Nursing 1234 TEST BANK FOR MEDICAL SURGICAL NURSING EXAM QUESTIONS AND ANSWERS BEST GRADED, Exams of Nursing

Download Nursing 1234 TEST BANK FOR MEDICAL SURGICAL NURSING EXAM QUESTIONS AND ANSWERS BEST GRADED and more Exams Nursing in PDF only on Docsity! 1 Nursing 1234 TEST BANK FOR MEDICAL SURGICAL NURSING EXAM QUESTIONS AND ANSWERS BEST GRADED A+ GUARANTEED SUCCESS LATEST UPDATE 2024 COMPLETION 1. is defined as the process by which information is exchanged between individuals verbally, nonverbally, and/or in writing or through information technology. ANS: Communication Communication is defined as the process by which information is exchanged between individuals verbally, nonverbally, and/or in writing or through information technology. DIF: Cognitive Level: Knowledge REF: p. 2 OBJ: 2 TOP: Communication KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. is the collection and processing of relevant data for the purpose of appraising the client’s health status. ANS: Assessment Assessment is the collection and processing of relevant data for the purpose of appraising the client’s health status. DIF: Cognitive Level: Knowledge REF: p. 2 OBJ: 1 | 2 TOP: Assessment KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 3. is concerned with the ethical questions that arise in the context of health care. ANS: Bioethics Bioethics is concerned with the ethical questions that arise in the context of health care. DIF: Cognitive Level: Knowledge REF: p. 4 OBJ: 3 TOP: Bioethics KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2 4. Place the corresponding letter to each stage of conflict in the correct order. (Place the events in the appropriate sequence with capital letters. Do not separate answers with a space or punctuation. Example: ABCD.) a. Outcomes b. Conceptualization c. Frustration d. Action ANS: CBDA The stages of conflict in order are frustration, conceptualization, action, and outcomes. DIF: Cognitive Level: Comprehension REF: p. 7 OBJ: 7 TOP: Conflict KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 5. Place the corresponding letter to each key step in solving an ethical dilemma in the correct order. (Place the events in the appropriate sequence. Do not separate answers with a space or punctuation. Example: ABCD.) a. Negotiate a plan. b. Clarify values. c. Ask if it is an ethical dilemma. d. Verbalize the problem. e. Gather information. f. Identify possible courses of action. g. Evaluate the plan over time. ANS: CEBDFAG The key step of solving an ethical dilemma in order are ask the question, is it an ethical dilemma, gather information, clarify values, verbalize the problem, identify possible course of action, negotiate a plan, and evaluate the plan over time. DIF: Cognitive Level: Analysis REF: p. 4 OBJ: 3 TOP: Ethical Dilemma KEY: Nursing Process Step: N/A MSC: NCLEX: N/A MULTIPLE RESPONSE 1. What care skills are safe and appropriate for the licensed practical nurse (LPN) to teach family members in the home health care setting? (Select all that apply.) a. Insulin injection b. Sterile dressing changes c. Venipunctures d. Periodic Foley catheter insertions e. Instillation of eye drops f. Changing dressings on small wounds ANS: A, E, F Insulin injections, instillation of eye drops, and small wound dressing changes are safe to teach a nonprofessional caregiver. Sterile dressings, venipunctures, and inserting Foley rest, but doing so also increases dependency on the staff. DIF: Cognitive Level: Application REF: pp. 11-12 OBJ: 10 | 11 TOP: Independence in Long-Term Care Center KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE CHOICE 1. What provides direction for individualized care and assures the delivery of accurate, safe care through a definitive pathway that promotes the client’s and the support persons’ progress toward positive outcomes? a. Physician’s orders b. Progress notes c. Nursing care plan d. Client health history ANS: C The nursing care plan provides direction for individualized care and assures the delivery of accurate, safe care through a definitive pathway that promotes the client’s and the support persons’ progress toward positive outcomes. DIF: Cognitive Level: Comprehension REF: p. 2 OBJ: 1 TOP: Nursing Care Plan KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 2. The nurse is performing behaviors and actions that assist clients and significant others in meeting their needs and the identified outcomes of the plan of care. What is the correct term for these nursing behaviors? a. Assessments b. Interventions c. Planning d. Evaluation ANS: B Caring interventions are those nursing behaviors and actions that assist clients and significant others in meeting their needs and the identified outcomes of the plan of care. DIF: Cognitive Level: Comprehension REF: p. 3 OBJ: 1 TOP: Interventions KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 3. The nurse understands the importance of being answerable for all actions and the possibility of being called on to explain or justify them. What term best describes this concept? a. Reliability b. Maturity c. Accountability d. Liability ANS: C Accountability means that a person is answerable for his or her actions and may be called on to explain or justify them. DIF: Cognitive Level: Comprehension REF: pp. 6-7 OBJ: 3 | 5 | 7 TOP: Accountability KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Reduction of Risk MULTIPLE RESPONSE 1. The nurse manager is providing an inservice about conflict resolution. What modes of conflict resolution should be addressed? (Select all that apply.) a. Suppression b. Accommodation c. Compromise d. Avoidance e. Collaboration f. Competition ANS: B, C, D, E, F The modes of conflict resolution include accommodation, collaboration, compromise, avoidance, and competition. DIF: Cognitive Level: Knowledge REF: p. 7|p. 8|Table 1.1 OBJ: 7 TOP: Conflict Resolution KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. What are the characteristics of an effective leader? (Select all that apply.) a. Effective communication b. Rigid rules and regulations c. Delegates appropriately d. Acts as a role model e. Consistently handles conflict f. Focuses on individual development ANS: A, C, D, E Characteristics of an effective leader include effective communication, consistency in managing conflict, knowledge and competency in all aspects of delivery of care, effective role model for staff, uses participatory approach in decision making, shows appreciation for a job well done, delegates work appropriately, sets objectives and guides staff, displays caring, understanding, and empathy for others, motivates and empowers others, is proactive and flexible, and focuses on team development. DIF: Cognitive Level: Comprehension REF: p. 6 OBJ: 5 TOP: Leadership KEY: Nursing Process Step: N/A MSC: NCLEX: N/A ANS: A The rehabilitation team usually consists of all of the choices except the laboratory technician, dietitian, and psychiatrist. (The mental health role is represented by the psychologist.) DIF: Cognitive Level: Comprehension REF: p. 17 OBJ: 7 TOP: Rehabilitation Team Members KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 7. A nurse explains the level of disability to a patient who was injured in a construction accident that resulted in the loss of both his right arm and right leg. This loss has affected his quality of life and ability to return to previous employment. At what level should the client be classified as being disabled? a. I b. II c. III d. IV ANS: B The patient is limited in the use of his right arm for feeding himself, dressing himself, and driving his car, which are three main activities of daily living. He may be able to work if workplace modifications are made. DIF: Cognitive Level: Application REF: p. 15 OBJ: 8 TOP: Levels of Disability KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 8. A nurse explains that in 1990, the Americans with Disabilities Act (ADA) was passed. For which extended services for the disabled persons did this act provide? a. Covering the costs for the rehabilitation of disabled World War I servicemen by providing job training b. Extending protection to the disabled in the military sector, such as wheelchair ramps on military bases c. Extending protection to the disabled in private areas, such as accessibility to public restaurant bathrooms and telephones d. Affording disabled persons full access to all health care services ANS: C The ADA of 1990 extended the previous legislative Acts of 1920, 1935, and 1973. The ADA now covers private sector individuals and public businesses in particular. DIF: Cognitive Level: Comprehension REF: p. 16 OBJ: 8 TOP: Americans with Disabilities Act (ADA) of 1990 KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 9. A frail patient in a long-term care facility asks the nurse if a bath is to be given this morning. What is the best reply by the nurse to encourage independence and give the patient the most flexibility? a. “Based on your room number, you get bathed on Monday, Wednesday, and Friday. Today is Tuesday.” b. “If you want to eat breakfast in the dining room with the others, you may sponge yourself off in your bathroom.” c. “When your daughter comes this evening, ask her if she can give you a bath.” d. “I will bring a basin of water for a sponge off for right now. After breakfast, we will talk about a bath schedule.” ANS: D The resident should be provided as much flexibility as possible and support for independence. DIF: Cognitive Level: Application REF: p. 22 OBJ: 11 TOP: Maintenance of Autonomy in Extended Care Facility KEY: Nursing Process Step: Implementation MSC: NCLEX Physiological Integrity: Basic Care and Comfort 10. A computer programmer who lost both legs is being retained by his employer, who has made arrangements for a ramp and a special desk to accommodate the patient’s wheelchair. What is the disability level of the computer programmer? a. I b. II c. III d. IV ANS: B Level II allows for workplace accommodation, which is the desk modification in this case. DIF: Cognitive Level: Analysis REF: p. 15 OBJ: N/A TOP: Reasonable Accommodation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 11. A partially paralyzed forklift operator is to be retrained by vocational rehabilitation services for less demanding office work. What law provides for this rehabilitation? a. Vocational Rehabilitation Act of 1920 b. Social Security Act of 1935 c. Rehabilitation Act of 1973 d. Americans with Disabilities Act of 1990 ANS: C The Rehabilitation Act of 1973 provided a comprehensive approach and expanded resources for public vocational training. DIF: Cognitive Level: Comprehension REF: p. 16 OBJ: 7 TOP: Rehabilitation Legislation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 12. The home health care nurse performs all the following actions. Which is the only action that is reimbursable under Medicare payment rules? a. Observing a spouse cleaning and changing a dressing b. Taking a frail couple for a walk to provide exercise c. Watching a patient measure out all medications d. Teaching a patient to self-administer insulin ANS: D Medicare reimburses skilled techniques that are clearly spelled out; these include teaching but not return demonstration–type actions by patient or family. DIF: Cognitive Level: Comprehension REF: pp. 12-13 OBJ: 4 TOP: Medicare Reimbursable Actions KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 13. A patient with multiple sclerosis must be fed, bathed, and dressed. How should the nurse assess this patient? a. Disabled b. Disadvantaged c. Handicapped d. Impaired ANS: D Feeding oneself, dressing, and bathing are activities of daily living. The patient is impaired in this scenario. DIF: Cognitive Level: Analysis REF: p. 15 OBJ: 7 TOP: Principles of Rehabilitation | Defining Levels of Loss of Functioning Independently KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. Which law initially provided for rehabilitation of disabled Americans? a. Vocational Rehabilitation Act of 1920 b. Social Security Act of 1935 c. Rehabilitation Act of 1973 d. Americans with Disabilities Act of 1990 ANS: A The U.S. government has passed four pieces of legislation to identify and meet the needs of disabled individuals with each one being more inclusive. The first one was passed in 1920. DIF: Cognitive Level: Knowledge REF: p. 16 OBJ: 8 TOP: Rehabilitation Legislation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 15. A client was admitted to a long-term residential care facility. On what should the admitting nurse tell the family the concepts of long-term care are based? a. Amount of activities the resident can do for herself b. Maintenance care with an emphasis on incontinence c. Successful adaptation to the regulations of the home d. Maintenance of as much function as possible ANS: D Maintenance of function and encouraging autonomy and independence are some of the basic concepts of long-term care. DIF: Cognitive Level: Comprehension REF: p. 18 OBJ: 11 TOP: Principles of Nursing Home Care KEY: Nursing Process Step: Implementation 2. What should the home health nurse do when teaching a family member the skill of injecting insulin effectively? Prioritize these nursing interventions for this situation. (Place the events in the appropriate sequence. Do not separate answers with a space or punctuation. Example: ABCD.) a. Offer instruction at an appropriate pace. b. Write down the steps of the procedure. c. Assess the level of knowledge of the family member. d. Inquire about the preferred learning style. e. Evaluate the family member’s performance. ANS: CBDAE Effective teaching depends on assessing the level of knowledge, breaking down the skill in steps, offering instruction in the preferred style, pacing the instruction appropriately, and evaluating the performance. DIF: Cognitive Level: Application REF: p. 14 OBJ: 1 TOP: Home Health Teaching KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 3. Prioritize the steps in solving an ethical dilemma. (Place the events in the appropriate sequence. Do not separate answers with a space or punctuation. Example: ABCD.) a. Evaluate the outcome. b. Plan an approach. c. Visualize the consequences. d. Take action. e. Identify the problem. ANS: EBCDA To solve an ethical dilemma, one must clearly identify the problem, plan an approach, visualize the consequences, take action, and evaluate the outcome. DIF: Cognitive Level: Comprehension REF: p. 11 OBJ: 7 TOP: Solving an Ethical Dilemma KEY: Nursing Process Step: N/A MSC: NCLEX: N/A Chapter 03: Medical-Surgical Patients: Individuals, Families, and Communities Linton: Medical-Surgical Nursing, 7th Edition MULTIPLE CHOICE 1. What should be included in a patient’s care plan in consideration of cultural similarities? a. Family, educational background, and economic level should all be considered. b. Subtle communication involving languages should be considered. c. Families have strong patriarchal leaders. d. Culture is learned, shared, and expressed similarly among members. ANS: D Different cultures have some similarities and some differences. How the culture is expressed in health care settings will be diverse. DIF: Cognitive Level: Comprehension REF: p. 26 OBJ: 4 TOP: Similarities among Cultures KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care 2. What is the basis for the health–illness continuum? a. Prevention of acute illness b. Individual response to health or illness c. Promotion of health and wellness d. Variation in degree of health or illness ANS: D Currently, health and illness are viewed as relative states along a continuum. Individuals are at neither absolute health nor absolute illness but are in an ever-changing state of being. DIF: Cognitive Level: Comprehension REF: pp. 25-26 OBJ: 5 TOP: Current View of Health-Illness Continuum KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control 3. What is the current concern of the health care system? a. Treating illness b. Preventing illness c. Promoting optimal function in the chronically ill d. Caring for patients with acute and chronic illness ANS: B Health promotion activities are directed toward maintaining or enhancing well-being as a protection against illness. DIF: Cognitive Level: Knowledge REF: pp. 25-26 OBJ: 2 | 5 TOP: Health Promotion KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control 4. What is the primary reason that family is an important unit in society? a. Offers unconditional love and acceptance. 11. For the past three evenings, shortly after their arrival in the hospital unit, the parents of a 14-year-old daughter begin to argue about the cost of the hospitalization and the time required to come to the hospital. The patient begins to cry and complains about her abdominal pain. What role is the patient assuming? a. Caretaker b. Martyr c. Blocker d. Scapegoat ANS: D A scapegoat usually assumes the role to maintain homeostasis, serving to divert attention from marital conflict between spouses. DIF: Cognitive Level: Analysis REF: p. 34 OBJ: 9 | 10 TOP: Family Role StructureKEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 12. A patient, a 36-year-old mother of four children, is crying. She relates to you that her best friend just told her, “You are a good mother and you do everything perfectly, but I don’t think you enjoy it.” What role is the patient assuming? a. Caretaker b. Martyr c. Contributor d. Harmonizer ANS: B A martyr sacrifices everything for the sake of the family. DIF: Cognitive Level: Analysis REF: p. 34 OBJ: 9 | 10 TOP: Family Role StructureKEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 13. What is the basis for the roles children assume in families? a. Obligation b. Instinct c. Observation d. Rewards ANS: D Parents reward children for fulfilling certain roles, which children adopt and maintain as they mature. DIF: Cognitive Level: Comprehension REF: p. 34|p. 35 OBJ: 9 TOP: Family Role StructureKEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 14. A patient confides that her husband shares only the incidental happenings of his day at work as he reads the paper, and he never tells her that he loves her anymore. She is beginning to wonder if their marriage is getting stale. What communication pattern should the nurse recognize? a. Affective b. Affectional c. Functional d. Dysfunctional ANS: D One type of dysfunctional communication involves using chitchat about unimportant daily occurrences to avoid discussing meaningful issues or expressing feelings. DIF: Cognitive Level: Analysis REF: p. 35 OBJ: 9 TOP: Functional Communication KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 15. What should a nurse consider when discussing the communication patterns of families with the patient? a. Cultural aspects of the family b. Age of the family members c. Role adopted by each family member d. Number of members in the family ANS: A Although each option has significance, cultural aspects must be considered in determining the functioning level of the family as it affects the roles taken. DIF: Cognitive Level: Comprehension REF: p. 35 OBJ: 9 TOP: Functional Communication KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 16. A patient states that her 5-year-old daughter is always running up to relatives and friends and wants to give them a big hug and kiss. The patient asks if her daughter is appropriate in her actions. What is the most appropriate reply based on the concepts of functional communication? a. “Your daughter’s actions are definitely dysfunctional.” b. “Your daughter is just being a ‘little girl’ and will outgrow being so affectionate.” c. “Your daughter is going through a normal developmental phase.” d. “Does your mother-in-law show signs of affection toward your daughter?” ANS: C Physical expression of emotion usually dominates in early childhood and is normal in the developmental pattern. DIF: Cognitive Level: Application REF: p. 35 OBJ: 9 TOP: Functional Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. For what should functional patterns of communication in the family setting provide a means? a. Nurturing b. Information c. Closeness d. Openness ANS: A Functional patterns of communication include emotional and affective communication that deals with the expression of feelings and nurturing. A healthy family is able to demonstrate a wide range of emotions and feelings. DIF: Cognitive Level: Comprehension REF: p. 35 OBJ: 9 TOP: Functional Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 18. What does the manner in which a family unit adapts to stress affect? a. Ability to communicate and function b. Health and function c. Level of affective communication d. Ability to adapt and function ANS: B The manner in which a family handles stress can affect the health of the family. DIF: Cognitive Level: Comprehension REF: pp. 36-37 OBJ: 11 TOP: Stress and Adaptation KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 19. A patient who was recently diagnosed with cancer tells the nurse that she is so grateful for her children and family because she does not know what she would do without them. Which coping response is being exhibited? a. Internal family b. External family c. Family communication d. Social support ANS: A The internal family coping responses are those that the family relationships use as support. DIF: Cognitive Level: Comprehension REF: p. 36 OBJ: 10 TOP: Coping Strategies KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 20. What is the main role of the nurse when assessing families and their coping strategies? a. Emotional support and reassurance b. Information and reassurance c. Emotional support and referral d. Elimination of the stressor ANS: B Families need information and reassurance. DIF: Cognitive Level: Comprehension REF: pp. 36-37 OBJ: 10 TOP: Role of the Nurse KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 21. What is the best description of the current view of the family as a unit? a. Functioning together to provide security and support to its members b. Functioning to meet the needs of society and support its members DIF: Cognitive Level: Comprehension REF: p. 37 OBJ: 12 TOP: Community Resources KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care COMPLETION 1. The process in which children mature and take on the values of their families and their society is called . ANS: enculturation Enculturation is the process of learning to be part of a culture. DIF: Cognitive Level: Comprehension REF: p. 26|p. 27|p. 33 OBJ: 3 TOP: Enculturation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. A nurse congratulates a patient for successfully coping with a family crisis. The state of having used coping strategies effectively is classified as . ANS: mastery Mastery is attained when coping skills are successful in coping with a crisis. DIF: Cognitive Level: Comprehension REF: p. 36 OBJ: 10 TOP: Mastery KEY: Nursing Process Step: Evaluation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 3. The nurse includes the family in patient care to maintain the family’s . ANS: self-esteem Self-esteem is supported and maintained when family is given opportunity to contribute to the planning of patient care. DIF: Cognitive Level: Comprehension REF: p. 37 OBJ: 8 TOP: Maintenance of Self-Esteem KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation Chapter 04: Health, Illness, Stress, and Coping Linton: Medical-Surgical Nursing, 7th Edition MULTIPLE CHOICE 1. What is the traditional view of health? a. Promotes optimal function. b. Views health and illness as separate concepts. c. Defines health as an absence of illness. d. Emphasizes the prevention of disease. ANS: B Traditionally, health and illness have been viewed as separate entities with a focus on the illness and not in attaining the highest quality of life possible when a cure is not possible. DIF: Cognitive Level: Comprehension REF: pp. 41-42 OBJ: 1 TOP: Traditional View of Health and Illness KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control 2. What is the current view of health? a. Promotes the highest quality of life possible, both mentally and socially. b. Includes mental, physical, social, and emotional adaptation to the environment. c. Includes the basic physiologic needs and self-actualization. d. Relies on alternative therapies for the treatment and cure of diseases. ANS: B A healthy person maintains stability and comfort by adapting physically, mentally, emotionally, and socially to internal and external events. DIF: Cognitive Level: Comprehension REF: pp. 41-42 OBJ: 1 TOP: Current View of Health and Illness KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control 3. During the initial gathering of data, a patient reveals a weight loss of 17 lb since the death of his spouse 5 weeks earlier. He says that he is not sleeping and has no appetite. What category of unmet needs should be considered by the nurse according to Maslow’s hierarchy of needs? a. Physiologic b. Safety and security c. Love and belonging d. Self-actualization ANS: A Physiologic needs include oxygen, fluids, and nutrition and must be met before the higher levels of needs are provided. DIF: Cognitive Level: Application REF: p. 41 OBJ: 2 TOP: Maslow’s Basic Human Needs KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control 4. What is the major advantage of using Maslow’s hierarchy of needs when planning nursing care for patients? a. Establishes a nursing diagnosis. b. Improves problem-solving techniques. c. Prioritizes patient care. d. Establishes priorities of care. ANS: C Priorities for nursing care can be based on the level of human needs; physical needs take priority over security needs. DIF: Cognitive Level: Comprehension REF: p. 41 OBJ: 2 TOP: Maslow’s Basic Human Needs KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 5. A nurse points out that a physiologic response to stress involves the total body. Which syndrome is this considered? a. General adaptation b. Local adaptation c. Negative feedback d. Total adaptation ANS: A General adaptation syndrome is the physiologic response of the whole body to stress. DIF: Cognitive Level: Knowledge REF: p. 43 OBJ: 4 TOP: Stress Response KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 6. What are the ability to solve problems and to maintain self-confidence and the willingness to accept criticism incorporated in according to Maslow? a. Safety and security b. Self-esteem c. Self-actualization d. Love and belonging ANS: C Self-actualization is characterized by the ability to solve problems, the willingness to accept suggestions and criticism from others, and the maintenance of broad interests and communication skills. DIF: Cognitive Level: Comprehension REF: p. 41 OBJ: 2 TOP: Maslow’s Basic Human Needs KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 7. A patient returning from surgery complains of incisional pain that is now rated 7 in intensity on the 1-to-10 pain scale. What should the nurse be aware that pain exemplifies? a. General adaptation syndrome b. Local adaptation syndrome c. Counter-current response d. Neuroendocrine response Chronic illness, such as asthma, usually involves lifetime impairment or disability and requires long-term rehabilitation and medical or nursing treatment. Examples of chronic illness include coronary artery disease, diabetes, and endocrine disorders. Acne, appendicitis, and a heart attack are conditions that are acute in nature, although they may indicate a serious illness. DIF: Cognitive Level: Comprehension REF: p. 42 OBJ: 1 TOP: Concept of Illness KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 14. A nurse assesses that smoking, drinking alcohol, and exercising compulsively may occur as responses to a stressful situation. What type of response should this be considered? a. External b. Withdrawal c. Denial d. Internal ANS: D Examples of internal resources are physiologic and psychologic responses such as smoking, drinking alcohol, eating, and crying. DIF: Cognitive Level: Comprehension REF: pp. 45-46 OBJ: 7 | 8 TOP: Adaptation to Stress KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 15. Which type of response is demonstrated when an individual seeks help from family, friends, or a community resource during a time of stress? a. Internal b. External c. Physiologic d. Psychologic ANS: B Patients who deal with stress may use external responses, including help from family, friends, and service agencies in the community. DIF: Cognitive Level: Comprehension REF: pp. 45-46 OBJ: 7 | 8 TOP: Coping and Adaptation KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 16. What is the term for activities directed toward maintaining or enhancing well-being against illness? a. Health promotion b. Health treatment c. Health evaluation d. Health assessment ANS: A Health promotion activities are directed toward maintaining or enhancing well-being as a protection against illness. DIF: Cognitive Level: Knowledge REF: pp. 48-49 OBJ: 5 TOP: Health Promotion KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 17. A home health nurse is assisting a patient who is chronically ill with congestive heart failure to reorder time. What is the best intervention to assist this patient? a. Encouraging the patient to get up earlier or to go to sleep later b. Developing a daily schedule that allows time for activities, as well as for medical regimens c. Giving up time-consuming activities such as watching television or answering e-mail messages d. Encouraging the patient to complete only one task a day ANS: B Reordering time is developing a schedule that includes not only a medical regimen, but it also includes social and interpersonal activities, as well as hobbies. DIF: Cognitive Level: Application REF: p. 49 OBJ: 14 TOP: Reordering Time KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 18. What type of illness are the common cold, appendicitis, and urinary tract infections considered? a. Chronic b. Disabling c. Emergency d. Acute ANS: D An acute illness or disease is one that has a relatively rapid onset and a short duration. DIF: Cognitive Level: Comprehension REF: p. 42 OBJ: 1 TOP: Concept of Illness KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 19. What is the first step in helping patients to increase adaptability? a. Assess past methods of coping with stress. b. Suggest using past coping strategies. c. Determine external coping strategies. d. Determine what the patient perceives as stressful. ANS: A Nurses can help patients deal with stress by identifying the patient’s usual methods of coping or adapting. DIF: Cognitive Level: Knowledge REF: p. 43 OBJ: 10 TOP: Adaptation KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 20. How should a nurse describe a patient who has a functional interaction of the cognitive, affective, behavioral, and social dimensions of his personality? a. Effectively organized b. Personally satisfied c. Well rounded d. Mentally healthy ANS: D Mental health depends on the functional integration of the four dimensions of the personality. DIF: Cognitive Level: Comprehension REF: p. 41 OBJ: 1 TOP: Definition of Mental Health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 21. A nurse assesses that a 42-year-old patient lives with her parents and is dependent on them for decisions about her life. Which mental health characteristic is this patient lacking? a. Reality orientation b. Autonomous behavior c. Spontaneity d. Ethical decision making ANS: B Autonomy is a mark of mental health. DIF: Cognitive Level: Comprehension REF: p. 41 OBJ: 1 TOP: Definition of Mental Health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 22. What is an example of a positive stressor? a. Test anxiety b. Loss of a job c. Paying income tax d. Single motherhood ANS: A Test anxiety can be beneficial to promote study and sharpen focus. DIF: Cognitive Level: Knowledge REF: p. 43 OBJ: 7 TOP: Stress KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 23. Which action is an example of a person attempting to maintain homeostasis as a newcomer in a community? a. Joins a local church. b. Buys a new car. c. Stays in his or her apartment watching television. d. Spends hours writing e-mail messages to old friends. ANS: A The newcomer who attempts to balance the newcomer status with belonging is an example of homeostasis. DIF: Cognitive Level: Comprehension REF: p. 43 OBJ: 5 TOP: Homeostasis KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 24. Which behavior best exemplifies developmental activities in a 13-year-old teenager? b. Impaired self-concept c. Decreased socialization d. Inadequate comfort ANS: B Athletes who sustain injuries can have impaired self-concept related to their altered body image. DIF: Cognitive Level: Application REF: p. 45 OBJ: 11 TOP: Self-Concept KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 32. A wife of a critically injured husband has been at his bedside constantly for 2 days. As the nurse speaks to the wife, the wife sobs, “This is awful. I can’t take it anymore.” What is the wife experiencing? a. Fear b. Denial c. Compensation d. Stress ANS: D Long-term stress causes fatigue and an inability to solve problems. DIF: Cognitive Level: Application REF: p. 45 OBJ: 8 | 9 TOP: Emotions: Stress KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 33. How does fear differ from anxiety? a. Fear is a useless emotion. b. Fear is an ineffective coping strategy. c. Fear is an irrational feeling. d. Fear is a response to a specific threat. ANS: D Fear is a response to a specific threat (e.g., a rattlesnake in the garden); anxiety is a response to a nonspecific threat (e.g., first day on a new job). DIF: Cognitive Level: Comprehension REF: p. 45 OBJ: 10 TOP: Emotions: Anxiety and Fear KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 34. An older Italian woman has an egg yolk in a bowl under her bed that she believes is absorbing the evil of her illness and making her feel better. Which action should a nurse implement? a. Move the egg yolk out of the way to the bathroom. b. Replace the egg yolk with a hard-boiled egg. c. Remove the egg for sanitary purposes. d. Include maintenance of the egg in the nursing care plan. ANS: D A nursing approach should help with coping, not increase the stress. DIF: Cognitive Level: Application REF: p. 44 OBJ: 11 TOP: Cultural Concepts KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 35. When a 25-year-old woman who had a hysterectomy 1 day earlier tearfully tells the nurse that she is grieving for the children she will never have, the nurse assesses the grief as positive. What does grief allow this patient to achieve? a. Focus on her loss. b. Forget about her concern. c. Reappraise her values for the future. d. Depend on others for grief support. ANS: C Grief and mourning signify an end to something. After the mourning, the patient is free to reappraise values for the future. DIF: Cognitive Level: Comprehension REF: p. 46 OBJ: 10 TOP: Perceived Loss and Grief KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 36. A 5-year-old patient was in an accident in which his cousin was killed. The patient starts to wet the bed at night. What question should the nurse ask the mother when she confirms that it has been several years since the patient had any difficulty with bedwetting? a. “Do you think this is related to the accident?” b. “Do others in the family have this problem?” c. “Does your child drink lots of fluids late at night?” d. “Are there any stressful situations in your family?” ANS: A Anxiety is the root of such defense mechanisms as regression. This behavior is an example of regression, in which the 5-year-old child has gone back to behavior more suited to a younger developmental age. DIF: Cognitive Level: Application REF: p. 47 OBJ: 10 TOP: Defense Mechanisms KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 37. A 24-year-old man scheduled for brain surgery in the morning constantly listens to music with his headphones on. What should a nurse recognize this behavior as? a. Conversion reaction b. Conscious coping strategy c. Defense mechanism of undoing d. Reaction formation ANS: B The use of a conscious coping strategy can help decrease stress. DIF: Cognitive Level: Comprehension REF: pp. 47-48 OBJ: 11 TOP: Conscious Coping Strategies KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 38. When a patient is asked whether he wants his pain medication, he says to you, “I don’t know; whatever you think is best.” What should the nurse recognize this maladaptive coping mechanism as? a. Powerlessness b. Helplessness c. Denial d. Depression ANS: A The patient feels that he has lost control of his situation and has started to defer decisions about his care to others. DIF: Cognitive Level: Application REF: p. 49 OBJ: 13 TOP: Maladaptive Coping Mechanisms KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 39. Which patient diagnosis and behavior should lead a nurse to conclude the patient is using the defense mechanism of denial? a. A patient with emphysema continues to smoke. b. A patient with diabetes mellitus uses a sugar substitute. c. A patient with a drug problem blames his mother for his habit. d. A patient with osteoarthritis angrily kicks the steps that he cannot climb. ANS: A The patient with emphysema is an example of denial, the patient with diabetes is an example of an adaptive response, the patient with a drug problem is an example of projection, and the patient with osteoarthritis is an example of regression. DIF: Cognitive Level: Comprehension REF: p. 49 OBJ: 13 TOP: Maladaptive Coping KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 40. What is the goal of nursing care for the patient with a chronic illness? a. Find the cause of the illness. b. Tell the patient that he or she will learn to live with the illness. c. Help the patient manage the illness. d. Give the patient websites that have information about the illness. ANS: C The goal of caring for patients with a chronic illness is to help them manage the illness and to develop coping skills. DIF: Cognitive Level: Comprehension REF: p. 42|p. 49|p. 50 OBJ: 14 TOP: Nursing Goals KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 41. What nursing action should be implemented when dealing with a patient who is an alcoholic in denial and claims to only drink in social situations? a. Insist that he stop drinking entirely. b. Point out that the patient is using denial. c. Help the patient investigate ways to reduce drinking. DIF: Cognitive Level: Knowledge REF: p. 43 OBJ: 5 TOP: Homeostasis KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. The term that a nurse uses to refer to persons who fail to maintain treatment protocols is . ANS: nonadherence Nonadherence is a term that describes the patient who fails to maintain treatment protocols. The term is less negative than the earlier term, noncompliant. DIF: Cognitive Level: Knowledge REF: p. 42 OBJ: 6 TOP: No Adherence KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 3. A student nurse who was terrified of giving an injection now gives many injections every shift. The change in the nurse is the result of . ANS: adaptation Adaptation refers to a person’s efforts to respond to stressors in such a way as to overcome the stress. DIF: Cognitive Level: Comprehension REF: p. 43 OBJ: 5 TOP: Adaptation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 4. A nurse recognizes that mild stress can be a positive force that stimulates the patient to a problem. ANS: solve Mild stress can cause a person to focus and be able to solve a problem. DIF: Cognitive Level: Comprehension REF: p. 43 OBJ: 2 TOP: Mild Stress KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation Chapter 05: Immunity, Inflammation, and Infection Linton: Medical-Surgical Nursing, 7th Edition MULTIPLE CHOICE 1. A patient in early labor says to the nurse, “I will pass on protection from diseases, and the baby will not ever need any shots.” What is the best response by the nurse? a. “Babies are born with innate (natural) immunity at birth.” b. “Babies are born with immunoglobulin E (IgE), an antibody that crosses the placenta, but it only briefly protects the baby.” c. “Yes, immediate antibody immunity from the mother is the first line of defense against disease for babies.” d. “Yes, the mother passes on cell-mediated immunity.” ANS: B Infants acquire antibodies from the mother, but they only last a few months. DIF: Cognitive Level: Application REF: p. 58 OBJ: 4 TOP: Newborn Immunity KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. A school nurse starts a clean-up campaign at a local elementary school in an effort to combat allergens. What is the most common allergic response disorder? a. Anaphylaxis b. Asthma c. Contact dermatitis d. Urticaria ANS: B Fungi are principle allergens that can trigger respiratory allergic responses such as asthma. DIF: Cognitive Level: Knowledge REF: p. 77 OBJ: 18 TOP: Reduction of Allergens KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. A nurse is discussing the body’s first and second lines of defense against infection with a community group. What does the body’s first line of defense include? a. Teeth b. Sweat c. White blood cells d. T lymphocytes ANS: B The sweat glands excrete an antimicrobial enzyme. DIF: Cognitive Level: Knowledge REF: p. 56 OBJ: 1 TOP: Lines of Defense KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. A nurse explains that a medication given to a patient with a severe inflammatory response mimics a hormone secreted by the adrenal cortex. To what hormone is the nurse referring? a. Aldosterone b. Testosterone c. Histamine d. Cortisol ANS: D Cortisol slows the release of antihistamine and stabilizes lysosomal membranes. DIF: Cognitive Level: Knowledge REF: p. 59 OBJ: 5 TOP: Anti-inflammatory Agents KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. With the exposure to an antigen, a nurse explains that the initiator of the inflammatory response is the presence of histamine. What is responsible for releasing histamine? a. Neutrophils b. Eosinophils c. Basophils d. Monocytes ANS: C Basophils release histamine. DIF: Cognitive Level: Knowledge REF: p. 57 OBJ: 5 TOP: Inflammatory Response KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. A nurse is bathing a patient who is immunodeficient and has a Cryptococcus infestation. What is the classification of this organism? a. Bacterium b. Virus c. Fungus d. Protozoa ANS: C Cryptococcus fungal infections can be life threatening. DIF: Cognitive Level: Knowledge REF: p. 62 OBJ: 9 TOP: Fungi KEY: Nursing Process Step: Knowledge MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 7. A mosquito or a fly carries an organism that infects another living organism. What is this mode of transmission of infection? a. Common vehicle b. Direct excretion c. Ingestion d. Vector ANS: D Vector-borne diseases are carried from one host to another. Part of the life cycle of the pathogen occurs in the body of the fly, mosquito, or tick. DIF: Cognitive Level: Comprehension REF: p. 63 OBJ: 10 TOP: Vector Transmission KEY: Nursing Process Step: N/A DIF: Cognitive Level: Application REF: p. 67 OBJ: 12 TOP: Iatrogenic Infections KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 14. A community picnic is held. A number of the attendees become ill after the picnic. How was the pathogen acquired? a. Indirect contact b. Common vehicle c. Airborne transmission d. Vector transmission ANS: B Food at the picnic that was shared in common became the vehicle for transmission. DIF: Cognitive Level: Comprehension REF: p. 63 OBJ: 10 TOP: Common Vehicle Transmission KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 15. A nurse caring for a patient who is immunosuppressed is diligent about protecting the patient from infection. When visitors come in, in addition to having them put on isolation attire, what should the nurse also prohibit? a. Battery-operated DVD player b. Book c. Potted plant d. Box of candy ANS: C The soil in the flowerpot is a reservoir for bacteria and fungi. DIF: Cognitive Level: Application REF: p. 73|p. 77 OBJ: 16 | 18 TOP: Reverse Isolation for Immunosuppressed Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 16. A nurse explains that although some drugs reduce inflammation, they also hinder the body’s immune response. What are examples of such drugs? a. Antihistamines and salicylates b. Bronchodilators and corticosteroids c. Cardiotonic and anticholinergics d. Diuretics and sedatives ANS: B The immune response is dampened by corticosteroids. DIF: Cognitive Level: Comprehension REF: p. 76 OBJ: 18 TOP: Pharmacologic Care for Allergies KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 17. A patient has had several increasingly severe allergic reactions during last year’s pollen season. This year, the patient comes regularly to the office to receive some antigen injections. What education will the nurse provide regarding these injections? a. They will combat infection brought on by the allergic response. b. They will act as a steroid to lessen the allergic response. c. They will increase tolerance to the antigen. d. They will decrease the production of the antibodies. ANS: C Injections of increasing amounts of minute doses of the antigen will desensitize the body against the antigen. DIF: Cognitive Level: Application REF: p. 76 OBJ: 18 TOP: Long-Term Pharmacologic Treatment of Allergies KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. A patient who is receiving daily steroids for the control of a condition calls the nurse to ask advice about whether a small child who has been exposed to influenza should come and visit because she has not had any symptoms. What is the most appropriate response by the office nurse? a. “Yes, let the child visit. There is no reason not to visit because this child is not sick.” b. “No, the child should not visit. Infectious diseases are often most communicable in the short period before the child actually becomes ill.” c. “It would be up to the patient. Plan not to get overtired with a small child running and bouncing around.” d. “Take the child who is not sick to her own physician and ask this question first.” ANS: B Children, especially those who have been exposed to a contagious disease but are not yet symptomatic, are still very contagious, especially to an immunocompromised patient. DIF: Cognitive Level: Application REF: pp. 63-64 OBJ: 10 TOP: Contagious Infections KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 19. A patient with the diagnosis of Clostridium difficile infection asks what has caused the diarrhea. What is the best response by the nurse? a. It is caused by a protozoal infection. b. It is caused by a fecal–oral contamination. c. It is caused by an inflammatory response. d. It is caused by a long-term antibiotic therapy. ANS: D Superinfections such as Clostridium difficile infections are caused by long-term antibiotic therapy, which kills all the natural flora of the bowel and causes diarrhea. DIF: Cognitive Level: Comprehension REF: p. 67 OBJ: 10 TOP: Superinfection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 20. A patient receiving a large intramuscular dose of antibiotic was asked to please wait 20 to 30 minutes before checking out. What is the reason for this request? a. The office staff needs to make sure that the right medicine was administered before the patient leaves. b. The nurse always forgets to ask the patient about allergies before administering the antibiotic. c. Antibiotics are a common source of severe allergic reactions within the first few minutes after an injection. d. The staff wants to make sure that the patient has time to pay for the services delivered that day. ANS: C Antibiotic administration is a common cause of anaphylaxis. The patient is asked to wait to allow medical personnel to reverse the condition should it occur within minutes after an injection. DIF: Cognitive Level: Comprehension REF: pp. 77-78 OBJ: 18 TOP: Antibiotic Anaphylaxis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 21. After receiving an injection of penicillin, a patient undergoes an anaphylactic reaction. What should the nurse do first? a. Administer oxygen. b. Prepare fluids to combat shock. c. Notify the charge nurse. d. Cover with several blankets. ANS: A The first intervention should be to supply oxygen. Notification of the charge nurse and the administration of fluids to combat hypovolemia will come afterward. Covering with blankets would increase the vasodilation and increase the shock. DIF: Cognitive Level: Application REF: p. 78 OBJ: 18 TOP: Anaphylaxis Assessment and Intervention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 22. The Centers for Disease Control and Prevention (CDC) has issued new guidelines for infection control. Nursing care plans for patients with infection should mainly address which protocol? a. Disease-specific precautions b. Manner in which clean gloves are worn c. Standard Precautions guidelines d. Placement of needles and sharps ANS: C The CDC has issued new guidelines for Standard Precautions for infection control. These cover disease-specific precautions, the manner in which clean gloves are worn, and the placement of needles and sharps. Only the Standard Precautions guidelines are all inclusive. DIF: Cognitive Level: Comprehension REF: p. 69 OBJ: 14 TOP: Centers for Disease Control and Prevention: Multiple Guidelines for Standard Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control High eosinophil counts are indicators of an allergic response. DIF: Cognitive Level: Comprehension REF: p. 57 OBJ: 18 TOP: Allergy Indicators KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. Persons with human immunodeficiency virus (HIV) have acquired Pneumocystis jiroveci (PCP), a serious pulmonary infection caused by . ANS: protozoa Protozoa cause the opportunistic pulmonary infection of PCP. DIF: Cognitive Level: Knowledge REF: p. 62 OBJ: 9 TOP: Pneumocystis jiroveciKEY: Nursing Process Step: N/A MSC: NCLEX: N/A 3. A nurse reminds the patient who is to undergo hyperbaric oxygen therapy that the clothing worn into the chamber must be made of . ANS: cotton Cotton clothing is worn in the hyperbaric chamber to reduce the threat of fire. Synthetic materials can cause a spark of static electricity. DIF: Cognitive Level: Knowledge REF: p. 75 OBJ: 13 TOP: Clothing in Hyperbaric Chamber KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 4. Prioritize the events of an antibody-mediated immunity response. (Place the events in the appropriate sequence. Do not separate answers with a space or punctuation. Example: ABCD.) a. Antibodies seek out and bind with specific antigen. b. Antigen binds to a B lymphocyte. c. Circulating antibody–antigen complexes are destroyed. d. Antibodies are produced. e. Antibodies are replenished. ANS: BDACE Antigen binds to a B lymphocyte, and antibodies are produced for that specific antigen. Antibodies seek out and bind with the specific antigen when it is reintroduced to the organism and bind with them. These circulating antigen–antibody complexes are targeted and destroyed by phagocytes. Antibodies are continually replenished in most cases. DIF: Cognitive Level: Analysis REF: pp. 58-59 OBJ: 2 TOP: Antibody-Mediated Immunity KEY: Nursing Process Step: N/A MSC: NCLEX: N/A Chapter 06: Fluid, Electrolyte, and Acid–Base Imbalance Linton: Medical-Surgical Nursing, 7th Edition MULTIPLE CHOICE 1. A nurse assesses that a patient’s urine has become much more concentrated. What is the most likely cause for the change? a. Adrenaline b. Aldosterone c. Antidiuretic hormone (ADH) d. Insulin ANS: B Aldosterone acts on the kidney tubules, affecting water retention and its attendant urine concentration. DIF: Cognitive Level: Comprehension REF: p. 85 OBJ: 6 TOP: Urine Concentration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. When the water absorption in the renal tubules becomes greater than normal, what assessment finding should a nurse anticipate? a. More concentrated urine b. Less concentrated urine c. More alkaline urine d. Less alkaline urine ANS: A When more water is kept back in the body, the water left to form urine is less; therefore, the urine is more concentrated. DIF: Cognitive Level: Analysis REF: p. 85 OBJ: 6 TOP: Water Reabsorption by Kidney KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. What process occurs when oxygen is directed out of the arteries and into the capillaries? a. Active transport b. Diffusion c. Filtration d. Osmosis ANS: B Diffusion is the movement from areas of higher concentration to areas of lower concentration. DIF: Cognitive Level: Knowledge REF: p. 84 OBJ: 2 TOP: Fluid Movements between Portions of the Circulatory System KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. A patient’s intravenous (IV) injection has been infusing at a very high rate. What assessment indicates fluid volume overload in this patient? a. Hypotension b. Tachycardia c. Pulmonary edema d. Kidney failure ANS: C An IV infusing at a high rate is used to increase intravascular fluid volume, but there is an equalization level, after which the patient goes into fluid overload; this results in pulmonary edema. DIF: Cognitive Level: Application REF: p. 87 OBJ: 4 TOP: Fluid Overload KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. A small child is hospitalized with severe metabolic acidosis after ingesting a whole bottle of baby aspirin approximately 8 hours earlier. In addition to providing reassurance to the patient, which nursing action is the most appropriate? a. Providing IV treatments as ordered but without sodium bicarbonate b. Frequently assessing the mental and neurologic status c. Taking daily weights and vital signs d. Inducing vomiting ANS: B The baby aspirin was ingested too long ago to have vomiting or stomach aspiration be of any use. The child requires frequent assessment of neurologic function because the child may need mechanical ventilation. DIF: Cognitive Level: Application REF: pp. 98-99 OBJ: 8 TOP: Metabolic Acidosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. What is primarily responsible for carrying fluids with nutrients and wastes on a random basis throughout the body? a. Filtrates b. Extracellular fluid c. Intracellular fluid d. Osmolytes ANS: B The blood and lymph are the main media for transporting nutrients and wastes in the body. DIF: Cognitive Level: Knowledge REF: p. 82 OBJ: 3 TOP: Fluid Transportation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. A nurse clarifies that electrolytes, such as sodium and potassium (K+), break down into smaller particles when dissolved. What are these smaller particles? a. Cells b. Elements c. Ions c. Respiratory alkalosis d. Thyroid imbalances ANS: C When in metabolic acidosis, the body attempts to compensate by increasing respirations and creating respiratory alkalosis. DIF: Cognitive Level: Application REF: p. 96 OBJ: 11 TOP: Acidosis and Compensatory Alkalosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 15. The K+ laboratory report shows a level of 5.2 mEq/L. What is the most important assessment for the nurse to make? a. Excessive thirst b. Irregular heartbeat c. Swelling of ankles d. Frightening hallucinations ANS: B Arrhythmias can be triggered by hyperkalemia. DIF: Cognitive Level: Comprehension REF: p. 96 OBJ: 8 TOP: Hyperkalemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. A patient has renal damage because of diabetes. What is the highest risk for this patient? a. Hypercalcemia b. Hypocalcemia c. Hyperkalemia d. Hypokalemia ANS: C When the renal system cannot rid the body of enough K+, this electrolyte builds up and a condition called hyperkalemia develops. DIF: Cognitive Level: Analysis REF: p. 96 OBJ: 6 TOP: Kidney Damage Limiting Excretion of Potassium KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 17. What is usually associated with hyperchloremia? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis ANS: A Chlorides bind with positively charged ions such as K+ in the patient with metabolic acidosis. DIF: Cognitive Level: Comprehension REF: p. 96 OBJ: 6 TOP: Hyperchloremia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. Older adults are at risk for dehydration because of reduced thirst and aging kidneys. What should the nurse assess as an early indicator of dehydration? a. Reduced skin turgor b. Constipation c. Concentrated urine d. Disorientation ANS: B Because older adults have poor skin turgor and urine concentration is difficult to assess, constipation is the earliest indicator of a fluid deficit. DIF: Cognitive Level: Application REF: p. 86 OBJ: 9 TOP: Fluid Loss in Older Adults KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. A nurse has two newly admitted patients with dehydration. One patient is dehydrated from heat exhaustion, and the other is dehydrated from an overdose of Lasix. What finding should be present in both patients? a. Increased skin turgor b. Decreased pulse and respirations c. Copious saliva and nasal secretions d. Increased laboratory values of hemoglobin and hematocrit ANS: D Water has been lost; therefore, the red blood cells will concentrate and show artificially high values of hemoglobin and hematocrit. DIF: Cognitive Level: Analysis REF: p. 92 OBJ: 4 TOP: Dehydration Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. A nurse understands that fluid balance is mainly monitored in the body by which two systems? a. Circulatory and renal b. Respiratory and circulatory c. Renal and gastrointestinal d. Hepatic and lymphatic ANS: A The monitoring of basic fluid balance in the body is performed by the renal and circulatory systems. DIF: Cognitive Level: Knowledge REF: p. 85 OBJ: 3 TOP: Fluid Balance KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 21. What primarily maintains extracellular fluid osmolarity? a. Chloride b. Magnesium c. Potassium d. Sodium ANS: D Sodium, as the primary extracellular electrolyte, controls the osmolarity (either too much or too little) of the extracellular fluid. DIF: Cognitive Level: Comprehension REF: p. 85 OBJ: 5 TOP: Extracellular Fluid Osmolarity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. How does the healthy kidney adjust the volume and composition of filtrate that prevents excessive fluid loss? a. Active transport b. Filtration in the lymphatic system c. Secretion of adrenalin d. Tubular reabsorption ANS: D The kidney reabsorbs water and other electrolytes in response to chemical receptors. DIF: Cognitive Level: Comprehension REF: p. 85 OBJ: 3 TOP: Renal Physiology KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. What process involves blood being brought by the incoming capillaries into the kidney, which contains nitrogenous substances to be excreted as waste? a. Active transport b. Diffusion c. Filtration d. Osmosis ANS: C Capillary blood from the renal arteries filters into the kidney for processing as the first step. DIF: Cognitive Level: Knowledge REF: p. 84 OBJ: 3 TOP: Kidney Filtration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 24. What should treatment focus on when a patient is hypovolemic? a. Extracellular fluid deficit and limiting drinking water b. Hypertonic intracellular deficit and limiting water intake c. Extracellular fluid deficit and encouraging fluid intake d. Circulatory system hormone deficit and limiting water intake ANS: C A fluid volume deficit occurs when the fluid volume in the body is inadequate; the nurse may encourage drinking fluids as a nursing action. DIF: Cognitive Level: Application REF: p. 91 OBJ: 8 TOP: Fluid Deficit KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation Chapter 07: The Patient with Cancer Linton: Medical-Surgical Nursing, 7th Edition MULTIPLE CHOICE 1. Which statement best defines concepts to be included in a teaching plan for a patient with cancer? a. Cancer is a group of diseases. The cancer cells are different from the cells in the tissue of its origin in both the growth and spreading of abnormal cells. b. Cancer is the third leading cause of death in the United States. Many hospitals have the highest number of patients with this diagnosis. c. Americans who have a diagnosis of cancer die within 1 year or less. d. When a person is genetically predisposed to a type of cancer, nothing can be done to prevent its occurrence. ANS: A Information about the disease and disease process is helpful to allay anxiety, as well as to instruct about its pathophysiologic changes. DIF: Cognitive Level: Comprehension REF: pp. 102-104 OBJ: 3 TOP: Morbidity and Mortality of Cancer KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. A nurse explains that the seven warning signs of cancer written by the American Cancer Society (ACS) can be recalled by the acronym CAUTION. What should the nurse change to point out that the A in the acronym represents? a. A sore that will not heal b. Alopecia c. Abscess d. Anorexia ANS: A The acronym is a change in bowel or bladder habits, a sore that will not heal, unusual bleeding or discharge, a thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, and a nagging cough or hoarseness. DIF: Cognitive Level: Knowledge REF: p. 106 OBJ: 4 TOP: Seven Danger Signs KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. A home health nurse is compiling a patient profile on a 23-year-old obese woman who smokes one-half pack of cigarettes a day and drinks 1 beer a week. She works as a cook in a long-term care facility. She has two children and eats a diet high in fats. She exercises 30 minutes a day. Both parents are dead of heart disease. How many risk factors for cancer in this profile should the nurse identify? a. 2 b. 3 c. 5 d. 6 ANS: B Cancer risks identified are obesity, smoker, and high-fat diet. DIF: Cognitive Level: Comprehension REF: p. 103|p. 106 OBJ: 4 TOP: Cancer Risks KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. What phase is considered the latent period before the period of rapid growth of tumors? a. Initiation b. Promotion c. Progression d. Metastasis ANS: B The stage of promotion is the latest period in which a cell is quiet, just before the rapid growth and tumor production, which begins in the progression phase. DIF: Cognitive Level: Knowledge REF: p. 105 OBJ: 3 TOP: Transformation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. Which is true about both malignant tumors and benign tumors? a. Both contain cells that closely resemble those in the tissue of origin. b. Both travel quickly to invade and destroy other tissues and organs. c. Both always grow and multiply very rapidly, competing for space and nutrients and causing severe pain. d. Both may press on nearby surrounding tissues, such as nerves and blood vessels, causing pain. ANS: D Both benign and malignant tumors may create pressure on or obstruct an organ. DIF: Cognitive Level: Comprehension REF: pp. 103-104 OBJ: 2 TOP: Characteristics of Benign and Malignant Cells KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. A patient newly diagnosed with cancer says, “I feel like I’ve lost my future. I feel so much harm has been done to me that I’m overwhelmed.” To what type of coping strategies should the nurse recognize this attitude will most likely lead the patient? a. Avoidant b. Problem solving c. Approach oriented d. Confrontational ANS: A Persons who appraise their cancer diagnosis as harm or loss are more likely to use avoidant coping strategies. DIF: Cognitive Level: Comprehension REF: p. 121 OBJ: 6 TOP: Coping Styles KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 7. A patient has a cancer that has been TNM staged as T3 (1-4, size of primary tumor), N2 (0-3, degree of spread to regional lymph nodes), and M1 (0-1, presence of metastasis). He has an as needed order of 4 mg of morphine intramuscularly every 4 hours. He requests another pain injection approximately 3.5 hours after the last one. What is the most appropriate nursing action? a. Inform the patient that this narcotic may be given only every 4 hours to prevent addiction. b. Ignore the call bell for 20 minutes and then take at least 10 minutes to prepare and administer the injection. c. Give the morphine and evaluate the results of pain relief. Arrange for the physician to evaluate for breakthrough pain. d. Ask the family to assist in helping the patient accept waiting longer to receive an addicting medication such as morphine. ANS: C Terminal care does not include concerns about morphine addiction. Medication may be given slightly before the allotted time. The occurrence of breakthrough pain is a real concern for this patient. DIF: Cognitive Level: Application REF: p. 127 OBJ: 7 TOP: Nursing Care of the Terminal Patient in Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 8. A patient is scheduled for a chemotherapy treatment in approximately 30 minutes. Breakfast trays have arrived and are being served on the unit. What is the nurse’s best intervention? a. Encourage the patient to eat all his breakfast to keep up his strength to fight the cancer. Remind the patient that breakfast is about one third of his daily intake. b. Listen attentively to any concerns that the patient expresses regarding the treatment. Offer to hold his tray until after the treatment. c. Offer to call the family to come and be present after the treatment. Encourage the patient to drink at least all of the orange juice and coffee. d. Suggest that the patient request a dose of strong analgesic instead of eating because this treatment is very painful. ANS: B Chemotherapy causes nausea and vomiting. Holding the tray until later provides for better intake and for holding the food in the stomach for digestion. DIF: Cognitive Level: Application REF: pp. 113-114 OBJ: 6 TOP: Care of the Patient Undergoing Chemotherapy Treatment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 9. A nurse explains that drugs such as cannabinoids or Benadryl are frequently ordered for patients with cancer who are taking chemotherapy. What do these types of drugs accomplish? a. Promote amnesia to dampen the fear. 15. A diagnosis of breast cancer is first made at stage T1 N0 M0. Which patient problem would be appropriate? a. “Altered body image, related to threats of anticipated changes.” b. “Anxiety, related to outcome of treatments.” c. “Potential for infection, related to decreased white blood cell count.” d. “Inadequate coping, related to husband’s expectations regarding anticipated treatments.” ANS: B Early stages of cancer create anxiety about the outcome of treatments for the patient. DIF: Cognitive Level: Application REF: p. 119 OBJ: 3 | 6 TOP: Nursing Diagnosis KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 16. What is the most common site of cancer in adult women? a. Breast b. Lung c. Kidney d. Uterus ANS: A The gender of the person determines the risk for some cancers and the need for early detection. The incidence of breast cancer is 31% of the reported cases of cancer. DIF: Cognitive Level: Knowledge REF: p. 103 OBJ: 1 TOP: Common Sites of Cancer in Women KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 17. Which complaint should a nurse consider a warning sign for cancer? a. Intense pain in an area such as a hip or groin after carrying several gallons of paint up a ladder and painting the garage b. Persistent indigestion associated with difficulty swallowing c. Diarrhea that lasts 2 days after an all-day picnic at the beach d. A painful lump under the umbilicus that recedes when pushed but comes out again with a sneeze or hard cough ANS: B Persistent indigestion associated with dysphagia is an American Cancer Society–published risk for a cancerous sign. DIF: Cognitive Level: Comprehension REF: p. 106 OBJ: 4 TOP: Warning Signs of Cancer KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 18. What is the most common site of cancer in adult men? a. Colon b. Lung c. Pancreas d. Prostate ANS: D Gender defines some of the potential risks for cancer. Prostate cancer accounts for 33% of the reported cases of cancer in men. DIF: Cognitive Level: Knowledge REF: p. 103 OBJ: 1 TOP: Cancer Sites in Men KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 19. Which cytologic test, usually performed in outpatient settings, suggests the probability of a need for further testing for cancer cells? a. Chest radiography b. Koch test c. Papanicolaou (Pap) test d. Tine test ANS: C Preventive testing (Pap test) and screening reduce the risks for cancer and increase the chances of early treatment and is the most commonly performed screening test. DIF: Cognitive Level: Knowledge REF: p. 108 OBJ: 4 TOP: Knowledge of Diagnostic Tests KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 20. What is the cause of cell death when a patient receives radiation as a treatment for cancer? a. Separation of the cell from normal cells b. Damage of the cell membrane c. Alteration of the DNA of the cell d. Reduction of cell nutrition ANS: B The immediate effect of radiation is cell death as a result of damage to the cell membrane. The delayed effect is the alteration of the DNS so that it cannot replicate. DIF: Cognitive Level: Comprehension REF: p. 111 OBJ: 6 TOP: Radiation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 21. What is the best menu choice for a patient with nausea who is undergoing radiation treatments every other day? a. Bowl of vegetable soup, chopped egg and pickle sandwich on wheat bread, one apple, and 8 oz of orange juice b. Broiled chicken with rice, vanilla yogurt, one-quarter cup of spinach, one-half ripe banana, and 8 oz of grape juice c. Spanish rice, one-half cup of mixed green salad, one-half cup of canned peaches, and 8 oz of Coke d. Spaghetti with tomato sauce, cheddar cheese toast strips, six celery sticks with peanut butter, and 8 oz of whole milk ANS: B Food choices for a nauseated patient should be mild and easily digested, with no spicy sauces or dark colas. DIF: Cognitive Level: Application REF: p. 125 OBJ: 6 TOP: Nutrition for Nauseated Patients KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 22. A patient is close to death with terminal liver cancer with widespread metastases and calls the nursing staff to his room every 5 minutes. Which interventions will be most supportive and in the best interest of the patient? a. Encourage and insist that the family request a transfer to hospice care because the general hospital does not have enough staff members to keep responding to the patient’s end-stage frequent calling and requests for minor help. b. Use fixed interval and cocktail medication administration. Frequently evaluate for breakthrough pain and anxieties. Answer the call bell quickly on the intercom or in person. c. Tell the family that as of this afternoon, all of the patient’s questions, comments, and expressed fears of dying and financial worries will be referred to the social worker, physician, or clergy. Otherwise, one of them can come in and sit beside the bed. d. Plan to limit strictly the time spent with the patient because the nurse cannot do much that could be beneficial at this point. ANS: B Therapeutic touch, the nurse’s presence, and sufficient pain medication to make the patient comfortable are appropriate nursing actions. DIF: Cognitive Level: Application REF: p. 127 OBJ: 7 TOP: Terminal Care Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 23. Which statement by a patient should lead the nurse to conclude that the precolonoscopy instruction provided has been effective? a. “I know that the lighted tube he will use will help the doctor look at my tumor, and he might take a small piece of tissue to look at in the lab.” b. “I know that the light on the tube will help cure my cancer.” c. “I know the colonoscopy is very painful and embarrassing, and I hope no one sees me in that position.” d. “My daughter is coming in to see me today. I am glad to be looking forward to something pleasant.” ANS: A Colonoscopy diagnostic procedures are essentially painless but have no curative benefit. DIF: Cognitive Level: Application REF: p. 109 OBJ: 5 TOP: Colonoscopy KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort MULTIPLE RESPONSE 1. Which factors in middle-aged persons promote the formation of malignant cells? (Select all that apply.) a. Childbearing One gray is equal to 100 rads. DIF: Cognitive Level: Knowledge REF: p. 111 OBJ: 2 TOP: Gray KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 3. List the tumors in order based on the following tissue of origin: 1, fat; 2, fibrous; 3, smooth muscle; 4, glands; 5, bone. (Place the events in the appropriate sequence. Do not separate answers with a space or punctuation. Example: ABCD.) a. Sarcoma b. Lipoma c. Leiomyoma d. Fibroma e. Carcinoma ANS: BDCEA Tumors are associated with the tissue from which they arise: fat tumors are lipomas, fibrous tissue tumors are fibromas, smooth muscle tumors are leiomyomas, and bone tumors are sarcomas. Carcinomas include glands. DIF: Cognitive Level: Comprehension REF: p. 105 OBJ: 3 TOP: Tumor Type KEY: Nursing Process Step: N/A MSC: NCLEX: N/A Chapter 08: Pain Linton: Medical-Surgical Nursing, 7th Edition MULTIPLE CHOICE 1. The length of time that a nurse should leave heat to an injured hip of a patient is no longer than a. 15 minutes. b. 20 minutes. c. 30 minutes. d. 1 hour. ANS: C If a heating device is left on more than 30 minutes, the effectiveness of the treatment is diminished, and injury to the tissues may occur. DIF: Cognitive Level: Comprehension REF: p. 142 OBJ: 8 TOP: Timing of Heat Application KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 2. A patient with an extensive abdominal surgical procedure is assessed by the nurse as having predictable pain. How often should the nurse administer analgesics to this patient to be most effective? a. As needed (PRN) b. Once a day c. Twice a day d. Around the clock ANS: D Using a preventive approach for managing this patient’s pain management is the best plan for the nurse because the pain is predictable and major. DIF: Cognitive Level: Application REF: p. 143 OBJ: 8 TOP: Predictable Pain and Analgesic Administration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 3. What sympathetic responses to pain might be assessed by the nurse? a. Increased blood pressure, increased pulse, and increased respiratory rate b. Decreased blood pressure, decreased pulse, and increased respiratory rate c. Increased blood pressure, decreased pulse, and increased respiratory rate d. Decreased blood pressure, decreased pulse, and decreased respiratory rate ANS: A The sympathetic nervous system controls blood pressure, pulse, and respiration; it is stimulated during pain. DIF: Cognitive Level: Comprehension REF: p. 134 OBJ: 7 TOP: Sympathetic Response to Pain KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. A health care provider has prescribed both heat and cold treatments for an older adult patient with a leg injury. The nursing care plan reflects secondary diagnoses of peripheral vascular disease (PVD), diabetes, and an allergy to latex. Which of the prescribed treatments should the nurse administer and why? a. The nurse will use cold treatment because patients with diabetes and a latex allergy cannot tolerate heat. b. The nurse will use cold treatment for this patient with a fracture because cold will help set the cast. c. The nurse will use heat treatment because cold is contraindicated for patients with PVD. d. The nurse will use heat treatment because heat will increase circulation and increase the threat of infection in the injured part. ANS: C Patients with PVD have blood flow problems that physiologically slow circulation. This problem would be exacerbated by cold. Heat will increase the circulation, which would be a desired effect. DIF: Cognitive Level: Application REF: p. 141 OBJ: 6 | 8 TOP: Thermal Applications with Secondary Diagnosis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 5. A nurse notices that a patient seems calm and peaceful despite an assessment that the patient’s injuries might be causing severe pain. The patient tells the nurse that using yoga and meditation lessens the perceptions of pain to tolerable levels. Which other alternative intervention should the nurse suggest to help relax this patient for pain relief? a. Indulging in a favorite food b. Music by a favorite artist c. Reading exciting science fiction d. Self-administration of drugs ANS: B Alternate methods of pain relief are effective for many patients. Activities such as yoga, meditation, and listening to music are helpful and relaxing. DIF: Cognitive Level: Application REF: p. 141 OBJ: 3 | 8 TOP: Alternate Methods of Pain Relief KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. What intervention of pain control exemplifies the gate control methods of pain relief? a. Assisting the patient to ambulate b. Giving a massage c. Providing an ice cold beverage d. Instructing the patient in stretching exercises ANS: B Massage, position change, hot or cold applications, and distraction all can close the gate. DIF: Cognitive Level: Comprehension REF: p. 132 OBJ: 2 TOP: Gate Theory KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. Every time the right arm is raised, a patient reports to the nurse that pain is triggered in the right shoulder. How should the nurse document this description? a. Referred pain b. Aggravating factor c. Alleviating factor d. Past experience with the pain ANS: B The aggravating factor that is causing pain is important information to gather by the nurse and to communicate specifically in the chart, as well as to the registered nurse. DIF: Cognitive Level: Comprehension REF: p. 137 OBJ: 2 TOP: Factors Defining the Pain Description KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care 14. A patient who had a myocardial infarction 2 days earlier has been eating well, is ambulating with assistance, and is receiving antibiotics and morphine by intravenous (IV) drip. The patient complains of constipation this morning. What should the nurse assess as the probable cause of the constipation? a. Inadequate fluid intake b. Lack of exercise c. Administration of antibiotics d. Administration of an analgesic medication ANS: D Opioid administration frequently causes constipation. This patient is eating, taking IV fluids, and walking. Antibiotics rarely cause constipation. DIF: Cognitive Level: Application REF: p. 147 OBJ: 9 TOP: Side Effects of Opioids KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. A patient who is obviously in pain refuses the morphine that has been prescribed for pain control because of a fear of addiction. What should the nurse explain is the estimated percentage of patients taking prescribed pain protocols who become addicted? a. Less than 1% b. 10% to 25% c. 30% to 50% d. 80% to 90% ANS: A When used for severe pain management relief, opioids rarely result in addiction. DIF: Cognitive Level: Knowledge REF: p. 151 OBJ: 9 TOP: Addiction Potential KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 16. Morphine sulfate (30 mg) IM PRN was prescribed for pain for an 80-year-old patient with emphysema who weighs 100 lb. What is the most appropriate action for the licensed practical/vocational nurse (LPN/LVN)? a. Transcribe the order and wait to see if the patient needs it. b. Transcribe the order for an oral dose instead of IM dose. c. Call the physician and clarify the order. d. Tell the RN about the order. ANS: D Morphine is usually given in a dose of 10 mg (one-sixth grain) IM. The usual oral dose is 0.5 gr (30 mg). The order should be called to the attention of the RN so that the intent can be clarified before transcribing the order for the older patient, who usually requires a smaller dose. DIF: Cognitive Level: Application REF: p. 145 OBJ: 6 TOP: Morphine Dosage KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 17. What assessment should a nurse make to evaluate the presence of pain in a patient who is cognitively impaired? a. Amount of time spent sleeping during the day b. Consistent stoic facial expression c. Increased social interaction d. Increasing confusion ANS: D Patients who are cognitively impaired may show pain by increased confusion, reduction in social contacts, grimacing, or squinting the eyes. DIF: Cognitive Level: Application REF: p. 140 OBJ: 7 TOP: Pain Assessment in Cognitively Impaired KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 18. Which steps should the LPN/LVN follow when performing a pain assessment? a. Assess vital signs, status of pain, and aggravating factors. b. Assess location, quality, and intensity on an identified scale. c. Assess the intensity on an identified scale and record findings. d. Assess vital signs and location, and report to the RN. ANS: B The assessment of pain requires the nurse assess location, quality, and intensity based on an identified scale. Vital signs are important in addition but are not part of the six steps. DIF: Cognitive Level: Application REF: pp. 137-138 OBJ: 7 TOP: Nurse’s Pain Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 19. Two patients are hospitalized with the same diagnosis, but one is 23 years old, with acute recent pain from an injury, and the other is 64 years old, with pain of long-standing duration of several years. What is the difference in the anticipated assessments? a. Acute pain for young patients is more intense at the same level, but these patients experience few changes in vital signs. b. Young patients with acute pain exhibit fewer changes in vital signs but still report true levels of pain at levels 8 to 10. c. Older adult patients with chronic pain exhibit increased changes in vital signs and report levels of pain lower than reality. d. Older adult patients with chronic pain usually report lower levels of pain much less severe than they really are. ANS: D Older adult patients with chronic pain do not report pain as severe at the same level as younger patients do for several reasons. For example, older adult patients believe that pain comes with old age, or they do not want to bother the staff. Frequently, chronic long-standing pain does not change normal values of the vital signs. DIF: Cognitive Level: Comprehension REF: p. 133 OBJ: 6 TOP: Age-Related Assessments of Pain KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 20. How does the International Association for the Study of Pain define the sensation of pain? a. Unpleasant sensory and emotional experience b. Whatever the person experiencing it says it is c. Psychogenic response to tissue injury d. Physical and psychogenic response to the need for drugs ANS: A The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience. DIF: Cognitive Level: Knowledge REF: p. 131 OBJ: 1 TOP: Definition of Pain KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 21. A nurse is notified when a patient, newly admitted with liver and gallbladder disease, complains of pain in the right middle back and asks for some pain medication. What is the best interpretation of this reported assessment by the nurse? a. The patient is just complaining to see whether the staff will give out pain medications. b. The patient has referred pain sensations. The nurse should follow orders for administering pain medication. c. The patient has an injury on the back from an unknown cause that needs immediate assessment. d. The patient is a chronic complainer with anxieties about his condition. ANS: B Referred pain is a very real physical complaint, and the nurse should give the patient the pain medication as ordered. DIF: Cognitive Level: Application REF: pp. 137-138 OBJ: 2 | 5 TOP: Referred Pain KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. What is the most common result of prolonged and unrelieved pain? a. Release of endorphins b. Lowered pain threshold c. Stimulated gate control d. Lowered blood pressure nociceptors Pain receptors that are called nociceptors activate the afferent pathways. DIF: Cognitive Level: Knowledge REF: p. 132 OBJ: 2 TOP: Nociceptors KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. and enkephalins are natural opioid-like substances that block pain perception. ANS: Endorphins Endorphins and enkephalins are natural opioid substances that help block the perception of pain. DIF: Cognitive Level: Knowledge REF: p. 132 OBJ: 2 TOP: Endorphins KEY: Nursing Process Step: N/A MSC: NCLEX: N/A Chapter 09: Shock Linton: Medical-Surgical Nursing, 7th Edition MULTIPLE CHOICE 1. What are the four types of shock? a. Multiple organ, cardiogenic, renal, and anaphylactic b. Cardiogenic, renal, hypovolemic, and septic c. Renal, hypervolemic, obstructive shock, and neurogenic d. Hypovolemic, cardiogenic, obstructive shock, and vasogenic ANS: D The four large categories of shock are hypovolemic (low-circulating volume), cardiogenic (low-cardiac output), obstructive (occluded vascular pathway), and vasogenic (massive vasodilation). DIF: Cognitive Level: Knowledge REF: p. 153 OBJ: 1 TOP: Types of Shock KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. Although several life-supporting systems of the body are involved in the pathophysiologic characteristics of shock, shock itself results from failure of which system? a. Circulatory b. Endocrine c. Neurologic d. Respiratory ANS: A When the heart fails as a pump, the lack of tissue perfusion follows and deprives all the body’s cells of oxygen and the removal of wastes. DIF: Cognitive Level: Knowledge REF: p. 153 OBJ: 2 TOP: Definition of Shock KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 3. A nurse is assessing a patient who is in shock. What should the nurse be aware that one common sign will be, regardless of the cause of the shock? a. The skin is cool and dry with cyanotic nail beds. b. The skin is cool and moist with cyanotic nail beds. c. The nail beds are reddened, and the skin is moist and warm. d. The nail beds are reddened, and the skin is dry and warm. ANS: B Venous blood pools in the extremities of the fingers as a result of the lack of adequate perfusion of tissues, which makes the skin cool and moist from a lack of oxygen and waste exchanges. DIF: Cognitive Level: Comprehension REF: p. 157 OBJ: 3 TOP: Common Signs of Shock KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. What should a nurse assessing a patient in the organ-dysfunction stage of shock expect to find? a. Bounding pulse, decreased respirations, and decreased blood pressure b. Bounding pulse, shallow respirations, and significantly increased blood pressure c. Thready pulse and deep respirations with decreased blood pressure d. Thready pulse and irregular respirations with increased blood pressure ANS: C When the cause of shock is not corrected, irreversible organ damage takes place. The pulse is weak; the respirations increase in an effort to decrease the carbon dioxide level; and, with less volume being pumped, the blood pressure falls. DIF: Cognitive Level: Comprehension REF: p. 156 OBJ: 3 TOP: Signs of Shock KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. A licensed practical/vocational nurse (LPN/LVN) is assisting in developing a nursing care plan for a patient in shock. Which patient problem should be included? a. Excess cardiac output, related to hypertension b. Excess cardiac output, related to hypotension c. Inadequate cardiac output, related to hypovolemia d. Inadequate cardiac output, related to hypertension ANS: C Decreased amount of blood is ejected from the heart because of a decreased volume of fluid in the intravascular compartment. DIF: Cognitive Level: Application REF: p. 153 OBJ: 7 TOP: Nursing Diagnosis for Patients in Shock KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. How does the intraaortic balloon pump (IABP) assist a patient who is in cardiogenic shock to increase cardiac output? a. Provides generalized vasoconstriction. b. Inflates during the diastole phase. c. Constricts the vena cava. d. Adds hypertonic fluid to the circulating volume. ANS: B The IABP inflates during diastole (relaxation) phase and deflates during the systole (constriction) phase, which improves cardiac output. DIF: Cognitive Level: Comprehension REF: p. 160 OBJ: 6 TOP: IABP KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. A nurse is explaining to a family member the pathophysiologic characteristic of distributive shock. What information should the nurse include? a. The intravascular compartment fills beyond capacity, allowing fluid to leak out, compressing vital organs. b. The circulating volume causes excessive constriction of the vessels, causing blood ANS: B The Trendelenburg position, with the patient’s head down, allows gravity to pull blood to the cerebrum. All other positions are ineffective for improving cerebral perfusion. DIF: Cognitive Level: Knowledge REF: p. 164 OBJ: 5 TOP: Positions to Counteract Shock KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. A nurse is administering heparin, subcutaneous twice daily, to a patient in cardiogenic shock. What is the expected action of this drug? a. Inotropic to improve cardiac contractibility b. Anticoagulant to prevent blood clots c. Antidysrhythmic to restore normal cardiac contractibility d. Vasopressor to increase blood pressure ANS: B Cardiogenic shock may produce clots because of blood stasis, and the heparin will delay clot formation. DIF: Cognitive Level: Knowledge REF: p. 163 OBJ: 5 | 6 TOP: Heparin for Anticoagulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 15. One of the most important assessments that a nurse makes is to check urine output. Which value objectively validates minimal acceptable renal perfusion for the average-size person? a. 0.5 mL/kg/hr b. 0.5 mL/lb/hr c. 1 mL/lb/hr d. 0.2 mL/kg/hr ANS: A When the kidneys produce at least 0.5 mL/kg/hr of urine, the indication is that the vital organs are also being perfused. DIF: Cognitive Level: Knowledge REF: p. 161 OBJ: 5 TOP: Urine Output As Measure of Tissue Perfusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. A patient is receiving norepinephrine as a first line treatment for shock in order to increase vascular resistance. Which type of shock is the patient being treated for? a. Septic b. Cardiogenic c. Anaphylactic d. Neurogenic ANS: A Norepinephrine is used as a first line treatment for septic shock in order to increase vascular resistance. DIF: Cognitive Level: Comprehension REF: p. 159 OBJ: 6 TOP: Pharmacologic Therapy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 17. A patient’s family voices concern regarding the purpose of some of the interventions for systemic inflammatory response syndrome (SIRS). What explanation by the nurse is most appropriate when explaining the rationale of treatment? a. “Applying a MAST garment is mandatory to promote and conserve body heat.” b. “Inserting an IABP is required to decrease fluid leaking into the extravascular space.” c. “Maintaining strict isolation is vital to prevent an overlying bacterial infection.” d. “Aggressive treatment is necessary to support the multiple failing organs.” ANS: D SIRS is the final and possibly fatal stage of shock. The body’s defenses are supported aggressively and rapidly. MAST and IABP are measures used to increase circulating volume. Isolation is not indicated. DIF: Cognitive Level: Comprehension REF: pp. 162-163 OBJ: 6 TOP: SIRS Treatment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk COMPLETION 1. A nurse explains that pericardial tamponade and tension pneumothorax can place the patient at risk for shock. ANS: obstructive Obstructive shock can result from pericardial tamponade or tension pneumothorax. DIF: Cognitive Level: Knowledge REF: p. 154 OBJ: 1 | 2 TOP: Obstructive Shock KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. A nurse explains that when shock forces the body into anaerobic metabolism, organ damage is caused by a product of that metabolism, which is . ANS: lactic acid Lactic acid, a by-product of anaerobic metabolism, can cause organ damage in the patient who is in shock. DIF: Cognitive Level: Knowledge REF: p. 156 OBJ: 2 TOP: Lactic Acid KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. A nurse explains that the minimal acceptable hourly urine output for a patient in shock who weighs 220 lb is mL. (Use numeric characters only.) ANS: 50 220 lb ÷ 2.2 lb = 100 kg; 0.5 mL/kg/hr x 100 kg = 50 mL. DIF: Cognitive Level: Analysis REF: p. 161 OBJ: 7 TOP: Minimum Urine Output KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. A nurse is aware that immobility and insertion of urinary catheters, although therapeutic, also places the patient at risk for . ANS: infection The insertion of a Foley catheter and long-term immobility can cause infections. DIF: Cognitive Level: Comprehension REF: p. 162 OBJ: 6 TOP: Infection KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 8. What is the most appropriate nursing action when planning activities to improve short-term memory for an older adult patient experiencing memory deficits? a. Maintain the same daily schedule. b. Rehearse memory training. c. Provide a varied and stimulating daily schedule. d. Conduct deep-breathing exercises. ANS: B Using mnemonics and memory rehearsal may improve memory performance in some older individuals. DIF: Cognitive Level: Application REF: p. 171 OBJ: 3 TOP: Physiologic Change KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. What is the best example of normal memory change or lapse of memory? a. Relying on another person to remember names or important events b. Occasional forgetfulness or inability to recall names or facts c. Difficulty in recalling recent events d. Difficulty in recalling past events ANS: B Memory lapses such as forgetting a name or misplacing an item are common, normal memory changes. DIF: Cognitive Level: Comprehension REF: p. 170 OBJ: 3 TOP: Physiologic Change KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 10. Which facts are generally accepted for most older adults? a. Intellectual capabilities are impaired. b. Functional brain activities decrease. c. Functional intellectual capability is maintained. d. Creativity and judgment are severely impaired. ANS: C Functional ability may not be significantly affected because reserve cells are able to compensate. DIF: Cognitive Level: Comprehension REF: p. 170 OBJ: 3 TOP: Physiologic Change KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 11. What factor increases the risk of respiratory infection for older adults? a. Decreased ciliary action b. Decreased physical activity c. Inadequate hydration d. Poor personal hygiene ANS: A The ability to perform strenuous work decreases with age. The ciliary action responsible for movement of secretions from the lung is compromised because of epithelial atrophy. DIF: Cognitive Level: Comprehension REF: p. 171 OBJ: 3 TOP: Physiologic Change KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 12. A nurse is caring for an older person whose renal changes make it impossible to concentrate or dilute urine. For what is this patient at the greatest risk? a. Urinary infection b. Dehydration c. Incontinence d. Renal failure ANS: B The kidney’s ability to concentrate urine is a major defense against dehydration. DIF: Cognitive Level: Application REF: p. 172 OBJ: 3 TOP: Physiologic Renal Change KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. Which assessment is the greatest priority to report when considering the gastrointestinal (GI) changes that take place in the geriatric patient? a. 24-hour urinary output of 1450 mL b. 24-hour dietary intake of 75% of meals c. Last bowel movement 4 days ago d. Weight loss of 2 lb since admission 2 months ago ANS: C GI changes include bloating, diarrhea, pernicious anemia, and constipation. DIF: Cognitive Level: Application REF: p. 173 OBJ: 3 TOP: Physiologic Change KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 14. Which assessment made by the nurse is a major sign of renal changes related to age? a. Hematuria b. Nocturia c. Urgency incontinence d. Renal calculi ANS: C Urgency incontinence is related to several age-related changes in the urinary musculature. Renal calculi and hematuria are pathologic symptoms and are not age related. Nocturia is not specifically related to aging. DIF: Cognitive Level: Comprehension REF: p. 172 OBJ: 3 TOP: Physiologic Change KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. What should be the most significant assessment when gathering data concerning the musculoskeletal system? a. Slow gait b. Degree of motion of all joints c. Enlarged joints d. Crepitus in joints ANS: B Determine mobility by assessing the range of motion in all joints; in addition, look for signs of inflammation and pain associated with mobility. DIF: Cognitive Level: Application REF: p. 173 OBJ: 3 TOP: Physiologic Change KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 16. What is the most appropriate nursing intervention for a patient with presbycusis? a. Speak clearly and distinctly while facing the patient. b. Announce your presence when entering the patient’s room. c. Place needed articles within easy reach. d. Orient the patient to time and place as needed. ANS: A Presbycusis is hearing loss. Get the patient’s attention so that the patient can concentrate on what you are saying or read lips. DIF: Cognitive Level: Application REF: p. 173 OBJ: 3 TOP: Physiologic Change KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 17. What should the nurse suspect a patient is developing when he is observed holding his Bible 6 inches from his face and turns his head to read out of the corner of his eyes? a. Cataracts b. Glaucoma c. Presbyopia d. Macular degeneration ANS: D The leading cause of new blindness in old age is macular degeneration, which results in the loss of central vision. DIF: Cognitive Level: Comprehension REF: p. 174 OBJ: 3 TOP: Macular Degeneration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. What is true regarding the chemosensory changes observed in older adults? a. They are directly related to the aging process. b. They are most often caused by disease. c. They begin in the fifth decade of life. d. They affect more women than men. ANS: B Major changes in the ability to taste are often caused by disease or a side effect of certain drugs. Chapter 11: Falls Linton: Medical-Surgical Nursing, 7th Edition MULTIPLE CHOICE 1. What recommendation should a nurse make to the family of a patient diagnosed with ataxia when preparing discharge to home? a. Remove all scatter rugs from the home. b. Rearrange the bedroom furniture. c. Arrange for someone to stay with the patient 24 hours a day. d. Purchase oversized shoes so that they are easy to get on. ANS: A Scatter rugs can slip and cause a patient to fall. DIF: Cognitive Level: Application REF: p. 186 OBJ: 5 TOP: Fall Prevention KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 2. What should be the first intervention when a nurse finds that a patient has fallen? a. Ask the patient to stand up. b. Document the fall according to agency policy. c. Remove or correct the cause of the fall. d. Assess the circumstances of the fall and any injuries sustained. ANS: D The first implementation should be to assess what happened, determine whether any injuries have occurred, and then document and correct the cause. DIF: Cognitive Level: Application REF: p. 188 OBJ: 6 TOP: Implementations for a Fall KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 3. What should discharge planning for a patient who lives alone and is at high risk for falling include? a. Cannot go home unless someone is with him all the time. b. Must go to a long-term care facility. c. Can wear devices around the neck that can signal for help. d. Needs to be aware of the dangers of living alone. ANS: C A person who is at risk for falling would be wise to have a call system to obtain help from others. Devices worn around the neck that can send signals to a control center are effective and provide a feeling of well-being for the individual who has the potential for falling. DIF: Cognitive Level: Comprehension REF: p. 188 OBJ: 5 TOP: Implementations for a Fall KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 4. A nurse explains that older adults account for a large percentage of the total deaths resulting from falls. What is this percentage? a. 13% b. 27% c. 40% d. 72% ANS: D Older adults constitute only 12% to 13% of the total U.S. population, but they account for 72% of the total deaths resulting from falls. DIF: Cognitive Level: Knowledge REF: p. 181 OBJ: 2 TOP: Incidence of Falls KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 5. A nurse is caring for an older adult patient who has undergone a total hip replacement. What is the best action to reduce the risk of further injury? a. Leave all the lights on in the room at night. b. Leave the side rails down at all times to enable the patient to get to the bathroom quickly. c. Keep the call bell and other frequently used items in easy reach. d. Keep the bed in the high position to discourage the patient from getting out of bed without assistance. ANS: C Keeping the call bell and other frequently used items within easy reach will prevent the patient from having to reach, which increases the risk for falling. DIF: Cognitive Level: Application REF: p. 187 OBJ: 5 TOP: Fall Prevention KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 6. A nurse is talking to the family of a patient who has fallen several times. What is the most important intervention for preventing falls that the nurse to relay to this family? a. Prevention b. Hospitalization c. Continuous observation d. Restraint ANS: A The most important implementation for falls is prevention. The best prevention is education that is aimed toward minimizing intrinsic and extrinsic factors. DIF: Cognitive Level: Comprehension REF: p. 184 OBJ: 5 TOP: Fall Prevention KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control 7. How often should a nurse remove and release restraints when caring for a patient who requires wrist restraints? a. Once every 8 hours for at least 30 minutes b. Once every 4 hours for at least 15 minutes c. Once every 2 hours for at least 10 minutes d. Once every 1 hour for at least 5 minutes ANS: C Physical restraints must be removed and released every 2 hours for 10 minutes. In addition, they should be frequently checked to ensure that the restraint is properly used and is providing adequate protection and comfort without impeding circulation or breathing. DIF: Cognitive Level: Knowledge REF: p. 183 OBJ: 4 TOP: Physical Restraints KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 8. An older adult patient in a long-term care facility is at risk for injury because of confusion. The patient’s gait is stable. What is the best method of restraint to prevent injury to the patient? a. Geriatric chair b. Ambularm bracelet c. Vest restraint d. Wrist or ankle restraint or both ANS: B If a physical restraint is used, the least restrictive device is best. This patient has a stable gait, so the alarm bracelet allows the patient to move about freely while preventing him from leaving the premises. DIF: Cognitive Level: Knowledge REF: pp. 183-184 OBJ: 4 TOP: Physical Restraints KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 9. A nurse is admitting a new patient to the nursing unit. When conducting the admission procedure, what is important for the nurse to ask in order to assess the patient’s risk for falling? a. “How many times have you fallen before?” b. “How many hours do you sleep at night?” c. “What are your eating habits?” d. “Do you smoke?” ANS: A People who are at the greatest risk for falls and injury are those who have fallen before. DIF: Cognitive Level: Application REF: p. 184 OBJ: 3 TOP: Fall Prevention KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 10. A patient has asked a nurse to assist him to ambulate to the bathroom. The nurse is aware that the patient is currently taking an antidepressant medication. What action should the nurse implement? a. Never leave the patient alone in his room. b. Ask the patient if he could use the bedside commode instead of going to the bathroom. c. Make suicidal precautions part of the care plan. d. Ask the patient to sit on the side of the bed for a minute or two before standing and then stand slowly.