disorders; Integrated
Copyright © 2010 F.A. Davis Company
596
Process–Assessment; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
17. Correct answer 2: This RBC count indicates anemia,
which would warrant intervention by the nurse
(4.6–6 million/mm3 is normal). Normal platelet
count is 150,000–400,000; the WBC count is
within normal limits of 4500–10,000/mm3, and
the sedimentation rate for a woman is 0–15 mm/hr.
Content–Medical; Category of Health Alteration–
Immune/Inflammatory Disorders; Integrated Process–
Assessment; Client Needs–Physiological Integrity,
Reduction of Risk Potential; Cognitive Level–Analysis.
SECTION THIRTEEN
Immune Inflammatory Disorders
597
18. The nurse is caring for a client diagnosed with RA.
20. The 31-year-old female client diagnosed with advanced
Which outcome would be priority for the client?
l 1. Maintain full function of the extremities.
l 2. Participate in low-impact aerobic exercises.
l 3. Report pain as a 2 or less on a 1–10 pain scale.
l 4. Eat three nutritionally balanced meals a day.
unremitting RA is being admitted to receive a regimen of
immunosuppressive medications. Which question should
the nurse ask during the admission process regarding the
medications?
l 1. “Is there any possibility you may be pregnant?”
l 2. “Have you had anything to eat in the last 8 hours?”
l 3. “When is the last time you had a bowel
movement?”
l 4. “Are you aware these are investigational drugs?”
19. The client recently diagnosed with RA is prescribed
4 g of aspirin daily. Which statement indicates the client
understands the medication teaching?
l 1. “Ringing in my ears is expected when I take this
much aspirin.”
l 2. “I should take my aspirin with meals, food, or milk.”
l 3. “I need to take the entire aspirin dose at night
before going to bed.”
l 4. “Uncoated aspirin works better than enteric-coated
aspirin.”
ANSWERS
18. Correct answer 3: The client has chronic pain,
which alters the quality of life, often leading to
depression and feelings of hopelessness; therefore,
pain less than 2 would be priority. Full function is
an unrealistic expectation for a progressively degenerative disease. Low–impact exercises and balanced
meals would be appropriate outcomes but not priority over control of pain. Content–Medical; Category
of Health Alteration–Immune/Inflammatory Disorders;
Integrated Process–Planning; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive
Level–Synthesis.
19. Correct answer 2: Gastrointestinal side effects
are common with aspirin therapy; therefore, the
client should take aspirin with food. Tinnitus is not
expected, and the client should reduce the dose by
two to three tablets per day until the tinnitus disappears. The aspirin should be taken in divided doses.
Enteric-coated and uncoated are equally effective.
Copyright © 2010 F.A. Davis Company
598
Content–Medical; Category of Health Alteration–
Immune/Inflammatory Disorders; Integrated Process–
Evaluation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Evaluation.
20. Correct answer 1: Many immunosuppressive drugs
are class C drugs (teratogenic) and should not be
taken while pregnant. The client does not have to be
nothing by mouth (NPO); bowel movements do not
affect the medication; and the drugs to be administered are not investigational drugs. Content–Medical;
Category of Health Alteration–Immune/Inflammatory
Disorders; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Analysis.
SECTION THIRTEEN
Immune Inflammatory Disorders
599
Systemic Lupus Erythematosus
21. The 24-year-old female client is being seen in the
23. The nurse is discussing SLE with a 25-year-old
clinic to rule out (R/O) systemic lupus erythematosus
(SLE). Which assessment data would indicate to the
nurse the client has SLE?
l 1. A low-grade fever, arthralgia, and a facial rash.
l 2. A bronze suntan from a recent trip to Mexico.
l 3. Weakness that starts in her toes and moves upward.
l 4. Difficulty swallowing and her voice gives out.
newly diagnosed client. Which is the most important
client goal for this disease?
l 1. Should be able to maintain reproductive ability.
l 2. Able to verbalize feelings of body image changes.
l 3. Body organs will remain functioning.
l 4. Skin will not have any breakdown.
22. The client diagnosed with SLE is being discharged
rule-out SLE. Which assessment data warrant immediate
intervention by the nurse?
l 1. Pericardial friction rub and crackles in the lungs.
l 2. A butterfly rash across the bridge of the nose.
l 3. Complaints of joint stiffness in the morning.
l 4. Fatigue and weight loss of 2 pounds.
from the medical unit. Which discharge instructions
should the nurse teach the client? Select all that apply.
l 1. Use a sunscreen of SPF of 15 or greater when in
the sunlight.
l 2. Notify the HCP immediately if a low-grade fever
develops.
l 3. Some dyspnea is expected and does not need
immediate attention.
l 4. The hands and feet may change color if exposed to
cold or heat.
l 5. Notify the HCP if the urine has a pink or red color.
24. The nurse is admitting a client diagnosed with
ANSWERS
21. Correct answer 1: Low-grade fever, arthralgia, facial
rash, and fatigue are symptoms of SLE. No single
laboratory test diagnoses SLE, but the client usually
presents with moderate-to-severe anemia, thrombocytopenia, leukopenia, and a positive antinuclear
antibody. Sunlight exacerbates symptoms. Option 3 is
Guillain-Barré syndrome, and option 4 is myasthenia
gravis. Content–Medical; Category of Health Alteration–
Immune/Inflammatory Disorders; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Analysis.
22. Correct answer 2, 5: A fever may be the first indication
of an exacerbation of SLE, so even low-grade temperatures are reported to the HCP. Red or pink urine may
indicate renal involvement. An SPF of at least 30 should
be used. Dyspnea may indicate lung involvement and
should be reported to the HCP. Option 4 is Raynaud
phenomenon. Content–Medical; Category of Health
Alteration–Immune/Inflammatory Disorders; Integrated
Process–Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
600
23. Correct answer 3: SLE can invade and destroy any
body system or organ, so maintaining organ function
is the primary goal of SLE treatment. Reproduction,
body image, and skin breakdown are not priority
when organ destruction is a possibility. Content–
Medical; Category of Health Alteration–Immune/
Inflammatory Disorders; Integrated Process–Planning;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Synthesis.
24. Correct answer 1: SLE can affect any organ. It can
cause pericarditis and myocardial ischemia as well as
pneumonia or pleural effusions. The nurse should
notify the HCP if friction rub and crackles in the
lungs are heard. A butterfly rash, joint stiffness, and
fatigue with weight loss are expected symptoms of
SLE. Content–Medical; Category of Health Alteration–
Immune/Inflammatory Disorders; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
SECTION THIRTEEN
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601
25. The female client diagnosed with an acute exacerbation
27. The nurse and unlicensed assistive personnel (UAP)
of SLE is placed on high-dose steroids. Which information
should the nurse teach the client regarding her therapy?
l 1. Take the steroid medications on an empty stomach.
l 2. Stop the medications if she notices a weight gain of
2–3 pounds.
l 3. Taper off the medications when they are discontinued.
l 4. Notify the HCP if she notices her face becoming
round.
are caring for a client with cutaneous lupus erythematosus.
Which intervention should the nurse delegate to the UAP?
l 1. Cleanse the facial skin using an astringent lotion.
l 2. Inspect the skin for any signs of breakdown or rash.
l 3. Assist with the bath and thoroughly pat the skin dry.
l 4. Apply anti-itch medication between the toes.
26. The nurse on a medical unit enters the room of a
female client diagnosed with SLE to find the client
crying. Which is the nurse's most therapeutic response?
l 1. “You're crying. Would you like to talk about your
feelings?”
l 2. “I can see you are upset. I will be back in a while to
check on you.”
l 3. “Would you like me to call someone for you to talk
to about your disease?”
l 4. “Tears and stress will make your disease worse.
Do you need a tranquilizer?”
28. The nurse is caring for clients on a medical floor.
Which client should be assessed first?
l 1. The female client diagnosed with SLE who is
complaining about chest pain.
l 2. The male client diagnosed with multiple sclerosis
(MS) who is complaining about muscle spasms.
l 3. The female client diagnosed with myasthenia gravis
(MG) who has dysphagia.
l 4. The male client diagnosed with Guillain-Barré
syndrome (GBS) who can barely move his toes.
ANSWERS
25. Correct answer 3: Steroids must be tapered to prevent
adrenal insufficiency, a potentially life-threatening
complication of steroid medications. Steroids are
administered with food to prevent gastric upset.
Weight gain and a moon face are expected side effects
of steroids. Content–Medical; Category of Health
Alteration–Drug Administration; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
26. Correct answer 1: This is a therapeutic response
that encourages the client to verbalize her feelings.
Putting the client off, calling someone else, and
tranquilizers are not therapeutic. Content–Medical;
Category of Health Alteration–Immune/Inflammatory
Disorders; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Application.
602
27. Correct answer 3: This action can be performed by
the UAP. Moisturizing lotions are applied, not astringents. “Inspection” is another word for assessment,
and the nurse cannot delegate assessment. Lotions are
not applied between the toes because this would foster
the development of a fungal infection between the
toes. Content–Medical; Category of Health Alteration–
Immune/Inflammatory Disorders; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
28. Correct answer 1: Chest pain is always a priority
regardless of the admitting diagnosis. Clients diagnosed
with SLE can develop cardiac complications. Muscle
spasms are a priority but not above chest pain.
Dysphagia is expected in clients diagnosed with MG.
Clients diagnosed with GBS have ascending muscle
weakness or paralysis. This client's problem is still very
low. Content–Medical; Category of Health Alteration–
Immune/Inflammatory Disorders; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
SECTION THIRTEEN
Immune Inflammatory Disorders
29. The nurse and a female UAP are caring for a group
of clients on a medical floor. Which action by the UAP
warrants immediate intervention by the nurse?
l 1. The UAP does not wash her hands after taking the
vital signs of a client.
l 2. The UAP dons unsterile gloves prior to removing
an indwelling catheter from a client.
l 3. The UAP uses an isolation set-up to take vital signs
of a client diagnosed with methicillin-resistant
Staphylococcus aureus (MRSA).
l 4. The UAP uses a fresh plastic bag to get ice for a
client's water pitcher.
30. The client recently diagnosed with SLE asks the
nurse “What is SLE, and how did I get it?” Which is the
nurse's best response?
l 1. “SLE is thought to occur because the kidneys do
not filter antibodies from the blood.”
l 2. “SLE occurs after a viral or fungal illness as a result
of damage to the endocrine system.”
l
l
603
3. “I wish I could give you a reason but there is no
identifiable reason for developing SLE.”
4. “SLE is an autoimmune disease that may have a
genetic or hormonal component.”
Multiple Sclerosis
31. The nurse is caring for a 46-year-old client diagnosed
with multiple sclerosis (MS). Which clinical manifestation
warrants immediate intervention?
l 1. The client has a congested cough and dysphagia.
l 2. The client has scanning speech and diplopia.
l 3. The client has dysarthria and scotomas.
l 4. The client has muscle weakness and spasticity.
ANSWERS
29. Correct answer 1: The UAP should wash her hands
before and after each client contact. Using unsterile
gloves to remove a catheter, using isolation set-ups,
and using a fresh plastic bag to get ice should
be praised. Content–Medical; Category of Health
Alteration–Immune/Inflammatory Disorders; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Synthesis.
30. Correct answer 4: There is familial and hormonal
evidence for the development of SLE. SLE is an
autoimmune disease process in which there is an
exaggerated production of auto-antibodies. Content–
Medical; Category of Health Alteration–Immune/
Inflammatory Disorders; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
604
31. Correct answer 1: Dysphagia is a common problem
of clients diagnosed with MS, and this places the
client at risk for aspiration pneumonia. Some clients
diagnosed with MS eventually become immobile
and are at risk for pneumonia. The other options
contain expected symptoms of MS. Content–Medical;
Category of Health Alteration–Immune/Inflammatory
Disorders; Integrated Process–Assessment; Client Needs–
Physiological Integrity, Reduction of Risk Potential;
Cognitive Level–Synthesis.
SECTION THIRTEEN
Immune Inflammatory Disorders
32. The clinic nurse is assessing a female client with
complaints of numbness, tingling, and double vision.
During the interview the client tells the nurse that these
symptoms come and go and no one seems to be able to
tell her what they mean. Which question would be
important for the nurse to ask the client?
l 1. “Have you experienced any pain during sexual
intercourse?”
l 2. “Are your symptoms associated with your monthly
menstrual cycle?”
l 3. “Do you get tired easily and sometimes have
problems swallowing?”
l 4. “What type of birth control pills do you take to
prevent conception?”
33. The client diagnosed with MS is crying and tells the
nurse, "Why me? I did not do anything to deserve this!”
Which is the nurse's most therapeutic response?
l 1. “Why are you crying? The medications will help
the disease.”
l 2. “This must be difficult for you. Would you like to
talk about your feelings?”
l
l
605
3. “Multiple sclerosis is a disease that has good times
and bad times.”
4. “I will have the chaplain come and stay with you
for a while.”
34. The client diagnosed with multiple sclerosis is
scheduled for an outpatient magnetic resonance imaging
(MRI) scan of the head. Which question should the nurse
ask the client?
l 1. “Do lights that flash off and on cause you to have a
seizure?”
l 2. “Do you have difficulty when you are in small
enclosed spaces?”
l 3. “Do you get sick when drinking contrast dye for
x-ray procedures?”
l 4. “Can you have someone drive you home after the
procedure is over?”
ANSWERS
32. Correct answer 3: The symptoms the client described
are symptoms of MS. Fatigue and difficulty swallowing are other symptoms of MS. Menses, sexual
intercourse, and birth control pills do not cause the
symptoms described. Content–Medical; Category of
Health Alteration–Immune/Inflammatory Disorders;
Integrated Process–Assessment; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive Level–
Analysis.
33. Correct answer 2: This is stating a fact and offering
self. Both are therapeutic techniques for conversations.
Asking “why” is requesting an explanation, and the
client does not owe the nurse an explanation. The
client did not ask about the nature of MS. Therapeutic responses are aimed at allowing the client to
verbalize feelings. Content–Medical; Category of
Health Alteration–Immune/Inflammatory Disorders;
Integrated Process–Implementation; Client Needs–
Psychosocial Integrity; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
606
34. Correct answer 2: Most MRIs are performed by
placing a client in a small tube in which the client
must lie very still while the machine performs the
procedure. If the client is claustrophobic, then the
nurse should arrange for the client to have an open
MRI or be sedated during the procedure. Content–
Medical; Category of Health Alteration–Immune/
Inflammatory Disorders; Integrated Process–Assessment;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Analysis.
SECTION THIRTEEN
Immune Inflammatory Disorders
607
35. The 45-year-old client is diagnosed with primary
37. The nurse and a licensed practical nurse (LPN) are
progressive MS, and the nurse writes the nursing
diagnosis of “anticipatory grieving related to progressive
loss.” Which intervention should be implemented?
l 1. Consult the physical therapist for assistive devices
for mobility.
l 2. Ask the dietitian to provide thickening on each tray.
l 3. Teach the client self-catheterization and bowel
management.
l 4. Discuss the client's wishes regarding end-of-life care.
caring for a group of clients on a medical oncology unit.
Which client activity should not be delegated/assigned?
l 1. Administer an oral skeletal muscle relaxant to a
client with an exacerbation of MS.
l 2. Discuss bowel regimen medications with the HCP
for the client diagnosed with MS.
l 3. Draw the morning blood work on the client with
secondary progressive MS.
l 4. Administer cylcophosphamide (Cytoxan), an
immunosuppressant, IVPB to a client with MS.
36. The home health nurse is making rounds on clients
diagnosed with MS. Which client should be seen first?
l 1. The 38-year-old male client who cannot perform
the gastrostomy feedings.
l 2. The 22-year-old female client who is deciding if
she should remain in college.
l 3. The 40-year-old male client who called to tell the
nurse that life is not worth living.
l 4. The 50-year-old female client who needs a
subcutaneous flu injection this morning.
ANSWERS
35. Correct answer 4: The problem is grieving, and all
608
37. Correct answer 4: Cytoxan is an immunosuppressant
interventions should be directed at helping the client
with this process. The client should make personal
choices about end-of-life issues while it is possible to
do so. This client is progressing toward immobility,
loss of independence, and death. Content–Medical;
and an antineoplastic medication. A chemotherapycompetent registered nurse must administer this
medication. The LPN can administer a muscle relaxant. The LPN can talk with a HCP about medications, and LPNs can draw blood. Content–Medical;
Category of Health Alteration–Immune/Inflammatory
Disorders; Integrated Process–Implementation; Client
Needs–Psychosocial Integrity; Cognitive Level–Analysis.
Category of Health Alteration–Immune/Inflammatory
Disorders; Integrated Process–Planning; Client Needs–
Safe Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
36. Correct answer 3: The nurse should see this client
first to determine if the client has a plan to carry out
the threat of suicide. This situation requires further
assessment. A missed feeding is not life-threatening.
Making life decisions and a flu injection can wait.
Content–Medical; Category of Health Alteration–
Immune/Inflammatory Disorders; Integrated
Process–Assessment; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Analysis.
Copyright © 2010 F.A. Davis Company
SECTION THIRTEEN
Immune Inflammatory Disorders
38. The male client diagnosed with MS discloses to the
nurse that he has been investigating alternate therapies to
treat his disease. What is an appropriate response by the
nurse?
l 1. Encourage the therapy if not contraindicated by
the medical regimen.
l 2. Tell the client that only the HCP should discuss
this with him.
l 3. Ask how his significant other feels about this
deviation from the medical regimen.
l 4. Suggest that the client try an investigational
therapy instead.
39. The nurse and UAP are caring for a client diagnosed
with an acute exacerbation of MS who is receiving
Solu-Medrol, a glucocorticosteroid, intravenous push
(IVP) every 6 hours. Which nursing intervention should
the nurse delegate to the UAP?
l 1. Show the client how to trim his toenails straight
across.
l 2. Discuss completing an advance directive with the
client.
l
l
609
3. Obtain bedside glucose readings before meals.
4. Give the client pancreatic enzymes to add to the
meals.
40. The nurse is administering methylprednisolone
(Solu-Medrol) IVP to a client diagnosed with MS. The
medication comes in an individual dose vial of 125 mg in
2 mL of solution. The order reads “administer 60 mg
every 6 hours.” How many milliliters of solution should
the nurse administer with each dose?
Answer: ____________________
ANSWERS
38. Correct answer 1: The nurse should listen without
being judgmental about any practice. Then the client
will feel free to discuss what alternative therapy is
actually being used by the client. Alternative therapies such as massage and relaxation are frequently
beneficial and enhance the medical regimen.
Content–Medical; Category of Health Alteration–
Immune/Inflammatory Disorders; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Application.
39. Correct answer 3: Steroids interfere with glucose
metabolism by blocking the action of insulin. The
UAP can perform bedside glucose monitoring. The
nurse interprets the meaning of the results. The UAP
cannot teach (option 1) or administer medications
(option 4). The nurse, not the UAP, should discuss
advance directives with clients. Content–Medical;
Category of Health Alteration–Immune/Inflammatory
Disorders; Integrated Process–Planning; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
610
40. Correct answer 0.96 mL: The nurse should set up
the equation:
60 : X = 125 : 2
Then cross-multiply: 60 × 2 = 120 = 125X
120 = 125X
Divide each side of the equation by 125 to arrive at
the answer:
X = 0.96 mL
Content–Medical; Category of Health Alteration–Drug
Administration; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level–Application.
SECTION THIRTEEN
Immune Inflammatory Disorders
611
Guillain-Barré Syndrome
41. The nurse and an LPN on a medical unit are caring
43. The nurse is caring for a client who is complaining
for a client diagnosed with Guillain-Barré syndrome
(GBS). Which instructions should the nurse provide
the LPN?
l 1. Instruct the LPN to call the nurse for assistance
when getting the client out of bed.
l 2. Have the LPN assess the client for cogwheel
motion, rigidity, and dysphagia.
l 3. Discuss the symptom of sudden severe unilateral
facial pain with the LPN.
l 4. Tell the LPN to notify the nurse if the client
becomes short of breath.
of weakness and tingling of the feet bilaterally. Which
assessment intervention should the nurse implement first?
l 1. Assess deep tendon reflexes.
l 2. Complete a Glasgow Coma Scale.
l 3. Check for Brudzinski reflex.
l 4. Take the client's vital signs.
42. The nurse is admitting a client diagnosed with
Guillain-Barré syndrome (GBS). Which question should
the nurse ask the client?
l 1. “Did you recently go on a trip to Asia or Africa?”
l 2. “Have you had a viral illness in the last few weeks?”
l 3. “Could you have been exposed to GBS where
you work?”
l 4. “Do you take over-the-counter herbs or vitamins?”
ANSWERS
41. Correct answer 4: Symptoms of GBS are ascending
paralysis and weakness. Dyspnea may indicate the
disease has progressed to the thoracic area, requiring
a transfer to the intensive care unit (ICU) and intubation. The LPN should ask the unlicensed assistive
personnel (UAP) for assistance when getting the
client out of bed. LPNs do not assess; these are
symptoms of Parkinson disease. Unilateral facial
pain is a symptom of trigeminal neuralgia. Content–
Medical; Category of Health Alteration–Immune/
Inflammatory Disorders; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
42. Correct answer 2: This syndrome is usually preceded by a respiratory or gastrointestinal infection
1–4 weeks prior to the onset of neurological deficits.
Visiting a foreign country is not a risk factor for
contracting this syndrome. This syndrome is not a
contagious or a communicable disease. Taking herbs
Copyright © 2010 F.A. Davis Company
612
is not a risk factor for developing GBS. Content–
Medical; Category of Health Alteration–Immune/
Inflammatory Disorders; Integrated Process–Assessment;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Analysis.
43. Correct answer 1: Hyporeflexia of the lower extremities is the classic clinical manifestation of GuillainBarré syndrome; therefore, assessing deep tendon
reflexes is appropriate. A Glasgow Coma Scale is
used for clients with a head injury or central neurological dysfunction. The Brudzinski reflex evaluates
for meningitis. The client's vital signs will not give
the nurse information related to these symptoms.
Content–Medical; Category of Health Alteration–
Immune/Inflammatory Disorders; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Synthesis.
SECTION THIRTEEN
Immune Inflammatory Disorders
613
44. The HCP scheduled a lumbar puncture for a client
46. The married male client diagnosed with Guillain-Barré
admitted with rule-out Guillain-Barré syndrome (GBS).
Which post-procedure intervention is priority?
l 1. Start the client on clear liquids.
l 2. Instruct the client to void.
l 3. Keep the client flat in bed.
l 4. Assess the client's brachial pulses.
syndrome (GBS) is on a ventilator. Which intervention
should the nurse implement?
l 1. Provide an erasable slate board for the client to
write on.
l 2. Arrange a case conference with members of other
health-care disciplines.
l 3. Tell the client's wife that the client will not be able
to understand she is there.
l 4. Have the wife talk with the social worker regarding
role reversal problems.
45. The ICU nurse is caring for the client diagnosed
with Guillain-Barré syndrome (GBS) whose paralysis has
reached the level of cranial nerve II. The nurse writes
the client problem “impaired physical mobility.” Which
interventions should the nurse implement?
l 1. Turn the client every 4 hours, and place the call
light within reach.
l 2. Perform passive range-of-motion (ROM) exercises,
and refer the client to physical therapy.
l 3. Refer the client for speech therapy consult and
teach about salt-restricted diets.
l 4. Encourage the client to verbalize feelings of
helplessness.
ANSWERS
44. Correct answer 3: The client should remain flat in
bed to prevent a possible spinal fluid leak resulting in
a headache. The client can resume a regular diet. The
client should void prior to the procedure. The pedal
pulses should be assessed post procedure, not the
brachial pulses. Content–Surgical; Category of Health
Alteration–Immune/Inflammatory Disorders; Integrated
Process–Planning; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Synthesis.
45. Correct answer 2: The client with GBS on a
ventilator will not be able to move the extremities,
and preventing muscle atrophy is important.
Passive ROM exercises and physical therapy would
accomplish this. The client should be turned every
2 hours or placed on a rotating bed. The client
will be on a ventilator and cannot speak with this
level of impairment. Salt is not restricted for
these clients. Content–Medical; Category of Health
Copyright © 2010 F.A. Davis Company
614
Alteration–Immune/Inflammatory Disorders; Integrated
Process–Implementation; Client Needs–Physiological
Integrity, Basic Care and Comfort; Cognitive Level–
Analysis.
46. Correct answer 2: GBS is a treatable disease that
requires care from many disciplines. The nurse
coordinates the care. The ascending paralysis has
reached his respiratory muscles; therefore, the client
will not be able to use his hands to write. The client
may not be able to respond to people in the room
but is fully aware of their presence. The nurse can
discuss role reversal problems with the spouse.
Content–Medical; Category of Health Alteration–
Immune/Inflammatory Disorders; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
SECTION THIRTEEN
Immune Inflammatory Disorders
615
47. The client diagnosed with Guillain-Barré syndrome
49. The client diagnosed with Guillain-Barré syndrome
(GBS) asks the nurse, “When will I be able to return to
work? I have responsibilities.” Which statement would be
the best response by the nurse?
l 1. “You may not be able to return to work for a few
months to a year.”
l 2. “Most clients with this syndrome go back to
normal activities in 2 weeks.”
l 3. “That is something you should discuss with the
health-care team.”
l 4. “The rehabilitation is short and you should be fully
recovered within a month.”
(GBS) has arterial blood gases (ABGs) of pH 7.32,
PaCO2 51 mm Hg, HCO3 27 mm Hg, and PaO2
50 mm Hg. Which intervention should the nurse
implement?
l 1. Prepare to place the client on the ventilator.
l 2. Have the client cough and deep-breathe.
l 3. Confirm the results with a pulse oximeter.
l 4. Perform pulmonary toileting procedures.
48. The client admitted with rule-out Guillain-Barré
syndrome (GBS) has just had a lumbar puncture. Which
intervention should the nurse implement post procedure?
l 1. Take the client's vital signs every 15 minutes.
l 2. Apply a pressure dressing to the puncture site.
l 3. Label the specimens and send to the laboratory.
l 4. Place the client on fluid restriction.
ANSWERS
47. Correct answer 1: Clients with GBS usually have a
full recovery, but it may take up to 1 year to recover
from the effects of the syndrome. The nurse should
answer the client's question. Content–Medical;
Category of Health Alteration–Immune/Inflammatory
Disorders; Integrated Process–Implementation; Client
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Application.
48. Correct answer 3: The nurse should label the specimens and send them to the laboratory for analysis.
Very little cerebrospinal fluid is removed; therefore,
postoperative vital signs are not required. A Band-Aid
is placed over the puncture site, and pressure does not
need to be applied. Increased fluid intake will help
prevent a post-procedure headache. Content–Medical;
Category of Health Alteration–Immune/Inflammatory
Disorders; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management of
Care; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
616
49. Correct answer 1: This client is in respiratory failure
because of the inability of the nerves to stimulate
breathing. The client must be intubated and placed
on a ventilator immediately. Coughing and deep
breathing will not help the client who cannot
initiate respirations. Arterial oxygen levels are
accurate, so confirmation with a pulse oximeter is
not necessary. Content–Medical; Category of Health
Alteration–Immune/Inflammatory Disorders; Integrated
Process–Implementation; Client Needs–Safe Effective
Care Environment, Management of Care; Cognitive
Level–Application.
SECTION THIRTEEN
Immune Inflammatory Disorders
617
50. The client diagnosed with Guillain-Barré syndrome
52. Which response to the Tensilon (edrophonium
(GBS) is admitted to the rehabilitation unit after several
weeks in the acute care hospital. Which interventions
should the nurse implement? Select all that apply.
l 1. Refer the client to the speech therapist.
l 2. Encourage the client to perform active ROM
exercises.
l 3. Request a social worker consult.
l 4. Provide the client with a patient-controlled
analgesia (PCA) pump.
l 5. Refer the client to the Guillain-Barré Syndrome
Foundation.
chloride) injection indicates the client has myasthenia
gravis?
l 1. The client has no apparent change in the
assessment data.
l 2. There is reduced amplitude of electrical stimulation
in the muscle.
l 3. The anti–acetylcholine receptor antibodies are
present.
l 4. The client shows a marked improvement of muscle
strength.
Myasthenia Gravis
MG. Which statement by the client indicates an
understanding of the discharge instructions?
l 1. “I can control the MG with medication, but an
adenectomy will cure it.”
l 2. “I should take a holiday from my medications
every 4 or 5 weeks.”
l 3. “I must take my medications on time every day, or
I could have problems.”
l 4. “I should take my steroid medications with food so
it won't upset my stomach.”
51. Which statement by the client supports the diagnosis
of myasthenia gravis (MG)?
l 1. “I have weakness and fatigue in my feet and legs.”
l 2. “My eyelids droop, and I see double everything.”
l 3. “I get chest pain and faint after I walk in the hall.”
l 4. “I gained 3 pounds this week, and I am spitting up
pink frothy sputum.”
53. The nurse is discharging a client diagnosed with
ANSWERS
50. Correct answer 2, 3, 5: The client will need physical
exercises to regain muscle strength. The social worker
could help with financial concerns, job issues, and
issues concerning the long rehabilitation associated
with this syndrome. The GBS Foundation is an
excellent resource for the client and the family. There
is no residual speech deficit. Pain may or may not be
an issue, but in the rehabilitation setting the route of
administration of pain-relieving medication would be
oral or topical, not via a PCA pump. Content–Medical;
Category of Health Alteration–Immune/Inflammatory
Disorders; Integrated Process–Implementation; Client
Needs–Safe Effective Care Environment, Management of
Care; Cognitive Level–Analysis.
51. Correct answer 2: These are ocular signs/symptoms
of MG. Ptosis is drooping of the eyelid, and diplopia
is unilateral or bilateral double vision. Weakness and
fatigue of upper body muscle occur with MG. Option
3 is angina. Option 4 is heart failure. Content–Medical;
Category of Health Alteration–Immune/Inflammatory
Disorders; Integrated Process–Evaluation; Client
Copyright © 2010 F.A. Davis Company
618
Needs–Physiological Integrity, Physiological Adaptation;
Cognitive Level–Evaluation.
52. Correct answer 4: Clients with myasthenia gravis
show a significant improvement of muscle strength
that lasts approximately 5 minutes when Tensilon
(edrophonium chloride) is injected. Content–Medical;
Category of Health Alteration–Drug Administration;
Integrated Process–Assessment; Client Needs–Physiological
Integrity, Pharmacological and Parenteral Therapies;
Cognitive Level–Analysis.
53. Correct answer 3: The anticholinesterase medications
used to treat MG must be taken on time in order to
prevent muscle weakness and respiratory complications. These medications are one of the very few that
the nurse should administer at the exact scheduled
time. Steroids are not prescribed for MG. Content–
Medical; Category of Health Alteration–Immune/
Inflammatory Disorders; Integrated Process–Evaluation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Evaluation.
SECTION THIRTEEN
Immune Inflammatory Disorders
619
54. The client diagnosed with MG is being discharged
56. The male client with MG is undergoing plasmapheresis
home. Which intervention should the nurse teach the
significant other?
l 1. Discuss how to perform the Heimlich maneuver.
l 2. Explain how to perform oral hygiene on a
conscious client.
l 3. Teach how to perform isometric exercises.
l 4. Demonstrate correct hand placement for chest
compressions.
at the bedside. Which assessment data would warrant
immediate intervention by the nurse?
l 1. The client complains of being lightheaded and
dizzy.
l 2. The client can smile and clamp his teeth together.
l 3. The client states that his leg cramps have gone away.
l 4. The client has a small hematoma at the vascular
access site.
55. Which referral is appropriate for the client in the late
stages of myasthenia gravis?
l 1. The infection control nurse.
l 2. The occupational health nurse.
l 3. A vocational guidance counselor.
l 4. The speech therapist.
ANSWERS
54. Correct answer 1: The client is at risk for choking,
and knowing specific measures to help the client
helps decrease the client's as well as significant
other's anxiety and promotes confidence in managing potential complications. The client should
perform oral care. The client should perform isotonic exercises, not isometric exercises, and the
client is not at an increased risk for cardiac complications, so teaching about chest compression is not
necessary. Content–Medical; Category of Health
Alteration–Immune/Inflammatory Disorders;
Integrated Process–Assessment; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
55. Correct answer 4: Speech therapists address swallowing problems, and clients with myasthenia gravis
are dysphagic and at risk for aspiration. The infection control and occupational health nurses do not
consult with the client. A vocational counselor helps
with the client finding a position suited for the
disability, but clients with late-stage myasthenia
Copyright © 2010 F.A. Davis Company
620
gravis are usually not able to work. Content–Medical;
Category of Health Alteration–Immune/Inflammatory
Disorders; Integrated Process–Planning; Client Needs–
Physiological Integrity, Physiological Adaptation;
Cognitive Level–Synthesis.
56. Correct answer 1: Hypovolemia is a complication
of plasmapheresis, especially during the procedure
when up to 15% of the blood volume is in the cell
separator. The nurse should immediately assess for
shock. All other options are expected. Content–Medical;
Category of Health Alteration–Immune/Inflammatory
Disorders; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
SECTION THIRTEEN
Immune Inflammatory Disorders
57. Which statement by the 20-year-old female client
diagnosed with MG indicates the client understands the
discharge teaching?
l 1. “I can have children, but I will have to see my
neurologist during my pregnancy.”
l 2. “I have a new job at a children's day care center to
help with expenses.”
l 3. “I should not take a bath because I could pass out
and drown while in the tub.”
l 4. “I will drink at least 1000 mL of water or other
liquid every day.”
58. The client diagnosed with MG is admitted to the
emergency department with a sudden exacerbation of
motor weakness. Which assessment data indicate the
client is experiencing a myasthenic crisis?
l 1. The serum assay of circulating acetylcholine
receptor antibodies is increased.
l 2. The client's symptoms improve when
administering on a cholinesterase inhibitor.
l
l
621
3. The client's blood pressure, pulse, and respirations
improve after intravenous (IV) fluid.
4. The Tensilon test does not show improvement in
the client's muscle strength.
59. The male client diagnosed with MG is prescribed the
cholinesterase inhibitor neostigmine (Prostigmin). Which
data indicate the medication is not effective?
l 1. The client is able to perform activities of daily
living (ADLs) independently.
l 2. The client states that his vision is clear.
l 3. The client cannot speak or look upward at the
ceiling.
l 4. The client is smiling and laughing with the nurse.
ANSWERS
57. Correct answer 1: MG will not prevent conception
or delivery but can cause the client to experience an
exacerbation of the disease. The client should be seen
regularly by the neurologist and the obstetrician.
Young children are ill frequently, and infections
can result in an exacerbation for the client. Option 3
applies to clients who have seizures. The client is
not restricted to 1000 mL of fluid per day. Content–
Medical; Category of Health Alteration–Immune/
Inflammatory Disorders; Integrated Process–Evaluation;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Evaluation.
58. Correct answer 2: This assessment datum indicates
a myasthenic crisis that is due to undermedication,
missed doses of medication, or developing an infection. Serum assays are useful in diagnosing the
disease, not in identifying a crisis. Vital signs do
not differentiate the type of crisis. No improvement
after Tensilon indicates a cholinergic crisis, not a
Copyright © 2010 F.A. Davis Company
622
myasthenic crisis. Content–Medical; Category of
Health Alteration–Immune/Inflammatory Disorders;
Integrated Process–Assessment; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Analysis.
59. Correct answer 3: Dysphonia and inability to utilize
the muscles of the eye and eyelid indicate the medication is not effective. Performing ADLs, having
clear vision, and smiling and laughing using the
facial muscles indicate the medication is effective.
Content–Medical; Category of Health Alteration–Drug
Administration; Integrated Process–Assessment; Client
Needs–Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Analysis.
SECTION THIRTEEN
Immune Inflammatory Disorders
60. The client is diagnosed with MG. Which intervention
should the nurse implement when administering the
anticholinesterase pyridostigmine (Mestinon)?
l 1. Assess for excess salivation and abdominal cramps.
l 2. Administer the medication before the client has
eaten.
l 3. Break the capsule and sprinkle the medication on
the food.
l 4. Assess the client's potassium level prior to
administering medication.
Allergies
61. The male nurse on the medical/surgical unit tells
charge nurse he is allergic to latex. Which intervention
should the charge nurse implement?
l 1. Tell the male nurse to use only sterile latex gloves
for nursing tasks.
l 2. Instruct the male nurse not to perform any tasks
requiring gloves.
l
l
623
3. Notify central supply to provide the male nurse
with a box of non-latex gloves.
4. Refer the male nurse to the hospital's infection
control nurse.
62. The client diagnosed with bee-sting allergy is being
discharged from the emergency department (ED). Which
question would be most important for the nurse to ask
the client?
l 1. “Do you always carry an epi-pen with you?”
l 2. “Do you wear long-sleeved shirts and pants when
you go outside?”
l 3. “Do you have over-the-counter Benadryl at home?”
l 4. “Do you wear a Medic-Alert bracelet when going
outside?”
ANSWERS
60. Correct answer 1: Anticholinesterase medications
can cause the client to have excessive salivation and
abdominal cramping. When this occurs, the client
receives the antidote atropine simultaneously in
small doses. Mestinon is administered with milk
and/or crackers to prevent stomach upset. Mestinon
does not affect potassium levels. Content–Medical;
Category of Health Alteration–Drug Administration;
Integrated Process–Implementation; Client Needs–
Physiological Integrity, Physiological Adaptation;
Cognitive Level–Application.
61. Correct answer 3: The nurse should be provided
with non-latex gloves that he can keep with him at
all times. The nurse cannot wear sterile or non-sterile
latex gloves. The charge nurse cannot have a nurse
caring for clients who cannot wear gloves. The infection control nurse would have no jurisdiction in
this situation. Content–Medical; Category of Health
Alteration–Immune/Inflammatory Disorders; Integrated
Copyright © 2010 F.A. Davis Company
624
Process–Implementation; Client Needs–Safe Effective
Care Environment, Safety and Infection Control;
Cognitive Level–Analysis.
62. Correct answer 1: The epi-pen can save the client's
life if the client is stung by a bee; therefore, this is
the most important question. Over-the-counter
Benadryl is used for allergies, but the client with a
bee-sting allergy may die before the medication is
effective. Protective clothing will not save the client's
life, and a Medic-Alert bracelet should be worn,
but it is not the most important question. Content–
Medical; Category of Health Alteration–Immune/
Inflammatory Disorders; Integrated Process–Assessment;
Client Needs–Physiological Integrity, Physiological
Adaptation; Cognitive Level–Analysis.
SECTION THIRTEEN
Immune Inflammatory Disorders
63. The male client comes to the emergency department
after eating shellfish. He is experiencing dyspnea and
wheezing, cannot speak, and has a bluish color around
the mouth. Which interventions should the nurse
implement? Rank in order of performance.
l 1. Initiate an intravenous line (IV) with normal
saline.
l 2. Obtain an intubation tray for the client.
l 3. Place nasal cannula with 100% oxygen on the
client.
l 4. Ask the client if he is allergic to iodine.
l 5. Administer subcutaneous epinephrine, an
adrenergic blocker.
64. The nurse is administering medications to
clients. Which medication would the nurse question
administering?
l 1. The H-1 receptor antagonist fexofenadine (Allegra)
to the client who has open-angle glaucoma.
l 2. The glucocorticoid steroid prednisone to the client
who has a moon face and buffalo hump.
l
l
625
3. The aminoglycoside antibiotic vancomycin to the
client who has a trough level of 10 mg/dL.
4. The antihistamine diphenhydramine (Benadryl) to
the client experiencing nasal congestion and
sneezing.
65. The client who is highly allergic to insect venom asks
the nurse, “What is venom immunotherapy? My doctor
wants me to have this done.” Which statement is the
nurse's best response?
l 1. “It will help prevent you from having reactions
from insect bites.”
l 2. “The therapy provides special cream you should
apply to any insect bite.”
l 3. “It will cure you from having any type of allergic
reactions in the future.”
l 4. “The therapy is experimental and your doctor
should have explained it to you.”
ANSWERS
63. Correct answer 3, 5, 1, 2, 4: Because the client is
cyanotic with dyspnea and wheezing, the nurse
should first administer oxygen and then subcutaneously administer the epinephrine, the drug of
choice for an allergic reaction. Then the nurse
should start an IV line for medication administration
and obtain an intubation tray. Assessing the client
for any allergy is the last intervention. Content–
Medical; Category of Health Alteration–Immune/
Inflammatory Disorders; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Application.
64. Correct answer 1: Fexofenadine is used with caution
in clients with glaucoma because of the muscarinic
blockade effects on the eyes. The nurse should
question administering this medication. All the other
medication would be appropriate to administer to
the clients. Content–Medical; Category of Health
Alteration Drug Administration; Integrated
Copyright © 2010 F.A. Davis Company
626
Process–Assessment; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Analysis.
65. Correct answer 1: Immunotherapy does not cure
any type of allergic reaction, but it prevents an
anaphylactic reaction by providing passive immunity
to the insect venom. The therapy is not applied
topically, and this therapy is not experimental.
Content–Medical; Category of Health Alteration–
Immune/Inflammatory Disorders; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Reduction of Risk Potential; Cognitive
Level–Analysis.
SECTION THIRTEEN
Immune Inflammatory Disorders
66. The client exposed to poison ivy has a red raised rash
covering the forearms, neck, and face and is complaining
of itching. Which statement indicates the client needs
more discharge teaching?
l 1. “I should wash my arms and neck with soap and
water.”
l 2. “I will use my epi-pen once a day until the rash
goes away.”
l 3. “I will take the medication in the steroid dose pack
as directed.”
l 4. “I should wear shirts with long sleeves when
working outside.”
67. The female client tells the nurse in the holding area
of the operating room she is allergic to iodine. Which
intervention should the nurse implement first?
l 1. Check to see if the allergy is noted on the client's
chart.
l 2. Notify the hospital pharmacy to make sure the
allergy is documented.
l
l
627
3. Call the medical surgical unit to notify the nurse of
the iodine allergy.
4. Determine if the client has an allergy band stating
the iodine allergy.
68. The nurse is discussing the topical steroid
hydrocortisone with a client diagnosed with allergic
dermatitis. Which statement indicates the client
understands the discharge teaching?
l 1. “I will keep the hydrocortisone cream in my
refrigerator at all times.”
l 2. “I need to cleanse the area with hydrogen peroxide
before applying the cream.”
l 3. “I should place sterile gauze over the affected area
after I apply the cream.”
l 4. “I will wash my hands before and after applying
the topical steroid cream.”
ANSWERS
66. Correct answer 2: The epi-pen is used for a
potential anaphylactic reaction at the time of the
sting/bite. It is not used daily; the client needs more
teaching. All the other statements indicate the client
understands the discharge teaching. Clients with
poison ivy are frequently prescribed a steroid
dose pack. Content–Medical; Category of Health
Alteration–Immune/Inflammatory Disorders; Integrated
Process–Evaluation; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive
Level–Evaluation.
67. Correct answer 4: The nurse should first make
sure the client has an allergy band so that povidoneiodine (Betadine), the usual skin preparation used
for surgeries, will not be used on the client. The
chart, the pharmacy, and the medical surgical unit
should be aware of the allergy, but the first intervention is to make sure the client has the allergy band.
Content–Medical; Category of Health Alteration–
Immune/Inflammatory Disorders; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Copyright © 2010 F.A. Davis Company
628
Environment, Management of Care; Cognitive
Level–Analysis.
68. Correct answer 4: The client should have clean
hands before applying the cream to the affected area
to help prevent infection. Hydrocortisone cream
does not need to be refrigerated, and the area should
be washed with warm water, not hydrogen peroxide.
The area should be left open after the medication
is applied. Content–Medical; Category of Health
Alteration–Immune/Inflammatory Disorders; Integrated
Process–Evaluation; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive
Level–Evaluation.
SECTION THIRTEEN
Immune Inflammatory Disorders
629
Management
69. The client with allergies is prescribed diphenhydramine
71. The charge nurse is making assignments on a medical
(Benadryl), an antihistamine. Which information should
the nurse discuss with the client?
l 1. Inform the client to call the HCP if ringing in
the ears occurs.
l 2. Tell the client the medication may cause drowsiness.
l 3. Explain that hirsutism may occur when taking
Benadryl.
l 4. Instruct the client not to abruptly discontinue the
medication.
floor. Which client should be assigned to the most
experienced nurse?
l 1. The client with Guillain-Barré syndrome whose
paralysis is now at the client's waist.
l 2. The client with systemic lupus erythematosus who
has hematuria.
l 3. The client with rheumatoid arthritis who is receiving
IV antineoplastic drugs.
l 4. The client with scleroderma who has hard waxy-like
skin near the eyes.
70. The clinic nurse is caring for a 26-year-old client
who is complaining of nasal congestion and sneezing.
Which assessment question is appropriate for the nurse
to ask the client?
l 1. “Do you wear gloves when washing your dishes?”
l 2. “Do you have any animals that live in your home?”
l 3. “Have you changed the soap you use to wash your
clothes?”
l 4. “Is there any possibility you may be pregnant?”
ANSWERS
69. Correct answer 2: Antihistamines cause drowsiness,
and the client should avoid driving or engaging in
hazardous activities. Tinnitus (ringing in the ears)
and hirsutism (facial hair on women) are not side
effects of antihistamines. This medication does
not require tapering when being discontinued.
Content–Medical; Category of Health Alteration–Drug
Administration; Integrated Process–Planning; Client
Needs–Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level–Synthesis.
70. Correct answer 2: The client may be having allergic
rhinitis, which can be caused by animal hair, pollen,
or mold; therefore, this is an appropriate question.
Gloves would be used for topical allergic reactions;
soap would cause topical allergic reactions; pregnancy
would not cause these symptoms, and the medications to treat the problem are not teratogenic.
Content–Medical; Category of Health Alteration–
Immune/Inflammatory Disorders; Integrated Process–
Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
630
71. Correct answer 1: The client with Guillain-Barré
syndrome who has paralysis at the waist should be
assigned to the most experienced nurse because the
paralysis is getting close to the respiratory muscles.
If the paralysis does reach the respiratory muscles,
the client may need to be placed on a ventilator.
None of the other clients' conditions are priority
over a client who may be having trouble breathing.
Content–Medical; Category of Health Alteration–
Management; Integrated Process–Planning; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
SECTION THIRTEEN
Immune Inflammatory Disorders
631
72. The nurse and LPN are caring for clients in a clinic.
74. The charge nurse observes a staff nurse caring for a
Which task should the nurse assign to the LPN?
l 1. Administer IVP methylprednisolone (Solu-Medrol)
to a client with multiple sclerosis.
l 2. Escort the client to the radiology department for
an MRI.
l 3. Demonstrate how to use clothing with Velcro
fasteners to the client with myasthenia gravis.
l 4. Discuss birth control with a client who is
prescribed a disease-modifying antirheumatic drug
(DMARD).
client diagnosed with AIDS. Which action by the nurse
warrants immediate intervention?
l 1. The staff nurse adheres to standard precautions
when caring for the client.
l 2. The staff nurse dons nonsterile gloves to administer
medications to the client.
l 3. The staff nurse checks the client for allergies prior
to administering medications.
l 4. The staff nurse requests the UAP to empty the
urinal at the client's bedside.
73. The nurse is preparing to administer morning
75. Which task would be most appropriate for the
medications. Which medication should the nurse
administer first?
l 1. The anticholinesterase medication to the client
with myasthenia gravis.
l 2. The NSAID to the client with rheumatoid
arthritis.
l 3. The glucocorticosteroid to a client diagnosed with
polymyositis.
l 4. The appetite stimulant to a client diagnosed
with AIDS.
medical/surgical nurse to delegate to the UAP?
l 1. Request the UAP to perform an electrocardiogram
(ECG) on the client with chest pain.
l 2. Ask the UAP to put oxygen on the client who is
having shortness of breath.
l 3. Instruct the UAP to clean the perineal area of a
client with an indwelling catheter.
l 4. Tell the UAP to transfer the client to the intensive
care unit.
ANSWERS
72. Correct answer 3: The LPN can demonstrate to
632
74. Correct answer 2: The nurse should implement
the client how to use adaptive clothing. The LPN
cannot administer IVP medications without
additional training; the UAP could assist the client
to the radiology department; and teaching cannot be
delegated to the LPN. Content–Medical; Category of
standard precautions for a client with AIDS; therefore, the nurse does not have to wear gloves when
administering medications. Checking for allergies
and having the UAP empty a urinal would not warrant immediate intervention from the charge nurse.
Health Alteration–Management; Integrated Process–
Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
Content–Medical; Category of Health Alteration–
Management; Integrated Process–Evaluation; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
73. Correct answer 1: Clients with myasthenia gravis
must take their anticholinesterase medication exactly
on time; therefore, this medication must be administered first. The NSAID and the steroid must be
administered with meals, but they are not the first
medication to be administered. The appetite stimulant would not be priority over a medication to help
prevent choking in a client with myasthenia gravis.
Content–Medical; Category of Health Alteration–
Management; Integrated Process–Planning; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
75. Correct answer 3: The UAP can provide perineal care
to a client with a catheter because this does not require
judgment. The clients with chest pain and shortness of
breath and the client being transferred to the ICU are
not stable; therefore the nurse cannot delegate these
tasks to the UAP. Content–Medical; Category of Health
Alteration–Management; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
SECTION THIRTEEN
Immune Inflammatory Disorders
633
76. The nurse on a medical unit has received the morning
78. The clinical manager suspects one of the staff nurses
shift report. Which client should the nurse assess first?
l 1. The client who is receiving a unit of blood who has
2+ pitting edema.
l 2. The client who reports itching after receiving an
initial dose of an antibiotic.
l 3. The client who has rheumatoid arthritis with back
pain of 6 on a 1–10 scale.
l 4. The client who has AIDS who is crying and
threatening to kill himself.
is stealing narcotics from the PIXIS (an automated
medication administration system). Which action should
the clinical manager implement first?
l 1. Notify the local police department.
l 2. Call the State Board of Nurse Examiners.
l 3. Notify the director of nurses immediately.
l 4. Talk to the staff nurse about the suspicion.
77. The HCP orders an intravenous pyelogram for the
female client diagnosed with rule-out renal calculi. Which
priority intervention should the nurse implement?
l 1. Ask the client if she is allergic to shellfish.
l 2. Request her to sign a permit for the procedure.
l 3. Ask the client if she is having her menses at
this time.
l 4. Schedule the intravenous pyelogram with the
hospital's radiology department.
ANSWERS
634
76. Correct answer 2: The client itching may be having
78. Correct answer 4: The clinical manager, the highest
an allergic reaction to the antibiotic and should be
seen first. The client with 2+ pitting edema may be
experiencing fluid volume overload, a client in pain,
and a psychosocial problem must be assessed, but
these clients are not priority over someone who
may go into anaphylactic shock. Content–Medical;
level of the chain of command on the unit, should
first talk to the staff nurse about the suspicion. If the
suspicion is verified, then the director of nurses or
peer review committee should be notified. Then,
depending on the circumstances, the local police
department or board of nurses should be notified.
Category of Health Alteration–Management; Integrated
Process–Assessment; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Analysis.
Content–Medical; Category of Health Alteration–
Management; Integrated Process–Planning; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Synthesis.
77. Correct answer 1: The intravenous pyelogram dye
contains iodine; therefore, the nurse should determine if the client has an allergy to shellfish, which
has iodine. A permit specifically for an intravenous
pyelogram is not required. The client being on her
menses (period) would not affect the pyelogram.
Content–Medical; Category of Health Alteration–
Management; Integrated Process–Implementation;
Client Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
SECTION THIRTEEN
Immune Inflammatory Disorders
635
79. The client receiving the initial dose of an intravenous
80. The client diagnosed with allergic rhinitis has been
antibiotic is having shortness of breath. Which intervention
should the nurse implement first?
l 1. Maintain a patent intravenous (IV) line.
l 2. Turn off the client's IV antibiotic.
l 3. Place oxygen on the client via nasal cannula.
l 4. Initiate the rapid response team (RRT).
taking an antihistamine, a glucocorticoid, and calcium
channel blocker. Which statement by the client would
warrant intervention by the nurse?
l 1. “I take my antihistamine at night so I am not so
sleepy during the day.”
l 2. “I will taper off the steroids when I am discontinuing
the medication.”
l 3. “I am careful to get up slowly when I stand up
from my recliner.”
l 4. “I love to have half a grapefruit and buttered toast
for breakfast.”
ANSWERS
79. Correct answer 2: The first intervention is to stop
636
80. Correct answer 4: Grapefruit juice can cause
the IV antibiotic because the client may be having
an allergic reaction. Then the nurse could place
oxygen on the client, maintain a patent IV line, and
notify the RRT. The RRT is a team of hospital staff
that responds to client emergencies prior to the
client coding. Content–Medical; Category of Health
calcium channel blockers to rise to toxic levels.
Grapefruit juice inhibits cytochrome P450-3A4
found in the liver and intestinal wall. This statement
warrants intervention by the nurse. None of the
other statements would warrant intervention from
the nurse. Content–Medical; Category of Health
Alteration–Drug Administration; Integrated Process–
Implementation; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Synthesis.
Alteration–Drug Administration; Integrated Process–
Evaluation; Client Needs–Physiological Integrity,
Pharmacological and Parenteral Therapies; Cognitive
Level–Synthesis.
Copyright © 2010 F.A. Davis Company
SECTION FOURTEEN
Integumentary
637
SECTION FOURTEEN
Integumentary
639
Burns
1. The client presents to the emergency room in severe
3. The client was admitted to the burn unit 8 hours ago
pain and reports falling asleep in the sun. The nurse’s
assessment reveals bright red skin that blanches with
pressure. Which depth of burn should the nurse
document?
l 1. Superficial partial-thickness.
l 2. Deep partial-thickness.
l 3. Full-thickness.
l 4. Third-degree burn.
with full-thickness burns to 60% of the body, including
the chest area. After establishing a patent airway, which
intervention is priority for the client?
l 1. Prevent the burns from getting infected.
l 2. Maintain the client’s circulatory status.
l 3. Prevent contractures of extremities.
l 4. Prepare to assist with an escharotomy.
2. The client with full-thickness burns to 43% of the
body, including both legs, is being transferred from a
community hospital to a burn center. Which intervention
should be implemented prior to transferring the client?
l 1. Place the client’s legs in the dependent position.
l 2. Cover both legs with moist sterile petroleum-based
dressings.
l 3. Administer a tetanus toxoid injection to the client.
l 4. Initiate an 18-gauge intravenous line with Ringer
lactate.
ANSWERS
1. Correct answer 1: Sunburn is a superficial partial-thickness
640
3. Correct answer 2: Next to handling respiratory
burn that affects the epidermis, causing reddened skin
that blanches with pressure. Deep partial-thickness burns
cause pain and blistered mottled red skin along with
edema. Full-thickness (third-degree) burns affect the
epidermis and dermis and may affect connective tissue,
muscle, and bone. Content–Medical; Category of
difficulties, the most urgent need is preventing
irreversible shock by maintaining circulatory status.
Preventing infection, preventing contractures, and
assisting with an escharotomy are pertinent interventions, but the priority is maintaining circulation due
to third spacing that occurs with full-thickness burns.
Health Alteration–Integumentary; Integrated Process–
Implementation; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Application.
Content–Medical; Category of Health Alteration–
Integumentary; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment, Safety
and Infection Control; Cognitive Level–Synthesis.
2. Correct answer 4: An 18-gauge catheter with lactated
Ringer infusing should be initiated to maintain a urine
output of at least 30 mL/hr. The legs should be elevated; the wounds should be covered with a clean,
dry sheet; and a tetanus toxoid is not priority for a
client with 43% full-thickness burns. Content–Medical;
Category of Health Alteration–Integumentary; Integrated
Process–Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Analysis.
Copyright © 2010 F.A. Davis Company
SECTION FOURTEEN
Integumentary
641
4. The nurse is applying mafenide acetate (Sulfamylon) to a
6. The client was admitted 4 days ago to the burn unit
client’s burn on the right lower extremity. Which assessment
data would require immediate attention by the nurse?
l 1. The client complains of pain when the medication
is administered.
l 2. The client’s potassium level is 4.2 mEq/L and
sodium level 139 mEq/L.
l 3. The client’s arterial blood gases (ABGs) are pH
7.38, PaO2 98, PaCO2 38, HCO3 24.
l 4. The client reports tingling and numbness of the
right foot.
with severe full-thickness and deep partial-thickness burns
over half the body. Which client problem has priority?
l 1. High risk for infection.
l 2. Ineffective coping.
l 3. Impaired physical mobility.
l 4. Knowledge deficit.
5. The client is being scheduled for a homograft. The
client asks the nurse, “What is a homograft?” Which
statement would be the nurse’s best response?
l 1. “The doctor will graft skin from your back to
your leg.”
l 2. “The skin from a donor will be used to cover
your burn.”
l 3. “The graft will come from an animal, probably a pig.”
l 4. “I think you should ask your doctor about the
graft.”
7. The nurse writes the nursing diagnosis “impaired skin
integrity” for the client with full-thickness and deep
partial-thickness burns to the lower part of the client’s
body. Which priority intervention would be appropriate
for this nursing diagnosis?
l 1. Provide analgesia before whirlpool treatments.
l 2. Clean the client’s wounds, body, and hair daily.
l 3. Perform passive range-of-motion (ROM) exercises.
l 4. Do not allow visitors to bring plants and flowers.
ANSWERS
4. Correct answer 4: Complaints of numbness and tingling indicate neurovascular compromise, which would
require immediate intervention. The client should be
pre-medicated with an analgesic before Sulfamylon is
administered because this agent causes severe burning
pain for up to 20 minutes. The electrolytes and ABGs
are within normal limits (WNL). Sulfamylon may cause
metabolic acidosis. Content–Medical; Category of Health
Alteration–Integumentary; Integrated Process–Assessment;
Client Needs–Physiological Integrity, Reduction of Risk
Potential; Cognitive Level–Analysis.
5. Correct answer 2: A homograft is skin obtained
from a tissue donor. Option 1 is the explanation for
an autograft, and option 3 is the explanation for a
xenograft or heterograft, in which skin is taken from
animals, usually pigs. Option 4 is “passing the buck”;
the nurse can and should answer this question with
factual information. Content–Medical; Category of
Health Alteration–Integumentary; Integrated Process–
Implementation; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Application.
Copyright © 2010 F.A. Davis Company
642
6. Correct answer 1: Even though this is a potential
problem, it is priority because the protective barrier
of skin has been compromised, and there is an
impaired immune answer. Psychosocial client problems, potential joint contractures that can cause
mobility deficits, and teaching are important, but
not priority. Content–Medical; Category of Health
Alteration–Integumentary; Integrated Process–Diagnosis;
Client Needs–Safe Effective Care Environment, Safety
and Infection Control; Cognitive Level–Analysis.
7. Correct answer 2: Preventing infection is the priority
for the client with impaired skin integrity; therefore,
daily cleaning that reduces bacterial colonization is the
priority intervention. Analgesia would address pain,
and ROM exercises would address contractures. Plants
may bring bacteria, but this would be for clients who
are immunosuppressed. Content–Medical; Category
of Health Alteration–Integumentary; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Safety and Infection Control; Cognitive
Level–Analysis.
Integumentary
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8. The client calls the emergency department (ED)
10. The husband calls the ED and tells the nurse, “My
and tells the nurse, “My husband just burned his right
hand really bad while burning the trash.” Which
intervention should the nurse discuss first with the wife?
l 1. Instruct the wife to apply an ice pack to the
right hand.
l 2. Tell the wife to put her husband’s hand under cool
running water.
l 3. Encourage the wife to bring her husband to the ED.
l 4. Recommend the wife place a clean white cloth on
the burned area.
wife just splashed chlorine into her eyes. She is yelling
and says ‘It burns, it burns.’” Which action should the
nurse implement first?
l 1. Instruct the husband to call 911 immediately.
l 2. Tell the husband to flush her eyes with tap water.
l 3. Have the husband place a cool cloth over his
wife’s eyes.
l 4. Recommend his wife keep her eyes closed at all
times.
9. The nurse is caring for a client with deep partialthickness and full-thickness burns to the chest area.
Which assessment data would warrant immediate
intervention?
l 1. The client’s pulse oximeter reading is 90%.
l 2. The client is complaining of severe pain.
l 3. The client’s telemetry exhibits sinus tachycardia.
l 4. The client’s urinary output is 400 mL in 8 hours.
Pressure Ulcers
11. The nurse in a long-term care facility is teaching a
group of new unlicensed assistive personnel (UAP).
Which information regarding skin care should the nurse
emphasize?
l 1. Allow the skin to air dry after each bath.
l 2. Use only petroleum jelly on the client’s skin.
l 3. Turn immobile clients at least every 2 hours.
l 4. The licensed nursing staff will be responsible for all
skin care.
ANSWERS
8. Correct answer 2: Cool water gives immediate and
striking relief from pain and limits local tissue edema
and damage; therefore, this is the first intervention.
Ice should never be applied to a burn because this will
increase the tissue damage. Placing a clean white cloth
over the burned area and bringing the husband to
the ED are appropriate interventions, but not the
first intervention. Content–Medical; Category of
Health Alteration–Integumentary; Integrated Process–
Implementation; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Application.
9. Correct answer 1: A pulse oximeter reading less than
93% indicates respiratory compromise; this reading
requires notifying the health-care provider (HCP).
Severe pain and sinus tachycardia require intervention
but are not priority over oxygenation problems.
Adequate urinary output would not require immediate
intervention. Content–Medical; Category of Health
Alteration–Integumentary; Integrated Process–Assessment;
Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
644
10. Correct answer 2: Anytime a chemical is splashed
into the eye, the client should flush with water or
normal saline. Calling 911 would allow emergency
medical technician (EMT) personnel to continue to
flush the eye. Cool cloth may ease some of the pain,
but the eye must be flushed first, and keeping the
eyes closed except when flushing is appropriate.
Content–Medical; Category of Health Alteration–
Integumentary; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Management of Care; Cognitive Level–Synthesis.
11. Correct answer 3: Clients should be turned at least
every 1–2 hours to prevent pressure areas on the
skin. The skin should be patted dry after a bath,
never left with moisture on it. The client can have
body lotion applied. All nursing staff, including
UAPs, should prevent skin breakdown. Content–
Medical; Category of Health Alteration–Integumentary;
Integrated Process–Planning; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
SECTION FOURTEEN
Integumentary
645
12. The nurse is caring for a client who has developed
14. The home health nurse is teaching the caregivers of
stage IV pressure ulcers on the left trochanter and coccyx.
Which independent nursing problem has the highest
priority?
l 1. Altered wound healing.
l 2. Altered nutrition.
l 3. Self-care deficit.
l 4. Altered coping.
an immobile client about prevention of pressure ulcers.
Which is the most important information to teach the
caregivers?
l 1. “Place a pad under the client to absorb any urinary
incontinence and contain stool.”
l 2. “Underpads do not need to be changed unless they
become saturated with urine.”
l 3. “Underpads will keep the caregiver from injuries
such as a pulled muscle.”
l 4. “The pads placed under the client will prevent
shearing when repositioning the client.”
13. The nurse is caring for clients in a long-term care
facility. Which is a modifiable risk factor for the
development of pressure ulcers?
l 1. Constant perineal moisture.
l 2. Decreased ability of the clients to reposition
themselves.
l 3. Decreased elasticity of the skin.
l 4. Impaired cardiovascular perfusion of the periphery.
15. Which assessment tool addressing the condition of
the client’s skin should be completed on admission to the
hospital?
l 1. Complete the Braden Scale.
l 2. Monitor the client on a Glasgow Scale.
l 3. Assess for a Babinski sign.
l 4. Initiate a Brudzinski flow sheet.
ANSWERS
12. Correct answer 3: Self-care deficit is an independent
nursing problem. The nurse should institute measures
to ensure relief of pressure on bony prominences,
such as turning the client frequently. Altered wound
healing and altered nutrition are collaborative
problems. Altered coping is a psychological problem.
According to Maslow’s Hierarchy of Needs, physiological
problems are priority. Content–Medical; Category of
Health Alteration–Integumentary; Integrated Process–
Diagnosis; Client Needs–Physiological Integrity,
Physiological Adaptation; Cognitive Level–Analysis.
13. Correct answer 1: Impaired circulation, decreased
ability of the clients, and decreased elasticity are not
modifiable. Constant perineal moisture is modifiable.
Content–Medical; Category of Health Alteration–
Integumentary; Integrated Process–Implementation;
Client Needs–Safe Effective Care Environment,
Reduction of Risk Potential; Cognitive Level–
Knowledge.
Copyright © 2010 F.A. Davis Company
646
14. Correct answer 4: Lifting the client with a “lift” pad
rather than pulling the client against the sheets helps to
prevent skin damage due to friction shearing. The pads
should be changed when there is moisture of any kind
or feces noted. Underpads will also help prevent injuries
to the caregiver, but the most important consideration
is care of the client. Content–Medical; Category of Health
Alteration–Integumentary; Integrated Process–Planning;
Client Needs–Safe Effective Care Environment, Reduction
of Risk Potential; Cognitive Level–Synthesis.
15. Correct answer 1: The Braden and Norton scales
are tools that identify clients at risk for skin problems.
Clients are ranked on this scale, and appropriate
measures are initiated for controlling skin damage.
The Glasgow scale is a neurological coma scale to
determine the depth of neurological injury. The
Babinski and Brudzinski signs are signs of neurological
dysfunction. Content–Medical; Category of Health
Alteration–Integumentary; Integrated Process–Planning;
Client Needs–Physiological Integrity, Basic Care and
Comfort; Cognitive Level–Synthesis.
Integumentary
SECTION FOURTEEN
16. The wound care nurse documented a client’s pressure
ulcers on admission as 3.3 cm × 4.0 cm stage II on the
coccyx. Which information indicates the treatment plan
is effective?
l 1. The skin now has an area 2.5 cm × 3.5 cm with
undermining and 0.5 cm depth.
l 2. There is a blister 3.2 cm × 4.1 cm that is red and
drains occasionally.
l 3. The skin covering the coccyx is intact, and no
erythema is noted by the nurse.
l 4. The coccyx wound extends to the subcutaneous
layer, and there is moderate drainage.
17. The nurse and a UAP on a medical unit are caring
for elderly, immobile clients. Which action by the UAP
warrants immediate intervention by the nurse?
l 1. The UAP empties the urinary drainage bag using
non-sterile gloves.
l 2. The UAP leaves a client lying on the left side for
3 hours.
l
l
647
3. The UAP uses a plastic bag to get ice for the clients.
4. The UAP leaves a glass of water with a straw at the
bedside.
18. The nurse is caring for clients on a medical unit.
After the shift report, which client should the nurse see
first?
l 1. The 34-year-old quadriplegic client who cannot
move the arms to use a call light.
l 2. The elderly client diagnosed with a cerebrovascular
accident (CVA), or stroke, who is weak on the
right side.
l 3. The 78-year-old client with pressure ulcers who
had a hyperbaric treatment this morning.
l 4. The young adult who is unhappy with the care that
was provided last shift.
ANSWERS
16. Correct answer 3: This indicates healing of the area
and indicates the plan is effective. Option 1 is stage
IV; option 2 is stage II and probably indicates no
significant change; and option 4 is stage III. Content–
Medical; Category of Health Alteration–Integumentary;
Integrated Process–Evaluation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Evaluation.
17. Correct answer 2: It is important to turn bedfast
clients every 1–2 hours and to encourage the client
to make minor readjustments in position at least
every 15 minutes, if the client is able. The other
options contain acceptable practice. Content–Medical;
Category of Health Alteration–Integumentary; Integrated Process–Implementation; Client Needs–Safe
Effective Care Environment, Management of Care;
Cognitive Level–Synthesis.
Copyright © 2010 F.A. Davis Company
648
18. Correct answer 1: The nurse should see the client
who cannot call for a need first. The other clients do
not have immediate or life-threatening problems.
After making sure this client does not need anything,
then the nurse can decide who to assess next. Content–
Medical; Category of Health Alteration–Integumentary;
Integrated Process–Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive
Level–Analysis.
Integumentary
SECTION FOURTEEN
19. The nurse is instructing the unlicensed assistive
personnel (UAP) on the care of an immobile client.
Which instructions should the nurse include?
l 1. Use a pillow to keep the heels raised off the bed
when the client is supine.
l 2. Order a low air loss therapy bed to be placed on
the client’s bed.
l 3. Set up the supplies for the nurse to insert a
nasogastric feeding tube.
l 4. Turn the client every 15 minutes from one side to
the other.
20. The client diagnosed with stage IV infected pressure
ulcers on the coccyx is scheduled for a fecal diversion
operation. The nurse knows that client teaching has been
effective when the client makes which statement?
l 1. “This surgery will create a skin flap to cover my
wounds.”
l 2. “This surgery will get all the old black tissue out of
the wound so it can heal.”
l
l
649
3. “The surgery is important to allow oxygen to get to
the tissue for healing to occur.”
4. “Stool will come out an opening in my abdomen
so it won’t get in the wound.”
Skin Cancer
21. The school nurse is preparing to teach a health
promotion class to high school seniors. Which information
regarding self-care should be included in the teaching?
l 1. Wear a sunscreen of 15 or greater when in the sun.
l 2. If you have acne, try to get a suntan on the face
and neck.
l 3. Individuals should perform a thorough skin check
yearly.
l 4. Caps and long sleeves should be worn at all times.
ANSWERS
19. Correct answer 1: Using a pillow to suspend the
heels off the bed when a client is supine prevents
the development of pressure ulcers on the heels. Low
air loss therapy beds are normally only provided for
clients who have stage III or stage IV pressure ulcers.
Content–Medical; Category of Health Alteration–
Integumentary; Integrated Process–Planning; Client
Needs–Physiological Integrity, Basic Care and Comfort;
Cognitive Level–Synthesis.
20. Correct answer 4: A fecal diversion is changing
the normal exit of stool from the body. A colostomy
is created to keep stool from contaminating the
wound and causing infection. A skin flap covers a
large wound with intact skin. Débridement removes
dead tissue to allow for healing. A hyperbaric chamber increases oxygenation of the wound. Content–
Medical; Category of Health Alteration–Integumentary;
Integrated Process–Evaluation; Client Needs–Physiological
Integrity, Physiological Adaptation; Cognitive
Level–Evaluation.
Copyright © 2010 F.A. Davis Company
650
21. Correct answer 1: The students should be taught to
use sunscreen when in the sun. An SPF of 15 is the
minimum; the higher the number, the better the
protection. Suntanning was recommended for
clients with acne in the past, but now research has
shown that this practice increases the client’s risk of
developing skin cancer. Skin checks are performed
monthly. Caps and long sleeves are not worn all
the time. Content–Medical; Category of Health
Alteration–Integumentary; Integrated Process–Planning;
Client Needs–Health Promotion and Maintenance;
Cognitive Level–Synthesis.
SECTION FOURTEEN
Integumentary
651
22. The nurse notes an irregular-shaped lesion with some
24. Which client is at the greatest risk for the development
scabbed areas surrounding the lesion on the client’s back.
Which action should the nurse implement first?
l 1. Place a note on the client’s chart for the HCP to
check the lesion on rounds.
l 2. Measure the lesion, note the color, and document
the finding in the chart.
l 3. Apply lotion to the lesion, and remind the client
not to scratch the area.
l 4. Instruct the client to make sure the HCP checks
the lesion.
of skin cancer?
l 1. The African-American male who lives in New York
City.
l 2. The Hispanic female who moved to Texas from
Mexico.
l 3. The client with a family history of basal cell
carcinoma.
l 4. The client with red hair and blue eyes who tries to
tan every year.
23. The nurse is caring for clients in an outpatient
surgery clinic. Which client should be assessed first?
l 1. The client scheduled for a skin biopsy who has
decided not to have the procedure.
l 2. The client who had surgery 2 hours ago and is
beginning to wake up.
l 3. The client who needs to see the physical therapist
to be fitted for crutches.
l 4. The client who has been discharged but cannot pay
for the prescription for pain.
ANSWERS
22. Correct answer 2: This is part of assessing the lesion
and should be completed. The ABCD of skin cancer
detection include: Asymmetry, Borders, Color, and
Diameter. The nurse should complete an assessment
on the lesion prior to notifying the HCP to check
it. Lotion may help as a comfort measure, but it is
not the first action. Content–Medical; Category of
Health Alteration–Integumentary; Integrated Process–
Implementation; Client Needs–Safe Effective Care
Environment, Management of Care; Cognitive
Level–Analysis.
23. Correct answer 1: This client has an unexpected
situation occurring and should be assessed before
any stable client. The client waking up and the client
needing to see a physical therapist or the social
worker to help with financial needs would not be
first. Content–Medical; Category of Health Alteration–
Integumentary; Integrated Process–Assessment; Client
Needs–Safe Effective Care Environment, Management
of Care; Cognitive Level–Analysis.
Copyright © 2010 F.A. Davis Company
652
24. Correct answer 4: Clients with very little melanin
in the skin (fair-skinned clients) have an increased
risk due to the ultraviolet (UV) damage to the
underlying membranes. Damage to the underlying
membranes never completely reverses itself; a lifetime of damage causes changes at the cellular level
that result in the development of cancer. Basal cell
carcinoma is directly related to sun exposure and is
not associated with family history. Content–Medical;
Category of Health Alteration–Integumentary; Integrated Process–Diagnosis; Client Needs–Health
Promotion and Maintenance; Cognitive Level–
Knowledge.
SECTION FOURTEEN
Integumentary
653
25. The middle-aged client has had a basal cell carcinoma
27. Which assessment data indicate a lesion is a malignant
removed. Which statement indicates the client understands
the discharge teaching?
l 1. “I am so glad that I don’t have to worry about skin
cancer anymore.”
l 2. “I need to see a prosthetic specialist to camouflage
the damaged area.”
l 3. “I will apply a sunscreen to the incision to make
sure no more cancer is found.”
l 4. “I will check my skin every month for any more
suspicious lesions.”
melanoma?
l 1. The lesion is asymmetrical and has irregular borders.
l 2. The lesion has a waxy appearance with pearl-like
borders.
l 3. The lesion has a thickened and scaly appearance.
l 4. The lesion appeared as a thickened area after an
injury.
26. The nurse and a UAP are caring for clients in a
dermatology clinic. Which interventions should be
delegated to the UAP? Select all that apply.
l 1. Stock the rooms with the equipment needed.
l 2. Obtain the clients’ weight and position the clients
for the examination.
l 3. Discuss problems the clients have experienced since
the previous visit.
l 4. Take the biopsy specimens to the laboratory.
l 5. Measure the skin lesions and document in the charts.
28. The client has had a squamous cell carcinoma removed
from the lip. Which discharge instructions should the
nurse provide?
l 1. Notify the HCP if a sore that does not heal
develops on the skin.
l 2. Squamous cell carcinoma tumors do not metastasize.
l 3. Limit foods to liquid or soft consistency for
1 month.
l 4. Apply heat to the area for 20 minutes every 4 hours.
ANSWERS
25. Correct answer 4: The client should check for any
lesion that could be cancerous monthly. The client
has had one skin cancer removed, but not just that
area of skin has been damaged by UV rays. Prostheses are usually not needed. Sunscreen is not applied
to incisions and does not guarantee that more cancer
cells will not be found. Content–Medical; Category
of Health Alteration–Integumentary; Integrated Process–
Evaluation; Client Needs–Psychological Integrity,
Physiological Adaptation; Cognitive Level–Evaluation.
26