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deWits Study guides
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Study Guide Answer Key
1
Study Guide Answer Key
CHAPTER 1: CARING FOR MEDICALSURGICAL PATIENTS
SHORT ANSWER
1. Answers will depend on student preference for
a work environment.
2. a. Promote and maintain health
b. Prevent disease and disability
c. Assist with rehabilitation
d. Assist the dying patient to the best quality
of life possible
3. Any three of these:
a. Attain healthy, thriving lives and wellbeing free of preventable disease, disability, injury, and premature death
b. Eliminate health disparities, achieve health
equity, attain health literacy to improve the
health and well-being of all
c. Create social, physical, and economic environments that promote attaining full potential for health and well-bei
d. Promote healthy development, healthy
behaviors, and well-being across all life
stages
e. Engage leadership, key constituents, and
the public across multiple sectors to take
action and design policies that improve the
health and well-being of all
Nursing Roles and Responsibilities
1. a. Caregiver
b. Educator
c. Collaborator
d. Advocate
e. Leader
f. Delegator
2. a. Right task
b. Right circumstances
c. Right person
d. Right direction and communication
e. Right supervision and evaluation
3. a. Provide patient-centered care
b. Collaborate with the interdisciplinary
health care team
c. Implement evidence-based practice
d. Use quality improvement in patient care
e. Use informatics in patient care
4.
Any five of these:
a. Teach about basic hygiene and nutrition in
the context of health promotion.
b. Reinforce what the RN or health care provider teaches regarding diagnostic tests
and treatments.
c. Teach how to take prescribed medication
and what side effects to report.
d. Teach self-care activities necessary to promote rehabilitation and independence.
e. Inform regarding lifestyle changes that
may be required.
f. Reinforce discharge instructions.
g. Provide information about community resources and self-help groups.
COMPLETION
1. communication; documentation; electronic
data access; data utilization
2. Capitation
dvocate
4. standards for care
5. cost containment
SHORT ANSWER
Dealing With Different Patient Behaviors
Scenario A
1. safety and security
2. Any four of these:
a. Provide consistent routine care of patient
so she knows what to expect.
b. Reduce environmental stress, confusion,
and disorder.
c. Limit the number of people assigned to
care for the patient.
d. Develop trust and instill confidence.
e. Do not joke with or tease patient.
f. Do not whisper or act secretive in her presence.
Scenario B
1. frustration; anger
2. be in control of what is happening to him
3. a. Allow him to release his anger by talking
about it.
b. Encourage physical activity to release pentup energy and frustration.
1
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Study Guide Answer Key
c.
Provide opportunities to take part in decisions affecting his care.
Scenario C
1. a. Tell her that you will put in an order for a
dietary consult with the dietitian.
b. Explain that you will check with the kitchen, but the fish is what she ordered.
c. Sit down and ask her if there are other
things bothering her.
d. Sit down and explain that she is making
progress and that recovery is slow.
PRIORITY SETTING
3 a. Ms. Bora is calling for assistance to the
bathroom. Help her to the bathroom, using
a matter-of-fact approach. (Note: Return
later and try to find an underlying cause
for her dependent behavior.)
2 b. Mr. Fogel has locked himself in the bathroom. You must rule out any intent or
means of self-harm before you can allow
him to remain isolated.
1 c. Mr. Ahrens had an abdominal surgery 2
days ago and states he is in pain.
5 d. Ms. Schott wants you to immediately call
her doctor because she wishes to go h
4 e. Mr. McGinnis refuses to sit in the chair per
orders. The nursing assistant has tried to
encourage him, but he just gazes off and
then starts crying.
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 1, 2, 4, 5 (3 is acceptable also)
2. 3
3. 1, 2, 4
4. 4
5. 1
6. 1
7. 1, 3, 4, 5
8. 3
9. 1, 2, 5
CRITICAL THINKING ACTIVITIES
1. those beliefs and values do not interfere with
the rights of others and are within the law
2. a. be open-minded and nonjudgmental
b. take differences at face value
c. accept people as they are
d. deliver high-quality care
3. Talking to classmates from different cultural
backgrounds is a good place to start. You can
share your insights into your own culture and
compare and contrast with theirs. Being openminded is important, and you should examine
your own philosophy of individual worth. Get
in the habit of asking patients about their personal preferences. Observe body language and
tactfully ask for validation of what you are seeing (i.e., “You seem a little sad today. Is there
something I can do to help?”).
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. collaborative
2. premium
3. fee-for-service
4. significant others
5. feedback
6. empathy
VOCABULARY EXERCISE
1. Answers will vary.
Examples: The nurse assessed the patient’s IV
site.
This is the site where the explosion occurred 50
years ago.
3.
b. site
c. cite
d. site
If medical personnel were demeaning and aloof
would that be good for the patient or not?
No. Why? They would be treating patients as
though they were children or less intelligent,
and would appear uncaring and cold.
SPECIAL VOCABULARY MEANINGS
1. Going slightly outside the rules without doing anything really wrong—which would be
“breaking the rules.”
2. Because it is going up very fast and exploding—like a skyrocket.
3. The systems are coming apart and not working
very well, and people are trying to put them
back in a different way. It is like knitting a
sweater or sewing clothes.
4. Because it is like a fancy shop that only rich
people can afford.
CLINICAL SCENARIOS
1. c
2. This is an example of an appropriate way to
delegate a task.
3. “Ann, I would like you to dangle and then
ambulate Ms. Paul at 10:00 am and again at
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Study Guide Answer Key
1:00 pm. Sit her up on the side of the bed with
her feet resting on the floor for 2 to 3 minutes,
and if she is not dizzy, help her to stand. Ambulate her using a gait belt and safety hold.
Take her to the end of the hall and back. Tell
me if she has any difficulty, becomes short of
breath, weak, dizzy, or extremely fatigued. I
will be in the nurses’ station or in one of my
patient’s rooms as posted on the main assignment board.” (Later, 2:00 pm) “Ann, tell me how
things went when you ambulated Ms. Paul.
Were there any problems either time?” (Check
with Ms. Paul to determine her view of the sessions.)
CHAPTER 2: CRITICAL THINKING AND THE
NURSING PROCESS
CRITICAL THINKING
1. Answers will vary according to the individual
student, but should include something similar
to “directed, purposeful, mental activity by
which you evaluate ideas, construct plans, and
determine desired outcomes; useful in solving
problems.”
2. Answers will depend on the student and could
include four of the characteristics from Box 2-1
in the text.
3. Clinical judgment is the result of critical thinking applied to clinical situations, and is derived
from experience.
4. The scientific method helps a nurse solve a
problem by incorporating it into critical thinking. The problem is defined and data are
gathered. Data are then analyzed, possible solutions are developed, and the best solution is
chosen.
5. Other standards are listed on the website National Association of Licensed Professional
Nurses: https://nalpn.org/nalpn-practice-standards/.
a. Legal-ethical status: The nurse shall hold a
license and know the scope of practice authorized in the state nurse practice act.
b. Practice: The nurse functions within the
limits of educational preparation and experience as related to assigned duties.
c. Continuing education: The nurse seeks and
participates in continuing education activities that are approved for credit by appropriate organizations.
3
IDENTIFICATION
Phases of the Nursing Process
1. Evaluation
2. Implementation
3. Planning
4. Implementation
5. Implementation
6. Data collection/Assessment
7. Data collection/Assessment
8. Implementation
COMPLETION
1. plan, implement and evaluate care.
2. identifying by data collection the patient’s pain
level, noting ordered medication to relieve it,
and recalling other comfort measures that have
helped relieve this type of pain in the past
3. assessing; planning; implementing
4. evaluation
5. patient
Assessment (Data Collection)
1. a. Reading the face sheet of the chart
b. Physical exam and history by health care
provider
c. Interviewing the patient and significant
others
2. private place
3. plan more time for the interview
4. spouse; significant other; relative; friend
5. the patient’s preferences
6. stress; coping
7. spirituality
8. 75
9. 960
SHORT ANSWER
LPN/LVN’s Role and Use of Nursing Process
1. The plan must be revised with different interventions.
2. It is important to provide a legal record of what
has been done for the patient and how she has
responded to treatment. Documentation of the
care given is needed to justify the charges for
this care. Documentation also provides evaluation data on the effectiveness of care and the
response of the patient to nursing actions.
APPLICATION OF THE NURSING PROCESS
Scenario A
Patient states pain is relieved after using patientcontrolled analgesia (PCA) for 2 hours. Reposi-
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Study Guide Answer Key
tioned at 8-10-2. Rest is interrupted by health care
providers, physical therapist, and medication
times. Rested undisturbed for 1½ hours after lunch.
Determination of pain level after undisturbed rest.
Scenario B
a. Pain will be relieved by medication sufficiently
for patient to assist with bathing.
b. Patient will be able to walk to the bathroom
with a walker within 2 days.
PRIORITY SETTING
Scenario A
1. c
Scenario B
1. d
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 3
2. 3, 1, 5, 2, 4
3. 2
4. 3
5. 1
6. 3
7. 4
8. 4
9. 1
10. analysis
CRITICAL THINKING ACTIVITIES
1. Select a, d, e, and f:
a. Using the incentive spirometer helps open
alveoli and relieve atelectasis.
d. Encouraging ambulation places the patient
upright and helps expand the lungs.
e. Sitting upright helps the lungs expand
more completely than does a supine position.
f. Splinting the incision decreases the pain
of coughing and helps the patient to effectively expel secretions.
Reject b, c:
b. Encouraging fluids won’t directly help
with Impaired respiration from the effects
of anesthesia, although it will help keep
secretions thinned so that they are more
easily expelled.
c. Respirations should be checked every 4
hours in the postoperative period, and
lungs should be auscultated at least once a
shift.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. input
2. hierarchy
3. prudent
4. discount; clues
5. enhance
6. correlate
7. entail
CLINICAL ACTIVITIES
Asking for Assistance
1. This is an example.
2. This is an example.
SHORT ANSWER
1. “Might I read to you after lunch?”
2. “Would you like me to pray with you?”
3. “Might I sit here quietly with you for a while?”
4. “May I call your spiritual advisor for you?”
5. “I could call a friend for you; would you like
that?”
Writing Expected Outcomes
a.
Patient
.
B
aC
OM will state that pain is less than 3/10
for 1 hour after each use of PCA pump.
b. Patient will state that relaxation exercises
decreased pain to less than 3/10 for at least
1 hour.
2. a. Patient will comb left side of hair by herself
within 1 week.
b. Patient will wash face with right hand
within 3 days.
3. a. Patient will increase fluid intake to 2000
mL per day within 2 days.
b. Constipation will be relieved within 4
days.
CHAPTER 3: FLUIDS, ELECTROLYTES,
ACID-BASE BALANCE, AND INTRAVENOUS
THERAPY
TABLE ACTIVITY
1. a, e
2. b, c, d
MATCHING
1. b
2. d
3. a
4. e
5. c
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Study Guide Answer Key
COMPLETION
1. water
2. calcium
3. failure, dysrhythmias, or arrest
4. rise
5 diuretics; vomiting; diarrhea; gastric suction
6. Any three: bananas, orange juice, potatoes,
meat
7. protein
8. raw spinach, rolled oats, avocado, tuna
9. adenosine triphosphate (ATP)
10. Phosphorus; buffer
SHORT ANSWER
Fluids and Electrolytes
1. 2500
2. 30
3. a. Forcing fluids without noting output and
trying to establish a balance
b. Giving intravenous fluids too rapidly or
when not needed
4. a. Remove odors from the room.
b. Apply a cool cloth to the forehead and
neck.
c. Administer an antiemetic.
5. potassium, sodium, some calcium
sium
6. a. Number of stools passed each 8-hour period
b. Color, consistency, unusual contents of
stools
c. Peculiar odor
7. a. Provide oral or parenteral fluids.
b. Administer medication to slow the diarrhea.
c. Restrict food intake and start slowly back
on a “BRAT” diet when diarrhea has
stopped.
d. Administer small sips of an electrolyte
fluid such as Gatorade.
8.
5
Any two: Decreased thirst sensation, decreased
total body water, use of laxatives, reluctance to
drink fluids due to incontinence.
9. Any three of these:
a. Daily weight
b. Measurement of intake and output
c. Restrict fluid intake as ordered
d. Skin care, frequent and gentle turning
e. Instruct patient about sodium intake limitations
10. Any three:
a. Fluid volume deficit
b. Potential for electrolyte imbalance
c. Impaired skin integrity related to irritation
from diarrhea
d. Risk for infection related to impaired skin
integrity
SHORT ANSWER
Signs and Symptoms of Fluid and Electrolyte
Imbalance
1. Fatigue, lethargy, headache, mental confusion,
altered level of consciousness, anxiety, coma,
anorexia, nausea, vomiting, muscle cramps,
seizures, decreased sensation, and decreased
lood pressure
2. Abdominal pain, paralytic ileus, gaseous distention of intestines, cardiac dysrhythmias,
muscle weakness, decreased reflexes, paralysis, urinary retention, increased urinary pH,
lethargy, confusion, electrocardiogram (ECG)
changes. This condition is dangerous because
of its potential for causing life-threatening
heart dysrhythmias.
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TABLE ACTIVITY
Fluid Deficits
Vomiting
Diarrhea
Draining Wounds
Clinical
manifestations to
be documented
“Sick to stomach”
Nausea
Abdominal pain
Epigastric discomfort or
burning
Losing gastric contents
through mouth
Pallor
Mild diaphoresis
Cold, clammy skin
Frequent, watery bowel
movements (15–20 per day)
Abdominal cramping
General weakness
Eventually:
Anemia
Malnutrition
Dehydration
Vary with cause, possibly:
Skin destruction
Shock
Pain
Infection
Dehydration
Possible causes
Varied, includes:
GI irritation from foods,
liquor, viruses, or
radiation
Some drugs and chemicals
Some anesthetics
Pregnancy
Local irritation of intestinal
mucosa—infection or
allergy
Increased peristaltic activity
Obstruction to flow of
intestinal contents
Fluid loss by drainage of
large open wounds
(abscess, fistulas)
Burns
Nursing
interventions
Place patient in quiet, cool
environment
When tolerable, gradually
offer small meals of cool
drinks and foods
Frequent oral hygiene
Emotional support
Cool cloth applied to
forehead and neck
Provide physical and mental
rest
Initially limit food intake to
adual
increase to solid foods
Provide privacy
Explanation of tests
Emotional support
Skin care
Record intake and output
accurately
Care for wound(s) and
document every dressing
change
Gentle handling
Monitor vital signs and
wound site often
Provide emotional support
Assess for dehydration
Medical
management
Antiemetic drugs
Other drugs include:
antihistamines
sedatives
hypnotics
anticholinergics
phenothiazine
Replacement of fluids
Eventually high-residue diet
Medications include:
Kaolin and bismuth
preparations
antidiarrheals
antispasmodics
sedatives
Fluid and electrolyte
replacement
Management of wound to
foster healing:
Grafts
Surgical closure
Open-closed technique
Pain-relieving drugs
Analgesics
IDENTIFICATION
Intravenous Therapies
1. T
2. T
3. F One of the goals of care for a patient receiving IV fluids is to deliver the correct fluid at the
prescribed time and at a safe rate of flow.
4.
5.
F When adding a new bottle or bag of IV
fluid for continuous infusion, strict surgical
asepsis must be observed.
T
CALCULATIONS
1. 42 gtts/min
2. 50 gtts/min
3. 700 mL
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Study Guide Answer Key
PRIORITY SETTING
1. b. Mr. Wilson should be first since he is in
danger of a transfusion reaction. a. Ms. Toms
should be next because fluid deficits are dangerous at her age. c. Mr. Whitts should be last.
2. Mr. Whitts, as he is probably the most stable
patient and is at less risk of vital sign swings
than the other two patients.
3. Assess Ms. Toms first; Mr. Wilson has been
checked at 15- to 30-minute intervals since the
blood transfusion was started.
IDENTIFICATION
Blood Gas Analysis
1.
pH
Pco2
HCO3–
PaO2
7.33
50 mm Hg 26 mEq/L 60 mm Hg
↓
↑­
◊
respiratory acidosis with hypoxemia
2.
PaO2
pH
Pco2
HCO3–
7.48
32 mm Hg 25 mEq/L 90 mm Hg
­↑­
↓
◊
respiratory alkalosis with normal oxygenation
3.
pH
Pco2
HCO3–
7.50
45 mm Hg 28 mEq/L
­↑­
◊
↓
metabolic alkalosis with hypoxemia
PaO
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 1, 2, 4
2. 3, 4
3. 2
4. 1, 4
5. 2, 3, 5, 6
6. 4
7. 63 gtts/min
8. See Figure 3-10.
9. 1
10. 1, 2, 3, 5
3.
7
dehydration, a rapid pulse, and low blood
pressure. Her intake was only 270 mL more
than her output, which does not account for
insensible loss. The crackles in the lungs can
be from hypostatic secretions from not deepbreathing and coughing effectively after anesthesia.
She is slightly hypokalemic with a potassium
level of 3.1 mEq/L. Her sodium is within normal range. She is slightly hypochloremic with a
chloride level of 91 mEq/L.
Scenario: Pneumonia
1. Check for signs of acid-base imbalance and
hyponatremia from the fever and diaphoresis.
Check for signs of dehydration. Check the
laboratory values for electrolytes and acid-base
balance.
2. Fever and any fluid and electrolyte imbalance
may cause confusion in the elderly. Hyponatremia is a frequent cause of confusion in this age
group.
3. The patient may have respiratory acidosis if
his shallow breathing is causing a buildup of
carbon dioxide. If his respirations are so rapid
that he is exhaling too much carbon dioxide, he
ould develop respiratory alkalosis.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. Synovial
2. crucial
3. diaphoresis
4. isotonic
5. hypertonic
6. intravascular
7. clammy
8. viscous
9. sprue
10. permeable
COMMUNICATION EXERCISE
CRITICAL THINKING ACTIVITIES
Scenario: Intestinal Surgery
1. You should assess skin turgor and condition of
mucous membranes.
2. She is experiencing a fluid volume deficit because her urine is dark amber and the specific
gravity is 1.030, showing concentrated urine.
She has a temperature elevation that goes with
Patient Teaching
B. Explain that potassium is available in many
fruits such as apricots, avocado, bananas, cantaloupes, dates, figs, honeydew melon (1/4 med),
mango, oranges and orange juice, prunes and
prune juice, and raisins. Some legumes and vegetables such as pinto beans, spinach, tomatoes, winter
squash, and potatoes are also high in potassium.
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Study Guide Answer Key
CHAPTER 4: CARE OF PREOPERATIVE AND
INTRAOPERATIVE SURGICAL PATIENTS
COMPLETION
Preoperative Care
1. laparoscope
2. signed consent
3. impaired renal, hepatic, respiratory, and cardiac function and chronic disease causing vulnerability to fluid and electrolyte imbalances
4. allergies; any medications
5. slower healing; infection
6. baseline vital signs
7. wound healing; pulmonary function
8. latex
9. delayed healing; infection
10. Any three: nonsteroidal antiinflammatory
drugs (NSAIDs); anticoagulants; antiplatelets;
vitamin E; fish oil; 7 to 14
PRIORITY SETTING
a. 6
b. 1
c. 2
d. 3
e. 4
f. 5
g. 7
h. 8
MATCHING
Surgical Risk Factors and Their Effects on
Recovery
1. d, g
2. b, f, h, i
3. a, c, e
COMPLETION
1. liver
2. circulating
3. thrombus
4. emotional/psychosocial
5. a. How long the surgery will take
b. Where they can wait
c. When they will be able to see the patient
6. Anesthesia depresses the gag reflex and sometimes causes nausea as the patient comes out of
the anesthesia. This makes the patient susceptible to vomiting and aspiration of secretions,
which can cause complications or even death.
APPLICATION OF THE NURSING PROCESS
1. Anxiety due to surgery and husband’s possible
reaction to the surgical changes; Grief over
impending loss of a body part and function;
Disrupted sleep pattern due to anticipation of
surgery and need to arise very early
2. Patient will manage anxiety with relaxation
exercises prior to surgery.
Patient will express concerns to husband about
his feelings regarding the loss of her breast before surgery.
Patient will obtain 6 to 8 hours of sleep prior to
surgery.
3. You should both check the patient’s ID bracelet
with the medical record. You would check one
last time for any jewelry or underwear on the
patient. You would help transfer the patient
to the stretcher and adequately cover her for
warmth and modesty. You would finish the
documentation note and check to see that the
preoperative checklist is complete. Remind her
that the surgeon will verify with her and mark
the correct breast prior to surgery. You should
wish her well and assure her she will be well
taken care of upon her return.
d evaluate whether the interventions
listed on the preoperative care plan were carried out and whether they were effective in
achieving the expected outcomes. Verify that
she discussed her concerns with her husband.
Ask if her anxiety about her husband’s reaction
has lessened. Did she express her grief about
losing her breast? Inquire as to whether she
practiced the relaxation exercises and if they
helped. Determine if she took her sleeping pill
last night and whether she was able to sleep for
6 to 8 hours.
SHORT ANSWER
Intraoperative Care
1. Blood is withdrawn from the patient at the
blood bank several weeks before surgery. It
is prepared and stored for reinfusion should
the patient need it after surgery. The purpose
is to have blood on hand (in case it is needed)
that is free from blood-borne viruses such as
HIV or hepatitis B or C. Autologous blood also
decreases the chance of a transfusion reaction
when it is infused, because the patient’s own
blood is being infused. If needed, the autologous blood is reinfused during or after surgery.
2. Regional anesthesia is more economical and is
less dangerous than general anesthesia.
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Study Guide Answer Key
3.
4.
5.
6.
7.
a. Tissue biopsy
b. Cyst excision
c. Pacemaker insertion
d. Vascular access device insertion
Any three of the following:
a. Positive air pressure is maintained to prevent the airborne entry of microorganisms.
b. The operating room cannot be entered unless the person has scrubbed and is dressed
in sterile attire.
c. Surgical asepsis is practiced by the personnel in the operating room.
d. The temperature of the room is kept low to
discourage microbial growth.
e. The room is thoroughly cleaned between
surgical procedures.
The surgical procedure to be performed is
verified as correct on the consent form by the
surgeon and the preoperative care nurse. The
patient’s ID bracelet is checked to make certain it matches the information on the medical
record, the preoperative checklist, the surgical
consent form, and the medical record. The site
is marked, with the patient verifying that the
mark is correct, before the patient is sent to
able in the operating room before the start of
surgery. Before surgery begins, a “time out”
occurs and a final verification of the correct
patient, procedure, site, and as applicable, implant is performed. Any questions or concerns
must be resolved before the procedure begins.
a. To prevent pain
b. To achieve adequate muscle relaxation
c. To calm fear, ease anxiety, and induce forgetfulness of an unpleasant experience
a. Perform a surgical skin preparation. Ensure that sterile technique is maintained
during surgery.
b. Maintain fluid infusions at the ordered
rates; monitor urine output during surgery
if a urinary catheter is inserted. Monitor
blood pressure levels during surgery; report amount of blood loss at intervals during surgery.
c. Monitor the patient’s temperature during
surgery; apply a warming blanket device
as needed to maintain body temperature
between desired limits; observe for signs of
beginning hypo- or hyperthermia.
d. Pad all bony prominences when patient is
positioned on the operating table. Secure
the patient with safety straps. Be certain
that measures to ensure the right patient
9
and right surgery in the right location have
been carried out. Check allergies before
the start of surgery and make certain that
the surgeon, assistants, anesthesiologist or
nurse anesthetist, the scrub nurse, and the
circulating nurse are aware of the patient’s
allergies.
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 4
2. 1, 4
3. 3, 5
4. 3
5. 2, 3, 5
6. 2, 3, 5, 6
7. 2
CRITICAL THINKING ACTIVITIES
1. You should verify that the patient is positive
she doesn’t want to have the surgery. Let the
charge nurse know and ask that the surgeon be
notified. Stop preoperative preparations. The
surgeon will need to come and speak to the patient.
MDocument your exact actions in the medical
record after noting the words the patient used
when stating she did not wish to have the surgery. Note the time the surgeon was notified
and who notified him or her.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. hemodilution
2. coercion
3. invasive
4. laparoscopic
GRAMMAR POINTS
Verb Forms—Future Tense
1. “You will need to refrain from eating or drinking anything after midnight the night before
surgery.”
2. “You will need to be at the outpatient surgery
desk at 6:00 am. Be sure you have showered
with the antibacterial soap both the night before and in the morning.”
3. “Your skin will be washed with an antimicrobial solution once you are on the operating table.
Clippers may be used to remove hair around
the operative site.”
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4.
“There will be a sleeping pill ordered for you
to take at bedtime to help you sleep. It is advisable to take it, as it is often difficult to sleep just
before surgery.”
5. will help
6. is
7. to ask
8. will be
9. will remove/take off
10. will be
CULTURAL POINTS
1. Does the person have hearing aids? Glasses or
contact lenses? Dentures or a dental bridge?
Use a cane or walker? Have a prosthesis?
2. You should state where you will put the particular item and/or when each will be given back
to the person. For example, “Your glasses are
in the drawer of the bedside table.” “Your leg
prosthesis is in the closet and I’ve noted that
on the chart.” “I have given your hearing aid to
your wife to keep until after surgery.”
CHAPTER 5: CARE OF POSTOPERATIVE SURGICAL PATIENTS
TABLE ACTIVITY
Anesthesia Implications
Type of Anesthesia
Postoperative Nursing Implications
Inhalation (general
anesthesia)
Patient may have little need for narcotics immediately after surgery because
effects of inhalant anesthetic may persist even after the patient has regained
consciousness.
Monitor for respiratory and circulatory difficulties.
Intravenous
drugs (procedural
sedation)
Monitor airway patency and vital signs.
RADbeEpresent
SLABpostoperatively
.COM
Nausea and vomitingGmay
if fentanyl was given.
Commonly used drugs are barbiturates, which may present problems of
laryngospasm and bronchospasm, so patient must be observed closely. Provide
quiet, nonstimulating environment while patient is emerging from the effects of
anesthesia if patient was given ketamine.
Monitor level of consciousness and ability to respond appropriately to verbal
commands.
Regional or topical
Patient remains conscious, so fewer respiratory difficulties and cardiovascular
complications occur.
Observe for depression of respirations and lowered blood pressure, which can
occur if anesthesia ascends beyond point of injection.
If patient underwent spinal surgery, keep the patient flat in bed for a designated
time (8 hours) and observe for headache, dizziness, numbness, and heavy feeling
in legs.
SHORT ANSWER
PACU Care
1. use the jaw-thrust maneuver; place the fingers
behind the angle of the jaw and lift the jaw forward
2. a. to help eliminate the anesthetic gases
b. to help meet the increased metabolic demand for oxygen caused by surgery
3. activity, respiration, circulation, consciousness,
skin color, and oxygen saturation level
Postoperative Care
1. if any area of the lung remains atelectatic for
more than 72 hours, hypostatic pneumonia
from retained secretions is likely to occur
2. a. Monitor frequently to be sure it is open
and draining.
b. Use strict aseptic technique when handling
the drain and changing dressings around
it.
lOMoARcPSD|9825609
Study Guide Answer Key
c.
3.
4.
5.
6.
7.
Measure the amount, note characteristics of
drainage, and document these in the medical record.
d. Assess the skin around the drain.
e. Maintain suction by periodically compressing device.
skin is warm to the touch; fingers or toes have
brisk capillary refill; there is no undue swelling; pulses are present
Reinforce the dressing as needed, report abnormal drainage to the surgeon, and confer with
the surgeon about orders for dressing change
during his or her next rounds.
Amount (estimate if necessary), color, odor,
viscosity, and if it contains clots or bits of tissue
Pain, redness, swelling and hardness in the
area, fever, purulent drainage, and elevated
white cell count
With the patient supine, cover wound and
intestinal contents with sterile towels or dressings moistened with normal saline. Notify surgeon immediately.
COMPLETION
1. quality; depth of respiration
2. warmth; nausea
3. thirst; restlessness; blurred vision; and difficult
respiration
4. a. increases; bounding at first, then thready
b. falls
c. rapid
d. cold and clammy, pale; cyanosis of lips and
nail beds occurs late
e. decreases until comatose
5. crackles in the lungs; shortness of breath; confusion
6. pulmonary embolus, but any patient with chest
pain should have myocardial infarction ruled
out
APPLICATION OF THE NURSING PROCESS
1. Altered breathing pattern due to analgesia and
pain; Pain, acute due to surgery; Altered skin
integrity due to surgical incision; Potential infection due to surgical wound
2. a. Patient will breathe effectively as demonstrated by an oxygen saturation above 95%.
b. Patient’s pain will be controlled with analgesia to a level of 2 to 5 within 1 hour.
c. Patient’s incision will remain clean, dry,
and intact until sutures/clips are removed.
d. Patient will have no signs of wound or systemic infection at time of discharge.
3.
4.
5.
6.
7.
11
The patient’s temperature, respirations, and
pulse should be monitored. Auscultate the
breath sounds. The CBC (complete blood
count) lab results should be tracked for elevations in the WBC (white blood cell) count.
Monitor oxygen saturation level at least every
4 hours. Check use of incentive spirometer. Increase activity level as soon as possible.
You should encourage relaxation exercises
such as deep-breathing, progressive muscle
relaxation, or imagery. You could also supply
distraction activities. Keep the room tidy and
quiet and the bed smooth, clean, and warm
enough. Discourage outside ambient noise by
keeping the door closed. Excess sensory stimulation can heighten perception of pain.
You should instruct the patient in the proper
use of the incentive spirometer, supervise its
use, and encourage its use every 2 hours while
awake and at the time of vital sign measurement at night. Sit the patient up with the back
away from the mattress to allow good expansion of the lungs. Encourage coughing after use
of the spirometer. Splint the incision well when
coughing is attempted. Teach to “huff” cough
regular cough cannot be achieved. Encourage adequate fluid intake if not NPO. Have the
patient do foot and leg exercises to promote
good circulation every 2 hours. Ambulate and/
or transfer to chair three times a day. Show
the patient how to do active range-of-motion
(ROM) exercises on upper body.
Chest expansion is adequate and equal bilaterally, depth of respiration is appropriate, there is
no sign of dyspnea, and the oxygen saturation
level is between 95% and 100%.
Pain is adequately controlled if the level is
between 0 and 4 on a pain scale, with decreasing pain over time and decrease in pain when
medication is administered. Ideally, pain level
should be no more than 2 on the pain scale
until just before another dose of medication is
due.
PRIORITY SETTING
a. 2
b. 3
c. 1
d. 6
e. 8
f. 9
g. 4
h. 12
i. 5
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Study Guide Answer Key
j. 10
k. 11
l. 7
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 2, 3, 4, 5
2. 4
3. 4
4. 4
5. 2
6. 2
7. 2
8. 1, 2, 3, 4, 5, 6
9. 28
10. 2
CRITICAL THINKING ACTIVITY
1. atelectasis and retained secretions
2. Fluid deficit/dehydration
3. Instructions should include diet, activity, medication schedule, possible side effects of medications, wound care, respiratory care, bathing
instructions, activity restrictions, signs of complications to report, when to see the surgeon
next.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. groggy
2. kinked
3. numb
4. malaise
5. induce
GRAMMAR POINTS
Verb Forms
1. You should
2. You must
3. You should not
4. You must not
5. You should
CHAPTER 6: INFECTION PREVENTION AND
CONTROL
COMPLETION
1. positive
2. immune system
3. health care–associated (formerly known as
nosocomial)
4.
5.
6.
7.
8.
sexual
airborne; contact; droplet
latent; oncogenic; active
active; lethal
“buddy”
SHORT ANSWER
Causes and Symptoms of Infection
1. Any four of these:
a. Cough
b. Fever
c. Malaise
d. Abnormal breath sounds
e. Increased respiratory rate
f. Production of sputum (yellow, green,
brown)
2. a. Heat
b. Redness
c. Swelling
d. Pain
e. Limitation or loss of function
3. a. Headache
b. Myalgia (muscle aches)
c. Fever
d. Diaphoresis (sweating)
f. Anorexia (loss of appetite)
g. Malaise (weakness)
Nursing Interventions for Patients with
Infections
1. Any three of these:
a. Increase fluid intake.
b. Administer antipyretic medication as ordered.
c. Control environmental temperature.
d. Provide tepid baths.
2. Any three of these:
a. Cover the mouth when sneezing or coughing.
b. Turn one’s head away to prevent coughing
into the face of another.
c. Dispose of soiled tissues in waste containers.
d. Perform hand hygiene after contact with
actual or potentially contaminated items.
e. Avoid contact with others who may have
an infection.
3. a. Perform hand hygiene; it is the key to
breaking the chain of infection.
b. If the patient has Clostridium difficile or
Candida albicans infection, the health care
worker must use soap and water to cleanse
the hands.
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Study Guide Answer Key
c. Inform housekeeping staff about C. difficile.
d. Perform hand hygiene before and after any
direct patient contact, before and after any
invasive or sterile procedure, after contact
e.
13
with infectious materials, and before contact with immunocompromised patients.
Do not place soiled or contaminated items
on the floor.
TABLE ACTIVITY
Category-Specific Isolation Expanded Precautions (Transmission-Based Precautions)
Isolation
Category
Private Room
Masks
Common Diseases
Placed into Isolation
Category
Gowns
Gloves
Airborne
Infection
Isolation
Always; door to
room must be
kept closed at all
times
Must wear a fittested NIOSHapproved N-95
respirator
No, unless
draining wounds
No, unless
draining wounds
Pulmonary
or laryngeal
tuberculosis
or draining
tuberculous skin
lesions; smallpox,
viral hemorrhagic
fever, severe
acute respiratory
syndrome (SARS);
measles; varicella,
disseminated
zoster
Contact
Precautions
Preferred;
cohorting of
patients with
same type of
infection is
acceptable
Situationdependent
Always; if
patients are
cohorted, staff
must perform
hand hygiene
and change PPE
between patients
Always; if
patients are
cohorted, staff
must perform
hand hygiene
and change PPE
between patients
Open or draining
wounds, MRSA,
VRE, ESBL
positive; diarrhea;
MDRO infections
Droplet
Precautions
Preferred;
cohorting of
patients with
same type of
infection is
acceptable
Wear a surgical
mask when
entering room;
patient should
wear mask during
transport and
observe cough
etiquette
Not usually
When helping
with coughinducing
procedures or
discarding of
used tissues
Pneumonia,
influenza,
rubella, pertussis,
streptococcal
pharyngitis,
meningitis caused
by Neisseria
meningitidis or
Haemophilus
influenzae type B
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Study Guide Answer Key
Isolation
Category
Ebola
Precautions
(Requires
“buddy”
to assist
donning/
doffing PPE)
Private Room
Mandatory
Masks
Gowns
Gloves
Must wear N-95
respiratory mask,
full-face shield,
cover hair
Change into
hospitalissued scrubs
or disposable
scrubs, then don
impervious cover
gown and hood
that covers all
of the neck and
chest. If activities
performed in the
patient’s room are
likely to dislodge
cuff or gown,
secure cuff with
Coban or tape
Don first pair
before donning
impervious shoe/
leg cover, don
cover gown.
Second pair is
donned after face
mask, hair cover,
and hood are
donned
Common Diseases
Placed into Isolation
Category
Airborne, Contact
Precautions
with “buddy”
observing all
aspects of care
being provided
to ensure no
exposure or
contamination
has occurred to
the nurse in the
room caring for
a patient with
Ebola
ESBL, extended-spectrum beta-lactamase; MDRO, multidrug-resistant organism; MRSA, methicillin-resistant Staphylococcus aureus;
NIOSH, National Institute of Occupational Safety and Health; PPE, personal protective equipment; VRE, vancomycin-resistant enterococci
PRIORITY SETTING
a. 1 Check the order and know why the patient
is to receive an antimicrobial drug.
b. 2 Check that the dosage of the antimicrobial
drug is appropriate for the patient.
c. 5 Verify allergies with the patient before administering an antimicrobial drug.
d. 4 Obtain cultures prior to administering the
antimicrobial agent.
e. 3 Check to see if serum drug levels or cultures have been ordered.
f. 6 Monitor patient for signs of allergic reaction, such as rash, hives, itching, fever,
swelling of the mucous membranes, difficulty breathing, or anaphylaxis.
WER
Sepsis
1. Any four of these: tachycardia, increased cardiac output, tachypnea (rapid breathing), fever,
an elevated WBC count, or an altered level of
consciousness
2. The elderly often experience hypothermia with
a subnormal body temperature when septic.
Change of mental status may be one of the first
signs for elderly patients who develop an infection.
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Study Guide Answer Key
15
APPLICATION OF THE NURSING PROCESS
Care of the Patient at Risk for Infection
Problem Statement/Nursing Diagnosis: Potential for infection due to poor circulation and skin
ulceration
Goals/Expected Outcomes
Patient will not demonstrate any
signs of infection (i.e., fever or
redness on legs) during this shift.
Patient will remain free from
infection during his stay at the
facility.
Nursing Interventions
1.
2.
3.
4.
5.
6.
7.
8.
9.
Promote good hand hygiene.
Encourage nutritious highprotein diet.
Assess for signs of local
infection (i.e., redness, purulent drainage).
Monitor temperature.
Be vigilant for signs of systemic infection (i.e., change
in mental status, fatigue,
sudden confusion, or irritability).
Elevate legs when in bed or
chair.
Encourage frequent flexion
and extension of toes and
ankles to increase circulation
or provide passive ROM if
Evaluation
Patient did not have any fever.
Skin appears scratched with
5-cm area of redness and swelling over left lateral malleolus.
Health care provider notified.
Patient continues to scratch at
leg despite reminders.
Short-term goal not met. Plan to
be revised.
Encourage (assist) patient to
keep skin clean and dry.
Instruct patient to avoid
scratching skin.
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 1, 2, 3, 4
2. 4
3. 2, 3, 4
4. 3
5. 2
6. 2, 3, 4
7. 2
8. 3
9. 4
10. 3
11. 1, 3
12. 2, 4, 5, 6
13. 4
14. 2.5 mL
15. 18.73 (rounded to 19 mL)
CRITICAL THINKING ACTIVITIES
Scenario A
1. Talk to the nursing assistant about the purpose
of neutropenic precautions. Advise him or her
to speak to the charge nurse and ask to be reassigned until the symptoms subside and the
danger of infecting the patient has passed.
Scenario B
1. Start with an attitude of caring; for example, “I
am really worried that you are exposing yourself to blood pathogens. You are good at your
job and I want you to continue to be healthy.”
Assess the technician’s belief that gloves are
not needed; for example, “How did you come
to the decision that the gloves were not necessary?” Suggest that the technician discuss the
situation with his or her supervisor.
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Study Guide Answer Key
STEPS TOWARD BETTER COMMUNICATION
MATCHING
1. d
2. a
3. e
4. b
5. c
PRONUNCIATION SKILLS
1. Draping the patient on the table before a procedure protects the patient’s privacy and modesty. It helps to maintain aseptic conditions.
2. Ms. Clay has fever and malaise and her wound
has green exudate.
3. Ms. James is not having any pain, but she has
gained more than eighteen pounds in weight.
COMMUNICATION EXERCISES
1. “Ms. Compton, I would like to share some
ways to prevent the infection under your arm
from spreading. You will need to wash your
hands, both before and after touching the infected area under your arm. This will help prevent the infection from being spread to other
parts of your body or to someone else. Us
2.
fresh towel every day when you take a shower.
Don’t use the same washcloth or towel that
you use to clean your underarm area to wash
or dry any other part of your body, and be especially careful to use only a clean washcloth
and towel in the area of your hysterectomy
incisions. Use hot water, detergent, and bleach
and separately wash the dirty towels. This will
help destroy any bacteria on them.”
“Infection spreads when the germs causing
your infection are carried to other areas. They
can be carried by hands that have touched
the area of infection, by dirty dressings, or by
anything the contaminated hands or dressings
have touched. To help prevent the infection
from spreading, wash your hands before and
after caring for the wound and wear gloves to
change the dressing. Dispose of the dirty dressings properly by placing them in a plastic bag
that can be sealed before putting them in the
trash container. The gloves must be removed
without touching the outside of them as soon
as you have finished removing the dirty dressing. I will show you how to remove the gloves
properly.”
CHAPTER 7: CARE OF PATIENTS WITH PAIN
TABLE ACTIVITY
Common Terms to Help Patients Describe Their Pain
Degree of pain (from
least to most severe)
Absent, minimal, mild, moderate, fairly severe, severe, very or extremely
severe, excruciating, faces scale or numeric scale.
Quality of pain
Crushing, tingling, itching, throbbing, pulsating, twisting, pulling, burning,
searing, stabbing, tearing, biting, blinding, nauseating, debilitating
Frequency of pain
Constant, intermittent, occasional, related to something specific (e.g., only
when coughing)
COMPLETION
1. endorphins
2. referred
3. increases
4. reddened by pressure
5. distract
6. reducing (or relieving)
7. morphine; hydromorphone; hydrocodone
8. activities of daily living
SHORT ANSWER
Pain and Pain Management
1. a. Pain may be present even though no cause
for it can be found.
b. Pain tolerance is a physiologic response to
pain that is made more complex by psychosocial factors, many of which may be
beyond the patient’s control.
c. Acute pain is generally associated with
anxiety, whereas chronic pain is associated
more often with depression.
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Study Guide Answer Key
2.
3.
4.
d. Only a very small percentage of patients
become addicted to drugs administered for
the purpose of relieving acute pain.
e. There is no basis for believing that a
patient who finds relief from pain after
receiving a placebo is pretending to have
pain or that it is “all in his mind.”
a. Culture
b. Pain experience
c. Expectations
d. Role behaviors
Any of these: sleep, warmth, distraction, relaxation, imagery and meditation, hypnosis,
biofeedback, music, cold, binders, massage,
acupuncture, transcutaneous electrical nerve
stimulation
They can induce relaxation, thereby decreasing
the pain experience.
TABLE ACTIVITY
Acute Versus Chronic Pain
See Table 7-2.
APPLICATION OF THE NURSING PROCESS
Caring for a Patient with Acute Pain
1. Any of these: rapid, shallow, or g
pirations; pallor; diaphoresis; increased pulse
and blood pressure; dilated pupils; tenseness of
skeletal muscles
2. Any of these: being withdrawn, irritable, demanding, or argumentative; “cradling” the
area; crying; refusing to eat or drink; any behavior out of the ordinary for the patient
3. a, b, c, d
4. a. Initial pain assessment
b. Measures taken to treat or relieve the pain
c. Evaluation of the effectiveness of the measures taken
d. Notification of the health care provider of
any problems or concerns
e. Patient and family teaching about pain and
its relief
PRIORITY SETTING
Scenario A
2 a. Verify PCA pump settings with order.
6 b. Reinforce teaching about medications.
4 c. Use nonpharmacologic measures, such as
elevation or ice packs.
5 d. Report to the health care provider when
measures are not effective.
1 e. Assess the patient’s pain.
3
f.
17
Check the medication record for last dose
of ibuprofen.
Scenario B
2 a. Mr. Johnson is postoperative. There is a
potential for complications such as hemorrhage or peritonitis.
1 b. Ms. Quick is having the signs and symptoms of a potential myocardial infarction.
3 c. Mr. Ben-David could be having complications related to his cast. This could cause
permanent damage if the circulation is impaired for more than 4 hours.
4 d. Mr. Ramous has chronic pain that needs
attention, but it does not represent an immediate danger.
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 2
2. 2
3. 3
4. 3
5. 3
6. 3
7. 1
C
8. M
4
9. 4
10. 4
CRITICAL THINKING ACTIVITIES
1. d
2. b
3. c
4. d
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. imagery
2. creeping
3. grimace
4. compounds
5. frail
6. placebo
7. “stiff upper lip”
8. tolerance
9. indicative
MATCHING
1. b
2. c
3. a
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Study Guide Answer Key
TERMINOLOGY
Evaluating Pain
1. absent
2. minimal
3. mild
4. moderate
5. fairly severe
6. severe
7. exquisite
8. very severe
9. extremely severe
MATCHING
1. a, h
2. g, i, m
3. d, e, l
4. b, f, k
5. c, j
COMMUNICATION EXERCISES
1. “Dr. Smith, this is Mary Harper, the nurse caring for Mr. Jones. I’m calling because Mr. Jones’
morphine 4 mg IV is not relieving his pain
for more than an hour. His blood pressure is
146/92, pulse is 94, and respirations are 22 per
minute. He is allergic to codeine. His last
of morphine was one hour ago and his current
pain level is 9/10. Could we try a PCA pump
for this patient?”
2. “Jane, Ms. Poson in room 312 received four mg
of morphine IV an hour ago. I just checked on
her again and her respirations have dropped to
10 per minute. They were 14 per minute when
she received the morphine. And her oxygen
saturation has dropped from 95% on room
air to 89%. I’m concerned about this change. I
have started her on 2 L of oxygen and tried to
get her to take deep breaths. What else should I
do?”
CHAPTER 8: CARE OF PATIENTS WITH
CANCER
COMPLETION
1. uncontrolled
2. neoplasm
3. sarcomas; carcinomas; leukemias and lymphomas; melanomas
4. primary tumor; regional nodes; metastasis
5. Viruses; radiation; hydrocarbons
6. surgery; radiation; chemotherapy
7. vesicants
8.
9.
10.
11.
bone marrow
protective clothing; sunglasses
diarrhea
2 mL
MATCHING
Risk Factors for Cancer
1. a
2. e
3. d
4. c
5. b
6. f
7. g
SHORT ANSWER
Interventions for the Side Effects of
Chemotherapy
1. Any five of these:
a. Teach to maintain a good balance of energy
expenditure and rest.
b. Assist to minimize emotional distress.
c. Help patient maintain activities of daily
living (ADLs).
Instruct
C
OM in the use of energy-saving devices.
e. Assist to prioritize activities.
f. Teach to maintain a good nutritional status
with high protein intake.
g. Administer supplemental feedings between meals as needed.
h. Explain that fatigue is a normal side effect
and that it may continue for 2 to 3 months
after completion of therapy.
i. Suggest light exercise, such as walking.
2. Any five of these:
a. Keep needle sticks to a minimum.
b. Use the smallest-gauge needle possible.
c. Apply pressure to insertion site for 5 to 10
minutes or until bleeding stops.
d. All urine and stool should be tested for the
presence of blood.
e. Abdominal girth is measured daily to
check for internal bleeding.
f. Ice is applied to any area that is bumped or
injured.
g. Stool softeners are given to keep the stool
soft.
h. No rectal suppositories or enemas are
given, and rectal temperatures are contraindicated.
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Study Guide Answer Key
3.
4.
Any five of these:
a. Encourage frequent oral intake of liquids
that are not chemically irritating.
b. Encourage use of artificial saliva.
c. Encourage frequent and consistent mouth
care.
d. Teach to brush teeth using a soft brush or
tooth sponges; use gentle strokes.
e. Teach to irrigate mouth with solutions such
as normal saline, mild solutions of peroxide, a bicarbonate of soda solution, or salt
solution.
f. Teach to disinfect toothbrushes with a
bleach solution or hydrogen peroxide and
then rinse with water before use.
g. Administer special topical compounds,
such as Xylocaine Viscous, that are
“swished and spit.”
h. Teach to avoid spicy foods, alcohol, and
tobacco.
Any five of these:
a. Staff and patient should practice good, frequent, and thorough hand hygiene.
b. Maintain strict asepsis in all aspects of patient care.
c. Protect from exposure to peop
ratory or other infections.
d. Teach to avoid sharing personal care items.
e. Assess for signs of infection (i.e., white
patches in mouth, foul-smelling drainage,
fever).
f. Teach to avoid raw or undercooked food.
g. Teach to avoid handling garden flowers,
plants, earth, or cat litter boxes and bird
cages.
APPLICATION OF THE NURSING PROCESS
Caring for a Patient with Non-Hodgkin’s
Lymphoma
1. a. Onset, frequency of symptoms, and approximate amount of fluid loss (if she has
been discarding the waste without telling
the staff)
b. Signs of dehydration (i.e., dry mucous
membranes, decreased skin turgor, records
of intake and output [I&O])
c. Whether antiemetics or antidiarrheals have
been ordered, and if so, when last administered; check documentation for patient’s
response to medication
d. Ms. Junic’s understanding of reporting side
effects and symptoms (refer to RN as appropriate)
2. b
3.
4.
5.
19
Any six of these:
a. Suggest eating before treatment.
b. Suggest eating toast or crackers before arising or engaging in activity.
c. Encourage patient to eat slowly and chew
thoroughly.
d. Inform patient that carbonated drinks or
tea are tolerated better than other liquids.
e. Give liquids 1 hour before or after meals,
not with meals.
f. Encourage patient not to lie down for at
least 2 hours after a meal.
g. Discourage caffeine and rich or fatty foods.
h. Make environment pleasant and free from
bothersome smells, sights, or sounds.
i. Suggest chewing gum or sucking on hard
or sour candy, or ice chips.
j. If nausea occurs, suggest slow, deep
breathing through the mouth.
Answers will vary. Five reputable web resources should be listed.
b
PRIORITY SETTING
4 a. Give Ms. Hobbs her am dose of Megace;
this is an adjunct to her chemotherapy. You
can attend to this need very quickly.
3 b. Ask the nursing assistant to help Ms.
Hiroshi with her breakfast. (Note: if there
is no assistant available, attend to Ms.
Hobbs and then help Ms. Hiroshi.)
1 c. Attend to Mr. Lopez first. With a platelet
count of 10,000/mm3, he should be assessed for signs of spontaneous bleeding;
the health care provider may order a transfusion.
2 d. Assess Mr. Nehru for pain, and give medication as appropriate.
5 e. Ms. Jaiswal has a psychosocial need. If you
are able to spend some unhurried time
with her, it is an opportunity to provide
therapeutic communication and teaching.
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 2, 4
2. 1, 3
3. 1, 2, 5
4. 3
5. 2
6. 2
7. 2
8. 1, 2, 3
9. 1
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Study Guide Answer Key
10. 1
11. 3
12. 2
CRITICAL THINKING ACTIVITIES
1. a, b, d
2. b
3. a, b, d
4. c
5. b
6. b
ods of radiation delivery, this is much less severe
than it once was. We also have better medicines
now to control diarrhea for the patients in whom
it occurs. Nausea is more common when organs
closer to the stomach are being treated. It is not
common in the treatment of prostate cancer.”
Mr. Tomm: “Oh, well that is good news. I guess
I will think positively and not worry about these
things unless they happen to me.”
Nurse: “That is an excellent attitude, Mr. Tomm.”
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. Metastasis
2. malignant
3. occult
4. carcinogen
5. transformation
6. benign
7. depletes
8. adjuvant
9. intrinsic
10. immunocompetent
11. in situ
12. metastasize
Types of Tissues
1. gland
2. smooth muscle (such as uterus)
3. lymphocytes (lymph glands)
4. skin (black-pigmented tumor)
5. bone
6. connective tissue (fibrous tissue)
COMMUNICATION EXERCISE
Nurse: “Can you tell me a little about your concerns?”
Mr. Tomm: “I’m wondering what it will feel like
during the treatment and what the side effects will
be. I have heard about terrible burns on the skin
and long bouts of diarrhea and nausea.”
Nurse: “You will hear some sounds as the machine
is turned on and off, but you will not feel anything
while the radiation is delivered. The new ways of
giving radiation treatments have nearly eliminated
the skin burns that used to occur. Some patients do
experience diarrhea because of irritation and cell
damage to the intestine, but with the newer meth-
CHAPTER 9: CHRONIC ILLNESS AND
REHABILITATION
SHORT ANSWER
Chronic Illness and Immobility
1. Any five of these (See Box 9-1)
a. Diabetes
b. Heart disease
c. Stroke
d. Rheumatoid arthritis
e. Asthma or chronic obstructive pulmonary
disease (COPD)
ologic diseases such as multiple sclerosis
g. Cerebral palsy
Any other chronic disease causing difficulty with
daily care or disability
2. a. to provide a safe environment
b. assist patients to maintain or attain as
much function as possible
c. promote individual independence
d. allow maintenance or achievement of autonomy
3. resilience
4. coping
5. muscle strengthening; balance
6. the patient no longer needs health care
7. a decrease in muscle strength, generalized
weakness, easy fatigue, joint stiffness, decreased coordination, abdominal distention,
and metabolic changes
8. a. hypostatic pneumonia
b. constipation
c. urinary problems
d. inadequate nutritional intake
e. loss of joint range of motion
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Study Guide Answer Key
TABLE ACTIVITY
Body System
Musculoskeletal
Gastrointestinal
Cardiovascular
Neurologic
Renal/urinary
Respiratory
Integumentary
Measures to Prevent
Complications
Active or passive ROM
exercises
Splinting of joints/foot
support
Ambulation
Weight-bearing exercises
Increased fluid intake
Increased fiber intake
Increased physical activity
Exercises and physical activity
Antiembolism stockings
Sequential compression
devices
Low–molecular-weight
heparin
Avoidance of leg massage
Appropriate sleep-wake
schedule
Frequent reorientation
Control of sensory stimulation
Avoidance of sudden position
changes
Increased fluid intake
Maintenance of acidic urine
Avoid indwelling catheter if
possible
Frequent repositioning
Respiratory exercises
Incentive spirometer use
Frequent repositioning
Pressure-relief devices
Skin care
Adequate nutrition
Skin monitoring
COMPLETION
1. captain
2. physical; occupational; speech; cognitive; recreational
3. the patient’s need for independence
4. help the patient; continuation of medical therapy
5. patients are at greatest risk
6. hazards in the environment
7. crouch (or stoop down); sit
8. immobility
9. ROM (range of motion) of legs, feet, and ankles
10. sight; hearing
11. electrolyte imbalances
21
12. risk for loneliness
13. as well as possible; to stay at home
14. the patient care assistants or CNAs
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 2
2. 4
3. 2
4. 2
5. 1, 2
6. 3
7. 3
8. 3
9. 4
10. 2
CRITICAL THINKING ACTIVITIES
Scenario A
1. A physical therapist and occupational therapist
would be involved in Mr. Timmons’ care. Every patient in a rehabilitation facility would be
receiving services from the physician, nurses,
pharmacist, and dietitian. Restorative or nursing care assistants would participate in his care
s well.
2. Skin care would include turning him every 2
hours when he is in bed and helping him reposition every 2 hours when in a wheelchair. Areas under the leg brace should be inspected at
least every shift. Skin at the leg fracture site is
inspected every shift. The pin insertion sites of
the halo traction device should be cleaned and
inspected according to the prescribed schedule,
usually every 8 to 12 hours. His skin should
be inspected each shift for signs of reddening
or breakdown. All skin assessments and care
must be documented.
3. Active ROM of the uninjured extremities
should be performed every shift; more frequently for the legs to prevent thrombus
formation. Passive ROM is performed on the
injured extremity. The neck is held in alignment by the halo traction and is not moved.
Isometric and active muscle exercise is supervised by the physical therapist to prevent
muscle atrophy. When the leg fracture is healed
sufficiently, quadriceps setting exercise will be
started.
Scenario B
1. The overall goals for this patient would be a
return to a state of reduced confusion. Ulti-
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22
2.
3.
Study Guide Answer Key
mately, a restful night’s sleep is desirable and
can be achieved if she is able to be calmed.
A night-light that gives illumination without
shining in the patient’s eyes or causing frightening shadows can be used. Keep the call bell
within reach and visit the patient frequently to
calm and reassure. Moving the patient closer to
the nurses’ station, touching, and other signs
of caring are all ways to intervene to minimize
nocturnal confusion. A bed alarm that alerts
staff when the patient attempts to get out of
bed is helpful. Door alarms that announce
when the patient has left his or her room or
designated area may be used in place of security devices and prevent patients from wandering in unsafe areas. Keeping the patient active
during the day and encouraging physical exercise helps promote sleep at night. Listening
to the patient to try to determine any possible
cause of unrest or fear can often help solve the
problem. Review her medication list and see
if any new medications have been added that
may be causing the confusion.
Physical concerns would be safety risks, such
as increased risk for falls and injury, sleep deficit, anxiety, and other psychosocial needs.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. coping
2. sundowning
3. ascertain
4. optimal
5. people skills
6. suboptimal
COMMUNICATION EXERCISES
1. The therapist will come to see you on Thursday. We will come together. I hope your arthritis is better by then. Take your bath and
brush your teeth before we come. These are the
breathing exercises that you need to practice.
They will help you feel better. Thanks for being
such a good sport.
2. “Tom, I am leaving for lunch now. Would you
cover my patients for me? I am assigned to
everyone in B wing. I just gave Ms. Holt her
pain medication. I will be back to give my 1:00
medications. Annie is assigned to take the noon
vital signs and should report any abnormalities
to you. Would you please check with her about
12:30? Mr. Tims must be watched because he
keeps trying to get out of his wheelchair. That
is why he is positioned at the nurses’ station. I
will be in the lunch room. Thanks a lot!”
CHAPTER 10: THE IMMUNE AND LYMPHATIC
SYSTEM
COMPLETION
Review of Anatomy and Physiology
1. Peyer’s
2. Antibodies
3. skin
4. phagocytosis
5. autoimmune
LABELING
Anatomy of the Organs of the Immune System
See Figure 10-2.
Caring for a Patient with an Immune Disorder
1. “Isolation is to protect you [the patient] from
being exposed to a health care–associated infection.”
2. a. Protect from infection
b. Improve health status
tain high degree of wellness to promote optimal immune function
3. Patient may fear that he may contract a serious
infection at any time. He also may believe that
isolation signals an “especially serious case.”
Patients in isolation experience loss of normal
social contacts and have the additional burden
of communicating with people who are wearing masks, which obscure facial expression and
muffle voice quality. Personal protective equipment (PPE) creates a psychological barrier of
being treated differently. In addition, caregivers
are likely to spend less time going in and out
of the room because of the time it takes to don
and discard PPE. There is disruption of normal
work and activities, and visitors may hesitate
because of generalized fear of contagion.
4. a. Assess for signs of infection continually
and report them immediately when they
occur.
b. Seek antimicrobial therapy at the first signs
of infection.
c. Avoid mingling in crowds and remember
to wash the hands frequently when out in
public.
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Study Guide Answer Key
PRIORITY SETTING
2 a. Inspect the skin for color, turgor, texture,
and presence of lesions.
3 b. Palpate lymph nodes in the neck to identify enlargement or tenderness.
1 c. Take vital signs, noting if there is an increase in temperature or pulse rate.
5 d. Auscultate lung fields and assess work of
breathing.
4 e. Inspect extremities for edema.
6 f. Analyze lab results such as CBC, C-reactive
protein, and antibody screening tests.
APPLICATION OF THE NURSING PROCESS
Caring for a Patient with an Allergic Reaction
1. Location of redness, rash, hives, or wheals.
Amount, type, odor of drainage (if any). Location of excoriation and skin breakdown and
places that she has scratched.
2. Patient’s skin will be intact without signs of
redness or infection due to scratching.
3. a. Administer topical and systemic medications as ordered.
b. Keep skin clean and dry, and use lotions
for lubrication.
c. Refrain from bathing in hot w
d. Suggest use of cool packs to decrease itching.
e. Keep nails short to reduce risk of injury
from scratching.
f. Suggest distraction activities to shift focus
from itching.
4. a, d
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 4
2. 2
3. 3
4. 3
5. 4
6. 1, 4, 6
7. 1
8. 2
9. 3
10. 3, 4, 5
CRITICAL THINKING ACTIVITIES
1. Instruct on the frequency of taking the vital
signs, especially if the frequency differs from
the normal routine. Instruct her to take temperature, pulse, respirations, and blood pressure (BP). Also, you may consider having her
23
take pulse oximeter readings, especially if your
patient is at risk for sepsis. Give her parameters
(e.g., report any pulse over 100/min or under
60/min, BP under 110/80 or over 135/85, temperature over 100.4° F or under 97° F, respirations over 30/min or under 16/min). Explain
why you are asking her to take them with
increased frequency, what signs and symptoms
to report and thank her for her help.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. immunoglobulins
2. neutralize
3. predispose
4. constitution
5. surveillance
6. badger
7. migrate
8. jog
COMPLETION
1. genic
2. auto
nti
4. penia
PRONUNCIATION SKILLS
1. Please use standard precautions for handling
body secretions.
2. Her fever has increased, but she is breathing
deeply.
3. Does he know the procedure for keeping the
needles clean?
CHAPTER 11: CARE OF PATIENTS WITH
IMMUNE AND LYMPHATIC DISORDERS
TERMINOLOGY
1. d
2. e
3. h
4. a
5. b
6. i
7. j
8. g
9. f
10. c
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24
Study Guide Answer Key
TABLE ACTIVITY
See Table 11-8.
APPLICATION OF THE NURSING PROCESS
Disorders of Inappropriate Immune Response
1. a. History of food intolerances, colic, abdominal cramping, bloating, or pain, vomiting,
and diarrhea in the absence of general illness
b. History of unusual reaction to any drug,
food, insect sting, odor, or fumes
c. History of recurrent respiratory problems
or seasonal flareups of any symptoms
d. History of fatigue, wheezing, or shortness
of breath on exertion
e. Exposure to new personal hygiene products or to cleaning products
2. a. Epinephrine
b. Antihistamines
c. Bronchodilators
d. Cortisone
3. Any four of these:
a. Drowsiness and impaired coordination
b. Dryness of the mouth
c. Urinary retention
d. Weakness
e. Blurred vision
4. Any six of these:
a. Remove carpeting and dust-harboring furnishings.
b. Perform routine cleaning as well as daily
dusting and vacuuming with electrostatic
filters.
c. Keep no pets and eliminate houseplants.
d. Overcome the habit of smoking and ask
others not to smoke.
e. Acquire an air-conditioning unit that effectively filters out airborne allergens.
f. Eliminate other common allergens found
in the home (e.g., cosmetics).
g. Use rubber gloves when using cleaning
agents.
h. Keep showers and bathing areas well ventilated.
i. Dehumidify basements.
PRIORITY SETTING
5 a. Provide psychological support.
2 b. Administer oxygen.
1 c. Establish a patent airway.
4 d. Administer antihistamine (diphenhydramine hydrochloride [Benadryl]).
3 e. Administer aqueous epinephrine.
COMPLETION
1. retrovirus
2. receptive; barrier precaution
3. Candida albicans
SHORT ANSWER
HIV/AIDS
1. Any five of these:
a. Flulike symptoms: fever, fatigue, diarrhea,
loss of appetite
b. Skin rashes
c. Night sweats
d. Swollen lymph glands
e. Memory or movement problems
2. Any four of these:
a. Sexual contact
b. Sharing needles and syringes for drug injection
c. Transmitted to babies from their mothers
before or during birth
d. To newborns through breast milk
e. To health care workers through needle
sticks or contaminated blood and body
fluids getting into an open cut or a mucous
membrane such as the eyes or inside of the
3.
Any four of these:
a. Encourage knowledge of the patient’s own,
and their partner’s, HIV status.
b. Encourage people who are HIV positive to
avoid sharing toothbrushes, razors, or other items that could become contaminated
with blood. Do not donate sperm, blood,
plasma, body organs, or other body tissues.
Inform all contacted health practitioners of
their HIV status. Clean blood or other body
fluid spills on household or other surfaces
with freshly diluted household bleach: 1
part bleach to 10 parts water.
c. Teach HIV-positive people who have no
signs or symptoms of immunodeficiency
to seek regular medical evaluation and
follow-up.
d. Encourage HIV-positive people to adhere
to drug regimen, especially antiretroviral
therapy (ART).
e. Teach HIV-infected people to begin or
maintain behaviors known to assist in
maintaining or improving immune function.
f. Encourage HIV-positive people to use safer
sex practices.
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Study Guide Answer Key
g. Encourage HIV-positive women to avoid
pregnancy.
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 1
2. 3
3. 4
4. 1, 2, 3, 4
5. 3
6. 4
7. 2
8. 1
9. 1, 2, 3, 5, 6
10. 1
11. 3
12. 2
13. 4
14. 2
CRITICAL THINKING ACTIVITIES
Scenario A
1. Call out for assistance (i.e., do not leave the
patient, stay calm). Seat the patient in a high
Fowler position. Obtain the equipment for
high-flow oxygen if needed. Anticipate the
health care provider’s order for epinephrine,
inhaled bronchodilators, antihistamines. Establish a peripheral IV as ordered. Obtain vital
signs and determine what other symptoms the
patient is experiencing. Emergency medications and equipment should be on standby according to availability and facility policy (i.e.,
equipment for intubation, cardiac monitoring).
(Note: Some facilities may have standing orders to give emergency medications such as
oxygen or epinephrine. Clinic settings may
have protocols for calling 911.)
2. Any four of these:
a. Difficult breathing
b. Hives
c. Angioedema
d. Wheals
e. Decreased blood pressure
Scenario B
1. What kind of protection do you use?
How did you come to the conclusion of HIVnegative status for you and your friends?
What types of diagnostic testing have you had?
If so, when was the last test performed?
Are you and your partners participating in
high-risk sexual behaviors, such as anal inter-
2.
3.
25
course or orogenital contact without using a
barrier?
Would you like more information about HIV
transmission and prevention?
See Box 11-8.
First, make sure that she has adequate information to make an informed decision. Second,
do not badger her, but very gently and kindly
express your concern for her health and that of
her friends. Suggest that her friends are welcome to come in at any time. If she continues
to decline, respect her decision, but make every
effort to welcome her or her friends back, if
more information is needed or if she changes
her mind. Try giving her alternative resources;
for example, you could suggest the FDAapproved home HIV test, with a follow-up
discussion of results, or you could recommend
another clinic. Also, offer resources for obtaining barrier protection. Document the incident
carefully to include patient teaching, other interventions, and patient’s reason for declining.
Scenario C
1. 600 mL
2. 200 mL/hour
C
3. M
125 mL/hour
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. remission
2. iatrogenic
3. syndrome
4. immunosuppression
5. gay
6. myth
7. relapse
TERMINOLOGY
1. eye
2. meninges of central nervous system
3. brain
4. kidney
5. skin
6. nerve
7. white blood cells
MATCHING
1. e
2. g
3. f
4. b
5. h
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26
6.
7.
8.
Study Guide Answer Key
a
c
d
5.
Osteoporosis may cause kyphosis, which impinges on lung expansion.
TERMINOLOGY
WORD ATTACK SKILLS
Other words from Chapter 11 using immuno:
immunosuppressive
immunosuppression
immunosuppressant
immunosuppressed
immunoglobulin
immunologic
immunoelectrophoresis
immunosorbent
CHAPTER 12: THE RESPIRATORY SYSTEM
REVIEW OF ANATOMY AND PHYSIOLOGY
Terminology
1. b
2. g
3. c
4. d
5. f
6. a
7. e
8. h
9. i
10. j
COMPLETION
1. Surfactant; expand; inspiration; expiration
2. low; edema
3. erythrocytes
4. bicarbonate
5. water; carbonic acid
SHORT ANSWER
Age-Related Changes Affecting the Respiratory
System
1. A decrease in immune system efficiency makes
the elderly more susceptible to respiratory infections.
2. The elderly have a weaker cough, thoracic wall
rigidity, and decreased ciliary movement, making aspiration potential greater.
3. The mucous and respiratory membranes are
not as moist as in younger individuals. Mucus
becomes much thicker.
4. The alveolar membrane becomes thickened,
decreasing the ease with which gases can diffuse across the membrane.
Assessment
1. h
2. a, c, g, i, j
3. f
4. d
5. e
SHORT ANSWER
1. Because smoking and alcohol intake over many
years is a risk factor for cancer of the larynx.
2. Cyanosis is a late sign of decreased oxygenation. Paleness of mucous membranes can indicate anemia and decreased oxygen-carrying
capacity of the blood.
3. Sitting up with the back away from the chair or
bed to allow for full chest expansion.
PRIORITY SETTING
a. 5
b. 1
c. 3
L
d.
e. 6
f 4
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 1
2. 1, 3, 5, 6, 7, 8
3. 3
4. 1
5. 4
6. 1
7. 14 gtts/min
8. See Figure 12-9.
9. 2
10. 2
11. 4
12. 3
13. 4
14. 2
15. 3
CRITICAL THINKING ACTIVITIES
1. Assess the patient’s vision and hearing (does
he or she wear glasses or use a hearing aid?).
You should make certain that the patient is able
to hear you and see properly. Assess understanding as information is given. Many elderly
lOMoARcPSD|9825609
Study Guide Answer Key
2.
patients have no cognitive impairment, while
others have difficulty remembering instructions. Go slowly over the steps. Stop frequently
and ask for feedback of what you have said
or shown. Allow rest periods if the patient becomes tired. Leave printed instructions in type
that is easily read.
Answers will depend on the family members.
a.
2.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. adventitious
2. malaise
3. surfactant
4. refrain
MATCHING
1. c
2. d
3. a
4. b
TERMINOLOGY
1. laryngoscopy
2. paranasal sinuses
3. adventitious
4. hypoxic
5. dyspnea
CHAPTER 13: CARE OF PATIENTS WITH
DISORDERS OF THE UPPER RESPIRATORY
SYSTEM
SHORT ANSWER
1. Any three of the following:
a. Headache
b. Purulent nasal drainage
c. Malaise
d. Nonproductive cough
e. Tenderness over the sinuses
f. Upper teeth pain
g. Fever
2. airway obstruction
3. To identify if streptococcus is present, which
can lead to rheumatic fever (causing heart
valve problems) or glomerulonephritis (causing kidney problems)
APPLICATION OF THE NURSING PROCESS
Upper Respiratory Disorders
1. Specifics of written outcomes may differ.
27
Patient will develop satisfactory communication method with communication board,
pencil and paper, white board, electronic
device, or magic slate before discharge.
b. Patient will not experience aspiration while
in the hospital.
c. Patient’s airway will provide adequate airflow at all times while in the hospital.
Interventions chosen may vary.
a. Provide teaching on changing sleeping
positions, avoiding alcohol before bedtime
and weight reduction.
b. Encourage adequate rest by pacing activities, naps, and other interventions while
definitive treatment is implemented.
COMPLETION
1. sinus irrigation
2. hoarseness or sore throat lasting 2 weeks or
longer, pain upon swallowing, difficulty swallowing, hemoptysis, and enlarged cervical neck
nodes
3. the tube to be expelled or coughed out
4. hemorrhage
5. swallowing
erile
7. tracheostomy
PRIORITY SETTING
1. 3 Provide preoperative care for M.S. including the preoperative checklist.
1 Assess O.T.’s status.
2 Assess M.R.’s status.
2. a. Airway is always top priority.
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 2
2. 4
3. 1, 3, 6 (perhaps 5, if the patient has fever)
4. 2
5. 1
6. 4
7. 2
8. 3
9. 30 drops
10. 1, 2, 5, 6
11. 2
12. 2
13. 3
14. 4
15. 1
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28
Study Guide Answer Key
CRITICAL THINKING ACTIVITIES
1. A laryngoscopy and a CT (computed tomography) scan or MRI (magnetic resonance imaging) of the larynx and throat. A biopsy and
pathologic exam may be performed.
2. A communication board with symbols, paper
and pencil, a laptop computer, a whiteboard
and markers, or a magic slate can be used for
communication
3. When there are adventitious sounds from
secretions in the lungs, when the patient is
coughing and cannot bring up secretions, when
oxygen saturation has fallen below the health
care provider’s ordered parameters, or when
the patient indicates the need
4. The two most important principles are to maintain sterility during the suctioning procedure
and to maintain adequate oxygenation by limiting time suction is applied
2.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. patent
2. diligent
3. susceptible
4. vigilant
5. prevalent
SHORT ANSWER
1. epistaxis
2. adenoidectomy
3. sinusitis
CHAPTER 14: CARE OF PATIENTS WITH
DISORDERS OF THE LOWER RESPIRATORY
SYSTEM
REVIEW OF ANATOMY AND PHYSIOLOGY
Terminology
1. g
2. c
3. b
4. d
5. f
6. e
7. a
APPLICATION OF THE NURSING PROCESS
1. Any four of the following:
a. Whether cough is productive or nonproductive
3.
5.
b. Events or circumstances that trigger an episode of coughing
c. Time of day when cough seems worse
d. Measures that bring relief
e. Other symptoms that occur simultaneously
Any four of the following:
a. Frequent turning, coughing, and deepbreathing
b. Carefully watching and properly turning
patients who are vomiting or not fully conscious
c. Elevating the head of the bed for eating
and administering tube feedings; leaving
head of bed up for 30–60 minutes after a
feeding
d. Frequent handwashing and attention to
asepsis when caring for debilitated patients
e. Administering pneumonia vaccine when
prescribed
f. Using interventions to strengthen immunity and natural defenses and teaching
patient to avoid infection
Teach patient effective coughing techniques;
encourage intake of fluids; humidify inhaled
oxygen.
ient ways of avoiding infection including vaccinations; encourage good personal
hygiene and good nutrition.
Plan care to allow more time for, and assistance
with, activities of daily living; schedule medications and treatment so that patient has periods of rest during the day.
MATCHING
1. b, c, d, f, g
2. b, c, d, e, f, g, h
3. a, b, c, e, g
SHORT ANSWER
1. Any four of the following:
a. Amount of effort he must exert to breathe
b. Number of words he can say between
breaths
c. Skin color
d. Shape of chest
e. Clubbing of fingers
f. Abnormal breathing patterns
g. Level of awareness
h. Abnormal breath sounds
2. a. Health care workers are likely to be exposed and early detection is important.
b. Early identification prevents the spread to
others.
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Study Guide Answer Key
c.
3.
Early treatment results in fewer complications and less disability.
Any five of the following:
a. COPD—emphysema, bronchitis
b. lung cancer
c. asthma
d. pulmonary fibrosis
e. pneumothorax
2.
3.
29
The patient is considered noncontagious when
three consecutive sputum cultures are negative.
Tuberculosis (TB) is predominantly found in
foreign-born persons (63% of cases). Other
countries do not have the means to monitor
and treat TB so it is more prevalent.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. Pneumonia
2. Empyema
3. coccidiomycosis; histoplasmosis
4. oxygen
5. surfactant
PRIORITY SETTING
a. 3 Thoracotomy patient’s pain needs to be
assessed and addressed.
b. 2 Ask nursing assistant to take in the linen
right away and help clean up the patient.
c. 4 Resolve the situation and have the nursing
assistant take in the tray.
d. 5 Chart should be reviewed, and the patient
should be assessed for other symptoms.
e. 1 Airway is top priority.
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 2
2. 3
3. 1, 3, 4, 5
4. 1
5. 2
6. 3
7. 1670 mL
8. 3
9. 3
10. 2
11. 1
12. 2, 3, 4
13. 4
14. 2
15. 3
CRITICAL THINKING ACTIVITIES
1. Medications usually prescribed for tuberculosis include rifampin, isoniazid, ethambutol,
streptomycin, and pyrazinamide. A combination of four of these is used. Teaching points
that are especially important are that the drugs
must be taken each day and that they must be
continued for the full duration of the treatment
prescribed.
COMPLETION
1. pursed
2. susceptible
3. fluctuate
4. combustion
5. paradoxical
6. flaring
7. hallmark
8. emerging
9. occluded
10. kyphosis; scoliosis
WORD ATTACK SKILLS
1. cyt/o/megal/o/virus—large cell virus
2. immun/o/compromised— having a weakened
mmune response
3. immun/o/suppressive—causing suppression
of the immune system
4. anti/infective—against infection
5. coccid/ioid/mycosis—fungal disease caused
by infection with spores of Coccidioides immitis
COMMUNICATION EXERCISE
This is an individual exercise. Your instructor can
give you feedback on your assessment documentation.
CHAPTER 15: THE HEMATOLOGIC SYSTEM
REVIEW OF ANATOMY AND PHYSIOLOGY
Completion
1. red blood cell (or erythrocyte)
2. 120 days
3. neutrophils; leukocytosis
4. 13–20 days
5. clotting
6. 50; susceptible to infection
7. liver; spleen
8. histamine
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30
Study Guide Answer Key
7.
8.
b. low platelet count
c. excessive production of red blood cells
d. nutritional deficiency
e. bleeding in urinary tract
f. hemiarthrosis or bleeding into joints
g. hypoxia
h. inadequate oxygen supply to brain cells
Exposure to various industrial chemicals, gases, or pesticides may cause a blood dyscrasia.
Various hobbies require the use of chemicals or
involve exposure to pesticides and industrial
chemicals that might cause a blood dyscrasia.
urinary tract bleeding
a. Obtaining a fresh morning specimen
b. Testing specimen immediately or refrigerating it
a. Maintain Standard Precautions using latex
or impermeable gloves.
b. Label the specimens correctly, use the correct collection tubes.
c. Staunch any bleeding from the venipuncture site.
more than normal eosinophils
pulmonary embolism or DIC
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
1
12
7
5
13
8
10
3
11
4
9
6
2
COMPLETION
Age-Related Changes Affecting the
Hematologic System
1. the potential for hemorrhagic shock when
more than minor bleeding occurs for whatever
reason
2. the immune system response is decreased,
causing greater susceptibility to infection
3. less platelet aggregation
4. thrombi and emboli that can cause myocardial
infarction or stroke
SHORT ANSWER
Causes and Prevention of Hematologic
Disorders
1. a. hemophilia
b. sickle cell disease
c. thalassemia
2. a. sickle cell disease
b. megaloblastic anemia
c. thalassemia
3. a. anemia
b. leukopenia or aplastic anemia
c. thrombocytopenia
d. anemia or thrombosis
4. folic acid, protein, and vitamin C deficiencies
5. eating a well-balanced diet with lots of fruits
and vegetables and sufficient protein; avoiding fast food, which is low in good nutrients;
and avoiding chemicals and pesticides that can
cause a blood dyscrasia
6. monitoring accident and surgery patients
closely for signs of hemorrhage and instituting
quick measures to stop bleeding when it occurs
7. a. being thorough and careful when hanging
blood; checking labels and armbands and
making every attempt to prevent infusion
of mismatched blood
b. monitoring for side effects of drugs and
particularly noting when a patient is taking
a drug that may cause a blood dyscrasia
SHORT ANSWER
Assessment and Diagnostics
1. a. Family history of hereditary blood disorder
b. History or evidence of easy bruising
c. History of blood in urine, bleeding gums,
excessively heavy menstrual periods
d. Excessive fatigue or shortness of breath
with little exertion
e. Previous anemia, frequent headaches
2. a. excessive destruction of red blood cells
3.
4.
5.
6.
TTING
Note: Filling out the labels and lab slips may be
done at the end of the procedure, but it is best to
do so before drawing the specimens in case you are
rushed or interrupted. That way the specimen is
labeled and not likely to get lost.
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 1, 2, 3, 5
2. 1, 3, 4, 5
3. 150,000–400,000/mm3
4. 2, 3, 5
5. 2, 4, 5, 6, 1, 3, 8, 7
6. 2, 4, 5
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Study Guide Answer Key
7.
8.
9.
10.
11.
12.
1
2
infection
3
2
3
CRITICAL THINKING ACTIVITIES
1. You should apply direct pressure with a folded
piece of cloth or your hands if a cloth isn’t
available. Hopefully, you carry latex gloves in
your car and a first aid kit. Ask someone to call
911. If the bleeding won’t slow or stop, apply
a tourniquet above the area, using a belt and
stick, shoelaces, or whatever you can find to
use. Loosen the tourniquet every 10 minutes so
that the area beneath the wound receives blood
flow.
2. You would assess the chest tube drainage and
track its level in the drainage chamber every
30–60 minutes initially. Monitor the patient’s
vital signs and watch his respirations for early
signs of hypoxia, such as flaring nostrils. Assess the bandage to determine the amount of
bleeding from the incisional site.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. aggregate
2. Pernicious
3. clot
4. plethora
5. brought on
PRONUNCIATION
Practicing with a partner improves pronunciation
of these words.
MATCHING
1. e
2. g
3. a
4. c
5. b
6. i
7. j
8. h
9. f
10. d
11. k
SHORT ANSWER
1. large phagocytic cell
2.
3.
4.
5.
6.
7.
8.
31
one color
increase in number of leukocytes in blood
substance that stimulates red cell production
cell that contains particles
cell with an affinity for immune complexes
cell that does not contain particles
normal color (erythrocyte)
CHAPTER 16: CARE OF PATIENTS WITH
HEMATOLOGIC DISORDERS
COMPLETION
Hematologic Disorders
1. red blood cells; hemoglobin
2. injections of vitamin B12 or liver extract
3. oxygen demands of the body
4. 8–10% Hispanics, South Asians, Southern Europe Caucasians, those from Middle Eastern
Countries.
5. 50%
6. narrowing or occlusion of blood vessels
7. not known
8. raw fruits and vegetables
9. acute myelocytic
C
OMincrease the absorption of iron
10.
11. increases the bleeding problems
12. administration of iron supplements, vitamin C,
encouraging foods high in iron, possible transfusion of packed red cells, and determining
reason for condition
13. hemoglobin (or red blood cells)
14. constipation or diarrhea, blackish stool, and
slight nausea
15. heredity; drug reaction; viral infection
16. 30%
17. falling blood pressure; rapid, weak pulse; cool,
damp skin; thirst; decreasing urine output;
and restlessness progressing to decreased consciousness
18. with the legs elevated 45 degrees or less with
the knees straight, the trunk flat or slightly
raised, and the head level with the chest or
slightly higher
19. iron; folic acid; protein
APPLICATION OF THE NURSING PROCESS
Any three of the following for each:
1. Patient will have adequate tissue perfusion as
evidenced by capillary refill < 3 seconds and
warm, dry extremities.
a. Encourage patient to eat foods high in iron
and vitamin C.
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32
2.
3.
Study Guide Answer Key
b. Assess for signs of occult bleeding.
c. Administer iron and vitamin supplements
as ordered.
d. Teach the patient which foods are high in
iron and vitamin C.
Patient will have no evidence of an infection at
discharge.
a. Protect the patient from others who have
symptoms of infection.
b. Use good medical asepsis and excellent
handwashing technique.
c. Assess for signs of infection (e.g., temperature elevation, malaise, and sore throat)
every shift.
d. Administer platelets or white cells as ordered.
Patient will be able to perform own activities of
daily living (ADLs) by spacing activities before
discharge.
a. Administer oxygen as ordered.
b. Plan rest periods between treatments and
activities.
c. Assist with ADLs to prevent fatigue.
d. Assist with range of motion (ROM) to prevent joint stiffness.
e. Assist with ambulation to prevent falls.
G
4.
Patient will not experience hemorrhage before
discharge.
a. Assess for areas of bleeding, purpura, or
petechiae.
b. Handle the patient gently and with care to
prevent bruising and bleeding.
c. Protect the patient from falls.
d. Coordinate lab work to prevent unnecessary needle sticks.
e. Monitor blood counts for signs of internal
bleeding.
The following interventions might be listed:
a. Teach how and when to take her iron supplement.
b. Inquire about her diet and explain which
foods are high in iron and should be included daily.
c. Advise to plan a rest period in the midmorning and mid-afternoon if possible.
d. Advise to increase fiber and fluids to prevent constipation from iron supplement.
e. Instruct to report diarrhea should it occur
in response to the iron supplement.
f. Instruct that vitamin C is beneficial in utilizing the iron to build hemoglobin and red
5.
TABLE ACTIVITY
Anemia
Characteristic RBC
Etiology
Iron-deficiency
anemia
Microcytic, hypochromic
Decreased hemoglobin
production
Decreased dietary intake,
malabsorption, blood loss
Only effects of anemia
Pernicious
anemia
Megaloblasts, immature
nucleated cells
Deficit of intrinsic factor
due to immune reaction
Neurologic damage
Achlorhydria
Aplastic
anemia
Often normal cells
Pancytopenia
Bone marrow damage or
failure
Excessive bleeding and
multiple infections
Sickle cell
anemia
RBC elongates and
hardens in “sickle” shape
when O2 levels are low—
short life span
Recessive inheritance
Painful crises with
multiple infarctions
Hyperbilirubinemia
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 1, 2, 3, 4, 5, 6
2. 1
3. 2
4. 1, 3, 4
5. 1, 3, 4
6. 3
7. 1
8.
9.
10.
11.
12.
13.
14.
15.
16.
Additional Effects
1, 3, 4
3
3
3
1
3
4
4
90%; Philadelphia chromosome
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Study Guide Answer Key
17. 1
18. 17 gtts/min.
6.
CRITICAL THINKING ACTIVITIES
7.
8.
Scenario A
1. It is a genetic disorder characterized by erythrocytes that contain more hemoglobin S than
hemoglobin A. When oxygenation drops below normal, the defective S hemoglobin forms
clumps in the red cells, causing them to form
a sickle shape. The sickled cells block blood
vessels, break apart, and form thrombi that
cause organ damage. The disease occurs when
the sickle cell gene is inherited from both parents. While 8–10% of African Americans have
the disease it Is also found in other races and
people groups.
2. The sickle cell patient develops anemia when
cells sickle and break apart, destroying the red
cells.
3. When cells sickle, they block blood vessels
causing tissue hypoxia beyond the blockage.
This is very, very painful. Pain raises the metabolic rate, causing cells to use more oxygen and
worsening the oxygen deficit. This makes the
situation worse by causing furthe
cells.
Scenario B
1. This type of hemophilia is genetically transmitted through the female to male infants. All
female infants will carry the gene and pass it
on to their offspring, but the females do not
develop the disease.
2. Christmas disease causes a deficiency of factor
IX, which is needed for normal blood coagulation. The patient will show prolonged bleeding
after surgery or injury.
3. Transfusion with replacement factor IX is the
correct treatment. Analgesics and corticosteroids are used to treat the joint inflammation
and pain caused by hemiarthrosis and the resultant arthritis.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. mitigate
2. meticulous
3. platelets
4. sickle
5. modality
33
chronic lymphocytic; chronic myelogenous;
acute lymphocytic/lymphoblastic; acute myelogenous
enhance
harvest
GRAMMAR POINTS
1. by cautioning
2. by reporting
3. by asking
4. by wearing (or using)
5. by using or (wearing)
6. by undergoing
7. by following
8. by suppressing
9. by destroying
10. by administering
COMMUNICATION EXERCISE
This is an oral exercise. Check to see that you have
covered the appropriate points in teaching the patient about these topics. See the Patient Teaching
features, the Nutritional Therapy Points, and the
Safety Alerts in the chapter.
CHAPTER 17: THE CARDIOVASCULAR
SYSTEM
REVIEW OF ANATOMY AND PHYSIOLOGY
Labeling
Structures of the Circulatory System
See Figure 17-1.
COMPLETION
1. rate; heart (venous return); contraction; resistance
2. right atrium; right ventricle; (part of posterior
wall of) left ventricle; AV node
3. Cardiac output
4. stiffer; stroke volume
5. Intermittent claudication
6. 24-hour
7. 2.5 mL
SHORT ANSWER
Risk Factors and Assessment for Cardiac
Disorders
1. Unmodifiable risk factors
a. Heredity
b. Race
c. Sex
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34
2.
3.
4.
Study Guide Answer Key
d. Age
Modifiable risk factors
a. Overweight: keep weight within normal
limits by diet and exercise
b. Diabetes: keep blood sugar within normal
limits (<100 mg/dL)
c. Cigarette smoking: quit smoking
d. Excessive stress: exercise, use relaxation
techniques, reduce hostility, maintain a
positive support system
e. Excessive alcohol intake: men—more than
two drinks per day; women—more than
one drink per day
Any of these:
a. Laboratory tests: lipid profile, homocysteine, creatinine phosphokinase (CPK),
troponin, glucose, CBC, C reactive protein,
hemoglobin A1C
b. Diagnostic tests: chest x-ray, electrocardiogram (ECG), echocardiogram, possible
computed tomography (CT) for calcium
index; others depending on results of these
tests.
See Focused Assessment.
COMPLETION
Diagnostic Testing for Cardiac Disorders
1. clot; degree of narrowing
2. radiopaque contrast
3. difference in left ventricular action before and
after exercise
4. inflation of the cuff
5. muscle; myocardial
APPLICATION OF THE NURSING PROCESS
Changes with Aging
1. Any six of these:
a. Stroke volume decreases.
b. The cardiac valves thicken; a systolic murmur is common over 80 years of age.
c. The sinoatrial (SA) node loses pacemaker
cells, predisposing to dysrhythmias or SA
node failure.
d. The aorta becomes stiffer, resulting in increase in systolic blood pressure.
e. Atherosclerosis and atherosclerotic plaque
begins to occur after age 20.
f. Varicose veins develop as veins lose their
elasticity.
g. Valve function lessens; the leg muscles
weaken and atrophy from decreased exercise.
2.
3.
4.
h. Platelet aggregation and increased coagulation create potential for thrombus formation.
a. Record the patient’s daily weight before
breakfast.
b. Supervise fluid and sodium restriction.
c. Accurately measure intake and output.
d. Assess for signs of both fluid deficit and
fluid overload (i.e., skin turgor, check for
edema).
e. Administer diuretics as ordered.
f. Observe for adverse effects of diuretic
medication, such as electrolyte imbalance
and postural hypotension or dehydration.
g. Auscultate lung sounds routinely
c
d
PRIORITY SETTING
3 a. Palpate the brachial artery.
2 b. Select the correct cuff size.
4 c. Center the bladder of the cuff over the brachial artery.
11 d. Listen until the sounds stop.
13 e. Report abnormal findings to the RN or
h care provider.
7 f. Release cuff and wait 30–60 seconds.
10 g. Deflate cuff slowly and smoothly to obtain
a correct diastolic reading.
12 h. Record your findings as soon as you obtain
the reading.
5 i. Support the patient’s arm, on which the
cuff is placed, at heart level.
1 j. Ensure the patient has not smoked or had
caffeine for the past 30 minutes.
8 k. Place the bell of your stethoscope over the
brachial artery.
9 l. Tighten the screw clamp and inflate the
cuff to 30 mm Hg above the palpated pressure.
6 m. Obtain a palpated systolic blood pressure.
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 1
2. 3
3. 1
4. 2
5. 4
6. 3
7. 3
8. 2
9 4
10. 2, 4, 3, 1
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Study Guide Answer Key
11. 2
12. elastic stockings
5.
CRITICAL THINKING ACTIVITIES
1. PQRST is a memory device used to assist in
obtaining information from any patient experiencing chest pain or discomfort. It includes:
Precipitating events, Quality of pain or discomfort, Radiation of pain, Severity of pain, and
Timing.
2. Ask whether the pain has occurred before,
whether it happens when sitting up or lying
down, with or without exercise; family history
of heart disease; other medical conditions; any
injury to the chest; any preceding respiratory
illness; and any of the questions in the assessment section of the chapter concerning chest
pain.
3. Many nurses are uncomfortable when family
members appear to dominate the patient. You
can examine your own feelings to identify how
you might feel about Mr. Eoyang and Ms. Eoyang and discuss this with your clinical instructor.
4. This behavior may be culturally based; Mr.
Eoyang may feel that it is his resp
to take care of and represent his wife in any
circumstance outside the family home. Mr.
Eoyang’s behavior could be related to his own
anxiety (e.g., he may be so worried about his
wife that dominating the conversation is a way
to have some feelings of control). Ms. Eoyang may defer to her husband as head of the
household. Total domineering behavior could
also be a sign of chronic spousal abuse. Further
conversation and interactions with the family
can help identify if the behaviors are culturally
based, anxiety based, or potentially reportable
behaviors.
VOCABULARY EXERCISE
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
Examples of sentences using vocabulary words:
1. The nurse realized that the patient’s cast might
be too tight because the foot was pale and mottled.
2. The technician calibrated the equipment before
he started the laboratory test.
3. Certain medications will precipitate if added to
an existing IV solution.
4. The patient and the nurse collaborated to make
the plan of care.
35
The Foley catheter was occluded with mucus
and blood clots.
Descriptors, Descriptive Terms, Special Uses
Person 1: 4+, rapid, full, bounding, hammerlike
Person 2: 1+, diminished, weak, barely palpable
Person 3: distant, rapid, irregular, apical
COMMUNICATION EXERCISE
History-Taking and Documenting Assessment
1. History-taking: family medical history; lifestyle: smoking, drinking, drug use; eating
habits, weight loss/gain, exercise, occupation,
stress, snacking, coffee, etc. Observation: skin
color, edema, weight, nervous habits, attitude,
and affect.
2. Each individual’s assessment will be different. Here is an example of documentation of
one assessment: 2-22-08 SOB only with rapid
climbing of stairs. No coughing. Sometimes
feels skipped heartbeats or “fluttering” for a
few minutes. Occurs several times a week. Up
once at night to urinate. Occasional lightheaddness. Skin pink, warm, and dry. P 86, regular,
BP 152/94, R 16. S1-S2 present; no abnormal
sounds. Peripheral pulses present; pedals 2+,
radials 3+. Bilateral breath sounds audible with
slight crackles in base of left lung. No clubbing
or JVD. Abdomen normal, no bruit. No pedal
edema. Weight 162 lbs.
COMMUNICATION EXERCISE
1. “How is your pain level now, Bobby? Does it
still hurt? Can you tell me about the pain—is
it sharp, and does it come and go? I’m sorry
you’re feeling bad. I know it is hard to just lie
here and be uncomfortable. Why don’t you tell
me about some of the things you like to do at
school? What about after school? What do you
and your friends like to do? Have you seen any
movies recently? Tell me about that one.”
2. “I think it will be better if we try to warm you
up all over, Mr. Johnson. Let me get you an extra blanket, and maybe tuck it up around your
feet. And I will get you some socks to put on.”
3. “Ms. Bennett, here is your pill. I need to have
you drink some of this fruit juice with it. I
know you aren’t hungry, but if you have something in your stomach it will be more effective
and won’t upset your stomach.”
4. Unmodifiable: heredity, race, sex, age. Modifiable: weight, cholesterol, hypertension, diabe-
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36
Study Guide Answer Key
tes, smoking, sedentary lifestyle, stress, alcohol, cocaine
CHAPTER 18: CARE OF PATIENTS WITH
HYPERTENSION AND PERIPHERAL VASCULAR
DISEASE
COMPLETION
Hypertension
1. brain; heart; kidneys
2. 130, 80
3. kidneys; adrenal gland
4. vasoconstriction
5. twice; 2
6. retina of the eye
SHORT ANSWER
Hypertension
1. Any four of these:
a. Maintain normal body weight (avoid obesity).
b. Stop smoking and gradually reduce caffeine consumption.
c. Aerobic exercise 30–45 minutes, three
five times per week.
d. Limit sodium intake to less than 2300 mg/
day.
e. Use relaxation techniques to cope with
stress and reduce tension.
f. Limit alcohol intake to one serving of liquor, wine, or beer for women per day or
two servings for men per day.
2. a. Occasional headache, dizziness, irritability,
fatigue, blurred vision, nervousness, blackouts
b. Accurate measurement of blood pressure
3. 120/80
4. a. Seek a smoking cessation program if a
smoker; institute a regular exercise plan
that will work on a daily basis, with at least
30 minutes of exercise most days of the
week. Learn ways to decrease stress, such
as with relaxation techniques, music, meditation, imagery exercises, massage, or other
measures. Restrict alcohol to no more than
one drink a day for women or two drinks a
day for men, and achieve a normal weight
using a weight loss program as needed.
b. Keep sodium intake less than 2300 mg/
day. Be alert for hidden sources of sodium
(e.g., soft drinks, catsup, canned soup,
or canned vegetables); read labels (look
5.
for the words salt, sodium, and the letters
NaCl); teach best kinds of foods to eat
(e.g., fresh or frozen vegetables); avoid
“convenience” foods (e.g., frozen dinners);
avoid smoked or preserved meats; use
one-fourth to one-half the amount of salt
that a recipe calls for; avoid adding salt to
food; use a salt substitute (e.g., Ms. Dash).
Avoid caffeine (i.e., soft drinks, coffee, and
tea); encourage use of caffeine-free drinks,
gradually reducing caffeine. Stick to a lowfat diet.
Any three of these: diuretics, beta blockers, calcium-channel blockers, vasodilators,
angiotensin-converting enzyme inhibitors.
APPLICATION OF THE NURSING PROCESS
Caring for a Patient with Arterial Insufficiency
1. Any three of these:
a. Do you smoke? If so, how much and for
how many years?
b. Do you have a history of hypertension?
c. Is there a history of arterial insufficiency,
hypertension, heart disease, or diabetes in
your family?
is your usual diet? Do you have high
cholesterol?
e. Do your legs swell?
2. Any five of these:
a. Pain in calves of legs after exercise
b. Pain at rest
c. Tingling and burning of feet and legs,
numbness of toes
d. Dark red color in feet and lower legs when
legs are dangled
e. Pallor when elevated
f. Skin appears tight and shiny
g. Coldness of skin
h. Abnormal peripheral pulse
3. “5 Ps”—pain, pallor, pulselessness, paralysis,
paresthesia
4. b
5. a. Maintaining arterial blood flow to the lower extremities
b. Protecting tissues from further injury
caused by pressure and constriction of
blood flow
c. Preventing wounds or infection
6. Any five of these:
a. Keep warm, but avoid extremes of heat
and cold.
b. Do not use tobacco in any form.
c. Exercise regularly (e.g., walking).
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Study Guide Answer Key
7.
d. Avoid restrictive clothing.
e. Do not sit with feet or legs crossed.
f. Change position frequently.
Examples
a. Verbalizes will walk vigorously for 20 minutes twice a day
b. Verbalizes will not wear tight stockings
c. Verbalizes will take frequent stretch breaks
while sitting at office desk
d. Demonstrates foot, ankle, and leg exercises
while sitting
PRIORITY SETTING
1. d
2. a
3. b
4. b
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 4
2. 3
3. 1
4. 3
5. 2
6. 4
7. 1
8. 3
9. 2
10. 4
11. 1, 4, 6
12. 1
13. 4
CRITICAL THINKING ACTIVITIES
1. correct
2. 1 mL
3. 40 units/mL
4. correct
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. dependent
2. tortuous
3. viscosity
4. peripheral
5. noncompliant
6. claudication
7. baroreceptor
8. incompetent
9. potentiated
10. “silent” symptoms
11. ischemia
37
12. syncope
13. side effect
WORD ATTACK SKILLS
Combining Forms
1. spasm of a vessel
2. agent that relaxes vessel, causing vasodilation
3. constriction of a vessel; muscle wall contracts,
narrowing the lumen
4. substance that stimulates contraction of the
muscle in vessels (arteries and capillaries)
5. affecting the caliber of the blood vessel
6. induration or hardening
7. radiography of veins after injection of contrast
media into the venous system
8. pertaining to the veins
9. excision of the clot
10. formation of a blood clot (thrombus)
11. blood clot that may cause obstruction to flow
in the vessel
12. decrease or stoppage of blood flow
13. narrow rod or threadlike device used to provide support for a tubular structure
PTER 19: CARE OF PATIENTS WITH
CARDIAC DISORDERS
COMPLETION
Cardiac Disorders
1. implantable cardioverter defibrillator (ICD)
2. Any four of these: cardiac murmur, progressive
fatigue, exertional dyspnea, irregular heart
rate, nocturnal dyspnea, dry cough
3. decreased pumping ability
4. decreased cardiac output
5. a pericardial friction rub
6. Electrolyte
7. rheumatic fever; heart valve disease
8. a pacemaker
APPLICATION OF THE NURSING PROCESS
Care of the Patient with Heart Failure
1. a. Subjective: complaints of shortness of
breath, feeling of “smothering” or difficulty taking a breath
Objective: use of two or more pillows
when lying down, abnormal breathing patterns or crackles in the lungs
b. Subjective: complaints of feeling “bloated,”
loss of appetite
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38
Study Guide Answer Key
c.
2.
3.
4.
5.
6.
7.
Objective: pitting edema in feet and ankles
or thighs and sacral region; weight gain
Subjective: complaints of feeling warm
when others are comfortably cool; feelings
of anxiety, irritability, depression
Objective: Pale, cool, dry skin; increased
capillary refill time; fleeting or absent peripheral pulses; reduced urinary output
d
Any three of these:
a. Administer oxygen as ordered.
b. Administer Lanoxin, hydrochlorothiazide,
and Isordil as ordered.
c. Space care activities to provide rest.
d. Assess vital signs and heart sounds every 2
to 4 hours per orders.
e. Gradually increase activity level as ordered.
b
Any five of these:
a. Instruct patient about nature of her illness
and purpose of diet restriction.
b. Reinforce dietitian’s instruction in lowcalorie, low-sodium diet.
c. Help patient set goals for weight loss.
d. Instruct patient about digoxin, hydroc
rothiazide, and Isordil including purpose
of medication, how to take (including how
to monitor pulse rate), side effects, when to
notify the health care provider.
e. Help patient set realistic goals for regular
exercise.
f. Teach patient symptoms (i.e., shortness
of breath [SOB], weight gain, progressive
fatigue) to be reported to health care provider.
g. Include family in teaching so they can get
questions answered and understand the
plan
a
yes; two tablets
PRIORITY SETTING
1. b
2. c, b, a, d
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 4
2. 2
3. 1
4.
5.
6.
7.
8.
9.
10.
1
3
1
4
1, 2, 4, 5
4
4
CRITICAL THINKING ACTIVITIES
Scenario
1. a. Normal sinus rhythm
b. No special action is required. This is a normal rhythm.
2. a. Atrial fibrillation
b. Patients with atrial fibrillation are more
likely to develop blood clot formation in
the atria.
3. a. Ventricular fibrillation
b. Check patient, establish unresponsiveness,
and call a code; initiate CPR, defibrillate as
soon as AED arrives.
4. a. Ventricular tachycardia
b. Check for a pulse. Amiodarone (Cordarone) if pulse present and stable, synchronized cardioversion if pulse present and
unstable and cardiac defibrillation if no
pulse
5. a. Complete heart block/Third-degree heart
block
b. Contractions of the atria and ventricles
are uncoordinated and cardiac output is
decreased and heart rate is slow, further
dropping cardiac output and blood pressure; therefore, the cerebral tissue does not
receive adequate oxygen and glucose.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. quivers
2. telemetry
3. Hypertrophy
4. engorged
5. invasive
6. cardiomyopathy
7. atrioventricular
8. fibrillation; fibrillation
9. bloated
10. interstitial
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CHAPTER 20: CARE OF PATIENTS WITH
CORONARY ARTERY DISEASE AND CARDIAC
SURGERY
TERMINOLOGY
1. Angina pectoris: chest pain that occurs when
blood supply to the heart is decreased or totally obstructed
2. Coronary insufficiency: narrowing of the coronary arteries, which causes decreased or insufficient blood flow
3. Drug-eluting stent: stainless steel stent that
acts as a brace for the artery wall; continually
releases an anticoagulant/antiplatelet drug
4. Myocardial infarction: loss of heart muscle
tissue; related to obstruction of blood flow
through one or more major coronary arteries,
cutting off oxygen and nutrients to the cardiac
cells
5. PCI: percutaneous coronary intervention—
using a balloon or stent to open a narrowed or
6.
39
blocked coronary artery. The coronary vessels
are accessed via the femoral or radial artery
from a skin puncture.
Ischemia: deficiency of blood supply to tissue
COMPLETION
1. chest tightness; angina; (or shortness of breath)
2. menopause; dietary; sedentary; increased
3. gastric esophageal reflux (or indigestion)
4. oxygen
5. size; amount
6. there is multivessel disease or a critical lesion
7. twice (preferably fatty fish)
8. 12
9. immunosuppressive drugs
10. infection; rejection
11. 20.83; round to 21 gtts/min
12. lower cholesterol
13. an aspirin (have the person chew it and swallow)
TABLE ACTIVITY
Cardiac Surgeries
Type of Surgery
Description
Coronary artery bypass graft
(CABG)
Surgery bypasses the blocked artery, replacing it with sections of a
vein or artery taken from another part of the patient’s body.
Minimally invasive direct
coronary artery bypass
(MIDCAB) or off-pump coronary
artery bypass (OPCAB)
Surgery bypasses the blocked artery but does not require stopping
the heart’s activity, and therefore does not require using the heart–
lung machine.
Percutaneous transluminal
coronary angioplasty (PTCA)
A catheter is introduced through the femoral artery and a balloon
catheter is used to open a coronary artery.
Valve replacement
Accomplished with a mechanical or biologic device.
Heart transplants
Performed for selected patients who have end-stage left
ventricular failure resulting from cardiomyopathy.
APPLICATION OF THE NURSING PROCESS
Care of a Patient with Angina
1. a. Where is the pain, and what brings you
relief from the pain?
b. Can you describe the pain? What, if anything, makes it worse?
c. Do you become short of breath when the
pain occurs? Do you need to sleep on two
or more pillows? What types of activities
bring on shortness of breath? What relieves
the shortness of breath?
2.
d. When you feel chest pain, do you experience palpitations or dizziness?
Pain (any three):
a. Administer nitroglycerin sublingually
when chest pain occurs; check vital signs;
administer up to two more tablets 5 minutes apart if pain does not ease.
b. Administer oxygen during episodes of
chest pain.
c. Assess whether patient can identify precipitating cause of chest pain.
d. Stop any activity and rest.
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40
3.
Study Guide Answer Key
Knowledge deficit (any three):
a. Teach the patient to avoid extremes in temperature when possible.
b. Instruct the patient to take nitroglycerin
before any strenuous exercise (e.g., sexual
intercourse or swimming).
c. Instruct the patient to keep a fresh supply
of nitroglycerin tablets on hand and to protect them from light.
d. Instruct the patient to pace activities and to
rest between strenuous tasks.
b
PRIORITY SETTING
5 a. If the pain has not eased or if BP increases,
administer second tablet.
3 b. Give one tablet, placed under the tongue.
9 c. Notify the health care provider regarding
pain.
1 d. Assist the patient to lie in bed.
4 e. Wait 5 minutes, reassess pain and blood
pressure.
2 f. Obtain a baseline BP.
6 g. After 5 minutes, reassess pain and recheck
blood pressure.
7 h. Administer a third tablet if pain persists.
G
8 i. Recheck BP; it should be decreased.
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 2, 3, 4, 5
2. 1
3. 3
4. 1
5. 2
6. 2
7. 2
8. 3
9. 1
10. 3
11. 3
12. 4
CRITICAL THINKING ACTIVITIES
Scenario A
1. denial
2. Denial is a common defense mechanism. She
has convinced herself that she is having an indigestion problem. In refusing to go to the hospital or to allow anyone to help her, this affirms
her stance that nothing is wrong.
3. “Ms. Grandville, it’s pretty normal for you to
want to minimize what you are feeling and just
hope that it will pass, but I am concerned that
something other than the potato salad might
be causing your discomfort. Women can have
atypical symptoms, like feelings of indigestion, when they are having problems with their
heart. Women have to look out for each other
because our lifestyles may include stress, poor
diet, and little time for exercise and all these
factors contribute to the rising incidence of
cardiac disease in women. Maybe it is indigestion, but those same symptoms can indicate a
problem with your heart. It is better to err on
the side of caution. Let me call your family so
they will know what is happening.”
Scenario B
1. Any five of these:
a. A history of hospitalizations for heart failure
b. Need for a left ventricular assist device
(LVAD)
c. Increasing types and doses of medication
d. Documentation of decreased oxygen supply to the body
e. Good renal function
f. Psychologically stable
the ability to comply with need for
antirejection medications
2. As the text mentions, there is some flexibility
for age. Although the criteria are based mainly
on health issues and expected outcomes, any
set of criteria can be subject to ethical dilemmas. For example, would a patient with a
chronic mental health problem (e.g., depression
or schizophrenia) meet the criteria of psychological stability, particularly if there was a history of frequent relapse and noncompliance? Is
the exclusion of people who are using tobacco
and alcohol a health rationale? Or are there
some prejudicial underpinnings to those criteria? If an organ is available (e.g., if there was a
death of a sibling) but the patient is predicted
to live another 18 months, would or should the
organ be given to another candidate?
3. Patients and family must consider cost of
health care before and after transplant. Patients must adhere to strict dietary and exercise
regimens. Family may have to move close to
a highly specialized medical center, or the patient may have to remain in the hospital for an
extended period of time if he is critically ill. Patients may have implanted mechanical devices
that sustain cardiac function, which can cause
apprehension. Patients may be given a special
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Study Guide Answer Key
pager and must be available for immediate admission to the hospital. The patient undergoes
a series of diagnostic tests and examinations.
There is considerable apprehension on the part
of the patient and the family who are faced
with transplant surgery.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. etiology
2. Fibrous
3. prognosis
4. compromise
5. compensatory; collateral
6. extracorporeal
7. weaning
11.
12.
13.
14.
41
d
m
f
h
COMMUNICATION EXERCISE
1. a. Heart attacks can be precipitated by physical exertion.
b. Heart attacks can also precipitated by exposure to extreme temperatures.
2. Grapefruit juice should not be consumed when
taking a statin drug.
CHAPTER 21: THE NEUROLOGIC SYSTEM
REVIEW OF ANATOMY AND PHYSIOLOGY
Terminology
1. f
2. i
3. g
4. c
5. h
6. j
7. b
MATCHING
1. j
2. e
3. i
4. a
5. n
6. c
7. g
8. k
9. l
10. b
9. e
10. d
TABLE EXERCISE
Functions of the Divisions of the Brain
Division
Function
Cerebrum
Center of intellect and consciousness
Receives and interprets sensory information; controls voluntary movements
and certain types of involuntary movements; responsible for thinking, learning,
language capability, judgment, and personality; stores memories
Cerebellum (Table
21-1)
Responsible for coordination of movement, posture, and muscle tone that are the
mechanisms of balance
Diencephalon
Consists of two parts
Thalamus
Relay center between spinal cord and cerebrum
Hypothalamus
Controls body temperature, appetite, and water balance; links nervous and
endocrine systems
Brainstem (Consists of three parts):
Midbrain
Mediates visual and auditory reflexes; controls cranial nerves III and IV and certain
eye movements
Pons
Links connecting various parts of the brain; helps regulate respiration
Medulla
oblongata
Contains reticular formation that regulates heartbeat, respiration, and blood
pressure; control center for swallowing, coughing, sneezing, and vomiting; relays
messages to other parts of the brain
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Study Guide Answer Key
SHORT ANSWER
Changes that Occur with Aging
1. slower reaction time
2. declines in the number of posterior nerve fibers
and sympathetic nerve fibers of the autonomic
nervous system
3. utilizing the brain with problem-solving and
learning activities
4. short-term; long-term memory
SHORT ANSWER
1. a. Does the patient awaken easily? Are they
oriented to person, place, and time? Are
they able to follow commands? Do they
respond to stimuli, even painful ones? Are
they restless, combative?
b. Are they able to respond to verbal commands to move their arms and legs? Do
they purposefully withdraw from a stimulus? Are there nonpurposeful movements?
c. Are pupils equal in size? Do pupils react to
light? Does only one pupil react to light?
COMPLETION
Nursing Management
1. skeletal muscle
2. involuntary
3. fanning outward
4. myelogram (or MRI)
5. pairs; 12
6. smile
7. increasing intracranial pressure
SHORT ANSWER
1. Any three of the following:
a. Staggers
b. Grasps at bed and door frame to steady
himself
c. Drops cup, glass, book, and other objects
frequently
d. Sways to one side when standing with feet
together and eyes closed
2. Any four of the following:
a. Wear helmets for sports.
b. Wear protective headgear in dangerous
work areas.
c. Use safety precautions while diving and
swimming.
d. Use appropriate vehicle restraints.
e. Avoid recreational drugs.
f. Avoid alcohol abuse.
g. Keep blood pressure under control.
3.
4.
h. Use precautions when using insecticides.
An electroencephalogram (EEG) is a recording
on paper of electrical impulses from the brain.
It is not a form of shock treatment, a way of
reading the mind, a measure of intelligence, a
type of lie-detector test, a method for detecting
mental or emotional illness, a treatment, or a
cure.
Any four of the following:
a. History of epilepsy or convulsions
b. Genetic disorder of the nervous system
c. Change in or difficulty concentrating,
remembering, speaking, or expressing
thoughts
d. Recent head injury
e. Changes in muscle strength or coordination
f. Infection localized in the head
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 2
2. 2
3. 4
4. electromyography
6.
7.
8.
9.
10.
3
1
3
1, 3, 4
2
CRITICAL THINKING ACTIVITIES
1. Because skin breakdown and pressure injuries
can occur quickly and because it is important
to maintain joints in functional positions to
prevent contractures
2. Explain that electrodes will be placed prior to
the test and that there will be some discomfort.
Some medications may need to be withheld
before the test. There are no food or fluid restrictions. Describe about how long the test will
take; this depends on what part of the body is
being tested.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. nystagmus
2. myriad
3. widened pulse pressure
4. mnemonic
5. mechanisms
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43
WORD ATTACK SKILLS
Prefixes
A.
Word Stem
1. -orders
2. -paired
3. -voluntary
4. -noxia
5. -oriented
6. -effective
7. -orientation
Combined Word
disorders
impaired
involuntary
anoxia
disoriented
ineffective
disorientation
Meaning
illnesses of mind or body
diminished, lessened
not voluntary; performed independently of the will
lack of oxygen
not oriented; confused
not effective
state of not being oriented; state of confusion as to person,
place, and/or time
Word
cerebrum
cerebellum
cerebral
hemiparesis
hemiplegia
dysphasia
Meaning
main part of the brain where thinking occurs
posterior part of the brain that coordinates body movement
pertaining to the cerebrum (e.g., his thoughts were cerebral,
meaning “intellectual”)
weakness on one side (half) of the body
paralysis on one side (half) of the body
impairment of speech such as failure to arrange words in the
correct order
B.
Suffix
1. -brum
2. -bellum
3. -bral
4. -paresis
5. -plegia
6. -phasia
COMMUNICATION EXERCISES
Dialogue Practice
This is an oral exercise.
Explanations
The knee-jerk tests the automatic response of nerve
pathways to and from the spinal cord. When the
knee is tapped, the nerve that receives this stimulus sends an impulse to the spinal cord, where it is
relayed to a motor nerve, which causes the muscle
at the top of the thigh to contract and move the
leg upward. It is a simple way to make sure these
nerves are functioning properly.
Orientation and Function Questions
1. What day is today? What month is it?
2. What was the last major holiday?
3. What is the sum of 8, 6, and 4?
4. What would you do if the trash can were on
fire?
5. Touch your cheek with your left hand.
CHAPTER 22: CARE OF PATIENTS WITH HEAD
AND SPINAL CORD INJURIES
COMPLETION
Head and Spinal Cord Injuries
1. headache; nausea or vomiting, confusion or
memory problems, feeling hazy, foggy, or just
not “right”
2. laceration; fractured
3. move; vessels
4. epidural; middle meningeal artery; intracranial
pressure
5. Battle’s sign; basal skull fracture
6. patent airway; the head 30 degrees
7. otorrhea; rhinorrhea
8. lethargy; decreasing
9. pulling and twisting
10. spinal shock
11. grasping the muscle
12. severe hypertension/stroke
13. urinary; urinary infections
14. above C5
15. remove or loosen the halo
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Study Guide Answer Key
SHORT ANSWER
Intracranial Pressure
1. rising systolic blood pressure; widening pulse
pressure; bradycardia with a full, bounding
pulse; rapid or irregular respirations
2. level of consciousness
3. space the interventions at intervals
4. correct positioning to prevent a rise in intracranial pressure
5. hypoxia; edema
6. vital signs; pupil reactions
7. there is pressure on the optic nerve as the brain
is compressed
8. promote venous drainage from the head; intracranial pressure
9. a. rising systolic blood pressure
b. widening pulse pressure
c. bradycardia with a full, bounding pulse
d. Lethargy and decrease in consciousness
e. Confusion and slowing of speech
f. Delay in response to verbal cues
g. Changes in pupil reactions with unequal
pupils
COMPLETION
Spinal Injury
1. save the victim’s life, prevent further injury,
implement treatment to limit secondary damage to the cord, establish a routine of care for
improved health
2. stabilize the neck
3. signs and symptoms of drug interaction
Back Pain and Ruptured Intervertebral Disk
1. repetitive lifting
2. posture; good body mechanics; lifting techniques
3. osteoporosis
4. 3 months; repeated basis
5. the leg; buttock; below the knee
6. neck; arm; numbness; tingling of the fingers
7. stand; sit
8. diskectomy
9. laminectomy
10. close to the center of the body
APPLICATION OF THE NURSING PROCESS
1. a. Patient’s intracranial pressure will not rise
further in the next 24 hours.
b. Any sustained increase in ICP will be
promptly identified and reported to the
provider.
2.
3.
positioning with the head raised 30 degrees;
administration of an osmotic diuretic; monitoring of intake and output; monitoring of arterial
blood gases; neurologic checks at regular intervals; spacing necessary nursing procedures
the intracranial pressure readings, vital signs,
and neurologic signs
PRIORITY SETTING
a, b, c (Also b, a, c would be acceptable too. You
could ask the nursing assistant to change Ms.
Chinn’s bed linens.)
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 4
2. 4
3. 3
4. 4
5. 1, 4, 5
6. 3
7. 88
8. 1
9. 4
INKING ACTIVITIES
Scenario A
1. Presence of bleeding, skull fracture, midline
shift
2. mannitol, Decadron
3. Because hypoxia will make intracranial pressure rise.
Scenario B
1. Keeping the neck midline and positioning him
according to the surgeon’s orders.
2. Noise and excessive sensory input cause intracranial pressure to rise.
3. The possibility of infection and maintaining
safety for the patient.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. precipitating
2. log rolling
3. contrecoup
4. Noxious
5. goose bumps
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45
WORD ATTACK SKILLS
Prefix
dysunderotorhinocontra(e)ipsihemahemohypohyperunpolyvasoiminoverre-
Word Stem
-reflexia
-lying
-rrhea
-rrhea
-lateral
-coup
-lateral
-toma
-dynamic
-thermia
-xia
-extension
-reflexia
-interrupted
-uria
-constriction
-dilation
-mobility
-nervation
-ability
-distended
-habilitation
Combined Word
dysreflexia
underlying
otorrhea
rhinorrhea
contralateral
contrecoup
ipsilateral
hematoma
hemodynamic
hypothermia
hypoxia
hyperextension
hyperreflexia
uninterrupted
polyuria
vasoconstriction
vasodilation
immobility
innervation
inability
overdistended
rehabilitation
COMMUNICATION EXERCISE
Dialogue Practice
“Your son has a head injury. That means he has
some swelling of the brain tissue, and he is being
monitored for complications. We need to know if
the pressure in his head rises from swelling of the
brain tissue. We arouse him on a schedule to determine what his level of consciousness is and whether it is deteriorating. Between times of arousal, he
needs to sleep and rest. That aids in helping the
swelling to go down. Rather than trying to keep
him awake, it would help him if you would exercise his joints two to three times a day. Let me show
you how to do that.”
Documentation
Condition and the need for rest explained to mother. Explained monitoring procedure. Showed how
to help with passive ROM. Stated she would do the
exercises twice a day.
CULTURAL POINTS
This is an oral exercise.
Meaning
disordered response to stimuli
at the base or bottom of, a cause
discharge from the ear
discharge from the nose
opposite side
a blow that affects the opposite side
the same side
collection of blood within the body
movement of the blood
low body temperature
low oxygen supply
extreme extension of a limb
exaggerated reflexes
not interrupted
overproduction of urine
narrowing of the vessels
expansion of the blood vessels
not mobile
distribution of nerves or energy
not able
spread beyond
make able again
CHAPTER 23: CARE OF PATIENTS WITH BRAIN
DISORDERS
COMPLETION
Seizure Disorders and Epilepsy
1. brain; oxygen
2. consciousness; incontinent
3. how it begins in the brain
4. least; fewest
5. one part of the brain; localized symptoms
6. normal saline
SHORT ANSWER
1. brain injury, brain tumor, infectious disease
with high fever, uremia, toxicity, tetanus
2. bilateral synchronous electrical discharges in
the brain
3. repetitive, automatic actions such as lipsmacking
4. the area of the brain affected by the abnormal
electrical activity and the type of onset
5. irreversible brain damage may occur
6. Any five from Focused Assessment.
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Study Guide Answer Key
MATCHING
COMPLETION
Cerebrovascular Accident
1. j
2. f
3. a
4. g
5. i
6. b
7. d
8. h
9. e
10. c
Brain Tumor
1. seizure activity
2. coordination; balance
3. personality changes; disturbances in judgment;
memory loss
4. MRI; X-ray; CT scan
5. hydrocephalus; intercerebral bleed; seizures
COMPLETION
1. a stroke may occur
2. hypertension; atrial fibrillation; diabetes
3. smile, raise the arms over the head, stick out
the tongue, speak
4. slowly; quickly
5. left
6. hydrocephalus
7. a severe headache
8. heart; atrial fibrillation
9. aneurysm; arteriovenous malformation
10. rapid onset; signs; consciousness
Infections and Inflammatory Disorders of the
Nervous System
1. inflammation; membranes; brain; spinal cord
2. upper respiratory
3. sudden fever, persistent headache, and stiff
neck
4. petechial; meningococcal
5. lumbar puncture (spinal tap); elevated; decreased (in the CSF)
6. increased intracranial pressure
7. headache; fever; photophobia; stiff neck
8. herpes simplex virus type 1
9. mosquitoes; ticks
10. immune-mediated
TABLE ACTIVITY
Drug
Action
Nursing Implications
t-PA (alteplase;
tissue
plasminogen
activator)
Converts fibrin
to plasminogen,
causing lysis
of thrombus or
embolus of CVA
Frequent VS; monitor for dysrhythmias; frequent neurologic
checks; assess for bleeding until 24 hrs after infusion.
Aspirin
(Ecotrin)
Decreases platelet
aggregation
Administer with food; observe for signs of intestinal bleeding,
tinnitus.
Monitor for hypersensitivity; monitor clotting/bleeding studies.
Do not give concurrently with anticoagulants, antiplatelet
aggregation drugs, or NSAIDs.
Monitor blood count and liver enzymes.
Phenytoin
(Dilantin)
Alters ion transport,
inhibiting spread of
seizure activity to
motor cortex
Assess for skin rash; monitor drug levels, CBC; observe for
respiratory depression.
Shake suspension well; dilute before giving via feeding tube.
Flush IV line with NS before and after administering slowly by
IV piggyback.
May cause Stevens-Johnson syndrome.
Nimodipine
(Nimotop)
Inhibits calcium ion
flux across cellular
membrane; decreases
or prevents cerebral
vasospasm
Frequent neurologic assessment and VS; monitor liver enzymes;
assess BP and apical pulse immediately before administration.
Hold if systolic BP is <90 mm Hg
Monitor for hypotension.
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PRIORITY SETTING
a. 1
b. 2
c. 4
d. 7
e. 5
f. 3
g. 6
h. 8
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 2
2. 1, 2, 5
3. 1, 2, 4, 6
4. blood vessel constriction
5. 1
6. 1
7. 1
8. 1, 4
9. 2
10. 1325 mg; 165.6
CRITICAL THINKING ACTIVITIES
Scenario A
1. It may be watched, it may be surg
sected, clipped or wrapped.; it may be treated
with embolization of the aneurysm with a coil
inserted into the aneurysm to promote clotting
of the area.
2. Ms. Rosario may experience a severe headache
and may develop neurologic deficits.
3. Either she will just be watched and her blood
pressure well-regulated, or she will be prepared for a surgical procedure. She will be
monitored for increasing intracranial pressure
with frequent neurologic signs and vital signs
and watched for seizure activity. Headache will
be treated with rest, decreased sensory stimulation, and analgesia that will not mask changing
neurologic signs.
4. The primary nursing responsibility is to monitor Ms. Rosario and carefully perform the neurologic checks. You will compare vital sign
readings with baseline readings to determine
changes. You will monitor her IV for patency
and correct drip rate.
Scenario B
1. It may take him longer to do things and to
make decisions. He may have aphasia with difficulty communicating. That may make it difficult for him to follow directions. He may have
2.
3.
4.
47
apraxia and that would make it difficult for
him to care for himself and do household tasks.
He will most likely be anxious and depressed
as he will be aware of his deficits.
He will be participating in speech therapy, occupational therapy, and physical therapy. The
physician, nurses, nursing and physical therapy assistants, pharmacist, and dietitian will be
working with him too. The social worker will
be called in as well to coordinate care and services for him when he returns home.
When he has a crying spell, which is very common with stroke and particularly a right brain
stroke, just be supportive and tell him that it
is a problem with the brain injury and not just
emotional. He needn’t feel “weak” because
he cries. Just accept it and continue with what
needs to be done. Try to provide rest periods
between activities, as crying is more frequent
with fatigue and with excessive frustration.
Medication depends on the type of cerebrovascular accident (CVA) he experienced. Was
it a thrombotic stroke, an embolic stroke, or an
intercerebral bleed? For a thrombotic stroke
he will be on an anticoagulant and possibly a
latelet aggregation inhibitor such as Plavix.
For an embolic stroke, medication to treat the
underlying cause is indicated. Arrhythmia
drugs would be used to prevent atrial fibrillation or anticoagulants if the atrial fibrillation is
chronic. For an intercerebral bleed, he may be
given medication to keep the blood pressure in
control. He may be prescribed an antidepressant if his depression is to the point of preventing him from participating in rehabilitation.
Scenario C
1. You should ask what seems to trigger the attacks of pain. Inquire about the specific area
in which the pain occurs. Ask about sensation
between pain attacks and when the attacks began.
2. If cerebellopontine angle tumor has been ruled
out, the diagnosis is most likely to be trigeminal neuralgia.
3. Trigeminal neuralgia may be treated with
anticonvulsants such as carbamazepine and
phenytoin and the muscle relaxant baclofen.
Glycerol injections into the terminal branch of
the trigeminal nerve may be helpful. If all else
fails, surgical intervention may be necessary.
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STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. groggy
2. spasm
3. susceptible
4. seizure
5. intractable
6. debilitating
7. aura
8. untoward
“You are really putting a lot of effort into learning
to walk.”
“All your effort and work is paying off.”
“I understand how frustrating it is not to be able to
do the things you used to do so easily. Let’s rest for
a bit and try again.”
CHAPTER 24: CARE OF PATIENTS WITH
PERIPHERAL NERVE AND DEGENERATIVE
NEUROLOGIC DISORDERS
COMMUNICATION EXERCISE
Explanations
A. A cardiovascular accident may have any of
these results: the same half (right or left) of
each eye is affected, paralysis of one side of
the body or paralysis affecting one side of the
body, inability to recognize various sensory impressions (taste, smell, touch, etc.), loss of the
ability to carry out familiar learned movements
on command, loss of the ability to use language, inability to arrange words in the proper
order.
B. A shunt is a bypass between two channels, such
as blood vessels. A stent is a tubular form
mold used to provide support to hold a tubular
structure (as an artery or vein) open.
MATCHING
1. no known cause
2. tumor
3. limp, hanging loose, weak, soft
4. narrowing of the blood vessels
5. both sides
COMMUNICATION EXERCISE
You could say things such as:
“You are getting that foot out there better today.”
COMPLETION
Degenerative Neurologic Disorders
1. environmental toxins (such as pesticides)
2. dopamine; balance; coordination
3. Any from Table 24-1; trihexyphenidyl (Artane),
pramipexole (Mirapex), benztropine (Cogentin), levodopa-carbidopa (Sinemet)
4. myelin
5. demyelination
6. relapsing remitting; primary progressive; secondary progressive; relapsing-progressive
7. varying rates of speed; death
L progressive;
B.COM gray matter; spinal cord
8.
9. viral infection; influenza
10. demyelination; inflammation; edema; nerve
root compression
11. cranial nerves
12. ascending paralysis
13. hyperesthesia
14. many; temporary; permanent
15. abnormal movements (chorea)
16. intellectual; emotional
17. autoimmune; activity; rest
18. circulating antibodies
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TABLE ACTIVITY
Parkinson Disease
Multiple Sclerosis
Myasthenia Gravis
Definition
Group of symptoms causing
disorders of part of brain
that controls balance and
coordination
Neurologic disorder affecting primarily the central
nervous system
Chronic autoimmune disease with circulating antibodies acting against neuromuscular receptor sites
Clinical
manifestations
Tremor
Poor coordination
Rigidity of muscles
Loss of motion
Body restlessness
Motor dysfunction
Sensory changes
Coordination problems
Mental changes
Fatigue worsened by heat
Diplopia
Ptosis
Difficulty chewing and
swallowing
Fatigue
Exhaustion
Severe muscle weakness
Cause
Idiopathic
Unknown
Autoimmune alteration
Diagnostic
measures
Clinical manifestations indicate diagnosis
Lab tests usually normal
Clinical manifestations indicate diagnosis that is definitive, probable, or possible
Magnetic resonance imaging, cerebrospinal fluid
(CSF) analysis
History and physical exam
Lab testing and electrodiagnostic testing
Medical
management
No cure
Medications used tool
contr
GRA
symptoms
Physical therapy
Sometimes surgery
No cure
Anticholinesterase therapy
Plasma exchange to remove
antibodies
Special
nursing
concerns
and patient
problems
Safety measures
Patient may require assistance with activities of daily
living
Measures to prevent immobility complications, incontinence problems, muscle
spasms
Consideration for patient’s
visual and speech problems
Support related to patient’s
possible sexual dysfunction
prevent infection, reduce
muscle spasms, decrease
symptoms
PRIORITY SETTING
a. 4 Biaxin should be given after she eats.
b. 2 You must take an apical pulse and check
blood pressure.
c. 1 Mestinon must be given on an empty
stomach and not later than ordered.
d. 3 Cogentin and Sinemet should be given
with food.
Metamucil should be given 1 to 2 hours after other
drugs, as it can interfere with drug absorption.
Monitor often for signs and
symptoms of crisis
Teach patient and family
about disease (patient’s
changing status)
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 1, 3, 5
2. 1
3. 4
4. 4
5. 3
6. 3
7. 2, 3, 4
8. 2
9. 4
10. 15 to 20
49
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Study Guide Answer Key
CRITICAL THINKING ACTIVITIES
COMMUNICATION EXERCISES
Scenario A
1. She will have unpredictable periods of remission of the disease and periods of exacerbation
of the symptoms.
2. You could assess whether there is a time of day
when vision is best and suggest studying then
if possible. You could suggest recording lectures and listening to the recording as a study
method. You could suggest contacting the Library for the Blind to get audio recordings of
the textbooks.
3. Tell her it works well for many people but has
some disagreeable side effects such as flulike
symptoms, local skin reactions, and depression. It can affect the blood cells and liver function and she would need to have blood drawn
every 3 months.
A. Dialogue Practice
This is an oral exercise to be performed with a partner.
Scenario B
1. Tell him it is an autoimmune disease that
causes muscle weakness. It is treated with
medication and lifestyle accommodations to
prevent undue stress and fatigue.
2. It can be life-threatening because of its effect on
breathing and swallowing.
3. It is treated by anticholinesterase agents such
as Mestinon. Mestinon must be taken at the
correct time and on an empty stomach. If an
exacerbation of the disease is severe, plasmapheresis may be used to remove the offending
antibodies.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. Ascending
2. collaborate
3. drooling
4. plateau
5. dyspepsia
B.
Explanations
“Because you can become critically ill and need immediate medical attention at any time, the bracelet
will alert the people around you and the medical
personnel who respond to your condition and they
will know immediately what should be done, and
whom to contact.”
Other reasons could be:
“It is easily seen if there is an accident or sudden
need.”
“It can alert people, especially medical personnel,
to illnesses, conditions, and allergies.”
“It can give contacts as to where to go for more information.”
“It can be used for children, as well as adults with
conditions like Alzheimer disease, or those who are
unable to speak or explain or are unconscious.”
CHAPTER 25: THE SENSORY SYSTEM: EYE
REVIEW OF ANATOMY AND PHYSIOLOGY
Terminology
1. h
2. c
3. k
4. e
5. b
6. j
7. a
8. d
9. i
10. f
Labeling
See Figure 25-1.
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51
TABLE ACTIVITY
Disease
Blepharitis: Infection of
glands and lash follicles
along lid margin
Chalazion: Internal stye;
infection of meibomian
gland
Signs and Symptoms
Medical Treatment and Nursing Interventions
Itching, burning, sensitivity to light
Warm compresses to soften secretions; scrub
eyelids with baby shampoo; stroke sideways to
remove exudate and scales
Mucus discharge and scaling; eyelids
crusted, glued shut, especially on
awakening
Loss of eyelashes
Antibiotic eyedrops; systemic and topical
antibiotics if skin is infected
Astigmatism or distorted vision,
depending on size and location of
chalazion
Chalazion may require surgical excision and
antibiotics to avoid chronic state and cyst
formation
Small, hard tumor on eyelid
Hordeolum: External stye; Sharp pain that becomes dull and
infected swelling near the throbbing
lid margin on inside
Rupture and drainage of pus bring
relief
Hordeolum usually resolves spontaneously
Warm compresses qid for 10–15 min to bring stye
to a head and hasten rupture
Caution patient never to squeeze swelling, as this
could spread infection; poor health status can
predispose a person to recurrence of styes
Localized redness and swelling of lid
Conjunctivitis:
Inflammation of the
conjunctiva; “pink eye”
is a specific type caused
by chemical irritants,
bacteria, or viruses
Varying degrees of pain and
discomfort
Depends on type of infecting organism; antibiotic
eyedrops and ointments for bacterial infections.
Not all bacterial infections need treatment. There
is no role for glucocorticoid use in treatment.
Itching; sens
the eye
Special care when handling infective material
Keratitis: Inflammation of
the cornea
Varying degrees of pain and
discomfort
Depends on specific causes; could be allergy,
microbes, ischemia, or decreased lacrimation.
Most superficial lesions are self-healing.
Antibiotic eyedrops or ointment used for
bacterial infections. Steroids can reduce
inflammation and discomfort; however, herpes
infection can rapidly worsen keratitis unless an
antiviral agent is given simultaneously
Increased tearing and mucus
production
Photophobia; blurred vision if center
of cornea is affected
Patient is encouraged to use good personal
hygiene, frequent hand hygiene
Corneal abrasion or
ulceration
Moderate to severe pain and
discomfort aggravated by blinking
Change or discontinue use of contact lens
Teach patient proper way to insert, remove, and
care for contact lens
History of trauma, contact lens wear
Caution patient not to moisten lens with saliva
Topical antibiotic ointment and cycloplegic drops
for pain
APPLICATION OF THE NURSING PROCESS
1. Any five of the following:
a. Persistent redness of the eye
b. Continuing pain or discomfort of the eye
following an eye injury
c. Disturbances of vision
d. Crossing of eyes, especially in children
e.
Growths on the eye or eyelids or opacities
visible in the normally transparent part of
the eye
f. Continuing discharge, crusting, or tearing
of the eyes
g. Pupil irregularities, either unequal size or
distorted shape
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2.
Study Guide Answer Key
a.
b.
c.
d.
e.
3.
a.
b.
c.
d.
Orient the person to the room, the bed controls, call light, TV/radio, and bathroom.
Speak to the person as you enter the room
and tell him or her when you are leaving.
Remove hazards from the environment.
Explain what you are going to do before
doing it.
Feed the patient if necessary. Prepare plate
and set up tray for patient who wishes to
feed him- or herself.
Verify that the bottle of drops is the correct
medication (use the “Five Rights” of medication administration).
Wash the hands thoroughly.
Without touching the eye or eyelashes, instill the drops into the small pouch created
by pulling the lower lid downward.
Do not contaminate the dropper or the top
of the container.
2.
3.
Any four of the following:
a. Cloudy or opaque appearance to the lens
of the eye
b. Blurring of vision
c. Distortion of vision when looking at distant objects
d. Vision may be better in low light when pupil is dilated
e. Photophobia may occur
Actions should be in this order of priority:
a. Have patient put on the gown.
b. Check items on the preoperative checklist
that could delay the surgery if undone.
c. Instill first eyedrops.
d. Check rest of preoperative checklist.
e. Instill second set of eyedrops.
f. Get IV started.
g. Instill third set of eyedrops.
SHORT ANSWER
COMPLETION
Eye Disorders
1. hyperopia
2. irritation; infection
3. continuous irrigation; 30 minutes; normal
line; water
4. to leave it in place; patch the eye; seek emergency treatment
5. lens; cloudy and opaque
6. affects the quality of
7. unnoticed; intraocular pressure; optic nerve
8. severe eye pain
9. enhance the outflow; aqueous humor; production
10. blindness
11. retinal detachment
12. overgrowth; rupture; bleeding
13. vividness; colors; details
14. elevated; affected
15. 5
APPLICATION OF THE NURSING PROCESS
1. Any five of the following:
a. Disturbed sensory perception
b. Risk for injury
c. Fear (of blindness)
d Knowledge deficit
e. Self-care deficit
f. Impaired home maintenance
g. Deficient diversional activity
Retinal Detachment and Eye Surgery
1. Any five of the following:
a. Positioning is important and is prescribed
by the health care provider.
b. The eye will be patched until the surgeon
says the patch may be left off.
c. A shield will need to be worn on the eye
for sleeping.
d. Treat any nausea promptly so as not to disrupt the surgical area with vomiting.
e. Eyedrops will need to be instilled on a
schedule and should not be skipped.
f. Hand asepsis when touching the eye is a
must.
g. Patient should not jar the head or move it
quickly.
h. Check with the health care provider to see
when sexual activity can be resumed.
2. a. Tell patient to ask for assistance to ambulate.
b. Instill eyedrops on schedule using aseptic
technique to prevent infection.
c. Answer call bell quickly so that the patient
doesn’t get up without assistance and risk
a fall.
d. Keep the pathway to the bathroom free
from obstacles.
3. a. Avoid heavy lifting and vigorous activity
for several weeks.
b. Wear eye shield during the day when
outdoors and at night for as many weeks
as the surgeon says after the patch is removed.
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Study Guide Answer Key
c.
4.
Sponge bathe, shave, and brush teeth carefully so that no water gets into the eye.
a. Patient will not develop infection in the
eye.
b. Patient will not experience vomiting during recovery.
53
c.
Patient will not experience a fall during
recovery.
d. Patient will comply with eyedrop routine
during recovery period.
e. Patient will not experience increased intraocular pressure postoperatively.
TABLE EXERCISE
Classification
Examples
Action/Nursing Implications
Drugs Used for Glaucoma
Miotics
Carbonic
anhydrase
inhibitors
Prostaglandin analogs:
latanoprost (Xalatan),
bimatoprost (Lumigan),
travoprost (Travatan),
unoprostone isopropyl
(Rescula)
Increase outflow of aqueous fluid through the ciliary muscle
by relaxation of the muscle.
Cholinergics: pilocarpine HCl
(Isopto Carpine), pilocarpine
nitrate (Ocusert Pilo-20, Ocusert
Pilo-40), carbachol (Miostat)
Constrict the pupil, promote outflow of aqueous humor, and
reduce intraocular pressure. Reduce visual acuity in dim light;
advise patient to avoid driving at night. Ocusert is placed in
conjunctival sac and replaced weekly.
Cholinesterase inhibitors:
echothiophate iodide
(Phospholine iodide),
demecarium bromi
(Humorsol)
Produce miosis, increase aqueous humor outflow, and
decrease intraocular pressure. Avoid touching tip of bottle to
eye; moisture may interfere with drug potency.
Beta-adrenergic blockers: timolol
maleate (Timoptic), betaxolol
(Betoptic), levobunolol
(Betagan), metipranolol
(OptiPranolol), carteolol
(Ocupress)
Reduce production of aqueous humor, thereby reducing
intraocular pressure. Betoptic reduces intraocular
hypertension. Monitor pulse and blood pressure during
initiation of therapy. Blurred vision decreases with continued
use. Use beta blockers cautiously in patients with a history of
asthma.
acetazolamide (Diamox),
dorzolamide (Trusopt),
brinzolamide (Azopt)
Interfere with carbonic acid production, thereby decreasing
aqueous humor formation and decreasing intraocular
pressure. Taken orally or as eyedrops (TruSopt). When
taken orally, these drugs have a diuretic action; observe for
dehydration and postural hypotension. Monitor electrolytes.
Confusion may occur in the older adult. Check interaction
with other drugs patient is receiving.
Sympathomimetics epinephrine (Epifrin),
dipivefrin (Propine),
apraclonidine (Iopidine)
Reduce intraocular pressure by increasing aqueous outflow.
May cause brow headache, headache, eye irritation, and
blurred vision. Used for open-angle glaucoma only. May cause
tachycardia and rise in blood pressure.
Alpha-2 adrenergic brimonidine tartrate
agonist
(Alphagan) L
Acts on alpha receptors in the blood vessels, decreasing the
production of aqueous humor. Do not use with soft contact
lenses. Contraindicated in heart disease.
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Study Guide Answer Key
Classification
Antiinflammatories
Examples
Corticosteroids: Pred Forte, OcuPred, Ophtho-Tate
Action/Nursing Implications
Decrease inflammation and swelling; reduce miosis. Interact
with contact lens materials.
NSAIDs: ketorolac (Acular),
flurbiprofen (Ocufen)
Prostaglandin analog: latanoprost
(Xalatan)
Drugs Used to Facilitate Diagnosis and Surgery of the Eye
Cycloplegics and
mydriatics
Anticholinergic
agents
atropine (Atropisol),
cyclopentolate (Cyclogyl),
homatropine (Isopto
Homatropine), scopolamine
(Isopto Hyoscine), tropicamide
(Mydriacyl)
Dilate the pupils and paralyze the muscles of accommodation,
causing mydriasis and cycloplegia. Mydriasis facilitates
observation of the eye’s interior during an examination.
Cycloplegia prevents movement of the lens during assessment
of the eye.
Adrenergic agonist Phenylephrine (Ocu-Phrin)
Induces mydriasis by action on the muscle of the iris. Causes
blurred vision. Photophobia may be eased by using dark
glasses.
Staining solution
Fluorescein
Turns corneal scratches bright green; a green ring surrounds
foreign bodies. Dye will filter through the lacrimal duct into
the nasal secretions.
Topical anesthetics
proparacaine (Alcaine, AKTaine), tetracaine (Pontocaine)
Anesthetize the eye. Caution patient not to rub the eye while
it is anesthetized. Patch eye when patient leaves the office if
medication is still in effect.
Anti-infective Optic Medications
Antibiotics
gentamicin sulfate (Garamycin Used to treat infection or for prophylaxis. Caution patient
ophthalmic), erythromycin
to use a clean washcloth and towel on the face each time to
(Ilotycin), polymyxin B
prevent reinfection.
sulfate, neomycin sulfate,
bacitracin, sulfonamides
(Sodium Sulamyd, Gantrisin),
ciprofloxacin (Ciloxan),
chlortetracycline (Aureomycin),
ofloxacin (Ocuflox)
Antifungal
natamycin (Natacyn
ophthalmic)
To treat Fusarium. Caution as above.
Antivirals
idoxuridine (IDV, Stoxil,
Herplex), trifluridine (Viroptic)
Store in refrigerator. Do not use with boric acid. If no
improvement, discontinue after 1 week.
vidarabine (Vira-A ophthalmic)
Effective against DNA viruses; used for keratoconjunctivitis.
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 4
2. 2
3. 3
4. 2
5. 1, 2, 4, 5
6. 2, 3, 4
7. 1, 4
8. 2, 3
9.
10.
11.
12.
4
1
4
0.6 mL
CRITICAL THINKING ACTIVITIES
1. A teaching plan should include information on:
a. protecting the eyes from injury during recreational activities, work, and hobbies.
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Study Guide Answer Key
2.
b. protecting the eyes from the sun’s damaging rays by wearing a hat and wearing
sunglasses that protect from UVA and UVB
rays.
c. the danger signs of eye disease and to seek
prompt attention if they occur.
d. fruits and vegetables that contain antioxidants beneficial to eye health.
e. timelines for recommended eye exams.
Explain in your own words. Each eye should
be occluded one at a time and the grid should
be at a normal reading distance from the eyes
and well-lit. If the lines appear wavy or abnormal in any way, an ophthalmologist should be
consulted.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. aptitude
2. phenomenon
3. bear in mind
4. opaque
5. acuity
6. take it for granted
COMMUNICATION EXERCISE
This is an individual exercise without “correct”
answers.
CHAPTER 26: THE SENSORY SYSTEM: EAR
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
REVIEW OF ANATOMY AND PHYSIOLOGY
Labeling
See Figure 26-1.
SHORT ANSWER
Prevention of Hearing Loss
1. a. By not putting cotton-tipped applicators or
other objects into the ear canal
b. Obtaining medical assistance when ear
pain occurs
c. Wearing ear protectors when constantly
exposed to loud noises at work, loud music, or loud motors
2. Any four of the following:
a. Failure to react to loud noises during infancy
b. Failure to vocalize by age 2 years
c. Speaking in loud or monotonous tone of
voice
. Habitually asking “What?”
e. Inappropriate responses to statements and
questions
f. Inattentiveness
3. a. Various antibiotics
b. Salicylates such as aspirin
c. Diuretics such as furosemide
d. Anticonvulsants such as phenytoin
e. Antiarrhythmics such as quinidine sulfate
TABLE ACTIVITY
Conductive Versus Sensorineural Hearing Loss
Characteristic
55
Conductive
Sensorineural
Location of dysfunction
External or middle ear
Inner ear or eighth cranial nerve
Common causes
See Box 26-1
See Box 26-1
Treatment
Removal of obstruction
Reconstructive surgery,
tympanoplasty
Hearing aid
Lip-reading and other
rehabilitative measures
Cochlear implant
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Study Guide Answer Key
COMPLETION
The Ear and Hearing Loss
1. air; bone
2. whisper
3. with feet together, arms out to the sides, and
eyes open
4. warmed to room temperature
5. 5 to 10
6. directly in front
7. is turned on and that the battery is working
8. money-back guarantee trial period
9. isolate
10. sensorineural
CRITICAL THINKING ACTIVITIES
1. Include information on noise protection during
recreational activities and when around loud
music. Encourage lowering the volume of music in the car. Inform that foam ear plugs can
cut the decibels of music at clubs and concerts.
Staying away from the direct path of speakers at concerts or other events cuts decibels
received by the ears. Ear plugs should be used
when mowing yards, using weed whackers,
and other power equipment. Ear protection
should be used when firing hunting rifles or
during shooting practice.
2. Decide what methods you would use for yourself when music is playing too loudly. Practice
what you would say to the performers in an
effort to get them to turn down the volume.
Carry foam ear plugs with you to use.
COMPLETION
Ear Disorders
1. a viral infection
2. nystagmus
3. tympanic membrane; the ossicles
4. tinnitus
5. hereditary; inner ear
6. bones (ossicles); conductive
7. hearing aid; stapedectomy or tympanoplasty
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 2
2. 1
3. 1
4. 2, 3, 4
5. back pressure
6. 2
7. 4
8.
9.
10.
11.
12.
13.
3
1, 3, 4
4
1, 3, 4
1
16 or 17 gtts/min
SHORT ANSWER
Tinnitus and Hearing Loss
1. Any four of the following:
a. Caution patient to avoid turning his head
or moving about suddenly.
b. Move slowly when helping the patient to
his feet.
c. Assist with activities of daily living; provide bedrest as need indicates.
d. Administer motion sickness medication on
schedule, before symptoms become severe.
e. Encourage limitation of salt and fluid intake.
f. Encourage smokers to stop smoking.
g. Teach patient to avoid overwork and physical and emotional stress.
2. Any four of the following:
a. Presbycusis
tant exposure to loud noise
c. Inflammations and infections of the ear
d. Otosclerosis
e. Labyrinthitis
f. Meniere’s disease
3. Any four of the following:
a. Engage in biofeedback training or relaxation techniques.
b. Listen to soft background music.
c. Provide “white noise” in working environment.
d. Use hearing aid to mask head noise.
e. Use local and national services for people
with tinnitus.
4. Any two of the following:
a. Speech therapy
b. Lip-reading
c. Sign language
d. Proper use of hearing aid
CRITICAL THINKING ACTIVITIES
Case Study: Otosclerosis
1. Otosclerosis may be hereditary.
2. Otoscopic exam, Rinne and Weber tests, audiometry
3. Because she has better hearing in her left ear.
Stapedectomies are never done on both ears at
the same time.
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Test Bank for deWit's Medical-Surgical Nursing 4th Edition Stromberg (Study Guide Answer
Key)
Study Guide Answer Key
4.
5.
6.
Give her instructions about restriction of food
and fluids starting at midnight the night before surgery. Tell her to shower and shampoo
her hair before coming to the surgery center.
Explain the preoperative routine and tell her
she will have an IV line started. Tell her approximately how long the surgery will last and
how long she will be in recovery. Explain postoperative do’s and don’ts and give her written
instructions.
Zofran would be administered for nausea.
For dizziness, meclizine (Antivert) should be
given.
If she has signed a release for their use, put
up the side rails; keep the bed in the low position. Place the call bell within reach. Check on
her frequently. Assist her to the bathroom and
have her rise slowly to a sitting position, then
a standing position. Wait until dizziness passes
to begin ambulation. Monitor for drainage
from the ear. Monitor vital signs per postoperative schedule.
7.
57
There may still be internal packing, but the bigger reason is edema in and around the surgical site that will prevent sound from traveling
through the tissues. This will resolve with time.
Explain that this is normal and why. Give her
an idea of when she might expect the edema to
subside.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. pitch
2. enunciate
3. Amplified
4. catch all
5. prompt
Other exercises in this section are relative to the individual and do not have “answers.”
CHAPTER 27: THE GASTROINTESTINAL SYSTEM
REVIEW OF ANATOMY
See Figure 27-1 in the textbook.
TABLE ACTIVITY
Causes and Prevention of Digestive Disorders
Causative Factors
Pathology (What Occurs)
Preventive Measures
Psychological and
emotional stress
and tension
Emotions influence appetite and motility of
stomach and intestines.
Excessive stimulation and release of digestive
acids and enzymes can cause breakdown of
tissues.
Teach relaxation techniques to cope with
excessive stress.
Help person identify life stressors.
Help person find ways to cope with identified
problems.
Mechanical and
chemical irritants
Produce irritation and inflammation.
Use of elimination diet to determine foods that
cause gastrointestinal upset.
Help person to avoid these foods and still
maintain adequate nutrition.
Identify and avoid medications (e.g., aspirin,
nonsteroidal antiinflammatory drugs [NSAIDs])
that irritate gastrointestinal (GI) tract.
Infectious agents:
bacteria, viruses,
parasites
Organism enters GI system and causes local
and/or generalized infections.
Teach and promote good hygiene (handwashing
before meals, etc.).
Care in cleaning, cooking, and eating utensils.
Follow rules of sanitation.
Adequate refrigeration of foods.
Use of proper canning and freezing methods.
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Study Guide Answer Key
APPLICATION OF THE NURSING PROCESS
1. a. Is there a family history of gallbladder disease, ulcers, or other digestive problems?
b. Are you taking corticosteroids, NSAIDs,
or other medications that affect the GI system?
c. What kinds of symptoms are you having?
d. When did the symptoms start?
e. What seems to make the symptoms worse?
f. What seems to make the symptoms better?
2. Blockage in the common duct that allows bile
to drain into the intestine, or liver inflammation, causes bilirubin to appear in the urine
making it a dark color.
3. If bile does not reach the intestine, the stool
may be white or clay-colored.
4. Potential for deficient fluid volume due to fluid
loss from nausea and vomiting
5. Patient will have normal bowel movements at
least every 3 days within 2 weeks.
6. a. Increase fluids to at least 2500 mL per day.
b. Increase fiber in the diet by adding more
vegetables, fruits, and whole grains.
c. Increase exercise by having patient walk
for 30 minutes each day.
7. You would monitor the patient’s bowel m
ments and whether the interventions were being followed by the patient. You should ask for
specific feedback about the diet, fluid intake,
and exercise.
8. a. It involves passing a flexible tube with a
light at the end through the mouth and
down into the stomach and small intestine
so the health care provider can look at the
inside lining of these organs. It is not painful, but a topical anesthetic will be used to
prevent gagging and procedural sedation
will be administered intravenously.
b. Solid food and dairy products should not
be ingested after midnight the day before
the procedure. Most providers allow clear
liquids until 4 hours before the procedure.
c. The patient is watched for signs of perforation or excessive bleeding. If topical
anesthetic is used, foods and liquids are
withheld until swallowing reflex returns.
Postsedation monitoring is performed.
PRIORITY SETTING
1. The correct sequence is inspection, auscultation, palpation, and percussion. Palpating first
can alter the bowel sounds.
2. c
3.
c
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 1
2. 2
3. 4
4. 1
5. 4
6. 38 gtts/min
7. 1, 2, 5, 6
8. 3
9. 4
CRITICAL THINKING ACTIVITIES
1. Start oral intake with small amounts of ice
chips. Cold items are usually tolerated better
when nausea is present. You should then provide very small sips of fluid every few minutes
to see if the patient tolerates oral intake. Use a
clear liquid such as Gatorade or similar drink
containing electrolytes. Increase the amount
of each drink as the patient tolerates the fluids
without vomiting. Clear liquids can include
strained clear fruit juices, light-colored soft
drinks that have been allowed to go flat, broth,
popsicles, and gelatin.
2. You should not give the patient fluids that are
high in sodium such as bouillon.
3. You should keep the room and bathroom odorfree and provide a lubricant for the rectal area
after the cleansing of each bowel movement. If
ordered, administer medication to slow the diarrhea. Refrain from feeding anything but clear
liquids until the diarrhea has stopped.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. atrophy
2. alleviate
3. absorbed
MATCHING
1. e
2. d
3. f
4. a
5. c
6. b
7. h
8. i
9. g
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Study Guide Answer Key
COMMUNICATION EXERCISE
1. Heavy lifting or strenuous activities are to be
avoided for 1–2 weeks.
2. A general or local anesthetic will be used.
3. Do you have a family history of digestive problems?
CHAPTER 28: CARE OF PATIENTS
WITH DISORDERS OF THE UPPER
GASTROINTESTINAL SYSTEM
COMPLETION
Upper Gastrointestinal Disorders
1. sleeve gastrectomy
2. anorexia nervosa (or bulimia)
3. reflux; Barrett esophagus
4. diaphragm
5. hiatal hernia
6. H. pylori bacteria
7. 20%
8. 4 to 6
9. subtotal gastrectomy with vagotomy or gastric
bypass
10. uremia
11. cancer of the mouth area
SHORT ANSWER
Ulcer Disease
1. A stress ulcer is more acute than a peptic ulcer
and more likely to produce hemorrhage; perforation occurs occasionally, and pain is rare. A
peptic ulcer is usually caused by an organism,
whereas stress ulcers are from altered perfusion to the stomach.
2. Pain is less in morning and after meals when
there is food in the stomach. Pain is more severe before meals and at bedtime. Pain may appear for 3 to 4 days or weeks and then subside,
reappearing after weeks or months.
3. Upper gastrointestinal (GI) series or if bleeding
is acute, then an endoscopy
4. a. Hemorrhage
b. Perforation
c. Obstruction
5. a. Relieve pain
b. Reduce the need for antacids
c. Promote healing of the ulcer
6. Teach Ms. Galt to regulate the types of foods
eaten. Mealtimes should be unhurried, relaxed,
and spaced at regular intervals. Control stress
and develop healthy coping techniques. Drink
7.
59
a lot of water. Refrain from smoking. Report
side effects of antacids should they occur, such
as constipation or diarrhea, flatulence, and
signs of edema. Check with the pharmacist
about possible drug interactions among all the
drugs being taken. Unless otherwise ordered,
take antacids 1 hour after meals. Avoid aspirin and nonsteroidal antiinflammatory drugs
(NSAIDs). Engage in stress reduction activities.
a. Plastic repair of perforated ulcer; pyloroplasty
b. Subtotal gastrectomy or gastric resection
c. Total gastrectomy
d. Vagotomy
APPLICATION OF THE NURSING PROCESS
1. a
2. Patient will have no further weight loss.
3. Any three of the following:
a. Measure blood glucose as ordered.
b. Keep the dressing over the central line site
clean and dry.
c. Inspect the IV site every shift for signs of
redness, drainage, or tenderness.
d. Monitor temperature and vital signs for
signs of infection.
e. Weigh the patient every 3 days or as ordered.
4. Keep the room odor-free, and decrease sensory
stimulation as much as possible. Offer mouth
care after vomiting episodes; apply a cool cloth
to the forehead and/or neck. Administer antiemetic medication as ordered. Provide pain
relief if pain is a factor in the nausea and vomiting.
5. Evidence that the patient has stopped vomiting
and that nausea has decreased
PRIORITY SETTING
a. 1 She is elderly and dehydrated, which places her at great risk for a fall. Helping her
can be delegated to a nursing assistant.
b. 2 You need to see if he is actively bleeding.
c. 3 Pain should be attended to ASAP.
d. 6 Bathing can wait until more pressing needs
have been met. Helping her can be delegated to a nursing assistant.
e. 4 It is getting close to time for him to go for
the procedure.
f. 5 Assessment takes precedence over bathing.
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 3
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60
2.
3.
4.
5.
6.
7.
8.
9.
10.
Study Guide Answer Key
1
3
4
1
4
360 mL output
4
2
2
CRITICAL THINKING ACTIVITIES
Scenario A
1. You should ask about his usual diet. Ask what
seems to trigger the heartburn. Inquire as to
whether he has gained weight in the last year
or lost weight. Ask about his eating pattern.
Does he eat or drink anything after dinner?
Inquire as to whether he sleeps with a wedge
pillow to elevate his upper body or if he has
risers under the head of the bed. Ask what
medications he is taking. Inquire about how
much coffee, tea, or soft drinks with caffeine he
drinks each day.
2. You would need to teach him to avoid caffeine,
chocolate, tomatoes, onions, spicy foods, and
any other foods that seem to cause him he
burn. Teach him not to eat or drink anything
for at least 2 hours before bedtime. Teach him
to wait at least 2 hours after eating to perform
tasks that require bending over such as gardening. Teach him why using a wedge pillow or
risers under the head of the bed will help his
heartburn. Teach him about his medications
and when to take them.
Scenario B
1. 3, 4, 5, 6
2. 1, 2, 5, 6, 7
3. 4
4. Family history of obesity, determining contributing factors, and obtaining an accurate record
of eating patterns for a 7-day period. Physical
assessment includes measuring weight and
height, figuring body mass index (BMI), and
taking a skinfold thickness measurement.
5. Lower-calorie diet and exercise are prescribed.
The patient is taught ways to change thinking
about food and weight. Participation in a support group and behavior modification with
some sort of reward for weight loss are part
of the total treatment plan. Teach patient that
stress reduction and alternate ways of coping
are essential to success. Medications that sup-
press appetite or block fat absorption may be
used on a short-term basis.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. dumping
2. regurgitation
3. intrinsic factor
4. adhere
5. abound
MATCHING
1. c
2. d
3. e
4. a
5. b
PRONUNCIATION SKILLS
This is an oral exercise.
CHAPTER 29: CARE OF PATIENTS
WITH DISORDERS OF THE LOWER
ESTINAL SYSTEM
SHORT ANSWER
Assessment and Pathophysiology
1. consumption of milk products, caffeine, food
intolerances or allergies, and stress
2. increases in abdominal pressure contribute
to the formation of diverticulum; food gets
caught in the diverticula and mix with bacteria,
causing inflammation
3. diffuse abdominal pain, malaise, and weakness
4. the organisms from the burst appendix cause
inflammation of the peritoneal membrane with
local redness and swelling. Serous fluid is produced and becomes increasingly purulent as
the bacteria multiply. Normal peristaltic action
of the intestines slows or ceases as intestinal
obstruction occurs
5. pain upon defecation and bright-red blood located on the outside of the stool
COMPLETION
Lower Gastrointestinal Disorders
1. total parenteral nutrition (TPN)
2. permanent
3. gangrene
4. Any two of the following: cryotherapy, photocoagulation, rubber banding, or scleropathy
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Study Guide Answer Key
5.
fat (or red meat)
61
g. Refer for professional counseling if clinical
depression develops.
LABELING
Ostomies
1. transverse colostomy (double-barrel)
2. descending colostomy
3. ileostomy
COMPLETION
1. liquid
2. constipation
3. temporary
4. liquid
5. ulcerative colitis
6. intermittent catheterization
7. sigmoid
8. mucus
9. hemicolectomy
SHORT ANSWER
1. a. Cleanliness
b. Use of a protective barrier
2. To establish a pattern of predictable bowel
movements at the convenience of the ostomate
3. a. Use a liquid that is nearly the same as body
temperature.
b. Allow irrigating fluid to flow in slowly.
c. Do not use more than 2 liters at any one
time.
4. a. Keep food diary to identify those foods
that cause gas in the individual.
b. Avoid garlic, cabbage, and other foods
known to cause gas.
c. Be aware that high-fiber foods increase
stool volume and can cause flatus in some
people.
5. a. Avoid eating hard foods that absorb water,
such as corn, hard nuts, and dried fruits.
b. Provide oral administration of enzymes to
encourage digestion.
c. Give gentle massage of the abdomen,
warm bath to relax abdominal muscles.
6. Any four of the following:
a. Be an active listener to the patient’s concerns and feelings.
b. Establish a trusting nurse-patient relationship.
c. Encourage social interaction with others.
d. Recommend contact with a support group
of other ostomy patients.
e. Treat the patient warmly and acceptingly.
f. Provide a chance for discussion of sexual
concerns.
COMPLETION
Medications
1. Any two of the following:
a. The drug will cause dry mouth.
b. Do not take more than the recommended
dose because toxicity may occur.
c. Do not operate machinery until effect on
nervous system is known.
d. Contact health care provider if acute diarrhea does not stop within 2 days.
2. Signs of bowel obstruction, such as constipation with abdominal pain and abnormal bowel
sounds
3. They are habit-forming and their action decreases over time.
4. Separate administration of the two drugs by at
least 1 hour.
5. The drug should be taken 30–60 minutes before
a meal.
6. Warn that an increased hypoglycemic effect
may occur; watch for signs of hypoglycemia.
RITY SETTING
You would check Ms. K. first to try to prevent her
from aspirating. Do a quick assessment while with
her. Do a quick assessment of Ms. T. and administer her pain medication. Attend to the assessment
of Ms. S. and check her blood sugar level. Then assess Mr. P. and do his wound irrigation and dressing change. This procedure will take the longest of
the tasks to be performed.
a. 4
b. 3
c. 7
d. 6
e. 1
f. 2
g. 5
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 1
2. 3
3. 1
4. 2
5. 1
6. 4
7. 1
8. 2
9. 4
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62
10.
11.
12.
13.
14.
15.
16.
17.
Study Guide Answer Key
1
I = 1835 mL; O = 1745 mL
25 gtts/min
1
3
4
3
3
CRITICAL THINKING ACTIVITIES
1. CBC, electrolytes, albumin, glucose
2. See Table 29-2.
3. Because Crohn disease is a progressive disease
that can affect all parts of the intestine. There
is a limit on how much bowel can be removed
and still have adequate nutrient absorption.
4. Infliximab is a monoclonal antibody. May
cause increased diarrhea initially. May adversely affect blood cells.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. mush
2. “worry wort”
3. effluent
4. adhere
5. offending
6. manifested
7. gurgle
8. blanching
9. adverse
10. bout
11. empathy
MATCHING
1. b
2. d
3. a
4. c
CHAPTER 30: CARE OF PATIENTS WITH
DISORDERS OF THE GALLBLADDER, LIVER,
AND PANCREAS
COMPLETION
Gallbladder Disease
1. gallstones (or cholelithiasis)
2. Cholelithiasis
3. dissolving the gallstones
4. a. are obese
5.
b. use oral contraceptives or have had multiple pregnancies
c. have a hemolytic disease
d. have had a bowel resection for treatment of
Crohn disease
a. Ultrasonography or computed tomography (CT) of the gallbladder and biliary
tract
b. Endoscopic retrograde cholangiopancreatography (ERCP)
c. Cholescintigraphy (hepatoiminodiacetic
acid [HIDA] scan)
d. Liver function tests are helpful. Alanine
aminotransferase (ALT) and aspartate
aminotransferase (AST) will be slightly elevated. Gamma-glutamyl transpeptidase is
elevated. In biliary obstruction, both direct
bilirubin and alkaline phosphatase levels
are elevated.
Diseases of the Liver and Pancreas
1. hypertension (or increased blood pressure)
2. sodium, water; diuretics
3. paracentesis
4. decreasing pressure; decrease the risk of bleeding from esophageal varices and reduce ascites
L
5.
ncephalopathy
6. bile; bile pigment
7. ammonia
8. infectious agents
9. hemorrhage from esophageal varices
10. liver cancer
11. liver transplantation
12. Any three: alcoholism; biliary disease; weight
loss; viral infections, trauma, ERCP, penetrating ulcers, drug toxicities, metabolic disorders
13. nonprotein foods such as applesauce; on the
skin or lips
14. smokers
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 3, 4
2. 2
3. 2
4. 4
5. 1
6. 1
7. 1
8. 1
9. 4
10. 1, 3, 4, 5
11. 1
12. 1
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Study Guide Answer Key
13. 1, 2, 5, 6
14. 1
15. 2
63
tentially damaging to the liver, so that he can
avoid exposure to those substances.
STEPS TOWARD BETTER COMMUNICATION
CRITICAL THINKING ACTIVITIES
1. Any four of the following:
a. Exposure to hepatotoxins (e.g., certain
drugs, pesticides, cleaning agents, chemicals)
b. Frequency and amount of alcohol ingestion
c. Exposure to infected individuals or to other sources of viruses and other infectious
organisms
d. Recent blood transfusions, past surgeries
e. Accidental injury or surgery of liver, pancreas, or spleen
2. Subjective data: fatigue, weakness, headache,
anorexia, pain, and nausea. Objective data:
yellowish cast to skin, mucous membranes, or
sclera; rashes; itching; fever; dark urine; lightcolored stools; thigh and leg edema; palmar
erythema; elevated levels of serum AST, ALT,
ALP; vomiting
3. a. Assess current level of energy.
Assist with activities of daily living (ADLs)
4.
5.
6.
7.
8.
Suggest that visitors come when energy
level is higher.
Cluster care and allow for periods of rest.
Help identify activities that require more
energy and help patient prioritize accordingly.
b. Keep needle sticks to a minimum.
Apply pressure for 5–10 minutes after a
needle stick.
Administer vitamin K as ordered.
c. Allow frequent rest periods.
Encourage nutritional intake.
Identify food preferences.
Administer antiemetic medications prior to
meals.
Offer frequent small meals.
Try to keep room odor-free.
Standard Precautions, contact precautions.
25 drops per minute
Immune globulin (IG) and immune globulin
for type B hepatitis (HBIG)
a. Chronic hepatitis
b. Cirrhosis of the liver
c. Primary carcinoma of the liver
He should know how the various types of
hepatitis can be prevented. A list of types of
hepatotoxins should be given to him, including
pesticides, chemicals, and drugs that are po-
COMPLETION
1. prevalent
2. plugged up
3. geared
4. accessory
PRONUNCIATION SKILLS
Practicing with a peer or partner helps you catch
any mistakes you might be making.
Short “i” Sound
liver, filter, topic, digestive, insulin, lipid, sluggish,
lipase, nutrition, cirrhosis, irritation, toxins, cholelithiasis, fluid, deficit, bilirubin, Pitressin infusion,
carcinogenic, phagocytic
WORD ATTACK SKILLS
Combining Forms
1. chol/e/lith/iasis: condition of having gallstones
hol/angio/pancreat/o/graphy: x-ray examination of the bile ducts and pancreas using a
contrast medium
CHAPTER 31: THE MUSCULOSKELETAL
SYSTEM
REVIEW OF ANATOMY AND PHYSIOLOGY
Completion
Changes Occurring With Aging
1. resorption of minerals
2. intervertebral cartilage; vertebra in the cervical
and thoracic spine
3. brittle; less compact
4. cartilage thinning; years of use
5. impaired circulation; metabolic wastes
SHORT ANSWER
Causes and Prevention of Musculoskeletal
Disorders
1. too little calcium and phosphorus or inadequate protein
2. a. by placing a large nutritional demand on
the body
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64
3.
Study Guide Answer Key
b. by invading bone and causing fractures
and by causing muscle wasting
a. consuming adequate amounts of calcium
and obtaining sufficient vitamin D through
sun exposure or through supplements
b. refraining from using steroids on a longterm basis
c. weight training and weight-bearing exercise throughout life
d. learning to lift and move objects correctly
e. using seat belts and safety helmets, consuming adequate protein, and not smoking
MATCHING
Diagnostic Tests
1. f
2. d
3. b
4. e
5. g
6. a
7. c
APPLICATION OF THE NURSING PROCESS
1. Any three of the following:
R
a. Personal history of degenerative boneG
disease, blood dyscrasia (sickle cell disease),
or psoriasis
b. Family history of bone, joint, or skin disease
c. Characteristics and location of pain
d. Joint stiffness
e. Loss of sensation
2. Any three of the following:
a. Complaints of joint pain
b. Limping
c. Poor posture
d. Awkward gait
e. Difficulty arising or walking
f. Wincing upon movement or difficulty with
balance or strength
3. a. Altered mobility due to joint pain and deformity
b. Pain due to joint inflammation
c. Altered self-care ability
4. a. Patient will be able to ambulate with walker by discharge.
b. Pain will be controlled with use of analgesics and comfort measures within 8 hours.
c. Patient will learn adaptive ways to bathe
and dress self before discharge.
COMPLETION
1. range of motion (ROM)
2. calcium
3. atrophy (or lose tone)
4. braced
5. Weight-bearing
6. 3 to 7 days
PRIORITY SETTING
a. 2
b. 11
c. 1
d. 14
e. 5
f. 8
g. 6
h. 4
i. 13
j. 3
k. 10
l. 9
m. 12
n. 7
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
LAB.COM
1. 2, 4, 5
2. 1, 3, 4
3. 1
4. 2
5. 1, 3, 4, 5
6. 2
7. 2
8. 1
9. 2
10. 1
CRITICAL THINKING ACTIVITIES
Scenario A
1. See Patient Teaching—Special Maneuvers on
Crutches.
2. Teach the patient to inspect the rubber tips on
the crutches frequently and to replace them if
they appear worn. Teach not to rest the axillae on the tops of the crutches as it may cause
compression of the nerves and circulation.
Caution to watch for wet places and to avoid
crutch walking through them. Caution to rest if
becomes tired.
Scenario B
1. You should explain what you will be doing and
medicate for pain 30–60 minutes before begin-
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Study Guide Answer Key
2.
ning. Warm compresses to joints may be helpful to relieve stiffness and pain.
Move the joint only to the point of pain and not
beyond that point.
2.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. distal
2. flaccid
3. trigger
4. deficit
5. initiate
6. dowager’s
3.
WORD ATTACK SKILLS
1. ankle
2. a. to attract substances away from another
source
b. to attract and retain substances to the surface
c. to be adsorbed again to another place
3. partial
COMMUNICATION EXERCISE
Assessment Questions: History-Ta
This is an oral exercise.
CHAPTER 32: CARE OF PATIENTS WITH
MUSCULOSKELETAL AND CONNECTIVE
TISSUE DISORDERS
COMPLETION
Musculoskeletal and Connective Tissue
Disorders
1. trauma
2. 3000
3. gangrene
4. weight-bearing exercise
5. Staphylococcus aureus
6. hamstring; quadriceps; calf
SHORT ANSWER
Arthritis
1. a. Have you had an injury, systemic illness,
immunization, or sudden change in physical activity recently?
b. When did joint pain first begin? Was onset
sudden or gradual?
c. What seems to relieve the pain?
4.
65
d. What makes joint pain worse? Does it
come and go? When is it worse? When is it
better? Is there a pattern to the appearance
of the pain and its abatement?
Any three of the following:
a. Evidence of swelling, redness, deformity in
joints
b. Limited range of motion; in what joints;
how much
c. Gait
d. Posture
e. Evidence of improper use of crutches or
cane, inappropriate shoes
Any five of the following:
a. Rest of the whole body is as important as
rest of the inflamed joints.
b. Take a rest before you become too tired.
c. During rest, be sure your body is in good
position. No pillows under the knees or
any other support that keeps the joints
flexed.
d. Always stop exercises at the point of real
pain.
e. Use your biggest muscles to do the work.
f. Learn to conserve your energy to do the
things you really want to do.
g. Let swollen, red, and inflamed joints rest as
much as possible.
h. Change your body position frequently.
See Patient Teaching—Instruction for Joint Protection.
LABELING
Fractures and Immobilization
1. longitudinal
2. spiral
3. greenstick
4. simple
5. compound
6. oblique
7. comminuted
8. transverse
APPLICATION OF THE NURSING PROCESS
Matching
1. e
2. a
3. d
4. c
5. b
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66
Study Guide Answer Key
SHORT ANSWER
1. a. Patient will be able to walk with walker
within 2 days.
b. Patient will be free from venous thrombosis at discharge.
c. Pain will be controlled by adequate analgesia at 3 or 4 on the pain scale of 0 to 10 during activity.
2. Assisting with use of continuous passive motion (CPM) machine, encouraging ambulation
with walker, encouraging active range of motion (ROM) of all other joints, instructing in
quadriceps and gluteal exercises
3. a. apply sequential compression devices or
antiembolic hose as ordered
b. encouraging ROM of feet and ankle and
other leg
c. administering subcutaneous heparin or
Lovenox as ordered
d. encouraging adequate intake of fluid
4. distraction with TV, video games, reading,
board games; massage, use of cold therapy,
meditation or relaxation techniques, a quiet
atmosphere, and visitors also could help
5. Pain is decreased or controlled. Patient demonstrates tolerance of CPM exercise of join
able to independently perform ROM exercises,
is able to ambulate independently or with assistive devices, SCDs or antiembolic hose are
used correctly and there are no signs of thrombosis.
PRIORITY SETTING
1. c, d, a, b
2. c
3. c, Mr. Rodriguez. He could be experiencing an
embolus. Also, because he had multiple injuries, he may be having internal bleeding at a
site other than the leg injury.
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 4
2. 2
3. 2, 4, 5, 6
4. 1, 2, 3, 4
5. 1
6. 3
7. 3
8. 31 gtts/min
9.
10.
11.
12.
2, 4, 5
1
3
4
CRITICAL THINKING ACTIVITIES
1. “Have you been out in the woods or the countryside lately? Have you noticed any ticks on
your animals or yourself? When did you first
notice the red spot? How are you feeling?”
After your neighbor has answered your questions, suggest that she write down her symptoms, time of onset, and other factors about
tick or insect exposure. Help her to develop
a list of questions and advise her to make an
appointment to discuss the symptoms and concerns with her health care provider.
2. If you or he are not aware of family history of
musculoskeletal problems, both of you should
talk to your parents to see if there is a family
history of conditions such as arthritis or gout.
He should see his health care provider, but in
the meantime, elevate the leg and foot and take
some antiinflammatory medication such as
ibuprofen. Tell him to drink a lot of fluid and
m drinking alcohol.
3. Teach him about a diet to avoid high-purine
foods and to increase his fluid intake to 3000
mL/day. Most patients do better if they refrain
from drinking alcohol. The health care provider can prescribe medication to help him avoid
gout attacks
4. Advise rest, splinting, elevation, and cold application after the initial injury.
5. Blood oozing from torn blood vessels forms a
hematoma between two broken ends. Granulation tissue is formed. Young bone cells enter
the area to form woven bone; ends are beginning to knit together. Immature cells are gradually replaced by mature cells so the union resembles normal bone tissue.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. impede
2. debris
3. impediment
4. knit
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Study Guide Answer Key
GRAMMAR POINTS
COMPLETION
Giving Instructions
Any examples of the types of phrases listed are acceptable, such as the following:
1. You may apply an ice pack to the outside of the
cast over the fracture area for 10 minutes of
each hour while awake.
2. You should keep your casted leg elevated to reduce swelling.
3. Be sure to cover the cast with plastic and tape it
down well when showering.
4. You must not bear weight on that foot for at
least 3 weeks.
Urinary Disorders
1. anuria
2. nocturia
3. Urinary frequency
4. Urinary hesitancy
5. urinary stasis
6. infection
CHAPTER 33: THE URINARY SYSTEM
REVIEW OF ANATOMY AND PHYSIOLOGY
Labeling
Anatomy of the Kidney
See Figure 33-2.
SHORT ANSWER
Assessing the Urinary System
1. See Focused Assessment.
2. a. Inspect the abdomen for any visible abnormalities.
b. Palpate all four quadrants for areas of tenderness.
c. Palpate above the pubic bone for evidence
of bladder distention.
d. Inspect genitals as appropriate (i.e., reports
of bleeding, discharge, presence of or recent discontinuation of indwelling catheter).
e. Examine the urine for color, clarity, volume, and smell.
MATCHING
Diagnostic Testing
1. e
2. f
3. b
4. g
5. a
6. d
7. c
8. j
9. i
10. h
67
APPLICATION OF THE NURSING PROCESS
Caring for a Patient with Urinary Incontinence
1. a. Immobility, urinary tract infection (UTI),
stool impaction, prostate surgery, delirium
or confusion, endocrine problems, and obesity
b. Alpha-adrenergic agents, beta-adrenergic
agonists, and calcium channel blockers
2. a. Check the urinary meatus for signs of infection or skin breakdown.
b. Check the patency of the system (i.e., urine
flowing, no kinks in tubing).
c. Measure intake and output (I&O).
3. Patient will remain free from UTI while the
catheter is in place.
. Keep perineal area and catheter clean per
hospital protocol.
b. Increase fluid intake to promote dilute
urine.
c. Use aseptic technique to empty catheter
drainage bag.
d. Keep drainage bag below level of bladder
to prevent backflow.
e. Maintain an enclosed system if at all possible.
5. 2000
6. a. Condom or external catheter drainage
b. Suprapubic catheter drainage
c. Intermittent self-catheterization (caregiver
assisting as needed)
d. Incontinence briefs
e. Bladder training
7. d
PRIORITY SETTING
Scenario A
1. b
Scenario B
1. c
Scenario C
1. d
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68
Study Guide Answer Key
TABLE ACTIVITY
See Table 33-5.
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 2
2. 3
3. 1
4. 1
5. 2
6. 1, 2
7. 1
8. 2
9. 3
10. 3
CRITICAL THINKING ACTIVITIES
1. Any two of these:
a. To determine cause of renal disease
b. To check for malignancy
c. To evaluate extent of transplant rejection
2. A local anesthetic is given. Intravenous pyelogram (IVP) or ultrasound is used to identify
the position for biopsy needle insertion into
the lower lobe of the kidney below the 12th rib.
3.
4.
5.
is inserted and withdrawn. A tissue sample is
extracted and sent to the lab.
Any two of these:
a. Give accurate information about the how
the procedure is performed, what to expect, and what the postprocedure care will
be. This will help Mr. Whipple prepare for
the procedure and will decrease his anxiety.
b. Encourage Mr. Whipple to express fears
and concerns; this helps to relieve stress
and also allows you to address specific
concerns.
c. Consult with the RN or clinical nurse specialist to see if Mr. Whipple can talk to another patient who had a “good” experience
with the same procedure.
b
d
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. patent
2. hypothesize
3. lithotripsy
WORD ATTACK SKILLS
1. Olig(o) = few, little, scanty
2. Poly = many, much
3. Supra = above
4. Extra = outside, in addition
5. Hypo = abnormally decreased or deficient
CHAPTER 34: CARE OF PATIENTS WITH
DISORDERS OF THE URINARY SYSTEM
COMPLETION
1. Azotemia
2. dysuria
3. thrill
4. nocturia
5. Glomerulonephritis
6. hydronephrosis
SHORT ANSWER
Cancers of the Urinary System
1. hematuria
2. a. Smoking
b. Living in an urban area
c. Being male
sure to nitrates, dyes, rubber, or leather processing
3. a. Urine cytology and tumor markers
b. Examining the bladder wall with a cystoscope
c. Biopsy of the tumor
4. An intravenous drug is administered, making abnormal cells sensitive to light. The area
sensitized is treated by laser introduced via a
cystoscope.
5. nephrectomy
Urinary Diversion
1. urine
2. continuous
3. kidney infection
4. a. urinary output every hour for first 24
hours
b. tubing to ensure free flow of urine
5. Patient will demonstrate an acceptance of ostomy by looking at ostomy and showing interest
in self-care prior to discharge.
6. Any three of these:
a. Removing the appliance too roughly
b. Changing faceplates too often
c. Allergic reaction to an adhesive or other
substance
d. Yeast infection
lOMoARcPSD|9825609
Study Guide Answer Key
7.
Any five of these:
a. Properly clean and store appliance.
b. Check for urinary tract infection.
c. Use vinegar or other acidic deodorant.
d. Check for leakage.
e. Avoid eating asparagus.
f. Drink cranberry juice.
LABELING
Different Types of Urinary Diversions
See Figure 34-2.
APPLICATION OF THE NURSING PROCESS
Caring for a Patient with a Kidney Stone
1. Any four of these:
a. Male gender
b. A family or personal history of renal stones
c. Immobility for any reason
d. History of recurrent urinary infections
2. b
3. a. Strain all urine.
b. Encourage high fluid intake.
c. Administer analgesics as ordered, and use
nursing measures to manage pain.
4. Any three of these:
a. Performed in the OR; sound waves are
passed through a water-filled mat.
b. The procedure takes 30–40 minutes.
c. Sedation or general anesthesia is given.
d. Ureteral stents may be placed to facilitate
stone passage.
e. Fluids must be increased afterward to 3000
to 4000 mL to wash out the stone fragments.
f. Early ambulation helps to mobilize fluid.
5. d
PRIORITY SETTING
1. e
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 1
2. 1, 4
3. 3
4. 4
5. 1
6. 3
7. 3
8. 1, 2, 3
9. 2
10. 3
11. 1
12.
13.
14.
15.
16.
17.
18.
19.
20.
69
1
4
4
2
4
3
2
4
1
CRITICAL THINKING ACTIVITIES
Scenario
1. Dialysis is performed to rid the body of excess
fluid and waste products and to maintain acidbase balance. Dialysis works by allowing water
and waste products to pass through a semipermeable membrane. In peritoneal dialysis, the
semipermeable membrane is the tissue covering of the intestines. Fluid is infused into the
abdomen and waste products move out of the
bloodstream through the semipermeable membrane into the fluid. The fluid is then drained
from the abdomen.
2. Any five of these:
a. Weigh the patient and take baseline vital
signs before beginning dialysis.
b. Maintain strict asepsis throughout the entire procedure.
c. Administer warmed solution slowly; monitor for discomfort.
d. Carefully track and record input and output.
e. Assess return fluid for cloudiness that
might indicate infection.
f. Turn the patient side-to-side to facilitate
drainage of solution.
g. Provide diversional activities during procedure.
h. Assess for signs of peritonitis.
3. a
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. flank
2. void
3 pertinent
4. urgency
5. linked
6. intermittent
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Study Guide Answer Key
WORD ATTACK SKILLS
TABLE ACTIVITY
Combining Forms
1. glomerul/o/nephr/itis
network of capillaries/kidney/inflammation
inflammation of the network of capillaries in
the kidneys
2. hypo/albumin/emia
less than normal/albumin/blood
too little albumin in the blood
3. nephr/o/lith/otomy
kidney/stone/incision into
removal of a kidney stone via an incision into
the kidney
4. pyel/o/nephr/o/lith/otomy
pelvis/kidney/stone/incision into
removal of a stone from the pelvis of the kidney via an incision
5. ureter/o/sigmoid/ostomy
ureter/sigmoid colon/opening into
implantation of the ureter into the sigmoid colon
Hormone Changes That Occur With Aging
PRONUNCIATION SKILLS
1. acute renal failure
2. chronic renal failure
3. glomerular filtration rate
4. acute tubular necrosis
5. urinary tract infection
6. nonspecific urethritis
7. end-stage renal disease
8. extracorporeal shock wave lithotripsy
9. transurethral resection of the bladder
10. arteriovenous
11. continuous ambulatory peritoneal dialysis
CHAPTER 35: THE ENDOCRINE SYSTEM
COMPLETION
1. pituitary gland
2. phosphorus; calcium
3. bone breakdown; digestive
4. aldosterone
5. epinephrine; norepinephrine
6. mineralocorticoids; glucocorticoids
7. electrolytes
8. carbohydrates; proteins; fats
9. cortisol
10. glucose; counteract
Hormones
that usually
decrease with
age
aldosterone, renin, calcitonin,
and growth hormone; in the
older female, estrogen and
prolactin; and in the older
male, testosterone
Hormones
that may
increase with
age
follicle-stimulating hormone
(FSH), luteinizing hormone
(LH), norepinephrine, and
antidiuretic hormone (ADH)
Hormones
that remain
unchanged
or are slightly
decreased
thyroid hormones (T3 and T4),
cortisol, insulin, epinephrine,
parathyroid hormone, and
25-hydroxyvitamin D
SHORT ANSWER
Hypothyroidism
1. a. Activate the cellular production of heat
b. Stimulate protein and lipid synthesis, mobilization, and degradation
c. Stimulate the manufacture of coenzymes
vitamins
d. Regulate many aspects of carbohydrate
metabolism
e. Affect tissue response to epinephrine and
norepinephrine
2. Any four:
a. Serum T4
b. Serum T3
c. TSH (thyroid-stimulating hormone)
d. Antithyroid antibody titer
e. Calcitonin
f. thyroglobulin
3. Any four:
a. Contrast media with iodine base for x-ray
studies
b. Furosemide
c. Aspirin
d. phenytoins
e. heparin
4. Any three of these:
a. Test must not be done during pregnancy or
lactation
b. Will not make the patient “radioactive”
c. How procedure is done: a gamma counter
or scintillation counter is placed over the
gland to measure the amount of radioactive iodine (RAI) absorbed
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Study Guide Answer Key
5.
d. Instruct how to collect 24-hour urine specimen if required
a. The thyroid becomes more lumpy or nodular.
b. Metabolism gradually declines.
c. Thyroid hormone levels may decrease with
aging, but the body decreases the rate of
breaking it down; therefore, resting levels
are usually normal.
d. Thyroid disorders are twice as common in
older adults; hypothyroidism is common,
especially in older women.
APPLICATION OF THE NURSING PROCESS
Caring for Patients at Risk for Type 2 Diabetes
1. See Focused Assessment—Data Collection for
the Endocrine System.
2. Patient will decrease weight and maintain
weight within normal limits within 6 months.
3. Any three of these:
a. Assist in designing diet according to preferences.
b. Teach to balance diet and exercise.
c. Teach techniques for substituting healthy
snacks for high-calorie snacks.
d. Reinforce dietary instructions
dietitian or health care provider.
4. Patient states that a normal value of a fasting
glucose is between 70 and 100 mg/dL. States
that postprandial means after a meal; therefore,
“I should have my blood sample taken 2 hours
after I eat for a postprandial blood glucose.
I will have to wait at least 6 to 8 weeks after
following the prescribed diet (or taking prescribed medication) to have a hemoglobin A1C.”
5. a. 18 months and about 3 weeks
b. 7 months and about 2 weeks
c. 4 months and about 3 weeks
PRIORITY SETTING
1. d
2. d
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 3
2. 1
3. 1
4. 2
5. 3
6. 4
7.
8.
9.
10.
71
2
1
4
3
CRITICAL THINKING ACTIVITIES
Scenario A
1. Be an active listener as your neighbor is talking. Many people believe in self-medicating
and in using nontraditional forms of selftreatment; regardless of your own opinions,
hear what she has to say first. Ask several
questions: Have you talked to your own health
care provider about helping you with a weightloss program? Do you have any additional
medication information about this “Internet
drug source”? Are you aware of the safety issues in starting this type of self-medication?
2. Blood pressure and heart rate could increase,
possibly to a dangerous level with excessive
thyroid hormone activity.
3. The Internet has created a vast highway of information that is not necessarily regulated or
validated by any method. In addition, the user
may be looking at a web page that may look
Authentic but is actually a mock-up of the
gen-uine source. Product exchange and
purchase via the Internet is also not wellregulated. This medication may be coming
from a source outside the United States and
would therefore not meet U.S. Food and Drug
Administration (FDA) standards.
Scenario B
1. “It is sometimes hard to understand what the
health care provider is saying or quickly ask
the right questions.” (Acknowledge her feelings of frustration and distrust.) “I have found
that in trying to talk to busy providers, I have
to be very direct and specific and know exactly
what I want to ask them.” (Explain appropriate behavior.) “I could help you make a list of
questions that you could use when you talk
to your provider, and we could even practice
what you want to say.” (Help her make an action plan.) “You need to know how to manage
your hypoglycemia.” (Acknowledge her need
for closure.)
2. a. Can I have hypoglycemia without being
diabetic? If so, how?
b. Why am I having hypoglycemia?
c. What should I do to prevent it?
d. Is hypoglycemia a dangerous condition? If
so, how?
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72
Study Guide Answer Key
e.
3.
If I were diabetic, what signs and symptoms should I watch for?
You may or may not feel comfortable giving an
opinion to your cousin; however, always use
caution when a patient (or a friend, relative,
etc.) asks you for an opinion that is counter to
the health care provider’s advice. You do not
have all of the information in this particular
situation, and you did not hear what the provider actually said to your cousin. Health care
providers are not always correct, nor do they
always fully understand or listen to what the
patient is saying. Conversely, patients do not
always understand or listen to the provider. If a
patient is adamant that the provider is wrong,
an alternative would be to seek a second medical opinion. With information readily available
on the Internet, people are sometimes confused
at all of the varying opinions about medical
topics. You can help your cousin identify credible sources so she can educate herself about
hypoglycemia unrelated to diabetes. She will
then be better able to discuss the situation with
her provider.
STEPS TOWARD BETTER COMMUNICATION
G
COMPLETION
1. sluggish
2. alter
3. lability
4. render
5. aspect
6. assay
7. synthesis
8. negative feedback
9. stalk
10. postprandial
11. elicit
CHAPTER 36: CARE OF PATIENTS WITH
PITUITARY, THYROID, PARATHYROID, AND
ADRENAL DISORDERS
COMPLETION
1. pressure on the neck structures
2. hyperthyroidism
3. hypotension
4. muscle mass
5. an excess (or retention)
6. adrenal medulla
APPLICATION OF THE NURSING PROCESS
Care of Patients with Hyperthyroidism
1. weight loss, nervousness, insomnia, tachycardia, palpitations, exertional dyspnea, and ankle
edema
2. emotional swings, including euphoria and depression, crying, and difficulty concentrating
3. e
4. Any three of the following:
a. Place in Fowler position.
b. Check vital signs continuously in the immediate postoperative period, progressing
to hourly once the patient is considered
stable.
c. Have tracheostomy set at bedside.
d. Check every hour for signs of bleeding, obstruction to breathing, difficulty swallowing, hoarseness, and symptoms of tetany.
5. Patient states, “I should notify my health care
provider if I feel muscle cramps or twitching or
have a seizure, which happen with low calcium
levels. I also should watch for a fever, fast heart
rate and breathing, and getting apprehensive.
My family will be with me and they also know
these signs.”
PRIORITY SETTING
Top five priorities:
1. b. O2 at 3 L per N/C
f. Peripheral IV access × 2 (saline lock × 1)
d. Blood glucose STAT
l. Give 1/2 amp IV push D10 for BS < 60
g. IV bolus 250 mL × 1 over 30 minutes STAT
2.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
RN
RN/LPN
NA
RN/LPN
RN
RN/LPN
RN/LPN
NA
NA
RN/LPN
UC
RN
Assign to the nursing assistant:
d. Blood glucose STAT (if allowed by scope of
practice and institutional policy)
c. VS q 2 hours; notify health care provider if
BP < 100/60 or > 160/90
h. Place on cardiac monitor
i. Place continuous pulse oximeter
lOMoARcPSD|9825609
Study Guide Answer Key
Note to student: RN and LPN could be starting O2
and IVs while the nursing assistant is doing the
blood glucose. (Many nursing assistants receive
training to do this task.) Instruct the nursing assistant to report vital signs, pulse oximeter readings,
and glucose readings to the RN. Many nursing assistants may know where to place the chest leads;
however, placement should be verified by licensed
personnel.
Delegate to the unit secretary:
k. Call for ECG now—complete order entry
into EHR
RN-only responsibilities:
l. Give 1/2 amp IV D10 for BS < 60
e. Levothyroxine sodium 0.5 mg IV slow
push now
a. Assess response to external warming blanket
Note to student: Some facilities will allow LPN/
LVNs to do IV push meds, but because of the critical nature of this patient, it is probably better to
have the RN take responsibility for giving emergency drugs and assessing immediate response to
treatments.
RN or the LPN/LVN could hang the bolus and
maintenance IVs, start O2, and establish peripheral
IV access.
g. IV bolus 250 mL × 1 over 30 minutes STAT
j. Maintenance IV D5.45 NS 150 mL/hr
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 4
2. 1
3. 2
4. 3
5. 3
6. 2, 3, 5
7. 3
8. 2
9. 3
10. 1
11. 2
12. 3
13. 4
14. 3
15. 1
16. 1
17. 2
18. 3
19. 1
20. 4
73
21. 1, 2, 5, 6, 7
22. 1, 2, 3, 4, 5
23. 83 mL/hr
CRITICAL THINKING ACTIVITIES
1. Hypertensive crisis
2. Tachycardia, severe hypertension (as high as
250/150 mm Hg), diaphoresis, anxiety, severe
headache, and palpitations
3. Any three of these:
a. Put the patient in high Fowler position to
decrease intracranial pressure related to
increased blood pressure (BP).
b. Give antihypertensives as ordered to decrease BP.
c. Notify RN of abnormal BP for additional
assessment of critical patient.
d. Notify health care provider of abnormal BP
for additional therapy orders.
e. Establish IV as ordered to give emergency
drugs as needed.
f. Assist patient to remain as calm as possible; excessive anxiety will only potentiate
catecholamine activity.
4. Check with the charge nurse or one of the senior staff nurses. Call the clinical nurse specialist. Often the health care provider can tell you
the most important things to watch for. Use
the computer database of information for the
nursing staff at the facility or authoritative internet resources. You might consider having a
quick reference book stashed in your backpack
or locker. Always check policy and procedure
manuals for institution-specific information.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. tetany
2. taper off
3. inertia
4. moody
5. idiopathic
6. slurred
7. undue
8. wringing
9. bulge
10. think straight
11. fidget
12. lethargic
CULTURAL POINT
Answers will vary with the individual.
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Study Guide Answer Key
COMPLETION
1. blood vessels
2. number; genetic closeness
3. body fluid; insulin
4. leukocytes
5. signs and symptoms
6. nephropathy
7. protein; fats
8. ketones
9. medical nutrition therapy
10. Any four of these: tremulousness, hunger,
headache, pallor, sweating, palpitations,
blurred vision, and weakness
Digestive juices in the gastrointestinal tract inactivate the insulin.
4. Roll the vial back and forth between the palms
for a few minutes to bring it to room temperature.
5. 14 units
6. hypoglycemia
7. Sulfonylurea
8. Gastrointestinal distress and skin reactions
9. Keeps liver from releasing excessive insulin;
makes muscle cells more sensitive to insulin
10. Contraindicated in people with inflammatory
bowel disease or other intestinal diseases
11. Many drugs increase or decrease the action of
oral hypoglycemics and can cause swings in
blood glucose levels.
SHORT ANSWER
APPLICATION OF THE NURSING PROCESS
Type 2 Diabetes
1. Elderly patients develop hypoglycemia more
quickly than younger people, and hypoglycemia may precipitate myocardial infarction,
angina, stroke, or seizures.
2. Many elderly people have difficulty eating due
to problems with teeth, financial inability to afford the correct food, or the inability to ob
and prepare desirable foods due to arthritis
or other disabilities. Weight loss is not recommended unless present weight is more than
one and a half times normal for height and age.
3. Physical limitations may make it difficult for
the elderly diabetic patient to exercise. If exercise is too strenuous, the elderly may experience hypoglycemia up to 24 hours after exercising.
4. Walking, swimming, and riding a stationary
exercise bicycle
5. a. The older adult metabolizes and excretes
drugs more slowly than the younger patient; drugs stay active in the body longer.
b. Some first-generation oral hypoglycemic
agents (Diabinese) have a long half-life and
remain active even longer in the older patient.
Caring for Patients with Diabetic Ketoacidosis
(DKA)
1. Any four of these:
a. Pathophysiology of diabetes
b. Expected testing and treatments
c. How to test blood glucose and give insulin
d. Diet
B C
OM and symptoms of hypoglycemia
e.
Signs
f. Exercise and activity guidelines
g. Sick day guidelines
2. Any six of these:
a. Increased thirst
b. Increased urination (polyuria)
c. Acetone breath odor (“fruity”)
d. Dry mucous membranes and sunken eyeballs (dehydration)
e. Nausea and vomiting
f. Deep respirations (Kussmaul respiration)
g. Abdominal pain and rigidity
h. Paresthesias, weakness, paralysis
i. Hypotension
j. Minimal urine output (oliguria) or none
(anuria) (late sign)
k. Stupor or coma (late sign)
3. a. Restore normal pH of the blood and other
body fluids.
b. Correct the fluid and electrolyte imbalance.
c. Lower the blood glucose level gradually.
d. Provide life-support measures as necessary.
4. Patient will regain and maintain adequate fluid
balance as manifested by pulse and blood pressure within normal limits, intake equal to output, and improved skin turgor within 24 hours.
5. a. Assess for signs of dehydration (i.e., skin
turgor, dry mucous membranes).
CHAPTER 37: CARE OF PATIENTS WITH
DIABETES AND HYPOGLYCEMIA
SHORT ANSWER
Medications for Diabetes
1. Regular insulin
2. The vial of NPH or Lente insulin, which is
cloudy in appearance, should be rolled gently
back and forth between the palms of the hands
to mix the insulin particles in the solution.
3.
lOMoARcPSD|9825609
Study Guide Answer Key
6.
7.
b. Strict intake and output (I&O).
c. Give IV and oral fluids as ordered.
Any two of these:
a. Electrolytes (especially potassium)
b. Arterial blood gases
c. Blood glucose
a
2.
3.
PRIORITY SETTING
2 a. Turn the patient on the side.
6 b. Give a fast-acting source of sugar and a
longer-acting source, such as crackers and
cheese or a meat sandwich, when alert
enough to swallow.
3 c. Administer 1 mg of glucagon by injection
after mixing the solution in the bottle until
it is clear.
4 d. If the patient does not awaken within 15
minutes, give another dose of glucagon
and inform health care provider of the situation immediately.
5 e. Assess ability to swallow after second dose
of glucagon.
1 f. Assess level of consciousness and ability to
swallow.
REVIEW QUESTION FOR THE NCLEX®
EXAMINATION
1. 1
2. 1
3. 2
4. 1
5. 3
6. 4
7. 2
8. 3
9. 2
10. 4
11. 2
12. 1, 3, 4
13. 2
14. 2
15. 3
16. 4
17. 1
18. 4
19. 2
20. 1, 2, 4, 5, 7
CRITICAL THINKING ACTIVITIES
1. Muscular activity improves utilization of glucose and improves circulation, which helps to
prevent cardiovascular complications of diabetes. It also lowers the levels of harmful fats in
75
the blood. It makes the insulin receptors more
sensitive to insulin, and it increases muscle
mass so that glucose can be catabolized more
readily.
You can start with short walks and then progress to longer walks, swimming, or whatever
kind of exercise you enjoy and can tolerate.
Yes. Keeping a record of diet, medications, exercise, and urine and blood sugars helps you
keep up with how well you are managing your
diabetes and helps us make decisions about
adjusting your diet, medications, and exercise
so that you can have better control.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. brittle
2. first-generation
3. unmask
4. sequelae
5. susceptible
6. postprandial
7. tight control
WORD
C
OM ATTACK SKILLS
1.
2.
a.
b.
a.
b.
hard to control, with wide daily variations
hard and thin, but easily broken; fragile
delicate membrane in the secreting glands
rooms under a house or building
CHAPTER 38: THE REPRODUCTIVE SYSTEM
REVIEW OF ANATOMY AND PHYSIOLOGY
Terminology
1. d
2. g
3. f
4. a
5. b
6. e
7. i
8. j.
9. c
10. h
COMPLETION
1. follicular; luteal
2. 30-80
3. hot flashes; hot flushes; night sweats
4. stress; drugs; nutrition; illness
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76
5.
6.
7.
8.
Study Guide Answer Key
luteinizing hormone (LH); follicle-stimulating
hormone (FSH)
puberty
abstinence
5
Examination and Diagnostic Testing
1. 1 week
2. monthly; moles, warts, growths; areas of pigment
3. monthly
4. cancer
5. endometrial biopsy
6. 55
7. colposcopy
8. thickness; size; fibroids
TABLE ACTIVITY
Contraceptive
Method
Abstinence
How Method Works
Sexual contact avoided.
Side Effects/Precautions
Degree of Effectiveness
Reliable method of preventing
pregnancy and STIs.
100%, if used consistently.
Temperature must be taken
before any activity, or it will
rise above its basal level. The
special thermometer should be
kept at bedside.
Varies based on patient’s
compliance with technique.
Can be moderately effective if
practiced carefully.
Not effective for woman with
Fertility awareness methods
that monitor multiple
parameters (e.g., symptothermal
method) may be more effective,
but most important aspect of
success is faithful adherence to
the method; also, the woman
must feel comfortable enough
with her body to make the
necessary observations each
month.
Fertility Awareness Methods
Basal body
temperature
(BBT)
BBT is measured and charted
daily on awakening. Coitus
is avoided on the day of
temperature rise and for 3
subsequent days.
Calendar or
rhythm method
Woman charts her monthly
menstrual cycle on a calendar
and avoids intercourse during
fertile period.
Ovulation or
Billings method
Cervical mucus changes are
assessed. During ovulation,
mucus is clear with high
stretchability (“egg white”
consistency). Degree of
stretch is tested by pinching
a small amount of cervical
mucus between the thumb
and forefinger and stretching
it between them (called
spinnbarkeit). During
ovulation, mucus smeared on a
glass slide will dry into a “fern”
pattern.
irregular
R
ADESmenstrual
LAB.Ccycles.
OM
Several months of charting are
necessary to establish clear
pattern of menstrual cycle.
Woman must feel very
comfortable with her body
and confident in her ability to
detect and assess changes.
Varies based on patient’s
compliance with technique.
Can be moderately effective if
practiced carefully.
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Study Guide Answer Key
Contraceptive
Method
How Method Works
Side Effects/Precautions
77
Degree of Effectiveness
Symptothermal
method
Variety of parameters are
recorded, including cervical
mucus changes, BBT pattern,
mittelschmerz (brief sharp
abdominal pain that may occur
with ovulation), increased
libido (sexual drive).
More effective for women
with regular menstrual cycles.
Requires significant accurate
recordkeeping.
Varies based on patient’s
compliance with technique. Can
be very effective if practiced
carefully.
Chemical
predictor test
A test kit that contains a
chemically treated strip that
will turn color when estrogen
or luteal hormone levels are
present in urine.
Increase in hormone levels
occurs 12–24 hours before
ovulation.
Varies based on patient’s
compliance with technique. Can
be very effective if practiced
carefully.
May increase menstrual flow
or cause cramping or low back
pain. Increased incidence of
PID in women with multiple
sex partners, women whose
partners have multiple
partners, and women with
previous incidence of PID.
Patient must check placement
by feeling for string once each
month.
Up to 99% effective; must
be removed by health care
provider.
Inexpensive, readily available,
easy to use correctly.
Precautions: (1) leave space
at tip for semen to collect
rather than being forced
upward out of the condom;
(2) store in a cool place and
not for excessively long to
avoid breakage due to aging
of the latex or heat damage;
(3) handle carefully to avoid
spilling semen and possibly
introducing it into the vagina.
82%–98% if used properly ; use
of spermicide increases efficacy.
Mechanical or Barrier Contraception
Intrauterine
device (IUD)
A small, sterile, flexible plastic
device that is inserted by a
provider into the uterus. Can
be a copper device (ParaGard)
which can provide 10 years
of protection, or a device
containing the hormone
levonorgestrel (Mirena),
which can provide 5 years of
protection.
Does not protect against STIs.
SLAB
Male condom
A sheath commonly made of
latex that is placed over the
erect penis prior to intercourse.
Oil-based lubricants such as
petroleum jelly can cause latex
to break down and reduce
effectiveness. Some condoms
made of polyurethane are
compatible with oil-based
lubricants.
Effectiveness enhanced with
use of spermicide.
Cervical cap
(FemCap)
A one-size, reusable, hormonefree, latex-free barrier that is
held in place by the vaginal
walls. Used with a spermicide
and inserted before each act of
intercourse.
Effectiveness enhanced with
use of spermicide.
Should not be left in place for
more than 48 hours or used
during menstruation. Woman
should urinate before and after
insertion.
92%
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Study Guide Answer Key
Contraceptive
Method
How Method Works
Side Effects/Precautions
Degree of Effectiveness
Female
(internal)
condom
Sheath with retaining ring that
is placed in the vagina prior
to intercourse. Open end with
large entrance ring extends
outside the vagina. Can be
inserted up to 8 hours before
intercourse.
The penis must remain inside
the sheath, not between
the sheath and the vaginal
wall. Acceptance of the
method has been slow as
it is more expensive and
more difficult and timeconsuming to place properly
than the male condom.
Effectiveness enhanced with
use of spermicide. Provides
protection against STIs.
79%; failures can occur when
the penis is withdrawn too far
and reenters the vagina beside
rather than within the condom.
Diaphragm
A latex or rubber dome-shaped
cup that fits snugly over the
cervix. Spermicide is applied
to the cervical side of the
diaphragm and it is inserted
into the vagina so the fitted
ring holds it securely in place
at the top of the vagina to wall
off the cervix. The spermicide
enhances effectiveness should
there be a leak around the edge
or tear in the diaphragm.
A diaphragm must be fitted
professionally and should be
refitted annually or with a
gain or loss of 7–10 lbs, and
particularly after pregnancy.
88%
Vaginal sponge
A nonprescription soft
polyurethane sponge traps
and absorbs semen and has
spermicidal properties.
R
ADEisSmoistened
LAB.CO
M
Sponge
with
76%–88%
2 tablespoons of water and
squeezed prior to insertion.
Must remain in place 6 hours
after intercourse. Prolonged
use can increase risk for toxic
shock syndrome.
Spermicidal Methods
Gels, foams,
creams
Work by killing sperm within
the vagina. Must be applied
before intercourse.
Available without prescription.
More effective when used
as an adjunct to condoms,
diaphragms, and caps.
71%
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Study Guide Answer Key
Contraceptive
Method
How Method Works
Side Effects/Precautions
79
Degree of Effectiveness
Hormonal Methods
Oral
contraceptives
(OCs)
“The pill” contains a
combination of synthetic
estrogen and progestin,
hormones that prevent
ovulation and thicken cervical
mucus, making it difficult for
sperm to travel upward (also
true for injectable and timedrelease hormonal methods).
Traditionally based on a 28day cycle with 7 hormone-free
days that result in monthly
menstruation.
Some formulations are
considered “low-dose
regimens.”
Prescription required. Must be 91%
taken faithfully to be effective. Does not protect against STIs.
Precautions: Not recommended
for women older than 35
who smoke or women with a
history of heart or liver disease,
breast or uterine cancer, blood
clots or venous inflammation,
or unexplained vaginal
bleeding. At least three regular
ovulatory cycles should be
evidenced before adolescents
start OC use. May cause
nausea.
A formulation is available that
reduces menstrual periods to
four times a year.
Injectable
contraceptives
(Depo-Provera)
Synthetic timed-release
Injections given in clinic
progesterone is injected every
or office. Must be repeated
12 weeks, preventing ovulation. every 12 weeks to remain
effective. Precautions: See oral
contraceptives.
94%
SustainedA thin, flexible rod containing
release implants synthetic hormone is placed
(Nexplanon)
under the skin of the forearm
in a minor surgical procedure.
Effective for 3 years.
Small incision required to
place and to remove. Less
popular now that injection is
available. Precautions: See oral
contraceptives.
99%
Emergency
contraception
(EC)
Taken orally the day after
unprotected intercourse, it
induces menses and prevents
implantation in the uterus.
Not to be used as a routine
form of contraception.
Varies depending on body
mass index (BMI), conception
probability based on cycle day,
and further intercourse after use
of emergency contraception.
Vaginal ring
The NuvaRing (etonogestrel
and ethinyl estradiol) is a
flexible silicone ring inserted
into vagina for 3 weeks and
removed for 1 week to allow
for menstruation.
Leukorrhea and vaginal
infection are possible side
effects. Other side effects
similar to OCs but fewer GI
problems since it does not pass
through GI tract.
91%
Skin patch
A transdermal skin patch
containing norelgestromin
and ethinyl estradiol applied
to dry skin of back, buttocks,
upper arm, or torso. Replaced
each week for 3 weeks. Not
applied 4th week to allow for
menstruation.
Some patients may have
sensitivity to the adhesive
used in the patch. Risk of
thromboembolus may be
higher than with OCs.
91%
Women receiving the
“morning-after” pill should
also get assistance in choosing
an effective, ongoing method of
contraception.
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Study Guide Answer Key
Contraceptive
Method
How Method Works
Side Effects/Precautions
Degree of Effectiveness
Permanent Contraception
Tubal ligation
(female,
surgical)
Fallopian tubes are surgically
cut or tied to prevent sperm
from reaching ovum.
Sterilization procedures are
considered permanent because
reversal may not be effective.
99%
Vasectomy
(male)
The vas deferens (sperm
ducts) are cut and tied to
prevent sperm from entering
ejaculatory fluid.
Use another form of birth
control until two sperm
analyses are negative.
99%
pain; conditions that aggravate pain and
discomfort
c. Feeling of fullness in pelvis and abdomen
d. Pruritus and vaginal discharge
e. mental and emotional symptoms: depression, postpartum blues, irritability related
to menstrual periods
Menopause
1. 12
2. moisture; elasticity
3. Any seven of these:
a. Hot flashes
b. Excessive perspiration
c. Dryness and itching of the vagina
d. Painful sexual relations and decreased libido
e. Increased susceptibility to infections
f. Fatigue
g. Insomnia
h. Emotional swings, depression, irritability
i. Back pain
j. Headache
Objective data: Any four of these:
a. Lumps and masses detected and their location
unt and character of vaginal discharge
c. Evidence of redness or swelling of vulva or
vagina
d. Blisters, ulceration, or other lesions of vagina or perineum
e. Number and type of peripads or tampons
used in 24-hour period, degree of saturation
f. Clots and bits of tissue passed vaginally
g. Contour, symmetry of breasts; condition of
nipples
SHORT ANSWER
Nursing Assessment of the Reproductive
System
1. Age is relevant because of unique developmental stages in the life of a female. Breast cancer
and endometrial cancer are more common in
postmenopausal women. Sexually transmitted
infections (STIs) are more prevalent in sexually
active young women.
2. The risk for cervical cancer and STIs is higher
in women who have certain patterns of sexual
activity.
3. a. Onset of menses
b. Usual length of menstrual periods
c. irregularity of menstrual periods
d. Episodes of irregular bleeding
e. Vaginal discharge other than menses
4. Subjective data:
a. Report of symptoms of premenstrual syndrome
b. Pain and discomfort: location, duration,
description; self-help measures that relieve
PRIORITY SETTING
2 a. Assemble clean gloves and supplies.
4 b. Encourage Ms. Gian to void because a full
bladder will make the exam more uncomfortable.
6
3
5
1
c.
Stay with Ms. Gian, encourage her, and
give information.
d. Orient Ms. Gian to the equipment and the
purpose of the exam.
e. Position Ms. Gian appropriately (i.e., lithotomy position).
f. The unit should provide privacy and good
lighting.
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Study Guide Answer Key
CRITICAL THINKING ACTIVITIES
Promoting Men’s Reproductive and Sexual
Health
1. Any three of the following:
a. Good hygiene practices
b. Careful choice of sexual partner
c. Use of condoms for intercourse
d. Prompt attention to minor problems
e. Practicing testicular exam
f. Obtaining a digital rectal exam and
prostate-specific antigen (PSA) exam each
year after age 50
2. a. At least once a month after a warm shower
b. Roll each testicle gently between the thumb
and fingers of both hands. Note any lumps
or nodules.
c. To detect testicular tumors; testicular cancer is the second major cause of death from
cancer in men between the ages of 25 and
35 years.
3. Any four of the following:
a. Teach and promote testicular self-exam.
b. Encourage a digital rectal exam and PSA
test each year for men over age 50.
c. Continuously assess older men for signs of
urinary retention.
d. Assess for sexual dysfunction and provide
counseling or referral for assistance.
e. Encourage the use of condoms for intercourse.
f. Teach perineal muscle exercises to decrease
the incidence of incontinence.
REVIEW QUESTION FOR THE NCLEX®
EXAMINATION
1. 4
2. 2
3. 1
4. 1, 3, 4
5. 1, 2, 3, 5
6. 4
7. 4
8. 2, 4
9. 1
10. 2, 3, 5, 6
CRITICAL THINKING ACTIVITIES
1. Physical health, sexual activity, desire to have
children at a future date, cultural and religious
beliefs about family regulation and lifestyle
2. Inexpensive, readily available, easy to use correctly, effective for both contraception and STI
3.
4.
81
protection, protection increases with use of a
spermicide.
Abstinence, use of birth control pills, intrauterine contraceptive devices, tubal ligation, vasectomy of partner
Sheath with retaining ring that is placed in the
vagina prior to intercourse. Open end with
large entrance ring extends outside the vagina.
Acceptance of the method has been slow as it
is more expensive and more difficult and timeconsuming to place properly than is the male
condom.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. slough
2. period
3. “change of life”
WORD ATTACK SKILLS
1. endoscopic examination of the vagina
2. branch of medicine dealing with the health of
women
3. X-ray of the breast
4. inflammation of the testicle
5. male hormone
ABBREVIATIONS
1. Oral contraceptive
2. Breast self-examination
3. Vaginal self-examination or vulvar selfexamination
4. Follicle-stimulating hormone
5. Intrauterine device
6. Prostate-specific antigen
7. Basal body temperature
8. Lesbian, gay, bisexual, transgender, questioning, intersex, asexual, or other
CHAPTER 39: CARE OF WOMEN WITH
REPRODUCTIVE DISORDERS
COMPLETION
Health Promotion
1. fluid intake; high-fiber; weight
2. alcohol; caffeine; cola
3. Primary prevention
4. bloating; abdominal, pelvic; feeling full quickly; frequency or urgency
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Study Guide Answer Key
f.
COMPLETION
Disorders of the Reproductive System
1. B vitamins; premenstrual syndrome
2. 21; 45; 7; 80
3. a heating pad
4. abdominal; frequency; incontinence
5. Depo-Provera; norethindrone (Micronor)
6. Staphylococcus aureus
7. myomectomy
8. extreme pain; bleeding
TABLE ACTIVITY
See Table 39-3.
Cancers of the Reproductive System
1. endometrial
2. a. Multiple sex partners
b. Sexual intercourse with uncircumcised
males
c. Starting intercourse at a young age (younger than 20 years)
d. Multiple pregnancies
e. Obesity
f. History of human papillomavirus (HPV)
infection or an STI
3. a. Sister or mother with the disease
b. Inheriting the BRCA1 or BRCA2 gene
c. Exposure to asbestos, talc powder, pelvic
irradiation, or mumps
4. Red, brown, or white patches on the skin of the
vulva
5. Signs and symptoms are often nonspecific or
vague, such as fatigue or abdominal distention
with no detectable precancerous changes in the
ovary
6. cervical cancer
7. Gardasil
APPLICATION OF THE NURSING PROCESS
Care of the Patient with Breast Cancer
1. a
2. 125 mL/hr
3. b
4. Any four of these:
a. Check dressing for bleeding.
b. Check for swelling, numbness, and inability to move arm on surgical side.
c. Monitor tubes and drainage.
d. Have patient turn, cough, and deepbreathe.
e. Meticulous skin care.
5.
6.
Take no blood pressure reading or venipuncture on affected side.
d
a. Continue exercises at home.
b. Do not carry a heavy handbag or other articles on affected arm.
c. Have blood pressure checked on unaffected arm.
d. Apply first aid measures immediately after
slightest injury to affected hand and arm.
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 3
2. 2
3. 2
4. 1, 2, 3, 4
5. 1, 3, 5
6. 4
7. 3
8. 2, 4
9. 2
10. 3
11. 4
12. 4
STEPS TOWARD BETTER COMMUNICATION
PRONUNCIATION SKILLS
This is an oral exercise.
WORD ATTACK SKILLS
1. monthly discharge
2. no monthly discharge
3. difficult or painful monthly discharge
4. irregular menstrual bleeding
5. monthly excessive bleeding or hemorrhage
ABBREVIATIONS
1. Assisted reproductive therapies
2. Dysfunctional uterine bleeding
3. abnormal uterine bleeding
4. Polycystic ovarian syndrome
5. Toxic shock syndrome
6. Dilation and evacuation
7. Premenstrual syndrome
8. human papillomavirus
9. Premenstrual dysphoric disorder
10. Hormone (estrogen) replacement therapy
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Study Guide Answer Key
CHAPTER 40: CARE OF MEN WITH
REPRODUCTIVE DISORDERS
COMPLETION
1. testosterone
2. psychological
3. privacy
4. 1 year
5. Chlamydia trachomatis
6. scrotum; painless
7. groin; swelling
8. elevated hormone; scrotal
9. Peyronie disease
10. testicular
11. sexually inactive
12. Transurethral resection of the prostate
13. hydronephrosis
14. urethra
15. 2; 4
16. intraabdominal
17. catheter; tubing
18. sterility
19. Gamma globulin
20. human papillomavirus (HPV); circumcised
21. varicocele
22. 15; 40
23. 50; prostate cancer
24. 2880–3360 mL
APPLICATION OF THE NURSING PROCESS
Care of the Patient with Epididymitis
1. Any four of these:
a. Be matter-of-fact and respectful.
b. Begin with questions about urinary patterns and then lead into more sensitive
ones.
c. Use open-ended questions that start out
with “Tell me about…”
d. Allow the patient to discuss only those
things he is comfortable talking about.
e. Relate his problem to the inconvenience it
has caused in his daily life.
2. Subjective data:
a. Difficulty or changes in pattern of urination
b. Tenderness or pain in external genitalia
c. Rectal pain
Objective data:
a. Penile discharge
b. Lesions of penis, scrotal sac
c. Skin breakdown in perineal area
d. Discoloration or swelling of penis or scrotal sac
3.
a.
b.
c.
d.
e.
4.
5.
a
a
83
Antibiotics
Ice packs
Analgesics
Elevation of the scrotum
Treatment of partner(s) is recommended
for chlamydia
SHORT ANSWER
Care of the Patient with Benign Prostatic
Hyperplasia
1. a. Difficulty starting urine stream
b. Hesitancy
c. Dribbling
d. Urinary retention
e. Urgency
2. a. Adrenergic blockers (doxazosin [Cardura],
terazosin [Hytrin], tamsulosin [Flomax])
b. Reductase inhibitors (finasteride [Proscar]
and dutasteride [Duagen])
3. a. Decreasing caffeine and artificial sweetener
consumption
b. Limiting spicy foods and alcohol intake
RITY SETTING
1.
a
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 1
2. 1
3. 1, 2, 4, 5
4. 2
5. 3
6. 4
7. 2
8. 4
9. 2
10. 2, 3, 4
11. 2
CRITICAL THINKING ACTIVITIES
1. No one can decide how you may feel about this
situation, and of course what you say to any
neighbor may depend on a variety of things,
such as the intimacy of your relationship or
the body language that your neighbor displays
while she is talking. However, a place to start is
to suggest that the neighbor and her husband
go to see their family health care provider and
get advice about how to pursue specialized fertility care.
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84
2.
3.
Study Guide Answer Key
a. Sperm count, sperm analysis
b. Lab tests performed include FSH (folliclestimulating hormone), LH (luteinizing hormone), and testosterone levels
c. A postejaculation urine specimen
d. An ultrasound of the seminal vesicles
e. A fine needle aspiration or biopsy of the
testicles
Any three of these:
a. Evaluate environment for toxins such as
pesticides, lead, mercury, or radiation exposure, which can affect fertility.
b. Instruct to avoid excessive heat around the
scrotal area, which could decrease sperm
development. This includes not using a
laptop in the lap.
c. Hot tubs and tight jockey shorts should be
avoided.
d. Stress-reduction techniques, information
concerning timing and technique of intercourse, and optimum nutrition and health
practices should be reviewed with both
partners.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. gonads
2. cessation
3. opened-ended questions
ABBREVIATIONS
1. benign prostatic hyperplasia
2. prostate-specific antigen
3. testicular self-exam
4. transurethral resection of the prostate
COMMUNICATION EXERCISE
Practice Assessment
Answers will vary depending on the individual.
CHAPTER 41: CARE OF PATIENTS WITH
SEXUALLY TRANSMITTED INFECTIONS
COMPLETION
1. blood; birth
2. adolescents; young adults
3. urinary tract infections
4. 11- to 265. pain; fever; purulent vaginal discharge
6. infertility
7. body fluids
8.
9.
10.
11.
12.
human papilloma; cervical cancer
they are healed
placenta
public health agency
douche
SHORT ANSWER
Care of the Patient with Syphilis
1. Any four of these:
a. “Do you currently have more than one
sexual partner?”
b. “Have you had other partners in the past?”
c. If yes to either of the last two questions,
“Do you understand the risks associated
with having multiple sexual partners?”
d. If currently in a nonmonogamous relationship, “Are you using condoms to help prevent sexually transmitted infections?”
e. “Have you ever had a sexually transmitted
infection?” If yes, ask for specific information (what, when, how treated, was followup done?).
f. “Do you have symptoms or reasons to believe you might have one now?” If yes, ask
for specific information (symptoms, duration are partner[s] symptomatic?).
2. After a 3-week incubation period, a chancre
(hard, painless sore) on the mucous membrane
of the mouth or genitals may develop.
3. Single-dose benzathine penicillin G or adequate blood levels of penicillin given over an
8- to 14-day period, or ceftriaxone 1 g IM for 14
days.
4. 4
5. a. Remember that the chancre is highly infectious.
b. Encourage naming of contacts so everyone
can be treated.
c. Encourage condom use to prevent reinfection.
d. Explain importance of follow-up (usually
3- and 6-month VDRL) to ensure treatment
has been effective.
PRIORITY SETTING
a. 4 Ms. Jones needs a copy of her medical records to take to her primary care provider
appointment next week.
b. 1 Ms. Rodriguez needs her first dose of IV
antibiotics for acute pelvic inflammatory
disease (PID).
c. 3 Mr. Kowolski needs reinforcement of
follow-up procedure for syphilis.
lOMoARcPSD|9825609
Study Guide Answer Key
Mr. Sakai needs a dose of IM ceftriaxone
for gonorrhea.
e. 5 Ms. Hantu needs encouragement to identify multiple sexual partners.
Note to student: Ms. Rodriguez is the most acutely
ill patient. Mr. Sakai may need to stay for a period
of observation after receiving IM antibiotics. Mr.
Kowolski just needs quick reinforcement since the
health care provider has already given the instructions. Ms. Jones may be helped by the office staff.
Ms. Hantu may need some extra time and emotional support to disclose the names of partners. If
you think that a patient like Ms. Hantu may leave,
consider quickly checking in on her before you
start with the other patients. (Treating her partners
is important.)
f.
d. 2
APPLICATION OF THE NURSING PROCESS
Care of the Patient with Pelvic Inflammatory
Disease
1. a. Sexually transmitted organisms, Neisseria
gonorrhoeae or Chlamydia trachomatis
b. Result of an infection following pelvic surgery or childbirth
2. a
3. Ask patient to rate pain on scale (
Ask location, onset, duration, and alleviating
and aggravating factors. Provide privacy and
expose the abdomen for inspection. Observe
for general body language (e.g., grimacing,
tension) and examine the skin surface (i.e.,
look for scars and breaks in skin). Auscultate
all four quadrants, starting in RLQ first. Note
quality and presence of bowel sounds. Palpate
gently and note guarding. Question patient
about pain as you palpate. Note: Patients with
PID usually cannot tolerate deep palpation due
to severity of pain.
4. Patient will state the abdominal pain is within
her acceptable tolerance range (i.e., 3/10) during this shift.
5. Any four or five of these:
a. Recommend condom use with concurrent
use of spermicides.
b. Urge patient to practice abstinence if self or
partners are being treated for an STI until
treatment is completed.
c. Teach patient to take full prescription of
prescribed antibiotics.
d. Advise about the increased risk of STIs
with multiple sexual partners.
e. Advise about the increased risk of infertility.
85
6.
Encourage the identification of partners to
ensure concurrent treatment.
Goal met. Patient states that she will consistently use condoms. She plans to have regular
gynecology appointments and she will think
about limiting the number of partners. She asks
for additional information about spermicides
and different brands of condoms.
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 2
2. orally; 7
3. 3
4. 2
5. 3, 5
6. 1
7. 1, 2, 4, 6
8. 4
9. 1
10. 3
11. 2
CRITICAL THINKING ACTIVITIES
1. STIs such as gonorrhea create tissue irritation
nd skin breakdown, which creates a favorable setting for HIV to enter the body. Multiple
partners increase the potential exposure to all
STIs and HIV.
2. The cervical lining and vaginal pH can be
altered by frequent douching or bacterial vaginosis, which increases risk for STI infection.
Male secretions and semen are in contact with
female mucous membranes for a longer period
of time during and after the sexual act. The
mucus plug in the cervix becomes more permeable around the menstrual period, which can
result in an increased risk for infection. Oral
contraceptives alter the cervical secretions and
create a more favorable setting for STI organisms. The use of long-acting contraceptives
may reduce the use of condoms. Females may
not experience symptoms and therefore fail to
seek medical care as quickly as males.
3. Single-dose treatments are good for any patients where noncompliance is an issue. For
commercial sex workers, there is often the issue
of false names or addresses; therefore, it is difficult to contact these patients with lab results or
to try to follow up with their sexual partners. It
may also be more difficult for certain groups of
patients to return for follow-up (e.g., because
of transportation difficulties or child care).
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Study Guide Answer Key
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. monogamous
2. reluctant
3. heterosexual
4. Homosexual
5. assurance
6. draping
7. nonjudgmental attitude
ABBREVIATIONS
1. oral contraceptives
2. sexually transmitted infection
3. hepatitis B immune globulin
4. human papillomavirus
5. pelvic inflammatory disease
6. hepatitis B virus
CHAPTER 42: THE INTEGUMENTARY SYSTEM
REVIEW OF ANATOMY AND PHYSIOLOGY
Terminology
1. d
2. g
3. i
4. l
5. h
6. b
7. m
8. e
9. f
10. n
11. k
12. j
13. o
14. a
15. c
COMPLETION
Age-Related Changes in the Skin
1. the number of elastic fibers; adipose
2. fragile; collagen fibers in the dermis
3. sebaceous gland activity
4. cold; heat exhaustion
5. hair follicles
6. fungal infections
7. sunburn; senile lentigines (brown spots)
8. wartlike, greasy lesions
SHORT ANSWER
Causes and Prevention of Skin Problems
1. a. Protects against invasion by bacteria
b. Helps regulate body temperature
c. Forms protective covering over entire body
surface
d. Prevents water loss and too much water
absorption during bathing or swimming
2. a. Neither bathe too often nor too little; keep
the skin clean but not to the point of excessive dryness.
b. Eat a diet that includes vitamins and minerals for skin maintenance.
c. Avoid contact with chemicals or substances
that irritate or damage the skin.
3. a. Use a hat and an appropriate sunscreen for
skin type when exposed to the sun.
b. Avoid purposely being in the sun between
11 am and 3 pm.
c. Wear protective clothing that prevents the
sun’s rays from penetrating.
d. Reapply sunscreen after swimming or after
becoming wet with perspiration.
APPLICATION OF THE NURSING PROCESS
Caring for a Patient with Fragile Skin Who Is at
Risk for Skin Tears
1. repositioned; transferred
2. friction; shearing
3. preventable
4. By lifting a fold of skin on the chest, forearm,
or abdomen between two fingers and seeing
how fast it falls back into place
5. See Box 42-1.
6. See Box 42-2.
7. c
8. a. Describe how the tear occurred.
b. Measure the size and describe the appearance.
c. Document all the treatment administered
and include any additional patient teaching.
d. Include the name and title of health care
team who were notified about the incident.
For example, Dr. John Smith and Marcie
Jones RN, home health supervisor, notified
about the skin tear and the measures taken.
SHORT ANSWER
1. many drugs may cause skin reactions
2. itching; pain
3. vitamins; minerals
4. Sebum
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TABLE ACTIVITY
Skin Lesions
See Table 42-1.
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 2
2. 1, 3
3. 1, 2, 3, 5
4. 1
5. 1, 3
6. 1
7. 3
8. 4
9. 3
10. 1.9 mL
CRITICAL THINKING ACTIVITIES
1. Teach her to bathe the affected areas with
warm water and no soap. She should not bathe
in really hot water. She should pat the skin dry
after bathing. An emollient lotion or cream
should be applied immediately after patting
the skin dry. Lotion or cream should be applied
at least twice a day.
2. She should be taught to keep the fingernails
really short so she doesn’t damage the skin
when rubbing itchy places. She should wear
long sleeves to protect the skin from her trying
to scratch. Tell her to try not to get overheated,
as being too warm increases the itching.
3. A few minor scratches may not be significant, especially if good skin care will alleviate
the problem. However, you should consider
gathering more data to determine if there is
a medical or environmental condition that is
causing the itching. Give the patient a specific
time frame to try the self-care measures and
describe signs and symptoms that indicate that
the problem is getting worse. Suggest that she
see her health care provider if self-care does
not resolve the problem.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. trauma
2. exasperating
CULTURAL POINT
You should have written a short script on how
you would explain that there is no such thing as a
“safe” tan. It should include information about the
87
danger of tanning booths, the causes of skin cancer,
and the potential lethality of melanoma.
CHAPTER 43: CARE OF PATIENTS WITH
INTEGUMENTARY DISORDERS AND BURNS
SHORT ANSWER
Integumentary Disorders
1. herpes simplex virus type 1 (HSV-1)
2. autoinoculation
3. herpes varicella zoster (or chickenpox virus)
4. keeping the skin clean and dry
5. intense itching
6. clothing; bed linen; pets
7. steroid creams, sunlight in small doses, tar
preparations, artificial ultraviolet radiation,
psoralen, calcipotriene, and antimetabolites
8. shielding the skin from direct sunlight
9. actinic keratoses
SHORT ANSWER
Caring for a Patient with Nail Fungus
1. warm; dark; moist
2. fingernails; toenails; onychomycosis
3. Instruct the patient to do the following:
• Wear shoes that provide ventilation for the
feet. Wear cotton socks when rubber-soled
shoes or sneakers must be worn.
• Wash and dry the feet at least daily, being
careful to completely dry the skin between
the toes.
• Sprinkle an antifungal powder on the feet
and between the toes if there is a tendency
to have athlete’s foot. An antifungal spray
may be used rather than powder.
• Change hose or socks daily; do not wear
them more than one day without washing.
• Change underpants or shorts daily; do
not wear them more than one day without
washing.
• Use only clean towels, changing them at
least every other day.
• Change bed linens at least once a week and
wash in hot water.
• Do not use the combs, hairbrushes, or hair
clips or ties of others, and do not allow
them to use yours.
• Inspect pets regularly for ringworm. Have
a veterinarian check the animal if an infection is suspected.
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Study Guide Answer Key
MATCHING
COMPLETION
1. The elderly (because they have had more exposure to environmental factors predisposing to
skin cancer)
2. Examination, biopsy, and pathologic examination
3. Melanoma is treated by wide excision with
regional lymph node removal, a variety of
diagnostic tests to determine if there has been
spread, chemotherapy, radiation, and interferon alfa-2b.
Skin Cancers
1. b, e, g
2. c, m
3. d, f, i, j
4. h, k
5. a, l, m
TABLE ACTIVITY
Burn Care
Pathophysiology
Medical Management
Nursing Interventions
Dilatation of capillaries
and small vessels in area;
increase in capillary permeability; plasma seeps
out; edema
If major, cleanse and débride in hospital
and use open method
If patient is discharged after a few days, use
closed method
Tetanus prophylaxis
Antibiotics for several days
Keep clean and warm.
Use of cradle to keep covers off of body or
positioned under radiant heat warmer.
Obtain wound cultures.
Monitor vital signs, especially temperature.
Fluid loss; hemoconcenIV therapy
tration; reduced efficiency Hematocrit
of circulation
Restrict or withhold oral fluids
Monitor intake and output.
Observe for inadequate or excessive fluid
administration.
GRADESLAB.COOral
M hygiene.
Fall in blood pressure;
hypovolemic shock; cellular dehydration
NPO: correct with IV fluids to maintain adequate urinary output
Blood gas studies and electrolyte monitoring
Sloughing of dead tissue; Antibiotics
large open wounds; infec- Closure of wounds; grafts
tion
Culture and sensitivity tests to keep track of
infection
Maintain supine position.
Check blood pressure every hour for 3–4
days.
Check bowel sounds.
Isolation precautions.
Use of special bed.
Comfort measures.
Emotional support.
Pulmonary and respiratory changes due to inhalation injury, pulmonary
edema, obstructed airway
Mechanical ventilation may be necessary
Endotracheal tube, possibly tracheotomy
before edema
Bronchodilators
Oxygen therapy; humidification
Elevate head of bed.
Suction as necessary.
Turn every hour.
Coughing and deep-breathing exercises.
Pain in response to injury
Morphine or Dilaudid IV in incremental
small doses; monitor vital signs
Prophylactic antibiotics
Help to cope with pain; use distraction and
adjunctive therapies to relieve pain.
Administer pain medication as needed with
vital sign monitoring.
Emotional shock due to
pain, long-term therapy,
changed body image; depression, boredom
Emotional support as adaptation to being a
burn patient occurs
Antidepressants for depression
Encourage to collaborate on plan of care.
Use of diversion such as TV, computer,
video games, visitors.
Nourish will to live and provide hope.
Encourage expression of feelings, concerns.
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c.
Wash clothes and linens separately in hot
soapy water.
d. Have patient remain as cool as possible
and not become overheated.
e. Apply topical lotion or ointment as directed.
f. Administer oral medication as directed if
prescribed.
g. Keep hands off of lesions as they can
spread to other skin that is touched.
APPLICATION OF THE NURSING PROCESS
Caring for a Patient with Poison Ivy
1. Impaired skin integrity related to exposure to
poison ivy and inflammatory reaction
2. Patient’s poison ivy will not spread over other
skin areas before healing or patient’s skin lesions will dry and heal with application of
topical ointment within 5 days.
3. Any five of the following:
a. Bathe only in lukewarm water.
b. Change towel and washcloth after each
bath.
TABLE ACTIVITY
Caring for Patients with Pressure Injury
Stage
Characteristics
Suspected
deep tissue
injury
Intact skin with a purple or maroon discoloration. Tissue may be firm, boggy, painful,
cool, or warm.
Stage I
Reddened or deep pink area or mottled skin. May feel warm and firm or tightly stretched
across the area. Does not blanch with pressure.
Stage II
Partial-thickness skin loss; looks blistered, abraded, or has a shallow crater. Involves the
GR
ADESsurrounding
LAB.COMthe area and surrounding skin feels warmer
epidermis and dermis.
Redness
than usual.
Stage III
Craterlike ulcer involving the subcutaneous tissue. May or may not be infected.
Stage IV
Deep ulceration and necrosis involving deep muscle and possibly bone. May be dry or
wet and with oozing dead cells and purulent exudate.
Unstageable
Full-thickness wounds with eschar and/or tissue that obscures depth determination.
SHORT ANSWER
1. the possibility of shearing
2. pressure-relieving
3. pressure points
4. to see if it blanches with light pressure
5. See Box 43-2.
6. Patient’s pressure injury will show granulation
tissue within 5 days of beginning treatment.
7. Measurement of the wound showing decrease
in size from initial measurement. Appearance
of pink granulation tissue in wound. Absence
of signs of infection.
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 1, 4, 5
2. 2, 4
3. 2
4. 1
5.
6.
7.
8.
9.
10.
3
1, 2, 3
2
3
3
13,280 mL (administered via more than one intravenous line)
CRITICAL THINKING ACTIVITIES
Scenario A
1. 54% total body surface burn
2. Full-thickness burns involve all layers of skin
and the destruction of the epidermal appendages. Color is variable, surface dry, severe
edema.
3. Fluid resuscitation and prevention of shock are
the two major concerns during the first hour
after a burn.
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4.
5.
Study Guide Answer Key
You should inspect the nares for singed hairs
and soot; monitor respiratory effort and listen
for stridor.
Prophylactic antibiotics would be administered and sterile technique would be utilized
throughout his care to prevent contamination
that might cause infection.
Scenario B
1. Tell him that burn scars may take as long as
12–24 months to mature completely. They will
become paler and less angry-looking with time.
2. You could explain that for him to maintain
function and mobility of the joints, the exercises are necessary. Point out what a difference
this could make in the quality of life after burn
recovery. You might have another burn victim
visit who was equally burned but has recovered and has good joint mobility.
3. A burn support group might be helpful. Antidepressants may be prescribed to help fight off
depression so that he can actively participate
in rehabilitation. Psychological counseling is
helpful. You can listen to his concerns and encourage verbalization of his feelings. Validate
those feelings and try to point out hope that
things will get better.
Scenario C
1. The patient should have a pressure-relief device on the bed and in the chair. A walker will
help encourage ambulation. A shower chair
aids in bathing and encourages keeping the
skin clean. Placing a lift sheet on the bed, or
having a hospital bed with a trapeze will make
it easier to reposition the patient at night.
2. You should teach wound care with whatever
the health care provider has prescribed to aid
with healing. Emphasize the need to keep the
wound covered and moist. Provide a schedule
for wound care and dressing changes. Teach
the patient and family about inspecting pressure points for beginning skin breakdown.
Instruct in proper skin hygiene to help prevent
other ulcer formation. Teach the patient about
the importance of maintaining adequate intake
of well-balanced meals with sufficient protein.
Scenario D
1. You would objectively document the location
and size of the affected area in millimeters and
describe the surrounding skin, the appearance of the open area, and type and amount of
drainage.
2.
3.
It could be a stage 2, but more data would be
needed to determine the stage, as it might be a
stage 3.
The skin care measures for the injury itself
depends on the staging. Skin care would be
instituted for pressure relief of the area, turning frequently (at least every 2 hours), not positioning the patient so the injury has pressure
on it, keeping the patient clean and dry, and
performing dressing changes as indicated by
the type of dressing chosen for the lesion.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. traumatic
2. proliferation
WORD ATTACK SKILLS
Using Word Elements
1. dermatology
2. epidermis
3. dermatologist
4. allograft
5. homograft
COMMUNICATION EXERCISES
A. You might say, “Excuse me, I hope you don’t
mind my bringing it to your attention, but I
am a nurse and I noticed this spot on your
(face, hand, neck, arm, leg). Have you had it
looked at by a health care provider? It may not
be harmful, but it has characteristics of skin
lesions that can turn cancerous and are best removed before that happens. It would be a good
idea to ask your provider about it.”
B. 1. My attitude should be calm, accepting, and
matter-of-fact. I should be willing to listen
and empathize.
2. TV, radio, computer, iPad, games, puzzles,
and books could help.
C. “Sir, one of the goals we have is to prevent the
development of pressure sores. Frequent movement and position change are essential. We are
here to assist you, but also if you would make
a conscious effort to shift your body weight
and move about, it would be very helpful. For
example, when you do simple activities such
as turning on the television or turning a page
of your magazine, change your position. When
you hear or see someone pass by your room,
use that as a cue to help you remember to shift
your weight. Of course if you want to get up
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and walk about, just call and someone will
come to assist you.”
CHAPTER 44: CARE OF PATIENTS IN
DISASTERS OR BIOTERRORISM ATTACK
COMPLETION
1. casualties
2. Surge capacity; crisis capacity
3. survival
4. Infection control
5. 3- to 6-week
SHORT ANSWER
Disaster Management Planning
1. a. Perform emergency nursing measures
b. Evaluate the environmental and physical
risks and shortages.
c. Know measures for prevention and control
of environmental health hazards
2. Any four of these:
a. Catheter insertion
b. Nasogastric tubes
c. IV insertion with IV fluid therapy
d. Draw blood
e. Pass out food, fluids, blankets, etc.
f. Give emotional support and use crisis intervention skills.
3. Any five of these:
a. Be prepared for self-survival.
b. Know the disaster plan for your workplace
and identify your duties accordingly.
c. Know warning signals of disaster and the
action to be taken.
d. Know measures for protection from radioactive, chemical, or biologic contamination.
e. Know the community disaster plans and
organized community health resources.
f. Know and interpret community resources
for citizen preparedness.
4. a. Pulmonary/choking agents
b. Blood agents
c. Vesicant agents
d. Incapacitating agents
e. Nerve agents
5. a. Anthrax
b. Plague
c. Smallpox
d. Botulism
e. Hemorrhagic fever
f. Tularemia
6.
91
a.
Recognize clusters of cases suggestive of
biologic terrorism.
b. Promptly evaluate and assist with medical
management.
c. Promptly communicate with local public
health department.
d. Work closely with law enforcement, emergency management, public health, etc.
APPLICATION OF THE NURSING PROCESS
Caring for a Patient with Botulism
1. a. Double vision
b. Drooping eyelids
c. Difficulty swallowing and speaking
2. a. Symmetric descending flaccid paralysis
progressing to respiratory weakness
b. Absence of fever
c. Alertness and orientation without sensory
deficits
3. a
4. a. Assess for ability to swallow before feeding or giving medications.
b. Place in Fowler or side-lying position.
c. Give semi-solids (e.g., yogurt), not thin liquids (i.e., milk).
. Have bedside suction ready.
5. c
PRIORITY SETTING
Disaster Triage
RED a. Middle-aged man who is having symptoms
of myocardial infarction.
GREEN b. Child with swollen ankle, decreased
ROM, good peripheral pulses.
GREEN c. Young woman with vomiting, low-grade
fever, and mild abdominal pain.
YELLOW d. Young man with dislocated shoulder
and decreased peripheral pulses.
BLACK e. Child with 90% total body burns.
RN/MD f. Teenager with blunt force abdominal
trauma, denies distress but is diaphoretic.
RED g. Elderly man with insect bite, reports tightness in throat, has angioedema.
Note to student: You may have decided that you
needed to refer the patient with a dislocated shoulder and the child with the 90% burns to RN/MD.
This is okay. YELLOW tag patients may seem borderline for RED or GREEN. On the other hand, it
is difficult for anyone to decide that patients are
BLACK tagged.
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REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 1
2. 2
3. 4
4. 1
5. 1
6. 3
7. 2
8. 2
9. 4
10. 3
11. 2
12. 3
13. 4
14. 2
15. 3
CRITICAL THINKING ACTIVITIES
Scenario A
1. It is normal to be fearful for yourself and your
family when the circumstances are unknown,
but potentially very dangerous. It is also normal to feel as though you should help others.
However, you have an obligation to take care
of yourself, because your family and patie
count on your health and well-being. Before
agreeing to go in, assess whether your family
is safe and able to maintain health and safety
while you are helping others. Finally, nobody
can tell you how to feel or react, but having
a plan that ensures family safety as much as
possible will make you feel better regardless of
your decision.
2. Habitually use Standard Precautions for EVERY patient EVERY day. Be familiar with the
facility’s disaster plan. Review safety precautions, routes of transmission, and treatments
for Category A agents. Ask for extra training as
needed.
Ask: Where would you most likely be assigned
to help if the disaster plan was activated? What
would your duties and roles include? What extra safety precautions would be taken to ensure
the health and safety of the staff?
Scenario B
1. Walk-in clinics and emergency departments are
likely to be the first places that victims will go
if they are having symptoms. Unfortunately,
financially disadvantaged people are likely to
delay seeking treatment for as long as possible.
Crowded shelters, overall poor general health,
2.
increased environmental exposure, and lack
of access to bathing/showering facilities will
further contribute to the spread of contagious
disease; therefore, a downtown walk-in clinic
may potentially see more victims than a suburban emergency department. In addition, these
victims may have late symptoms.
a. Large numbers of patients with similar
symptoms of disease
b. Higher than expected illness and death incidence with common disease
c. Unusual disease presentation
d. Large numbers of patients with unexplained symptoms, diseases, or deaths
e. Disease typical to the area with a sudden
unexplained increase in incidence
f. Atypical incidence of disease in patients
not usually affected
g. Sudden death of many animals in the community
Scenario C
1. 41.6, round to 42 gtts/min
2. 31.25, round to 31 gtts/min
3. 20.8, round to 21 gtts/min
4. 125 gtts/min
L
5.
drip set is not the best choice for
trauma patients, because when large volumes
of fluid need to be delivered quickly (e.g., hypotension related to blood loss), the smaller
diameter of the mini-drip set will impede the
flow. However, mini-drip tubing may be a suitable choice for persons who are at risk for fluid
overload, such as children or elderly people
with chronic heart, lung, or kidney problems.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. duress
2. improvise
3. disparity
4. catastrophe
5. triage
WORD ATTACK SKILLS
Word Meanings
1. reduce
2. perception
3. lack of energy
4. suspend solid particles in a gas
ABBREVIATIONS
1. Office of Emergency Services
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2.
3.
4.
5.
Federal Emergency Management Agency
Disaster Medical Assistance Team
Crisis Standards of Care
National Oceanic and Atmospheric Administration
6. Centers for Disease Control
7. critical incident stress debriefing (team)
8. posttraumatic stress disorder
9. Environmental Protection Agency
10. emergency medical service
11. high-efficiency particulate air
2.
3.
COMMUNICATION EXERCISE
Idioms
1. Telephone tree: a system for contacting people
via phone. For example, Supervisor calls Person A; Person A calls Person B and Person C;
Person B calls D and F; Person C calls E and G;
Person D calls H and I, etc.
2. Ground rules: basic rules or principles for
acting or behaving. For example, one of the
ground rules in class may be to raise your hand
if you have something to say.
CHAPTER 45: CARE OF PATIENTS
EMERGENT CONDITIONS, TRAUMA, AND
SHOCK
TERMINOLOGY
Emergent Conditions
1. d
2. f
3. b
4. c
5. g
6. e
7. a
8. j
9. h
10. i
COMPLETION
1. “Good Samaritan”
2. flexing; hyperextending
3. Flail chest
4. voltage; time
5. Lyme disease; Rocky Mountain spotted fever
6. dysrhythmias
CARING FOR A TRAUMA PATIENT IN THE
EMERGENCY DEPARTMENT
1. A: Airway
4.
5.
93
B: Breathing
C: Circulation
D: Defibrillation or Disability
E: Expose all areas of the body
See Focused Assessment—Evaluation of Accident and Emergency Patients.
Emergency Medical Services (EMS) providers
are well-trained and will usually offer relevant
information immediately upon arrival, but
if they do not, or you did not hear it, ask for
circumstances at the scene of the accident. For
example, was she walking around at the scene?
Unconscious or have periods of mental confusion? Was she thrown from the vehicle or was
she in a seat belt? Was the extrication from the
vehicle difficult or prolonged? Was the vehicle
itself crushed, or totaled? Was the vehicle
struck in the front, rear, or “T-boned” on the
side where she was sitting? Were other persons
from the vehicle dead at the scene? Was there
evidence of drugs or alcohol at the scene?
c
The health care provider suspects that the patient may have blunt abdominal trauma that
is not manifesting obvious signs right now.
he purpose of the vital signs and the repeat
abdominal assessment is to see if the patient
is developing a slow hemorrhage or possibly
peritonitis. You should compare the vital signs
and the assessment to baseline findings for
downward trends. Recall that the pulse may be
higher if there is blood loss, so this is the first
vital sign that will change if there is blood loss.
At 1 hour, the hematocrit is probably not going to show any change, unless the bleeding is
extensive, but again there is a need to establish
a trend. Hemoglobin will more likely drop if
there is bleeding present.
SHORT ANSWER
Domestic Violence
1. a. Have you been hit or hurt in any way in
the past year?
b. Who injured you? Has it occurred before?
c. Are you afraid of anyone?
d. Do you feel safe at home?
e. Does your partner use drugs or alcohol?
How does his or her behavior change after
using them?
2. a. Bruises
b. Swellings
c. Lacerations
d. Fractures
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3.
4.
5.
Study Guide Answer Key
e. Hematomas
f. Blackened eyes
g. Abdominal injuries (especially during
pregnancy)
h. Burns and open wounds
Bruises
a. Depression
b. Low self-esteem
c. Anxiety
d. Stress
d
APPLICATION OF THE NURSING PROCESS
Allergic Reaction
1. b
2. a. Hives
b. Swelling
c. General weakness
d. Tightness in the chest
e. Abdominal cramps
f. Constriction of the throat
g. Loss of consciousness
h. Possibly death
3. For a systemic reaction: aqueous epinephrine
(1/1000 solution) in dosages of 0.3–0.4 mL for
adults
4. An antihistamine, such as Benadryl 25 mg
5. a. Apply an ice pack to reduce swelling and
relieve pain.
b. Apply a paste of baking soda and water or
household ammonia and a cold compress.
c. Apply meat tenderizer.
d. Apply a topical cortisone cream to relieve
inflammation and itching.
6. b
PRIORITY SETTING
a. 6
b. 1
c. 5
d. 4
e. 2
f. 3
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 4
2. 2
3. 2
4. 3
5. 1
6. 2
7. 3
8.
9.
10.
11.
12.
13.
14.
15.
1
3, 4, 5, 7
1
3
3
3
4
4
CRITICAL THINKING ACTIVITIES
1. 125 mL/hr
2. 600 mL/hr
3. 300 mL/hr
4. 125 mL/hr; total infusion time 4 hours
5. The “volume to be infused”(VTBI) can be set
to call you back after a given volume. For example, you may want to recheck Mr. Swan’s
blood pressure after he receives half of bolus;
therefore, you would set the VTBI at 150 mL
and the pump would alarm in 15 minutes. You
could also choose to set the VTBI several mL
short of the desired total volume to prevent
air from entering the line. So, for example, you
may choose to set the VTBI for Ms. Philo at 97
mL. Check with your instructor for additional
ut how to use various pump features.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. triage
2. aspirate
3. combative
4. extremities
5. battering
6. corrosive
7. perfusion
WORD ATTACK SKILLS
Word Meanings
1. stopping
2. change into bad condition
WORD ELEMENTS
1. around the mouth
COMMUNICATION EXERCISE
This is an oral practice.
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CHAPTER 46: CARE OF PATIENTS WITH
COGNITIVE FUNCTION DISORDERS
TERMINOLOGY
1. c
2. h
3. d
4. b
5. f
6. g
7. e
8. a
COMPLETION
Delirium and Dementia
1. speech
2. medications
3. long period of time
4. Alzheimer disease
5. smallest
SHORT ANSWER
Caring for a Patient with Acute Confusion
1. Any four of these:
a. Anesthetics
b. Analgesics
c. Sedative hypnotics
d. Drugs with anticholinergic activity
e. Histamine-blocking agents
f. Beta blockers
g. Nonsteroidal antiinflammatory drugs
(NSAIDs)
2. a. Judgment
b. Affect
c. Memory
d. Cognition
e. Orientation
3. Any five of these:
a. Cerebrovascular accident
b. Drug overdose
c. Toxicity or withdrawal
d. Tumors
e. Systemic infections
f. Fluid and electrolyte imbalances
g. Malnutrition
h. Head trauma
4. See Box 46-3.
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APPLICATION OF THE NURSING PROCESS
Caring for a Patient with Alzheimer Disease
1. Any four of these:
a. Is unable to recognize familiar objects and
people
b. Needs repeated instructions for simple
tasks
c. Needs total care—can be very burdensome
for the family
d. Wanders away
e. Is incontinent
f. Has outbursts of anger, hostility, paranoia
2. 65.9 kg
3. d
4. a. Assist her in recognizing that denial, irritability, anxiety, sleeplessness, and anger are
signs of caregiver role strain.
b. Encourage her to consider day care or respite care.
c. Refer her to local chapters of the Alzheimer
Association for assistance and support
groups.
5. Any five of these:
a. Place a nonremovable identification bracelet on the patient’s wrist, or sew labels into
clothing.
b. Fit the doors with high-up locks.
c. Do not allow the person to drive.
d. Alert police and neighbors to watch for the
elder.
e. Place written block-letter signs on doors.
f. Remove visual stimuli that prompt leaving
(e.g., coats, keys).
g. Provide a safe enclosed outside area if possible.
6. c
PRIORITY SETTING
2 a. Mr. Russell has a need that can be addressed relatively quickly (i.e., his insulin
may be very delayed if the nurse goes to
others first, because they have complex
problems that need assessment and intervention).
4 b. Ms. Eoyang should be assessed for changes
compared to her baseline and signs of
acute delirium. Check her chart to see if
there have been any additions (or deletions) of medications or other events that
may be contributing to her confusion.
6 c. Mr. Murray will need therapeutic communication. If rushed, he will only become
more upset and dissatisfied.
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5
1
3
Study Guide Answer Key
d. Mr. Tosh should be assessed for other signs
and symptoms of infection, and then the
health care provider or RN should be notified accordingly.
e. Ms. Peters needs to be assessed immediately for responsiveness and injury.
f. Mr. Husein also has a need that can be addressed relatively quickly.
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 1
2. 3
3. 2
4. 2
5. 3
6. 4
7. 1, 3, 4, 5
8. 3
9. 4
10. 4
11. 3
12. 4
13. 2
14. 4
15. 2
CRITICAL THINKING ACTIVITIES
Scenario A
1. d. Assess the patient first and remove the
restraints. (Note: If the patient is confused,
combative, or at risk for self-injury, ensure
safety and continue to seek the source of
the behavior; notify the health care provider/RN of your findings.)
2. During report, clarify what the nurse means by
“inappropriate behavior.” Ask some questions;
for example, what is the patient’s baseline
behavior? When did it start? How long did it
last? What actions were taken to discover the
cause of the behavior? What actions were taken
before resorting to restraints? Was a health
care provider’s order obtained? What types of
restraints were applied? How is the patient responding to the restraints?
3. Your ethical obligations are to protect the rights
and safety of the patient. Acting on these obligations could result in several situations. First,
the immediate situation could be corrected; patient’s rights and safety are restored, and nothing else happens. Second, the unit becomes
more aware of restraint policy, and care is improved. Third, the relations with the nurse who
restrained the patient may become awkward,
or that nurse could be dismissed from the job.
Fourth, the patient or family could initiate a
lawsuit against the hospital, and the involved
nurse and you could be called upon to report
your actions.
Scenario B
1. Label the bathroom door with a drawing of a
toilet, stick to a daily schedule, keep the environment quiet, break down ADLs into simple
steps and give directions one at a time; use distraction if agitated; keep the house well-lit.
2. Put locks at the top of outside doors; use childsafe practices in the house, install safety grab
bars in the bathroom; place an ID bracelet on
the patient that can’t be easily removed; label
clothes with the patient’s name and address.
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. blunted
2. abstract
3. confabulation
4. cognition
L
5.
re
6. insight
7. remote memory
8. advance directives
SHORT ANSWER
Memory Examples
Individual answers will differ. Here are some examples:
1. a. I just ate my lunch.
b. I put the newspaper on the table.
2. a. I watered the plants yesterday.
b. I saw Joan last Friday.
3. a. I graduated in 1957.
b. We went to Canada when I was 15 years
old.
WORD ATTACK SKILLS
Word Meanings
1. b
2. c
3. f
4. g
5. e
6. a
7. h
8. d
lOMoARcPSD|9825609
Study Guide Answer Key
PRONUNCIATION SKILLS
-id
-d
blunted
disorganized
disoriented
disturbed
distorted
impaired
-t
6.
diminished
fragmented
CHAPTER 47: CARE OF PATIENTS WITH
ANXIETY, MOOD, AND EATING DISORDERS
COMPLETION
1. calm; supportive
2. extreme life-threatening or life-altering events
3. hopelessness; despair
4. bipolar
5. inability to concentrate; indecisiveness
6. psychomotor
7. 6
8. addictive
9. Substance abuse of alcohol
10. Flight of ideas
11. obsession; anxiety
12. time; normal activities
APPLICATION OF THE NURSING PROCESS
Anxiety
1. Any six of these:
a. Dry mouth
b. Elevated blood pressure
c. Increased respirations
d. Increased heart rate
e. Perspiration
f. Nausea
g. Irritability
h. Diarrhea
i. Increased urination
2. a. Fear
b. Impending doom
c. Helplessness
d. Low self-esteem
e. Anger
3. a. Upset stomach
b. Fatigue
c. Increased need to urinate
4. a. Thyroid problems (hyperthyroidism)
b. Cardiac problems (dysrhythmias)
c. Alterations in blood sugar (hypoglycemia)
5. Patient will demonstrate decreased symptoms
of anxiety (i.e., decreased shaking, crying, and
7.
8.
9.
97
inability to follow simple commands) within 15
to 30 minutes.
Any three of these:
a. Project calm, reassuring attitude.
b. Stay with the person and attend to physical
needs as necessary.
c. Decrease stimuli if possible.
d. Limit the number of people who attempt to
interact with the anxious person.
e. Use clear, simple statements and repeat as
necessary.
a
a. Friendships
b. Social activities
c. Participation in religious organization activities
use of essential oils; lavender
SHORT ANSWER
Depression
1. a. have not responded to repeated trials of
medication
b. are severely depressed
c. are suicidal
2. an electrical shock inducing a grand mal seiure lasting 30–90 seconds.
3. short-term memory loss, occasional headaches,
and confusion
4. a. promoting safety
b. providing adequate nutrition
c. promoting rest
5. protect the patient from acting on impulses to
harm himself
6. antidepressant medication becomes effective
and the patient has the energy to complete an
act of self-harm
7. family history of suicide, history of a previous
suicide attempt, terminal illness, addiction to
drugs or alcohol, diagnosis of major depressive disorder or bipolar disorder, and excessive
stress
8. a. Level of risk of accomplishing the act
b. A thought-out plan
c. A means of accomplishing the act
COMPLETION
1. involves threatened death or serious injury to
self or others
2. feelings of intense distress, anxiety, nightmares,
and/or flashbacks that are recurrent
3. military combat; rape or assault; being held
prisoner; natural disaster
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98
4.
5.
Study Guide Answer Key
dissociative experiences where the event is relived and the person reacts as if it is happening
now
desensitization, therapy and support groups,
exercise regimens, and medications
3.
PRIORITY SETTING
3 a. Instruct the nursing assistant to help Mr.
Canale to the shower. Assigning this is
relatively quick; help the nursing assistant
with Mr. Canale after you have dealt with
the other patients.
2 b. Ms. Phillips needs intervention to calm
down. Her loud tone will trigger anxiety
in the rest of the patients and her behavior
can rapidly escalate to physical aggression.
1 c. Mr. Souza has suicidal ideation, and his
behavior suggests that he is trying to hide
something.
4 d. In a matter-of-fact tone, instruct Ms. Tobin to stop exercising and redirect her to
a different activity. This should also be
relatively quick; remember to avoid power
struggles.
5 e. Mr. Buchanan needs extra time and emotional support with therapeutic comm
cation.
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 4
2. 4
3. 4
4. 3
5. 2
6. 2
7. 2
8. 4
9. 1, 2, 3, 4, 6
10. 1
11. 4
12. 3
13. 4
14. 1
15. 2
16. 2, 3, 4, 6
17. 4
CRITICAL THINKING ACTIVITIES
Scenario A
1. d
2. Any three of these:
a. Maintain a calm demeanor.
4.
b. Set limits in clear, simple sentences.
c. Avoid long explanations based on logic
when patient is acute.
d. Redirect to quiet areas and noncompetitive
activities.
a. Decrease stimuli (eliminate sounds, lower
lights).
b. Remove patient from the common dayroom.
First, know your own strengths and weaknesses and discuss these with a colleague or supervisor. Also realize that therapeutic use of self
is a learned skill that will develop over time,
similar to other skills. Realize that maintaining a therapeutic demeanor is not always easy
when patients are persistent in behavior that
is disruptive or annoying and that although
it is normal to feel annoyed, you can learn to
control your own response to someone else’s
behavior.
Scenario B
1. “Ms. Jones, I am concerned because it sounds
like you are vomiting very frequently.” (State
specific behavior.) “Is there anything I can do?”
(Offer self.) “It’s important that you take care
ealth. We all want you to remain as
part of our team.” (State desired outcome.)
“Seeing a health care provider for a physical
checkup might be a place to start.” (Make appropriate referral to rule out underlying physical problems. Also, Ms. Jones may be more
amenable to discuss things in a professional
setting.)
2. There is no correct answer to this question;
however, consider several points. Does the
health problem interfere (or potentially interfere) with her job performance? What are the
long-term consequences of not intervening?
Once Ms. Jones discloses information to you,
how will you feel if she decides not to change
her behavior?
STEPS TOWARD BETTER COMMUNICATION
COMPLETION
1. overwhelming
2. somatic
3. conducive
4. elation
5. precipitate
6. lethargy
7. differentiate
8. mimic
lOMoARcPSD|9825609
Study Guide Answer Key
9.
10.
11.
12.
13.
14.
15.
lethality
debilitating
recur
hypervigilant
escalate
deprivation
frivolity
2.
3.
CHAPTER 48: CARE OF PATIENTS WITH
SUBSTANCE-RELATED AND ADDICTIVE
DISORDERS
COMPLETION
1. 1
2. barbiturates; anxiolytics
3. respiratory depression
4. social factors; environment
5. nail polish remover; aerosol-packaged products (e.g., deodorants); paint thinner
6. Inhalants
4.
5.
6.
7.
SHORT ANSWER
Caring for a Patient with Cocaine Use
1. a. Euphoria and a sense of well-being
b. Increased energy
c. Intense emotional highs and lows
2. a. It is smoked in a pipe, often with marijuana or tobacco.
b. It is “snorted” (inhaled nasally).
c. The powder is dissolved and injected intravenously.
d. It is freebased and smoked (crack).
3. a. It is highly addictive.
b. It can cause death, even in small doses.
4. Any four of these:
a. Anger
b. Rage
c. Embarrassment
d. Guilt
e. Shame
f. Hopelessness
5. a. Calls in sick for Ms. Jackson.
b. Brings Ms. Jackson to the clinic for vitamins (i.e., not acknowledging the real
problem).
APPLICATION OF THE NURSING PROCESS
Caring for a Patient with Chronic Alcohol Use
1. a. Presence of withdrawal symptoms when
alcohol is discontinued and significant impairment in family relationships
b. Impairment in occupational productivity
8.
9.
99
c. Blackouts
d. Drinking in spite of serious consequences
to health and occupation
e. Evidence of tolerance
a. Type of substance used
b. Amount of substance taken
c. Pattern of use
a. Promotion of physical and psychological
safety
b. Provision for safe withdrawal from the
substance
c. Provision for adequate nutrition and
sleep
b
b
Patient will remain free from injury (i.e., falls
or injury related to seizures) during this shift.
Any three of these:
a. Assess for symptoms of withdrawal as
early as 6 hours after ingestion of alcohol.
b. Administer medications as ordered at the
first sign of withdrawal symptoms.
c. Remain with the patient during times of
confusion and disorientation.
d. Obtain an order for restraints if the patient
becomes a danger to self or others.
e. Monitor the withdrawal process closely.
333 mL/hour
a
PRIORITY SETTING
Prioritizing for a Patient with Alcohol
Withdrawal
5 a. Orient the patient to person, place, and
time; will need to be done repeatedly until
the confusion passes.
3 b. IV fluids are administered to correct dehydration as ordered.
4 c. Encourage a balanced diet high in proteins
and multivitamins; patient may not be able
to take solid food in the acute phase, but
replacement of nutrients and particular vitamins can be given IV as needed.
2 d. Give chlordiazepoxide hydrochloride (Librium) as ordered. Librium decreases neurologic irritability and decreases likelihood
of seizures and other symptoms, such as
tachycardia.
1 e. Establish IV access, in case the patient has
a seizure or needs emergency drugs.
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100
Study Guide Answer Key
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 3
2. 2
3. 1
4. 1
5. 2
6. 3
7. 2
8. 2
9. 1
10. 1, 2, 5
11. 4
12. 2
13. 3
14. 3
15. 4
2.
3.
rationalize; to explain something in a way that
seems reasonable but is not necessarily true;
verb
rational; reasonable; adjective
validate; to confirm; verb
valid; effective, well-founded; noun
PRONUNCIATION SKILLS
1. predisposition
sz
2. arousal
z
CHAPTER 49: CARE OF PATIENTS WITH
THOUGHT AND PERSONALITY DISORDERS
TERMINOLOGY
CRITICAL THINKING ACTIVITIES
Scenario A
1. d
2. Increased respiratory rate, decreased pulmonary function, chronic cough
3. Irritability, tension, decrease heart rate, insomnia
4. Nicotine patches, medications, self-help
groups, hypnosis, acupuncture, smoking cessation programs
Scenario B
1. stops using heroin and changes environmental
and social factors, such as breaking off relationships with friends who use substances
2. a supervised alternative living program, group,
individual, behavioral, and referral and participation in a 12-step program.
3. methadone; buprenorphine (Suboxone or Subutex)
Thought Disorders
1. g
2. a
3. d
4. f
5. e
6. h
7. c
8. b
9. i
10. j
COMPLETION
Schizophrenia
1. brief; remain focused
2. 15–25
3. clozapine (Clozaril); aripiprazole (Abilify); risperidone (Risperdal); quetiapine (Seroquel)
4. social withdrawal; apathy
STEPS TOWARD BETTER COMMUNICATION
SHORT ANSWER
WORD ATTACK SKILLS
Thought Disorders
1. a. Decrease in psychomotor retardation
b. Increase in self-care
c. Improved affect
d. An increase in motivation
e. Exhibit a trusting attitude toward others
f. A decrease in social withdrawal
2. a. Presence of psychotic features
b. Bizarre appearance or behavior
c. Appears to be having hallucinations or delusional thinking
d. Difficulty performing activities of daily living (ADLs)
Word Meanings
1. enabling
2. withdrawal
3. foster
Number Words in Order
a. 2
b. 3
c. 1
Word Elements
1. predispose; to make susceptible; verb
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Study Guide Answer Key
3.
4.
5.
6.
7.
a, b, d, e, f
Any three of these:
a. Do not make unnecessary demands.
b. Do not touch the patient.
c. Do not mix medications with food.
d. Be honest with the patient.
See Table 49-2.
See Table 49-2.
10 glasses of water
APPLICATION OF THE NURSING PROCESS
Caring for a Patient with Schizophrenia
1. a
2. d
3. b
4. c
5. d
6. b
SHORT ANSWER
Borderline Personality Disorder
1. a. marked emotional and mood instability
b. self-image distortion
c. impulsivity
d. difficulty in interpersonal relationships
2. a. View of self and others
b. The way feelings are expressed
c. History of relationships
d. History of impulsive behavior
3. Patient will identify two areas where she excels
(e.g., work, home, school) while talking to the
nurse today.
4. a. Set clear and realistic limits on specific behaviors.
b. Establish realistic and enforceable consequences.
PRIORITY SETTING AND ASSIGNMENT
1. d
2. d
3. b
4. c
5. b
REVIEW QUESTIONS FOR THE NCLEX®
EXAMINATION
1. 1
2. 1
3. 4
4. 3
5. 1, 3, 4
6. 3
7. 4
8.
9.
10.
11.
12.
13.
14.
101
3
3
3
1
3
3
1, 2, 3, 6
CRITICAL THINKING ACTIVITIES
1. There are no right or wrong answers to this
question, but self-awareness and application of
nursing knowledge will help you prepare. For
example, does the scenario trigger a fear that
you may have about caring for patients with
mental health disorders? Nursing students are
often fearful of psychiatric patients because of
stories they may have heard or because the patients seem uncontrollable and unpredictable.
If you are having these concerns, talk to your
clinical instructor.
2. Ms. Sutton may have felt abandoned and was
unable to verbalize her feelings, so aggression
became a way of expressing her feelings. Ms.
Sutton may have felt angry because of your
having left or having misunderstood your
xplanation. It is also possible that Ms. Sutton
displaced feelings onto you (i.e., was actually
angry at something or somebody else). (Also
recall that disease processes or environmental
factors may have interrupted achievement of
developmental tasks; therefore, Ms. Sutton
may be functioning at a lower level than expected.)
3. See Box 49-2.
STEPS TOWARD BETTER COMMUNICATION
CHOOSING THE CORRECT WORD
1. impulsive
2. acting out
3. odd
4. boundaries
5. trigger
6. traits
DESCRIPTIVE TERMS
Cluster A
1. odd
2. suspicious
3. eccentric
4. distorted thinking
5. distrustful
6. distorted feelings
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102
Study Guide Answer Key
Cluster B
1. lacks empathy
2. impulsive
3. need for admiration
4. attention-seeking
5. grandiosity
6. extremely emotional
7. lability of emotions
8. disregards rights of others
Cluster C
1. need for control
2. feels inadequate
3. submissiveness
4. clinging
5. perfectionist
6. fears rejection
7. needy
8. socially inhibited