Test Bank for Davis Advantage for Understanding Medical- Surgical Nursing 7th Edition by Williams and Hopper

Test Bank for Davis Advantage for Understanding Medical-
Surgical Nursing 7th Edition by Williams and Hopper. This test bank is available for download immediately after making your payment. If you face any difficulty in when downloading it, plase contact me ASAP and I will send you a pdf copy directly to your email.

Sample Questions
Chapter 1. Critical Thinking and the Nursing Process
MULTIPLE CHOICE
1. The nursing practitioner is caring for a group of hospital patients on a
medical-surgical unit. Which hospital patient should the licensed practical
nurse/licensed vocational nurse (LPN/LVN) assess first?
1. A hospital patient with a blood glucose of 42 mg/dL
2. A hospital patient who reports a pain level of 2
3. A hospital patient who has just received a diagnosis of cancer
4. A hospital patient who has a respiratory rate of 22
RIGHT ANSWER> 1
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize hospital patient care activities based on the
Maslow hierarchy of human needs.
Pages: 6–7
Heading: Prioritize Care
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Coordinated Care
CL: Application [Applying] Concept:
Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 This hospital patient has a dangerously low blood glucose level and requires
immediate
intervention.
2 This hospital patient will need to be assessed, but is not as high a priority.
3 According to Maslow, psychosocial needs are not as high of a priority as
physiological needs.
4 A respiratory rate of 22 is within normal range.
PTS: 1 CON: Hospital patient-Centered Care
2. The LPN/LVN enters the room of a hospital patient who is angry and yells,
“I asked 5 minutes ago for my pain medication. I’m going to call the CEO of
the hospital if you don’t get it for me now.” Which statement by the nursing
practitioner demonstrates intellectual empathy?
1. “We are short-staffed today, so it will take me longer to meet your needs.”
2. “I am sorry you had to wait, I know you must be in a lot of pain.”
3. “I had another hospital patient who had severe pain, and I had to get to them first.”
4. “I will get you the number for the CEO, but he is aware of how busy we are.”
RIGHT ANSWER> 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 2. Describe attitudes and skills that promote good
critical thinking Source: pp. 2
Heading: Intellectual Empathy
Integrated Process: Communication and
Documentation Hospital patient Need:
Psychosocial Integrity
CL: Application
[Applying] Concept:
Communication
Difficulty: Moderate
CLARIFICATION
1 This statement does not consider an individual’s situation.
2 This statement demonstrates intellectual empathy by considering this hospital
patient’s situation and will likely alleviate the hospital patient’s anger.
3 This statement does not consider a hospital patient’s situation and does not
demonstrate
intellectual empathy.
4 This statement addresses the hospital patient’s statement of wanting to call the
CEO, but does not demonstrate intellectual empathy by considering the
hospital patient’s situation.
PTS: 1 CON: Communication
3. The nursing practitioner is collecting data on a hospital patient. Which data
are described as subjective?
1. Respiratory rate of 26 per minute
2. Hospital patient report of shortness of breath
3. Coarse lung sounds bilaterally
4. Cough producing green sputum
RIGHT ANSWER> 2
Chapter: Chapter 1 Critical Thinking and the
Nursing Process Objective: 5. Differentiate
between objective and subjective data. Source: pp.
4
Heading: Subjective Data
Integrated Process: Communication and
Documentation Hospital patient Need:
Communication and
Documentation CL: Application (Applying)
Concept: Communication
Difficulty: Moderate
CLARIFICATION
1 Respiratory rate of 26 per minute is an example of objective data.
2 A hospital patient reporting symptoms to the nursing practitioner is an example
of subjective data.
3 Coarse lung sounds is an example of objective data.
4 A productive cough is an example of objective data.
PTS: 1 CON: Communication
4. A hospital patient with a newly fractured femur reports a pain level of 8/10
and analgesic medication is not due for another 50 minutes. Which action should
the nursing practitioner take first?
1. Reposition the hospital patient.
2. Give the medication in 30 minutes.
3. Notify the registered nursing practitioner (RN) or physician.
4. Tell the hospital patient it is too early for pain
medication. RIGHT ANSWER> 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 4. Identify the role of a licensed practical nurse/licensed
vocational nursing practitioner in using the nursing process.
Source: pp. 3
Heading: Clinical Judgement
Integrated Process: Clinical Problem-solving Process (Nursing Process)
Hospital patient Need: SECE—Coordinated Care
CL: Application [Applying] Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The hospital patient who has a fractured femur is having acute pain.
Repositioning a
hospital patient with a new fracture is not likely to relieve pain.
2 Giving the medication before the prescribed time is beyond the nurse’s scope
of practice.
3 The hospital patient should not have to wait for pain relief, so the LPN should
inform
the RN or physician so new pain relief orders can be obtained.
4 The nursing practitioner needs to do more than expect the hospital patient to
wait for pain relief.
PTS: 1 CON: Hospital patient-Centered Care
5. The nurse practitioner is prioritizing patient care according to
Maslow’s hierarchy of needs. Which need does the nurse
practitioner recognize as the most important?
1. Job-related stress
2. Feeling of loneliness
3. Pain level of 9 on 0 -to-10 scale
4. Lack of confidence
RIGHT ANSWER> 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize hospital patient care activities based on the
Maslow hierarchy of human nee ds
Source: pp. 7
Heading: Prioritize Care
Integrated Process: Caring
Hospital patient Need: SECE –
Coordinated Care CL: Application
[Applying] Concept: Hospital patient-
Centered Care Difficulty: Moderate
CLARIFICATION
1 Job-related stress falls under safety according to Maslow and is addressed after
physiological needs.
2 According to Maslow, loneliness is addressed under social needs following
physiological and safety.
3 Pain is a physiological need and is the highest priority.
4 Lack of confidence falls under esteem according to Maslow and is addressed
following physiological, safety, and social needs.
PTS: 1 CON: Hospital patient-Centered Care
6. When a nursing practitioner is designing care plans and establishing goals for a newly
admitted patient, who should be directly involved in these actions?
1. The patient
2. The nursing manager
3. The hospital chaplain
4. The patient’s health care provider (HCP)
Correct Answer: 1
Chapter: Chapter 1: Critical Thinking and the Nursing Process
Objective: Identify the role of a licensed practical nurse/licensed vocational nurse (LPN/LVN)
in using the nursing process.
Reference: Page 6
Topic: Prioritizing Care
Focus Area: Communication and Documentation
Need: Management of Care
Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
Explanation:
 1: Care planning and goal-setting should always involve the patient. Engaging the
patient ensures that the plan is effective and aligned with the desired outcomes.
 2: While the nursing manager may have some knowledge, they might not be directly
aware of the patient’s specific needs.
 3: The chaplain may not have a direct role in the patient’s clinical care plan.
 4: Nursing care focuses on different aspects than the HCP’s medical care.
7. While caring for a post-surgery patient four hours after the operation, the nurse observes
serosanguineous drainage on the dressing. How should this observation be documented?
1. “Normal drainage noted.”
2. “Moderate drainage recently noted.”
3. “Scant serosanguineous drainage seen on dressing.”
4. “Pale pink drainage measuring 2 cm by 1 cm noted on dressing.”
Correct Answer: 4
Chapter: Chapter 1: Critical Thinking and the Nursing Process
Objective: Document subjective and objective data.
Reference: Page 5
Topic: Documentation of Data
Focus Area: Communication and Documentation
Need: Physiological Adaptation
Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
Explanation:
 1, 2, 3: These options use vague terms and lack measurable, specific details, which are
essential in documentation.
 4: The documentation includes objective and factual data, specifically describing what
was observed.
8. The nursing practitioner is providing care for a hospitalized patient using the nursing
process. What is the first step the nurse should take?
1. Implementation
2. Planning
3. Nursing diagnosis
4. Assessment
Correct Answer: 4
Chapter: Chapter 1: Critical Thinking and the Nursing Process
Objective: Identify the role of a licensed practical nurse/licensed vocational nurse (LPN/LVN)
in using the nursing process.
Reference: Page 4
Topic: Data Collection
Focus Area: Clinical Problem-Solving Process (Nursing Process)
Need: Coordinated Care
Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Explanation:
 1, 2, 3: These steps occur later in the nursing process.
 4: Assessment, which involves data collection, is the initial phase of the nursing
process. This step evaluates the patient’s condition before care planning and
intervention.
9. The nurse practitioner administers morphine to a patient who reports a pain level of 8 on a
0–10 scale. This describes which step in the nursing process?
1. Assessment
2. Nursing diagnosis
3. Implementation
4. Evaluation
Correct Answer: 3
Chapter: Chapter 1: Critical Thinking and the Nursing Process
Objective: Identify the role of a licensed practical nurse/licensed vocational nurse (LPN/LVN)
in using the nursing process.
Reference: Page 8
Topic: Identify Interventions
Focus Area: Clinical Problem-Solving Process (Nursing Process)
Need: Coordination of Care
Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Explanation:
 1, 2, 4: Administering medication is not part of assessment, nursing diagnosis, or
evaluation.
 3: Implementation involves carrying out planned actions, such as administering
medication, to help the patient achieve desired outcomes.
10. A nurse practitioner formulates an outcome for a patient experiencing an asthma
exacerbation. Which outcome is most appropriate?
1. The patient will not experience shortness of breath.
2. The patient will maintain a respiratory rate of 16–20 breaths per minute.
3. The patient will ambulate without reporting shortness of breath.
4. The patient will not require the use of an inhaler.
Correct Answer: 2
Chapter: Chapter 1: Critical Thinking and the Nursing Process
Objective: Describe the thought process involved in each step of the nursing process.
Reference: Page 8
Topic: Establish Outcomes
Focus Area: Clinical Problem-Solving (Nursing Process)
Need: Coordinated Care
Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Explanation:
 1, 3, 4: These outcomes are vague and not measurable.
 2: A respiratory rate of 16–20 breaths per minute is measurable and clearly defines the
desired outcome.
11. The nurse practitioner suspects adverse effects from a newly prescribed antihypertensive
medication. After being informed the effects are expected, the nurse conducts further research.
Which critical thinking behavior does this demonstrate?
1. Sense of justice
2. Intellectual courage
3. Intellectual empathy
4. Intellectual perseverance
Correct Answer: 4
Chapter: Chapter 1: Critical Thinking and the Nursing Process
Objective: Describe attitudes and skills that promote critical thinking.
Reference: Page 2
Topic: Intellectual Perseverance
Focus Area: Caring
Need: Psychosocial Integrity
Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
Explanation:
 1, 2, 3: These traits are unrelated to the situation.
 4: Intellectual perseverance involves persistence in seeking the truth or additional
information, as shown by further research on the patient’s symptoms.
12. A nurse practitioner plans outcomes for a patient with a fluid volume deficit. Which
outcome should guide care?
1. The patient’s intake will be measured daily.
2. The patient’s intake will reach 3,000 mL daily.
3. Fluids will be placed at the patient’s bedside.
4. The patient’s preferred fluids will be provided.
Correct Answer: 2
Chapter: Chapter 1: Critical Thinking and the Nursing Process
Objective: Describe the thought process involved in each step of the nursing process.
Reference: Page 7
Topic: Establish Outcomes
Focus Area: Clinical Problem-Solving (Nursing Process)
Need: Coordinated Care
Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Explanation:
 1, 3, 4: These describe actions rather than measurable outcomes.
 2: This provides a clear, objective, and measurable goal.
13. A nurse practitioner is developing nursing diagnoses for a patient with chronic obstructive
pulmonary disease (COPD). Which diagnosis should be the highest priority?
1. Activity intolerance
2. Impaired gas exchange
3. Risk for injury
4. Deficient knowledge
Correct Answer: 2
Chapter: Chapter 1: Critical Thinking and the Nursing Process
Objective: Prioritize patient care activities using Maslow’s hierarchy of needs.
Reference: Page 6
Topic: Prioritize Care
Focus Area: Clinical Problem-Solving (Nursing Process)
Need: Coordinated Care
Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Difficult
Explanation:
 1, 3, 4: Although relevant, they are not the highest priority.
 2: Impaired gas exchange takes precedence according to Maslow’s hierarchy, as it
involves oxygenation, a fundamental physiological need.
14. An RN assigns a task to an LPN/LVN. Which phase of the nursing process can the
LPN/LVN independently carry out?
1. Assessment
2. Planning care
3. Implementation
4. Nursing diagnosis
Correct Answer: 3
Chapter: Chapter 1: Critical Thinking and the Nursing Process
Objective: Identify the role of an LPN/LVN in the nursing process.
Reference: Page 22
Topic: Role of the Licensed Practical Nurse/Licensed Vocational Nurse
Focus Area: Clinical Problem-Solving (Nursing Process)
Need: Coordinated Care
Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Explanation:
 1, 2, 4: The LPN/LVN assists in these areas but does not independently perform them.
 3: The LPN/LVN independently provides direct patient care as part of the
implementation phase.
15. The LPN/LVN reviews the care plan of a post-surgical patient with a priority diagnosis of
acute pain. Which intervention should be implemented first?
1. Teach the patient to splint the abdomen when coughing.
2. Assist with early ambulation.
3. Encourage increased fluid intake.
4. Administer hydromorphone (Dilaudid) as prescribed for pain.
Correct Answer: 4
Chapter: Chapter 1: Critical Thinking and the Nursing Process
Objective: Prioritize patient care activities using Maslow’s hierarchy of needs.
Reference: Page 6
Topic: Prioritize Care
Focus Area: Clinical Problem-Solving (Nursing Process)
Need: Coordinated Care
Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Difficult
Explanation:
 1, 2, 3: These are important interventions but do not address the immediate priority of
pain relief.
 4: Pain management should be addressed first to ensure the patient’s comfort and
ability to participate in other interventions.
16. An LPN/LVN feels uncertain about performing a dressing change and seeks guidance from
an RN. Which critical thinking trait does this demonstrate?
1. Intellectual courage
2. Intellectual integrity
3. Intellectual humility
4. Intellectual empathy
Correct Answer: 3
Chapter: Chapter 1: Critical Thinking and the Nursing Process
Objective: Describe attitudes and skills that promote critical thinking.
Reference: Page 2
Topic: Intellectual Humility
Focus Area: Communication and Documentation
Need: Psychosocial Integrity
Level: Comprehension [Understanding]
Concept: Communication
Difficulty: Moderate
Explanation:
 1, 2, 4: These traits apply in different situations.
 3: Intellectual humility involves recognizing one’s limitations and seeking help when
necessary.
17. During morning report, the LPN/LVN is assigned a group of patients. Which patient should
be attended to first?
1. A patient scheduled for an MRI due to back pain.
2. A patient experiencing constipation and stomach cramps.
3. A post-surgical patient (day 2) with pain rated at 6.
4. A pneumonia patient who is short of breath and anxious.
Correct Answer: 4
Chapter: Chapter 1: Critical Thinking and the Nursing Process
Objective: Prioritize patient care activities using Maslow’s hierarchy of needs.
Reference: Page 3
Topic: Prioritize Care
Focus Area: Clinical Problem-Solving (Nursing Process)
Need: Coordinated Care
Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Difficult
Explanation:
 1, 2, 3: These conditions are important but not immediately life-threatening.
 4: Shortness of breath is the most urgent concern, requiring immediate intervention.
18. An LPN/LVN asks a patient who received 2 mg of IV morphine 30 minutes ago to rate
their pain. This corresponds to which step of the nursing process?
1. Assessment
2. Planning
3. Implementation
4. Evaluation
Correct Answer: 4
Chapter: Chapter 1: Critical Thinking and the Nursing Process
Objective: Describe the thought process involved in each step of the nursing process.
Reference: Page 8
Topic: Evaluation of Outcomes
Focus Area: Clinical Problem-Solving (Nursing Process)
Need: Coordinated Care
Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
Explanation:
 1, 2, 3: These occur before medication administration.
 4: Evaluating the effectiveness of pain relief after medication administration is part of
the evaluation phase.
19. An LPN/LVN assists an RN in planning patient interventions. Which is an example of a
collaborative action?
1. Administering medication
2. Giving a back rub
3. Assessing the patient
4. Teaching relaxation techniques
Correct Answer: 1
Chapter: Chapter 1: Critical Thinking and the Nursing Process
Objective: Describe the thought process involved in each step of the nursing process.
Reference: Page 6
Topic: Nursing Diagnosis
Focus Area: Clinical Problem-Solving (Nursing Process)
Need: Coordinated Care
Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Explanation:
 2, 3, 4: These are independent nursing actions.
 1: Medication administration requires an HCP order, making it a collaborative
intervention.
20. An LPN/LVN is reviewing nursing diagnoses for a patient. Which diagnosis should be
reported to the RN as incorrect?
1. Risk for injury
2. Heart failure
3. Ineffective gas exchange
4. Activity intolerance
Correct Answer: 2
Chapter: Chapter 1: Critical Thinking and the Nursing Process
Objective: Identify the role of an LPN/LVN in the nursing process.
Reference: Page 6
Topic: Nursing Diagnosis
Focus Area: Clinical Problem-Solving (Nursing Process)
Need: Coordinated Care
Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Explanation:
 1, 3, 4: These are valid nursing diagnoses.
 2: Heart failure is a medical diagnosis, not a nursing diagnosis, and should be
corrected.
21. The LPN/LVN is caring for a group of hospitalized patients. Which patient
should be assessed first?
1. A patient with an oxygen saturation of 96% on room air
2. A patient with a blood pressure of 208/114 mm Hg
3. A patient reporting a pain level of 7 on a 0-to-10 scale
4. A patient with a temperature of 100.2°F
Correct Answer: 2
Chapter: Chapter 1: Critical Thinking and the Nursing Process
Objective: Prioritize patient care activities using Maslow’s hierarchy of needs.
Reference: Page 7
Topic: Prioritize Care
Focus Area: Clinical Problem-Solving Process (Nursing Process)
Need: Coordinated Care
Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Difficult
Explanation:
 1, 3, 4: These conditions are not as critical as an extremely high blood pressure reading.
 2: A blood pressure of 208/114 mm Hg is dangerously high and requires immediate
attention, making this the highest priority.
22. The LPN/LVN is caring for a hospitalized patient who develops shortness of
breath and chest pain. What should be the nurse’s first action?
1. Administer medication as prescribed.
2. Notify the RN.
3. Document the findings in the chart.
4. Reposition the patient.
Correct Answer: 2
Chapter: Chapter 1: Critical Thinking and the Nursing Process
Objective: Prioritize patient care activities using Maslow’s hierarchy of needs.
Reference: Page 3
Topic: Prioritize Care
Focus Area: Clinical Problem-Solving Process (Nursing Process)
Need: Coordinated Care
Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Difficult
Explanation:
 1, 3, 4: While important, they do not address the immediate need to escalate the
situation.
 2: The LPN/LVN must report the change in patient condition to the RN immediately to
ensure timely intervention.
23. While teaching a patient how to apply a topical medication, the patient
begins vomiting. What should the nurse do first?
1. Provide a clean gown before continuing the teaching.
2. Position an emesis basin for the patient while continuing the teaching.
3. Administer medication prescribed for nausea and vomiting.
4. Wait for the vomiting to stop and then resume teaching.
Correct Answer: 3
Chapter: Chapter 1: Critical Thinking and the Nursing Process
Objective: Prioritize patient care activities using Maslow’s hierarchy of needs.
Reference: Page 7
Topic: Prioritize Care
Focus Area: Clinical Problem-Solving Process (Nursing Process)
Need: Coordinated Care
Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Explanation:
 1, 2, 4: These actions do not address the patient’s immediate physiological needs.
 3: Managing nausea and vomiting takes priority, as physiological needs must be met
before teaching can be effective.
24. A nurse practitioner notices someone in a restaurant appearing to be in
respiratory distress. What should the nurse do first?
1. Diagnose the problem.
2. Assist the person to lie down.
3. Gather information from others nearby.
4. Collect data on the person’s condition.
Correct Answer: 4
Chapter: Chapter 1: Critical Thinking and the Nursing Process
Objective: Describe the thought process involved in each step of the nursing process.
Reference: Page 7
Topic: Subjective Data
Focus Area: Clinical Problem-Solving Process (Nursing Process)
Need: Coordinated Care
Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Explanation:
 1, 2, 3: These actions follow after assessing the situation.
 4: The first step in the nursing process is collecting data, ensuring the appropriate
intervention is chosen.
25. Which nursing diagnosis is correctly written?
1. Acute pain related to tissue trauma as evidenced by facial grimacing and pain rated
9/10.
2. Pain related to appendicitis as evidenced by moaning and guarding.
3. Acute pain related to guarding abdomen and pain rated 9/10.
4. Pain as evidenced by post-surgical procedure.
Correct Answer: 1
Chapter: Chapter 1: Critical Thinking and the Nursing Process
Objective: Describe the thought process involved in each step of the nursing process.
Reference: Page 6
Topic: Nursing Diagnosis
Focus Area: Clinical Problem-Solving Process (Nursing Process)
Need: Coordinated Care
Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
Explanation:
 2, 3, 4: These contain errors such as using a medical diagnosis (appendicitis) or missing
key elements.
 1: This diagnosis correctly follows the three-part format (problem, etiology, and
evidence).
26. After determining nursing diagnoses, the nurse practitioner sets outcomes
for a patient with gastroesophageal reflux disease (GERD). Which outcome is
best for evaluating the patient’s care?
1. The patient will experience less heartburn.
2. The patient will sleep through the night.
3. The patient’s esophageal burning will resolve within 30 minutes after taking an antacid.
4. The patient will report that burning only occurs when eating acidic foods.
Correct Answer: 3
Chapter: Chapter 1: Critical Thinking and the Nursing Process
Objective: Describe the thought process involved in each step of the nursing process.
Reference: Page 8
Topic: Nursing Diagnosis
Focus Area: Clinical Problem-Solving Process (Nursing Process)
Need: Coordinated Care
Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
Explanation:
 1, 2, 4: These outcomes are vague and not measurable.
 3: The outcome is specific, measurable, and time-bound, making it a strong evaluation
criterion.
MULTIPLE RESPONSE
1. After gathering patient data, the nursing practitioner identifies diagnoses to direct the
hospital patient’s care. Which of the following diagnoses were correctly documented by the
nursing practitioner? (Select all that apply.)
1. Diabetes
2. Acute pain
3. Pancreatitis
4. Activity intolerance
5. Impaired physical mobility
Correct Answers: 2, 4, 5
Chapter: 1 – Critical Thinking and the Nursing Process
Objective: 3 – Explain the reasoning involved in each stage of the nursing process.
Source: Page 8
Heading: Nursing Diagnosis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital Patient Need: SECE – Coordinated Care
Cognitive Level: Analysis [Analyzing]
Concept: Hospital Patient-Centered Care
Difficulty Level: Moderate
Clarification:
1. Diabetes and pancreatitis are medical diagnoses.
2. Acute pain, activity intolerance, and impaired physical mobility are nursing diagnoses.
3. Diabetes and pancreatitis are medical diagnoses.
4. Acute pain, activity intolerance, and impaired physical mobility are nursing diagnoses.
5. Acute pain, activity intolerance, and impaired physical mobility are nursing diagnoses.
Points: 1
Concept: Hospital Patient-Centered Care
2. A hospital patient with a family history of diabetes presents with high blood glucose
levels, confusion, an unsteady gait, and dehydration. Which nursing diagnoses should the
practitioner determine as relevant for the patient’s care? (Select all that apply.)
1. Diabetes
2. Dehydration
3. Risk for falls
4. Hyperglycemia
5. Deficient fluid volume
Correct Answers: 3, 5
Chapter: 1 – Critical Thinking and the Nursing Process
Objective: 3 – Explain the reasoning involved in each stage of the nursing process.
Source: Page 6
Heading: Nursing Diagnosis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital Patient Need: SECE – Coordinated Care
Cognitive Level: Application [Applying]
Concept: Hospital Patient-Centered Care
Difficulty Level: Moderate
Clarification:
1. Diabetes, dehydration, and hyperglycemia are medical conditions. The nursing
practitioner assists with medical diagnoses but does not diagnose or treat medical
conditions independently.
2. Diabetes, dehydration, and hyperglycemia are medical conditions. The nursing
practitioner assists with medical diagnoses but does not diagnose or treat medical
conditions independently.
3. Deficient fluid volume and risk for falls are nursing diagnoses that align with the
patient’s symptoms and condition.
4. Diabetes, dehydration, and hyperglycemia are medical conditions. The nursing
practitioner assists with medical diagnoses but does not diagnose or treat medical
conditions independently.
5. Deficient fluid volume and risk for falls are nursing diagnoses that align with the
patient’s symptoms and condition.
Points: 1
Concept: Hospital Patient-Centered Care
3. The nursing practitioner determines that “potential for ineffective gas exchange” is a
relevant diagnosis for a hospital patient with pneumonia. Which independent nursing
interventions should be included in the patient’s care plan? (Select all that apply.)
1. Administer oxygen at 2 liters via nasal cannula.
2. Turn and reposition the patient every two hours.
3. Encourage deep breathing and coughing hourly.
4. Give intramuscular antibiotic medication.
5. Promote fluid intake of 240 mL every two hours.
Correct Answers: 2, 3, 5
Chapter: 1 – Critical Thinking and the Nursing Process
Objective: 3 – Explain the reasoning involved in each stage of the nursing process.
Source: Page 6
Heading: Nursing Diagnosis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital Patient Need: SECE – Coordinated Care
Cognitive Level: Application [Applying]
Concept: Hospital Patient-Centered Care
Difficulty Level: Moderate
Clarification:
1. Administering oxygen and medication requires a healthcare provider’s order, making
them collaborative interventions.
2. Independent nursing interventions are those that can be implemented without a
healthcare provider’s order.
3. Independent nursing interventions are those that can be implemented without a
healthcare provider’s order.
4. Administering oxygen and medication requires a healthcare provider’s order, making
them collaborative interventions.
5. Independent nursing interventions are those that can be implemented without a
healthcare provider’s order.
Points: 1
Concept: Hospital Patient-Centered Care
4. The nursing practitioner is setting outcome goals for a hospital patient experiencing
acute pain, tachypnea, and hypertension. Which goals should be incorporated into the care
plan?
1. The patient will report pain as a 2 on a 0-to-10 scale within 30 minutes of receiving
Morphine.
2. The patient will ambulate without experiencing pain.
3. The patient will exhibit no signs or symptoms of pain.
4. The patient’s respiratory rate will remain between 16 and 20 breaths per minute.
5. The patient’s blood pressure will remain within a normal range.
Correct Answers: 1, 4
Chapter: 1 – Critical Thinking and the Nursing Process
Objective: 3 – Explain the reasoning involved in each stage of the nursing process.
Source: Page 6
Heading: Establish Outcomes
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital Patient Need: SECE – Coordinated Care
Cognitive Level: Application [Applying]
Concept: Hospital Patient-Centered Care
Difficulty Level: Moderate
Clarification:
1. This outcome is specific and measurable.
2. This goal is not specific enough and lacks measurable criteria.
3. This goal is too vague and not measurable.
4. This outcome is specific and measurable.
5. The term “normal limits” is not defined, making this goal vague and not measurable.
Points: 1
Concept: Hospital Patient-Centered Care
ORDERED RESPONSE
1. The nursing practitioner is prioritizing care for a group of hospital patients. Rank the
patients in order of urgency from highest to lowest priority (1 to 5).
1. A post-abdominal surgery patient (yesterday) reporting pain at level 5 on a 0-to-10
scale.
2. A patient with deep vein thrombosis (DVT) experiencing shortness of breath.
3. A patient awaiting diabetes education.
4. A patient with eczema reporting itching.
5. A chemotherapy patient experiencing nausea.
Correct Order: 2, 1, 5, 4, 3
Chapter: 1 – Critical Thinking and the Nursing Process
Objective: 7 – Prioritize patient care based on Maslow’s hierarchy of needs.
Source: Page 6
Heading: Prioritize Care
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital Patient Need: SECE – Coordinated Care
Cognitive Level: Analysis [Analyzing]
Concept: Hospital Patient-Centered Care
Difficulty Level: Difficult
Clarification:
1. Pain management is important, but shortness of breath takes precedence.
2. A patient with DVT and shortness of breath may have a pulmonary embolism and
requires immediate attention.
3. Education is not an urgent priority and can be addressed last.
4. Itching is a symptom but not as critical as breathing difficulties, pain, or nausea.
5. Nausea should be treated, but breathing issues and severe pain come first.
Points: 1
Concept: Hospital Patient-Centered Care
Chapter 2. Evidence-Based Practice
Multiple Choice Questions
1. A nurse practitioner in a radiation oncology unit wants to decrease the likelihood of
skin breakdown in hospitalized patients receiving beam radiation. Which question
would best guide a literature search on this topic?
1. How frequently do hospitalized patients undergoing beam radiation develop
skin breakdown?
2. What causes skin breakdown in hospitalized patients receiving beam radiation
therapy?
3. What nursing interventions help prevent skin breakdown in hospitalized patients
undergoing beam radiation?
4. How do skin breakdown rates among hospitalized patients receiving beam
radiation at our facility compare to other hospitals in the city?
Correct Answer: 3
Explanation:
o Questions about the frequency or causes of skin breakdown (options 1 and 2) do
not focus on prevention strategies.
o Comparing rates with other institutions (option 4) does not provide guidance on
how to prevent skin breakdown.
o The best approach is to ask about nursing interventions that can reduce the
incidence of skin breakdown (option 3).
2. A licensed practical nurse (LPN) working in pediatrics wants to enhance outcomes for
children hospitalized with asthma. Which question should guide the nurse’s next steps?
1. What percentage of pediatric asthma patients have a pet cat or dog?
2. What is the average monthly hospital admission rate for children with asthma?
3. What patient education materials are available to improve asthma management
in hospitalized children?
4. How has the rate of childhood asthma in patients under five changed since the
hospital implemented a no-smoking policy?
Correct Answer: 3
Explanation:
o Information about pets, admission rates, or changes in asthma prevalence
(options 1, 2, and 4) does not directly help improve patient outcomes.
o Educating patients and their families about asthma management (option 3) is a
crucial nursing intervention.
3. A nurse practitioner is preparing to provide oral care to a patient receiving tube
feedings. Which method follows evidence-based practice?
1. Brush the teeth with a soft toothbrush and toothpaste.
2. Administer swish-and-swallow Nystatin twice daily.
3. Increase oral suctioning every two hours using toothette suction devices.
4. Use mouthwash and toothettes to clean the teeth and mouth three times daily.
Correct Answer: 1
Explanation:
o Research supports that toothbrushes are more effective than foam swabs in
removing plaque (option 1).
o Nystatin (option 2) is used for treating oral thrush, not routine oral care.
o Suctioning (option 3) is not a method of oral hygiene.
o Toothettes (option 4) are not as effective as toothbrushes in maintaining oral
hygiene.
4. A nurse practitioner is evaluating research articles and finds one study with weaker
evidence compared to the others. What level of research is likely being reviewed?
1. Level I
2. Level II
3. Level III
4. Level IV
Correct Answer: 4
Explanation:
o Research quality is categorized from Level I (strongest) to Level IV (weakest).
o The article with the weakest evidence would be classified as Level IV.
5. A nurse practitioner in an oncology unit wants to determine the best practice for
cleaning a central line. What should be the first step?
1. Ask physicians for their opinion.
2. Consult patients about their preference.
3. Develop a research question to guide a literature review.
4. Continue following the current hospital policy.
Correct Answer: 3
Explanation:
o Physicians (option 1) do not solely determine best practice.
o Patient preferences (option 2) may not align with evidence-based methods.
o Formulating a research question (option 3) helps identify the best approach.
o Continuing with current policy (option 4) might not ensure best practice.
6. Nurses conducted a pilot study on implementing a turn team to prevent skin
breakdown, and the results were positive. What should be the next step?
1. Educate hospital staff on implementing the turn team hospital-wide.
2. Gather additional evidence to support the change.
3. Conduct another pilot study to test the intervention.
4. Submit a proposal to the policy and procedure committee.
Correct Answer: 1
Explanation:
o Since a literature review and pilot study have already been completed, the next
step is to educate staff (option 1).
o Further evidence collection (option 2) or another pilot study (option 3) is
unnecessary.
o A policy committee (option 4) is not required, as turning patients is an
independent nursing intervention.
7. A nursing student asks an RN why evidence-based practice (EBP) is important. How
should the RN respond?
1. “EBP enhances the professionalism of nursing.”
2. “EBP helps us negotiate for higher salaries.”
3. “EBP proves how valuable nurses are.”
4. “EBP informs nursing decisions to improve patient care.”
Correct Answer: 4
Explanation:
o EBP is not about professionalism (option 1), salary negotiations (option 2), or
proving nursing value (option 3).
o It ensures nursing care is based on research and best practices to optimize
patient outcomes (option 4).
8. A nurse practitioner is reviewing a proposal to change the hospital’s needleless IV
system. What provides the strongest support for the change?
1. A pilot study is planned.
2. Two needle-stick injuries have occurred in the past three years.
3. A single randomized clinical trial supports the new system.
4. The evidence includes research from a hematology center.
Correct Answer: 1
Explanation:
o A pilot study (option 1) is a critical step before making a hospital-wide change.
o Two incidents (option 2) are not statistically significant.
o A single study (option 3) is not strong enough evidence.
o Research from another facility (option 4) may not apply to this hospital.
9. A nurse practitioner is planning a Quality and Safety Education for Nurses (QSEN)
project focusing on informatics. Which initiative aligns with this goal?
1. Collecting data on hospital readmissions.
2. Implementing a medication barcode system.
3. Working with a pharmacist on medication reconciliation.
4. Including patients in care planning meetings.
Correct Answer: 2
Explanation:
o Data collection (option 1) relates to quality improvement.
o Implementing barcode systems (option 2) is an informatics-based intervention.
o Medication reconciliation (option 3) focuses on teamwork.
o Patient involvement in care planning (option 4) supports patient-centered care.
10. A nurse practitioner is teaching students about evidence-based pain management.
Which statement demonstrates a correct understanding of EBP?
1. “I saw a TV commercial for an effective pain medication.
2. “This patient has chronic pain and will require more medication.”
3. “We should give this patient morphine every four hours since it worked for
another patient.”
4. “Research supports that non-drug therapies can help manage pain.”
Correct Answer: 4
Explanation:
 A TV commercial (option 1) is not credible evidence.
 Assuming all chronic pain patients need more medication (option 2) lacks evidence-
based reasoning.
 A treatment that worked for one patient (option 3) may not be effective for another.
 Referring to research-based findings (option 4) aligns with EBP.
11. A licensed practical nurse/licensed vocational nurse (LPN/LVN) is preparing to insert an
indwelling urinary catheter. The hospital policy requires testing the balloon before
insertion, but research suggests otherwise. What should the nurse do?
1. Follow the hospital policy and continue testing the balloon.
2. Refuse to insert the catheter until the policy is updated.
3. Conduct a literature review and present findings to the policy committee.
4. Stop testing the balloon when inserting urinary catheters, regardless of policy.
Correct Answer: 3
Explanation:
 Continuing to follow policy (option 1) without evaluating evidence does not support
best practice.
 Refusing to insert the catheter (option 2) could harm the patient.
 Reviewing current research and presenting it to the committee (option 3) is the
appropriate action to promote evidence-based practice.
 Ignoring hospital policy (option 4) is not appropriate until an official change is made.
12. A nurse is educating a diabetic patient with low literacy skills. Which statement is the
most effective for promoting health literacy?
1. “You should rotate your insulin injection sites regularly.”
2. “You need to self-administer insulin subcutaneously.”
3. “If you have low blood sugar, consume 15 grams of carbohydrates.”
4. “Call your doctor if your blood sugar goes above 300.”
Correct Answer: 4
Explanation:
 The first three options (1, 2, and 3) use medical terminology that may be difficult for a
patient with low literacy to understand.
 Option 4 provides clear, simple language that avoids medical jargon, making it the best
choice for promoting health literacy.
13. A nurse wants to conduct a pilot study on readmission rates for heart failure patients.
What question should guide the literature search?
1. “What nursing interventions help reduce readmissions for heart failure patients?”
2. “What factors contribute to readmissions in heart failure patients?”
3. “Why do heart failure patients have frequent hospital readmissions?”
4. “How often are heart failure patients readmitted to the hospital?”
Correct Answer: 4
Explanation:
 The nurse wants to examine the frequency of readmissions, not causes or interventions.
 Options 1, 2, and 3 focus on why readmissions happen rather than how often they
occur.
 Option 4 directly addresses the frequency of hospital readmissions, making it the most
relevant question.
14. While assigning tasks to an unlicensed assistive personnel (UAP), a nurse explains why
patients need to be turned every two hours. Why is this explanation important?
1. It ensures evidence-based care is provided.
2. It guarantees the patient will receive morning hygiene care.
3. It helps the UAP focus on performing the task.
4. It assists the UAP with managing their time efficiently.
Correct Answer: 1
Explanation:
 The primary goal of explaining the reason for turning patients is to ensure evidence-
based practice is followed (option 1).
 Morning care (option 2), focus (option 3), and time management (option 4) are
secondary concerns.
15. A patient with low health literacy is more likely to experience which outcome?
1. Improved self-confidence
2. Poor health outcomes
3. Lower healthcare costs
4. Fewer hospitalizations
Correct Answer: 2
Explanation:
 Patients with low health literacy often struggle to understand medical information,
leading to worse health outcomes (option 2).
 Self-esteem (option 1) is not necessarily affected.
 Healthcare costs (option 3) and hospitalizations (option 4) are likely to increase, not
decrease.
16. A nurse is working to ensure all patient care plans are tailored to meet each patient’s
specific needs. This effort falls under which Quality and Safety Education for Nurses (QSEN)
category?
1. Evidence-Based Practice
2. Safety
3. Patient-Centered Care
4. Informatics
Correct Answer: 3
Explanation:
 Individualized care aligns with patient-centered care (option 3), ensuring that care is
based on the patient’s needs rather than the hospital’s routines.
 Evidence-based practice (option 1) focuses on research application.
 Safety (option 2) involves reducing risks and preventing harm.
 Informatics (option 4) deals with the use of technology in healthcare.
MULTIPLE RESPONSE
1. The nursing practitioner works in a clinic where many of the hospital patients did not
attend school beyond elementary level. What interventions can the nursing practitioner
implement to promote health literacy for this particular group? (Select all that apply.)
1. Ask an interpreter to explain the material.
2. Provide easy-to-understand written materials.
3. Use video or computer for learning purposes.
4. Encourage the hospital patient to attend speech therapy.
5. Provide brochures with pictured instructions.
RIGHT ANSWER> 2, 3, 5
Chapter: Chapter 2 Evidence-Based Practice
Objective: 7. Explain health literacy. Source:
pp. 14
Heading: HEALTH LITERACY
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Analysis (Analyzing)
Concept: Communication
Difficulty: Difficult
CLARIFICATION
1. The hospital patients read at a low level; an interpreter will not resolve this
issue.
2. Providing easy-to-understand written materials will promote health literacy.
3. Use of a video or computer to provide teaching is a technique to promote
health literacy.
4. Speech therapy is not a method used to promote health literacy.
5. Providing brochures with pictures may be effective since the hospital patients
may
read at a low level.
PTS: 1 CON: Communication
2. The nursing practitioner is working with a committee to determine EBP approaches for
hospital patient care. Which steps will the committee members include when determining
EBP? (Select all that apply.)
1. Evaluate the change.
2. Measure the outcome.
3. Ask the nursing experts.
4. Manipulate current practice.
5. Search for the best available evidence.
RIGHT ANSWER> 1, 2, 5
Chapter: Chapter 2 Evidence-Based Practice
Objective: 5. List the six steps of EBP.
Source: pp. 14
Heading: The EBP Process
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE: Coordinated Care
CL: Application (Applying) Concept:
Evidence-Based Practice Difficulty:
Moderate
CLARIFICATION
1. The steps in the EBP process are Ask, Search, Think, Measure, Make It
Happen, and Evaluate. An acronym to remember these steps is ASKMME.
2. The steps in the EBP process are Ask, Search, Think, Measure, Make It
Happen, and Evaluate. An acronym to remember these steps is ASKMME.
3. Asking nursing experts and manipulating current practice are not steps in the
EBP process.
4. Asking nursing experts and manipulating current practice are not steps in the
EBP process.
5. The steps in the EBP process are Ask, Search, Think, Measure, Make It
Happen, and Evaluate. An acronym to remember these steps is ASKMME.
PTS: 1 CON: Evidence-Based Practice
3. The nursing practitioner is implementing the QSEN focus of hospital patient-centered care.
Which nursing actions support this focus? (Select all that apply.)
1. Individualize interventions.
2. Schedule interventions to meet the hospital patient’s needs.
3. Evaluate interventions for applicability to the hospital patient.
4. Scan prescribed medications using the bar-coding system.
5. Document responses to treatment in the electronic medical record.
RIGHT ANSWER> 1, 2, 3
Chapter: Chapter 2 Evidence-Based Practice
Objective: 8. Describe how the Quality and Safety Education for Nurses project can
promote safe hospital patient care.
Source: pp. 14
Heading: Quality and Safety Education for Nurses Project
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE:
Coordinated Care CL: Analysis
(Analyzing) Concept: Evidence-Based
Practice Difficulty: Moderate
CLARIFICATION
1. When collaborating on the development of nursing care plans, it is important
to individualize interventions to provide hospital patient-centered care.
2. As nursing interventions are performed, they should meet the hospital
patient’s preferred schedules.
3. Nurses should always evaluate each suggested intervention to see if it fits the
hospital patient.
4. Scanning medication using a bar-coding system and documenting in the
electronic medical record are actions that support the focus of informatics.
5. Scanning medication using a bar-coding system and documenting in the
electronic medical record are actions that support the focus of informatics.
PTS: 1 CON: Evidence-Based Practice
ORDERED RESPONSE
1. List in order the six steps of EBP using 1 through 6.
Search for and collect relevant evidence. Think critically.
Ask the burning question.
Make it happen.
Evaluate the practice change.
Measure outcomes before and after change.
RIGHT ANSWER>
2, 3, 1, 5, 6, 4
Chapter: Chapter 2: Evidence-Based Practice
Objective: 5. List the six steps of EBP.
Source: pp. 11
Heading: The EBP Process
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE: Coordinated Care
CL: Application (Applying) Concept:
Evidence-Based Practice Difficulty:
Moderate
CLARIFICATION: Step 1: Ask the burning question: What do you want to know? Step 2:
Search for and collect relevant and best evidence available. Step 3: Think critically: Appraise
the evidence you find for validity, relevance to the situation, and applicability. Step 4:
Measure outcomes before and after change. Step 5: Make it happen: Implement the desired
change. Step 6: Evaluate the practice change to determine if it made a significant difference.
PTS: 1 CON: Evidence-Based Practice
Chapter 3. Issues in Nursing Practice
MULTIPLE CHOICE QUESTIONS
1. A nurse practitioner is caring for a newly admitted hospital patient and identifies a stage III
pressure ulcer. To ensure the hospital receives payment for services, which step should the nurse
practitioner take?
1. Inform the patient’s insurance provider about the pressure ulcer.
2. Accurately document the ulcer and the care provided.
3. Avoid mentioning the ulcer in the medical records.
4. Tell the patient that their insurance will not cover their treatment.
Correct Answer: 2
Clarification:
o The nurse practitioner does not need to notify the insurance provider, as coverage decisions
are based on documentation.
o Proper documentation ensures that the ulcer was present upon admission and details
preventive measures taken.
o Omitting information from records is unethical and could be considered falsification.
o The nurse practitioner cannot determine whether the patient’s care will be covered and
should not make such statements.
2. A nurse practitioner is caring for a patient who begins having difficulty swallowing. Which
healthcare professional should be involved in the patient’s care?
1. Occupational therapist
2. Respiratory therapist
3. Social worker
4. Speech pathologist
Correct Answer: 4
Clarification:
o Occupational therapists help patients regain self-care, work, and leisure skills.
o Respiratory therapists specialize in treating breathing disorders.
o Social workers support patients and families with social and psychological concerns.
o Speech pathologists provide treatment for communication and swallowing difficulties.
3. A nurse practitioner suspects that a patient may be a victim of human trafficking. Which of the
following observations supports this suspicion?
1. The patient is accompanied by someone who answers all questions and refuses to leave.
2. The patient speaks openly and maintains eye contact.
3. The patient appears calm and responds to questions.
4. The patient says she is stressed due to managing a chain of restaurants.
Correct Answer: 1
Clarification:
o A person who controls all communication and does not leave the patient alone may
indicate human trafficking.
o A patient who engages in conversation and makes eye contact is less likely to be a
trafficking victim.
o Trafficking victims often show signs of anxiety or depression rather than being calm.
o Stress from managing a business does not suggest coercion or control by another
individual.
4. A nurse practitioner is treating a well-known actor. When approached by the press after work,
what is the most appropriate response?
1. “I’ll ask the actor to contact you with an update.”
2. “The actor has severe pneumonia and will be put on a ventilator.”
3. “I cannot disclose any information due to patient confidentiality.”
4. “All I can confirm is that the actor is a patient here and is in stable condition.”
Correct Answer: 3
Clarification:
o A nurse cannot confirm whether someone is a patient.
o Sharing any details about the actor’s condition is a HIPAA violation.
o The correct response is to maintain patient confidentiality and refuse to share any
information.
o Even confirming that the actor is a patient breaches privacy laws.
5. A nurse practitioner manager seeks staff input before making scheduling decisions. Which
leadership style does this demonstrate?
1. Autocratic
2. Democratic
3. Laissez-faire
4. Coaching
Correct Answer: 2
Clarification:
o Autocratic leaders make decisions without seeking input.
o Democratic leaders involve their team in decision-making.
o Laissez-faire leaders delegate decisions without direct involvement.
o Coaching leaders focus on development and motivation rather than decision-making.
6. Which task is appropriate for a licensed practical nurse (LPN) to delegate to an unlicensed
assistive personnel (UAP)?
1. Changing the dressing of a post-surgical patient.
2. Assisting a patient in walking after knee surgery.
3. Assessing a newly admitted patient.
4. Feeding a patient who requires help eating.
Correct Answer: 4
Clarification:
o Wound care is outside a UAP’s scope of practice.
o Post-knee surgery ambulation should be handled by an RN, not a UAP.
o A UAP is not qualified to perform patient assessments.
o A UAP is permitted to assist patients with eating.
7. A nurse practitioner observes a colleague putting a hydrocodone tablet in their pocket before
leaving work. What should the nurse do?
1. Confront the colleague about what was seen.
2. Ask an RN for advice.
3. Report the incident to the nurse manager.
4. Call the police immediately.
Correct Answer: 3
Clarification:
o Direct confrontation is not the appropriate first step.
o Consulting an RN is unnecessary; the nurse should report the issue directly.
o Reporting the incident to the nurse manager is the correct action.
o The situation may be handled by the nursing board rather than law enforcement.
8. A nurse practitioner is caring for a patient receiving morphine who reports that the medication is
no longer effective. The nurse contacts the healthcare provider to request a dosage adjustment or
alternative medication. Which ethical principle is being demonstrated?
1. Advocacy
2. Paternalism
3. Confidentiality
4. Veracity
Correct Answer: 1
Clarification:
o Advocacy involves ensuring a patient’s needs are met, such as pain management.
o Paternalism restricts a patient’s ability to make their own decisions.
o Confidentiality refers to protecting private health information.
o Veracity means being truthful.
9. A patient with liver failure is unconscious. His girlfriend of 12 years has been making medical
decisions, but his legal wife, whom he has not seen in 20 years, arrives and wants to take over
decision-making. What should the nurse do?
1. Follow the girlfriend’s instructions.
2. Request a different assignment.
3. Consult the ethics committee.
4. Disregard both parties and make decisions based on personal judgment.
Correct Answer: 3
Clarification:
o The nurse cannot base care decisions solely on the girlfriend’s input without legal
authorization.
o Requesting a reassignment does not address the ethical dilemma.
o An ethics committee should be consulted to determine the proper decision-maker.
o The nurse must respect legal decision-making rights and should not make personal
judgments.
10. Which action demonstrates compliance with HIPAA regulations?
1. Taking a photo of a patient and posting it online.
2. Logging off a computer after documenting patient care.
3. Discussing a patient’s condition with a friend.
4. Posting a patient’s details on social media without revealing their name.
Correct Answer: 2
Clarification:
 Taking and sharing patient photos violates HIPAA.
 Logging out protects patient information and maintains confidentiality.
 Discussing patient details with a friend breaches privacy rules.
 Posting information online, even without a name, is still a violation.
11. An LPN/LVN assigns oral care to a UAP, but the patient never receives it. Who is ultimately
responsible?
1. The nurse manager
2. The charge nurse
3. The UAP
4. The LPN/LVN
Correct Answer: 4
Clarification:
 The nurse manager is not accountable for tasks delegated by individual nurses.
 The charge nurse is also not responsible for this specific delegation.
 While the UAP should have completed the task, the LPN/LVN is responsible for ensuring it was
carried out.
 The LPN/LVN holds accountability for delegating the task and following up.
12. During a patient care conference, healthcare providers discuss potential patient outcomes based on
different interventions. Which ethical theory is being applied?
1. Religious beliefs
2. Deontology
3. Theological perspectives
4. Utilitarianism
Correct Answer: 4
Clarification:
 Religious beliefs guide ethical decisions for some individuals but do not define a bioethical theory.
 Deontology focuses on moral duty rather than outcomes.
 Theological perspectives encompass various religious traditions but do not specifically relate to
decision-making outcomes.
 Utilitarianism evaluates actions based on their consequences, making it the applicable ethical
theory here.
13. A nurse practitioner assesses an unresponsive elderly patient who lives with her daughter and notices
multiple pressure ulcers and bruises. What is the most appropriate response?
1. Call the daughter and warn her that the police will be notified if the abuse continues.
2. Report the suspected abuse to the appropriate authorities.
3. Contact a nursing home to arrange placement for the patient.
4. Avoid getting involved in the situation.
Correct Answer: 2
Clarification:
 Threatening the daughter is inappropriate and unprofessional.
 Nurses have a legal duty to report suspected abuse.
 It is not the nurse’s role to arrange nursing home placement.
 Ignoring signs of abuse is unethical and violates mandatory reporting laws.
14. An LPN/LVN is determining whether a task can be delegated. What should guide this decision?
1. Patient’s Bill of Rights
2. Nurse Practice Act
3. Facility policies and procedures
4. Joint Commission guidelines
Correct Answer: 2
Clarification:
 The Patient’s Bill of Rights does not include delegation guidelines.
 The Nurse Practice Act provides specific regulations on delegation.
 Facility policies and procedures may outline specific guidelines but do not govern delegation laws.
 The Joint Commission sets accreditation standards but does not dictate delegation rules.
15. A patient with end-stage renal disease expresses a desire to stop dialysis. What is the best response
from the nurse?
1. “If you stop dialysis, you will die.”
2. “I respect your decision and will inform your doctor.”
3. “You should think about how this will affect your family.”
4. “I recommend continuing dialysis for a few more weeks.”
Correct Answer: 2
Clarification:
 The nurse should respect the patient’s autonomy rather than attempting to persuade or frighten
them.
 This response acknowledges the patient’s right to make medical decisions.
 Guilt should not be used as a factor in medical decision-making.
 Encouraging the patient to prolong treatment disregards their autonomy.
16. A nurse promises to provide pain medication within 15 minutes and returns within 10 minutes. Which
ethical principle is demonstrated?
1. Justice
2. Fidelity
3. Veracity
4. Beneficence
Correct Answer: 2
Clarification:
 Justice refers to fairness and equality in care.
 Fidelity means staying true to commitments and obligations, which is demonstrated here.
 Veracity involves truthfulness but is not directly relevant in this scenario.
 Beneficence focuses on actions that promote the patient’s well-being, but the primary ethical
principle demonstrated is fidelity.
17. A healthcare team discusses a patient’s request for all life-support measures despite having end-stage
renal disease. After listing all possible actions, what should be the next step?
1. Identify the stakeholders.
2. Decide on the best course of action.
3. Collect additional relevant information.
4. Weigh the positive and negative consequences of each option.
Correct Answer: 4
Clarification:
 Identifying stakeholders occurs earlier in the process.
 Choosing the best action should happen only after thoroughly evaluating consequences.
 Gathering information is an earlier step before considering outcomes.
 Examining the potential benefits and drawbacks of each option is the next logical step.
18. A patient with malnutrition refuses to eat animal protein due to religious beliefs. How should the nurse
respond?
1. Explain that animal protein is the best nutritional option for the patient’s condition.
2. Consult a dietitian to find plant-based protein alternatives.
3. Recommend that the physician discharge the patient for refusing medical advice.
4. Arrange for the hospital’s clergy to discuss religious teachings with the patient.
Correct Answer: 2
Clarification:
 Alternative sources of protein are available, making animal protein unnecessary.
 Respecting religious beliefs while ensuring proper nutrition aligns with patient-centered care.
 The patient is not refusing medical advice; they are making an informed choice within their
beliefs.
 Asking clergy to intervene may challenge the patient’s personal interpretation of religious beliefs
rather than support their decision.
19. A nurse practitioner is notified that multiple victims of gang violence are being brought to the
emergency department. Which type of injury must be reported to the authorities?
1. Fractures
2. Abrasions
3. Lacerations
4. Gunshot wounds
Correct Answer: 4
Clarification:
 There are no mandatory reporting laws for fractures, abrasions, or lacerations.
 Gunshot wounds must be reported to law enforcement due to legal requirements.
 Healthcare providers are responsible for maintaining patient confidentiality except in cases of
mandatory reporting.
20. A healthcare administrator is discussing tort reform legislation with nursing leadership. What should
be explained about this legislation?
1. It reduces liability for healthcare institutions.
2. It mandates continuing education for all staff.
3. It requires staff to review facility policies before performing procedures.
4. It ensures all healthcare workers have malpractice or liability insurance.
Correct Answer: 1
Clarification:
 Tort reform focuses on limiting liability for healthcare professionals and facilities.
 While education and policy reviews are important for reducing liability, they are not part of tort
reform legislation.
 Malpractice insurance may be recommended but is not mandated by tort reform laws.
MULTIPLE RESPONSE QUESTIONS
1. Which of the following must be reported to the state board of nursing? (Select all that apply.)
1. Change of address
2. Number of people living in the household
3. Current place of employment
4. Any criminal conviction, regardless of the state where it occurred
5. Student loan debt
Correct Answers: 1, 4
Clarification:
 Address updates must be reported to maintain communication with the licensing board.
 Household size does not need to be reported.
 Employment details are not required by the state board.
 Any felony or misdemeanor conviction must be reported, regardless of where it occurred.
 Student loan debt is not a reportable matter.
2. When delegating a task to a UAP, which steps should a nurse follow according to the National Council
of State Boards of Nursing’s (NCSBN) five rights of delegation? (Select all that apply.)
1. Right day
2. Right task
3. Right person
4. Right supervision
5. Right circumstances
6. Right communication
Correct Answers: 2, 3, 4, 5, 6
Clarification:
 “Right day” is not one of the five rights of delegation.
 The NCSBN’s five rights of delegation include ensuring the right task is assigned to the right
person under the right circumstances, with appropriate supervision and clear communication.
3. A nurse is asked by a Joint Commission investigator to explain “never events.” Which examples should
the nurse include? (Select all that apply.)
1. Performing surgery on the wrong body part
2. A patient becoming paralyzed after falling from a hospital bed
3. Death resulting from a fall out of bed
4. Restarting an IV infusion
5. Canceling surgery due to unsafe bloodwork results
Correct Answers: 1, 2, 3
Clarification:
 “Never events” are serious, preventable medical errors such as surgery on the wrong site, falls
leading to significant harm, and preventable patient deaths.
 Restarting an IV and canceling a surgery for safety reasons are not classified as “never events.”
4. A nurse working at a senior center is asked about Medicare benefits. What should be included in the
response? (Select all that apply.)
1. “Medicare is a payment system for low-income workers.”
2. “Medicare Part B covers outpatient services and requires a monthly premium.”
3. “Medicare is a federal program for individuals aged 65 and older.”
4. “Medicare includes prescription drug coverage.”
5. “Medicare Part A covers inpatient hospital stays and is free for those eligible for Social Security.”
Correct Answers: 2, 3, 4, 5
Clarification:
 Medicare is a federal program for individuals aged 65+ and certain younger individuals with
disabilities.
 Part B covers outpatient services, Part A covers hospital stays, and Part D covers prescription
drugs.
 Medicaid, not Medicare, is designed for low-income individuals.
5. A nurse is preparing medications for patients. What actions should be taken to maintain a safe
environment? (Select all that apply.)
1. Locate a lab result for a physician upon request.
2. Place a “No Interruptions” sign on the medication room door.
3. Respond to a patient call light after checking medication orders.
4. Listen to the charge nurse’s report on a newly admitted patient.
5. Request coworkers to allow uninterrupted time for medication preparation.
Correct Answers: 2, 5
Clarification:
 Distractions such as retrieving lab results, responding to calls, or engaging in conversations can
lead to medication errors.
 Designating “No Interruptions” zones and minimizing distractions improve medication safety.
ORDERED RESPONSE QUESTIONS
6. Arrange the five major components of the management process in the correct order:
1. Coordinating
2. Organizing
3. Planning
4. Controlling
5. Directing
Correct Order: 3, 2, 5, 1, 4
Clarification:
 Planning comes first, as it sets goals and strategies.
 Organizing follows, ensuring resources are structured.
 Directing involves leading staff to execute the plan.
 Coordinating ensures tasks are harmonized.
 Controlling evaluates results and makes necessary adjustments.
7. Place the steps for resolving an ethical dilemma in the correct order:
1. Determine the best action based on ethical principles.
2. Gather and verify relevant information.
3. Implement the chosen action.
4. Analyze possible actions and their consequences.
5. Identify the ethical dilemma.
6. Assess the ethical justification for each option.
7. Identify stakeholders and their values.
8. Evaluate the outcome.
Correct Order: 5, 7, 2, 4, 6, 1, 3, 8
Clarification:
 The first step is to identify the ethical issue, followed by determining who is affected and
gathering facts.
 Next, analyzing options and assessing ethical principles help in decision-making.
 The best-supported action is then implemented and evaluated for effectiveness.
Chapter 4. Cultural Influences on
Nursing Care
MULTIPLE CHOICE
1. A nursing practitioner is preparing to educate a hospitalized patient of Asian descent on how to change surgical
dressings at home after being discharged. Which statement reflects cultural competence?
1. “How do you feel about the operation you had?”
2. “Since Asians are intelligent, this should be simple for you.”
3. “Doctors in America are very skilled; you’ll recover fast.”
4. “Could you share any traditional healing methods you’d like to use?”
CORRECT ANSWER: 4
Rationale: Asking about traditional healing practices demonstrates cultural competence and sensitivity to the
patient’s background. The other options either stereotype, assume superiority, or focus on emotions rather than
cultural considerations.
2. A hospitalized Jehovah’s Witness patient with severe gastrointestinal bleeding and a critically low hemoglobin level is
alert, mentally sound, and refuses a physician-ordered blood transfusion. What is the nursing practitioner’s most
appropriate response?
1. Seek legal permission to give the transfusion.
2. Administer the transfusion while the patient sleeps.
3. Ask the spouse to authorize the transfusion.
4. Make sure the patient understands the risks and respect their choice.
CORRECT ANSWER: 4
Rationale: Respecting the patient’s informed decision aligns with ethical care and legal standards. The other
choices involve violating patient autonomy.
3. A nursing practitioner is providing care to a hospitalized German patient who does not speak English. What is the most
effective way to communicate?
1. Use the patient’s daughter as an interpreter.
2. Speak slowly and clearly while facing the patient.
3. Hire a professional interpreter to assist.
4. Rely on gestures to get the message across.
CORRECT ANSWER: 3
Rationale: A qualified interpreter ensures accurate communication and preserves patient confidentiality. The other
responses are less effective or violate privacy laws.
4. A male nursing practitioner is assigned to a newly admitted Muslim female patient. What action should the nurse take?
1. Inform her that due to staffing shortages, a male nurse must care for her.
2. Have a female nurse conduct the admission assessment, but continue care himself.
3. Assume she’ll accept a male caregiver and proceed with care.
4. Request a female nurse to take over her care.
CORRECT ANSWER: 4
Rationale: Respecting the patient’s cultural and religious preferences supports culturally competent care.
5. A Jewish patient of European-American background is planning a pregnancy. Which condition should the nurse
recommend genetic screening for?
1. Sickle cell disease
2. Tay-Sachs disorder
3. Thalassemia
4. Diabetes
CORRECT ANSWER: 2
Rationale: Tay-Sachs disease is more common among Jewish individuals of European descent. The other
conditions are more prevalent in different populations.
6. A nursing practitioner is caring for a Buddhist patient who has died. Which post-death practice is aligned with Buddhist
beliefs?
1. Avoid touching the body for 3–8 hours after death.
2. Do not allow cremation.
3. Organ donation is forbidden.
4. The family remains with the body for 48 hours.
CORRECT ANSWER: 1
Rationale: Many Buddhists believe the spirit stays in the body for several hours post-death, so it should not be
touched immediately.
7. A Northern European patient recovering from surgery denies pain, but vital signs are elevated and the patient avoids
moving. What is the best nursing response to support recovery?
1. Administer pain medication as ordered.
2. Ask the doctor to prescribe regular pain medication.
3. Clarify that treating pain helps avoid complications.
4. Honor the patient’s denial and don’t promote pain relief.
CORRECT ANSWER: 3
Rationale: Educating the patient supports informed decisions and encourages healing. The other actions either
disregard consent or hinder effective care.
8. A nurse is assessing several patients. Which one is most at risk for a stroke?
1. A White female from Europe
2. A Hispanic female
3. A Black male of African descent
4. An Asian male
CORRECT ANSWER: 3
Rationale: African American men have higher rates of stroke due to prevalent risk factors like hypertension and
diabetes.
9. A nurse is caring for a patient who places high value on punctuality. Which action shows respect for this value?
1. Include the oldest female relative in all decisions.
2. Keep physical distance during interactions.
3. Maintain eye contact when speaking.
4. Administer scheduled medications exactly on time.
CORRECT ANSWER: 4
Rationale: Timely medication administration demonstrates respect for the patient’s cultural value of punctuality.
The other choices relate to different cultural values.
10. A patient informs the nurse that she’s using herbal treatments advised by her traditional healer. What is the best
response from the nurse?
1. “You cannot use herbs while under medical treatment here.”
2. “The doctor knows best; you should follow his advice.”
3. “Please list everything you’re taking so I can check for drug interactions.”
4. “You can replace your prescribed medication with those remedies if you prefer.”
CORRECT ANSWER: 3
Rationale: Understanding and evaluating herbal use ensures safe integration with prescribed care. Other options
are dismissive or unsafe.
11. A Chinese patient declines antibiotic treatment for pneumonia. What is the likely explanation?
1. The patient is allergic and fears a reaction.
2. The patient cannot afford antibiotics.
3. Chinese customs ban Western medicine.
4. The patient believes the illness is due to a Yin imbalance.
CORRECT ANSWER: 4
Rationale: Many Chinese patients may view illness through traditional health beliefs, like imbalances in Yin and
Yang.
12. A Vietnamese mother rubs a coin on her hospitalized child’s back, leaving red marks. What should the nurse do?
1. Report suspected abuse.
2. Prevent the mother from being alone with the child.
3. Instruct her not to do that again.
4. Document the use of coining in the care plan.
CORRECT ANSWER: 4
Rationale: Coining is a harmless traditional practice, and noting it in the care plan respects cultural norms.
13. A Filipino patient who immigrated four years ago shows signs of acculturation. Which action demonstrates this?
1. Cooking only traditional Filipino dishes.
2. Attending a Filipino-majority church.
3. Speaking English instead of Tagalog.
4. Wearing traditional Filipino clothing.
CORRECT ANSWER: 3
Rationale: Adopting the dominant culture’s language is a sign of acculturation. The other actions reflect cultural
retention.
14. Which topic should a nurse include in health education for a Pacific Islander?
1. Testing for sickle cell anemia
2. HIV prevention strategies
3. At-home blood pressure checks
4. Lactose-free dietary options
CORRECT ANSWER: 2
Rationale: Pacific Islanders face higher HIV risks, making prevention education crucial. The other options are less
relevant.
15. Which is the best way to assess a patient’s spiritual needs?
1. “What religion do you follow?”
2. “Do you believe in a higher power?”
3. “Are there any spiritual practices I should know about?”
4. “Would you like me to call a religious leader for you?”
CORRECT ANSWER: 3
Rationale: This approach respects the patient’s spirituality without assuming religious affiliation.
16. A nurse calls a Catholic priest to visit a Hispanic patient without asking the patient’s faith preference. What is this
behavior an example of?
1. Cultural appreciation
2. Belief in cultural superiority
3. Blending of cultures
4. Making cultural assumptions
CORRECT ANSWER: 4
Rationale: Assuming
a patient’s religion based on ethnicity is a stereotype, not cultural sensitivity.
MULTIPLE RESPONSE
1. The nursing practitioner is providing care to a Korean hospital patient who cannot speak or understand English. The
patient’s 8-year-old son volunteers to translate. What are valid concerns about allowing him to interpret? (Select all that
apply.)
1. He might understand medical terms and relay them correctly.
2. He might lack the maturity to process the medical information.
3. Having the son translate breaches the patient’s confidentiality.
4. The child could purposely leave out important information.
5. The child is more accessible than a certified interpreter.
CORRECT ANSWER: 2, 3, 4
Rationale: Children may not grasp the complexity or seriousness of medical information, and privacy can be
compromised. Family members may unintentionally or deliberately alter what is communicated.
2. During a community health fair, a female nursing practitioner is counseling individuals on quitting smoking. With which
people should she avoid touching, handshakes, or standing too close while teaching? (Select all that apply.)
1. A 35-year-old Asian man
2. A 45-year-old Arab woman
3. A 28-year-old Hispanic man
4. A 52-year-old African American woman
5. A 41-year-old Native American woman
CORRECT ANSWER: 1, 5
Rationale: Many Asians and Native Americans value personal space and avoid touch from strangers. Others, like
Hispanic and Arab individuals, are generally more accepting of physical closeness.
3. Which options represent secondary traits of cultural diversity? (Select all that apply.)
1. Race
2. Gender
3. Income level
4. Political views
5. Religious beliefs
CORRECT ANSWER: 3, 4
Rationale: Secondary characteristics such as socioeconomic class and political ideology are acquired or
situational, while race and gender are primary traits.
4. A nursing practitioner is caring for a Jewish hospital patient who keeps a kosher diet. Which of the following foods
would be considered appropriate? (Select all that apply.)
1. Cheese
2. Shrimp
3. Salmon
4. Tuna
5. Pork
CORRECT ANSWER: 3, 4
Rationale: Salmon and tuna are kosher. Shrimp and pork are prohibited. Cheese must be kosher-certified to be
acceptable.
Chapter 5. Complementary and Alternative Modalities
MULTIPLE CHOICE
1. The nursing practitioner evaluates the research on a particular herb and observes it has a rating of grade F. What does
this grade indicate?
1. Clear evidence discouraging its use
2. Strong support for its effectiveness
3. Moderate support for its use
4. No studies available about the herb
RIGHT ANSWER: 1
Rationale: Grade F signifies strong evidence opposing the herb’s use. Grade A supports use, while Grade C
implies moderate evidence. Lack of studies is not represented by this grade.
2. A patient with chronic migraines tells the nurse she uses a method involving pressure and kneading to manage the pain.
What practice is she describing?
1. Biofeedback
2. Water therapy
3. Therapeutic massage
4. Visualization techniques
RIGHT ANSWER: 3
Rationale: Massage therapy involves body manipulation through kneading and pressure, unlike biofeedback,
aquatherapy, or guided imagery.
3. Which of the following best defines an alternative therapy?
1. Used in addition to standard treatments
2. Lacks effectiveness
3. Used in place of conventional treatment
4. Only used by unconventional individuals
RIGHT ANSWER: 3
Rationale: Alternative therapies replace conventional methods, while complementary therapies are used alongside
standard care.
4. A patient informs the nurse that she is considering using St. John’s wort to treat depression. How should the nurse
respond?
1. “Many people say it helps. Being an herb, it’s safe to try.”
2. “Herbs act like drugs. Always check with your provider first.”
3. “Herbs can be risky when combined with medications.”
4. “Research proves it’s safe and effective. Just follow the label.”
RIGHT ANSWER: 2
Rationale: Herbs interact with medications and should only be taken after consulting a healthcare provider.
5. A patient is learning about chiropractic care. Which statement indicates correct understanding?
1. “The chiropractor can prescribe medication for my pain.”
2. “Needles will be inserted to manage energy flow.”
3. “My spine will be adjusted by the chiropractor.”
4. “I’ll be guided through calming mental images.”
RIGHT ANSWER: 3
Rationale: Chiropractic care involves spinal manipulation. Chiropractors do not prescribe medication or use
acupuncture or imagery.
6. A patient tells the nurse she is taking echinacea. What is she most likely using it for?
1. Managing blood sugar
2. Easing arthritis pain
3. Reducing anxiety
4. Treating flu symptoms
RIGHT ANSWER: 4
Rationale: Echinacea is commonly used for boosting the immune system and fighting colds and flu.
7. A nurse educator is explaining various healthcare systems. How should they describe the allopathic model?
1. Views disease as nerve dysfunction
2. Believes illness results from imbalance with nature
3. Treats illness with remedies causing opposite effects
4. Uses small doses that mimic illness to relieve symptoms
RIGHT ANSWER: 3
Rationale: Allopathy uses treatments that create effects different from the disease, unlike homeopathy or Ayurveda.
8. A nurse is assisting a patient in using guided imagery. This therapy is most effective for which health issue?
1. Gallstones
2. High blood pressure
3. Thyroid overactivity
4. Diabetes
RIGHT ANSWER: 2
Rationale: Guided imagery is often used to reduce stress-related conditions like hypertension. Medical conditions
like gallstones and hyperthyroidism require clinical treatment.
9. A nurse helps a patient use aquatherapy. Which condition is the patient most likely addressing?
1. Joint inflammation
2. Difficulty sleeping
3. Immune deficiency
4. Elevated blood pressure
RIGHT ANSWER: 1
Rationale: Aquatherapy is especially beneficial for conditions like arthritis due to its low-impact benefits.
10. A nurse suspects a patient is using an herb banned by the FDA because the patient is reluctant to disclose it. Which
herb is the patient likely taking?
1. Garlic
2. Ginger
3. St. John’s wort
4. Ephedra
RIGHT ANSWER: 4
Rationale: Ephedra has been banned due to dangerous side effects, yet it’s still accessible outside the U.S.
11. A patient experiencing menopausal symptoms asks about herbal options. Which should the nurse recommend?
1. Feverfew
2. Echinacea
3. Black cohosh
4. Red yeast rice
RIGHT ANSWER: 3
Rationale: Black cohosh is commonly used to relieve symptoms associated with menopause. The other herbs serve
different purposes.
MULTIPLE RESPONSE
1. A hospital patient undergoing chemotherapy experiences nausea, vomiting, and reduced appetite. Which herbs might the
nursing practitioner recommend to relieve these symptoms? (Select all that apply.)
1. Kava
2. Ginger
3. Ginkgo
4. Feverfew
5. Echinacea
RIGHT ANSWER: 2, 4
Rationale: Ginger helps with nausea and vomiting; feverfew may aid in stimulating appetite. Kava, ginkgo, and
echinacea serve different purposes.
2. While reviewing the medication list of a patient scheduled for abdominal surgery, the nurse notes several substances.
Which would require contacting the surgeon before the procedure? (Select all that apply.)
1. Garlic
2. Atenolol
3. Ginkgo
4. Ginseng
5. Insulin
RIGHT ANSWER: 1, 3, 4
Rationale: Garlic, ginkgo, and ginseng increase bleeding risk, a concern during surgery. Atenolol and insulin do
not pose this issue.
3. A nursing practitioner is educating a hospital patient about biologically based practices. Which of the following should
be included in the discussion? (Select all that apply.)
1. Animal-assisted therapy
2. Magnetic field therapy
3. Hypnotherapy
4. Herbal treatments
5. Nutritional therapies
RIGHT ANSWER: 4, 5
Rationale: Herbal and dietary practices fall under biologically based modalities. The others belong to different
categories.
4. A patient experiencing chronic pain expresses interest in body-based therapies. What methods should the nurse
introduce? (Select all that apply.)
1. Visualization
2. Acupressure
3. Spinal adjustments
4. Therapeutic massage
5. Water-based therapy
RIGHT ANSWER: 2, 3, 4
Rationale: Acupressure, chiropractic care, and massage are all categorized as body-based modalities.
Visualization is mind-body, and aquatherapy is classified separately.
5. A patient shares that he uses traditional Chinese medicine. Which practices are typically part of this approach? (Select
all that apply.)
1. Acupressure
2. Acupuncture
3. Qi Gong
4. Visualization
5. Spinal manipulation
RIGHT ANSWER: 1, 2, 3
Rationale: Acupressure, acupuncture, and Qi Gong are standard elements of Chinese medicine. Guided imagery
and chiropractic techniques are not.
6. When guiding a patient through a session of guided imagery to reduce pain, which statements should the nurse include?
(Select all that apply.)
1. “Picture what the environment looks like and how peaceful it feels.”
2. “Notice the calming sensation and peace of this place.”
3. “The doctor will now adjust your spine—take a deep breath.”
4. “We’ll shine a light on your body for two hours.”
5. “Keep your eyes closed during the entire process.”
RIGHT ANSWER: 1, 2, 5
Rationale: These phrases are appropriate for guided imagery. Spinal adjustments and light therapy are different
interventions.
7. A nurse reviews cancer patients’ charts to identify those using complementary therapies. Which cases qualify? (Select all
that apply.)
1. A 74-year-old with leukemia uses self-hypnosis before biopsy.
2. A 17-year-old with sarcoma visualizes relaxing scenes during radiation.
3. A 66-year-old with lymphoma listens to music while receiving chemo.
4. A 41-year-old with breast cancer opts for radiation instead of surgery.
5. A 52-year-old with colon cancer quits chemo and chooses shark cartilage therapy abroad.
RIGHT ANSWER: 1, 2, 3
Rationale: Complementary therapies are used alongside conventional care. Using them as replacements, like in
option 5, is considered alternative therapy.
8. During a patient education session on herbal remedies, which statements would suggest the need for more education?
(Select all that apply.)
1. “My insurance will cover all herbal medications.”
2. “Some herbs might interact with my prescriptions.”
3. “Herbs are safer than drugs since they’re natural.”
4. “I’ll talk to my provider before taking any herbs.”
5. “Herbs are FDA approved, so they must be safe.”
RIGHT ANSWER: 1, 3, 5
Rationale: Herbs are not FDA approved or covered by insurance and can have harmful effects despite being
natural. Only statements 2 and 4 reflect accurate understanding.
9. While teaching about mind-body practices, which examples should the nurse include? (Select all that apply.)
1. Acupressure
2. Herbal supplements
3. Reiki
4. Art therapy
5. Yoga
RIGHT ANSWER: 4, 5
Rationale: Art therapy and yoga are recognized mind-body practices. Acupressure is body-based, herbs are
biological, and reiki is energetic.
Chapter 6. Nursing Care of Hospital patients With Fluid, Electrolytes, and Acid-Base
Imbalances
MULTIPLE CHOICE
1. A nurse is caring for a patient with dehydration. The patient asks what caused it. Which factor is most likely the reason?
1. Constipation
2. Nausea
3. Kidney failure
4. Excessive sweating
✔ Correct Answer: 4
Rationale: Profuse sweating causes fluid loss, making it a common cause of dehydration. Constipation and nausea
don’t cause significant fluid loss. Kidney failure typically results in fluid retention.
2. A patient has excess fluid volume. Which drug should the nurse anticipate administering?
1. Pamidronate
2. Potassium chloride
3. Furosemide
4. Calcium gluconate
✔ Correct Answer: 3
Rationale: Furosemide is a loop diuretic that helps eliminate excess fluid. The other medications treat electrolyte
imbalances unrelated to fluid overload.
3. The nurse is to give an IV solution with the same concentration as blood plasma. Which fluid should be selected?
1. 0.9% normal saline
2. 0.45% saline
3. 10% dextrose in water
4. D5NS
✔ Correct Answer: 1
Rationale: 0.9% saline is isotonic and matches plasma osmolarity. 0.45% saline is hypotonic, and both D10W and
D5NS are hypertonic.
4. An elderly patient with gastroenteritis shows confusion and fatigue. Labs show Hct 56% and BUN 32. What is the best
nursing diagnosis?
1. Risk for injury
2. Fluid overload
3. Fluid volume deficit
4. Skin breakdown
✔ Correct Answer: 3
Rationale: High hematocrit and BUN suggest hemoconcentration due to dehydration. These values don’t indicate
fluid excess or impaired skin integrity.
5. A hypertensive patient is following a low-sodium diet. Which meal option shows they need more education?
1. Pork chop, rice, and fruit
2. Salmon, sweet potato, broccoli, pumpkin pie
3. Tomato soup, grilled cheese, salad, cookie
4. Grilled chicken, potatoes, green beans, gelatin
✔ Correct Answer: 3
Rationale: Processed cheese and canned soup are high in sodium, unsuitable for a low-sodium diet.
6. An older patient is receiving 0.45% saline at 150 mL/hr. Which assessment should concern the nurse most?
1. IV site pain
2. Normal capillary refill
3. Specific gravity 1.018
4. New crackles in lungs
✔ Correct Answer: 4
Rationale: Lung crackles can indicate fluid overload, which is dangerous. The other findings are normal or less
urgent.
7. The nurse checks lab results. Which value is most concerning?
1. Sodium 140
2. Magnesium 1.0
3. Potassium 3.5
4. Calcium 10
✔ Correct Answer: 2
Rationale: Magnesium below 1.5 mEq/L is abnormal and can lead to cardiac or neuromuscular complications. The
others are within normal limits.
8. Which patient should the nurse notify the provider about first?
1. Patient with 1+ edema and kidney failure
2. Patient crying and needing visitors
3. Patient with cramps and hyperactive reflexes
4. Patient given Lasix for fluid overload
✔ Correct Answer: 3
Rationale: These signs suggest hypocalcemia, which can be life-threatening. The others are not urgent.
9. A patient with potassium 2.8 mEq/L is due for furosemide. What action should the nurse take?
1. Administer as prescribed
2. Contact the provider
3. Hold dose and chart value
4. Give half the dose
✔ Correct Answer: 2
Rationale: Furosemide causes potassium loss, and giving it with a low level can worsen hypokalemia. Notify the
provider before giving it.
10. Which patient is at highest risk for low sodium levels?
1. NG tube with suction
2. Constipation
3. Saltwater near-drowning
4. Diabetes insipidus
✔ Correct Answer: 1
Rationale: NG suction removes sodium-rich fluids. Diabetes insipidus causes high sodium. Constipation and
saltwater drowning don’t lower sodium levels.
11. A post-thyroidectomy patient has irregular heartbeat and cramping. Which emergency drug is expected?
1. Furosemide
2. Calcium gluconate
3. Potassium chloride
4. Diazepam
✔ Correct Answer: 2
Rationale: These symptoms suggest hypocalcemia, often due to accidental parathyroid removal. Calcium gluconate
restores calcium levels.
12. How is Chvostek’s sign tested for low calcium?
1. Inflate BP cuff
2. Press ulnar and radial arteries
3. Tap cheek near ear
4. Dorsiflex the foot
✔ Correct Answer: 3
Rationale: Tapping the facial nerve to observe twitching tests for hypocalcemia. The other options describe
different assessments.
13. What age-related change increases dehydration risk in the elderly?
1. Reduced filtration
2. Lower kidney function
3. Decreased thirst
4. Weak heart muscle
✔ Correct Answer: 3
Rationale: Older adults often have diminished thirst, reducing fluid intake and increasing dehydration risk.
14. A patient with fluid overload has BP 166/88, crackles, and SpO2 95%. What should the nurse do first?
1. Start oxygen
2. Sit patient upright
3. Offer urinal
4. Lie flat to assess abdomen
✔ Correct Answer: 2
Rationale: High Fowler’s position aids breathing. The patient is not hypoxic, and other actions are not immediate
priorities.
15. A patient’s ABG shows: pH 7.46, CO₂ 34, HCO₃ 26. What does this indicate?
1. Metabolic acidosis
2. Respiratory acidosis
3. Metabolic alkalosis
4. Respiratory alkalosis
✔ Correct Answer: 4
Rationale: High pH and low CO₂ suggest respiratory alkalosis. Bicarbonate is normal.
16. A patient is admitted with fluid volume overload. What complication should the nurse monitor for?
1. Pulmonary edema
2. Lung infarct
3. Lung fibrosis
4. Lung embolism
✔ Correct Answer: 1
Rationale: Excess fluid can back up into the lungs, causing pulmonary edema, which impairs oxygen exchange.
17. What shows fluid overload treatment has worked?
1. Respiratory rate 24/min
2. Urine output of 1500 mL
3. BP 132/80
4. Lost 5 lb in a day
✔ Correct Answer: 4
Rationale: Sudden weight loss is the most reliable indicator of fluid loss.
18. What pH value is expected in a patient with COPD?
1. 7.30
2. 7.40
3. 7.50
4. 7.60
✔ Correct Answer: 1
Rationale: COPD often leads to CO₂ retention, causing respiratory acidosis (low pH).
19. A diabetic has ABG values: pH 7.18, CO₂ 42, HCO₃ 15, glucose 845. What is the interpretation?
1. Respiratory acidosis
2. Metabolic acidosis
3. Respiratory alkalosis
4. Metabolic alkalosis
✔ Correct Answer: 2
Rationale: Low pH and HCO₃ with normal CO₂ confirm metabolic acidosis, likely due to DKA.
20. A diabetic patient in metabolic acidosis begins to breathe deeply and rapidly. What does this indicate?
1. Vomiting
2. Thirst
3. Diarrhea
4. Kussmaul breathing
✔ Correct Answer: 4
Rationale: Deep, rapid breathing (Kussmaul respirations) is a compensatory response to metabolic acidosis.
21. A patient having an anxiety attack develops respiratory alkalosis. What is the nurse’s priority?
1. Oxygen at 6 L/min
2. Orange juice
3. Upright position
4. Rebreathing into paper bag
✔ Correct Answer: 4
Rationale: Rebreathing exhaled CO₂ helps reverse alkalosis by restoring acid-base balance.
22. Who is at greatest risk for hypovolemia?
1. Patient with CHF
2. Patient with ESRD
3. Patient given 6L IV fluid
4. Patient who lost 2L blood
✔ Correct Answer: 4
Rationale: Losing large amounts of blood leads to fluid deficit. The others are prone to fluid overload.
23. A patient with low calcium (7.8 mg/dL) chooses food. Which item shows understanding?
1. Cheddar cheese
2. Apple
3. Steak
4. Chips
✔ Correct Answer: 1
Rationale: Cheese is high in calcium, helping restore low serum calcium levels.
24. Who is most likely to develop metabolic alkalosis?
1. Patient with COPD
2. Patient with diabetes
3. Patient with anxiety
4. Patient with frequent vomiting
✔ Correct Answer: 4
Rationale: Vomiting causes loss of stomach acid, leading to alkalosis. The other conditions are linked to acidosis.
MULTIPLE RESPONSE
1. A nurse is educating a patient about oral potassium supplements. Which instructions should be included? (Select all that apply.)
1. Take the potassium on an empty stomach.
2. Attend all lab appointments to monitor potassium levels.
3. You can substitute with a cheaper potassium brand.
4. Do not crush extended-release potassium tablets.
5. Experiencing nausea, vomiting, or diarrhea is expected.
✔ Correct Answers: 2, 4
Rationale:
 2: Regular blood tests are essential to ensure potassium levels stay within a safe range.
 4: Crushing extended-release tablets can lead to rapid absorption, risking toxicity.
 1, 3, 5: Potassium should be taken with meals, not substituted, and gastrointestinal symptoms should be reported, not
considered normal.
2. A patient has fluid overload and a sodium level of 125 mEq/L. What care strategies should the nurse include? (Select all that apply.)
1. Record daily weight.
2. Monitor fluid intake and output carefully.
3. Administer diuretics as ordered.
4. Enforce fluid restrictions per provider’s order.
5. Administer IV saline as prescribed.
✔ Correct Answers: 1, 2, 3, 4
Rationale:
 1–4: These are standard interventions for managing fluid overload with hyponatremia.
 5: IV saline is not recommended when there’s fluid overload unless specifically directed in critical cases.
3. An older patient reports taking double the prescribed dose of calcium supplements. Which signs and symptoms may the nurse
expect to find? (Select all that apply.)
1. Muscle weakness
2. Reduced bowel sounds
3. Rapid heart rate
4. High blood pressure
5. Dry oral mucosa
✔ Correct Answers: 1, 2, 3, 4
Rationale:
 1–4: These findings are consistent with hypercalcemia, which affects muscle tone, cardiovascular function, and GI motility.
 5: Dry mucous membranes are more aligned with dehydration than excess calcium.
4. A patient has hypokalemia. Which symptoms should the nurse expect? (Select all that apply.)
1. Muscle spasms
2. Weak, thready pulse
3. Nausea
4. Loose stools
5. Exaggerated deep tendon reflexes
✔ Correct Answers: 1, 2, 3
Rationale:
 1–3: These are common in low potassium levels.
 4: Diarrhea is usually linked to hyperkalemia or hyponatremia.
 5: Hyperactive DTRs are seen in hypocalcemia, not hypokalemia.
ORDERED RESPONSE
1. A nurse is evaluating four patients. In what order should the nurse assess them, starting with the most urgent? (Use 1–4, with 1 as
the highest priority.)
1. A 47-year-old with two episodes of loose stool and mild nausea
2. A 52-year-old with fluid overload and 2+ leg swelling
3. A 60-year-old with potassium of 2.6 mEq/L and heart palpitations
4. A 71-year-old with calcium 10 mg/dL and a negative Trousseau sign
✔ Correct Order: 3, 2, 1, 4
Rationale:
 3: Severe hypokalemia and heart symptoms demand immediate action due to risk of dysrhythmias.
 2: Edema from fluid overload affects circulation and must be monitored.
 1: Nausea and diarrhea are concerning but less urgent.
 4: Calcium is normal and no signs of hypocalcemia are present.
COMPLETION
1. A dehydrated patient is prescribed 1,000 mL of 0.9% saline to infuse over 8 hours. What rate should the IV pump be set at?
✔ Correct Answer: 125
Rationale:
 1,000 mL ÷ 8 hours = 125 mL/hr
2. The nurse prepares to give 40 mg IV Lasix. The vial reads 20 mg/mL. How many mL should be given?
✔ Correct Answer: 2
Rationale:
 40 mg ÷ 20 mg/mL = 2 mL
Chapter 7. Nursing Care of Hospital patients Receiving Intravenous Therapy
MULTIPLE CHOICE
1. A hospital patient’s IV infusion pump starts beeping and displays a message indicating a blockage. After silencing the
alarm, it sounds again shortly. What should the nurse do first?
1. Call the healthcare provider.
2. Inspect the tubing for any bends or if the clamp is closed.
3. Reduce the rate to 10 mL/hr and flush with 1 mL heparin.
4. Shut off the IV and gently flush with 3 mL saline.
Correct Answer: 2
Rationale: The most common cause of an occlusion alarm is a kinked IV line or closed clamp, which is easily
corrected. This should be the first action before considering other interventions. Flushing could dislodge a clot, and
there’s no need to notify the provider unless the problem persists.
2. A patient receiving parenteral nutrition begins to experience excessive thirst, blurry vision, and a headache. What is the
most appropriate nursing action?
1. Measure the patient’s blood glucose.
2. Take the patient’s blood pressure.
3. Stop the parenteral nutrition immediately.
4. Administer oxygen therapy.
Correct Answer: 1
Rationale: These symptoms suggest hyperglycemia, which is a known side effect of parenteral nutrition. Blood
glucose levels should be checked promptly to determine the need for further intervention.
3. The nurse suspects that a patient receiving peripheral IV therapy has developed septicemia. Which sign would confirm
this suspicion?
1. Sudden, intense pain at the IV site
2. Fever and chills
3. Cool skin around the IV insertion site
4. Difficulty flushing the IV line
Correct Answer: 2
Rationale: Fever and chills are hallmark symptoms of septicemia. Pain, coolness, or flushing resistance are more
indicative of local IV site issues like phlebitis or infiltration.
4. Which patient is most appropriate for receiving a port?
1. A patient getting a single dose of Zosyn
2. A dehydrated patient receiving IV fluids
3. A patient receiving a blood transfusion
4. A chemotherapy patient
Correct Answer: 4
Rationale: Ports are used for long-term therapies like chemotherapy. They’re not suitable for short-term or single-
use treatments.
5. Which patient would be the best candidate for hypodermoclysis?
1. A 5-year-old child with limited venous access needing normal saline
2. A 16-year-old needing frequent blood transfusions
3. A 24-year-old undergoing chemotherapy
4. A 35-year-old receiving multiple antibiotics through IV
Correct Answer: 1
Rationale: Hypodermoclysis (subcutaneous fluid administration) is ideal for pediatric or elderly patients with poor
IV access who require low-volume fluid therapy, not for medications or transfusions.
6. A nurse notices a white substance forming in IV tubing during administration of a piggyback antibiotic. What is the first
step?
1. Stop the infusion immediately.
2. Contact the healthcare provider.
3. Call the pharmacy to verify if this is a normal reaction.
4. Wait until the infusion is complete, then send tubing for testing.
Correct Answer: 1
Rationale: The appearance of precipitate indicates an incompatibility or contamination. Infusion must be stopped
immediately to prevent embolism or harm. Notify pharmacy and provider afterward.
7. While assessing a patient on IV therapy, the nurse hears crackles in the lungs and observes swelling around the eyes.
What should be done next?
1. Notify the RN at once.
2. Discontinue IV and change fluids.
3. Position the patient in semi-Fowler’s.
4. Collect cultures from the IV site.
Correct Answer: 3
Rationale: These signs indicate fluid overload. Placing the patient in semi-Fowler’s or high-Fowler’s position
improves breathing. The nurse should then inform the RN, but positioning comes first.
8. A nurse is about to administer fluids using a microdrop set. Which drop factor should be selected?
1. 10 drops/mL
2. 15 drops/mL
3. 20 drops/mL
4. 60 drops/mL
Correct Answer: 4
Rationale: Microdrip sets always deliver 60 drops per mL and are used for precise, low-volume infusions. All
other choices are macrodrip sets.
9. At a team meeting, it’s announced that central line kits will now include 2% chlorhexidine for skin prep. What is the best
evidence to support this change?
1. This reduces overall hospital expenses by 7%.
2. Scientific studies show 2% CHG is the most effective cleanser.
3. The supplier now includes 2% CHG in bundled products.
4. The surgical chief wants to study infection rates and catheter duration.
Correct Answer: 2
Rationale: Evidence-based practice must be grounded in research that improves patient outcomes. CHG has been
proven superior in preventing central line infections.
10. What risk arises from checking a patient’s blood pressure on the arm with an IV line?
1. Fluid overload
2. Increased venous pressure
3. Bloodstream infection
4. Imbalanced electrolytes
Correct Answer: 2
Rationale: Applying a blood pressure cuff to an IV-infused arm can cause increased venous pressure, potentially
leading to infiltration or damage to the IV site.
11. A patient is ordered to receive two units of packed red blood cells. Which IV fluid should the nurse use for this
transfusion?
1. 0.9% normal saline
2. 0.45% saline
3. D5W (5% dextrose in water)
4. D5NS (5% dextrose in normal saline)
Correct Answer: 1
Rationale: Only 0.9% sodium chloride (normal saline) is approved for use with blood products. Dextrose solutions
can cause red cell hemolysis.
12. When inserting an IV, which action by the nurse increases the risk of introducing infection?
1. Wearing gloves
2. Using a tourniquet to locate a vein
3. Cleaning the skin with alcohol
4. Blowing on the cleaned area
Correct Answer: 4
Rationale: Blowing on the area reintroduces bacteria and compromises the sterile field. This increases the risk of
infection.
MULTIPLE RESPONSE
1. The nurse is preparing to administer a hypertonic IV solution to a patient with fluid volume deficit. Which of the
following are classified as hypertonic fluids? (Select all that apply.)
1. 5% dextrose in 0.9% sodium chloride (D5NS)
2. 25% albumin
3. 0.45% sodium chloride (½NS)
4. 5% dextrose in water (D5W)
5. 0.9% sodium chloride (NS)
Correct Answers: 1, 2
Rationale: D5NS and 25% albumin are hypertonic and draw fluid into the vascular space. In contrast, ½NS is
hypotonic, while D5W and NS are isotonic.
2. A patient receiving continuous IV fluids suddenly develops shortness of breath, chest discomfort, and confusion. Which
actions should the nurse take? (Select all that apply.)
1. Contact the healthcare provider.
2. Position the patient in high-Fowler’s.
3. Administer oxygen as prescribed.
4. Check the patient’s vital signs.
5. Obtain a culture from the IV site.
Correct Answers: 1, 3, 4
Rationale: These signs suggest a venous air embolism. Immediate priorities include notifying the provider, giving
oxygen, and monitoring vitals. The proper positioning is Trendelenburg or left lateral, not high-Fowler’s. Culturing
the site is not indicated.
3. Before giving an IV push medication, what steps should the nurse perform? (Select all that apply.)
1. Check IV catheter patency.
2. Review the medication’s administration rate.
3. Dilute the drug with saline.
4. Replace the IV dressing.
5. Verify any allergies.
6. Flush with heparin.
Correct Answers: 1, 2, 5
Rationale: Patency must be verified, the correct rate known, and allergy history checked. Not all IV meds require
dilution or heparin flushes, and dressing changes are unnecessary unless clinically indicated.
COMPLETION
1. A patient is ordered to receive 500 mg of levofloxacin in 100 mL normal saline over 1 hour. At what rate (in mL/hr)
should the infusion pump be set?
Correct Answer: 100
Rationale: The volume (100 mL) divided by 1 hour equals a rate of 100 mL/hr.
2. A patient is prescribed D5W to be infused over 12 hours using a tubing set delivering 15 gtt/mL. What is the correct drip
rate? (Round to the nearest whole number. Enter number only.)
Correct Answer: 21
Rationale:
gtt/min=1000 mL×15 gtt/mL12×60=15000720≈20.83⇒21 gtt/min\text{gtt/min} = \frac{1000 \text{ mL} \times 15 \text{
gtt/mL}}{12 \times 60} = \frac{15000}{720} \approx 20.83 \Rightarrow 21 \text{
gtt/min}gtt/min=12×601000 mL×15 gtt/mL=72015000≈20.83⇒21 gtt/min
3. A patient has an order for 500 mL of lactated Ringer’s solution to infuse over 2 hours. At what rate (in mL/hr) should the
IV pump be programmed?
Correct Answer: 250
Rationale:
Rate=500 mL2 hr=250 mL/hr\text{Rate} = \frac{500 \text{ mL}}{2 \text{ hr}} = 250 \text{ mL/hr}Rate=2 hr500 mL
=250 mL/hr
4. A patient is to receive 100 mL of 25% albumin over 1 hour via tubing with a drop factor of 60 gtt/mL. What is the
correct drip rate in gtt/min? (Round to the nearest whole number. Enter number only.)
Correct Answer: 100
Rationale:
gtt/min=60×10060=100 gtt/min\text{gtt/min} = \frac{60 \times 100}{60} = 100 \text{ gtt/min}gtt/min=6060×100
=100 gtt/min
Chapter 8. Nursing Care of Hospital patients With Infections
1. A nursing practitioner is educating a student nurse about the concept of infection. Which option represents an example
of an infection reservoir?
1. An insect
2. A virus
3. Bacteria
4. Droplets
RIGHT ANSWER → 1
Clarification: Insects, humans, water, soil, or medical equipment can serve as infection reservoirs.
2. The clinic has a limited supply of influenza vaccines. Which individual should the nursing practitioner prioritize for
vaccination?
1. A 15-year-old who plays hockey
2. A 26-year-old with three young children
3. A 49-year-old food service worker
4. An 88-year-old living in senior housing
RIGHT ANSWER → 4
Clarification: Older adults are at greater risk for infection due to factors like age and potential chronic illness.
3. Among these hospital patients, who is most likely at increased risk for infection?
1. A 12-year-old who participates in sports
2. A 24-year-old bank employee living at home
3. A 45-year-old homemaker living with a roommate
4. A 60-year-old residing in a long-term care facility
RIGHT ANSWER → 4
Clarification: Living in long-term care increases infection risk due to communal living and older age.
4. A patient develops a localized infection after a spider bite to the foot. What symptom should the nurse expect?
1. Redness around the bite
2. Low blood pressure
3. Reduced urine output
4. Rapid heart rate
RIGHT ANSWER → 1
Clarification: Redness is a typical sign of a localized infection.
5. A patient asks about the differences between Ebola and Zika viruses. What is the correct response?
1. “Zika is spread by fruit bats.”
2. “Zika may cause long-term joint and eye problems.”
3. “Patients with Zika are placed in isolation.”
4. “ELISA tests are used to diagnose Ebola.”
RIGHT ANSWER → 4
Clarification: ELISA testing is used for Ebola virus diagnosis.
6. A patient acquires a surgical wound infection in the hospital. Which organism is most commonly responsible?
1. Shigella
2. Salmonella
3. Campylobacter
4. Staphylococcus aureus
RIGHT ANSWER → 4
Clarification: Staph aureus is the primary cause of surgical wound infections in hospitals.
7. A patient reports illness without recent contact with anyone sick. Which scenario represents indirect transmission?
1. Handling a toy used by a sick child
2. Talking with a sick person
3. Passing by someone who is coughing
4. Standing near someone who sneezes
RIGHT ANSWER → 1
Clarification: Picking up contaminated objects is an example of indirect transmission.
8. A patient with an infection requires several procedures. Which should be performed last?
1. Administer antibiotics
2. Culture the wound
3. Collect a urine sample
4. Collect a sputum sample
RIGHT ANSWER → 1
Clarification: Cultures must be obtained before antibiotic administration.
9. For which patient situation must the nurse use soap and water instead of alcohol-based hand sanitizer?
1. Giving pills to a patient with HIV
2. Cleaning stool from a patient with C. difficile
3. Taking the temperature of an asthma patient
4. Opening a milk container for a vertigo patient
RIGHT ANSWER → 2
Clarification: Soap and water are required after caring for patients with C. difficile.
10. Which lab test would help confirm a systemic infection in a newly admitted patient?
1. Capillary blood glucose
2. Complete metabolic panel
3. Complete blood count
4. Pancreatic enzyme test
RIGHT ANSWER → 3
Clarification: A CBC checks WBCs to assess for infection.
11. A patient with mononucleosis asks about recovery. What should the nurse recommend?
1. Exercise
2. Rest periods
3. Liquid diet
4. Restrict fluids
RIGHT ANSWER → 2
Clarification: Rest is essential due to fatigue associated with mononucleosis.
12. A patient develops red man syndrome. Which drug is likely responsible?
1. Azithromycin
2. Metronidazole
3. Vancomycin
4. Levofloxacin
RIGHT ANSWER → 3
Clarification: Vancomycin can cause red man syndrome.
13. How should a patient with active TB be transported to radiology?
1. Have the patient wear a surgical mask
2. Use a protective gown
3. Have the patient wear gloves
4. Nurse wears a surgical mask
RIGHT ANSWER → 1
Clarification: The patient must wear a surgical mask during transport.
14. A procedure may cause body fluid splatter. What PPE should the nurse wear?
1. Cap
2. Gown
3. Face shield
4. Shoe covers
RIGHT ANSWER → 3
Clarification: A face shield protects against blood or body fluid splashes.
15. After staff training on standard precautions, which nursing assistant statement shows proper understanding?
1. “We assume all patients could be infectious.”
2. “Isolation isn’t needed for most diseases.”
3. “Only infected patients are isolated.”
4. “Infection status must be confirmed first.”
RIGHT ANSWER → 1
Clarification: Standard precautions assume all patients may be infectious.
16. In staff education on bacterial spores, which method effectively destroys spores?
1. Extended drying
2. Sustained high heat
3. Washing with soap and water
4. Room temperature exposure
RIGHT ANSWER → 2
Clarification: Prolonged high temperatures kill bacterial spores.
17. During discharge teaching for a patient with herpes simplex, what should the nurse explain about its transmission?
1. “Herpes is airborne.”
2. “HEPA filters are needed for herpes.”
3. “Herpes spreads through direct contact.”
4. “Vehicle transmission involves air particles.”
RIGHT ANSWER → 3
Clarification: Herpes simplex spreads via direct contact.
18. A patient is transported wearing a mask. Which condition is likely?
1. Measles
2. Cellulitis
3. Diphtheria
4. C. difficile
RIGHT ANSWER → 1
Clarification: A mask is required for diseases like measles.
19. For an immunocompromised patient, which nursing action helps prevent hospital-acquired infection?
1. Restrict fluids
2. Moisturize dry skin
3. Use alcohol-based mouthwash
4. Apply drying agents to the back
RIGHT ANSWER → 2
Clarification: Moisturizing protects the skin barrier against infection.
20. A patient’s serum antibody test is positive. What does this mean?
1. There is an active infection.
2. It’s more accurate than a culture.
3. The body was exposed to an antigen.
4. The correct antibiotic was identified.
RIGHT ANSWER → 3
Clarification: A positive antibody test indicates prior antigen exposure.
21. While teaching school children about cough etiquette, what should the nurse emphasize?
1. Sneeze into hands if no tissue is available.
2. Store used tissues in backpacks or pockets.
3. Wash hands with soap and water for 20 seconds after blowing nose.
4. Move 1 foot away from others when sneezing.
RIGHT ANSWER → 3
Clarification: Children should wash hands with soap and water for 20 seconds after sneezing or nose blowing.
MULTIPLE RESPONSE
1. A nursing practitioner is managing several patients under droplet precautions. For which of the following illnesses are
droplet precautions required? (Select all that apply.)
1. Influenza
2. Pertussis
3. Measles
4. Mumps
5. HIV
6. Tuberculosis
RIGHT ANSWER → 1, 2, 4
Clarification:
 Influenza, pertussis, and mumps require droplet precautions.
 Measles and TB need airborne precautions.
 HIV is managed with standard precautions.
2. In an infection control training, which diseases should the nurse practitioner highlight as spread via direct contact?
(Select all that apply.)
1. Malaria
2. Measles
3. Impetigo
4. Influenza
5. Chickenpox
6. Lyme disease
RIGHT ANSWER → 3, 4
Clarification:
 Impetigo and influenza can be transmitted via direct contact.
 Malaria and Lyme disease are vector-borne.
 Measles and chickenpox are airborne.
3. A patient is admitted for a viral infection. Which of the following illnesses are viral in origin? (Select all that apply.)
1. Measles
2. Shingles
3. Gonorrhea
4. Trichomoniasis
5. Candida albicans
6. Infectious mononucleosis
RIGHT ANSWER → 1, 2, 6
Clarification:
 Measles, shingles, and infectious mononucleosis are viral.
 Gonorrhea (bacterial), trichomoniasis (protozoan), and Candida albicans (fungal).
4. Which patients in this group are at elevated risk for infection? (Select all that apply.)
1. Patient with third-degree burns
2. Patient with HIV
3. Patient with atrial fibrillation
4. Patient on corticosteroids for asthma
5. Patient who recently completed chemotherapy
6. Patient with ADHD
RIGHT ANSWER → 1, 2, 4, 5
Clarification:
 Burns, HIV, corticosteroid use, and chemotherapy increase infection risk.
 A-fib and ADHD do not significantly raise infection risk.
5. When developing a community infection prevention program, what topics should the nurse practitioner suggest
including? (Select all that apply.)
1. Cough etiquette
2. Hand hygiene
3. Safe food handling
4. Sports safety equipment
5. Immunization importance
RIGHT ANSWER → 1, 2, 3, 5
Clarification:
 Cough etiquette, hand hygiene, food safety, and immunization education help prevent infection.
 Sports safety is injury-related, not infection-related.
COMPLETION
1. The nurse is preparing to infuse metronidazole (Flagyl) 500 mg in 100 mL normal saline over 1 hour. What rate should
be set on the IV pump? (Enter the number only.)
RIGHT ANSWER → 100
Clarification:
 Infusing over 1 hour means the pump rate is 100 mL/hour.
2. The nurse is preparing to infuse fluconazole (Diflucan) 50 mg in 100 mL normal saline over 30 minutes. What rate
should be set on the IV pump? (Enter the number only.)
RIGHT ANSWER → 200
Clarification:
 For a 30-minute infusion, the pump rate is doubled → 200 mL/hour.
ORDERED RESPONSE
1. When teaching about the chain of infection, in which sequence do the links occur? (Order from 1 to 6.)
1. Mode of transmission
2. Reservoir
3. Susceptible host
4. Portal of exit
5. Portal of entry
6. Infectious agent
RIGHT ANSWER → 6, 2, 4, 1, 5, 3
Clarification:
 Correct order: infectious agent → reservoir → portal of exit → mode of transmission → portal of entry →
susceptible host.
2. When teaching handwashing steps to students, in which order should the steps be performed? (Order from 1 to 5.)
1. Rub hands for 20 seconds
2. Use paper towel to turn off faucet
3. Rinse with fingertips down
4. Dry with paper towel
5. Wet hands with warm water and soap
RIGHT ANSWER → 5, 1, 3, 4, 2
Clarification:
 Start by wetting and lathering → rub for 20 seconds → rinse → dry → use towel to shut off faucet.
Chapter 9. Nursing Care of Hospital patients in Shock
MULTIPLE CHOICE
1. A patient with gastrointestinal bleeding is alert and oriented. Vital signs are: BP 130/90 mm Hg, HR 118 bpm, RR
18/min, Temp 98.6°F (37°C). Which sign could indicate the onset of shock?
A. Respiratory rate of 18/min
B. Heart rate of 118 bpm
C. Temperature of 98.6°F
D. Blood pressure of 130/90 mm Hg
Correct Answer: B
Rationale: A rapid heart rate (tachycardia) is often an early compensatory mechanism in shock, as the body attempts to
maintain cardiac output and tissue perfusion.
2. A patient in anaphylactic shock requires medication. Which drug should be administered first?
A. Dobutamine
B. 0.9% Normal Saline
C. Epinephrine
D. Dexamethasone
Correct Answer: C
Rationale: Epinephrine is the initial and most critical medication to reverse the life-threatening effects of anaphylaxis,
such as bronchoconstriction and hypotension.
3. A confused, diaphoretic patient in shock has BP 82/40 mm Hg and urine output of 10 mL/hr despite IV fluids. What
should the nurse assess first?
A. Encourage oral hydration
B. Flush the catheter
C. Increase the IV rate
D. Inspect for catheter obstruction
Correct Answer: D
Rationale: Before taking further action, the nurse must rule out mechanical causes of decreased urine output, such as a
kinked or blocked catheter.
4. A trauma patient arrives with hypotension, confusion, tachycardia, reduced urine output, and cool skin. What is the
priority nursing intervention?
A. Apply warm blankets
B. Conduct a rapid physical assessment
C. Ask the family about medical history
D. Reorient the patient
Correct Answer: B
Rationale: A rapid assessment focusing on airway, breathing, and circulation is essential for identifying and addressing
life-threatening conditions.
5. A patient experiencing hemorrhage presents with pallor, BP 92/52 mm Hg, HR 160 bpm, and RR 30/min. What is the
likely cause of the high respiratory rate?
A. Electrolyte imbalance
B. Poor tissue perfusion
C. Fast IV infusion
D. Blood transfusion reaction
Correct Answer: B
Rationale: The body responds to inadequate oxygen delivery by increasing the respiratory rate in an attempt to
compensate for tissue hypoxia.
6. A patient recovering from surgery for internal bleeding has urine output of 15 mL/hr. What finding requires the nurse’s
immediate action?
A. Blood pH of 7.36
B. Decreased bowel sounds
C. Low urine output
D. Reactive pupils
Correct Answer: C
Rationale: The kidneys are highly sensitive to low perfusion. Prolonged hypoperfusion may cause irreversible kidney
damage, so low output requires prompt attention.
7. A patient lost 2 liters of blood during a procedure. What type of shock is most likely?
A. Cardiogenic
B. Anaphylactic
C. Hypovolemic
D. Obstructive
Correct Answer: C
Rationale: Hypovolemic shock results from significant fluid or blood loss, reducing circulating volume and impairing
perfusion.
8. What is the underlying cause of septic shock in a patient?
A. Hemorrhage
B. Allergic reaction
C. Infection
D. Cardiac failure
Correct Answer: C
Rationale: Septic shock is triggered by a systemic infection leading to widespread inflammation and circulatory collapse.
9. Which patient is most at risk of developing obstructive shock?
A. Patient with a chronic wound
B. Patient with myocarditis
C. Patient with minor blood loss
D. Patient with a tension pneumothorax
Correct Answer: D
Rationale: A tension pneumothorax can obstruct venous return to the heart, reducing cardiac output and leading to
obstructive shock.
10. The UAP reports the following. Which patient should be seen first?
A. BP 110/74 mm Hg
B. Respirations 36/min
C. HR 78 bpm
D. Urine output 120 mL over 3 hours
Correct Answer: B
Rationale: A respiratory rate of 36/min is abnormally high and may indicate respiratory distress or shock requiring urgent
evaluation.
11. A nurse reviews medications for a patient in early shock. Which one should be questioned?
A. Diphenhydramine
B. Morphine
C. Dopamine
D. Methylprednisolone
Correct Answer: B
Rationale: Morphine can cause vasodilation and lower blood pressure, which may worsen hypotension in a patient in
shock.
12. When blood flow is diverted from the kidneys during shock, how long can the kidneys function before damage occurs?
A. 1 hour
B. 2 hours
C. 3 hours
D. 4 hours
Correct Answer: A
Rationale: The kidneys can tolerate low perfusion for about 1 hour before irreversible cellular injury may begin.
13. A patient with crackles, JVD, chest pain, weight gain, and hypotension is being evaluated. Which order should the
nurse question?
A. STAT ECG
B. 500 mL 0.9% NS over 30 minutes
C. Oxygen 2 L/min
D. ABG now and in 1 hour
Correct Answer: B
Rationale: This patient may have cardiogenic shock, and fluid overload could worsen the condition. IV fluids should be
used cautiously.
14. A patient with a history of MI reports chest pain and has hypotension, an irregular HR, and gray skin. What should the
nurse do first?
A. Lay patient flat
B. Notify charge nurse
C. Test urine specific gravity
D. Rapidly infuse saline
Correct Answer: B
Rationale: The nurse should immediately report the deterioration so orders can be initiated. Positioning and fluids may be
contraindicated.
15. A patient has ischemic liver injury. What finding is most likely?
A. Low bilirubin
B. Elevated ammonia
C. Decreased liver enzymes
D. Increased plasma proteins
Correct Answer: B
Rationale: Hepatic hypoxia impairs ammonia detoxification, leading to elevated blood ammonia levels.
16. A patient asks what happens during shock. What is the nurse’s correct response?
A. “You breathe faster to supply your tissues with oxygen.”
B. “Your heart slows down to reduce its workload.”
C. “Hormones lower blood sugar to conserve energy.”
D. “Blood vessels dilate and sodium is lost.”
Correct Answer: A
Rationale: The body compensates for hypoxia by increasing respiratory rate to improve oxygen delivery to tissues.
17. A patient in shock develops metabolic acidosis. What is the cause?
A. Too much aerobic metabolism
B. Excessive anaerobic metabolism
C. Reduced anaerobic metabolism
D. Hormonal changes
Correct Answer: B
Rationale: Inadequate oxygen supply leads to anaerobic metabolism, which produces lactic acid and results in metabolic
acidosis.
18. A patient receives 3 liters of saline for shock. Which finding suggests the treatment is effective?
A. Cool, clammy skin
B. Reduced urine output
C. Increased blood pressure
D. Rapid heart rate
Correct Answer: C
Rationale: An increase in blood pressure indicates improved perfusion and fluid responsiveness to therapy.
19. Which patient has the highest risk of developing sepsis?
A. 20-year-old athlete with allergies
B. 25-year-old with HIV
C. 30-year-old with mood disorder
D. 35-year-old with fibromyalgia
Correct Answer: B
Rationale: Immunocompromised individuals, such as those with HIV, have a higher susceptibility to severe infections like
sepsis.
20. Which patient should the nurse prioritize during a shift handoff?
A. Pressure ulcer dressing due
B. Diabetic eating with glucose of 85
C. Patient with cellulitis reporting throat tightness
D. Sickle cell patient with knee pain
Correct Answer: C
Rationale: Throat tightness may signal the beginning of anaphylaxis, which requires immediate intervention to prevent
airway obstruction.
21. What should the nurse consider when repositioning an elderly patient in septic shock?
A. Move slowly
B. Lower oxygen flow
C. Increase IV rate
D. Use Trendelenburg position
Correct Answer: A
Rationale: Older adults have decreased cardiovascular compensation and may develop orthostatic hypotension; position
changes should be gradual.
22. A patient in shock becomes unresponsive. CPR is started immediately. Why is this critical?
A. Brain cells die in 1 minute
B. Brain cells die in 2 minutes
C. Brain cells die in 4 minutes
D. Brain cells die in 8 minutes
Correct Answer: C
Rationale: Brain tissue starts to suffer irreversible damage after 4 minutes without oxygen and glucose due to inadequate
perfusion.
MULTIPLE RESPONSE
1. A nurse is helping manage a patient showing early indicators of shock. Which diagnostic tests would most likely be
ordered? (Select all that apply.)
A. Urinalysis
B. Chest X-ray
C. Arterial blood gas (ABG)
D. Complete blood count (CBC)
E. Electroencephalogram (EEG)
F. Blood typing and crossmatch
Correct Answers: A, B, C, D, F
Rationale: Evaluation of a patient in shock includes tests that assess organ function, oxygenation, blood loss, and potential
need for transfusion. An EEG is unrelated to shock.
2. A nurse caring for a patient in shock considers potential complications. Which of the following may occur due to shock?
(Select all that apply.)
A. Acute respiratory distress syndrome (ARDS)
B. Cancer
C. Diabetes
D. Disseminated intravascular coagulation (DIC)
E. Multiple organ dysfunction syndrome (MODS)
Correct Answers: A, D, E
Rationale: ARDS, DIC, and MODS are severe complications of prolonged or untreated shock. Cancer and diabetes are not
consequences of shock.
3. A patient is suspected to be experiencing anaphylactic shock. What symptoms would the nurse expect to find? (Select all
that apply.)
A. Excessive urination
B. Hives (urticaria)
C. Bronchial constriction
D. Muscle cramps
E. Swelling of the larynx
Correct Answers: B, C, E
Rationale: Anaphylaxis commonly includes hives, airway swelling, and bronchospasm. Muscle cramps and polyuria are
not typical symptoms.
4. Which patients are at a greater risk for developing cardiogenic shock? (Select all that apply.)
A. A patient with myocarditis
B. A patient diagnosed with cardiomyopathy
C. A patient who has atrial fibrillation
D. A patient allergic to bee stings
E. A patient with heatstroke
Correct Answers: A, B, C
Rationale: Conditions impairing heart function like myocarditis, cardiomyopathy, or arrhythmias increase the risk of
cardiogenic shock. Bee allergies relate to anaphylaxis; heatstroke may cause hypovolemic shock.
ORDERED RESPONSE
1. A patient in shock is en route to the emergency department. Upon arrival, which sequence should the nurse follow to
prioritize care? (Place the actions in the correct order.)
1. Ensure the patient is breathing
2. Establish an open airway
3. Check blood pressure and heart rate
4. Control external bleeding
5. Evaluate level of consciousness
6. Prepare the patient for diagnostics (e.g., x-rays)
Correct Sequence: 2 → 1 → 6 → 5 → 3 → 4
Rationale: Care must be guided by patient stability. The ABCs (Airway, Breathing, Circulation) come first, followed by
bleeding control, neurologic status, and diagnostics.
COMPLETION
1. A nurse is teaching a patient how to inject 0.5 mg of epinephrine intramuscularly. The vial reads 0.5 mg/0.5 mL. How
many mL should the patient draw up?
Correct Answer: 0.5
Rationale: The dosage and concentration are equal, so 0.5 mg = 0.5 mL.
2. A patient weighing 84 kg is prescribed dobutamine at 0.5 mcg/kg. How many micrograms (mcg) will the patient
receive?
Correct Answer: 42
Rationale: 84 kg × 0.5 mcg = 42 mcg.
3. The nurse is ordered to administer 1 liter (1,000 mL) of normal saline over 2 hours. What should the infusion pump be
set to in mL/hour?
Correct Answer: 500
Rationale: 1,000 mL ÷ 2 hours = 500 mL/hr.
Chapter 10. Nursing Care of Hospital patients in Pain
MULTIPLE CHOICE
1.
A hospitalized patient has been taking opioids for pain from injuries sustained in a car crash for three months. The patient
asks about the risk of withdrawal when stopping the medication. How should the nurse practitioner respond?
A. “Ask your doctor about getting a sedative to help you deal with any severe withdrawal.”
B. “If you gradually lower your dose, you should not have withdrawal symptoms.”
C. “You would need to be on these medicines for much longer than three months to have withdrawal issues.”
D. “Since you were using them for pain, you won’t experience withdrawal when you stop.”
Correct Answer: B
Rationale:
Opioid withdrawal can occur even after a few weeks of use, but tapering the opioid dose slowly minimizes or prevents
withdrawal symptoms. Sedatives are not typically recommended because of risk of additional dependence, and the reason
the patient used opioids does not prevent physical dependence.
2.
A patient with lung cancer has been on morphine for two weeks and says it no longer helps. What is the patient most likely
experiencing?
A. Physical dependence
B. Tolerance
C. Addiction
D. Pseudoaddiction
Correct Answer: B
Rationale:
Tolerance develops when a medication becomes less effective over time, requiring higher doses to achieve the same pain
relief. This is common with opioid therapy. Physical dependence is expected with consistent opioid use but does not
explain loss of pain relief. Addiction involves compulsive drug seeking, and pseudoaddiction refers to inadequate pain
relief leading to drug-seeking behavior.
3.
A patient with chronic pain is on a sustained-release opioid every 12 hours but complains of pain returning after 6 hours.
What should the nurse practitioner do?
A. Request an immediate-release opioid for breakthrough pain.
B. Teach the patient relaxation methods until the next scheduled dose.
C. Check the patient’s vital signs and give the opioid dose early.
D. Tell the patient the medication should last 12 hours.
Correct Answer: A
Rationale:
Breakthrough pain is treated with immediate-release opioids, which are given in addition to the sustained-release schedule.
Simply encouraging relaxation or giving the next dose early does not address breakthrough pain safely or consistently.
4.
Before giving an opioid for a patient’s post-op pain, what should the nurse practitioner do first?
A. Check the respiratory rate.
B. Look at the patient’s skin color.
C. Measure the patient’s oral temperature.
D. Ask when the patient last ate.
Correct Answer: A
Rationale:
Opioids can cause respiratory depression, so the priority assessment is checking respiratory rate. While other assessments
are helpful, they do not take precedence when giving a respiratory depressant.
5.
A patient with peripheral neuropathy says, “I don’t understand why the doctor gave me an antidepressant. I’m not
depressed!” What is the best response?
A. “Depression often plays a role in pain, so treating depression helps pain.”
B. “Maybe you’re more depressed than you think. Would you like to talk about it?”
C. “Antidepressants can help with nerve pain like yours.”
D. “Try it, and if you don’t improve, you can ask to stop it.”
Correct Answer: C
Rationale:
Certain antidepressants, particularly tricyclics and SNRIs, are effective for neuropathic pain even if the patient is not
clinically depressed. They work on neurotransmitters involved in pain pathways.
6.
A patient receiving high doses of opioids is drowsy, hard to arouse, with a breathing rate of 6 per minute and constricted
pupils. Which drug should the nurse practitioner expect to administer?
A. Naloxone (Narcan)
B. Furosemide (Lasix)
C. Diazepam (Valium)
D. Flumazenil (Romazicon)
Correct Answer: A
Rationale:
Naloxone is an opioid antagonist used to reverse opioid overdose symptoms such as severe respiratory depression and
sedation. Furosemide is a diuretic, Valium is a sedative that would worsen sedation, and flumazenil reverses
benzodiazepine—not opioid—overdose.
7.
A physician orders a saline injection for a patient who has been requesting frequent meperidine (Demerol). What should
the licensed practical nurse (LPN) do first?
A. Tell the patient that the doctor ordered a placebo.
B. Administer the saline and carefully document the patient’s response.
C. Tell the patient it is a pain shot without explaining further.
D. Discuss discomfort with giving saline if the patient thinks it is Demerol.
Correct Answer: D
Rationale:
Administering a placebo without informed consent is unethical. The nurse should discuss concerns with the provider and
supervisor to protect the patient’s right to honest, ethical care.
8.
A patient with chronic back pain is starting a fentanyl patch and says, “I’m really glad to get that patch on because I’m
hurting so bad.” How should the nurse practitioner respond?
A. “You’ll feel better in about half an hour.”
B. “The patch takes time to work. Would you like a pain injection while it takes effect?”
C. “No other pain meds can be given while the patch is on, so please wait.”
D. “Since it absorbs through the skin, you’ll feel relief in minutes.”
Correct Answer: B
Rationale:
Fentanyl patches may take up to 72 hours to reach steady pain control, so short-acting opioids may be needed in the
meantime. Other analgesics can still be used while the patch is starting to work.
9.
The nurse practitioner enters a patient’s room as the patient’s daughter presses the button on his PCA pump. How should
the nurse practitioner respond?
A. “Thanks for helping. Is he too weak to press it himself?”
B. “If you push the button, check that he’s breathing more than 10 per minute.”
C. “Only your dad should press the button. Remind him to do it himself if he needs pain relief.”
D. “If you push it again, I’ll have to report this to the supervisor.”
Correct Answer: C
Rationale:
PCA (patient-controlled analgesia) should only be operated by the patient to prevent overdose. Family members can
remind but should never press the button for the patient.
10.
When performing a pain assessment on a new patient, which question best measures pain severity?
A. “When did the pain start?”
B. “What makes the pain better or worse?”
C. “Can you show me where the pain is?”
D. “How would you rate your pain on a 0-to-10 scale?”
Correct Answer: D
Rationale:
Pain scales (like 0–10) are validated tools to quantify severity. Other questions assess timing, location, or modifying
factors, but only a scale directly measures intensity.
11.
A patient after abdominal surgery says, “I know relaxation exercises, so I won’t need pain medication.” How should the
nurse practitioner respond?
A. Relaxation therapy is like a placebo.
B. Relaxation won’t help for severe post-op pain.
C. Relaxation is a good addition to pain medication.
D. Relaxation can replace pain medications completely.
Correct Answer: C
Rationale:
Relaxation techniques can support pain relief but do not replace analgesics, especially after major surgery. They work best
as complementary therapies.
12.
The nurse practitioner is trying to assess pain in a cognitively impaired patient with a developmental level around 4 years
old. Which method is best?
A. Use the FACES scale
B. Ask “Are you hurting?”
C. Watch facial expressions
D. Explain the 0–10 scale
Correct Answer: A
Rationale:
The FACES pain scale is designed for children and patients with limited communication skills, making it most appropriate
for someone with the mental capacity of a 4-year-old.
13.
Which patient is experiencing chronic pain?
A. Heart surgery two days ago
B. Leg fracture from a motorcycle crash
C. Back injury 6 months ago
D. Sprained wrist yesterday
Correct Answer: C
Rationale:
Pain lasting beyond normal healing time, typically over three months, is classified as chronic. Six months is well beyond
acute healing.
14.
A patient on morphine via PCA shows these findings. Which is most concerning?
A. Blood pressure 114/72
B. Pulse 76
C. Respirations 10 per minute
D. Pain level 3 out of 10
Correct Answer: C
Rationale:
A respiratory rate of 10 or lower signals possible opioid-induced respiratory depression and should be addressed
immediately.
15.
A patient reports having bloody stools for the past month. Which medication is most likely responsible?
A. Gabapentin
B. Duloxetine
C. Naproxen
D. Fentanyl
Correct Answer: C
Rationale:
NSAIDs like naproxen increase the risk of gastrointestinal bleeding, which can result in bloody stools. Other options do not
carry that risk.
16.
Which medication should the nurse practitioner expect to see ordered for a patient with diabetic neuropathy?
A. Carbamazepine
B. Midazolam
C. Oxycodone
D. Celecoxib
Correct Answer: A
Rationale:
Carbamazepine is an anticonvulsant used for treating neuropathic pain. Midazolam is a sedative, oxycodone an opioid for
nociceptive pain, and celecoxib an NSAID for inflammatory pain.
17.
A patient after arm amputation reports a pain level of 9 out of 10. What should the nurse practitioner do?
A. Encourage non-drug pain control methods
B. Give normal saline and say it’s morphine
C. Remind the patient there is nothing there to hurt
D. Administer 4 mg morphine IV as ordered
Correct Answer: D
Rationale:
Phantom limb pain is real pain and requires treatment. It is unethical to deceive the patient or deny effective pharmacologic
pain relief.
18.
A patient with fractures from a car crash rates pain 9 out of 10. Which route is fastest for pain relief?
A. Oral
B. Rectal
C. Intramuscular
D. IV
Correct Answer: D
Rationale:
IV administration provides the quickest onset of pain relief compared to other routes.
19.
A cancer patient on PRN morphine and PRN hydrocodone says the medicine helps but wears off too soon. Which order is
likely next?
A. Change to another opioid
B. Switch to around-the-clock dosing
C. Add another drug
D. Increase the current dose
Correct Answer: B
Rationale:
For predictable, ongoing pain, scheduled around-the-clock analgesia is recommended instead of PRN, to maintain
consistent pain control.
20.
Which patient is experiencing acute pain?
A. Back pain for two years
B. Pancreatitis
C. Knee injury 12 years ago
D. Osteoarthritis diagnosed last year
Correct Answer: B
Rationale:
Pancreatitis causes sudden, severe pain and is classified as acute. Other options are examples of chronic pain.
21.
A cancer patient taking hydromorphone reports constipation. What should the nurse practitioner advise?
A. Take a mild laxative
B. Learn how to give a Fleet enema
C. Slowly reduce the hydromorphone dose
D. Eat more fiber and drink extra fluids
Correct Answer: D
Rationale:
High fiber and increased fluid intake are the best first-line prevention for opioid-induced constipation. Laxatives or enemas
should be backup options if preventive measures fail.
22.
An order reads: extra-strength Tylenol 1,000 mg every 4 hours around the clock. What should the nurse practitioner do?
A. Clarify with the provider
B. Give as ordered
C. Give half the dose
D. Switch to regular Tylenol 325 mg
Correct Answer: A
Rationale:
This order exceeds the safe daily acetaminophen limit and should be clarified to avoid liver toxicity.
23.
A patient with a gastrostomy tube is prescribed a sustained-release opioid. What should the nurse practitioner do?
A. Give the medication to swallow
B. Crush it and give via tube
C. Dissolve it in water for the tube
D. Request a liquid formulation
Correct Answer: D
Rationale:
Sustained-release tablets must not be crushed or dissolved as that may cause dangerous overdose. A liquid alternative is
safer.
24.
Which patient should be seen first?
A. 2 hours post-appendectomy, pain 8/10
B. 3 days post-knee replacement, pain 2/10
C. Chronic back pain, pain 8/10
D. Sprained ankle, pain 5/10
Correct Answer: A
Rationale:
This is a postoperative patient with severe acute pain. Prompt pain control is critical for recovery and to rule out
complications.
MULTIPLE RESPONSE
1.
The nurse practitioner is reviewing medications prescribed for a hospitalized patient in pain. Which of the following should
the nurse recognize as adjuvant agents used for pain management? (Select all that apply.)
A. Steroids
B. Antibiotics
C. Cyclooxygenase-2 (COX-2) inhibitors
D. Anticonvulsants
E. Benzodiazepines
F. Tricyclic antidepressants
Correct Answers: A, D, E, F
Rationale:
 A (Steroids): Steroids help reduce inflammation, which can indirectly relieve pain.
 D (Anticonvulsants): These are used to manage neuropathic or nerve pain syndromes.
 E (Benzodiazepines): These can relieve anxiety and muscle spasms associated with pain.
 F (Tricyclic antidepressants): These help in managing neuropathic pain by altering pain perception.
 B (Antibiotics): Treat infection, not pain.
 C (COX-2 inhibitors): These are NSAIDs, not classified as adjuvants.
2.
The nurse practitioner is teaching a hospitalized patient about nonpharmacologic ways to help control pain. Which topics
should be included? (Select all that apply.)
A. Guided imagery
B. Taking medication on a fixed schedule
C. Watching television for distraction
D. Biofeedback techniques
E. Applying heat
F. Applying a Duragesic patch
Correct Answers: A, C, D, E
Rationale:
 A (Guided imagery): A recognized non-drug pain relief method.
 C (Watching television): Distraction is a nonpharmacological coping tool.
 D (Biofeedback techniques): Helps patients control physiological responses to pain.
 E (Heat application): Nonpharmacological comfort measure.
 B (Taking medication on a fixed schedule): Pharmacologic therapy.
 F (Duragesic patch): A fentanyl patch is a pharmacologic agent, not nonpharmacological.
3.
The nurse practitioner is educating a patient who is going home with a fentanyl (Duragesic) patch. Which statements by the
patient show correct understanding? (Select all that apply.)
A. “This medicine will help me because I need something that acts fast.”
B. “I should put heat on the patch to help it stick better.”
C. “Since I smoke, this medicine might not work as well.”
D. “If I have a fever, I should avoid using this medicine.”
E. “I should try not to touch the medicine when applying the patch.”
Correct Answers: C, D, E
Rationale:
 C: Smoking may impact fentanyl’s effectiveness by altering metabolism.
 D: Fever can increase fentanyl absorption, potentially leading to overdose.
 E: Contact with the medication should be avoided to prevent unintended absorption.
 A: Fentanyl patches are slow-acting and not meant for rapid pain relief.
 B: Applying heat over the patch is dangerous because it increases absorption and could cause overdose.
COMPLETION
1.
The nurse practitioner prepares to give morphine 5 mg IV to a patient with cancer pain. The stock solution is 10 mg/mL.
How many milliliters will be given? (Enter the numeral only.)
Correct Answer: 0.5
Rationale:
 You need 5 mg.
 Available concentration: 10 mg per 1 mL
 Calculation: 5 mg ÷ 10 mg/mL = 0.5 mL
2.
The nurse practitioner is about to give midazolam (Versed) 1 mg IV. The available concentration is 1 mg/mL. How many
milliliters should be given? (Enter the numeral only.)
Correct Answer: 1
Rationale:
 You need 1 mg.
 Available concentration: 1 mg per 1 mL
 Calculation: 1 mg ÷ 1 mg/mL = 1 mL
3.
The nurse practitioner is preparing to give Roxanol 5 mg by mouth. The available solution is 20 mg/mL. How many
milliliters should be given? (Enter the numeral only.)
Correct Answer: 0.25
Rationale:
 You need 5 mg.
 Available concentration: 20 mg per 1 mL
 Calculation: 5 mg ÷ 20 mg/mL = 0.25 mL
Chapter 11. Nursing Care of Hospital patients With Cancer
MULTIPLE CHOICE
1. Which field of medicine specializes in the prevention, diagnosis, and treatment of cancerous tumors?
A. Cardiology
B. Podiatry
C. Oncology
D. Endocrinology
Correct Answer: C
Rationale:
 A: Cardiology focuses on heart diseases.
 B: Podiatry is concerned with foot health.
 C: Oncology is the correct term for cancer care.
 D: Endocrinology deals with hormone-related conditions.
2. A patient has been diagnosed with a cancerous growth in the bone. Which term should the nurse use to describe this
condition?
A. Sarcoma
B. Osteoma
C. Adenoma
D. Carcinoma
Correct Answer: A
Rationale:
 A: Malignancies in connective tissues, including bone, are called sarcomas.
 B: Osteomas are benign bone tumors.
 C: Adenomas stem from glandular tissues.
 D: Carcinomas involve epithelial cell cancers.
3. A breast cancer patient’s lab report shows an abnormal result. Which lab value is most concerning for metastasis?
A. High calcium levels in the blood
B. Low calcium levels
C. Elevated potassium levels
D. Reduced potassium levels
Correct Answer: A
Rationale:
 A: Increased calcium can result from bone breakdown due to cancer spread.
 B–D: Potassium levels and low calcium are not direct indicators of metastasis.
4. A patient with prostate cancer asks about a high PSA result. What is the nurse’s best explanation?
A. “PSA is a tumor indicator that often increases in prostate cancer.”
B. “PSA checks if the cancer has spread.”
C. “It monitors the drug levels of your chemotherapy.”
D. “It lets the lab observe your cancer cells under a microscope.”
Correct Answer: A
Rationale:
 A: PSA is a marker used to detect and monitor prostate cancer.
 B–D: PSA does not confirm metastasis, chemotherapy levels, or microscopic analysis.
5. A patient asks what “benign” means. What is the most appropriate response?
A. “It spreads to nearby organs and lymph nodes.”
B. “The organ typically keeps working normally.”
C. “It’s an abnormal group of cancerous cells.”
D. “These tumors grow faster than cancer cells.”
Correct Answer: B
Rationale:
 B: Benign tumors do not usually affect organ function.
 A, C, D: These descriptions apply to malignant tumors.
6. A cancer patient is having surgery for symptom relief, not cure. What kind of surgery is this?
A. Surgery to rebuild tissue damaged by cancer
B. Surgery to relieve discomfort when a cure isn’t feasible
C. Surgery to fully eliminate the cancer
D. Surgery to remove lymph nodes to stop spread
Correct Answer: B
Rationale:
 B: Palliative surgery improves quality of life when cure isn’t possible.
 A, C, D: These describe reconstructive or curative surgeries.
7. A patient receiving chemotherapy says she’s too nauseated to eat. What should the nurse do first?
A. Prepare to begin total parenteral nutrition (TPN)
B. Suggest brushing teeth before meals
C. Give the prescribed promethazine 1 hour before eating
D. Offer her favorite foods
Correct Answer: C
Rationale:
 C: Antiemetics help reduce nausea, making eating more tolerable.
 A, B, D: These are secondary to managing nausea effectively first.
8. A patient on chemotherapy is in the nadir phase. What complication is the nurse most concerned about?
A. Infection
B. Mouth inflammation
C. Hair loss
D. Diarrhea
Correct Answer: A
Rationale:
 A: Low white blood cells during the nadir phase increase infection risk.
 B–D: These are also chemo side effects but not related to low immunity.
9. A patient with cancer affecting the lymphatic system has which type of cancer?
A. Melanoma
B. Sarcoma
C. Lymphoma
D. Carcinoma
Correct Answer: C
Rationale:
 C: Lymphoma refers to cancer in the lymph tissue.
 A, B, D: These terms refer to other tissue types.
10. A patient with lung cancer shows facial redness, shortness of breath, and neck vein swelling. Which emergency is
suspected?
A. Low platelet count
B. Spinal cord pressure
C. Superior vena cava syndrome
D. High calcium levels
Correct Answer: C
Rationale:
 C: These symptoms are classic for superior vena cava syndrome.
 A, B, D: These have different clinical signs.
11. A chemotherapy IV line with a vesicant drug has disconnected and the drug is leaking onto the floor. What is the
nurse’s immediate action?
A. Reconnect the tubing at once
B. Clean the spill quickly with disposable towels
C. No special action is necessary
D. Put on gloves and a protective gown, then clean the area following facility protocol
Correct Answer: D
Rationale:
 D: Vesicants are hazardous. Cleanup must follow safety protocols with protective gear.
 A: The tubing is no longer sterile.
 B: Special procedures must be used.
 C: Precautions are always needed for chemotherapy spills.
12. A nurse observes slight swelling at the IV site of a patient receiving a vesicant chemo agent. What should the nurse do
first?
A. Monitor the site hourly
B. Chart the finding
C. Stop the infusion and notify the RN
D. No action; this is expected
Correct Answer: C
Rationale:
 C: Vesicants can cause severe tissue damage if infiltration occurs. Stop the infusion immediately.
 A, B, D: Delay in action can worsen injury.
13. A provider orders a carcinoembryonic antigen (CEA) test. Which type of cancer does this test help detect?
A. Breast cancer
B. Liver cancer
C. Colon cancer
D. Ovarian cancer
Correct Answer: C
Rationale:
 C: CEA is used to detect colon and rectal cancer.
 A: CA 15-3 is for breast cancer.
 B: AFP is for liver.
 D: CA 125 is for ovarian.
14. A post-operative chemotherapy patient develops thrombocytopenia. Which symptom must be reported immediately?
A. Headache
B. Black, tarry stool
C. Surgical wound discomfort
D. Blood pressure of 136/88 mm Hg
Correct Answer: B
Rationale:
 B: Tarry stools signal gastrointestinal bleeding, a serious risk with low platelets.
 A, C, D: Less urgent in this context.
15. Before starting doxorubicin (Adriamycin), which assessment should the nurse expect to perform?
A. PET scan
B. Kidney function tests
C. Chest x-ray
D. Echocardiogram
Correct Answer: D
Rationale:
 D: Doxorubicin can affect cardiac function; baseline heart assessment is needed.
 A–C: Not as relevant or prioritized.
16. Which is the top nursing priority when caring for a chemo patient with leukopenia?
A. Prevent injury
B. Monitor for bleeding
C. Promote strict hand hygiene
D. Help with daily self-care
Correct Answer: C
Rationale:
 C: With low WBCs, infection prevention is critical. Handwashing is key.
 A, B: Apply more to low platelets.
 D: Related to fatigue or anemia.
17. A patient receiving radiation is experiencing fatigue. What is the best nursing intervention?
A. Discuss blood transfusion preferences
B. Suggest regular physical activity
C. Recommend eating more high-protein, high-calorie food
D. Encourage planning activities around rest
Correct Answer: D
Rationale:
 D: Resting between tasks helps manage fatigue from radiation.
 A–C: Not the most suitable based on fatigue alone.
18. A nurse is educating a patient on tamoxifen (Nolvadex). What should be included in the instructions?
A. Avoid antacids within 2 hours of taking it
B. Take it with mesna to protect the bladder
C. Monitor your weight daily
D. Watch for changes in brain function
Correct Answer: A
Rationale:
 A: Antacids can affect absorption and should be spaced out.
 B: Mesna isn’t used with tamoxifen.
 C, D: Not typical concerns.
19. Which patient needs immediate attention?
A. Calcium level of 9.2 mg/dL
B. Platelet count of 250,000/mm³
C. WBC count of 2,000/μL
D. Hemoglobin of 14.5 g/dL
Correct Answer: C
Rationale:
 C: A low WBC count indicates neutropenia, increasing infection risk.
 A, B, D: All are within normal limits.
20. A nurse teaches a patient with thrombocytopenia. Which statement indicates a need for more instruction?
A. “I won’t take aspirin while my platelet count is low.”
B. “I’ll use an electric razor instead of blades.”
C. “I’ll be gentle when blowing my nose.”
D. “I’ll make sure to floss daily.”
Correct Answer: D
Rationale:
 D: Flossing increases the risk of bleeding with low platelets.
 A–C: Show good understanding.
21. A patient receiving radiation therapy is being taught about skin care. Which response needs further correction?
A. “Wearing tight clothes helps protect the skin.”
B. “I’ll use sunscreen and wear a hat outside.”
C. “I won’t wash off the radiation markings.”
D. “I’ll skip the baby powder after bathing.”
Correct Answer: A
Rationale:
 A: Tight clothing should be avoided as it can irritate skin.
 B–D: These are correct precautions.
22. The nurse reviews labs and suspects one patient may need nutrition support. Which finding confirms this?
A. An 18-year-old with albumin of 2.5 g/dL
B. A 60-year-old with calcium of 8 mg/dL
C. A 43-year-old with platelet count of 180,000/mm³
D. A 56-year-old with WBC count of 6,000/μL
Correct Answer: A
Rationale:
 A: Low albumin suggests poor nutritional status.
 B–D: Not directly tied to nutrition.
23. A nurse is preparing an oral chemotherapy dose. What should the nurse do to protect themselves?
A. Wear gloves while preparing the medication
B. Wash hands before administering
C. Use a lead apron
D. Crush the tablet before giving it
Correct Answer: A
Rationale:
 A: Chemotherapy safety gloves are essential during handling.
 B: Handwashing alone isn’t enough.
 C: Not necessary for oral chemo.
 D: Oral chemotherapy should never be crushed.
24. A patient is prescribed cyclophosphamide (Cytoxan). What additional medication should the nurse expect to give to
protect the bladder?
A. Dexrazoxane (Zinecard)
B. Mesna (Mesnex)
C. Filgrastim (Neupogen)
D. Doxorubicin (Adriamycin)
Correct Answer: B
Rationale:
 B: Mesna is given to prevent hemorrhagic cystitis from Cytoxan.
 A: Dexrazoxane protects the heart.
 C: Filgrastim boosts neutrophils.
 D: Doxorubicin is another chemo drug, not protective.
MULTIPLE RESPONSE
1. The nurse is teaching a patient about reducing cancer risk through diet. Which of the following items should the patient
be instructed to limit or avoid? (Select all that apply)
A. Alcohol
B. Whole grains
C. Smoked meats
D. Root vegetables
E. Charbroiled meat
F. Cruciferous vegetables
Correct Answers: A, C, E
Rationale:
 A, C, E: Patients are advised to minimize intake of alcohol, and meats that are smoked, salted, charred, or cooked
at high heat, as these can increase cancer risk.
 B, F: Whole grains and cruciferous vegetables (like broccoli and cabbage) are beneficial and encouraged.
 D: Root vegetables are neutral in regard to cancer prevention.
2. A nurse is preparing educational material for a Native American community to support cancer prevention. What content
should be included in the session? (Select all that apply)
A. Promote traditional activities involving physical movement
B. Provide educational materials in their native dialect
C. Integrate tribal healing traditions with modern care
D. Emphasize matching patients with same-gender providers
E. Discuss healthy cooking and proper portion sizes
Correct Answers: A, C, E
Rationale:
 A, C, E: Cancer prevention education should encourage physical activity rooted in cultural tradition, support
incorporating spiritual and healing practices, and promote healthy eating habits.
 B: Language barriers are generally minimal with this group.
 D: Preference for same-sex caregivers is not a common concern in this population.
COMPLETION
1. A nurse is preparing to infuse 500 mL of D5W over 8 hours using a drop factor of 15 gtt/mL. What is the drip rate in
drops per minute? (Round to the nearest whole number.)
Correct Answer: 16
Rationale:
Calculation:
15 gtt/mL×500 mL8 hr×60 min=15.625≈16 gtt/min\frac{15 \text{ gtt/mL} \times 500 \text{ mL}}{8 \text{ hr} \times 60
\text{ min}} = 15.625 \approx 16 \text{ gtt/min}8 hr×60 min15 gtt/mL×500 mL=15.625≈16 gtt/min
2. The nurse is preparing to give ondansetron 4 mg IV. The available concentration is 2 mg/mL. How many mL should be
administered?
Correct Answer: 2
Rationale:
4 mg2 mg/mL=2 mL\frac{4 \text{ mg}}{2 \text{ mg/mL}} = 2 \text{ mL}2 mg/mL4 mg=2 mL
3. A nurse is to administer epoetin alfa (Procrit) at a dose of 50 units/kg to a 60 kg patient. The vial contains 3,000
units/mL. How many mL will the nurse give?
Correct Answer: 1
Rationale:
50 units/kg × 60 kg = 3,000 units
3,000 units3,000 units/mL=1 mL\frac{3,000 \text{ units}}{3,000 \text{ units/mL}} = 1 \text{
mL}3,000 units/mL3,000 units=1 mL
ORDERED RESPONSE
1. The nurse is caring for multiple cancer patients. In which sequence should the patients be seen? Arrange from highest to
lowest priority:
1. A post-mastectomy patient ready for discharge education
2. A patient with multiple myeloma who just had a transfusion
3. A neutropenic patient with a temperature of 102.8°F
4. A thrombocytopenic patient who recently received platelets
5. A patient with colon cancer reporting pain at level 6/10
Correct Order: 3, 5, 4, 2, 1
Rationale:
 1st: The neutropenic patient with a high fever is at immediate risk of sepsis.
 2nd: Pain rated 6/10 should be addressed to improve comfort and function.
 3rd: The patient with low platelets is at risk for bleeding complications.
 4th: Post-transfusion monitoring is important but less urgent.
 5th: Discharge education is the lowest clinical urgency.
Chapter 12. Nursing Care of Hospital patients Having Surgery
MULTIPLE CHOICE
1. A hospitalized patient who is NPO for a planned surgery has been on long-term oral steroid treatment and is scheduled
to receive Prednisone 10 mg orally at 0600. What should the nurse do?
1. Inform the registered nurse (RN).
2. Inquire about the reason for the patient’s steroid use.
3. Administer the oral steroid with a small amount of water.
4. Call the pharmacy for an IV alternative.
Correct Answer: 1
Rationale: Patients on chronic steroids must not abruptly discontinue them, even when NPO, due to the risk of
serious complications like circulatory collapse. The nurse must notify the RN, who will consult with the provider to
likely change the route of administration.
(Ref: p. 177)
2. A patient recovering from abdominal hysterectomy is experiencing discomfort from gas. What should the nurse do?
1. Offer a hot drink.
2. Provide another blanket.
3. Assist the patient to walk.
4. Use an abdominal binder.
Correct Answer: 3
Rationale: Encouraging ambulation promotes bowel movement and relieves gas pains by enhancing GI function.
Other options do not address the gas pain directly.
(Ref: p. 193)
3. A nurse responds to a call light and finds a patient sitting upright with visible evisceration. What is the immediate
nursing action?
1. Call the physician at once.
2. Ready the patient for emergency surgery.
3. Lay the patient in low Fowler position.
4. Cover the wound with moist sterile towels.
Correct Answer: 3
Rationale: First, place the patient in low Fowler position with knees slightly flexed to minimize strain on the
abdomen. Cover the wound next and then alert the physician.
(Ref: p. 196)
4. The nurse is checking lab results before a patient’s surgery. Which lab value should be reported to the surgeon?
1. BUN 12 mg/dL
2. Glucose 383 mg/dL
3. Potassium 4.1 mEq/L
4. Sodium 140 mEq/L
Correct Answer: 2
Rationale: Glucose of 383 mg/dL is abnormally high and should be communicated to the surgeon before
proceeding. The other values are within normal limits.
(Ref: p. 175)
5. While caring for a postoperative patient, the nurse notes the following: O₂ saturation 82%, temp 99.1°F, pulse 74 bpm,
BP 112/64 mm Hg. What should be reported?
1. O₂ saturation
2. Temperature
3. Pulse
4. Blood pressure
Correct Answer: 1
Rationale: An O₂ saturation of 82% is dangerously low and requires immediate attention. The other readings are
within expected postoperative ranges.
(Ref: p. 187)
6. A patient scheduled for a mastectomy has not signed the consent form and states, “The doctor didn’t go over the risks
with me.” What should the nurse do?
1. Read the consent aloud and request a signature.
2. Explain the surgery’s risks and have the patient sign.
3. Sign the form on behalf of the patient.
4. Contact the surgeon and inform them the patient is uninformed.
Correct Answer: 4
Rationale: Nurses cannot obtain informed consent if the patient has not been properly educated. The provider must
address the patient’s concerns before proceeding.
(Ref: p. 179)
7. A patient had a colostomy yesterday and has not urinated since the catheter was removed one hour post-op. What is the
nurse’s best action?
1. Reinsert the Foley catheter.
2. Notify the provider.
3. Perform a straight catheterization.
4. Massage the bladder.
Correct Answer: 2
Rationale: The nurse should not act without a physician’s order. Notify the provider for further instructions.
Bladder massage can cause discomfort after abdominal surgery.
(Ref: pp. 193–194)
8. Which patient scheduled for surgery has the greatest risk of postoperative complications?
1. 32-year-old volleyball player
2. 41-year-old social drinker
3. 52-year-old vegan construction worker
4. 65-year-old smoking half a pack daily
Correct Answer: 4
Rationale: Older age and smoking significantly increase surgical risk. The other individuals do not present serious
risk factors.
(Ref: p. 174)
9. A patient develops a fever within 24 hours of surgery. What is the appropriate nursing response?
1. Limit fluid intake.
2. Give antipyretic.
3. Encourage deep breathing and coughing.
4. Begin passive ROM exercises.
Correct Answer: 3
Rationale: Fever soon after surgery often indicates atelectasis. Deep breathing and coughing help reopen alveoli
and prevent respiratory complications.
(Ref: p. 187)
10. During the pre-op interview, which medication requires urgent reporting to the surgeon?
1. Warfarin
2. Regular insulin
3. Atenolol
4. Gabapentin
Correct Answer: 1
Rationale: Warfarin is a blood thinner and poses bleeding risks during surgery. The other drugs typically do not
require immediate reporting.
(Ref: p. 177)
11. While assisting in the OR, which action observed by the LPN/LVN requires correction?
1. A scrub tech scrubs while wearing a ring.
2. A scrub tech wears scrubs, shoe covers, cap, and mask.
3. The circulating nurse sets the OR temperature to 74.6°F.
4. The surgeon removes their watch before scrubbing.
Correct Answer: 1
Rationale: Jewelry, including rings, should be removed before scrubbing to prevent contamination. The other
practices are appropriate and follow OR protocol.
(Ref: p. 184)
12. A patient scheduled for surgery states he ate two hours ago, despite NPO orders. What should the nurse do?
1. Document and send the patient to surgery.
2. Inform the surgeon immediately.
3. Reschedule the surgery later in the day.
4. Ask what he ate because liquids may be allowed.
Correct Answer: 2
Rationale: Eating before surgery, especially under general anesthesia, increases aspiration risk. The surgeon must
be notified to determine whether to delay the procedure.
(Ref: p. 176)
13. A patient undergoing surgery experiences malignant hyperthermia. What action should the nurse prepare for?
1. Continue anesthesia and surgery while administering oxygen.
2. Warm the patient and resume surgery after fluids.
3. Switch to a different anesthetic agent.
4. Stop surgery, cool the patient, and administer dantrolene.
Correct Answer: 4
Rationale: Malignant hyperthermia is a medical emergency requiring immediate cessation of surgery and
anesthesia. Dantrolene sodium is the drug of choice to treat the condition.
(Ref: p. 186)
14. A nurse is teaching a patient about a high-protein diet for recovery. Which food choice shows understanding?
1. A large apple and a serving of leafy greens
2. A grilled chicken breast and a small egg
3. Half a cup of rice and broccoli
4. One cup of plain pasta and bread
Correct Answer: 2
Rationale: Chicken and eggs are protein-rich, supporting wound healing. The other options are primarily
carbohydrates or fiber with minimal protein.
(Ref: p. 198)
15. A patient with advanced lung cancer is undergoing surgery. What is the most likely purpose?
1. Cosmetic
2. Curative
3. Diagnostic
4. Palliative
Correct Answer: 4
Rationale: In advanced cancer cases, surgery is often palliative, aimed at relieving symptoms such as airway
obstruction, not curing the disease.
(Ref: p. 171)
16. After outpatient surgery, which oxygen saturation reading supports readiness for discharge?
1. 70%–79%
2. 80%–85%
3. 86%–90%
4. Greater than 90%
Correct Answer: 4
Rationale: Patients must have an oxygen saturation above 90% to meet safe discharge criteria following
ambulatory procedures.
(Ref: p. 189)
17. When should the nurse give a prophylactic antibiotic to a surgical patient?
1. During the procedure
2. One hour before the operation
3. Four hours before surgery
4. Within two hours after surgery
Correct Answer: 2
Rationale: Prophylactic antibiotics are most effective in preventing surgical infections when administered within
one hour before incision.
(Ref: p. 181)
18. A patient reports pain level 4 after hernia surgery. Orders include ibuprofen 400 mg every 6 hours PRN. What should
the nurse do?
1. Administer ibuprofen as prescribed.
2. Call for a stronger pain medication.
3. Wait until the second day to start ibuprofen.
4. Hold the ibuprofen due to GI concerns.
Correct Answer: 1
Rationale: Ibuprofen is appropriate for a moderate pain level of 4. There is no indication the patient is at high risk
of GI upset, and the order should be followed.
(Ref: p. 193)
19. Which procedure indicates surgical removal of an organ?
1. Endoscopy
2. Urostomy
3. Angioplasty
4. Gastrectomy
Correct Answer: 4
Rationale: A gastrectomy refers to the removal of the stomach. The other terms relate to procedures involving
viewing, creating an opening, or repairing.
(Ref: p. 171)
20. A patient is scheduled for an appendectomy for a ruptured appendix. What level of surgical urgency does this
represent?
1. Elective
2. Emergency
3. Urgent
4. Optional
Correct Answer: 2
Rationale: A ruptured appendix requires emergency surgery to prevent severe complications such as peritonitis.
(Ref: p. 171)
21. A post-op patient rates their pain at 8/10. Vitals: BP 80/54, RR 10/min, HR 64. Morphine 4 mg IV is ordered PRN.
What is the nurse’s priority action?
1. Tell the patient they cannot receive more medication.
2. Give 2 mg of morphine IV.
3. Administer the full 4 mg dose.
4. Report to the RN.
Correct Answer: 4
Rationale: The patient’s low blood pressure and respiratory rate make it unsafe to administer morphine. The RN
must be notified to reassess and consider alternatives.
(Ref: p. 189)
MULTIPLE RESPONSE
1. A postoperative patient is at risk for deep vein thrombosis (DVT). Which interventions should the nurse include in the
care plan? (Select all that apply.)
1. Assist with early ambulation
2. Apply anti-embolism stockings
3. Massage the patient’s legs every day
4. Put a pillow under the knees
5. Encourage leg exercises 10 times every hour while awake
Correct Answers: 1, 2, 5
Rationale: Early movement, compression stockings, and regular leg exercises help prevent DVT by promoting
circulation. Massaging the legs can dislodge clots, and pillows under knees can impede blood flow.
(Ref: p. 191)
2. The nurse is reinforcing pre-op teaching on coughing and deep breathing. Which patient statements show correct
understanding? (Select all that apply.)
1. “I shouldn’t breathe deeply after surgery.”
2. “Shallow breathing helps reduce pain.”
3. “Deep breathing and coughing prevent lung issues.”
4. “I’ll practice these every hour while awake.”
5. “I’ll begin coughing and deep breathing two days after surgery.”
Correct Answers: 3, 4
Rationale: Deep breathing prevents atelectasis, and coughing mobilizes secretions to prevent pneumonia. These
should begin immediately and be done hourly while awake.
(Ref: p. 176)
3. The nurse is reviewing labs before a patient’s liver surgery. Which results must be on the chart? (Select all that apply.)
1. Potassium
2. Complete blood count (CBC)
3. Type and crossmatch
4. Bleeding time
5. Amylase
6. Thyroid-stimulating hormone (TSH)
Correct Answers: 1, 2, 3, 4
Rationale: Electrolytes, CBC, blood typing, and coagulation studies are vital for surgical preparation. Amylase and
TSH are not routinely required for liver surgery.
(Ref: p. 175)
4. Before witnessing a surgical consent, what must the nurse confirm? (Select all that apply.)
1. The patient’s next of kin
2. When the patient last ate
3. When a sedative was last given
4. That the patient understands the surgery
5. That the family’s questions were answered
Correct Answers: 3, 4
Rationale: Patients must not sign consent while sedated. Nurses must ensure the patient understands the procedure
before witnessing consent. Family understanding is not legally required.
(Ref: p. 179)
5. Which patient statements suggest they understand discharge instructions after abdominal surgery? (Select all that apply.)
1. “I’ll make an appointment to see the surgeon.”
2. “I can remove the stitches myself in a few days.”
3. “If pain meds don’t work, I’ll take a second dose.”
4. “My spouse will help change my dressing every day.”
5. “I’ll tell my doctor if I get a fever at home.”
Correct Answers: 1, 4, 5
Rationale: Scheduling follow-up, seeking help with dressing care, and monitoring for fever indicate proper
understanding. Patients should not self-remove sutures or take extra medication doses.
(Ref: p. 197)
6. Why should deep breathing exercises be taught before a cholecystectomy? (Select all that apply.)
1. Pain from incision reduces lung expansion
2. Anesthesia causes secretions to build up
3. Anesthesia decreases mucus production
4. Incision location hinders full lung expansion
5. Post-op immobility promotes secretion buildup
Correct Answers: 2, 4, 5
Rationale: General anesthesia suppresses coughing and encourages mucus buildup. Upper abdominal incisions and
immobility also reduce lung expansion and increase the risk of respiratory complications.
(Ref: p. 197)
7. A nurse is helping teach older adults preparing for joint surgery. Which actions enhance learning? (Select all that apply.)
1. Avoid repeating important content
2. Use medical terms to boost understanding
3. Give handouts with black print on white, glare-free paper
4. Teach in a room with bright fluorescent lighting
5. Show a positive attitude and emphasize self-care
Correct Answers: 3, 5
Rationale: Older patients benefit from simple handouts with good contrast and encouragement to promote self-
care. Avoiding repetition or using medical jargon hinders understanding.
(Ref: p. 173)
8. Six hours after an epidural block, which symptoms should the nurse report to the RN? (Select all that apply.)
1. Clear fluid at the injection site
2. Headache
3. Dizziness
4. Nausea
5. Oxygen saturation of 97%
6. Blurry vision
Correct Answers: 1, 2, 3, 4, 6
Rationale: Symptoms like fluid leakage, headache, and neurological signs are complications of epidural anesthesia.
Normal oxygen saturation does not need reporting.
(Ref: p. 199)
COMPLETION
1. A patient had two 240-mL juice boxes, 800 mL of water, 120 mL of gelatin, two 40-mL sodas, and 1,000 mL of IV
fluids. What is the total intake in mL?
Correct Answer: 2480
Rationale: 240 + 240 + 800 + 120 + 40 + 40 + 1000 = 2480 mL
(Ref: p. 199)
2. A nurse is administering 1 g of cefazolin in 100 mL NS to infuse over 30 minutes. What rate should be set on the IV
pump (mL/hr)?
Correct Answer: 200
Rationale: 100 mL in 30 minutes = 200 mL/hr infusion rate.
(Ref: p. 199)
3. A provider orders 1,000 mL of Lactated Ringer’s over 2 hours. What infusion rate will the nurse use?
Correct Answer: 500
Rationale: 1,000 mL ÷ 2 hrs = 500 mL/hr
(Ref: p. 199)
4. The nurse needs to administer 1 mg of Dilaudid. Available: 2 mg/mL. How many mL should be given?
Correct Answer: 0.5
Rationale: 1 mg ÷ 2 mg/mL = 0.5 mL
(Ref: p. 199)
Chapter 13. Nursing Care of Hospital patients With Emergent Conditions and
Disaster/Bioterrorism Response
MULTIPLE CHOICE
1. A patient arrives at the emergency department with a partial-thickness thermal burn. What treatment should the nurse
anticipate being ordered?
1. Apply wet dressings
2. Use a clean (non-sterile) dressing method
3. Apply moisturizing lotion
4. Apply silver sulfadiazine cream
Correct Answer: 4
Rationale: Partial-thickness burns are typically treated by cleaning the area with sterile saline and applying a thin
layer (about 1/8 inch) of silver sulfadiazine cream, followed by dry, bulky dressings. Wet dressings increase
infection risk and heat loss, and lotions are not appropriate due to infection risk.
(Ref: p. 211)
2. A patient who has swallowed a corrosive substance begins vomiting. What complication is the nurse most likely to
prepare to manage?
1. Coma
2. Esophageal injury
3. Chemical pneumonitis
4. Aspiration pneumonia
Correct Answer: 2
Rationale: Vomiting after ingesting a corrosive chemical can burn the esophagus as the substance travels upward.
Chemical pneumonitis is more common with inhaled poisons, and aspiration pneumonia is linked to impaired
airway protection.
(Ref: p. 211)
3. During a safety training session, an oilfield worker learns how to manage snake bites. Which statement shows accurate
understanding?
1. “I should elevate the affected arm or leg above the heart.”
2. “I won’t cover the wound with a bandage.”
3. “I should use ice to control the swelling.”
4. “I need to clean the wound using soap and water.”
Correct Answer: 4
Rationale: Snake bite sites should be gently cleaned with soap and water. Elevation, cold application, or avoiding a
dressing can worsen outcomes and are not recommended.
(Ref: p. 215)
4. A provider informs the nurse that a patient has blood leaking into the chest cavity, leading to a collapsed lung. Which
condition is this?
1. Cardiac tamponade
2. Pneumothorax
3. Myocardial contusion
4. Hemothorax
Correct Answer: 4
Rationale: A hemothorax involves blood accumulation in the pleural space, which can collapse the lung.
Pneumothorax involves air, not blood; cardiac tamponade involves the pericardium, and myocardial contusion is
heart bruising.
(Ref: p. 208)
5. Which patient should the nurse prioritize for assessment?
1. Patient with wheezing after epinephrine treatment for anaphylaxis
2. Car accident victim cleared of spinal injury
3. Patient treated with antivenom for a snake bite yesterday
4. Patient with a tetanus booster after a nail puncture
Correct Answer: 1
Rationale: The patient with wheezing after an anaphylactic event is the most critical and should be seen first, as
airway compromise may still occur.
(Ref: p. 206)
6. A patient has frostbite on their foot. What nursing intervention is most appropriate?
1. Rub the area briskly to improve circulation
2. Apply a snug, moist, sterile bandage
3. Encourage walking
4. Elevate the foot above heart level
Correct Answer: 4
Rationale: Elevating the frostbitten extremity helps reduce swelling and supports circulation. Rubbing can cause
more tissue damage, and ambulation should be avoided.
(Ref: p. 212)
7. A patient with heat exhaustion has the following lab results. Which should concern the nurse most?
1. Calcium 9.1 mg/dL
2. Sodium 128 mEq/L
3. Glucose 72 mg/dL
4. Potassium 4.0 mEq/L
Correct Answer: 2
Rationale: A sodium level of 128 indicates hyponatremia, which is common in heat exhaustion due to excessive
fluid loss and needs to be addressed.
(Ref: p. 213)
8. A patient in hypovolemic shock may have internal bleeding. What should the nurse do first?
1. Give prescribed antibiotics
2. Insert a large-bore IV
3. Start a blood transfusion
4. Begin IV fluid infusion
Correct Answer: 2
Rationale: Establishing IV access with a large-bore catheter is the initial priority to administer fluids or blood.
Antibiotics are not the priority in hypovolemic shock.
(Ref: p. 205)
9. A head injury patient scores: eye opening to pain, verbal response as incomprehensible, and motor response as
withdrawal from pain. What is their Glasgow Coma Scale score?
1. 15
2. 11
3. 8
4. 3
Correct Answer: 3
Rationale: The GCS score totals 8 (Eye = 2, Verbal = 2, Motor = 4). This suggests a serious neurological deficit.
(Ref: p. 203)
10. A spinal cord injury at L2–L4 would most likely cause what functional deficit?
1. Loss of anal sphincter control
2. Inability to flex the foot and extend toes
3. Inability to move the legs
4. Inability to move the arms
Correct Answer: 3
Rationale: L2–L4 injuries affect leg movement. Arm movement and sphincter control are associated with injuries
higher or lower in the spinal column.
(Ref: p. 204)
11. Which of the following is considered a source of an open penetrating injury?
1. Knife
2. Bullet
3. Shrapnel from an explosion
4. Baseball bat
Correct Answer: 1
Rationale: A knife results in an open penetrating wound. Bullets and shrapnel typically cause closed penetrating
injuries, while a baseball bat causes blunt trauma.
(Ref: p. 208)
12. A patient reports stepping on a nail while gardening. What is the most important question for the nurse to ask?
1. “Was the nail rusty or new?”
2. “How long was the nail?”
3. “When did you last receive a tetanus shot?”
4. “Did the nail break the skin?”
Correct Answer: 3
Rationale: Tetanus prevention is the priority, so confirming the date of the last tetanus immunization is essential.
Nail age or length are not as clinically significant.
(Ref: p. 210)
13. While assisting at a football game, the nurse cares for an injured player. Which action is incorrect?
1. Helping the patient sit upright
2. Asking if there is pain
3. Checking vital signs
4. Assessing breathing effort
Correct Answer: 1
Rationale: The patient should not be moved or repositioned until a spinal injury is ruled out. Sitting the patient up
prematurely could worsen a neck or spine injury.
(Ref: p. 210)
MULTIPLE RESPONSE
1. A near-drowning victim is being treated. Which factors are associated with a more favorable outcome? (Select all that
apply.)
1. Submersion lasted over an hour
2. Water was clean
3. Water temperature was warm
4. Patient is elderly
5. Patient has a family history of drowning
Correct Answers: 2, 3
Rationale: Clean water and warmer temperatures reduce complications. Prolonged submersion and older age
worsen prognosis. Family history is not a relevant factor.
(Ref: p. 215)
2. A patient has been diagnosed with botulism. What actions should the nurse plan to carry out? (Select all that apply.)
1. Evaluate gag reflex
2. Monitor oxygen levels
3. Administer blood transfusion
4. Begin parenteral nutrition
5. Prepare for lumbar puncture
Correct Answers: 1, 2, 4
Rationale: Botulism affects neuromuscular function and respiratory status, so assessing swallowing and
oxygenation is vital. Parenteral nutrition may be needed. Blood transfusions and lumbar punctures are not part of
standard botulism care.
(Ref: p. 217)
3. When receiving a patient with an amputated limb, which actions should the nurse take? (Select all that apply.)
1. Place the limb on ice
2. Rinse the limb with saline
3. Soak the limb in ice water
4. Wrap the limb in sterile gauze
5. Place the limb in a sealed plastic bag
Correct Answers: 1, 2, 4, 5
Rationale: The proper approach is to rinse the limb, wrap it in sterile gauze, seal it in a bag, and place that bag on
ice. Immersing the part in ice water is contraindicated.
(Ref: p. 206)
ORDERED RESPONSE
1. You are triaging patients after an explosion. Rank them in order of treatment priority based on triage principles:
1. 15-year-old with a minor bleeding foot laceration
2. 36-year-old with no pulse or respirations and a severe head wound
3. 70-year-old short of breath but no arrhythmias
4. 5-year-old with a suspected arm fracture
5. 58-year-old with abdominal swelling and pain
Correct Order: 3, 5, 4, 1, 2
Rationale: Priority is given to those with severe but survivable injuries. A patient with airway issues comes first,
then one with abdominal signs, followed by fractures, minor wounds, and finally deceased or non-viable patients.
(Ref: p. 216)
2. When conducting a primary assessment in the ER, in what order should the nurse perform the survey?
1. Exposure
2. Breathing
3. Disability
4. Airway
5. Circulation
Correct Order: 4, 2, 5, 3, 1
Rationale: The correct sequence for trauma assessment is ABCDE—Airway, Breathing, Circulation, Disability
(neurological status), and Exposure (undressing and evaluating injuries).
(Ref: p. 202)
COMPLETION
1. The nurse is preparing to give morphine 6 mg IV to a gunshot wound patient. The concentration available is 10 mg/mL.
How many mL should the nurse administer?
Correct Answer: 0.6
Rationale: (6 mg ÷ 10 mg/mL) = 0.6 mL
(Ref: p. 205)
2. A nurse is administering 1,000 mL of D5NS over 4 hours using a 15 gtt/mL set. What is the IV flow rate in drops per
minute (gtt/min)?
Correct Answer: 63
Rationale:
1000 mL×15 gtt/mL240 min=62.5≈63 gtt/min\frac{1000 \, \text{mL} \times 15 \, \text{gtt/mL}}{240 \, \text{min}} = 62.5 \approx 63
\, \text{gtt/min}240min1000mL×15gtt/mL=62.5≈63gtt/min
(Ref: p. 205)
Chapter 14. Developmental Considerations and Chronic Illness in the Nursing
Care of Adults
MULTIPLE CHOICE
1. The nursing practitioner is caring for a group of hospital patients. Which hospital patient
is at highest risk for the nursing diagnosis of risk for caregiver role strain?
1. A 20-year-old who attends college and works nights
2. A 30-year-old who recently got married and switched jobs
3. A 45-year-old with three children who is caring for his older father with cancer
4. A 65-year-old who is living with her daughter and son-in-law
RIGHT ANSWER> 3
Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care
of Adults
Objective: 3. Describe special needs that caregivers have.
Source: pp. 229
Heading: Roles
Integrated Process: Caring
Hospital patient Need: Psychosocial
Integrity CL: Analysis (Analyzing)
Concept: Family Dynamics
Difficulty: Moderate
CLARIFICATION
1 This hospital patient is not at risk for caregiver role strain.
2 This hospital patient is not at risk for caregiver role strain.
3 This hospital patient is at high risk for caregiver role strain because he is caring
for
children and a parent.
4 This hospital patient is not at risk for caregiver role strain.
PTS: 1 CON: Family Dynamics
2. The nursing practitioner is caring for a hospital patient with a chronic illness. What should
the nursing practitioner encourage the hospital patient to use as a coping resource?
1. Empower caregivers.
2. Develop a power base.
3. Be hopeful for a disease cure.
4. Develop a realistic, hopeful attitude.
RIGHT ANSWER> 4
Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care
of Adults
Objective: 5. Plan interventions for a hospital patient who is
chronically ill. Source: pp. 227
Heading: Nursing Care
Integrated Process: Caring
Hospital patient Need: Physiological
Integrity CL: Application (Applying)
Concept: Stress
Difficulty: Moderate
CLARIFICATION
1 Empowering caregivers and developing a power base are not strategies to cope
with a chronic illness.
2 Empowering caregivers and developing a power base are not strategies to cope
with a chronic illness.
3 Hope should not be directed toward a cure that may not be possible, but rather
at living a quality life with the functional capacity that the hospital patient has.
4 Before coping resources can be used, hope must be established by the hospital
patient. False hope is not beneficial and should be replaced with realistic hope.
Providing hospital patients with accurate knowledge regarding his or her fears
helps do this.
PTS: 1 CON: Stress
3. The nursing practitioner is teaching an older adult about avoidance of risky behaviors.
Which statement made by the hospital patient would be of most concern to the nurse?
1. “I exercise after work to help alleviate stress.”
2. “My husband and I go to a meditation class every week.”
3. “I drink two or three beers after work to help me relax.”
4. “I play the piano a few times every week to unwind.”
RIGHT ANSWER> 3
Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care
of Adults
Objective: 4. Explain health promotion methods.
Source: pp. 223
Heading: Common Health Concerns
Integrated Process: Communication and Documentation
Hospital patient Need: Health Promotion and
Maintenance CL: Evaluation (Evaluating)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1 Exercise is a healthy way to relax.
2 Meditation is a good way to relax.
3 Drinking alcohol daily can lead to chronic illness.
4 Music is a healthy way to relax.
PTS: 1 CON: Health Promotion
4. The nursing practitioner is assessing an older adult. The nursing practitioner would
expect to classify the hospital patient in which Erikson’s stage of development?
1. Trust versus mistrust
2. Industry versus inferiority
3. Identity versus role confusion
4. Integrity versus despair
RIGHT ANSWER> 4
Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care
of Adults
Objective: 1. List Erikson’s eight stages of psychosocial development.
Source: pp. 222
Heading: Erikson’s Stages of Psychosocial Development (Table 14.1)
Integrated Process: Caring
Hospital patient Need: Psychosocial
Integrity CL: Analysis (Analyzing)
Concept: Self
Difficulty: Moderate
CLARIFICATION
1 An infant is in trust versus mistrust stage.
2 A school-age child is in the industry versus inferiority stage.
3 An adolescent is in the identity versus role confusion stage.
4 The hospital patient is in integrity versus despair stage of development.
PTS: 1 CON: Self
5. The nursing practitioner is discussing sexual intimacy with an older hospital patient. Which
statement made by the hospital patient requires correction by the nurse?
1. “Getting my hair and nails done boosts my self-esteem.”
2. “Sexual intimacy is only achieved by sexual intercourse.”
3. “I may need to discuss medication to help with impotence with my doctor.”
4. “I am going to meet with a sexual counselor this week.”
RIGHT ANSWER> 2
Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care
of Adults
Objective: 5. Plan nursing interventions for a hospital patient who is
chronically ill. Source: pp. 228
Heading: Sexuality
Integrated Process: Communication and Documentation
Hospital patient Need: Psychosocial Integrity
CL: Evaluation (Evaluating) Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 This statement does not require correction.
2 Sexual intimacy can be achieved by hugging, touching, or spending time
together.
3 This statement does not require correction.
4 This statement does not require correction.
PTS: 1 CON: Sexuality
6. The nursing practitioner is caring for a hospital patient with a chronic illness who no
longer works and does not qualify for disability. To whom should the nursing practitioner
refer the hospital patient?
1. The physician
2. A social worker
3. A pharmacist
4. A dietitian
RIGHT ANSWER> 2
Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care
of Adults
Objective: 5. Plan nursing interventions for a hospital patient who is
chronically ill. Source: pp. 229
Heading: Finances
Integrated Process: Caring
Hospital patient Need: Health Promotion and
Maintenance CL: Application (Applying)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1 A physician does not help the hospital patient and family with finding financial
resources.
2 A social worker can assist the hospital patient and family with finding
financial resources.
3 A pharmacist does not assist the hospital patient and family with finding
financial
resources.
4 A dietitian does not assist the hospital patient and family with finding financial
resources.
PTS: 1 CON: Health Promotion
7. The nursing practitioner is caring for a hospital patient who just received a diagnosis of
terminal cancer. Which might the nursing practitioner observe in this hospital patient?
1. Despair
2. Hopefulness
3. Gratitude
4. Serenity
RIGHT ANSWER> 1
Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care
of Adults
Objective: 2. Identify the effects of chronic illness.
Source: pp. 226
Heading: Health, Wellness, and Illness
Integrated Process: Caring
Hospital patient Need: Psychosocial
Integrity CL: Evaluation (Evaluating)
Concept: Stress
Difficulty: Moderate
CLARIFICATION
1 This hospital patient is likely experiencing despair.
2 This hospital patient is likely not experiencing hopefulness.
3 This hospital patient is likely not experiencing gratitude.
4 This hospital patient is likely not experiencing serenity.
PTS: 1 CON: Stress
8. The nursing practitioner is teaching a class about suicide prevention. Which individual is
at highest risk for suicide?
1. A 25-year-old woman
2. A 30-year-old man
3. A 60-year-old woman
4. A 70-year-old man
RIGHT ANSWER> 4
Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care
of Adults
Objective: 2. Identify effects of chronic disease.
Source: pp. 224
Heading: Common Health Concerns
Integrated Process: Caring
Hospital patient Need: Psychosocial
Integrity CL: Analysis (Analyzing)
Concept: Stress
Difficulty: Moderate
CLARIFICATION
1 An accumulation of losses for the older adult can lead to depression and a
feeling of hopelessness. Hopelessness is related to a high rate of suicide in
older adults, especially older men.
2 An accumulation of losses for the older adult can lead to depression and a
feeling of hopelessness. Hopelessness is related to a high rate of suicide in
older adults, especially older men.
3 An accumulation of losses for the older adult can lead to depression and a
feeling of hopelessness. Hopelessness is related to a high rate of suicide in
older adults, especially older men.
4 An accumulation of losses for the older adult can lead to depression and a
feeling of hopelessness. Hopelessness is related to a high rate of suicide in
older adults, especially older men.
PTS: 1 CON: Stress
9. The nursing practitioner is caring for a 23-year-old hospital patient who is in the intimacy
versus isolation stage of development. Which statement would confirm this?
1. “I wish I would have spent more time with my family when I was younger.”
2. “I feel like I’ve been working at my job and have nothing to show for.”
3. “I am considering going to dinner with a guy I like, but I am happy with my life
the way it is.”
4. “I am not afraid to die because I will get to be with my darling husband.”
RIGHT ANSWER> 3
Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care
of Adults
Objective: 1. List Erickson’s eight stages of psychosocial development.
Source: pp. 223
Heading: Erikson’s Stages of Psychosocial Development (Table 14.1)
Integrated Process: Caring
Hospital patient Need: Psychosocial
Integrity CL: Analysis (Analyzing)
Concept: Self
Difficulty: Moderate
CLARIFICATION
1 This is the integrity versus despair stage.
2 This is the generativity versus stagnation stage.
3 This is the intimacy versus isolation stage.
4 This is the integrity versus despair stage.
PTS: 1 CON: Self
10. The nursing practitioner is talking to a 45-year-old hospital patient who states she
switched jobs, bought a red convertible, and pierced her nose. The nursing practitioner
suspects the hospital patient is experiencing which of the following?
1. Midlife crisis
2. Suicidal ideation
3. Empty nest
4. Chronic illness
RIGHT ANSWER> 1
Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care
of Adults
Objective: 1. List Erickson’s eight stages of psychosocial development.
Source: pp. 223
Heading: The Middle-Aged Adult
Integrated Process: Psychosocial
Hospital patient Need: Psychosocial
Integrity
CL: Application (Applying) Concept:
Stress
Difficulty: Moderate
CLARIFICATION
1 This individual is experiencing a midlife crisis.
2 The hospital patient is not experiencing suicidal ideation.
3 The hospital patient is not experiencing signs of empty nest.
4 The hospital patient is not experiencing signs of chronic illness.
PTS: 1 CON: Stress
11. Which is the leading cause of death among the middle-adult age group?
1. Emphysema
2. Liver disease
3. Kidney failure
4. Cardiovascular disease
RIGHT ANSWER> 4
Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care
of Adults
Objective: 2. Identify the effects of chronic illness.
Source: pp. 223
Heading: Common Health Concerns
Integrated Process: Caring
Hospital patient Need: PHYS—Basic Care and
Comfort CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Emphysema is not the leading cause of death among middle-aged adults.
2 Liver disease is not the leading cause of death among middle-aged adults.
3 Kidney disease is not the leading cause of death among middle-aged adults.
4 Cardiovascular disease and cancer are the leading causes of death among the
middle-aged adult group.
PTS: 1 CON: Perfusion
MULTIPLE RESPONSE
1. Which are factors leading to the development of chronic disease? (Select all that apply.)
1. Frequent exercise
2. Exposure to air pollution
3. Substance abuse
4. Eating a balanced diet
5. Stress
RIGHT ANSWER> 2, 3, 5
Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care
of Adults
Objective: 2. Identify the effects of chronic illness.
Source: pp. 223
Heading: Incidence of chronic disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Health Promotion
Difficulty: Moderate
CLARIFICATION
1. Exercise does not contribute to the development of chronic disease.
2. Exposure to air and water pollution can contribute to chronic disease.
3. Substance abuse can contribute to chronic disease.
4. Eating a balanced diet can prevent chronic disease.
5. Stress is a contributing factor to chronic disease.
PTS: 1 CON: Health Promotion
2. The nursing practitioner is contributing to a staff education program about adult health
concerns. Which common health concerns of middle-aged adults should the nursing
practitioner include? (Select all that apply.)
1. Stroke
2. Hypertension
3. Kidney failure
4. Visual changes
5. Alzheimer disease
6. Cardiovascular disease
RIGHT ANSWER> 2, 4, 6
Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care
of Adults
Objective: 2. Identify the effects of chronic illness.
Source: pp. 223
Heading: Types of Chronic Illness
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Health Promotion and Maintenance
CL: Application (Applying) Concept:
Health Promotion
Difficulty: Moderate
CLARIFICATION
1. Kidney disease, stroke, and Alzheimer disease typically occur in older
adults.
2. Middle-aged adults are those ages 45 to 65 years. Visual changes,
hypertension, and heart disease are major health concerns of middle age.
3. Kidney disease, stroke, and Alzheimer disease typically occur in older
adults.
4. Middle-aged adults are those ages 45 to 65 years. Visual changes,
hypertension, and heart disease are major health concerns of middle age.
5. Kidney disease, stroke, and Alzheimer disease typically occur in older
adults.
6. Middle-aged adults are those ages 45 to 65 years. Visual changes,
hypertension, and heart disease are major health concerns of middle age.
PTS: 1 CON: Health Promotion
3. The nursing practitioner is contributing to a staff education program about chronic illness.
What should the nursing practitioner include as being congenital diseases? (Select all that
apply.)
1. Cancer
2. Spina bifida
3. Cystic fibrosis
4. Sickle cell anemia
5. Huntington disease
6. Malabsorption syndrome
RIGHT ANSWER> 2, 6
Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care
of Adults
Objective: 2. Identify the effects of chronic illness.
Source: pp. 225
Heading: Examples of Chronic Illnesses by Cause
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Basic Care and
Comfort CL: Application (Applying) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1. Cancer is an acquired disease.
2. Malabsorption syndrome and spina bifida are congenital diseases.
3. Cystic fibrosis is a genetic disorder.
4. Sickle cell anemia is a genetic disorder.
5. Huntington disease is a genetic disorder.
6. Malabsorption syndrome and spina bifida are congenital diseases.
PTS: 1 CON: Hospital patient-Centered Care
4. The nursing practitioner is teaching health promotion to a group of hospital patients. Which
hospital patients are at highest risk for developing chronic disease? (Select all that
1. apply.)
A hospital patient who smokes pack per day
2. A hospital patient who drinks alcohol daily
3. A hospital patient who exercises three times weekly
4. A hospital patient who has a family history of heart disease
5. A hospital patient who lives near a fossil fuel–burning plant
RIGHT ANSWER> 1, 2, 4, 5
Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care
of Adults
Objective: 2. Identify the effects of chronic illness.
Source: pp. 225
Heading: Common Health Concerns
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Health Promotion and Maintenance
CL: Analysis (Analyzing) Concept:
Health Promotion
Difficulty: Moderate
CLARIFICATION
1. This hospital patient is at high risk for developing chronic disease.
2. This hospital patient is at high risk for developing chronic disease.
3. This hospital patient is not at risk for developing chronic disease.
4. This hospital patient is at risk for developing chronic disease.
5. This hospital patient is at risk for developing chronic disease.
PTS: 1 CON: Health Promotion
5. The nursing practitioner is teaching a group of chronically ill adults about coping with their
illness. Which statements indicate an understanding of the teaching? (Select all that apply.)
1. “If I have worse symptoms, I will call my doctor.”
2. “I will join a support group of others who have my disease.”
3. “If I feel better, I don’t need to take my daily medications.”
4. “I will check my blood glucose four times every day.”
5. “I should schedule activities during times I have less energy.”
6. “I am going to meet my daughter twice a week for lunch.”
RIGHT ANSWER> 1, 2, 4, 6
Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care
of Adults
Objective: 5. Plan nursing interventions for a hospital patient who is
chronically ill. Pages: 226–227
Heading: Nursing Care
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Evaluation (Evaluating)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1. The hospital patient understands teaching when they state they will notify
the doctor for worsening symptoms.
2. Joining a support group indicates an understanding of the teaching.
3. This requires further teaching; medication should be taken as prescribed.
4. This indicates an understanding of the teaching.
5. Activities should be scheduled when the hospital patient has more energy;
this requires further teaching.
6. This indicates an understanding of teaching.
PTS: 1 CON: Health Promotion
6. The nursing practitioner is teaching a group of caregivers about risk factors for elder abuse.
Which of the following psychosocial factors should the nursing practitioner assess for in the
caregiver? (Select all that apply.)
1. Depression
2. Grieving
3. Burnout
4. Stress
5. Extra energy
6. Role strain
RIGHT ANSWER> 1, 2, 3, 4, 6
Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care
of Adults
Objective: 3. Describe the special needs that caregivers have.
Pages: 228–229
Heading: Roles
Integrated Process: Caring
Hospital patient Need: Psychosocial
Integrity CL: Application (Applying)
Concept: Family Dynamics
Difficulty: Moderate
CLARIFICATION
1. A caregiver experiencing this emotion is at risk for abusing the hospital
patient.
2. A caregiver experiencing this emotion is at risk for abusing the hospital
patient.
3. A caregiver experiencing this emotion is at risk for abusing the hospital
patient.
4. A caregiver experiencing this emotion is at risk for abusing the hospital
patient.
5. This does not lead to elder abuse.
6. A caregiver experiencing this emotion is at risk for abusing the hospital
patient.
PTS: 1 CON: Family Dynamics
7. Which can lead to a loss of independence for older adults? (Select all that apply.)
1. Inability to drive
2. Loss of hearing
3. Ability to cook
4. Loss of vision
5. Dementia
RIGHT ANSWER> 1, 2, 4, 5
Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care
of Adults
Objective: 2. Identify the effects of chronic illness.
Source: pp. 230
Heading: Common Health Concerns
Integrated Process: Caring
Hospital patient Need: PHYS—Basic Care and
Comfort CL: Application (Applying) Concept:
Safety
Difficulty: Moderate
CLARIFICATION
1. Inability to drive leads to loss of dependence.
2. Loss of hearing leads to loss of dependence.
3. Ability to cook does not lead to loss of dependence.
4. Loss of vision leads to loss of dependence.
5. Dementia leads to loss of dependence.
PTS: 1 CON: Safety
8. The nursing practitioner is participating in the creation of a teaching seminar about healthy
behaviors for the young adult. What topics should the nursing practitioner suggest be included in
this seminar? (Select all that apply.)
1. Diet and exercise
2. Avoiding tobacco use
3. Avoiding sun exposure
4. Restricting hours of sleep
5. Performing self-examinations
RIGHT ANSWER> 1, 2, 3, 5
Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care
of Adults
Objective: 4. Explain health promotion methods.
Source: pp. 222
Heading: Health Promotion
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Application (Applying)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1. Young adults should understand the importance of diet and exercise in
maintaining health for themselves and their children. Lifelong positive
health practices help prevent long-term health complications. Avoiding sun
exposure and using sunscreen are important to avoid sunburn, permanent
sun damage to the skin, and increased risk of skin cancer. Tobacco use
started in the teen years is often carried on throughout young adulthood and
is linked to chronic bronchitis; emphysema; and oral, throat, and lung cancer
in later life. Additional preventive measures that may be taught at this stage
include breast self-examination for women and testicular self- examination
for men.
2. Young adults should understand the importance of diet and exercise in
maintaining health for themselves and their children. Lifelong positive
health practices help prevent long-term health complications. Avoiding sun
exposure and using sunscreen are important to avoid sunburn, permanent
sun damage to the skin, and increased risk of skin cancer. Tobacco use
started in the teen years is often carried on throughout young adulthood and
is linked to chronic bronchitis; emphysema; and oral, throat, and lung cancer
in later life. Additional preventive measures that may be taught at this stage
include breast self-examination for women and testicular self- examination
for men.
3. Young adults should understand the importance of diet and exercise in
maintaining health for themselves and their children. Lifelong positive
health practices help prevent long-term health complications. Avoiding sun
exposure and using sunscreen are important to avoid sunburn, permanent
sun damage to the skin, and increased risk of skin cancer. Tobacco use
started in the teen years is often carried on throughout young adulthood and
is linked to chronic bronchitis; emphysema; and oral, throat, and lung
cancer in later life. Additional preventive measures that may be taught at
this stage include breast self-examination for women and testicular self-
examination for men.
4. Restricting hours of sleep is not a healthy behavior.
5. Young adults should understand the importance of diet and exercise in
maintaining health for themselves and their children. Lifelong positive
health practices help prevent long-term health complications. Avoiding sun
exposure and using sunscreen are important to avoid sunburn, permanent
sun damage to the skin, and increased risk of skin cancer. Tobacco use
started in the teen years is often carried on throughout young adulthood and
is linked to chronic bronchitis; emphysema; and oral, throat, and lung cancer
in later life. Additional preventive measures that may be taught at this stage
include breast self-examination for women and testicular self- examination
for men.
PTS: 1 CON: Health Promotion
9. The nursing practitioner is teaching a group of hospital patients about illness caused by
genetics. Which topics should the nursing practitioner include in the teaching? (Select all
that apply.)
1. Emphysema
2. Multiple sclerosis
3. Huntington disease
4. Cystic fibrosis
5. Sickle cell anemia
6. Spina bifida
RIGHT ANSWER> 3, 4, 5
Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care
of Adults
Objective: 2. Identify the effects of chronic illness.
Source: pp. 225
Heading: Examples of Chronic Illnesses by Cause (Box 14.1)
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Application (Applying)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1. Emphysema is an acquired condition.
2. Multiple sclerosis is an acquired condition.
3. Huntington disease is a genetic condition.
4. Cystic fibrosis is a genetic condition.
5. Sickle cell anemia is a genetic condition.
6. Spina bifida is a congenital anomaly.
PTS: 1 CON: Health Promotion
Chapter 15. Nursing Care of Older Adult Hospital patients
MULTIPLE CHOICE
1. The nursing practitioner is concerned about medication safety for a hospital patient with
confusion. Which action should the nursing practitioner recommend be included in the
hospital patient’s plan of care to address this issue?
1. Instruct the hospital patient to take all of the medications together.
2. Have the hospital patient set up the medications for an entire week.
3. Have a family member set up and administer the medications.
4. Have the hospital patient turn medication bottles upside down after taking medication.
RIGHT ANSWER> 3
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 4. Plan nursing care for the physiological and psychological changes associated
with advancing age.
Source: pp. 243
Heading: Medication Management
Integrated Process: Communication and Documentation
Hospital patient Need: SECE—Safety and Infection
Control CL: Application (Applying)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 This is not helpful as medications have specific instructions for how to take and
when to take them and taking them all at once could lead to complications.
2 This is not useful for a hospital patient with confusion as he or she may have
issues with known time or date which could lead to skipping or doubling the
medication.
3 Having a family member assist with the medications is the best option for
someone with confusion.
4 The hospital patient could become more confused if expected to turn medication
bottles upside down after use.
PTS: 1 CON: Safety
2. The nursing practitioner is caring for an older adult who is experiencing early signs
of inadequate oxygenation. Which clinical manifestation can the nursing practitioner
expect to find?
1. Increased energy
2. New-onset confusion
3. Elevated blood glucose
4. Respiratory rate of 18
RIGHT ANSWER> 2
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients Objective: 2.
Describe basic physiological changes associated with advancing age. Source: pp.
242
Heading: Nursing Care
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Analysis (Analyzing) Concept:
Oxygenation
Difficulty: Moderate
CLARIFICATION
1 Increased energy is not an early sign of decreased oxygenation.
2 Cough, fatigue, and confusion are early signs of inadequate oxygenation.
3 Elevated blood glucose is not a sign of inadequate oxygenation.
4 The respiratory rate is normal and not a sign of inadequate oxygenation.
PTS: 1 CON: Oxygenation
3. The nursing practitioner is caring for a group of older adult hospital patients. Which
hospital patient should the nursing practitioner see first?
1. A hospital patient awaiting education for foot care
2. A hospital patient with a reduced gag reflex
3. A hospital patient who just received a pneumonia vaccination
4. A hospital patient reporting constipation
RIGHT ANSWER> 2
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 4. Plan nursing care for the physiological and psychological changes associated
with advancing age.
Source: pp. 246
Heading: Nursing Care
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Coordinated Care
CL: Analysis (Analyzing) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 This hospital patient is not the highest priority.
2 This hospital patient should be seen first. A reduced gag reflex can cause
aspiration pneumonia or additional lung problems.
3 This hospital patient is not a priority; he or she received a vaccination.
4 This hospital patient should be seen but is not a priority.
PTS: 1 CON: Hospital patient-Centered Care
4. The nursing practitioner is providing care to a person who has difficulty hearing high-
pitched tones. Which action should the nursing practitioner take when caring for this
hospital patient?
1. Speak loudly from across the room.
2. Speak softly, using a near-whisper tone.
3. Speak slowly, emphasizing lip movements.
4. Speak rapidly, using multiple hand gestures.
RIGHT ANSWER> 2
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 2. Describe basic physiological changes associated with advancing age.
Source: pp. 240
Heading: Nursing Care
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Communication
Difficulty: Moderate
CLARIFICATION
1 Speaking loudly, emphasizing lip movements, or speaking rapidly with hand
gestures is not going to enhance communication with this hospital patient.
2 For older hospital patients, the first difficult sounds to discriminate are
high-pitched tones. It is often more effective to whisper when
communicating with the hearing-impaired individual, because whispering
decreases the pitch of the
sounds.
3 Speaking loudly, emphasizing lip movements, or speaking rapidly with hand
gestures is not going to enhance communication with this hospital patient.
4 Speaking loudly, emphasizing lip movements, or speaking rapidly with hand
gestures is not going to enhance communication with this hospital patient.
PTS: 1 CON: Communication
5. A 70-year-old hospital patient asks what can be done to protect his hearing. What should
the nursing practitioner recommend to the hospital patient?
1. Clean the ears of ear wax every day.
2. Cover the ears if loud noises are expected.
3. Have a hearing test performed twice a year.
4. Raise the volume on televisions and radios in the home.
RIGHT ANSWER> 2
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 4. Plan nursing care for the physiological and psychological changes associated
with advancing age.
Source: pp. 240
Heading: Nursing Care
Integrated Process: Communication and Documentation
Hospital patient Need: PHYS—Basic Care and
Comfort CL: Application (Applying)
Concept: Communication
Difficulty: Moderate
CLARIFICATION
1 Cleaning the ears of earwax everyday could lead to an ear infection.
2 It is important to use hearing protection throughout life because noise damage
to the ear is usually not reversible. The hospital patient should be encouraged
to cover
the ears if loud noises are expected.
3 Hearing tests do not need to be performed twice a year.
4 Raising the volume on televisions and radios could potentiate hearing loss.
PTS: 1 CON: Communication
6. The nursing practitioner is making a home health visit to a frail, but healthy 86-year-old
hospital patient. The nursing practitioner assesses a heart rate of 104 beats/minute. What
action should the nursing practitioner take?
1. Inform the physician of the heart rate immediately.
2. Teach the hospital patient deep-breathing exercises to reduce heart rate.
3. Ask about liquids the hospital patient is drinking and urination frequency.
4. Have the hospital patient request a tranquilizer from the physician at the next visit.
RIGHT ANSWER> 3
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 4. Plan nursing care for the physiological and psychological changes associated
with advancing age.
Source: pp. 246
Heading: Nursing Care
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Fluid and Electrolyte Balance Difficulty:
Moderate
CLARIFICATION
1 Further data are needed to report to the physician.
2 Deep-breathing exercises may not affect the heart rate.
3 One of the first signs of dehydration is tachycardia.
4 The hospital patient does not need a tranquilizer for this heart rate.
PTS: 1 CON: Fluid and Electrolyte Balance
7. The nursing practitioner is caring for a group of older adult hospital patients. Which
hospital patient is at highest risk for suicide?
1. A hospital patient who lives at a retirement center with his spouse and plays bingo daily
2. A hospital patient with terminal lung cancer whose spouse recently suffered a
debilitating stroke
3. A hospital patient who is single and occasionally goes on cruises with a friend
4. A hospital patient with diabetes who lives with her daughter and grandchildren
RIGHT ANSWER> 2
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 3. Describe psychological and cognitive changes associated with advancing age.
Source: pp. 242
Heading: Depression
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Psychosocial Integrity
CL: Analysis (Analyzing) Concept:
Mood
Difficulty: Moderate
CLARIFICATION
1 This hospital patient is not at highest risk for suicide.
2 This hospital patient is at high risk for suicide.
3 This hospital patient is not at highest risk for suicide.
4 This hospital patient is not at highest risk for suicide.
PTS: 1 CON: Mood
8. The nursing practitioner is caring for an older adult who has normal fine tremors of the
hand. The nursing practitioner knows that which can cause these tremors to increase?
1. Overeating
2. Depression
3. Heat
4. Activity
RIGHT ANSWER> 4
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 2. Describe basic psychological and cognitive changes associated with advancing
age.
Source: pp. 239
Heading: Nursing Care
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Neurologic Regulation Difficulty:
Moderate
CLARIFICATION
1 Hunger can lead to fine tremors of the hand.
2 Excitement can cause fine tremors of the hand.
3 Cold can cause tremors of the hand.
4 Activity can lead to fine tremors of the hand.
PTS: 1 CON: Neurologic Regulation
9. The nursing practitioner is teaching an older adult about methods to avoid constipation.
Which statement made by the hospital patient indicates a need for further teaching?
1. “I try to drink eight glasses of water each day.”
2. “I go walking for 30 minutes every day.”
3. “I take a suppository and enema daily.”
4. “My spouse bought me some high-fiber foods.”
RIGHT ANSWER> 3
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 4. Plan nursing care for the physiological and psychological changes associated
with advancing age.
Source: pp. 237
Heading: Changes in the Gastrointestinal System
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Basic Care and
Comfort CL: Evaluation (Evaluating)
Concept: Elimination
Difficulty: Moderate
CLARIFICATION
1 This statement indicates an understanding of teaching.
2 This statement indicates an understanding of teaching.
3 This statement requires further education; the hospital patient is overusing
enemas and
suppositories.
4 This statement indicates an understanding of teaching.
PTS: 1 CON: Elimination
10. The nursing practitioner is reviewing a medication history for an older adult. Which
medication would be of most concern to the nursing practitioner for a hospital patient taking
furosemide (Lasix)?
1. Atenolol (Tenormin)
2. Spironolactone (Aldactone)
3. Levothyroxine (Synthroid)
4. Azithromycin (Zithromax)
RIGHT ANSWER> 2
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 5. Identify nursing practices that promote safety for the older hospital
patient. Source: pp. 244
Heading: Evidence
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Analysis (Analyzing) Concept:
Safety
Difficulty: Moderate
CLARIFICATION
1 Atenolol is not contraindicated with furosemide.
2 Spironolactone is a diuretic as is furosemide. The nursing practitioner should
notify the health care provider (HCP) about polypharmacy.
3 Levothyroxine is not contraindicated to be taken with furosemide.
4 Azithromycin is not contraindicated to be taken with furosemide.
PTS: 1 CON: Safety
11. The nursing practitioner is caring for a hospital patient who is prone to developing
constipation. Which action should the nursing practitioner take to help this hospital
patient?
1. Give the hospital patient a Fleet enema.
2. Help the hospital patient develop an exercise routine.
3. Instruct the hospital patient to use suppositories once a week.
4. Instruct the hospital patient to take an oral laxative every night.
RIGHT ANSWER> 2
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 4. Plan nursing care for the physiological and psychological changes associated
with advancing age.
Source: pp. 238
Heading: Changes in the Gastrointestinal System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Elimination
Difficulty: Moderate
CLARIFICATION
1 Enemas, suppositories, and medications are considered only after dietary
management is found to be ineffective.
2 Educate the older hospital patient about the important relationship between
intake of fiber and water and exercise in the promotion of effective bowel
evacuation.
3 Enemas, suppositories, and medications are considered only after dietary
management is found to be ineffective.
4 Enemas, suppositories, and medications are considered only after dietary
management is found to be ineffective.
PTS: 1 CON: Elimination
12. The nursing practitioner is caring for a group of older adult hospital patients. Which
hospital patient is at highest risk for developing delirium?
1. A hospital patient with autism attending outhospital patient support groups
2. A hospital patient with a family history of dementia
3. A hospital patient who is in the intensive care unit following hip surgery
4. A hospital patient attending self-care seminars at the senior center
RIGHT ANSWER> 3
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 3. Describe the psychological and cognitive changes associated with advancing
age.
Pages: 242–243
Heading: Delirium
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Psychosocial Integrity
CL: Analysis (Analyzing) Concept:
Cognition
Difficulty: Moderate
CLARIFICATION
1 This hospital patient is not at risk for delirium.
2 This hospital patient is not at risk for delirium.
3 This hospital patient is at risk for delirium being in an unfamiliar environment
and
undergoing surgery.
4 This hospital patient is not at high risk for delirium.
PTS: 1 CON: Cognition
13. A hospital patient tells the nursing practitioner he hit a large sign at a store with his
vehicle. The nursing practitioner suspects which as a contributing factor to the accident?
1. Longer reaction time
2. Inability to maintain balance
3. Decreased hypothalamus function
4. Increased motor coordination
RIGHT ANSWER> 1
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 2. Describe basic physiological changes associated with advancing age.
Source: pp. 241
Heading: Key Changes in the Neurological System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Application (Application) Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 A longer reaction time means the hospital patient may not have been able to
react
quickly to avoid hitting the sign.
2 This would not be a contributing factor to the accident.
3 This would affect body temperature, but not contribute to the accident.
4 A decrease in motor coordination, not an increase, could contribute to the
accident.
PTS: 1 CON: Safety
14. The nursing practitioner is teaching a hospital patient with neuropathy about foot care.
Which statement made by the hospital patient indicates a need for further teaching?
1. “I should examine my feet once per week for any sores.”
2. “I will wear tennis shoes when working outside.”
3. “I should avoid putting lotion between my toes.”
4. “I need to ask my podiatrist to treat the corn on my foot.”
RIGHT ANSWER> 1
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 5. Identify nursing practices that promote safety for the older hospital
patient. Source: pp. 246
Heading: Nursing Care
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Evaluation (Evaluating)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1 Feet should be examined daily, not weekly.
2 This statement indicates an understanding.
3 This statement indicates an understanding.
4 This statement indicates an understanding.
PTS: 1 CON: Health Promotion
15. Which does the nursing practitioner identify as an extrinsic factor of aging?
1. Environmental influences
2. Biological clock theory
3. Perception of aging
4. Wear-and-tear theory
RIGHT ANSWER> 1
Chapter: Chapter 15. Nursing Care of Older Adult Hospital
patients Objective: 1. Define aging.
Source: pp. 234
Heading: Nursing Care Tip
Integrated Process: Caring
Hospital patient Need: Psychosocial
Integrity CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Environmental influences, such as pollutants, are extrinsic factors of aging.
2 The biological clock theory is an intrinsic factor based on genetic theories of
aging.
3 Perception of aging is not an extrinsic or intrinsic factor, but does influence
how an individual adapts to body structure and function over time.
4 Wear-and-tear theory is an intrinsic factor based on physiological theories of
aging.
PTS: 1 CON: Hospital patient-Centered Care
MULTIPLE RESPONSE
1. The nursing practitioner is contributing to the care plan of an immobile hospital patient.
What should the nursing practitioner recognize as increasing the hospital patient’s risk of
developing a pressure ulcer on the heels? (Select all that apply.)
1. Being obese
2. Turning every hour
3. Lying on wet linens
4. Impaired circulation
5. Elevating legs on pillows
6. Wearing oxygen at 2 L per nasal cannula
RIGHT ANSWER> 3, 4
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 4. Plan nursing care for the physiological and psychological changes associated
with advancing age.
Source: pp. 235
Heading: Nursing Care
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Application (Applying) Concept:
Mobility
Difficulty: Moderate
CLARIFICATION
1. Obesity does not necessarily increase the hospital patient’s risk for
developing a
pressure ulcer on the heels.
2. Turning every hour, elevating the legs on pillows, and using oxygen would
not contribute to the development of pressure ulcers.
3. Pressure ulcers are caused by ischemia, which results from continuous
pressure that reduces blood flow to the area. Those with impaired
circulation are at greater risk of developing a pressure ulcer. Linens should
be kept clean, dry, and wrinkle free.
4. Pressure ulcers are caused by ischemia, which results from continuous
pressure that reduces blood flow to the area. Those with impaired
circulation are at greater risk of developing a pressure ulcer. Linens should
be kept clean, dry, and wrinkle free.
5. Turning every hour, elevating the legs on pillows, and using oxygen would
not contribute to the development of pressure ulcers.
6. Turning every hour, elevating the legs on pillows, and using oxygen would
not contribute to the development of pressure ulcers.
PTS: 1 CON: Mobility
2. The nursing practitioner is contributing to a staff education program about the physical
changes of aging. What should the nursing practitioner include as a common change in the
skeletal system of an older adult? (Select all that apply.)
1. Osteoporosis
2. Eroded cartilage
3. Thickening of bone
4. Increased flexibility
5. Shortening in height
6. Increasing bone density
RIGHT ANSWER> 1, 2, 5
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 2. Describe basic physiological changes associated with advancing age.
Source: pp. 234
Heading: Key Changes in the Skeletal System
Integrated Process: Communication and Documentation
Hospital patient Need: PHYS—Basic Care and
Comfort CL: Application (Applying)
Concept: Communication
Difficulty: Moderate
CLARIFICATION
1. Some key age-related changes in the skeletal system include osteoporosis,
eroding cartilage, and shortening of height.
2. Some key age-related changes in the skeletal system include osteoporosis,
eroding cartilage, and shortening of height.
3. Age-related changes in bone structure include exaggerated bony
prominences. Flexibility decreases with aging. Bone density decreases with
aging.
4. Age-related changes in bone structure include exaggerated bony
prominences. Flexibility decreases with aging. Bone density decreases with
aging.
5. Some key age-related changes in the skeletal system include osteoporosis,
eroding cartilage, and shortening of height.
6. Age-related changes in bone structure include exaggerated bony
prominences. Flexibility decreases with aging. Bone density decreases with
aging.
PTS: 1 CON: Communication
3. The nursing practitioner is collecting data for a hospital patient who has a developing
pressure ulcer. What should the nursing practitioner expect to assess as early manifestations of a
pressure ulcer? (Select all that apply.)
1. Coolness of site to touch
2. Cyanosis of site observed
3. Report of redness at the site
4. Report of burning at the site
5. Tenderness at site when touched
6. Report of decreased sensation at site
RIGHT ANSWER> 3, 4, 5
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 4. Plan nursing care for the physiological and psychological changes associated
with advancing age.
Source: pp. 235
Heading: Key Changes in the Integumentary System
Integrated Process: PHYS—Basic Care and Comfort
Hospital patient Need: PHYS—Basic Care and
Comfort CL: Evaluation (Evaluating)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1. Early manifestations of pressure ulcer formation do not include coolness,
cyanosis, or decreased sensation at the site.
2. Early manifestations of pressure ulcer formation do not include coolness,
cyanosis, or decreased sensation at the site.
3. Early signs of pressure ulcer formation are warmth, redness, tenderness, and
a burning sensation at the potential ulcer site.
4. Early signs of pressure ulcer formation are warmth, redness, tenderness, and
a burning sensation at the potential ulcer site.
5. Early signs of pressure ulcer formation are warmth, redness, tenderness, and
a burning sensation at the potential ulcer site.
6. Early manifestations of pressure ulcer formation do not include coolness,
cyanosis, or decreased sensation at the site.
PTS: 1 CON: Mobility
4. The nursing practitioner is teaching a class about muscular age-related changes. Which
should the nursing practitioner include in her education? (Select all that apply.)
1. Increased elasticity of tendons
2. Decreased muscle tone
3. Increased muscle mass
4. Slower muscle response
5. Decreased elasticity of ligaments
RIGHT ANSWER> 2
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 2. Describe basic physiological changes associated with advancing age.
Source: pp. 235
Heading: Key Changes in the Muscular System
Integrated Process: Communication and Documentation
Hospital patient Need: PHYS—Basic Care and
Comfort CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1. The hospital patient will experience decreased elasticity of tendons.
2. The hospital patient will experience decreased muscle tone.
3. The hospital patient will experience a decrease in muscle mass.
4. The hospital patient will experience slower muscle response.
5. The aging hospital patient will experience a decreased elasticity of
PTS: 1 CON: Hospital patient-Centered Care
5. The nursing practitioner is teaching a group of older adults about medication safety.
Which statements made by these individuals would be of most concern to the nurse?
(Select all that apply.)
1. “I will not crush my pill that has a coating on it.”
2. “It is safe for me to take herbal medications with my prescription pills.”
3. “I need to cut my medication in half until my next Social Security check comes.”
4. “I will take my medicine just like my doctor explained to me.”
5. “I can’t see the label too well on my medication.”
6. “I put all my medicine in a dose divider.”
RIGHT ANSWER> 2, 3, 5
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 5. Identify nursing practices that promote safety for the older hospital
patient. Source: pp. 243
Heading: Medication Management
Integrated Process: Communication and Documentation
Hospital patient Need: SECE—Safety and Infection
Control CL: Evaluation (Evaluating)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1. This statement is a safe way to take medication.
2. This statement requires correction; the hospital patient should notify the HCP
before taking herbal medication.
3. This statement is concerning; the hospital patient should not cut pills in half
to save
money. The HCP may be able to prescribe a cheaper medication.
4. This is a safe way to take medications.
5. This should concern the nurse; the hospital patient may not be taking
medication
accurately if he or she cannot see.
6. This is a safe way to take medications.
PTS: 1 CON: Safety
6. The nursing practitioner is teaching a hospital patient at risk for osteoporosis about foods
high in calcium. Which food choices made by the hospital patient indicate an
understanding of the teaching? (Select all that apply.)
1. 1/2 cup of spinach
2. One small chicken breast
3. 2 ounces of cheese
4. 1 cup of low-fat milk
5. 1/2 cup of black beans
6. 3/4 cup of yogurt
RIGHT ANSWER> 3, 4, 6
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 4. Plan nursing care for the physiological and psychological changes associated
with advancing age.
Source: pp. 224
Heading: Nursing Care
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Evaluation (Evaluating)
Concept: Nutrition
Difficulty: Moderate
CLARIFICATION
1. Spinach is low in calcium.
2. Chicken is low in calcium.
3. Cheese is high in calcium.
4. Milk is high in calcium.
5. Black beans are low in calcium.
6. Yogurt is high in calcium.
PTS: 1 CON: Nutrition
7. The nursing practitioner is contributing to a staff education program to prevent falls in the
older population. What should the nursing practitioner include as areas to assess for fall
prevention? (Select all that apply.)
1. Use of alcohol
2. History of falls
3. Medication side effects
4. Pressure sore development
5. Gait and balance screening
RIGHT ANSWER> 1, 2, 3, 5
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 5. Identify nursing practices that promote safety for the older hospital
patient. Source: pp. 225
Heading: Evidence
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Application (Applying) Concept:
Safety
Difficulty: Moderate
CLARIFICATION
1. Assessment may include the use of alcohol; a history of falls; and review
for medications that may cause dizziness, weakness, or sleepiness, as well
as gait and balance screening.
2. Assessment may include the use of alcohol; a history of falls; and review
for medications that may cause dizziness, weakness, or sleepiness, as well
as gait and balance screening.
3. Assessment may include the use of alcohol; a history of falls; and review
for medications that may cause dizziness, weakness, or sleepiness, as well
as gait and balance screening.
4. Pressure sore development is not assessed for fall prevention in the older
hospital patient.
5. Assessment may include the use of alcohol; a history of falls; and review
for medications that may cause dizziness, weakness, or sleepiness, as well
as gait and balance screening.
PTS: 1 CON: Safety
8. The nursing practitioner is identifying ways to ensure environmental safety for an older
hospital patient. Which actions should the nursing practitioner recommend for this hospital
patient’s plan of care? (Select all that apply.)
1. Place call light within reach.
2. Demonstrate confidence during care.
3. Ask for permission before moving items.
4. Return items to hospital patient’s preferred location.
5. Plan ahead and communicate plans to hospital patient.
RIGHT ANSWER> 1, 3, 4
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 5. Identify nursing practices that promote safety for the older hospital
patient. Source: pp. 225
Heading: Evidence
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and
Infection Control CL: Application (Applying)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1. Nursing actions to ensure for environmental safety include placing the call
light within reach, asking for permission before moving items, and
returning items to the hospital patient’s preferred location.
2. Demonstrating confidence during care, planning ahead, and communicating
plans to the hospital patient are interventions to support deliberate actions.
3. Nursing actions to ensure for environmental safety include placing the call
light within reach, asking for permission before moving items, and
returning items to the hospital patient’s preferred location.
4. Nursing actions to ensure for environmental safety include placing the call
light within reach, asking for permission before moving items, and
returning items to the hospital patient’s preferred location.
5. Demonstrating confidence during care, planning ahead, and communicating
plans to the hospital patient are interventions to support deliberate actions.
PTS: 1 CON: Safety
9. The nursing practitioner is caring for a hospital patient who reports an alteration in
taste. When reviewing the health history, the nursing practitioner notes which
contributing factors to altered taste? (Select all that apply.)
1. Periodontal disease
2. Loratadine (Claritin)
3. Smokes pack per day
4. Well-fitting dentures
5. Meticulous oral care
RIGHT ANSWER> 1, 2, 3
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 4. Plan nursing care for the physiological and psychological changes associated
with advancing age.
Source: pp. 246
Heading: Nursing Care
Integrated Process: Caring
Hospital patient Need: PHYS—Basic Care and
Comfort CL: Evaluation (Evaluating) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1. Periodontal disease can result in alteration in taste.
2. Loratadine (Claritin) can cause an alteration in taste.
3. Smoking can lead to alteration in taste.
4. Well-fitting dentures do not cause an alteration in taste.
5. Meticulous oral care does not lead to alteration in taste.
PTS: 1 CON: Hospital patient-Centered Care
10. The nursing practitioner is caring for an older adult who received 2 liters of IV fluid and now
has edema of the lower extremities. Which interventions should the nursing practitioner
implement? (Select all that apply.)
1. Administer another liter of IV fluid.
2. Apply compression stockings.
3. Notify the HCP.
4. Elevate the lower extremities.
5. Encourage ambulation.
RIGHT ANSWER> 2, 3, 4
Chapter: Chapter 15. Nursing Care of Older Adult Hospital patients
Objective: 4. Plan nursing care for the physiological and psychological changes associated
with advancing age.
Source: pp. 236
Heading: Nursing Care
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1. The hospital patient has edema of the legs; more IV fluid will result in
worsening of
edema.
2. Compression stockings will reduce edema.
3. The HCP should be notified of the edema.
4. Elevating the legs will reduce edema.
5. The hospital patient should not ambulate but elevate the legs to reduce
edema.
PTS: 1 CON: Hospital patient-Centered Care
Chapter 16. Hospital patient Care Settings
MULTIPLE CHOICE
1. The nursing practitioner is making a home care visit and notes the hospital patient who is
usually talkative and alert has become lethargic and has low blood pressure. Which action
should the nursing practitioner take first?
1. Notify the registered nursing practitioner (RN).
2. Take the hospital patient to the emergency department (ED).
3. Administer a 1-liter bolus of normal saline.
4. Encourage the hospital patient to drink some caffeine.
RIGHT ANSWER> 1
Chapter: Chapter 16. Hospital patient Care Settings
Objective: 15. Plan nursing interventions for the home health care hospital patient and
caregiver. Source: pp. 257
Heading: Transition From Hospital-Based Nursing to Home Health Care
Integrated Process: Caring
Hospital patient Need: SECE—
Coordinated Care CL: Application
(Applying) Concept: Hospital patient-
Centered Care Difficulty: Moderate
CLARIFICATION
1 The licensed practical nurse/licensed vocational nursing practitioner
(LPN/LVN) should first notify the RN for any further orders from the health-
care provider (HCP).
2 The nursing practitioner does not need to take the hospital patient to the hospital
unless orders
received by the RN/HCP are not effective.
3 The LPN/LVN needs to have an order to infuse IV fluid.
4 The nursing practitioner needs to notify the RN for any further orders.
PTS: 1 CON: Hospital patient-Centered Care
2. The nursing practitioner is working with a social worker to determine proper care for a
group of hospital patients. Which hospital patient would be best suited for a private duty
nurse?
1. A hospital patient with dementia who requires total care and IV antibiotics
2. A hospital patient who is incarcerated and requires insulin injections every 4 hours
3. A hospital patient who needs assistance with cleaning and taking the correct medications
4. A hospital patient who requires blood pressure monitoring and daily dressing changes
RIGHT ANSWER> 3
Chapter: Chapter 16. Hospital patient Care Settings
Objective: 9. Explain differences in hospital versus home health nursing care.
Source: pp. 255
Heading: Private-Duty Nursing
Integrated Process: Caring
Hospital patient Need: SECE—
Coordinated Care CL: Application
(Applying) Concept: Hospital patient-
Centered Care Difficulty: Moderate
CLARIFICATION
1 A private duty nursing practitioner provides companionship and respite care;
this hospital patient needs a long-term care facility.
2 A private duty nursing practitioner provides companionship and respite care;
this hospital patient
needs a correctional nurse.
3 A private duty nursing practitioner provides companionship and respite care.
4 A private duty nursing practitioner provides companionship and respite care;
this hospital patient
needs home health care.
PTS: 1 CON: Hospital patient-Centered Care
3. During a home visit, the nursing practitioner notes that an older hospital patient is sitting in
a poorly lit room listening to the radio. When the nursing practitioner turns on a light before
starting to evaluate the hospital patient and change a dressing on a wound, the hospital patient
says, “Oh, you don’t need that light. I try to keep the lights off. Electricity is too expensive.”
Which response by the nursing practitioner is most appropriate?
1. “Oh, I didn’t realize you were pinching pennies. I’ll use my flashlight.”
2. “I will turn off the light as soon as I finish changing the dressing on your wound.”
3. “It sounds like it would be helpful for you to talk with the social worker who can
identify financial programs that could help you.”
4. “If you can’t afford electricity, you may need to consider a new residence. I can set
up a visit to a nice assisted-living complex near here.”
RIGHT ANSWER> 3
Chapter: Chapter 16. Hospital patient Care Settings
Objective: 12. Identify home safety interventions for the hospital
patient. Source: pp. 260
Heading: Safety Considerations
Integrated Process: Caring
Hospital patient Need: SECE—
Coordinated Care CL: Application
(Applying) Concept: Hospital patient-
Centered Care Difficulty: Moderate
CLARIFICATION
1 Good lighting is important to provide safe care associated with the dressing
change.
2 This option does not recognize the potential financial hardship faced by the
hospital patient.
3 The case manager can relay concerns of the home-care team to the physician
and obtain an order for a social service visit. Social workers help the hospital
patient with financial assistive services.
4 Identifying the hospital patient’s wishes and financial options would be
necessary
before exploring alternative living arrangements.
PTS: 1 CON: Hospital patient-Centered Care
4. During a home visit, the nursing practitioner documents arrival and departure time, hospital
patient vital signs, data collected for the hospital patient, and a narrative note of the hospital
patient’s response to medications and understanding of care being given. Which action does the
nursing practitioner need to take prior to submitting this documentation?
1. Obtain signature of case manager.
2. Obtain signature of hospital patient or caregiver.
3. Comment about hospital patient’s home surroundings.
4. Record the time of documentation submission.
RIGHT ANSWER> 2
Chapter: Chapter 16. Hospital patient Care Settings
Objective: 14. Identify documentation required for a home visit with a hospital
patient. Source: pp. 260
Heading: Documentation
Integrated Process: Caring
Hospital patient Need: SECE—
Coordinated Care CL: Application
(Applying) Concept: Hospital patient-
Centered Care Difficulty: Moderate
CLARIFICATION
1 The case manager does not need to sign the nurse’s documentation.
2 Items generally included in all home health documentation are the arrival and
departure times of the nurse, assessment findings, vital signs, a narrative note,
and the hospital patient’s signature verifying the nursing practitioner was
present in the home.
3 Information about the hospital patient’s home surroundings is not necessary.
4 The time of submission is not a part of the home-care documentation note.
PTS: 1 CON: Hospital patient-Centered Care
5. During a home health visit, the nursing practitioner learns that the family member who is
the primary caregiver of the hospital patient is exhausted and tense. Which nursing
diagnosis should the nursing practitioner recommend for the hospital patient’s plan of
care?
1. Social isolation
2. Caregiver role strain
3. Altered role performance
4. Ineffective therapeutic regimen management
RIGHT ANSWER> 2
Chapter: Chapter 16. Hospital patient Care Settings
Objective: 15. Plan nursing interventions for the home health care hospital patient and
caregiver. Source: pp. 260
Heading: Nursing Diagnoses, Planning, and Implementation
Integrated Process: Caring
Hospital patient Need: SECE—
Coordinated Care CL: Application
(Applying) Concept: Hospital patient-
Centered Care Difficulty: Moderate
CLARIFICATION
1 The caregiver is not demonstrating signs of social isolation, altered role
performance, or ineffective management of the therapeutic regimen.
2 Caregiver role strain is related to the management of a chronic illness and lack
of understanding of resources available. The caregiver is exhibiting signs of
role strain: exhaustion and being tense.
3 The caregiver is not demonstrating signs of social isolation, altered role
performance, or ineffective management of the therapeutic regimen.
4 The caregiver is not demonstrating signs of social isolation, altered role
performance, or ineffective management of the therapeutic regimen.
PTS: 1 CON: Hospital patient-Centered Care
6. While traveling to a hospital patient’s home for a visit, the home-care nursing
practitioner becomes lost in an unfamiliar part of town and sees a group of teenagers
hanging around a boarded-up building. Which action should the nursing practitioner take?
1. Proceed to the next appointment.
2. Pull over to the curb to look at a map.
3. Seek assistance from one of the teens.
4. Drive to a familiar area and call the hospital patient for directions.
RIGHT ANSWER> 4
Chapter: Chapter 16. Hospital patient Care Settings
Objective: 11. Explain safety practices for the nursing practitioner while making
home visits. Source: pp. 258
Heading: Safety Guidelines for Home Health Care Nursing (Box 16.3)
Integrated Process: Caring
Hospital patient Need: SECE—
Coordinated Care CL: Application
(Applying) Concept: Hospital patient-
Centered Care Difficulty: Moderate
CLARIFICATION
1 Skipping the appointment could jeopardize the hospital patient’s health and
welfare.
2 Pulling over to the curb to look at a map and asking for help could jeopardize
the nurse’s safety.
3 Pulling over to the curb to look at a map and asking for help could jeopardize
the nurse’s safety.
4 If lost in an unknown area, the home-care nursing practitioner should leave, go
to a familiar place, and contact the hospital patient for directions. The agency
also can be contacted with any concerns about home safety.
PTS: 1 CON: Hospital patient-Centered Care
7. The nursing practitioner is making home visits for a group of hospital patients. Which
hospital patient should the nursing practitioner visit first?
1. A 35-year-old reporting chest pain and dyspnea
2. A 40-year-old with a blood glucose of 160 mg/dL
3. A 45-year-old who reports vomiting twice
4. A 50-year-old awaiting a dressing change on the lower leg
RIGHT ANSWER> 1
Chapter: Chapter 16. Hospital patient Care Settings
Objective: 15. Plan nursing interventions for the home health hospital patient and
caregiver. Source: pp. 257
Heading: Steps in the Home Health Care Visit
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Coordinated Care
CL: Application (Applying) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The nursing practitioner should see this hospital patient first as she could be
experiencing a myocardial infarction (MI).
2 This blood glucose is slightly elevated, but this hospital patient does not need to
be seen
urgently.
3 This hospital patient does not need to be seen urgently; the hospital patient
with chest pain should be seen first.
4 This hospital patient does not need to be seen urgently; the hospital patient with
symptoms of an
MI should be seen first.
PTS: 1 CON: Hospital patient-Centered Care
8. During a home visit, the hospital patient asks if his spouse could take one of the hospital
patient’s prescribed pain pills for a severe headache. How should the nursing practitioner
respond to this request?
1. Explain that only 1 dose is permitted to be taken.
2. Suggest the spouse use an over-the-counter pain medication instead.
3. Discuss how frequently the spouse can safely take the prescribed pain medication.
4. Ask the spouse to contact the HCP for a prescription for the medication.
RIGHT ANSWER> 4
Chapter: Chapter 16. Hospital patient Care Settings
Objective: 15. Plan nursing interventions for the home health hospital patient and
caregiver. Source: pp. 259
Heading: Hospital patient
Education Integrated
Process: Caring
Hospital patient Need: SECE—
Coordinated Care CL: Application
(Applying) Concept: Hospital patient-
Centered Care Difficulty: Moderate
CLARIFICATION
1 The nursing practitioner cannot prescribe medication; therefore, explaining the
number of doses to be taken, suggesting the use of over-the-counter pain
medication, and discussing the frequency of taking the medication are all
outside of the nurse’s
scope of practice, could jeopardize the nurse’s license, and should not be done.
2 The nursing practitioner cannot prescribe medication; therefore, explaining the
number of doses to be taken, suggesting the use of over-the-counter pain
medication, and discussing the frequency of taking the medication are all
outside of the nurse’s scope of practice, could jeopardize the nurse’s license,
and should not be done.
3 The nursing practitioner cannot prescribe medication; therefore, explaining the
number of
doses to be taken, suggesting the use of over-the-counter pain medication, and
discussing the frequency of taking the medication are all outside of the nurse’s
scope of practice, could jeopardize the nurse’s license, and should not be done.
4 Nurses are not able to prescribe medications. The best response would be for
the spouse to contact the HCP and ask for a prescription for pain medication.
PTS: 1 CON: Hospital patient-Centered Care
9. Prior to leaving a hospital patient’s home after a visit, the nursing practitioner makes a
note in the hospital patient’s home- care folder. Why did the nursing practitioner write a note
to be kept in the hospital patient’s home?
1. Explains the amount of time each visit takes to complete
2. Provides a reminder to the hospital patient of what care is needed
3. Serves as communication between HCPs who are visiting the hospital patient
4. Provides information to justify the type and level of skilled care the
hospital patient requires
RIGHT ANSWER> 3
Chapter: Chapter 16. Hospital patient Care Settings
Objective: 14. Identify documentation required for a home health care nurse.
Source: pp. 259
Heading: Documentation
Integrated Process: Caring
Hospital patient Need: SECE—
Coordinated Care CL: Application
(Applying) Concept: Hospital patient-
Centered Care Difficulty: Moderate
CLARIFICATION
1 The communication note is not used to explain the amount of time each visit
takes to complete.
2 The communication note is not used by the hospital patient.
3 A folder with information is kept at the hospital patient’s residence. It usually
consists of relevant hospital patient information and a communication form that
all staff members complete at each visit. Similar to hospital charting, this
documentation is important to ensure continuity of care. It is even more vital in
the home setting because staff members do not receive verbal report.
4 The communication note is not used to establish homebound status or skill
level required when providing hospital patient care.
PTS: 1 CON: Hospital patient-Centered Care
MULTIPLE RESPONSE
1. The nursing practitioner completes the Outcome and Assessment Information Set
(OASIS) form upon a hospital patient’s admission to a home health care program. For which
reasons does the nursing practitioner complete this form? (Select all that apply.)
1. To determine per-visit payments
2. To collect information about hospital patient outcomes
3. To document skills used in a specific home visit
4. To develop a plan of care that meets the hospital patient’s needs
5. To generate information about the home health care agency
6. To identify relatives who will be trained as hospital patient caregivers
RIGHT ANSWER> 2, 4, 5
Chapter: Chapter 16. Hospital patient Care Settings
Objective: 14. Identify documentation required for a home visit with a hospital
patient. Source: pp. 259
Heading: Documentation
Integrated Process: Caring
Hospital patient Need: SECE—
Coordinated Care CL: Application
(Applying) Concept: Hospital patient-
Centered Care Difficulty: Moderate
CLARIFICATION
1. The OASIS form is not used to determine payment structures, document
skills used during the visit, or identify relatives to train as caregivers for the
hospital patient.
2. OASIS is used to generate information about the home health agency and
hospital patient outcomes, and to help develop a plan of care that best meets
the hospital patient’s problems.
3. The OASIS form is not used to determine payment structures, document
skills used during the visit, or identify relatives to train as caregivers for the
hospital patient.
4. OASIS is used to generate information about the home health agency and
hospital patient outcomes, and to help develop a plan of care that best meets
the
hospital patient’s problems.
5. OASIS is used to generate information about the home health agency and
hospital patient outcomes, and to help develop a plan of care that best meets
the
hospital patient’s problems.
6. The OASIS form is not used to determine payment structures, document
skills used during the visit, or identify relatives to train as caregivers for the
hospital patient.
PTS: 1 CON: Hospital patient-Centered Care
2. The nursing practitioner is visiting the home of an 80-year-old hospital patient who has
hypertension and diabetes. In addition to obtaining vital signs and blood glucose levels, what
other actions would be appropriate for the nursing practitioner to do? (Select all that apply.)
1. Inspect bathroom cupboards for contents.
2. Search the kitchen for high-salt or sugar foods.
3. Ask why the bed has not been made or the dishes washed.
4. Check the bathroom for safety bars in the tub/shower area.
5. Note the presence of scatter rugs or other impediments to free movement.
6. Ask the hospital patient about lighting at night when getting up to use the bathroom.
RIGHT ANSWER> 4, 5, 6
Chapter: Chapter 16. Hospital patient Care Settings
Objective: 12. Identify home safety interventions for the hospital patient.
Source: pp. 260
Heading: Safety Considerations
Integrated Process: Caring
Hospital patient Need: SECE—
Coordinated Care CL: Application
(Applying) Concept: Hospital patient-
Centered Care Difficulty: Moderate
CLARIFICATION
1. Searching the bathroom is not appropriate.
2. Education related to appropriate dietary measures is important, but searching
the kitchen is not appropriate.
3. Housekeeping is not within the realm of the nursing practitioner unless it is
noted to
endanger the hospital patient.
4. Checks that the nursing practitioner should do during a home visit to promote
safety for the hospital patient include checking the bathroom for safety bars,
noting the presence of scatter rugs or other hazards that impede movement,
and checking for adequate lighting.
5. Checks that the nursing practitioner should do during a home visit to
promote safety for the hospital patient include checking the bathroom for
safety bars, noting the presence of scatter rugs or other hazards that impede
movement, and checking for
adequate lighting.
6. Checks that the nursing practitioner should do during a home visit to promote
safety for the hospital patient include checking the bathroom for safety bars,
noting the presence of scatter rugs or other hazards that impede movement,
and checking for adequate lighting.
PTS: 1 CON: Safety
3. The nursing practitioner is making a third home health visit. Which observations indicate
that the hospital patient and family have understood safety instructions and recommendations
made by the nursing practitioner on an earlier visit? (Select all that apply.)
1. The hospital patient is wearing an emergency response call device.
2. The family has removed scatter rugs and installed wall-to-wall carpeting.
3. The bathtub has no nonslip mat and there is no grab bar near the shower.
4. The hospital patient’s telephone, eyeglasses, and TV remote are near the hospital patient’s
seat.
5. The hospital patient reports getting up frequently at night, but there is no
visible night- light.
6. The hospital patient’s medications are in labeled bottles with a checklist for
medication times.
RIGHT ANSWER> 1, 2, 4, 6
Chapter: Chapter 16. Hospital patient Care Settings
Objective: 12. Identify home safety interventions for the hospital
patient. Source: pp. 260
Heading: Safety Considerations
Integrated Process: Caring
Hospital patient Need: SECE—
Coordinated Care CL: Application
(Applying)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1. Observations that promote home safety include the hospital patient wearing
an emergency response call device; removal of scatter rugs throughout the
home; personal items, such as eyeglasses and the remote for the TV, located
in the hospital patient’s seating area; and medications being appropriately
labeled
with a checklist.
2. Observations that promote home safety include the hospital patient wearing
an emergency response call device; removal of scatter rugs throughout the
home; personal items, such as eyeglasses and the remote for the TV, located
in the hospital patient’s seating area; and medications being appropriately
labeled with a checklist.
3. A lack of safety devices in the bathroom and insufficient lighting indicate
that additional teaching is required by the nurse.
4. Observations that promote home safety include the hospital patient wearing
an emergency response call device; removal of scatter rugs throughout the
home; personal items, such as eyeglasses and the remote for the TV, located
in the hospital patient’s seating area; and medications being appropriately
labeled with a checklist.
5. A lack of safety devices in the bathroom and insufficient lighting indicate
that additional teaching is required by the nurse.
6. Observations that promote home safety include the hospital patient wearing
an emergency response call device; removal of scatter rugs throughout the
home; personal items, such as eyeglasses and the remote for the TV, located
in the hospital patient’s seating area; and medications being appropriately
labeled with a checklist.
PTS: 1 CON: Safety
4. The nursing practitioner is preparing a home health bag to bring to a hospital patient’s
home visit. Which supplies should the nursing practitioner carry? (Select all that apply.)
1. Gloves
2. Alcohol wipes
3. Food
4. Biohazard bag
5. Disposable underpads
RIGHT ANSWER> 2, 4, 5
Chapter: Chapter 16. Hospital patient Care Settings
Objective: 13. Describe methods of infection control for the home health care nurse.
Source: pp. 258
Heading: Infection Control
Integrated Process: Caring
Hospital patient Need: SECE—
Coordinated Care CL: Application
(Applying) Concept: Hospital patient-
Centered Care Difficulty: Moderate
CLARIFICATION
1. A nursing practitioner should always carry extra personal protective
equipment (gloves,
gown, mask, goggles).
2. A nursing practitioner should always carry alcohol wipes to clean
thermometers or other devices.
3. Nurses do not need to carry food in the home care bag.
4. The nursing practitioner should carry biohazard bags at all times.
5. The nursing practitioner should carry disposable underpads.
PTS: 1 CON: Hospital patient-Centered Care
5. The LPN/LVN is planning to work at a long-term care facility. Which skills should the
nursing practitioner plan to perform? (Select all that apply.)
1. Administer medications.
2. Supervise the RN.
3. Educate nursing assistants.
4. Document care provided.
5. Make rounds on residents.
6. Order necessary treatments.
RIGHT ANSWER> 1, 3, 4, 5
Chapter: Chapter 16. Hospital patient Care Settings
Objective: 6. Describe the role of the LPN/LVN in long-term care settings.
Source: pp. 253
Heading: Role of the LPN/LVN in Long-Term Care Services
Integrated Process: Caring
Hospital patient Need: SECE—
Coordinated Care CL: Application
(Applying) Concept: Hospital patient-
Centered Care Difficulty: Moderate
CLARIFICATION
1. The role of the LPN/LVN is to administer medication.
2. The LPN/LVN does not supervise the RN.
3. The role of the LPN/LVN is to educate and mentor nursing assistants.
4. The role of the LPN/LVN is to document care provided.
5. The LPN/LVN will make rounds on residents.
6. It is not within the LPN/LVN scope of practice to write orders for hospital
patients.
PTS: 1 CON: Hospital patient-Centered Care
6. The nursing practitioner is making a first home-care visit to a hospital patient
recently discharged after hip replacement surgery. Which home observations should the
nursing practitioner document as safety concerns? (Select all that apply.)
1. The hospital patient’s recliner faces the television.
2. A safety bar has been installed in the shower.
3. A bathmat towel is on the floor in front of the tub.
4. Smoke detectors are located in the kitchen and near the bedrooms.
5. The hospital patient has a large birdcage sitting on the floor in the middle of
the living room.
6. The hallway between the bedroom and bathroom is partially blocked by a cedar
chest.
RIGHT ANSWER> 3, 5, 6
Chapter: Chapter 16. Hospital patient Care Settings
Objective: 12. Identify home safety interventions for the hospital
patient. Source: pp. 258
Heading: Safety Considerations
Integrated Process: Caring
Hospital patient Need: SECE—
Coordinated Care CL: Application
(Applying) Concept: Hospital patient-
Centered Care Difficulty: Moderate
CLARIFICATION
1. The recliner facing the television is not a safety risk. A safety bar in the
shower is not a safety risk. Smoke detectors support home safety.
2. The recliner facing the television is not a safety risk. A safety bar in the
shower is not a safety risk. Smoke detectors support home safety.
3. The home health nursing practitioner should always assess the hospital
patient’s safety in the home. Safety concerns would include an obstruction
on the floor, such as a birdcage, and a walkway being blocked by a cedar
chest. The bathmat towel
needs to be replaced with a nonskid mat.
4. The recliner facing the television is not a safety risk. A safety bar in the
shower is not a safety risk. Smoke detectors support home safety.
5. The home health nursing practitioner should always assess the hospital
patient’s safety in the home. Safety concerns would include an obstruction on
the floor, such as a
birdcage, and a walkway being blocked by a cedar chest. The bathmat towel
needs to be replaced with a nonskid mat.
6. The home health nursing practitioner should always assess the hospital
patient’s safety in the home. Safety concerns would include an obstruction on
the floor, such as a
birdcage, and a walkway being blocked by a cedar chest. The bathmat towel
needs to be replaced with a nonskid mat.
PTS: 1 CON: Hospital patient-Centered Care
7. The nursing practitioner is preparing to make a telehealth visit to a hospital patient with a
foot wound. Which types of technology will the nursing practitioner use to complete this
visit? (Select all that apply.)
1. E-mail
2. Telephone
3. Fax machine
4. Blood pressure cuff
5. Video conferencing
RIGHT ANSWER> 1, 2, 3, 5
Chapter: Chapter 16. Hospital patient Care Settings
Objective: 15. Plan nursing interventions for the home health hospital patient and
caregiver. Source: pp. 260
Heading: Telenursing
Integrated Process: Caring
Hospital patient Need: SECE—
Coordinated Care CL: Application
(Applying) Concept: Hospital patient-
Centered Care Difficulty: Moderate
CLARIFICATION
1. Telenursing, a branch of telehealth, uses information technology and
telecommunication to provide nursing care. Various types of technology can
be used, including telephone, fax, e-mail, and video/audio conferencing.
2. Telenursing, a branch of telehealth, uses information technology and
telecommunication to provide nursing care. Various types of technology can
be used, including telephone, fax, e-mail, and video/audio conferencing.
3. Telenursing, a branch of telehealth, uses information technology and
telecommunication to provide nursing care. Various types of technology can
be used, including telephone, fax, e-mail, and video/audio conferencing.
4. A blood pressure cuff would not be used during a telehealth visit because the
nursing practitioner is not in the same room as the hospital patient.
5. Telenursing, a branch of telehealth, uses information technology and
telecommunication to provide nursing care. Various types of technology can
be used, including telephone, fax, e-mail, and video/audio conferencing.
PTS: 1 CON: Hospital patient-Centered Care
8. The nursing practitioner is planning to make home-care visits throughout the day. What
tasks should the nursing practitioner perform before beginning these visits? (Select all that
apply.)
1. Place a map in the door sleeve.
2. Plug the cell phone into the charger.
3. Check that the car’s gas tank is full.
4. Check the home-care bag for a whistle.
5. Check the wallet for at least $50 in cash.
RIGHT ANSWER> 1, 2, 3, 4
Chapter: Chapter 16. Hospital patient Care Settings
Objective: 11. Explain safety practices for the nursing practitioner while making
home visits. Source: pp. 257
Heading: Safety Guidelines for Home Health Care Nurses
Integrated Process: Caring
Hospital patient Need: SECE—
Coordinated Care CL: Application
(Applying) Concept: Safety
Difficulty: Moderate
CLARIFICATION
1. Safety tips for the nursing practitioner preparing to conduct home-care visits
includes having a map in the car, having a cell phone, making sure the car’s
gas tank
is full, and having a whistle in case help is needed.
2. Safety tips for the nursing practitioner preparing to conduct home-care visits
includes having a map in the car, having a cell phone, making sure the car’s
gas tank
is full, and having a whistle in case help is needed.
3. Safety tips for the nursing practitioner preparing to conduct home-care visits
includes having a map in the car, having a cell phone, making sure the car’s
gas tank is full, and having a whistle in case help is needed.
4. Safety tips for the nursing practitioner preparing to conduct home-care visits
includes having a map in the car, having a cell phone, making sure the car’s
gas tank
is full, and having a whistle in case help is needed.
5. Carrying a large sum of money is not required while conducting home-care
visits.
PTS: 1 CON: Hospital patient-Centered Care
9. After entering a hospital patient’s home for a visit, the nursing practitioner notes that the
living room floor is littered with trash, and pet hair is on furniture and table stands. What
should the nursing practitioner do to maintain a clean home-care bag? (Select all that apply.)
1. Take the bag back to the car.
2. Wear the bag as a shoulder bag.
3. Place the bag on a disposable pad.
4. Cleanse the bag after leaving the home.
5. Place the bag on the nearest unupholstered chair.
RIGHT ANSWER> 3, 4
Chapter: Chapter 16. Hospital patient Care Settings
Objective: 13. Describe methods of infection control for the home health care nursing
practitioner Source: pp. 258
Heading: Infection Control
Integrated Process: Caring
Hospital patient Need: SECE-
Coordinated Care CL: Application
(Applying) Concept: Hospital patient-
Centered Care Difficulty: Moderate
CLARIFICATION
1. The nursing practitioner might need something from the bag during the visit,
so taking the
bag back to the car is not safe nursing care.
2. Wearing the bag as a shoulder bag could limit the nurse’s ability to provide
safe nursing care.
3. Disposable pads can be put on the floor and the home health bag placed on
these. After the visit, the nursing practitioner should disinfect the bag before
the next visit.
4. Disposable pads can be put on the floor and the home health bag placed on
these. After the visit, the nursing practitioner should disinfect the bag before
the next visit.
5. Placing the bag on an unupholstered chair could expose the bag to
environmental hazards.
PTS: 1 CON: Hospital patient-Centered Care
Chapter 17. Nursing Care of Hospital patients at the End of Life
MULTIPLE CHOICE
1. A family member is concerned that a hospital patient near the end of life is not eating or
drinking and asks the nursing practitioner how the family can help the hospital patient
increase oral intake. Which response by the nursing practitioner is most appropriate?
1. “The best way to feed the hospital patient is with a syringe and small amounts of
water or liquid feeding.”
2. “The less the hospital patient drinks, the less urination will be necessary, and
urination can be uncomfortable at this point in the dying process.”
3. “The starvation process at the end of life is quite natural; a side benefit is that
lower doses of medications are needed to keep the hospital patient
comfortable.”
4. “As your family member becomes dehydrated from not eating or drinking, natural
endorphins will be released, which increase comfort near the end of life.”
RIGHT ANSWER> 4
Chapter: Chapter 17. Nursing Care of Hospital patients at the End of Life
Objective: 5. Describe physical changes to expect during the dying process.
Source: pp. 267
Heading: Eating and Drinking
Integrated Process: Communication and Documentation
Hospital patient Need: PHYS—Physiological
Adaptation CL: Application (Applying)
Concept: Grief and Loss
Difficulty: Moderate
CLARIFICATION
1 Feeding may not be the best action.
2 Urination is not uncomfortable.
3 Use of the word starvation may be distressing to the family.
4 Benefits in withholding artificial feeding and hydration in the final weeks of
life in actively dying hospital patients include fewer pharyngeal and lung
secretions, which can reduce dyspnea; reduced swelling around tumors, which
can reduce associated pain; and less urination, resulting in dryer skin with
fewer breakdowns. It has also been theorized that as dehydration occurs, the
body produces a form of endorphin, which enhances comfort.
PTS: 1 CON: Grief and Loss
2. The nursing practitioner is discussing a terminal diagnosis with a hospital patient. Which is
most appropriate for the nursing practitioner to include?
1. “Tell me what you know about your diagnosis.”
2. “You shouldn’t be angry or blame God for this.”
3. “The sooner you accept this diagnosis, the better.”
4. “There is a good support group you should attend.”
RIGHT ANSWER> 1
Chapter: Chapter 17. Nursing Care of Hospital patients at the End of Life
Objective: 4. Demonstrate appropriate communication with dying hospital patients and
their families.
Source: pp. 270
Heading: Communicating With Dying Hospital patients and Their Loved
Ones Integrated Process: Communication And Documentation
Hospital patient Need: Physiological
Integrity CL: Application (Applying)
Concept: Grief and Loss
Difficulty: Moderate
CLARIFICATION
1 The nursing practitioner should find out what the hospital patient knows about
his or her diagnosis.
2 The nursing practitioner cannot tell the hospital patient not to be angry.
3 The nursing practitioner should not force the hospital patient to accept the
diagnosis.
4 The hospital patient may not be ready for a support group. First, find out what
he or she
knows about his or her diagnosis.
PTS: 1 CON: Grief and Loss
3. A hospital patient with lung cancer who is expected to die within a few days is being given a
blood transfusion. Family members, who realize death is imminent, ask, “Why are you giving a
blood transfusion when we all know death is just around the corner?” Which response by the
nursing practitioner to the family is most appropriate?
1. “That question is best answered by the physician during rounds.”
2. “It is my duty as a nursing practitioner to continue to administer life-prolonging
treatments until the hospital patient dies.”
3. “The blood will raise the hemoglobin level, which will increase energy level and
sense of well-being.”
4. “The transfusion will help increase the hospital patient’s oxygen levels. It will not
prolong life, but will increase comfort.”
RIGHT ANSWER> 4
Chapter: Chapter 17. Nursing Care of Hospital patients at the End of
Life Objective: 6. Plan nursing interventions for hospital patients at the
end of life. Source: pp. 264
Heading: Nursing Care Plan for Hospital patients at the
End of Life Integrated Process: Communication and
Documentation Hospital patient Need: PHYS—
Physiological Adaptation
CL: Application (Applying) Concept:
Grief and Loss
Difficulty: Moderate
CLARIFICATION
1 It is not necessary for the family to wait for an answer from the physician.
Teaching is a nursing role.
2 It is not the nurse’s duty to provide life-prolonging treatments until the hospital
patient
dies. Nurses often administer comfort care at the end of life.
3 Comfort is the goal at the end of life, not increased energy.
4 Blood transfusions may be given to improve oxygenation and reduce dyspnea,
and are not intended to prolong life, but to promote comfort.
PTS: 1 CON: Grief and Loss
4. The nursing practitioner is caring for a hospital patient who is unconscious and begins to
make a gurgling sound, or death rattle. Which action should the nursing practitioner take?
1. Administer oxygen as ordered.
2. Instruct the hospital patient to cough.
3. Give the hospital patient a sip of water.
4. Suction the hospital patient.
RIGHT ANSWER> 4
Chapter: Chapter 17. Nursing Care of Hospital patients at the End of
Life Objective: 6. Plan nursing interventions for hospital patients at the
end of life. Source: pp. 270
Heading: The Dying Process
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Application) Concept: Grief
and Loss
Difficulty: Moderate
CLARIFICATION
1 Oxygen will not help for secretions.
2 The hospital patient is unconscious and cannot cough.
3 The hospital patient is unconscious and cannot sip water.
4 Suctioning the hospital patient will help remove secretions.
PTS: 1 CON: Grief and Loss
5. A hospital patient asks what a do not resuscitate (DNR) order means. What should the
nursing practitioner explain to the hospital patient?
1. “A DNR order means that you will not be placed on a ventilator if your heart stops
and you require CPR.”
2. “A DNR order means you will not be resuscitated if your heart stops and that all
therapeutic support will be withdrawn.”
3. “A DNR order means that you will receive everything you need to remain
comfortable, but you will not receive treatment that will prolong life.”
4. “A DNR order means you will not be resuscitated if your heart stops; you can
specify whether you still want treatment to prolong your life or only care that
keeps you comfortable.”
RIGHT ANSWER> 4
Chapter: Chapter 17. Nursing Care of Hospital patients at the End of Life
Objective: 2. List necessary legal documents for hospital patients with life-limiting
illness. Source: pp. 265
Heading: Do Not Resuscitate Orders
Integrated Process: Communication and Documentation
Hospital patient Need: Psychosocial Integrity
CL: Application (Applying) Concept:
Grief and Loss
Difficulty: Moderate
CLARIFICATION
1 A DNR order does not direct care prior to death—type and extent of treatment
prior to death is still determined by the hospital patient.
2 A DNR order does not direct care prior to death—type and extent of treatment
prior to death is still determined by the hospital patient.
3 A DNR order does not direct care prior to death—type and extent of treatment
prior to death is still determined by the hospital patient.
4 DNR simply means do not resuscitate if a hospital patient’s heart stops.
PTS: 1 CON: Grief and Loss
6. A hospital patient asks the nursing practitioner to explain a durable power of attorney.
Which statement by the nursing practitioner is most accurate?
1. “A durable power of attorney is a person you choose to speak for you when you
cannot make decisions.”
2. “It is a document that provides instruction to the health care provider regarding
your preferences.”
3. “This is a document stating you do not want to be resuscitated if your heart stops.”
4. “This gives the nursing practitioner power to make any medical decisions on your behalf.”
RIGHT ANSWER> 1
Chapter: Chapter 17. Nursing Care of Hospital patients at the End of Life Objective:
1. List necessary legal documents for hospital patients with life-limiting illness.
Source: pp. 265
Heading: Advance Directives, Living Wills, and Durable Medical Power of Attorney
Integrated Process: Communication and Documentation
Hospital patient Need: Psychosocial
Integrity CL: Application (Applying)
Concept: Grief and Loss
Difficulty: Moderate
CLARIFICATION
1 This describes a durable power of attorney.
2 This describes a living will.
3 This describes a DNR order.
4 This does not accurately describe a durable power of attorney.
PTS: 1 CON: Grief and Loss
7. The licensed practical nurse/licensed vocational nursing practitioner (LPN/LVN) notifies
the registered nursing practitioner (RN) that a hospital patient under hospice care is in
respiratory distress. Which clinical manifestation supports this finding?
1. Increased oxygen saturation
2. Decreased respiratory rate
3. Increased respiratory effort
4. Respiratory rate of 12 breaths/min
RIGHT ANSWER> 3
Chapter: Chapter 17. Nursing Care of Hospital patients at the End of Life
Objective: 5. Describe physical changes to expect during the dying process.
Source: pp. 270
Heading: Nursing Care Plan for the Hospital patient at the End of
Life Integrated Process: Clinical Problem-Solving Process
Hospital patient Need: PHYS—Physiological
Adaptation CL: Application (Applying) Concept:
Grief and Loss
Difficulty: Moderate
CLARIFICATION
1 An increased oxygen saturation does not indicate respiratory distress.
2 Decreased respiratory rate does not indicate respiratory distress.
3 Increased respiratory effort indicates respiratory distress.
4 A respiratory rate of 12 breaths/min does not indicate respiratory distress.
PTS: 1 CON: Grief and Loss
8. During the last vital signs assessment, a hospital patient with end-stage heart failure has
a body temperature of 102.6°F. Which action should the nursing practitioner take at this
time?
1. Provide additional blankets.
2. Assist to a side-lying position.
3. Encourage increased oral fluid intake.
4. Administer acetaminophen as prescribed.
RIGHT ANSWER> 4
Chapter: Chapter 17. Nursing Care of Hospital patients at the End of
Life Objective: 6. Plan nursing interventions for hospital patients at the
end of life. Source: pp. 275
Heading: Nursing Care Plan for the Hospital patient at the End of
Life Integrated Process: Caring
Hospital patient Need: PHYS—Physiological
Adaptation CL: Application (Applying) Concept:
Grief and Loss
Difficulty: Moderate
CLARIFICATION
1 Providing additional blankets would be appropriate if the hospital patient’s
temperature was subnormal.
2 Assisting to a side-lying position has no clinical significance for the hospital
patient
experiencing a fever.
3 The hospital patient’s health status may not support an increase in oral fluids.
4 For the terminally ill hospital patient experiencing a fever, the nursing
practitioner should provide acetaminophen, an antipyretic, as prescribed.
PTS: 1 CON: Grief and Loss
9. The nursing practitioner is reviewing the chart of a hospital patient to determine if he is
appropriate for hospice. Which qualification supports hospice care?
1. Hospital patient unresponsive
2. Need for 24-hour care
3. Prognosis of 6 months or less
4. Diagnosis of cancer
RIGHT ANSWER> 3
Chapter: Chapter 17. Nursing Care of Hospital patients at the End of Life
Objective: 3. Explain choices that are available to hospital patients at the end
of life. Source: pp. 267
Heading: Hospice Care
Integrated Process: Caring
Hospital patient Need: SECE—
Coordinated Care CL: Application
(Applying) Concept: Grief and Loss
Difficulty: Moderate
CLARIFICATION
1 Being unresponsive is not a qualification for hospice.
2 Hospice typically does not provide 24-hour care.
3 The qualification for hospice is a 6-month or less prognosis.
4 Hospice takes hospital patients of any diagnosis as long as it is terminal.
PTS: 1 CON: Grief and Loss
10. The nursing practitioner is caring for a dying hospital patient under hospice care.
Which is an example of nonverbal communication?
1. Make eye contact with the hospital patient.
2. Encourage the hospital patient to reminisce.
3. Ask close-ended questions.
4. Answer any questions the hospital patient may have.
RIGHT ANSWER> 1
Chapter: Chapter 17. Nursing Care of Hospital patients at the End of Life Objective: 4.
Describe appropriate communication with dying hospital patients and their families.
Source: pp. 264
Heading: Communicating With Hospital patients and Their Loved
Ones Integrated Process: Communication and Documentation
Hospital patient Need: Psychosocial
Integrity CL: Application (Applying)
Concept: Grief and Loss
Difficulty: Moderate
CLARIFICATION
1 Eye contact is a form of nonverbal communication.
2 This is verbal communication.
3 This is verbal communication.
4 This is verbal communication.
PTS: 1 CON: Grief and Loss
MULTIPLE RESPONSE
1. The nursing practitioner is providing care to a hospital patient with a terminal illness. What
should be the nurse’s priorities when providing care to this hospital patient? (Select all that
apply.)
1. Helping the hospital patient define goals of care
2. Preparing the family for life after the hospital patient has died
3. Encouraging the hospital patient to have hope for a full recovery
4. Supporting the hospital patient through losses leading to a good death
5. Helping the hospital patient communicate care wishes to health care providers (HCPs)
RIGHT ANSWER> 1, 4, 5
Chapter: Chapter 17. Nursing Care of Hospital patients at the End of
Life Objective: 6. Plan nursing interventions for hospital patients at the
end of life. Source: pp. 264
Heading: Communicating With Hospital patients and Their Loved
Ones Integrated Process: Caring
Hospital patient Need: Psychosocial
Integrity CL: Application (Applying)
Concept: Grief and Los
Difficulty: Moderate
CLARIFICATION
1. The role of the nursing practitioner with hospital patients nearing the end of
life include helping to identify hospital patients with life-limiting illnesses
early, so they and their families have the opportunity to redefine their goals
of care; help hospital patients communicate their wishes to HCPs, both orally
and in writing; to ensure that their wishes are understood; and give hospital
patients support and validation as they move through the series of losses
leading to a good death.
2. Preparing the family for life after the hospital patient has died is not a priority
at this
time.
3. Encouraging the hospital patient to have hope for a full recovery would be
unrealistic
and not fair to the hospital patient.
4. The role of the nursing practitioner with hospital patients nearing the end of
life include helping to identify hospital patients with life-limiting illnesses
early, so they and their families have the opportunity to redefine their goals
of care; help hospital patients communicate their wishes to HCPs, both
orally and in writing; to ensure that their wishes are understood; and give
hospital patients support and validation as they
move through the series of losses leading to a good death.
5. The role of the nursing practitioner with hospital patients nearing the end of
life include helping to identify hospital patients with life-limiting illnesses
early, so they and their families have the opportunity to re-define their goals
of care; help hospital patients communicate their wishes to HCPs, both orally
and in writing; to ensure that their wishes are understood; and give hospital
patients support and validation as they move through the series of losses
leading to a good death.
PTS: 1 CON: Grief and Loss
2. The nursing practitioner is reviewing the nutritional status for a group of hospital patients.
In which hospital patients would a feeding tube most likely be beneficial? (Select all that
apply.)
1. An 80-year-old patent with dementia
2. A 76-year-old hospital patient with terminal cancer
3. A 65-year-old hospital patient recovering from pneumonia
4. A 90-year-old hospital patient with diabetes and heart failure
5. A 55-year-old with esophageal cancer who is receiving radiation therapy
6. A 55-year-old hospital patient receiving chemotherapy and experiencing loss of appetite
RIGHT ANSWER> 3, 5, 6
Chapter: Chapter 17. Nursing Care of Hospital patients at the End of
Life Objective: 6. Plan nursing interventions for hospital patients at the
end of life. Source: pp. 266
Heading: Artificial Feeding and Hydration
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Analysis (Analyzing) Concept:
Grief and Loss
Difficulty: Moderate
CLARIFICATION
1. Using a feeding tube for a hospital patient with dementia will not improve
quality of life. The hospital patients with terminal cancer, heart failure, and
diabetes are not going to survive and tube feeding can increase
complications and reduce
comfort at the end of life.
2. Using a feeding tube for a hospital patient with dementia will not improve
quality of life. The hospital patients with terminal cancer, heart failure, and
diabetes are not going to survive and tube feeding can increase
complications and reduce comfort at the end of life.
3. Hospital patients who are expected to recover from an acute process or are
experiencing an intervention that currently complicates oral intake would
benefit the most from a feeding tube. This includes the hospital patient
recovering from pneumonia, receiving radiation treatment for esophageal
cancer, and
receiving chemotherapy.
4. Using a feeding tube for a hospital patient with dementia will not improve
quality of life. The hospital patients with terminal cancer, heart failure, and
diabetes are not going to survive and tube feeding can increase
complications and reduce
comfort at the end of life.
5. Hospital patients who are expected to recover from an acute process or are
experiencing an intervention that currently complicates oral intake would
benefit the most from a feeding tube. This includes the hospital patient
recovering from pneumonia, receiving radiation treatment for esophageal
cancer, and receiving chemotherapy.
6. Hospital patients who are expected to recover from an acute process or are
experiencing an intervention that currently complicates oral intake would
benefit the most from a feeding tube. This includes the hospital patient
recovering from pneumonia, receiving radiation treatment for esophageal
cancer, and
receiving chemotherapy.
PTS: 1 CON: Grief and Loss
3. A hospital patient with terminal cancer has just died. Which actions should the nursing
practitioner take during the immediate postmortem period? (Select all that apply.)
1. Bathe and dress the hospital patient.
2. Ask the family if they want the hospital patient’s face covered or uncovered.
3. Remove all tubes, medical supplies, and equipment from the bedside.
4. Provide the family a place away from the hospital patient’s room to talk and grieve.
5. Notify the physician with the hospital patient’s time of death per institutional policy.
6. Recommend that the family donate the hospital patient’s organs as a way to find
meaning from the death.
RIGHT ANSWER> 1, 2, 3, 5
Chapter: Chapter 17. Nursing Care of Hospital patients at the End
of Life Objective: 7. Describe postmortem care.
Source: pp. 275
Heading: Care at the Time of Death and Afterward
Integrated Process: Caring
Hospital patient Need: PHYS—Physiological
Adaptation CL: Application (Applying) Concept:
Grief and Loss
Difficulty: Moderate
CLARIFICATION
1. After death, the nursing practitioner will provide postmortem care. First,
remove the tubes, medical supplies, and equipment. Bathing and dressing
the hospital patient and making him or her look presentable for the family
shows respect.
2. After death, the nursing practitioner will provide postmortem care. First,
remove the tubes, medical supplies, and equipment. Bathing and dressing the
hospital patient and
making him or her look presentable for the family shows respect.
3. After death, the nursing practitioner will provide postmortem care. First,
remove the tubes, medical supplies, and equipment. Bathing and dressing
the hospital patient and making him or her look presentable for the family
shows respect.
4. Allow the family time with the hospital patient; do not remove the body until
they are ready. Contacting the physician and funeral home are carried out
according to institutional policy. Covering or uncovering the face at removal
should be done according to the family’s wishes.
5. After death, the nursing practitioner will provide postmortem care. First,
remove the tubes, medical supplies, and equipment. Bathing and dressing the
hospital patient and
making him or her look presentable for the family shows respect.
6. Information about organ donation should be provided according to agency
policy, but the nursing practitioner should not make recommendations.
PTS: 1 CON: Grief and Loss
4. A dying hospital patient is experiencing copious secretions, difficulty in swallowing,
and labored breathing. Which interventions should the nursing practitioner perform?
(Select all that apply.)
1. Suction secretions.
2. Encourage oral fluids.
3. Place a dehumidifier in the room.
4. Administer scopolamine as ordered.
5. Increase oxygen to 3 L per nasal cannula.
6. Place the hospital patient in Fowler or semi-Fowler position.
RIGHT ANSWER> 1, 4, 6
Chapter: Chapter 17. Nursing Care of Hospital patients at the End of
Life Objective: 6. Plan nursing interventions for the hospital patients at
the end of life. Source: pp. 270-271
Heading: Nursing Care Plan for the Hospital patient at the End of
Life Integrated Process: Caring
Hospital patient Need: PHYS—Physiological
Adaptation CL: Application (Applying) Concept:
Grief and Loss
Difficulty: Moderate
CLARIFICATION
1. Suctioning can help reduce aspiration of secretions and help with swallowing and
breathing.
2. Encouraging oral fluids increases the risk of aspiration.
3. A dehumidifier is not helpful as it makes the air dryer and that may make the hospital
patient less comfortable.
4. Scopolamine (an anticholinergic medication) helps dry secretions, making breathing
and swallowing less difficult.
5. Increasing oxygen will not reduce secretions.
6. Positioning the hospital patient in an upright position can help reduce aspiration of
secretions and helps with lung expansion for better breathing.
PTS: 1 CON: Grief and Loss
5. The nursing practitioner is concerned that a hospital patient has a short time left to live.
Which criterion is the nursing practitioner using that indicates a prognosis of 6 months or
less to live? (Select all that apply.)
1. Incontinence
2. Functional decline
3. Increased agitation
4. Recurrent infections
5. Frequent hospitalizations
6. Weight loss of 10% or more
RIGHT ANSWER> 2, 4, 5, 6
Chapter: Chapter 17. Nursing Care of Hospital patients at the End of Life
Objective: 1. Identify characteristics of the hospital patient who is approaching the end
of life. Source: pp. 268
Heading: Hospice Care
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Analysis (Analyzing) Concept:
Grief and Loss
Difficulty: Moderate
CLARIFICATION
1. Agitation and incontinence can occur for many reasons and do not
necessarily predict death.
2. Some indicators of a prognosis of 6 months or less regardless of diagnosis
are functional decline, recurrent infections, frequent hospitalizations, and a
10% loss of weight in 6 months.
3. Agitation and incontinence can occur for many reasons and do not
necessarily predict death.
4. Some indicators of a prognosis of 6 months or less regardless of diagnosis
are functional decline, recurrent infections, frequent hospitalizations, and a
10% loss of weight in 6 months.
5. Some indicators of a prognosis of 6 months or less regardless of diagnosis
are functional decline, recurrent infections, frequent hospitalizations, and a
10% loss of weight in 6 months.
6. Some indicators of a prognosis of 6 months or less regardless of diagnosis
are functional decline, recurrent infections, frequent hospitalizations, and a
10% loss of weight in 6 months.
PTS: 1 CON: Grief and Loss
6. The nursing practitioner is scheduling a hospice team to meet with the family of a dying
hospital patient. Which individuals will most likely participate in this meeting? (Select all
that apply.)
1. Nursing practitioner to manage symptoms of pain and nausea
2. Social worker to assist with community resources
3. Chaplain to provide spiritual and emotional support
4. Physical therapist working to regain hospital patient ability to walk
5. Bereavement counselor to provide assistance to family and loved ones
6. Hospitalist to direct an emergency response team and provide cardiopulmonary
resuscitation (CPR)
RIGHT ANSWER> 1, 2, 3, 5
Chapter: Chapter 17. Nursing Care of Hospital patients at the End of
Life Objective: 6. Plan nursing interventions for hospital patients at the
end of life. Source: pp. 267
Heading: Communicating With Hospital patients and Their Loved
Ones Integrated Process: Caring
Hospital patient Need: SECE-
Coordinated Care CL: Application
(Applying) Concept: Grief and Loss
Difficulty: Moderate
CLARIFICATION
1. The hospice team is multidisciplinary and includes the nurse, social worker,
chaplain, and bereavement counselor in addition to the physician and home
health aide.
2. The hospice team is multidisciplinary and includes the nurse, social worker,
chaplain, and bereavement counselor in addition to the physician and home
health aide.
3. The hospice team is multidisciplinary and includes the nurse, social worker,
chaplain, and bereavement counselor in addition to the physician and home
health aide.
4. Because the hospice philosophy is one of support and symptom management,
physical therapy designed to restore function would not be involved.
5. The hospice team is multidisciplinary and includes the nurse, social worker,
chaplain, and bereavement counselor in addition to the physician and home
health aide.
6. CPR would not be appropriate for a hospice hospital patient.
PTS: 1 CON: Grief and Loss
7. The nursing practitioner is providing hospice care for a hospital patient in the terminal phase
of lung cancer. Which nursing actions would be appropriate? (Select all that apply.)
1. Provide low-dose morphine.
2. Place a fan at the hospital patient’s bedside.
3. Encourage the hospital patient to bathe daily.
4. Administer diuretic therapy as ordered.
5. Position the hospital patient upright in a recliner with pillows.
6. Teach family members how to perform deep tracheal suctioning.
RIGHT ANSWER> 1, 2, 4, 5
Chapter: Chapter 17. Nursing Care of Hospital patients at the End
of Life Objective: 6. Plan interventions for hospital patients at the
end of life.
Source: pp. 270
Heading: Nursing Care Plan for Hospital patients at the End of
Life Integrated Process: Caring
Hospital patient Need: PHYS—Physiological
Adaptation CL: Application (Applying)
Concept: Grief and Loss
Difficulty: Moderate
CLARIFICATION
1. Activities should be planned to conserve energy. Low-dose morphine reduces
pulmonary edema and anxiety. A fan or breeze reduces the feeling of
dyspnea. Diuretic therapy may increase comfort and treat dyspnea. An upright
position will help alleviate dyspnea.
2. Activities should be planned to conserve energy. Low-dose morphine reduces
pulmonary edema and anxiety. A fan or breeze reduces the feeling of
dyspnea. Diuretic therapy may increase comfort and treat dyspnea. An upright
position will help alleviate dyspnea.
3. Daily bathing is not required.
4. Activities should be planned to conserve energy. Low-dose morphine reduces
pulmonary edema and anxiety. A fan or breeze reduces the feeling of
dyspnea. Diuretic therapy may increase comfort and treat dyspnea. An upright
position will help alleviate dyspnea.
5. Activities should be planned to conserve energy. Low-dose morphine reduces
pulmonary edema and anxiety. A fan or breeze reduces the feeling of
dyspnea. Diuretic therapy may increase comfort and treat dyspnea. An upright
position will help alleviate dyspnea.
6. Deep tracheal suctioning would be invasive and painful and often irritates
tissue rather than aiding with breathing.
PTS: 1 CON: Grief and Loss
8. A terminally ill hospital patient is experiencing mouth discomfort. Which actions should
the nursing practitioner take to help this hospital patient? (Select all that apply.)
1. Offer ice chips.
2. Offer sips of water.
3. Apply lanolin to the lips.
4. Provide an alcohol-based mouthwash.
5. Use sponge-tipped toothettes for mouth care.
RIGHT ANSWER> 1, 2, 3, 5
Chapter: Chapter 17. Nursing Care of Hospital patients at the End of
Life Objective: 6. Plan nursing interventions for hospital patients at the
end of life. Source: pp. 271
Heading: Nursing Care Plan for Hospital patients at the End of
Life Integrated Process: Caring
Hospital patient Need: PHYS—Physiological
Adaptation CL: Application (Applying) Concept:
Grief and Loss
Difficulty: Moderate
CLARIFICATION
1. In the terminally ill hospital patient, a dry mouth can be due to lack of oral
intake,
disease process, or medication. The nursing practitioner should offer the
hospital patient ice chips or sips of water, apply lanolin to the lips, and use
sponge-tipped toothettes for
mouth care.
2. In the terminally ill hospital patient, a dry mouth can be due to lack of oral
intake, disease process, or medication. The nursing practitioner should offer
the hospital patient ice chips or sips of water, apply lanolin to the lips, and use
sponge-tipped toothettes for
mouth care.
3. In the terminally ill hospital patient, a dry mouth can be due to lack of oral
intake, disease process, or medication. The nursing practitioner should offer
the hospital patient ice chips or sips of water, apply lanolin to the lips, and use
sponge-tipped toothettes for mouth care.
4. An alcohol-based mouthwash can cause the oral tissues to dry further adding
to the hospital patient’s discomfort.
5. In the terminally ill hospital patient, a dry mouth can be due to lack of oral
intake, disease process, or medication. The nursing practitioner should offer
the hospital patient ice chips or sips of water, apply lanolin to the lips, and use
sponge-tipped toothettes for mouth care.
PTS: 1 CON: Grief and Loss
9. A terminally ill hospital patient who is not able to talk is demonstrating restlessness.
What actions can the nursing practitioner take to help this hospital patient achieve
comfort? (Select all that apply.)
1. Medicate for pain.
2. Elevate the head of the bed.
3. Measure oxygen saturation.
4. Reposition the hospital patient in bed.
5. Ensure incontinence pad is clean and dry.
RIGHT ANSWER> 1, 3, 4, 5
Chapter: Chapter 17. Nursing Care of Hospital patients at the End
of Life Objective: 6. Plan interventions for hospital patients at the
end of life.
Source: pp. 271
Heading: Terminal Restlessness
Integrated Process: Caring
Hospital patient Need: Psychosocial
Integrity CL: Application (Applying)
Concept: Grief and Loss
Difficulty: Moderate
CLARIFICATION
1. For the terminally ill hospital patient who is unable to verbally
communicate needs but is demonstrating restlessness, the nursing
practitioner can medicate for pain, measure oxygen saturation, reposition
the hospital patient in bed, and ensure that an
incontinence pad is clean and dry.
2. Elevating the head of the bed may increase discomfort and is used for the
hospital patient who is experiencing dyspnea or other respiratory difficulty.
3. For the terminally ill hospital patient who is unable to verbally
communicate needs but is demonstrating restlessness, the nursing
practitioner can medicate for pain, measure oxygen saturation, reposition
the hospital patient in bed, and ensure that an
incontinence pad is clean and dry.
4. For the terminally ill hospital patient who is unable to verbally communicate
needs
but is demonstrating restlessness, the nursing practitioner can medicate for
pain, measure oxygen saturation, reposition the hospital patient in bed, and
ensure that an incontinence pad is clean and dry.
5. For the terminally ill hospital patient who is unable to verbally communicate
needs but is demonstrating restlessness, the nursing practitioner can medicate
for pain, measure
oxygen saturation, reposition the hospital patient in bed, and ensure that an
incontinence pad is clean and dry.
PTS: 1 CON: Grief and Loss
10. The adult daughter of a terminally ill hospital patient is upset because the hospital patient is
confused and is talking to people who are not in the room. What should the nursing practitioner do
to help the hospital patient and daughter? (Select all that apply.)
1. Encourage the hospital patient to continue to talk.
2. Make sure that a dim light is on in the hospital patient’s room.
3. Suggest the daughter provide the hospital patient with sips of fluids.
4. Explain to the daughter that confusion is common and expected.
5. Encourage the daughter to provide tactile stimulation to the hospital patient.
RIGHT ANSWER> 1, 2, 4
Chapter: Chapter 17. Nursing Care of Hospital patients at the End of Life
Objective: 4. Demonstrate appropriate communication with dying hospital patients and
their families.
Source: pp. 273
Heading: Communicating With Dying Hospital patients and Their Loved
Ones Integrated Process: Communication and Documentation
Hospital patient Need: Psychosocial
Integrity CL: Application (Applying)
Concept: Grief and Loss
Difficulty: Moderate
CLARIFICATION
1. The terminally ill hospital patient may demonstrate acute confusion. The
family will be better prepared for this confusion if they understand why it is
occurring, and that confusion is common and expected. The hospital patient
should be encouraged to talk. A dim light in the room helps the hospital
patient remain oriented.
2. The terminally ill hospital patient may demonstrate acute confusion. The
family will be better prepared for this confusion if they understand why it is
occurring,
and that confusion is common and expected. The hospital patient should be
encouraged to talk. A dim light in the room helps the hospital patient remain
oriented.
3. Providing the hospital patient with sips of fluid would be helpful if the
hospital patient were
experiencing a dry mouth.
4. The terminally ill hospital patient may demonstrate acute confusion. The
family will be better prepared for this confusion if they understand why it is
occurring, and that confusion is common and expected. The hospital patient
should be
encouraged to talk. A dim light in the room helps the hospital patient remain
oriented.
5. Tactile stimulation does not help reduce the hospital patient’s confusion.
PTS: 1 CON: Grief and Loss
Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
MULTIPLE CHOICE
1. The nursing practitioner is caring for a hospital patient who reports enlarged, painful, and
moveable preauricular lymph nodes, postauricular lymph nodes, and cervical lymph
nodes. Which does the nursing practitioner infer from these findings?
1. Infection
2. Cancer
3. Liver failure
4. Thyroid disorder
RIGHT ANSWER> 1
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 6. Explain objective data that are collected when caring for a hospital patient
with a disorder of the immune system.
Source: pp. 286
Heading: Objective Data
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Analysis (Analyzing) Concept:
Infection
Difficulty: Moderate
CLARIFICATION
1 A hospital patient with an infection will experience tenderness and movable
lymph nodes.
2 A hospital patient with cancer will experience nonmovable lymph nodes.
3 These do not describe symptoms of liver disease.
4 These do not describe symptoms of thyroid disease.
PTS: 1 CON: Infection
2. The nursing practitioner is caring for a group of hospital patients. Which hospital patient
is at highest risk for developing systemic lupus erythematosus (SLE)?
1. An African American female
2. A Caucasian female
3. An Asian male
4. A Hispanic male
RIGHT ANSWER> 1
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 5. Explain subjective data that are collected when caring for a hospital patient
with a disorder of the immune system.
Source: pp. 309
Heading: Demographic Data
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Analysis
(Analyzing) Concept:
Immunity Difficulty:
Moderate
CLARIFICATION
1 This hospital patient is at highest risk for developing SLE.
2 This hospital patient is not as high risk as an African American female.
3 This hospital patient is not as high risk as an African American female.
4 This hospital patient is not as high risk as an African American female.
PTS: 1 CON: Immunity
3. The nursing practitioner is assisting a health care provider with subcutaneous
immunotherapy (SCIT). Which is a priority to have readily available?
1. Emergency equipment
2. Restraints
3. Antibiotic
4. Family contact information
RIGHT ANSWER> 1
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures Objective:
7. Describe nursing care provided for hospital patients undergoing diagnostic tests for the immune
system.
Pages: 292–293
Heading: Immunotherapy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Application (Applying) Concept:
Safety
Difficulty: Moderate
CLARIFICATION
1 Emergency equipment should be readily available in case of anaphylaxis.
2 The hospital patient should not be restrained.
3 An antibiotic will not be useful in immunotherapy.
4 Although contact information for family is important, it is more important to
ensure emergency equipment is on hand.
PTS: 1 CON: Safety
4. The nursing practitioner is working in a clinic when a hospital patient presents with
shortness of breath, wheezing, and hives. The nursing practitioner should plan to
implement which order first?
1. Administer morphine IV
2. Administer epinephrine IV
3. Administer ketorolac (Toradol) IV
4. Administer furosemide (Lasix) IV
RIGHT ANSWER> 2
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 8. Describe common therapeutic measures used for disorders of the immune
system.
Source: pp. 297
Heading: Allergies
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Application (Applying) Concept:
Inflammation
Difficulty: Moderate
CLARIFICATION
1 This hospital patient is likely experiencing an anaphylactic reaction; morphine is
not administered.
2 This hospital patient is likely experiencing an anaphylactic reaction; epinephrine
will be
administered.
3 This hospital patient is likely experiencing an anaphylactic reaction; Toradol
will not be given.
4 This hospital patient is likely experiencing an anaphylactic reaction; Lasix may
be
given to ease breathing and remove fluid, but it is not a priority.
PTS: 1 CON: Inflammation
5. The nursing practitioner is caring for a group of hospital patients. Which hospital patients should
the nursing practitioner see first?
1. A hospital patient with allergic rhinitis reporting frequent sneezing
2. A hospital patient who had an anaphylactic reaction 2 days ago
3. A hospital patient who just received an influenza vaccination
4. A hospital patient receiving chemotherapy with a temperature of 103°F
RIGHT ANSWER> 4
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 6. Explain objective data that are collected when caring for a hospital patient
with a disorder of the immune system.
Source: pp. 288
Heading: Objective Data
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Analysis (Analyzing) Concept:
Infection
Difficulty: Moderate
CLARIFICATION
1 This hospital patient is not the highest priority.
2 This hospital patient should be seen, but is not as high a priority as an
immunocompromised hospital patient with a fever.
3 This hospital patient is not a priority.
4 This hospital patient should be seen first because he or she is
immunocompromised and has a high fever.
PTS: 1 CON: Infection
6. The nursing practitioner is caring for a hospital patient being tested for rheumatoid
arthritis. In reviewing laboratory values, which should the nursing practitioner recognize
as being diagnostic of rheumatoid arthritis?
1. C-reactive protein = 12 mg/L
2. Negative rheumatoid factor
3. White blood cells (WBC) = 6,000/mm3
4. Negative antinuclear antibody (ANA) test
RIGHT ANSWER> 1
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 7. Describe nursing care provided for hospital patients undergoing diagnostic tests for
the immune system.
Source: pp. 289
Heading: Diagnostic Laboratory Tests for the Immune System (Table 18.4)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Analysis (Analyzing) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1 A normal C-reactive protein level is less than 10 mg/L; an elevated level is
present in rheumatoid arthritis, cancer, and SLE.
2 ANA and rheumatoid factor are positive in the presence of rheumatoid arthritis.
3 This is a normal WBC count, which measures immune function.
4 ANA and rheumatoid factor are positive in the presence of rheumatoid arthritis.
PTS: 1 CON: Immunity
7. The nursing practitioner is reinforcing teaching to a person who has tested positive for
HIV. Which test should the nursing practitioner explain is done to confirm the diagnosis of
HIV?
1. Western blot
2. Rheumatoid factor
3. ANA
4. Immunoglobulin assay
RIGHT ANSWER> 1
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 7. Describe nursing care provided for hospital patients undergoing diagnostic tests for
the immune system.
Source: pp. 290
Heading: Diagnostic Laboratory Tests for the Immune System
Integrated Process: Clinical Problem-Solving Process (nursing Process)
Hospital patient Need: SECE—Safety and Infection Control CL: Application (Applying)
Concept: Immunity
Difficulty: Moderate
CLARIFICATION
1 Western blot is used as a confirmation test for HIV.
2 This test is done to determine the presence of rheumatoid arthritis.
3 This test is done to determine the presence of rheumatoid arthritis.
4 Immunoglobulin assays are completed to determine the presence of an
infection.
PTS: 1 CON: Immunity
8. The nursing practitioner is reviewing laboratory results for a group of hospital patients
and notes a CD4 count of 120 cells/μL. For which hospital patient would the nursing
practitioner expect to see this result?
1. A hospital patient with gastroenteritis
2. A hospital patient with HIV
3. A hospital patient with allergic rhinitis
4. A hospital patient with atrial fibrillation
RIGHT ANSWER> 2
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 7. Describe nursing care provided for hospital patients undergoing diagnostic tests for
the immune system.
Source: pp. 290
Heading: Diagnostic Laboratory Tests for the Immune System (Table 18.4)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Analysis (Analyzing) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1 A CD4 count is typically used to test treatment effectiveness for an HIV
positive hospital patient.
2 This low CD4 count is seen in hospital patients with HIV.
3 A CD4 count is typically used to test treatment effectiveness for an HIV
positive hospital patient.
4 A CD4 count is typically used to test treatment effectiveness for an HIV
positive hospital patient.
PTS: 1 CON: Immunity
9. The nursing practitioner is caring for a hospital patient with a diagnosis of malaria.
Which antibody would the nursing practitioner expect to see increased?
1. Immunoglobulin G (IgG)
2. IgM
3. IgA
4. IgE
RIGHT ANSWER> 2
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 3. Discuss the function of each class of immunoglobulin and how each behaves
in a particular immune response.
Source: pp. 290
Heading: Diagnostic Laboratory Tests for the Immune System (Table 18.4)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Application (Applying) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1 IgG is not increased in malaria.
2 IgM is increased in malaria.
3 IgA is not increased in malaria.
4 IgE is not increased in malaria.
PTS: 1 CON: Immunity
10. The nursing practitioner is taking a medication history for a newly admitted hospital
patient. The hospital patient states he is allergic to levofloxacin (Levaquin). Which
response by the nursing practitioner is most appropriate?
1. “We will be sure to add this to your chart so you never receive this medication.”
2. “You need to wear a medical alert bracelet to show you have an allergy.”
3. “What happens to you when you take the medication?”
4. “You can take the medication as long as you carry an EpiPen.”
RIGHT ANSWER> 3
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 5. Explain subjective data that are collected when caring for a hospital patient
with a disorder of the immune system.
Source: pp. 288
Heading: Subjective Data Collection for the Immune System (Table 18.2)
Integrated Process: Communication and Documentation
Hospital patient Need: SECE—Pharmacological
Therapies CL: Application (Applying) Concept:
Safety
Difficulty: Moderate
CLARIFICATION
1 The nursing practitioner should first determine if the hospital patient is truly
allergic to the
medication.
2 The nursing practitioner should first determine if the hospital patient is truly
allergic to the medication.
3 The nursing practitioner should determine if the hospital patient is actually
allergic to the medication
or just has side effects. Many hospital patients think an allergy is diarrhea and
nausea.
4 The nursing practitioner should never suggest a hospital patient take a
medication he or she may be allergic to and use an EpiPen.
PTS: 1 CON: Safety
11. The nursing practitioner has administered prescribed allergen injections twice a week for
several weeks to an individual with a bee sting allergy. The hospital patient misses three
appointments. What action should the nursing practitioner take during the hospital patient’s next
visit?
1. Consult the physician to confirm the dosage to be given.
2. Administer the same dosage as was given at the last visit.
3. Administer the dosage as originally prescribed for that visit.
4. Tell the hospital patient that the entire immunotherapy schedule needs to be restarted.
RIGHT ANSWER> 1
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 8. Discuss common therapeutic measures used for disorders of the immune
system.
Source: pp. 291
Heading: Immunotherapy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Application (Applying) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1 It is important that the hospital patient does not miss an allergen injection
dose. If this happens, the allergen strength may need to be reduced, so the
physician should be consulted.
2 The same dose given during the last visit might be too strong since the hospital
patient
missed three injections.
3 The same dose given during the last visit might be too strong since the hospital
patient missed three injections.
4 The physician will determine the immunotherapy schedule. This is beyond the
nurse’s scope of practice.
PTS: 1 CON: Immunity
12. The nursing practitioner is caring for a group of hospital patients. Which hospital patient is
at highest risk for developing a latex allergy?
1. A banker
2. A construction worker
3. A nurse
4. A computer technician
RIGHT ANSWER> 3
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 5. Explain subjective data that are collected when caring for a hospital patient
with a disorder of the immune system.
Source: pp. 286
Heading: Health History
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Analysis (Analyzing) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1 A banker is not at high risk for developing a latex allergy.
2 A construction worker is not at high risk for developing a latex allergy.
3 A nursing practitioner is at high risk for developing a latex allergy.
4 A computer technician is not at high risk for developing a latex allergy.
PTS: 1 CON: Immunity
13. The nursing practitioner is reviewing laboratory values for a hospital patient and notes an
absolute neutrophil count of 300 cells/μL. The nursing practitioner knows this result means the
hospital patient is experiencing which condition?
1. Anemia
2. Neutropenia
3. Thrombocytopenia
4. Leukopenia
RIGHT ANSWER> 2
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 7. Describe nursing care provided for hospital patients undergoing diagnostic tests for
the immune system.
Source: pp. 289
Heading: Diagnostic Laboratory Tests for the Immune System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Analysis (Analyzing) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1 Anemia is a low red blood cell (RBC) count.
2 This hospital patient is experiencing neutropenia and is at high risk for infection.
3 Thrombocytopenia is low platelet count.
4 Leukopenia is a low WBC count.
PTS: 1 CON: Immunity
14. The nursing practitioner is teaching a class for older adults regarding the importance
of vaccinations. Which vaccine should the nursing practitioner suggest for this age group?
1. Meningococcal vaccine
2. Polio vaccine
3. Human papilloma virus (HPV) vaccine
4. Pneumococcal vaccine
RIGHT ANSWER> 4
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 4. Describe how the aging system affects immunity.
Source: pp. 285
Heading: Gerontological Issues
Integrated Process: Communication and Documentation
Hospital patient Need: SECE—Safety and Infection
Control CL: Application (Applying)
Concept: Immunity
Difficulty: Moderate
CLARIFICATION
1 An older adult does not need a meningococcal vaccine.
2 A polio vaccine is not required for an older adult.
3 An older adult does not require an HPV vaccine.
4 Older adults should receive the herpes zoster vaccine, influenza vaccine,
pneumococcal vaccine, and a booster for tetanus and diphtheria every 10 years.
PTS: 1 CON: Immunity
MULTIPLE RESPONSE
1. The nursing practitioner is teaching the family of a child who is allergic to peanuts about
important topics regarding the allergy. Which statements made by the parents indicate an
understanding of the teaching? (Select all that apply.)
1. “I will make sure my child wears a medical alert bracelet at all times.”
2. “I need to notify my child’s school of the peanut allergy.”
3. “I will be sure we seek medical care within hours after injecting the EpiPen.”
4. “I will make sure my child consumes a minimal amount of food with peanuts.”
5. “I am going to ensure my child carries an EpiPen at all times.”
RIGHT ANSWER> 1, 2, 5
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 8. Discuss common therapeutic measures used for disorders of the immune
system.
Source: pp. 292
Heading: Allergies
Integrated Process: Teaching/Learning
Hospital patient Need: SECE—Safety and
Infection Control CL: Application (Applying)
Concept: Immunity
Difficulty: Moderate
CLARIFICATION
1. This statement indicates an understanding of the teaching.
2. This statement indicates an understanding of the teaching.
3. Emergency care should be sought immediately after injecting the EpiPen.
4. The hospital patient with a peanut allergy cannot be exposed to any amount
of peanuts.
5. This statement indicates an understanding of the teaching.
PTS: 1 CON: Immunity
2. The nursing practitioner is caring for a hospital patient with anemia. Which laboratory
results should the nursing practitioner identify as being consistent with this diagnosis?
(Select all that apply.)
1. Red blood cell distribution width (RDW) = 12% in a 28-year-old female
2. Mean corpuscular volume (MCV) = 72/mm3 in a 19-year-old female
3. WBC = 7 × 109/L in a 39-year-old male
4. RBC = 4.4 × 1012/L in a 31-year-old male
5. WBC = 5.2 × 109/L in a 22-year-old female
6. RBC = 5.7 × 1012/L in a 43-year-old female
RIGHT ANSWER> 2, 4, 6
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 7. Describe nursing care provided for hospital patients undergoing diagnostic tests for
the immune system.
Source: pp. 289
Heading: Diagnostic Laboratory Tests for the Immune System (Table
18.4) Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: SECE—Safety and Infection Control
CL: Analysis (Analyzing) Concept:
Immunity
Difficulty: Difficult
CLARIFICATION
1. This is normal.
2. The normal number of RBCs per mm of blood for a man is 4.7 to 6.1 ×
1012/L; for a female is 4.2 to 5.4 × 1012/L; low values indicate anemia. MCV
and RDW are used to help determine the cause of anemia.
3. WBC count is indicative of immune function and is not used to determine the
presence of anemia.
4. The normal number of RBCs per mm of blood for a man is 4.7 to 6.1 ×
1012/L; for a female is 4.2 to 5.4 × 1012/L; low values indicate anemia. MCV
and RDW are used to help determine the cause of anemia.
5. WBC count is indicative of immune function and is not used to determine the
presence of anemia.
6. The normal number of RBCs per mm of blood for a man is 4.7 to 6.1 ×
1012/L; for a female is 4.2 to 5.4 × 1012/L; low values indicate anemia. MCV
and RDW are used to help determine the cause of anemia.
PTS: 1 CON: Immunity
3. The nursing practitioner is taking a health history of a hospital patient who has a weakened
immune system. Which does the nursing practitioner conclude contributed to weakening the
immune system? (Select all that apply.)
1. Craniotomy
2. Parathyroidectomy
3. Knee replacement
4. Splenectomy
5. Rhinoplasty
6. Thymectomy
RIGHT ANSWER> 4, 6
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 5. Explain subjective data that are collected when caring for a hospital patient
with a disorder of the immune system.
Source: pp. 286
Heading: Health History
Integrated Process: Communication and Documentation
Hospital patient Need: SECE—Safety and Infection
Control CL: Analysis (Analyzing)
Concept: Immunity
Difficulty: Moderate
CLARIFICATION
1. A craniotomy does not place a hospital patient at risk for a weakened immune
system.
2. A parathyroidectomy does not place a hospital patient at risk for a weakened
immune
system.
3. A knee replacement does not place a hospital patient at risk for a weakened
immune
system.
4. A splenectomy places a hospital patient at risk for a weakened immune
system.
5. Rhinoplasty does not place a hospital patient at risk for a weakened immune
system.
6. A thymectomy places a hospital patient at risk for a weakened immune
system.
PTS: 1 CON: Immunity
4. While collecting data, the nursing practitioner suspects that a hospital patient is
experiencing an immune disorder. Which data did the nursing practitioner use to come to this
conclusion? (Select all that apply.)
1. Rash
2. Fever
3. Joint pain
4. Muscle cramps
5. Swollen glands
RIGHT ANSWER> 1, 2, 3, 5
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 6. Explain objective data that are collected when caring for a hospital patient
with a disorder of the immune system.
Source: pp. 286
Heading: Objective Data
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Application (Applying) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1. A rash is a common clinical manifestation of an immune disorder.
2. Fever is a common clinical manifestation of an immune disorder.
3. Joint pain can be indicative of an immune disorder.
4. Muscle cramping is typical of an electrolyte imbalance, not an immune
disorder.
5. Swollen glands are a common clinical manifestation of an immune disorder.
PTS: 1 CON: Immunity
COMPLETION
1. The nursing practitioner is preparing to administer diphenhydramine (Benadryl) 50 mg
intravenously to a hospital patient with severe allergies. Available is diphenhydramine
(Benadryl) 25 mg/1 mL. How many mL will the nursing practitioner administer? Enter the
numeral only.
RIGHT ANSWER>
2
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 8. Discuss common therapeutic measures used for disorders of the immune
system.
Source: pp. 286
Heading: Medications
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Analysis (Analyzing) Concept:
Safety
Difficulty: Moderate
CLARIFICATION: mL = 1 mL/25 mg × 50
mg = 2 mL PTS: 1 CON: Safety
2. The nursing practitioner is administering clindamycin (Cleocin) 300 mg in 100 mL of
normal saline intravenously to run over 1 hour to a hospital patient with an infection. At
what rate will the nursing practitioner set the infusion pump? Enter the numeral only.
RIGHT ANSWER>
100
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 8. Discuss common therapeutic measures used for disorders of the immune
system.
Source: pp. 286
Heading: Medications
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Analysis (Analyzing) Concept:
Safety
Difficulty: Moderate
CLARIFICATION: mL/hr = 100 mL/1 hr =
100 mL/hr PTS: 1 CON: Safety
Chapter 19. Nursing Care of Hospital patients With Immune Disorders
MULTIPLE CHOICE
1. The nursing practitioner is contributing to a group of hospital patients care plans. Which
hospital patient should the nursing practitioner identify as being at risk for developing serum
sickness?
1. A hospital patient who receives IV penicillin for an infection
2. A hospital patient who has a transfusion with packed red blood cells (RBCs)
3. A hospital patient who is given cryoprecipitate and factor IX after an abdominal injury
4. A hospital patient given steroids and immunosuppressant therapy
after organ transplantation
RIGHT ANSWER> 1
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 2. Explain the pathophysiology of disorders of the immune system.
Source: pp. 304
Heading: Pathophysiology and Etiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS–Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1 Serum sickness is seen occasionally after administration of penicillin and
sulfonamide.
2 Serum sickness is not associated with blood transfusions, cryoprecipitate, factor
IX, steroids, or immunosuppressant therapy.
3 Serum sickness is not associated with blood transfusions, cryoprecipitate, factor
IX, steroids, or immunosuppressant therapy.
4 Serum sickness is not associated with blood transfusions, cryoprecipitate, factor
IX, steroids, or immunosuppressant therapy.
PTS: 1 CON: Immunity
2. The nursing practitioner is caring for a hospital patient with idiopathic autoimmune
hemolytic anemia. Which action should the nursing practitioner include in the plan of care
for this hospital patient?
1. Assist with ambulation
2. Teach good hand hygiene.
3. Avoid intramuscular injections.
4. Obtain manual blood pressures.
RIGHT ANSWER> 1
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 308
Heading: Nursing Care
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Safety
Difficulty: Moderate
CLARIFICATION
1 With anemia, the hospital patient will be fatigued and may have activity
intolerance and be a fall risk. Assistance with ambulation should be done for
safety.
2 This action would be appropriate if the hospital patient had neutropenia.
3 This action would be appropriate if the hospital patient had thrombocytopenia.
4 This action would be appropriate if the hospital patient had thrombocytopenia.
PTS: 1 CON: Safety
3. The nursing practitioner is reviewing orders for a hospital patient with systemic lupus
erythematosus (SLE). For which medication should the nursing practitioner request
clarification?
1. Levothyroxine (Synthroid)
2. Phenytoin (Dilantin)
3. Promethazine (Phenergan)
4. Pantoprazole (Protonix)
RIGHT ANSWER> 2
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 309
Heading: Medications Associated With Triggering Lupus Erythematosus (Box 19.1)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological
Therapies CL: Analysis (Analyzing)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 Levothyroxine does not trigger SLE.
2 Phenytoin is known to trigger SLE and should be avoided.
3 Promethazine does not trigger SLE.
4 Promethazine does not trigger SLE.
PTS: 1 CON: Safety
4. The nursing practitioner is caring for a hospital patient who is stung by a wasp. Which
manifestation should the nursing practitioner expect if an allergic reaction develops?
1. Hives
2. Retinal hemorrhage
3. Jugular vein distention
4. Pallor around the sting sites
RIGHT ANSWER> 1
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 3. Identify the etiologies, signs, and symptoms of immune system disorders.
Source: pp. 297
Heading: Signs and Symptoms
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1 Hives is one of several symptoms of an allergic reaction.
2 This manifestation is not associated with an allergic reaction.
3 This manifestation is not associated with an allergic reaction.
4 This manifestation is not associated with an allergic reaction.
PTS: 1 CON: Immunity
5. A hospital patient with type O blood is scheduled to undergo open heart surgery. Which
blood type would this hospital patient receive?
1. A
2. B
3. AB
4. O
RIGHT ANSWER> 4
Chapter: Chapter 19. Nursing Care of Hospital patients with Immune Disorders
Objective: 8. Plan nursing care for hospital patients With disorders of the immune
system. Source: pp. 303
Heading: Etiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Application (Applying) Concept:
Safety
Difficulty: Moderate
CLARIFICATION
1 Hospital patients with type O blood can only receive type O blood.
2 Hospital patients with type O blood can only receive type O blood.
3 Hospital patients with type O blood can only receive type O blood.
4 Hospital patients with type O blood can only receive type O blood.
PTS: 1 CON: Safety
6. A hospital patient is stabilized after having an allergic reaction. Which preventive
instructions should the nursing practitioner reinforce with the hospital patient?
1. Wear medical alert identification.
2. Stay indoor as much as possible.
3. Wear insect repellent when outdoors.
4. Take corticosteroids before going outdoor.
RIGHT ANSWER> 1
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 299
Heading: Nursing Care
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Application (Applying) Concept:
Safety
Difficulty: Moderate
CLARIFICATION
1 The nursing practitioner should teach the hospital patient to wear medical alert
identification for allergies for prompt medical attention to be given if the
hospital patient is unable to give information.
2 Being outside might not be the reason for the hospital patient’s allergic reaction.
3 The hospital patient might not be allergic to stinging insects.
4 This medication should not be taken prophylactically.
PTS: 1 CON: Safety
7. The nursing practitioner contributed to the teaching plan for a hospital patient with a
history of allergies to pollen. Which hospital patient action indicates an understanding of how
to control this disease?
1. Gardening outdoors on dry, windy days
2. Wearing a mask when mowing the lawn
3. Driving the car with the windows open during high pollen counts
4. Taking frequent walks outside in spring when the weather is warm
RIGHT ANSWER> 2
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 299
Heading: Therapeutic Measures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Application (Applying) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1 This would increase the hospital patient’s risk of having an allergic reaction.
2 Allergen avoidance might involve wearing a mask when mowing the lawn or
working outdoor, having heating ducts cleaned, or covering heating registers
with filters.
3 This would increase the hospital patient’s risk of having an allergic reaction.
4 This would increase the hospital patient’s risk of having an allergic reaction.
PTS: 1 CON: Immunity
8. The nursing practitioner is contributing to the teaching plan for a hospital patient who is
allergic to dust. Which environmental modification should the nursing practitioner
recommend be included in the teaching plan to help control symptoms?
1. Installing a hot air heater
2. Covering heating ducts with filters
3. Installing wall-to-wall carpeting
4. Using heavy draperies on sunny windows
RIGHT ANSWER> 2
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 299
Heading: Therapeutic Measures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Application (Applying) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1 A hot air heater will not reduce the amount of dust in the hospital patient’s
environment.
2 Filtering the air will reduce dust particles, which the other items do not do.
3 Carpeting traps dust and is harder to clean.
4 Heavy draperies will trap dust.
PTS: 1 CON: Immunity
9. The nursing practitioner is preparing to administer levofloxacin (Levaquin) to a hospital
patient with pneumonia. Which is most important for the nursing practitioner to ask prior to
administering the medication?
1. “Have you experienced nausea or vomiting from antibiotics?”
2. “Are you allergic to any medication?”
3. “Do you know why you are receiving this medication?”
4. “Do you have an allergy to latex?”
RIGHT ANSWER> 2
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 300
Heading: Nursing Care and Education
Integrated Process: Communication and Documentation
Hospital patient Need: SECE—Safety and Infection
Control CL: Application (Applying)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 The most important question to ask is about allergies to medications.
2 The most important question to ask is about allergies to medications.
3 The most important question to ask is about allergies to medications.
4 The most important question to ask is about allergies to medications.
PTS: 1 CON: Safety
10. A hospital patient is receiving a transfusion of packed RBCs. Ten minutes after the
infusion begins, the hospital patient reports low back pain and a headache. Which action
should the nursing practitioner take first?
1. Stop the blood infusion.
2. Notify the physician STAT.
3. Start a normal saline infusion.
4. Check vital signs.
RIGHT ANSWER> 1
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 301
Heading: Therapeutic Measures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Application (Applying) Concept:
Safety
Difficulty: Moderate
CLARIFICATION
1 Low back pain and headache can be symptoms of a transfusion reaction. If
symptoms of a reaction are noted, the blood is immediately stopped so that no
more blood is infused into the hospital patient.
2 The physician and blood should be notified after the transfusion is stopped and
the saline infusion is started.
3 A normal saline infusion with new tubing is started after the blood infusion is
stopped. This will keep the vein patent should medications need to be
administered as ordered. New tubing must be used so that not one more drop of
blood enters the hospital patient.
4 The hospital patients vital signs should be checked and monitored after the
blood infusion has been stopped, a normal saline solution has been started, and
the physician and blood bank have been notified.
PTS: 1 CON: Safety
11. A hospital patient is to receive a transfusion of packed RBCs. Before administering the
transfusion, which action should the nursing practitioner take?
1. Verify the hospital patient’s kidney function.
2. Verify the hospital patient’s hematocrit level.
3. Verify blood type of the hospital patient and donor.
4. Verify the hospital patient’s admitting medical diagnosis.
RIGHT ANSWER> 3
Chapter: Chapter 19. Nursing Care of Hospital patients with Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 303
Heading: Therapeutic Measures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and
Infection Control CL: Application (Applying)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 This action will not help prevent the development of a transfusion reaction.
2 This action will not help prevent the development of a transfusion reaction.
3 Prevention of hemolytic reactions is crucial. At the bedside, double-check the
hospital patient’s name and identification number on the chart, unit of blood,
and hospital patient’s identification bracelet, as well as check the hospital
patient’s blood type in the chart, on the unit of blood, and paperwork with the
unit of blood.
4 This action will not help prevent the development of a transfusion reaction.
PTS: 1 CON: Safety
12. The nursing practitioner is caring for a hospital patient with angioedema. Which nursing
action should have the highest priority?
1. Monitor for restlessness.
2. Identify cause of the angioedema.
3. Identify the presence of skin lesions.
4. Teach the hospital patient about immunotherapy.
RIGHT ANSWER> 1
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 298
Heading: Pathophysiology and Etiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Application (Applying) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1 If the angioedema reaction is severe, maintenance of a patent airway is a
priority. Any symptoms of respiratory distress must be reported immediately
and remain the highest priority.
2 Because the condition is already present, monitoring the hospital patient takes
priority,
although the cause needs to be identified.
3 This may be addressed later, but is not the priority.
4 This may be addressed later, but is not the priority.
PTS: 1 CON: Immunity
13. The nursing practitioner is caring for a hospital patient with SLE. The nursing
practitioner notes that the hospital patient has foamy, “coke”-colored urine. Which action
should the nursing practitioner take?
1. Notify the health care provider (HCP).
2. Encourage the hospital patient to increase fluid intake.
3. Prepare the hospital patient for dialysis.
4. Instruct the hospital patient to eat high-protein meals.
RIGHT ANSWER> 1
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 310
Heading: Education
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1 This is indicative of proteinuria and hematuria. The HCP should be notified
immediately.
2 The nursing practitioner should first notify the HCP before encouraging or
restricting fluids.
3 The hospital patient may not require dialysis; the HCP should be notified.
4 The hospital patient should not follow a high-protein diet if he or she has
proteinuria.
PTS: 1 CON: Immunity
14. The nursing practitioner is teaching a hospital patient about atopic dermatitis (Eczema).
Which statement made by the hospital patient indicates an understanding of the teaching?
1. “I will keep my nails long so I can scratch easier.”
2. “I should soak in bleach daily.”
3. “I will soak in a lukewarm bath at night.”
4. “It is better for me to scratch than to rub the itchy area.”
RIGHT ANSWER> 3
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 297
Heading: Therapeutic Measures
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Basic Care and
Comfort CL: Evaluation (Evaluating) Concept:
Inflammation
Difficulty: Moderate
CLARIFICATION
1 The hospital patient should keep his or her nails short.
2 The hospital patient can soak in diluted bleach twice weekly.
3 This statement indicates an understanding of teaching.
4 The hospital patient should be taught to rub the area instead of scratch.
PTS: 1 CON: Inflammation
15. The nursing practitioner is teaching a hospital patient with SLE about avoiding triggers.
Which statement made by the hospital patient indicates a need for further teaching?
1. “Instead of working in the yard, I got plenty of rest.”
2. “I am practicing yoga to help alleviate stress in my life.”
3. “If I get plenty of sunlight, it will help reduce symptoms.”
4. “I need to check with my doctor before stopping any medication.”
RIGHT ANSWER> 3
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 309
Heading: Common Systemic Lupus Erythematosus Flare Triggers (Table 19.2)
Integrated Process: Teaching/Learning
Hospital patient Need: SECE—Safety and
Infection Control CL: Evaluation (Evaluating)
Concept: Immunity
Difficulty: Moderate
CLARIFICATION
1 This statement indicates an understanding of the teaching.
2 This statement indicates an understanding of the teaching.
3 This statement requires correction; hospital patients with SLE should avoid
direct sunlight and wear a hat, sunscreen, and long sleeves.
4 This statement indicates an understanding of the teaching.
PTS: 1 CON: Immunity
16. The nursing practitioner is caring for a group of hospital patients. Which hospital patient should
the nursing practitioner see first?
1. A hospital patient with SLE with a butterfly rash
2. A hospital patient with Hashimoto thyroiditis who reports diarrhea and weight loss
3. A hospital patient with allergic rhinitis with copious amounts of clear nasal drainage
4. A hospital patient receiving a blood transfusion who is reporting chills and low back pain
RIGHT ANSWER> 4
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 301
Heading: Signs and Symptoms
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Analysis (Analyzing) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1 A butterfly rash is a hallmark sign of hospital patients with SLE.
2 Diarrhea and weight loss are expected findings in a hospital patient with
Hashimoto thyroiditis.
3 Nasal drainage is expected in a hospital patient with allergic rhinitis.
4 This hospital patient is likely experiencing a hemolytic reaction and should be
seen
immediately.
PTS: 1 CON: Immunity
17. The nursing practitioner is caring for a hospital patient who underwent a liver transplant and is
taking cyclosporine (Sandimmune) and azathioprine (Imuran). Which important information
should the nursing practitioner teach the hospital patient regarding the medication?
1. Take on an empty stomach.
2. Report signs of infection immediately.
3. Monitor for signs of abnormal bleeding.
4. Urine will turn orange.
RIGHT ANSWER> 2
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 306
Heading: Medications Used to Treat Systemic Lupus Erythematosus (SLE) (Table 19.7)
Integrated Process: Communication and Documentation
Hospital patient Need: PHYS—Pharmacological
Therapies CL: Application (Applying) Concept:
Safety
Difficulty: Moderate
CLARIFICATION
1 These medications are taken with food.
2 These medications are immunosuppressants; the hospital patient should report
signs of
infection.
3 These medications do not cause an increase in bleeding.
4 These medications do not turn urine orange.
PTS: 1 CON: Safety
18. The nursing practitioner is caring for a hospital patient with serum sickness. Which
intervention should the nursing practitioner implement?
1. Administer acetaminophen (Tylenol) as ordered.
2. Prepare the hospital patient for a blood transfusion.
3. Teach the hospital patient about immunosuppressive drugs.
4. Restrict the hospital patient’s fluid intake.
RIGHT ANSWER> 1
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 304
Heading: Therapeutic Measures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Application (Applying) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1 Tylenol is given for fever and discomfort for hospital patients with serum
sickness.
2 There is no indication this hospital patient requires a blood transfusion.
3 The hospital patient will not require immunosuppressive drugs.
4 The hospital patient is at risk for hypovolemia; fluid is not restricted.
PTS: 1 CON: Immunity
19. The nursing practitioner is caring for a hospital patient with pernicious anemia. Which
deficiency is this hospital patient experiencing?
1. Vitamin A
2. Vitamin B12
3. Vitamin C
4. Vitamin D
RIGHT ANSWER> 2
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 2. Explain the pathophysiology of disorders of the immune system.
Source: pp. 307
Heading: Pathophysiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Comprehension (Understanding) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1 The hospital patient is not deficient in vitamin A.
2 The hospital patient is deficient in vitamin B12.
3 The hospital patient is not deficient in vitamin C.
4 The hospital patient is not deficient in vitamin D.
PTS: 1 CON: Immunity
20. The nursing practitioner is teaching a hospital patient about allergic rhinitis. Which
statement indicates a need for further teaching?
1. “I will wear a mask when I mow the yard.”
2. “I can take my nasal medication any time my allergies bother me.”
3. “I will dust my house every day.”
4. “I cannot receive immunotherapy since my allergies are not severe.”
RIGHT ANSWER> 2
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 296
Heading: Therapeutic Measures
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Basic Care and
Comfort CL: Evaluation (Evaluating) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1 This statement indicates understanding.
2 Nasal medication should be taken as prescribed; not only when allergies flare
up.
3 This statement indicates an understanding.
4 This statement indicates an understanding.
PTS: 1 CON: Immunity
21. The nursing practitioner is caring for a group of hospital patients. Which hospital patient should
the nursing practitioner see first?
1. A hospital patient with serum sickness experiencing fever and malaise
2. A hospital patient with atopic dermatitis with red, weeping lesions
3. A hospital patient with ankylosing spondylitis reporting level 4 back pain
4. A hospital patient stung by an insect experiencing angioedema
RIGHT ANSWER> 4
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 3. Identify the etiologies, signs, and symptoms of immune system disorders.
Source: pp. 298
Heading: Pathophysiology and Etiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Coordinated Care
CL: Analysis (Analyzing) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1 This hospital patient should be seen, but is not as high of a priority as the
hospital patient with
angioedema (fever and malaise are common in serum sickness).
2 This hospital patient is not a high priority; red and weeping lesions are normal
findings.
3 This hospital patient should be seen, but is not as high of a priority as the
hospital patient with
angioedema; back pain and stiffness is common in ankylosing spondylitis.
4 This hospital patient should be seen first; the airway could be compromised.
PTS: 1 CON: Immunity
22. The nursing practitioner is caring for a hospital patient who develops a hemolytic
reaction during a blood transfusion. The nursing practitioner should expect to implement
which order from the HCP first?
1. Call the blood bank to send up a different unit of blood.
2. Administer diphenhydramine (Benadryl) 50 mg IV.
3. Place the hospital patient in Trendelenburg’s position.
4. Administer acetaminophen (Tylenol).
RIGHT ANSWER> 2
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 300
Heading: Medications Used in Hemolytic Transfusion Reactions (Table 19.3)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Application (Applying) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1 The HCP may not want the hospital patient to receive a blood transfusion for the
time being, after experiencing a hemolytic reaction.
2 The nursing practitioner should plan to administer diphenhydramine
immediately.
3 The hospital patient should be placed in high-Fowler’s position.
4 The hospital patient may receive Tylenol, but not before the diphenhydramine.
PTS: 1 CON: Immunity
MULTIPLE RESPONSE
1. The nursing practitioner is assessing a hospital patient with pernicious anemia. Which
clinical manifestations can the nursing practitioner expect to document? (Select all that
apply.)
1. Pallor
2. Wheals on the skin
3. Butterfly rash
4. Weakness
5. Glossitis
6. Peripheral neuropathy
RIGHT ANSWER> 1, 4, 5, 6
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 3. Explain the etiologies, signs, and symptoms of immune system disorders.
Source: pp. 307
Heading: Signs and Symptoms
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1. Pallor is a clinical manifestation of pernicious anemia.
2. Wheals is a sign of urticaria.
3. A butterfly rash is a sign of SLE.
4. Weakness is a clinical manifestation of pernicious anemia.
5. Glossitis is a sign of pernicious anemia.
6. Peripheral neuropathy is a sign of pernicious anemia.
PTS: 1 CON: Immunity
2. The nursing practitioner is contributing to the teaching plan for a hospital patient diagnosed
with Hashimoto thyroiditis who has progressed to hypothyroidism with a goiter. Which self- care
instructions should the nursing practitioner recommend? (Select all that apply.)
1. Eat a soft diet.
2. Increase activity slowly.
3. Eat more foods high in iodine.
4. Keep home at a cool temperature.
5. Eat a high-carbohydrate, high-protein diet.
6. During low-energy periods, use anti-embolism stockings.
RIGHT ANSWER> 1, 2, 6
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 308
Heading: Nursing Care
Integrated Process: Communication and Documentation
Hospital patient Need: PHYS—Basic Care and
Comfort CL: Application (Applying)
Concept: Inflammation
Difficulty: Moderate
CLARIFICATION
1. If the hospital patient has a goiter, a soft diet may be necessary for comfort.
Frequent rest periods may be necessary as well as slowly increasing hospital
patient activity. Anti-embolic stockings may help prevent venous stasis
during the low-
energy, decreased-activity phase.
2. If the hospital patient has a goiter, a soft diet may be necessary for comfort.
Frequent rest periods may be necessary as well as slowly increasing hospital
patient activity. Anti-embolic stockings may help prevent venous stasis
during the low- energy, decreased-activity phase.
3. Foods high in iodine should be avoided.
4. The hospital patient will be sensitive to cold, so room temperature will need
to be increased for comfort.
5. During the hyperthyroidism phase, a diet high in protein and carbohydrates
encourages weight gain.
6. If the hospital patient has a goiter, a soft diet may be necessary for comfort.
Frequent rest periods may be necessary as well as slowly increasing hospital
patient activity. Anti-embolic stockings may help prevent venous stasis
during the low- energy, decreased-activity phase.
PTS: 1 CON: Inflammation
3. The nursing practitioner is assisting in the care of a hospital patient with ankylosing
spondylitis. What should the nursing practitioner expect to find in the hospital patient’s
collaborative plan of care? (Select all that apply.)
1. Physical therapy daily
2. Sitz baths three times daily
3. Tylenol #3 every 4 hours prn for pain
4. Administering Remicade as prescribed
5. Activity as tolerated; up with assistance
RIGHT ANSWER> 1, 3, 4, 5
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 313
Heading: Nursing Care
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1. Nursing care focuses on hospital patient education and administration and
evaluation of prescribed medications. Pain management, rest periods, and
assistance with activities of daily living are provided.
2. Sitz baths are not indicated for this health problem.
3. Nursing care focuses on hospital patient education and administration and
evaluation of prescribed medications. Pain management, rest periods, and
assistance with activities of daily living are provided.
4. Nursing care focuses on hospital patient education and administration and
evaluation of prescribed medications. Pain management, rest periods, and
assistance
with activities of daily living are provided.
5. Nursing care focuses on hospital patient education and administration and
evaluation of prescribed medications. Pain management, rest periods, and
assistance with activities of daily living are provided.
PTS: 1 CON: Immunity
4. The nursing practitioner is contributing to the plan of care for a hospital patient with
SLE. Which interventions should the nursing practitioner recommend for this hospital
patient? (Select all that apply.)
1. Eat a balanced diet.
2. Report “foamy urine” to physician.
3. Take cool showers or baths to relieve joint stiffness.
4. Avoid naps and obtain a minimum of 6 hours of sleep.
5. Exercise when pain and inflammation in joints are increased.
6. Use a daily personal schedule to plan activities to reduce fatigue.
RIGHT ANSWER> 1, 2, 6
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 311
Heading: Nursing Care
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1. Fatigue during activities of daily living is minimized through the use of a
daily personal schedule. Additionally, a minimum of 8 hours of sleep per
night with naps as necessary are important to combat fatigue. Because the
majority of hospital patients with SLE develop transitory arthralgia,
maintaining fitness and joint range of motion through a regular fitness
program while decreasing activity during flares is vital. Warm baths may help
with morning stiffness. Because renal disease is a major complication of SLE,
hospital patients must learn the signs of impending problems that need to be
relayed to the physician immediately. These are such findings as facial
puffiness and “foamy” urine or “coke-colored” urine indicative of proteinuria
and hematuria, respectively. Eating a well-balanced diet will also influence
level
of fatigue and weight gain from the corticosteroids.
2. Fatigue during activities of daily living is minimized through the use of a
daily personal schedule. Additionally, a minimum of 8 hours of sleep per
night with naps as necessary are important to combat fatigue. Because the
majority of hospital patients with SLE develop transitory arthralgia,
maintaining fitness and joint range of motion through a regular fitness
program while decreasing activity during flares is vital. Warm baths may help
with morning stiffness. Because renal disease is a major complication of SLE,
hospital patients must learn the signs of impending problems that need to be
relayed to the physician immediately. These are such findings as facial
puffiness and “foamy” urine or “coke-colored” urine indicative of proteinuria
and hematuria, respectively. Eating a well-balanced diet will also influence
level of fatigue and weight gain from the corticosteroids.
3. Cool showers will not help relieve the pain and stiffness associated with this
disorder.
4. Rest is beneficial for this disorder.
5. Exercise should be reduced during flare-ups.
6. Fatigue during activities of daily living is minimized through the use of a
daily personal schedule. Additionally, a minimum of 8 hours of sleep per
night with naps as necessary are important to combat fatigue. Because the
majority of hospital patients with SLE develop transitory arthralgia,
maintaining fitness and joint range of motion through a regular fitness
program while decreasing activity during flares is vital. Warm baths may help
with morning stiffness. Because renal disease is a major complication of SLE,
hospital patients must learn the signs of impending problems that need to be
relayed to the physician immediately. These are such findings as facial
puffiness and “foamy” urine or “coke-colored” urine indicative of proteinuria
and hematuria, respectively. Eating a well-balanced diet will also influence
level of fatigue and weight gain from the corticosteroids.
PTS: 1 CON: Immunity
5. The nursing practitioner applies clean, white, cotton socks over the hands of a
hospital patient with contact dermatitis. What should the nursing practitioner explain
to the hospital patient about the purposes of this intervention? (Select all that apply.)
1. Cotton allows air movement.
2. White cotton has no dye in the material.
3. White cotton prevents the wounds from spreading.
4. The cotton will absorb the drainage from the wounds.
5. Scratching is less during sleep when the area is covered.
RIGHT ANSWER> 1, 2, 5
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 297
Heading: Nursing Care Plan for the Hospital patient with Contact Dermatitis
Integrated Process: Communication and Documentation
Hospital patient Need: PHYS—Basic Care and
Comfort CL: Application (Applying) Concept:
Inflammation
Difficulty: Moderate
CLARIFICATION
1. Cotton allows air movement. White cloth is less irritating than those with
dyes. Scratching is decreased during sleep with the use of gloves or mittens
or by covering affected area.
2. Cotton allows air movement. White cloth is less irritating than those with
dyes. Scratching is decreased during sleep with the use of gloves or mittens
or by covering affected area.
3. The use of white, cotton socks over the hands of a hospital patient with
contact dermatitis is not done to prevent the wounds from spreading or to
absorb the
drainage from the wounds.
4. The use of white, cotton socks over the hands of a hospital patient with
contact dermatitis is not done to prevent the wounds from spreading or to
absorb the drainage from the wounds.
5. Cotton allows air movement. White cloth is less irritating than those with
dyes. Scratching is decreased during sleep with the use of gloves or mittens
or by covering affected area.
PTS: 1 CON: Inflammation
COMPLETION
1. A hospital patient with SLE is prescribed Prednisone, 60 mg PO, in three equal doses. If
using 5-mg tablets, how many tablets should the nursing practitioner provide for each
dose?
RIGHT ANSWER>
4
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 5. Describe current medical treatment for immune system disorders.
Source: pp. 302
Heading: Medications Used to Treat Systemic Lupus Erythematosus (SLE)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Analysis (Analyzing) Concept:
Safety
Difficulty: Moderate
CLARIFICATION: The nursing practitioner should use the equation Dosage
Required/Dosage Available × 1 tablet or 20 mg/5 mg × 1 = 4 tablets.
PTS: 1 CON: Safety
2. The nursing practitioner is administering methylprednisolone (Solu-Medrol) 40 mg IM to a
hospital patient with SLE. The available dose is 80 mg/mL. How many mL will the nursing
practitioner administer? Enter the numeral only.
RIGHT ANSWER>
0.5
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system. Source: pp. 302
Heading: Medications Used to Treat Systemic Lupus Erythematosus (SLE) (Table 19.7)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological
Therapies CL: Analysis (Analyzing)
Concept: Safety
Difficulty: Moderate
CLARIFICATION: mL = 1 mL/80 mg × 40 mg
= 0.5 mL PTS: 1 CON: Safety
ORDERED RESPONSE
1. A hospital patient is receiving a transfusion of packed RBCs. Ten minutes after the
infusion begins, the hospital patient reports low back pain and a headache. Place the actions
in order, from 1 to 5, of importance of performance.
1. Stop the blood infusion.
2. Notify the physician STAT.
3. Obtain vital signs and assess hospital patient.
4. Start the new 0.9% normal saline infusion.
5. Prepare a new 0.9% normal saline infusion.
RIGHT ANSWER>
1, 3, 2, 5, 4
Chapter: Chapter 19. Nursing Care of Hospital patients With Immune Disorders
Objective: 8. Plan nursing care for hospital patients with disorders of the immune
system Source: pp. 300
Heading: Therapeutic Measures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Analysis (Analyzing) Concept:
Safety
Difficulty: Difficult
CLARIFICATION: Low back pain and headache can be symptoms of a transfusion reaction.
If symptoms of a reaction are noted, the blood transfusion is immediately stopped and agency
policy for a suspected transfusion reaction is followed. A normal saline infusion with new
tubing is started to keep the vein patent. The physician and blood bank are immediately
notified. A nursing practitioner remains with the hospital patient for reassurance and
monitoring of symptoms and vital signs. If a blood incompatibility is suspected, the unused
blood and blood tubing are returned to the blood bank for testing. A series of blood and urine
specimens are collected and sent to the laboratory for analysis. The physician’s orders are
followed to treat the hospital patient’s symptoms.
PTS: 1 CON: Safety
Chapter 20. Nursing Care of Hospital patients With HIV Disease and AIDS
MULTIPLE CHOICE
1. The nursing practitioner is teaching a group of older adults about prevention of HIV.
Which statement made by the hospital patient indicates an understanding of the teaching?
1. “I will use a condom with each sexual contact.”
2. “I can share a needle with my friend when shooting up.”
3. “After 50, it is no longer necessary to get tested for HIV.”
4. “I have only had three partners, so it would be hard for me to get HIV.”
RIGHT ANSWER> 1
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease
and AIDS Objective: 5. Develop a teaching plan for prevention of an HIV
infection.
Pages: 321–322
Heading: Prevention
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Evaluation (Evaluating)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1 This statement indicates an understanding of the teaching.
2 A clean needle should be used with each injection.
3 Individuals can contract HIV at any age; HIV testing is essential for all at-risk
individuals.
4 Any individual can contract HIV even if he or she only had one partner.
PTS: 1 CON: Health Promotion
2. The nursing practitioner is caring for a group of hospital patients. Which hospital patient
is at highest risk for contracting HIV?
1. A 30-year-old IV drug user who is part of a clean needle program
2. A 40-year-old male who is in a monogamous relationship
3. A 50-year-old nursing practitioner at a health department who administers multiple vaccines
4. A 60-year-old homosexual male who has had two partners
RIGHT ANSWER> 4
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease
and AIDS Objective: 2. Explain how HIV is transmitted.
Source: pp. 321
Heading: Sexual Transmission
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Health Promotion and Maintenance
CL: Analysis (Analyzing) Concept:
Health Promotion
Difficulty: Moderate
CLARIFICATION
1 This hospital patient is at moderate risk; he or she is using clean needles.
2 This hospital patient is not at high risk; he is in a monogamous relationship.
3 This hospital patient is at minimal risk; only if he or she experiences a
needlestick injury from an HIV positive individual can HIV be transmitted, and
that risk is still minimal.
4 Anal sex has the highest risk for sexual transmission.
PTS: 1 CON: Health Promotion
3. The nursing practitioner is caring for a hospital patient with cytomegalovirus (CMV)
retinitis. The nursing practitioner should plan to teach the hospital patient about which
medication?
1. Trimethoprim-sulfamethoxazole (Bactrim)
2. Ethambutol (Myambutol)
3. Amphotericin B (Fungizone)
4. Ganciclovir (Cytovene)
RIGHT ANSWER> 4
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease and AIDS
Objective: 7. Develop a teaching plan for a hospital patient with HIV receiving antiretroviral
therapy. Source: pp. 326
Heading: Treatment for AIDS-Related Conditions
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Pharmacological
Therapies CL: Application (Applying) Concept:
Safety
Difficulty: Moderate
CLARIFICATION
1 This is used to treat phencyclidine.
2 This is used to treat tuberculosis.
3 This is used to treat candidiasis.
4 The nursing practitioner will teach the hospital patient about ganciclovir
(Cytovene) for CMV retinitis.
PTS: 1 CON: Safety
4. The nursing practitioner is preparing to teach a group of hospital patients about the pre-
exposure prophylaxis (PrEP) to prevent HIV transmission. The nursing practitioner should plan
to teach the group about which medication?
1. Delavirdine mesylate (Rescriptor)
2. Abacavir sulfate/lamivudine (Epzicom)
3. Emtricitabine/tenofovir disoproxil (Truvada)
4. Fosamprenavir calcium (Lexiva)
RIGHT ANSWER> 3
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease
and AIDS Objective: 5. Develop a teaching plan for prevention of an HIV
infection.
Source: pp. 321
Heading: Pre-Exposure Prophylaxis (PrEp)
Integrated Process: Teaching and Learning
Hospital patient Need: PHYS—Pharmacological
Therapies CL: Application (Applying) Concept:
Health Promotion
Difficulty: Difficult
CLARIFICATION
1 Emtricitabine/tenofovir disoproxil (Truvada) is the only medication approved
to be used as PrEP.
2 Emtricitabine/tenofovir disoproxil (Truvada) is the only medication approved
to be used as PrEP.
3 Emtricitabine/tenofovir disoproxil (Truvada) is the only medication approved
to be used as PrEP.
4 Emtricitabine/tenofovir disoproxil (Truvada) is the only medication approved
to be used as PrEP.
PTS: 1 CON: Health Promotion
5. The nursing practitioner is reviewing the CD4 count results of a hospital patient with
AIDS. What can the nursing practitioner expect to find?
1. A CD4 count of 800/μL
2. A CD4 count of 500/μL
3. A CD4 count of 300/μL
4. A CD4 count of 100/μL
RIGHT ANSWER> 4
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease
and AIDS Objective: 3. Explain tests for diagnosing HIV.
Source: pp. 323
Heading: HIV Signs and Symptoms
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Analysis (Analyzing) Concept:
Infection
Difficulty: Moderate
CLARIFICATION
1 AIDS is diagnosed when a CD4 count is below 200 or opportunistic infections
occur.
2 AIDS is diagnosed when a CD4 count is below 200 or opportunistic infections
occur.
3 AIDS is diagnosed when a CD4 count is below 200 or opportunistic infections
occur.
4 AIDS is diagnosed when a CD4 count is below 200 or opportunistic infections
occur.
PTS: 1 CON: Infection
6. The licensed practical nurse/licensed vocational nursing practitioner (LPN/LVN) is
watching a nursing student administer medications to a hospital patient with HIV. Which
action by the student requires correction by the nurse?
1. The student recaps the needle and places it in the sharps container.
2. The student uses a needleless system to administer the medication.
3. The student wears gloves when administering the medication.
4. The student washes her hands before and after administering the medication.
RIGHT ANSWER> 1
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease
and AIDS Objective: 5. Develop a teaching plan for prevention of an HIV
infection.
Source: pp. 322
Heading: Health Care Providers and HIV Prevention
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Evaluation (Evaluating) Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 The student should never recap a needle.
2 This action is appropriate and does not require correction.
3 This action is appropriate and does not require correction.
4 This action is appropriate and does not require correction.
PTS: 1 CON: Safety
7. The nursing practitioner is providing care to a hospital patient who has had diagnostic
testing for HIV. Which test should the nursing practitioner review to monitor the response to
antiretroviral therapy?
1. Western blot
2. Viral load testing
3. P24 antigen testing
4. Enzyme-linked immunosorbent assay
RIGHT ANSWER> 2
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease
and AIDS Objective: 3. Explain tests for diagnosing HIV.
Source: pp. 325
Heading: Viral Load Testing
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Application (Applying) Concept:
Infection
Difficulty: Moderate
CLARIFICATION
1 The Western blot test is done to detect the presence of antibodies to four major
HIV antigens.
2 Viral load testing measures the amount of HIV RNA in plasma and is
extremely important for determining prognosis and monitoring the response to
antiretroviral therapy.
3 These tests are not used to measure the response to antiretroviral therapy.
4 These tests are not used to measure the response to antiretroviral therapy.
PTS: 1 CON: Infection
8. The nursing practitioner is preparing to care for a hospital patient who is HIV positive.
Which action should the nursing practitioner take when following standard precautions for
protection from HIV exposure?
1. Put on gloves before touching body fluids.
2. Recap intramuscular needles after injection.
3. Wash own open skin lesion after providing care.
4. Remove one finger on a glove during venipuncture.
RIGHT ANSWER> 1
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease
and AIDS Objective: 2. Explain how HIV is transmitted.
Source: pp. 322
Heading: Mode of Transmission
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Application (Applying) Concept:
Infection
Difficulty: Moderate
CLARIFICATION
1 Gloves should be worn before touching body fluids, as all hospital patients are
considered to be infected per standard precautions.
2 Gloves should be worn before touching body fluids, as all hospital patients are
considered to be infected per standard precautions.
3 A nursing practitioner should not provide care with open lesions.
4 Do not remove one glove finger as it defeats the purpose of glove protection.
PTS: 1 CON: Infection
9. A hospital patient who has HIV asks the nursing practitioner why blood work has to be
done so frequently. Which response should the nursing practitioner make to the hospital
patient?
1. “B-lymphocyte levels increase if you have an acute infection.”
2. “Phagocytes are decreased when the disease is in an active phase.”
3. “Neutrophil counts help the doctor titrate medication levels to keep you healthy.”
4. “CD4+ lymphocyte counts are monitored to determine the progression of the
disease.”
RIGHT ANSWER> 4
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease
and AIDS Objective: 3. Explain tests for diagnosing HIV.
Source: pp. 325
Heading: CD4 T Lymphocyte Count
Integrated Process: Teaching/Learning
Hospital patient Need: SECE—Safety and
Infection Control CL: Application (Applying)
Concept: Infection
Difficulty: Moderate
CLARIFICATION
1 This response does not appropriately explain the need for frequent blood
analyses in the hospital patient with HIV.
2 This response does not appropriately explain the need for frequent blood
analyses in the hospital patient with HIV.
3 This response does not appropriately explain the need for frequent blood
analyses in the hospital patient with HIV.
4 A low ratio of CD4 cells to CD8 cells is seen as HIV/AIDS progresses. It is
recommended that CD4/CD8 T-lymphocyte counts be performed at 3-month
intervals for most hospital patients.
PTS: 1 CON: Infection
10. The nursing practitioner is contributing to a teaching plan. What should the nursing
practitioner emphasize as being the most effective method known to control the spread of HIV
infection?
1. Premarital serological screening
2. Prophylactic exposure treatment
3. HIV screening for pregnant women
4. Education about preventive behaviors
RIGHT ANSWER> 4
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease
and AIDS Objective: 5. Develop a teaching plan for prevention of an HIV
infection.
Source: pp. 322
Heading: Prevention
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Application (Applying)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1 Premarital screening, prophylactic exposure treatment, and screening for
pregnant women are not the best approaches to control the spread of HIV
infection.
2 Premarital screening, prophylactic exposure treatment, and screening for
pregnant women are not the best approaches to control the spread of HIV
infection.
3 Premarital screening, prophylactic exposure treatment, and screening for
pregnant women are not the best approaches to control the spread of HIV
infection.
4 Prevention and education are the best ways to manage the HIV/AIDS epidemic.
Education should begin with older, school-age children through older adults.
PTS: 1 CON: Health Promotion
11. The nursing practitioner is teaching a hospital patient about antiretroviral therapy. Which
statement made by the hospital patient indicates an understanding of the teaching?
1. “If I feel sick from the medication, I need to stop taking it.”
2. “I will most likely take one medication daily.”
3. “I should set an alarm so I remember to take my pills.”
4. “I can’t infect anybody while I’m taking medications.”
RIGHT ANSWER> 3
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease and AIDS
Objective: 7. Develop a teaching plan for a hospital patient with HIV receiving antiretroviral
therapy. Source: pp. 325
Heading: Antiretroviral Therapy
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Evaluation (Evaluating)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1 The hospital patient should contact the health care provider before stopping a
medication.
2 The hospital patient will likely have to take multiple pills daily.
3 This statement indicates an understanding of teaching.
4 A hospital patient is still contagious even while taking antiretroviral therapy.
PTS: 1 CON: Health Promotion
12. The nursing practitioner is caring for a group of hospital patients with HIV. Which
hospital patient is at highest risk for developing CMV?
1. A hospital patient who works on a farm
2. An individual who works in a homeless shelter
3. A hospital patient who works in a day care
4. A hospital patient who works as a gardener
RIGHT ANSWER> 3
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease and AIDS
Objective: 6. Identify prevention methods used to decrease infection and opportunistic
diseases for hospital patients with HIV.
Source: pp. 324
Heading: Hospital patient Teaching: Preventing Opportunistic Infections
(Table 20.6) Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: SECE—Safety and Infection Control
CL: Analysis (Analyzing) Concept:
Infection
Difficulty: Moderate
CLARIFICATION
1 Individuals who work in a childcare setting are at high risk for CMV. They
should be instructed to wash hands after changing diapers.
2 Individuals who work in a childcare setting are at high risk for CMV. They
should be instructed to wash hands after changing diapers.
3 Individuals who work in a childcare setting are at high risk for CMV. They
should be instructed to wash hands after changing diapers.
4 Individuals who work in a childcare setting are at high risk for CMV. They
should be instructed to wash hands after changing diapers.
PTS: 1 CON: Infection
13. A hospital patient asks, “What is the main purpose of these medications I take for my
HIV?” Which response by the nursing practitioner is most appropriate?
1. “They encapsulate the virus-infected cells.”
2. “They mark the virus for natural killer cells to destroy.”
3. “They attract macrophages to the cells making the virus.”
4. “They inhibit enzymes to interfere with viral production.”
RIGHT ANSWER> 4
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease and AIDS
Objective: 7. Develop a teaching plan for a hospital patient with HIV receiving antiretroviral
therapy. Source: pp. 326
Heading: Antiretroviral Therapy
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Pharmacological
Therapy CL: Application (Applying) Concept:
Infection
Difficulty: Moderate
CLARIFICATION
1 Antiretroviral drugs do not encapsulate the virus-infected cells, mark the virus
to be destroyed, or attract macrophages to the cells making the virus.
2 Antiretroviral drugs do not encapsulate the virus-infected cells, mark the virus
to be destroyed, or attract macrophages to the cells making the virus.
3 Antiretroviral drugs do not encapsulate the virus-infected cells, mark the virus
to be destroyed, or attract macrophages to the cells making the virus.
4 Antiretroviral drugs that inhibit reproduction of the virus in various ways by
blocking enzyme action are used to treat HIV infection.
PTS: 1 CON: Infection
14. The nursing practitioner is caring for a hospital patient receiving abacavir sulfate (Ziagen).
For which complication should the nursing practitioner monitor the hospital patient?
1. Breathing difficulty
2. Flu-like symptoms
3. Elevated blood glucose
4. Pancreatitis
RIGHT ANSWER> 2
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease and AIDS
Objective: 7. Develop a teaching plan for a hospital patient with HIV receiving antiretroviral
therapy. Source: pp. 327
Heading: Antiretroviral Medications for HIV Infection
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Evaluation (Evaluating) Concept: Safety
Difficulty: Difficult
CLARIFICATION
1 Breathing difficulty is not a complication of abacavir sulfate (Ziagen).
2 The nursing practitioner should monitor the hospital patient for flu-like
symptoms which could be life threatening.
3 This medication does not cause an elevation in blood glucose.
4 This medication does not cause pancreatitis.
PTS: 1 CON: Safety
15. The nursing practitioner is reviewing the use of a condom to prevent the transmission of
HIV with a young adult hospital patient seeking testing for HIV. Which hospital patient
statement indicates an understanding of how to use a condom?
1. Use a non-latex condom.
2. Apply adequate oil-based lubricant.
3. Apply condom before penile erection occurs.
4. Withdraw from partner while the penis is erect.
RIGHT ANSWER> 4
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease
and AIDS Objective: 5. Describe a teaching plan for prevention of an HIV
infection. Source: pp. 321
Heading: Prevention
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Evaluation (Evaluating)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1 Use latex condom (or polyurethane if allergic to latex), because other materials
have large pores that allow HIV to pass.
2 Use water-soluble lubricants, as oil-based lubricants can damage latex
condoms.
3 Apply condom after erection for correct fit.
4 When using a condom, withdraw from partner by holding condom against base
of erect penis to avoid semen leakage.
PTS: 1 CON: Health Promotion
16. The nursing practitioner is caring for a hospital patient with AIDS who develops oral
candidiasis. Which action should the nursing practitioner take?
1. Encourage the hospital patient to rinse with an antiseptic mouth wash.
2. Administer penicillin as ordered.
3. Encourage the hospital patient to use a soft toothbrush.
4. Encourage the hospital patient to eat spicy foods.
RIGHT ANSWER> 1
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease and AIDS
Objective: 6. Identify prevention measures used to decrease infection and opportunistic
diseases for hospital patients with HIV.
Source: pp. 324
Heading: Impaired Oral Mucous Membrane
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Infection
Difficulty: Moderate
CLARIFICATION
1 Antiseptic mouth wash can make the lesions more painful.
2 Penicillin is not used to treat oral candidiasis.
3 A soft toothbrush will help decrease further discomfort.
4 Spicy foods will make the lesions more painful.
PTS: 1 CON: Infection
17. A hospital patient diagnosed with HIV asks the nursing practitioner how soon the
virus can be transmitted to others. Which time frame should the nursing practitioner inform
the hospital patient?
1. 2 to 4 weeks
2. 6 to 8 weeks
3. 10 to 12 weeks
4. 14 to 16 weeks
RIGHT ANSWER> 1
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease
and AIDS Objective: 2. Explain how HIV is transmitted.
Source: pp. 323
Heading: Learning Tip
Integrated Process: Communication and Documentation
Hospital patient Need: PHYS—Basic Care and
Comfort CL: Application (Applying)
Concept: Infection
Difficulty: Moderate
CLARIFICATION
1 The HIV virus can be spread within 2 to 4 weeks of infection and throughout
all stages of HIV and AIDS infection.
2 The HIV virus can be spread within 2 to 4 weeks of infection and throughout
all stages of HIV and AIDS infection.
3 The HIV virus can be spread within 2 to 4 weeks of infection and throughout
all stages of HIV and AIDS infection.
4 The HIV virus can be spread within 2 to 4 weeks of infection and throughout
all stages of HIV and AIDS infection.
PTS: 1 CON: Infection
18. A health care worker is exposed to blood from a hospital patient who has HIV. What
action should the worker take after the exposure?
1. Apply alcohol to the site.
2. Cleanse the site with soap and water.
3. Flush the site with hot running water.
4. Apply a topical antibiotic to the site.
RIGHT ANSWER> 2
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease
and AIDS Objective: 5. Develop a teaching plan for prevention of an HIV
infection.
Source: pp. 322
Heading: Health Care Providers and HIV Prevention
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Application (Applying) Concept:
Safety
Difficulty: Moderate
CLARIFICATION
1 Alcohol should not be applied to the site. Flushing the site with hot running
water is not sufficient. Soap is needed. A topical antibiotic should not be
applied to the site.
2 Alcohol should not be applied to the site. Flushing the site with hot running
water is not sufficient. Soap is needed. A topical antibiotic should not be
applied to the site.
3 After exposure to HIV, the site should be immediately washed with soap and
water and then seek immediate medical care for assessment and treatment.
4 Alcohol should not be applied to the site. Flushing the site with hot running
water is not sufficient. Soap is needed. A topical antibiotic should not be
applied to the site.
PTS: 1 CON: Safety
MULTIPLE RESPONSE
1. The nursing practitioner is caring for a hospital patient in the symptomatic stage
of HIV. Which clinical manifestations can the nursing practitioner expect to
document? (Select all that apply.)
1. Constipation
2. Night sweats
3. Fever
4. Weight gain
5. Shortness of breath
RIGHT ANSWER> 2, 3, 5
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease and AIDS
Objective: 1. Define human immunodeficiency virus (HIV) and acquired immunodeficiency
syndrome (AIDS).
Source: pp. 323
Heading: Signs and Symptoms
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Infection
Difficulty: Moderate
CLARIFICATION
1. This is not a symptom of HIV.
2. This is a symptom of HIV.
3. This is a symptom of HIV.
4. This is not a symptom of HIV.
5. This is a symptom of HIV.
PTS: 1 CON: Infection
2. The nursing practitioner has been discussing actions to prevent AIDS-related wasting
syndrome with a hospital patient being treated for AIDS. Which hospital patient
statements indicate an understanding of this teaching? (Select all that apply.)
1. Eat a low-residue diet.
2. Drink liquids before meals.
3. Enjoy food odors to stimulate appetite.
4. Numb painful oral sores with ice or popsicles.
5. Eat three high-calorie, high-protein meals a day, plus snacks.
6. Increase consumption of caffeine-containing foods and fluids.
RIGHT ANSWER> 1, 4, 5
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease and AIDS
Objective: 8. Plan nursing care for hospital patients with HIV and AIDS related to
medications, coinfection prevention, and maintaining nutritional status.
Source: pp. 324
Heading: Imbalance Nutrition: Less Than Body Requirements
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Basic Care and
Comfort CL: Application (evaluation) Concept:
Nutrition
Difficulty: Moderate
CLARIFICATION
1. To prevent AIDS-related wasting syndrome the hospital patient should eat a
low- residue diet to control diarrhea, numb painful oral sores with ice or
popsicles so eating is not painful, and eat three high-calorie, high-protein
meals a day,
plus snacks, to maintain weight.
2. Drinking before meals may fill hospital patients up so they do not want to eat.
Food odors may cause anorexia. Caffeine and alcohol should be avoided to
help prevent diarrhea.
3. Drinking before meals may fill hospital patients up so they do not want to eat.
Food odors may cause anorexia. Caffeine and alcohol should be avoided to
help
prevent diarrhea.
4. To prevent AIDS-related wasting syndrome the hospital patient should eat a
low- residue diet to control diarrhea, numb painful oral sores with ice or
popsicles so eating is not painful, and eat three high-calorie, high-protein
meals a day, plus snacks, to maintain weight.
5. To prevent AIDS-related wasting syndrome the hospital patient should eat a
low- residue diet to control diarrhea, numb painful oral sores with ice or
popsicles
so eating is not painful, and eat three high-calorie, high-protein meals a day,
plus snacks, to maintain weight.
6. Drinking before meals may fill hospital patients up so they do not want to eat.
Food odors may cause anorexia. Caffeine and alcohol should be avoided to
help prevent diarrhea.
PTS: 1 CON: Nutrition
3. The nursing practitioner is teaching a group of individuals about HIV prevention.
Which statements indicate an understanding of the teaching? (Select all that apply.)
1. “I wear gloves to protect my hands during genital contact.”
2. “My friends share needles only once after each injection.”
3. “I take birth control, so I am safe from contracting HIV.”
4. “My sister is pregnant, so she should get tested for HIV.”
5. “I have HIV, so I should take the PrEP for prophylaxis.”
6. “Condoms are the number-one way to prevent sexually transmitted HIV.”
RIGHT ANSWER> 1, 4
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease
and AIDS Objective: 5. Develop a teaching plan for prevention of an HIV
infection.
Source: pp. 321
Heading: Prevention
Integrated Process: Teaching and Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Evaluation (Evaluating)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1. This statement indicates teaching is understood.
2. Needles should not be shared.
3. Birth control does not prevent HIV.
4. This statement indicates teaching is understood.
5. PrEP is prophylactic (before HIV).
6. Abstinence is the number-one method to prevent HIV transmission.
PTS: 1 CON: Health Promotion
4. A hospital patient with AIDS is prescribed the nucleoside reverse transcriptase inhibitor
lamivudine (Epivir). What information should the nursing practitioner ensure that the
hospital patient receives about this medication? (Select all that apply.)
1. Report any onset of bleeding.
2. Report any yellowing of the skin.
3. Report any change in urine output.
4. Report any flu-like symptoms.
5. Report any numbness or tingling of the hands or feet.
RIGHT ANSWER> 2, 3, 4, 5
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease and AIDS
Objective: 7. Develop a teaching plan for a hospital patient with HIV receiving antiretroviral
therapy. Source: pp. 327
Heading: Antiretroviral Medications for HIV Infection
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Pharmacological
Therapies CL: Application (Applying) Concept:
Safety
Difficulty: Difficult
CLARIFICATION
1. Bleeding is not an adverse reaction to this medication.
2. When taking this medication, the hospital patient should monitor and report
any skin yellowing, which could indicate jaundice or liver failure; changes in
urine output, which could indicate kidney failure; flu-like symptoms, which
would be life threatening when taking this medication; and numbness or
tingling of the hands or feet, which could indicate the onset of peripheral
neuropathy.
3. When taking this medication, the hospital patient should monitor and report
any skin yellowing, which could indicate jaundice or liver failure; changes in
urine output, which could indicate kidney failure; flu-like symptoms, which
would be life threatening when taking this medication; and numbness or
tingling of
the hands or feet, which could indicate the onset of peripheral neuropathy.
4. When taking this medication, the hospital patient should monitor and report
any skin yellowing, which could indicate jaundice or liver failure; changes in
urine output, which could indicate kidney failure; flu-like symptoms, which
would be life threatening when taking this medication; and numbness or
tingling of the hands or feet, which could indicate the onset of peripheral
neuropathy.
5. When taking this medication, the hospital patient should monitor and report
any skin yellowing, which could indicate jaundice or liver failure; changes in
urine output, which could indicate kidney failure; flu-like symptoms, which
would be life threatening when taking this medication; and numbness or
tingling of
the hands or feet, which could indicate the onset of peripheral neuropathy.
PTS: 1 CON: Safety
5. While collecting admission data, the nursing practitioner suspects a hospital patient with
AIDS is experiencing an HIV-associated neurocognitive disorder. What observations did the
nursing practitioner make to come to this conclusion? (Select all that apply.)
1. Audible bowel sounds
2. Inappropriate laughter
3. Inability to state home address
4. Knee buckling while walking
5. Asking if the bugs could be removed from the walls
RIGHT ANSWER> 2, 3, 4, 5
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease and AIDS
Objective: 8. Plan nursing care for hospital patients with HIV and AIDS related to
medications, coinfection prevention, and maintaining nutritional status.
Source: pp. 324
Heading: HIV-Associated Neurocognitive Disorder
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Analysis (Analyzing) Concept:
Infection
Difficulty: Moderate
CLARIFICATION
1. Audible bowel sounds are not a manifestation of HIV-associated
neurocognitive disorder.
2. Symptoms of an HIV-associated neurocognitive disorder include memory
impairment, personality changes, hallucinations, and leg weakness.
Inappropriate laughter could indicate personality changes. Inability to state
the home address could indicate memory impairment. Knee buckling while
walking could indicate leg weakness. Asking for the bugs to be removed
from the walls could indicate hallucinations.
3. Symptoms of an HIV-associated neurocognitive disorder include memory
impairment, personality changes, hallucinations, and leg weakness.
Inappropriate laughter could indicate personality changes. Inability to state
the home address could indicate memory impairment. Knee buckling while
walking could indicate leg weakness. Asking for the bugs to be removed
from the walls could indicate hallucinations.
4. Symptoms of an HIV-associated neurocognitive disorder include memory
impairment, personality changes, hallucinations, and leg weakness.
Inappropriate laughter could indicate personality changes. Inability to state
the home address could indicate memory impairment. Knee buckling while
walking could indicate leg weakness. Asking for the bugs to be removed
from the walls could indicate hallucinations.
5. Symptoms of an HIV-associated neurocognitive disorder include memory
impairment, personality changes, hallucinations, and leg weakness.
Inappropriate laughter could indicate personality changes. Inability to state
the home address could indicate memory impairment. Knee buckling while
walking could indicate leg weakness. Asking for the bugs to be removed
from the walls could indicate hallucinations.
PTS: 1 CON: Infection
COMPLETION
1. The nursing practitioner is administering fluconazole (Diflucan) 100 mg in 50 mL of
normal saline to run over 30 minutes using a 30 gtt/mL drop factor. Calculate the flow rate.
Round to the nearest whole number. Enter the numeral only.
RIGHT ANSWER>
50
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease and AIDS
Objective: 8. Plan nursing care for hospital patients with HIV and AIDS related to
medications, coinfection prevention, and maintaining nutritional status.
Source: pp. 326
Heading: Cancer and Opportunistic Infections
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological
Therapies CL: Analysis (Analyzing)
Concept: Safety
Difficulty: Moderate
CLARIFICATION: gtt/mL = 30 gtt/mL × 50 mL/30 min = 1,500 mL/30 min =
50 gtt/min PTS: 1 CON: Safety
2. The nursing practitioner is preparing to administer acyclovir (Zovirax) to a hospital patient
with HIV who also has a diagnosis of herpes zoster. The prescribed dose is 10 mg/kg to a
hospital patient who weighs 60 kg. Available are 200-mg tablets. How many tablets will the
nursing practitioner administer?
RIGHT ANSWER>
3
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease and AIDS
Objective: 8. Plan nursing care for hospital patients with HIV and AIDS related to
medications, coinfection prevention, and maintaining nutritional status.
Source: pp. 326
Heading: Treatment for AIDS-Related Conditions
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS-Pharmacological Therapies
CL: Analysis (Analyzing) Concept:
Safety
Difficulty: Moderate
CLARIFICATION: Figure out the weight-based dosing first: 10 × 60 = 600 mg. Available
tablets are 200 mg. So, the number of tablets is 1 tab/200 mg × 600 mg = 3 tab.
PTS: 1 CON: Safety
ORDERED RESPONSE
1. Place in order, from 1 to 7, the steps of the HIV replication process.
1. After fusion, the HIV capsid is released into the host cell.
2. Packaging of HIV RNA and IV proteins within a viral envelope
created from part of the cell membrane occurs.
3. Immature, noninfectious HIV buds from the host cell.
4. HIV uses the machinery of the host cell to replicate long chains of HIV
proteins for building more HIV.
5. Attachment to the CD4 receptor of the host cell occurs.
6. Binding leads to fusion of the HIV envelope and host cell membrane.
7. HIV releases integrase, which incorporates its HIV DNA into the host
cell’s DNA.
RIGHT ANSWER>
5, 6, 1, 7, 4, 2, 3
Chapter: Chapter 20. Nursing Care of Hospital patients With HIV Disease and AIDS
Objective: 1. Define human immunodeficiency virus (HIV) and acquired immunodeficiency
syndrome (AIDS).
Source: pp. 320
Heading: Pathophysiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Comprehension (Understanding) Concept:
Infection
Difficulty: Moderate
CLARIFICATION: The first is binding (attachment) to the CD4 receptor of the host cell.
Binding leads to fusion of the HIV envelope (membrane) and host cell membrane. After
fusion, the HIV capsid is released into the host cell. HIV releases the enzyme integrase,
which incorporates its HIV DNA into the host cell’s DNA. HIV then uses the machinery o f
the host cell to replicate long chains of HIV proteins for building more HIV. Packaging of
HIV RNA and HIV proteins within a viral envelope created from part of the cell membrane
occurs next. The immature, noninfectious HIV then buds from the host cell.
PTS: 1 CON: Infection
Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
MULTIPLE CHOICE
1. A hospital patient asks the nursing practitioner what the action of the arteries is. Which
response by the nursing practitioner is most appropriate?
1. “The arteries act as valves of the heart.”
2. “The arteries carry blood from capillaries to the heart.”
3. “The arteries are the natural pacemaker of the heart.”
4. “The arteries carry blood from the heart to capillaries.”
RIGHT ANSWER> 4
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 2. Explain the normal function of the cardiovascular system.
Source: pp. 342
Heading: Arteries and Veins
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Physiological
Adaptation CL: Application (Applying) Concept:
Perfusion
Difficulty: Easy
CLARIFICATION
1 This does not describe the role of arteries.
2 This describes veins.
3 Arteries do not act as a pacemaker.
4 This is the correct description of the action of arteries.
PTS: 1 CON: Perfusion
2. The nursing practitioner is assessing the heart rate for a person who plays basketball and
runs track. Which heart rate can the nursing practitioner expect to document?
1. 50 beats/min
2. 70 beats/min
3. 90 beats/min
4. 110 beats/min
RIGHT ANSWER> 1
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 2. Explain the normal function of the cardiovascular system.
Source: pp. 341
Heading: Pulses
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The nursing practitioner can expect an athlete to have a pulse rate around 50
beats/min.
2 The nursing practitioner can expect an athlete to have a pulse rate around 50
beats/min.
3 The nursing practitioner can expect an athlete to have a pulse rate around 50
beats/min.
4 The nursing practitioner can expect an athlete to have a pulse rate around 50
beats/min.
PTS: 1 CON: Perfusion
3. The nursing practitioner is caring for a hospital patient recovering from a cardiac
catheterization with a right femoral artery entry site. Which action should the nursing
practitioner take?
1. Ambulate every 2 hours.
2. Position knees with 40-degree bend.
3. Avoid movement of right leg as ordered.
4. Perform passive range of motion of right leg hourly.
RIGHT ANSWER> 3
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 5. Plan nursing care for hospital patients undergoing diagnostic tests for cardiovascular
disorders.
Source: pp. 356
Heading: Cardiac Catheterization
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Since the extremity should not be moved, this action is contraindicated.
2 Since the extremity should not be moved, this action is contraindicated.
3 The extremity used for catheter insertion must not be moved or flexed for
several hours after the procedure.
4 Since the extremity should not be moved, this action is contraindicated.
PTS: 1 CON: Perfusion
4. The nursing practitioner is caring for a hospital patient admitted with chest pain and
suspected myocardial infarction (MI). Which laboratory value should the nursing
practitioner expect to see an elevation?
1. Ammonia
2. Glucose
3. Amylase
4. Troponin
RIGHT ANSWER> 4
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 4. Identify diagnostic tests commonly performed to diagnose disorders of the
cardiovascular system.
Source: pp. 354
Heading: Cardiac Biomarkers
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This laboratory value is used to determine liver disease.
2 Glucose does not determine cardiac damage or function.
3 This laboratory value is used to diagnose pancreatitis.
4 This laboratory value is used to assess cardiac damage for a hospital patient with
a suspected MI.
PTS: 1 CON: Perfusion
5. The nursing practitioner is caring for a group of hospital patients. Which hospital patient
is at highest risk of death related to cardiovascular disease?
1. An African American male who smokes
2. A Caucasian female who works a high-stress job
3. A Hispanic female who exercises daily
4. An Asian male who is vegetarian
RIGHT ANSWER> 1
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 3. List data to collect when caring for a hospital patient with a disorder of
the cardiovascular system.
Source: pp. 346
Heading: Cultural Considerations
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This hospital patient is at highest risk for death caused by cardiovascular
disease; he is male, African American, and a smoker.
2 This hospital patient is not at highest risk for death caused by cardiovascular
disease.
3 This hospital patient is not at highest risk for death caused by cardiovascular
disease.
4 This hospital patient is not at highest risk for death caused by cardiovascular
disease.
PTS: 1 CON: Perfusion
6. The nursing practitioner is explaining the regulation of blood pressure (BP) to a hospital
patient newly diagnosed with hypertension. What tissues within the artery wall that helps
maintain diastolic BP should the nursing practitioner identify for the hospital patient?
1. Smooth muscle and elastic connective tissue
2. Smooth muscle and simple squamous epithelium
3. Elastic connective tissue and fibrous connective tissue
4. Fibrous connective tissue and simple squamous epithelium
RIGHT ANSWER> 1
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 2. Explain the normal function of the cardiovascular system.
Pages: 344–345
Heading: Blood Pressure
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The middle artery layer of smooth muscle and elastic connective tissue
maintains normal BP, especially diastolic BP, by changing the diameter of the
artery.
2 These tissues are not within the layers of the arterial walls.
3 These tissues are not within the layers of the arterial walls.
4 These tissues are not within the layers of the arterial walls.
PTS: 1 CON: Perfusion
7. The nursing practitioner instructs a hospital patient on beverages to avoid when taking the
prescribed medication warfarin (Coumadin). Which beverage should the hospital patient state
that indicates teaching has been effective?
1. Beer
2. Orange juice
3. Grapefruit juice
4. Cranberry juice
RIGHT ANSWER> 4
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 5. Plan nursing care for hospital patients undergoing diagnostic tests for cardiovascular
disorders.
Source: pp. 357
Heading: Nutrition Notes
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 There is no reason for the hospital patient to avoid this beverage.
2 There is no reason for the hospital patient to avoid this beverage.
3 There is no reason for the hospital patient to avoid this beverage.
4 Warfarin is mainly metabolized by the cytochrome P450 isoenzyme CYP2C9,
and cranberry juice contains flavonoids known to inhibit P450 enzymes.
Bleeding problems and hemorrhage have been attributed to this interaction.
PTS: 1 CON: Perfusion
8. A hospital patient has sustained damage to the sinoatrial (SA) node. Which heart rates
indicate that the hospital patient’s atrioventricular (AV) node has taken over as the
pacemaker for the heart?
1. 10 to 20
2. 20 to 35
3. 40 to 60
4. 80 to 100
RIGHT ANSWER> 3
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 2. Explain formal function of the cardiovascular system.
Source: pp. 341
Heading: Cardiac Conduction Pathway and Cardiac Cycle
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 No cardiac tissue will generate this heart rate.
2 The Bundle of His can generate a heartbeat at the rate of 20 to 35.
3 If the SA node becomes nonfunctional, the AV node can initiate each heartbeat,
but at a slower rate of 40 to 60 beats per minute.
4 This is a normal heartbeat that would be generated by the SA node.
PTS: 1 CON: Perfusion
9. The nursing practitioner is reinforcing teaching to a hospital patient about to
undergo angiography. Which statement made by the hospital patient indicates a
need for further teaching?
1. “I cannot have anything to eat or drink for 4 hours before the test.”
2. “I will stay at the hospital after my test so the nursing practitioner can monitor the injection
site.”
3. “This test will assess the electrical system of my heart.”
4. “I may feel a hot, burning feeling when I am injected with dye.”
RIGHT ANSWER> 3
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 5. Plan nursing care for hospital patients undergoing diagnostic tests for cardiovascular
disorders.
Source: pp. 355
Heading: Angiography
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This statement indicates teaching has been effective.
2 This statement indicates teaching has been effective.
3 This statement requires correction; this describes an electrophysiological study.
4 This statement indicates teaching has been effective.
PTS: 1 CON: Perfusion
10. The nursing practitioner is reviewing laboratory values for a hospital patient and notes a
potassium level of 6.4 mEq/L. Which clinical manifestation can the nursing practitioner expect
the hospital patient to report?
1. Constipation
2. Fast heart rate
3. Muscle cramps
4. High blood pressure
RIGHT ANSWER> 3
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 4. Identify diagnostic tests commonly performed to diagnose disorders of the
cardiovascular system.
Source: pp. 355
Heading: Potassium
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Constipation may be seen in hypokalemia.
2 Bradycardia is seen in hyperkalemia.
3 Muscle twitches and cramps may be seen with hyperkalemia.
4 Hypotension is seen with hyperkalemia.
PTS: 1 CON: Perfusion
11. The nursing practitioner is observing a hospital patient apply antiembolism stockings.
Which action by the hospital patient requires correction by the nurse?
1. The hospital patient pulls the stockings up to 1 to 2 inches below the
bottom of the kneecap.
2. The hospital patient uses an assistive device in applying the stockings.
3. The hospital patient rolls the stockings down.
4. The hospital patient wears the stockings all day as instructed.
RIGHT ANSWER> 3
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 6. Describe current therapeutic measures for disorders of the cardiovascular
system.
Source: pp. 356
Heading: Elastic stockings
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This action is correct.
2 This action is correct.
3 This requires correction; allowing the stockings to roll down can cause stasis.
4 This action is correct.
PTS: 1 CON: Perfusion
12. The nursing practitioner is assessing a hospital patient and notices the radial pulse has
fewer beats than the apical pulse. Which action should the nursing practitioner take?
1. Document the finding as normal.
2. Encourage the hospital patient to ambulate and recheck.
3. Notify the health care provider (HCP).
4. Encourage the hospital patient to increase
fluid intake. RIGHT ANSWER> 3
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 2. Explain the normal function of the cardiovascular system.
Source: pp. 348
Heading: Pulses
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This is not a normal finding.
2 The nursing practitioner should notify the HCP; this intervention will likely not
change the assessment finding.
3 The nursing practitioner should notify the HCP for further orders.
4 The HCP should be notified; this intervention will likely not change the
assessment finding.
PTS: 1 CON: Perfusion
13. The nursing practitioner is caring for a hospital patient who had a cardiac catheterization
using the left femoral site for entry. Which data is most important for the nursing practitioner to
monitor?
1. Pupil reaction
2. Left pedal pulse
3. Orientation status
4. Right foot sensation
RIGHT ANSWER> 2
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 5. Plan nursing care for hospital patients undergoing diagnostic tests for cardiovascular
disorders.
Source: pp. 355
Heading: Cardiac Catheterization
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 A cardiac catheterization should not affect pupil reaction or orientation status.
2 The priority assessment is to ensure that circulation is not compromised. The
puncture site and, most important, the peripheral pulses, which are distal to the
procedure site, are verified as being present.
3 A cardiac catheterization should not affect pupil reaction or orientation status.
4 The hospital patient’s left femoral artery was the entry site. The hospital
patient’s right foot
should not be affected.
PTS: 1 CON: Perfusion
14. A hospital patient is being instructed about a Holter monitor. Which statement
indicates that the hospital patient knows what to do when a symptom occurs while
wearing a Holter monitor?
1. “Call an ambulance.”
2. “Notify the physician.”
3. “Take an apical pulse.”
4. “Push the event button.”
RIGHT ANSWER> 4
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 5. Plan nursing care for hospital patients undergoing diagnostic tests for cardiovascular
disorders.
Source: pp. 353
Heading: Holter Monitoring (Ambulatory ECG)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This action does not need to be taken if a symptom occurs while wearing the
monitor.
2 This action does not need to be taken if a symptom occurs while wearing the
monitor.
3 This action does not need to be taken if a symptom occurs while wearing the
monitor.
4 When wearing a Holter monitor, the hospital patient is to record a diary of
activities and
symptoms and push the event button if symptoms occur.
PTS: 1 CON: Perfusion
15. A hospital patient will be wearing a Holter monitor for 2 days. What should the nursing
practitioner instruct the hospital patient about bathing while wearing the monitor?
1. “Take a sponge bath.”
2. “You may take a tub bath.”
3. “Take a shower with the monitor on.”
4. “Remove the monitor before showering.”
RIGHT ANSWER> 1
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 5. Plan nursing care for hospital patients undergoing diagnostic tests for cardiovascular
disorders.
Source: pp. 353
Heading: Holter Monitoring (Ambulatory ECG)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The hospital patient wears loose-fitting clothing and may only sponge bathe
while wearing the monitor.
2 The hospital patient should not take a tub bath, shower, or remove the monitor.
3 The hospital patient should not take a tub bath, shower, or remove the monitor.
4 The hospital patient should not take a tub bath, shower, or remove the monitor.
PTS: 1 CON: Perfusion
16. The nursing practitioner is assessing a hospital patient and notes that the nailbed angle
exceeds 180 degrees and feels spongy when squeezed. Which intervention should the nursing
practitioner implement?
1. Tell the hospital patient he has a congenital heart defect.
2. Document the normal finding in the chart.
3. Encourage the hospital patient to elevate his extremities.
4. Notify the HCP.
RIGHT ANSWER> 4
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 3. List data to collect when caring for a hospital patient with a disorder of
the cardiovascular system.
Source: pp. 350
Heading: Inspection
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 It is not within the nurse’s scope of practice to tell a hospital patient he or she
has a congenital heart defect.
2 This finding should not be documented as normal.
3 Elevating the extremities will not help.
4 The nursing practitioner should notify the HCP.
PTS: 1 CON: Perfusion
17. The nursing practitioner takes the BP of a hospital patient with a result of 120/80 mm Hg.
Which action should the nursing practitioner take?
1. Document the finding as normal.
2. Notify the HCP.
3. Instruct the hospital patient to follow a salt-free diet.
4. Prepare to administer a bolus of normal saline IV.
RIGHT ANSWER> 1
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 4. Identify diagnostic tests commonly performed to diagnose disorders of the
cardiovascular system.
Source: pp. 346
Heading: Blood Pressure
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This BP is normal and will be documented.
2 This is a normal BP reading.
3 Although all hospital patients should follow a low-sodium diet, this BP
reading is normal and diet modification is not necessary.
4 This is a normal BP and does not require intervention.
PTS: 1 CON: Perfusion
18. The nursing practitioner is auscultating heart sounds and notes an S4 heart sound. The
nursing practitioner knows an S4 sound may be heard in a hospital patient with which
condition?
1. Hypertension
2. Crohn disease
3. Liver failure
4. Asthma
RIGHT ANSWER> 1
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 2. Explain the normal function of the cardiovascular system.
Source: pp. 350
Heading: Auscultation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 An S4 sound may be heard with hypertension, coronary artery disease, and
pulmonary stenosis.
2 An S4 sound may be heard with hypertension, coronary artery disease, and
pulmonary stenosis.
3 An S4 sound may be heard with hypertension, coronary artery disease, and
pulmonary stenosis.
4 An S4 sound may be heard with hypertension, coronary artery disease, and
pulmonary stenosis.
PTS: 1 CON: Perfusion
19. The nursing practitioner is caring for a hospital patient recovering from a cardiac
catheterization. Which action should the nursing practitioner take?
1. Force 1,000 mL of fluid per hour.
2. Keep hospital patient NPO until gag reflex is present.
3. Encourage the hospital patient to drink plenty of liquids.
4. Hold fluid intake for 2 hours after the procedure.
RIGHT ANSWER> 3
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 5. Plan nursing care for hospital patients undergoing diagnostic tests for cardiac
disorders. Source: pp. 355
Heading: Cardiac Catheterization
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This volume of oral fluid intake is unrealistic for the hospital patient to perform.
2 The procedure did not affect the hospital patient’s gag reflex
3 The nursing practitioner should encourage the hospital patient to drink plenty of
liquids to help eliminate the dye, which helps to prevent damage to the kidneys.
4 Fluids do not need to be held after the procedure.
PTS: 1 CON: Perfusion
20. The nursing practitioner is caring for a hospital patient recovering from a cardiac
catheterization. Which actions for site care should the nursing practitioner take?
1. Keep the site uncovered.
2. Apply an adhesive bandage to the site.
3. Maintain pressure dressing on the site.
4. Apply a gauze bandage to the puncture site.
RIGHT ANSWER> 3
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 5. Plan nursing care for hospital patients undergoing diagnostic tests for cardiovascular
disorders.
Source: pp. 355
Heading: Cardiac Catheterization
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This action could promote bleeding at the site and should not be done.
2 This action could promote bleeding at the site and should not be done.
3 Pressure is maintained at the site with a pressure dressing or sandbag to prevent
bleeding and hematoma development.
4 This action could promote bleeding at the site and should not be done.
PTS: 1 CON: Perfusion
21. The nursing practitioner is reviewing the medication history for a hospital patient about to
undergo cardiac surgery. Which medication should the nursing practitioner report to the
surgeon?
1. Furosemide (Lasix)
2. Warfarin (Coumadin)
3. Metformin (Glucophage)
4. Lisinopril (Prinivil)
RIGHT ANSWER> 2
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 5. Plan nursing care for hospital patients undergoing tests for cardiovascular
disorders. Source: pp. 357
Heading: Preparation for Surgery
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This medication can be taken before surgery.
2 This medication is a blood thinner; the surgeon should be notified if the
hospital patient is taking this prior to surgery.
3 This medication can be taken prior to surgery.
4 This medication can be taken prior to surgery.
PTS: 1 CON: Perfusion
22. The nursing practitioner is caring for a hospital patient with a potassium level of 7.6
mEq/L. For which HCP- ordered test should the nursing practitioner prepare the hospital
patient?
1. Angiography
2. Electrocardiogram
3. Nuclear radioisotope imaging
4. Cardiac catheterization
RIGHT ANSWER> 2
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 4. Identify diagnostic tests commonly performed to diagnose disorders of the
cardiovascular system.
Source: pp. 355
Heading: Electrocardiogram
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This test is used to assess blood clot formation, PV4, and test vessels for
grafting use.
2 The nursing practitioner should prepare the hospital patient for an
electrocardiogram.
3 This test assesses cardiac blood flow, myocardial ischemia, and ventricle size
and motion.
4 This test provides information on cardiac output and oxygen saturation; it
allows the heart’s anatomy and physiology to be studied.
PTS: 1 CON: Perfusion
23. The nursing practitioner is assessing a hospital patient and notes a prolonged, very loud
swishing sound. The nursing practitioner knows this describes which of the following?
1. Pericardial friction rub
2. Murmur
3. Ventricular gallop
4. Atrial gallop
RIGHT ANSWER> 2
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 3. List data to collect when caring for a hospital patient with a disorder of
the cardiovascular system.
Source: pp. 351
Heading: Auscultation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This does not describe a pericardial friction rub.
2 This describes a murmur.
3 This does not describe a ventricular gallop.
4 This does not describe an atrial gallop.
PTS: 1 CON: Perfusion
24. A hospital patient being treated for a severe blood loss has a BP of 90/56 mm Hg and urine
output of 10 mL over the last hour. Which physiological mechanism should the nursing
practitioner recall is occurring in this hospital patient?
1. Starling’s law
2. Medulla-brainstem
3. Sodium-potassium pump
4. Renin-angiotensin-aldosterone
RIGHT ANSWER> 4
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 2. Explain the normal function of the cardiovascular system.
Pages: 344–345
Heading: Hormones and the Heart
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Starling’s law is used to explain how the heart adjusts blood flow to the body
based on activity.
2 There is no specific medulla-brainstem mechanism that affects blood loss, BP,
and urine output.
3 The sodium-potassium pump is a mechanism to maintain electrolyte balance
within the body.
4 The kidneys are of great importance in the regulation of BP. If blood flow
through the kidneys decreases, renal filtration decreases and urinary output
decreases to preserve blood volume. Decreased BP stimulates the kidneys to
secrete renin, which initiates the renin-angiotensin-aldosterone mechanism,
raising BP.
PTS: 1 CON: Perfusion
25. While collecting data, a hospital patient expectorates pink, frothy sputum. Which health
problem should the nursing practitioner consider is occurring in this hospital patient?
1. Gastritis
2. Pneumonia
3. Heart failure
4. Hepatic failure
RIGHT ANSWER> 3
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 3. List data to collect when caring for a hospital patient with a disorder of
the cardiovascular system.
Source: pp. 347
Heading: Respirations
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Pink, frothy sputum is not associated with gastritis, pneumonia, or hepatic
failure.
2 Pink, frothy sputum is not associated with gastritis, pneumonia, or hepatic
failure.
3 Pink, frothy sputum is an indicator of acute heart failure.
4 Pink, frothy sputum is not associated with gastritis, pneumonia, or hepatic
failure.
PTS: 1 CON: Perfusion
26. The nursing practitioner notes that a hospital patient’s lower legs are brown and the feet
are blue when they are in the dependent position. For which health problem should the nursing
practitioner collect additional data?
1. Anemia
2. Insufficient oxygenation
3. Decreased arterial blood flow
4. Venous blood flow problems
RIGHT ANSWER> 4
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 3. List data to collect when caring for a hospital patient with a disorder of
the cardiovascular system.
Source: pp. 350
Heading: Inspection
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Pallor may indicate anemia or lack of arterial blood flow.
2 Cyanosis shows an oxygen distribution deficiency.
3 A reddish-brown discoloration (rubor) found in the lower extremities occurs
from decreased arterial blood flow.
4 A brown discoloration and cyanosis when the extremity is dependent may be
seen in the presence of venous blood flow problems.
PTS: 1 CON: Perfusion
MULTIPLE RESPONSE
1. The nursing practitioner is caring for a hospital patient with decreased arterial
blood flow. Which clinical manifestations can the nursing practitioner expect to
document? (Select all that apply.)
1. Decreased hair distribution
2. Varicose veins
3. Thick, brittle nails
4. Shiny skin
5. Moist skin
RIGHT ANSWER> 1, 3, 4
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 3. List data to collect when caring for a hospital patient with a disorder of
the cardiovascular system.
Source: pp. 340
Heading: Inspection
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1. In a hospital patient with decreased arterial blood flow, the nursing
practitioner will note a decrease in hair distribution; thick and brittle nails;
and shiny, taught, and dry skin.
2. In a hospital patient with decreased arterial blood flow, the nursing
practitioner will note a decrease
in hair distribution; thick and brittle nails; and shiny, taught, and dry skin.
3. In a hospital patient with decreased arterial blood flow, the nursing
practitioner will note a decrease in hair distribution; thick and brittle nails;
and shiny, taught, and dry skin.
4. In a hospital patient with decreased arterial blood flow, the nursing
practitioner will note a decrease
in hair distribution; thick and brittle nails; and shiny, taught, and dry skin.
5. In a hospital patient with decreased arterial blood flow, the nursing
practitioner will note a decrease in hair distribution; thick and brittle nails;
and shiny, taught, and dry skin.
PTS: 1 CON: Perfusion
2. The nursing practitioner is reinforcing teaching for a hospital patient who is to wear a Holter
monitor. Which of the following should the nursing practitioner include? (Select all that apply.)
1. Avoid strenuous activity.
2. Transmit data over the phone.
3. Push the event button when symptoms occur.
4. Keep an accurate diary of symptoms and activities.
5. Avoid showers or baths while wearing the monitor.
6. Take nothing by mouth for 6 hours before applying the monitor.
RIGHT ANSWER> 3, 4, 5
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 4. Identify diagnostic tests commonly performed to diagnose disorders of the
cardiovascular system.
Source: pp. 353
Heading: Holter Monitoring (Ambulatory ECG)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1. This action does not need to be done by the hospital patient while wearing a
Holter
monitor.
2. This action does not need to be done by the hospital patient while wearing a
Holter monitor.
3. Hospital patient teaching for wearing a Holter monitor includes keeping an
accurate
diary, pushing the event button for symptoms, to not take showers or baths,
and making a return visit.
4. Hospital patient teaching for wearing a Holter monitor includes keeping an
accurate diary, pushing the event button for symptoms, to not take showers or
baths,
and making a return visit.
5. Hospital patient teaching for wearing a Holter monitor includes keeping an
accurate diary, pushing the event button for symptoms, to not take showers or
baths,
and making a return visit.
6. This action does not need to be done by the hospital patient while wearing a
Holter monitor.
PTS: 1 CON: Perfusion
3. The nursing practitioner is caring for a hospital patient who is having an exercise treadmill
test. What interventions would be appropriate for the test? (Select all that apply.)
1. Remove all metal objects.
2. Monitor vital signs throughout the test.
3. Administer antianxiety medication as ordered.
4. Monitor electrocardiogram before, during, and after the test.
5. Ask the hospital patient about allergies to dyes used in diagnostic procedures.
RIGHT ANSWER> 2, 4
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 4. Identify diagnostic tests commonly performed to diagnose disorders of the
cardiovascular system.
Source: pp. 353
Heading: Exercise Stress Test
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1. For magnetic resonance imaging, metal objects are contraindicated and
antianxiety medications are used.
2. Monitor vital signs and electrocardiogram before, during, and after the test to
detect symptoms.
3. For magnetic resonance imaging, metal objects are contraindicated and
antianxiety medications are used.
4. Monitor vital signs and electrocardiogram before, during, and after the test to
detect symptoms.
5. No dyes are used.
PTS: 1 CON: Perfusion
4. The nursing practitioner is caring for a hospital patient with peripheral vascular disease.
Which signs or symptoms should the nursing practitioner expect to observe in this hospital
patient? (Select all that apply.)
1. Pain
2. Pruritus
3. Purpura
4. Paralysis
5. Paresthesia
6. Pulselessness
RIGHT ANSWER> 1, 4, 5, 6
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 3. List data to collect when caring for a hospital patient with a disorder of
the cardiovascular system.
Source: pp. 354
Heading: Learning Tip
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1. The six Ps characterize peripheral vascular disease: pain, poikilothermia,
pulselessness, pallor, paralysis, and paresthesia (decreased sensation).
2. Pruritus and purpura are not manifestations of peripheral vascular disease.
3. Pruritus and purpura are not manifestations of peripheral vascular disease.
4. The six Ps characterize peripheral vascular disease: pain, poikilothermia,
pulselessness, pallor, paralysis, and paresthesia (decreased sensation).
5. The six Ps characterize peripheral vascular disease: pain, poikilothermia,
pulselessness, pallor, paralysis, and paresthesia (decreased sensation).
6. The six Ps characterize peripheral vascular disease: pain, poikilothermia,
pulselessness, pallor, paralysis, and paresthesia (decreased sensation).
PTS: 1 CON: Perfusion
COMPLETION
1. A hospital patient has a stroke volume of 75 mL and a heart rate of 88 beats/min. What
should the nursing practitioner calculate this hospital patient’s cardiac output to be?
RIGHT ANSWER>
6,600 mL/6.6 L
Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic
Measures
Objective: 4. Identify diagnostic tests commonly performed to diagnose disorders of the
cardiovascular system.
Source: pp. 342
Heading: Cardiac Output
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Difficult
CLARIFICATION: Cardiac output is the amount of blood ejected from the left ventricle in 1
minute and is determined by multiplying stroke volume by heart rate. Stroke volume is the
amount of blood ejected by a ventricle in one contraction and averages 60 to 80 mL/beat. With
an average resting heart rate of 75 beats per minute, average resting cardiac output is 5 to 6 L.
To calculate the stroke volume, the nursing practitioner should multiply: 75 mL × 88
= 6,600 mL or 6.6 L.
PTS: 1 CON: Perfusion
Chapter 22. Nursing Care of Hospital patients With Hypertension
MULTIPLE CHOICE
1. A hospital patient on antihypertensive medication has no insurance, three children, and
reports feeling great and exercising daily. What should the nursing practitioner include in this
hospital patient’s teaching plan to promote compliance?
1. Encourage increased rest periods.
2. Provide names of support groups.
3. Refer the hospital patient for financial assistance.
4. Schedule an annual physical examination.
RIGHT ANSWER> 3
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 8. Plan nursing care for a hospital
patients with hypertension. Source: pp. 369
Heading: Nursing Care Plan for the Hospital patient With
Hypertension Integrated Process: Communication and
Documentation Hospital patient Need: PHYS—Basic Care
and Comfort
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Rest, support groups, and annual physical examinations will not improve
compliance with this hospital patient’s teaching plan.
2 Rest, support groups, and annual physical examinations will not improve
compliance with this hospital patient’s teaching plan.
3 The nursing practitioner should refer the hospital patient for financial assistance.
If the hospital patient cannot afford the medication, it will not be taken in spite
of any teaching that is done.
4 Rest, support groups, and annual physical examinations will not improve
compliance with this hospital patient’s teaching plan.
PTS: 1 CON: Perfusion
2. The nursing practitioner is reviewing orders for a hospital patient taking digoxin
(Lanoxin). Which additional medication should the nursing practitioner question?
1. Ramipril (Altace)
2. Carvedilol (Coreg)
3. Verapamil (Calan SR)
4. Clonidine (Catapres)
RIGHT ANSWER> 3
Chapter: Chapter 22. Nursing Care of Hospital patients With Hypertension
Objective: 5. Describe classifications and treatment recommendations for hypertension in
adults.
Source: pp. 369
Heading: Medications Used to Treat Hypertension (Table 22.3)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological
Therapies CL: Analysis (Analyzing)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 This medication is not contraindicated with digoxin.
2 This medication is not contraindicated with digoxin.
3 Calcium channel blockers can increase blood level of digoxin.
4 This medication is not contraindicated with digoxin.
PTS: 1 CON: Perfusion
3. The nursing practitioner is caring for a group of hospital patients. Which hospital patient should
the nursing practitioner see first?
1. A hospital patient with a blood pressure of 140/70 mm Hg who is asymptomatic
2. A hospital patient with a blood pressure of 150/60 mm Hg who is anxious
3. A hospital patient with a blood pressure of 170/80 mm Hg with a headache
4. A hospital patient with a blood pressure of 180/120 mm Hg reporting a nosebleed
RIGHT ANSWER> 4
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 6. Define hypertensive emergency.
Source: pp. 363
Heading: Hypertensive Emergency
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This hospital patient should be seen last.
2 This hospital patient should be seen third.
3 This hospital patient should be seen second.
4 This hospital patient is showing signs of hypertensive emergency and should be
seen
first.
PTS: 1 CON: Perfusion
4. The nursing practitioner is measuring blood pressures during a screening clinic. Which
recommended follow-up time frame should the nursing practitioner suggest to a hospital
patient for a blood pressure reading of 118/72 mm Hg?
1. 1 month
2. 2 months
3. l year
4. 2 years
RIGHT ANSWER> 4
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 8. Plan nursing care for hospital patients
with hypertension.
Source: pp. 369
Heading: Nursing Care Plan for the Hospital patient With
Hypertension Integrated Process: Communication and
Documentation Hospital patient Need: Health Promotion and
Maintenance
CL: Application (Applying) Concept:
Health Promotion
Difficulty: Moderate
CLARIFICATION
1 Follow-up of 1 month, 2 months, or 1 year are not necessary for a normal blood
pressure.
2 Follow-up of 1 month, 2 months, or 1 year are not necessary for a normal blood
pressure.
3 Follow-up of 1 month, 2 months, or 1 year are not necessary for a normal blood
pressure.
4 This is a normal blood pressure and requires a 2-year follow-up.
PTS: 1 CON: Health Promotion
5. A hospital patient tells the nursing practitioner he has started experiencing impotence since
beginning treatment for hypertension. Which statement by the nursing practitioner is most
appropriate?
1. “This is a normal side effect of the medication and you will get used to it.”
2. “You should stop taking this medication immediately.”
3. “I will talk to your doctor and see about referring you for sexual counseling.”
4. “You can start taking sildenafil (Viagra); this should fix the problem.”
RIGHT ANSWER> 3
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 7. List common complications of
hypertension.
Source: pp. 367
Heading: Therapeutic Measures for Hypertension
Integrated Process: Communication and Documentation
Hospital patient Need: PHYS—Reduction of Risk
Potential CL: Application (Applying)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 The hospital patient is telling the nursing practitioner because he wants to fix the
side effect; the nursing practitioner should not suggest doing nothing.
2 The nursing practitioner should not suggest the hospital patient quit taking a
medication.
3 This response is most appropriate.
4 The nursing practitioner cannot suggest a medication without speaking to the
health care
provider (HCP).
PTS: 1 CON: Perfusion
6. The nursing practitioner is planning care for hospital patients with hypertension. Which
ethnic group should the nursing practitioner understand is most sensitive to the effects of the
beta blocker propranolol (Inderal)?
1. Chinese
2. Koreans
3. African Americans
4. Japanese Americans
RIGHT ANSWER> 3
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 2. Identify causes and risk factors for
hypertension.
Source: pp. 363
Heading: Race and Ethnicity
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Chinese people are more sensitive than Caucasians to the effects of propranolol
on heart rate and blood pressure, requiring only half the blood level of
European Americans to achieve a therapeutic effect. Propranolol is eliminated
from the bodies of many Chinese people at double the rate of European
Americans. They are more likely to suffer fatigue as a side effect. The nursing
practitioner must carefully monitor the Chinese hospital patient for therapeutic
and side effects.
2 There is no information to suggest that individuals of Korean or Japanese
descent cannot take propranolol (Inderal).
3 Hypertension among African Americans is usually caused by increased renin
activity resulting in greater sodium and fluid retention. African Americans
respond better to diuretics such as furosemide (Lasix) than to beta blockers
such as propranolol (Inderal).
4 There is no information to suggest that individuals of Korean or Japanese
descent cannot take propranolol (Inderal).
PTS: 1 CON: Perfusion
7. The nursing practitioner is planning care for a group of hospital patients. Which
individual should the nursing practitioner identify as being at the highest risk for
developing hypertension?
1. A 60-year-old Japanese American man
2. A 56-year-old African American woman
3. A 45-year-old female tourist from China
4. A 51-year-old man who recently emigrated from Korea
RIGHT ANSWER> 2
Chapter: Chapter 22. Nursing Care of Hospital patients With Hypertension
Objective: 2. Identify causes and risk factors for hypertension.
Source: pp. 363
Heading: Race and Ethnicity
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Hypertension is not as serious of a health problem in individuals from Japan,
China, or Korea.
2 Hypertension continues to be the most serious health problem for African
Americans in the United States.
3 Hypertension is not as serious of a health problem in individuals from Japan,
China, or Korea.
4 Hypertension is not as serious of a health problem in individuals from Japan,
China, or Korea.
PTS: 1 CON: Perfusion
8. A hospital patient asks the nursing practitioner what the doctor meant by the phrase,
“hypertensive emergency.” Which explanation should the nursing practitioner provide?
1. “It means that you’ve had a small stroke.”
2. “It refers to an episode of very high blood pressure.”
3. “It’s when the heart is failing to pump blood effectively.”
4. “It means the heart has become hyperactive and is beating too fast.”
RIGHT ANSWER> 2
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 6. Define hypertensive emergency.
Source: pp. 368
Heading: Hypertensive Emergency
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Basic Care and
Comfort CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 A hypertensive emergency is not a small stroke.
2 Hypertensive emergency is a severe type of hypertension, characterized by
elevations in systolic blood pressure (SBP) greater than 180 mm Hg and
diastolic blood pressure (DBP) greater than 120, which are complicated by risk
for or progression of target organ dysfunction.
3 This does not mean that the heart is failing to pump blood effectively.
4 This does not mean that the heart is hyperactive and beating too fast.
PTS: 1 CON: Perfusion
9. The nursing practitioner is reinforcing teaching for a hospital patient with hypertension. If a
hospital patient states, “I understand that if I do not eat or cook with salt, my hypertension will go
away.” What is the nurse’s best response?
1. “Reducing salt in the diet increases blood pressure.”
2. “Hospital patients who take diuretics do not need to reduce salt intake.”
3. “Excessive salt intake is responsible for most types of hypertension.”
4. “Some hospital patients’ blood pressure may not respond to salt restriction alone.”
RIGHT ANSWER> 4
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 4. Describe therapeutic measures for
hypertension.
Source: pp. 364
Heading: Modifiable Risk Factors
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Evaluation (Evaluating)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1 This statement is not necessarily true for all people.
2 This statement is not necessarily true for all people.
3 This statement is not necessarily true for all people.
4 The nursing practitioner should explain that some hospital patients’ blood
pressure may not respond to salt restriction alone, so it is important to follow
prescribed therapy.
PTS: 1 CON: Health Promotion
10. The nursing practitioner is reinforcing teaching provided to a hospital patient who has
been taught ways to decrease blood pressure. Which hospital patient statement indicates a
need for further teaching?
1. “I eat fried foods three times a week.”
2. “I don’t add salt to my food anymore.”
3. “I walk my dog for 30 minutes every day.”
4. “I take high blood pressure medication daily.”
RIGHT ANSWER> 1
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 9. Evaluate effectiveness of nursing
interventions.
Source: pp. 363–365
Heading: Modifiable Risk Factors
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Evaluation (Evaluating)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1 Fried foods should be reduced to decrease saturated fat intake.
2 This statement indicates teaching about ways to control blood pressure were
effective.
3 This statement indicates teaching about ways to control blood pressure were
effective.
4 This statement indicates teaching about ways to control blood pressure were
effective.
PTS: 1 CON: Health Promotion
11. The nursing practitioner is teaching a hospital patient with hypertension about the
DASH diet. Which statement made by the hospital patient indicates a need for further
1.2.teac““hiIInwhgai?vlleeeaat t3enouncceups oof fbcaookeked fdisbhefaonrs difonnr diernn.” er
four times this week.”
3. “I ate a hamburger with a small order of fries last night.”
4. “My spouse has begun to cook using only 1 teaspoon of canola oil.”
RIGHT ANSWER> 3
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 4. Describe therapeutic measures for
hypertension.
Source: pp. 364
Heading: Nutrition Notes
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Evaluation (Evaluating)
Concept: Nutrition
Difficulty: Moderate
CLARIFICATION
1 This statement indicates an understanding of the DASH diet.
2 This statement indicates an understanding of the DASH diet.
3 A burger and fries are not on the DASH diet.
4 This statement indicates an understanding of the DASH diet.
PTS: 1 CON: Nutrition
12. The nursing practitioner is teaching a group of hospital patients about hypertension. Which
hospital patient is at highest risk for developing hypertension?
1. A 50-year-old Caucasian female who is 5 foot 6 inches and weighs 150 pounds
2. A 30-year-old Asian male who is 5 foot 5 inches and weighs 110 pounds
3. A 60-year-old African American female who is 5 foot 7 inches and weighs 275
pounds
4. A 40-year-old Hispanic female who is 5 foot 7 inches and weighs 120 pounds
RIGHT ANSWER> 3
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 2. Identify causes of risk factors for
hypertension.
Source: pp. 363
Heading: Race and Ethnicity
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This hospital patient is not at highest risk for hypertension.
2 This hospital patient is not at high risk for hypertension.
3 This hospital patient is overweight, African American, and female, making
this hospital patient at highest risk for hypertension.
4 This hospital patient is not at highest risk for hypertension.
PTS: 1 CON: Perfusion
13. The nursing practitioner is preparing to administer furosemide (Lasix) to a hospital patient
with hypertension. The nursing practitioner reviews the hospital patient’s potassium and notes a
level of 4.6 mEq/L. Which action should the nursing practitioner take?
1. Notify the HCP.
2. Administer the medication as prescribed.
3. Withhold the medication.
4. Wait an hour and administer the medication.
RIGHT ANSWER> 2
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 9. Evaluate effectiveness of nursing
interventions.
Source: pp. 364
Heading: Medications Used to Treat Hypertension
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 There is no reason to notify the HCP.
2 This potassium level is normal; the medication should be administered.
3 The medication should not be withheld.
4 There is no reason to wait to administer the medication.
PTS: 1 CON: Perfusion
14. A hospital patient who has unsuccessfully implemented lifestyle modifications for
high blood pressure asks what else can be done. What should the nursing practitioner
respond to this hospital patient?
1. “You should get more rest.”
2. “You should decrease your exercise plan.”
3. “You should consider more strenuous exercise.”
4. “Your doctor may discuss medication with you.”
RIGHT ANSWER> 4
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 2. Identify causes and risk factors for
hypertension.
Source: pp. 363
Heading: Modifiable Risk Factors
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Application (Applying)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1 Rest is not going to reduce the hospital patient’s blood pressure.
2 Exercise is helpful to reduce blood pressure.
3 Strenuous exercise is not recommended for anyone with high blood pressure.
4 The no- or low-risk hypertensive hospital patient’s therapy begins with lifestyle
modifications. If lifestyle modification alone does not result in a blood pressure
at the target goal, then drug therapy is recommended.
PTS: 1 CON: Health Promotion
15. The nursing practitioner is caring for a hospital patient who has possible kidney damage
from high blood pressure. Which action should the nursing practitioner take?
1. Monitor glucose.
2. Encourage fluids.
3. Monitor urine color.
4. Review creatinine level.
RIGHT ANSWER> 4
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 7. List common complications of
hypertension.
Source: pp. 354
Heading: Complications of Hypertension
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Glucose level is not altered with kidney function.
2 Fluids will not reduce the amount of kidney damage.
3 Urine color is not going to be influenced by kidney function or damage.
4 Creatinine is a measurement of kidney function. With kidney damage, the
creatinine level will be elevated.
PTS: 1 CON: Perfusion
16. The nursing practitioner is caring for a group of hospital patients. Which hospital patient should
the nursing practitioner see first?
1. A hospital patient who received a dose of furosemide (Lasix) and reports an
increase in urine output
2. A hospital patient receiving spironolactone (Aldactone) with a potassium
level of 4.8 mEq/L
3. A hospital patient who received a dose of Metoprolol (Lopressor) with a blood
pressure of 126/74 mm Hg
4. A hospital patient receiving atenolol (Tenormin) with a blood pressure of 188/114 mmHg
RIGHT ANSWER> 4
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 6. Define hypertensive emergency.
Source: pp. 353
Heading: Hypertensive Emergency
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The symptoms are not always present.
2 In hypertension, symptoms may not always be present. That is why
hypertension is referred to as the silent killer.
3 Symptoms can appear with all types of hypertension.
4 The presence of symptoms does not mean that a stroke is pending.
PTS: 1 CON: Perfusion
17. The nursing practitioner is caring for a hospital patient with stage 1 hypertension. Which
medication should the nursing practitioner expect to be prescribed for this hospital patient?
1. Verapamil (Calan)
2. Minoxidil (Loniten)
3. Diltiazem (Cardizem)
4. Hydrochlorothiazide (HydroDIURIL)
RIGHT ANSWER> 4
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 4. Describe therapeutic measures for
hypertension.
Source: pp. 362
Heading: Medications Used to Treat Hypertension
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This medication is not appropriate for the hospital patient with stage 1
hypertension.
2 This medication is not appropriate for the hospital patient with stage 1
hypertension.
3 This medication is not appropriate for the hospital patient with stage 1
hypertension.
4 For most hospital patients with hypertension, initial drug therapy should be
thiazide- type diuretics such as hydrochlorothiazide.
PTS: 1 CON: Perfusion
18. The nursing practitioner is teaching a hospital patient about furosemide (Lasix). Which
statement made by the hospital patient indicates an understanding of the teaching?
1. “If my blood pressure is really high, I will take a second dose.”
2. “I will be sure to avoid potassium while taking this medication.”
3. “I should take the medication in the morning so I am not up all night going to the
bathroom.”
4. “I need to be sure to take this pill without food or milk.”
RIGHT ANSWER> 3
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 4. Describe therapeutic measures for
hypertension.
Source: pp. 365
Heading: Medications Used to Treat Hypertension (Table 22.3)
Integrated Process: Teaching/Learning
Hospital patient Need: SECE—Safety and
Infection Control CL: Evaluation (Evaluating)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 The hospital patient should not take a second dose of Lasix without consulting
the HCP.
2 The hospital patient should not avoid potassium because Lasix is a potassium-
wasting diuretic.
3 This statement is accurate.
4 The medication should be taken with food or milk.
PTS: 1 CON: Perfusion
19. The nursing practitioner is contributing to a teaching session about hypertension. Which
hospital patient should the nursing practitioner identify as having the greatest risk for
hypertension?
1. A 43-year-old married mother of three teenagers
2. A 40-year-old man whose brother has hypertension
3. A 35-year-old male construction worker who smokes
4. A 34-year-old single female who is an administrative assistant
RIGHT ANSWER> 2
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 2. Identify causes and risk factors for
hypertension.
Source: pp. 363
Heading: Risk Factors for Hypertension
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This individual has risk factors that can be modified and reduce the risk of
developing hypertension.
2 Nonmodifiable risk factors—those that cannot be changed—include a family
history of hypertension, age, ethnicity, and diabetes mellitus.
3 This individual has risk factors that can be modified and reduce the risk of
developing hypertension.
4 This individual has risk factors that can be modified and reduce the risk of
developing hypertension.
PTS: 1 CON: Perfusion
20. The nursing practitioner is assessing a hospital patient who has been taking prazosin
(Minipress) for 3 months. Which indicates treatment is effective?
1. The hospital patient reports a 4-pound weight loss in 3 months.
2. The hospital patient states they work out at the gym every morning.
3. The hospital patient tells the nursing practitioner she has been following a low-sodium diet.
4. The hospital patient’s blood pressure is 114/66 mm Hg.
RIGHT ANSWER> 4
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 9. Evaluate effectiveness of nursing
interventions.
Source: pp. 365
Heading: Medications
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Evaluation (Evaluating) Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 Blood pressure within normal limits is indicative of effective treatment.
2 Blood pressure within normal limits is indicative of effective treatment.
3 Blood pressure within normal limits is indicative of effective treatment.
4 Blood pressure within normal limits is indicative of effective treatment.
PTS: 1 CON: Perfusion
21. The nursing practitioner is taking a medication history of a hospital patient with a
chronic cough. Which medication can the nursing practitioner suspect as contributing to
the cough?
1. Chlorothiazide (Diuril)
2. Furosemide (Lasix)
3. Nadolol (Corgard)
4. Lisinopril (Zestril)
RIGHT ANSWER> 4
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 4. Describe therapeutic measures for
hypertension.
Source: pp. 365
Heading: Medications Used to Treat Hypertension (Table 22.3) Integrated
Process: Clinical Problem-Solving Process (Nursing Process) Hospital
patient Need: PHYS—Pharmacological Therapies
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This medication doesn’t cause a cough.
2 This medication doesn’t cause a cough.
3 This medication doesn’t cause a cough.
4 This is an ace inhibitor and places the hospital patient at risk for cough.
PTS: 1 CON: Perfusion
22. The nursing practitioner is preparing to administer atenolol (Tenormin) to a hospital patient
with hypertension. The hospital patient’s blood pressure is 72/40 mm Hg. Which action should the
nursing practitioner take?
1. Administer the medication as ordered.
2. Notify the HCP.
3. Reassess the hospital patient’s blood pressure in 8 hours.
4. Administer half of the prescribed dose.
RIGHT ANSWER> 2
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 4. Describe therapeutic measures for
hypertension Source: pp. 365
Heading: Medications Used to Treat Hypertension (Table 22.3) Integrated
Process: Clinical Problem-Solving Process (Nursing Process) Hospital
patient Need: SECE-Safety and Infection Control
CL: Application (Applying) Concept:
Safety
Difficulty: Moderate
CLARIFICATION
1 The hospital patient’s blood pressure is low; the HCP should be notified before
taking action.
2 The hospital patient’s blood pressure is low; the HCP should be notified before
taking
action.
3 The hospital patient’s blood pressure is low; the HCP should be notified before
taking action.
4 The hospital patient’s blood pressure is low; the HCP should be notified before
taking
action.
PTS: 1 CON: Safety
23. The nursing practitioner is assessing a blood pressure of a hospital patient and obtains a
reading of 110/60 mm Hg. The nursing practitioner knows the hospital patient falls under which
category?
1. Stage 1 hypertension
2. Elevated blood pressure
3. Normal blood pressure
4. Stage 2 hypertension
RIGHT ANSWER> 3
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 1. Explain the pathophysiology of
hypertension.
Source: pp. 362
Heading: Blood Pressure Categories (Table 22.1)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This blood pressure is normal.
2 This blood pressure is normal.
3 This blood pressure is normal.
4 This blood pressure is normal.
PTS: 1 CON: Perfusion
24. The nursing practitioner is caring for a hospital patient in hypertensive emergency. What
should the nursing practitioner expect to be the goal when treatment is provided for this
hospital patient?
1. Increase urine output.
2. Negate the impact of sodium in the body.
3. Ensure an adequate potassium blood level.
4. Reduce blood pressure by 25% in 1 hour.
RIGHT ANSWER> 4
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 6. Define hypertensive emergency.
Source: pp. 368
Heading: Hypertensive Emergency
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The goals of therapy for a hospital patient in hypertensive emergency are not to
increase urine output, negate the impact of sodium in the body, or to ensure an
adequate potassium blood level.
2 The goals of therapy for a hospital patient in hypertensive emergency are not to
increase urine output, negate the impact of sodium in the body, or to ensure an
adequate
potassium blood level.
3 The goals of therapy for a hospital patient in hypertensive emergency are not to
increase urine output, negate the impact of sodium in the body, or to ensure an
adequate potassium blood level.
4 In some cases of hypertensive emergency, blood pressure may need to be
reduced by 25% within 1 hour.
PTS: 1 CON: Perfusion
25. The nursing practitioner becomes concerned that a male hospital patient’s blood pressure is
168/98 mm Hg after 6 months on antihypertensive medication. What question should the nursing
practitioner ask after measuring this blood pressure?
1. Is the hospital patient taking the medication?
2. What is the volume of alcohol ingested each day?
3. Which pharmacy is filling the prescribed medications?
4. How many hours of sleep does the hospital patient receive each night?
RIGHT ANSWER> 1
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 9. Evaluate effectiveness of nursing
interventions.
Source: pp. 369
Heading: Therapeutic Measures for Hypertension
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Antihypertensive medications can have unpleasant side effects. For the male
hospital patient, erectile dysfunction might occur, and the hospital patient may
choose to stop
the medication. The nursing practitioner needs to find out if the hospital patient
is taking the
medication.
2 These questions do not focus on why the hospital patient’s blood pressure
continues to
be elevated after taking medication for 6 months.
3 These questions do not focus on why the hospital patient’s blood pressure
continues to be elevated after taking medication for 6 months.
4 These questions do not focus on why the hospital patient’s blood pressure
continues to
be elevated after taking medication for 6 months.
PTS: 1 CON: Perfusion
MULTIPLE RESPONSE
1. The nursing practitioner is reviewing complications of hypertension with a hospital
patient. Which should the nursing practitioner include in the teaching? (Select all that
apply.)
1. Heart failure
2. Liver disease
3. Hypothyroidism
4. Stroke
5. Myocardial infarction
6. Kidney Failure
RIGHT ANSWER> 1, 4, 5, 6
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 7. List common complications of
hypertension.
Source: pp. 368
Heading: Hypertension Summary
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Physiological
Adaptation CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1. This is a complication of hypertension.
2. This is not a complication of hypertension.
3. This is not a complication of hypertension.
4. This is a complication of hypertension.
5. This is a complication of hypertension.
6. This is a complication of hypertension.
PTS: 1 CON: Perfusion
2. The nursing practitioner is caring for a hospital patient with hypertension who is being
discharged home with a prescription of propranolol (Inderal). Which topics should the
nursing practitioner include in the teaching? (Select all that apply.)
1. Check the heart rate and blood pressure before taking the medication.
2. Get up slowly to avoid dizziness.
3. Keep appointments to have potassium level checked.
4. Wear sunscreen to avoid photosensitivity.
5. Talk to the doctor before the medication is stopped.
RIGHT ANSWER> 1, 2, 5
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 4. Describe therapeutic measures for
hypertension.
Source: pp. 365
Heading: Medications Used to Treat Hypertension (Table 22.3)
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Pharmacological
Therapies CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1. The hospital patient will be taught to take a blood pressure and heart rate
before
taking the medication.
2. The hospital patient should be taught to rise slowly to avoid dizziness.
3. This medication does not require monitoring potassium levels.
4. This medication does not cause photosensitivity.
5. The nursing practitioner should instruct the hospital patient to avoid ceasing
medication to avoid
rebound hypertension.
PTS: 1 CON: Perfusion
3. The infection control nursing practitioner observes a nursing practitioner on a cardiac
unit. Which actions by the nursing practitioner would require intervention by the infection
control nurse? (Select all that apply.)
1. Wipes stethoscope with a soft cloth before each hospital patient use
2. Carries stethoscope in a laboratory coat pocket when not in use
3. Performs hand hygiene before and after contact with each hospital patient
4. Leaves a thermometer in the room of a hospital patient on contact precautions
5. Takes own stethoscope into the room of a hospital patient on contact precautions
6. Uses a stethoscope and blood pressure cuff supplied in the hospital patient’s room
RIGHT ANSWER> 1, 5
Chapter: Chapter 22. Nursing Care of Hospital patients With
Hypertension Objective: 8. Plan nursing care for hospital patients
with hypertension.
Source: pp. 358
Heading: Therapeutic Measures for Hypertension
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Evaluation (Evaluating) Concept: Safety
Difficulty: Moderate
CLARIFICATION
1. The nursing practitioner should not wipe the stethoscope with a cloth before
use or use own stethoscope for a hospital patient on contact precautions.
2. Stethoscopes become contaminated with hospital patient use. To protect
hospital patients,
stethoscopes should be cleansed with ethanol-based cleanser or isopropyl
alcohol pads as frequently between each hospital patient use as hands are
washed. Hospital patients with contact precautions or isolation should have
dedicated equipment in the room.
3. Stethoscopes become contaminated with hospital patient use. To protect
hospital patients, stethoscopes should be cleansed with ethanol-based cleanser
or isopropyl alcohol pads as frequently between each hospital patient use as
hands are washed. Hospital patients with contact precautions or isolation
should have dedicated
equipment in the room.
4. Stethoscopes become contaminated with hospital patient use. To protect
hospital patients, stethoscopes should be cleansed with ethanol-based
cleanser or isopropyl alcohol pads as frequently between each hospital
patient use as hands are washed. Hospital patients with contact precautions
or isolation should have dedicated equipment in the room.
5. The nursing practitioner should not wipe the stethoscope with a cloth before
use or use own
stethoscope for a hospital patient on contact precautions.
6. Stethoscopes become contaminated with hospital patient use. To protect
hospital patients, stethoscopes should be cleansed with ethanol-based
cleanser or isopropyl alcohol pads as frequently between each hospital
patient use as hands are washed. Hospital patients with contact precautions
or isolation should have dedicated equipment in the room.
PTS: 1 CON: Safety
COMPLETION
1. The nursing practitioner is preparing to administer furosemide (Lasix) 20 mg
intravenously to a hospital patient with hypertension. The available dose is 40 mg/mL.
How many mL will the nursing practitioner administer? Enter the numeral only.
RIGHT ANSWER>
0.5
Chapter: Chapter 22. Nursing Care of Hospital patients With Hypertension
Objective: 5. Define classifications and treatment recommendations for hypertension in
adults.
Source: pp. 365
Heading: Medications Used to Treat Hypertension (Table 22.3)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Analysis (Analyzing) Concept:
Safety
Difficulty: Moderate
CLARIFICATION: mL = 1 mL/40 mg × 20 mg
= 0.5 mL PTS: 1 CON: Safety
2. The nursing practitioner is preparing to administer lisinopril (Prinivil) 40 mg by mouth to a
hospital patient with hypertension. The available does is 20 mg per tablet. How many
tablets will the nursing practitioner administer? Enter the numeral only.
RIGHT ANSWER>
2
Chapter: Chapter 22. Nursing Care of Hospital patients With Hypertension
Objective: 5. Define classifications and treatment recommendations for hypertension in
adults.
Source: pp. 365
Heading: Medications Used to Treat Hypertension (Table 22.3)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Analysis (Analyzing) Concept:
Safety
Difficulty: Moderate
CLARIFICATION: tab = 1 tab/20 mg × 40 mg
= 2 tablets PTS: 1 CON: Safety
Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory,
and Infectious Cardiac or Venous Disorders
MULTIPLE CHOICE
1. The nursing practitioner is reinforcing teaching for a hospital patient who has had a
mechanical valve replacement. What should be included regarding safety during warfarin
(Coumadin) therapy?
1. Wear medial alert identification.
2. Use a straight razor when shaving.
3. Keep yearly blood test appointments.
4. Increase intake of green leafy vegetables.
RIGHT ANSWER> 1
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 3. Identify postoperative complications that can occur following any type of
cardiac valve replacement.
Source: pp. 375
Heading: Nursing Diagnoses, Planning, Implementation, and Evaluation
Integrated Process: Teaching/Learning
Hospital patient Need: SECE—Safety and
Infection Control CL: Application (Applying)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 If the hospital patient is on anticoagulants for mechanical valve replacement,
medical identification should be used.
2 Avoid a straight razor to avoid cuts and bleeding.
3 Monthly blood tests are done.
4 A steady (rather than fluctuating) amount of green leafy vegetables should be
eaten so that international normalized ratio (INR) values do not fluctuate due to
the vitamin K found in these foods.
PTS: 1 CON: Safety
2. The nursing practitioner is caring for a group of hospital patients on the cardiac unit.
Which hospital patient is at highest risk for mitral valve prolapse?
1. A 12-year-old male
2. An 18-year-old female
3. A 25-year-old male
4. A 40-year-old female
RIGHT ANSWER> 2
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 1. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests,
therapeutic measures, and nursing care for each of the valvular disorders.
Source: pp. 375
Heading: Pathophysiology and Etiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This hospital patient is not at high risk for mitral valve prolapse.
2 This hospital patient is both between the ages of 15 and 30 and a female, placing
this
hospital patient at highest risk.
3 This hospital patient is not at highest risk for mitral valve prolapse.
4 This hospital patient is not at highest risk for mitral valve prolapse.
PTS: 1 CON: Perfusion
3. The nursing practitioner is teaching a hospital patient about mitral valve prolapse and
lifestyle modifications. Which statement made by the hospital patient indicates a need for
further teaching?
1. “I should cut coffee out of my diet.”
2. “I need to avoid physical activity.”
3. “I have been practicing yoga to reduce stress.”
4. “I will need to follow a balanced diet.”
RIGHT ANSWER> 2
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 1. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests,
therapeutic measures, and nursing care for each of the valvular disorders.
Source: pp. 375
Heading: Therapeutic Measures
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Evaluation (Evaluating)
Concept: Heath Promotion
Difficulty: Moderate
CLARIFICATION
1 Caffeine should be avoided; this is an accurate statement.
2 Exercise should be encouraged, not avoided.
3 This is an accurate statement.
4 This is an accurate statement.
PTS: 1 CON: Health Promotion
4. The nursing practitioner is caring for a hospital patient with aortic regurgitation. Which
interventions should the nursing practitioner implement?
1. Encourage the hospital patient to perform all activities of daily living at once.
2. Schedule activities with periods of rest.
3. Elevate the head of bed (HOB) to 30 degrees.
4. Apply oxygen at 2 liters/nasal cannula.
RIGHT ANSWER> 2
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 1. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests,
therapeutic measures, and nursing care for each of the valvular disorders.
Source: pp. 376
Heading: Nursing Care Plan for the Hospital patient With a Cardiac Valvular
Disorder Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The nursing practitioner should schedule activities with periods of rest.
2 This is an appropriate intervention.
3 The HOB should be elevated to 45 degrees.
4 The nursing practitioner needs an order to apply oxygen.
PTS: 1 CON: Perfusion
5. The nursing practitioner is caring for a hospital patient receiving heparin for
thrombophlebitis. The nursing practitioner observes the hospital patient has bleeding gums
and black tarry stools. Which prescribed medication should the nursing practitioner plan to
administer?
1. Vitamin K
2. Naloxone (Narcan)
3. Protamine sulfate
4. Flumazenil (Romazicon)
RIGHT ANSWER> 3
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 6. Explain the pathophysiology, signs and symptoms, prevention, complications,
diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis.
Source: pp. 393
Heading: Anticoagulant Medications (Table 23.8)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Application (Applying) Concept:
Safety
Difficulty: Moderate
CLARIFICATION
1 This is the antidote for Coumadin.
2 This is given for opioid overdose.
3 This is the antidote for heparin.
4 This is the antidote for benzodiazepines.
PTS: 1 CON: Safety
6. The nursing practitioner is assessing a hospital patient who underwent valve replacement
surgery. Which finding should concern the nursing practitioner the most?
1. Wet lung sounds
2. Urine output 50 mL/hr
3. Temperature of 99.1°F
4. Chest tube drainage of 100 mL/hr
RIGHT ANSWER> 1
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 3. Identify postoperative complications that can occur following any type of
cardiac valve replacement.
Source: pp. 379
Heading: Nursing Care Plan for the Postoperative Hospital patient Undergoing Cardiac
Surgery Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 Wet lung sounds are indicative of heart failure or pulmonary edema.
2 This is normal urine output.
3 A low-grade temperature is not concerning in the first 24 hours.
4 This is normal chest tube drainage.
PTS: 1 CON: Perfusion
7. The nursing practitioner is caring for a hospital patient with infective endocarditis (IE).
Which statement made by the hospital patient leads the nursing practitioner to suspect the cause
of the IE?
1. “When I was a child, I had rheumatic fever.”
2. “I have not been to the dentist in 8 years.”
3. “I had a myocardial infarction last year.”
4. “I have to sit in one spot for a long time for my job.”
RIGHT ANSWER> 2
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 4. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests,
therapeutic measures, and nursing care for infective endocarditis, pericarditis, and
myocarditis.
Source: pp. 384
Heading: Pathophysiology and Etiology
Integrated Process: Communication and Documentation
Hospital patient Need: SECE—Safety and Infection
Control CL: Analysis (Analyzing)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 This does not lead to IE.
2 Poor dental hygiene is a cause of IE.
3 This does not lead to IE.
4 This does not lead to IE.
PTS: 1 CON: Perfusion
8. The nursing practitioner is providing discharge teaching for a hospital patient with mitral
stenosis. What should the nursing practitioner include in this teaching?
1. “The medications you will be taking make your blood thicker, so you are at risk
for small clots to form.”
2. “It is important that you increase your fluid intake and take iron supplements so
that your body can make enough blood for your heart to pump around.”
3. “Your blood is rushing through your heart so fast that it may not give your heart
enough oxygen and you may have something called angina, or heart pain.”
4. “Because of your heart condition, the blood flow through your heart is slower and
blood may tend to pool in certain areas, which might allow tiny clots to form.”
RIGHT ANSWER> 4
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 1. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests,
therapeutic measures, and nursing care for each of the valvular disorders.
Pages: 376–377
Heading: Therapeutic Measures
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Physiological
Adaptation CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Hospital patients are often placed on blood thinners, so this is a false statement.
2 Iron supplementation is provided for iron deficiency anemia, not for valvular
disorders.
3 Blood flow through the heart is slowed, so this is a false statement.
4 Emboli form from the stasis of blood in the heart caused by valvular disorders
and decreased cardiac output.
PTS: 1 CON: Perfusion
9. The nursing practitioner is caring for a hospital patient who has aortic stenosis. During data
collection, which of these manifestations should indicate to the nursing practitioner that the
hospital patient is experiencing myocardial oxygen deficiency?
1. Angina
2. Sacral edema
3. Jugular vein distention
4. Pericardial friction rub
RIGHT ANSWER> 1
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 1. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests,
therapeutic measures, and nursing care for each of the valvular disorders.
Source: pp. 375
Heading: Signs and Symptoms
Integrated Process: Clinical Problem-Solving Process (Nursing Process
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Angina results if cardiac oxygen needs are not met.
2 A lack of myocardial oxygen does not cause sacral edema, jugular vein
distention, or pericardial friction rub.
3 A lack of myocardial oxygen does not cause sacral edema, jugular vein
distention, or pericardial friction rub.
4 A lack of myocardial oxygen does not cause sacral edema, jugular vein
distention, or pericardial friction rub.
PTS: 1 CON: Perfusion
10. The nursing practitioner is evaluating care provided to a hospital patient with the
nursing diagnosis of activity intolerance because of aortic regurgitation. Which
outcome indicates that care has been effective?
1. Stated maintained bedrest to reduce fatigue
2. Engaged in desired daily and social activities
3. Completed activities of daily living with assistance
4. Reported no longer participates in gardening hobby
RIGHT ANSWER> 2
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 1. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests,
therapeutic measures, and nursing care for each of the valvular disorders.
Pages: 378–379
Heading: Nursing Care Plan for the Hospital patient With a Cardiac Valvular
Disorder Integrated Process: Psychosocial Integrity
Hospital patient Need: PHYS—Physiological
Adaptation CL: Evaluation (Evaluating)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 Needing bedrest to reduce fatigue indicates that interventions to address
activity intolerance have not been effective.
2 The desired outcome for activity intolerance would be for the hospital patient
to be able to engage in desired daily and social activities.
3 Needing assistance to complete activities of daily indicates that interventions to
address activity intolerance have not been effective.
4 No longer participating in a gardening hobby indicates that interventions to
address activity intolerance have not been effective.
PTS: 1 CON: Perfusion
11. The nursing practitioner is reviewing care for a group of hospital patients. Which
hospital patient with a heart valve disorder should the nursing practitioner identify as being
susceptible to developing the complication of fluid volume excess?
1. A 27-year-old male on atenolol (Tenormin)
2. A 68-year-old female on digoxin (Lanoxin)
3. A 44-year-old male taking amoxicillin (Amoxil)
4. An 18-year-old female taking warfarin (Coumadin)
RIGHT ANSWER> 2
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 1. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests,
therapeutic measures, and nursing care for each of the valvular disorders.
Source: pp. 375
Heading: Complications
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 These hospital patients would be less prone to developing fluid volume excess
with a heart valve disorder.
2 Older adults generally would be more likely to experience the complication of
fluid volume excess due to aging changes and less cardiac reserve. None of the
listed medications are expected to cause fluid volume retention.
3 These hospital patients would be less prone to developing fluid volume excess
with a heart valve disorder.
4 These hospital patients would be less prone to developing fluid volume excess
with a
heart valve disorder.
PTS: 1 CON: Perfusion
12. The nursing practitioner is reinforcing teaching about dilated cardiomyopathy. Which
statement made by the hospital patient indicates a need for further teaching?
1. “My condition could be genetic; I should get my kids tested.”
2. “I may have heart failure since I have the dilated type of cardiomyopathy.”
3. “I have the more common type of cardiomyopathy.”
4. “I will not have to receive treatment, since it is not useful.”
RIGHT ANSWER> 4
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 5. Explain the pathophysiology, etiology, signs and symptoms, complications,
diagnostic tests, therapeutic measures, and nursing care for dilated, hypertrophic, and
restrictive cardiomyopathy.
Source: pp. 391
Heading: Therapeutic Measures
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Physiological
Adaptation CL: Evaluation (Evaluating)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 This statement is accurate.
2 This statement is accurate.
3 This statement is accurate.
4 Treatment is not useful for restrictive cardiomyopathy.
PTS: 1 CON: Perfusion
13. The nursing practitioner is caring for a group of hospital patients. Which hospital patient
is at highest risk for developing deep vein thrombosis (DVT)?
1. A cashier
2. A truck driver
3. A nurse
4. A mail carrier
RIGHT ANSWER> 2
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention,
complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis.
Source: pp. 394
Heading: Immobility
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 A cashier is not at high risk for developing a DVT.
2 A truck driver is at highest risk because of siting for long periods of time.
3 A nursing practitioner is not at high risk for developing a DVT.
4 A mail carrier is not at high risk for developing a DVT.
PTS: 1 CON: Perfusion
14. A hospital patient who has aortic stenosis develops severe dyspnea and chest pain.
Which action should the nursing practitioner take?
1. Obtain vital signs.
2. Give nitroglycerin.
3. Raise the head of the bed.
4. Encourage the hospital patient to sleep.
RIGHT ANSWER> 1
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 1. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests,
therapeutic measures, and nursing care for each of the valvular disorders.
Source: pp. 378
Heading: Therapeutic Measures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Data collection is the first action the nursing practitioner should take in any
situation to plan further care.
2 These actions can be done after the vital signs are assessed.
3 These actions can be done after the vital signs are assessed.
4 A hospital patient with severe dyspnea and chest pain is not going to be able to
sleep.
PTS: 1 CON: Perfusion
15. The nursing practitioner is monitoring a hospital patient with aortic stenosis and notes
crackles in the lungs and a cough. Which complication should the nursing practitioner
suspect is occurring in this hospital patient?
1. Pneumonia
2. Heart failure
3. Hypertension
4. Rheumatic fever
RIGHT ANSWER> 2
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 1. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests,
therapeutic measures, and nursing care for each of the valvular disorders.
Source: pp. 378
Heading: Complications
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Change in lung sounds and a cough does not necessarily indicate the
development of pneumonia, hypertension, or rheumatic fever.
2 Heart failure can occur with heart valve disorders. Lung symptoms are
indicative of heart failure.
3 Change in lung sounds and a cough does not necessarily indicate the
development of pneumonia, hypertension, or rheumatic fever.
4 Change in lung sounds and a cough does not necessarily indicate the
development of pneumonia, hypertension, or rheumatic fever.
PTS: 1 CON: Perfusion
16. A hospital patient with mitral stenosis is prescribed a preoperative antibiotic.
Which hospital patient statement indicates an understanding for taking this
medication?
1. “To prevent postoperative pneumonia.”
2. “To prevent an increase in body temperature.”
3. “To prevent a bacterial infection in the heart.”
4. “To prevent infection of the surgical incision.”
RIGHT ANSWER> 3
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 2. Compare and contrast the difference between commissurotomy, annuloplasty,
and valve replacement.
Source: pp. 377
Heading: Cardiac Valve Repairs
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Reduction of Risk
Potential CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This medication is not provided to prevent postoperative pneumonia, fever, or
infection of the surgical incision.
2 This medication is not provided to prevent postoperative pneumonia, fever, or
infection of the surgical incision.
3 Prophylactic antibiotic therapy helps prevent a bacterial infection in the heart,
rheumatic fever, and subsequent rheumatic heart disease and is recommended
to prevent valvular disease.
4 This medication is not provided to prevent postoperative pneumonia, fever, or
infection of the surgical incision.
PTS: 1 CON: Perfusion
17. The nursing practitioner is caring for a group of hospital patients. Which hospital patient
is at highest risk for developing pericarditis?
1. A hospital patient with DVT of the right leg
2. A hospital patient with a history of rheumatic fever
3. A hospital patient with ankylosing spondylitis
4. A hospital patient with renal disease and systemic lupus
erythematosus (SLE) RIGHT ANSWER> 4
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 4. Explain the pathophysiology, etiology, signs and symptoms, complications,
diagnostic tests, therapeutic measures, and nursing care for infective endocarditis,
pericarditis, and myocarditis.
Source: pp. 389
Heading: Pathophysiology and Etiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This hospital patient is not at risk for pericarditis.
2 This hospital patient is at moderate risk for pericarditis.
3 This hospital patient is not at risk for pericarditis.
4 This hospital patient is at highest risk for pericarditis.
PTS: 1 CON: Perfusion
18. The nursing practitioner is caring for a hospital patient with pericarditis who develops
hypotension, confusion, tachycardia, tachypnea, and jugular venous distension. For which
procedure should the nursing practitioner prepare the hospital patient?
1. Pericardiocentesis
2. Myectomy
3. Endometrial biopsy
4. Commissurotomy
RIGHT ANSWER> 1
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 4. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests,
therapeutic measures, and nursing care for infective endocarditis, pericarditis, and
myocarditis.
Source: pp. 389
Heading: Complications
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The hospital patient is experiencing cardiac tamponade. A pericardiocentesis is
the
treatment.
2 This is not the treatment for cardiac tamponade.
3 This is not the treatment for cardiac tamponade.
4 This is not the treatment for cardiac tamponade.
PTS: 1 CON: Perfusion
19. The nursing practitioner is collecting data on a hospital patient recovering from a
hysterectomy who is experiencing left calf tenderness. Data include the following: left calf
17.5 inches; right calf 14 inches; left thigh 32 inches; right thigh 28 inches; shiny, warm,
and reddened left leg. Which actions should the nursing practitioner recommend for this
hospital patient’s plan of care?
1. Maintain bedrest.
2. Encourage ambulation daily.
3. Place anti-embolism stocking on left leg.
4. Place anti-embolism stocking on both legs.
RIGHT ANSWER> 1
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention,
complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis.
Source: pp. 394
Heading: Therapeutic Measures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Hospital patient has developed thrombophlebitis, and bedrest should be
maintained as ordered until acute phase is resolved to prevent an emboli.
2 Ambulation could lead to a pulmonary embolism and should be avoided.
3 Anti-embolism stockings are placed on the unaffected leg only during the acute
phase to prevent emboli.
4 Anti-embolism stockings are placed on the unaffected leg only during the acute
phase to prevent emboli.
PTS: 1 CON: Perfusion
20. The nursing practitioner is caring for a hospital patient who develops a fever and
reports right calf pain with a reddened and swollen calf. Which action should the
nursing practitioner take?
1. Massage the affected calf.
2. Place ice on the affected calf.
3. Place elastic stocking on right leg.
4. Measure bilateral calf circumference daily.
RIGHT ANSWER> 4
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention,
complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis.
Source: pp. 394
Heading: Therapeutic Measures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application
(Applying) Concept:
Perfusion Difficulty:
Moderate
CLARIFICATION
1 Massaging the calf is contraindicated, and anti-embolism stockings are placed
on the unaffected leg only during acute phase to prevent emboli. Warm, moist
heat may be used for superficial thrombophlebitis.
2 Massaging the calf is contraindicated, and anti-embolism stockings are placed
on the unaffected leg only during acute phase to prevent emboli. Warm, moist
heat may be used for superficial thrombophlebitis.
3 Massaging the calf is contraindicated, and anti-embolism stockings are placed
on the unaffected leg only during acute phase to prevent emboli. Warm, moist
heat may be used for superficial thrombophlebitis.
4 The calf should be measured bilaterally for comparison and documented daily
to note changes.
PTS: 1 CON: Perfusion
21. The nursing practitioner is caring for a group of hospital patients. Which hospital patient should
the nursing practitioner see first?
1. A hospital patient with IE who is receiving IV antibiotic therapy
2. A hospital patient who underwent valve replacement surgery 4 hours ago and
reports level 9 pain
3. A hospital patient with aortic regurgitation awaiting an echocardiogram
4. A hospital patient with myocarditis who has a 99.1°F fever
RIGHT ANSWER> 2
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 3. Identify postoperative complications that can occur following any type of
cardiac valve replacement.
Source: pp. 382
Heading: Data Collection
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 It is typical for this hospital patient to receive antibiotics; this hospital patient is
not the highest
priority.
2 This hospital patient should be seen first and given pain medication.
3 This hospital patient is not the highest priority.
4 This hospital patient should be seen after the hospital patient with level 9 pain.
PTS: 1 CON: Perfusion
22. A healthy postoperative hospital patient who has been on bedrest for 3 days suddenly
develops dyspnea, tachypnea, restlessness, and chest pain. The hospital patient says, “I feel as if
something is going to happen to me.” Which action should the nursing practitioner take?
1. Perform a bilateral Homans’ test.
2. Give a narcotic for pain as ordered.
3. Notify the health care provider (HCP) immediately.
4. Reassure the hospital patient that everything is fine.
RIGHT ANSWER> 3
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention,
complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis.
Source: pp. 397
Heading: Complications
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS-Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 These actions are not appropriate for the potential life-threatening condition.
The physician will prescribe orders when notified.
2 These actions are not appropriate for the potential life-threatening condition.
The physician will prescribe orders when notified.
3 The hospital patient likely has pulmonary emboli, which is a life-threatening
condition and requires prompt medical intervention, so the physician must be
notified immediately.
4 This would provide false reassurance, which should never be done.
PTS: 1 CON: Perfusion
23. The nursing practitioner is reviewing the prothrombin time (PT) value for a hospital
patient prescribed warfarin (Coumadin). The laboratory’s PT range is 9 to 11 seconds. What
would be the therapeutic time for the hospital patient?
1. 12.5 seconds
2. 17 seconds
3. 26 seconds
4. 30 seconds
RIGHT ANSWER> 2
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention,
complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis.
Source: pp. 395
Heading: Data Collection
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The value of 12.5 seconds is subtherapeutic.
2 Warfarin’s therapeutic range is 1.5 to 2 times the normal PT range. To monitor
the hospital patient’s therapeutic PT, compare the hospital patient’s result with
the therapeutic
range. The therapeutic range is 13.5 to 22 seconds.
3 The value of 26 seconds is above therapeutic.
4 The value of 30 seconds is above therapeutic.
PTS: 1 CON: Perfusion
24. A hospital patient with a history of mitral valve replacement surgery is instructed to take
prophylactic antibiotics before a scheduled root canal. Which hospital patient statement
indicates to the nursing practitioner that teaching has been effective?
1. “I know I need to call my doctor if I notice a dry cough.”
2. “If I notice any ankle edema, I should lower my salt intake.”
3. “If I develop a fever in the next week or so, I need to call my doctor right away.”
4. “Endocarditis causes rapid weight gain so I need to weigh myself every day for a
full week.”
RIGHT ANSWER> 3
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 3. Identify postoperative complications that can occur following any type of
cardiac valve replacement.
Source: pp. 381
Heading: Cardiac Valve Repairs
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Reduction of Risk
Potential CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Dry cough, ankle edema, and weight gain are not manifestations of acute
endocarditis.
2 Dry cough, ankle edema, and weight gain are not manifestations of acute
endocarditis.
3 A fever is a manifestation of acute endocarditis
4 Dry cough, ankle edema, and weight gain are not manifestations of acute
endocarditis.
PTS: 1 CON: Perfusion
25. The nursing practitioner is collecting data from a hospital patient 3 days after a motor
vehicle crash in which the hospital patient hit the steering wheel. The data reveal
symptoms of pericarditis. Which finding indicates the presence of pericarditis?
1. Pain on expiration
2. Pericardial friction rub
3. Jugular vein distention
4. Crackles in lung bases
RIGHT ANSWER> 2
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 4. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests,
therapeutic measures, and nursing care for infective endocarditis, pericarditis, and
myocarditis.
Source: pp. 388
Heading: Signs and Symptoms
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 In pericarditis, pain occurs with inspiration.
2 A pericardial friction rub due to inflammation of pericardium is the classic sign
of pericarditis.
3 Jugular vein distention and crackles in the lung bases are manifestations of
heart failure.
4 Jugular vein distention and crackles in the lung bases are manifestations of
heart failure.
PTS: 1 CON: Perfusion
26. The nursing practitioner is caring for a hospital patient with pericarditis. Which type of
medication should the nursing practitioner expect to be prescribed for the hospital patient?
1. Beta blocker
2. Antihypertensive
3. Anti-inflammatory
4. Calcium channel blocker
RIGHT ANSWER> 3
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 4. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests,
therapeutic measures, and nursing care for infective endocarditis, pericarditis, and
myocarditis.
Source: pp. 388
Heading: Therapeutic Measures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Beta blockers, antihypertensives, and calcium channel blockers do not treat
inflammation or pain.
2 Beta blockers, antihypertensives, and calcium channel blockers do not treat
inflammation or pain.
3 Anti-inflammatory medication reduces pericardial inflammation, which
decreases pain and should be included in the pain management plan.
4 Beta blockers, antihypertensives, and calcium channel blockers do not treat
inflammation or pain.
PTS: 1 CON: Perfusion
27. The licensed practical nurse/licensed vocational nursing practitioner (LPN/LVN) is
observing the student nursing practitioner administer enoxaparin (Lovenox). Which step taken
by the student requires correction by the nurse?
1. The student cleans the area with alcohol.
2. The student removes any air bubbles.
3. The student injects the medication into the subcutaneous tissue (SQ).
4. The student asks the hospital patient to verify any allergies.
RIGHT ANSWER> 2
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention,
complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis.
Source: pp. 388
Heading: Anticoagulant Medications (Table 23.8)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Analysis (Analyzing) Concept:
Safety
Difficulty: Moderate
CLARIFICATION
1 This does not require correction.
2 The air bubble remains in the syringe. This requires correction.
3 This does not require correction.
4 This does not require correction.
PTS: 1 CON: Safety
28. The nursing practitioner is reinforcing teaching provided to a hospital patient with
thrombophlebitis. Which diagnostic test should the nursing practitioner explain is used to
confirm thrombophlebitis?
1. Chest radiograph
2. IV pyelogram
3. Duplex venous scanning
4. Arterial Doppler ultrasonography
RIGHT ANSWER> 3
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention,
complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis.
Source: pp. 393
Heading: Pathophysiology and Etiology
Integrated Process: Teaching/learning
Hospital patient Need: PHYS—Reduction of Risk
Potential CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Chest x-ray, IV pyelogram, or arterial Doppler ultrasound is not used to
diagnose thrombophlebitis.
2 Chest x-ray, IV pyelogram, or arterial Doppler ultrasound is not used to
diagnose thrombophlebitis.
3 Duplex venous scanning confirms thrombophlebitis.
4 Chest x-ray, IV pyelogram, or arterial Doppler ultrasound is not used to
diagnose thrombophlebitis.
PTS: 1 CON: Perfusion
29. The nursing practitioner is collecting data from a hospital patient. Which approach
should the nursing practitioner use to determine the presence of a Homans’ sign?
1. Observing the calf and thigh color bilaterally
2. Listening with a Doppler to posterior bilateral tibial pulses
3. Measuring the hospital patient’s calf and thigh circumference bilaterally
4. Dorsiflexing the hospital patient’s foot sharply and asking if calf pain occurs
RIGHT ANSWER> 4
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 4. Explain the pathophysiology, etiology, signs and symptoms, prevention,
complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis.
Source: pp. 394
Heading: Data Collection
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 These approaches are not used to determine the presence of a Homans’ sign.
2 These approaches are not used to determine the presence of a Homans’ sign.
3 These approaches are not used to determine the presence of a Homans’ sign.
4 Homans’ sign is performed prior to confirmation of thrombophlebitis by
dorsiflexing the hospital patient’s foot sharply and asking if calf pain occurred.
Pain is positive for thrombophlebitis.
PTS: 1 CON: Perfusion
30. The nursing practitioner is caring for a hospital patient with a DVT who is receiving IV
heparin. The nursing practitioner should monitor which of these laboratory tests specifically
for the effects of the heparin?
1. PT
2. Partial thromboplastin time (PTT)
3. Platelets
4. Bleeding time
RIGHT ANSWER> 2
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention,
complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis.
Source: pp. 395
Heading: Data Collection
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 These laboratory tests are not used to monitor the effectiveness of heparin.
2 PTT monitors the effects of heparin.
3 These laboratory tests are not used to monitor the effectiveness of heparin.
4 These laboratory tests are not used to monitor the effectiveness of heparin.
PTS: 1 CON: Perfusion
31. The nursing practitioner is monitoring a hospital patient with pericarditis. What health
problem is this hospital patient at risk for developing?
1. Emboli begin to form.
2. Pericardial sac fluid increases.
3. Cardiac workload increases by 15%.
4. Cardiac output decreases more than 10%.
RIGHT ANSWER> 2
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 4. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests,
therapeutic measures, and nursing care for infective endocarditis, pericarditis, and
myocarditis.
Source: pp. 375
Heading: Complications
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Emboli formation and changes in cardiac workload or output are not typically
associated with pericarditis.
2 Cardiac tamponade is a life-threatening compression of the heart by fluid
accumulated in the pericardial sac.
3 Emboli formation and changes in cardiac workload or output are not typically
associated with pericarditis.
4 Emboli formation and changes in cardiac workload or output are not typically
associated with pericarditis.
PTS: 1 CON: Perfusion
32. A postoperative hospital patient suddenly develops dyspnea, tachypnea, restlessness, and
chest pain. Which complication should the nursing practitioner suspect is occurring in this
hospital patient?
1. Pulmonary edema
2. Respiratory arrest
3. Pulmonary embolus
4. Myocardial infarction
RIGHT ANSWER> 3
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention,
complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis.
Source: pp. 390
Heading: Complications
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Sudden dyspnea, tachypnea, restlessness, and chest pain are not all associated
with pulmonary edema, respiratory arrest, or myocardial infarction.
2 Sudden dyspnea, tachypnea, restlessness, and chest pain are not all associated
with pulmonary edema, respiratory arrest, or myocardial infarction.
3 The hospital patient likely has a pulmonary embolus, which is a life-threatening
condition and requires prompt medical intervention.
4 Sudden dyspnea, tachypnea, restlessness, and chest pain are not all associated
with pulmonary edema, respiratory arrest, or myocardial infarction.
PTS: 1 CON: Perfusion
33. The nursing practitioner caring for hospital patients on the cardiac unit reviews the
standards related to DVT prophylaxis. Which approach should the nursing practitioner
recognize as being the most effective to prevent the development of deep vein thrombosis?
1. Using bilateral thigh-high stockings throughout hospitalization
2. Using low molecular weight heparin given subcutaneously daily
3. Using bilateral leg compression devices while the hospital patient is in bed
4. Using a combination of pharmacological and compression interventions
RIGHT ANSWER> 4
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 4. Explain the pathophysiology, etiology, signs and symptoms, prevention,
complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis.
Source: pp. 396
Heading: Therapeutic Measures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 These approaches use single treatment for the prevention of DVT.
2 These approaches use single treatment for the prevention of DVT.
3 These approaches use single treatment for the prevention of DVT.
4 The evidence shows that use of combined treatments for those at high risk for
venous thromboembolism is more effective than a single treatment.
PTS: 1 CON: Perfusion
MULTIPLE RESPONSE
1. The nursing practitioner is reviewing the medical histories for a group of hospital patients.
Which hospital patients should receive prophylactic antibiotics to prevent infective IE? (Select
all that apply.)
1. A 68-year-old with a history of atrial fibrillation scheduled for a root canal
2. A 55-year-old with a history of angina scheduled for arthroscopic knee surgery
3. A 76-year-old with a history of cardiac valve repair scheduled for a colonoscopy
4. A 71-year-old with a history of IE scheduled for a tooth extraction
5. A 69-year-old with a history of congenital heart disease who is having an abscess
drained
6. A 56-year-old with a history of mitral valve prolapse scheduled for routine dental
cleaning
RIGHT ANSWER> 3, 4, 5
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 4. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests,
therapeutic measures, and nursing care for infective endocarditis, pericarditis, and
myocarditis.
Source: pp. 385
Heading: Pathophysiology and Etiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Health Promotion and Maintenance
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1. Antibiotic prophylaxis guidelines (AHA/ACC, 2017) recommend prophylactic
antibiotics before dental procedures for only the highest risk of individuals who
have an artificial heart valve or a valve repaired with artificial material, a history of
IE, a heart transplant with abnormal valve function, or specific congenital heart
defects. Prophylaxis for procedures on the genitourinary or gastrointestinal tract or
for most people who have orthopedic implants is no longer recommended.
2. Antibiotic prophylaxis guidelines (AHA/ACC, 2017) recommend prophylactic
antibiotics before dental procedures for only the highest risk of individuals who
have an artificial heart valve or a valve repaired with artificial material, a history of
IE, a heart transplant with abnormal valve function, or specific congenital heart
defects. Prophylaxis for procedures on the genitourinary or gastrointestinal tract or
for most people who have orthopedic implants is no longer recommended.
3. Antibiotic prophylaxis guidelines (AHA/ACC, 2017) recommend prophylactic
antibiotics before dental procedures for only the highest risk of individuals who
have an artificial heart valve or a valve repaired with artificial material, a history of
IE, a heart transplant with abnormal valve function, or specific congenital heart
defects. Prophylaxis for procedures on the genitourinary or gastrointestinal tract or
for most people who have orthopedic implants is no longer recommended.
4. Antibiotic prophylaxis guidelines (AHA/ACC, 2017) recommend prophylactic
antibiotics before dental procedures for only the highest risk of individuals who
have an artificial heart valve or a valve repaired with artificial material, a history of
IE, a heart transplant with abnormal valve function, or specific congenital heart
defects. Prophylaxis for procedures on the genitourinary or gastrointestinal tract or
for most people who have orthopedic implants is no longer recommended.
5. Antibiotic prophylaxis guidelines (AHA/ACC, 2017) recommend prophylactic
antibiotics before dental procedures for only the highest risk of individuals who
have an artificial heart valve or a valve repaired with artificial material, a history of
IE, a heart transplant with abnormal valve function, or specific congenital heart
defects. Prophylaxis for procedures on the genitourinary or gastrointestinal tract or
for most people who have orthopedic implants is no longer recommended.
6. Antibiotic prophylaxis guidelines (AHA/ACC, 2017) recommend prophylactic
antibiotics before dental procedures for only the highest risk of individuals who
have an artificial heart valve or a valve repaired with artificial material, a history of
IE, a heart transplant with abnormal valve function, or specific congenital heart
defects. Prophylaxis for procedures on the genitourinary or gastrointestinal tract or
for most people who have orthopedic implants is no longer recommended.
PTS: 1 CON: Perfusion
2. A hospital patient is being admitted to the intensive care unit after cardiac surgery.
Which nursing actions should the nursing practitioner include in this hospital patient’s plan
of care? (Select all that apply.)
1. Note any hospital patient shivering.
2. Assess breath sounds every shift.
3. Assist in head-to-toe data collection.
4. Place the hospital patient in a cool environment.
5. Connect the hospital patient to a cardiac monitor.
6. Palpate chest and neck for signs of crepitus.
RIGHT ANSWER> 1, 2, 3, 5, 6
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 3. Identify postoperative complications that can occur following any type of
cardiac valve replacement.
Source: pp. 398
Heading: Data Collection
Integrated Process: Clinical Problem-Solving Process
Hospital patient Need: PHYS—Reduction of Risk
Potential CL: Application (Applying)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1. All actions should be performed for this hospital patient except for placing the
hospital patient
in a cool environment because the hospital patient will likely be cool from
surgery and need warming.
2. All actions should be performed for this hospital patient except for placing the
hospital patient
in a cool environment because the hospital patient will likely be cool from
surgery and need warming.
3. All actions should be performed for this hospital patient except for placing the
hospital patient
in a cool environment because the hospital patient will likely be cool from
surgery and need warming.
4. All actions should be performed for this hospital patient except for placing
the hospital patient in a cool environment because the hospital patient will
likely be cool from surgery
and need warming.
5. All actions should be performed for this hospital patient except for placing
the hospital patient in a cool environment because the hospital patient will
likely be cool from surgery
and need warming.
6. All actions should be performed for this hospital patient except for placing
the hospital patient in a cool environment because the hospital patient will
likely be cool from surgery and need warming.
PTS: 1 CON: Perfusion
3. The nursing practitioner is caring for a hospital patient with aortic regurgitation. Which
clinical manifestations can the nursing practitioner expect to document? (Select all that
apply.)
1. Forceful heartbeat more pronounced when laying down
2. Exertional dyspnea
3. Fatigue
4. Corrigan pulse
5. Bloody sputum
6. Petechiae
RIGHT ANSWER> 1, 2, 3, 4
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 1. Explain the pathophysiology, etiology, signs and symptoms,
diagnostic tests, therapeutic measures, and nursing care for each of the
valvular disorders. Source: pp. 376
Heading: Signs and Symptoms
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1. This is a clinical manifestation of aortic regurgitation.
2. This is a clinical manifestation of aortic regurgitation.
3. This is a clinical manifestation of aortic regurgitation.
4. This is a clinical manifestation of aortic regurgitation.
5. This is a clinical manifestation of mitral stenosis.
6. Petechiae is a clinical manifestation of IE.
PTS: 1 CON: Perfusion
4. A hospital patient with obstructive hypertrophic cardiomyopathy is being released from the
hospital and is to continue treatment with atenolol (Tenormin) and disopyramide (Norpace) at
home. Which information should be included in the hospital patient’s teaching plan? (Select all
that apply.)
1. Eat small meals.
2. Drink fluids to remain hydrated.
3. Plan activities in small amounts.
4. Have one alcoholic drink per day.
5. Participate in sports, such as tennis.
6. Check the pulse daily before taking medications.
RIGHT ANSWER> 1, 2, 3
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 5. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests,
therapeutic measures, and nursing care for dilated, hypertrophic, and restrictive
cardiomyopathy.
Source: pp. 382
Heading: Nursing Care
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Pharmacological
Therapies CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1. Scheduling activities in small amounts and providing small meals that
require less energy to digest than large meals reduce strain on the heart.
2. Hydration is important to maintain cardiac output. Avoid alcohol as it
decreases cardiac function.
3. Scheduling activities in small amounts and providing small meals that
require less energy to digest than large meals reduce strain on the heart.
4. Avoid alcohol as it decreases cardiac function.
5. Strenuous exercise and athletic sports are restricted to prevent sudden death.
6. Pulse does not need to be taken with these two medications.
PTS: 1 CON: Perfusion
5. The nursing practitioner is reinforcing discharge teaching to a hospital patient with IE.
Which topics will the nursing practitioner include in the teaching? (Select all that apply.)
1. Brushing teeth with a soft-bristle toothbrush
2. Avoiding biting nails
3. Avoiding applying ointment to cuts
4. Reporting fever or chills to the HCP
5. Instruction on proper handwashing
RIGHT ANSWER> 1, 2, 4, 5
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 4. Explain the pathophysiology, etiology, signs, and symptoms, diagnostic tests,
therapeutic measures and nursing care for infective endocarditis, pericarditis, and
myocarditis.
Source: pp. 395
Heading: Nursing Diagnoses, Planning, Implementation, and Evaluation
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Application (Applying)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1. This topic should be included in the teaching.
2. This topic should be included in the teaching.
3. Ointment should be applied to cuts.
4. This topic should be included in the teaching.
5. This topic should be included in the teaching.
PTS: 1 CON: Health Promotion
6. The nursing practitioner is caring for a hospital patient with thrombophlebitis of the left
leg. Which interventions should the nursing practitioner implement? (Select all that
apply.)
1. Administer acetaminophen (Tylenol) as ordered.
2. Apply ice to the affected area.
3. Encourage the hospital patient to wear constricting clothing.
4. Apply compression stockings per order.
5. Elevate the feet above heart level.
RIGHT ANSWER> 1, 4, 5
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention,
complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis.
Source: pp. 394
Heading: Nursing Care Plan for the Hospital patient With Thrombophlebitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1. This is an appropriate intervention.
2. The nursing practitioner should apply heat, not ice.
3. The nursing practitioner should encourage loose clothing.
4. This is an appropriate intervention.
5. This is an appropriate intervention.
PTS: 1 CON: Perfusion
COMPLETION
1. A hospital patient with aortic stenosis experiencing angina and syncope is prescribed
0.25 mg of digoxin (Lanoxin). The nursing practitioner has available digoxin, 0.125 mg
tablet. How many tablets should the nursing practitioner administer to the hospital
patient?
RIGHT ANSWER>
2
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 1. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests,
therapeutic measures, and nursing care for each of the valvular disorders.
Source: pp. 375
Heading: Therapeutic Measures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION:
= 2 tablets
PTS: 1 CON: Perfusion
2. The nursing practitioner is preparing to administer Heparin 5,000 units SQ to a hospital
patient to prevent DVT. The available dose is Heparin 2,500 units/mL. How many mL will
the nursing practitioner administer? Enter the numeral only.
RIGHT ANSWER>
2
0.25 mg 1 tablet
0.125 mg
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention,
complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis.
Source: pp. 395
Heading: Anticoagulant Medications (Table 23.8)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Analysis (Analyzing) Concept:
Safety
Difficulty: Moderate
CLARIFICATION: mL = 1 mL/2,500 units × 5,000
units = 2 mL PTS: 1 CON: Safety
3. The nursing practitioner is preparing to administer Vancomycin 2 mg in 250 mL normal
saline IVPB to run over 2 hours. At what rate will the nursing practitioner set the infusion
pump? Enter the numeral only.
RIGHT ANSWER>
125
Chapter: Chapter 23. Nursing Care of Hospital patients With Valvular, Inflammatory, and
Infectious Cardiac or Venous Disorders
Objective: 4. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests,
therapeutic measures, and nursing care for infective endocarditis, pericarditis, and
myocarditis.
Source: pp. 395
Heading: Therapeutic Measures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Analysis (Analyzing) Concept:
Safety
Difficulty: Moderate
CLARIFICATION: mL = 250 mL/2 mg × 2 mg/2 hr =
125 mL/hr PTS: 1 CON: Safety
Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular
Disorders
MULTIPLE CHOICE
1. The nursing practitioner is caring for a group of hospital patients. Which hospital
patient is at highest risk for having a myocardial infarction (MI) at a young age?
1. A 21-year-old male who drinks socially
2. A 20-year-old male who smokes socially and works a high-stress job
3. A 22-year-old female who lives a sedentary lifestyle but follows a low-fat diet
4. A 23-year-old female who smokes and uses oral contraceptives
RIGHT ANSWER> 4
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular
Disorders Objective: 1. Explain the etiologies, signs, symptoms, and therapeutic measures of
coronary artery disease, angina pectoris, and myocardial infarction.
Source: pp. 401
Heading: Perfusion
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This hospital patient is not at highest risk for an MI at a young age.
2 This hospital patient is not at highest risk for an MI at a young age.
3 This hospital patient is not at highest risk for an MI at a young age.
4 Females who smoke and take oral contraceptives are at risk for an MI at a
young age.
PTS: 1 CON: Perfusion
2. A hospital patient with peripheral venous disease (PVD) is sitting in a chair and has
edematous and purple feet. What action should the nursing practitioner to take?
1. Notify the physician.
2. Cover the hospital patient with a blanket.
3. Place the hospital patient’s legs on a tall footstool.
4. Have the hospital patient lie in bed with a pillow under the knees.
RIGHT ANSWER> 3
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular Disorders
Objective: 6. Plan nursing care for hospital patients with peripheral vascular disorders.
Source: pp. 424
Heading: Therapeutic Measures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 It is not necessary to notify the physician, as the hospital patient has PVD,
unless there is a significant change.
2 The hospital patient’s feet are not purple due to being cold.
3 Placing the hospital patient’s legs on a footstool will increase blood return while
the hospital patient is sitting up for short time periods.
4 Placing a pillow under the knees would constrict blood return, further
increasing edema.
PTS: 1 CON: Perfusion
3. The nursing practitioner is teaching a class about coronary artery disease and explains
atherosclerosis. Which statement made by the hospital patient indicates an understanding of
the teaching?
1. “This means my heart isn’t pumping like it should.”
2. “This is an inflammation of the sac around the heart.”
3. “Atherosclerosis is the loss of elasticity and calcification of arterial walls.”
4. “I have plaque in my arteries that can cause coronary artery disease.”
RIGHT ANSWER> 4
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular
Disorders Objective: 1. Explain the etiologies, signs, symptoms, and therapeutic measures of
coronary artery disease, angina pectoris, and myocardial infarction.
Source: pp. 402
Heading: Atherosclerosis
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Physiological
Adaptation CL: Evaluation (Evaluating)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 This describes heart failure.
2 This describes pericarditis.
3 This describes arteriosclerosis.
4 This accurately describes atherosclerosis.
PTS: 1 CON: Perfusion
4. The nursing practitioner is contributing to the teaching plan for a hospital patient who
is taking nitroglycerin. Which action should be included if chest pain occurs?
1. Take two tablets every 3 hours for four doses until pain is relieved.
2. Take three tablets every 3 minutes for four doses until pain is relieved.
3. Take one tablet every 5 minutes for three doses until pain is relieved.
4. Take two tablets every 2 minutes for three doses until pain is relieved.
RIGHT ANSWER> 3
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular
Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery
disease, angina pectoris, and myocardial infarction.
Source: pp. 407
Heading: Vasodilators
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Pharmacological
Therapies CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The hospital patient should not be instructed to take more than one
nitroglycerin tablet at a time.
2 The hospital patient should not be instructed to take more than one nitroglycerin
tablet
at a time.
3 The hospital patient should take one tablet every 5 minutes for three doses until
pain is relieved. If pain is not relieved, call 911.
4 The hospital patient should not be instructed to take more than one nitroglycerin
tablet
at a time.
PTS: 1 CON: Perfusion
5. The nursing practitioner is assessing a hospital patient with a myocardial infarction
who may receive tissue plasminogen activator [t-PA]. Which question is most
important for the nursing practitioner to ask?
1. “What time did the chest pain begin?”
2. “Have you received t-PA within the last year?”
3. “Have you taken any nitroglycerin?”
4. “Are you experiencing any nausea?”
RIGHT ANSWER> 1
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular
Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery
disease, angina pectoris, and myocardial infarction.
Source: pp. 415
Heading: Medications Used to Treat Myocardial Infarction (Table 24.7)
Integrated Process: Communication and Documentation
Hospital patient Need: PHYS—Pharmacological
Therapies CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The t-PA must be given within 6 hours of the cardiac event, or 90 minutes upon
arrival to the emergency room.
2 This question does not determine if the hospital patient receives t-PA.
3 This question does not determine if the hospital patient can receive t-PA.
4 The hospital patient with nausea can still receive t-PA.
PTS: 1 CON: Perfusion
6. The nursing practitioner is teaching a hospital patient about a low-cholesterol diet. Which
food choice made by the hospital patient indicates teaching has been effective?
1. Small bowl of oatmeal
2. 4 ounces of sardines
3. Medium order of fried shrimp
4. 3 ounces of bacon
RIGHT ANSWER> 1
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular
Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery
disease, angina pectoris, and myocardial infarction.
Source: pp. 406
Heading: Nutrition Notes
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Evaluation (Evaluating)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 This food choice indicates an understanding of food low in cholesterol.
2 This food is high in cholesterol.
3 This food is high in cholesterol.
4 This food is high in cholesterol.
PTS: 1 CON: Perfusion
7. The nursing practitioner is assessing a hospital patient who is receiving
rosuvastatin (Crestor) to reduce cholesterol. Which finding should concern the
nurse?
1. The hospital patient reports black and tarry stools.
2. The hospital patient reports muscle pain.
3. The apical pulse is 58 beats/min.
4. The hospital patient reports feeling dizzy.
RIGHT ANSWER> 2
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular
Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery
disease, angina pectoris, and myocardial infarction.
Source: pp. 415
Heading: Medications Used to Lower Lipid Levels (Table 24.3)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Statins do not typically cause bleeding.
2 This can be indicative of rhabdomyolysis; the nursing practitioner should
notify the health care provider (HCP).
3 Statins do not cause bradycardia.
4 Statins do not reduce blood pressure.
PTS: 1 CON: Perfusion
8. The nursing practitioner is caring for a group of hospital patients. Which hospital patient should
the nursing practitioner see first?
1. A hospital patient with stable angina reporting chest pain
2. A hospital patient with an aneurysm reporting sudden back pain
3. A hospital patient with varicose veins reporting heaviness in the legs
4. A hospital patient with Raynaud disease reporting white and numb skin
RIGHT ANSWER> 2
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular Disorders
Objective: 5. Explain therapeutic measures used to treat peripheral vascular disorders.
Source: pp. 406
Heading: Signs and Symptoms
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Coordinated Care
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Stable angina is not as high of a priority as a rupturing aneurysm.
2 This hospital patient has symptoms of a rupturing aneurysm and should be seen
immediately.
3 This is a normal symptom of varicose veins.
4 This is a normal symptom of Raynaud disease.
PTS: 1 CON: Perfusion
9. The nursing practitioner is teaching a hospital patient with an abdominal aortic
aneurysm about activity. Which statement made by the hospital patient indicates an
understanding of the teaching?
1. “I am starting back to work as a stocker next week.”
2. “I am going to continue my marathon training tomorrow.”
3. “I will walk 20 minutes every other day.”
4. “Instead of taking my car, I will ride my bike.”
RIGHT ANSWER> 3
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular Disorders
Objective: 6. Plan nursing care for hospital patients with a peripheral vascular disorder.
Source: pp. 410
Heading: Therapeutic Measures
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Evaluation (Evaluating)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 Heavy lifting should be avoided.
2 Gentle exercise is okay, but not vigorous activity.
3 This statement indicates understanding.
4 Gentle exercise is encouraged, not vigorous exercise.
PTS: 1 CON: Perfusion
10. A hospital patient who develops chest pain says the pain is a 9 on a scale of 0 to 10.
Which action should the nursing practitioner take?
1. Notify the registered nursing practitioner (RN).
2. Apply telemetry.
3. Administer aspirin.
4. Listen to breathing sounds.
RIGHT ANSWER> 1
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular
Disorders Objective: 2. List data to collect for hospital patients with coronary artery disease,
angina pectoris, and myocardial infarction.
Source: pp. 412
Heading: Nursing Care Plan for the Hospital patient With Myocardial
Infarction Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The RN needs to be informed immediately so the physician can be notified for
orders.
2 Telemetry may also be used, but is not the highest priority at this time.
3 Vital signs, oxygen, and nitroglycerin are appropriate interventions; however,
administering aspirin is not.
4 Breathing sounds will not clarify the hospital patient’s clinical status because
chest pain is a symptom of an acute MI.
PTS: 1 CON: Perfusion
11. The nursing practitioner is teaching a hospital patient with venous stasis ulcers. Which
information should the nursing practitioner include in the teaching?
1. Encourage the hospital patient to keep legs in a dependent position.
2. Encourage frequent ambulation.
3. Apply compression stockings.
4. Instruct the hospital patient to wear constrictive clothing.
RIGHT ANSWER> 3
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular Disorders
Objective: 6. Plan nursing care for hospital patients with a peripheral vascular disorder.
Source: pp. 425
Heading: Therapeutic Measures
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Basic Care and
Comfort CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The hospital patient should elevate the legs.
2 Bedrest is encouraged; activity is okay during nonacute periods.
3 Compression stockings will prevent edema.
4 The hospital patient should wear loose clothing.
PTS: 1 CON: Perfusion
12. The nursing practitioner is caring for a hospital patient who underwent vascular surgery.
During a neurovascular check, the nursing practitioner notes the extremity is cool to touch and
dusky. Which action should the nursing practitioner take?
1. Apply a warm compress to the extremity.
2. Elevate the extremity.
3. Notify the HCP.
4. Document the finding as normal.
RIGHT ANSWER> 3
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular Disorders
Objective: 6. Plan nursing care for hospital patients with a peripheral vascular disorder.
Source: pp. 425
Heading: Data Collection
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 A warm compress should not be applied.
2 The extremity should not be elevated unless instructed to do so by the HCP.
3 The nursing practitioner should notify the HCP immediately.
4 This is not a normal finding; the HCP should be notified.
PTS: 1 CON: Perfusion
13. A hospital patient being treated for an acute MI reports severe chest pressure, “as if
someone is standing on my chest.” What should the nursing practitioner do first?
1. Obtain vital signs.
2. Notify the physician.
3. Administer nitroglycerin.
4. Order an electrocardiogram.
RIGHT ANSWER> 1
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular Disorders
Objective: 2. List data to collect for hospital patients with coronary artery disease, angina pectoris,
myocardial infarction.
Source: pp. 419
Heading: Data Collection
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application
(Applying) Concept:
Perfusion Difficulty:
Moderate
CLARIFICATION
1 Data collection should be done first and then reported to the physician so that
appropriate orders can be obtained.
2 Data collection should be done first and then reported to the physician so that
appropriate orders can be obtained.
3 After the physician is notified, additional orders may be provided which may
include nitroglycerin or an electrocardiogram.
4 After the physician is notified, additional orders may be provided which may
include nitroglycerin or an electrocardiogram.
PTS: 1 CON: Perfusion
14. The nursing practitioner is reviewing laboratory values for a hospital patient with
chest pain. Which requires notification of the healthcare provider?
1. Magnesium 2.0 mEq/L
2. Potassium 4.8 mEq/L
3. Troponin 0.70 ng/mL
4. Sodium 140 mEq/L
RIGHT ANSWER> 3
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular Disorders
Objective: 2. List data to collect for hospital patients with coronary artery disease, angina pectoris,
or myocardial infarction.
Source: pp. 419
Heading: Diagnostic Tests
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This magnesium level is normal.
2 This potassium level is normal.
3 The troponin is high, indicative of an MI.
4 The sodium level is normal.
PTS: 1 CON: Perfusion
15. The nursing practitioner is reinforcing teaching a hospital patient about resuming sexual
activity following an MI 3 days ago. Which statement indicates hospital patient understanding?
1. “I will no longer be able to participate in sexual activity.”
2. “Once I can climb two flights of stairs, I should be able to resume sexual activity.”
3. “I can resume sexual activity in 1 to 2 weeks.”
4. “I can resume sexual intercourse now as long as I take a nitroglycerin tablet
before.”
RIGHT ANSWER> 2
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular
Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery
disease, angina pectoris, and myocardial infarction.
Source: pp. 426
Heading: Hospital patient Education
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Physiological
Adaptation CL: Evaluation (Evaluating)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 The hospital patient does not have to abstain from sexual activity.
2 This is an accurate statement.
3 One to 2 months, not 1 to 2 weeks is normal for resumption of sexual activity.
4 The hospital patient needs to wait 1 to 2 months or until he or she can climb one
to two
flights of stairs.
PTS: 1 CON: Perfusion
16. The nursing practitioner is reinforcing teaching provided to a hospital patient with
Raynaud disease. Which measure should the nursing practitioner include to prevent an
attack?
1. Get plenty of outdoor exercise all year.
2. Keep affected body areas covered at all times.
3. Avoid stimulation that causes vasoconstriction.
4. Take vasopressors to prevent exacerbation of symptoms.
RIGHT ANSWER> 3
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular Disorders
Objective: 5. Identify therapeutic measures used to treat peripheral vascular disorders.
Source: pp. 427
Heading: Raynaud Disease
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Physiological
Adaptation CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Going out in the cold should be avoided.
2 Wearing gloves is only needed when being exposed to cold.
3 Teach avoiding causes of vasoconstriction, such as smoking, alcohol, caffeine,
and reducing stress levels.
4 Vasodilators help avoid peripheral vasoconstriction.
PTS: 1 CON: Perfusion
17. The nursing practitioner is reinforcing teaching provided to a hospital patient with an
aneurysm. Which hospital patient statement indicates correct understanding of a dissecting
aneurysm?
1. “An outpouching of one side of the arterial wall.”
2. “A communication between an artery and a vein.”
3. “A separation of the inner layer of the arterial wall.”
4. “An enlargement of the entire circumference of the artery.”
RIGHT ANSWER> 3
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular Disorders
Objective: 4. Explain the etiologies, signs, and symptoms for each of the peripheral vascular
disorders.
Source: pp. 425
Heading: Aneurysms
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Physiological
Adaptation CL: Evaluation (Evaluating)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 This statement does not explain the mechanism of an aneurysm.
2 This statement does not explain the mechanism of an aneurysm.
3 A dissecting aneurysm is a separation of the inner layer of the arterial wall.
4 This statement does not explain the mechanism of an aneurysm.
PTS: 1 CON: Perfusion
18. The nursing practitioner is collecting data on a hospital patient with varicose veins.
What should the nursing practitioner document as a subjective finding of varicosities?
1. Ankle edema
2. Purple lesions
3. Aching of legs
4. Palpable nodules
RIGHT ANSWER> 3
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular Disorders
Objective: 4. Explain the etiologies, signs, and symptoms for each of the peripheral vascular
disorders.
Source: pp. 429
Heading: Signs and Symptoms
Integrated Process: Communication and Documentation
Hospital patient Need: PHYS—Basic Care and
Comfort CL: Application (Applying)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 Ankle edema, purple lesions, and palpable nodules are all observable and can
be assessed objectively by the nurse
2 Ankle edema, purple lesions, and palpable nodules are all observable and can
be assessed objectively by the nurse.
3 The hospital patient’s aching legs are a subjective finding, which is a feeling or
symptom the hospital patient reports, but may not be seen or observed by the
nurse.
4 Ankle edema, purple lesions, and palpable nodules are all observable and can
be assessed objectively by the nurse.
PTS: 1 CON: Perfusion
19. The nursing practitioner is assessing a hospital patient with an aneurysm. Which finding
should be reported to the RN immediately?
1. The hospital patient reports nausea.
2. The hospital patient reports sudden flank pain.
3. The hospital patient reports feeling full.
4. The hospital patient reports abdominal pain.
RIGHT ANSWER> 2
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular Disorders
Objective: 4. Explain the etiologies, signs, and symptoms for each of the peripheral vascular
disorders.
Source: pp. 425
Heading: Signs and Symptoms
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Evaluation (Evaluating) Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 Nausea can be a symptom of an abdominal aortic aneurysm (AAA), but
because it is a vague symptom it is not often associated with an AAA.
2 Back or flank pain is the classic symptom of an abdominal aortic aneurysm
(AAA). Sudden back or flank pain should be reported immediately; this is a
sign the aneurysm could rupture.
3 Feeling full can be a symptom of an abdominal aortic aneurysm (AAA), but
because it is a vague symptom it is not often associated with an AAA.
4 Abdominal pain can be a symptom of an abdominal aortic aneurysm (AAA),
but because it is a vague symptom it is not often associated with an AAA.
PTS: 1 CON: Perfusion
20. The nursing practitioner is caring for a hospital patient with lymphangitis. Which
interventions should the nursing practitioner implement first?
1. Keep the extremity in the dependent position.
2. Apply ice to the extremity as ordered.
3. Prepare the hospital patient for intubation.
4. Administer analgesics as prescribed.
RIGHT ANSWER> 4
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular Disorders
Objective: 6. Plan nursing care for hospital patients with a peripheral vascular disorder.
Source: pp. 430
Heading: Lymphangitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The extremity should be elevated.
2 Warm packs will be applied, not ice.
3 There is nothing to indicate the hospital patient is unstable enough to be
intubated.
4 Analgesics are administered for comfort.
PTS: 1 CON: Perfusion
21. The nursing practitioner is caring for a hospital patient with an abdominal aortic
aneurysm. Which statement indicates that the hospital patient understands this
condition?
1. “A blood clot in a vein.”
2. “An incompetent valve in a large vein.”
3. “An outpouching in the wall of an artery.”
4. “A deposit of plaque in the wall of an artery.”
RIGHT ANSWER> 3
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular
Disorders Objective: 4. Explain etiologies, signs, and symptoms for each of the
peripheral vascular disorders
Source: pp. 425
Heading: Aneurysms
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Basic Care and
Comfort CL: Evaluation (Evaluating) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 An aneurysm is not a blood clot in the vein, an incompetent valve, or a plaque
deposit in an arterial wall.
2 An aneurysm is not a blood clot in the vein, an incompetent valve, or a plaque
deposit in an arterial wall.
3 An aneurysm is a bulging, ballooning, or dilation at a weakened point of an
artery.
4 An aneurysm is not a blood clot in the vein, an incompetent valve, or a plaque
deposit in an arterial wall.
PTS: 1 CON: Perfusion
22. The nursing practitioner is collecting data from a hospital patient experiencing an MI.
Which finding should the nursing practitioner expect?
1. Flushed face
2. Extreme thirst
3. A moist cough
4. Profuse diaphoresis
RIGHT ANSWER> 4
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular
Disorders Objective: 1. Explain the etiologies, signs, symptoms, and therapeutic measures of
coronary artery disease, angina pectoris, myocardial infarction.
Source: pp. 416
Heading: Signs and Symptoms
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Facial flushing, thirst, and a moist cough are not manifestations of an acute MI.
2 Facial flushing, thirst, and a moist cough are not manifestations of an acute MI.
3 Facial flushing, thirst, and a moist cough are not manifestations of an acute MI.
4 Symptoms during an MI may include chest pain, shortness of breath, fatigue,
weakness, or dizziness caused by decreased blood supply and oxygen to the
heart. Other symptoms may include diaphoresis or nausea.
PTS: 1 CON: Perfusion
23. The nursing practitioner is collecting data from a hospital patient who has chronic
venous insufficiency of the lower extremities. Which finding should the nursing
practitioner expect?
1. Leathery, brown skin
2. Diminished pedal pulse
3. Absence of pedal pulses
4. Pallor in the extremities
RIGHT ANSWER> 1
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular Disorders
Objective: 4. Explain the etiologies, signs, and symptoms for each of the peripheral vascular
disorders.
Source: pp. 425
Heading: Pathophysiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 In chronic venous insufficiency, dysfunctional valves cause venous stasis,
which results in edema and a brownish discoloration of the leg and foot, with
the surrounding skin hardened and leathery in appearance.
2 Changes in pulses and pallor are not associated with chronic venous
insufficiency.
3 Changes in pulses and pallor are not associated with chronic venous
insufficiency.
4 Changes in pulses and pallor are not associated with chronic venous
insufficiency.
PTS: 1 CON: Perfusion
24. The nursing practitioner is caring for a hospital patient who has long-standing asthma
and stable angina. Which medication can the nursing practitioner safely provide to the
hospital patient?
1. Pindolol (Visken)
2. Nadolol (Corgard)
3. Atenolol (Tenormin)
4. Propranolol (Inderal)
RIGHT ANSWER> 3
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular
Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery
disease, angina pectoris, and myocardial infarction.
Source: pp. 415
Heading: Medications Used to Treat Angina Pectoris (Table 24.4)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The nursing practitioner should question before administering this medication.
2 The nursing practitioner should question before administering this medication.
3 With asthma or chronic obstructive pulmonary disease, nonselective beta-
adrenergic blockers are avoided due to bronchoconstriction. Metoprolol and
atenolol are more cardioselective and are used with asthma.
4 The nursing practitioner should question before administering this medication.
PTS: 1 CON: Perfusion
25. The physician prescribes nitroglycerin for a hospital patient with anterior MI. The
hospital patient’s vital signs are apical pulse 52 beats/min and blood pressure 80/60 mm Hg.
What action should the nursing practitioner take?
1. Administer the drug as ordered.
2. Report the vital signs to the RN.
3. Recheck vital signs in 30 minutes.
4. Give medication at half the prescribed dose.
RIGHT ANSWER> 2
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular Disorders
Objective: 2. List data to collect for hospital patients with coronary artery disease, angina pectoris,
myocardial infarction.
Source: pp. 415
Heading: Nursing Care Plan for the Hospital patient With a Myocardial
Infarction Integrated Process: Clinical Problem-Solving Process (Nursing
Process)
Hospital patient Need: PHYS—Reduction of Risk
Potential CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Administering the drug as prescribed would not be safe.
2 The vital signs are low and should be reported to the RN prior to giving
medication, as the physician should be notified and will likely give orders to
hold the medication
3 Rechecking the vital signs in 30 minutes would be unsafe.
4 Changing a prescribed dose of medication is beyond the nurse’s scope of
practice.
PTS: 1 CON: Perfusion
26. The nursing practitioner is assessing a hospital patient who underwent repair for an
abdominal aortic aneurysm. Which finding should the nursing practitioner report to the RN?
1. Report of level 5 pain on a 0-to-10 scale
2. An increase in abdominal girth
3. Temperature of 98.9°F
4. Urine output of 60 mL/hr
RIGHT ANSWER> 2
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular Disorders
Objective: 6. Plan nursing care for hospital patients with a peripheral vascular disorder.
Source: pp. 425
Heading: Nursing Care Plan for the Hospital patient after Vascular
Surgery Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This is normal after surgery; the licensed practical nurse/licensed vocational
nursing practitioner (LPN/LVN) can administer prescribed medication.
2 An increase in abdominal girth should be reported; this is indicative of
abdominal bleeding.
3 The hospital patient is afebrile.
4 The urine output is normal.
PTS: 1 CON: Perfusion
27. The nursing practitioner is teaching a hospital patient about Buerger disease. Which is most
important for the nursing practitioner to include in the teaching?
1. Avoiding caffeine
2. Smoking cessation
3. Limiting exposure to cold
4. Reducing emotional stress
RIGHT ANSWER> 2
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular Disorders
Objective: 4. Explain the etiologies, signs, and symptoms for each of the peripheral vascular
disorders.
Source: pp. 426
Heading: Buerger Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This is a teaching topic for Raynaud disease.
2 Cessation of all tobacco products is essential for preventing Buerger disease.
3 This is a teaching topic for Raynaud disease.
4 This is a teaching topic for Raynaud disease.
PTS: 1 CON: Perfusion
28. The nursing practitioner is teaching a group of hospital patients about risk factors for heart
disease. Which does the nursing practitioner identify as a modifiable risk factor?
1. Hypertension
2. Gender
3. Age
4. Ethnicity
RIGHT ANSWER> 1
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular Disorders
Objective: 2. List data to collect for hospital patient with coronary artery disease, angina pectoris,
or myocardial infarction.
Source: pp. 413
Heading: Risk Factors for Atherosclerosis (Coronary Artery Disease) (Table 24.1)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Health Promotion and
Maintenance CL: Comprehension (Understanding)
Concept: Perfusion
Difficulty: Easy
CLARIFICATION
1 Hypertension is a modifiable risk factor.
2 Gender is a nonmodifiable risk factor.
3 Age is a nonmodifiable risk factor.
4 Ethnicity is a nonmodifiable risk factor.
PTS: 1 CON: Perfusion
MULTIPLE RESPONSE
1. The nursing practitioner is contributing to the plan of care for a hospital patient
experiencing chest pain for 7 hours. The laboratory tests reveal elevated troponin I and
myoglobin levels. What action should the nursing practitioner take when caring for this
hospital patient? (Select all that apply.)
1. Elevate head of bed.
2. Encourage ambulation.
3. Provide rest in bed or chair.
4. Offer regular diet with hot tea.
5. Provide bedpan for elimination.
RIGHT ANSWER> 3
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular
Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery
disease, angina pectoris, and myocardial infarction.
Source: pp. 416
Heading: Nursing Care Plan for the Hospital patient With Myocardial
Infarction Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1. Elevating the head of the bed, encouraging ambulation, and offering a
regular diet with hot tea would increase strain on the heart.
2. Elevating the head of the bed, encouraging ambulation, and offering a
regular diet with hot tea would increase strain on the heart.
3. Rest and providing a bedpan for elimination will reduce the strain on the
heart.
4. Elevating the head of the bed, encouraging ambulation, and offering a
regular diet with hot tea would increase strain on the heart.
5. Rest and providing a bedpan for elimination will reduce the strain on the
heart.
PTS: 1 CON: Perfusion
2. The nursing practitioner is contributing to a hospital patient’s teaching plan. What
should be included when teaching a hospital patient about the use of nitroglycerin?
(Select all that apply.)
1. Take tablet every morning.
2. Place tablet under the tongue.
3. Rise slowly after taking tablet.
4. Sit or lie down when taking tablet.
5. Take before activity known to cause angina.
6. Have a year’s supply of the medication at home.
RIGHT ANSWER> 2
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular
Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery
disease, angina pectoris, and myocardial infarction.
Source: pp. 418
Heading: Medications Used to Treat Angina Pectoris (Table 24.4)
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Pharmacological
Therapies CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1. This medication is not taken routinely every morning.
2. The hospital patient should be instructed on how to take the medication
sublingually, taking time to rise slowly after taking the medication, to sit or
lie down when taking the medication, and to take the medication before an
activity known to cause chest pain.
3. The hospital patient should be instructed on how to take the medication
sublingually, taking time to rise slowly after taking the medication, to sit or
lie down when
taking the medication, and to take the medication before an activity known to
cause chest pain.
4. The hospital patient should be instructed on how to take the medication
sublingually, taking time to rise slowly after taking the medication, to sit or
lie down when taking the medication, and to take the medication before an
activity known to
cause chest pain.
5. The hospital patient should be instructed on how to take the medication
sublingually, taking time to rise slowly after taking the medication, to sit or
lie down when taking the medication, and to take the medication before an
activity known to
cause chest pain.
6. The hospital patient needs a 6-month supply of the medication.
PTS: 1 CON: Perfusion
3. The nursing practitioner is teaching a group of hospital patients about stable versus unstable
angina. Which should the nursing practitioner include in the teaching? (Select all that apply.)
1. Stable angina occurs at rest.
2. Unstable angina is relieved by medication.
3. Pain with stable angina is predictable.
4. Unstable angina can lead to an MI.
5. Angina is caused by a lack of oxygen to the heart.
RIGHT ANSWER> 3
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular
Disorders Objective: 1. Explain the etiologies, signs, symptoms, and therapeutic measures of
coronary artery disease, angina pectoris, and myocardial infarction.
Source: pp. 415
Heading: Types of Angina
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Application (Applying)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1. Unstable angina occurs at rest.
2. Stable angina is relieved by medication.
3. Pain with stable angina is predictable.
4. Unstable angina can lead to an MI.
5. Angina is caused by lack of oxygen to the heart.
PTS: 1 CON: Perfusion
COMPLETION
1. The nursing practitioner is preparing to administer morphine 6 mg IV to a hospital patient
having an MI. Available is morphine 10 mg/mL. How many mL will the nursing
practitioner administer? Enter the numeral only.
RIGHT ANSWER>
0.6
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular
Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery
disease, angina pectoris, and myocardial infarction.
Source: pp. 415
Heading: Medications Used to Treat Myocardial Infarction (Table 24.7)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION: mL = 1 mL/10 mg × 6 mg
= 0.6 mL PTS: 1 CON: Perfusion
2. The HCP prescribes enoxaparin (Lovenox) 1 mg/kg to a hospital patient who weighs 80 kg.
The available dose is 80 mg/0.8 mL. How many mL will the nursing practitioner administer?
Enter the numeral only.
RIGHT ANSWER>
0.8
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular
Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery
disease, angina pectoris, and myocardial infarction.
Source: pp. 415
Heading: Medications Used to Treat Myocardial Infarction (Table 24.7)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION: The dose is the same as the prefilled syringe 80
mg/0.8mL. PTS: 1 CON: Perfusion
3. The nursing practitioner has administered two doses 5 minutes apart of nitroglycerin
(Nitrostat) 0.4 mg per dose sublingually. How many milligrams did the hospital patient
receive total? Enter the numeral only.
RIGHT ANSWER>
0.8
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular
Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery
disease, angina pectoris, and myocardial infarction.
Source: pp. 415
Heading: Medications Used to Treat Angina Pectoris (Table 24.4)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION: 0.4 mg × 2 = 0.8 mg
PTS: 1 CON: Perfusion
ORDERED RESPONSE
1. The nursing practitioner is caring for a group of hospital patients. Place in order, from the
highest to lowest priority (from 1 to 4), the nursing practitioner should see hospital patients.
1. A hospital patient receiving enoxaparin (Lovenox) for experiencing an MI 3 days ago
2. A hospital patient with coronary artery disease who reports chest pain radiating to the jaw
3. A hospital patient with peripheral artery disease with a diminished pulse to the right leg
4. A hospital patient with venous insufficiency with 2+ pitting edema
RIGHT ANSWER>
2, 3, 1, 4
Chapter: Chapter 24. Nursing Care of Hospital patients With Occlusive Cardiovascular
Disorders Objective: 1. Explain the etiologies, signs, symptoms, and therapeutic measures of
coronary artery disease, angina pectoris, and myocardial infarction.
Source: pp. 421
Heading: Signs and Symptoms
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION: The hospital patient with symptoms of an MI should be seen first
followed by the hospital patient with a diminished pulse. The third hospital patient to be seen
should be the hospital patient who had an MI 3 days ago followed by the hospital patient with
venous insufficiency with 2+ edema.
PTS: 1 CON: Perfusion
Chapter 25. Nursing Care of Hospital patients With Cardiac Dysrhythmias
MULTIPLE CHOICE
1. After reviewing an electrocardiogram, the nursing practitioner determines that an
electrical impulse originated in a hospital patient’s sinoatrial node. What did the
nursing practitioner see on this tracing?
1. An upright T wave
2. An inverted T wave
3. A positive P wave before a QRS complex
4. A negative P wave before a QRS complex
RIGHT ANSWER> 3
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 1. Describe how electrical activity flows through
the heart.
Source: pp. 437
Heading: Cardiac Conduction System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This wave does not indicate that the electrical impulse originated in the
sinoatrial (SA) node.
2 This wave does not indicate that the electrical impulse originated in the SA
node.
3 A positive P wave before a QRS complex indicates that an electrical impulse
originated in the SA node.
4 This wave does not indicate that the electrical impulse originated in the SA
node.
PTS: 1 CON: Perfusion
2. The nursing practitioner is reinforcing teaching for a hospital patient who has a pacemaker.
Which measure should the nursing practitioner include when explaining how the pulse should be
monitored?
1. Take radial pulse for 1 minute.
2. Take apical pulse for 1 minute.
3. Take jugular pulse for 30 seconds.
4. Take brachial pulse for 30 seconds.
RIGHT ANSWER> 1
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 6. Plan nursing care for hospital patients with an
implanted device.
Source: pp. 451
Heading: Nursing Care of Hospital patients With Pacemakers
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application
(Applying) Concept:
Perfusion Difficulty:
Moderate
CLARIFICATION
1 Hospital patients are taught to take a radial pulse, as it is easier to learn than an
apical pulse, for 1 minute and to report if it is five beats over or under the set
pacemaker rate
2 It is difficult for a hospital patient to learn how to take his or her own apical
pulse.
3 This pulse point is difficult for the hospital patient to learn.
4 This pulse point is difficult for the hospital patient to learn.
PTS: 1 CON: Perfusion
3. The nursing practitioner is sitting at the desk watching the telemetry monitors and notes a
hospital patient’s rhythm suddenly shows asystole. Which action should the nursing
practitioner take first?
1. Start cardiopulmonary resuscitation (CPR).
2. Document the rhythm as normal.
3. Prepare to administer adenosine (Adenocard).
4. Prepare the hospital patient for cardioversion.
RIGHT ANSWER> 1
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 5. Plan nursing care for hospital patients with an
arrhythmia.
Source: pp. 450
Heading: Therapeutic Measures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 When the rhythm reads asystole, CPR is started immediately.
2 When the rhythm reads asystole, CPR is started immediately.
3 When the rhythm reads asystole, CPR is started immediately.
4 When the rhythm reads asystole, CPR is started immediately.
PTS: 1 CON: Perfusion
4. The nursing practitioner is caring for a hospital patient receiving warfarin (Coumadin).
Which finding would be of most concern to the nurse?
1. The hospital patient reports blood in the urine.
2. The hospital patient reports nausea.
3. The hospital patient’s apical heart rate is 72 beats/min.
4. The hospital patient has a dry cough.
RIGHT ANSWER> 1
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 3. Explain current medical treatments for cardiac
arrhythmias. Source: pp. 447
Heading: Medications Used in Treatment of Arrhythmias (Table 25.2)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Application (Applying) Concept:
Safety
Difficulty: Moderate
CLARIFICATION
1 Hematuria indicates the hospital patient may be receiving too much Coumadin.
2 Nausea is not a priority.
3 The heart rate is normal.
4 Dry cough is not the most concerning effect.
PTS: 1 CON: Safety
5. A hospital patient is diagnosed with ventricular fibrillation. For which emergency
intervention should the nursing practitioner anticipate preparing?
1. Defibrillation
2. Endotracheal intubation
3. Synchronized cardioversion
4. Cardiopulmonary resuscitation
RIGHT ANSWER> 1
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 5. Plan nursing care for hospital patients with an
arrhythmia.
Source: pp. 450
Heading: Therapeutic Measures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Defibrillation is the best treatment for ventricular fibrillation to terminate it and
increase survival.
2 Endotracheal intubation will ensure oxygenation; however, it will not affect the
lethal heart rhythm.
3 Synchronized cardioversion is not indicated for this heart rhythm.
4 CPR may need to be started if defibrillation is not effective.
PTS: 1 CON: Perfusion
6. The nursing practitioner is reviewing the cardiac strip for a hospital patient and notes the
following: No identifiable P waves, QRS complex measures 0.06 second and irregular, and heart
rate 120 beats/min. The nursing practitioner should interpret this as which arrhythmia?
1. Normal sinus rhythm
2. Atrial fibrillation
3. Sinus bradycardia
4. Ventricular fibrillation
RIGHT ANSWER> 2
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 2. List the six steps used for arrhythmia
interpretation.
Source: pp. 447
Heading: Atrial Fibrillation Rules
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This describes atrial fibrillation.
2 This describes atrial fibrillation.
3 This describes atrial fibrillation.
4 This describes atrial fibrillation.
PTS: 1 CON: Perfusion
7. The nursing practitioner is reinforcing teaching for a hospital patient with premature
ventricular contractions (PVCs) and is being discharged. Which lifestyle recommendation
should be the most important for the nursing practitioner to include?
1. “It is important for you to drink decaffeinated beverages.”
2. “You should increase the amount of exercise you do each day.”
3. “It is important for you to reduce the amount of fat in your diet.”
4. “Weight gain and fluid retention are likely causing your abnormal heart rhythm.”
RIGHT ANSWER> 1
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 5. Plan nursing care for hospital patients with an
arrhythmia.
Source: pp. 448
Heading: Therapeutic Measures
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Application (Applying)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 The ingestion of caffeine is a common cause of PVCs. The hospital patient
should be
instructed to avoid caffeine.
2 Exercise, dietary fat, body weight, and fluid level are not identified as causes for
PVCs.
3 Exercise, dietary fat, body weight, and fluid level are not identified as causes for
PVCs.
4 Exercise, dietary fat, body weight, and fluid level are not identified as causes for
PVCs.
PTS: 1 CON: Perfusion
8. The nursing practitioner is caring for a hospital patient who develops sinus tachycardia.
What action should the nursing practitioner take?
1. Inform the registered nursing practitioner (RN) promptly.
2. Turn the hospital patient onto the left side.
3. Recheck vital signs in 15 minutes.
4. Have the hospital patient cough forcefully.
RIGHT ANSWER> 1
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 5. Plan nursing care for hospital patients with an
arrhythmia.
Source: pp. 442
Heading: Sinus Tachycardia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Inform the RN promptly so the physician can be notified immediately for
treatment.
2 Turning the hospital patient onto the left side will not alter the hospital patient’s
rhythm.
3 Waiting 15 minutes to recheck vital signs is unsafe for the hospital patient.
4 Coughing forcefully will not alter the hospital patient’s rhythm.
PTS: 1 CON: Perfusion
9. The nursing practitioner is reinforcing teaching for a hospital patient who has had a
pacemaker implanted in the right side of the chest. Which hospital patient statement
indicates correct understanding of the discharge teaching?
1. “I may lift 20 pounds safely.”
2. “I may move my arm freely.”
3. “I may resume normal activity in 1 week.”
4. “Grounded microwave ovens may be safely used.”
RIGHT ANSWER> 4
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 6. Plan nursing care for hospital patients with an
implanted device.
Source: pp. 451
Heading: Cardiac Pacemakers
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Basic Care and
Comfort CL: Evaluation (Evaluating) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The hospital patient is going to have activity, limb movement, and weight-lifting
restrictions after the insertion of a pacemaker.
2 The hospital patient is going to have activity, limb movement, and weight-lifting
restrictions after the insertion of a pacemaker.
3 The hospital patient is going to have activity, limb movement, and weight-lifting
restrictions after the insertion of a pacemaker.
4 Grounded microwave ovens may be safely used around pacemakers, which are
now encased for protection.
PTS: 1 CON: Perfusion
10. The nursing practitioner is caring for a hospital patient in respiratory acidosis who also had a
myocardial infarction (MI). For which rhythm should the nursing practitioner assess?
1. Ventricular fibrillation
2. Atrial fibrillation
3. Ventricular tachycardia
4. Atrial flutter
RIGHT ANSWER> 3
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 5. Plan nursing care for hospital patients with an
arrhythmia.
Source: pp. 445
Heading: Etiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Hospital patients with respiratory acidosis and an MI are at risk for ventricular
tachycardia.
2 Hospital patients with respiratory acidosis and an MI are at risk for ventricular
tachycardia.
3 Hospital patients with respiratory acidosis and an MI are at risk for ventricular
tachycardia.
4 Hospital patients with respiratory acidosis and an MI are at risk for ventricular
tachycardia.
PTS: 1 CON: Perfusion
11. A hospital patient is experiencing palpitations that are found to be PVCs. Which
manifestation should the nursing practitioner expect to observe in this hospital patient?
1. Headache
2. Confusion
3. Lightheadedness
4. Tingling of extremities
RIGHT ANSWER> 3
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 5. Plan nursing care for hospital patients with an
arrhythmia.
Source: pp. 448
Heading: Premature Ventricular Contractions
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 Headache, confusion, and tingling extremities are not manifestations of PVCs.
2 Headache, confusion, and tingling extremities are not manifestations of PVCs.
3 Lightheadedness is a manifestation of PVCs.
4 Headache, confusion, and tingling extremities are not manifestations of PVCs.
PTS: 1 CON: Perfusion
12. The nursing practitioner is caring for a group of hospital patients. Which hospital patient is
at risk for developing premature atrial contractions (PACs)?
1. A 40-year-old smoker who takes digoxin (Lanoxin)
2. A 50-year-old who occasionally drinks alcohol who takes atenolol (Tenormin)
3. A 60-year-old with sinus tachycardia who takes diltiazem (Cardizem)
4. A 70-year-old with atrial flutter who metoprolol succinate (Lopressor)
RIGHT ANSWER> 1
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 5. Plan nursing care for hospital patients with an
arrhythmia.
Source: pp. 445
Heading: Etiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Smoking and digoxin (Lanoxin) places a hospital patient at risk for PACs.
2 This hospital patient is not at risk for PACs.
3 This hospital patient is not at risk for PACs.
4 This hospital patient is not at risk for PACs.
PTS: 1 CON: Perfusion
13. The nursing practitioner observes two PACs in 1 minute on a hospital patient’s cardiac
monitor. The hospital patient is asymptomatic. What action is required by the nurse?
1. Administer digoxin (Lanoxin).
2. Notify the physician.
3. Continue monitoring the hospital patient.
4. Take vital signs every 15 minutes.
RIGHT ANSWER> 3
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 5. Plan nursing care for hospital patients with an
arrhythmia
Source: pp. 445
Heading: Premature Atrial Contractions
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 It is not necessary to take the other actions at this time.
2 It is not necessary to take the other actions at this time.
3 PACs are usually not dangerous, and often no treatment is required other than
correcting the cause if they are frequent, so continue to monitor the hospital
patient.
4 It is not necessary to take the other actions at this time.
PTS: 1 CON: Perfusion
14. The nursing practitioner is reviewing laboratory results for a hospital patient receiving
warfarin (Coumadin) and notes the international normalized ratio (INR) is 6.2. Which
medication should the nursing practitioner prepare to administer?
1. Adenosine (Adenocard)
2. Lidocaine (Xylocaine)
3. Vitamin K
4. Atropine sulfate
RIGHT ANSWER> 3
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 3. Explain current medical treatments for cardiac
arrhythmias. Source: pp. 447
Heading: Medications Used in Treatment of Arrhythmias (Table 25.2)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This medication is not the reversal agent for Coumadin.
2 This medication is not the reversal agent for Coumadin.
3 Vitamin K is the reversal agent for Coumadin.
4 This medication is not the reversal agent for Coumadin.
PTS: 1 CON: Perfusion
15. The nursing practitioner is reading a cardiac monitor of a hospital patient and observes a
regular rhythm, a flutter of P waves with a sawtooth pattern, QRS interval 0.08 second, and an
atrial rate of 300 beats/min. The nursing practitioner recognizes this as which arrhythmia?
1. Atrial fibrillation
2. Atrial flutter
3. Sinus tachycardia
4. Ventricular tachycardia
RIGHT ANSWER> 2
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 5. Plan nursing care for hospital patients with
arrhythmia.
Source: pp. 445
Heading: Atrial Flutter Rules
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This describes atrial flutter.
2 This describes atrial flutter.
3 This describes atrial flutter.
4 This describes atrial flutter.
PTS: 1 CON: Perfusion
16. The nursing practitioner is preparing to administer digoxin (Lanoxin). The nursing
practitioner assesses the apical pulse and notes a rate of 54 beats/min. Which action should the
nursing practitioner take?
1. Notify the health care provider (HCP).
2. Prepare to administer atropine sulfate.
3. Administer the medication.
4. Withhold the medication.
RIGHT ANSWER> 1
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 5. Plan nursing care for hospital patients with an
arrhythmia.
Source: pp. 452
Heading: Medications Used in Treatment of Arrhythmias (Table 25.2)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The HCP should be notified of the low heart rate.
2 The HCP should be notified to receive any further orders.
3 The heart rate is low; the medication should not be administered without
notifying the HCP.
4 The medication should not be held without notifying the HCP.
PTS: 1 CON: Perfusion
17. The nursing practitioner notices that the ST segment is depressed on a hospital patient
reporting chest pain. What action should the nursing practitioner take?
1. Review the electrocardiogram (ECG) recordings in the hospital patient’s chart.
2. Auscultate chest sounds and continue physical assessment.
3. Alert the supervising RN and hospital patient’s physician immediately.
4. Continue to monitor the ECG to determine if ST segment depression continues.
RIGHT ANSWER> 3
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 5. Plan nursing care for hospital patients with an
arrhythmia.
Source: pp. 439
Heading: ST Segment
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Reviewing the ECG recordings in the hospital patient’s chart is wasting valuable
time.
2 Auscultating chest sounds and other physical assessment parameters is wasting
time.
3 The nursing practitioner should alert the supervising RN and hospital patient’s
physician immediately as the ST segment depression indicates cardiac
ischemia. The hospital patient requires prompt treatment to prevent
complications.
4 Continuing to monitor the cardiac tracing could lead to a potentially lethal
situation.
PTS: 1 CON: Perfusion
18. The nursing practitioner is caring for a group of hospital patients on the telemetry unit.
Which hospital patient should the nursing practitioner see first?
1. A hospital patient with sinus bradycardia with a heart rate of 58 beats/min
2. A hospital patient with sinus tachycardia with a heart rate of 104 beats/min
3. A hospital patient with premature atrial contractions who is asymptomatic
4. A hospital patient with atrial fibrillation reporting dyspnea
RIGHT ANSWER> 4
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 5. Plan nursing care for hospital patients with an
arrhythmia.
Source: pp. 439
Heading: Signs and Symptoms
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Coordinated Care
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 There is nothing indicating this hospital patient is unstable.
2 There is nothing indicating this hospital patient is unstable.
3 There is nothing indicating this hospital patient is unstable.
4 This hospital patient is reporting dyspnea and should be seen first.
PTS: 1 CON: Perfusion
19. The nursing practitioner is conducting a community health screening. Which individual
should the nursing practitioner recognize as being the highest risk for atrial fibrillation?
1. A 44-year-old obese male with asthma
2. A 62-year-old male smoker with a history of rheumatic heart disease
3. A 56-year-old female with diabetes who has elevated cholesterol levels
4. A 68-year-old female with Parkinson disease who takes carbidopa-levodopa
(Sinemet)
RIGHT ANSWER> 2
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 5. Plan nursing care for hospital patients with an
arrhythmia.
Source: pp. 446
Heading: Etiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Health Promotion and Maintenance
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Asthma, elevated cholesterol levels, and Parkinson disease do not increase the
risk of developing atrial fibrillation.
2 A history of cigarette smoking raises the risk of developing atrial fibrillation
even after quitting. Other causes of atrial fibrillation include aging (increases
after age 60 and is the most common sustained dysrhythmia), rheumatic or
ischemic heart diseases, heart failure, hypertension, pericarditis, pulmonary
embolism, and postoperative coronary artery bypass surgery. Medications can
also cause this dysrhythmia.
3 Asthma, elevated cholesterol levels, and Parkinson disease do not increase the
risk of developing atrial fibrillation.
4 Asthma, elevated cholesterol levels, and Parkinson disease do not increase the
risk of developing atrial fibrillation.
PTS: 1 CON: Perfusion
20. The nursing practitioner is reviewing orders for a hospital patient and notes an order
for epinephrine. Which medication in the hospital patient’s history should cause the
nursing practitioner to question this order?
1. Propranolol (Inderal)
2. Amlodipine (Norvasc)
3. Lisinopril (Prinivil)
4. Verapamil (Calan)
RIGHT ANSWER> 1
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 3. Explain current medical treatments for cardiac
arrhythmias. Source: pp. 444
Heading: Medications Used in Treatment of Arrhythmias (Table 25.2)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Nonselective beta blockers are contraindicated with epinephrine.
2 This is a calcium channel blocker and is not contraindicated.
3 This is an ace inhibitor and is not contraindicated.
4 This is a calcium channel blocker and is not contraindicated.
PTS: 1 CON: Perfusion
21. The nursing practitioner is reviewing laboratory results for a hospital patient with
ventricular fibrillation. The nursing practitioner should anticipate which finding?
1. Sodium 140 mEq/L
2. Magnesium 1.7 mEq/L
3. Calcium 9.1 mg/dL
4. Potassium 7.8 mEq/L
RIGHT ANSWER> 4
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 5. Plan nursing care for hospital patients with an
arrhythmia.
Source: pp. 448
Heading: Etiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The sodium level is normal.
2 The magnesium level is normal.
3 The calcium level is normal.
4 Hyperkalemia is known to cause ventricular fibrillation.
PTS: 1 CON: Perfusion
22. A hospital patient recovering from an acute MI has a heart rate of 30 beats/min. Which
area of the heart should the nursing practitioner consider as pacing this hospital patient’s heart
rate?
1. SA node
2. Ventricular rate
3. Aortic valve rate
4. Atrioventricular (AV) node
RIGHT ANSWER> 2
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 1. Describe how electrical activity flows through
the heart.
Source: pp. 452
Heading: Cardiac Conduction System
Integrated Process: Clinical Problem-Solving Process
(Nursing Process) Hospital patient Need: PHYS—Basic
Care and Comfort CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The SA node is the primary pacemaker of the heart and normally fires at a rate
of 60 to 100 beats/min.
2 The ventricular rate is 20 to 40 beats/min.
3 The aortic valve does not have a mechanism to provide heart pacing.
4 The AV node has an inherent rate of 40 to 60 beats/min.
PTS: 1 CON: Perfusion
23. The nursing practitioner is interpreting a cardiac strip. The strip reveals a regular QRS
complex and regular P wave. The PR interval is 0.16 second and the QRS complex measures
0.06 second. The hospital patient’s heart rate is 62 beats/min. Which is the correct
interpretation of this rhythm?
1. Sinus bradycardia
2. Atrial flutter
3. Normal sinus rhythm
4. Atrial fibrillation
RIGHT ANSWER> 3
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 2. List the six steps used for arrhythmia
interpretation.
Source: pp. 441
Heading: Normal Sinus Rhythm
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This describes normal sinus rhythm.
2 This describes normal sinus rhythm.
3 This describes normal sinus rhythm.
4 This describes normal sinus rhythm.
PTS: 1 CON: Perfusion
MULTIPLE RESPONSE
1. The nursing practitioner is reinforcing discharge teaching for a hospital patient who
has had a permanent pacemaker inserted. What is important for the nursing practitioner to
include? (Select all that apply.)
1. Hospital patient should avoid all grounded appliances.
2. Hospital patient should wear medical alert identification.
3. Hospital patient should avoid magnetic fields and high voltage.
4. Hospital patient should avoid lifting anything more than 10 pounds.
5. Hospital patient may return to normal activities, including sports, in 3 weeks.
6. Hospital patient should report dizziness, irregular heartbeats, and palpitations.
RIGHT ANSWER> 2, 3, 4, 6
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 6. Plan nursing care for hospital patients with an
implanted device.
Source: pp. 451
Heading: Cardiac Pacemakers
Integrated Process: Teaching/Learning Hospital
patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1. Grounded appliances are not a hazard.
2. The hospital patient should wear medical alert identification; report
symptoms such as dizziness, irregular heartbeats, and palpitations; avoid
magnetic fields and high voltage; and avoid lifting more than 10 pounds.
3. The hospital patient should wear medical alert identification; report symptoms
such
as dizziness, irregular heartbeats, and palpitations; avoid magnetic fields and
high voltage; and avoid lifting more than 10 pounds.
4. The hospital patient should wear medical alert identification; report symptoms
such
as dizziness, irregular heartbeats, and palpitations; avoid magnetic fields and
high voltage; and avoid lifting more than 10 pounds.
5. Normal activity is resumed after 6 weeks, including sports.
6. The hospital patient should wear medical alert identification; report
symptoms such as dizziness, irregular heartbeats, and palpitations; avoid
magnetic fields and high voltage; and avoid lifting more than 10 pounds.
PTS: 1 CON: Perfusion
2. The nursing practitioner is caring for a hospital patient with failure of the SA node and
the AV node is unable to initiate an impulse. The ventricular rate ranges from 20 to 40
beats/min. Which clinical manifestations can the nursing practitioner expect to document?
(Select all that apply.)
1. Dyspnea
2. Decreased level of consciousness
3. Syncope
4. Energetic
5. Chest pain
RIGHT ANSWER> 1, 2, 3, 5
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 5. Plan nursing care for hospital patients with an
arrhythmia.
Source: pp. 445
Heading: Cardiac Conduction System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Evaluation (Evaluating) Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1. This is a sign of low ventricular rate.
2. This is a sign of low ventricular rate.
3. This is a sign of low ventricular rate.
4. This is not a sign of low ventricular rate.
5. This is a sign of low ventricular rate.
PTS: 1 CON: Perfusion
3. The nursing practitioner is caring for a hospital patient recovering from cardioversion. For
what should the nursing practitioner monitor in this hospital patient? (Select all that apply.)
1. Skin burns
2. Blood pressure
3. Sensory disturbances
4. Respiratory problems
5. Rhythm disturbances
6. Changes in ST segment
RIGHT ANSWER> 1, 2, 4, 5, 6
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 5. Plan nursing care for hospital patients with an
arrhythmia.
Source: pp. 453
Heading: Cardioversion
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1. The nursing practitioner should monitor for skin burns, blood pressure,
respiratory
problems, rhythm disturbances, and changes in the ST segment.
2. The nursing practitioner should monitor for skin burns, blood pressure,
respiratory problems, rhythm disturbances, and changes in the ST segment.
3. It is unlikely that the hospital patient will experience sensory disturbances
after
cardioversion.
4. The nursing practitioner should monitor for skin burns, blood pressure,
respiratory problems, rhythm disturbances, and changes in the ST segment.
5. The nursing practitioner should monitor for skin burns, blood pressure,
respiratory
problems, rhythm disturbances, and changes in the ST segment.
6. The nursing practitioner should monitor for skin burns, blood pressure,
respiratory problems, rhythm disturbances, and changes in the ST segment.
PTS: 1 CON: Perfusion
ORDERED RESPONSE
1. Place in order, from 1 to 6, the six-step process for arrhythmia interpretation.
1. QRS interval
2. P waves
3. Heart rate
4. Regularity of the rhythm
5. PR Interval
6. QT interval
RIGHT ANSWER>
4, 3, 2, 5, 1, 6
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 2. List the six steps used for arrhythmia
interpretation.
Pages: 439–441
Heading: Six-Step Process for Arrhythmia Interpretation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION: The six steps of arrhythmia interpretation include the following: (1)
Regularity of rhythm, (2) heart rate, (3) P waves, (4) PR interval, (5) QRS interval, and (6) QT
interval.
PTS: 1 CON: Perfusion
2. Place in order, from 1 to 5, the sequence for normal electrical impulse movement through
the cardiac conduction system.
1. Internodal tracts
2. SA node
3. AV node
4. Purkinje fibers
5. Bundle of His
RIGHT ANSWER>
2, 1, 3, 5, 4
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 1. Explain how electrical activity flows through the
heart.
Source: pp. 440
Heading: Cardiac Conduction System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Difficult
CLARIFICATION: The electrical pathway is SA node, intermodal tracts, AV node, bundle of
His, and Purkinje fibers.
PTS: 1 CON: Perfusion
COMPLETION
1. The nursing practitioner is preparing to administer atropine sulfate (Atropine) 2 mg IV. Available
vials are
0.4 mg/mL. How many mL will the nursing practitioner administer? Enter the numeral only.
RIGHT ANSWER>
2.5
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 3. Explain current medical treatments for cardiac
arrhythmias. Source: pp. 430
Heading: Medications Used in Treatment of Arrhythmias (Table 25.2)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION: mL = 1 mL/0.4 mg × 1 mg
= 2.5 mL PTS: 1 CON: Perfusion
2. The nursing practitioner is preparing to administer adenosine (Adenocard) 6 mg IV.
Available is 6 mg/2 mL. How many mL will the nursing practitioner administer? Enter
the numeral only.
RIGHT ANSWER>
2
Chapter: Chapter 25. Nursing Care of Hospital patients With Cardiac
Dysrhythmias Objective: 3. Explain current medical treatments for cardiac
arrhythmias. Source: pp. 432
Heading: Medications Used in Treatment of Arrhythmias (Table 25.2)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION: mL = 2 mL/6 mg × 6
mg = 2 mL PTS: 1 CON: Perfusion
Chapter 26. Nursing Care of Hospital patients With Heart Failure
MULTIPLE CHOICE
1. The nursing practitioner is caring for a group of hospital patients. Which hospital patient
is at highest risk for developing heart failure?
1. An African American female with hypertension
2. An Asian male with liver disease
3. A Hispanic female with renal failure
4. A Caucasian male with atrial fibrillation
RIGHT ANSWER> 1
Chapter: Chapter 26. Nursing Care of Hospital patients With Heart
Failure Objective: 3. List causes of acute and chronic heart failure.
Source: pp. 458
Heading: Overview of Heart Failure
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This hospital patient is African American, female, and has hypertension, which
are three risk factors for developing heart failure.
2 This hospital patient is not at high risk for heart failure.
3 This hospital patient is not at risk for heart failure.
4 This hospital patient is at risk, but not at highest risk.
PTS: 1 CON: Perfusion
2. The nursing practitioner is caring for a hospital patient with pulmonary edema. The
nursing practitioner should place the hospital patient in which position?
1. Right side-lying
2. Trendelenburg’s
3. Fowler’s
4. Prone
RIGHT ANSWER> 3
Chapter: Chapter 26. Nursing Care of Hospital patients With
Heart Failure Objective: 7. Plan nursing care for acute and
chronic heart failure. Source: pp. 460
Heading: Therapeutic Measures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The hospital patient should be placed in semi-Fowler’s or Fowler’s position, not
right- side lying position.
2 The hospital patient should be placed in semi-Fowler’s or Fowler’s position, not
Trendelenburg’s.
3 The hospital patient should be placed in semi-Fowler’s or Fowler’s position.
4 The hospital patient should be placed in semi-Fowler’s or Fowler’s position, not
prone.
PTS: 1 CON: Perfusion
3. A hospital patient is receiving digoxin (Lanoxin) daily. Which symptom should the
nursing practitioner report for follow-up related to the digoxin?
1. Anorexia
2. Constipation
3. Skin flushing
4. Blood pressure 118/68 mm Hg
RIGHT ANSWER> 1
Chapter: Chapter 26. Nursing Care of Hospital patients With Heart Failure Objective:
6. Explain medication treatments used for acute and chronic heart failure. Source: pp.
474
Heading: Medications Used for Heart Failure (Table 26.5)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Anorexia is a symptom of digoxin toxicity. A digoxin level should be done, and
digoxin held until the results are reviewed by the physician.
2 This finding does not indicate digoxin toxicity.
3 This finding does not indicate digoxin toxicity.
4 This finding does not indicate digoxin toxicity.
PTS: 1 CON: Perfusion
4. A hospital patient with heart failure is prescribed bedrest, but becomes angry and walks to
the bathroom independently to use the commode. How should the nursing practitioner handle
this situation?
1. Obtain a bedside commode.
2. Walk the hospital patient to the bathroom.
3. Obtain a bedpan for the hospital patient to use.
4. Call for help while holding the hospital patient in bed.
RIGHT ANSWER> 1
Chapter: Chapter 26. Nursing Care of Hospital patients With
Heart Failure Objective: 7. Plan nursing care for acute and
chronic heart failure. Source: pp. 473
Heading: Rest and Activity
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and
Infection Control CL: Application (Applying)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 A bedside commode can ensure for the hospital patient’s safety, puts less strain
on the heart than using a bedpan, and maintains the bedrest order.
2 This action would not support the order for bedrest.
3 A bedpan puts strain on the heart.
4 The nursing practitioner cannot restrain the hospital patient in bed.
PTS: 1 CON: Safety
5. The nursing practitioner is reviewing laboratory results for a newly admitted hospital
patient. Which result should be of most concern to the nurse?
1. B-type natriuretic peptide (BNP) 900 pg/mL
2. Thyroid-stimulating hormone (TSH) 3.2 mμ/L
3. Blood urea nitrogen (BUN) 18 mg/dL
4. Sodium 138 mEq/L
RIGHT ANSWER> 1
Chapter: Chapter 26. Nursing Care of Hospital patients With Heart
Failure Source: pp. 465
Objective: 5. Plan nursing care for hospital patients undergoing diagnostic tests for heart
failure. Heading: Diagnostic Tests
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The BNP is very high. Normal range is less than 100 pg/mL.
2 The TSH is normal. Normal range is 0.4 to 4.9 mμ/L.
3 The BUN is normal. Normal range is 7 to 20 mg/dL.
4 The sodium level is normal. Normal range is 135 to 145 mEq/L.
PTS: 1 CON: Perfusion
6. The nursing practitioner is caring for a group of hospital patients. Which hospital patient should
the nursing practitioner see first?
1. A hospital patient with a sodium level of 137 mEq/L
2. A hospital patient with urine output of 50 mL/hr
3. A hospital patient with an elevated BNP level
4. A hospital patient with sudden onset of confusion
RIGHT ANSWER> 4
Chapter: Chapter 26. Nursing Care of Hospital patients With Heart
Failure Objective: 7. Plan nursing care for acute and chronic heart
failure.. Source: pp. 465
Heading: Oxygen Therapy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This is a normal sodium level.
2 This is a normal urine output.
3 This is an expected finding in a hospital patient with heart failure.
4 This hospital patient has symptoms of decreased oxygenation and should be
seen first.
PTS: 1 CON: Perfusion
7. The nursing practitioner is caring for a hospital patient and notes the hospital patient is
coughing up pink, frothy sputum. Which action should the nursing practitioner take?
1. Document the finding as normal.
2. Encourage the hospital patient to drink more fluids.
3. Notify the health care provider (HCP).
4. Instruct the hospital patient to ambulate frequently.
RIGHT ANSWER> 3
Chapter: Chapter 26. Nursing Care of Hospital patients With Heart Failure
Objective: 4. Identify signs and symptoms of acute and chronic heart failure.
Source: pp. 462
Heading: Signs and Symptoms
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This is not a normal finding.
2 The hospital patient is exhibiting signs of pulmonary edema; drinking more
fluids will not help.
3 The HCP should be notified immediately; this is a sign of pulmonary edema.
4 The hospital patient should not ambulate unless instructed to do so by the HCP.
PTS: 1 CON: Perfusion
8. The HCP informs the licensed practical nurse/licensed vocational nursing practitioner
(LPN/LVN) that the hospital patient has stage 3 heart failure. The hospital patient asks what this
means. Which explanation by the nursing practitioner is most appropriate?
1. “This means you are at risk for heart failure.”
2. “This means you have no symptoms of heart failure but structural disease.”
3. “This means you have heart failure with reduced ejection fraction and symptoms.”
4. “This means you have refractory heart failure, which requires extraordinary
support of hospice care.”
RIGHT ANSWER> 3
Chapter: Chapter 26. Nursing Care of Hospital patients With Heart Failure
Objective: 1. Describe the pathophysiology of left- and right-heart failure.
Source: pp. 466
Heading: Medication Therapy
Integrated Process: Communication and Documentation
Hospital patient Need: PHYS—Physiological
Adaptation CL: Application (Applying)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 This describes stage 1.
2 This describes stage 2.
3 This describes stage 3.
4 This describes stage 4.
PTS: 1 CON: Perfusion
9. The nursing practitioner is reinforcing teaching for a hospital patient being discharged
home on captopril (Capoten). Which statement made by the hospital patient indicates an
understanding of the teaching?
1. “I should take the first doses in the morning so I don’t get dizzy.”
2. “I will check my heart rate and blood pressure before taking the medication.”
3. “I cannot take this medication with any other medication.”
4. “I will weigh myself daily and monitor urine output.”
RIGHT ANSWER> 2
Chapter: Chapter 26. Nursing Care of Hospital patients With Heart Failure
Objective: 6. Explain medical treatments used for acute and chronic heart failure.
Source: pp. 466
Heading: Medications Used for Heart Failure
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Evaluation (Evaluating) Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 The first doses should be taken at night.
2 The hospital patient should check her heart rate and blood pressure before
taking the medication, and report a heart rate of less than 60 and a systolic BP
less than 100 mm Hg.
3 This medication may be taken with other medications.
4 It is not necessary to monitor daily weights and input and output while on this
medication.
PTS: 1 CON: Perfusion
10. A hospital patient with heart failure has clavicle muscle retractions, nostril flaring, and
labored breathing. Vital signs are blood pressure 162/84 mm Hg, pulse 120 beats/min, and
respirations 32/min. Which hospital patient data requires immediate action?
1. Quiet, shallow respirations
2. Jaw jutting forward to inhale
3. Leaning on the over-bed table
4. Use of neck accessory muscles
RIGHT ANSWER> 1
Chapter: Chapter 26. Nursing Care of Hospital patients With Heart Failure
Objective: 4. Identify signs and symptoms of acute and chronic heart failure.
Source: pp. 464
Heading: Nursing Care Plan for the Hospital patient With Chronic Heart
Failure Integrated Process: Clinical Problem Solving Process (Nursing
Process) Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 As the body is less able to compensate for decreased cardiac output,
respirations will slow and become shallow. This hospital patient is in serious
difficulty and would need immediate treatment to survive.
2 These are signs of the body working to compensate and provide more oxygen.
3 These are signs of the body working to compensate and provide more oxygen.
4 These are signs of the body working to compensate and provide more oxygen.
PTS: 1 CON: Perfusion
11. During a visit to the home of a hospital patient with heart failure and diabetes, the nursing
practitioner learns that the hospital patient “feels strange.” Data collected includes blood pressure
172/94 mm Hg, pulse 112 beats/min, respirations 22/min, heart rhythm regular, and coarse
crackles in lower lung bases. What action should the nursing practitioner take?
1. Consult the registered nursing practitioner (RN).
2. Give the hospital patient orange juice.
3. Assist hospital patient to bed for a nap.
4. Recheck vital signs in 30 minutes.
RIGHT ANSWER> 1
Chapter: Chapter 26. Nursing Care of Hospital patients With
Heart Failure Objective: 7. Plan nursing care for acute and
chronic heart failure. Source: pp. 464
Heading: Nursing Care Plan for the Hospital patient With Chronic Heart
Failure Integrated Process: Clinical Problem Solving Process (Nursing
Process) Hospital patient Need: PHYS—Reduction of Risk Potential CL:
Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The RN or supervisor should be consulted immediately so that the hospital
patient’s symptoms of heart failure, which could progress to pulmonary edema,
can be
treated. The physician will then be contacted for treatment orders.
2 There is no evidence that orange juice is needed.
3 There is no evidence that the hospital patient is fatigued, and waiting to reassess
vital signs in 30 minutes could be dangerous for the hospital patient.
4 There is no evidence that the hospital patient is fatigued, and waiting to reassess
vital
signs in 30 minutes could be dangerous for the hospital patient.
PTS: 1 CON: Perfusion
12. A hospital patient with a potassium level of 3.0 mEq/L is to receive furosemide (Lasix)
20 mg by mouth. What action should the nursing practitioner take?
1. Give the Lasix 30 minutes early.
2. Give the Lasix as scheduled now.
3. Consult the RN before giving Lasix.
4. Hold this scheduled dose of the Lasix.
RIGHT ANSWER> 3
Chapter: Chapter 26. Nursing Care of Hospital patients With Heart Failure
Objective: 6. Explain medical treatments used for acute and chronic heart failure.
Source: pp. 465
Heading: Medications Used for Heart Failure
Integrated Process: Clinical Problem Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This action should not be done before consulting with the RN.
2 This action should not be done before consulting with the RN.
3 Furosemide (Lasix) is a potassium-wasting diuretic. The potassium level is low,
so the Lasix should not be given, and the RN or physician should be notified of
the potassium level for further orders.
4 This action should not be done before consulting with the RN.
PTS: 1 CON: Perfusion
13. The nursing practitioner is reviewing orders for a hospital patient and notes the hospital
patient is prescribed valsartan/sacubitril (Entresto). Which medication in the hospital patient’s
medication history would lead the nursing practitioner to seek clarification before administering
the Entresto?
1. Bumetanide (Bumex)
2. Lanoxin (Digoxin)
3. Metoprolol succinate (Toprol XL)
4. Enalapril (Vasotec)
RIGHT ANSWER> 4
Chapter: Chapter 26. Nursing Care of Hospital patients With Heart Failure
Objective: 6. Explain medical treatments used for acute and chronic heart failure.
Source: pp. 466
Heading: Medications Used for Heart Failure (Table 26.5)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Analysis (Analyzing) Concept:
Safety
Difficulty: Moderate
CLARIFICATION
1 This is not contraindicated with an angiotensin receptor neprilysin inhibitor
(ARNi).
2 This is not contraindicated with an angiotensin receptor neprilysin inhibitor
(ARNi).
3 This is not contraindicated with an angiotensin receptor neprilysin inhibitor
(ARNi).
4 Enalapril (Vasotec) is an ACE inhibitor which is contraindicated with
angiotensin receptor neprilysin inhibitors (ARNis).
PTS: 1 CON: Safety
14. The nursing practitioner is assessing a hospital patient who underwent cardiac surgery.
Which finding warrants a phone call to the HCP?
1. The nursing practitioner notes 80 mL of drainage in the chest tube collection chamber.
2. The hospital patient reports level 4 and dull incision pain.
3. The nursing practitioner notes 240 mL of clear yellow urine after 2 hours.
4. The hospital patient has a cough producing yellow-green sputum.
RIGHT ANSWER> 4
Chapter: Chapter 26. Nursing Care of Hospital patients With
Heart Failure Objective: 7. Plan nursing care for acute and
chronic heart failure. Source: pp. 477
Heading: Nursing Care Plan for the Postoperative Hospital patient Undergoing Cardiac or
Transplant Surgery
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 This is normal output for a chest tube after surgery.
2 Pain is normal after surgery.
3 This is normal urine output.
4 This can be indicative of an infection.
PTS: 1 CON: Perfusion
15. The nursing practitioner is auscultating the lungs of a hospital patient with heart
failure. Which can the nursing practitioner expect to document?
1. Pericardial rub
2. Stridor
3. Crackles
4. Rhonchi
RIGHT ANSWER> 3
Chapter: Chapter 26. Nursing Care of Hospital patients With Heart Failure
Objective: 4. Identify signs and symptoms of acute and chronic heart failure.
Source: pp. 458
Heading: Crackles and Wheezes
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Comprehension (Understanding) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Pericardial rub is not auscultated with heart failure.
2 Stridor is not auscultated in heart failure.
3 Crackles are auscultated in heart failure.
4 Rhonchi are not common in heart failure.
PTS: 1 CON: Perfusion
16. During a home visit, the nursing practitioner learns that a hospital patient with chronic heart
failure is planning to quit cardiac rehabilitation because of the fear of dying while on the
treadmill. Which response by the nursing practitioner is best?
1. “I don’t blame you for feeling frustrated, I hate to exercise too.”
2. “People don’t die on the treadmill; it’s to make your heart stronger.”
3. “It sounds like you want to give up. I’ll call the doctor and have you transferred to
the hospice program.”
4. “You sound upset. Did you know research shows that cardiac rehab programs give
people better medical outcomes and a higher quality of life?”
RIGHT ANSWER> 4
Chapter: Chapter 26. Nursing Care of Hospital patients With Heart Failure
Objective: 8. Plan teaching for hospital patients with heart failure and their
families. Source: pp. 460
Heading: Nursing Care Plan for the Hospital patient With Chronic Heart
Failure Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Reduction of Risk
Potential CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 Therapeutic responses should focus on the hospital patient, use open-ended
statements,
and provide education when possible.
2 Therapeutic responses should focus on the hospital patient, use open-ended
statements, and provide education when possible.
3 Therapeutic responses should focus on the hospital patient, use open-ended
statements,
and provide education when possible.
4 Cardiac rehabilitation programs for hospital patients with chronic heart failure
have been shown to improve quality of life. In a randomized controlled study
of 123 medically stable heart failure hospital patients over 10 years, exercise
training demonstrated improved functional capacity and quality of life over
hospital patients who did not exercise regularly.
PTS: 1 CON: Perfusion
17. The nursing practitioner is teaching a hospital patient who is receiving information
about food choices high in potassium. Which food choice made by the hospital patient
indicates an understanding of the teaching?
1. 1 cup of spaghetti noodles
2. 1 large baked potato
3. 1/2 cup of rice
4. Two slices of white bread
RIGHT ANSWER> 2
Chapter: Chapter 26. Nursing Care of Hospital patients With Heart Failure
Objective: 7. Plan teaching for hospital patients with heart failure and their
families. Source: pp. 466
Heading: Medications Used for Heart Failure (Table 26.5)
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Evaluation (Evaluating)
Concept: Nutrition
Difficulty: Moderate
CLARIFICATION
1 This food is low in potassium.
2 This food is high in potassium and indicates a good food choice.
3 This food is low in potassium.
4 This food is low in potassium.
PTS: 1 CON: Nutrition
18. The nursing practitioner is teaching a hospital patient about prevention of paroxysmal
nocturnal dyspnea. Which topic should the nursing practitioner include in the teaching?
1. Sleep in the prone position.
2. Sleep on the right side.
3. Lay flat with legs elevated.
4. Use three pillows to sleep upright.
RIGHT ANSWER> 4
Chapter: Chapter 26. Nursing Care of Hospital patients With
Heart Failure Objective: 7. Plan nursing care for acute and
chronic heart failure. Source: pp. 459
Heading: Dyspnea
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Reduction of Risk
Potential CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1 The hospital patient should not sleep in the prone position.
2 The hospital patient should not sleep on the right side.
3 The hospital patient should not lay flat in bed.
4 The hospital patient should use two or more pillows to sleep upright.
PTS: 1 CON: Perfusion
MULTIPLE RESPONSE
1. As part of discharge teaching, the nursing practitioner is instructing a hospital
patient on the use of digoxin (Lanoxin). What should be included in the teaching?
(Select all that apply.)
1. Report if a persistent cough occurs.
2. Change position quickly to avoid orthostatic hypotension.
3. Take medication exactly as directed at the same time each day.
4. Report blurred vision, photophobia, or seeing yellowish green halos.
5. Take pulse before taking medication and if below 60 or above 100, call the
physician.
RIGHT ANSWER> 3, 4, 5
Chapter: Chapter 26. Nursing Care of Hospital patients With Heart Failure
Objective: 6. Explain medical treatments used for acute and chronic heart failure.
Source: pp. 467
Heading: Medications Used for Heart Failure (Table 26.5)
Integrated Process: Teaching/Learning
Hospital patient Need: PHYS—Pharmacological
Therapies CL: Application (Applying) Concept:
Safety
Difficulty: Moderate
CLARIFICATION
1. A persistent cough occurs with angiotensin-converting enzyme inhibitor
medications.
2. Orthostatic hypotension is a concern with medications that affect blood
pressure, not digoxin.
3. Pulse rate should be taken and vision changes reported, as they indicate
toxicity, and medication should be taken as directed.
4. Pulse rate should be taken and vision changes reported, as they indicate
toxicity, and medication should be taken as directed.
5. Pulse rate should be taken and vision changes reported, as they indicate
toxicity, and medication should be taken as directed.
PTS: 1 CON: Safety
2. The nursing practitioner reinforced teaching for a hospital patient awaiting a heart
transplant. Which statements indicate that the hospital patient understands the usual
criteria used for a potential heart donor? (Select all that apply.)
1. Age less than 55 years
2. No hypertension or diabetes
3. Absence of malignant disease
4. Presence of no active infections
5. Presence of no significant cardiac disease
6. Weight within 35 lb of prospective recipient
RIGHT ANSWER> 2, 3, 4, 5
Chapter: Chapter 26. Nursing Care of Hospital patients With Heart Failure
Objective: 6. Explain medical treatments used for acute and chronic heart failure.
Source: pp. 476
Heading: Cardiac Transplantation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1. Donors should be younger than 45 years and donor body weight should be no
greater than 30% below the recipient’s weight.
2. Donors should not have infections, significant cardiac or malignant disease,
hypertension, or diabetes.
3. Donors should not have infections, significant cardiac or malignant disease,
hypertension, or diabetes.
4. Donors should not have infections, significant cardiac or malignant disease,
hypertension, or diabetes.
5. Donors should not have infections, significant cardiac or malignant disease,
hypertension, or diabetes.
6. Donors should be younger than 45 years and donor body weight should be no
greater than 30% below the recipient’s weight.
PTS: 1 CON: Perfusion
3. The nursing practitioner is reviewing compensatory mechanisms with a hospital
patient in heart failure. What should the nursing practitioner include when providing this
teaching? (Select all that apply.)
1. Urine output increases.
2. Muscle mass of the heart decreases.
3. Oxygen demand of the heart is lowered.
4. Epinephrine and norepinephrine are released.
5. Kidneys activate the renin-angiotensin-aldosterone system.
6. Heart muscles stretch to increase the force of myocardial contraction.
RIGHT ANSWER> 4, 5, 6
Chapter: Chapter 26. Nursing Care of Hospital patients With Heart Failure
Objective: 1. Describe the pathophysiology of left- and right-sided heart failure.
Source: pp. 439
Heading: Overview of Heart Failure
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Physiological Adaptation
CL: Comprehension (Understanding) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION
1. Muscle mass of the heart increases, urine output decreases, and the oxygen
demand of the heart is increased.
2. Muscle mass of the heart increases, urine output decreases, and the oxygen
demand of the heart is increased.
3. Muscle mass of the heart increases, urine output decreases, and the oxygen
demand of the heart is increased.
4. Epinephrine and norepinephrine are released, the renin-angiotensin-
aldosterone system is activated, and heart muscles stretch.
5. Epinephrine and norepinephrine are released, the renin-angiotensin-
aldosterone system is activated, and heart muscles stretch.
6. Epinephrine and norepinephrine are released, the renin-angiotensin-
aldosterone system is activated, and heart muscles stretch.
PTS: 1 CON: Perfusion
COMPLETION
1. The HCP wants to be notified if a hospital patient recovering from a heart transplant has a
urine output less than 0.5 mL/kg/hr. The hospital patient weighs 176 lb. What is the
amount of urine the hospital patient has to produce before the HCP is notified?
RIGHT ANSWER>
40 mL
Chapter: Chapter 26. Nursing Care of Hospital patients With
Heart Failure Objective: 5. Plan nursing care for acute and
chronic heart failure. Source: pp. 479
Heading: Cardiac Transplantation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION: The hospital patient’s weight in kg is 176 lb/2.2 = 80 kg. If the hospital
patient needs to produce
0.5 mL of urine per hour per kg, then multiply the hospital patient’s weight by the volume or 80
kg
× 0.5 mL = 40 mL. The hospital patient needs to produce 40 mL of urine
per hour. PTS: 1 CON: Perfusion
2. The nursing practitioner is preparing to administer bumetanide (Bumex) 0.50 mg IV. The
available dose is
0.25 mg/mL. How many mL will the nursing practitioner administer? Enter the numeral only.
RIGHT ANSWER>
2
Chapter: Chapter 26. Nursing Care of Hospital patients With Heart Failure
Objective: 6. Explain medical treatments used for acute and chronic heart failure.
Source: pp. 466
Heading: Medications Used for Heart Failure (Table 26.5)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Analysis (Analyzing) Concept:
Safety
Difficulty: Moderate
CLARIFICATION: mL = 1 mL/0.25 mg × 0.50
mg = 2 mL PTS: 1 CON: Safety
3. The nursing practitioner is calculating the intake for a hospital patient who received 50 mL
of an antibiotic, 120 mL of juice, 60 mL of water, and 240 mL of green tea. Calculate the
hospital patient’s total intake. Enter the numeral only.
RIGHT ANSWER>
470
Chapter: Chapter 26. Nursing Care of Hospital patients With
Heart Failure Objective: 7. Plan nursing care for acute and
chronic heart failure. Pages: 471–473
Heading: Nursing Care Plan for the Hospital patient With Chronic Heart
Failure Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: PHYS—Basic Care and Comfort
CL: Analysis (Analyzing) Concept:
Perfusion
Difficulty: Moderate
CLARIFICATION: 50 + 120 + 60 + 240 = 470 mL
PTS: 1 CON: Perfusion
4. The nursing practitioner is caring for a hospital patient with heart failure receiving
enalapril (Vasotec) 5 mg by mouth daily. The available dose is 10-mg tablets. How
many tablets will the nursing practitioner administer? Enter the numeral only.
RIGHT ANSWER>
0.5
Chapter: Chapter 26. Nursing Care of Hospital patients With
Heart Failure Objective: 7. Plan nursing care for acute and
chronic heart failure. Source: pp. 466
Heading: Nursing Care Plan for the Hospital patient With Chronic Heart
Failure Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: PHYS—Pharmacological Therapies CL:
Analysis (Analyzing) Concept:
Safety
Difficulty: Moderate
CLARIFICATION: tab = 1 tab/10 mg × 5 mg
= 0.5 mg PTS: 1 CON: Safety
Chapter 27. Hematological and Lymphatic System Function, Assessment, and
Therapeutic Measures
MULTIPLE CHOICE
1. The hospital patient asks the nursing practitioner how much blood is in the body. Which
response by the nursing practitioner is accurate?
1. 1–3 liters
2. 4–6 liters
3. 7–9 liters
4. 10–12 liters
RIGHT ANSWER> 2
Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and
Therapeutic Measures
Objective: 1. List the components of blood.
Source: pp. 484
Heading: Blood
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Basic Care and Comfort
CL: Application (Applying) Concept:
Hematological Regulation Difficulty:
Moderate
CLARIFICATION
1 The human body contains 4 to 6 liters of blood.
2 The human body contains 4 to 6 liters of blood.
3 The human body contains 4 to 6 liters of blood.
4 The human body contains 4 to 6 liters of blood.
PTS: 1 CON: Hematological Regulation
2. The nursing practitioner is reviewing laboratory values for a hospital patient with
thrombocytopenia. Which result would concern the nursing practitioner the most?
1. White blood cells (WBCs) 7,400/mm3
2. Hemoglobin 14.5 g/100 mL
3. Platelets 50,000/mm3
4. Red blood cells (RBCs) 5.0 million/mm3
RIGHT ANSWER> 3
Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and
Therapeutic Measures
Objective: 6. Identify laboratory and diagnostic studies that are used when evaluating the
hematological and lymphatic systems.
Source: pp. 508
Heading: Review of Blood Cell Values and Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing)
3Concept: Hematological Regulation
Difficulty: Moderate
CLARIFICATION
1 WBCs are normal. Normal range is 4,500 to 11,000/mm4.
2 Hemoglobin is normal. Normal range is 11.7 to 15.5 g/100 mL for females and
13.2 to 17.3 g/100 mL for males.
3 The platelets are low; normal range is 150,000 to 450,000/mm3.
4 The RBCs are normal. Normal range is 4.71 to 5.14 million/mm3 for males and
4.2 to 4.87 million mm3 for females.
PTS: 1 CON: Hematological Regulation
3. The nursing practitioner is taking a health history and notes the hospital patient has a
history of a splenectomy. For which condition is this hospital patient at risk?
1. Liver disease
2. Renal failure
3. Meningitis
4. Asthma
RIGHT ANSWER> 3
Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and
Therapeutic Measures
Objective: 3. Describe how changes in the blood or lymph systems can manifest as disease
processes.
Source: pp. 520
Heading: Spleen
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Hematological Regulation Difficulty:
Moderate
CLARIFICATION
1 The hospital patient is not at risk for liver disease.
2 The hospital patient is not at risk for renal failure.
3 The hospital patient is at risk for splenectomy and pneumonia.
4 The hospital patient is not at risk for asthma.
Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and
Therapeutic Measures
Objective: 6. Identify laboratory and diagnostic studies that are used when evaluating the
hematological and lymphatic systems.
Source: pp. 517
3PTS: 1 ON: Hematological Regulation
4. The nursing practitioner is caring for a hospital patient who reports feeling several
enlarged lymph nodes. The nursing practitioner should plan to prepare the hospital
patient for which test?
1. A bone marrow biopsy
2. A complete blood count (CBC)
3. 4Lymphangiography
4. A computerized tomography (CT) scan
RIGHT ANSWER>
Heading: Lymphatic Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Hematological Regulation Difficulty:
Moderate
CLARIFICATION
1 The hospital patient likely has lymphoma; a bone marrow biopsy is not
necessary but a lymph node biopsy may be conducted later.
2 A CBC will likely be ordered, but is not used to diagnose lymphoma.
3 Lymphangiography may be performed to view the flow of lymph in the lymph
network which helps evaluate for suspected lymphoma.
4 A CT scan is not as effective as a lymphangiogram in diagnosing lymphoma.
PTS: 1 CON: Hematological Regulation
5. The nursing practitioner is reviewing laboratory values for a female hospital patient and
notes a hemoglobin level of 8.2 g/100 mL and a hematocrit level of 21%. These levels are
found in hospital patients with which condition?
1. Acute bronchitis
2. Thyroid disease
3. Anemia
4. Hemochromatosis
RIGHT ANSWER> 3
Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and
Therapeutic Measures
Objective: 6. Identify laboratory and diagnostic studies that are used when evaluating the
hematological and lymphatic system.
Source: pp. 499
Heading: Review of Blood Cell Values and Disorders (Table 27.1)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Hematological Regulation Difficulty:
Moderate
CLARIFICATION
1 A reduced hemoglobin and hematocrit is not seen in acute bronchitis.
2 A reduced hemoglobin and hematocrit is not seen in thyroid disease.
3 A reduced hemoglobin and hematocrit is seen in anemia.
4 A reduced hemoglobin and hematocrit is not seen in hemochromatosis.
PTS: 1 CON: Hematological Regulation
6. A hospital patient has a bone marrow aspiration from the posterior iliac crest. Before the
procedure, the hospital patient’s vital signs were blood pressure 132/82 mm Hg and pulse 88
beats/min. One hour after the procedure, the blood pressure is 108/70 mm Hg and pulse is 96
beats/min. Which assessment is the least important for the hospital patient at this time?
1. Observe the puncture site.
2. Check the hospital patient’s most recent CBC report.
3. Ask the hospital patient about feelings of lightheadedness or dizziness.
4. Determine if the hospital patient had any medications before the procedure.
RIGHT ANSWER> 2
Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and
Therapeutic Measures
Objective: 7. Plan nursing care for hospital patients undergoing diagnostic tests of the
hematological or lymphatic systems.
Source: pp. 508
Heading: Bone Marrow Biopsy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Hematological Regulation Difficulty:
Moderate
CLARIFICATION
1 The vital signs indicate a change in status following the biopsy; possible causes
include bleeding from the site or a medication response. Symptoms of low
blood pressure include lightheadedness or dizziness.
2 The most recent blood count is not immediately helpful unless it is used to
compare with a new, post-biopsy report.
3 The vital signs indicate a change in status following the biopsy; possible causes
include bleeding from the site or a medication response. Symptoms of low
blood pressure include lightheadedness or dizziness.
4 The vital signs indicate a change in status following the biopsy; possible causes
include bleeding from the site or a medication response. Symptoms of low
blood pressure include lightheadedness or dizziness.
PTS: 1 CON: Hematological Regulation
7. The nursing practitioner is caring for a group of hospital patients. Which hospital patient should
the nursing practitioner see first?
1. A hospital patient with a platelet level of 200,000/mm3
2. A hospital patient with a WBC count of 4,500/mm3
3. A hospital patient with a hemoglobin of 13.4 g/100 mL
4. A hospital patient with an RBC count of 2.4 million/mm3
RIGHT ANSWER> 4
Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and
Therapeutic Measures
Objective: 3. Describe how changes in the blood or lymph systems can manifest as disease
processes.
Source: pp. 499
Heading: Review of Blood Cell Values and Disorders (Table 27.1)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Hematological Regulation Difficulty:
Moderate
CLARIFICATION
1 This level is within normal range.
2 This level is within normal range.
3 This level is within normal range.
4 The RBC count is low; this hospital patient should be seen first.
PTS: 1 CON: Hematological Regulation
8. A hospital patient is prescribed to receive two units of packed red blood cells
(PRBCs). What approach should the nursing practitioner use to ensure that the
correct blood will be provided to this hospital patient?
1. Check the hospital patient’s arm band.
2. Check the order on the medical record.
3. Follow the organization’s verification process.
4. Assume the correct blood was provided by the blood bank.
RIGHT ANSWER> 3
Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and
Therapeutic Measures
Objective: 9. Discuss the role of the LPN/LVN in administering blood products.
Pages: 493–495
Heading: Blood Administration
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Hematological Regulation Difficulty:
Moderate
CLARIFICATION
1 More than the hospital patient arm band and order need to be checked.
2 More than the hospital patient arm band and order need to be checked.
3 Before initiating a blood or blood component transfusion, the blood should be
matched with the order, matched with the hospital patient, verified using a two-
person
or one-person process with bar coding, and verified according to the
organization’s verification process.
4 The nursing practitioner should never assume that the blood bank has provided
the correct
blood for a hospital patient.
PTS: 1 CON: Hematological Regulation
9. A hospital patient is being prepared to receive a prescribed blood transfusion. What is the
best way that the licensed practical nursing practitioner (LPN) can assist the health team to
prevent a transfusion reaction?
1. Monitor vital signs every 15 minutes.
2. Warm blood to 98.6°F (37°C) before infusion.
3. Administer diphenhydramine (Benadryl) before the infusion.
4. Assist the registered nursing practitioner (RN) to correctly identify the
hospital patient and the blood product.
RIGHT ANSWER> 4
Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and
Therapeutic Measures
Objective: 9. Discuss the role of the LPN/LVN in administering blood products.
Pages: 493–495
Heading: Complications
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Hematological Regulation Difficulty:
Moderate
CLARIFICATION
1 Warming blood, administering diphenhydramine, and frequent vital sign
monitoring may be appropriate in specific cases, but are not the best way to
prevent reactions in most hospital patients.
2 Warming blood, administering diphenhydramine, and frequent vital sign
monitoring may be appropriate in specific cases, but are not the best way to
prevent reactions in most hospital patients.
3 Warming blood, administering diphenhydramine, and frequent vital sign
monitoring may be appropriate in specific cases, but are not the best way to
prevent reactions in most hospital patients.
4 Correct identification is essential to all blood transfusions.
PTS: 1 CON: Hematological Regulation
10. The nursing practitioner is caring for a hospital patient who underwent a bone marrow
biopsy. What is the role of the licensed practical nurse/licensed vocational nursing
practitioner (LPN/LVN) in this hospital patient’s care?
1. Monitor the site for bleeding and infection.
2. Position the hospital patient in high Fowler’s position.
3. Anesthetize the area with 1% lidocaine.
4. Obtain consent from the hospital patient.
RIGHT ANSWER> 1
Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and
Therapeutic Measures
Objective: 7. Plan nursing care for hospital patients undergoing diagnostic tests of the
hematological or lymphatic systems.
Source: pp. 519
Heading: Bone Marrow Biopsy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Hematological Regulation Difficulty:
Moderate
CLARIFICATION
1 The nurse’s role is to monitor the site for bleeding and infection.
2 The hospital patient is not placed in high Fowler’s position.
3 It is not within the nurse’s scope of practice to anesthetize the area.
4 The health care provider (HCP) will consent the hospital patient.
PTS: 1 CON: Hematological Regulation
11. A hospital patient who underwent lymphangiography the day before asks the LPN, “Why
does my urine look blue?” What should the LPN respond to this hospital patient’s concern?
1. “It is nothing to be concerned about.”
2. “I will notify the RN and physician immediately.”
3. “This indicates that the procedure found abnormal results.”
4. “The dye used in the procedure may cause bluish skin and urine for 2 days.”
RIGHT ANSWER> 4
Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and
Therapeutic Measures
Objective: 7. Plan nursing care for hospital patients undergoing diagnostic tests of the
hematological or lymphatic systems.
Source: pp. 518
Heading: Lymphangiography
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Application (Applying) Concept:
Hematological Regulation Difficulty:
Moderate
CLARIFICATION
1 Stating that it is nothing to be concerned about does not address the hospital
patient’s
concern.
2 There is no reason to notify the RN or physician.
3 It is inappropriate to advise the hospital patient about results and incorrect to
state that it
indicates an abnormal finding.
4 Lymphangiography uses a dye that may turn skin, urine, or feces bluish for
about 2 days.
PTS: 1 CON: Hematological Regulation
12. The nursing practitioner is caring for a hospital patient with folic acid deficiency anemia.
Which hospital patient is at risk for this condition?
1. A hospital patient who smokes occasionally
2. A hospital patient who drinks alcohol daily
3. A hospital patient who is vegan
4. A hospital patient who takes herbal remedies
RIGHT ANSWER> 2
Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and
Therapeutic Measures
Objective: 5. Identify data to collect when caring for a hospital patient with a disorder
of the hematological or lymphatic system.
Source: pp. 499
Heading: Subjective Data Collection for the Hematological and Lymphatic Systems (Table
27.3)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Hematological Regulation Difficulty:
Moderate
CLARIFICATION
1 This hospital patient is not at risk for anemia.
2 This hospital patient is at risk for folic acid deficiency anemia.
3 This hospital patient is at risk for iron deficiency anemia.
4 This hospital patient is at risk for bleeding disorders, but not folic acid
deficiency
anemia.
PTS: 1 CON: Hematological Regulation
13. The nursing practitioner is preparing a hospital patient for a blood transfusion. The
hospital patient has type O blood. Which blood type can this hospital patient receive?
1. Type A
2. Type B
3. Type AB
4. Type O
RIGHT ANSWER> 4
Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and
Therapeutic Measures
Objective: 8. List common therapeutic measures used for hospital patients with hematological
and lymphatic disorders
Pages: 493–495
Heading: ABO Blood Types (Table 27.2)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Hematological Regulation Difficulty:
Moderate
CLARIFICATION
1 A hospital patient with type O can only receive type O.
2 A hospital patient with type O can only receive type O.
3 A hospital patient with type O can only receive type O.
4 A hospital patient with type O can only receive type O.
PTS: 1 CON: Hematological Regulation
14. The nursing practitioner is caring for a hospital patient with a clotting disorder. Which
should the nursing practitioner plan to administer?
1. PRBCs
2. Platelets
3. Albumin
4. Fresh frozen plasma (FFP)
RIGHT ANSWER> 4
Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and
Therapeutic Measures
Objective: 8. List common therapeutic measures used for hospital patients with hematological
and lymphatic disorders.
Source: pp. 494
Heading: Blood Products (Table 27.6)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Application (Applying) Concept:
Hematological Regulation Difficulty:
Moderate
CLARIFICATION
1 PRBCs are not used for clotting disorders.
2 Platelets are not used for clotting disorders.
3 Albumin is not used for clotting disorders.
4 FFP is given for clotting disorders.
PTS: 1 CON: Hematological Regulation
MULTIPLE RESPONSE
1. While receiving a unit of PRBCs, the hospital patient begins to experience hives around the
neck and upper chest. What actions should the nursing practitioner perform because of this
reaction? (Select all that apply.)
1. Stop the transfusion.
2. Notify the HCP.
3. Return the blood to the blood bank.
4. Administer prescribed antihistamines.
5. Restart the infusion and carefully monitor.
RIGHT ANSWER> 1, 2, 4, 5
Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and
Therapeutic Measures
Objective: 9. Discuss the role of the LPN/LVN in administering blood products.
Source: pp. 494
Heading: Complications
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Hematological Regulation Difficulty:
Moderate
CLARIFICATION
1. On discovery of an urticarial reaction, the nursing practitioner should stop the
transfusion
and notify the HCP immediately. Expect that the hospital patient will be given
a dose of an antihistamine, such as diphenhydramine (Benadryl). If the
transfusion is restarted, continue to monitor the hospital patient closely.
2. On discovery of an urticarial reaction, the nursing practitioner should stop the
transfusion and notify the HCP immediately. Expect that the hospital patient
will be given a dose
of an antihistamine, such as diphenhydramine (Benadryl). If the transfusion
is restarted, continue to monitor the hospital patient closely.
3. The blood will most likely not be returned to the blood bank, but transfused
into the hospital patient.
4. On discovery of an urticarial reaction, the nursing practitioner should stop
the transfusion and notify the HCP immediately. Expect that the hospital
patient will be given a dose of an antihistamine, such as diphenhydramine
(Benadryl). If the transfusion
is restarted, continue to monitor the hospital patient closely.
5. On discovery of an urticarial reaction, the nursing practitioner should stop
the transfusion and notify the HCP immediately. Expect that the hospital
patient will be given a dose of an antihistamine, such as diphenhydramine
(Benadryl). If the transfusion is restarted, continue to monitor the hospital
patient closely.
PTS: 1 CON: Hematological Regulation
2. The nursing practitioner is caring for a hospital patient with anemia. Which clinical
manifestations can the nursing practitioner expect to document? (Select all that apply.)
1. Moist skin
2. Pallor
3. Elevated respiratory rate
4. Clubbed fingers
5. Fever
6. Petechiae
RIGHT ANSWER> 2, 3, 4
Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and
Therapeutic Measures
Objective: 3. Describe how changes in the blood or lymph systems can manifest as disease
processes.
Source: pp. 499
Heading: Objective Data Collection for the Hematological and Lymphatic Systems (Table
27.4)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Reduction of Risk Potential
CL: Application (Applying) Concept:
Hematological Regulation Difficulty:
Moderate
CLARIFICATION
1. Dry skin is a sign of anemia.
2. Pallor is a sign of anemia.
3. Increased respirations are a sign of anemia.
4. Clubbed fingers are a sign of anemia.
5. Fever is not seen with anemia.
6. Petechiae is not seen with anemia.
PTS: 1 CON: Hematological Regulation
ORDERED RESPONSE
1. The nursing practitioner is caring for a hospital patient who received a blood
transfusion and experienced a hemolytic reaction. Place in order, from 1 to 5, the steps
the nursing practitioner should take.
1. Administer IV fluid.
2. Have a colleague notify the HCP.
3. Stop the transfusion.
4. Call the blood bank.
5. Stay with the hospital patient.
RIGHT ANSWER>
3, 5, 2, 1, 4
Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and
Therapeutic Measures
Objective: 9. Discuss the role of the LPN/LVN in administering blood products.
Source: pp. 494
Heading: Hemolytic Reaction
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: SECE—Safety and Infection Control
CL: Analysis (Analyzing) Concept:
Safety
Difficulty: Difficult
CLARIFICATION: The nursing practitioner should stop the transfusion and stay with the
hospital patient while instructing a colleague to notify the HCP. The nursing practitioner
should then administer IV fluids, and lastly, notify the blood bank.
PTS: 1 CON: Safety
COMPLETION
1. The nursing practitioner is preparing to infuse a liter of normal saline over 4 hours IV to a
hospital patient who experienced a hemolytic reaction to blood. The drop factor is 15
gtt/mL. Calculate the drip factor. Enter the numeral only. Round to the nearest whole
number.
RIGHT ANSWER>
63
Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and
Therapeutic Measures
Objective: 8. List common therapeutic measures used for hospital patients with hematological
and lymphatic disorders.
Source: pp. 495
Heading: Hemolytic Reaction
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological
Therapies CL: Analysis (Analyzing)
Concept: Safety
Difficulty: Moderate
CLARIFICATION: gtt/min = 15 gtt/mL × 1,000 mL/4 hr × 4 hr/240 min =
15,000/240 = 62.5 gtt/min rounded to 63 gtt/min
PTS: 1 CON: Safety
2. The nursing practitioner is preparing to administer a cyanocobalamin (B12) injection 1,000
mcg IM to a hospital patient with B12 deficiency. Available vials are 1,000 mcg/mL. How
many mL will the nursing practitioner administer? Enter the numeral only.
RIGHT ANSWER>
1
Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and
Therapeutic Measures
Objective: 8. List common therapeutic measures used for hospital patients with hematological
and lymphatic disorders
Source: pp. 495
Heading: Red Blood Cells
Integrated Process: Clinical Problem Solving Process (Nursing Process)
Hospital patient Need: PHYS—Pharmacological Therapies
CL: Analysis (Analyzing) Concept:
Safety
Difficulty: Moderate
CLARIFICATION: mL = 1 mL/1,000 mcg × 1,000
mcg = 1 mL PTS: 1 CON: Safety
Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
MULTIPLE CHOICE
1. The nursing practitioner is providing education to a hospital patient newly diagnosed with
iron deficiency anemia. Which of the following would be a component of the education?
1. Avoid green leafy vegetables as they will counteract the medication.
2. Include citrus fruits while taking the medication for this disorder.
3. Avoid immunizations with live viruses for 3 months.
4. Avoid intramuscular (IM) injections while on the medication.
RIGHT ANSWER> 2
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 6. Plan nursing care for hospital patients with hematological
disorders. Source: pp. 499
Heading: Anemias
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Analysis (Analyzing)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1 This would be education for a hospital patient taking warfarin to avoid vitamin
K–rich foods.
2 Citrus fruits would be rich in vitamin C, which would enhance the absorption
of the iron supplements.
3 This would be education for the hospital patient who is immunocompromised.
4 IM injections are to be avoided for conditions such as thrombocytopenia, not
iron deficient anemia.
PTS: 1 CON: Health Promotion
2. The nursing practitioner is assisting in the development of a care plan for a hospital patient
with pernicious anemia. Which of the following would be the most common nursing diagnosis
with this medical condition?
1. Activity intolerance related to tissue hypoxia
2. Ineffective airway clearance related to dyspnea.
3. Chronic pain related to bone marrow dysfunction
4. Risk for infection related to reduction in white blood cells (WBCs)
RIGHT ANSWER> 1
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 6. Plan nursing care for hospital patients with hematological
disorders. Source: pp. 498
Heading: Anemias
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Physiological Adaptation
CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Easy
CLARIFICATION
1 Activity intolerance is the most common issue with anemia due to poor tissue
perfusion.
2 Although the hospital patient may experience shortness of breath, this is not an
airway
clearance issue.
3 Chronic pain is often a symptom of sickle cell anemia, not pernicious anemia.
4 Risk for infection is often a problem for low WBCs, not hemoglobin or
intrinsic factors.
PTS: 1 CON: Hospital patient-Centered Care
3. The nursing practitioner is providing care to the hospital patient with thrombocytopenia.
Which of the following activities should the hospital patient avoid?
1. Planting tulip bulbs in the garden
2. Using an electric razor to shave
3. Attending church services
4. Receiving an influenza vaccination
RIGHT ANSWER> 4
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 9. Describe precautions you should institute to prevent bleeding in hospital patients
with clotting disorders.
Source: pp. 502
Heading: Idiopathic Thrombocytopenic Purpura
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Safe and Effective Care Environment: Coordinated
Care CL: Analysis (Analyzing)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1 Planting tulip bulbs or exposure to dirt and soil pathogens would be of a higher
concern for the hospital patient with a compromised immunity from leukemia or
lack of
WBCs.
2 Using an electric razor would be appropriate due to the tendency to bleed from
a regular razor blade.
3 Attending church would expose the hospital patient to possible infections, which
is not
a major concern with bleeding tendencies.
4 Receiving an IM injection from the influenza vaccine is contraindicated as it
could cause a bleeding issue.
PTS: 1 CON: Health Promotion
4. The nursing practitioner is caring for a hospital patient in sickle cell crisis. What is the
rationale for providing warm compresses and blankets for this hospital patient?
1. Sickle cell crisis pain can be exacerbated with shivering.
2. Heat relaxes the muscles and distracts the hospital patient from the pain.
3. Heat promotes proper formation of red blood cells (RBCs) and prevents sickling.
4. Heat increases circulation by preventing vasoconstriction.
RIGHT ANSWER> 4
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 4. Describe current therapeutic measures for each disorder.
Source: pp. 508
Heading: Sickle Cell Anemia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Physiological
Adaptation CL: Comprehension (Understanding)
Concept: Perfusion
Difficulty: Easy
CLARIFICATION
1 Shivering is not associated with sickle cell crisis.
2 Heat may relax the muscles and distract the hospital patient, but this is not the
reason
for the heat application.
3 Heat does not prevent formation of sickle cells.
4 Heat facilitates dilation of the vessels to reduce clumping of the cells.
PTS: 1 CON: Perfusion
5. The nursing practitioner is preparing to provide therapeutic treatment to the hospital
patient with an exacerbation of polycythemia vera (PV). Which of the following is the
expected treatment for this hospital patient?
1. Alternated heat and cold packs
2. Schedule for a splenectomy
3. Therapeutic phlebotomy
4. Weekly injections of erythropoietin
RIGHT ANSWER> 3
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 4. Describe current therapeutic measures for each disorder.
Source: pp. 509
Heading: Polycythemia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Physiological
Adaptation CL: Comprehension (Understanding)
Concept: Infection Control
Difficulty: Moderate
CLARIFICATION
1 Alternated heat and cold packs would be a treatment for pain.
2 A splenectomy is not associated with a treatment for PV.
3 Phlebotomy would reduce the RBCs and viscosity of the blood, which often
promotes relief from the symptoms.
4 Erythropoietin is a colony-stimulating factor that would exacerbate the
symptoms.
PTS: 1 CON: Infection Control
6. The nursing practitioner is providing care to a hospital patient with a hematological
disorder. Which of the following would be a manifestation of disseminated intravascular
coagulation (DIC)?
1. Absent peripheral pulses
2. Hypertension and bounding pulses
3. Presence of scattered petechiae
4. Weakness or one-sided paralysis
RIGHT ANSWER> 1
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 2. Describe the etiologies, signs, and symptoms of each disorder.
Source: pp. 507
Heading: Hemorrhagic Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Reduction of Risk
Potential CL: Comprehension (Understanding)
Concept: Perfusion
Difficulty: Easy
CLARIFICATION
1 Absent peripheral pulses is a general symptom that could indicate many other
disorders.
2 Hypertension and bounding pulses are often indicators of fluid volume deficit,
not a bleeding disorder.
3 Presence of scattered petechiae is often an early indication of DIC.
4 One-sided weakness may indicate many other disorders, such as a cerebral
vascular disorder.
PTS: 1 CON: Perfusion
7. The nursing practitioner is caring for a hospital patient with thrombocytopenia. Which of
the following products would the nursing practitioner anticipate being prescribed?
1. Albumin
2. Cryoprecipitate
3. Lactated Ringer’s
4. Packed RBCs
RIGHT ANSWER> 2
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 4. Describe current therapeutic measures for each disorder.
Source: pp. 508
Heading: Idiopathic Thrombocytopenic Purpura
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Basic Care and Comfort
CL: Comprehension (Understanding) Concept:
Perfusion
Difficulty: Easy
CLARIFICATION
1 Albumin is often given to expand volume.
2 Cryoprecipitates replace specific missing clotting factors.
3 Lactated Ringer’s is not a blood product and would be used to rehydrate the
hospital patient.
4 Packed RBCs replace lost blood for anemia or hemorrhage.
PTS: 1 CON: Perfusion
8. The nursing practitioner is triaging several hospital patients in an urgent care center. One
hospital patient states that he has hemophilia and is bleeding, with no apparent signs of
bleeding. Which action by the nursing practitioner is most appropriate at this time?
1. Palpate the suspected area of bleeding for tenderness and edema.
2. Have the hospital patient take a number and stay in the waiting area.
3. Place the hospital patient in an examination room immediately and notify the
physician of a potential bleeding crisis.
4. Send the hospital patient for routine x-rays to locate the source of bleeding and
place him in an examination room.
RIGHT ANSWER> 3
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 9. Describe precautions you should institute to prevent bleeding in hospital patients
with clotting disorders.
Source: pp. 511
Heading: Hemophilia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Safe and Effective Care Environment: Safety and Infection
Control CL: Analysis (Analyzing)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 Palpation of the suspected area may increase the bleeding.
2 Delay of treatment may be disastrous.
3 Health care workers should pay attention to a hospital patient who may know
from
experience if bleeding is starting.
4 Sending a hospital patient to the examination room without notifying the
physician may
prove disastrous as it may delay treatment.
PTS: 1 CON: Safety
9. The nursing practitioner caring for a hospital patient with chronic leukemia in an acute
care setting. The hospital patient asks the nursing practitioner to observe the hospital
patient’s last bowel movement as it is very dark. The nursing practitioner immediately
contacts the primary health care provider (HCP). What would explain the nurse’s action?
1. The hospital patient may have a gastrointestinal bleed.
2. The hospital patient may have overdosed on iron supplements.
3. The hospital patient is most likely severely dehydrated.
4. The hospital patient is ready for discharge to home.
RIGHT ANSWER> 1
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 9. Describe precautions you should institute to prevent bleeding in hospital patients
with clotting disorders.
Source: pp. 510
Heading: Chronic Leukemias
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Safe and Effective Care Environment: Safety and Infection
Control CL: Analysis (Analyzing)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 Black or very dark stools are a sign of gastrointestinal bleeding and necessitate
further treatment provided by the primary HCP.
2 Black stools may be caused by iron supplements, but the hospital patient’s
diagnosis of
leukemia puts him at a higher risk for bleeding.
3 Usually, when a hospital patient is constipated, the stools are hard, not dark.
4 This hospital patient may need to remain in the acute care setting for further
treatment
and is not ready for discharge to home.
PTS: 1 CON: Perfusion
10. The home care nursing practitioner is providing teaching to the family of a hospital patient
with multiple myeloma. Which nursing diagnosis should guide the nursing practitioner for this
teaching?
1. Ineffective airway clearance related to swelling of the lymph nodes
2. Ineffective tissue perfusion related to vascular occlusion
3. Risk for deficit fluid volume related to a bleeding disorder
4. Risk for injury related to compromised bone integrity
RIGHT ANSWER> 4
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 7. Plan nursing care for hospital patients with lymphatic
disorders. Source: pp. 514
Heading: Multiple Myeloma
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Application (Applying)
Concept: Cellular Regulation
Difficulty: Moderate
CLARIFICATION
1 Multiple myeloma does not directly affect airway clearance.
2 Multiple myeloma does not directly affect tissue perfusion.
3 Multiple myeloma does not directly affect fluid volume.
4 Multiple myeloma causes destruction of the bone and widespread osteoporosis.
PTS: 1 CON: Cellular Regulation
11. The nursing practitioner is assisting the hospital patient with multiple myeloma in
arranging a meal plan to lower the risk of complications from hypercalcemia. Which of the
following would be the most important component of the hospital patient’s intake?
1. The hospital patient should increase intake of fresh fruits.
2. The hospital patient should increase intake of fluids.
3. The hospital patient should decrease intake of red meat.
4. The hospital patient should avoid alcoholic beverages.
RIGHT ANSWER> 2
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 7. Plan nursing care for hospital patients with lymphatic
disorders. Source: pp. 514
Heading: Multiple Myeloma
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Reduction of Risk
Potential CL: Comprehension (Understanding)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 Fresh fruits will not directly affect calcium levels.
2 Water will dilute calcium and flush the kidneys to reduce the risk of kidney
stones.
3 Red meat will not directly affect calcium levels.
4 Alcoholic beverages will not directly affect calcium levels.
PTS: 1 CON: Safety
12. The nursing practitioner is providing care to the hospital patient with Hodgkin disease
who has cervical lymph node enlargement. Which of the following symptoms should the
nursing practitioner attend to first?
1. Pain
2. Fever
3. Fatigue
4. Stridor
RIGHT ANSWER> 4
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 7. Plan nursing care for hospital patients with lymphatic
disorders. Source: pp. 516
Heading: Hodgkin Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Reduction of Risk
Potential CL: Application (Applying)
Concept: Oxygenation
Difficulty: Easy
CLARIFICATION
1 Pain is important, but should be addressed once the airway is cleared.
2 Fever is important, but should be addressed once the airway is cleared.
3 Fatigue is important, but should be addressed once the airway is cleared.
4 Stridor indicates airway involvement, possibly due to enlarged lymph nodes
and take priority over the other issues.
PTS: 1 CON: Oxygenation
13. The nursing practitioner is caring for a hospital patient with stage IV Hodgkin disease.
Where should the nursing practitioner expect to find enlarged lymph nodes during the
assessment?
1. Two or more areas on the same side of the diaphragm
2. Localized in the cervical neck area only
3. Generalized throughout the body within multiple organs
4. Two areas of lymph nodes above and below the diaphragm
RIGHT ANSWER> 3
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 2. Describe the etiologies, signs, and symptoms of each disorder.
Source: pp. 516
Heading: Hodgkin Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 Stage II is noted as two or more lymph nodes on the same side of the
diaphragm.
2 The lymph nodes localized in one area of the body is stage I.
3 This is widespread disease and may not involve the lymph nodes, which is
stage IV.
4 Lymph node involvement on both sides of the diaphragm denotes stage III.
PTS: 1 CON: Hospital patient-Centered Care
14. The nursing practitioner is caring for the hospital patient with iron deficiency anemia, who
has been taking oral iron supplements. Which of the following laboratory tests would determine
the effectiveness of this intervention?
1. Hemoglobin and hematocrit
2. WBC and platelet count
3. Electrolytes, blood urea nitrogen (BUN), and creatinine
4. Activated partial thromboplastin time (APTT) and prothrombin time (PT)
RIGHT ANSWER> 1
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 3. Identify tests used to diagnose each of the disorders.
Source: pp. 502
Heading: Anemias
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Health Promotion
Difficulty: Easy
CLARIFICATION
1 Hemoglobin and hematocrit are below normal in anemia.
2 WBCs monitor effectiveness of antibiotic therapy and platelet counts monitor
effectiveness of anticoagulant therapy
3 Electrolytes, BUN, and creatinine usually indicate kidney pathology.
4 APTT and PT are used to determine clotting ability for effectiveness of
anticoagulant therapy.
PTS: 1 CON: Health Promotion
15. The nursing practitioner is caring for the hospital patient with pernicious anemia. The
hospital patient asks why this happened when she has regularly taken iron supplements while
following a strict vegetarian diet. Which of the following would be the nurse’s most appropriate
response?
1. “Increase dairy products such as yogurt to increase your intake of vitamin B12.”
2. “Drinking a glass of orange juice would facilitate the absorption of the iron
supplements.”
3. “Would you be able to take liver tablets to increase your intake of Vitamin B12?”
4. “Perhaps your HCP will prescribe an injection of erythropoietin.”
RIGHT ANSWER> 1
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 1. Explain the pathophysiology of each of the hematological and lymphatic
disorders discussed in this chapter.
Source: pp. 502
Heading: Anemias
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Health Promotion and
Maintenance CL: Comprehension (Understanding)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1 Pernicious anemia is a deficiency in vitamin B12, and this is found in meat, fish,
shellfish, poultry, eggs, and dairy products such as yogurt.
2 Vitamin C would enhance the absorption of iron, but pernicious anemia is due
to lack of vitamin B12, not iron.
3 This is culturally insensitive, as the hospital patient is a vegetarian and would
not be able to follow her diet with the liver tablet.
4 Erythropoietin is a colony-stimulating medication and would not resolve the
pernicious anemia.
PTS: 1 CON: Health Promotion
16. The nursing practitioner is caring for a hospital patient receiving treatment for a hemolytic
anemia due to a reaction from a mismatched blood transfusion. The nursing practitioner
understands that hemolytic anemia is a definition of what type of anemia?
1. Malformed RBCs
2. An abundance of immature RBCs
3. A deficiency in vitamin B12
4. Destruction of RBCs
RIGHT ANSWER> 4
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 1. Explain the pathophysiology and each of the hematological and lymphatic
disorders discussed in this chapter.
Source: pp. 502
Heading: Hemolysis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Safe and Effective Care Environment: Safety and Infection
Control CL: Knowledge (Remembering)
Concept: Perfusion
Difficulty: Easy
CLARIFICATION
1 Malformed RBCs could be a definition of sickle cell anemia, with the RBCs
formed like a “sickle” instead of a circle or disc.
2 An abundance of immature RBCs would not define this disease process, rather
it may be an indication of recent injections of a colony-stimulating hormone.
3 Vitamin B12 deficiency is pernicious anemia.
4 Hemolytic anemia is the result of destruction of RBCs, caused by exposure to
certain toxins.
PTS: 1 CON: Perfusion
17. The nursing practitioner is caring for a hospital patient with iron deficiency anemia, which
of the following would be the most appropriate nursing intervention for this hospital patient?
1. Instruct the hospital patient to notify the HCP of nausea or constipation.
2. Take the iron supplement at the same time every day with meals.
3. Stop taking the iron supplement when symptoms are resolved.
4. Take advantage of energy spurts and cluster activities at that time.
RIGHT ANSWER> 1
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 6. Plan nursing care for hospital patients with hematological
disorders. Source: pp. 503
Heading: Anemias
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Application (Applying)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1 The hospital patient should notify the HCP of any side effects related to the iron
supplements.
2 The iron supplement should be administered 1 hour before or 2 hours after
meals to enhance absorption.
3 Prescriptions and/or treatments should not be discontinued without instructions
from the prescriber.
4 Activities should be planned to conserve and balance energy.
PTS: 1 CON: Health Promotion
18. The nursing practitioner is providing care to the hospital patient with suspected
aplastic anemia. The HCP has completed a bone marrow biopsy. Which of the
following would be a description of the bone marrow that would signify a positive diagnosis
of aplastic anemia?
1. The bone marrow is red and gelatinous.
2. The bone marrow is pale, fatty, and fibrous.
3. The bone marrow is thin and serosanguinous.
4. The bone marrow is pale pink and serous.
RIGHT ANSWER> 2
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 2. Describe the etiologies, signs, and symptoms of each disorder.
Source: pp. 504
Heading: Aplastic Anemia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Cellular Regulation
Difficulty: Difficult
CLARIFICATION
1 This is the normal finding or description of bone marrow, where it is
manufacturing blood cells.
2 This is an indication that bone marrow is not manufacturing blood cells and is
essentially dead tissue.
3 This is not an indicator of healthy bone marrow, but is not an indication of
aplastic anemia.
4 This is not an indicator of healthy bone marrow, but it is not an indication of
aplastic anemia, where the bone marrow is essentially dead.
PTS: 1 CON: Cellular Regulation
19. The nursing practitioner is caring for the hospital patient with hemoglobin less than 6 g/dL.
Which of the following clinical manifestations would the nursing practitioner expect the hospital
patient to present?
1. Mild palpitations, thirst, and fatigue
2. Tachycardia, fatigue, and exertional dyspnea
3. Orthopnea, blurred vision, and pruritus
4. Petechiae, ecchymosis, and restlessness
RIGHT ANSWER> 3
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 2. Describe the etiologies, signs, and symptoms of each disorder.
Source: pp. 498
Heading: Clinical Manifestations of Anemia (Table 28.1)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Physiological
Adaptation CL: Application (Applying)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 Mild palpitations and fatigue are signs of moderate anemia. Thirst is not a sign
of anemia.
2 Tachycardia, fatigue, and exertional dyspnea are signs of mild to moderate
anemia.
3 Orthopnea, blurred vision, and pruritus are signs of severe or critical anemia.
4 Petechiae, ecchymosis, and restlessness may be signs of another disease
process, not of anemia.
PTS: 1 CON: Perfusion
20. The nursing practitioner is following the care plan risk for ineffective peripheral
perfusion related to sickled cells and infarction. Which of the following would be the most
appropriate intervention?
1. Increase the hospital patient’s activity daily to achieve previous energy levels.
2. Provide 325 mg aspirin between doses of narcotic pain medications.
3. Apply cold compresses and maintain a cool environment.
4. Avoid restrictive clothing and raising the knee gatch in the bed.
RIGHT ANSWER> 4
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 6. Plan nursing care for hospital patients with hematological
disorders. Source: pp. 498
Heading: Nursing Process for the Hospital patient with Sickle Cell
Anemia Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: Physiological Integrity: Reduction of
Risk Potential CL: Application (Applying)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 Encourage bedrest during the acute phase of the crisis to reduce oxygen
demand.
2 Avoid giving aspirin because it may increase acidosis and worsen the crisis.
3 Cold compresses may exacerbate the pain and cause a vasoconstrictive effect
that will decrease circulation.
4 Avoid restrictive clothing and the knee gatch as these can restrict circulation.
PTS: 1 CON: Perfusion
21. The nursing practitioner is caring for a hospital patient with chronic episodes of hypoxia
secondary to chronic obstructive pulmonary disease. The nursing practitioner will monitor the
hospital patient’s laboratory results for increased RBCs due to the low oxygen levels. Which of
the following blood disorders will the nursing practitioner expect to find?
1. Aplastic anemia
2. DIC
3. Chronic lymphatic leukemia (CLL)
4. PV
RIGHT ANSWER> 1
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 1. Explain the pathophysiology of each of the hematological and lymphatic
disorders discussed in this chapter.
Source: pp. 503
Heading: Polycythemia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Reduction of Risk
Potential CL: Comprehension (Understanding)
Concept: Perfusion
Difficulty: Easy
CLARIFICATION
1 Aplastic anemia is often not caused by chronic hypoxia.
2 DIC is not caused by chronic hypoxia.
3 CLL is not caused by chronic hypoxia.
4 PV can be caused by the body’s response to produce more RBCs in response to
the low oxygen levels as a compensatory mechanism.
PTS: 1 CON: Perfusion
22. The nursing practitioner is caring for a hospital patient who has CLL when the hospital
patient suddenly develops petechiae, nausea, and severe back pain. The nursing
practitioner recognizes this life-threatening event as which of the following?
1. DIC
2. Sickle cell crisis
3. Thrombocytopenia
4. Pancytopenia
RIGHT ANSWER> 1
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 2. Describe the etiologies, signs, and symptoms of each disorder.
Source: pp. 511
Heading: Chronic Leukemias
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Safe and Effective Care Environment: Safety and Infection
Control CL: Comprehension (Understanding)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 These are cardinal signs of DIC and necessitate emergency interventions.
2 Sickle cell crisis often does not present with nausea or petechiae.
3 Thrombocytopenia, lack of clotting ability, may have petechiae, but does not
often present with nausea or severe back pain.
4 Pancytopenia may have petechiae, but does not often present with nausea or
back pain.
PTS: 1 CON: Perfusion
23. The nursing practitioner is caring for the hospital patient who recently underwent a
colectomy due to a bowel perforation and peritonitis. The nursing practitioner is preparing to
administer the anticoagulant heparin to prevent which of the following blood disorders?
1. PV
2. DIC
3. Pancytopenia
4. Thrombocytopenia
RIGHT ANSWER> 2
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 9. Describe precautions you should institute to prevent bleeding in hospital patients
with clotting disorders.
Source: pp. 516
Heading: Disseminated Intravascular Coagulation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Reduction of Risk
Potential CL: Application (Applying)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 PV is described as overproduction of the RBC count, which can be either a
genetic mutation or a result of hypoxia.
2 DIC could result from tissue necrosis secondary to extensive abdominal
surgery with leakage of intestinal contents.
3 Pancytopenia may be a result of aplastic anemia, which has varied causes that
do not include peritonitis.
4 Thrombocytopenia would not be treated with the anticoagulant heparin, as it
would exacerbate the issue of lack of clotting factors.
PTS: 1 CON: Perfusion
24. The nursing practitioner is caring for the hospital patient who underwent emergency
treatment for DIC. The hospital patient voices concern over how to explain the tubes and
extensive bruising to his family members. Which of the following would be an appropriate
nursing intervention for disturbed body image related to physical evidence of aggressive
treatment procedures?
1. Cover the ecchymotic areas with bandages and disconnect the IV tubes
temporarily.
2. Limit the number of visitors to two at a time for short intervals.
3. Enlist the aid of other members of the health care team to support the family.
4. Place educational materials in the waiting area prior to visitor’s arrival.
RIGHT ANSWER> 3
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 9. Describe precautions you should institute to prevent bleeding in hospital patients
with clotting disorders.
Source: pp. 508
Heading: Disseminated Intravascular Coagulation
Integrated Process: Caring
Hospital patient Need: Physiological Integrity: Reduction of Risk
Potential CL: Application (Applying)
Concept: Collaboration
Difficulty: Difficult
CLARIFICATION
1 This could exacerbate the hospital patient’s perception of disturbed body image
by
covering the areas. Disconnecting the IV tubing could cause a disruption of
treatment for the disorder.
2 This may be a policy of the intensive care unit, but this would not be an
intervention for the body image disturbance.
3 Enlisting the aid form other health care team members, such as social workers
and chaplains, may facilitate acceptance of the signs of DIC treatment and
support the family members.
4 Educational materials placed in the visiting area may be missed as the visitors
may not recognize that the material is placed for them to review prior to seeing
the hospital patient.
PTS: 1 CON: Collaboration
25. The nursing practitioner is caring for a hospital patient who must undergo a
splenectomy for treatment for idiopathic thrombocytopenic purpura (ITP).Which of the
following statements best describes the rationale for the splenectomy?
1. The spleen becomes engorged and ischemic during an ITP crisis.
2. The spleen causes an overabundance of immature platelets.
3. The spleen is at risk for infection due to the critical loss of WBCs.
4. The spleen is the primary site for platelet destruction.
RIGHT ANSWER> 4
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 1. Explain the pathophysiology of each of the hematological and lymphatic
disorders discussed in this chapter.
Source: pp. 516
Heading: Idiopathic Thrombocytopenic Purpura
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Perfusion
Difficulty: Difficult
CLARIFICATION
1 ITP is a bleeding disorder due to antibodies destroying platelets.
2 The spleen would not cause an overabundance of immature platelets, rather the
spleen would destroy viable platelets.
3 If the spleen would be infected, the treatment typically does not include
removal of the spleen.
4 The spleen would destroy platelets, leaving immature platelets that would have
a considerably short life span of a few hours.
PTS: 1 CON: Perfusion
26. The nursing practitioner is providing education to a hospital patient with mild hemophilia on
how to avoid bleeding episodes. Which one of the following would be most appropriate to
include in the teaching plan?
1. Administer desmopressin intranasally prior to any dental procedure or sports.
2. Carry an epinephrine pen (EpiPen) that is readily available for emergencies.
3. Maintain compression to injection sites for at least 4 hours with a sterile pads.
4. Prepare for blood transfusions after any invasive procedure such as dental
extractions.
RIGHT ANSWER> 1
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 6. Plan nursing care for hospital patients with hematological
disorders. Source: pp. 510
Heading: Hemophilia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Reduction of Risk
Potential CL: Application (Applying)
Concept: Safety
Difficulty: Easy
CLARIFICATION
1 Desmopressin stimulates the body to release more clotting factors, which
would be administered prior to any dental procedures or sports.
2 An epinephrine pen is not used for clotting disorders or bleeding emergencies,
rather it is used for allergic reactions.
3 Maintaining compression would not increase the clotting factors that are
diminished with hemophilia.
4 Blood transfusions may be a component of severe trauma or surgery, which is
not often the case for dental procedures.
PTS: 1 CON: Safety
27. The nursing practitioner is assisting in developing a plan of care for the hospital patient
with hemophilia who is experiencing severe acute pain. Which of the following would
be the most appropriate intervention based on the nursing diagnosis acute pain related to
bleeding into tissues?
1. Administer desmopressin injections as prescribed prior to any invasive procedure.
2. Administer opioids as prescribed, avoiding IM injections.
3. Instruct the hospital patient on bleeding precautions and signs and symptoms of bleeding.
4. Instruct the hospital patient on community services and hemophilia treatment centers.
RIGHT ANSWER> 2
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 9. Describe precautions you should institute to prevent bleeding in hospital patients
with clotting disorders.
Source: pp. 510
Heading: Hemophilia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Health Promotion and Maintenance
CL: Application (Applying) Concept:
Comfort
Difficulty: Easy
CLARIFICATION
1 Desmopressin would be effective for mild hemophilia prior to invasive
procedures, not for pain control.
2 Opioid administered via IV, possibly a hospital patient-controlled analgesia
(PCA),
would be an effective pain control option. IM injections could exacerbate the
bleeding and pain.
3 Instructing the hospital patient on bleeding precautions would be a teaching to
prevent a
bleeding issue after the hospital patient is stabilized.
4 Community services and hemophilia treatment centers may be used after the
crisis of severe pain were resolved. This may be a component of discharge
teaching.
PTS: 1 CON: Comfort
28. The nursing practitioner is assessing the hospital patient recently diagnosed with chronic
myelogenous leukemia (CML). What of the following indicates a positive diagnosis for CML?
1. CBC reveals decrease of platelets and RBCs.
2. Lumbar puncture shows presence of Reed-Sternberg cells.
3. Genetic analysis of bone marrow reveals Philadelphia chromosome.
4. Laboratory results reveal a prolonged PTT and low factor IX.
RIGHT ANSWER> 3
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 3. Identify tests used to diagnose each of the disorders.
Source: pp. 511
Heading: Chronic Leukemias
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Cellular Regulation
Difficulty: Difficult
CLARIFICATION
1 This could be a screening laboratory result for any number of disorders.
2 Reed-Stenberg cells are indicative of Hodgkin lymphoma.
3 This would be definitive result, especially from the bone marrow.
4 This would be indicative of hemophilia.
PTS: 1 CON: Cellular Regulation
29. The nursing practitioner is providing education to the hospital patient with the nursing
diagnosis of impaired oral membrane integrity related to chemotherapy and pancytopenia. The
nursing practitioner is aware that the hospital patient understands the teaching by which of the
following actions?
1. The hospital patient keeps her dentures in at all times except for cleaning.
2. The hospital patient chooses orange juice and hot coffee for breakfast.
3. The hospital patient avoids smoking and commercial mouthwash.
4. The hospital patient chooses ice cream and popsicles for between-meal snacks.
RIGHT ANSWER> 1
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 6. Plan nursing care for hospital patients with hematological disorders.
Source: pp. 518
Heading: Nursing Care Plan for the Hospital patient With
Leukemia Integrated Process: Teaching/Learning Hospital
patient Need: Health Promotion and Maintenance CL:
Analysis (Analyzing)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1 The dentures should be removed for cleaning and at bedtime to improve
circulation and decrease risk for lesions.
2 Acidic and hot foods can be irritating to the mucosa.
3 Smoking and commercial mouthwashes can irritate the mucosa.
4 Extremely hot or cold foods can irritate the mucosa lining.
PTS: 1 CON: Health Promotion
30. The nursing practitioner is caring for the hospital patient who is 1 day status
postsplenectomy. The hospital patient complains of pain with breathing especially with
inspiration. What would be the most appropriate nursing intervention for this hospital
patient?
1. Medicate with opioids for pain and assist the hospital patient to deep breathe,
cough, and ambulate.
2. Contact the surgeon to obtain orders for a nebulizer treatment from respiratory
therapy.
3. Provide the hospital patient with a heating pad alternated with a cold pack for
incisional pain.
4. Contact the surgeon to request a chest x-ray and a laboratory draw for CBC with
differential.
RIGHT ANSWER> 1
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 10. Identify nursing care and teaching you will provide for hospital patients
undergoing a splenectomy.
Source: pp. 516
Heading: Splenectomy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Physiological
Adaptation CL: Application (Applying)
Concept: Comfort
Difficulty: Difficult
CLARIFICATION
1 Respiratory problems may occur due to the incision’s location near the
diaphragm. If these problems are not addressed early on, the hospital patient is
at risk for pneumonia and respiratory problems.
2 The nebulizer treatment may be appropriate if the hospital patient is not able
clear the
lungs, but at this time, there is no indication of this problem.
3 Although alternating heat and cold for pain control may help other medical
issues, it may not work as well as medicating.
4 The chest x-ray and laboratory draw may not be necessary on day 1 after
surgery.
PTS: 1 CON: Comfort
MULTIPLE RESPONSE
1. The nursing practitioner is caring for a hospital patient with a folic acid deficiency. What
foods should the nursing practitioner encourage the hospital patient to improve this
deficiency? (Select all that apply.)
1. Almond milk and toasted white bread
2. Split pea soup with whole grain crackers
3. Garden salad with green leafy vegetables
4. Cereals made with fortified grain and wheat germ
5. Yogurt and aged cheeses with crackers
RIGHT ANSWER> 2, 3, 4
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 4. Describe current therapeutic measures for each disorder.
Source: pp. 502
Heading: Anemias
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Health Promotion and Maintenance
CL: Application (Applying) Concept:
Health Promotion
Difficulty: Moderate
CLARIFICATION
1. Almonds and white bread that is not made from fortified flour are not good
sources of folic acid.
2. Good sources of folic acid include dried peas and wheat germ.
3. Good sources of folic acid include green leafy vegetables.
4. Cereals made with fortified grains and wheat germ are good sources of folic
acid.
5. Dairy products, such as yogurt and aged cheeses, are rich in calcium not,
folic acid.
PTS: 1 CON: Health Promotion
2. The nursing practitioner is assessing a hospital patient in a family practice clinic. The
hospital patient had extensive testing to rule out Hodgkin disease. Which of the following
characteristics would indicate Hodgkin disease? (Select all that apply.)
1. The hospital patient complained of blurred vision and excessive thirst.
2. The hospital patient complained of skeletal and generalized pain.
3. The laboratory results show presence of Reed-Sternberg cells.
4. The hospital patient has painless swelling of the cervical and axillary nodes.
5. The hospital patient’s laboratory results indicate presence of Philadelphia chromosomes.
RIGHT ANSWER> 3, 4
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 2. Describe the etiologies, signs, and symptoms of each disorder.
Source: pp. 515
Heading: Hodgkin Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1. Blurred vision and excessive thirst may indicate another disease process
other than Hodgkin.
2. Skeletal pain can indicate leukemia or multiple myeloma, not Hodgkin.
3. Reed-Sternberg cells indicate Hodgkin disease.
4. Hodgkin disease is a lymphoma, and painless swelling in one or more
common lymph chains is a usual presentation.
5. Philadelphia chromosomes can indicate CML.
PTS: 1 CON: Hospital patient-Centered Care
3. The nursing practitioner is caring for a hospital patient who has been recently
diagnosed with aplastic anemia. Which of the following are indicators of this disease
process? (Select all that apply.)
1. Bone marrow that is pale, fatty, and fibrous
2. A CBC with all low values
3. Presence of Reed-Sternberg cells
4. Decreased serum iron levels
5. Increased total iron-binding capacity (TIBC)
RIGHT ANSWER> 1, 2, 5
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 3. Identify tests used to diagnose each of the disorders.
Source: pp. 502
Heading: Aplastic Anemia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Physiological
Adaptation CL: Comprehension (Understanding)
Concept: Cellular Regulation
Difficulty: Moderate
CLARIFICATION
1. Bone marrow that is pale, fatty, yellow, and fibrous denotes dead bone
marrow, which is an indicator of aplastic anemia.
2. Often a low CBC can be an indicator for anemia.
3. Reed-Sternberg cells are indicative of Hodgkin lymphoma, not aplastic
anemia.
4. Typically, the iron levels will increase as the RBCs are not being produced
and not using the stores of iron in the production of hemoglobin.
5. Increased TIBC can be an indicator of aplastic anemia due to the
overabundance of unused iron stores.
PTS: 1 CON: Cellular Regulation
4. The nursing practitioner is caring for a hospital patient with a platelet count of
<20,000/mm3. Which of the following precautions should the nursing practitioner take in
providing care for this hospital patient? (Select all that apply.)
1. Immediately report any fever to the HCP.
2. Administer NSAIDs for pain control.
3. Monitor for black tarry stools.
4. Avoid blood draws when possible.
5. Use soft toothbrush to clean the teeth.
RIGHT ANSWER> 3, 4, 5
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 5. List data you should collect when caring for hospital patients with disorders of the
hematological or lymphatic systems.
Source: pp. 502
Heading: Idiopathic Thrombocytopenic Purpura
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Safe and Effective Care Environment: Safety and Infection
Control CL: Analysis (Analyzing)
Concept: Cellular Regulation
Difficulty: Easy
CLARIFICATION
1. This hospital patient is at risk for bleeding, not infection due to the low
platelet count.
2. The hospital patient should avoid any drugs that interfere with platelet
functions, such
as NSAIDs or aspirin.
3. Black tarry stools can be indicative of a gastrointestinal bleed.
4. Avoid blood draws whenever possible; use established access sites or group
specimen collections into once-daily draws.
5. Avoid trauma to the oral mucosa; use a soft toothbrush or gauze to clean the
teeth.
PTS: 1 CON: Cellular Regulation
5. The nursing practitioner is providing care to the hospital patient who has arrived at the
clinic to discuss his diagnostic results. The HCP suspects multiple myeloma. Which of the
following results may confirm the HCP’s suspicions? (Select all that apply.)
1. Reed-Stenberg cells are present in the bone marrow.
2. Magnetic resonance imaging (MRI) shows diffuse osteoporosis in the bones.
3. Blood chemistries reveal an increase in serum calcium.
4. Lymph node biopsies reveal Philadelphia chromosome.
5. Blood and urine studies are positive for M-type globulins.
RIGHT ANSWER> 2, 3, 5
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 2. Describe the etiologies, signs, and symptoms of each disorder.
Source: pp. 514
Heading: Multiple Myeloma
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Cellular Regulation
Difficulty: Difficult
CLARIFICATION
1. Reed-Stenberg cells are not indicative of multiple myeloma.
2. X-rays and MRIs may show changes in the lungs and diffuse osteoporosis.
3. Blood chemistries will reveal increases in serum calcium due to the
breakdown of the bones.
4. Philadelphia chromosomes can indicate CML, which is a blood test, not
lymph node.
5. Blood and urine studies are positive for M-type globulins in 40 percent of
hospital patients.
PTS: 1 CON: Cellular Regulation
COMPLETION
1. The nursing practitioner is providing a blood transfusion and sets the infusion pump to
run at 300 mL/hr for 15 minutes. What is the amount of blood that will be transfused at that
time (in mL)?
RIGHT ANSWER>
75
Chapter: Chapter 28. Nursing Care of Hospital patients With Hematological and
Lymphatic Disorders
Objective: 6. Plan nursing care for hospital patients with hematological
disorders. Source: pp. 498
Heading: Therapeutic Measures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION: =
PTS: 1 CON: Hospital patient-Centered Care
=
Chapter 29. Respiratory System Function, Assessment, and Therapeutic
Measures
MULTIPLE CHOICE
1. The nursing practitioner is reviewing a hospital patient’s pulmonary function tests.
Which of the following best describes functional residual capacity?
1. It is the air inspired and expired in one breath.
2. It is the maximum amount of air beyond tidal volume.
3. It is the air remaining in the lungs after normal expiration.
4. It is the amount of air expired forcefully after maximum inspiration.
RIGHT ANSWER> 3
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 5. Identify common diagnostic tests performed to diagnose disorders of the
respiratory system.
Source: pp. 537
Heading: Normal Values for Pulmonary Function Studies (Table 29.6)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Health Promotion and Maintenance
CL: Knowledge (Remembering) Concept: Health
Promotion
Difficulty: Easy
CLARIFICATION
1 Tidal volume is the air inspired and expired in one breath.
2 Expiratory reserve is the amount of air beyond tidal volume in the most
forceful exhalation.
3 Functional residual capacity is the air remaining in the lungs after normal
expiration.
4 Forced vital capacity is the amount of air expired forcefully after maximum
inspiration.
PTS: 1 CON: Health Promotion
2. The nursing practitioner recognizes that the elderly hospital patient’s poor perfusion of
body tissues is due to the hospital patient’s diagnosis of a blood disorder. Which of the
following would best explain the hospital patient’s issue?
1. The hospital patient’s dehydration prevents circulation of free oxygen in the blood plasma.
2. The hospital patient’s low red blood cell (RBC) count prevents oxygen from
adhering to the membranes.
3. The hospital patient’s low hemoglobin count provides less surface for the
adherence of oxygen.
4. The hospital patient’s high white blood cell (RBC) count signifies an infection and
need for more oxygen.
RIGHT ANSWER> 3
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 2. Identify how aging affects the respiratory system.
Source: pp. 538
Heading: Exhalation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Basic Care and Comfort
CL: Knowledge (Remembering) Concept: Health
Promotion
Difficulty: Easy
CLARIFICATION
1 Dehydration is not considered a blood disorder, rather a symptom.
2 Oxygen is not transported or perfused via the membranes of RBCs.
3 Hemoglobin carries oxygen in the blood, which is in the RBCs, not in the
membranes or plasma.
4 Although an infection may increase the demand for oxygen, it is not the best
answer to this issue, which is the decreased hemoglobin.
PTS: 1 CON: Health Promotion
3. The nursing practitioner is caring for a hospital patient who becomes dyspneic, which the
hospital patient states is a “6 out of 10” on the dyspnea scale. Which action should the nursing
practitioner do first?
1. Contact the health care provider (HCP) for an order for supplemental oxygen.
2. Assist the hospital patient to sit at the edge of the bed to lean over the bedside table.
3. Apply nasopharyngeal suction intermittently until the airway is cleared.
4. Apply supplemental oxygen and notify the HCP of this action.
RIGHT ANSWER> 2
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 7. Discuss therapeutic measures used to help hospital patients with respiratory
disorders. Pages: 539–540
Heading: Nursing Assessment of the Respiratory System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Physiological
Adaptation CL: Application (Applying)
Concept: Oxygenation
Difficulty: Moderate
CLARIFICATION
1 This may be a step after assisting the hospital patient to breathe easier, once the
urgency
of the matter is controlled.
2 The tripod position may facilitate easier breathing by displacing the diaphragm.
3 There is no indication for suction at this time.
4 Applying supplemental oxygen without an order is working outside the scope
of the nurse’s practice.
PTS: 1 CON: Oxygenation
4. The nursing practitioner is auscultating a hospital patient’s chest and hears an adventitious
sound in the left lower lobe. What is the first step in determining whether this is an
abnormality?
1. Ask the hospital patient to cough and note the characteristics of secretions.
2. Ask the hospital patient to drink some water and then reassess the breath sounds.
3. Have the HCP listen and verify what the nursing practitioner is hearing.
4. Listen to the corresponding area in the hospital patient’s right lower lobe.
RIGHT ANSWER> 4
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 4. Recognize expected findings when inspecting, palpating, percussing, and
auscultating the chest.
Source: pp. 533
Heading: Abnormal Lung Sounds (Table 29.4)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Basic Care and Comfort
CL: Analysis (Analyzing) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 There is no indication of a cough, secretions, or of the type of adventitious
sounds.
2 This would help thin any secretions, but this does not facilitate auscultation of
the lung fields.
3 This may help once the nursing practitioner is able to locate and identify the
type of sounds to notify the HCP.
4 Comparing sounds on each side can help identify normal versus abnormal
sounds.
PTS: 1 CON: Hospital patient-Centered Care
5. The nursing practitioner is assessing the hospital patient diagnosed with pulmonary edema
and hears lung sounds, and moist bubbling sounds are heard on inspiration and expiration.
What medical term best defines the sound?
1. Coarse crackles
2. Fine crackles
3. Pleural friction rub
4. Wheezing
RIGHT ANSWER> 1
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 4. Recognize expected findings when inspecting, palpating, percussing, and
auscultating the chest.
Source: pp. 534
Heading: Abnormal Lung Sounds (Table 29.4)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Basic Care and Comfort
CL: Knowledge (Remembering) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Moist bubbling sounds heard on inspiration and expiration define coarse
crackles.
2 Fine crackles are finer and less “bubbly,” and occur with heart failure or
atelectasis.
3 Pleural friction rub sounds like leather rubbing together.
4 Wheezing sounds are often described as musical.
PTS: 1 CON: Hospital patient-Centered Care
6. A hospital patient’s arterial blood gas analysis shows a PaCO2 of 68 mm Hg. What action
should the nursing practitioner take first?
1. Notify the HCP.
2. Remove the hospital patient’s oxygen mask.
3. Have the hospital patient breathe into a paper bag.
4. Place the hospital patient in a Fowler’s position.
RIGHT ANSWER> 4
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 5. Identify common diagnostic tests performed to diagnose disorders of the
respiratory system.
Source: pp. 538
Heading: Arterial Blood Gas Analysis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Acid/Base Balance, Collaboration
Difficulty: Moderate
CLARIFICATION
1 The hospital patient’s abnormally high PaCO2 should be reported but the
hospital patient’s
immediate needs must be met first.
2 Removing the oxygen will exacerbate the PaCO2 levels.
3 Breathing into a paper bag will exacerbate the PaCO2 levels via retention.
4 Placing the hospital patient into a Fowler’s position will help with ventilation
while contacting the HCP. The hospital patient’s immediate needs must be met
first.
PTS: 1 CON: Acid/Base Balance | Collaboration
7. The hospital patient returns to the medical unit after a pulmonary angiography. Which
instructions by the nursing practitioner would help prevent complications from the test?
1. “Lie flat for 8 hours so the injection site does not bleed.”
2. “You may sit up for short periods of time, such as mealtime.”
3. “To prevent irritation to your throat, try not to cough for 6 hours.”
4. “Don’t drink anything for 6 hours after the test, as you may choke.”
RIGHT ANSWER> 1
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 5. Identify common diagnostic tests performed to diagnose disorders of the
respiratory system.
Source: pp. 537
Heading: Pulmonary Angiography
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Safe and Effective Care Environment: Safety and Infection
Control CL: Analysis (Analyzing)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 Post angiography, place the hospital patient in the supine position for 3 to 8
hours, as ordered by the HCP.
2 Sitting up for short periods of time may add pressure to the insertion site and
cause bleeding.
3 The throat is not affected by an angiography.
4 Fluids are encouraged to promote excretion of the dye used in the testing.
PTS: 1 CON: Safety
8. The nursing practitioner places a hospital patient who is experiencing dyspnea in the
Fowler’s position. What is the rationale for the nursing practitioner to use this position?
1. Fowler’s position moves the tonsils from the back of the throat.
2. Fowler’s position allows maximum lung expansion.
3. Fowler’s position augments the use of accessory muscles.
4. Fowler’s position relieves stress on the abdominal cavity.
RIGHT ANSWER> 2
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 7. Discuss therapeutic measures used to help hospital patients with respiratory
disorders. Source: pp. 539
Heading: Positioning
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Basic Care and Comfort
CL: Application (Applying) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 There is no indication of the tonsils obstructing the throat.
2 Fowler’s position allows maximum lung expansion by keeping the abdominal
contents from crowding the lungs and thoracic area.
3 Use of accessory muscles is a sign of respiratory distress.
4 Relieving stress on the abdominal cavity does not necessarily improve
breathing.
PTS: 1 CON: Hospital patient-Centered Care
9. The nursing practitioner is caring for a hospital patient with chronic lung disease who is
receiving oxygen via a nonrebreathing mask. Which observation indicates to the nursing
practitioner that the system is functioning as expected?
1. Both side vents open on expiration, reservoir bag inflated
2. Both side vents open on inspiration, reservoir bag deflated
3. Both side vents closed on inspiration, reservoir bag inflated
4. Both side vents closed on expiration, reservoir bag deflated
RIGHT ANSWER> 3
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 3. List data to collect when caring for a hospital patient with a respiratory disorder.
Source: pp. 540
Heading: Masks
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Basic Care and Comfort
CL: Analysis (Analyzing) Concept:
Oxygenation
Difficulty: Moderate
CLARIFICATION
1 A nonrebreather mask has one or both sides closed to limit the mixing of room
air with oxygen. When a hospital patient is using a partial rebreather or
nonrebreather mask, ensure that the reservoir is never allowed to collapse to
less than half full.
2 This would allow outside oxygen to mix with the concentrated oxygen supply.
When a hospital patient is using a partial rebreather or nonrebreather mask,
ensure that the reservoir is never allowed to collapse to less than half full.
3 The nonrebreather mask has one or both side vents closed to limit the mixing
of room air with oxygen. The vents open to expiration but close on inspiration.
It is used to deliver oxygen concentration of 70 to 100 percent.
4 The nonrebreather mask has one or both side vents closed to limit the mixing
of room air with oxygen. The vents open to expiration but close on inspiration
When a hospital patient is using a partial rebreather or nonrebreather mask,
ensure that
the reservoir is never allowed to collapse to less than half full.
PTS: 1 CON: Oxygenation
10. The nursing practitioner is providing discharge instructions for a hospital patient who is
to use an adrenergic bronchodilator. Which of the following responses would best
demonstrate the hospital patient’s understanding?
1. “The metered-dose inhaler (MDI) may keep me up at night, so I will avoid using
the MDI at night.”
2. “If my symptoms are not relieved, I may take one puff every 5 minutes until I feel
better.”
3. “Using the MDI more often than prescribed can result in worsening symptoms.”
4. “Whenever I feel short of breath, I will take 2 puffs, but no more than 12 puffs a
day.”
RIGHT ANSWER> 3
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 7. Discuss therapeutic measures used to help hospital patients with respiratory
disorders. Source: pp. 541
Heading: Inhalers
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Health Promotion and Maintenance
CL: Analysis (Analyzing) Concept:
Health Promotion
Difficulty: Moderate
CLARIFICATION
1 MDIs are used at night to prevent nighttime symptoms.
2 Using as needed may be too frequent, and every 5 minutes is not appropriate.
3 Adrenergic bronchodilators, when used too often, can cause severe rebound
bronchoconstriction and even death.
4 Adrenergic bronchodilators, when used too often, can cause severe rebound
bronchoconstriction and even death.
PTS: 1 CON: Health Promotion
11. The hospital patient arrives to the emergency department with a stab wound to the chest.
The HCP places two chest tubes to drain air and blood from the hospital patient’s thoracic
cavity. The nursing practitioner sets up the chest tube drainage system. Where should the
nursing practitioner place the system?
1. Attached to the foot of the bed
2. Along the side of the hospital patient’s knee
3. Below the level of the hospital patient’s chest
4. At the level of the hospital patient’s clavicle
RIGHT ANSWER> 3
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 7. Discuss therapeutic measures used to help hospital patient with respiratory
disorders. Source: pp. 544
Heading: Chest Drainage
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 If the chest tube system were attached to the foot of the bed, whenever the foot
was raised or lowered, it could cause excessive tension in the tubing.
2 If it were along the knee, it may not be upright while the hospital patient was in
the bed. Although it would be below the chest, it may be pulled by the hospital
patient’s movements while in bed and not stabilized.
3 The drainage system must always be kept upright and below the level of the
chest to prevent drainage from returning to the chest.
4 The clavicle is at chest level and could cause the drainage to return to the chest.
PTS: 1 CON: Safety
12. A hospital patient with a chest drainage system is admitted to the medical-surgical unit. The
nursing practitioner notes vigorous bubbling in the water seal chamber of the system. What should
the nursing practitioner do?
1. Decrease the level of suction until bubbling ceases.
2. Ask the hospital patient to splint the site and cough forcefully.
3. No action is necessary; this is an expected finding.
4. Examine the entire system and tubing for air leaks.
RIGHT ANSWER> 4
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 3. List data to collect when caring for a hospital patient with a respiratory disorder.
Source: pp. 544
Heading: Chest Drainage
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Safe and Effective Care Environment: Safety and Infection
Control CL: Analysis (Analyzing)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 Lowering the suction level will help if vigorous bubbling is seen in the suction
control chamber.
2 Coughing forcefully can help mobilize clots.
3 Doing nothing is inappropriate and could cause harm to the hospital patient.
4 Vigorous bubbling in the water seal chamber indicates an air leak.
PTS: 1 CON: Safety
13. The nursing practitioner is preparing to suction a hospital patient’s tracheostomy. What is
the maximum of time that the nursing practitioner can suction safely with each pass of the
catheter?
1. 3 to 5 seconds
2. 10 to 15 seconds
3. 15 to 25 seconds
4. 25 to 45 seconds
RIGHT ANSWER> 2
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 7. Discuss therapeutic measures used to help hospital patients with respiratory
disorders. Source: pp. 543
Heading: Tracheostomy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Reduction of Risk
Potential CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Easy
CLARIFICATION
1 Less than 15 seconds may not clear the secretions.
2 The nursing practitioner can safely suction the hospital patient for 15 seconds.
3 More than 15 seconds can irritate mucosa and suction out too much oxygen.
4 More than 15 seconds can irritate mucosa and suction out too much oxygen.
PTS: 1 CON: Hospital patient-Centered Care
14. The nursing practitioner is caring for a hospital patient who is on a ventilator and the high-
pressure alarm sounds. What should the nursing practitioner consider as the cause for this alarm?
1. The hospital patient is being weaned.
2. The tubing is disconnected.
3. The electricity is interrupted.
4. The tubing is obstructed.
RIGHT ANSWER> 4
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 7. Discuss therapeutic measures used to help hospital patients with respiratory
disorders. Source: pp. 550
Heading: Ventilator Alarms
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 There would not be an alarm for the weaning process.
2 Disconnected tubing causes a low-pressure alarm.
3 Loss of power causes its own alarm.
4 High-pressure alarms sound for higher-than-normal resistance to air flow. This
might occur if the hospital patient needs to be suctioned; if the hospital patient is
biting on the tube, coughing, or trying to talk; if tubing is kinked or otherwise
obstructed; or
if worsening respiratory disease causes decreased lung compliance.
PTS: 1 CON: Hospital patient-Centered Care
15. The nursing practitioner is caring for hospital patients in a respiratory unit and hears a
ventilator alarm from the hallway. Which action should the nursing practitioner take first?
1. Assess the hospital patient.
2. Call a code blue.
3. Check the machine.
4. Suction the hospital patient.
RIGHT ANSWER> 1
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 7. Discuss therapeutic measures used to help hospital patients with respiratory
disorders. Source: pp. 550
Heading: Ventilator Alarms
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Safe and Effective Care Environment: Safety and Infection
Control CL: Comprehension (Understanding)
Concept: Hospital patient-Centered Care
Difficulty: Easy
CLARIFICATION
1 Always check the hospital patient first, in case the hospital patient needs support
while the ventilator is being checked.
2 The nursing practitioner would need to check the hospital patient and ventilator
before calling for help
or a code blue.
3 Once it is assured that the hospital patient is safe, the machine can be checked.
4 Always check the hospital patient first and then determine the next action, whether it
is checking the machine, providing suction, or calling a code.
PTS: 1 CON: Hospital patient-Centered Care
16. The nursing practitioner is reviewing the results of a hospital patient’s pulmonary
function studies. Which result indicates the hospital patient’s resting tidal volume is within
normal limits?
1. 200 to 400 mL
2. 400 to 600 mL
3. 600 to 800 mL
4. 800 to 1,000 mL
RIGHT ANSWER> 2
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 5. Identify common diagnostic tests performed to diagnose disorders of the
respiratory system.
Source: pp. 538
Heading: Pulmonary Function Studies
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Health Promotion and Maintenance
CL: Analysis (Analyzing) Concept:
Health Promotion
Difficulty: Moderate
CLARIFICATION
1 This is too low tidal volume, which may not be compatible with life.
2 The normal values for tidal volume at rest are 400 to 600 mL.
3 These are too high and should be questioned for potential reading errors.
4 These are too high and should be questioned for potential reading errors.
PTS: 1 CON: Health Promotion
17. The nursing practitioner instructs the hospital patient with chronic obstructive
pulmonary disease (COPD) on methods to lower the risk of lung complications. One
technique is the “long huff” cough. What is the rationale for this type of coughing exercise?
1. Increases oxygenation
2. Removes excess carbon dioxide
3. Ensures thorough lung expansion
4. Helps to open and clear smaller airways
RIGHT ANSWER> 4
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 7. Discuss therapeutic measures used to help hospital patients with respiratory
disorders. Source: pp. 538
Heading: Huff Coughing
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Physiological Adaptation
CL: Evaluation (Evaluating)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1 The shorter “huff” is used to clear larger airways, such as the bronchus and
throat.
2 The shorter “huff” is used to clear larger airways, such as the bronchus and
throat, not the longer huff.
3 The shorter “huff” is used to clear larger airways, such as the bronchus and
throat, not the smaller airways.
4 The longer “huff” held out for several seconds helps open and clear smaller
airways, such as the bronchioles, which connect the alveoli to the bronchus.
PTS: 1 CON: Health Promotion
18. The nursing practitioner recognizes that the hospital patient is experiencing a
respiratory emergency when the hospital patient has wheezes and stridor. What do these
sounds indicate?
1. This is an indication of bronchospasm.
2. This is an indication of a foreign body in the alveoli.
3. This is an indication of fluid in the bases of the lungs.
4. This is an indication of a crepitus in the thoracic area.
RIGHT ANSWER> 1
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 4. Recognize expected findings when inspecting, palpating, percussing, and
auscultating the chest.
Source: pp. 534
Heading: Trachea and Bronchial Tree
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Reduction of Risk
Potential CL: Comprehension (Understanding)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 Bronchioles have no cartilage in the wall to maintain patency and can close
completely by bronchoconstriction.
2 A foreign body in the alveoli would not induce stridor or wheezes, as that is in
the lower airway.
3 This would be rales or crackles in the bases of the lung fields.
4 Crepitus in the thoracic area is an indication of an air leak, typically from a
leaky chest tube.
PTS: 1 CON: Safety
19. The nursing practitioner is caring for a hospital patient who has been diagnosed with
respiratory acidosis. Which of the following medical condition would be the contributing
factor?
1. Acetaminophen overdose
2. Chronic obstructive pulmonary disease
3. End-stage renal disease
4. Acute hypoxemia due to high altitudes
RIGHT ANSWER> 2
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 5. Identify common diagnostic tests performed to diagnose disorders of the
respiratory system.
Source: pp. 528
Heading: Respiration and Acid–Base Balance
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Acid/Base Balance
Difficulty: Difficult
CLARIFICATION
1 Acetaminophen overdose would cause metabolic acidosis.
2 This could cause an accumulation of excess hydrogen and CO2, thus increase
the acidity via the respiratory system.
3 Chronic kidney disease would cause metabolic acidosis, not respiratory
acidosis.
4 Acute hypoxemia, caused by “altitude sickness,” would cause a temporary
respiratory alkalosis, due to the hyperventilation needed to acclimate to the
higher altitude.
PTS: 1 CON: Acid/Base Balance
20. The nursing practitioner is caring for the hospital patient who is experiencing uncontrolled
diabetes mellitus. The hospital patient is exhibiting Kussmaul’s respirations. What best describes
the compensatory action for the respirations?
1. The body is compensating for the metabolic acidosis by releasing CO2 via the
lungs.
2. The body is compensating for the metabolic alkalosis by retaining CO2 via the
lungs.
3. The body is compensating for the respiratory acidosis by retaining the CO2 in the
lungs.
4. The body is compensating for the respiratory alkalosis by releasing the CO2 in the
lungs.
RIGHT ANSWER> 1
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 5. Identify common diagnostic tests performed to diagnose disorders of the
respiratory system.
Source: pp. 550
Heading: Respiration and Acid–Base Balance
Integrated Process: Clinical Problem-Solving Process
(Nursing Process) Hospital patient Need: Physiological
Integrity: Physiological Adaptation CL: Analysis (Analyzing)
Concept: Acid/Base Balance
Difficulty: Moderate
CLARIFICATION
1 Kussmaul’s respirations are a sign of diabetic ketoacidosis (DKA), a form of
metabolic acidosis. The lungs compensate by releasing the acidic CO2 with
deep frequent respirations.
2 Kussmaul’s respirations releases the CO2 to compensate for metabolic acidosis,
not alkalosis.
3 Kussmaul’s respirations are a sign of metabolic acidosis, not respiratory
acidosis. The respiratory system is compensating for the metabolic state.
4 Kussmaul’s respirations releases the CO2 to compensate for metabolic acidosis,
not alkalosis.
PTS: 1 CON: Acid/Base Balance
21. The nursing practitioner is caring for the hospital patient who has recently
recovered from a spontaneous pneumothorax. The nursing practitioner palpates the
hospital patient’s left shoulder area and feels a “Rice Krispies” presence under the skin.
What best describes this symptom?
1. It is a sign of recovery from a pneumothorax.
2. It occurs when air leaks into the subcutaneous tissues.
3. It is a symptom of a pending recurrence of a pneumothorax.
4. It is a sign that the chest tube was removed too soon.
RIGHT ANSWER> 2
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 4. Recognize expected findings when inspecting, palpating, percussing, and
auscultating the chest.
Source: pp. 560
Heading: Palpation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 This is not a sign of recovery from a pneumothorax.
2 It is crepitus, which is air trapped into the subcutaneous tissues, from either a
pneumothorax or leaking chest tube.
3 This is not a sign of a recurrence of a pneumothorax.
4 It is crepitus, which is air trapped into the subcutaneous tissues.
PTS: 1 CON: Safety
22. The nursing practitioner has obtained a noninvasive measurement of the hospital patient’s
oxygen saturation. What is this test called?
1. Arterial blood gas (ABG)
2. Incentive spirometer
3. Peak flow meter
4. Pulse oximetry
RIGHT ANSWER> 4
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 5. Identify common diagnostic tests performed to diagnose disorders of the
respiratory system.
Source: pp. 550
Heading: Oxygen Saturation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Reduction of Risk
Potential CL: Knowledge (Remembering)
Concept: Hospital patient-Centered Care
Difficulty: Easy
CLARIFICATION
1 ABG is an invasive method of measuring the hospital patient’s gases, to
diagnose an abnormality in the body regarding homeostasis of the blood
chemistry.
2 Incentive spirometer is a device used to facilitate expansion of the lungs, not
diagnosis an issue.
3 Peak flow meter measures lung capacity to monitor breathing disorders.
4 Pulse oximetry measure the oxygen saturation by placing a probe on the
hospital patient’s finger or ear.
PTS: 1 CON: Hospital patient-Centered Care
23. The LPN/LVN is caring for a hospital patient with COPD who is using oxygen therapy at 2
L/min. The hospital patient becomes short of breath and requests that the oxygen flow rate to be
increased. What is the LPN/LVN’s next step?
1. Increase the flow rate by 2 L.
2. Increase the flow rate by 1 L.
3. Contact the respiratory therapist (RT) for guidance.
4. Instruct the hospital patient on huff coughing.
RIGHT ANSWER> 3
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 7. Discuss therapeutic measures used to help hospital patients with respiratory
disorders. Source: pp. 541
Heading: Risks of Oxygen Therapy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Pharmacological
Therapies CL: Application (Applying)
Concept: Oxygenation
Difficulty: Moderate
CLARIFICATION
1 It is outside the scope of practice for the LPN/LVN to increase the oxygen rate
without an order.
2 It is outside the scope of practice for the LPN/LVN to increase the oxygen rate
without an order.
3 The RT would be a valuable resource when questions arise.
4 Instructing the hospital patient during an episode of huff coughing will not help
the
hospital patient at that time.
PTS: 1 CON: Oxygenation
24. The nursing practitioner is caring for the hospital patient receiving oxygen therapy.
Which of the following is correct regarding a simple face mask?
1. Is can deliver a precise percentage of oxygen therapy.
2. It can be worn while the hospital patient is eating or drinking.
3. It is less claustrophobic for the hospital patient than the other masks.
4. It can deliver oxygen at a concentration from 40 to 60 percent.
RIGHT ANSWER> 4
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 7. Discuss therapeutic measures used to help hospital patients with respiratory
disorders. Source: pp. 540
Heading: Oxygen Therapy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Basic Care and Comfort
CL: Comprehension (Understanding) Concept:
Oxygenation
Difficulty: Moderate
CLARIFICATION
1 Precise percentages of oxygen therapy are delivered via a venture mask.
2 Oxygen masks prevent hospital patients from eating or drinking, so a nasal
cannula may be used temporarily while the hospital patient eats or drinks.
3 It appears that all oxygen masks may give the hospital patient a feeling of
claustrophobia.
4 When delivered at rate between 5 to 10 L/min, it can deliver a concentration
from 40 to 60 percent.
PTS: 1 CON: Oxygenation
25. The nursing practitioner is coaching a hospital patient who is using a transtracheal catheter.
The nursing practitioner recognizes that the hospital patient understands the care for the catheter
by which of the following statements?
1. “I will clean the catheter once a day to prevent mucous obstructions.”
2. “I will be able cover the site with a loose scarf or collar.”
3. “I will use a nasal cannula when I want to eat or drink.”
4. “I will not remove the catheter until the site is healed.”
RIGHT ANSWER> 2
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 7. Discuss therapeutic measures used to help hospital patients with respiratory
disorders. Source: pp. 555
Heading: Transtracheal Catheter
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Analysis (Analyzing)
Concept: Health Promotion
Difficulty: Difficult
CLARIFICATION
1 The catheter should be removed and cleaned two to three times a day to
remove mucous obstructions.
2 This is an alternative to a face mask as the hospital patient may cover the site
with a
loose scarf or collar.
3 The nasal cannula will not deliver a high flow rate and the transtracheal
catheter does not obstruct the nose or mouth.
4 The catheter should be removed and cleaned two to three times a day to
remove mucous obstructions.
PTS: 1 CON: Health Promotion
26. The LPN/LVN is caring for a hospital patient with a chest tube. The nursing practitioner
notes that the dressing over the insertion site is soiled. What is the most appropriate step for the
nursing practitioner to take?
1. Change the dressing with sterile petroleum gauze and label the dressing with date
and initials.
2. Cleanse the area after removing the old dressing and apply a sterile petroleum
gauze over the site.
3. Reinforce the dressing and contact the HCP and assist with the changing of the
dressing.
4. Apply the two padded clamps at the bedside and change the dressing using sterile
technique.
RIGHT ANSWER> 3
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 7. Discuss therapeutic measures used to help hospital patients with respiratory
disorders. Source: pp. 545
Heading: Chest Tube Insertion
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Safe and Effective Care Environment: Safety and Infection
Control CL: Application (Applying)
Concept: Professionalism
Difficulty: Moderate
CLARIFICATION
1 The LPN/LVN scope of practice does not include changing the dressing.
2 The LPN/LVN scope of practice does not include changing the dressing.
3 The LPN/LVN scope of practice does not include changing the dressing, so the
LPN/LVN will contact the HCP and assist with the care.
4 The LPN/LVN scope of practice does not include changing the dressing; the
clamps are to be used if the chest tube becomes accidentally disconnected from
the tubing.
PTS: 1 CON: Professionalism
27. The LPN/LVN is caring for a hospital patient with a chest tube and notices that the tubing
appears to be occluded with clots. What is the LPN/LVN’s next step with this issue?
1. Gently squeeze portions of the tubing form the hospital patient to the system until
the clots are moved to the system.
2. Hold the proximal end of the tubing between two fingers while sliding the fingers
toward the system.
3. Document the findings and prepare to assist the HCP for removal of the chest
tube.
4. If tubing appears to be occluded, consult with the HCP for specific orders.
RIGHT ANSWER> 4
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 7. Discuss therapeutic measures used to help hospital patients with respiratory
disorders. Source: pp. 545
Heading: Stripping and Milking
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Safe and Effective Care Environment: Safety and Infection
Control CL: Application (Applying)
Concept: Professionalism
Difficulty: Moderate
CLARIFICATION
1 This is milking, which is somewhat safer than stripping, but not done routinely.
2 This is stripping and can cause harm to the hospital patient by causing negative
pressure at the openings in the tubing and can suck lung tissue into the system
and cause damage.
3 Documenting and preparing for removal is not the appropriate nursing action,
as there is no indication that this is necessary.
4 The HCP should be notified and the orders carried out per the scope of practice
of the LPN/LVN.
PTS: 1 CON: Professionalism
28. The nursing practitioner is assessing a hospital patient’s respiratory system and notices
upon auscultation bibasilar crackles. How would the nursing practitioner explain these
findings to the hospital patient?
1. “When you said ‘99’ during my assessment, I heard some unusual vibrations.”
2. “When you said ‘ee’ during my assessment, it sounded like ‘ay.’”
3. “When you took a deep breath, I heard sounds like cellophane being crumpled.”
4. “When I placed my hands on your back during a deep breath, I felt unusual
movement.”
RIGHT ANSWER> 3
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 4. Recognize expected findings when inspecting, palpating, percussing, and
auscultating the chest.
Source: pp. 540
Heading: Auscultation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Basic Care and Comfort
CL: Application (Applying) Concept:
Hospital patient-Centered Care
Difficulty: Easy
CLARIFICATION
1 This would define bronchophony. Usually the sounds are muffled.
2 This is indicative of egophony. The “ee’ would be understandable when
auscultated.
3 This is indicative of fluid buildup in the lungs and can sound like cellophane
being crumpled or bubbling.
4 This would not indicate crackles, which are auscultated, not palpated.
PTS: 1 CON: Hospital patient-Centered Care
29. The nursing practitioner is preparing to perform a routine cleaning of the hospital patient’s
cuffed tracheostomy. The nursing practitioner notes that the cuff has been deflated since the
hospital patient’s weaning off of the mechanical ventilator. What is the nursing intervention at
this time?
1. Contact the HCP for further orders.
2. Do not start the cleaning until the cuff is properly inflated.
3. Continue with the cleaning of the tracheostomy.
4. Contact the RT to have the cuff inflated.
RIGHT ANSWER> 3
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 7. Discuss therapeutic measures used to help hospital patients with respiratory
disorders. Source: pp. 560
Heading: Tracheostomy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Safe and Effective Care Environment: Safety and Infection
Control CL: Application (Applying)
Concept: Oxygenation, Safety
Difficulty: Moderate
CLARIFICATION
1 The cuff is to be deflated routinely to prevent tissue damage. No need to
contact the HCP.
2 The cuff is to be deflated routinely to prevent tissue damage.
3 Continue with the cleaning, as the cuff is deflated routinely after mechanical
ventilation is discontinued. The cuff is used to prevent air leakage during
mechanical ventilation.
4 The cuff is to be deflated routinely to prevent tissue damage. No need to
contact the RT.
PTS: 1 CON: Oxygenation | Safety
30. The nursing practitioner is using the nursing diagnosis of ineffective airway clearance.
The nursing practitioner is implementing the intervention of ambulating or turning the
hospital patient every 2 hours. What is the rationale for this intervention?
1. Movement helps mobilize secretions.
2. Movement facilitates intestinal motility.
3. Movement facilitates circulation of the extremities.
4. Movement protects the hospital patient from pressure ulcers.
RIGHT ANSWER> 1
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 7. Discuss therapeutic measures used to help the hospital patient with respiratory
disorders.
Source: pp. 562
Heading: Nursing Care Plan for the Hospital patient With a
Tracheostomy Integrated Process: Clinical Problem-Solving Process
(Nursing Process) Hospital patient Need: Physiological Integrity: Basic
Care and Comfort
CL: Application (Applying)
Concept: Hospital patient-Centered Care, Health
Promotion Difficulty: Easy
CLARIFICATION
1 Movement helps to mobilize secretions. Although the other rationales are
appropriate to explain movement, they do not pertain to the airway clearance.
2 Although this rationale is appropriate to explain movement, it does not pertain
to the airway clearance, the focus of the plan of care.
3 Although this rationale is appropriate to explain movement, it does not pertain
to the airway clearance, the focus of the plan of care.
4 Although this rationale is appropriate to explain movement, it does not pertain
to the airway clearance, the focus of the plan of care.
PTS: 1 CON: Hospital patient-Centered Care | Health Promotion
31. The nursing practitioner is administering a pneumococcal vaccine to an older hospital
patient. What is the rationale for this vaccine?
1. There is a decline in effectiveness of lung defense mechanisms.
2. Many older adults are exposed to more pathogens as they age.
3. Many older adults develop immunity to viral pneumonia, not bacterial.
4. Many older adults become residents in extended-care facilities (ECFs).
RIGHT ANSWER> 1
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 2. Identify how aging affects the respiratory system.
Source: pp. 567
Heading: Effects of Aging on the Respiratory System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Health Promotion and Maintenance
CL: Knowledge (Remembering) Concept: Health
Promotion
Difficulty: Easy
CLARIFICATION
1 The aging process decreases lung defense mechanisms, such as effective
coughing, airway clearance, and lung expansion.
2 Exposure to pathogens facilitates immunity if the hospital patient is healthy
overall.
3 There is no differentiation between immunity from viral versus bacterial
pneumonia.
4 There is no correlation between hospital patients in extended care facilities and
pneumonia, other than hospital patients in an ECF are often
immunocompromised due to comorbidity.
PTS: 1 CON: Health Promotion
32. The nursing practitioner is preparing a hospital patient for a spirometer test to diagnose
COPD. The hospital patient asks how to prepare for this test. How should the nursing
practitioner respond?
1. “Refrain from using a short-acting inhaler 6 to 8 hours prior to testing.”
2. “Do not eat or drink anything for 6 to 8 hours prior to the testing.”
3. “Refrain from vigorous exercise 6 to 8 hours prior to the testing.”
4. “Take all medications, including inhalers prior to the testing.”
RIGHT ANSWER> 1
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 6. Plan nursing care for hospital patients undergoing each of the diagnostic tests.
Source: pp. 555
Heading: Incentive Spirometry
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Application (Applying)
Concept: Health Promotion
Difficulty: Easy
CLARIFICATION
1 As the spirometer test is assessing function of inhalation and exhalation, the
short-acting inhaler may skew the results.
2 This is not necessary as this is a lung function test performed without
anesthesia and there typically is no risk for aspiration. Should the hospital
patient need a bronchoscopy, the hospital patient would be NPO.
3 This should not affect the testing.
4 This may skew the results if the hospital patient takes all inhalers; the usual
daily medications should be taken, but if the hospital patient is taking a short-
acting inhaler, it may skew the results.
PTS: 1 CON: Health Promotion
MULTIPLE RESPONSE
1. A hospital patient is diagnosed with respiratory acidosis. Which health problems should
the nursing practitioner consider as causing this hospital patient’s diagnosis? (Select all that
apply.)
1. Acute aspirin overdose
2. Kidney failure
3. Hyperventilation
4. Shallow respirations
5. Chronic lung disease
RIGHT ANSWER> 4, 5
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 4. Recognize expected findings when inspecting, palpating, percussing, and
auscultating the chest.
Source: pp. 528
Heading: Respiration and Acid–Base Balance
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Physiological
Adaptation CL: Comprehension (Understanding)
Concept: Acid/Base Balance
Difficulty: Easy
CLARIFICATION
1. Acute aspirin overdose can cause initial respiratory alkalosis.
2. Kidney or renal failure is associated with metabolic acidosis.
3. Hyperventilation is associated with respiratory alkalosis.
4. Chronic lung disease and shallow respirations both are associated with
hypoventilation, which causes respiratory acidosis.
5. Chronic lung disease and shallow respirations both are associated with
hypoventilation, which causes respiratory acidosis.
PTS: 1 CON: Acid/Base Balance
2. The nursing practitioner is providing care to a hospital patient who has been receiving
high oxygen concentration therapy for 36 hours. Which of the following symptoms, if
exhibited by the hospital patient, should the nursing practitioner contact the HCP for
suspected lung damage from this therapy? (Select all that apply.)
1. Numbness in the extremities
2. Hypoactive bowel sounds
3. Crepitus in the scapular area
4. Dry cough, and chest pain
5. PaO2 greater than 100 mm Hg
RIGHT ANSWER> 1, 5
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measure
Objective: 4. Recognize expected findings when inspecting, palpating, percussing, and
auscultating the chest.
Source: pp. 530
Heading: Masks
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Safe and Effective Care Environment: Coordinated
Care CL: Analysis (Analyzing)
Concept: Oxygenation
Difficulty: Difficult
CLARIFICATION
1. Numbness in the extremities can be a sign of lung damage from the high
oxygen concentration given over 24 hours.
2. Nausea, not hypoactive bowel sounds, can be a sign of lung damage from the
high oxygen concentration over 24 hours.
3. Crepitus is trapped air in the subcutaneous tissue from either a pneumothorax
or leaky chest tube.
4. Dry cough and chest pain can be signs of lung damage from the high oxygen
concentration given over 24 hours.
5. PaO2 >100 mm Hg can be a sign of lung damage from the high oxygen
concentration given over 24 hours.
PTS: 1 CON: Oxygenation
3. Which of the following are effects of aging on the respiratory system? (Select all that apply.)
1. Decrease in peak airflow and gas exchange
2. Weakening of respiratory muscles
3. Increased lung surfactant levels
4. Decline of effectiveness of lung defense mechanisms
5. Increased tidal lung capacity
RIGHT ANSWER> 1, 2, 4
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 2. Identify how aging affects the respiratory system.
Source: pp. 532
Heading: Effects of Aging on the Respiratory System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Health Promotion and Maintenance
CL: Knowledge (Remembering) Concept:
Hospital patient-Centered Care
Difficulty: Easy
CLARIFICATION
1. The lung capacity decreases with age.
2. All muscles decrease with the effects of aging, including the respiratory
muscles.
3. There is no correlation of the lung surfactant levels.
4. As the body ages, the ability to defend against pathogens decreases, hence
the need for influenza and pneumonia immunizations for the older
population.
5. The tidal volume actually decreases with aging.
PTS: 1 CON: Hospital patient-Centered Care
4. The nursing practitioner is assessing a hospital patient who has a history of COPD. What
are some of the expected findings during the assessment? (Select all that apply.)
1. Barrel chest
2. Bradypnea
3. Chronic cough
4. Nail clubbing
5. Weight loss
RIGHT ANSWER> 1, 4, 5
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 4. Recognize expected findings when inspecting, palpating, percussing, and
auscultating the chest.
Source: pp. 535
Heading: Huff Coughing
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Physiological
Adaptation CL: Knowledge (Remembering)
Concept: Oxygenation
Difficulty: Easy
CLARIFICATION
1. Barrel chest occurs with the chronic retention within the alveolar tissue.
2. This is not a typical finding of COPD. The hospital patient may have a longer
than normal exhalation.
3. A chronic cough may indicate other health issues.
4. This is a sign of chronic tissue hypoxia.
5. Weight loss may occur due to dyspnea, interfering with eating and need for
extra calories for breathing.
PTS: 1 CON: Oxygenation
COMPLETION
1. The HCP ordered azithromycin 500 mg for the first day, then 250 mg a day for 4 days for a
hospital patient with pneumonia. The pharmacy has azithromycin 250-mg tablets in stock. How
many tablets will be sent to the facility for the hospital patient’s medication?
RIGHT ANSWER>
6
Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures
Objective: 7. Discuss therapeutic measures used to help hospital patients with respiratory
disorders. Source: pp. 535
Heading: Respiratory System Function, Assessment, and Therapeutic Measures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity: Pharmacologic
Therapies CL: Application (Applying)
Concept: Collaboration
Difficulty: Easy
CLARIFICATION: The medication order is 500 mg for 1 day, followed by 4 days of 250
mg. The supply is 250-mg tablets. The first day will be two tablets, followed by 4 days of
250-mg = 4 tablets. The total needed to complete this order/prescription is 2 + 4 = 6 tablets.
PTS: 1 CON: Collaboration
Chapter 30. Nursing Care of Hospital patients With Upper Respiratory Tract
Disorders
MULTIPLE CHOICE
1. The nursing practitioner instructs a hospital patient with a nosebleed to sit up and lean
slightly forward. For which reason does the nursing practitioner teach the hospital patient to
maintain this posture?
1. To prevent dizziness or syncope
2. To reduce bleeding from the anterior plexus
3. To help prevent symptoms of shock due to blood loss
4. To avoid unseen blood from being swallowed or aspirated
RIGHT ANSWER> 4
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract Disorders
Objective: 3. Describe current therapeutic measures for disorders of the upper respiratory
tract.
Pages: 556–567
Heading: Disorders of the Nose and Sinuses—Epistaxis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Professionalism
Difficulty: Moderate
CLARIFICATION
1 The suggested position is not used to prevent dizziness or syncope.
2 The question does not provide specific information regarding the bleeding site.
3 The positioning of the hospital patient will not prevent shock due to blood loss.
4 Instructing the hospital patient with a nosebleed to sit in a chair and lean slightly
forward is done to avoid aspirating or swallowing blood.
PTS: 1 CON: Professionalism
2. After positioning a hospital patient with epistaxis, which action will the nursing practitioner take
next?
1. Monitor for the level of pain.
2. Place warm packs on the nose.
3. Apply ice to the nose and eye area.
4. Irrigate the nasal passages with sterile saline.
RIGHT ANSWER> 3
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract
Disorders Objective: 4. Plan nursing care for the hospital patient with an upper
respiratory disorder. Source: pp. 567
Heading: Disorders of the Nose and Sinuses—Epistaxis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Professionalism
Difficulty: Moderate
CLARIFICATION
1 There is no information that indicates the hospital patient is experiencing pain.
2 Warm compresses will cause vasodilation and promote bleeding.
3 Ice packs to the nose and eye area may be used to constrict the bleeding
vessels.
4 Irrigation can dislodge clots, resulting in bleeding.
PTS: 1 CON: Professionalism
3. A hospital patient is discharged from the emergency department after treatment for
epistaxis. The physician orders that all home medications be continued. Which medication will
the nursing practitioner question?
1. Ibuprofen
2. Furosemide
3. Amlodipine
4. Montelukast sodium
RIGHT ANSWER> 1
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract Disorders
Objective: 3. Describe current therapeutic measures for disorders of the upper respiratory
tract.
Source: pp. 567
Heading: Disorders of the Nose and Sinuses—Epistaxis
Integrated Process: Communication and Documentation
Hospital patient Need: Physiological Integrity—Pharmacological and Parenteral
Therapies CL: Analysis (Analyzing)
Concept: Professionalism
Difficulty: Moderate
CLARIFICATION
1 NSAIDs, such as ibuprofen, have antiplatelet action and can increase bleeding
risk.
2 Antihypertensives and diuretics can control high blood pressure, a risk factor
for epistaxis.
3 Antihypertensives and diuretics can control high blood pressure, a risk factor
for epistaxis.
4 Leukotriene inhibitors do not influence bleeding.
PTS: 1 CON: Professionalism
4. A hospital patient returns to the observation area after outhospital patient septoplasty for a
deviated septum. Which observation will most concern the nurse?
1. The hospital patient swallows frequently.
2. The hospital patient’s blood pressure is 136/88 mm Hg.
3. The hospital patient complains of tenderness in the nasal area.
4. The hospital patient’s moustache dressing has a 2-centimeter area of
blood on it. RIGHT ANSWER> 1
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract
Disorders Objective: 4. Plan nursing care for the hospital patient with an upper
respiratory disorder. Source: pp. 558
Heading: Deviated Septum
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Frequent swallowing is an indication of continued bleeding after septoplasty;
the blood runs down the back of the throat.
2 The blood pressure is within normal limits.
3 Some tenderness and bleeding is expected.
4 The area of blood on the dressing is not indicative of abnormal bleeding.
PTS: 1 CON: Hospital patient-Centered Care
5. The nursing practitioner is collecting data from a hospital patient with a sinus infection.
The hospital patient has purulent nasal drainage, fever, and pain over the cheeks and upper
teeth. Which sinuses does the nursing practitioner identify as being involved in the hospital
patient’s condition?
1. Ethmoid
2. Frontal
3. Nasal
4. Maxillary
RIGHT ANSWER> 4
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract
Disorders Objective: 1. Explain the pathophysiology of disorders of the upper
respiratory tract. Source: pp. 560
Heading: Sinusitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 In ethmoid sinusitis, pain occurs between and behind the eyes.
2 Pain in the forehead typically indicates frontal sinusitis.
3 All of the mentioned sinuses are generally referred to as nasal sinuses.
4 The hospital patient usually has pain over the region of the affected sinuses and
purulent nasal discharge. If a maxillary sinus is affected the hospital patient
experiences pain over the cheek and upper teeth.
PTS: 1 CON: Hospital patient-Centered Care
6. An obese hospital patient is being evaluated by the health care provider (HCP) for
sleep apnea. Which recommendation by the HCP does the nursing practitioner find
unexpected?
1. Using a sedative before sleeping
2. Implementing a weight loss program
3. Removing excess tissue with surgery
4. Using a mandibular advancement device
RIGHT ANSWER> 1
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract Disorders
Objective: 3. Describe current therapeutic measures for disorders of the upper respiratory
tract.
Source: pp. 553
Heading: Sleep Apnea
Integrated Process: Caring
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 Using a sedative before sleeping can worsen the hospital patient’s sleep apnea
by relaxing the muscles of the pharynx. Alcohol consumption will have the
same effect.
2 Weight loss is important for the hospital patient with sleep apnea.
3 If all interventions and treatments fail, surgery may be needed to remove
excess tissue in the throat and around the pharynx.
4 Use of a mandibular advancement device is prescribed early in treatment for
sleep apnea.
PTS: 1 CON: Safety
7. The nursing practitioner is providing care for an adult hospital patient with a diagnosis of
viral rhinitis. The HCP orders acetaminophen and a decongestant. Comfort measures
include rest and an increase in vitamin C and oral fluids. Which hospital patient health
information will cause the nursing practitioner to question one of the treatments?
1. Urinary stress incontinence
2. History of hypertension
3. Allergic reaction to sulfa
4. Gastric irritation and reflux
RIGHT ANSWER> 2
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract Disorders
Objective: 3. Describe current therapeutic measures for disorders of the upper respiratory
tract.
Source: pp. 560
Heading: Viral Rhinitis/Common Cold
Integrated Process: Physiological Integrity—Pharmacological Therapies
Hospital patient Need: Physiological Integrity—Pharmacological
Therapies CL: Analysis (Analyzing)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 None of the prescribed treatments are questionable for a hospital patient with
urinary stress incontinence.
2 Decongestants cause vasoconstriction, which reduces swelling and congestion.
However, hospital patients with a history of hypertension or heart disease
should use
any vasoconstrictor with caution.
3 None of the prescribed treatments contain sulfa.
4 None of the prescribed treatments are contraindicated for hospital patients with
gastric
irritation and reflux.
PTS: 1 CON: Safety
8. A hospital patient comes to the HCP’s office reporting a serious sore throat that “has
lasted for 2 weeks.” A rapid streptococcal antigen test is positive for strep throat. Which is the
most important diagnostic test the nursing practitioner expects the HCP to order?
1. Identifying the exudate in the throat
2. Culture and sensitivity testing
3. Laboratory tests for renal function
4. Antibiotic allergy testing
RIGHT ANSWER> 3
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract
Disorders Objective: 1. Explain the pathophysiology of disorders of the upper
respiratory tract. Source: pp. 564
Heading: Pharyngitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process) Hospital
patient Need: Physiological Integrity—Pharmacological and Parenteral Therapies
CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The hospital patient’s diagnosis is already known. There is no need to identify
the
exudate in the throat.
2 The HCP will want a culture and sensitivity performed to identify the most
effective antibiotic; however, a broad-spectrum antibiotic will be prescribed
initially.
3 Untreated strep throat can result in the development of glomerulonephritis, and
after 2 weeks of untreated infection, the hospital patient’s renal function should
be
assessed. The hospital patient is also at risk for rheumatic fever.
4 Antibiotic allergy testing is not routinely performed. Known allergy history
will be considered.
PTS: 1 CON: Hospital patient-Centered Care
9. The nursing practitioner is previewing teaching information for a hospital patient who is
diagnosed with noncancerous, chronic laryngitis. Which topic is least useful in addressing
modifiable causes of the hospital patient’s condition?
1. History of smoking two packs daily
2. Repeated treatment for alcohol abuse
3. 35 pounds overweight
4. Sensitivity to multiple allergens
RIGHT ANSWER> 4
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract
Disorders Objective: 1. Explain the pathophysiology of disorders of the upper
respiratory tract. Source: pp. 564
Heading: Laryngitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Smoking two packs of cigarettes daily can cause chronic laryngitis, but the
behavior can be modified.
2 Alcohol abuse can cause chronic laryngitis; the hospital patient needs to
continue
treatment to modify this behavior.
3 Chronic laryngitis can be caused by gastric reflux related to obesity; however,
the behavior is modifiable.
4 Sensitivity to multiple allergens is the least modifiable cause of the hospital
patient’s
chronic laryngitis.
PTS: 1 CON: Hospital patient-Centered Care
10. The nursing practitioner is providing care for a hospital patient immediately after a
tonsillectomy. Which action by the nursing practitioner should be avoided?
1. Maintain the hospital patient in a semi-Fowler’s position.
2. Monitor the hospital patient for bleeding and airway maintenance.
3. Provide the hospital patient with warm tea sweetened with honey.
4. Place a humidifier and suction equipment in the hospital patient’s room.
RIGHT ANSWER> 3
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract
Disorders Objective: 4. Plan nursing care for the hospital patient with an upper
respiratory disorder. Source: pp. 564
Heading: Tonsillitis/Adenoiditis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The hospital patient is maintained in a semi-Fowler’s position to reduce
swelling and promote drainage.
2 The maintenance of a patent airway and the presence of bleeding needs to be
closely monitored.
3 Following a tonsillectomy, the hospital patient will be encouraged to prevent
dehydration with oral fluids. Cool fluids will be soothing; warm or hot fluids
can increase bleeding and should be avoided.
4 Placing a humidifier in the room will prevent drying, and suction equipment is
available in case of bleeding.
PTS: 1 CON: Hospital patient-Centered Care
11. The nursing practitioner is providing care for a hospital patient who is hospitalized for
complications from West Nile virus. Which data is most indicative that the hospital patient is
improving?
1. The hospital patient is alert and oriented.
2. Hospital patient states skin itching has subsided.
3. The hospital patient has completed IV antibiotics.
4. Hospital patient shows no mosquito allergy symptoms.
RIGHT ANSWER> 1
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract
Disorders Objective: 5. Discuss how you will know whether your care has been
effective. Source: pp. 570
Heading: Other Respiratory Viruses
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 A complication of West Nile virus is encephalitis, which causes confusion,
seizures, loss of sensation, among other manifestations. The hospital patient
being alert
and orientated is an indication of effective treatment.
2 Itching is not a symptom of West Nile virus.
3 West Nile virus is not responsive to antibiotics; there is no information about a
bacterial-related complication.
4 West Nile virus is not caused by a mosquito allergy.
PTS: 1 CON: Hospital patient-Centered Care
12. The nursing practitioner is providing care for a hospital patient diagnosed with influenza.
The hospital patient has a fever, chills, sore throat, and a cough. Breath sounds include crackles
and wheezes. For which reason will the nursing practitioner contact the physician?
1. The antiviral medication appears to be ineffective.
2. The hospital patient needs IV fluids to loosen lung secretions.
3. The breath sounds indicate development of pneumonia.
4. The hospital patient is experiencing bronchial irritation from coughing.
RIGHT ANSWER> 3
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract Disorders
Objective: 2. Describe etiologies, signs, and symptoms of disorders of the upper respiratory
tract.
Source: pp. 565
Heading: Influenza
Integrated Process: Communication and Documentation
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Collaboration
Difficulty: Moderate
CLARIFICATION
1 There is no validation or timeline regarding the use of an antiviral medication.
2 The question does not describe the cough as being either productive or
nonproductive. There is no indication that the hospital patient is NPO.
3 The most common complication of influenza is pneumonia, which may be
caused by the same virus as the flu or by a secondary bacterial infection. This
should be considered if the hospital patient experiences persistent fever and
shortness of breath or if the lungs develop crackles or wheezes.
4 It is possible that the hospital patient has bronchial irritation from coughing;
however,
the presence of crackles and wheezes are most likely related to pneumonia.
PTS: 1 CON: Collaboration
13. The nursing practitioner is preparing to reinforce teaching to a hospital patient scheduled for a
laryngectomy due to cancer. Which preoperative teaching review is least necessary for the
immediate postoperative period?
1. The loss of the ability to breathe through the nose and mouth.
2. The process of performing tracheostomy care and suctioning.
3. The initial feelings associated with the inability to speak.
4. The reason for performing a dietary consult prior to surgery.
RIGHT ANSWER> 2
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract
Disorders Objective: 6. Identify the special needs of a hospital patient who has
undergone a laryngectomy. Source: pp. 565
Heading: Cancer of the Larynx
Integrated Process: Teaching/Learning
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 It is important to review that the hospital patient will be unable to breathe
through the
nose and mouth. Understanding will help to defer feelings of panic.
2 The hospital patient will need to learn about performing tracheostomy care and
suctioning, but this is the least important information during the immediate
postoperative period.
3 The nursing practitioner needs to review the hospital patient’s inability to speak
after a laryngectomy.
Understanding will help to defer feelings of panic.
4 Hospital patients with cancer of the larynx may not be able to eat and may be
malnourished. Dietary therapy needs to be discussed preoperatively.
PTS: 1 CON: Hospital patient-Centered Care
14. The nursing practitioner is providing care for a hospital patient who is 4 days
postoperative for a laryngectomy. Which data about the hospital patient indicates the need
to modify the expected outcomes?
1. The hospital patient has clear lung sounds and coughs up secretions.
2. The hospital patient achieves an acceptable pain level with use of a hospital
patient-controlled pump.
3. The hospital patient begins to ask about how to perform tracheostomy care.
4. The hospital patient uses both a magic slate and picture board for communication.
RIGHT ANSWER> 2
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract
Disorders Objective: 6. Identify the special needs of a hospital patient who has
undergone a laryngectomy. Source: pp. 568
Heading: Cancer of the Larynx
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 It is expected that the hospital patient will have clear lung sounds and cough
up secretions 4 days after surgery.
2 After 3 days, the hospital patient should not need the around-the-clock pain
management from a hospital patient-controlled pump, which is usually used for
2 to 3 days.
3 Asking about how to perform tracheostomy care indicates acceptance of the
changes related to a laryngectomy.
4 The use of multiple communication devices is acceptable.
PTS: 1 CON: Hospital patient-Centered Care
15. The nursing practitioner is caring for a hospital patient who is malnourished due to throat
cancer. During the hospital stay following a laryngectomy, how does the nursing practitioner
conclude that the hospital patient’s diet is adequate?
1. The hospital patient’s weight is stable postoperatively.
2. The hospital patient’s incision displays complete healing.
3. The hospital patient has active bowel sounds in all quadrants.
4. The hospital patient is tolerating intermittent tube feedings.
RIGHT ANSWER> 4
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract Disorders
Objective: 6. Identify the special needs of a hospital patient who has undergone a
laryngectomy. Source: pp. 566
Heading: Cancer of the Larynx
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 If the malnourished hospital patient’s weight is stable, nutrition therapy is likely
to be inadequate.
2 The hospital patient will not experience complete healing during hospitalization.
3 Active bowel sounds are not an indication of adequate nutrition.
4 Monitoring a hospital patient’s nutrition status is important especially if the
hospital patient is initially malnourished. After a laryngectomy, the nursing
practitioner will conclude that
nutrition status is adequate if alternate feeding methods are tolerated well.
PTS: 1 CON: Hospital patient-Centered Care
16. The family of a hospital patient awaiting a laryngectomy for cancer asks how the
hospital patient will communicate. Which explanation will the nursing practitioner
provide to the family?
1. “Classes on sign language will be provided for the hospital patient and family.”
2. “A special valve that diverts air into the trachea allows hospital patients to talk.”
3. “Hospital patients can be taught to swallow air and talk as air is let out of the esophagus.”
4. “I’m sorry, but unfortunately, hospital patients with laryngectomies cannot communicate.”
RIGHT ANSWER> 3
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract Disorders
Objective: 6. Identify the special needs of the hospital patient who has undergone a
laryngectomy. Source: pp. 566
Heading: Cancer of the Larynx
Integrated Process: Teaching/Learning
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Communication
Difficulty: Moderate
CLARIFICATION
1 The hospital patient will have options for developing a method of speech. Sign
language is most effective for hospital patients who are deaf.
2 A valve can divert air into the esophagus, not the trachea.
3 Esophageal speech is one method of communicating with a laryngectomy.
4 Hospital patients with laryngectomies can communicate.
PTS: 1 CON: Communication
17. The nursing practitioner is reviewing hospital patient teaching with a hospital patient
scheduled for a laryngectomy. For which reason will the nursing practitioner reinforce
careful use of narcotics for postsurgical pain management?
1. To avoid unnecessary incision stress from straining for a bowel movement
2. To decrease the possibility of drug dependency after discharge home
3. To avoid pneumonia from increased respiratory tract secretions
4. To prevent ineffective deep breathing and coughing to clear the airway
RIGHT ANSWER> 4
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract Disorders
Objective: 6. Identify the special needs of the hospital patient who has undergone a
laryngectomy. Source: pp. 566
Heading: Cancer of the Larynx
Integrated Process: Teaching/Learning
Hospital patient Need: Physiological Integrity—Pharmacological and Parenteral
Therapies CL: Analysis (Analyzing)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 Narcotics can cause constipation, but this is not a reason to withhold them from
a postsurgical hospital patient. Straining for a bowel movement will not cause
stress on the laryngectomy incision.
2 Narcotics can be addicting, but the length of use should not cause drug
dependency after discharge home.
3 Narcotics do not increase respiratory secretions and alone are not a cause of
postsurgical pneumonia.
4 It is important for hospital patients with laryngectomies to be able to deep
breathe and cough to clear the airway as a method to prevent pneumonia.
Narcotics can
depress the cough reflex and interfere with deep-breathing compliance.
PTS: 1 CON: Safety
18. During the postoperative period, the nursing practitioner reinforces teaching to a hospital
patient recovering from a laryngectomy about how to live with a tracheostomy. Which
information will the nursing practitioner review?
1. “Avoid suctioning your tracheostomy at home; you could damage your trachea.”
2. “When in public, you should be prepared for people to ask questions about your
condition.”
3. “You will be able to return to your normal activities, including showering and
swimming.”
4. “Be sure to protect your tracheostomy from pollutants such as powders, hair, and
chemicals.”
RIGHT ANSWER> 4
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract Disorders
Objective: 6. Identify the special needs of the hospital patient who has undergone a
laryngectomy. Source: pp. 566
Heading: Cancer of the Larynx
Integrated Process: Clinical Hospital patient-Centered Process
(Nursing Process) Hospital patient Need: Physiological Integrity—
Reduction of Risk Potential CL: Application (Applying)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 The hospital patient should be taught to suction the tracheostomy at home;
damage to the trachea is unlikely with correct technique.
2 The hospital patient may have some curiosity-driven encounters; however, the
nursing practitioner has
more important teaching to review.
3 Activities that would allow water to enter the tracheostomy, such as showering
or swimming, should be avoided.
4 Pollutants, such as powders, chemicals, and hair, can enter the tracheostomy and
cause irritation or infection. The nursing practitioner needs to reinforce this
teaching.
PTS: 1 CON: Safety
MULTIPLE RESPONSE
1. A hospital patient sees an HCP for symptoms of viral rhinitis. Which treatments does
the nursing practitioner expect to be prescribed for this hospital patient? (Select all that
apply.)
1. Rest
2. Fluids
3. Decongestants
4. Bronchodilators
5. Antibacterial agents
RIGHT ANSWER> 1, 2, 3
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract Disorders
Objective: 3. Describe current therapeutic measures for disorders of the upper respiratory
tract.
Source: pp. 560
Heading: Viral Rhinitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Collaboration
Difficulty: Difficult
CLARIFICATION
1. Rest, fluids, and decongestants are helpful for the treatment of viral rhinitis
(common cold).
2. Rest, fluids, and decongestants are helpful for the treatment of viral rhinitis
(common cold).
3. Rest, fluids, and decongestants are helpful for the treatment of viral rhinitis
(common cold).
4. Bronchodilators are used for obstructive airway disease such as asthma.
Rhinitis does not affect the lungs.
5. Antibiotics are used for bacterial infections.
PTS: 1 CON: Collaboration
2. A hospital patient reports having a cold to the nursing practitioner in a HCP’s office.
Which symptoms does the hospital patient report that causes the nursing practitioner to
suspect influenza instead? (Select all that apply.)
1. Sore throat
2. Severe muscle aches
3. Runny nose
4. Persistent cough
5. Sudden onset of symptoms
RIGHT ANSWER> 1, 2, 4, 5
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract Disorders
Objective: Describe the etiologies, signs, and symptoms of disorders of the upper respiratory
tract.
Source: pp. 564
Heading: Influenza
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Safe and Effective Care Environment Safety and Infection
Control CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. The nursing practitioner will suspect influenza instead of a cold if the hospital
patient has a sudden onset of symptoms. Severe muscle aches, a sore throat,
and persistent cough
are also associated with influenza.
2. The nursing practitioner will suspect influenza instead of a cold if the
hospital patient has a sudden onset of symptoms. Severe muscle aches, a sore
throat, and persistent cough are also associated with influenza.
3. A runny nose is less common with influenza, but common with a cold. This
symptom alone does not cause the nursing practitioner to suspect influenza,
especially in
the presence of more definitive manifestations.
4. The nursing practitioner will suspect influenza instead of a cold if the
hospital patient has a sudden onset of symptoms. Severe muscle aches, a sore
throat, and persistent cough are also associated with influenza.
5. The nursing practitioner will suspect influenza instead of a cold if the hospital
patient has a sudden
onset of symptoms. Severe muscle aches, a sore throat, and persistent cough
are also associated with influenza.
PTS: 1 CON: Hospital patient-Centered Care
3. A hospital patient is diagnosed with nasal polyps. For which additional health problems
should the nursing practitioner assess this hospital patient? (Select all that apply.)
1. Asthma
2. Chronic sinusitis
3. Allergy to aspirin
4. Chronic bronchitis
5. Allergy to pet dander
RIGHT ANSWER> 1, 3
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract
Disorders Objective: 1. Explain the pathophysiology of disorders of the upper
respiratory tract. Source: pp. 563
Heading: Nasal Polyps
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. Some hospital patients with nasal polyps also have asthma and are allergic to
aspirin. This is called aspirin triad asthma because the three components
often occur
together.
2. Nasal polyps are not associated with chronic sinusitis, chronic bronchitis, or
an allergy to pet dander.
3. Some hospital patients with nasal polyps also have asthma and are allergic to
aspirin. This is called aspirin triad asthma because the three components
often occur
together.
4. Nasal polyps are not associated with chronic sinusitis, chronic bronchitis, or
an allergy to pet dander.
5. Nasal polyps are not associated with chronic sinusitis, chronic bronchitis, or
an allergy to pet dander.
PTS: 1 CON: Hospital patient-Centered Care
4. A hospital patient is demonstrating signs of pharyngitis. Which symptoms will the
nursing practitioner expect to assess in this hospital patient? (Select all that apply.)
1. Headache
2. Dysphagia
3. Sore throat
4. Extreme thirst
5. Exudate in the throat
RIGHT ANSWER> 1, 2, 3, 5
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract Disorders
Objective: Describe the etiologies, signs, and symptoms of disorders of the upper respiratory
tract.
Source: pp. 561
Heading: Pharyngitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. Exudate usually signifies bacterial infection and may be accompanied by
fever, chills, headache, and generalized malaise.
2. Some hospital patients may also experience dysphagia.
3. The most common symptom of pharyngitis is a sore throat.
4. Extreme thirst is not a symptom of pharyngitis.
5. The throat appears red and swollen and exudate may be present, which may
signify an infection.
PTS: 1 CON: Hospital patient-Centered Care
COMPLETION
1. The release of histamine and other substances causes vasodilation and edema. The resulting
inflammation of the nasal mucous membranes is called .
RIGHT ANSWER>
rhinitis
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract Disorders
Objective: Describe the etiologies, signs, and symptoms of disorders of the upper respiratory
tract.
Source: pp. 561
Heading: Rhinitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation Cognitive: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION: The presence and cause of histamines will help the nursing practitioner to
identify conditions and symptoms. In the case of rhinitis, inflammation of the mucous
membranes is indicative of some degree of nasal airway obstruction.
PTS: 1 CON: Hospital patient-Centered Care
2. A hospital patient is diagnosed with sinusitis and reports pain over the cheeks and
upper teeth in addition to pain between and behind the eyes. The pain locations are
indicative of inflammation in the maxillary and sinuses.
RIGHT ANSWER>
ethmoid
Chapter: 30. Nursing Care for Hospital patients With Upper Respiratory Tract Disorders
Objective: Describe the etiologies, signs, and symptoms of disorders of the upper respiratory
tract.
Source: pp. 561
Heading: Sinusitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Need: Physiological Integrity—Physiological
Adaptation
CL: Analysis (Analyzing) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION: It is important for nurses to have knowledge of anatomy, physiology, and
pathophysiology to implement the Clinical Problem-Solving Process (Nursing Process). The
type and location of the hospital patient’s pain and condition will assist with nursing care
decisions such as positioning and environment management.
PTS: 1 CON: Hospital patient-Centered Care
Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders
MULTIPLE CHOICE
1. A hospital patient is admitted to a respiratory unit with a diagnosis of pneumonia.
Assessment data reveal the hospital patient to be febrile and experiencing a weak, congested-
sounding cough, with moist crackles throughout the lung fields. Based on the data provided,
the nursing practitioner will focus care on which issue?
1. Confusion from fever
2. Inadequate oxygen level
3. Difficulty with breathing
4. Inability to clear the airway
RIGHT ANSWER> 4
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Describe the etiologies, signs, and symptoms of each of the disorders.
Source: pp. 577
Heading: Pneumonia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 There is no information indicating the hospital patient is experiencing
2 There is no information indicating the hospital patient’s oxygen level.
3 The hospital patient may have difficulty breathing due to congestion; airway
clearance is the priority.
4 The hospital patient has a weak, congested-sounding cough, which indicates an
inability
to clear the airway.
PTS: 1 CON: Hospital patient-Centered Care
2. The nursing practitioner is caring for a hospital patient with pneumonia. Which set of
laboratory tests will be most helpful to the nursing practitioner to monitor the condition of this
hospital patient?
1. Electrolytes and serum creatinine
2. Complete blood count (CBC) and urinalysis
3. Partial thromboplastin time (PTT) and serum potassium
4. White blood cell (WBC) count and arterial blood gases (ABGs)
RIGHT ANSWER> 4
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Identify tests that are used to diagnose lower respiratory disorders.
Source: pp. 577
Heading: Pneumonia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Physiological Integrity—Physiological Adaptation
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Urinalysis, electrolytes, and creatinine are useful in monitoring kidney and
bladder problems.
2 Urinalysis, electrolytes, and creatinine are useful in monitoring kidney and
bladder problems.
3 PTT and potassium may be ordered for cardiovascular problems, among other
disorders.
4 WBCs are elevated in infection, and ABGs may be abnormal if gas exchange is
impaired as with pneumonia. CBC may be helpful, but WBC is more specific.
PTS: 1 CON: Hospital patient-Centered Care
3. The nursing practitioner is reviewing data collected on a hospital patient with a respiratory
disorder. Which factors does the nursing practitioner identify as placing the hospital patient at
risk for lung cancer?
1. Smoking and exposure to radon gas
2. Living in a cold climate and having pets
3. Eating foods high in beta carotene and fiber
4. Living in crowded conditions and a lack of sunlight
RIGHT ANSWER> 1
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: List data to collect when caring for hospital patients with disorders
of the lower respiratory tract.
Source: pp. 578
Heading: Lung Cancer
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Smoking is the biggest risk factor for lung cancer. Radon exposure is also a
significant factor.
2 Living in a cold climate, having pets, eating foods high in beta carotene and
fiber, living in crowded conditions, and lack of sunlight are not identified risk
factors for the development of lung cancer.
3 Living in a cold climate, having pets, eating foods high in beta carotene and
fiber, living in crowded conditions, and lack of sunlight are not identified risk
factors for the development of lung cancer.
4 Living in a cold climate, having pets, eating foods high in beta carotene and
fiber, living in crowded conditions, and lack of sunlight are not identified risk
factors for the development of lung cancer.
PTS: 1 CON: Hospital patient-Centered Care
4. A hospital patient with lung cancer develops pleural effusion. Which explanation by the
nursing practitioner would help the hospital patient understand this problem?
1. “Pus has developed in your alveoli that must be removed to improve your
breathing.”
2. “You have large amounts of fluid collecting in your airways because of your
diagnosis.”
3. “Fluid has collected in the space between your lungs and the sac surrounding your
lungs.”
4. “Fluid in your pericardial sac places pressure on your lungs, making it difficult to
breathe.”
RIGHT ANSWER> 3
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Describe the etiologies, signs, and symptoms of each of the disorders.
Source: pp. 583
Heading: Lung Cancer
Integrated Process: Communication and Documentation
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Empyema is a collection of pus in the plural space, not the alveoli.
2 Pleural effusion collects in the pleural space and not the airways.
3 When excess fluid collects in the pleural space, it is called a pleural effusion.
Fluid normally enters the pleural space from surrounding capillaries and is
reabsorbed by the lymphatic system. When a pathological condition causes an
increase in fluid production or inadequate reabsorption of fluid, excess fluid
collects.
4 Pleural effusion fluid is not in the airways, alveoli, or around the heart.
PTS: 1 CON: Hospital patient-Centered Care
5. A hospital patient diagnosed with a pleural effusion is experiencing severe dyspnea.
With which procedure does the nursing practitioner anticipate assisting?
1. Tracheostomy
2. Thoracentesis
3. Bronchoscopy
4. Pericardiocentesis
RIGHT ANSWER> 2
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Identify interventions for hospital patients experiencing impaired gas
exchange, ineffective airway clearance, or ineffective breathing pattern.
Source: pp. 543
Heading: Pleural Effusion
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk Potential
CL: Application (Applying) Concept:
Collaboration
Difficulty: Moderate
CLARIFICATION
1 Tracheostomy creates a stoma for the placement of an artificial airway.
2 Thoracentesis is done by a physician to remove some of the fluid that has
collected in the pleural space and is compressing lung tissue. The nursing
practitioner can anticipate assisting.
3 Bronchoscopy visualizes the major airways with an endoscope.
4 Pericardiocentesis removes fluid from around the heart.
PTS: 1 CON: Collaboration
6. A hospital patient who is planning to become pregnant expresses concern about the high
incidence of asthma in her family. Which recommendation by the nursing practitioner is least
helpful?
1. Suggest the hospital patient undergo genetic studies and counseling.
2. Prevent exposure to environmental tobacco smoke during pregnancy.
3. During the first year of life, avoid giving a child acetaminophen.
4. Avoid broad-spectrum antibiotics during the child’s first year of life.
RIGHT ANSWER> 1
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Describe therapeutic measures used for disorders of the lower
respiratory tract. Source: pp. 590
Heading: Asthma
Integrated Process: Communication and Documentation
Hospital patient Need: Hospital patient-Centered Care
CL: Application (Applying) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 It is not confirmed that asthma has a genetic link; however, there is a tendency
for the condition to run in families. This is the least helpful recommendation.
2 The mother should avoid environmental tobacco smoke during pregnancy and
the child should be protected from exposure during the first year of life.
3 Avoiding the use of acetaminophen with a child during the first year of life is
recommended to decrease the incidence of asthma.
4 Not giving a child broad-spectrum antibiotics before the age of 1 year is
recommended to decrease the incidence of asthma.
PTS: 1 CON: Hospital patient-Centered Care
7. A summer camp worker reports shortness of breath and audible wheezing to the camp nurse.
Which inhaled medication will the nursing practitioner provide?
1. Albuterol
2. Cromolyn sodium
3. Triamcinolone
4. Nedocromil sodium
RIGHT ANSWER> 1
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Identify interventions for hospital patients experiencing impaired gas
exchange, ineffective airway clearance, or ineffective breathing pattern.
Source: pp. 591
Heading: Asthma
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Pharmacological and Parenteral
Therapies CL: Application (Applying)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 Albuterol is an adrenergic bronchodilator and would be used to help
immediately relieve acute bronchospasm.
2 Cromolyn and nedocromil are mast cell inhibitors.
3 Triamcinolone is a corticosteroid.
4 Cromolyn and nedocromil are mast cell inhibitors.
PTS: 1 CON: Safety
8. The nursing practitioner is providing care for a hospital patient admitted for a lower
respiratory infection. On admission, the hospital patient’s vital signs were blood pressure (BP)
140/80 mm Hg, apical pulse (AP) 112 beats/min, respirations (R) 32 breaths/min, and pain
level of 8 on a scale of 0 to
10. After assisting the hospital patient to bed and applying the prescribed oxygen, which
finding helps the nursing practitioner evaluate the effectiveness of nursing care?
1. BP 130/78 mm Hg
2. AP 100 beats/min
3. R 20 breaths/min
4. Pain level of 6/10
RIGHT ANSWER> 3
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Explain how you will know whether your nursing interventions have
been effective.
Source: pp. 589
Heading: Nursing Care Plan for the Hospital patient With a Lower Respiratory Tract
Disorder Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The change in BP does not evaluate nursing care effectiveness.
2 The change in AP is not the best indication of nursing care effectiveness.
3 The hospital patient’s respiratory rate was elevated, indicating shortness of
breath
related to either poor gas exchange or activity intolerance. This improvement is
the best evaluation of nursing care effectiveness.
4 The hospital patient’s pain level is still significant.
PTS: 1 CON: Hospital patient-Centered Care
9. A hospital patient with chronic obstructive pulmonary disease (COPD) is prescribed
methylprednisolone. For what reason should the nursing practitioner realize that
corticosteroids are used in the treatment of this health problem?
1. To dry up respiratory secretions
2. To treat infection from secretion stasis
3. To reduce airway inflammation
4. To improve the blood capacity to carry oxygen
RIGHT ANSWER> 3
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Describe therapeutic measures used for disorders of the lower
respiratory tract. Source: pp. 589
Heading: Obstructive Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Pharmacological and Parenteral
Therapies CL: Analysis (Analyzing)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 Corticosteroids do not dry secretions.
2 Corticosteroids may mask the manifestations of infection and cause the
infection to worsen.
3 Corticosteroids are potent anti-inflammatory agents.
4 Corticosteroids do not directly affect oxygenation or change the function of the
blood.
PTS: 1 CON: Safety
10. The nursing practitioner is providing care for a hospital patient admitted with an acute
lower respiratory infection. The nursing practitioner notices that the hospital patient is
stifling the cough reflex and exhibiting shallow respirations due to pain. The nursing
practitioner will focus nursing care on the prevention of which condition?
1. Atelectasis
2. Pulmonary emboli
3. Chronic airway obstruction
4. Respiratory failure
RIGHT ANSWER> 1
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Plan nursing care for hospital patients with disorders of the lower
respiratory tract.
Source: pp. 578
Heading: Atelectasis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Atelectasis can be caused by any condition that causes hypoventilation,
especially pain. Failure to prevent or resolve hypoventilation causes the air sacs
to adhere to each other.
2 Pulmonary emboli is the presence of blood clot in the lungs.
3 The question identifies the hospital patient as having an acute, not chronic,
condition.
4 Atelectasis can lead to respiratory failure if not effectively treated; however,
the hospital patient’s condition is acute and treatable.
PTS: 1 CON: Hospital patient-Centered Care
11. The nursing practitioner is performing a follow up visit with a hospital patient recently
diagnosed with a GOLD 1 classification of COPD. Which statement by the hospital patient
indicates the most important compliance with previous hospital patient teaching?
1. “I am attending an exercise class three times a week.”
2. “I am including more fresh foods in my daily diet.”
3. “I successfully completed a smoking-cessation program.”
4. “I am wearing a respiratory filter when I work outside.”
RIGHT ANSWER> 3
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Explain how you will know whether your nursing interventions have
been effective.
Source: pp. 589
Heading: Obstructive Disorders
Integrated Process: Teaching/Learning
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The hospital patient’s COPD classification indicates mild airflow limitation;
exercise
can increase and maintain respiratory function, but smoking cessation is most
important.
2 Nutritional status is more important as COPD worsens and interferes with
dietary intake.
3 The greatest risk for the development and worsening of COPD is smoking; a
hospital patient indicating the completion of a smoking-cessation program
indicates important compliance.
4 Preventing exposure to irritants is effective in arresting development of the
condition. However, smoking is the greatest risk for worsening COPD.
PTS: 1 CON: Hospital patient-Centered Care
12. The nursing practitioner enters the room of a hospital patient who is acutely short of
breath. Which action should the nursing practitioner take first?
1. Assist the hospital patient into Sims’ position.
2. Encourage use of pursed-lip breathing.
3. Ask the hospital patient what caused the dyspnea.
4. Teach the hospital patient use of accessory muscles.
RIGHT ANSWER> 2
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Identify interventions for hospital patients experiencing impaired gas
exchange, ineffective airway clearance, or ineffective breathing pattern.
Source: pp. 539
Heading: Obstructive Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Fowler’s, not Sims’, position will help lung expansion.
2 Pursed-lip breathing can help open alveoli and promote excretion of carbon
dioxide.
3 Asking the hospital patient the cause is appropriate after the dyspnea is resolved.
4 Accessory muscle use is a sign of respiratory distress, not a therapeutic
measure.
PTS: 1 CON: Hospital patient-Centered Care
13. The nursing practitioner is reviewing the medications prescribed by the health care
provider (HCP) for a hospital patient with COPD. Which prescription will cause the
nursing practitioner to verify the ordered medication?
1. Corticosteroid inhaler
2. Antitussive
3. Short-term antibiotic therapy
4. Theophylline bronchodilator
RIGHT ANSWER> 2
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Describe therapeutic measures used for disorders of the lower
respiratory tract. Source: pp. 585
Heading: Obstructive Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Need: Physiological Integrity—Pharmacological and Parenteral
Therapies CL: Application (Applying)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 A corticosteroid inhaler is commonly prescribed to decrease inflammation.
2 When a hospital patient has COPD, an antitussive is not prescribed because it
interferes
with the ability to cough up secretions.
3 Short-term antibiotic therapy is appropriate and is prescribed as needed.
4 While the side effects are significant, theophylline bronchodilators are used as
needed.
PTS: 1 CON: Safety
14. The nursing practitioner is providing care for a hospital patient diagnosed with an
obstructive respiratory disorder. Which hospital patient finding indicates that nursing
interventions may be ineffective?
1. Respiratory secretions are coughed up.
2. Daily care is performed independently.
3. The hospital patient uses oxygen only when active.
4. The hospital patient reports a low level of anxiety.
RIGHT ANSWER> 3
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Explain how you will know whether your nursing interventions have
been effective.
Source: pp. 585
Heading: Nursing Process for the Hospital patient With an Obstructive
Disorder Integrated Process: Teaching/Learning
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Nursing interventions are effective if the hospital patient can cough up
respiratory
secretions.
2 Nursing interventions are effective if the hospital patient can perform daily care
independently.
3 A hospital patient with an obstructive respiratory disorder may need to have
oxygen when both active and inactive. This finding alone is not an indication
of
effective nursing interventions.
4 Nursing interventions are effective if the hospital patient reports a decreased
or low level of anxiety.
PTS: 1 CON: Hospital patient-Centered Care
15. The licensed practical nurse/licensed vocational nursing practitioner (LPN/LVN) is
reviewing laboratory results for a hospital patient with COPD. Which action does the
LPN/LVN take if the ABG analysis shows a PaCO2 of 62 mm Hg?
1. Notify the registered nursing practitioner (RN) of the high laboratory result.
2. Have the hospital patient breathe into a paper bag.
3. Increase the flow rate of the hospital patient’s nasal oxygen.
4. No action is necessary; this is a normal PaCO2 level.
RIGHT ANSWER> 1
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: List data to collect when caring for hospital patients with disorders
of the lower respiratory tract.
Source: pp. 586
Heading: Obstructive Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Professionalism
Difficulty: Moderate
CLARIFICATION
1 Normal PaCO2 is 35 to 45 mm Hg. The value 62 mm Hg is evidence of
hypoventilation and the inability to excrete carbon dioxide (CO2). The RN or
physician should be notified.
2 Breathing into a paper bag will increase the CO2 level.
3 Increasing nasal oxygen will not help CO2 excretion.
4 This is not a normal level and action must be taken immediately.
PTS: 1 CON: Professionalism
16. The nursing practitioner is providing care for a hospital patient with a lower respiratory
tract infection who is having difficulty expectorating secretions. The hospital patient is weak
and easily fatigued. Which action by the nursing practitioner will best assist the hospital
patient in maintaining a clear airway?
1. Review effective coughing technique.
2. Plan activities with rest periods between.
3. Explain the importance of fluid intake.
4. Encourage abdominal and pursed-lip breathing.
RIGHT ANSWER> 3
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Identify interventions for hospital patients experiencing impaired gas
exchange, ineffective airway clearance, or ineffective breathing pattern.
Source: pp. 582
Heading: Obstructive Disorder
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The hospital patient may or may not need a review of coughing technique.
2 Rest and relaxation can help with activity intolerance and anxiety but will not
assist with airway clearance.
3 Fluids help reduce viscosity of secretions and make them easier to expectorate.
4 Breathing exercises help correct impaired gas exchange, but will not assist with
airway clearance.
PTS: 1 CON: Hospital patient-Centered Care
17. The nursing practitioner is researching the dietary recommendations by the American
Lung Association for hospital patients with lower respiratory tract disease. Which strategy is
not supported by the American Lung Association?
1. Eat more food early in the day if fatigue occurs late in the day.
2. Consume a daily diet high in complex carbohydrates.
3. Consult with the HCP regarding a multivitamin.
4. Maintain a diet that is low in fats and high in carbohydrates.
RIGHT ANSWER> 4
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Describe therapeutic measures used for disorders of the lower
respiratory tract. Source: pp. 582
Heading: Optimizing Nutrition in Hospital patients With Respiratory
Disease Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 If a hospital patient routinely is too fatigued to eat well late in the day, he or she
is encouraged to eat more food early in the day.
2 Complex carbohydrates are recommended for high-fiber content; simple
carbohydrates should be avoided.
3 The HCP should be consulted regarding the use of a multivitamin.
4 The hospital patient with lower respiratory tract disease needs a diet with
increased fat
and lower carbohydrates (fats produce less CO2 when metabolized).
PTS: 1 CON: Hospital patient-Centered Care
18. The nursing practitioner is providing care for a hospital patient with a suspected
pulmonary emboli. Which data will the nursing practitioner gather about this hospital
patient?
1. BP from both arms
2. Heart sounds and peripheral edema
3. Activity prior to manifestations
4. Side effects of medications
RIGHT ANSWER> 2
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: List data to collect when caring for hospital patients with disorders
of the lower respiratory tract.
Source: pp. 576
Heading: Pulmonary Embolism
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 There is no need to monitor the BP in both arms for a hospital patient suspected
of a pulmonary emboli.
2 Because an emboli in the lungs can cause right-sided heart failure, the nurse
should monitor heart sounds and the presence of peripheral edema.
3 Ascertaining the activity prior to the manifestations of a pulmonary emboli will
not be useful.
4 It is not necessary to evaluate the side effects of medications.
PTS: 1 CON: Hospital patient-Centered Care
19. The nursing practitioner works in a clinic and is performing tuberculosis (TB) screening
with the purified protein derivative (PPD). Which option about PPD screening is correct?
1. The test is positive if reddened area occurs within 48 to 72 hours.
2. If a person is anergic, a larger area of induration will appear.
3. A positive reaction to the test indicates active disease process.
4. A reddened area without induration is considered negative.
RIGHT ANSWER> 4
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Identify tests that are used to diagnose lower respiratory disorders.
Source: pp. 580
Heading: Tuberculosis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Pharmacological and Parenteral
Therapies CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 An area of induration must appear within 48 to 72 hours for a PPD test to be
considered positive.
2 In persons with a limited ability to react to the test due to immune dysfunction
(anergic), a smaller area of induration is considered positive.
3 A positive reaction is indicative of exposure to TB and not of active disease
process.
4 In regard to PPD testing for TB, a reddened area without induration is
considered negative; induration must be present for a positive response.
PTS: 1 CON: Hospital patient-Centered Care
20. A hospital patient with TB who is in respiratory isolation must go to the x-ray
department. Which action will the nursing practitioner take?
1. Place a gown and gloves on the hospital patient.
2. Place a mask over the hospital patient’s nose and mouth.
3. Notify the x-ray department that the test must be cancelled.
4. Call the x-ray department to make sure the waiting room is empty.
RIGHT ANSWER> 2
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Plan nursing care for hospital patients with disorders of the lower
respiratory tract.
Source: pp. 580
Heading: Tuberculosis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Gown and gloves are not necessary; the hospital patient has a respiratory
infection.
2 The hospital patient is in respiratory isolation, so a mask over the nose and
mouth is
essential when moving the hospital patient into other areas of the facility.
3 The x-ray is an important evaluation test for the hospital patient and should not
be cancelled, even if bedside x-ray is not available.
4 It is not necessary that the x-ray waiting room be vacated; however, the
hospital patient’s exposure to others should be minimized.
PTS: 1 CON: Hospital patient-Centered Care
21. The nursing practitioner finds a hospital patient gasping for breath and looking very anxious.
Based on the hospital patient’s history, the nursing practitioner believes the hospital patient may be
experiencing a pulmonary embolism (PE). Which action should the nursing practitioner take first?
1. Contact the physician.
2. Call for help and start oxygen.
3. Check the hospital patient’s vital signs.
4. Place the hospital patient in a left lateral position.
RIGHT ANSWER> 2
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Identify interventions for hospital patients experiencing impaired gas
exchange, ineffective airway clearance, or ineffective breathing pattern.
Source: pp. 582
Heading: Pulmonary Embolism
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Leaving the hospital patient to call the physician is not appropriate—someone
else can
contact the physician.
2 Be alert to the presence of risk factors and obtain immediate assistance if the
cause of dyspnea might be PE. Death can occur if treatment is not quick and
effective.
3 Checking vital signs is important but is not more important than oxygen. The
nursing practitioner should not assess a hospital patient who is in distress.
4 Left lateral position will not help.
PTS: 1 CON: Hospital patient-Centered Care
22. The nursing practitioner auscultates the lung sounds of a hospital patient with a
pneumothorax every 4 hours. Which finding indicates to the nursing practitioner that the
hospital patient’s condition is improving?
1. Hospital patient anxiety is decreased.
2. Crackles or wheezes are heard.
3. Bilateral lung sounds are present.
4. Symmetry of the chest is noted.
RIGHT ANSWER> 3
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Explain how you will know whether your nursing interventions have
been effective.
Source: pp. 599
Heading: Pneumothorax
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Decreased hospital patient anxiety is not an indication that a pneumothorax is
improving.
2 Crackles, wheezes, secretions, or obstruction are concerning, but do not
provide direct information about pneumothorax.
3 Lung sounds are absent over a pneumothorax. Return of bilateral sounds
signifies that the lung is reinflated.
4 Chest symmetry is restored via treatment for a pneumothorax, but alone is not
indicative of improvement.
PTS: 1 CON: Hospital patient-Centered Care
23. A hospital patient is diagnosed with respiratory failure. Which acid-base abnormality
should the nursing practitioner expect the hospital patient to demonstrate?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
RIGHT ANSWER> 3
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract Disorders
Objective: Explain the pathophysiology of each of the disorders of the lower respiratory
tract.
Source: pp. 528
Heading: Respiratory Failure
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Metabolic imbalances are not caused by respiratory dysfunction.
2 Metabolic imbalances are not caused by respiratory dysfunction.
3 ABGs in respiratory failure show decreasing PaO2 and pH and increasing
PaCO2, which lead to respiratory acidosis.
4 Respiratory alkalosis is associated with hyperventilation.
PTS: 1 CON: Hospital patient-Centered Care
24. The nursing practitioner works primarily with hospital patients diagnosed with lung
cancer. Which hospital patient with lung cancer does the nursing practitioner recognize as
having the best prognosis?
1. Small cell lung cancer
2. Large cell carcinoma
3. Adenocarcinoma
4. Squamous cell carcinoma
RIGHT ANSWER> 4
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Explain the pathophysiology of each of the disorders of the lower
respiratory tract.
Source: pp. 603
Heading: Lung Cancer/Pathophysiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 This hospital patient has a poor prognosis. Small cell lung cancer grows rapidly and is
often metastasized by the time of diagnosis.
2 This hospital patient has a poor prognosis. Large cell carcinoma is a rapidly growing
cancer that can occur anywhere in the lungs; it also metastasizes early.
3 This hospital patient has a poor prognosis. Adenocarcinoma occurs most often in
women and is most often on the peripheral lung fields. It grows slowly but is often not
diagnosed until metastasis occurs.
4 This hospital patient has the best prognosis. Squamous cell carcinoma usually
in the
bronchial lining and metastasizes late in the disease; this type has a better prognosis
than the other types of lung cancer.
PTS: 1 CON: Hospital patient-Centered Care
MULTIPLE RESPONSE
1. The nursing practitioner is providing care for a hospital patient admitted to the hospital for a
respiratory disorder. The HCP is prescribing diagnostic tests to rule out bronchiectasis. Which
manifestations does the nursing practitioner recognize as possible indicators for the diagnosis?
(Select all that apply.)
1. Radiographic studies reveal areas of bronchial dilation.
2. Adult hospital patient has a history of cystic fibrosis since birth.
3. Family history reveals multiple members with lung cancer.
4. The hospital patient has recurring episodes of lower extremity edema.
5. Bronchitis occurred three times in the last three years.
RIGHT ANSWER> 1, 2, 4
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Describe the etiologies, signs, and symptoms of each of the disorders.
Source: pp. 582
Heading: Bronchiectasis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. Bronchiectasis involves dilation of the bronchial tree; the radiographic
studies support the possibility of the condition.
2. Hospital patients with cystic fibrosis are at greater risk for bronchiectasis.
3. A tumor or cancer in the lungs can be a cause of bronchiectasis; however,
family history of lung cancer alone is not specific to the diagnosis.
4. Bronchiectasis can cause right-sided heart failure; recurring episodes of
lower extremity edema may be a symptom.
5. If bronchitis occurs three times a year for 2 consecutive years, the diagnosis
of bronchiectasis should be ruled out.
PTS: 1 CON: Hospital patient-Centered Care
2. The nursing practitioner is caring for a hospital patient with a suspected PE. Which
diagnostic tests or procedures should the nursing practitioner expect to be prescribed for this
hospital patient? (Select all that apply.)
1. D-dimer
2. Spirometry
3. Angiogram
4. Ventilation-perfusion lung scan
5. Spiral computed tomography (CT) scan
RIGHT ANSWER> 1, 3, 4
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Identify tests that are used to diagnose lower respiratory disorders.
Source: pp. 597
Heading: Pulmonary Embolism
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. D-dimer is a fibrin fragment that is found in the blood after any thrombus
formation. It can be present in a number of disorders, but if it is negative, PE
can be eliminated as a possible cause of the hospital patient’s symptoms.
2. Spirometry is not a diagnostic test.
3. A pulmonary angiogram can outline the pulmonary vessels with a radiopaque
dye injected via a cardiac catheter.
4. If a CT scan is not available, a lung scan (ventilation-perfusion scan) is done
to assess the extent of ventilation of lung tissue and the areas of blood
perfusion.
5. A spiral CT scan is a new and fast type of CT scan that is noninvasive and
can diagnose PE quickly.
PTS: 1 CON: Hospital patient-Centered Care
3. Management of asthma involves avoidance of triggers. Which environmental triggers will
the nursing practitioner suggest the hospital patient eliminate?
1. Carpet and drapes in the bedroom
2. Exposure to secondhand smoke
3. Pets and foods that cause symptoms
4. Cardiovascular exercise
5. Beta-blocking medications
RIGHT ANSWER> 1, 2, 3
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Describe therapeutic measures used for disorders of the lower
respiratory tract. Source: pp. 582
Heading: Asthma
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. Carpet and drapes harbor dust, which can trigger asthma attacks.
2. Smoking and exposure to secondhand smoke can trigger asthma attacks.
3. Pet dander and certain foods can cause asthma attacks.
4. Cardiovascular exercise can trigger asthma attacks, but exercise is not an
environmental trigger, it is activity.
5. Beta-blocking medications can trigger asthma attacks, but it is not an
environmental trigger.
PTS: 1 CON: Hospital patient-Centered Care
4. A young adult is admitted with manifestations associated with cystic fibrosis. What should
the nursing practitioner expect to find when collecting data from this hospital patient? (Select
all that apply.)
1. Extreme thirst
2. Finger clubbing
3. Body mass index 16
4. Thick sputum production
5. Complaints of frequent foul-smelling stool
RIGHT ANSWER> 2, 3, 4, 5
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Describe the etiologies, signs, and symptoms of each of the disorders.
Source: pp. 594
Heading: Cystic Fibrosis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. Extreme thirst is not a manifestation of cystic fibrosis.
2. Symptoms of cystic fibrosis usually first appear in infancy or childhood,
although a few individuals are not diagnosed until adulthood. Manifestations
include finger clubbing.
3. Symptoms of cystic fibrosis usually first appear in infancy or childhood,
although a few individuals are not diagnosed until adulthood. Manifestations
include malnutrition.
4. Symptoms of cystic fibrosis usually first appear in infancy or childhood,
although a few individuals are not diagnosed until adulthood. Manifestations
include thick sputum production.
5. Symptoms of cystic fibrosis usually first appear in infancy or childhood,
although a few individuals are not diagnosed until adulthood. Manifestations
include frequent foul-smelling stools.
PTS: 1 CON: Hospital patient-Centered Care
5. The nursing practitioner works on a pulmonary care unit and provides care for multiple
hospital patients with obstructive pulmonary conditions. Which specific symptoms will
prompt the nursing practitioner to identify a hospital patient’s diagnosis as chronic bronchitis
as opposed to other pulmonary diseases? (Select all that apply.)
1. Chronic productive cough
2. Classic barrel-shaped chest
3. Use of accessory muscles to breath
4. Condition worsening in the winter
5. Clear breath sounds with coughing
RIGHT ANSWER> 1, 4, 5
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Describe the etiologies, signs, and symptoms of each of the disorders.
Source: pp. 586
Heading: Obstructive Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. The hospital patient with chronic bronchitis will exhibit a chronic productive
cough
and crackles and wheezing that clears with coughing.
2. The classic barrel-shaped chest is seen in the hospital patient with COPD and
is the result of trapped air in the lungs.
3. Hospital patients with emphysema will use the accessory muscles to breathe.
4. The hospital patient will likely notice the condition worsening during the
winter months.
5. The hospital patient with chronic bronchitis will exhibit a chronic productive
cough
and crackles and wheezing that clears with coughing.
PTS: 1 CON: Hospital patient-Centered Care
COMPLETION
1. Some lung cancers produce hormones that mimic the body’s own hormones.
RIGHT ANSWER>
ectopic
Chapter: Chapter 31. Nursing Care of Hospital patients With Lower Respiratory Tract
Disorders Objective: Describe the etiologies, signs, and symptoms of each of the disorders.
Source: pp. 603
Heading: Ectopic Hormone Production
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION: Some lung cancers can produce ectopic hormones, which mimic the
body’s hormones. Ectopic production of antidiuretic hormone can produce syndrome of
inappropriate antidiuretic hormone production, with resulting fluid retention. Ectopic
production of adrenocorticotropic hormone can cause Cushing syndrome. High calcium
levels can be caused by ectopic secretion of a parathyroid-like hormone.
PTS: 1 CON: Hospital patient-Centered Care
Chapter 32. Gastrointestinal, Hepatobiliary, and Pancreatic Systems Function,
Assessment, and Therapeutic Measures
MULTIPLE CHOICE
1. The nursing practitioner is inspecting a hospital patient’s oral cavity and notices
reddened areas on the gums, several teeth with cavities, and multiple loose teeth. Which
finding is of greatest safety concern to the nurse?
1. Reddened area on the gums can be a source of infection.
2. Dental cavities can be painful and a possible source of infection.
3. Loose teeth concern due to possible aspiration and airway blockage.
4. Abnormal findings in the oral cavity can lead to poor nutrition status.
RIGHT ANSWER> 3
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Differentiate normal and abnormal data collection findings.
Source: pp. 612
Heading: Oral Cavity
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Health Promotion
Difficulty: Moderate
CLARIFICATION
1 Reddened areas on the hospital patient’s gums can be indicative of infection
or abscesses. The condition should be evaluated and treated by a dentist. This
is not the greatest safety concern.
2 Cavities can be a source of pain and infection. The condition should be
evaluated and treated by a dentist. This is not the greatest safety concern.
3 Loose teeth can be aspirated into the airway and become a choking risk or
airway blockage. This finding is the nurse’s greatest safety concern. The
hospital patient needs to see a dentist as soon as possible.
4 It is true that abnormal oral cavity findings can interfere with the hospital
patient’s
nutritional status, but this is not the nurse’s greatest safety concern.
PTS: 1 CON: Health Promotion
2. The nursing practitioner is providing care for a hospital patient whose nasogastric (NG)
tube is attached to low intermittent suction for decompression of a bowel obstruction. The
nursing practitioner notes the NG tube is not draining. After checking placement, which action
should the nursing practitioner take?
1. Advance the NG tube 2 inches.
2. Change the suction setting to high.
3. Reinsert the NG tube into the other nares.
4. Irrigate the NG tube with 30 milliliters of normal saline.
RIGHT ANSWER> 4
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Plan nursing care for the insertion and maintenance of nasogastric tubes.
Source: pp. 631
Heading: Gastrointestinal Intubation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The tube should not be advanced without a health care provider’s (HCP) order
unless it has migrated from the initial position. The question does not address
the possibility of this issue.
2 Suction should remain on a low setting to prevent damage to the lining of the
stomach.
3 The NG tube should not be pulled and reinserted without an HCP’s order.
There are a variety of methods to reestablish patency of the NG tube.
4 The nursing practitioner should irrigate the NG tube with 30 mL of normal
saline to see if the
tube is blocked with secretions.
PTS: 1 CON: Hospital patient-Centered Care
3. During the inspection of a hospital patient’s abdomen, which data finding is most unlikely
indicative of a serious disorder?
1. Jaundice
2. Caput medusae
3. Visible mound
4. Silver-colored lines
RIGHT ANSWER> 4
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Differentiate normal and abnormal data collection findings.
Source: pp. 620
Heading: Abdomen
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Jaundice (icterus) is a yellowing of the skin and is usually associated with liver
dysfunction or disease.
2 Caput medusae is the appearance of a bluish-purple, swollen vein pattern
extending out from the navel. When found in an adult, it can be indicative of
portal hypertension or advanced alcoholic cirrhosis of the liver.
3 A visible mound noted with inspection of the abdomen can be indicative of a
tumor or other intra-abdominal issues.
4 Silver or thin red lines on the skin of the abdomen is the finding most unlikely
to indicate a serious disorder. Striae can develop during pregnancy or obesity
from stretching of the skin.
PTS: 1 CON: Hospital patient-Centered Care
4. The nursing practitioner is auscultating the bowel sounds of a hospital patient who is
severely constipated and exhibits a swollen abdomen and pain. Which bowel sounds cause
the nursing practitioner to suspect a bowel obstruction?
1. A series of soft clicks and gurgles
2. A complete absence of sounds
3. A high-pitched tinkling sound
4. A variety of nearly constant sounds
RIGHT ANSWER> 3
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Differentiate normal and abnormal data collection findings.
Source: pp. 659
Heading: Abdomen
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 A series of soft clicks and gurgles is considered to be normal bowel sounds.
2 A complete absence of bowel sounds may occur for a period following
anesthesia or indicate bowel disease.
3 A high-pitched tinkling sound is commonly associated with a bowel
obstruction especially if bowel sounds are absent distal to the area of
auscultation.
4 A variety of nearly constant bowel sounds is defined as hyperactive bowel
sounds and can occur for a variety of reasons.
PTS: 1 CON: Hospital patient-Centered Care
5. The nursing practitioner is providing care for a hospital patient who has just undergone a
needle biopsy to rule out liver disease. Which nursing intervention is most critical
following the procedure?
1. Monitor vital signs every 4 hours.
2. Instruct to avoid coughing or straining.
3. Remain positioned on right side for 2 hours.
4. Medicate as needed for pain.
RIGHT ANSWER> 3
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Plan nursing care for hospital patients having diagnostic tests of the
gastrointestinal tract. Source: pp. 628
Heading: Percutaneous Liver Biopsy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Vital signs will be monitored several hours as prescribed. Vital signs are
indicative of hospital patient stability or instability following a procedure.
2 The hospital patient will be instructed to avoid coughing or straining, exercise
and
heavy lifting for a period of 1 week.
3 The most important nursing intervention following a percutaneous liver biopsy
is to keep the hospital patient positioned on the right side for 2 hours to apply
pressure on the site and prevent bleeding. Risk for bleeding is associated with
the vascularity of the liver, and because liver disease can cause reduced clotting
ability.
4 The nursing practitioner will medicate the hospital patient as needed for
postprocedure pain; however, this intervention is not as critical as monitoring
for and preventing bleeding
from the biopsy site.
PTS: 1 CON: Hospital patient-Centered Care
6. A hospital patient is being prepared for an upper gastrointestinal (GI) series involving a
barium swallow. Which statement indicates that the hospital patient understands the
preparation for this test?
1. “I should eat a soft diet the night before the procedure.”
2. “I must not eat or drink for 4 hours after the procedure.”
3. “I’ll be given a clear liquid diet the night after the procedure.”
4. “I can’t have anything to eat or drink for 6 hours before the procedure.”
RIGHT ANSWER> 4
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Plan nursing care for hospital patients having diagnostic tests of the
gastrointestinal tract. Source: pp. 627
Heading: Barium Swallow
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 It is not necessary for the hospital patient to eat a soft diet the night before the
test.
2 There is no reason to restrict oral intake following a barium swallow.
3 There is no reason for the hospital patient to be on a clear liquid diet following
the procedure.
4 An appropriate hospital patient diet preparation for an upper GI series is placing
the
hospital patient on NPO restriction 6 hours before the procedure for best
visualization.
PTS: 1 CON: Hospital patient-Centered Care
7. The nursing practitioner is ready to begin a tube feeding via an NG feeding tube for a
hospital patient who is comatose. What action should the nursing practitioner take before
starting the feeding?
1. Listen to bowel sounds.
2. Check the pH of gastric aspirate.
3. Secure the NG tube with additional tape.
4. Irrigate the tube with 10 mL of sterile water.
RIGHT ANSWER> 2
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Plan nursing care for insertion and maintenance of nasogastric tubes.
Source: pp. 631
Heading: Gastrointestinal Intubation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 Bowel sounds can be auscultated at any time and are not specifically indicative
of NG tube placement.
2 Prior to instilling anything into the NG tube, it is essential to verify placement
of the NG tube; after x-ray is performed, the preferred method of verification is
to check the pH of the gastric aspirate.
3 The NG tube should have been secured after insertion.
4 The tube is irrigated with normal saline and not sterile water.
PTS: 1 CON: Safety
8. The nursing practitioner reviews the results of a hospital patient’s stool occult blood test,
which tests positive. Which additional data is unlikely to cause a false positive for the
testing?
1. If the hospital patient has bleeding gums following a recent dental procedure
2. If the hospital patient ingested red meat within 3 days of testing
3. If the hospital patient took oral laxatives in preparation for the test
4. If the hospital patient ate turnips, fish, or horseradish prior to testing
RIGHT ANSWER> 3
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Plan nursing care for hospital patients having diagnostic tests of the
gastrointestinal tract. Source: pp. 626
Heading: Stool Tests
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Medium
CLARIFICATION
1 Bleeding gums from a recent dental procedure can cause a false positive for a
stool occult blood test.
2 Ingesting red meat within 3 days of a stool occult blood test can cause a false-
positive result.
3 The use of oral laxatives in preparation for the test is unlikely to cause a false-
positive stool blood occult test.
4 Eating spicy foods can irritate the digestive tract and cause a false-positive
result on a stool occult blood test.
PTS: 1 CON: Hospital patient-Centered Care
9. The nursing practitioner is caring for a hospital patient who has a nonvented NG
tube. Which suction setting should the nursing practitioner select?
1. Low continuous suction
2. High continuous suction
3. Low intermittent suction
4. High intermittent suction
RIGHT ANSWER> 3
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Plan nursing care for insertion and maintenance of nasogastric tubes.
Source: pp. 654
Heading: Gastrointestinal Intubation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Low continuous suction is inappropriate for this type of NG tube.
2 High continuous suction is inappropriate for this type of NG tube.
3 If suction is ordered, low intermittent suction is used with nonvented NG tubes.
4 High intermittent suction is inappropriate for this type of NG tube.
PTS: 1 CON: Hospital patient-Centered Care
10. The nursing practitioner is planning to reinforce teaching to a hospital patient regarding the
function of the organs in the GI tract. Which information is correct?
1. The presence of food is necessary to trigger the release of gastric juices.
2. The colon is the last 3 feet of GI tract where digestion is completed.
3. The duodenum is where the common bile and pancreatic duct enters the small
intestine.
4. The singular function of the liver is to remove potentially toxic substances from
the blood.
RIGHT ANSWER> 3
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: List the structures of the gastrointestinal tract and of the accessory glands: liver,
gallbladder, and pancreas.
Pages: 611–612
Heading: Normal Gastrointestinal, Hepatobiliary, and Pancreatic Systems Anatomy and
Physiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The secretion of gastric juices begins with the sight and smell of food; the
response is parasympathetic.
2 The colon is 5 feet in length and no additional digestion takes place in this
organ. Fluids are reabsorbed and feces are passed along for defecation.
3 The first 10 inches of the small intestine is called the duodenum, which is the
location of the ampulla of Vater consisting of the common bile and pancreatic
duct.
4 The liver is responsible for removing potentially toxic substances from the
blood. However, the liver also aids in digestion through the production of bile.
PTS: 1 CON: Hospital patient-Centered Care
11. The nursing practitioner is performing research to obtain best practice information on the
topic of enteral feedings. Which information is least likely to be included in best practice
recommendations?
1. Residual checks can cause clogged tubes and the stoppage of feeding.
2. Measurement of residual volumes reflect gastric emptying and aspiration risk.
3. Stopping tube feedings based solely on residual findings can result in malnutrition.
4. Eliminating residual volume checks does not decrease hospital patient safety
with enteral feedings.
RIGHT ANSWER> 2
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Explain types of nasogastric tubes and their uses.
Source: pp. 632
Heading: Method of Enteral Feeding Delivery
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Evidence-Based Practice
Difficulty: Difficult
CLARIFICATION
1 Research reveals that residual checks can cause clogged tubes and the stoppage
of feeding.
2 Research does not support the belief that measurement of residual volumes
reflects gastric emptying and aspiration risk.
3 Research supports that stopping tube feedings based solely on residual findings
can result in malnutrition of the hospital patient.
4 Research states that eliminating residual volume checks does not decrease
hospital patient safety with enteral feedings.
PTS: 1 CON: Evidence-Based Practice
12. The nursing practitioner is providing care for a hospital patient who requires gastric
irrigation for a medication overdose. The nursing practitioner understands the use of an
orogastric tube requires which intervention?
1. The abdominal incision requires regular wound care.
2. The hospital patient needs careful observation for a sinus infection.
3. Suction equipment is needed at the bedside for nasal drainage.
4. The tube is temporary and is removed following treatment.
RIGHT ANSWER> 4
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Describe therapeutic measures used for hospital patients with gastrointestinal
disorders. Source: pp. 630
Heading: Therapeutic Measures for the Gastrointestinal, Hepatobiliary, and Pancreatic
Systems
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 An orogastric tube is not placed through an abdominal incision.
2 The use of an orogastric tube decreases the possibility of a sinus infection
because the tube is not inserted through the nares.
3 There is no reason to place suction equipment at the bedside for nasal drainage.
The orogastric tube is placed through the mouth.
4 The orogastric tube is placed through the hospital patient’s mouth and is
primarily used for short-term interventions such as flushing the stomach and
obtaining gastric secretions for diagnostics.
PTS: 1 CON: Hospital patient-Centered Care
13. The nursing practitioner is palpating the abdomen of a hospital patient reporting mild
abdominal pain in the upper right quadrant. How deep should the nursing practitioner
depress this hospital patient’s abdomen?
1. 1 inch
2. 2 inches
3. 3 inches
4. 4 inches
RIGHT ANSWER> 1
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Explain techniques used to conduct a physical examination of the abdomen.
Source: pp. 621
Heading: Abdomen
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Health Promotion and Maintenance
CL: Application (Applying) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 When palpating the abdomen of a hospital patient reporting mild abdominal
pain in the upper right quadrant, the nursing practitioner should depress the
abdomen no more than 1 inch.
2 Deep palpation of the abdomen is done only by physicians and highly skilled
nurses.
3 Deep palpation of the abdomen is done only by physicians and highly skilled
nurses.
4 Deep palpation of the abdomen is done only by physicians and highly skilled
nurses.
PTS: 1 CON: Hospital patient-Centered Care
14. The nursing practitioner is gathering data from a hospital patient in a physician’s office.
The hospital patient reports severe diarrhea, nausea, and abdominal pain. Which additional
data information will cause the nursing practitioner to report possible Clostridium difficile to
the HCP?
1. Osteoarthritis treated with anti-inflammatories
2. Currently in outhospital patient treatment for alcohol abuse
3. Recent hospitalization for treatment of pneumonia
4. History of poorly controlled type 2 diabetes mellitus
RIGHT ANSWER> 3
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: List data to collect when caring for a hospital patient with a disorder of the
gastrointestinal system, liver, gallbladder, or pancreas.
Source: pp. 663
Heading: Nursing Assessment of the Gastrointestinal, Hepatobiliary, and Pancreatic Systems
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Safe and Effective Care Environment—Coordinated
Care CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Hospital patients treated with anti-inflammatories for osteoarthritis are not likely
candidates for C difficile.
2 Hospital patients being treated for alcohol abuse are more likely to have other
gastrointestinal disorders rather than C difficile.
3 C difficile is a risk for hospital patients who have been recently hospitalized or
treated for an infection. The hospital patient was hospitalized and likely treated
with antibiotics for a respiratory infection.
4 A history of poorly controlled type 2 diabetes mellitus is not a reason to suspect
C difficile.
PTS: 1 CON: Hospital patient-Centered Care
15. The nursing practitioner is preparing to perform an abdominal examination. For which
reason will the nursing practitioner perform auscultation before palpation and percussion?
1. Palpation will alter or stimulate bowel sounds.
2. Percussion is painful and makes auscultation difficult.
3. Auscultation is expected and will relax the hospital patient.
4. Inspection is normally followed by auscultation.
RIGHT ANSWER> 1
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Explain the techniques used to conduct a physical examination of the abdomen.
Source: pp. 621
Heading: Physical Examination
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Health Promotion and Maintenance
CL: Analysis (Analyzing) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The nursing practitioner will need to listen to current bowel sounds. Palpation is
a physical
examination of the abdomen and will alter or stimulate bowel sounds.
2 Percussion is not expected to be painful.
3 Auscultation is an expected part of a physical examination of the abdomen, but
it does not necessarily relax the hospital patient.
4 Except when examining the abdomen, the routine order of physical
examination is inspection, percussion, palpation, and the auscultation.
PTS: 1 CON: Hospital patient-Centered Care
16. The nursing practitioner is providing care for a hospital patient 1 day after major
abdominal surgery. The hospital patient’s abdomen is distended and bowel sounds are
absent. Which treatment does the nursing practitioner expect the HCP to prescribe?
1. Insertion of a nasointestinal tube to stimulate peristalsis
2. Administration of medication to dissipate abdominal gas
3. Placement of a NG tube for decompression
4. Use of a rectal tube to clear flatus from the distal colon
RIGHT ANSWER> 3
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Explain the types of nasogastric tubes and their uses.
Source: pp. 672
Heading: Gastrointestinal Decompression
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 A nasointestinal tube is not used to stimulate peristalsis. This type of tube is
rarely used for decompression because it is difficult and slower to place and
may be uncomfortable.
2 Medication to dissipate abdominal gas is not an effective way to achieve
abdominal decompression.
3 The most common way to achieve abdominal decompression is by the
placement of an NG tube. The NG tube will also remove any fluid
accumulation related to poor or absent peristalsis.
4 The hospital patient with a distended abdomen 1 day after major abdominal
surgery is
not likely to benefit from a rectal tube to clear flatus from the colon.
PTS: 1 CON: Hospital patient-Centered Care
17. The nursing practitioner is caring for a hospital patient admitted with malnutrition related to
gastric disease. The HCP orders parenteral nutrition (PN). Which information does the nursing
practitioner consider regarding insulin therapy for this hospital patient?
1. The PN will likely cause diabetes mellitus.
2. A combination of insulins is used for control.
3. The hospital patient was identified as a prediabetic.
4. Temporary insulin coverage uses regular insulin.
RIGHT ANSWER> 4
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Describe therapeutic measures used for hospital patients with gastrointestinal
diseases. Source: pp. 673
Heading: Parenteral Nutrition
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 PN therapy causes elevated glucose levels as a response to the glucose in the
PN; the condition is temporary and glucose levels will return to normal after
the therapy is discontinued.
2 A combination of insulins is not used to control elevated glucose levels for a
hospital patient on PN therapy. Regular insulin is rapid acting and reduces the
current blood glucose level.
3 Elevated glucose blood levels with PN therapy do not occur because the hospital
patient
is identified as being prediabetic.
4 PN related hyperglycemia is a temporary condition that is treated with regular
insulin coverage.
PTS: 1 CON: Hospital patient-Centered Care
18. A hospital patient is being scheduled for a barium swallow test to rule out esophageal
strictures and gastric ulcer. Which pretesting information will the nursing practitioner
provide for the hospital patient?
1. Remain NPO for 12 hours prior to the procedure.
2. Increased fluid intake afterward should be water.
3. Do not smoke on the morning of the testing.
4. Notify the HCP if stools are abnormal in color.
RIGHT ANSWER> 3
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Describe therapeutic measures used for hospital patients with gastrointestinal
diseases. Source: pp. 612
Heading: Barium Swallow
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Medium
CLARIFICATION
1 The hospital patient having a barium swallow needs to be NPO for 6 hours
before the
test.
2 After the barium swallow, the hospital patient will need to increase fluid intake,
but the liquid is not restricted to water.
3 The hospital patient is encouraged not to smoke the morning of the barium
swallow
because smoking can stimulate gastric motility.
4 There is no reason to notify the HCP if the hospital patient’s stools are an
abnormal color after a barium swallow; stools are expected to be white in
appearance for 2 to 3 days.
PTS: 1 CON: Hospital patient-Centered Care
19. The nursing practitioner is providing care for a hospital patient prescribed to undergo a
basal cell secretion test. Which nursing action is incorrect?
1. An NG tube is inserted.
2. A syringe is used to suction specimens.
3. The NG tube is left unconnected between specimens.
4. Specimens are labeled in order of obtainment.
RIGHT ANSWER> 3
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Plan nursing care for hospital patients having diagnostic tests of the
gastrointestinal tract. Source: pp. 652
Heading: Gastric Analysis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 An NG tube is inserted to obtain gastric secretions every 15 minutes for a
period of 1 hour.
2 A syringe is used to suction specimens from the stomach. This method of
obtaining the specimens assures that no contamination occurs.
3 Between obtainment of the specimens, the NG tube is connected to wall
suction. The amount of gastric acid is also measured; too much hydrochloric
acid may indicate a peptic ulcer, and too little can indicate cancer or pernicious
anemia.
4 Collected specimens are labeled in the order by which they are obtained.
PTS: 1 CON: Hospital patient-Centered Care
MULTIPLE RESPONSE
1. The nursing practitioner is providing care for a hospital patient with gallbladder disease.
The hospital patient states, “What good is a gallbladder anyway?” The nursing practitioner is
aware that which digestive processes are a function of the gallbladder? (Select all that apply.)
1. Bile causes emulsification of large globules of fats into small globules.
2. Bile carries bilirubin and excess cholesterol through the intestines.
3. Bile secretion by the gallbladder is stimulated by the hormone secretin.
4. The solitary function of the gallbladder is to produce bile.
5. The liver ceases to produce bile if the gallbladder is diseased.
RIGHT ANSWER> 1, 2, 3
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Describe the function of each organ of the gastrointestinal tract and the accessory
glands: liver, gallbladder, and pancreas.
Source: pp.
615 Heading:
Liver
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. Bile is primarily responsible for the digestion of fats by a process called
emulsification, which breaks large fat globules into small globules.
2. Bile is responsible for carrying bilirubin and excess cholesterol through the
intestines to be excreted in the feces.
3. Bile secretion is stimulated by the hormone secretin. Ejection of bile from
the gallbladder is stimulated by cholecystokinin.
4. Bile is produced by the liver and stored in the gallbladder until secretion is
stimulated by secretin to aid in the digestion of fats.
5. When the gallbladder is diseased or removed, the liver will continue to
produce bile. However, without the stored bile in the gallbladder, fat
digestion is affected.
PTS: 1 CON: Hospital patient-Centered Care
2. The nursing practitioner is contributing to a hospital patient’s plan of care. Which
hospital patients does the nursing practitioner recommend as benefiting from PN?
(Select all that apply.)
1. A hospital patient who has esophageal cancer
2. A hospital patient scheduled for leg amputation
3. A hospital patient who is NPO for esophageal varices
4. A hospital patient who is postoperative for an appendectomy
5. A hospital patient with severe burns across the face and chest
RIGHT ANSWER> 1, 3, 5
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Describe therapeutic measures used for hospital patients with gastrointestinal
diseases. Pages: 634–635
Heading: Enteral Nutrition
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. The hospital patient with esophageal cancer may have difficulty swallowing
and need nutritional support via PN.
2. Surgery for the amputation of a limb does not routinely require PN nutrition.
3. The hospital patient being treated with esophageal varices is at risk for
bleeding if food passes through the esophagus. The hospital patient will
benefit from nutrition via PN.
4. A hospital patient who is postoperative for an appendectomy is not likely to
benefit
from nutrition via PN.
5. The hospital patient with burns across the face and chest may have difficulty
swallowing and need nutritional support via PN.
PTS: 1 CON: Hospital patient-Centered Care
3. The nursing practitioner is providing care for an older adult hospital patient. The hospital
patient states, “I don’t eat much anymore and I have terrible problems with my bowels.” Which
information does the nursing practitioner share with the hospital patient to explain the changes
as related to age? (Select all that apply.)
1. Decreased GI peristalsis contributes to constipation.
2. Constipation requires an increased intake of fluids and roughage.
3. Decreased sense of taste can cause a loss of desire to eat.
4. Periodontal disease can interfere with eating and healthy nutrition.
5. Decline of eating habits and nutrition is an expected part of aging.
RIGHT ANSWER> 1, 2, 3, 4
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Discuss how age affects the gastrointestinal tract and accessory glands.
Source: pp. 630
Heading: Aging and the Gastrointestinal, Hepatobiliary, and Pancreatic Systems
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Health Promotion and
Maintenance CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. Constipation is compounded by decreased GI peristalsis, which is an
expected manifestation of aging.
2. Older hospital patients need information about how to increase fluids and
dietary
roughage to improve bowel function.
3. An expected decrease in the sense of taste is a contribution to loss of appetite
in older adult hospital patients. Information of how to healthfully improve the
taste of food may be helpful.
4. With aging, periodontal disease can contribute to the inability to maintain
healthy nutrition. Dental care is encouraged and soft food preparation is
suggested.
5. A decline in eating habits and healthy nutrition is not considered an expected
part of aging.
PTS: 1 CON: Hospital patient-Centered Care
4. The nursing practitioner is providing care for a hospital patient with an NG tube for PN, an
IV line for fluids and medications, and a nasal cannula for oxygen therapy. Which safety
interventions does the nursing practitioner implement during care for this hospital patient?
(Select all that apply.)
1. Label or color-code feeding tubes and connectors.
2. Physically arrange the tubes for quick identification.
3. Write “Alert! For enteral use only” on all tube feeding bags.
4. Mark enteral tubes with a black marker for quick recognition.
5. During the handoff process, check tube origins and connections.
RIGHT ANSWER> 1, 3, 4
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Describe therapeutic measures used for hospital patients with gastrointestinal
diseases. Source: pp. 630
Heading: Method of Enteral Feeding Delivery
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Safe and Effective Care Environment—Safety and Infection
Control CL: Analysis (Analyzing)
Concept: Safety
Difficulty: Difficult
CLARIFICATION
1. When caring for a hospital patient with multiple tubes, all tubes should be
labeled as to
use. Color-coded tubes and connectors will assure that tubes are connected
correctly.
2. Arranging various tubes for quick identification is not fail-safe. If the hospital
patient
is repositioned, the tubes can be moved or displaced.
3. A warning needs to be written on all enteral feeding bags to prevent infusion
into the wrong tubes.
4. Marking the enteral tubes with a black marker is not safe unless it is part of
facility policy; other health care members may not recognize the meaning of
the marks.
5. At handoff, all tubes need to be checked for correct origins and connections.
PTS: 1 CON: Safety
COMPLETION
1. is the procedure performed via a GI intubation to remove a toxic substance that has
been ingested.
RIGHT ANSWER>
Lavage
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Explain types of nasogastric tubes and their uses.
Source: pp. 629
Heading: Gastrointestinal Intubation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION: Lavage is the process used to remove toxic substances ingested, either
accidently or intentionally, in a timely manner. An NG tube can be placed quickly and the
stomach “flushed” as often as needed to remove the ingested substance.
PTS: 1 CON: Hospital patient-Centered Care
2. The digestive enzymes are involved in the digestion of all four of the organic
molecule categories.
RIGHT ANSWER>
pancreatic
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Describe the functions of each organ of the gastrointestinal tract and of the
accessory glands: liver, gallbladder, and pancreas.
Source: pp. 625
Heading: Pancreas
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION: The enzyme pancreatic amylase digests starch to maltose. Pancreatic
lipase converts emulsified fats to fatty acids and monoglycerides. Trypsinogen is an inactive
enzyme that is changed to active trypsin in the duodenum. Trypsin digests polypeptides to
shorter chains of amino acids.
PTS: 1 CON: Hospital patient-Centered Care
Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal Disorders
MULTIPLE CHOICE
1. The nursing practitioner is providing care for a hospital patient who had surgical repair of a
paraesophageal hernia. The nursing practitioner observes that the hospital patient exhibits signs
of dysphagia during the first postoperative meal. Which action does the nursing practitioner take?
1. Offer the hospital patient fluids.
2. Cut the food into small pieces.
3. Report observation to the health care provider (HCP).
4. Assure hospital patient the problem is temporary.
RIGHT ANSWER> 3
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: Plan nursing care for hospital patients with hiatal hernia, peptic ulcer
disease, gastric bleeding, and gastric cancer.
Source: pp. 644
Heading: Hiatal Hernia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 If a hospital patient is having difficulty swallowing, fluids may increase the
problem and result in aspiration.
2 Cutting food into small pieces may improve the situation, but is considered an
attempt to correct the problem without addressing the cause.
3 After the repair of a paraesophageal hernia, dysphagia should be reported to the
HCP. The corrective fundoplication surgery may have the stomach fundus
wrapped too tight around the esophagus, causing food obstruction.
4 Food obstruction following repair of a paraesophageal hernia is not a
temporary or self-correcting condition.
PTS: 1 CON: Hospital patient-Centered Care
2. The nursing practitioner is teaching a hospital patient with gastroesophageal reflux related to
a hiatal hernia about body position for management of the disease process. Which hospital
patient statement indicates that teaching has been effective?
1. “I elevate the head of the bed 4 to 6 inches on blocks.”
2. “I elevate the foot of the bed 12 to 16 inches on blocks.”
3. “I sleep on my back with several pillows under my head.”
4. “I sleep in a recliner to elevate my head correctly.”
RIGHT ANSWER> 1
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal Disorders
Objective: Plan nursing care for hospital patients with hiatal hernia, peptic ulcer disease,
gastric bleeding, and gastric cancer.
Source: pp. 646
Heading: Gastroesophageal Reflux Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The hospital patient with gastroesophageal reflux needs to keep the head
elevated during sleep or when prone to rest. The head of the bed needs to be
solidly elevated with blocks to a height of 4 to 6 inches.
2 Elevating the foot of the bed to any height will place the hospital patient with
gastroesophageal reflux at risk for aspiration of gastric contents.
3 Ideally, the hospital patient with gastroesophageal reflux should sleep on the
back with the head elevated. However, pillows are not adequate to maintain a
solid, permanent elevation.
4 Not all hospital patients have a recliner or will be able to sleep comfortably in
one.
PTS: 1 CON: Hospital patient-Centered Care
3. The nursing practitioner is collecting health information from a hospital patient. Which
hospital patient statement will cause the nursing practitioner the most concern?
1. “My stool has been dark green and hard to pass lately.”
2. “Lately, I’ve had two or three loose, sticky, black stools every day.”
3. “Usually I move my bowels every day and the stool is light brown.”
4. “My stool is soft and dark brown; I usually move my bowels twice a day.”
RIGHT ANSWER> 2
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: Explain the pathophysiology, signs and symptoms, and diagnostic
testing for hiatal hernia, peptic ulcer disease, gastric bleeding, and gastric cancer. Source:
pp. 647
Heading: Gastric Bleeding
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Stool that is dark green and hard to pass can indicate constipation caused by an
iron preparation.
2 The nursing practitioner is most concerned from the hospital patient’s
description, which is indicative of blood loss causing black tarry stools
(melena) caused by slow bleeding from the upper gastrointestinal (GI) area.
3 The hospital patient’s description describes normal bowel function for many
persons.
More information is needed before becoming concerned about these
descriptions.
4 The hospital patient’s description describes normal bowel function for many
persons. More information is needed before becoming concerned about these
descriptions.
PTS: 1 CON: Hospital patient-Centered Care
4. The nursing practitioner is reinforcing teaching with a hospital patient who had a large
portion of the stomach surgically removed. For which condition related to the surgery will
the hospital patient need to receive vitamin B12 for life?
1. Sickle cell anemia
2. Pernicious anemia
3. Iron-deficiency anemia
4. Acquired hemolytic anemia
RIGHT ANSWER> 2
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: Explain the pathophysiology, signs and symptoms, and diagnostic
testing for hiatal hernia, peptic ulcer disease, gastric bleeding, and gastric cancer. Source:
pp. 655
Heading: Nursing Process for the Hospital patient Having Gastric
Surgery Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: Physiological Integrity—Reduction of
Risk Potential CL: Analysis (Analyzing)
Concept: Nutrition
Difficulty: Moderate
CLARIFICATION
1 Sickle cell anemia is an inherited blood disorder.
2 Vitamin B12 deficiency can occur after some or all of the stomach is removed
because intrinsic factor secretion is reduced or gone. Normally, vitamin B12
combines with intrinsic factor to prevent its digestion in the stomach and
promote its absorption in the intestines. Lifelong administration of vitamin B12
is required to prevent the development of pernicious anemia.
3 Iron deficiency anemia is caused by a low dietary intake of iron-rich foods.
4 Acquired hemolytic anemia is not related to gastric surgery.
PTS: 1 CON: Nutrition
5. The nursing practitioner reviews the laboratory results for a hospital patient during a
routine office visit. The results indicate a low hemoglobin level. The hospital patient
denies any obvious signs of illness. For which primary reason does the nursing
practitioner suspect the HCP will order gastric studies?
1. The condition can be related to low intrinsic factor.
2. Gastric bleeding is the likely cause of the anemia.
3. Type A chronic gastritis is asymptomatic.
4. The laboratory results have been noted previously.
RIGHT ANSWER> 1
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: Plan nursing care for hospital patients with acute and chronic
gastritis.
Source: pp. 655
Heading: Chronic Gastritis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction in Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 Chronic type A gastritis is often symptomatic except for anemia. In this
condition there is usually a deficiency of intrinsic factor secreted from the
stomach cells, which results in difficulty absorbing vitamin B12, resulting in
pernicious anemia.
2 Endoscopy and upper GI x-ray studies will be performed; however, gastric
aspirate analysis for the intrinsic factor will confirm the diagnosis in the
absence of bleeding.
3 Type A chronic gastritis is symptomatic; however, gastric studies will be
ordered to rule out type A or B gastritis as the cause of the hospital patient’s
anemia.
4 If the hospital patient’s laboratory results have been noted previously, the HCP
may
suspect a chronic condition. There is a need to rule out both type A and B
gastritis.
PTS: 1 CON: Hospital patient-Centered Care
6. The nursing practitioner is providing care for a hospital patient with a body mass index
(BMI) of 44, type 2 diabetes mellitus, sleep apnea, and was recently hospitalized for
congestive heart failure. The hospital patient is short of breath and ambulates with difficulty.
Which therapeutic management does the nursing practitioner suspect the HCP will initially
recommend?
1. Psychiatric treatment for poor self-esteem
2. Enrollment in an exercise program for the obese
3. Attendance at a weight-loss support group
4. Initiation of the process for bariatric surgery
RIGHT ANSWER> 4
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: Describe medical, surgical, and nursing management for obesity.
Source: pp. 653
Heading: Obesity
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 The hospital patient is likely to have poor self-esteem and may benefit from
psychiatric
treatment. However, the hospital patient needs immediate attention to the
manifestations
of obesity.
2 The hospital patient may benefit from an exercise program tailored to the needs
of a person who is obese. However, the hospital patient’s current condition and
abilities do
not support this as an initial response by the HCP.
3 Once the hospital patient’s condition is stabilized, continued weight loss can
be achieved by attending a weight-loss support group.
4 The hospital patient is exhibiting medical and physical indications that bariatric
surgery
is essential. The nursing practitioner should suspect this as the HCP’s initial
recommendation.
PTS: 1 CON: Hospital patient-Centered Care
7. The nursing practitioner is providing care to a hospital patient 3 days after a Billroth I
procedure. About which observation should the nursing practitioner be most concerned?
1. Pulse 58 beats per minute
2. Incisional pain score of 4 on a 1-to-10 scale
3. Hospital patient tearful while viewing the incision
4. Reports of abdominal cramping shortly after eating
RIGHT ANSWER> 4
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: Plan nursing care for hospital patients with hiatal hernia, peptic ulcer
disease, gastric bleeding, and gastric cancer.
Source: pp. 654
Heading: Gastric Surgery
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 A pulse of 58 beats per minute could be within the hospital patient’s normal
pulse
range.
2 Pain and the emotional reaction to the incision are psychosocial concerns and
are not the highest priority at this time.
3 Pain and the emotional reaction to the incision are psychosocial concerns and
are not the highest priority at this time.
4 Dumping syndrome is a complication of Billroth I procedure and occurs 5 to 30
minutes after eating. Symptoms include dizziness, tachycardia, fainting,
sweating, nausea, diarrhea, a feeling of fullness, and abdominal cramping.
PTS: 1 CON: Hospital patient-Centered Care
8. The nursing practitioner is reinforcing teaching provided to a hospital patient with a peptic
ulcer. Which hospital patient statement indicates understanding of the medication ranitidine?
1. “It clings to the ulcer.”
2. “It coats your stomach.”
3. “It neutralizes stomach acid.”
4. “It reduces production of gastric acid.”
RIGHT ANSWER> 4
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: List current pharmacological treatments used for peptic ulcer
disease.
Source: pp. 647
Heading: Peptic Ulcer Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Pharmacological
Therapies CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 This statement does not explain the purpose or mechanism of ranitidine.
2 This statement does not explain the purpose or mechanism of ranitidine.
3 This statement does not explain the purpose or mechanism of ranitidine.
4 Ranitidine reduces production of gastric acid, which aids in healing the ulcer.
PTS: 1 CON: Hospital patient-Centered Care
9. The nursing practitioner is asking about the type of bariatric surgery the hospital patient
had. The hospital patient states, “They folded my stomach inward and sutured the folds in
place.” Which surgery description does the nursing practitioner recognize?
1. Sleeve gastrectomy
2. Gastric plication
3. Roux-en-Y bypass
4. Gastric banding
RIGHT ANSWER> 2
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: Describe medical, surgical, and nursing management for obesity.
Source: pp. 655
Heading: Gastric Bypass
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 A sleeve gastrectomy is a bariatric surgery that removes approximately 75
percent of the stomach, leaving a slim, narrow tube.
2 The gastric plication is a bariatric surgery that folds the stomach inward and
sutures the folds together.
3 The Roux-en-Y bypass is a bariatric surgery that reduces the stomach size and
bypasses some of the small intestine.
4 Gastric banding involves the placement of an inflatable silicone band around
the upper portion of the stomach. The pouch can be made bigger or smaller by
injecting saline into the band through a skin port. The procedure is reversible.
PTS: 1 CON: Hospital patient-Centered Care
10. The nursing practitioner is caring for a hospital patient who has developed esophagitis
from gastroesophageal reflux disease (GERD). For which additional complication should
the nursing practitioner anticipate providing care to this hospital patient?
1. Laryngospasm
2. Bronchospasm
3. Barrett’s esophagus
4. Aspiration pneumonia
RIGHT ANSWER> 3
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: Explain the pathophysiology, signs and symptoms, and diagnostic
testing for hiatal hernia, peptic ulcer disease, gastric bleeding, and gastric cancer. Source:
pp. 645
Heading: Gastroesophageal Reflux Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Laryngospasm is not a complication typically associated with GERD.
2 Bronchospasm is not a complication typically associated with GERD.
3 Complications of GERD can result in esophagitis. Over time, this can lead to
changes in the epithelium of the esophagus and lead to Barrett’s esophagus, a
precancerous lesion.
4 Aspiration pneumonia is not a complication typically associated with GERD.
PTS: 1 CON: Hospital patient-Centered Care
11. The nursing practitioner is collecting data for a hospital patient who is taking lansoprazole
for peptic ulcer disease. Which data collection finding requires immediate intervention?
1. A rash
2. Tarry stools
3. Constipation
4. Changes in mental status
RIGHT ANSWER> 2
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: List current pharmacological treatments used for peptic ulcer
disease.
Source: pp. 647
Heading: Peptic Ulcer Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Pharmacological
Therapies CL: Application (Applying)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 A rash is not identified as an adverse effect of lansoprazole.
2 With lansoprazole administration, the nursing practitioner should assess for
epigastric or abdominal pain and for blood in stool (tarry stools), emesis, or
gastric aspirate.
Notify the physician if any evidence of bleeding has occurred.
3 Constipation is not identified as an adverse effect of lansoprazole.
4 Changes in mental status is not identified as an adverse effect of lansoprazole.
PTS: 1 CON: Safety
12. The nursing practitioner is providing care for a hospital patient who is experiencing
nausea and vomiting. Which pathological manifestation is unlikely to occur with
prolonged vomiting?
1. Anemia
2. Dehydration
3. Metabolic alkalosis
4. Electrolyte imbalance
RIGHT ANSWER> 1
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: Explain anorexia, nausea, and vomiting.
Source: pp. 651
Heading: Anorexia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The hospital patient is unlikely to experience anemia with prolonged vomiting.
However, vomiting of blood in any form can be a cause of anemia.
2 Dehydration is a risk related to prolonged vomiting due to the loss of body
fluids.
3 Metabolic alkalosis can occur with prolonged vomiting due to the loss of
hydrochloric acid from the stomach.
4 When there is a loss of fluid, there is also the risk for electrolyte imbalance
with prolonged vomiting.
PTS: 1 CON: Hospital patient-Centered Care
13. The nursing practitioner is providing care for a hospital patient who reports nausea
following chemotherapy. Which nursing intervention is unlikely to effectively manage
the hospital patient’s nausea?
1. Provide a quiet, odor-free, visually clean environment.
2. Give an antiemetic as needed and prescribed by the HCP.
3. Bring the hospital patient a small, bland meal to ease any hunger.
4. Provide frequent mouth care to remove noxious tastes.
RIGHT ANSWER> 3
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: Describe therapeutic measures and nursing care for anorexia,
nausea, and vomiting.
Source: pp. 645
Heading: Anorexia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The nursing practitioner needs to provide an environment that removes any
triggering stimuli for nausea.
2 An antiemetic medication is given to alleviate the sensation of nausea and
prevent vomiting.
3 Even a small, bland meal can trigger nausea and vomiting. The hospital patient
may be able to tolerate clear liquids, preferably water or ice chips. If liquids are
tolerated, crackers or dry toast may also be tolerated.
4 When hospital patients have sensations of nausea, it may be compounded by
noxious tastes in the mouth. Frequent mouth care is effective for eliminating
this
trigger, especially if the hospital patient has vomited.
PTS: 1 CON: Hospital patient-Centered Care
14. A hospital patient who had bariatric surgery presents at the HCP’s office and is diagnosed
with aphthous stomatitis. Given the hospital patient’s medical history, the nursing practitioner
recognizes which cause of the condition is most likely?
1. Vitamin B12 deficiency
2. Emotional stress
3. Recent dental work
4. Menstruation
RIGHT ANSWER> 1
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: Describe medical, surgical, and nursing management for obesity.
Source: pp. 642
Heading: Oral Inflammatory Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The hospital patient has oral inflammation. Given the medical history of
bariatric
surgery, the most likely cause of the condition is the lack of vitamin B12.
2 The hospital patient may or may not have emotional stress. There is no specific
information in the question to support this cause.
3 Oral inflammation may occur after recent dental work; however, there is no
specific information in the question to support this cause.
4 Menstruation can be a trigger for oral inflammation; however, there is no
specific information in the question to support this cause.
PTS: 1 CON: Hospital patient-Centered Care
15. The nursing practitioner is providing care for a hospital patient who underwent a Billroth
I surgery for stomach cancer. Which nursing care is most important during the postoperative
period for this hospital patient?
1. Medicating for pain to promote coughing and deep breathing
2. Assisting the hospital patient out of bed to prevent clot formation
3. Observing the surgical dressing to recognize excessive bleeding
4. Monitoring the amount and type of drainage from the NG tube
RIGHT ANSWER> 1
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: Plan care for hospital patients with hiatal hernia, peptic ulcer disease,
gastric bleeding, and gastric cancer.
Source: pp. 643
Heading: Gastric Cancer
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction in Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 After any surgery with general anesthesia, the most important issue is the
establishment and maintenance of a patent airway. The location of this hospital
patient’s surgery will make it difficult to cough and deep breathe; adequate pain
management is essential.
2 All surgical hospital patients need to be out of bed and/or ambulating as soon
as possible to prevent the formation of blood clots. However, airway
maintenance and oxygenation are the most important postoperative care.
3 Surgical hospital patients always need to be monitored for bleeding or
hemorrhage; in
this situation, airway management and oxygenation is the most important
concern.
4 It is likely that this hospital patient will have an NG tube. The nursing
practitioner will need to monitor for patency and drainage characteristics.
However, airway maintenance and
oxygenation are still the most important.
PTS: 1 CON: Hospital patient-Centered Care
16. The nursing practitioner is providing care for a hospital patient who is receiving
chemotherapy and radiation as treatment for esophageal cancer. Which factor in the care
of this hospital patient is the nurse’s least concern?
1. Risk of choking
2. The ability to speak
3. Meeting nutritional needs
4. Effective pain management
RIGHT ANSWER> 2
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: Plan care for hospital patients with hiatal hernia, peptic ulcer disease,
gastric bleeding, and gastric cancer.
Source: pp. 643
Heading: Esophageal Cancer
Integrated Process: Clinical Problem-Solving Process (Nursing Process) CL:
Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 With esophageal cancer, it is possible for the esophagus to become narrow; the
condition is exacerbated by the radiation therapy. The risk for choking and/or
aspiration is high and of great concern.
2 The hospital patient may or may not be able to speak. Alternate methods of
communication make this the least concern for the nurse.
3 Due to the disease process and treatments, the hospital patient may have
difficulty meeting nutritional needs. Nutritional deficiency is of great concern
to the nurse.
4 Pain related to the diagnosis and treatment of esophageal cancer can be intense.
Management of pain is more important than concern about the ability to speak.
PTS: 1 CON: Hospital patient-Centered Care
17. The nursing practitioner works with cancer hospital patients. Which factor does the
nursing practitioner identify as a cause of gastric cancer?
1. The female gender
2. Oxidants in fruit and vegetables
3. High intake of smoked fish and meats
4. Medical history of iron deficiency anemia
RIGHT ANSWER> 3
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: Explain the pathophysiology, signs and symptoms, and diagnostic
testing for hiatal hernia, peptic ulcer disease, gastric bleeding, and gastric cancer. Source:
pp. 652
Heading: Gastric Cancer
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The male gender has a higher incidence of gastric cancer does than the female
gender.
2 Fruits and vegetables are a high source of antioxidants, which help prevent
cancer.
3 Hospital patients with a diet high in smoked fish and meats have an increased
risk for gastric cancer.
4 A medical history of pernicious anemia, not iron deficiency anemia, is a cause
of gastric cancer.
PTS: 1 CON: Hospital patient-Centered Care
18. The nursing practitioner is preparing to provide care for a hospital patient diagnosed with
peptic ulcer disease. Which pathophysiological characteristic will the nursing practitioner
correctly associate with the hospital patient’s diagnosis?
1. Erosion is confined to the stomach and esophagus.
2. A common cause is an infection from Helicobacter pylori.
3. Surgery to increase mucus will heal the ulcerations.
4. Gastric ulcers occur more frequently than do peptic ulcers.
RIGHT ANSWER> 2
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: Explain the pathophysiology, signs and symptoms, and diagnostic
testing for hiatal hernia, peptic ulcer disease, gastric bleeding, and gastric cancer. Source:
pp. 647
Heading: Peptic Ulcer Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 With peptic ulcer disease, the stomach, esophagus, pylorus, and duodenum can
all be involved.
2 The most common cause of peptic ulcer disease is infection from H pylori.
3 Surgery for peptic ulcer disease is not performed to increase mucous secretion.
4 Peptic ulcers occur more frequently than gastric ulcers.
PTS: 1 CON: Hospital patient-Centered Care
19. The nursing practitioner is providing care for a hospital patient who is diagnosed with
a Mallory-Weiss tear (MWT). Which treatment for the condition is the nursing practitioner
expecting?
1. Immediate emergency surgery
2. Ice lavage to the damaged esophagus
3. Positioning in reverse Trendelenburg’s
4. An injection of epinephrine
RIGHT ANSWER> 4
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: Explain the pathophysiology, signs and symptoms, and diagnostic
testing for hiatal hernia, peptic ulcer disease, gastric bleeding, and gastric cancer.
Source: pp. 646
Heading: Mallory-Weiss Tear
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 An MWT does not require immediate emergency surgery. The tear is usually
self-healing without intervention and bleeding stops within a few hours. During
endoscopy, endoclips may be placed to stop bleeding.
2 Ice lavage is not used in the treatment of MWT. Ice lavage is likely to be used
to stop the bleeding of esophageal varices.
3 Positioning the hospital patient in reverse Trendelenburg’s is
contraindicated with a MWT. The position will cause blood to move
upward in the esophagus and increase the risk for aspiration.
4 The hospital patient with MWT may receive an injection of epinephrine, which
is a
vasoconstrictor, to control bleeding.
PTS: 1 CON: Hospital patient-Centered Care
20. The nursing practitioner is providing care for a hospital patient with multiple injuries from
a serious car accident. The HCP prescribes a diet as tolerated and administration of sucralfate
orally. Which condition and goal does the nursing practitioner associate with the HCP’s
prescriptions?
1. Prevention of peptic ulcer disease
2. Decreased healing from malnutrition
3. Management of causes of shock
4. Formation of stress ulcers
RIGHT ANSWER> 4
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: Plan care for hospital patients with hiatal hernia, peptic ulcer disease,
gastric bleeding, and gastric cancer.
Source: pp. 652
Heading: Stress-Induced Gastritis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The HCP’s prescriptions are aimed at the prevention of stress ulcers.
2 The HCP is attempting to prevent the formation of stress ulcers by making an
effort to keep food in the stomach and reduce gastric erosion.
3 Neither of the HCP’s prescriptions will manage shock.
4 The stress response to illness causes decreased blood flow to the stomach and
small intestine, which can result in damage to the gastric mucosa. The goal of
the HCP’s prescription is to reduce stress ulcers. Feeding the hospital patient
within 24 hours and giving prophylactic sucralfate (to form a gel that binds to
the base of the ulcer) are appropriate treatments. Antacids and histamine can
also be prescribed.
PTS: 1 CON: Hospital patient-Centered Care
21. The nursing practitioner is planning care for a hospital patient admitted for gastric
bleeding, which is presently controlled. If the hospital patient experiences a recurrence of
bleeding, which manifestation will indicate to the nursing practitioner that the hospital
patient is experiencing hypovolemic shock?
1. Tachycardia and tachypnea
2. Dry mucous membranes
3. Change in level of consciousness
4. Reports of fatigue and thirst
RIGHT ANSWER> 1
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: Plan care for hospital patients with hiatal hernia, peptic ulcer disease,
gastric bleeding, and gastric cancer.
Source: pp. 651
Heading: Gastric Bleeding
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Tachycardia and tachypnea, along with hypotension, chills, palpations, and
diaphoresis, are all signs of hypovolemic shock.
2 Dry mucous membranes are indicative of a decrease in circulating blood
volume.
3 A change in the level of consciousness is indicative of a decrease in circulating
blood volume.
4 Hospital patient reports of fatigue and thirst are indicative of a decrease in
circulating
blood volume.
PTS: 1 CON: Hospital patient-Centered Care
MULTIPLE RESPONSE
1. The nursing practitioner is contributing to the care plan of a hospital patient admitted after a
massive gastric bleed. Which goals will the nursing practitioner consider during this process of
planning care? (Select all that apply.)
1. Recognize and treat hypovolemic shock.
2. Reassess for pain and medicate as needed.
3. Monitor and report signs of stress-induced ulcers.
4. Reassess for indications of electrolyte imbalances.
5. Implement measures to prevent or treat dehydration.
RIGHT ANSWER> 1, 4, 5
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: Plan care for hospital patients with hiatal hernia, peptic ulcer disease,
gastric bleeding, and gastric cancer.
Source: pp. 651
Heading: Gastric Bleeding
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. The hospital patient who experiences a massive gastric bleed is susceptible to
hypovolemic shock, which can be fatal.
2. The hospital patient who experiences a massive gastric bleed is not likely to
have pain (the question does not provide information to support the presence
of pain).
3. Stress-induced ulcers usually occur from serious illness or trauma. There is
no indication that the hospital patient is at risk for this development.
4. Because the hospital patient is likely to be hypovolemic due to a massive
gastric bleed, the nursing practitioner should be alert to signs of electrolyte
imbalances.
5. After a massive gastric bleed, the hospital patient is likely to be dehydrated
due to the
loss of blood. The option includes measures to correct the condition.
PTS: 1 CON: Hospital patient-Centered Care
2. The nursing practitioner instructs a hospital patient prescribed omeprazole for peptic ulcer
disease about the use of the medication. Which hospital patient statements indicate
understanding of the instructions? (Select all that apply.)
1. “I should not take antacids while I’m on this medication.”
2. “If I wish, I can open the capsule and sprinkle it on food.”
3. “I will take the capsule before eating a meal in the morning.”
4. “I will need to take this drug for 3 weeks for my ulcer to heal.”
5. “I will report any abdominal pain, diarrhea, or bleeding that occurs.”
RIGHT ANSWER> 3, 5
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: List current pharmacological treatments used for peptic ulcer
disease.
Source: pp. 647
Heading: Peptic Ulcer Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Safety
Difficulty: Difficult
CLARIFICATION
1. Antacids are not contraindicated when omeprazole is prescribed; instructions
are not understood.
2. Omeprazole is a time-released medication and the capsule should not be
opened, or the contents sprinkled on food; instructions are not understood.
3. The hospital patient is instructed to take omeprazole in the morning before a
meal;
instructions are understood.
4. The hospital patient will need to take omeprazole for 4 to 8 weeks for ulcer
healing to occur; instructions are not understood.
5. The hospital patient needs to report abdominal pain, diarrhea, or bleeding to
the HCP
during the medication therapy; instructions are understood.
PTS: 1 CON: Safety
3. A hospital patient who had extensive gastric surgery for stomach cancer reports feeling sick
and diaphoretic with abdominal cramping about 20 minutes after eating. The nursing
practitioner is providing information about dumping syndrome. Which information is correct?
(Select all that apply.)
1. The hospital patient is experiencing one of the most common complications.
2. Food enters the jejunum without adequate amounts of digestive juices.
3. The condition is lifelong and may require treatment with insulin.
4. High concentrations of electrolytes and sugar draws fluid into the bowel.
5. The hospital patient will need to eat some candy or drink juice containing sugar.
RIGHT ANSWER> 1, 2, 4, 5
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: Plan care for hospital patients with hiatal hernia, peptic ulcer disease,
gastric bleeding, and gastric cancer.
Source: pp. 653
Heading: Dumping Syndrome
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. Dumping syndrome is one of the most common complications following
extensive gastric surgery.
2. Dumping syndrome occurs when food rapidly enters the jejunum without
being thoroughly mixed with digestive juices.
3. The dumping syndrome may last up to 6 months after gastric surgery and
will gradually decrease over time.
4. The concentration of electrolytes and sugar is diluted when the body draws
fluid into the bowel and from the circulating blood volume. The rapid drop in
circulating fluid volume causes many of the symptoms of dumping syndrome.
5. In addition, high sugar concentrations trigger the release of insulin, which
results in hypoglycemia about 2 hours after eating. The hospital patient needs
a rapid source of oral sugar to alleviate the symptoms.
PTS: 1 CON: Hospital patient-Centered Care
COMPLETION
1. A hospital patient’s ideal body weight is 150 lb. At which weight would the hospital
patient be considered obese? Enter the numeral only.
RIGHT ANSWER>
180
Chapter: Chapter 33. Nursing Care of Hospital patients With Upper Gastrointestinal
Disorders Objective: Describe medical, surgical, and nursing management of obesity.
Source: pp. 655
Heading: Obesity
Integrated Process: Clinical Problem-Solving Process
Hospital patient Need: Physical Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION: A weight that is 20 percent over ideal weight is considered obese.
Calculate this by multiplying the current weight by 20 percent, or 150 × 0.20 = 30. Then
add this value of 30 to the current weight of 150 lb. The hospital patient would need to
weigh 180 lb to be considered obese
PTS: 1 CON: Hospital patient-Centered Care
Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders
MULTIPLE CHOICE
1. The nursing practitioner is providing care for a hospital patient diagnosed with obstipation.
Which condition is the nursing practitioner aware as being unrelated to the hospital patient’s
diagnosis?
1. History of repeatedly ignoring the urge to defecate
2. Colon and rectal tissue insensitive to presence of feces
3. Medical history of obesity and cardiovascular disorders
4. Stronger stimulation needed to produce a peristaltic rush
RIGHT ANSWER> 3
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Identify the causes, signs and symptoms, and therapeutic
measures of constipation and diarrhea.
Source: pp. 659
Heading: Constipation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Moderate
CLARIFICATION
1 Obstipation is the term for long-standing constipation. A hospital patient history
of repeatedly ignoring the urge to defecate is a strong contributor to the
condition.
2 The musculature of the bowel and rectal mucous membrane become insensitive
to the presence of feces.
3 A medical history of obesity and cardiovascular disorders are unrelated to
intermittent or long-standing constipation.
4 Once obstipation occurs, stronger stimulation is needed to produce the
peristaltic rush required for defecation.
PTS: 1 CON: Elimination
2. The nursing practitioner is providing care for a hospital patient who reports feeling
constipated, yet passes frequent small liquid stools. The nursing practitioner suspects an
impaction. Which statement by the hospital patient causes the nursing practitioner concern?
1. “I took some medication to stop the diarrhea.”
2. “I have strained but cannot have a good bowel movement.”
3. “When I do pass feces, they are small, hard, and dry.”
4. “My stomach is so bloated that I am uncomfortable.”
RIGHT ANSWER> 1
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Identify the causes, signs and symptoms, and therapeutic
measures of constipation and diarrhea.
Source: pp. 659
Heading: Constipation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Moderate
CLARIFICATION
1 Fecal impaction results when the fecal mass is so dry it cannot be passed. Small
amounts of liquid stool ooze around the fecal mass and cause incontinence of
liquid stools. The nursing practitioner is concerned if the hospital patient takes
antidiarrheal medication, which can make the condition worse.
2 Straining is not uncommon by a hospital patient who has constipation or a
bowel impaction. There is no information in the question to indicate a cardiac,
neurologic, or respiratory concern.
3 The hospital patient is describing the expected appearance of feces during
constipation; the passage of some stool does not support the presence of an
impaction.
4 With constipation or impaction, the hospital patient will frequently experience
bloating
and pain.
PTS: 1 CON: Elimination
3. The nursing practitioner notes that a hospital patient with a history of a myocardial
infarction is straining during defecation. Which response by the nursing practitioner is best?
1. “Be careful, you might get a headache when you push so hard.”
2. “It is important that you not strain because it could cause damage to your heart.”
3. “Your blood pressure gets very low when you strain like that and you could faint.”
4. “Chronic constipation often causes a dilated colon, it is good that you are staying
empty.”
RIGHT ANSWER> 2
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Plan nursing care and teaching for hospital patients with
constipation or diarrhea. Source: pp. 659
Heading: Constipation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Moderate
CLARIFICATION
1 The nurse’s response does not address the greatest concern for the hospital
patient.
2 Straining to have a bowel movement (Valsalva’s maneuver) can result in
cardiac, neurologic, and respiratory complications. If the hospital patient has a
history of heart failure, hypertension, or recent myocardial infarction, straining
can lead to cardiac rupture and death.
3 When straining, Valsalva’s maneuver can actually cause the hospital patient’s
blood
pressure to rise.
4 Chronic constipation can cause a dilated colon (megacolon) proximal to the dry
fecal mass and obstruct the colon. However, this is not the greatest concern for
this hospital patient.
PTS: 1 CON: Elimination
4. The nursing practitioner is providing care for a hospital patient postoperative for the
placement of a colostomy for colon cancer. When examining the stoma, which finding
causes the nursing practitioner to immediately contact the health care provider (HCP)?
1. Large, beefy-red in color
2. Small in size and pink color
3. Large and seeping drainage
4. Dusky color, dryness noted
RIGHT ANSWER> 4
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Plan nursing care and teaching for a hospital patient with an
ostomy.
Source: pp. 679
Heading: Colostomy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The colostomy stoma appears large and beefy-red in color after surgery and
during a period of healing.
2 The colostomy stoma will eventually appear small and pink in color.
3 The initial appearance of a colostomy stoma is large and may exhibit some
seeping drainage.
4 A dusky-colored stoma that appears dry needs to be reported immediately to the
HCP. The finding is indicative of compromised circulation to the stoma and
additional surgery may be necessary.
PTS: 1 CON: Hospital patient-Centered Care
5. The nursing practitioner is gathering data on a hospital patient with severe diarrhea for 3
days. The hospital patient reports being out of the country for 2 weeks. Laboratory results
indicate the presence of red blood cells (RBCs) and mucus in a stool sample. For which
conditions does the nursing practitioner expect further testing?
1. Cholera, typhoid, typhus, or amebiasis
2. Shigellosis, salmonellosis, or reginal enteritis
3. Large bowel cancer or intestinal tuberculosis
4. Celiac disease, or irritable bowel syndrome
RIGHT ANSWER> 1
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal Disorders
Objective: Describe pathophysiology, therapeutic measures, nursing care, and teaching for
hospital patients with inflammatory and infectious disorders of the lower gastrointestinal
tract.
Source: pp. 662
Heading: Diarrhea
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Difficult
CLARIFICATION
1 The presence of diarrhea after traveling out of the country and the hospital
patient’s manifestations and laboratory test results indicate possible cholera,
typhoid, typhus, or amebiasis. The most applicable information is the presence
of RBCs and mucus in the stool sample.
2 Shigellosis, salmonellosis, or reginal enteritis would manifest with the presence
of white blood cells (WBCs) and mucus in the stool sample.
3 Intestinal tuberculosis would test with WBCs in the stool; large bowel cancer
would cause RBCs in the stool. The most significant clue to the hospital
patient’s condition is travel outside the country.
4 Celiac disease and irritable bowel syndrome may cause some of the same
laboratory results, but are not linked to travel outside of the country.
PTS: 1 CON: Elimination
6. The nursing practitioner is providing discharge teaching to a hospital patient with
diarrhea. Which hospital patient statement indicates that teaching has been effective?
1. “It is important that I increase fluid intake to prevent dehydration.”
2. “I am at increased risk for a ruptured bowel, so I must remain on bedrest.”
3. “I should tell future health care workers that I’ve been diagnosed with
obstipation.”
4. “My risk for a urinary tract infection is very high, so I should call the doctor if I
have pain.”
RIGHT ANSWER> 1
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Plan nursing care and teaching for hospital patients with
constipation or diarrhea. Source: pp. 662
Heading: Diarrhea
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Moderate
CLARIFICATION
1 Weakness and dehydration from fluid loss may occur with diarrhea.
2 A ruptured bowel is not an adverse effect of diarrhea.
3 Obstipation is a term for chronic constipation.
4 The hospital patient’s risk for urinary tract infection is not high because of
diarrhea.
PTS: 1 CON: Elimination
7. The nursing practitioner is contributing to the plan of care for a hospital patient with
gluten enteropathy (celiac disease). Which food(s) does the nursing practitioner
recommend be eliminated from the diet of the hospital patient?
1. Red meats
2. Milk and milk products
3. Fresh fruits and vegetables
4. Wheat, rye, oats, and barley
RIGHT ANSWER> 4
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Plan nursing care and teaching for hospital patients with
absorption disorders.
Source: pp. 675
Heading: Absorption Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Elimination
Difficulty: Moderate
CLARIFICATION
1 Gluten is not found in red meats.
2 Gluten is not found in milk and milk products.
3 Gluten is not found in fresh fruits and vegetables.
4 Gluten is a protein found in wheat, barley, oats, and rye. In celiac disease, a
high-calorie, high-protein, gluten-free diet is ordered to relieve symptoms and
improve nutritional status.
PTS: 1 CON: Elimination
8. The nursing practitioner is collecting data from a hospital patient who is reporting
abdominal pain. Which symptom suggests that the hospital patient is experiencing
appendicitis?
1. Suprapubic pain
2. Midepigastric pain
3. Substernal pain that radiates to the back
4. Pain in the right lower abdominal quadrant
RIGHT ANSWER> 4
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: List data to collect when caring for hospital patients with lower
gastrointestinal disorders. Source: pp. 663
Heading: Inflammatory and Infectious Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing)
Concept: Inflammation
Difficulty: Moderate
CLARIFICATION
1 Appendicitis pain is not located in the suprapubic area.
2 Appendicitis pain is not located in the midepigastric area.
3 Appendicitis pain is not located in the substernal area with radiation to the
back.
4 Signs and symptoms of appendicitis include fever, increased white blood cells,
and generalized pain in the upper abdomen. Within hours of onset, the pain
usually becomes localized to the right lower quadrant at McBurney’s point.
PTS: 1 CON: Inflammation
9. The nursing practitioner is monitoring a hospital patient recovering from an emergency
appendectomy. Which finding does the nursing practitioner report immediately to the HCP?
1. Pain at the operative site
2. Absence of bowel sounds
3. Abdomen rigid on palpation
4. 3-cm spot of bloody drainage on dressing
RIGHT ANSWER> 3
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Describe pathophysiology, therapeutic measures, nursing care, and
teaching for hospital patients with inflammatory and infectious disorders of the lower
gastrointestinal tract.
Source: pp. 663
Heading: Inflammatory and Infectious Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Inflammatory and Infectious Disorders
Difficulty: Moderate
CLARIFICATION
1 The hospital patient is expected to experience postoperative pain.
2 Absence of bowel sounds is expected after anesthesia.
3 With peritonitis, a life-threatening complication, abdominal rigidity is present.
The physician should be notified promptly for treatment orders.
4 Some bleeding is expected after surgery.
PTS: 1 CON: Inflammatory and Infectious Disorders
10. A hospital patient is informed, after a colonoscopy, of diverticulosis. The hospital patient
asks the nursing practitioner about the causes and management of the condition. Which
information shared by the nursing practitioner is inaccurate?
1. Chronic constipation is a common precursor to the condition.
2. A major management intervention is an increase in dietary fiber.
3. Nuts and foods with seeds and hulls are avoided to prevent infection.
4. Weight control, a healthy diet, and exercise are good management interventions.
RIGHT ANSWER> 3
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Describe pathophysiology, therapeutic measures, nursing care, and
teaching for inflammatory bowel disease.
Source: pp. 664
Heading: Diverticulosis and Diverticulitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Moderate
CLARIFICATION
1 Diverticulosis is most common in hospital patients who have had chronic
constipation, which increases the pressure in the bowel and causes outpouching
in weaker/weakened areas.
2 Hospital patients with diverticulosis are encouraged to increase dietary fiber to
help
promote healthy bowel function and prevent diverticulitis.
3 Some HCPs will recommend avoidance of nuts, seeds, and hulls with a
diagnosis of diverticulosis; however, this is not proven to prevent diverticulitis.
4 Weight control, a healthy diet, and exercise will all promote healthy bowel
function.
PTS: 1 CON: Elimination
11. The nursing practitioner is reinforcing teaching to a hospital patient with
diverticulosis about how to avoid complications. Which hospital patient statement
indicates that teaching has been effective?
1. “I will avoid milk and milk products.”
2. “I should avoid very hot and spicy foods.”
3. “I will increase fluids and fiber in my diet.”
4. “I should cook vegetables thoroughly before eating.”
RIGHT ANSWER> 3
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Describe pathophysiology, therapeutic measures, nursing care, and
teaching for hospital patients with inflammatory and infectious disorders of the lower
gastrointestinal tract.
Source: pp. 664
Heading: Diverticulosis and Diverticulitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Inflammatory and Infectious Disorders
Difficulty: Moderate
CLARIFICATION
1 Avoiding milk products will not prevent the development of complications
from diverticulosis.
2 Avoiding hot and spicy foods will not prevent the development of
complications from diverticulosis.
3 Diverticulosis is managed by preventing constipation. Diverticulitis can be
prevented by increasing dietary fiber to prevent constipation and onset of
diverticulosis.
4 Cooking vegetables will not prevent the development of complications from
diverticulosis. However, it does decrease the fiber content of the vegetables.
PTS: 1 CON: Inflammatory and Infectious Disorders
12. A hospital patient receives a diagnosis of Crohn disease and states, “I don’t understand
anything about this disease.” Which information provided by the nursing practitioner is most
helpful at this time?
1. The condition is an autoimmune inflammatory bowel disease.
2. Treatment will focus on symptom management and medications.
3. Inflamed areas are not continuous lesions along the intestine.
4. Connections between organs called fistulas and fissures may develop.
RIGHT ANSWER> 2
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Describe pathophysiology, therapeutic measures, nursing care, and
teaching for hospital patients with inflammatory and infectious disorders of the lower
gastrointestinal tract.
Source: pp. 667
Heading: Inflammatory Bowel Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Elimination
Difficulty: Difficult
CLARIFICATION
1 The hospital patient will eventually want to know more about the pathology of
the disease; however, initially the greatest interest or concern will be focused on
treatment and management.
2 The most helpful information for the hospital patient at this time will be that
treatment will focus on symptom management and medications.
3 The hospital patient will eventually want to know more about the pathology of
the disease. The most helpful information at this time is focused on management
and treatment.
4 Informing the hospital patient about the formation of fistulas and fissures at this
time is likely to cause hospital patient distress and/or confusion.
PTS: 1 CON: Elimination
13. The nursing practitioner is providing care for a hospital patient with advanced Crohn
disease who has developed multiple complications of the disease and no longer responds to
treatment. The HCP is recommending surgery. Which detail about the hospital patient’s
surgery does the nursing practitioner comprehend?
1. The hospital patient is not a candidate for a Kock pouch.
2. The hospital patient will be considered cured after the surgery.
3. The narrowed parts of the colon will be removed.
4. The formation of a colostomy is the surgical goal.
RIGHT ANSWER> 1
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Describe pathophysiology, therapeutic measures, nursing care, and
teaching for hospital patients with inflammatory and infectious disorders of the lower
gastrointestinal tract.
Source: pp. 667
Heading: Crohn Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Difficult
CLARIFICATION
1 The hospital patient is not a candidate for the formation of a Kock pouch, which
is formed from part of the hospital patient’s ileum. With Crohn disease, there is
a high risk
that the pouch will also become diseased.
2 There is no cure for Crohn disease; the goal of care is for the management of
symptoms and medication therapy. When the disease no longer responds to
treatment, surgery is recommended.
3 Because Crohn disease is a progressive condition with lesions intermittently
located throughout the length of the intestine (skip-lesions), removing the
narrowed parts of the colon will not arrest the manifestations.
4 The surgery for this hospital patient is likely to involve removal of the colon.
The ostomy will be either an ileostomy or an ileorectal anastomosis.
PTS: 1 CON: Elimination
14. The nursing practitioner is monitoring a hospital patient and finds a bulging area in the
hospital patient’s groin. Which additional finding causes the nursing practitioner the most
concern?
1. The bulging disappears at times.
2. The WBC count is 10,000/mm3.
3. The hospital patient develops pain at the site and vomiting.
4. The bulging occurs when the hospital patient coughs or strains.
RIGHT ANSWER> 3
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Plan nursing care for an abdominal hernia.
Source: pp. 644
Heading: Abdominal Hernias
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The disappearance of the bulge means the hernia can be reduced.
2 An elevated WBC count means an infection is present, which is not expected or
common with a hernia.
3 An incarcerated hernia may become strangulated if the blood and intestinal
flows are completely cut off. Symptoms are pain at the site of the strangulation,
nausea and vomiting, and colicky abdominal pain.
4 Bulging with coughing or straining is an indication that a hernia is present.
PTS: 1 CON: Hospital patient-Centered Care
15. The nursing practitioner is providing care for a hospital patient diagnosed with celiac
disease. The hospital patient initially presented with a skin rash with severe pruritus and
blistering. Which additional manifestation is the nursing practitioner unlikely to associate with
the hospital patient’s condition?
1. Gas and abdominal bloating
2. Frequent loose bulky stools
3. Moderate amount of weight gain
4. Foul-smelling, gray-colored stool
RIGHT ANSWER> 3
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Planning nursing care and teaching for hospital patients with
absorption disorders. Source: pp. 675
Heading: Absorption Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Moderate
CLARIFICATION
1 The nursing practitioner will associate gas and abdominal bloating with celiac
disease.
2 The nursing practitioner will associate frequent loose bulky stools with celiac
disease, related to passage of underdigested food.
3 The hospital patient with celiac disease is likely to exhibit signs of malnutrition;
weight
gain is not expected.
4 Foul-smelling, gray-colored stool (steatorrhea) is caused by increased fat due to
malabsorption.
PTS: 1 CON: Elimination
16. The nursing practitioner is caring for a hospital patient admitted with a possible bowel
obstruction. Which hospital patient symptom should cause the nursing practitioner the most
concern?
1. Flank pain
2. Fecal vomiting
3. Watery diarrhea
4. Occult blood in the stool
RIGHT ANSWER> 2
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Describe causes, signs and symptoms, therapeutic measures, and
nursing care for intestinal obstruction.
Source: pp. 676
Heading: Intestinal Obstruction
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Moderate
CLARIFICATION
1 Flank pain is not associated with a bowel obstruction.
2 As a bowel obstruction becomes more extreme, peristaltic waves reverse,
propelling the intestinal contents toward the mouth, eventually leading to fecal
vomiting.
3 Watery diarrhea would not be present with a bowel obstruction.
4 Occult blood in the stool is not present with a bowel obstruction.
PTS: 1 CON: Elimination
17. A hospital patient with ulcerative colitis is scheduled for a colectomy with formation of an
ileoanal pouch. The hospital patient is reviewing information presented by the HCP regarding
possible surgical complications. Which statement by the hospital patient causes the nursing
practitioner to report a misunderstanding to the HCP?
1. “I will defecate in a normal manner after healing with the pouch.”
2. “I will still need to watch for obstruction or pouch inflammation.”
3. “The placement of an ileostomy is temporary until healing is complete.”
4. “Formation of the pouch is part of the cure of my condition.”
RIGHT ANSWER> 4
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Describe pathophysiology, therapeutic measures, nursing care, and
teaching for hospital patients with inflammatory and infectious disorders of the lower
gastrointestinal tract.
Source: pp. 682
Heading: Ulcerative Colitis
Integrated Process: Communication and Documentation
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Collaboration
Difficulty: Difficult
CLARIFICATION
1 The hospital patient will be able to defecate normally with the formation of an
ileoanal pouch, which will hold stool and preserve the function of the retained
anal
sphincter.
2 With the described surgery, the hospital patient will need to be aware of the
symptoms of a bowel obstruction or pouch inflammation (pouchitis).
3 An ileostomy will be temporarily placed until the ileoanal pouch is healed.
4 The nursing practitioner needs to report a hospital patient misunderstanding to
the HCP about the planned surgery being curative. A colectomy is curative for
ulcerative colitis; however, the placement of an ileoanal pouch is not curative.
The retained tissue is still subject to the disease process.
PTS: 1 CON: Collaboration
18. On admission, a hospital patient with gastrointestinal bleeding had the following vital signs:
blood pressure (BP) 140/80 mm Hg, pulse 72 beats/min, respirations 14 breaths/min, and
temperature 98.8°F (37.1°C) orally. Which finding does the licensed practical nurse/licensed
vocational nursing practitioner (LPN/LVN) report immediately to the registered nursing
practitioner (RN) or HCP?
1. Pulse 78 beats/min
2. Crampy abdominal pain
3. Occult blood in the stool
4. BP 104/68 mm Hg
RIGHT ANSWER> 4
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Describe causes, signs and symptoms, therapeutic measures, and
nursing care for lower gastrointestinal bleeding.
Source: pp. 679
Heading: Inflammatory Bowel Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Collaboration
Difficulty: Moderate
CLARIFICATION
1 The hospital patient’s pulse remains within normal range.
2 Crampy abdominal pain does not indicate acute distress.
3 Occult blood in the stool would be expected in the hospital patient with
gastrointestinal
bleeding.
4 A BP of 104/68 mm Hg is a significant drop from the hospital patient’s prior
pressure and may indicate that the hospital patient is going into shock. Prompt
treatment is needed.
PTS: 1 CON: Collaboration
19. The nursing practitioner is providing care for a hospital patient admitted with a complete,
nonmechanical small bowel obstruction. Which manifestation indicates to the nursing
practitioner that the hospital patient’s condition is improving?
1. Flatus and feces are passed.
2. Peristaltic waves are visible.
3. Hospital patient verbally reports thirst.
4. Abdominal circumference decreases.
RIGHT ANSWER> 4
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Describe causes, signs and symptoms, therapeutic measures, and
nursing care for intestinal obstruction.
Source: pp. 676
Heading: Intestinal Obstruction
Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: Physiological Integrity—
Physiological Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 Initially, flatus and feces already in the distal part of the colon may be passed.
This is not an indication of improvement.
2 When peristaltic waves are visible through the abdominal wall, it indicates that
the obstruction remains and the bowel is attempting to move bowel contents.
This is not an indication of improvement.
3 When the hospital patient verbally reports thirst, it is indicative of dehydration
and not an indication of improvement.
4 When the abdominal circumference decreases, it is a sign that the obstruction is
resolved or resolving.
PTS: 1 CON: Hospital patient-Centered Care
20. The spouse of a hospital patient with an ascending ostomy asks if the hospital patient
will always have to wear an ostomy bag. Which is the correct response by the nurse?
1. “An ostomy bag will be needed all of the time.”
2. “An ostomy bag will be needed only during the night.”
3. “An ostomy bag will be needed only to protect the stoma.”
4. “An ostomy bag will be needed until discharge from the hospital.”
RIGHT ANSWER> 1
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Plan nursing care and teaching for a hospital patient with an
ostomy.
Source: pp. 682
Heading: Ostomy and Continent Ostomy Management
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Elimination
Difficulty: Medium
CLARIFICATION
1 An ostomy bag will be needed all of the time as the stool will be liquid to
mushy.
2 The drainage from an ostomy at the ascending colon will pass as needed and
not only at night.
3 Ostomy bags are not used to protect the stoma; they are applied to manage the
passage of feces.
4 An ostomy bag will be needed all of the time, even after discharge from the
hospital.
PTS: 1 CON: Elimination
21. The nursing practitioner provides care to older adult residents in an extended-care facility.
One resident is experiencing diarrhea. The resident reports loss of appetite, weakness, and
drowsiness. Which body system is most important for the nursing practitioner examine?
1. Respiratory system
2. Skin condition
3. Cardiovascular system
4. Gastrointestinal system
RIGHT ANSWER> 3
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: List data to collect when caring for hospital patients with lower
gastrointestinal disorders. Source: pp. 661
Heading: Diarrhea
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Moderate
CLARIFICATION
1 The highest risk for an older adult with diarrhea is for dehydration and
hypokalemia. The respiratory system is not a priority.
2 Older adults with diarrhea are at risk for skin breakdown; however, this is not
the most important body system for the nursing practitioner to examine.
3 Older adults with diarrhea are at great risk to quickly develop dehydration and
hypokalemia, which can cause the listed symptoms along with life-threatening
cardiac manifestations. Both fluid and potassium are lost through the stools.
4 The gastrointestinal system is involved when a hospital patient has diarrhea.
Monitoring
is necessary, but this is not the most important system to examine.
PTS: 1 CON: Elimination
22. The nursing practitioner is reviewing teaching with a hospital patient scheduled for an
ileostomy and placement of a continent ostomy reservoir. Which teaching is most important
for the nursing practitioner to review?
1. The selected surgery takes longer than conventional surgery.
2. The pouch must be emptied regularly to prevent rupture.
3. The management of a continent pouch requires extra teaching.
4. Valve slipping or leakage will require additional surgery.
RIGHT ANSWER> 2
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Plan nursing care and teaching for a hospital patient with an
ostomy.
Source: pp. 682
Heading: Ostomy and Continent Ostomy Management
Integrated Process: Teaching/Learning
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 The hospital patient needs to be aware that the surgical procedure and
recovery with a continent ileostomy is longer than with a conventional
ileostomy. However, this is not the most important information to review.
2 The most important information for the nursing practitioner to review is that
failure to empty the continent ileostomy on a regular basis can result in rupture
of the internal
pouch. Preservation of the pouch is of great importance.
3 It is important that the nursing practitioner remind the hospital patient that the
management of a continent pouch requires additional hospital patient teaching;
however, this is not the most important information to review.
4 The hospital patient needs to be aware that valve slipping or leakage will require
additional surgery for correction. This is not the most important information to
review.
PTS: 1 CON: Hospital patient-Centered Care
23. A hospital patient is scheduled for colon surgery that will require the placement of a
colostomy. The wound, ostomy, and continence nursing practitioner (WOCN) will evaluate
the hospital patient for correct stoma placement. Which consideration by the nursing
practitioner will directly impact skin integrity?
1. The placement that will prevent interference with clothing
2. The placement that promotes visibility and easy care
3. The placement that will prevent leaking or poor appliance fit
4. The placement that promotes comfort when sitting
RIGHT ANSWER> 3
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Plan nursing care and teaching for a hospital patient with an
ostomy.
Source: pp. 682
Heading: Ostomy and Continent Ostomy Management
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 It is important for the WOCN to consider placement that will not interfere with
clothing, but the consideration does not directly impact skin integrity.
2 The hospital patient must be able to have stoma placement that is easy to view
and care for, but the consideration does not directly impact skin integrity.
3 The consideration about placement that will prevent leaking or poor appliance
fit directly impacts skin integrity. Maintenance of skin integrity is crucial for a
hospital patient with a colostomy. Skin breakdown from stool and/or moisture
can
interfere with the ability to place or use a colostomy appliance.
4 The hospital patient needs to be comfortable when sitting, but the
consideration does not directly impact skin integrity.
PTS: 1 CON: Hospital patient-Centered Care
24. The nursing practitioner is gathering data on a hospital patient who was recently treated for
colon cancer with the endoscopic removal of a small tumor. Which data will the nursing
practitioner determine most important to relay to the HCP?
1. Ecchymosis and tenderness in the groin
2. Mild discomfort during palpation of the abdomen
3. A 4-pound weight loss over a period of a month
4. Auscultation of active bowel sounds in all quadrants
RIGHT ANSWER> 1
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Describe the causes, signs and symptoms, therapeutic measures, and
nursing care of colon cancer.
Source: pp. 684
Heading: Colorectal Cancer
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 Metastasis from colon cancer is commonly to the lymphatic system and the
liver. Ecchymosis (bruising) can indicate liver dysfunction, and tenderness in
the groin can be related to swollen lymph nodes. This is the most important
information to relay to the HCP.
2 Mild discomfort in the abdomen can be from a variety of causes and should be
investigated further. The nursing practitioner should consider the passage of
time from the
removal of the tumor in the colon.
3 A 4-pound weight loss is not significant. The nursing practitioner should
gather data regarding the intention to lose weight, dietary changes, activity
levels, and so forth.
4 Active bowel sounds in all abdominal quadrants is a normal finding.
PTS: 1 CON: Hospital patient-Centered Care
25. The nursing practitioner is gathering information from a hospital patient who reports
anal pain. Which finding upon physical examination supports the presence of an anal
abscess?
1. Thrombosed vessels
2. Pain with defecation
3. Fever and drainage
4. Pain-induced constipation
RIGHT ANSWER> 3
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Plan nursing care for anorectal problems.
Source: pp. 678
Heading: Anorectal Problems
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Inflammation
Difficulty: Moderate
CLARIFICATION
1 Thrombosed vessels of the anal area are indicative of external hemorrhoids.
2 Pain with defecation is present with hemorrhoids, anal fissures, or an anal
abscess. However, pain is subjective and not objective information.
3 If a hospital patient exhibits a fever and drainage with rectal pain, the nursing
practitioner recognizes the possibility of an anal abscess.
4 Pain-induced constipation can be caused by any condition or treatment of
anorectal problems. However, constipation is subjective and not objective
information.
PTS: 1 CON: Inflammation
26. The nursing practitioner is providing care for a hospital patient diagnosed with an
obstructed colon related to colon cancer. The hospital patient receives endoscopic treatment prior to
surgical intervention to remove the obstructing tumor. Which observation will the nursing
practitioner expect?
1. Decrease in pain level
2. Increased rectal bleeding
3. Rectal passage of stool
4. Improved dietary intake
RIGHT ANSWER> 3
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Describe the causes, signs and symptoms, therapeutic measures, and
nursing care for colon cancer.
Source: pp. 676
Heading: Colorectal Cancer
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Cellular Regulation
Difficulty: Difficult
CLARIFICATION
1 The placement of a colon stint may or may not decrease the hospital patient’s
pain.
2 The placement of a colon stint is not expected to increase rectal bleeding.
3 The hospital patient who is obstructed by a cancerous colon tumor cannot
defecate.
Endoscopically, a stent will be placed in the colon to allow the passage of stool
until surgery is performed. The nursing practitioner can expect to see the
passage of feces.
4 The placement of a colon stint is not expected to improve the hospital patient’s
dietary
intake.
MULTIPLE RESPONSE
PTS: 1 CON: Cellular Regulation
MULTIPLE RESPONSE
1. The nursing practitioner is reinforcing teaching with a hospital patient about appropriate diet
modifications to help prevent exacerbations of inflammatory bowel disease. Which hospital
patient statements indicate that teaching has been effective? (Select all that apply.)
1. “I should avoid caffeine and spicy fiber foods.”
2. “I should avoid concentrated sweets and starches.”
3. “It is important to eat more whole grains and bran.”
4. “High-fiber foods should not be included in my diet.”
5. “Milk and other dairy products should be limited in my diet.”
RIGHT ANSWER> 1, 4, 5
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Describe pathophysiology, therapeutic measures, nursing care, and
teaching for inflammatory bowel disease.
Source: pp. 671
Heading: Inflammatory Bowel Disease
Integrated Process: Teaching/Learning
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Difficult
CLARIFICATION
1. High-fiber foods, caffeine, spicy foods, and milk products are avoided with
inflammatory bowel disease.
2. The hospital patient with inflammatory bowel disease needs to avoid
concentrated sweets and starches.
3. The hospital patient with inflammatory bowel disease needs to avoid high-
fiber
foods.
4. High-fiber foods, caffeine, spicy foods, and milk products are avoided with
inflammatory bowel disease.
5. High-fiber foods, caffeine, spicy foods, and milk products are avoided with
inflammatory bowel disease.
PTS: 1 CON: Elimination
2. The nursing practitioner is reinforcing teaching to a hospital patient who is being discharged
with a new colostomy. Which comments by the hospital patient indicate understanding of the
discharge teaching? (Select all that apply.)
1. “I will empty the pouch when it is less than half full.”
2. “I can spray deodorant into the pouch after I clean it.”
3. “I will not be concerned if there is no stool for several days.”
4. “I always check the seal and tape around the stoma after I shower.”
5. “I should change the pouch each morning and evening to prevent infection.”
RIGHT ANSWER> 1, 2, 4
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Describe pathophysiology, therapeutic measures, nursing care, and
teaching for inflammatory bowel disease.
Source: pp. 684
Heading: Ostomy and Ostomy Management
Integrated Process: Teaching/Learning
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. The hospital patient should empty the pouch before it is less than half full, use
a
deodorant spray in the pouch, and check the stoma seal after showering.
2. The hospital patient should empty the pouch before it is less than half full, use
a deodorant spray in the pouch, and check the stoma seal after showering.
3. Lack of stool could indicate a blockage and should be reported.
4. The hospital patient should empty the pouch before it is less than half full, use
a deodorant spray in the pouch, and check the stoma seal after showering.
5. Pouches are changed as needed, from every 3 days to every 14 days. Daily
changing can cause a breakdown in skin integrity.
PTS: 1 CON: Hospital patient-Centered Care
3. The nursing practitioner reinforces teaching to a hospital patient prescribed
budesonide for Crohn disease inflammation. Which hospital patient statements
indicate that additional teaching is necessary? (Select all that apply.)
1. “I should avoid grapefruit juice.”
2. “I must avoid the sun while taking this drug.”
3. “I should swallow the pill whole, not crushed.”
4. “I will take the pill each evening before going to bed.”
5. “I can stop taking the medication once I feel better.”
RIGHT ANSWER> 2, 4, 5
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Describe pathophysiology, therapeutic measures, nursing care, and
teaching for inflammatory bowel disease.
Source: pp. 667
Heading: Inflammatory Bowel Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Teaching/Learning
CL: Analysis (Analyzing) Concept:
Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. Grapefruit juice should be avoided.
2. This medication does not cause photosensitivity.
3. The medication should be swallowed whole.
4. The medication should be taken as prescribed in the morning and not stopped
when the hospital patient feels better.
5. The medication should be taken as prescribed in the morning and not stopped
when the hospital patient feels better.
PTS: 1 CON: Hospital patient-Centered Care
4. The nursing practitioner is reinforcing teaching to a hospital patient newly diagnosed with
ulcerative colitis about triggers for exacerbation of the disease. Which recommendation does the
nursing practitioner make to the hospital patient to prevent a future exacerbation? (Select all that
apply.)
1. Do not use tobacco.
2. Reduce exposure to stress.
3. Restrict fluids to 2 liters per day.
4. Read food labels to avoid food additives.
5. Avoid ingesting foods sprayed with pesticides.
RIGHT ANSWER> 1, 2, 4, 5
Chapter: Chapter 34. Nursing Care of Hospital patients With Lower Gastrointestinal
Disorders Objective: Describe pathophysiology, therapeutic measures, nursing care, and
teaching for hospital patients with inflammatory and infectious disorders of the lower
gastrointestinal tract.
Source: pp. 667
Heading: Ulcerative Colitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. Environmental agents such as pesticides, tobacco, radiation, and food
additives may precipitate an exacerbation. Diet or psychological stress may
trigger or worsen an attack of symptoms.
2. Environmental agents such as pesticides, tobacco, radiation, and food
additives may precipitate an exacerbation. Diet or psychological stress may
trigger or worsen an attack of symptoms.
3. There is no need for the hospital patient to restrict fluids.
4. Environmental agents such as pesticides, tobacco, radiation, and food
additives may precipitate an exacerbation. Diet or psychological stress may
trigger or worsen an attack of symptoms.
5. Environmental agents such as pesticides, tobacco, radiation, and food
additives may precipitate an exacerbation. Diet or psychological stress may
trigger or worsen an attack of symptoms.
PTS: 1 CON: Hospital patient-Centered Care
Chapter 35. Nursing Care of Hospital patients With Liver, Pancreatic, and
Gallbladder Disorders
MULTIPLE CHOICE
1. A hospital patient reports that a family member is diagnosed with hepatitis and asks the
nursing practitioner the best way to prevent becoming infected. Which is the best
information for the nursing practitioner to provide?
1. Expose fabric or unwashable items to ultraviolet light.
2. Thoroughly scrub hard surfaces with a strong bleach solution.
3. Perform frequent hand washing and do not share personal items.
4. Immediately start and complete a prophylactic antibiotic regimen.
RIGHT ANSWER> 3
Chapter: Chapter 35. Nursing Care of Hospital patients With Liver, Pancreatic, and
Gallbladder Disorders
Objective: Explain the causes, risk factors, and pathophysiology of the various types of liver
disease.
Source: pp. 693
Heading: Hepatitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Hepatitis viruses are very resistant to a wide range of anti-infective measures,
including exposure to ultraviolet light.
2 Hepatitis viruses are very resistant to a wide range of anti-infective measures,
including exposure to bleach and other disinfectants.
3 The best information the nursing practitioner can provide is the correct way to
perform hand hygiene and to not share personal items. If personal items are
contaminated, they are to be discarded if possible; boiling in water for 30
minutes is also effective.
4 Hepatitis is a virus and is not responsive to antibiotic therapy. Prevention is
dependent on minimizing or avoiding exposure to the causative pathogen.
PTS: 1 CON: Hospital patient-Centered Care
2. The nursing practitioner is providing care for a hospital patient admitted with acute
liver failure related to an acetaminophen overdose. Which goal is associated with care
for the hospital patient?
1. Maintain functional ability of the liver.
2. Keep the hospital patient on complete bed rest.
3. Monitor for the need to initiate intubation.
4. Provide a diet high in vitamins and protein.
RIGHT ANSWER> 1
Chapter: Chapter 35. Nursing Care of Hospital patients With Liver, Pancreatic, and
Gallbladder Disorders
Objective: Describe therapeutic measures for hospital patients with liver
disease. Source: pp. 700
Heading: Acute Liver Failure
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 The overall goal when caring for a hospital patient in acute liver failure is to
attempt to put the liver completely at rest to maintain functional ability.
2 The hospital patient will be placed on complete bedrest in a quiet environment
to decrease stimulation; however, this is an intervention and not a goal.
3 Protection and maintenance of a patent airway is important in the care of a
hospital patient in acute liver failure. However, this is an intervention and not a
goal.
4 The hospital patient in acute liver failure will be NPO; food will stimulate the
liver and
initiate the digestive process.
PTS: 1 CON: Hospital patient-Centered Care
3. A hospital patient with liver failure and esophageal varices is prescribed to receive
vasopressin. For which purpose does the nursing practitioner recognize the need for this
medication?
1. To promote portal circulation
2. To reduce ammonia buildup and encephalopathy
3. To constrict vessel dilation to the esophageal varices
4. To maintain hypotension related to bleeding varices
RIGHT ANSWER> 3
Chapter: Chapter 35. Nursing Care of Hospital patients With Liver, Pancreatic, and
Gallbladder Disorders
Objective: Describe therapeutic measures for hospital patients with liver
disease. Source: pp. 700
Heading: Liver Failure
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Pharmacological
Therapies CL: Analysis (Analyzing)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 Vasopressin does not promote circulation.
2 Vasopressin does not affect ammonia levels.
3 Vasopressin is a vasoconstrictor and will reduce the possibility or help manage
bleeding related to esophageal varices.
4 Vasopressin can maintain blood pressure, but it is not the primary reason the
drug is given to hospital patients with esophageal varices. There is no
information
confirming that the esophageal varices are bleeding.
PTS: 1 CON: Safety
4. The nursing practitioner is obtaining information from a hospital patient who is obese and has
diabetes mellitus (DM). Upon physical examination, the nursing practitioner notes generalized
ecchymosis, an enlarged and tender liver with palpation, and evidence of ascites with percussion.
Which possible disease condition does the nursing practitioner identify from the findings?
1. Diabetic complications
2. Liver dysfunction
3. Acute kidney disorder
4. Deficient blood clotting
RIGHT ANSWER> 2
Chapter: Chapter 35. Nursing Care of Hospital patients With Liver, Pancreatic, and
Gallbladder Disorders
Objective: Explain the causes, risk factors, and pathophysiology of the various types of liver
disease.
Source: pp. 700
Heading: Chronic Liver Disease and Cirrhosis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 The hospital patient’s diabetes mellitus is a likely contributor to the current
disease process. DM can cause a fatty liver, which can lead to cirrhosis, but the
symptoms are related to liver disease and not diabetes.
2 The manifestations and medical history are common for the development of
liver dysfunction. The hospital patient is likely to be diagnosed with cirrhosis
of the liver.
3 The hospital patient may be experiencing acute kidney disorder related to the
portal hypertension related to liver dysfunction/cirrhosis. However, this is not
the primary cause of the hospital patient’s condition.
4 Deficient blood clotting is related to generalized ecchymosis. Liver
disease/cirrhosis causes deficiency in clotting.
PTS: 1 CON: Hospital patient-Centered Care
5. The nursing practitioner is reinforcing teaching provided to a hospital patient with
esophageal varices. Which suggestion is the least important?
1. Avoid lifting heavy objects.
2. Bleeding is a reason to call 911.
3. Keep appointments with the health care provider (HCP).
4. Maintain low physical activity.
RIGHT ANSWER> 4
Chapter: Chapter 35. Nursing Care of Hospital patients With Liver, Pancreatic, and
Gallbladder Disorders
Objective: Plan nursing care for a hospital patient with liver
disease. Source: pp. 703
Heading: Esophageal Varices
Integrated Process: Clinical Problem-Solving Process
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Lifting heavy objects should be avoided to prevent straining that will put
pressure on esophageal varices and cause bleeding.
2 If esophageal varices begin to bleed, it is a medical emergency and 911 needs
to be called immediately.
3 Esophageal varices is a serious complication of liver disease/cirrhosis; the
hospital patient needs to be closely monitored by the HCP.
4 There is no indication that the hospital patient needs to maintain a low physical
activity; however, any activity that increases the blood pressure or
intraabdominal
pressure should be avoided.
PTS: 1 CON: Hospital patient-Centered Care
6. The nursing practitioner is collecting data from a hospital patient with liver failure to
detect hepatic encephalopathy. Which instruction does the nursing practitioner give to the
hospital patient to collect the data?
1. “Stand with your eyes closed.”
2. “Hold out your arms and hands.”
3. “Kneel on your hands and knees.”
4. “Perform a Valsalva’s maneuver.”
RIGHT ANSWER> 2
Chapter: Chapter 35. Nursing Care of Hospital patients With Liver, Pancreatic, and
Gallbladder Disorders
Objective: Plan nursing care for a hospital patient with liver
disease. Source: pp. 703
Heading: Hepatic Encephalopathy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Standing with the eyes closed is not part of the process of identifying hepatic
encephalopathy.
2 Neuromuscular function is monitored by asking the hospital patient to hold his
or her arms out straight in front and steady. If asterixis, or liver flap, is present,
the hospital patient’s hands will unwillingly dip and return to the horizontal
position in a
flapping motion.
3 Kneeling on the hands and knees is not part of the process of identifying
hepatic encephalopathy.
4 Performing the Valsalva’s maneuver is not part of the process of identifying
hepatic encephalopathy.
PTS: 1 CON: Hospital patient-Centered Care
7. The nursing practitioner is collecting data from a hospital patient with acute pancreatitis.
Which symptoms should the nursing practitioner anticipate?
1. Low abdominal pain, bradycardia, and confusion
2. Shortness of breath, hypotension, and restlessness
3. Fever, tachycardia, right upper quadrant pain, and jaundice
4. Abdominal distention, respiratory distress, and midepigastric pain
RIGHT ANSWER> 4
Chapter: Chapter 35. Nursing Care of Hospital patients With Liver, Pancreatic, and
Gallbladder Disorders
Objective: Explain the causes, risk factors, and pathophysiology of the various pancreatic
disorders.
Source: pp. 706
Heading: Disorders of the Pancreas
Integrated Process: Clinical Problem-Saving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 Low abdominal pain, bradycardia, and confusion are not associated with acute
pancreatitis.
2 Shortness of breath, hypotension, and restlessness are not together associated
with acute pancreatitis. Shortness of breath may be expected with fluid
accumulation in the retroperitoneal space.
3 Fever, tachycardia, right upper quadrant pain, and jaundice are not together
associated with acute pancreatitis. Right upper quadrant pain and fever is
expected.
4 Hospital patients with acute pancreatitis are very ill, with dull abdominal pain,
guarding, a rigid abdomen, hypotension or shock, and respiratory distress from
accumulation of fluid in the retroperitoneal space. The abdominal pain is
generally located in the midline just below the sternum, with radiation to the
spine, back, and flank.
PTS: 1 CON: Hospital patient-Centered Care
8. The nursing practitioner is providing care for a hospital patient diagnosed with chronic
pancreatitis. The hospital patient’s vital signs are blood pressure 130/78 mm Hg, respirations 28
breaths/min and labored with O2 saturation rate of 90%, pulse 102 beats/min, and pain level of 7
on a 0-to-10 scale. Which immediate nursing action is appropriate?
1. Observe for use of accessory or intercostal muscles.
2. Validate when the last pain medication was administered.
3. Place in an upright or slightly leaning forward position.
4. Seek approval to begin or increase delivery of oxygen therapy.
RIGHT ANSWER> 3
Chapter: Chapter 35. Nursing Care of Hospital patients With Liver, Pancreatic, and
Gallbladder Disorders
Objective: Plan nursing care for a hospital patient with a pancreatic
disorder. Source: pp. 708
Heading: Chronic Pancreatitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 The nursing practitioner can observe for the use of respiratory or intercostal
muscles, but this is not the immediate nursing intervention.
2 The most obvious issue for the hospital patient is related to respiratory
problems. The
nursing practitioner can address the level of pain when oxygenation is
3 The nursing practitioner should immediately ascertain that the hospital patient
is experiencing breathing and oxygenation issues. The hospital patient should
be immediately placed upright or slightly leaning forward to promote lung
expansion and oxygenation.
4 Beginning or increasing the delivery of oxygen therapy is not effective if the
hospital patient’s breathing is affected by the presence of fluid in the
retroperitoneal
space.
PTS: 1 CON: Hospital patient-Centered Care
9. A hospital patient just receives a diagnosis of pancreatic cancer with metastasis to the liver,
gallbladder, and stomach. The nursing practitioner is informed that the hospital patient has
agreed to palliative care. Which intervention seems unexpected to the nurse?
1. Performance of a Whipple procedure
2. Surgery to bypass a blocked bile duct
3. Chemotherapy and radiation therapy
4. Surgical placement of a bile duct stent
RIGHT ANSWER> 1
Chapter: Chapter 35. Nursing Care of Hospital patients With Liver, Pancreatic, and
Gallbladder Disorders
Objective: Describe therapeutic measures used for hospital patients with pancreatic
disorders. Source: pp. 706
Heading: Cancer of the Pancreas
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Basic Care and
Comfort CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 An unexpected intervention would be for performance of a Whipple procedure
that is aimed at curing pancreatic cancer.
2 The hospital patient receiving palliative care for pancreatic cancer may undergo
surgery
to bypass a blocked bile duct. The procedure decreases pain.
3 The hospital patient receiving palliative care for pancreatic cancer may receive
chemotherapy and/or radiation therapy to shrink the pancreatic tumors and
promote comfort.
4 If the bile duct is blocked, pain will increase. The hospital patient receiving
palliative
care may have a surgical placement of a bile duct stent to promote comfort.
PTS: 1 CON: Hospital patient-Centered Care
10. The nursing practitioner is assisting with the care of a hospital patient following a liver
transplant for cirrhosis. Which finding will the nursing practitioner report immediately to the
RN or HCP?
1. Surgical pain greater than 4 on a 0-to-10 scale
2. Decrease in the amount of bile in the T-tube
3. Difficulty with taking deep breaths or coughing
4. A regular apical pulse rate of 98 beats/min
RIGHT ANSWER> 2
Chapter: Chapter 35. Nursing Care of Hospital patients With Liver, Pancreatic, and
Gallbladder Disorders
Objective: Plan nursing care for the hospital patient experiencing a liver
disorder. Source: pp. 706
Heading: Liver Transplantation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 Following surgery for a liver transplant, the nursing practitioner expects the
hospital patient to have pain. The hospital patient may or may not want or need
pain medication at the level
rating of 4.
2 A decrease in the amount of bile in the T-tube drainage system is an indication
of impending rejection of the newly transplanted liver. The nursing
practitioner needs to inform the RN or HCP immediately.
3 Difficulty with deep breathing or coughing is expected after abdominal surgery.
Liver transplant surgery is performed in close proximity to the diaphragm.
4 The nursing practitioner will report a pulse rate greater than 100 beats/min to
the RN or HCP as an indication of impending rejection. The pulse rate of 98
will be closely monitored.
PTS: 1 CON: Hospital patient-Centered Care
11. The nursing practitioner is reinforcing hospital patient teaching regarding the causes
of gallbladder disorders. Which condition does the nursing practitioner present as being a
common cause?
1. Metastasis of cancer from the liver
2. Obesity and high dietary intake of fats
3. Gallstones and inflammations
4. History of excessive alcohol intake
RIGHT ANSWER> 3
Chapter: Chapter 35. Nursing Care of Hospital patients With Liver, Pancreatic, and
Gallbladder Disorders
Objective: Explain the causes, risk factors, and pathophysiology of gallbladder disorders.
Source: pp. 713
Heading: Disorders of the Gallbladder
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Gallbladder disorders are not commonly caused by metastasis of cancer from
the liver.
2 Obesity and high dietary intake of fats are contributing factors but are not alone
a common cause of gallbladder disorders.
3 The presence of gallstones and inflammations are the most common cause of
gallbladder disorders.
4 A history of excessive alcohol intake is most likely to contribute to liver
disorders.
PTS: 1 CON: Hospital patient-Centered Care
12. A hospital patient presents at the HCP’s office with epigastric pain. The hospital patient’s
temperature and pulse and respiration rates are all elevated. Which additional symptom will the
nursing practitioner associate as a possible sign of cholelithiasis?
1. Jaundice
2. Vomiting
3. Heartburn
4. Flatulence
RIGHT ANSWER> 1
Chapter: Chapter 35. Nursing Care of Hospital patients With Liver, Pancreatic, and
Gallbladder Disorders
Objective: Explain the causes, risk factors, and pathophysiology of gallbladder disorders.
Source: pp. 713
Heading: Cholelithiasis
Integrated Process: Clinical Problem-Solving Process
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Jaundice is most commonly indicative of cholelithiasis because the common
bile duct is either inflamed or blocked by a gallstone.
2 Vomiting can occur with gallbladder disorders, but is not exclusive to
cholelithiasis.
3 Heartburn is not commonly associated with cholelithiasis and is seen with
cholecystitis.
4 Flatulence is not commonly associated with cholelithiasis and is seen with
cholecystitis.
PTS: 1 CON: Hospital patient-Centered Care
13. A hospital patient is being treated for acute cholecystitis. The hospital patient is instructed
on dietary measures to reduce the possibility of recurrent episodes. Which hospital patient
comment indicates a need to reinforce teaching?
1. “I will need to limit the amount of fat in my diet.”
2. “I can increase my intake of nuts and avocados.”
3. “While I am having an attack, I may need to be NPO.”
4. “I need to get my extra weight off as quick as possible.”
RIGHT ANSWER> 4
Chapter: Chapter 35. Nursing Care of Hospital patients With Liver, Pancreatic, and
Gallbladder Disorders
Objective: Describe therapeutic measures used for hospital patients with gallbladder
disorders. Source: pp. 713
Heading: Cholecystitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Inflammation
Difficulty: Moderate
CLARIFICATION
1 The hospital patient with cholecystitis needs to limit the amount of fat in the diet
to
avoid a recurrence of the condition.
2 The hospital patient can consume healthy fats, such as nuts and avocados, which
supply monosaturated fats.
3 Acute attacks of cholecystitis may require the hospital patient to be NPO.
4 Fasting or strict weight-loss diets can trigger cholecystitis; the hospital patient
needs to aim for a slow, steady weight loss. This comment warrants additional
teaching.
PTS: 1 CON: Inflammation
14. A hospital patient with biliary colic is prescribed an anticholinergic medication to help
treat the condition. For which medical diagnosis should the nursing practitioner question the
administration of this medication?
1. Asthma
2. Psoriasis
3. DM
4. Prostatic hypertrophy
RIGHT ANSWER> 4
Chapter: Chapter 35. Nursing Care of Hospital patients With Liver, Pancreatic, and
Gallbladder Disorders
Objective: Describe therapeutic measures used for hospital patients with gallbladder
disorders. Source: pp. 716
Heading: Cholelithiasis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Pharmacological
Therapies CL: Analysis (Analyzing)
Concept: Safety
Difficulty: Difficult
CLARIFICATION
1 Anticholinergic medications are not contraindicated in diabetes, asthma, or
psoriasis.
2 Anticholinergic medications are not contraindicated in diabetes, asthma, or
psoriasis.
3 Anticholinergic medications are not contraindicated in diabetes, asthma, or
psoriasis.
4 Anticholinergic medications are contraindicated in hospital patients with
prostatic
hypertrophy; there is a high risk for urinary retention.
PTS: 1 CON: Safety
15. The nursing practitioner is providing care for a hospital patient following an open
cholecystectomy involving the removal of large gallstones and placement of a T-tube. Which
third day postsurgical manifestation will cause the nursing practitioner to report the finding?
1. Deep breathing and coughing improves with incisional splinting.
2. Pain level remains between 3 and 5 depending on hospital patient activity.
3. T-tube drainage is 600 mL over the past 24-hour period.
4. Hospital patient complains about receiving a soft, low-fat diet.
RIGHT ANSWER> 3
Chapter: Chapter 35. Nursing Care of Hospital patients With Liver, Pancreatic, and
Gallbladder Disorders
Objective: Plan nursing care for the hospital patient with a gallbladder
disorder. Source: pp. 715
Heading: Disorders of the Gallbladder
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physical Integrity—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The nursing practitioner should expect deep breathing and coughing to improve
with
incisional splinting. This is not a concern.
2 It is not unexpected for some hospital patients to have a pain level between 3
and 5 on the third postoperative day. However, by this time, pain will be
affected by
hospital patient activity.
3 By the third postoperative day, the hospital patient’s T-tube drainage should not
be more than 200 mL; an amount of 600 mL is a matter of concern and should
be reported.
4 The nursing practitioner is not concerned when a hospital patient complains
about dietary restrictions;
the nursing practitioner should use this opportunity to reinforce hospital patient
dietary teaching.
PTS: 1 CON: Hospital patient-Centered Care
16. The nursing practitioner is providing care for an older adult hospital patient with a diagnosis
of small noncalcified gallstones. The HCP prefers to avoid surgery on the hospital patient due to
age and a medical history of cardiac disorders. Which medical treatment does the nursing
practitioner most likely expect the HCP to prescribe?
1. Dietary alterations and limitations
2. Management of cholecystitis flare-ups
3. Routine anti-inflammatory medications
4. Long-term treatment with a dissolution drug
RIGHT ANSWER> 4
Chapter: Chapter 35. Nursing Care of Hospital patients With Liver, Pancreatic, and
Gallbladder Disorders
Objective: Describe therapeutic measures used for hospital patients with gallbladder
disorders. Source: pp. 715
Heading: Medication
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Pharmacological
Therapies CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Dietary alterations and limitations may or may not be effective for the hospital
patient
who already has gallstones.
2 The HCP will medically manage cholecystitis flare-ups but will most likely
focus on resolution and prevention.
3 The routine use of anti-inflammatory medications have side effects that are
undesirable and more likely to occur in the older adult. Gastric irritation and
bleeding is the main concern.
4 Due the fact that the hospital patient is considered a high surgical risk, the HCP
is likely to use long-term treatment with a dissolution drug to get rid of the
gallstones. However, the treatment may take up to 2 years, and the gallstones
are apt to return.
PTS: 1 CON: Hospital patient-Centered Care
17. The nursing practitioner is gathering information about a new hospital patient in an adult
clinic. The hospital patient states, “I have severe arthritis, but I control the pain with two 650-
mg acetaminophen tablets four times a day.” Which condition does the nursing practitioner
associate with the hospital patient’s medication regimen?
1. Urinary retention
2. Gastric bleeding
3. Liver failure
4. Kidney disease
RIGHT ANSWER> 3
Chapter: Chapter 35. Nursing Care of Hospital patients With Liver, Pancreatic, and
Gallbladder Disorders
Objective: Explain the causes, risk factors, and pathophysiology of the various types of liver
disease.
Source: pp. 704
Heading: Chronic Liver Disease and Cirrhosis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 There is no connection between the hospital patient’s medication regimen and
urinary retention. Anticholinergic medications would cause this condition.
2 There is no connection between the hospital patient’s medication regimen and
gastric
bleeding. Aspirin or NSAIDs would cause gastric bleeding.
3 Liver failure is frequently connected to the overuse of acetaminophen.
4 The hospital patient’s medication regimen is not connected to kidney failure;
acetaminophen is cleared by the liver and not the kidneys.
PTS: 1 CON: Hospital patient-Centered Care
18. The nursing practitioner is providing care for a hospital patient admitted with serious acute
pancreatitis. The hospital patient is in guarded condition and exhibits multiple manifestations of
pancreatitis complications. The nursing practitioner is aware that which body system is unlikely
to lead to hospital patient death?
1. Neurologic
2. Cardiovascular
3. Respiratory
4. Renal/kidney
RIGHT ANSWER> 1
Chapter: Chapter 35. Nursing Care of Hospital patients With Liver, Pancreatic, and
Gallbladder Disorders
Objective: Explain the causes, risk factors, and pathophysiology of the various pancreatic
disorders.
Source: pp. 706
Heading: Acute Pancreatitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Any involvement of the neurologic system is unlikely to occur with acute
pancreatitis.
2 Acute pancreatitis causes cardiovascular manifestations such as hemorrhage
and peripheral vascular collapse that can cause death.
3 Acute pancreatitis causes respiratory manifestations, such as hypoxia, from
compromised function related to ascites. Respiratory complications can cause
death.
4 Acute pancreatitis causes renal/kidney manifestations such as electrolyte
imbalances that can cause death.
PTS: 1 CON: Hospital patient-Centered Care
MULTIPLE RESPONSE
1. A hospital patient recovering from hepatitis is concerned about liver damage from the
infection. Which instructions does the nursing practitioner provide the hospital patient to
prevent long-term liver damage? (Select all that apply.)
1. Get adequate rest.
2. Ingest nutritious foods.
3. Abstain from all alcohol.
4. Restrict physical activity.
5. Limit the intake of dairy products.
RIGHT ANSWER> 1, 2, 3
Chapter: Chapter 35. Nursing Care of Hospital patients With Liver, Pancreatic, and
Gallbladder Disorders
Objective: Describe therapeutic measures used for hospital patients with liver
disease. Source: pp. 702
Heading: Disorders of the Liver
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. Recovery varies and depends on the type of hepatitis. Full recovery is
measured by the return to normal of all liver function tests and may take as
long as 1 year. The effects of hepatitis can be considered reversible if the
hospital patient complies with a medical regimen of adequate rest, proper
nutrition, and abstinence from alcohol or other liver-toxic agents for at least
1 year after liver function laboratory values return to normal.
2. Recovery varies and depends on the type of hepatitis. Full recovery is
measured by the return to normal of all liver function tests and may take as
long as 1 year. The effects of hepatitis can be considered reversible if the
hospital patient complies with a medical regimen of adequate rest, proper
nutrition, and abstinence from alcohol or other liver-toxic agents for at least
1 year after liver function laboratory values return to normal.
3. Recovery varies and depends on the type of hepatitis. Full recovery is
measured by the return to normal of all liver function tests and may take as
long as 1 year. The effects of hepatitis can be considered reversible if the
hospital patient complies with a medical regimen of adequate rest, proper
nutrition, and abstinence from alcohol or other liver-toxic agents for at least
1 year
after liver function laboratory values return to normal.
4. Restricting physical activity does not prevent the development of long-term
liver damage.
5. Limiting the intake of dairy products does not prevent the development of
long-term liver damage.
PTS: 1 CON: Hospital patient-Centered Care
2. The nursing practitioner is preparing to reinforce discharge teaching for a hospital
patient who underwent a cholecystectomy. Which information does the nursing
practitioner plan to cover? (Select all that apply.)
1. Increase high-quality protein to promote healing.
2. Avoid dietary fats to prevent postoperative nausea or pain.
3. Call the HCP if fever, redness, or drainage indicates infection.
4. Increase fluid intake to flush excess bilirubin from the system.
5. Reintroduce fats slowly back into the diet to prevent rebound effects.
RIGHT ANSWER> 1, 2, 3, 5
Chapter: Chapter 35. Nursing Care of Hospital patients With Liver, Pancreatic, and
Gallbladder Disorders
Objective: Plan care for the hospital patient with a gallbladder
disorder. Source: pp. 715
Heading: Disorders of the Gallbladder
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. The nursing practitioner needs to reinforce the importance of dietary protein
to promote healing.
2. Initially, the hospital patient should avoid dietary fats to prevent postoperative
intolerance. The duodenum needs to become accustomed to the constant
infusion of bile from the liver.
3. All surgical hospital patients need to be aware of the signs of infection and
when to call the HCP.
4. Changes in the color of urine and stool are not related to cholecystectomy
where the gallbladder is completely removed. The mentioned changes are
more likely to occur with pancreatic or liver disorders.
5. Fats need to be reintroduced in small amounts and over a period of time to
allow the duodenum to become accustomed to the constant infusion of bile
from the liver.
PTS: 1 CON: Hospital patient-Centered Care
Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures
MULTIPLE CHOICE
1. The nursing practitioner understands that a major function of the kidneys is to remove
potentially toxic waste products from the blood. Which function is inaccurate?
1. Regulate blood pressure through the conservation of fluids.
2. Regulate minerals to maintain electrolyte balance.
3. Manage hydrogen or bicarbonate for acid-base balance.
4. Manage erythrocyte production in the bone marrow.
RIGHT ANSWER> 1
Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures
Objective: Describe the normal function of the urinary system.
Source: pp. 719
Heading: Normal Urinary System Anatomy and Physiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 The kidneys regulate blood pressure through the excretion or conservation of
water.
2 The kidneys regulate electrolyte balance of the blood through the excretion or
conservation of minerals.
3 The kidneys maintain the acid-base balance of the blood through the excretion
or conservation of ions such as hydrogen and bicarbonate.
4 The kidneys produce erythropoietin, which stimulates erythrocyte production
in the bone marrow.
PTS: 1 CON: Hospital patient-Centered Care
2. The nursing practitioner is providing care for a hospital patient admitted for a suspected
kidney infection. Which area of the body does the nursing practitioner expect the hospital
patient to identify as a source of pain?
1. Lower abdomen
2. Bilateral flanks
3. Midepigastric
4. Pelvic floor
RIGHT ANSWER> 2
Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures
Objective: Identify the normal anatomy of the urinary system.
Source: pp. 742
Heading: Normal Urinary System Anatomy and Physiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Application (Applying) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The kidneys are located in the retroperitoneal cavity; pain would not be
expected in the lower abdomen.
2 The kidneys are located in the retroperitoneal cavity; pain would be located in
the bilateral flank areas.
3 The kidneys are located in the retroperitoneal cavity; pain would not be
expected in the midepigastric area of the abdomen.
4 The kidneys are located in the retroperitoneal cavity; pain would not be
expected in the pelvic floor area.
PTS: 1 CON: Hospital patient-Centered Care
3. A hospital patient’s urinalysis results are white blood cells (WBCs) 100+/hpf; red blood cells
(RBC) 4/hpf; bacteria, moderate amount; nitrite, positive; specific gravity, 1.025; and urine,
cloudy. What should the nursing practitioner recognize these findings indicate?
1. Dehydration
2. Urinary tract infection
3. Contamination from menstruation
4. Presence of bacteria from the perineum
RIGHT ANSWER> 2
Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures
Objective: Explain data to collect when caring for a hospital patient with a disorder of the
urinary system.
Source: pp. 741
Heading: Diagnostic Tests for the Urinary System
Integrated Process: Clinical Problem-Solving Process
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 The laboratory findings do not indicate dehydration.
2 Elevated WBCs, bacteria, nitrites, and cloudy urine indicate an infection.
3 There is no information in the question to indicate menstruation.
4 There is no information regarding the preparation of the perineum.
PTS: 1 CON: Hospital patient-Centered Care
4. The nursing practitioner is collecting data on a hospital patient who experienced a sport
injury to the lower back area. Which finding will cause the nursing practitioner greatest
concern?
1. Report of nausea and anxiety
2. Ecchymosis and pain in area of injury
3. Flank edema and bloody urine
4. Pain in the lower abdomen
RIGHT ANSWER> 3
Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures
Objective: Identify the normal anatomy of the urinary system.
Source: pp. 742
Heading: Blood Vessels of the Kidney
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 It is expected that a hospital patient may experience nausea and anxiety
following an injury.
2 Ecchymosis and pain in the area of the injury is expected, but require
additional monitoring. Ecchymosis is most likely associated with soft tissue
injury.
3 The nurse’s greatest concern is the presence of flank edema and bloody urine.
The kidneys are highly vascular and major vessels include a renal artery and a
renal vein. Both findings are indicative of blood vessel damage.
4 The kidneys are located in the retroperitoneal cavity; pain in the lower
abdomen is not expected with this injury.
PTS: 1 CON: Hospital patient-Centered Care
5. The formation of urine is a critical physiological function. The nursing practitioner is
aware that multiple processes are involved. Which process does the nursing practitioner
recognize as not part of the formation of urine?
1. Micturition
2. Glomerular filtration
3. Tubular excretion
4. Tubular reabsorption
RIGHT ANSWER> 1
Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures
Objective: Describe the normal function of the urinary system.
Source: pp. 723
Heading: Formation of Urine
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Micturition is the terminology for the process of urinating, which is not
involved in the process of urine production.
2 Glomerular filtration is the initial process of urine formation. Blood pressure
forces water and small solutes out of the glomeruli and into Bowman capsules.
The fluid is then called renal filtrate.
3 Tubular excretion is the final process of urine formation. In excretion,
substances are actively secreted from the blood in the peritubular capillaries
into the filtrate in the renal tubules.
4 Tubular reabsorption is the second process of urine formation. Tubular
reabsorption is the recovery of useful materials from the renal filtrate and their
return into the blood in the peritubular capillaries.
PTS: 1 CON: Hospital patient-Centered Care
6. The nursing practitioner is providing care for a hospital patient with a diagnosis of kidney
disease. The hospital patient’s last laboratory result indicates metabolic acidosis. Which
kidney activity does the nursing practitioner recognize for the condition?
1. The kidneys are absorbing more bicarbonate.
2. The kidneys are unable to excrete hydrogen ions.
3. The kidneys are compensating for respiratory function.
4. The kidneys are responding to vomiting related to disease.
RIGHT ANSWER> 2
Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures
Objective: Describe the normal function of the urinary system.
Source: pp. 728
Heading: The Kidneys and Acid-Base Balance
Integrated Process: Clinical Problem-Solving Process
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Difficult
CLARIFICATION
1 If the kidneys were absorbing more bicarbonate into the blood, the laboratory
test would not indicate metabolic acidosis.
2 When the kidneys are unable to excrete hydrogen ions into the blood, the
laboratory test indicates metabolic acidosis. The process is related to kidney
disease.
3 If the kidneys were compensating for respiratory function, the pH would be
balanced when the kidneys reabsorbed bicarbonate.
4 Vomiting can cause metabolic alkalosis when hydrochloric acid is lost.
However, there is no indication that the hospital patient’s renal disease is
causing vomiting.
PTS: 1 CON: Elimination
7. The nursing practitioner is providing care for a hospital patient with a thoracic spinal cord
injury. For which reason does the nursing practitioner understand the presence of a suprapubic
catheter?
1. The hospital patient is unable to stand to void.
2. The hospital patient is less likely to have bladder infections.
3. The hospital patient is unable to detect the need to urinate.
4. The hospital patient is at risk for skin breakdown from incontinence.
RIGHT ANSWER> 3
Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures
Objective: Plan preparation and postprocedure care for hospital patients undergoing
diagnostic tests of the urinary system.
Source: pp. 738
Heading: Elimination of Urine
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The inability to stand to void is not alone the reason to place a suprapubic
catheter.
2 Hospital patients with any type of catheter are a high risk for developing bladder
infections.
3 The hospital patient with a thoracic spinal cord injury will have lost the
sensation of urinary reflex over which urinary control may be exerted. The
detrusor muscles
of the bladder wall and two urethral sphincters will all be involved.
4 Incontinence and the risk for skin breakdown are not reasons alone to place a
suprapubic catheter.
PTS: 1 CON: Hospital patient-Centered Care
8. The nursing practitioner is testing the urine pH for a hospital patient in the HCP’s office. The test
indicates a pH of
7.0. Which question does the nursing practitioner ask the hospital patient?
2. “Do you have pain when you urinate?”
3. “Are you following a vegetarian diet?”
4. “How much aspirin do you take daily?”
5. “Is there a family history of renal disease?”
RIGHT ANSWER> 2
Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures
Objective: Describe the normal function of the urinary system.
Source: pp.
728
Heading: pH
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The hospital patient’s urine pH is within normal limits; there is no reason to
suspect a bladder infection.
2 Diet has the greatest influence over urine pH. The hospital patient’s urine pH is
normal, but is in the higher range. Vegetarians are likely to have a more alkaline
urine,
which makes the pH higher.
3 Diet has the greatest influence over urine pH. There is no reason for the
nursing practitioner to inquire about aspirin use. The urine pH is within
normal limits.
4 There is no reason to ask if the hospital patient has a family history of renal
disease.
The urine pH is within normal limits.
PTS: 1 CON: Hospital patient-Centered Care
9. The nursing practitioner is reviewing the laboratory results for a hospital patient. Which
question does the nursing practitioner ask the hospital patient if the creatinine level is
elevated?
1. “Have you been sick lately?”
2. “Are you lactose intolerant?”
3. “Do you have flank pain?”
4. “How much do you exercise?”
RIGHT ANSWER> 4
Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures
Objective: Describe the normal function of the urinary system.
Source: pp. 728
Heading: Constituents
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Illness does not affect the creatinine level in urine.
2 Being lactose intolerant does not affect the creatinine level in urine.
3 The nursing practitioner should not expect flank pain in a hospital patient with
an elevated creatinine
level.
4 Creatinine is a product of metabolism of creatine phosphate, which is an energy
source in muscles. The amount and type of exercise can affect creatinine levels.
PTS: 1 CON: Hospital patient-Centered Care
10. A hospital patient with pneumonia has a blood urea nitrogen (BUN) of 32 mg/dL and creatinine
of
0.8 mg/dL. What should the nursing practitioner realize is the most probable explanation for this
finding?
1. The hospital patient is dehydrated.
2. The hospital patient has septicemia.
3. The hospital patient is malnourished.
4. The hospital patient has kidney damage.
RIGHT ANSWER> 1
Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures
Objective: Explain data to collect when caring for a hospital patient with a disorder of the
urinary system.
Source: pp. 728
Heading: Constituents.
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 BUN elevates with dehydration, because the loss of water makes the blood
more concentrated. Creatinine levels are a very good indicator of kidney
function.
2 There is not enough information to determine if the hospital patient is septic.
3 There is not enough information to determine if the hospital patient is
malnourished.
4 There is not enough information to determine if the hospital patient has kidney
damage.
PTS: 1 CON: Hospital patient-Centered Care
11. The nursing practitioner is collecting information from an older adult hospital patient in
the health care provider’s (HCP) office. The hospital patient reports frequent urination. Which
effect of aging does the nursing practitioner recognize?
1. A decrease in glomerular filtration
2. The presence of an early bladder infection
3. Decreased bladder size and muscle tone
4. General decrease in renal functioning
RIGHT ANSWER> 3
Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures
Objective: Discuss the effects of aging on the urinary system.
Source: pp. 722
Heading: Aging and the Urinary System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Older adult hospital patients do have a decrease in glomerular filtration;
however, this change does not cause frequent urination.
2 The older adult hospital patient’s need for frequent urination is likely associated
with physical functioning. There are no other indications of a bladder infection
such
as fever or painful urination.
3 Older adult hospital patients normally experience a decrease in bladder size
and a decrease in the tone of the detrusor muscle. The result is frequent
urination or the presence of residual urine after voiding.
4 Older adult hospital patients do have a decrease in renal function; up to half of
the original nephrons can be lost by age 70 or 80. However, this is not related to
frequent urination.
PTS: 1 CON: Hospital patient-Centered Care
12. The nursing practitioner is providing care for a hospital patient who is on fluid restrictions
due to renal failure. The hospital patient’s intake & output (I&O) should be carefully
measured. Which substance does the nursing practitioner exclude from the intake total?
1. Mashed potatoes and creamed corn
2. All oral and IV fluids
3. Water, coffee, juices, and gelatin
4. Any tube feeding administered
RIGHT ANSWER> 1
Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures
Objective: Explain data to collect when caring for a hospital patient with a disorder of the
urinary system.
Source: pp. 726
Heading: Nursing Assessment of the Urinary System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Elimination
Difficulty: Moderate
CLARIFICATION
1 The nursing practitioner does not need to include foods that are not either a
liquid form or liquefy at body temperature. Mashed potatoes and creamed corn
are not
considered liquids.
2 All oral and IV fluids are counted as fluid intake.
3 Water, coffee, juices, and gelatin are considered liquids. The gelatin will
become a liquid at body temperature.
4 Tube feedings are considered liquids when the hospital patient’s I&O is being
measured.
PTS: 1 CON: Elimination
13. The nursing practitioner is providing care for a hospital patient scheduled for
diagnostic studies of the gastrointestinal system using contrast medium. Which finding
in the hospital patient’s medical history warrants the nursing practitioner contacting the
HCP?
1. The hospital patient reports an allergy to shellfish.
2. The hospital patient recently had pneumonia.
3. The hospital patient had food intake 12 hours previous.
4. The hospital patient has a history of renal dysfunction.
RIGHT ANSWER> 4
Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures
Objective: Plan preparation and postprocedure care for hospital patients undergoing
diagnostic tests of the urinary system.
Source: pp. 728
Heading: Contrast-Induced Nephropathy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Contrast media does not always contain radioactive isotopes, which are given
with caution to hospital patients with iodine allergies.
2 A recent incidence of pneumonia will not warrant the nursing practitioner
contacting the
HCP.
3 A gastrointestinal study with contrast medium is performed after the hospital
patient has been NPO; 12 hours without food does not warrant the nursing
practitioner contacting the HCP.
4 The use of contrast media can nephrotoxic and cause contrast-induced
nephropathy. The nursing practitioner needs to contact the HCP regarding the
hospital patient’s history of renal dysfunction, which places the hospital patient
at high risk for nephropathy.
PTS: 1 CON: Hospital patient-Centered Care
14. The nursing practitioner is catheterizing a hospital patient after voiding to determine the
amount of residual urine in the bladder. What should the nursing practitioner consider as being
the normal amount of urine within the bladder after urination?
1. 25 mL
2. 75 mL
3. 100 mL
4. 150 mL
RIGHT ANSWER> 1
Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures
Objective: Explain data to collect when caring for a hospital patient with a disorder of the
urinary system.
Source: pp. 737
Heading: Management of Urinary Retention
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Normally the bladder contains less than 50 mL after urination.
2 This represents excessive amounts of residual urine after voiding.
3 This represents excessive amounts of residual urine after voiding.
4 This represents excessive amounts of residual urine after voiding.
PTS: 1 CON: Hospital patient-Centered Care
15. An older male hospital patient expresses frustration at need to urinate often, dribbling of
urine, and feelings of inability to empty his bladder. Which suggestion by the nursing practitioner
is most helpful to the hospital patient?
1. Obtain and wear incontinence pads.
2. Encourage an appointment with a urologist.
3. Review medications with the primary HCP.
4. Set up a schedule for regular voiding.
RIGHT ANSWER> 2
Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures
Objective: Plan nursing care for hospital patients with incontinence.
Source: pp. 725
Heading: Overflow Incontinence
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Moderate
CLARIFICATION
1 The hospital patient is likely to be experiencing overflow incontinence and the
suggestion to obtain and use incontinence pads is helpful in managing the
manifestations. However, the most helpful suggestion will address the cause.
2 Older men commonly experience overflow incontinence related to an enlarged
prostate. The most helpful suggestion is to encourage an appointment with a
urologist for treatment of the condition.
3 Medication is sometimes a cause for incontinence; however, medications and
their effects can be reviewed during a visit with a urologist.
4 Setting a schedule for regular voiding is appropriate for bladder training, but
overflow incontinence will not improve with this intervention.
PTS: 1 CON: Elimination
16. The nursing practitioner is reinforcing teaching to a hospital patient who is preparing to
perform intermittent self- catheterization at home. Which information by the nursing
practitioner is inappropriate?
1. The bladder should be emptied every 3 hours.
2. An overfilled bladder can be a source of infection.
3. Catheters can be washed and reused repeatedly.
4. Wear a urinary incontinence pad if away from home.
RIGHT ANSWER> 4
Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures
Objective: Discuss nursing actions to decrease the risk of infection in urinary catheterized
hospital patients.
Source: pp. 728
Heading: Intermittent Catheterization
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integration—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Moderate
CLARIFICATION
1 It is appropriate for the nursing practitioner to inform the hospital patient to
empty the bladder every 3 hours when performing intermittent self-
catheterization.
2 It is important for the hospital patient to understand that an overfilled urinary
bladder is
a source of infection. Urine is a good medium for bacteria growth.
3 When in the home environment, urinary catheters used for self-catheterization
can be washed and reused. All types of catheterizations in the clinical
environment require sterile technique.
4 When away from home, the hospital patient can still perform intermittent self-
catheterization and there is no need to wear an incontinence pad. However, the
hospital patient is taught to use appropriate hand washing and to be particularly
careful
to avoid touching the catheter to places or items in surrounding area.
PTS: 1 CON: Elimination
17. The nursing practitioner is making a visit to the home of a hospital patient with
functional incontinence. Which observation indicates that teaching about the disorder has
been effective?
1. Hospital patient wearing sweat pants
2. Hospital patient drinking a cup of coffee
3. Hospital patient sitting with the legs elevated
4. Hospital patient restricting fluid intake after 6 p.m.
RIGHT ANSWER> 1
Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures
Objective: Plan nursing care for hospital patients with incontinence.
Source: pp. 725
Heading: Management of Urinary Incontinence
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 If clothing is inhibiting timely voiding for the hospital patient with functional
incontinence, the hospital patient should be instructed to wear clothing with
Velcro fasteners or sweat pants.
2 Coffee with caffeine is a bladder stimulant and increases the need to void.
3 Elevating the legs is not an action appropriate for functional incontinence.
4 Restricting fluids after 6 p.m. is not an appropriate action for functional
incontinence.
PTS: 1 CON: Hospital patient-Centered Care
18. The nursing practitioner is providing care for a hospital patient who has undergone
placement of a suprapubic catheter. Which postprocedure nursing care is avoided?
1. Change the surgical dressing as needed.
2. Tape the catheter in place to avoid tension.
3. Change the catheter with sterile technique daily.
4. Apply a skin barrier to prevent skin breakdown.
RIGHT ANSWER> 3
Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures
Objective: Discuss nursing actions to decrease the risk of infection in urinary catheterized
hospital patients.
Source: pp. 728
Heading: Suprapubic Catheter
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Postprocedure for the placement of a suprapubic catheter, it is correct for the
nursing practitioner to change the surgical dressing as needed.
2 The suprapubic catheter will need to be taped in a manner that prevents tension
on the catheter.
3 Postprocedure, the nursing practitioner will not be changing the suprapubic
catheter, which may result in closure of the abdominal incision. After healing,
the hospital patient will
learn when and how the catheter will be changed.
4 Because of a likelihood of urine leakage, a skin barrier can be applied to
prevent skin irritation or breakdown from exposure to urine.
PTS: 1 CON: Hospital patient-Centered Care
19. A hospital patient shares a long-standing problem of urinary incontinence with the
nurse. Which intervention does the nursing practitioner recognize as taking priority?
1. Referring the hospital patient to a urologist
2. Providing caring support to the hospital patient
3. Recommending a continence clinic
4. Keeping a voiding diary for evaluation
RIGHT ANSWER> 2
Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures
Objective: Plan nursing care for hospital patients with incontinence.
Source: pp. 725
Heading: Management of Urinary Incontinence
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 The nursing practitioner is likely to refer the hospital patient to a urologist for
evaluation of the condition and proposed treatment. However, this is not the
priority nursing intervention.
2 Because the hospital patient reveals a long-standing problem, the nursing
practitioner is aware that the
hospital patient has possibly delayed reporting the condition due to
embarrassment. The nurse’s priority intervention is to provide caring support to
the hospital patient.
3 The hospital patient may need to be recommended to a continence clinic;
however, this
is not the priority nursing intervention.
4 Keeping a voiding diary is helpful in determining when incontinence occurs and
identifying of predisposing events. However, this is not the priority nursing
intervention.
PTS: 1 CON: Hospital patient-Centered Care
MULTIPLE RESPONSE
1. The nursing practitioner is reviewing the results of a hospital patient’s urinalysis.
Which components does the nursing practitioner identify as being abnormal in urine?
(Select all that apply.)
1. Urea
2. Hormones
3. Protein
4. RBCs
5. Water
RIGHT ANSWER> 3, 4
Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures
Objective: Explain data to collect when caring for a hospital patient with a disorder of the
urinary system.
Source: pp. 728
Heading: Constituents
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. Urea is present in normal urine and is formed by liver cells when excess
amino acids are metabolized.
2. Hormones, in small quantities, are normally present in urine.
3. Proteins are not normally found in urine and can indicate renal dysfunction
from injury or disease.
4. RBCs are not normally found in urine and can indicate renal dysfunction
from injury or disease.
5. Water makes up 95 percent of urine and is a solvent for waste products and
salts.
PTS: 1 CON: Hospital patient-Centered Care
Chapter 37. Nursing Care of Hospital patients With Disorders of the Urinary System
MULTIPLE CHOICE
1. A female hospital patient with a history of diabetes mellitus presents at the health care
provider’s (HCP) office with chills, a high fever, and flank pain. The nursing practitioner notes
that a collected urine specimen appears cloudy. Which condition does the nursing practitioner
expect?
1. Diabetic related sepsis
2. Infection from hepatitis
3. Urethritis and bladder infection
4. Complicated pyelonephritis
RIGHT ANSWER> 4
Chapter: Chapter 37. Nursing Care of Hospital patients With Disorders of the
Urinary System Objective: Explain the predisposing causes, symptoms, laboratory
abnormalities, and treatment of urinary tract infections.
Source: pp. 742
Heading: Urinary Tract Infections
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Moderate
CLARIFICATION
1 The hospital patient’s symptoms support a diagnosis involving the urinary
tract. Diabetic related sepsis is too broad of a term to apply to the hospital
patient’s manifestations.
2 There is no information in the question to support the presence of infection
from hepatitis.
3 The symptoms presented indicate an involvement of upper urinary tract rather
than the urethra and bladder.
4 The hospital patient is exhibiting the symptoms of complicated pyelonephritis,
which
includes a high fever, flank pain, and existing diabetes mellitus.
PTS: 1 CON: Elimination
2. The nursing practitioner is collecting data from a male hospital patient who reports
hematuria and bladder cramping. The hospital patient’s history indicates a 20-year history of
smoking and long-term employment in a tool factory. Which specific test does the nursing
practitioner expect the HCP to order?
1. Complete blood count
2. Urine test for telomerase
3. Urinalysis for bladder infection
4. Urine culture for presence of bacteria
RIGHT ANSWER> 2
Chapter: Chapter 37. Nursing Care of Hospital patients With Disorders of the Urinary
System Objective: List risk factors and signs and symptoms of cancer of the bladder.
Source: pp. 747
Heading: Cancer of the Bladder
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing)
Concept: Cellular Regulation
Difficulty: Difficult
CLARIFICATION
1 Routinely, the HCP may order a complete blood count.
2 A urine test for the presence of the enzyme telomerase is 90 percent accurate
for the diagnosis of early or late bladder cancer. Given the hospital patient’s
symptoms
and history, this is the most specific test that the HCP can order.
3 The hospital patient does not exhibit the symptoms of a bladder infection. Urine
for cytology can be obtained to determine the presence of cancer cells.
4 A urine culture can be done because the symptoms of a bladder infection can
be similar to the symptoms of bladder cancer. However, this is not the most
specific test.
PTS: 1 CON: Cellular Regulation
3. The nursing practitioner is providing postoperative care for a hospital patient with a newly
formed ileal conduit for a diagnosis of cancer. Which factor regarding the hospital patient’s
surgery does the nursing practitioner identify as incorrect?
1. The nursing practitioner can expect the urine to contain mucus.
2. Urine will drain continuously from the reservoir.
3. Bladder continence will develop after healing.
4. The surgery includes the formation of an ileostomy.
RIGHT ANSWER> 3
Chapter: Nursing Care of Hospital patients With Disorders of the Urinary System
Objective: Discuss nursing care for a hospital patient with an ileal conduit or continent
reservoir. Source: pp. 751
Heading: Incontinent Urinary Diversion
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Cellular Regulation
Difficulty: Moderate
CLARIFICATION
1 The nursing practitioner will expect mucus in the hospital patient’s urine
because the diversionary
pouch is created from part of the bowel, which is mucus producing.
2 With an ileal conduit, the urine will drain continuously from the reservoir.
3 Bladder continence is never obtained with an ileal conduit, the reservoir
continuously drains from the stoma into a collection bag.
4 The surgery for an ileal conduit always includes the formation of an ileostomy
through which the urine is drained.
PTS: 1 CON: Cellular Regulation
4. The nursing practitioner is providing care for a hospital patient admitted with severe flank
pain identified as renal colic. Urinalysis is positive for microscopic hematuria. Which nursing
intervention is most important for the nursing practitioner to implement?
1. Administer prescribed narcotic medication.
2. Maintain IV fluids and encourage oral fluids.
3. Promote assisted ambulation as tolerated.
4. Strain urinary output and observe for stones.
RIGHT ANSWER> 4
Chapter: Chapter 37. Nursing Care of Hospital patients With Disorders of the Urinary
System Objective: Explain the predisposing causes, symptoms, treatment, and teaching for
kidney stones.
Source: pp. 747
Heading: Renal Calculi (Urolithiasis)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Moderate
CLARIFICATION
1 The hospital patient with severe flank pain described as renal colic is frequently
prescribed narcotic medication for pain control. However, this is not the most
important intervention.
2 The nursing practitioner is aware that an increase in fluids will assist in flushing
the kidney
stone through the urinary system. However, this is not the most important
intervention.
3 Ambulation can be effective in moving a renal stone through the urinary
system. If the hospital patient is in extreme pain or medicated with a narcotic,
assistance
is warranted.
4 The most important intervention for the nursing practitioner to implement
involves straining all urinary output for the collection of any passed stones.
The stones are then sent to the laboratory where the type can be identified and
appropriate
treatment implemented.
PTS: 1 CON: Elimination
5. The nursing practitioner is preparing a hospital patient for a cystectomy and the
creation of a continent urinary diversion. For which reason does the nursing
practitioner identify creation of this type of diversion?
1. Convenience for the hospital patient
2. Extensive bladder destruction exists
3. Prevention of skin breakdown
4. Failed previous incontinent diversion
RIGHT ANSWER> 1
Chapter: Chapter 37. Nursing Care of Hospital patients With Disorders of the Urinary
System Objective: Discuss nursing care for a hospital patient with an ileal conduit or
continent reservoir. Pages: 751–752
Heading: Continent Urinary Diversion
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Applying (Application)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Continent urinary diversion, of either a Kock or Indiana pouch, is created for
the convenience of the hospital patient. An incontinent diversion requires the
formation of a stoma and constant use of a collection pouch as opposed to
intermittent catheterization through a valve opening.
2 If the bladder is destroyed by disease, either a continent or incontinent
diversion can be considered.
3 The possibility of skin breakdown is more likely with an incontinent diversion;
however, this reason alone is not a determination for formation of a continent
diversion.
4 The failure of an incontinent urinary diversion is not necessarily a reason to
form a continent urinary diversion.
PTS: 1 CON: Hospital patient-Centered Care
6. The nursing practitioner is providing care for older adult hospital patients in an extended
care facility. Which hospital patient will the nursing practitioner monitor most closely for
symptoms of urosepsis?
1. The hospital patient with continuous urinary incontinence
2. The hospital patient who is unable to obtain fluids independently
3. The hospital patient who has an indwelling catheter for a urinary tract infection (UTI)
4. The hospital patient who has surgery for placement of an ileostomy
RIGHT ANSWER> 3
Chapter: Chapter 37. Nursing Care of Hospital patients With Disorders of the
Urinary System Objective: Explain the predisposing causes, symptoms, laboratory
abnormalities, and treatment of urinary tract infections.
Source: pp. 742
Heading: Types of Urinary Tract Infections
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Continuous incontinence places the hospital patient at risk for skin breakdown
and not
for urosepsis.
2 The hospital patient who is unable to independently obtain fluids is at risk for
dehydration or for a UTI.
3 The hospital patient with an indwelling urinary catheter is at high risk for
urosepsis; the
possibility is increased by an already existing UTI.
4 The hospital patient who had surgery for the placement of an ileostomy may be
at risk
for urosepsis; however, the hospital patient with an indwelling catheter and a
UTI is at greatest risk.
PTS: 1 CON: Hospital patient-Centered Care
7. The nursing practitioner is providing care for a hospital patient who is diagnosed with
urinary obstruction from a blockage of the urethra. An emergency surgery is scheduled. The
nursing practitioner is aware of which complication occurring without resolution of the
condition?
1. Bilateral hydronephrosis
2. Urinary bladder rupture
3. Irreparable kidney damage
4. Dilation of the ureters
RIGHT ANSWER> 3
Chapter: Chapter 37. Nursing Care of Hospital patients With Disorders of the Urinary
System Objective: Explain the pathophysiology and nursing care for diabetic
nephropathy, nephrosclerosis, hydronephrosis, and glomerulonephritis.
Source: pp. 744
Heading: Hydronephrosis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Moderate
CLARIFICATION
1 Bilateral hydronephrosis will occur from a blocked urethra when the urine
backs up to the kidneys. The condition is reversible with surgical resolution of
the blockage.
2 With a blockage of the urethra, urine will back up into the bladder, but the
bladder is not at risk for rupture. The urine will continue to back up past the
bladder.
3 Irreparable damage to the kidneys can occur with the formation of
hydronephrosis. Within hours, the blood vessels and renal tubules can be
extensively damaged. Both kidneys are at risk with a urethral blockage.
4 With blockage of the urethra, it is possible for the urine to back up to the point
of dilating the ureters. However, this condition is reversible with resolution of
the blockage.
PTS: 1 CON: Elimination
8. The nursing practitioner is providing support for a hospital patient who just finished a
hemodialysis session. Which hospital patient symptom is considered to be a complication of
hemodialysis?
1. Headache from a drop-in blood pressure
2. Increased clotting time from dialysate
3. Cardiac arrhythmias and angina from fluid loss
4. High energy level related to loss of toxins
RIGHT ANSWER> 3
Chapter: Chapter 37. Nursing Care of Hospital patients With Disorders of the Urinary
System Objective: Plan nursing care for hospital patients on hemodialysis.
Source: pp. 766
Heading: Hemodialysis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The hospital patient is likely to experience low blood pressure causing
weakness, dizziness, and nausea.
2 The hospital patient is likely to experience increased clotting time related to the
use of
heparin to prevent blood clotting during dialysis.
3 Cardiac arrhythmias and angina can occur after dialysis because of a sudden
fluid drop.
4 After dialysis, the hospital patient is more likely to feel weak and fatigued, and
possibly
unable to even eat.
PTS: 1 CON: Hospital patient-Centered Care
9. The nursing practitioner is reinforcing teaching about the most serious side effect of
peritoneal dialysis with a hospital patient scheduled for the first treatment. Which side
effect stated by the hospital patient indicates correct understanding?
1. Peritonitis
2. Paralytic ileus
3. Respiratory distress
4. Cramps in the abdomen
RIGHT ANSWER> 1
Chapter: Chapter 37. Nursing Care of Hospital patients With Disorders of the Urinary
System Objective: Planning care for hospital patients on peritoneal dialysis.
Source: pp. 766
Heading: Peritoneal Dialysis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 A major complication of peritoneal dialysis is peritonitis, which can be life
threatening. The major cause of peritonitis is poor technique when connecting
the bag of dialyzing solution to the peritoneal catheter.
2 Paralytic ileus and respiratory distress are not associated with peritoneal
dialysis.
3 Paralytic ileus and respiratory distress are not associated with peritoneal
dialysis.
4 Abdominal cramps can occur with this type of dialysis; however, they are not
the most serious side effect of this treatment.
PTS: 1 CON: Hospital patient-Centered Care
10. The nursing practitioner is providing care for a hospital patient with glomerulonephritis.
Which form of kidney injury should the nursing practitioner realize has occurred with this
hospital patient?
1. Prerenal
2. Postrenal
3. Intrarenal
4. Suprabladder
RIGHT ANSWER> 3
Chapter: Chapter 37. Nursing Care of Hospital patients With Disorders of the Urinary
System Objective: Explain the pathophysiology and nursing care for diabetic
nephropathy, nephrosclerosis, hydronephrosis, and glomerulonephritis.
Source: pp. 755
Heading: Intrarenal Injury
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 This hospital patient’s kidney injury is not caused by a pre- or postrenal injury.
2 This hospital patient’s kidney injury is not caused by a pre- or postrenal injury.
3 Intrarenal kidney injury occurs when there is damage to the nephrons inside the
kidney. Causes are ischemia, reduced blood flow, toxins, infectious processes
leading to glomerulonephritis, trauma to the kidney, allergic reactions to
radiograph dyes, and severe muscle injury.
4 Suprabladder is not a type of kidney injury.
PTS: 1 CON: Hospital patient-Centered Care
11. A 19-year-old hospital patient reports flank pain and scanty urination. The nursing
practitioner notices periorbital edema, and the urinalysis reveals white blood cells, red blood
cells, albumin, and casts. Which question will provide important information for the nursing
practitioner to include in data collection?
1. “Have you noticed changes in your vision?”
2. “Have you ever had unprotected sex?”
3. “Have you had any gastrointestinal problems lately?”
4. “Have you had any type of strep infection recently?”
RIGHT ANSWER> 4
Chapter: Chapter 37. Nursing Care of Hospital patients With Disorders of the Urinary
System Objective: Explain the pathophysiology and nursing care for diabetic
nephropathy, nephrosclerosis, hydronephrosis, and glomerulonephritis. Source: pp. 741
Heading: Acute Poststreptococcal Glomerulonephritis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Moderate
CLARIFICATION
1 Asking about blurred vision, sexual activity, and gastrointestinal problems will
not provide important information regarding the hospital patient’s condition.
2 Asking about blurred vision, sexual activity, and gastrointestinal problems will
not provide important information regarding the hospital patient’s condition.
3 Asking about blurred vision, sexual activity, and gastrointestinal problems will
not provide important information regarding the hospital patient’s condition.
4 The hospital patient has symptoms of glomerulonephritis, which can be caused
by a variety of factors, but is most commonly associated with a beta-hemolytic
streptococcus infection following a streptococcal infection of the throat or skin.
PTS: 1 CON: Elimination
12. The nursing practitioner is providing care for a hospital patient scheduled for surgery for
the formation of an orthotopic bladder substitution. Which hospital patient teaching is important
for the nursing practitioner to review during the hospital patient’s recovery?
1. How to monitor the stoma
2. How to prevent skin injury
3. How to perform catheterization
4. How to apply an ostomy appliance
RIGHT ANSWER> 3
Chapter: Chapter 37. Nursing Care of Hospital patients With Disorders of the Urinary
System Objective: Discuss nursing care for a hospital patient with an ileal conduit or
continent reservoir. Source: pp. 770
Heading: Orthotopic Bladder Substitution
Integrated Process: Teaching/Learning
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The hospital patient who has orthotopic bladder substitution does not have a
stoma. A “new” bladder is surgically formed and both the ureters and urethra are
implanted.
2 The hospital patient who has orthotopic bladder substitution is not prone to skin
breakdown even though incontinence is sometimes a problem.
3 The hospital patient who has orthotopic bladder substitution may need to
perform intermittent catheterization as needed. The nursing practitioner needs to
review this procedure
during the recovery period.
4 The hospital patient who has orthotopic bladder substitution will not need to
wear an
appliance. The hospital patient will be able to urinate through the urethra
normally.
PTS: 1 CON: Hospital patient-Centered Care
13. Which hospital patient will the nursing practitioner consider to be at greatest risk for cancer of
the kidney?
1. A 30-year-old male who smokes a pack a day and is treated for hypertension
2. A 46-year-old female who is obese and works full time as an x-ray technician
3. A 55-year-old female who has undergone dialysis for 6 years for renal disease
4. A 50-year-old male with a 20-year history of smoking and works in a chemical
laboratory
RIGHT ANSWER> 4
Chapter: Chapter 37. Nursing Care of Hospital patients With Disorders of the Urinary
System Objective: List risk factors and signs and symptoms of cancer of the kidneys.
Source: pp. 750
Heading: Cancer of the Kidney
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integration—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Cellular Regulation
Difficulty: Difficult
CLARIFICATION
1 Men are more likely to develop cancer of the kidney, but rarely under the age of
45; smoking is a high risk for the disease; and hypertension can be caused by
multiple conditions. This hospital patient has two possible risks, smoking and
gender.
2 This hospital patient has three risks for kidney cancer: age, obesity, and
radiation exposure.
3 This hospital patient has two risks for kidney cancer: age and long-term kidney
dialysis.
4 This hospital patient has four risks for kidney cancer: gender, age, smoking
history, and
chemical exposure.
PTS: 1 CON: Cellular Regulation
14. The nursing practitioner is collecting data on a hospital patient admitted for symptoms
of renal insufficiency. Which factor will cause the nursing practitioner to suspect prerenal
injury?
1. A family history of polycystic kidney disease (PKD)
2. Medications for chronic joint pain and hypertension
3. Laboratory results indicating a high level of an aminoglycoside
4. A tumor obstruction diagnosed as being present in the right ureter
RIGHT ANSWER> 2
Chapter: Chapter 37. Nursing Care of Hospital patients With Disorders of the Urinary
System Objective: Plan nursing care for a hospital patient with an acute kidney injury.
Source: pp. 730
Heading: Prerenal Injury
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Difficult
CLARIFICATION
1 The hospital patient may or may not have PKD; however, the condition is an
intrarenal injury.
2 Medications such as NSAIDs for joint pain and cyclooxygenase-2 inhibitors
for hypertension can cause prerenal injury by impairing the autoregulatory
responses of the kidney by blocking prostaglandin, which is needed for renal
perfusion.
3 An aminoglycoside is an antibiotic that is cleared by the kidneys and is
nephrotoxic. However, nephrotoxicity from any cause is an intrarenal injury.
4 Any obstruction to the outflow of urine is considered to be a postrenal injury.
PTS: 1 CON: Elimination
15. The nursing practitioner is planning care for a hospital patient diagnosed with chronic
renal failure. The nursing practitioner notes that the hospital patient’s output is 620 mL for the
last 24 hours. The hospital patient has periorbital edema and crackles in all lung fields upon
auscultation. Which intervention is most important for the nursing practitioner to implement
during care of this hospital patient?
1. Administer oxygen therapy.
2. Measure abdominal girth.
3. Obtain daily weights.
4. Maintain fluid restrictions.
RIGHT ANSWER> 3
Chapter: Chapter 37. Nursing Care of Hospital patients With Disorders of the Urinary
System Objective: Plan nursing care for hospital patients with chronic kidney disease.
Source: pp. 753
Heading: Nursing Care for the Hospital patient With Chronic Kidney
Disease Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Moderate
CLARIFICATION
1 The hospital patient may or may not need oxygen therapy; this intervention
requires a
prescription by the HCP.
2 Measurement of abdominal girth provides information about ascites. Hospital
patients with renal failure may not initially exhibit abdominal ascites. There is
a better nursing intervention.
3 Hospital patients with acute or chronic renal failure must be weighed daily at the
same time, on the same scale, wearing the same type of clothing. Any weight
gain of
2 pounds or more indicates fluid retention. This is the most important nursing
intervention.
4 Fluids may or may not need to be restricted; this intervention requires a
prescription by the HCP.
PTS: 1 CON: Elimination
16. The nursing practitioner is visiting a hospital patient who performs peritoneal dialysis at
home. The nursing practitioner is evaluating the hospital patient’s technique and
environment. Which situation is least likely to cause the nursing practitioner concern?
1. The hospital patient has several pets who roam around the house.
2. The hospital patient verbally expresses symptoms to report to the HCP.
3. The hospital patient uses clean technique when instilling the dialysate.
4. The hospital patient voices the reasons for limiting dietary protein intake.
RIGHT ANSWER> 2
Chapter: Chapter 37. Nursing Care of Hospital patients With Disorders of the Urinary
System Objective: Plan nursing care for hospital patients on peritoneal dialysis. Source:
pp. 765
Heading: Peritoneal Dialysis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The hospital patient on peritoneal dialysis needs to perform the procedure in a
clean environment. The nursing practitioner needs to be concerned about the
cleanliness with several pets roaming around in the house.
2 It is important that the hospital patient understands the symptoms that need to
be reported to the HCP. The symptoms of infection or peritonitis must have
immediate treatment. This is the nurse’s least concern.
3 The hospital patient must use sterile technique when attaching and instilling
the dialysate to prevent the introduction of pathogens or microbes into the
abdominal cavity. Clean technique is a matter of concern.
4 The nursing practitioner is concerned if the hospital patient limits dietary
protein intake. The hospital patient on peritoneal dialysis loses proteins
through the peritoneal membrane.
Increased protein is needed. This is a matter of concern for the nurse.
PTS: 1 CON: Hospital patient-Centered Care
17. The nursing practitioner is providing care for a hospital patient who is scheduled for the
formation of access for hemodialysis. Which important action does the nursing practitioner
take with this hospital patient?
1. Refrains from drawing blood or placing IV lines in the nondominate arm
2. Prepares the hospital patient for permanent placement of a central venous catheter
3. Instructs the hospital patient about the need for showering with antimicrobial soap
4. Reviews the type of underclothing that will be worn to protect the access
RIGHT ANSWER> 1
Chapter: Chapter 37. Nursing Care of Hospital patients With Disorders of the Urinary
System Objective: Discuss nursing care for a vascular access site.
Source: pp. 763
Heading: Vascular Access
Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: Physiological Integrity—Reduction
of Risk Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The hospital patient will have an arteriovenous (AV) fistula formed; placement
is in the nondominate arm. Therefore, all needle sticks and blood pressures
should be avoided in this arm to prevent damage to the veins.
2 A central venous catheter may be placed temporarily until the AV fistula is
healed and developed. Long use of a central catheter should be avoided due to
the risk for infection.
3 There is no need for the hospital patient to shower with antimicrobial soap
before or after the establishment of an AV fistula.
4 The AV fistula is most commonly placed on the hospital patient’s arm. Tight
clothing on
the arm needs to be avoided, but there are no restrictions about under clothing.
PTS: 1 CON: Hospital patient-Centered Care
MULTIPLE RESPONSE
1. The nursing practitioner is reinforcing teaching provided to a hospital patient with a
history of calcium oxalate kidney stones. The nursing practitioner recognizes that teaching
has been effective if the hospital patient avoids which foods? (Select all that apply.)
1. Bread
2. Cocoa
3. Lettuce
4. Spinach
5. Instant coffee
RIGHT ANSWER> 2, 4, 5
Chapter: Chapter 37. Nursing Care of Hospital patients With Disorders of the Urinary
System Objective: Plan nursing care for a hospital patient with acute kidney injury.
Source: pp. 744
Heading: Urological Obstructions
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Difficult
CLARIFICATION
1. Bread does not need to be restricted on a low-oxalate diet.
2. A low-oxalate diet restricts foods such as beets, rhubarb, spinach, cocoa, and
instant coffee.
3. Lettuce does not need to be restricted on a low-oxalate diet.
4. A low-oxalate diet restricts foods such as beets, rhubarb, spinach, cocoa, and
instant coffee.
5. A low-oxalate diet restricts foods such as beets, rhubarb, spinach, cocoa, and
instant coffee.
PTS: 1 CON: Elimination
2. The nursing practitioner is reinforcing teaching provided to a hospital patient about caring
for a new arteriovenous (AV) fistula in the left arm for dialysis. Which hospital patient
statements indicate correct understanding? (Select all that apply.)
1. “Do not sleep on my arm.”
2. “Keep my arm elevated at all times.”
3. “Keep a firm bandage on my arm.”
4. “Wear loose clothing on my left arm.”
5. “Avoid carrying heavy things with my left arm.”
RIGHT ANSWER> 1, 4, 5
Chapter: Chapter 37. Nursing Care of Hospital patients With Disorders of the Urinary
System Objective: Discuss nursing care for a vascular access site.
Source: pp. 764
Heading: Vascular Access
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Difficult
CLARIFICATION
1. The fistula must be protected from anything causing pressure or restriction of
blood flow. The hospital patient should not sleep on the left arm.
2. The left arm does not need to be elevated at all times.
3. A firm bandage does not need to be on the left arm.
4. The fistula must be protected by anything causing pressure or restriction of
blood flow. Loose clothing should be worn on the left arm.
5. The fistula must be protected by anything causing pressure or restriction of
blood flow. Heavy objects should not be carried with the left arm.
PTS: 1 CON: Elimination
3. The nursing practitioner is preparing to reinforce teaching to a hospital patient newly
diagnosed with PKD. Which information does the nursing practitioner include? (Select all that
apply.)
1. Typically, first signs of the disease appear during late childhood.
2. Grape-like cysts will replace normal, functioning structures.
3. Initial symptoms are dull heaviness in the flank area and hematuria.
4. Hospital patients are at risk for brain aneurysms and diverticulosis in the colon.
5. Disease is likely to require additional treatment for hypertension and UTIs.
RIGHT ANSWER> 2, 3, 4, 5
Chapter: Chapter 37. Nursing Care of Hospital patients With Disorders of the Urinary
System Objective: Plan nursing care for hospital patients with chronic kidney disease.
Source: pp. 760
Heading: Polycystic Kidney Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Difficult
CLARIFICATION
1. The first signs of PKD occur in adulthood.
2. Grape-like structures do replace normal, functioning kidney structures. The
cysts contain serous fluid, blood, or urine.
3. The initial symptoms will include a dull heaviness in the flank or lumbar
region, accompanied by hematuria.
4. Persons with inherited PKD are at risk for brain aneurysms and diverticulosis
in the colon.
5. Persons diagnosed with PKD are likely to have hypertension and UTIs that
require treatment.
PTS: 1 CON: Elimination
Chapter 38. Endocrine System Function and Assessment
MULTIPLE CHOICE
1. The nursing practitioner is reviewing information with a hospital patient about the normal
anatomy and physiology of the endocrine system. Which factor is inaccurate?
1. All endocrine glands are anatomically separate in location.
2. All endocrine glands function independently of each other.
3. Most hormone levels are regulated by a negative CLARIFICATION system.
4. Each hormone is secreted in response to a specific stimulus.
RIGHT ANSWER> 2
Chapter: Chapter 38. Endocrine System Function and Assessment
Objective: Identify the glands of the endocrine system.
Pages: 773–778
Heading: Normal Endocrine System Anatomy and Physiology Integrated
Process: Clinical Problem-Solving Process (Nursing Process) Hospital
patient Need: Physiological Integrity—Physiological Adaptation CL:
Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Unlike other organ systems, all endocrine glands are anatomically separate in
location.
2 Endocrine glands may function separately, but some hormones are secreted in
response to hormones secreted by other endocrine glands.
3 Most hormone levels are regulated by a negative CLARIFICATION system, as
when hormone levels are low or body functions are not normal.
4 Each specific hormone is secreted in response to a specific stimulus and affects
target cells for that specific hormone.
PTS: 1 CON: Hospital patient-Centered Care
2. The nursing practitioner is researching information for a hospital patient newly diagnosed
with diabetes mellitus. The nursing practitioner wants to present the responses by
hormones other than insulin. Which information does the nursing practitioner avoid?
1. Growth hormones (GHs) secreted by the anterior pituitary play a part in glucose
regulation.
2. Growth hormone-releasing hormone (GHRH) is secreted during hypoglycemia or
when there is a high blood level of amino acids.
3. GH and growth hormone-inhibiting hormone (GHIH) are secreted to maintain
blood glucose levels and metabolism rates are normal.
4. GHIH is secreted during hyperglycemia when carbohydrates are available for
energy production.
RIGHT ANSWER> 3
Chapter: Chapter 38. Endocrine System Function and Assessment Objective:
Explain the function of each of the hormones in the endocrine system. Source: pp.
782
Heading: Anterior Pituitary Gland
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 The anterior pituitary hormones play a part in blood glucose regulation with the
secretion of GHRH and GHIH.
2 The option correctly explains the function of GHRH during hypoglycemia and
high blood level of amino acids.
3 GH and GHIH are growth hormones secreted by the anterior pituitary gland, but
GH has no influence on the regulation of blood glucose levels. GH stimulates
growth and GHIH inhibits growth. However, GHIH also plays a part in glucose
regulation.
4 This correctly explains the function of GHIH during hyperglycemia when
adequate carbohydrates are available for energy production and fat
mobilization is not necessary.
PTS: 1 CON: Metabolism
3. An older adult hospital patient is experiencing a reduction in energy. Which comment by the
nursing practitioner is most appropriate?
1. “Mild diabetes often develops with age; I’ll see about checking your blood sugar.”
2. “Your tiredness is because your body increases the release of growth hormone as
you age.”
3. “Aging causes the basal metabolic rate to change, and it’s often normal to have
less energy.”
4. “A decrease in parathyroid hormone secretion occurs with age, and that can make
you feel tired.”
RIGHT ANSWER> 3
Chapter: Chapter 38. Endocrine System Function and Assessment
Objective: Describe the effects of aging on endocrine system function.
Source: pp. 795
Heading: Aging and the Endocrine System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Most of the endocrine glands decrease their secretions with age, but normal
aging usually does not lead to serious hormone deficiencies or illness. Unless
specific pathological conditions develop, the endocrine system usually
continues to function adequately in old age.
2 Most of the endocrine glands decrease their secretions with age, but normal
aging usually does not lead to serious hormone deficiencies or illness. Unless
specific pathological conditions develop, the endocrine system usually
continues to function adequately in old age.
3 Decreases in thyroid-stimulating hormone (TSH) and thyroid hormone cause a
decrease in the basal metabolic rate and may result in decreased energy. The
decrease in secretion is normal with aging.
4 Low parathyroid hormone is not a common cause of tiredness.
PTS: 1 CON: Hospital patient-Centered Care
4. After reviewing the hospital patient’s medical record, the nursing practitioner plans to
perform a physical examination. Which finding will change the usual process of physical
examination?
1. The hospital patient had surgery for a goiter.
2. The hospital patient is being treated for diabetes mellitus.
3. The hospital patient has elevated thyroid hormones.
4. The hospital patient is diagnosed with a posterior pituitary tumor
RIGHT ANSWER> 3
Chapter: Chapter 38. Endocrine System Function and Assessment
Objective: List data to collect when caring for a hospital patient with a disorder of the
endocrine system.
Source: pp. 796
Heading: Thyroid Gland
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physical Integrity—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The finding that the hospital patient had surgery for a goiter will not alone
change the
nurse’s process of physical examination.
2 The finding that the hospital patient is being treated for diabetes mellitus will
not change the nurse’s process of physical examination.
3 Elevated thyroid hormones are indicative of a hyperactive thyroid gland. The
nursing practitioner will not assist the health care provider (HCP) during thyroid
examination. The HCP will avoid palpating the thyroid to avoid stimulation.
4 Because the nursing practitioner would be unable to perform a physical
examination on the posterior pituitary gland, this finding alone is not going to
change the nurse’s process of physical examination.
PTS: 1 CON: Hospital patient-Centered Care
5. The HCP prescribes a 24-hour urine specimen for cortisol. The hospital patient is
incontinent. Which method will the nursing practitioner use to collect the specimen?
1. Place the hospital patient on a bedpan every half hour during the test.
2. Obtain an order for an indwelling catheter for the duration of the test.
3. Review the use of the nursing practitioner call light and have the hospital patient indicate a
need to void.
4. Place a bedside commode in a position to enable the hospital patient to
make a safe transfer.
RIGHT ANSWER> 2
Chapter: Chapter 38. Endocrine System Function and Assessment
Objective: Plan nursing care for hospital patients undergoing testing for an endocrine
disorder. Source: pp. 780
Heading: Adrenal Cortex
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Safe and Effective Care Environment—Safety and Infection
Control CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Placing the hospital patient on a bedpan every half hour is not going assure that
all urine is collected; the hospital patient may have continuous incontinence.
2 If the hospital patient is incontinent or otherwise unable to participate in the test,
a catheter may need to be inserted. If the hospital patient already has an
indwelling
catheter, a new bag and tubing should be attached before the start of the test.
3 Reviewing the use of the call light may not be effective. The hospital
patient may or may not be able to determine the need to void or may not be
able to wait for help without voiding.
4 There is not enough information to determine if the hospital patient is able to
use a
bedside commode safely. Functional incontinence would not support this
method of collection.
PTS: 1 CON: Hospital patient-Centered Care
6. The nursing practitioner is providing care for a hospital patient diagnosed with posterior
pituitary tumor resulting in oversecretion of hormones. Which manifestation of this disorder
will the nursing practitioner expect?
1. Significant increase in urinary output
2. Notable increase in blood pressure
3. Physical indications of dehydration
4. Severe blood loss associated with injury
RIGHT ANSWER> 2
Chapter: Chapter 38. Endocrine System Function and Assessment
Objective: List data to collect when caring for a hospital patient with a disorder of the
endocrine system.
Source: pp. 790
Heading: Posterior Pituitary Gland
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Difficult
CLARIFICATION
1 Oversecretion of antidiuretic hormone (ADH) will result in a decrease, not
increase, in urinary output related to fluid reabsorption.
2 Oversecretion of antidiuretic hormone (ADH) will result in a significant
increase in blood pressure related to increased fluid reabsorption.
3 With the oversecretion of antidiuretic hormone (ADH), fluid will be retained
and the hospital patient will not exhibit signs of dehydration.
4 ADH normally constricts blood vessels and prevents blood loss in the case of
injury. Oversecretion of antidiuretic hormone (ADH) will not cause severe
blood loss with injury.
PTS: 1 CON: Metabolism
7. The nursing practitioner is providing care for a hospital patient diagnosed with type 2
diabetes mellitus. Which information will the nursing practitioner give the hospital patient
about the response of the pancreas to hypoglycemia?
1. Pancreatic alpha cells are stimulated to inhibit insulin.
2. Pancreatic beta cells are stimulated to move glucose from cells.
3. Pancreatic alpha cells are stimulated to release glucagon.
4. Pancreatic beta cells are stimulated to decrease insulin.
RIGHT ANSWER> 3
Chapter: Chapter 38. Endocrine System Function and Assessment
Objective: Explain the function of each of the hormones in the endocrine system.
Source: pp. 816
Heading: Pancreas
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 Pancreatic alpha cells will stimulate the release of glucagon to raise glucose
blood levels in response to hypoglycemia. Alpha cells do not inhibit the release
of insulin.
2 Hyperglycemia stimulates pancreatic beta cells to release insulin; the beta cells
do not move glucose from the cells and into the blood in the event of
hypoglycemia.
3 Pancreatic alpha cells will stimulate the release of glucagon in response to
hypoglycemia. Glucagon raises blood glucose levels and makes it available to
body cells.
4 Pancreatic beta cells are stimulated to increase the secretion of insulin with
hyperglycemia. The beta cells do not have a role with hypoglycemia.
PTS: 1 CON: Metabolism
8. The nursing practitioner is assisting with care to a hospital patient who underwent
surgery for removal of the thyroid gland. Which symptom contradicts a possible
complication of the surgery?
1. Decreased calcium in blood
2. Prolonged clotting time
3. Decreased calcitonin levels
4. Hyperactive bowel sounds
RIGHT ANSWER> 4
Chapter: Chapter 38. Endocrine System Function and Assessment
Objective: Explain the function of each of the hormones in the endocrine system.
Source: pp. 800
Heading: Parathyroid Glands
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 A possible complication related to removal of the thyroid is accidental removal
or damage to the parathyroid glands, which secrete parathyroid hormone
(PTH). A complication of thyroid surgery is hypocalcemia, or a decrease in
calcium in the blood.
2 Parathyroid hormone (PTH) is necessary to assist in blood clotting. With the
accidental removal or damage to the parathyroid glands, blood clotting will be
prolonged.
3 Calcitonin is an antagonist to parathyroid hormone (PTH). If the secretion of
PTH is decreased by the accidental removal or damage to the parathyroid
glands, the level of calcitonin is also decreased.
4 The delivery of calcium ions is essential for normal excitability of neurons and
muscle cells and blood clotting. A decrease or lack of parathyroid hormone
(PTH) will affect bone, the small intestine, and kidneys. Hyperactive bowels
sound are a contraindication.
PTS: 1 CON: Metabolism
9. The licensed practical nurse/licensed vocational nursing practitioner (LPN/LVN) is
assisting with the physical examination of a hospital patient in the HCP’s office. Which
physical examination does the LPN/LVN perform?
1. Observe for abnormal physical characteristics.
2. Palpation of the flank for adrenal gland disorders.
3. Gently palpate the thyroid gland for enlargement.
4. Percuss the abdomen to validate normal pancreas size.
RIGHT ANSWER> 1
Chapter: Chapter 38. Endocrine System Function and Assessment
Objective: List data to collect when caring for a hospital patient with a disorder of the
endocrine system.
Source: pp. 790
Heading: Nursing Assessment of the Endocrine System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The LPN/LVN is able to observe the hospital patient for abnormal physical
characteristics during a physical examination. The nursing practitioner will
note the presence of exophthalmos, buffalo hump, and dry and thin hair as an
example.
2 The adrenal glands cannot be palpated; the only palpable gland is the thyroid.
3 The LPN/LVN may assist the HCP with palpation of the thyroid gland by
positioning the hospital patient and providing water to sip and swallow.
4 Auscultation and percussion are not part of the physical assessment of the
endocrine system.
PTS: 1 CON: Hospital patient-Centered Care
10. A hospital patient is identified with a thyroid disorder resulting in hormone deficiency.
The HCP prescribes a stimulation test. Which process does the nursing practitioner expect for
the test?
1. The hospital patient will drink a contrast medium.
2. Hormone measurements will occur after a meal.
3. A substance will be injected into the hospital patient.
4. The hospital patient is evaluated after monitored exercise.
RIGHT ANSWER> 3
Chapter: Chapter 38. Endocrine System Function and Assessment
Objective: Plan nursing care for hospital patients undergoing testing for an endocrine
disorder. Source: pp. 780
Heading: Stimulation Tests
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 A contrast medium is not used for a stimulation test. Contrast medium is used
for radiographic studies.
2 The function of the thyroid is not measured after a meal. The function of the
pancreas is often stimulated by the ingestion of food or nutrients.
3 A substance will be injected into the hospital patient to stimulate the thyroid
gland;
reactions and hormone measurements will be noted.
4 Exercise is not an element used to stimulate thyroid function; cardiac and
respiratory assessment may involve exercise.
PTS: 1 CON: Metabolism
11. A hospital patient is diagnosed with adrenal gland dysfunction and is scheduled for a 24-
hour urine test. Which action by the nursing practitioner in regard to the test is incorrect?
1. The test is complete when the last voiding is collected.
2. The first morning urine sample is retained for testing.
3. The test will need to be restarted if a urine sample is missed.
4. Urine samples are collected immediately after voiding.
RIGHT ANSWER> 2
Chapter: Chapter 38. Endocrine System Function and Assessment
Objective: Plan nursing care for hospital patients undergoing testing for an endocrine
disorder. Source: pp. 780
Heading: Urine Tests
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Safe and Effective Care Environment—Coordinated
Care CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The test is complete when the last voiding is collected at the end of the 24-hour
period. The nursing practitioner needs to ask the hospital patient to void at the
time the test ends.
2 The first morning sample of urine is discarded because it is a product of a time
period before the test began.
3 The urine collection is a continuous collection during a designated 24-hour
period. If a sample is missed, the test is restarted.
4 Urine samples for a 24-hour urine collection should be collected immediately
to prevent deterioration of the sample. Most collections are refrigerated and
may have added preservatives.
PTS: 1 CON: Hospital patient-Centered Care
12. The nursing practitioner is preparing a hospital patient to undergo a suppression test to
verify adrenal cortex dysfunction. Which reply will the nursing practitioner make when the
hospital patient asks about the expected test procedure?
1. “You will be injected with an adrenal stimulant to see how the adrenal glands
work.”
2. “You will be injected with a steroid hormone that should suppress cortisol
release.”
3. “A failure of adrenal cortex function is indicated by a low blood cortisol level.”
4. “You will be injected with epinephrine to stimulate your metabolic functions.”
RIGHT ANSWER> 2
Chapter: Chapter 38. Endocrine System Function and Assessment
Objective: Plan nursing care for hospital patients undergoing testing for an endocrine
disorder. Source: pp. 807
Heading: Suppression Tests
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Integrity
CL: Analysis (Analyzing) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 A suppression test does not stimulate organ activity; this would result from a
stimulation test.
2 A suppression test for adrenal cortex function incudes the injection of a steroid
hormone, which should result in a suppression of cortisol release. If the cortisol
level is not suppressed, it is indicative of adrenal cortex dysfunction and verifies
the hospital patient’s diagnosis.
3 The indicator of adrenal cortex dysfunction is a high blood cortisol level even
after the administration of a suppressor.
4 The hospital patient will not be injected with epinephrine as part of a
suppression test.
Epinephrine is a metabolic stimulant.
PTS: 1 CON: Hospital patient-Centered Care
13. The nursing practitioner is preparing a hospital patient for a thyroid scan to rule out
thyroid cancer. Which instruction does the nursing practitioner give the hospital patient
prior to the testing?
1. Do not leave the area after the radioactive material is injected.
2. Collect all urine for 4 hours so it can be evaluated for radiation.
3. Use the bathroom before the scanning part of the test is performed.
4. Multiple series of x-rays will be taken over a period of 2 hours.
RIGHT ANSWER> 3
Chapter: Chapter 38. Endocrine System Function and Assessment
Objective: Plan nursing care for hospital patients undergoing testing for an endocrine
disorder. Source: pp. 800
Heading: Thyroid Scan
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 There is no reason for the hospital patient to remain in a specific area after
radioactive
material is injected or ingested. The amount of radioactive material is small and
unlikely to cause harm to the hospital patient or others.
2 After a thyroid scan, the hospital patient does not need to collect urine for any
period of
time to be evaluated for radiation.
3 The hospital patient does need to go to the bathroom prior to the scanning part
of the test; the scanning can take approximately 30 minutes to complete. The
test
should not be interrupted for the hospital patient to void.
4 The scanning is performed by a scintillation camera and is completed in 30
minutes. Hot spots are indicative of healthy thyroid tissue, and cold spots are
indicative of malignancies.
PTS: 1 CON: Hospital patient-Centered Care
14. The nursing practitioner receives information that an assigned hospital patient is scheduled
for an ultrasound of an endocrine gland. Which instruction does the nursing practitioner give the
hospital patient?
1. Wear clothing with an elastic waistband.
2. Remain NPO for 12 hours prior to testing.
3. Do not wear a tight or high-necked shirt.
4. Wash hair with antimicrobial shampoo.
RIGHT ANSWER> 1
Chapter: Chapter 38. Endocrine System Function and Assessment
Objective: Plan nursing care for hospital patients undergoing testing for an endocrine
disorder. Source: pp. 800
Heading: Ultrasound
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Ultrasound is not performed to examine the adrenal glands, which would
require elastic waistband clothing. Other testing methods will provide more
definitive results.
2 Even with ultrasound of the abdominal cavity, it is not necessary to remain
NPO for 12 hours. The only endocrine gland in the abdomen is the pancreas
and other more definitive testing is available.
3 The thyroid and parathyroid glands are easily examined by ultrasound. The
location and accessibility will result in definitive results. The ultrasound is able
to detect enlargement or masses. However, the hospital patient is instructed not
to wear
clothing with a tight or high neckline.
4 The only endocrine gland in the head is the pituitary. The pituitary gland is
encased in the skull and would not be an appropriate area to examine with
ultrasound.
PTS: 1 CON: Hospital patient-Centered Care
15. A hospital patient has returned to the unit after a needle biopsy of the thyroid gland to
rule out cancer. Which observation is expected by the nursing practitioner following the
procedure?
1. Pain level of 2 on a 0-to-10 scale
2. Moderate amount of bleeding on the bandage
3. Inability to swallow or speak clearly
4. An oxygen saturation level of 90 percent
RIGHT ANSWER> 1
Chapter: Chapter 38. Endocrine System Function and Assessment
Objective: Plan nursing care for hospital patients undergoing testing for an endocrine
disorder. Source: pp. 803
Heading: Biopsy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 After a needle biopsy of the thyroid, the hospital patient may express a low
level of pain; this observation is expected.
2 It is unlikely that a needle biopsy will produce a moderate amount of bleeding
on the bandage used to cover the puncture site. This is an unexpected
observation.
3 The inability to swallow or speak after a thyroid needle biopsy is unexpected.
The throat is not involved in the procedure.
4 An oxygen saturation level of 90 percent is unexpected after a needle biopsy of
the thyroid. The procedure is not likely to interfere with the hospital patient’s
airway.
PTS: 1 CON: Hospital patient-Centered Care
16. The nursing practitioner is aware that a 12-year-old male hospital patient is at the fifth
percentile on the growth chart for height. Which medical intervention does the nursing
practitioner expect the HCP to prescribe?
1. Surgery to lengthen the long bones and increase height
2. Administration of GH therapy for added height
3. Maintaining a wait-and-see approach until the hospital patient is age 18
4. Diagnostic testing to identify any adrenal gland dysfunction
RIGHT ANSWER> 2
Chapter: Chapter 38. Endocrine System Function and Assessment
Objective: Explain the function of each of the hormones in the endocrine system.
Source: pp. 794
Heading: Anterior Pituitary Gland
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 Surgery to lengthen the long bones and increase height is a long and painful
process, which is usually not performed on adolescent hospital patients when
growth can
be promoted in less invasive ways.
2 It is expected for an adolescent to experience notable increases in height. When
height lags behind, the hospital patient may be treated with GH to stimulate
height increase.
3 By the age of 18 years, the most responsive time for growth stimulation may
have passed.
4 Growth hormones are secreted by the hypothalamus; testing of the adrenal
glands is not needed.
PTS: 1 CON: Hospital patient-Centered Care
17. The nursing practitioner is aware that the pancreas is the only gland that is both endocrine
and exocrine. Which secretion is related to the endocrine function of the pancreas?
1. Insulin
2. Bile
3. Amylase
4. Lipase
RIGHT ANSWER> 1
Chapter: Chapter 38. Endocrine System Function and Assessment
Objective: Explain the function of each of the hormones in the endocrine system.
Source: pp. 820
Heading: Pancreas
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 An endocrine function of the pancreas is to excrete insulin in response to blood
glucose levels.
2 Bile is excreted by the liver to aid in digestion; the liver is not a gland.
3 Amylase is secreted by the pancreas to assist in the digestion of carbohydrates;
the excretion is an exocrine function.
4 Lipase is secreted by the pancreas to assist in the digestion of fats; the
excretion is an exocrine function.
PTS: 1 CON: Hospital patient-Centered Care
18. The nursing practitioner is aware that the adrenal cortex secretes a variety of
hormones. Which is an incorrect function of glucocorticoids?
1. In both genders, they contribute to libido.
2. They are small amounts of male androgens.
3. In females, they counterbalance estrogen effects.
4. They are the only source of estrogen after menopause.
RIGHT ANSWER> 3
Chapter: Chapter 38. Endocrine System Function and Assessment
Objective: Explain the function of each of the hormones in the endocrine system.
Source: pp. 807
Heading: Adrenal Cortex
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 In both genders, glucocorticoids contribute to sexual desire, known as libido.
2 Glucocorticoids are small amounts of male androgens.
3 Glucocorticoids do not counterbalance estrogen effects in females. Male
androgens are converted to estrogen in females.
4 After menopause, the only source of estrogen for females is from
glucocorticoids.
PTS: 1 CON: Hospital patient-Centered Care
MULTIPLE RESPONSE
1. A hospital patient is prescribed a dose of epinephrine. Which effects does the nursing
practitioner expect the hospital patient to exhibit after receiving this medication? (Select all that
apply.)
1. Decreases peristalsis
2. Constricts bronchioles
3. Increases heart rate and force of contraction
4. Stimulates the liver to convert glycogen to glucose
5. Stimulates vasoconstriction in skin and most viscera
RIGHT ANSWER> 1, 3, 4, 5
Chapter: Chapter 38. Endocrine System Function and Assessment
Objective: Explain the function of each of the hormones in the endocrine system.
Source: pp. 819
Heading: Adrenal Medulla
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. Epinephrine increases the heart rate and force of contraction, stimulates
vasoconstriction in skin and most viscera and vasodilation in skeletal
muscles, dilates the bronchioles, decreases peristalsis, stimulates the liver to
convert glycogen to glucose, increases the use of fats for energy, and
increases the rate of cell respiration.
2. Epinephrine does not constrict the bronchioles.
3. Epinephrine increases the heart rate and force of contraction, stimulates
vasoconstriction in skin and most viscera and vasodilation in skeletal
muscles, dilates the bronchioles, decreases peristalsis, stimulates the liver to
convert glycogen to glucose, increases the use of fats for energy, and
increases the rate of cell respiration.
4. Epinephrine increases the heart rate and force of contraction, stimulates
vasoconstriction in skin and most viscera and vasodilation in skeletal
muscles, dilates the bronchioles, decreases peristalsis, stimulates the liver to
convert glycogen to glucose, increases the use of fats for energy, and
increases the rate of cell respiration.
5. Epinephrine increases the heart rate and force of contraction, stimulates
vasoconstriction in skin and most viscera and vasodilation in skeletal
muscles, dilates the bronchioles, decreases peristalsis, stimulates the liver to
convert glycogen to glucose, increases the use of fats for energy, and
increases the rate of cell respiration.
PTS: 1 CON: Hospital patient-Centered Care
2. A hospital patient is experiencing an increased level of corticotropin-releasing
hormone (CRH). What should the nursing practitioner consider is occurring with this
hospital patient? (Select all that apply.)
1. Body stressed
2. Low blood volume
3. Presence of an injury
4. Low blood glucose level
5. Elevated blood glucose level
RIGHT ANSWER> 1, 3, 4
Chapter: Chapter 38. Endocrine System Function and Assessment
Objective: Explain the function of each of the hormones in the endocrine system.
Source: pp. 781
Heading: Adrenal Cortex
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. CRH is produced during any type of stress such as injury, disease, exercise,
or hypoglycemia.
2. Antidiuretic hormone is released in response to low blood volume.
3. CRH is produced during any type of stress such as injury, disease, exercise,
or hypoglycemia.
4. CRH is produced during any type of stress such as injury, disease, exercise,
or hypoglycemia.
5. Growth hormone–inhibiting hormone is secreted during hyperglycemia.
PTS: 1 CON: Hospital patient-Centered Care
3. While collecting data, the nursing practitioner suspects that a hospital patient is
experiencing Cushing syndrome. Which findings does the nursing practitioner use to come
to this conclusion? (Select all that apply.)
1. Bulging eyes
2. Mood swings
3. Buffalo hump
4. Water weight gain
5. Round “moon” face
RIGHT ANSWER> 2, 3, 4, 5
Chapter: Chapter 38. Endocrine System Function and Assessment
Objective: List data to collect when caring for a hospital patient with a disorder of the
endocrine system.
Source: pp. 808
Heading: Adrenal Glands
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing) Concept:
Metabolism
Difficulty: Difficult
CLARIFICATION
1. Bulging eyes are a manifestation of Graves disease.
2. Manifestations of Cushing syndrome include water weight gain, mood
swings, fat pads on neck and shoulders (“buffalo hump”), and a round
“moon” face.
3. Manifestations of Cushing syndrome include water weight gain, mood
swings, fat pads on neck and shoulders (“buffalo hump”), and a round
“moon” face.
4. Manifestations of Cushing syndrome include water weight gain, mood
swings, fat pads on neck and shoulders (“buffalo hump”), and a round
“moon” face.
5. Manifestations of Cushing syndrome include water weight gain, mood
swings, fat pads on neck and shoulders (“buffalo hump”), and a round
“moon” face.
PTS: 1 CON: Metabolism
Chapter 39. Nursing Care of Hospital patients With Endocrine Disorders
MULTIPLE CHOICE
1. A hospital patient is scheduled for diagnostic tests for hypothyroidism. Which symptoms
does the nursing practitioner expect to observe in a hospital patient with this disorder?
1. Tremor and oily skin
2. Anxiety and tachycardia
3. Dry skin and slowed heart rate
4. Increase in appetite and diarrhea
RIGHT ANSWER> 3
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine Disorders
Objective: Describe the etiologies, signs, and symptoms of each of the endocrine orders.
Source: pp. 795
Heading: Hypothyroidism
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 Tremor and oily skin are not related to hypothyroidism.
2 Anxiety and tachycardia are not related to hypothyroidism.
3 Symptoms of hypothyroidism are related to the reduced metabolic rate and
include fatigue, weight gain, bradycardia, constipation, mental dullness, feeling
cold, shortness of breath, decreased sweating, and dry skin and hair.
4 Increase in appetite and diarrhea are not related to hypothyroidism.
PTS: 1 CON: Metabolism
2. The nursing practitioner is monitoring a hospital patient admitted for testing of
diabetes insipidus. Which observation by the nursing practitioner is unexpected?
1. Low specific gravity of urine
2. Expressions of extreme thirst
3. Elevated blood glucose levels
4. Large amounts of clear urine
RIGHT ANSWER> 3
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine Disorders
Objective: Describe the etiologies, signs, and symptoms of each of the endocrine orders.
Source: pp. 790
Heading: Disorders Related to Antidiuretic Hormone Imbalance
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 Low specific gravity of urine (<1.005) is indicative of diabetes insipidus.
2 When a hospital patient has diabetes insipidus, dehydration occurs, which
results in
feelings of extreme thirst.
3 Diabetes insipidus is not to be confused with diabetes mellitus, which is a
condition related to insulin and blood glucose levels.
4 A hospital patient with diabetes insipidus may void 3 to 15 liters of urine daily.
This is a
classic manifestation of the disorder.
PTS: 1 CON: Metabolism
3. A hospital patient who is 1 day postoperative thyroidectomy reports feeling numb around
the mouth and is experiencing random muscle twitches. Which IV medication does the
nursing practitioner anticipate being prescribed by the health care provider (HCP)?
1. Iodine
2. Calcium gluconate
3. Potassium chloride
4. Sodium bicarbonate
RIGHT ANSWER> 2
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine Disorders
Objective: Describe current therapeutic measures used for each of the selected endocrine
disorders.
Source: pp. 800
Heading: Nursing Process for the Hospital patient Undergoing
Thyroidectomy Integrated Process: Clinical Problem-Solving Process
(Nursing Process) Hospital patient Need: Physiological Integrity—
Reduction of Risk Potential CL: Application (Applying)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 The hospital patient is exhibiting symptoms of hypocalcemia; iodine will not
help to
restore the calcium level.
2 In the absence of parathyroid hormone, serum calcium levels drop and tetany
results. IV calcium gluconate is given to treat acute tetany.
3 Potassium chloride will not help to restore the calcium level.
4 Sodium bicarbonate will not help to restore the calcium level.
PTS: 1 CON: Metabolism
4. The nursing practitioner is providing care for a hospital patient with syndrome of
inappropriate antidiuretic hormone (SIADH). Which additional diagnosis does the
nursing practitioner need to identify as a contributor to the hospital patient’s disorder?
1. Diabetes insipidus
2. History of renal calculi
3. Ulcerative colitis
4. Mental health disorder
RIGHT ANSWER> 4
Chapter: Nursing Care of Hospital patients With Endocrine Disorders
Objective: Identify disorders caused by variations in the hormones of the pituitary, thyroid,
parathyroid, and adrenal glands.
Pages: 791–792
Heading: Syndrome of Inappropriate Antidiuretic Hormone
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 Diabetes insipidus is the result of too much antidiuretic hormone (ADH)
causing fluid deficit, and not SIADH, which causes fluid retention.
2 A history of renal calculi is not a current diagnosis and does not provide
information related to the hospital patient’s diagnosis of SIADH.
3 Ulcerative colitis is not a condition that contributes to the hospital patient’s
diagnosis of SIADH.
4 Mental health disorders treated with antipsychotics is a condition that can
contribute to or cause the hospital patient’s diagnosis of SIADH.
PTS: 1 CON: Metabolism
5. The nursing practitioner is monitoring a hospital patient 6 hours after a thyroidectomy for
cancer. Vital signs are temperature 104°F, pulse 144 beats/min, respirations 24/min, and
blood pressure 184/108 mm Hg. Which prescription does the nursing practitioner
anticipate from the HCP?
1. Aspirin and bedrest
2. Beta blockers and a cooling blanket
3. Epinephrine and compression dressings
4. Diphenhydramine and Fowler’s position
RIGHT ANSWER> 2
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine Disorders
Objective: Describe current therapeutic measures used for each of the selected endocrine
disorders.
Source: pp. 800
Heading: Thyrotoxic Crisis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 Aspirin is avoided because it binds with the same serum protein as T4, freeing
additional T4 into the circulation.
2 If thyrotoxic crisis occurs, treatment is first directed toward relieving the life-
threatening symptoms. Acetaminophen is given for the fever. IV fluids and a
cooling blanket may be ordered to cool the hospital patient. A beta-adrenergic
blocker, such as propranolol, is given for tachycardia.
3 Epinephrine will make symptoms worse. Compression dressing on the thyroid
could compromise the airway.
4 Diphenhydramine and Fowler’s position do not address the problem.
PTS: 1 CON: Metabolism
6. The nursing practitioner is gathering information from a hospital patient in a HCP’s
office. The hospital patient reports difficulty speaking and swallowing and, recently, frequent
headaches. Which additional manifestation does the nursing practitioner observe that
indicates a possible glandular dysfunction?
1. Large fleshy hands
2. Sleep apnea
3. Visual disturbances
4. Carbohydrate intolerance
RIGHT ANSWER> 1
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine Disorders Objective:
Describe the etiologies, signs, and symptoms of each of the endocrine disorders. Source: pp.
810
Heading: Acromegaly
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Difficult
CLARIFICATION
1 The question is asking for an objective manifestation. The nursing practitioner
will be able to observe large fleshy hands, which in addition to the hospital
patient’s report, can be an indication of acromegaly.
2 Sleep apnea is a manifestation that can be associated with acromegaly;
however, the information is subjective.
3 Visual disturbances can occur with acromegaly from pressure in the brain from
a tumor; however, the information is subjective.
4 Hospital patients with acromegaly can develop diabetes mellitus. Carbohydrate
intolerance does not necessarily indicate this disorder; this information is
subjective.
PTS: 1 CON: Metabolism
7. The nursing practitioner is contributing to the plan of care for an adult hospital patient
diagnosed with growth hormone (GH) deficiency. Which nursing intervention is
appropriate for this hospital patient?
1. Teach the importance of weight reduction.
2. Monitor and report blood cholesterol levels.
3. Reassess for cardio- and cerebrovascular changes.
4. Promote a caring, supportive relationship.
RIGHT ANSWER> 4
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine
Disorders Objective: Plan nursing care for hospital patients with each of the
disorders.
Source: pp. 811
Heading: Growth Hormone Deficiency
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Psychosocial Integrity
CL: Analysis (Analyzing) Concept:
Metabolism
Difficulty: Difficult
CLARIFICATION
1 The adult hospital patient with GH deficiency may have excess body fat, which
may or
may not respond to dietary changes. Teaching should focus on healthy dietary
practices.
2 If the HCP prescribes cholesterol testing, the nursing practitioner is always
responsible to
report results. The question is asking for a nursing intervention.
3 Adult hospital patients with GH deficiency may develop cardio- or
cerebrovascular changes. Assessment and reassessment of these body systems is
routine nursing
care.
4 The adult hospital patient with GH deficiency may exhibit mental slowness
and/or psychological disturbances. The nursing practitioner needs to promote a
caring, supportive relationship so that a trusting hospital patient-nursing
practitioner relationship can be established.
PTS: 1 CON: Metabolism
8. The nursing practitioner determines that treatment has been effective for a hospital patient
with diabetes insipidus. Which laboratory value did the nursing practitioner use to come to this
conclusion?
1. Urine ketones
2. Serum potassium
3. Fasting blood glucose
4. Urine specific gravity
RIGHT ANSWER> 4
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine Disorders
Objective: Explain how you will know if nursing interventions have been effective.
Source: pp. 790
Heading: Diabetes Insipidus
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 Blood glucose and urine ketones are monitored in diabetes mellitus, not
diabetes insipidus.
2 Diabetes insipidus does not directly affect potassium level.
3 Blood glucose and urine ketones are monitored in diabetes mellitus, not
diabetes insipidus.
4 Urine specific gravity is a good measure of urine concentration and ADH
function.
PTS: 1 CON: Metabolism
9. The nursing practitioner is providing care for a hospital patient who is postoperative for a
transsphenoidal surgery for the removal of a pituitary tumor. Which nursing care is
inappropriate in the postsurgical period?
1. Promote use of spirometer and deep breathing.
2. Change nasal packing and moustache dressing.
3. Obtain and report results of urine specific gravity.
4. Monitor for signs of cerebrospinal fluid drainage.
RIGHT ANSWER> 2
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine
Disorders Objective: Plan nursing care for hospital patients with each of the
disorders.
Source: pp. 795
Heading: Nursing Care for Hospital patients Undergoing
Hypophysectomy Integrated Process: Clinical Problem-Solving Process
(Nursing Process) Hospital patient Need: Physiological Integrity—
Reduction of Risk Potential CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 The hospital patient needs to be reminded to use spirometry and to take deep
breaths to
improve respiratory status. However, coughing is prohibited to avoid increasing
pressure on the surgical site.
2 The hospital patient’s method of surgery will require nasal packing and a
moustache dressing to absorb any drainage. The packing and dressing is not to
be changed
without a HCP’s order.
3 After pituitary gland surgery, the hospital patient is at risk for diabetes
insipidus. The most effective manner for monitoring for this complication is
by monitoring
urine specific gravity.
4 The transsphenoidal surgical approach for pituitary surgery can cause a leakage
of cerebrospinal fluid through the nares. Due to the presence of glucose in the
fluid, a glucose dip stick is used to check for the source of the drainage.
PTS: 1 CON: Metabolism
10. A hospital patient arrives at the emergency department and states, “I was outside shoveling
snow and suddenly started to feel really bad.” The hospital patient’s medical history indicates
treatment for hypothyroidism for the past 10 years. Which possible condition causes the nursing
practitioner the greatest concern?
1. Cardiac failure
2. Myxedema coma
3. Thyrotoxic crisis
4. Respiratory failure
RIGHT ANSWER> 2
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine Disorders Objective:
Describe the etiologies, signs, and symptoms of each of the endocrine disorders. Source: pp.
795
Heading: Disorders of the Thyroid Gland
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 The possibility of cardiac failure can occur as result of the complication
myxedema coma.
2 The nurse’s greatest concern is for the development of myxedema coma, which
includes the complications of cardiac or respiratory failure, reduced kidney
perfusion, and hypoglycemia.
3 Thyrotoxic crisis occurs with hyperthyroidism.
4 The possibility of respiratory failure can occur as a result of the complication
myxedema coma.
PTS: 1 CON: Metabolism
11. A hospital patient enters the emergency department in adrenal crisis. The hospital patient is
lethargic and vital signs are blood pressure 85/52 mm Hg and pulse 88 beats/min. Which event in
the hospital patient’s week most likely precipitated this crisis?
1. Eating a high-fat diet
2. Being laid off from a job
3. Taking Tylenol for a headache
4. Nightly walking exercise
RIGHT ANSWER> 2
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine Disorders
Objective: Identify disorders caused by variations in the hormones of the pituitary, thyroid,
parathyroid, and adrenal glands.
Source: pp. 799
Heading: Disorders of the Adrenal Glands
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 Consuming a high-fat diet is not a source of stress.
2 Stress causes a need for an increase in cortisol, the body’s stress hormone.
Being laid off is a stressor and can preclude adrenal crisis.
3 Taking Tylenol for a headache is not a source of stress.
4 Walking for exercise is not a source of stress, and, in fact, can be a stress
reliever.
PTS: 1 CON: Metabolism
12. The nursing practitioner is reinforcing teaching to a hospital patient who is diagnosed
with genetically related hypoparathyroidism. Which comment by the hospital patient
indicates that hospital patient teaching is successful?
1. “I will immediately report numbness and tingling of the fingers, tongue, and lips.”
2. “I understand that muscle spasms and twitching mean I need more calcium in my
diet.”
3. “If I make funny noises when I breathe, I will drink more fluids and get a
humidifier.”
4. “I will switch to whole milk instead of skim milk and increase my intake of
cheese.”
RIGHT ANSWER> 1
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine Disorders
Objective: Explain how you will know if nursing interventions have been effective.
Source: pp. 801
Heading: Hypoparathyroidism
Integrated Process: Teaching/Learning
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 Numbness and tingling of the fingers, tongue, and lips are signs of impending
tetany and should be reported immediately. The statement indicates
understanding of teaching.
2 Muscle spasms and twitching are signs of impending tetany, which is a medical
emergency. Eating more calcium will not solve the problem quickly enough.
3 Laryngospasms are an indication of tetany; drinking more fluids and using a
humidifier are not appropriate actions for this medical emergency.
4 Whole and skim milk have nearly the same calcium content. Cheese is a source
of calcium, but the hospital patient needs a better understanding of alternate
sources of calcium in addition to dairy products.
PTS: 1 CON: Metabolism
13. The licensed practical nurse/licensed vocational nursing practitioner (LPN/LVN) is
assisting in the care of a 51-year-old hospital patient recovering from a hypophysectomy. Which
observation should the nursing practitioner identify as needing immediate intervention?
1. Urine specific gravity of 1.19
2. Hemoglobin level of 13.2 g/dL
3. Urinary output of 800 mL in 4 hours
4. Complaints of pain at a 5 on a scale of 0 to 10
RIGHT ANSWER> 3
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine Disorders
Objective: Identify disorders caused by variations in the hormones of the pituitary, thyroid,
parathyroid, and adrenal glands.
Source: pp. 795
Heading: Nursing Process for the Hospital patient With Diabetes
Insipidus Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 The listed urine specific gravity is within normal limits for the hospital patient.
2 The listed hemoglobin is within normal limits for the hospital patient.
3 Tumors, trauma, or other problems to the hypothalamus or pituitary gland can
lead to decreased production or release of ADH, causing diabetes insipidus and
resulting in excess urinary output.
4 Pain is not the highest priority in this scenario.
PTS: 1 CON: Metabolism
14. The nursing practitioner is providing care for a hospital patient scheduled to receive
radioactive iodine as treatment for thyroid cancer. Which care intervention for this hospital patient
is inappropriate?
1. All urine, vomitus, and body secretions are handled as contaminated.
2. Hospital policy and the radiation safety officer are consulted for instructions.
3. Pregnant caretakers will wear a lead apron during hospital patient contact.
4. The toilet is flushed twice after disposing of contaminated body products.
RIGHT ANSWER> 3
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine
Disorders Objective: Plan nursing care for hospital patients with each of the
disorders.
Source: pp. 801
Heading: Nursing Care for the Hospital patient Receiving Radioactive
Iodine Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: Physiological Integrity—Reduction of
Risk Potential CL: Application (Applying)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 When the hospital patient is hospitalized for treatment with radioactive iodine,
the dose is high. All urine, vomitus, and body secretions are considered
contaminated.
2 Because of radioactive contamination, the nursing practitioner needs to consult
the hospital
policy and radiation safety officer for specific instructions.
3 Pregnant caretakers need to avoid all contact with the hospital patient receiving
radioactive iodine.
4 When disposing of contaminated body products, the toilet needs to be flushed
twice to be sure that radioactive residue is removed.
PTS: 1 CON: Metabolism
15. The LPN/LVN is monitoring a hospital patient with a goiter who is scheduled for surgery.
Physical inspection reveals only slight swelling in the anterior base of the neck. Which
manifestation will prompt the LPN/LVN to notify the registered nursing practitioner (RN)?
1. Hospital patient expresses difficulty with swallowing.
2. Hospital patient reports sensation of heaviness in the neck.
3. Hospital patient expresses a fear of choking on food.
4. A whistling sound is heard with breathing.
RIGHT ANSWER> 4
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine Disorders
Objective: Explain the pathophysiology of each of the endocrine disorders presented.
Pages: 801–802
Heading: Goiter
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 The lack of swelling in the anterior base of the neck indicates that the hospital
patient is likely to have posterior swelling, which causes difficulty with
swallowing.
2 Hospital patients with goiters will frequently express feelings of heaviness in the
neck
with a goiter. However, the sensation is more likely with anterior swelling.
3 The hospital patient is likely to have posterior goiter swelling, which will
create problems with swallowing food. The nursing practitioner will consult
with the RN about a soft diet along with a swallowing consult.
4 The manifestation of greatest concern, which requires immediate reporting to
the RN, is stridor (whistling sound during breathing). The presence of stridor is
an ominous indication that the airway is compromised.
PTS: 1 CON: Metabolism
16. The nursing practitioner is assigned to provide care for a hospital patient diagnosed with
diabetes insipidus. While reviewing the nursing care planned for the hospital patient, which
intervention will the nursing practitioner recognize as being least important?
1. Monitoring daily weight, intake and output, vital signs, and urine specific gravity
2. Providing free access of the hospital patient to oral fluids as desired
3. Reporting a significant drop in blood pressure and increase in pulse
4. Determining the hospital patient’s understanding of her condition
RIGHT ANSWER> 4
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine
Disorders Objective: Plan nursing care for hospital patients with each of the
disorders presented. Pages: 790–791
Heading: Nursing Process for the Hospital patient With Diabetes Insipidus
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 Because of the symptoms and manifestations of diabetes insipidus, the nursing
practitioner will carefully monitor all indicators of the hospital patient’s fluid
status.
2 When caring for a hospital patient with diabetes insipidus, it is important to
replenish
the hospital patient’s fluid volume to prevent hypovolemic shock.
3 The nursing practitioner needs to report any significant drop in blood pressure
and increase in pulse rate to the RN or HCP. These changes are indicative of
hypovolemic shock.
4 The least important intervention by the nursing practitioner with a hospital
patient diagnosed with diabetes insipidus is the determination of the hospital
patient’s understanding of her
condition. The hospital patient needs careful monitoring and care to prevent a
crisis.
PTS: 1 CON: Metabolism
17. The nursing practitioner is monitoring the effects of a water deprivation test on a hospital
patient suspected of diabetes insipidus related to pituitary dysfunction. Which test result
supports the diagnosis?
1. Body weight and urine osmolality remains unchanged.
2. The hospital patient is unable to void after 6 hours of deprivation.
3. Urine continues to be diluted with a high specific gravity.
4. Weight loss occurs due to the large amount of urine voided.
RIGHT ANSWER> 4
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine Disorders
Objective: List data to collect when caring for hospital patients with each of the endocrine
disorders discussed.
Source: pp. 790
Heading: Diabetes Insipidus
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 During a water deprivation test, the urine osmolality may or may not change;
however, the hospital patient is expected to lose weight related to dehydration
and lack
of fluid replacement.
2 After 6 hours of fluid deprivation, an inability to void indicates that the
hospital patient does not have diabetes insipidus; the hospital patient will
continue to void large amounts of dilute urine if the test is positive.
3 With positive results to a water deprivation test, the hospital patient will
continue to
void diluted urine, but the specific gravity will be low.
4 During a water deprivation test for diabetes insipidus, the hospital patient will
continue to lose weight because of the large volume of urine that is passed.
This is the option that supports the diagnosis.
PTS: 1 CON: Metabolism
18. The nursing practitioner is providing care for a hospital patient diagnosed with
complications related to Cushing syndrome. Which situation indicates a need for a
change in nursing intervention?
1. Insulin for high blood glucose is administered by the nurse.
2. The hospital patient’s skin has remained intact during hospitalization.
3. Complications of fluid overload are recognized and treated early.
4. The hospital patient is receptive to and appreciative of help with personal care.
RIGHT ANSWER> 1
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine Disorders
Objective: Explain how you will know if nursing interventions have been effective.
Source: pp. 808
Heading: Disorders of the Adrenal Glands
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 The hospital patient needs to demonstrate an ability to perform self-care for the
management of diabetes mellitus. This situation indicates a need for change in
nursing intervention.
2 Hospital patients with Cushing syndrome are susceptible to skin breakdown;
maintenance of skin integrity indicates appropriate nursing intervention.
3 The early recognition and treatment for complications related to fluid retention
indicates appropriate nursing intervention.
4 When the hospital patient is receptive and appreciative of help with personal
care, the
indication is that the nursing practitioner has established a caring relationship
with the hospital patient. The hospital patient responses are also an indication
of self-acceptance.
PTS: 1 CON: Metabolism
19. The nursing practitioner is gathering data from a hospital patient who voices concerns
about feeling dizzy upon standing, fatigue, and recent weight loss. Which additional
information will most likely cause the nursing practitioner to suspect a problem with
adrenal insufficiency?
1. Periods of tachycardia
2. Bronzed skin coloration
3. Low blood pressure reading
4. Indications of dehydration
RIGHT ANSWER> 2
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine Disorders Objective:
Describe the etiologies, signs, and symptoms of each of the endocrine disorders.
Source: pp. 806
Heading: Adrenal Insufficiency/Addison Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 With adrenal deficiency and the development of Addison disease, the hospital
patient can have periods of tachycardia due to electrolyte imbalance and
dehydration.
However, this symptom also occurs with multiple other causes.
2 Bronzed skin coloration is a classic sign for primary adrenal gland deficiency,
which results in the development of Addison disease.
3 Hospital patients with adrenal deficiency or Addison disease will exhibit low
blood pressure related to fluid loss. However, this symptom also occurs with
multiple other causes.
4 Indications of dehydration such as poor skin turgor and sticky membranes can
occur with Addison disease and multiple other medical conditions.
PTS: 1 CON: Metabolism
20. The nursing practitioner is reviewing information with a hospital patient about endocrine
gland disorders. The hospital patient asks, “I have pituitary insufficiency, what is happening?”
Which information from the nursing practitioner is incorrect?
1. “You may have an ectopic growth on the pituitary secreting hormones.”
2. “There are a variety of tests that will help distinguish the cause.”
3. “Too little hormone is secreted when a gland does not work properly.”
4. “Target tissue insensitivity results in too little hormone activity.”
RIGHT ANSWER> 1
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine Disorders
Objective: Explain the pathophysiology of each of the endocrine disorders presented.
Source: pp. 790
Heading: Introduction
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Teaching/Learning
CL: Analysis (Analyzing) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 When an ectopic growth on a gland is secreting hormones, the result is an
excess of the hormone, not an insufficiency. This statement is incorrect.
2 The statement about a variety of tests that can identify the cause of a gland
insufficiency is a true statement.
3 The statement about a gland secreting an insufficient amount of hormone when
it is not functioning correctly is a true statement.
4 The statement that hormone insufficiency can be related to target tissue
insensitivity is a true statement.
PTS: 1 CON: Hospital patient-Centered Care
21. The nursing practitioner is attending to hospital patients in an assisted-living facility. For
which reason is the nursing practitioner aware that the recognition of hyperthyroidism is
difficult in older hospital patients?
1. The manic and psychotic behavior mimics dementia.
2. The presenting symptoms tend to mimic cardiac concerns.
3. Nervousness and tremor are common in this population.
4. This age category has difficulty describing signs and symptoms.
RIGHT ANSWER> 2
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine Disorders Objective:
Describe the etiologies, signs, and symptoms of each of the endocrine disorders. Source: pp.
799
Heading: Hyperthyroidism
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 Manic and psychotic behavior is typical in younger hospital patients; older
hospital patients may not have typical signs and symptoms of
hyperthyroidism.
2 In older hospital patients, the signs and symptoms of hyperthyroidism are
atypical. This population may experience heart failure, atrial fibrillation, fatigue,
apathy, and depression; all signs are also indicative of other disorders, making
diagnosis
difficult.
3 Nervousness and tremor are typical symptoms of hyperthyroidism in younger
hospital patients; older hospital patients exhibit more atypical symptoms, which
make diagnosis difficult.
4 It is not true that older hospital patients have difficulty describing signs and
symptoms;
this statement is an example of ageism.
PTS: 1 CON: Metabolism
22. The nursing practitioner is assisting with discharge of a hospital patient with Addison
disease following an adrenal crisis. Which instruction is most important for the nursing
practitioner to reinforce?
1. The need for a well-balanced diet
2. How to monitor blood glucose levels
3. The importance of 30 minutes of exercise each day
4. The importance of taking steroid replacements as prescribed
RIGHT ANSWER> 4
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine Disorders
Objective: Describe current therapeutic measures used for each of the selected endocrine
disorders.
Source: pp. 807
Heading: Adrenal Insufficiency/Addison Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 The hospital patient with Addison disease may be placed on a high-sodium
diet due to the loss of sodium and water associated with hyposecretion of
adrenal gland hormones.
2 Because hospital patients with Addison disease are prone to hypoglycemia, the
hospital patient
needs to understand how and when to test blood glucose levels. However, this
is not as important as appropriate hormone replacement.
3 There is no particular reason why a hospital patient with Addison disease needs
30
minutes of exercise daily.
4 Hormone replacement for the hospital patient with Addison disease is lifelong
therapy. Hormones are given in divided doses; 2/3 in the morning and 1/3 in the
evening to mimic the body’s own diurnal rhythm. This is the most important
teaching to reinforce.
PTS: 1 CON: Metabolism
MULTIPLE RESPONSE
1. A hospital patient is being discharged with prescribed treatment for long-term
hypoparathyroidism. Which does the nursing practitioner include in discharge teaching?
(Select all that apply.)
1. Eat a diet high in calcium.
2. Limit dietary phosphates.
3. Have regular eye examinations.
4. Add iron-rich foods to your diet.
5. Follow up with regular laboratory tests.
RIGHT ANSWER> 1
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine Disorders
Objective: Describe current therapeutic measures used for each of the selected endocrine
disorders.
Source: pp. 804
Heading: Hypothyroidism
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Difficult
CLARIFICATION
1. A high calcium diet with calcium supplements is necessary to maintain
serum calcium levels.
2. A high-phosphate diet may lower serum calcium levels, which are already
low.
3. Eye examinations are important because calcifications can occur in the eyes
and cataracts can develop.
4. Hypoparathyroidism will not alter iron stores; increased intake of iron-rich
foods is not necessary.
5. Follow-up laboratory tests are important to be sure the calcium level is
normal.
PTS: 1 CON: Metabolism
2. A hospital patient with suspected hyperthyroidism is scheduled for a radioactive iodine
uptake test. Which symptoms of hyperthyroidism does the nursing practitioner note on the
medical record? (Select all that apply.)
1. Fatigue
2. Tremor
3. Weight loss
4. Constipation
5. Buffalo hump
RIGHT ANSWER> 1
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine Disorders Objective:
Describe the etiologies, signs, and symptoms of each of the endocrine disorders. Source: pp.
799
Heading: Hypothyroidism
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Difficult
CLARIFICATION
1. Weight loss, fatigue, heat intolerance, tremor, increased pulse and blood
pressure, and agitation or nervousness may be seen with hyperthyroidism.
2. Weight loss, fatigue, heat intolerance, tremor, increased pulse and blood
pressure, and agitation or nervousness may be seen with hyperthyroidism.
3. Weight loss, fatigue, heat intolerance, tremor, increased pulse and blood
pressure, and agitation or nervousness may be seen with hyperthyroidism.
4. Constipation is seen with hypothyroidism.
5. Buffalo hump is seen in Cushing syndrome.
PTS: 1 CON: Metabolism
3. A hospital patient diagnosed with SIADH is scheduled for surgery in a few days. Which
does the nursing practitioner expect to be prescribed for this hospital patient to help manage
the symptoms until surgery? (Select all that apply.)
1. Salt restriction
2. Fluid restriction
3. Furosemide
4. Conivaptan
5. Hypertonic saline infusion
RIGHT ANSWER> 2, 3, 4, 5
Chapter: Chapter 39. Nursing Care of Hospital patients With Endocrine Disorders
Objective: Describe current therapeutic measures used for each of the selected endocrine
disorders.
Source: pp. 791
Heading: Pituitary Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Difficult
CLARIFICATION
1. Oral salt may be encouraged to maintain the serum sodium level.
2. Symptoms of SIADH can be alleviated by restricting fluids to 800 to 1,000
mL per 24 hours.
3. A loop diuretic such as furosemide increases water excretion.
4. A vasopressin receptor antagonist such as conivaptan may be used to block
the action of ADH in the kidney.
5. Hypertonic saline fluids may be administered intravenously.
PTS: 1 CON: Metabolism
Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine
Pancreas
MULTIPLE CHOICE
1. The nursing practitioner is providing information to a hospital patient recently diagnosed
with type 1 diabetes mellitus (DM). The hospital patient expresses a desire to understand the
disease. Which information provided by the nursing practitioner is accurate?
1. Insulin is released into the gastrointestinal tract to aid in the digestion process.
2. Glucose is carried into cells when glucose transporters are activated in the
membrane.
3. Diabetes is most frequently caused by the inability of the pancreas to release
insulin.
4. Type 1 and type 2 DM are reversible with dietary, weight loss, and exercise
programs.
RIGHT ANSWER> 2
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine
Pancreas Objective: Describe causes, signs and symptoms, and treatment of high and low
blood glucose levels.
Source: pp. 817
Heading: Pathophysiology and Etiology
Integrated Process: Teaching/Learning
Hospital patient Need: Physiological Integrity/Physiological
Adaptation CL: Application (Applying)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 Insulin is destroyed by gastric juices, which is the reason why insulin is not
taken orally. The pancreas does release other hormones such as lipase and
amylase to aid in digestion.
2 When blood glucose (BG) touches a cell membrane, glucose transporters are
activated and move the glucose into the cell for energy.
3 The inability of the pancreas to produce insulin is type 1 DM; type 2 DM is the
most common. In type 2 DM, the pancreas is able to produce insulin.
4 Type 2 DM can be reversed with dietary, weight loss, and exercise programs.
Type 1 DM is irreversible.
PTS: 1 CON: Metabolism
2. The nursing practitioner is evaluating the knowledge of a hospital patient recently
diagnosed with type 1 DM. Which statement by the hospital patient indicates a need for
additional information?
1. “My pancreas may have started to attack itself after a childhood viral infection”
2. “I may be genetically prone since diabetes goes back for several generations.”
3. “I will learn to carefully check my BG since I am prone to ketoacidosis.”
4. “I know that I am obese and can reduce my need for insulin with weight loss.”
RIGHT ANSWER> 4
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine Pancreas
Objective: Explain the pathophysiologies of type 1 and type 2 diabetes mellitus.
Source: pp. 817
Heading: Type 1 Diabetes
Integrated Process: Teaching/Learning
Hospital patient Need: Pathological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 When the hospital patient understands that type 1 DM may have been caused by
a viral infection, additional teaching is not necessary.
2 It is a true statement that hospital patients with type 1 DM may be genetically
prone to
the disease; no additional teaching is necessary.
3 Hospital patients with type 1 DM are prone to developing ketoacidosis; the
hospital patient’s statement is correct and does not require additional teaching.
4 Type 2 DM can be caused by obesity and may respond positively to weight
loss. However, the pancreas of a hospital patient with type 1 DM cannot trigger
insulin production with weight loss.
PTS: 1 CON: Metabolism
3. The nursing practitioner is assisting with nutrition teaching for a hospital patient who voices
concern over coping with a diabetic diet. Which response by the nursing practitioner about
medical nutrition therapy is correct?
1. “Your diet will be a well-balanced, individualized meal plan that is healthy for
your whole family.”
2. “Sugars and fats need to be avoided, but the dietitian will help you find acceptable
alternatives.”
3. “You will require special foods, but stores now stock a variety of choices for
people with diabetes.”
4. “The diet stresses high-protein and low-carbohydrate intake, but people adapt to
the restrictions.”
RIGHT ANSWER> 1
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine
Pancreas Objective: Identify therapeutic measures to help hospital patients with diabetes
mellitus control blood glucose levels.
Source: pp. 821
Heading: Nutrition Therapy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 Because all diabetic nutrition recommendations emphasize low-fat intake and
balanced intake of other food groups, it is healthy for the whole family.
2 Hospital patients with diabetes do not have to avoid all sugars and fats.
3 Special foods are not necessary.
4 High protein is not recommended; low protein may be necessary if
nephropathy occurs.
PTS: 1 CON: Metabolism
4. The nursing practitioner is providing care for a marathon runner who is recently
diagnosed with DM. Which explanation regarding exercise is best for the nursing
practitioner to provide?
1. “You will need to avoid regular exercise since it will lower your blood sugar.”
2. “You can still exercise, but running is too strenuous for someone with diabetes.”
3. “You always need to take some emergency glucose with you when you are
running.”
4. “Exercise needs to be coordinated with the time your insulin is peaking.”
RIGHT ANSWER> 3
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine
Pancreas Objective: Identify therapeutic measures to help hospital patients with diabetes
mellitus control blood glucose levels.
Source: pp. 820
Heading: Exercise
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 Exercising at similar times each day also helps prevent BG fluctuations.
2 Running is not too strenuous for someone who is used to doing it, but hospital
patients
with neuropathy or foot problems should consult with a physician first.
3 Persons with diabetes should always carry a quick source of sugar when
exercising in case the BG drops too low.
4 Individuals on intermediate-acting insulin are taught to avoid exercising at the
time of day when their BG is at its lowest point (i.e., when insulin or
medication is peaking) and to have a carbohydrate snack before exercising if
BG is less than 100 mg/dL.
PTS: 1 CON: Metabolism
5. The nursing practitioner is reinforcing teaching for a hospital patient who is on four
injections of regular insulin daily. About how many hours after each injection of insulin
does the nursing practitioner teach the hospital patient to be alert for symptoms of
hypoglycemia?
1. 1/2 hour
2. 3 hours
3. 8 hours
4. 12 hours
RIGHT ANSWER> 2
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine
Pancreas Objective: Identify therapeutic measures to help hospital patients with diabetes
mellitus control blood glucose levels.
Source: pp. 823
Heading: Medication: Onset, Peak, Duration
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 Onset is a half hour, and duration is 5 to 8 hours.
2 Regular insulin peaks in 2 to 5 hours, so blood sugar will be lowest at this time.
3 Onset is a half hour, and duration is 5 to 8 hours.
4 Onset is a half hour, and duration is 5 to 8 hours.
PTS: 1 CON: Metabolism
6. The nursing practitioner is providing information to a hospital patient recently diagnosed
with type 2 DM. The health care provider (HCP) prescribes an oral hypoglycemic
medication for BG control. Which information is the best comparison the nursing
practitioner can give the hospital patient between insulin and an oral hypoglycemic?
1. Oral hypoglycemic agents act as an insulin replacement.
2. Oral hypoglycemic agents stimulate a partially working pancreas.
3. Insulin is used for a type 2 diabetic with a history of ketoacidosis.
4. Insulin is used by a type 2 diabetic to control BG levels.
RIGHT ANSWER> 2
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine
Pancreas Objective: Differentiate the action of insulin and oral hypoglycemic agents in
lowering blood glucose levels.
Source: pp. 817
Heading: Oral Hypoglycemic Medication
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 Oral hypoglycemic agents are not an insulin replacement; they work to
stimulate the pancreas to make more insulin or to make tissues more sensitive
to insulin.
2 Oral hypoglycemic agents are prescribed for type 2 DM because there is a
partially working pancreas. This is the best comparison the nursing practitioner
can present
about the difference between insulin and oral hypoglycemic agents.
3 Type 2 diabetics do not experience ketoacidosis, which is a serious
complication for type 1 diabetics related to an inability for the body to produce
insulin.
4 With a type 2 diabetic, insulin is prescribed when the hospital patient is having
difficulty controlling BG levels. In contrast, the type 1 diabetic uses insulin to
sustain life.
PTS: 1 CON: Metabolism
7. The nursing practitioner is providing care for a hospital patient with type 2 DM who has
been treated with an oral hypoglycemic agent. The HCP prescribes for the addition of insulin.
Which situation does the nursing practitioner recognize as being the least valid reason for
giving this hospital patient insulin?
1. The hospital patient is unable to effectively follow a diabetic diet.
2. The hospital patient’s pancreas is unable to produce adequate insulin.
3. The amount of insulin is high, but the body cells are resistant.
4. The pancreas has worn out leading to little or no insulin production.
RIGHT ANSWER> 1
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine Pancreas
Objective: Explain the pathophysiologies for type 1 and type 2 diabetes mellitus.
Source: pp. 823
Heading: Type 2 Diabetes
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 The HCP may need to eventually prescribe insulin to a hospital patient who
cannot effectively follow a diabetic diet to promote BG control. However, other
interventions such as education and support would be considered before adding
insulin to the therapy.
2 When a hospital patient’s pancreas is unable to produce adequate insulin, the
HCP will
prescribe insulin in addition to an oral hypoglycemic agent.
3 When a hospital patient’s pancreas is producing a normal or high amount of
insulin, but the BG level remains elevated, the hospital patient is likely to have
body cells that are resistant. The HCP will prescribe insulin in addition to an
oral hypoglycemic
agent.
4 If the hospital patient’s pancreas wears out and little or deficient amounts of
insulin are produced, the HCP will prescribe insulin to be added to the oral
hypoglycemic regimen.
PTS: 1 CON: Metabolism
8. A hospital patient is admitted to the hospital with hyperosmolar hyperglycemia. The
hospital patient is 40 percent overweight and has a BG value of 987 mg/dL. Which is the
priority focus while planning nursing care for this hospital patient?
1. BG level
2. Hydration status
3. Presence of an illness
4. Age-related changes
RIGHT ANSWER> 2
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine
Pancreas Objective: Describe causes, signs and symptoms, and treatment of high and low
blood glucose levels.
Source: pp. 829
Heading: Hyperosmolar Hyperglycemic State
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 The BG level can be elevated as high as 1,500 mg/dL in a hospital patient with
hyperosmolar hyperglycemia. BG level is not the nurse’s priority focus.
2 The nurse’s priority focus for a hospital patient with hyperosmolar
hyperglycemia is the state of hydration. A reduced fluid intake is often a
contributing factor;
however, as BG levels rise, polyuria can cause profound dehydration.
3 The presence of an illness can contribute to the hospital patient’s
condition, but the nurse’s priority focus is on stabilizing the hospital
patient to avoid shock, coma, or death.
4 Older hospital patients with type 2 DM are more inclined to experience
hyperosmolar
hyperglycemia, but hospital patient’s age is not the nurse’s focus.
PTS: 1 CON: Metabolism
9. The nursing practitioner is collecting data on a new hospital patient in a HCP’s office. Data
includes the following: 65-year-old male, abdominal obesity with waist circumference of 42
inches, blood pressure 140/88 mm Hg, and fasting glucose of 120 mg/dL. Which health concerns
by the HCP is least expected?
1. Probability of type 2 diabetes
2. Risk of cardiovascular issues
3. Damage to weight bearing joints
4. History of family health issues
RIGHT ANSWER> 3
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine
Pancreas Objective: Discuss how diabetes mellitus increases risk of complications such as
heart disease, blindness, and kidney failure.
Source: pp. 830
Heading: Metabolic Syndrome
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 The hospital patient is exhibiting risk factors related to metabolic syndrome;
the hospital patient is at high risk for type 2 DM.
2 The hospital patient is exhibiting risk factors related to metabolic syndrome; the
hospital patient
is at high risk for cardiovascular issues.
3 The hospital patient may be at risk for damage to weight-bearing joints, due to
age and weight; however, this is not likely to be the HCP’s greatest concern.
4 The HCP will be concerned about the hospital patient’s family medical history;
a genetic predisposition for type 2 DM puts the hospital patient at greater risk.
PTS: 1 CON: Metabolism
10. The nursing practitioner is monitoring laboratory BG levels for a hospital patient
diagnosed with type 2 DM. Which test result does the nursing practitioner use to
evaluate the hospital patient’s compliance with treatment?
1. Fasting BG test
2. Random BG testing
3. Oral glucose tolerance test
4. Glycohemoglobin testing
RIGHT ANSWER> 4
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine Pancreas
Objective: Identify diagnostic tests used to diagnose and monitor diabetes mellitus and its
complications.
Source: pp. 827
Heading: Diagnostic Tests
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 Fasting BG test is effective for diagnosing diabetes; however, this is not a test
to indicate compliance with treatment.
2 Random BG testing is most effective in diagnosing diabetes; however, this is
not a test to indicate compliance with treatment.
3 An oral glucose tolerance test is effective in diagnosing diabetes; however, this
is not a test to indicate compliance with treatment.
4 The glycohemoglobin test (HbA1c) measures the glucose attached to red blood
cells (RBCs), which have a lifespan of about 3 months. The test provides a
good analysis of the average BG level for the previous 2 to 3 months, which
indicates compliance with treatment regimen.
PTS: 1 CON: Metabolism
11. A female hospital patient is prescribed glyburide for control of BG. What precaution does
the nursing practitioner teach the hospital patient about this medication?
1. “Avoid drinking alcohol.”
2. “Do not take it if you skip a meal.”
3. “You will need to use two forms of birth control.”
4. “Be sure it is discontinued before any tests involving contrast dye.”
RIGHT ANSWER> 1
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine Pancreas
Objective: Plan nursing care and education for the hospital patient with diabetes mellitus. Source:
pp. 824
Heading: Oral Hypoglycemic Medication
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Pharmacological
Therapies CL: Application (Applying)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 Sulfonylureas, such as glyburide, interact with alcohol and can make the
hospital patient very ill.
2 This action should be taken for meglitinides and alpha-glucosidase inhibitors.
3 Glitazones may interfere with birth control.
4 This action should be taken for metformin.
PTS: 1 CON: Metabolism
12. A hospital patient with type 1 diabetes has frequent episodes of hypoglycemia, even with
multiple daily BG self-monitoring throughout the day. Which method of self-monitoring does
the nursing practitioner recognize as being more effective for this hospital patient?
1. The hospital patient needs a pocket-sized glucose monitor.
2. The hospital patient will benefit from continuous monitoring.
3. The hospital patient needs to check for urine ketones regularly.
4. The hospital patient is a good candidate for a therapy pet.
RIGHT ANSWER> 2
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine Pancreas
Objective: Identify diagnostic tests used to diagnose and monitor diabetes mellitus and its
complications.
Source: pp. 827
Heading: Self-Monitoring of Blood Glucose
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 The hospital patient has two issues, multiple monitoring needs and frequent
hypoglycemia; this suggestion does not effectively or efficiently address either.
2 This hospital patient will benefit from continuous monitoring. This newer type
of device monitors BG via a small catheter inserted into the abdomen. The
device
monitors BG regularly and can be set to alarm if BG drops too low.
3 Checking for urine ketones on a regular basis does not effectively address
either hospital patient issue.
4 Some hospital patients with either hyper- or hypoglycemia can benefit from a
therapy pet trained to identify either condition. However, this would not
address the
issue of multiple BG checks throughout the day.
PTS: 1 CON: Metabolism
13. The nursing practitioner is providing care for a hospital patient with diabetes who
experiences frequent periods of hyperglycemia. Which comment by the hospital patient is
indicative to the nursing practitioner of a major cause of this BG imbalance?
1. “My job is really busy in tax season.”
2. “My diet never seems to fill me up.”
3. “I have increased my daily exercise.”
4. “I frequently substitute cookies for bread.”
RIGHT ANSWER> 1
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine
Pancreas Objective: Describe causes, signs and symptoms, and treatment of high and low
blood glucose levels.
Source: pp. 827
Heading: Hyperglycemia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 A major cause of hyperglycemia for a diabetic is stress; the hospital patient is
expressing a cause of stress.
2 A common cause of hyperglycemia for a diabetic is eating more than the meal
plan prescribes. Without further assessment, stress is still the major cause.
3 Increasing a daily exercise plan is more likely to cause hypoglycemia.
4 Mismanagement of the prescribed meal plan can cause hyperglycemia. Cookies
are not a good substitute for bread.
PTS: 1 CON: Metabolism
14. A hospital patient being treated with rosiglitazone for type 2 DM is receiving a routine
follow-up assessment. In addition to HbA1c and a fasting plasma glucose test, which other
laboratory test should the nursing practitioner expect to be monitored in this hospital patient?
1. Blood lipids
2. Liver function tests
3. Urine for microalbumin
4. Complete blood count (CBC)
RIGHT ANSWER> 2
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine Pancreas
Objective: Plan nursing care and education for the hospital patient with diabetes mellitus. Source:
pp. 827
Heading: Oral Hypoglycemic Medication
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Pharmacological
Therapies CL: Application (Applying)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 Lipids are important to monitor in any diabetic hospital patient, but are not
unique to glitazones.
2 Liver function must be monitored in hospital patients taking glitazones.
3 Microalbumin is important to monitor in any diabetic hospital patient but, is not
unique
to glitazones.
4 A CBC test would supply nonspecific information.
PTS: 1 CON: Metabolism
15. The nursing practitioner is discussing the management of an older adult hospital patient
recently diagnosed with type 2 DM. Which information is least helpful?
1. An emergency call system should be placed in the home.
2. The family can promote healthy eating by supplying meals.
3. If hyperglycemia is controlled, BG levels can be relaxed.
4. A week’s supply of insulin can be drawn up and refrigerated.
RIGHT ANSWER> 2
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine
Pancreas Objective: Identify therapeutic measures to help hospital patients with diabetes
mellitus control blood glucose levels.
Source: pp. 817
Heading: Gerontological Issues
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Metabolism
Difficulty: Moderate
CLARIFICATION
1 Especially if the older adult lives alone, an emergency call system should be
placed in the home.
2 Food delivery services have become common and are a good source for the
hospital patient living alone. The family cannot always be depended on to
deliver the
hospital patient’s meals. This information is the least helpful.
3 The BG parameters can be relaxed for the older adult hospital patient, especially
if hyperglycemia is controlled and incidents are rare.
4 Having a week’s supply of insulin drawn up and stored in the refrigerator can
be helpful for the older adult who is diabetic.
PTS: 1 CON: Metabolism
16. The nursing practitioner is researching the current information available regarding
the long-term complications for hospital patients diagnosed with diabetes. Which finding
is accurate?
1. Chronic hypoglycemia causes a variety of serious complications.
2. Most complications involve either the large or tiny vessels of the body.
3. Type 1 diabetics are at greatest risk for complications even with tight control.
4. Hospital patients with HbA1c levels below 6 percent are less likely to
experience complications.
RIGHT ANSWER> 2
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine
Pancreas Objective: Identify therapeutic measures to help hospital patients with diabetes
mellitus control blood glucose levels.
Pages: 830–832
Heading: Long-Term Complications
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction in Risk
Potential CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 It is chronic hyperglycemia, not hypoglycemia, which causes a variety of
serious complications for the hospital patient with diabetes.
2 It is a factual statement that most complications for the hospital patient with
diabetes involves either the large vessels (macrovascular complications) or the
tiny vessels (microvascular complications) in the body. Tiny vessels found in
the eyes and kidneys are commonly effected.
3 In general, type 2 diabetics are at greater risk for complications. However, type
1 diabetics decrease the likelihood of having complications if tight control is
maintained on BG levels.
4 Hospital patients with an HbA1c below 7 percent are less likely to develop
complications related to diabetes.
PTS: 1 CON: Metabolism
17. The nursing practitioner is preparing a hospital patient with type 2 DM for surgery. The
hospital patient expresses concern about the use of insulin at this time. Which reason does the
nursing practitioner understand that insulin therapy is appropriate in regard to surgery?
1. Surgery is a stressor causing counter-regulatory hormones to increase BG.
2. Insulin promotes healing and eliminates the common causes of infection.
3. Critically ill hospital patients with diabetes require a lower BG from insulin therapy.
4. Ongoing insulin therapy is required for the type 2 diabetic after having surgery.
RIGHT ANSWER> 1
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine
Pancreas Objective: List measures to increase the safety of the hospital patient with diabetes
mellitus who is undergoing surgery.
Source: pp. 832
Heading: Special Consideration for the Hospital patient Undergoing
Surgery Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: Physiological Integrity—Reduction of
Risk Potential CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 Surgery is a stressor that causes an elevation in BG even if the hospital patient
is fasting. Insulin is an effective and efficient method of controlling BG levels
for the surgical hospital patient.
2 Insulin does not promote healing or eliminate the common causes of infection.
Insulin prevents high BG, which can interfere with these processes.
3 Critically ill hospital patients with diabetes require a higher level of BG; a
range of 140 to 180 mg/dL is recommended.
4 The type 2 diabetic will revert to presurgical management after the stress of
surgery has passed.
PTS: 1 CON: Metabolism
18. A hospital patient with diabetes has peripheral neuropathy. What should the nursing
practitioner do to prevent related complications?
1. Wash, dry, and inspect feet daily.
2. Use a lubricating lotion on feet daily.
3. Wear loose comfortable shoes in the house.
4. Soak feet in soap and water for 20 minutes daily.
RIGHT ANSWER> 1
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine Pancreas
Objective: Plan nursing care and education for the hospital patient with diabetes mellitus. Source:
pp. 830
Heading: Foot Complications
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 The feet must be washed, dried, and inspected daily to recognize pressure
points or red areas before they turn into wounds that are difficult to treat.
2 Lubricating lotion can be a medium for bacterial or fungal growth and should
be avoided, especially between the toes.
3 Sturdy, well-fitting shoes should be worn all the time to protect the feet from
injury.
4 Soaking the feet can cause maceration of the skin, increasing the risk for sores.
PTS: 1 CON: Metabolism
19. The nursing practitioner is planning to review information with a hospital patient
diagnosed with diabetes. Which information does the nursing practitioner include
regarding an increased risk for and treatment of infection?
1. IV antibiotics are the preferable for effective treatment of infection.
2. White blood cells (WBCs) become sluggish and ineffective against infection with
hypoglycemia.
3. Circulation may not be adequate to heal a wound or fight infection.
4. Routine vaccinations to prevent infection are not effective with diabetes.
RIGHT ANSWER> 3
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine Pancreas
Objective: Plan nursing care and education for the hospital patient with diabetes mellitus. Source:
pp. 830
Heading: Infection
Integrated Process: Clinical Problem-Solving (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 A hospital patient with diabetes is at risk for poor circulation, which decreases
the effectiveness of IV antibiotic treatment. Topical antibiotics may be more
effective.
2 WBCs become sluggish and ineffective against infections in the presence of
hyperglycemia, not hypoglycemia.
3 Hospital patients with diabetes are at risk for poor circulation, which slows
down the ability to heal a wound or fight an infection.
4 Hospital patients with diabetes are encouraged to receive routine vaccinations
against
flu, pneumonia, and hepatitis; prevention of illness or infection is crucial.
PTS: 1 CON: Metabolism
20. A hospital patient with type 1 DM expresses concern about developing retinopathy due to a
chronic disease. Which information does the nursing practitioner provide to give the hospital
patient the best reassurance?
1. Newer laser surgery can improve sight after retinal hemorrhage.
2. The high incidence of cataracts can be surgically corrected.
3. Diabetes is low as a cause for blindness in the United States.
4. Good control of BG and blood pressure can reduce the risk.
RIGHT ANSWER> 4
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine Pancreas
Objective: Plan nursing care and education for the hospital patient with diabetes mellitus. Source:
pp.
831 Heading:
Eyes
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Moderate
CLARIFICATION
1 If the hospital patient experiences retinal hemorrhage, information about newer
laser surgery that can improve sight may be reassuring; however, information
about prevention is the most reassuring.
2 Hospital patients with diabetes are at greater risk for developing cataracts and it
may be reassuring to know that the condition can be surgically corrected.
However, the
hospital patient is more likely interested in prevention.
3 Diabetes is the leading cause of blindness in adults in the United States. The
presented information is untrue.
4 Good control of BG and blood pressure can reduce the risk of vision
complications in the hospital patient who is diabetic. Prevention is always
preferred
over treatment when possible.
PTS: 1 CON: Metabolism
21. The nursing practitioner is employed at a clinic for hospital patients diagnosed with
diabetes. Which hospital patient does the nursing practitioner identify as being at greatest risk
for needing dialysis?
1. The non-Hispanic adult with type 1 DM since early childhood
2. The older adult with type 2 DM, unstable BG, and hypertension
3. The hospital patient who is African American with type 2 DM and hypertension
4. The hospital patient who is Asian with type 1 DM and well-controlled BG
RIGHT ANSWER> 2
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine
Pancreas Objective: Discuss how diabetes mellitus increases risk of complications such as
heart disease, blindness, and kidney failure.
Source: pp. 834
Heading: Kidneys
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Difficult
CLARIFICATION
1 The non-Hispanic hospital patient with type 1 DM since childhood does not
exhibit any risks other than longevity of the disease process.
2 The older adult with type 2 DM, unstable BG, and hypertension is at greatest
risk for needing dialysis. Four risk factors exist: diabetes, age, uncontrolled
BG, and hypertension.
3 The hospital patient with diabetes who is African American with type 2 DM and
hypertension exhibits three risk factors for needing dialysis: ethnicity, diabetes,
and hypertension.
4 The hospital patient who is Asian with type 1 DM and well-controlled BG does
not exhibit any risks other than the disease process. Duration of the disease is
not included.
PTS: 1 CON: Metabolism
22. The nursing practitioner is contributing to a dietary presentation for hospital patients in a
multicultural community with diabetes. Which intervention will be least likely to meet the needs
of the attendees?
1. Suggestions for culture sensitive substitutes
2. Presentation of the standard diabetic diet
3. Opportunity for hospital patients to ask questions privately
4. Advance preparation regarding culturally preferred foods
RIGHT ANSWER> 2
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine Pancreas
Objective: Plan nursing care and education for hospital patients with diabetes mellitus.
Source: pp. 829
Heading: Cultural Considerations
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Teaching/Learning
CL: Application (Applying) Concept:
Metabolism
Difficulty: Moderate
CLARIFICATION
1 Suggestions for culture-sensitive food substitutes will be likely to meet the
needs of hospital patients with diabetes in a multicultural community.
2 Due to the expected multicultural attendees, the presentation of the standard
diabetic diet is least likely to meet the needs of the attendees.
3 It is important for the nursing practitioner to provide the opportunity for hospital
patients to ask questions privately. The hospital patients may not be comfortable
asking group
questions due to language, culture, and dietary differences.
4 The nursing practitioner will be able to meet the needs of multicultural attendees
if advance preparation is made regarding culturally preferred foods.
PTS: 1 CON: Metabolism
MULTIPLE RESPONSE
1. The nursing practitioner is providing teaching to a hospital patient with reactive
hypoglycemia. Which instructions related to glucose monitoring should the nursing
practitioner provide? (Select all that apply.)
1. “It is important to check your BG at bedtime.”
2. “It is important to check your BG 1 hour before meals.”
3. “You will need to check your BG 2 hours after meals.”
4. “You should check your BG when you get up in the morning.”
5. “Checking your BG once a day, at the same time each day, is sufficient.”
RIGHT ANSWER> 1, 3, 4
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine Pancreas
Objective: Explain reactive hypoglycemia and its treatment.
Source: pp. 836
Heading: Reactive Hypoglycemia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Difficult
CLARIFICATION
1. Low BG may occur as an overreaction of the pancreas to eating. The
pancreas senses a rising BG and produces more insulin than is necessary for
the use of that glucose. As a result, the BG drops to below normal. Readings
should be taken in the morning on arising, 2 hours after each meal, at
bedtime, and during symptoms of hypoglycemia.
2. Checking BG levels 1 hour before meals will not help the hospital patient
control reactive hypoglycemia.
3. Low BG may occur as an overreaction of the pancreas to eating. The
pancreas senses a rising BG and produces more insulin than is necessary for
the use of that glucose. As a result, the BG drops to below normal. Readings
should be taken in the morning on arising, 2 hours after each meal, at
bedtime, and during symptoms of hypoglycemia.
4. Low BG may occur as an overreaction of the pancreas to eating. The
pancreas senses a rising BG and produces more insulin than is necessary for
the use of that glucose. As a result, the BG drops to below normal. Readings
should be taken in the morning on arising, 2 hours after each meal, at
bedtime, and during symptoms of hypoglycemia.
5. Checking BG once daily at the same time will not help the hospital patient
control
reactive hypoglycemia.
PTS: 1 CON: Metabolism
2. A hospital patient is diagnosed with diabetic ketoacidosis. Which manifestations should
the nursing practitioner expect to observe in this hospital patient? (Select all that apply.)
1. Dehydration
2. Hypertension
3. Flulike symptoms
4. Kussmaul’s respirations
5. Edema associated with fluid overload
RIGHT ANSWER> 1, 3, 4
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine
Pancreas Objective: Describe causes, signs and symptoms, and treatment of high and low
blood glucose levels.
Source: pp. 829
Heading: Diabetic Ketoacidosis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Metabolism
Difficulty: Difficult
CLARIFICATION
1. With such high BG and the accompanying polyuria, the body becomes
dehydrated very quickly.
2. Tachycardia, hypotension, and shock can result.
3. The combination of dehydration, potassium imbalance, and acidosis causes
the hospital patient to develop flu-like symptoms, including abdominal pain
and
vomiting.
4. The body attempts to compensate for acidosis by deepening respirations,
thereby blowing off excess carbon dioxide. The deep, sighing respiratory
pattern is called Kussmaul’s respirations.
5. With such high BG and the accompanying polyuria, the body becomes
dehydrated quickly.
PTS: 1 CON: Metabolism
COMPLETION
1. A hospital patient is upset to learn that a recent HbA1c level is 10.3 percent. Which average
BG level does the nursing practitioner provide based upon this percentage if the equation
28.7 × HbA1c – 46.7 is used? (Round to the nearest whole number.)
RIGHT ANSWER>
249 mg/dL
Chapter: Chapter 40. Nursing Care of Hospital patients With Disorders of the Endocrine
Pancreas Objective: Identify therapeutic measures to help hospital patients with diabetes
mellitus control blood glucose levels.
Source: pp. 826
Heading: Estimated Average Glucose
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Metabolism
Difficulty: Difficult
CLARIFICATION: When using this equation, the hospital patient’s average BG level is
calculated as: 28.7 × 10.3 – 46.7 = 248.91. With rounding, it would be 249 mg/dL.
PTS: 1 CON: Metabolism
Chapter 41. Genitourinary and Reproductive System Function and Assessment
MULTIPLE CHOICE
1. The nursing practitioner is preparing a presentation about the normal reproductive system
of the female. Which condition is incorrect?
1. Females have a definite limit to reproductive capability.
2. The mammary glands are considered part of the reproductive system.
3. Normal pH of the vagina is alkaline to prevent microbial growth.
4. Internal structures include paired ovaries and fallopian tubes, a vagina, and uterus.
RIGHT ANSWER> 3
Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment
Objective: Explain the normal structures and functions of the reproductive system. Pages:
839–840
Heading: Female Reproductive System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 Females do have a definite limit to reproductive capability, which ends when
ovulation stops (menopause).
2 Mammary glands are considered accessory organs to the reproductive system.
3 The normal pH of the vagina is acidic, not alkaline, which helps retard
microbial growth. After puberty, the vagina mucosa is relatively resistant to
infection.
4 Internal structures of the female reproductive system include paired ovaries and
fallopian tubes, a vagina, and a uterus.
PTS: 1 CON: Sexuality
2. The nursing practitioner is preparing a presentation about the normal reproductive
system of the male. Which statement is incorrect?
1. The scrotum keeps the testes at a temperature slightly lower than the body.
2. Spermatogenesis is constant after puberty and usually continues through life.
3. Alkaline secretions ensure sperm viability in the acidic environment of the vagina.
4. The arterioles of the penis constrict to hold blood in the penis for an erection.
RIGHT ANSWER> 4
Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment
Objective: Explain the normal structures and functions of the reproductive system.
Source: pp. 841
Heading: Male Reproductive System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Application (Applying) Concept:
Sexuality
Difficulty: Moderate
CLARIFICATION
1 The testes are located in the scrotum, which is located between the thighs. The
temperature of the scrotum is slightly lower than the body, which is necessary
for the production of viable sperm.
2 The male begins to produce sperm after puberty, a process that usually
continues throughout the male’s lifetime.
3 The gland secretions in the ejaculate are alkaline to ensure sperm viability in
the acidic environment of the female vagina.
4 During sexual arousal, the arterioles of the penis dilate, the penile sinuses
become filled with blood, and the penis becomes firm and erect.
PTS: 1 CON: Sexuality
3. A female hospital patient who is 40 years of age is scheduled for a baseline
mammography. The hospital patient becomes concerned when she learns a digital
mammography is planned. The hospital patient states, “I thought that test was for high risk
women.” Which answer by the nursing practitioner is most appropriate?
1. “This type of testing is more effective in detecting cancer in younger women.”
2. “The test is more expensive, but the cost is offset by the benefits of earlier
detection.”
3. “The image is computerized, allowing the radiologist to look more closely at
specific areas.”
4. “This method of testing is much quicker, easier, and with less discomfort for the
woman.”
RIGHT ANSWER> 3
Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment
Objective: Identify commonly performed tests used to diagnose disorders of the
reproductive system.
Source: pp. 849
Heading: Mammography
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 Digital mammography is more effective in detecting breast cancer in younger
women who have denser breast tissue. This is an accurate statement, but there
is another statement that more closely addresses the hospital patient’s concern.
2 It is inappropriate for the nursing practitioner to make a reference to the cost of
the test in relation to the benefit. The hospital patient may feel compelled to
make a decision about the type of test based on cost.
3 The most appropriate statement by the nursing practitioner is the one that
provides a benefit
and rationale for the selected method of testing. The computerized imagery is
clearer and allows the radiologist to closely examine any specific area.
4 The routine for digital mammography is the same as for previous methods. The
time frame is unchanged. The comfort level is unchanged because the breast
tissue is still compressed as much as possible.
PTS: 1 CON: Sexuality
4. The nursing practitioner is providing information on breast self-examination to a female
hospital patient. Which palpation pattern does the nursing practitioner instruct the hospital
patient to use when performing this examination?
1. Spiral pattern
2. Parallel lines
3. Wheel-spoke pattern
4. Any pattern that is consistent and thorough
RIGHT ANSWER> 4
Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment
Objective: Identify commonly performed tests used to diagnose disorders of the
reproductive system.
Source: pp. 848
Heading: Breast Self-Examination
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 Spiral pattern is an accepted method of breast self-examination.
2 Parallel lines is an accepted method of breast self-examination.
3 Wheel-spoke pattern is an accepted method of breast self-examination.
4 Whether the breasts are examined in parallel lines, a spiral formation, or a
wedge pattern is probably insignificant. It is important, however, to encourage
that the examination be methodical and cover all areas of the breast, the tail of
Spence, and the axilla.
PTS: 1 CON: Sexuality
5. The nursing practitioner is collecting information from a female hospital patient who is 55
years of age. The hospital patient is postmenopausal for 8 years. The hospital patient is also
small boned, Caucasian, and has never been pregnant. Which type of bone testing does the
nursing practitioner suggest to the hospital patient?
1. A heel scan that is performed at the local pharmacy
2. A dual energy x-ray absorptiometry (DEXA) scan
3. A laboratory test to determine estrogen levels
4. A blood test to determine circulating calcium levels
RIGHT ANSWER> 2
Chapter: Chapter 41. Genitourinary and Reproductive System Function and
Assessment Objective: Identify commonly performed tests used to diagnose
disorders of the reproductive system.
Source: pp. 850
Heading: Bone Health Assessment
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 The hospital patient has numerous risk factors for osteoporosis. A heel scan at
the local drug store may serve as a good screening option; however, it is not the
most conclusive test for bone density in this hospital patient.
2 The DEXA scan measures bone density at the hip or spine, which are areas that
are prone to bone loss leading to injuries or joint damage.
3 A laboratory test for estrogen levels is not necessary; the hospital patient is past
menopause and estrogen levels are expected to be low unless the hospital patient
is on hormone replacement therapy.
4 A blood test for the levels of circulating calcium levels is not effective in
determining bone density.
PTS: 1 CON: Sexuality
6. The nursing practitioner is discussing menstruation with a hospital patient who is present for
her yearly physical. The hospital patient is 11 years of age and states, “I have not had a period
yet and I hear so much at school it is confusing.” Which detail about the function is unnecessary
at this time?
1. Normally, a cycle will occur approximately every 28 days.
2. A period usually lasts about 5 days and bleeding is not excessive.
3. The process is related to fluctuating estrogen and progesterone hormones.
4. Cramping can occur, but is not usually severe and can be managed fairly easy.
RIGHT ANSWER> 3
Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment
Objective: Explain the normal structures and functions of the reproductive system.
Source: pp. 845
Heading: The Ovarian and Menstrual Cycles
Integrated Process: Teaching/Learning
Hospital patient Need: Health Promotion and
Maintenance CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 The frequency of menstruation is appropriate information for this hospital
patient.
2 The length and characteristics of the menstrual cycle is appropriate information
for this hospital patient.
3 At this point in time and at the hospital patient’s age, information about the
function of
hormones is unnecessary. The hospital patient is most likely seeking information
about
the actual manifestations and related expectations.
4 It is appropriate for the nursing practitioner to mention the possibility of
cramping and
including that it is a manageable condition.
PTS: 1 CON: Sexuality
7. A 60-year-old hospital patient receives information that a prostate-specific antigen (PSA)
laboratory value is 11 ng/mL. Which intervention by the health care provider (HCP) does the
nursing practitioner expect?
1. Needle biopsy of the prostate
2. A prostatic acid phosphatase test
3. Retesting as usual in 1 year
4. Informing the hospital patient of cancer
RIGHT ANSWER> 2
Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment
Objective: Identify commonly performed tests used to diagnose disorders of the
reproductive system.
Source: pp. 901
Heading: Male Reproductive System Data Collection
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 The HCP provider will defer a needle biopsy until additional laboratory tests
are performed.
2 The HCP is most likely to prescribe for a prostatic acid phosphatase test, which
will confirm or rule out the presence of prostate cancer.
3 The normal PSA level is less than 4 ng/mL. The hospital patient’s PSA level is
significantly elevated and requires intervention. Waiting a year may put the
hospital patient at risk for disease or complications related to an enlarged
prostate.
4 It is too early to inform the hospital patient of having cancer; additional testing
is needed to either confirm or rule out the condition.
PTS: 1 CON: Sexuality
8. The nursing practitioner is collecting data from a female hospital patient regarding normal
function baselines of the reproductive system. Which question is appropriate for the nursing
practitioner to ask?
1. “Do you have any questions about sex?”
2. “How many sexual partners have you had?”
3. “Have you ever been treated for a sexually transmitted infection, or STI?”
4. “Has sexual functioning and desire changed?”
RIGHT ANSWER> 4
Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment
Objective: Explain the normal structures and functions of the reproductive system.
Source: pp. 840
Heading: Female Reproductive System Data Collection
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 The question is closed ended and will not provide adequate information to add
to a function baseline. The question is also very broad.
2 When gathering data for a normal function baseline, it is not necessary to
ascertain the number of sexual partners. The question is inappropriate because
it also insinuates the hospital patient has had more than one sexual partner.
3 Obtaining a normal function baseline is not the time to ask about treatment of
STIs.
4 Asking about changes in sexual functioning and desire is appropriate as deviations
from the normal function baseline may be indicative of a hormone imbalance. The
expected functioning of the reproductive system changes throughout the process of
aging, so the normal function baseline will depend on the hospital patient’s age.
PTS: 1 CON: Sexuality
9. After finding a mass in the scrotum of a male hospital patient, the nursing practitioner
provides the HCP with a flashlight and turns off the lights. For which reason did the
nursing practitioner perform these actions?
1. Preparation for identifying a varicocele
2. Preparation for a digital rectal examination
3. Preparation for transillumination of the testes
4. Preparation for a PSA to be drawn
RIGHT ANSWER> 3
Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment
Objective: Identify commonly performed tests used to diagnose disorders of the
reproductive system.
Source: pp. 911
Heading: Male Reproductive System Data Collection
Integrated Process: Clinical Problem-Solving Problems (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 Identification of a varicocele is done by palpating the spermatic cord.
2 A flashlight and darkened room are not needed for a digital rectal examination
and PSA blood test.
3 A simple noninvasive test called transillumination is used to determine if a
mass is fluid filled or solid. With the room lights out, a flashlight is held behind
the scrotum. If the mass is fluid, a red glow appears; if it is solid, it appears
opaque.
4 A flashlight and darkened room are not needed for a digital rectal examination
and PSA blood test.
PTS: 1 CON: Sexuality
10. The nursing practitioner reviews laboratory values for a male hospital patient with an
elevated PSA level and notes that the alkaline phosphatase and serum calcium levels are also
elevated. Which condition do these findings suggest to the nurse?
1. The hospital patient has a fulminating bladder infection.
2. The hospital patient has a sexually transmitted infection.
3. The hospital patient has an obstruction of the spermatic cord.
4. The hospital patient has cancer that has metastasized to the bone.
RIGHT ANSWER> 4
Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment
Objective: Identify commonly performed tests used to diagnose disorders of the
reproductive system.
Source: pp. 909
Heading: Male Reproductive System Data Collection
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 Elevated alkaline phosphatase and serum calcium levels are not associated with
a bladder infection.
2 Elevated alkaline phosphatase and serum calcium levels are not associated with
an STI.
3 Elevated alkaline phosphatase and serum calcium levels are not associated with
an obstruction of the spermatic cord.
4 If prostate cancer is suspected or diagnosed, additional tests may be done.
Alkaline phosphatase and serum calcium levels may be elevated if metastasis
to the bone has occurred.
PTS: 1 CON: Sexuality
11. A hospital patient is scheduled for a surgical biopsy for removal of a lesion suspected to
be breast cancer. Which care by the nursing practitioner is most important?
1. Presenting a calm and understanding attitude
2. Explaining the reasons for the surgical biopsy
3. Sharing that most breast biopsies are benign
4. Providing the hospital patient with antianxiety medication
RIGHT ANSWER> 1
Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment
Objective: Plan nursing care for hospital patients undergoing each of the diagnostic tests.
Source: pp. 865
Heading: Diagnostic Tests of the Breast
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Application (Applying)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 Any concern about breast cancer can cause the hospital patient extreme
anxiety; the most important care the nursing practitioner can provide at this
time is presenting a caring and understanding attitude.
2 The HCP has likely provided the reasons for surgical biopsy at the time of
obtaining surgical consent; there is no need for the nursing practitioner to
explain further at
this time.
3 It is inappropriate for the nursing practitioner to share that most breast
biopsies are benign; this is giving the hospital patient false hope.
4 The hospital patient may need some antianxiety medication; however, this is not
the
most important care the nursing practitioner can provide.
PTS: 1 CON: Sexuality
12. A female hospital patient is scheduled for her first pelvic examination. Which action by
the nursing practitioner will provide the hospital patient with physical comfort?
1. Offer to allow the hospital patient to squeeze the nurse’s hand during the procedure.
2. Allow the hospital patient to remain in a sitting position until the HCP is present.
3. Instruct the hospital patient to blow out a deep breath as the speculum is inserted.
4. Explain the details of the examination as the procedure is performed.
RIGHT ANSWER> 3
Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment
Objective: Plan nursing care for hospital patients undergoing each of the diagnostic tests.
Source: pp. 850
Heading: Pelvic Examination
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Basic Care and
Comfort CL: Application (Applying)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 Offering to allow the hospital patient to squeeze the nurse’s hand through the
examination is not likely to provide the greatest comfort. In addition, the
nurse’s assistance is needed by the HCP.
2 Allowing the hospital patient to remain in a sitting position until the HCP
enters the room may or may not provide the hospital patient with comfort.
This action can also delay the start of the examination.
3 The suggestion that will provide the hospital patient with the most comfort
during a
pelvic examination is to instruct the hospital patient to take a deep breath and
blow it
out as the speculum is inserted.
4 Explaining the details of the examination as it is performed is most commonly
done by the HCP. Performance by the nursing practitioner is not likely to
provide a better
sense of comfort.
PTS: 1 CON: Sexuality
13. A female hospital patient has not achieved pregnancy after 8 months of attempting to do so
and is undergoing hormone testing. Which additional reason other than infertility does the
nursing practitioner identify for hormone testing?
1. To confirm a hospital patient’s stage of puberty
2. To assess hormone-producing tumors
3. To verify the achievement of pregnancy
4. To identify bone loss after menopause
RIGHT ANSWER> 2
Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment
Objective: Identify commonly performed tests used to diagnose disorders of the
reproductive system.
Source: pp. 860
Heading: Additional Diagnostic Tests of the Female Reproductive System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 Hormone testing is not done to confirm a hospital patient’s stage of puberty.
2 One of the reasons for performing hormone testing is to assess hormone-
producing tumors. In addition, the testing is performed to measure potential
infertility, find reasons for abnormal menses, and to evaluate the effectiveness
of hormone therapy.
3 Hormone testing is not performed to verify the achievement of pregnancy.
4 Hormone testing is not performed to identify bone loss after menopause.
PTS: 1 CON: Sexuality
14. A female hospital patient is scheduled for laparoscopy for determination of endometriosis.
Following the procedure, which nursing care will the nursing practitioner perform?
1. Place the hospital patient on the left side to centralize carbon dioxide.
2. Keep the hospital patient in a supine position for 8 hours postoperative.
3. Monitor the hospital patient for pain in the neck, shoulders, and upper back.
4. Check the surgical dressing for signs of infectious drainage.
RIGHT ANSWER> 3
Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment
Objective: Plan nursing care for hospital patients undergoing each of the diagnostic tests.
Source: pp. 873
Heading: Endoscopic Examinations
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 There is no need to place the hospital patient on the left side to centralize
carbon dioxide. The gas, if used, will be absorbed by the body.
2 There is no need to keep a hospital patient in a supine position, for any amount
of time, following a laparoscopy unless the hospital patient had a spinal
anesthesia, which was
not indicated in this scenario.
3 The hospital patient may experience pain in the neck, shoulders, and upper
back following a laparoscopy if carbon dioxide was pumped into the body
cavity being examined. The “insufflation” increases the distance between
structures for better visualization.
4 The hospital patient will likely have a small dressing on the small incisions
that are made in the abdominal wall for the insertion of the endoscope. The
procedure
is often referred to as “Band Aid” surgery. The presence of infectious drainage
would require, at minimum, the use of a wound drainage system.
PTS: 1 CON: Sexuality
15. The nursing practitioner is assisting the HCP in a procedure used for cytology of the
surface of the cervix. Which procedure does the nursing practitioner understand is being
performed?
1. Conization
2. Endometrial biopsy
3. Lesion extraction
4. Papanicolaou
RIGHT ANSWER> 4
Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment
Objective: Identify commonly performed tests used to diagnose disorders of the
reproductive system.
Source: pp. 875
Heading: Cytology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 Conization is a procedure performed to obtain cells from the cervical canal for
cytology.
2 An endometrial biopsy involves taking cells from the lining of the uterus using
a small spoon-shaped tool called a curet.
3 Extraction of small parts of or an entire lesion is a process to obtain cells for
cytology. This procedure can be used at multiple locations.
4 Papanicolaou (PAP) tests are done by gently scraping the cervix to obtain cells
from the surface of the cervical canal. The cells are then affixed to a glass slide
for cytology.
PTS: 1 CON: Sexuality
16. A male hospital patient is scheduled for an outhospital patient cystourethrography to
evaluate the degree of obstruction by an enlarged prostate. Which nursing care will the
nursing practitioner provide after the procedure?
1. Maintain strict input and output until discharge
2. Place a warm moist cloth over the urethra for pain
3. Perform intermittent catheterization for urine retention
4. Monitor for effects of analgesics before allowing to drive
RIGHT ANSWER> 2
Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment
Objective: Plan nursing care for hospital patients undergoing each of the diagnostic tests.
Source: pp. 902
Heading: Cystourethrography
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 The hospital patient is actually maintained on input and output for 24 hours
following
the procedure.
2 The nursing practitioner can apply a warm moist cloth over the urethra for
reduction of pain.
3 If the hospital patient has alterations in the normal voiding pattern, bleeding, or
the
absence of urination, the nursing practitioner contacts the HCP. Intermittent
catheterization is performed only with a HCP’s prescription.
4 If analgesics are used during the procedure, the hospital patient must have
someone
who can drive the hospital patient home.
PTS: 1 CON: Sexuality
17. The nursing practitioner is collecting health history on a female hospital patient who is
considered a high-risk pregnancy. Which information will the nursing practitioner record if the
hospital patient has had four pregnancies, a miscarriage at 16 weeks, one 22-week stillborn
delivery, and delivery at term to a set of twins and a single birth?
1. G4P4A1
2. G4P2A2
3. G4P2A1
4. G4P3A2
RIGHT ANSWER> 3
Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment
Objective: List data you should collect when caring for a hospital patient with a disorder of the
reproductive system.
Source: pp. 845
Heading: Female Reproductive System Data Collection
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 The hospital patient has not had four live births.
2 The hospital patient has not had two abortions, either spontaneous or
3 The hospital patient has four pregnancies (G), two deliveries resulting in live
births (P), and one spontaneous abortion (A). The birth at 22 weeks is not
considered an abortion, but is also not a live birth. The hospital patient has three
children from two pregnancies.
4 The hospital patient has not delivered live fetuses from three pregnancies and
had only
one spontaneous abortion.
PTS: 1 CON: Sexuality
18. The nursing practitioner is in the initial stage of physical examination with a male
hospital patient. Which observation by the nursing practitioner is most likely unrelated
to a hormone imbalance?
1. Gynecomastia
2. Absence of facial hair
3. Lack of pubic hair
4. Short stature
RIGHT ANSWER> 4
Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment
Objective: List data you should collect when caring for a hospital patient with a disorder of the
reproductive system.
Source: pp. 856
Heading: Male Reproductive System Data Collection
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 Gynecomastia is a male condition where there is an excess of breast tissue
related to excess female hormones.
2 An absence of facial hair is considered to be unexpected in a male hospital
patient. Abnormal hair patterns are frequently an indication of hormone
imbalance.
3 A lack of pubic hair is an abnormal hair pattern that frequently indicates a
hormone imbalance.
4 Short stature may be related to genetics and is not commonly associated with
hormone imbalances.
PTS: 1 CON: Sexuality
MULTIPLE RESPONSE
1. The nursing practitioner is reviewing the anatomy of the reproductive tract with a female
hospital patient. Which structures do the nursing practitioner identify as being part of the
vulva? (Select all that apply.)
1. Mons pubis
2. Bartholin’s glands
3. Cervix
4. Clitoris
5. Vagina
RIGHT ANSWER> 1, 2, 4
Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment
Objective: Explain the normal structures and functions of the reproductive system.
Source: pp. 840
Heading: Female Reproductive System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Difficult
CLARIFICATION
1. Also called the vulva, the female external genital structures are the clitoris,
mons pubis, labia majora and minora, and Bartholin’s glands.
2. Also called the vulva, the female external genital structures are the clitoris,
mons pubis, labia majora and minora, and Bartholin’s glands.
3. The cervix is not part of the vulva.
4. Also called the vulva, the female external genital structures are the clitoris,
mons pubis, labia majora and minora, and Bartholin’s glands.
5. The vagina is not part of the vulva.
PTS: 1 CON: Sexuality
2. The licensed practical nursing practitioner is providing instructions on testicular self-
examination. Which statements do the nursing practitioner include in this teaching? (Select all
that apply.)
1. “The testicles should be examined monthly while in the shower.”
2. “The spermatic cord generally cannot be felt without deep palpation.”
3. “The left side of the scrotum usually hangs a little lower than the right.”
4. “If you notice any lumps or unusual changes, you should call your doctor.”
5. “Hold the scrotum in one hand and massage gently to note any tenderness.”
RIGHT ANSWER> 1, 3, 4
Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment
Objective: Explain the normal structures and functions of the reproductive system.
Source: pp. 860
Heading: Male Reproductive System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Difficult
CLARIFICATION
1. Testicular self-examination is to be performed monthly and while in the
shower. When the skin is wet, the hospital patient’s hand will glide more
smoothly
across the testicles, and the warm water will facilitate relaxation of the
scrotum.
2. The spermatic cord usually feels firm, smooth, and movable and can be
readily identified.
3. The left side of the scrotum usually hangs a little lower than the right.
4. Testicular self-examination should be done monthly and lumps or unusual
changes should be communicated to the physician.
5. Both hands are used to hold the scrotum and gently roll each testicle between
the thumb and first three fingers, feeling for any lumps or hard spots.
PTS: 1 CON: Sexuality
Chapter 42. Nursing Care of Women With Reproductive System Disorders
MULTIPLE CHOICE
1. The nursing practitioner is contributing to information for women in a fibrocystic breast
disease support group. Which information does the nursing practitioner suggest including?
1. The manifestations of the condition usually subside with menopause.
2. One cause is related to the use of hormonal birth control medications.
3. The disease process frequently results in the development of cancer.
4. Women between the ages of 20 and 30 years are most susceptible.
RIGHT ANSWER> 1
Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders
Objective: Explain the pathophysiology of each of the disorders of the female reproductive
system.
Source: pp. 865
Heading: Fibrocystic Breast Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Fibrocystic breast disease is due to a hormonal response, primarily to estrogen.
Because estrogen levels decrease after menopause, the symptoms are likely to
subside at that time.
2 Limitation of dietary fats and caffeine, along with the addition of oral
contraceptives may help control hormonal changes associated with the
condition.
3 Fibrocystic breast disease is not related to the development of breast cancer.
However, the presence of fibrous tissue in the breasts make it more difficult to
diagnose breast cancer should it develop.
4 Fibrocystic disease is most common in women between the ages of 30 and 50
years.
PTS: 1 CON: Hospital patient-Centered Care
2. The nursing practitioner is providing care for a hospital patient who had a mastectomy for
breast cancer 2 days ago and is now developing pulmonary congestion. For which reason is a
mastectomy hospital patient at risk for pulmonary complications?
1. Breast cancer often metastasizes to the lungs prior to diagnosis.
2. Pathogens may have been introduced during the surgical procedure.
3. The chest incision makes the hospital patient hesitant to deep-breathe and cough.
4. Mastectomy hospital patients are on bedrest for the first 48 to 72 hours postoperatively.
RIGHT ANSWER> 3
Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders
Objective: Explain the pathophysiology of each of the disorders of the female reproductive
system.
Source: pp. 867
Heading: Malignant Breast Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Breast cancer does not often spread to the lungs before the diagnosis of breast
cancer.
2 Pathogens should not be introduced during surgery and the mastectomy site is
not the same as the lungs.
3 Hospital patients can have ineffective breathing patterns and difficulty coughing
because of pain with chest movement.
4 Bedrest is not necessary and may actually contribute to postsurgical
complications.
PTS: 1 CON: Hospital patient-Centered Care
3. A hospital patient at age 23 reports severe pelvic and back pain, which increases during her
menses. After testing, she is diagnosed with endometriosis. Which information provided by the
nursing practitioner is likely to be considered premature?
1. “The condition is called retrograde menstruation.”
2. “Removal of the ovaries is the most effective treatment.”
3. “Migrated endometrium cells attach to the abdominal organs.”
4. “The cells in the abdomen will build up and slough like the uterus.”
RIGHT ANSWER> 2
Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders
Objective: Explain the pathophysiology of each of the disorders of the female reproductive
system.
Source: pp. 874
Heading: Endometriosis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Teaching/Learning
CL: Analysis (Analyzing) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Endometriosis is considered to be retrograde menstruation because of the
backward leakage of blood and tissue into the fallopian tubes and pelvic cavity.
2 The management of endometriosis is related to the management of hormones
involved in menstruation. Reduction of ovulation via medications or surgical
removal of the ovaries can be effective. However, the treatment results in
infertility; this information can be premature to a young hospital patient newly
diagnosed with the condition.
3 The migrated endometrium cells will attach to or grow into tissues such as the
intestinal walls, ovaries, and other abdominal structures/organs.
4 On a cyclic basis mediated by ovarian hormones, the endometrial cells in the
abdomen will buildup and slough like those in the uterus. The difference is that
the bleeding occurs within the abdominal cavity, causing pain, swelling, and
damage to abdominal organs and structures. The scar tissue will result in
infertility.
PTS: 1 CON: Hospital patient-Centered Care
4. A 50-year-old woman states, “It is such a relief not to need birth control any more. I haven’t
had a period in 3 months.” Which response by the nursing practitioner is correct?
1. “Birth control is usually unnecessary after age 50, even if you are still having
periods.”
2. “It is still possible for you to get pregnant and you should consider having a tubal
ligation.”
3. “You should continue to use birth control for at least 6 months after cessation of
your periods.”
4. “Without confirmation, you are still considered to be perimenopausal and should
continue birth control.”
RIGHT ANSWER> 4
Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders
Objective: Describe the etiologies, signs, and symptoms of each disorder.
Source: pp. 875
Heading: Menopause
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 To prevent conception, the hospital patient needs to continue to practice birth
control until she receives confirmation from her health care provider (HCP)
that menopause is complete.
2 A tubal ligation is not necessary because only a brief time of needing protection
remains.
3 Six months is not a magic number; menopause needs to be confirmed by an
HCP.
4 It is important to remind perimenopausal women that they may still be fertile
even after several months of amenorrhea.
PTS: 1 CON: Hospital patient-Centered Care
5. The nursing practitioner is collecting data from a female hospital patient who is having
difficulty conceiving. The nursing practitioner notes that the hospital patient has increased
amounts of body and facial hair, is moderately overweight, and has acne-like lesions on the
face. Which medical condition is the nursing practitioner likely to suspect?
1. Polycystic ovary syndrome (PCOS)
2. Decreased estrogen hormone
3. Severe endometriosis
4. Immature ovaries
RIGHT ANSWER> 1
Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders
Objective: Describe the etiologies, signs, and symptoms of each disorder.
Source: pp. 881
Heading: Polycystic Ovary Syndrome
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The hospital patient is exhibiting and reporting the classic manifestations of
PCOS.
2 With PCOS, many symptoms are a result of insulin resistance with excessive
levels of insulin in the blood, which in turn stimulates the secretion of
androgens.
3 Severe endometriosis does not exhibit the listed manifestations and is not
related to PCOS.
4 PCOS is not related to immature ovaries.
PTS: 1 CON: Hospital patient-Centered Care
6. The nursing practitioner is providing care for a female patent diagnosed with
displacement disorders currently being treated with placement of a pessary. Which
nursing care is the most important for the nursing practitioner implement?
1. Provide information about weight management.
2. Suggest methods to avoid constipation.
3. Discuss how to perform Kegel exercises.
4. Inform of symptoms to report to the HCP.
RIGHT ANSWER> 3
Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders
Objective: Plan nursing care for females with reproductive disorders.
Source: pp. 879
Heading: Displacement Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 It is important for a hospital patient with displacement disorders to maintain a
healthy weight because obesity will worsen the condition. However, there is
another consideration that is more important.
2 Constipation can increase the manifestations of displacement disorders;
however, another nursing action is more important.
3 The most important action by the nursing practitioner for a hospital patient
with displacement disorders is to discuss the importance and performance of
Kegel exercises, which keep the pubococcygeus muscles strong and able to
support pelvic organs.
4 With a pessary, the hospital patient needs to report pink, bloody, or purulent
drainage from the vagina to the HCP. This is important if it occurs. Kegel
exercises are
more important because they address an existing condition.
PTS: 1 CON: Hospital patient-Centered Care
7. The nursing practitioner is assisting with teaching to a woman who is having difficulty
conceiving. Which instruction does the nursing practitioner provide about keeping a basal body
temperature chart?
1. “Record your temperature in the late afternoon each day for 3 months.”
2. “Record your temperature every 4 hours, starting the first day of each month.”
3. “Record your temperature three times each day of your period, then once a day
thereafter.”
4. “Starting with the first day of your period, record your temperature first thing each
morning.”
RIGHT ANSWER> 4
Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders
Objective: Compare different forms of contraceptives and their effectiveness. Source:
pp. 884
Heading: Natural Family Planning
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Teaching/Learning
CL: Application (Applying) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The method described is incorrect to measure basal body temperature.
2 The method described is incorrect to measure basal body temperature.
3 The method described is incorrect to measure basal body temperature.
4 The nursing practitioner teaches the hospital patient to keep a precise record of
her oral temperatures with a basal thermometer each morning on awakening,
before any other activity. The first day of her menses is day 1 on the
temperature chart.
Changing levels of hormones result in slight temperature changes, which can
be used to identify when ovulation seems to be occurring and when particular
hormone levels should be tested.
PTS: 1 CON: Hospital patient-Centered Care
8. A hospital patient is inquiring about the insertion of an intrauterine device (IUD) for
contraception. Which information from the nursing practitioner is incorrect?
1. Perforation of the vaginal wall is common.
2. Effectiveness ranges between 5 to 10 years.
3. Insertion is best during the first 7 days of menses.
4. Procedure is performed in the HCP’s office.
RIGHT ANSWER> 1
Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders
Objective: Compare different forms of contraceptives and their effectiveness. Source:
pp. 884
Heading: Intrauterine Devices
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Teaching/Learning
CL: Analysis (Analyzing) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Perforation of the vaginal wall with an IUD rarely occurs.
2 The effectiveness of an IUD is between 5 to 10 years, depending on the
specific product.
3 It is best to insert an IUD during the first 7 days of menses because the cervix
is slightly open at this time.
4 The procedure is commonly performed in the HCP’s office.
PTS: 1 CON: Hospital patient-Centered Care
9. A female reports being conflicted between the effectiveness of a condom versus a
diaphragm for contraception. Which information does the nursing practitioner
provide regarding effectiveness?
1. Diaphragms are more expensive.
2. Condoms can be part of foreplay.
3. Spermicide is a good addition to both.
4. A female condom is more effective.
RIGHT ANSWER> 3
Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders
Objective: Compare different forms of contraceptives and their effectiveness. Source:
pp. 885
Heading: Barrier Methods
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 It is true that a diaphragm is more expensive and may need to be refitted and
replaced for a variety of reasons. However, this does not address effectiveness.
2 Male condoms can be applied as part of sexual foreplay; however, this does not
address effectiveness.
3 The addition of spermicide with the use of any barrier contraception device
improves the effectiveness.
4 There is no evidence that female condoms are more effective; they are more
expensive and may break or be defective.
PTS: 1 CON: Hospital patient-Centered Care
10. A female hospital patient who is in the last trimester of pregnancy is considering
sterilization as a permanent method of birth control. The hospital patient states, “I know this is
what I want, but I don’t want to do this until the baby is a little older.” Which information does
the nursing practitioner provide?
1. Removal of the uterus can be performed later.
2. The hospital patient’s partner can opt for a vasectomy.
3. Tiny implants can be nonsurgically placed later.
4. The procedure is best performed after birth.
RIGHT ANSWER> 3
Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders
Objective: Compare different forms of contraceptives and their effectiveness. Source:
pp. 886
Heading: Sterilization
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Teaching/Learning
CL: Application (Applying) Concept:
Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Removal of the uterus is a hysterectomy; there are effective methods of
sterilization that are less invasive and with fewer possible complications.
2 The male partner of the hospital patient can opt for a vasectomy; however, this
statement does not specifically address the hospital patient’s wishes.
3 A nonsurgical procedure (Essure) uses an endoscope to place tiny implants into
each fallopian tube to block tube patency. The procedure can be performed at
any time.
4 There is no indication that the procedure is best performed after child birth
unless the hospital patient delivers via cesarean.
PTS: 1 CON: Hospital patient-Centered Care
11. The nursing practitioner is providing care for a female hospital patient diagnosed with
stage II breast cancer. The hospital patient states, “I have done some research about targeted
therapies and I’m not sure it is the best option.” Which information does the nursing
practitioner provide?
1. They will decrease positive body responses for some hospital patients.
2. They are still experimental and are not available for stage II cancer.
3. They require positive testing for HER2 protein on the cancer cells.
4. They target cancer cells and are less toxic to normal body cells.
RIGHT ANSWER> 4
Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders
Objective: Describe current therapeutic management for each disorder.
Source: pp. 885
Heading: Targeted Therapies
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Pharmacological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 Some targeted therapies will intensify positive body responses and decrease
negative body responses.
2 Many targeted therapies are beyond the experimental stage and can be used
when appropriate for treatment of cancer.
3 Three drugs target the protein HER2, which is found on the surface of some
breast cancer cells. The drugs are trastuzumab, pertuzumab, and lapatinib.
4 Because targeted therapy targets cancer cells specifically, they are less toxic to
normal body cells.
PTS: 1 CON: Hospital patient-Centered Care
12. The nursing practitioner is providing care to a female hospital patient who just received a
diagnosis of agenesis of the ovaries. Which nursing care is most appropriate for the hospital
patient?
1. Monitor for physical pain related to testing.
2. Express a willingness to listen if the hospital patient wishes.
3. Check surgical dressings for signs of bleeding.
4. Provide for privacy so the hospital patient can consider options.
RIGHT ANSWER> 2
Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders
Objective: Plan nursing care for female hospital patients with reproductive disorders.
Source: pp. 878
Heading: Disorders Related to the Development of Genital Organs
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The hospital patient may have been diagnosed by testing procedures that do not
cause
pain, such as ultrasound.
2 The nursing practitioner needs to express a willingness to listen if the hospital
patient wishes to talk. The information can be emotionally devastating and
cause intense feelings.
3 There is no indication that the hospital patient has experienced surgery.
4 The hospital patient will need privacy to deal with emotions and the meaning
of the diagnosis. However, the most important nursing action is to project a
caring and supportive attitude toward the hospital patient.
PTS: 1 CON: Hospital patient-Centered Care
13. A female hospital patient who is experiencing symptoms related to menopause is denied
hormone replacement therapy by the HCP because of a family history of breast cancer and heart
disease. Which suggestion does the nursing practitioner make for management of symptoms that
is likely to be ineffective?
1. Initiate a calcium and vitamin regimen.
2. Increase weight-bearing exercise and activity.
3. Discuss the benefit of including dietary phytoestrogens.
4. Dress in layers to promote comfort during hot flashes.
RIGHT ANSWER> 1
Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders
Objective: Describe current therapeutic management for each disorder.
Source: pp. 874
Heading: Hormone Replacement Therapy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 To be effective, calcium and vitamin D therapy should begin in early
adulthood. This suggestion is likely to be ineffective.
2 Increasing weight-bearing exercise and activity is appropriate to promote bone
health, which is no longer protected by estrogen.
3 Phytoestrogens can provide the benefits of estrogen without hormone
replacement therapy. However, phytoestrogens do carry some risks; food and
supplement additions should be discussed with the HCP.
4 The suggestion to dress in layers so that clothing can be removed easily during
hot flashes is an effective intervention during menopause.
PTS: 1 CON: Hospital patient-Centered Care
14. The nursing practitioner is collecting data from a female hospital patient with a
possible Bartholin gland cyst. Which data does the nursing practitioner need to
validate?
1. Lack of pain with intercourse
2. Difficulty when attempting to sit
3. Foul odor drainage from perineum
4. Inability to void related to pain
RIGHT ANSWER> 2
Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders
Objective: List data to collect when caring for hospital patients with disorders of the
female reproductive system.
Source: pp. 890
Heading: Bartholin Cysts
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The hospital patient with a Bartholin cyst is expected to have pain with
intercourse.
2 The hospital patient with a Bartholin cyst will express pain and difficulty with
sitting.
3 Foul odor drainage is not expected with a Bartholin cyst.
4 The hospital patient with a Bartholin cyst is not expected to have difficulty
voiding.
PTS: 1 CON: Hospital patient-Centered Care
15. The nursing practitioner is reviewing discharge teaching for a hospital patient who has
undergone laparoscopic surgery. Which hospital patient statement indicates that discharge
teaching is effective?
1. “I will report feelings of dizziness to my physician.”
2. “I will call for a refill prescription if pain is intense.”
3. “I will maintain a full liquid diet until nausea passes.”
4. “I will refrain from showering until the staples are removed.”
RIGHT ANSWER> 1
Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders
Objective: Explain how you will know whether nursing interventions have been effective.
Source: pp. 891
Heading: Gynecological Surgery
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The nursing practitioner can determine that teaching is effective if the hospital
patient understands the
necessity of reporting dizziness, which can be indicative of internal bleeding.
2 Teaching has not necessarily been effective if the hospital patient feels that a
need to manage pain requires additional prescription pain medication. Most
laparoscopic surgery does not require long-term use of pain medications.
3 Dietary restrictions are not commonly required after discharge for laparoscopic
surgery.
4 Showering is not prohibited until staples are removed. The hospital patient
needs to follow the HCP’s directions.
PTS: 1 CON: Hospital patient-Centered Care
16. A female hospital patient is diagnosed with premenstrual dysphoric disorder (PMDD). The
HCP prescribes, along with hormonal contraceptives, supplements of calcium, magnesium, and
vitamins E and B6. Which information is most important for the nursing practitioner to provide
to the hospital patient?
1. Food sources high in calcium and magnesium
2. Side effects of hormonal contraceptives
3. Instructions that vitamin increases need HCP approval
4. Natural sources of vitamins E and B6
RIGHT ANSWER> 3
Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders
Objective: Plan nursing care for female hospital patients with reproductive disorders.
Source: pp. 874
Heading: Premenstrual Syndrome and Premenstrual Dysphoric Disorder
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The nursing practitioner does not need to provide information about foods
high in calcium and magnesium. The hospital patient needs a healthy,
balanced diet.
2 The nursing practitioner can provide information regarding the side effects of
hormonal
contraceptives; however, this is not the most important information.
3 The nursing practitioner needs to give the hospital patient instructions not to
increase vitamin doses without HCP approval because vitamins are
medications as well as nutrients. High doses of some vitamins can cause
physiological damage.
4 The nursing practitioner does not need to provide information about foods high
in vitamins E
and B6.
PTS: 1 CON: Hospital patient-Centered Care
17. The nursing practitioner works in the office of an HCP specializing in female health.
Which hospital patient does the nursing practitioner identify as being at greatest risk due to
prescribed oral contraceptives?
1. A 20-year-old hospital patient with a family history of cardiovascular disease
2. A 45-year-old hospital patient who smokes and is treated for diabetes and hypertension
3. A 30-year-old hospital patient with a history of thrombophlebitis and high cholesterol
4. A 38-year-old hospital patient with a high-stress job who is being treated for anxiety
RIGHT ANSWER> 2
Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders
Objective: Compare different forms of contraceptives and their effectiveness. Source:
pp. 876
Heading: Oral Contraceptives
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1 The 20-year-old hospital patient has only one risk related to oral
contraceptives, and that is a family history of cardiovascular disease.
2 The 45-year-old hospital patient has three risk factors related to oral
contraceptives: smoking, treatment for diabetes, and treatment for hypertension.
This is the
hospital patient at greatest risk.
3 The 30-year-old hospital patient with a history of thrombophlebitis is considered
at high risk. However, having high cholesterol is not alone considered a risk.
4 The 38-year-old hospital patient with a high-stress job who is being treated for
anxiety
has no risk factors directly related to the use of oral contraceptives.
PTS: 1 CON: Hospital patient-Centered Care
18. The nursing practitioner is providing care and support to a female hospital patient who
tested positive for the BRCA 1 and BRCA 2 genes. Which statement by the hospital patient
indicates that additional information from the nursing practitioner is necessary?
1. “I think this requires that I be closely monitored for breast cancer.”
2. “The only choice I have at this point is to have a bilateral mastectomy.”
3. “This may explain why there is such a high incidence of family breast cancer.”
4. “I feel blessed to have this information, it may save my female family members.”
RIGHT ANSWER> 2
Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders
Objective: Explain how you will know whether nursing interventions have been effective.
Source: pp. 866
Heading: Malignant Breast Disorders
Integrated Process: Clinical Problem-Solving Process
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Moderate
CLARIFICATION
1 The recognition that close monitoring is necessary does not indicate a need for
additional information.
2 If the hospital patient thinks that a bilateral mastectomy is her only option, the
nursing practitioner may need to provide additional information.
3 The hospital patient is making a correct connection between the genetics and
family
incidence of breast cancer. This does not indicate a need for additional
information.
4 If the hospital patient realizes that early identification of genetic tendencies to
have breast cancer can be a blessing for future female family members, no
additional
information is needed.
MULTIPLE RESPONSE
PTS: 1 CON: Hospital patient-Centered Care
MULTIPLE RESPONSE
1. The nursing practitioner is caring for a woman who has just had a spontaneous
abortion. Which instructions do the nursing practitioner provide? (Select all that
apply.)
1. “Call if you experience bleeding for more than 3 days.”
2. “Call if there is more bleeding than during a heavy period.”
3. “The discharge often has a foul odor due to the procedure.”
4. “You can expect to pass large clots the size of golf balls.”
5. “Abstain from sexual intercourse as directed by your physician.”
RIGHT ANSWER> 1, 2, 5
Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders
Objective: Plan nursing care for female hospital patients with reproductive disorders.
Source: pp. 888
Heading: Pregnancy Termination
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. The hospital patient should be instructed to notify the physician if bleeding
lasts
longer than 3 days.
2. Bleeding should not exceed that of a heavy period.
3. The discharge should not have a foul odor.
4. Clots larger than a golf ball should be reported.
5. The hospital patient should abstain from sexual intercourse for the time
specified by
the HCP, usually 3 weeks.
PTS: 1 CON: Hospital patient-Centered Care
2. After reviewing data, the nursing practitioner suspects that a young female hospital
patient is experiencing manifestations of toxic shock syndrome. Which findings does the
nursing practitioner use to make this decision? (Select all that apply.)
1. Sore throat
2. Peeling skin
3. Fluid retention
4. Red palms and soles of feet
5. Muscle pain and weakness
RIGHT ANSWER> 1, 2, 4, 5
Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders
Objective: Describe the etiologies, signs, and symptoms of each disorder.
Source: pp. 877
Heading: Toxic Shock Syndrome
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Hospital patient-Centered Care
Difficulty: Difficult
CLARIFICATION
1. Individuals with toxic shock syndrome may experience a sore throat, rash,
blisters, and petechiae, followed by peeling of the skin, redness of the palms
and soles of the feet, and muscle pain and weakness.
2. Individuals with toxic shock syndrome may experience a sore throat, rash,
blisters, and petechiae, followed by peeling of the skin, redness of the palms
and soles of the feet, and muscle pain and weakness.
3. Fluid retention is not a manifestation of toxic shock syndrome.
4. Individuals with toxic shock syndrome may experience a sore throat, rash,
blisters, and petechiae, followed by peeling of the skin, redness of the palms
and soles of the feet, and muscle pain and weakness.
5. Individuals with toxic shock syndrome may experience a sore throat, rash,
blisters, and petechiae, followed by peeling of the skin, redness of the palms
and soles of the feet, and muscle pain and weakness.
PTS: 1 CON: Hospital patient-Centered Care
Chapter 43. Nursing Care of Male Hospital patients With Genitourinary Disorders
MULTIPLE CHOICE
1. The nursing practitioner is providing care for a male hospital patient diagnosed with
acute prostatitis. Which intervention is unnecessary for the nursing practitioner to discuss
with this hospital patient?
1. Methods of pain management
2. Need for surgery intervention
3. Monitoring of ability to void
4. Information about prevention
RIGHT ANSWER> 2
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary
Disorders Objective: Plan nursing care for men with genitourinary and reproductive
disorders. Source: pp. 899
Heading: Prostatitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 The nursing practitioner needs to be sure the hospital patient understands the
methods of pain management, which will include both medication and
nonmedication interventions.
2 At this point, it is likely to be unnecessary to discuss the need for surgery. If the
condition persists and is unresponsive to treatment or becomes chronic, surgery
is considered to rule out other conditions.
3 The nursing practitioner needs to explain the necessity and process for
monitoring the ability to void. The hospital patient will need to keep a diary
with times and amounts of urination.
4 Information about prevention is important. The nursing practitioner will discuss
all measures
that can cause prostatitis and how to prevent reinfection.
PTS: 1 CON: Sexuality
2. A hospital patient diagnosed with benign prostatic hyperplasia is prescribed the alpha-
blocking medication tamsulosin to reduce symptoms. For which side effect does the
nursing practitioner monitor this hospital patient?
1. Dry mouth
2. Headaches
3. Hypotension
4. Urinary frequency
RIGHT ANSWER> 3
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary
Disorders Objective: Describe the etiologies, signs and symptoms, and treatments of
prostate disorders.
Source: pp. 902
Heading: Benign Prostatic Hyperplasia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Pharmacological
Therapies CL: Analysis (Analyzing)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 Headache, dry mouth, and urinary frequency are also possible but are not life
or health threatening.
2 Headache, dry mouth, and urinary frequency are also possible but are not life
or health threatening.
3 Alpha-blocking medications dilate vessels, so the nursing practitioner should
monitor the hospital patient for hypotension, which under some circumstances
can be life or health threatening.
4 Headache, dry mouth, and urinary frequency are also possible but are not life
or health threatening.
PTS: 1 CON: Safety
3. A 70-year-old male arrives in the emergency department and says, “I haven’t urinated in 24
hours. I feel like I have to go, but I can’t.” Which care does the nursing practitioner anticipate
providing first?
1. STAT administration of IV fluids
2. Emergency preparation for a cystoscopy
3. STAT insertion of an indwelling catheter
4. Emergency preparation for an intravenous pyelogram (IVP)
RIGHT ANSWER> 3
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary
Disorders Objective: Plan nursing care for men with genitourinary and reproductive
disorders. Source: pp. 903
Heading: Prostate Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Moderate
CLARIFICATION
1 IV fluids will further add to his need to urinate.
2 Preparation for tests would wait until he is safe from immediate harm.
3 First, the hospital patient must be assisted to empty his bladder to avoid rupture
or other
complications.
4 Preparation for tests would wait until he is safe from immediate harm.
PTS: 1 CON: Elimination
4. The nursing practitioner is providing preoperative care for an 80-year-old hospital patient
who is scheduled to have prostate surgery. The hospital patient says, “I know a man who was
impotent after this surgery. Will that happen to me?” Which response by the nursing
practitioner is most appropriate?
1. “There are many treatments available if it does occur.”
2. “Most men your age learn to deal with erectile dysfunction if it does occur.”
3. “Impotence should not be a problem; sperm production is not affected by this
surgery.”
4. “Prostate surgery can cause erectile dysfunction. I’ll ask your surgeon to explain
the risks to you.”
RIGHT ANSWER> 4
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary
Disorders Objective: Describe the etiologies, signs and symptoms, and treatments of
prostate disorders.
Source: pp. 903
Heading: Prostate Disorders
Integrated Process: Clinical Problem-Solving Process
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Elimination
Difficulty: Moderate
CLARIFICATION
1 It is inappropriate for the nursing practitioner to talk about treatments. It is not
known from the information given if the hospital patient is having a high-risk
procedure. There is no reason to alarm the hospital patient unnecessarily.
2 This reply is inappropriate because it makes an assumption about the hospital
patient’s
sexual function based on age.
3 It is inappropriate for the nursing practitioner to talk about treatments. It is not
known from the information given if the hospital patient is having a high-risk
procedure. There is no reason to alarm the hospital patient unnecessarily.
4 Some types of prostate procedures can lead to erectile dysfunction. The
physician needs to address this risk with the hospital patient.
PTS: 1 CON: Elimination
5. A hospital patient has just returned from a transurethral resection of the prostate (TURP).
Which explanation does the nursing practitioner provide if the hospital patient asks why
he needs a urinary catheter?
1. “The catheter keeps your bladder empty to reduce risk for infection”
2. “The catheter is keeping pressure on the surgery area to prevent bleeding.”
3. “We can take the catheter out when you are able to urinate on your own.”
4. “The catheter is being used to irrigate your bladder with antibiotics.”
RIGHT ANSWER> 2
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary
Disorders Objective: Describe the etiologies, signs and symptoms, and treatments of
prostate disorders.
Source: pp. 903
Heading: Transurethral Resection of the Prostate
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Moderate
CLARIFICATION
1 Antibiotics are not routine.
2 As the tissue is removed during TURP, bleeding occurs. A Foley catheter is left
in place with 30 to 60 mL of sterile water inflating the balloon. The balloon is
overfilled and may be secured tightly to the leg or abdomen to tamponade
(compress) the prostate area and stop the bleeding.
3 The health care provider (HCP) will remove the Foley catheter after the danger
of hemorrhage has passed.
4 Irrigation solution generally flows continuously; manual irrigation may be done
for the first 24 hours to help maintain catheter patency by removing clots and
tissue shreds.
PTS: 1 CON: Elimination
6. A male hospital patient who is 60 years old is diagnosed with prostate cancer. Which
condition does the nursing practitioner recognize as the best indication for a radical
prostatectomy?
1. The cytology tests indicate slow-growing cells.
2. A digital examination locates a small prostate nodule.
3. The hospital patient is experiencing bone pain.
4. Age indicates lack of the need for fertility.
RIGHT ANSWER> 3
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary
Disorders Objective: Describe the etiologies, signs and symptoms, and treatments of
prostate disorders.
Source: pp. 907
Heading: Cancer of the Prostate
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Cellular Regulation
Difficulty: Moderate
CLARIFICATION
1 When prostate cancers are determined to be slow growing, treatment does not
always indicate the need for a radical prostatectomy.
2 A digital examination of the prostate will reveal a small hardened lump or lobe.
The decision to perform a radical prostatectomy will depend on the type of
cancer and whether metastases has occurred.
3 Metastases of prostate cancer frequently involves pain in bone tissue, most
often of the back or hip. Bone pain may be an indication for a radical
prostatectomy.
4 The decision for a radical prostatectomy is made based on physiological
indications. Age is not a determining factor, and the hospital patient’s age is not
necessarily an indication of sexual or reproductive functioning.
PTS: 1 CON: Cellular Regulation
7. The nursing practitioner in the emergency department is providing care for a male hospital
patient with priapism, which has lasted for 6 hours. For which serious condition will the nursing
practitioner monitor the hospital patient?
1. The ability to urinate
2. The current level of pain
3. The inability for an erection
4. The signs of necrotic tissue
RIGHT ANSWER> 1
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary
Disorders Objective: Plan nursing care for men with genitourinary and reproductive
disorders. Source: pp. 910
Heading: Priapism
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 Prolonged priapism can result in the inability to urinate, which can lead to
bladder distention, dilation of the ureters, and hydronephrosis. This condition is
considered serious.
2 The hospital patient’s pain level is to be monitored, but the presence of pain is
expected
and not considered to be serious.
3 After priapism, the hospital patient may have an inability to have an erection.
However, the nursing practitioner will not be monitoring for this condition.
Diagnosis will occur after recovery from the episode.
4 The hospital patient with prolonged priapism is at risk for penile tissue necrosis
due to a lack of oxygen. However, the condition is not likely to occur during
emergency
care.
PTS: 1 CON: Sexuality
8. A male hospital patient has been diagnosed with acute epididymitis. The HCP has prescribed
bedrest, elevation of the scrotum on ice packs, and antibiotics. The nursing practitioner is aware
that which complication is least likely to develop with the hospital patient’s diagnosis?
1. Abscess
2. Orchitis
3. Sterility
4. Chronic epididymitis
RIGHT ANSWER> 2
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary
Disorders Objective: Explain the pathophysiology associated with each male
genitourinary and reproductive disorder discussed in this chapter.
Source: pp. 910
Heading: Epididymitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 With the diagnosis of epididymitis, it is possible for the hospital patient to
develop an abscess as a complication.
2 Orchitis is inflammation/infection of the testicles; it can be caused by trauma or
infection from epididymitis, urinary tract infections (UTIs), sexually transmitted
infections (STIs), or systemic diseases. However, because orchitis is a rare
condition, it is the least likely complication.
3 It is possible for the hospital patient with epididymitis to develop sterility.
4 Acute epididymitis can become a chronic condition if not treated or not
responsive to treatment.
PTS: 1 CON: Sexuality
9. A 30-year-old male hospital patient has just received a diagnosis of testicular cancer. He
appears sad and states, “I always wanted to have children. Now it will be impossible.” Which
information does the nursing practitioner provide to assist the hospital patient?
1. Contact information for a support group.
2. Provide the hospital patient with literature about adoption.
3. Validate the impossibility of the hospital patient fathering a child.
4. Share that it is possible to bank sperm before treatment.
RIGHT ANSWER> 4
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary
Disorders Objective: Plan nursing care for men with genitourinary and reproductive
disorders. Source: pp. 910
Heading: Cancer of the Testicles
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Cellular Regulation
Difficulty: Moderate
CLARIFICATION
1 The hospital patient may benefit from a support group; however, the hospital
patient’s current
concern is the possibility of having children.
2 Providing adoption literature is inappropriate at this time.
3 Having children is possible even with the diagnosis of testicular cancer.
4 If the hospital patient wants to have children, he should be encouraged to make
deposits in a sperm bank before any surgery or treatment is started.
PTS: 1 CON: Cellular Regulation
10. The nursing practitioner is reviewing a hospital patient’s understanding about a
scheduled vasectomy. Which statement by the hospital patient indicates the need for
additional teaching?
1. “There is no change in the way an ejaculation looks or feels.”
2. “Another kind of birth control should be used for 3 months.”
3. “Sperm will no longer be produced once healing is completed.”
4. “A semen sample evaluation will confirm success of the surgery.”
RIGHT ANSWER> 3
Chapter: Nursing Care of Male Hospital patients With Genitourinary Disorders
Objective: Plan nursing care for men with genitourinary and reproductive disorders.
Source: pp. 910
Heading: Vasectomy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 When the hospital patient states no change in the way an ejaculation looks or
feels,
there is no need for additional teaching.
2 Three months of additional birth control provides protection until the lack of
sperm passage is validated.
3 This statement indicates a need for additional teaching. Sperm will continue to
be produced by the testes, but they will be absorbed by the body.
4 The evaluation of a semen sample is the most effective way to confirm the
success of a vasectomy. Unprotected intercourse should not be experienced
before this confirmation.
PTS: 1 CON: Sexuality
11. A male hospital patient in an HCP’s office, tells the nurse, “I am impotent and
cannot have a fulfilling sex life with my spouse.” In which way can the nursing
practitioner support the hospital patient?
1. “We see many hospital patients with your condition and it is usually emotional.”
2. “You should discuss the problem with your spouse and share feelings.”
3. “We no longer use negative terms as reference to erectile dysfunction.”
4. “The problem is usually related to fatigue and stress and can be managed.”
RIGHT ANSWER> 3
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary
Disorders Objective: Discuss the nurse’s role in helping men cope with loss of sexual
function. Source: pp. 912
Heading: Sexual Functioning
Integrated Process: Caring
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Difficult
CLARIFICATION
1 Before the 1980s, 90 percent of erectile dysfunction was thought to be caused
by emotional issues. Researchers now believe that 80 to 90 percennt are caused
by physical problems.
2 This statement does not provide the hospital patient with support. Also, the
nursing practitioner does
not know if the hospital patient and spouse have already discussed the issue.
3 The nursing practitioner can support the hospital patient by replacing the
hospital patient’s negative terminology with the term of erectile dysfunction.
The term impotence carries a negative meaning of “powerlessness.”
4 The problem may be related to fatigue and stress, but there is no indication that
the hospital patient is experiencing either outside the problem itself. This does
not provide the hospital patient with the best support.
PTS: 1 CON: Sexuality
12. A hospital patient has just received a new prescription for a transurethral suppository
for erectile dysfunction. Which instruction should the nursing practitioner provide
regarding the use of this medication?
1. “Urinate before you insert the suppository into your urethra.”
2. “Remove the suppository after you are finished having intercourse.”
3. “Lubricate the suppository well and insert it into your rectum before intercourse.”
4. “Insert the suppository into the urethra at least 2 hours before anticipated
intercourse.”
RIGHT ANSWER> 1
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary
Disorders Objective: Discuss the nurse’s role in helping men cope with loss of sexual
function. Source: pp. 912
Heading: Transurethral Suppository
Integrated Process: Teaching/Learning
Hospital patient Need: Physiological Integrity—Pharmacological
Therapies CL: Application (Applying)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 The hospital patient is instructed to urinate before use of the suppository.
2 The suppository will be absorbed and is not removable.
3 A tiny pellet (microsuppository) is inserted into the urethra using a specialized
single-dose applicator. The medication usually begins to work in 5 to 10
minutes, and the effects last for approximately 30 to 60 minutes.
4 Two hours is too long to insert before having intercourse.
PTS: 1 CON: Sexuality
13. The nursing practitioner is reviewing the report on fertility testing for a male hospital
patient who is 28 years of age. The report designates the cause of infertility as a low sperm
count with no other identified physiological disorders. Which type of infertility does the
nursing practitioner recognize?
1. Pretesticular
2. Testicular
3. Posttesticular
4. Hormonal
RIGHT ANSWER> 2
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary Disorders
Objective: Identify disorders of the male reproductive system that interfere with fertility.
Source: pp. 913
Heading: Infertility
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Difficult
CLARIFICATION
1 Pretesticular infertility is usually associated with pituitary or adrenal tumors,
thyroid problems, or uncontrolled diabetes mellitus. The report notes no
physiological disorders.
2 Testicular infertility is caused by two factors: varicoceles and idiopathic. The
report notes no physiological disorder, which would include varicoceles.
However, idiopathic causes are numerous: A common cause is anything that
raises the temperature of the testes or causes damage or injury.
3 Posttesticular infertility is caused by any surgery or injury along the path of the
sperm from the testes to the outside of the body, such as vasectomy or any other
surgery that can cause retrograde ejaculation.
4 Hormonal infertility by definition is considered pretesticular.
PTS: 1 CON: Sexuality
14. The nursing practitioner is participating in the care of a male hospital patient in the
emergency department for a severe episode of hypotension. The hospital patient takes sildenafil
for erectile dysfunction. Medical history indicates management of hypertension and diabetes.
Which information does the nursing practitioner provide related to meeting this hospital
patient’s needs?
1. The need to have antihypertensive medication adjusted
2. Testing to determine compromised penile circulation
3. The effectiveness of herbs for erectile dysfunction
4. Testing to validate an adequate testosterone level
RIGHT ANSWER> 3
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary
Disorders Objective: List treatment options available for treatment of male infertility.
Source: pp. 913
Heading: Erectile Dysfunction
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Pharmacological Therapies
CL: Analysis (Analyzing) Concept:
Sexuality
Difficulty: Moderate
CLARIFICATION
1 If the hospital patient is being treated for hypertension, adjustment of the
medication can be considered, but may not be possible. Any antihypertensive
medication will likely cause a hypotensive episode when sildenafil is used.
2 The hospital patient is a diabetic and may very well have compromised penile
circulation. Acquisition of this knowledge does not alone meet the hospital
patient’s
need.
3 Several herbal remedies may be effective in resolving erectile dysfunction,
such as yohimbine, ginseng, gingko, and others. The hospital patient needs to
understand that herbal therapies can have side effects and the HCP should be
aware of the therapy.
4 Testing to validate an adequate testosterone level will not alone meet the
hospital patient’s need.
PTS: 1 CON: Sexuality
15. The nursing practitioner is told during a physical examination that a male hospital patient
has a curved penis during erection. Which term does the nursing practitioner use to document
this observation?
1. Priapism
2. Phimosis
3. Paraphimosis
4. Peyronie disease
RIGHT ANSWER> 4
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary Disorders
Objective: Describe disorders of the testicles and penis and how they affect sexual function.
Source: pp. 916
Heading: Penile Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 Priapism is a painful erection that lasts too long.
2 Phimosis describes a condition in which the foreskin of an uncircumcised male
becomes so tight it is difficult or impossible to pull back, away from the head
of the penis.
3 Paraphimosis occurs when the uncircumcised foreskin is pulled back, during
intercourse or bathing, and not immediately replaced in a forward position.
This causes constriction of the dorsal veins, which leads to edema and pain.
4 Peyronie disease often gives the penis a curved or crooked look when it is
erect.
PTS: 1 CON: Sexuality
16. The nursing practitioner is contributing to hospital patient teaching for a hospital patient
who is not circumcised and diagnosed with penile cancer. The small red lesion was removed by
laser surgery. Which postprocedure information does the nursing practitioner recognize as
being least beneficial?
1. Refraining from unprotected sexual activity
2. Maintaining good hygiene due to being uncircumcised
3. The importance of early reporting of additional lesions
4. The benefits and complications related to adult circumcision
RIGHT ANSWER> 4
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary Disorders
Objective: Describe disorders of the testicles and penis and how they affect sexual function.
Source: pp. 910
Heading: Penile Cancer
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Cellular Regulation
Difficulty: Moderate
CLARIFICATION
1 Penile cancer can be spread to a sexual partner. Because the hospital patient is
at risk for additional lesions, the hospital patient and the hospital patient’s
partner may benefit by having protected sex.
2 It is important for the hospital patient to understand the importance of good
hygiene,
especially when uncircumcised.
3 The hospital patient is at risk for reoccurrence of penile cancer. Monitoring for
lesions regularly allows for early treatment.
4 If a male hospital patient has had penile cancer, he may want to consider being
circumcised to decrease the risk of reoccurrence of the disease. However, this
is the least beneficial information at this time.
PTS: 1 CON: Cellular Regulation
17. The parent of a newborn male is informed of a condition called cryptorchidism. The HCP
states if the condition does not resolve within a few months, surgery will be required before the
age of 1 year. The parent asks the nursing practitioner why surgery is so important. Which reason
does the nursing practitioner provide in support of the surgery?
1. The child will be teased for looking different.
2. Formation of sexual characteristics are delayed.
3. Lack of correction can result in infertility.
4. Normal sexual functioning will not be possible.
RIGHT ANSWER> 3
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary Disorders
Objective: Identify disorders of the male reproductive system that interfere with fertility.
Source: pp. 910
Heading: Testicular Disorders
Integrated Process: Teaching/Learning
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Difficult
CLARIFICATION
1 The reason that the child will be teased for looking different is not necessarily
supportive of surgery.
2 Cryptorchidism does not delay the formation of sexual characteristics if surgery
is not performed.
3 The nursing practitioner should inform the parent that not having the surgery
can result in the development of infertility. This factor is strongly supportive of
surgery.
4 Cryptorchidism does not interfere with normal sexual functioning.
PTS: 1 CON: Sexuality
18. A male hospital patient expresses the desire to have a vasectomy reversed that was
performed 5 years ago. Which information about vasectomy reversal does the nursing
practitioner recognize as the most likely cause of an unsuccessful surgery?
1. Sections of the vas deferens were removed.
2. Testing will be needed to confirm sperm production.
3. The period of time passed may be too long.
4. It may be necessary to reconnect at the epididymis.
RIGHT ANSWER> 3
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary
Disorders Objective: List treatment options available for male infertility. Source:
pp. 912
Heading: Vasectomy Reversal
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 When a section of the vas deferens is removed during a vasectomy, the HCP
may not be able to reconnect the ends. However, another type of surgery is
available.
2 It is true that sperm production may be limited or absent, depending on the time
lapse for the vasectomy. However, this fact alone does not reflect the success of
the surgery.
3 Reversed vasectomy is more likely to be successful if the time span from the
vasectomy is short. The reconstruction process and sperm production both
decline with the passage of time.
4 When the ends of the vas deferens are too short or are unable to be
reconnected, the vas deferens can be connected directly to the epididymis.
PTS: 1 CON: Sexuality
19. A male hospital patient is unable to achieve or maintain a penile erection long enough
for ejaculation. The erectile dysfunction is considered the reason for the hospital patient’s
infertility. Which treatment does the nursing practitioner expect the HCP to prescribe
initially?
1. Dehydroepiandrosterone
2. Oral doses of tadalafil
3. Testosterone replacement
4. Penile injections
RIGHT ANSWER> 2
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary Disorders
Objective: Identify disorders of the male reproductive system that interfere with fertility.
Source: pp. 912
Heading: Erectile Dysfunction
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Pharmacological
Therapies CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Difficult
CLARIFICATION
1 Dehydroepiandrosterone (DHEA) is a steroid hormone that is listed under
herbal remedies in this book. Treatment from this category may or may not be
effective. This is unlikely to be the HCP’s initial prescription.
2 Oral medications such as tadalafil, sildenafil, and vardenafil are now the first
line of therapy used to treat erectile dysfunction.
3 Testosterone replacement can be prescribed if a deficiency is identified. The
HCP must assure that the hospital patient does not have contraindications
such as prostate cancer. This is not likely to be the HCP’s first approach.
4 Penile injections are a possible treatment for erectile dysfunction; however, it
requires careful evaluation of the hospital patient and the hospital patient’s
partner to determine their ability to perform the injections. This is not likely the
HCP’s first
approach.
PTS: 1 CON: Sexuality
20. A male hospital patient reports that he is uncircumcised and has been having a problem
retracting his foreskin for several months. The penis now looks reddened with a noticeable
discharge. Which is the most likely reason the hospital patient has delayed reporting the
condition?
1. Fear of a serious disease such as cancer
2. Not wanting a circumcision as an adult
3. Confident about success with self-treatment
4. Embarrassment about such a personal issue
RIGHT ANSWER> 4
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary Disorders
Objective: Describe disorders of the testicles and penis and how they affect sexual function.
Source: pp. 910
Heading: Phimosis
Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: Physiological Integrity—
Physiological Adaptation CL: Application (Applying)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 Fear of a serious disease may cause some hospital patients to report phimosis,
but this is not the most likely reason to delay seeking medical help.
2 Not wanting a circumcision as an adult is not likely to be the reason to delay
seeking medical help.
3 Being confident about success with self-treatment may be motivated by
embarrassment, but alone it is not the likely reason to delay seeking medical
help.
4 Many male hospital patients have difficulty reporting penile disorders to HCPs
because
of embarrassment about reporting such a personal problem.
PTS: 1 CON: Sexuality
21. A male hospital patient seeks medical advice about intermittent erectile
dysfunction. Which comment by the hospital patient prompts the nursing
practitioner to collect additional information?
1. “After a few drinks, I always ask my partner for sex.”
2. “I have a very busy job, but feel up to the challenge.”
3. “I function well with 7 hours of sleep each night.”
4. “I have been really healthy except for the flu last year.”
RIGHT ANSWER> 1
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary
Disorders Objective: List selected physical and emotional causes of erectile
dysfunction.
Source: pp. 912
Heading: Erectile Dysfunction
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 Excessive use of drugs or alcohol can cause erectile dysfunction. The nursing
practitioner needs to collect more specific information about how much alcohol
the hospital patient
consumes, especially before a sexual encounter.
2 Stress can be a cause of erectile dysfunction. The hospital patient’s comment
about his job does not indicate a source of stress.
3 Many adults function well with 7 hours of nightly sleep; this comment does not
prompt the need to seek additional information. The hospital patient has not
reported
fatigue.
4 Illness can be a cause for penile dysfunction; however, the hospital patient
reports good health during the past year.
PTS: 1 CON: Sexuality
22. A hospital patient arrives in the emergency department with pain in the scrotum. The
scrotal skin is tender, red, and warm to the touch. Which information will cause the nursing
practitioner to suspect the hospital patient has epididymitis?
1. The hospital patient is single but has a monogamous sexual relationship.
2. The hospital patient has not traveled out of the country before.
3. The hospital patient started a new task on his job using a jack hammer.
4. The hospital patient has not been treated for any illness for 6 months.
RIGHT ANSWER> 3
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary Disorders
Objective: Describe disorders of the testicles and penis and how they affect sexual function.
Source: pp. 910
Heading: Epididymitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Moderate
CLARIFICATION
1 One source of epididymitis can be an STI; the hospital patient is in a
monogamous relationship, which does not indicate the likelihood of an STI
infection.
2 Travel outside the country can sometimes expose a hospital patient to illnesses
or
diseases from parasites. This is not a likely source for this hospital patient’s
symptoms.
3 Epididymitis can be caused by trauma. The hospital patient’s new job task,
using a jack hammer, is a likely source of epididymitis.
4 Bacterial or viral infections can cause epididymitis; however, the hospital
patient has
not been ill for 6 months.
PTS: 1 CON: Sexuality
MULTIPLE RESPONSE
1. The nursing practitioner is collecting a medication history from a man with erectile
dysfunction. For which class of medication and lifestyle substances should the nursing
practitioner focus because they can cause erectile dysfunction? (Select all that apply.)
1. Alcohol
2. Caffeine
3. Antibiotics
4. Antihistamines
5. Beta-blocking agents
RIGHT ANSWER> 1, 2, 4, 5
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary
Disorders Objective: List selected physical and emotional causes of erectile
dysfunction.
Source: pp. 912
Heading: Erectile Dysfunction
Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: Physiological Integrity—Reduction
of Risk Potential CL: Analysis (Analyzing)
Concept: Sexuality
Difficulty: Difficult
CLARIFICATION
1. Beta blockers, alcohol, antihistamines, and caffeine can all contribute to
erectile dysfunction.
2. Beta blockers, alcohol, antihistamines, and caffeine can all contribute to
erectile dysfunction.
3. Antibiotics do not cause erectile dysfunction.
4. Beta blockers, alcohol, antihistamines, and caffeine can all contribute to
erectile dysfunction.
5. Beta blockers, alcohol, antihistamines, and caffeine can all contribute to
erectile dysfunction.
PTS: 1 CON: Sexuality
2. A male hospital patient reports that manifestations of benign prostatic hyperplasia (BPH)
have been occurring for several years. On which problems related to this condition does the
nursing practitioner focus when collecting health information? (Select all that apply.)
1. Urosepsis
2. Bladder cancer
3. Renal insufficiency
4. Evidence of hydronephrosis
5. Recurrent urinary tract infections
RIGHT ANSWER> 1, 3, 4, 5
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary
Disorders Objective: Describe the etiologies, signs and symptoms, and treatments of
prostate disorders.
Source: pp. 902
Heading: Benign Prostatic Hyperplasia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Difficult
CLARIFICATION
1. When BPH is untreated and obstruction is prolonged, serious complications
can occur. Urine that sits in the bladder for too long can back up into the
kidneys, causing hydronephrosis, renal insufficiency, or urosepsis; it can also
damage the bladder walls, leading to bladder dysfunction and recurrent
urinary tract infections.
2. Bladder cancer is not an adverse effect of untreated BPH.
3. When BPH is untreated and obstruction is prolonged, serious complications
can occur. Urine that sits in the bladder for too long can back up into the
kidneys, causing hydronephrosis, renal insufficiency, or urosepsis; it can also
damage the bladder walls, leading to bladder dysfunction and recurrent
urinary tract infections.
4. When BPH is untreated and obstruction is prolonged, serious complications
can occur. Urine that sits in the bladder for too long can back up into the
kidneys, causing hydronephrosis, renal insufficiency, or urosepsis; it can also
damage the bladder walls, leading to bladder dysfunction and recurrent
urinary tract infections.
5. When BPH is untreated and obstruction is prolonged, serious complications
can occur. Urine that sits in the bladder for too long can back up into the
kidneys, causing hydronephrosis, renal insufficiency, or urosepsis; it can also
damage the bladder walls, leading to bladder dysfunction and recurrent
urinary tract infections.
PTS: 1 CON: Elimination
3. The nursing practitioner reviews orders from the HCP for a hospital patient recovering from a
TURP. The hospital patient is prescribed for bladder irrigation, antispasmodic medication, and IV
antibiotics every 6 hours. Which potential complications are these orders specifically addressing?
(Select all that apply.)
1. Infection
2. Blood clots
3. Bladder spasms
4. Urinary retention
5. Nausea and vomiting
RIGHT ANSWER> 1, 2, 3
Chapter: Chapter 43. Nursing Care of Male Hospital patients With Genitourinary
Disorders Objective: Describe the etiologies, signs and symptoms, and treatments of
prostate disorders.
Source: pp. 903
Heading: Transurethral Resection of the Prostate
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Elimination
Difficulty: Difficult
CLARIFICATION
1. Complications associated with prostate surgery depend on the type and
extent of the procedure performed. The main medical complications include
clot formation, bladder spasms, and infection.
2. Complications associated with prostate surgery depend on the type and
extent of the procedure performed. The main medical complications include
clot formation, bladder spasms, and infection.
3. Complications associated with prostate surgery depend on the type and
extent of the procedure performed. The main medical complications include
clot formation, bladder spasms, and infection.
4. Bladder irrigation, antispasmodic medication and IV antibiotics are not
prescribed to prevent urinary retention or nausea and vomiting.
5. Bladder irrigation, antispasmodic medication and IV antibiotics are not
prescribed to prevent urinary retention or nausea and vomiting.
PTS: 1 CON: Elimination
Chapter 44. Nursing Care of Hospital patients With Sexually Transmitted Infections
MULTIPLE CHOICE
1. The nursing practitioner is providing care for a hospital patient who presents with
redness, itching, pain, and burning of the vulva and vagina. Which additional
manifestation will support the nurse’s suspicion of vulvovaginitis?
1. A thin watery vaginal discharge
2. History of treatment for multiple sexually transmitted infections (STIs)
3. Presence of Bartholin gland abscesses
4. Nausea, vomiting, and loss of appetite
RIGHT ANSWER> 2
Chapter: Chapter 44. Nursing Care of Hospital patients With Sexually Transmitted
Infections Objective: Describe the signs and symptoms of each of the common STIs.
Source: pp. 920
Heading: Vulvovaginitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Infection
Difficulty: Moderate
CLARIFICATION
1 A thin watery vaginal discharge does not support the presence of
vulvovaginitis.
2 A hospital patient can have vulvovaginitis with or without sexual contact. A
variety of sexually and nonsexually transmitted infectious agents can cause
vulvovaginitis.
3 Bartholin glands can develop abscesses as a result of infection with
nonsexually transmitted microbes or STIs such as gonorrhea and Chlamydia.
4 Nausea, vomiting, and loss of appetite can present for a variety of reasons and
is not a manifestation exclusively of vulvovaginitis.
PTS: 1 CON: Infection
2. The nursing practitioner is collecting health information from a hospital patient who
has presented with penile condyloma. Which comment by the hospital patient indicates
the greatest need for additional information from the nurse?
1. “I am glad that I received Gardasil as a teen.”
2. “I only have oral sex with my sexual partner.”
3. “I received two vaccinations before the age of 14.”
4. “I know I am still at risk for some types of human papilloma virus (HPV).”
RIGHT ANSWER> 2
Chapter: Chapter 44. Nursing Care of Hospital patients With Sexually Transmitted
Infections Objective: Plan teaching to promote STI prevention.
Source: pp. 920
Heading: Human Papillomavirus
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Infection
Difficulty: Moderate
CLARIFICATION
1 Being vaccinated with Gardasil before the age of 15 years does not protect the
hospital patient against all types of high- and low-risk HPVs. The hospital
patient needs this information, but it is not the greatest need.
2 High-risk HPV can cause cancer of the cervix, vagina, and vulva in women.
Men can develop cancer of the penis. Both genders are at risk for anal and
oropharyngeal cancers. This is the greatest need for information for this hospital
patient.
3 The Gardasil vaccine is effective in two doses if they are received before the
age of 15; after 15, three doses are required. There is no need for additional
information.
4 The hospital patient is correct about still being at risk for types of HPV.
Additional
information may be helpful, but it is not the greatest need for this hospital
patient.
PTS: 1 CON: Infection
3. The nursing practitioner is collecting data on a hospital patient with Chlamydia. Which
assessment finding should be reported immediately to the registered nursing practitioner (RN)
or physician?
1. Painful urination
2. Red conjunctivae
3. Vaginal discharge
4. Sharp pain at the base of the ribs
RIGHT ANSWER> 4
Chapter: Chapter 44. Nursing Care of Hospital patients With Sexually Transmitted
Infections Objective: Describe the signs and symptoms of each of the common STIs.
Source: pp. 921
Heading: Chlamydia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Infection
Difficulty: Moderate
CLARIFICATION
1 Painful urination is a concern, but is not as health threatening as liver
inflammation.
2 Conjunctivitis is a concern but is not as health threatening as liver
inflammation.
3 Vaginal discharge is a concern but is not as health threatening as liver
inflammation.
4 Fitz-Hugh-Curtis syndrome, a surface inflammation of the liver, can also be
caused by Chlamydia trachomatis. This inflammation may cause nausea,
vomiting, and sharp pain at the base of the ribs that sometimes refers to the
right shoulder and arm.
PTS: 1 CON: Infection
4. The nursing practitioner is gathering information from a male hospital patient who is
presenting with difficult, painful, and frequent urination and a clear penile discharge.
Which additional information supports urethritis?
1. “My partner also has some of the same symptoms.”
2. “I could have gotten something from swimming in a river.”
3. “I don’t have tenderness anywhere else in my genitals.”
4. “I drank cranberry juice in case it was my bladder.”
RIGHT ANSWER> 1
Chapter: Chapter 44. Nursing Care of Hospital patients With Sexually Transmitted
Infections Objective: Describe the signs and symptoms of each of the common STIs.
Source: pp. 920
Heading: Urethritis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Infection
Difficulty: Moderate
CLARIFICATION
1 Female partners of men with urethritis can also exhibit the symptoms of
urethritis. This information supports the diagnosis.
2 Urethritis is caused by a variety of microorganisms such as Neisseria
gonorrhoeae, C trachomatis, Ureaplasma urealyticum, Trichomonas vaginalis,
Candida albicans, and herpes simplex virus. These are all microorganisms that
are sexually transmitted. The hospital patient is not likely to become infected by
swimming in a river.
3 Urethritis can also cause epididymitis in the male hospital patient, which
accounts for tenderness on the testicles. The lack of genital tenderness may or
may not support the diagnosis.
4 The hospital patient’s statement about drinking cranberry juice does not support
urethritis. The hospital patient suspected and responded to a possible bladder
infection.
PTS: 1 CON: Infection
5. The nursing practitioner is providing care for a hospital patient admitted for pneumonia.
Which discovery made during admission will cause the nursing practitioner to notify the
RN or HCP immediately?
1. Shortness of breath and coughing
2. Poor intake of food and liquids
3. An open, but painless ulcer on the penis
4. Low output via an indwelling catheter
RIGHT ANSWER> 3
Chapter: Chapter 44. Nursing Care of Hospital patients With Sexually Transmitted Infections
Objective: Describe the signs and symptoms of each of the common STIs.
Source: pp. 920
Heading: Genital Ulcers
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Infection
Difficulty: Moderate
CLARIFICATION
1 It is expected for a hospital patient admitted with pneumonia to experience
shortness of breath and coughing.
2 It is not unexpected for a hospital patient admitted with pneumonia to have a
poor
intake of food and liquids. The nursing practitioner will encourage intake as
tolerated.
3 The nursing practitioner will report the presence of an open ulcer on the
hospital patient’s penis immediately to the RN or HCP. Genital ulcers can be
caused by syphilis, herpes, and HIV. The absence of pain is most indicative of
a syphilic ulcer.
4 Because of the poor fluid intake, it is expected that the hospital patient may have
a low
urinary output. However, the nursing practitioner will monitor this finding
carefully.
PTS: 1 CON: Infection
6. A hospital patient with hepatitis B virus (HBV) delivers a 6-pound, 2-ounce baby. Which
action does the nursing practitioner anticipate will be needed for the infant?
1. IV antibiotics for 12 hours
2. Antiviral eye medication less than 2 hours after birth
3. There is no treatment that is safe and effective for infants.
4. HBV-immune globulin before 12 hours and HBV vaccine series
RIGHT ANSWER> 4
Chapter: Chapter 44. Nursing Care of Hospital patients With Sexually Transmitted
Infections Objective: Identify the pathogens involved with each of the common sexually
transmitted infections (STIs).
Source: pp. 928
Heading: Hepatitis B
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Infection
Difficulty: Moderate
CLARIFICATION
1 Antibiotics are not effective against viruses.
2 Eye medication may be necessary for gonorrhea or Chlamydia.
3 The infant needs to receive the HBV vaccination.
4 It is recommended that all babies of HBV-positive mothers receive HBV
immune globulin less than 12 hours after birth and then be immunized with
HBV vaccine 1 week, 1 month, and 6 months after birth.
PTS: 1 CON: Infection
7. The nursing practitioner is providing care for a female hospital patient who is pregnant and
tests positive for genital HSV-2 (herpes simplex virus type 2). Which comment by the hospital
patient indicates to the nursing practitioner that hospital patient teaching is effective?
1. “At least I have the least serious type of herpes virus.”
2. “I know that an active lesion will mean a cesarean section.”
3. “At least the baby is at low risk for having serious effects.”
4. “I will decline antiviral medications to avoid birth defects.”
RIGHT ANSWER> 2
Chapter: Chapter 44. Nursing Care of Hospital patients With Sexually Transmitted
Infections Objective: Explain how you will know whether your nursing interventions
have been effective.
Source: pp. 926
Heading: Herpes
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Infection
Difficulty: Moderate
CLARIFICATION
1 Herpes simplex virus type 2 (HSV-2) is more serious than HSV-I.
2 Nursing teaching has been effective if the hospital patient understands that an
active
lesion close to the time of birth will result in a cesarean section.
3 Babies born to women with genital herpes always carry a risk for skin, eye,
mucous membrane, and nervous system involvement. If the newborn develops
a disseminated herpes infection, it can be life threatening.
4 If the hospital patient declines prophylactic antiviral medications at 36 weeks
gestation,
teaching has not been effective. The hospital patient needs to know that
medication at this point in pregnancy will not cause birth defects.
PTS: 1 CON: Infection
8. The nursing practitioner is collecting data on a hospital patient in a HCP’s office. The
hospital patient tells the nursing practitioner he or she has the flu. The nursing practitioner
notices a skin rash on the palms of the hands and soles of the feet, mouth sores, and
lymphadenopathy. Which question is most important for the nursing practitioner to ask?
1. “Do you ever have unprotected sex?”
2. “Have you had any painless sores lately?”
3. “Does your hair appear to be thinning?”
4. “Is your activity hindered by joint pain?”
RIGHT ANSWER> 2
Chapter: Chapter 44. Nursing Care of Hospital patients With Sexually Transmitted
Infections Objective: Describe the signs and symptoms of each of the common STIs.
Source: pp. 925
Heading: Syphilis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing) Concept:
Infection
Difficulty: Moderate
CLARIFICATION
1 The hospital patient may be exhibiting manifestations of secondary syphilis.
Inquiring about unprotected sex may provide a source of an STI, but the nursing
practitioner needs additional information before drawing any conclusions about
the hospital patient’s condition.
2 The initial sign of syphilis is a painless, red, ulcerated area called a chancre,
which can appear anywhere on the hospital patient’s body. Chancres are the
only manifestation of the primary stage of syphilis. This question is most
important
in determining if the hospital patient is experiencing the secondary stage of
syphilis.
3 During the secondary stage of syphilis, the hair may thin; however, this is not a
manifestation specific to syphilis.
4 Joint pain may occur during the second stage of syphilis; however, this is not a
manifestation specific to syphilis.
PTS: 1 CON: Infection
9. The nursing practitioner reviews the medical record for a hospital patient who is
diagnosed with genital warts. Which method of treatment is unexpected if the hospital
patient is pregnant?
1. Cryotherapy
2. Immunity stimulation
3. Laser
4. Electrocautery
RIGHT ANSWER> 2
Chapter: Chapter 44. Nursing Care of Hospital patients With Sexually Transmitted
Infections Objective: Describe treatment options for common STIs.
Source: pp. 927
Heading: Genital Warts (Low-Risk HPV)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Infection
Difficulty: Moderate
CLARIFICATION
1 Cryotherapy is a safe treatment of genital warts during pregnancy. The freezing
of the wart is performed by touching it with a cryoprobe or with a liquid-
nitrogen soaked swab.
2 Immunity stimulation treatment is not considered safe during pregnancy. The
therapy uses medications to manipulate the hospital patient’s immunity system
into attacking the virus. The cytotoxic effects can damage the fetus.
3 Laser treatment on genital warts is safe during pregnancy. The laser causes
destruction of the wart tissue.
4 Electrocautery is a safe treatment of genital warts during pregnancy. The
process produces heat that causes proteins to coagulate, resulting in death of
the wart tissue.
PTS: 1 CON: Infection
10. The nursing practitioner is involved with a follow up visit for a female hospital patient
who contracted and had been self-treating for pubic lice. Which comment by the hospital
patient indicates that hospital patient teaching is effective?
1. “I read the instructions for oral permethrin very carefully.”
2. “I have not seen any new red tracks in my external genital area.”
3. “I plan to have a serious talk to the guy who gave me an STI.”
4. “I plan to be much more discriminate about who I have sex with.”
RIGHT ANSWER> 4
Chapter: Chapter 44. Nursing Care of Hospital patients With Sexually Transmitted
Infections Objective: Explain how you will know whether your nursing interventions
have been effective.
Source: pp. 928
Heading: Genital Parasites
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Infection
Difficulty: Moderate
CLARIFICATION
1 Permethrin is a topical medication used for the treatment of scabies, not pubic
lice. All medications for scabies or pubic lice are topical.
2 The lack of new red tracts under the skin is an indication that the hospital
patient does
not have scabies. Resolution of pulic lice is supported by a lack of itching,
redness, or visualization of the parasites.
3 The hospital patient needs to understand that pubic lice or scabies are not true
STIs.
4 Teaching is determined to be effective when the hospital patient states a new
cautious
attitude about sexual partners.
PTS: 1 CON: Infection
11. The nursing practitioner is providing care for residents in an extended-care facility. An
oriented, older adult female states to the nurse, “I think my boyfriend made me sick. My
private parts itch and hurt.” Which action by the nursing practitioner is appropriate?
1. Ask permission for the RN to do a physical examination.
2. Inquire if the male who was involved forced her to have sex.
3. Request immediate STI testing for the male counterpart.
4. Understand the female resident is likely confused about the event.
RIGHT ANSWER> 1
Chapter: Chapter 44. Nursing Care of Hospital patients With Sexually Transmitted
Infections Objective: Plan nursing care for hospital patients with STIs.
Source: pp. 920
Heading: Gerontological Issues
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Infection
Difficulty: Moderate
CLARIFICATION
1 The nursing practitioner needs to immediately inform the RN, who will ask for
permission to perform a physical examination.
2 Before asking if the male forced the female to have sex, data must be gathered
to support or rule out the event. It is possible that geriatric residents may have
consensual sex.
3 If the female exhibits the manifestations indicative of an STI, the male will
need to be tested. Older adults who engage in high-risk sexual behaviors are
also at risk for STIs. However, the situation must be validated.
4 It states in the question that the female resident is oriented. The nursing
practitioner needs to understand that older adults may have consensual sex.
However, the condition
of the female must be assessed.
PTS: 1 CON: Infection
12. The nursing practitioner is teaching a hospital patient the importance of completing
treatment for gonorrhea. On which information is the nursing practitioner basing this
teaching?
1. Gonorrhea is not treatable.
2. Only men experience symptoms; women are usually asymptomatic.
3. Men and women may be asymptomatic and still transmit the infection.
4. Treatment is associated with many serious side effects, so compliance is low.
RIGHT ANSWER> 3
Chapter: Chapter 44. Nursing Care of Hospital patients With Sexually Transmitted
Infections Objective: Plan nursing care for hospital patients with STIs.
Source: pp. 921
Heading: Gonorrhea
Integrated Process: Teaching/Learning
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Comprehension (Understanding)
Concept: Infection
Difficulty: Moderate
CLARIFICATION
1 Gonorrhea is treatable with antibiotics, which have side effects, but not such
serious side effects that compliance is affected.
2 Men may be asymptomatic or may have urethritis with a yellow urethral
discharge.
3 Women who have gonorrhea may have either no noticeable symptoms or have
a sore throat, mucopurulent cervicitis (MPC), urethritis, or abnormal menstrual
symptoms such as bleeding between periods.
4 The antibiotics used to treat gonorrhea do not have side effects so serious that
compliance is affected.
PTS: 1 CON: Infection
13. A hospital patient who is pregnant is being treated for MPC. Which information is correct
when the hospital patient asks the nursing practitioner about the cause of the condition?
1. Imbalanced flora of the vagina
2. Presence of organisms that cause STIs
3. Risks of antibiotics during gestation
4. Continued sexual activity during pregnancy
RIGHT ANSWER> 2
Chapter: Chapter 44. Nursing Care of Hospital patients With Sexually Transmitted
Infections Objective: Identify the pathogens involved with each of the common sexually
transmitted infections (STIs).
Source: pp. 920
Heading: Mucopurulent Cervicitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Infection
Difficulty: Moderate
CLARIFICATION
1 MPC is not caused by an imbalance of the vaginal flora.
2 MPC is caused by the same organisms that cause urethritis. Some causative
agents include N gonorrhoeae, C trachomatis, U urealyticum, T vaginalis, C
albicans, and herpes simplex virus, which are associated with STIs.
3 Needing or receiving antibiotics during gestation does not cause MPC.
4 Sexual activity during pregnancy, either prolonged absence or frequent activity,
does not cause MPC.
PTS: 1 CON: Infection
14. A female hospital patient has been hospitalized multiple times requiring IV antibiotics for
the treatment of pelvic inflammatory disease (PID). The nursing practitioner provides
information to the hospital patient emphasizing the potential for infertility from PID. Which
statement by the hospital patient indicates effectiveness of the presented information?
1. The hospital patient understands the importance of antibiotic therapy.
2. The hospital patient cries when learning about possible infertility.
3. The hospital patient asks about the available surgery to restore fertility.
4. The hospital patient promises to work on a monogamous relationship.
RIGHT ANSWER> 1
Chapter: Chapter 44. Nursing Care of Hospital patients With Sexually Transmitted
Infections Objective: Explain how you will know whether your nursing interventions
have been effective.
Source: pp. 920
Heading: Pelvic Inflammatory Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Infection
Difficulty: Moderate
CLARIFICATION
1 It is extremely important for the hospital patient with PID to complete both the
IV and oral antibiotics regimens to cure the infection. When the hospital patient
states an understanding, teaching is considered successful. Compliance is
evaluated later.
2 The hospital patient may be upset about the possibility of infertility, but without
a
specific plan, the nursing practitioner cannot be certain the information has been
effective.
3 Asking about surgery to restore fertility does not indicate that information has
been effective. The hospital patient is seeking a resolution and not deciding on
a change.
4 Becoming monogamous may or may not indicate the information was
effective. A promise to change is not an indicator of change.
PTS: 1 CON: Infection
15. A hospital patient with frequent recurrent episodes of proctitis is diagnosed with rectal cancer.
The hospital patient is distraught and asks how cancer could develop. Which answer by the nursing
practitioner is best?
1. Frequent inflammation of the anus and rectum causes cellular changes.
2. The hospital patient is likely to have a family history of gastrointestinal cancer.
3. Cancer could have been prevented if the hospital patient had followed medical advice.
4. The hospital patient could have avoided the disease with dietary and vitamin therapy.
RIGHT ANSWER> 1
Chapter: Chapter 44. Nursing Care of Hospital patients With Sexually Transmitted
Infections Objective: Identify the pathogens involved with each of the common sexually
transmitted infections (STIs).
Source: pp. 928
Heading: Cellular Changes
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Infection
Difficulty: Moderate
CLARIFICATION
1 Cellular changes can be related to STIs and result in precancerous or cancerous
changes. Herpes viruses, HIV, and human papilloma have all been linked to the
development of cancer. Proctitis is especially prevalent among persons who
engage in anal intercourse.
2 The hospital patient may or may not have a family history of gastrointestinal
cancer. Given the hospital patient’s medical history, proctitis is the most likely
cause.
3 There is no information regarding medical advice given to the hospital patient
by the
HCP.
4 Dietary and vitamin therapy are not always the best preventions of cancer; the
hospital patient has a history of a precancerous or cancerous condition related to
cellular changes caused by inflammation.
PTS: 1 CON: Infection
16. A female hospital patient is at the HCP’s office for an annual gynecological examination.
When a bimanual examination is performed, the hospital patient reports significant pain. Which
medical condition is the hospital patient likely to have?
1. Cystic ovaries
2. Ectopic pregnancy
3. PID
4. MPC
RIGHT ANSWER> 3
Chapter: Chapter 44. Nursing Care of Hospital patients With Sexually Transmitted
Infections Objective: Describe the signs and symptoms of each of the common STIs.
Source: pp. 926
Heading: Pelvic Inflammatory Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Infection
Difficulty: Moderate
CLARIFICATION
1 Cystic ovaries are not diagnosed from pain during a bimanual examination.
2 An ectopic pregnancy is not diagnosed from pain during a bimanual
examination.
3 PID can be asymptomatic until the performance of a bimanual examination,
which causes pain.
4 MPC is not diagnosed from pain during a bimanual examination. It may
produce mucopurulent yellow exudate on the cervix or be asymptomatic.
PTS: 1 CON: Infection
17. The nursing practitioner is visited by a teenage neighbor who asks, “I have a friend who
thinks she has an STI and she is afraid to ask anyone about it. Can you give me some
information for her?” Which reply does the nursing practitioner make?
1. “Are you sure that the ‘friend’ isn’t you?”
2. “Tell me some of the symptoms so I can help.”
3. “Would it help if I approached her mother with her?”
4. “Delayed treatment can result in serious lifelong complications.”
RIGHT ANSWER> 4
Chapter: Chapter 44. Nursing Care of Hospital patients With Sexually Transmitted
Infections Objective: Describe treatment options for common STIs.
Source: pp. 920
Heading: Nursing Care Tip
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk Potential
CL: Application (Applying) Concept:
Infection
Difficulty: Moderate
CLARIFICATION
1 Probing about the identity of the “friend” may keep the teenager from getting
needed advice.
2 With or without symptoms, the nursing practitioner should encourage medical
care. It is not
within the nurse’s scope of practice to diagnose a condition.
3 The nursing practitioner needs to make sure the teenage friend gets appropriate
help. Offering to approach the teenager’s mother may interfere with getting
medical help.
4 It is most important for the nursing practitioner to explain why the teenager
needs to seek
medical attention for a possible STI. The nurse’s goal is to provide information
and encourage early treatment to prevent complications.
PTS: 1 CON: Infection
18. The nursing practitioner is presenting information about preventing STIs to a group of
female students. The nursing practitioner identifies that teaching is ineffective if which
statement is made by a student?
1. “I don’t know why I need all this information, I don’t have sex.”
2. “I know my boyfriend loves me and will always keep me safe.”
3. “It sounds like serious things can happen after getting an STI.”
4. “I feel better knowing there are people and places to help me.”
RIGHT ANSWER> 2
Chapter: Chapter 44. Nursing Care of Hospital patients With Sexually Transmitted
Infections Objective: Explain how you will know whether your nursing interventions
have been effective.
Source: pp. 920
Heading: Nursing Diagnosis, Planning, and Implementation
Integrated Process: Teaching/Learning
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Infection
Difficulty: Moderate
CLARIFICATION
1 Teaching can be valuable for future reference; just because the student is not
sexually active does not mean that teaching is ineffective.
2 The prevention of STIs has nothing to do with how a boyfriend feels; the desire
to have sex can prompt irresponsible behaviors. This comment indicates that
teaching is ineffective for this student.
3 Understanding and voicing the seriousness of an STI indicate that teaching has
been effective.
4 Teaching is effective if the student is aware of available resources, and how and
where they can be accessed.
PTS: 1 CON: Infection
MULTIPLE RESPONSE
1. The nursing practitioner is providing care for a hospital patient recently diagnosed
with Chlamydia. Which information does the nursing practitioner recommend be
included in hospital patient teaching? (Select all that apply.)
1. “Women with Chlamydia may complain of a sore throat.”
2. “Chlamydia is characterized by the development of chancres.”
3. “Ophthalmia neonatorum is seen in infants born to women with Chlamydia.”
4. “Chlamydia can be transmitted sexually and by blood and body fluid contact.”
5. “The risk of ectopic pregnancy is increased in women with a history of
Chlamydia.”
RIGHT ANSWER> 4, 5
Chapter: Chapter 44. Nursing Care of Hospital patients With Sexually Transmitted
Infections Objective: Describe the signs and symptoms of each of the common STIs.
Source: pp. 921
Heading: Chlamydia
Integrated Process: Clinical Problem-Solving Process
Hospital patient Need: Clinical Problem-Solving Process (Nursing
Process) CL: Analysis (Analyzing)
Concept: Infection
Difficulty: Difficult
CLARIFICATION
1. Women who have gonorrhea may have either no noticeable symptoms or
have a sore throat.
2. Chancres can develop with syphilis.
3. Newborns born to mothers who have gonorrhea can develop ophthalmia
neonatorum.
4. Chlamydia is the most commonly diagnosed STI in the United States. It can
be transmitted sexually and by blood and body fluid contact. Chlamydia is a
frequent cause of PID and infertility, and it increases the risk of ectopic
pregnancy.
5. Chlamydia is the most commonly diagnosed STI in the United States. It can
be transmitted sexually and by blood and body fluid contact. Chlamydia is a
frequent cause of PID and infertility, and it increases the risk of ectopic
pregnancy.
PTS: 1 CON: Infection
2. A hospital patient in labor is diagnosed with MPC. For which health problems does
the nursing practitioner anticipate providing care to the newborn? (Select all that apply.)
1. Pneumonia
2. Conjunctivitis
3. Irregular heart rate
4. Flaccid extremities
5. Cyanotic extremities
RIGHT ANSWER> 1, 2
Chapter: Chapter 44. Nursing Care of Hospital patients With Sexually Transmitted
Infections Objective: Describe the signs and symptoms of each of the common STIs.
Source: pp. 921
Heading: Mucopurulent Cervicitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Infection
Difficulty: Difficult
CLARIFICATION
1. MPC during pregnancy can result in conjunctivitis and pneumonia in
newborn infants.
2. MPC during pregnancy can result in conjunctivitis and pneumonia in
newborn infants.
3. MPC does not cause irregular heart rate or flaccid or cyanotic extremities in
the newborn.
4. MPC does not cause irregular heart rate or flaccid or cyanotic extremities in
the newborn.
5. MPC does not cause irregular heart rate or flaccid or cyanotic extremities in
the newborn.
PTS: 1 CON: Infection
Chapter 45. Musculoskeletal Function and Assessment
MULTIPLE CHOICE
1. The nursing practitioner is preparing material for a presentation about the musculoskeletal
system. Which information is inaccurate in regard to the functioning of this system?
1. Voluntary muscles require nerve impulses to contract.
2. A continuous supply of blood is needed from the circulatory system.
3. Joint articulations are maintained by moisture from the lymph system.
4. Adequate oxygenation is supplied by respiratory system functioning.
RIGHT ANSWER> 3
Chapter: Chapter 45. Musculoskeletal Function and Assessment
Objective: Explain the anatomy and function of the musculoskeletal system.
Pages: 934–936
Heading: Musculoskeletal System Anatomy and Physiology
Integrated Process: Teaching/Learning
Hospital patient Need: Physiological Integrity/Physiological
Adaptation CL: Application (Applying)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 Voluntary muscles do require nerve impulses to contract and create movement.
2 A continuous supply of blood to maintain muscle health and promote
functionality is needed from the circulatory system.
3 Joint articulations are not maintained by moisture from the lymph system; joint
capsules are lined with membranes that create synovial fluid.
4 Oxygen is needed for muscle function, which is supplied by the respiratory
system.
PTS: 1 CON: Mobility
2. The nursing practitioner is helping a hospital patient understand all of the functions of the
skeleton. Which function is incorrect?
1. It protects organs and tissues from mechanical injury.
2. It is the main system responsible for body movement.
3. Long, flat, and irregular bones store blood-forming tissue.
4. The entire system is responsible for the storage of excess calcium.
RIGHT ANSWER> 2
Chapter: Chapter 45. Musculoskeletal Function and Assessment
Objective: Explain the anatomy and function of the musculoskeletal system.
Pages: 934–936
Heading: Musculoskeletal Tissues and Their Functions
Integrated Process: Teaching/Learning
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 The brain is protected by the skull, and the heart and lungs are protected by the
thoracic cage.
2 The skeletal system is not the main system responsible for movement. The
skeletal system supports the muscles of the body; muscles are responsible for
movement.
3 Bone marrow (hematopoietic tissue) is stored in the ends of long bones of the
arms and legs, in flat bones such as the ribs, and in irregular bones such as
vertebrae and the pelvis.
4 The bones store excess calcium, a process to maintain blood homeostasis.
Calcium is also used for clotting and proper functioning of nerves and muscles.
PTS: 1 CON: Mobility
3. The nursing practitioner is caring for a hospital patient with a suspected bone tumor. Which
serum laboratory result indicates to the nursing practitioner that this health problem is present?
1. Decreased calcium
2. Increased magnesium
3. Increased creatine kinase (CK)
4. Elevated alkaline phosphatase (ALP)
RIGHT ANSWER> 4
Chapter: Chapter 45. Musculoskeletal Function and Assessment
Objective: Identify diagnostic tests for musculoskeletal problems.
Source: pp. 962
Heading: Laboratory Tests
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 Serum calcium tends to decrease in hospital patients with osteoporosis or in
people who consume inadequate amounts of calcium in their diets. Serum
calcium levels
increase in hospital patients with bone cancer.
2 Magnesium is not an identified laboratory test to monitor for this hospital
patient.
3 CK is monitored for muscle disease.
4 ALP is an enzyme that increases when bone or liver tissue is damaged. In
metabolic bone diseases and bone cancer, ALP increases to reflect osteoblast or
bone-forming cell activity.
PTS: 1 CON: Mobility
4. The nursing practitioner is collecting data on an older adult hospital patient. Which finding
is indicative of normal changes in the musculoskeletal system of this hospital patient?
1. Presence of pain in knees joints in the morning
2. Flaccid muscle tone in major muscle groups
3. A notable “S” curve of the spinal column
4. A recent history of falls and accidents
RIGHT ANSWER> 1
Chapter: Chapter 45. Musculoskeletal Function and Assessment
Objective: Describe the effects of aging on the musculoskeletal system.
Pages: 934–936
Heading: Aging and the Musculoskeletal System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 Weight-bearing joints, such as the knees, are subject to damage over many
years. The articular cartilage will wear down, which becomes rough and causes
pain and stiffness. This is a normal change with aging.
2 Muscle strength will decline with age due to a decrease in protein synthesis.
Flaccid muscle tone in major muscle groups is not a normal change in the older
hospital patient.
3 A notable “S” curve of the spinal column is most often associated with
osteoporosis in the older hospital patient. This is not a normal change.
4 Recent history of falls and accidents for an older hospital patient is a result of
failure to
maintain muscle strength through exercise. This is not a normal change.
PTS: 1 CON: Mobility
5. The nursing practitioner is collecting data on a hospital patient who is experiencing hip
pain. Which data does the nursing practitioner consider to be subjective?
1. The presence of a notable limp
2. Limited range of motion in the hip
3. A pain level of 7 on a 0-to-10 scale
4. Wincing when the hip joint is moved
RIGHT ANSWER> 3
Chapter: Chapter 45. Musculoskeletal Function and Assessment
Objective: List subjective data that are collected when caring for a hospital patient with a
disorder of the musculoskeletal system.
Source: pp. 962
Heading: Musculoskeletal System Data Collection
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 The presence of a notable limp is objective data; the nursing practitioner
observes the manifestation.
2 Limited range of motion of the hip is objective data; the nursing practitioner
observes the
manifestation.
3 A pain level of 7 on a scale of 0-to-10 is subjective data; the nursing
practitioner is relying on the hospital patient’s evaluation.
4 When the hospital patient winces when the hip joint is moved, the nursing
practitioner is able to
observe the hospital patient’s reaction. This is objective information.
PTS: 1 CON: Mobility
6. The nursing practitioner is providing care for a hospital patient scheduled for an
arthrography. Which explanation about pain during the procedure does the nursing
practitioner provide?
1. “There is no pain during the procedure.”
2. “There is pain while the x-ray is taken.”
3. “There is temporary pain during dye injection.”
4. “The procedure will be uncomfortable until it is completed.”
RIGHT ANSWER> 3
Chapter: Chapter 45. Musculoskeletal Function and Assessment
Objective: Identify diagnostic tests for musculoskeletal problems.
Source: pp. 944
Heading: Radiographs (X-Rays)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Teaching/Learning
CL: Application (Applying) Concept:
Mobility
Difficulty: Moderate
CLARIFICATION
1 There is pain during the injection so this statement would not be true.
2 The pain will be diminished by the time the x-ray is taken.
3 Inform the hospital patient that the test is uncomfortable during injection.
4 The entire procedure will not be uncomfortable.
PTS: 1 CON: Mobility
7. A hospital patient diagnosed with curvature of the spine asks the nursing practitioner why
breathing is so much more difficult. Which answer by the nursing practitioner best answers
the question?
1. “The spine curvature is caused by a respiratory problem.”
2. “The curvature is caused by leaning over to breathe.”
3. “The thoracic cage expands with a spinal curvature.”
4. “The thoracic cage has lost some flexibility.”
RIGHT ANSWER> 4
Chapter: Chapter 45. Musculoskeletal Function and Assessment
Objective: Explain the anatomy and function of the musculoskeletal system.
Source: pp. 935
Heading: Bone Tissue and Bone Growth
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Application (Applying)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 The spinal curvature is not caused by a respiratory problem. Some respiratory
disorders will remodel the thoracic cage. An example is a barrel chest caused
by chronic obstructive pulmonary disease.
2 The spinal curvature is not caused from leaning over to breathe because of a
respiratory disorder.
3 A spinal curvature decreases the space of the thoracic cage and causes
difficulty with breathing.
4 Spinal curvatures cause the thoracic cage to lose some flexibility, which makes
breathing more difficult.
PTS: 1 CON: Mobility
8. The nursing practitioner is collecting data for a hospital patient with osteoporosis.
Which serum calcium result indicates the typical changes that occur in serum calcium
levels with osteoporosis?
1. 6.5 mg/dL
2. 8.9 mg/dL
3. 9.7 mg/dL
4. 11.2 mg/dL
RIGHT ANSWER> 1
Chapter: Chapter 45. Musculoskeletal Function and Assessment
Objective: Identify diagnostic tests for musculoskeletal problems.
Source: pp. 940
Heading: Laboratory Tests
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 Serum calcium tends to decrease in hospital patients with osteoporosis or in
people who
consume inadequate amounts of calcium in their diets. Normal serum calcium
levels are 8.5 to 10.5 mg/dL.
2 Normal serum calcium levels are 8.5 to 10.5 mg/dL.
3 Normal serum calcium levels are 8.5 to 10.5 mg/dL.
4 Calcium levels greater than 10.5 mg/dL indicate hypercalcemia, which may be
related to metastatic bone disease or extended immobilization.
PTS: 1 CON: Mobility
9. The nursing practitioner is collecting data on a hospital patient with manifestations of
osteoarthritis. Which method of physical examination is unnecessary?
1. Auscultating for joint deformity
2. General visual inspection
3. Palpating for abnormal conditions
4. Observing ability to perform range of motion (ROM)
RIGHT ANSWER> 1
Chapter: Chapter 45. Musculoskeletal Function and Assessment
Objective: List the objective data that are collected when caring for a hospital patient with a
disorder of the musculoskeletal system.
Source: pp. 963
Heading: Physical Examination
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 The nursing practitioner does not auscultate for joint deformity, which is
usually identified with visual inspection. If the joint has crepitus, it can be
heard and palpated.
2 General visual inspection allows the nursing practitioner to identify joint
deformities, the use
of assistive devices, and mobility.
3 Palpating allows the nursing practitioner to identify pain, tenderness,
temperature, and edema.
4 Observing the hospital patient’s ability to perform ROM allows the nursing
practitioner to determine
the ability for the hospital patient to be mobile and perform self-care.
PTS: 1 CON: Mobility
10. The nursing practitioner is providing care for a hospital patient who is diagnosed with
rhabdomyolysis from a crushing injury. Laboratory results indicate elevated levels of CK,
myoglobin, and serum potassium. Which nursing care is most important for the nursing
practitioner implement?
1. Alternate heat and cold applications.
2. Observe the color and amount of urine.
3. Perform passive ROM hourly.
4. Monitor for signs of muscle deterioration.
RIGHT ANSWER> 2
Chapter: Chapter 45. Musculoskeletal Function and Assessment
Objective: Describe the nursing care provided for hospital patients undergoing diagnostic tests of
the musculoskeletal system.
Source: pp. 956
Heading: Rhabdomyolysis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 The hospital patient will experience myalgia from this very serious and life-
threatening condition; however, alternating heat and cold therapy is not
commonly used.
2 The most important care for the nursing practitioner to implement is close
monitoring of the color and amount of urine. Typically, the urine will appear
dark in color. The
goal is to restore normal fluid balance.
3 The hospital patient with this diagnosis experiences muscle weakness and
pain; however, there is no specific reason to perform passive ROM hourly.
4 The diagnosis is indicative of muscle destruction, which is validated by
laboratory levels.
PTS: 1 CON: Mobility
11. A hospital patient arrives at a clinic with a knee joint that is noticeably swollen, warm to
the touch, and painful. The HCP plans to perform an arthrocentesis. Given the hospital
patient’s symptoms, which is the least likely reason for the procedure?
1. To aspirate synovial fluid from the joint and relieve pressure
2. To inject corticosteroids or anti-inflammatories into the joint
3. To mechanically inhibit the production of synovial fluid
4. To visually inspect the withdrawn fluid for the presence to hemarthrosis
RIGHT ANSWER> 3
Chapter: Chapter 45. Musculoskeletal Function and Assessment
Objective: Identify diagnostic tests for musculoskeletal problems.
Source: pp. 943
Heading: Arthrocentesis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 One reason for arthrocentesis is to aspirate synovial fluid from a swollen joint
to decrease pressure and pain.
2 When arthrocentesis is performed, the HCP can inject corticosteroids or anti-
inflammatories into the joint to promote comfort. Antibiotics can also be
injected if necessary.
3 Performance of an arthrocentesis in not done to mechanically inhibit the
production of synovial fluid.
4 When synovial fluid is withdrawn, it can be visually inspected or analyzed
microscopically for the presence of hemarthrosis (blood in the joint cavity),
noninflammatory conditions, or septic arthritis.
PTS: 1 CON: Mobility
12. The nursing practitioner is reviewing the laboratory results for a hospital patient with
severe bone pain. Which condition does the nursing practitioner suspect if the ALP level is
elevated?
1. Osteoarthritis
2. Bone cancer
3. Unhealed fracture
4. Osteoporosis
RIGHT ANSWER> 2
Chapter: Chapter 45. Musculoskeletal Function and Assessment
Objective: Identify diagnostic tests for musculoskeletal disorders.
Source: pp. 943
Heading: Alkaline Phosphatase
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 Elevated ALP levels are not indicative of osteoarthritis.
2 Elevated ALP levels are indicative of bone cancer; the presence of bone pain is
an additional manifestation of the disease.
3 Elevated ALP levels are not indicative of an unhealed fracture.
4 Elevated ALP levels are not indicative of osteoporosis.
PTS: 1 CON: Mobility
13. A hospital patient is scheduled for arthroscopic surgery on a knee. The hospital patient
is to receive light general anesthesia and will be discharged home. Which action will cause
the nursing practitioner to contact the HCP or registered nursing practitioner (RN)?
1. Small amount of blood noted on the elastic wrap
2. A pain level of 8 on a 0-to-10 scale after mild analgesia
3. Assistance of two are needed to get into bedside chair
4. Grogginess lingers for several hours after the procedure
RIGHT ANSWER> 2
Chapter: Chapter 45. Musculoskeletal Function and Assessment
Objective: Describe the nursing care provided for hospital patients undergoing diagnostic tests of
the musculoskeletal system.
Source: pp. 971
Heading: Arthroscopy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Mobility
Difficulty: Difficult
CLARIFICATION
1 A small amount of bleeding is expected from the surgical site after an
arthroscopy; this finding does not warrant contacting the HCP or RN.
2 After arthroscopy, the pain is usually managed effectively with a mild
analgesic; a pain level of 8 on a 0-to-10 scale is unexpected. The nursing
practitioner needs to contact the HCP or the RN.
3 It is not unusual or unexpected for the hospital patient to need assistance into a
bedside chair following arthroscopy. The number of assistants is dependent on
the size
and condition of the hospital patient.
4 Every hospital patient will respond to anesthesia differently. There is no reason
to contact the HCP or RN if the hospital patient remains groggy after several
hours of light general anesthesia.
PTS: 1 CON: Mobility
14. The nursing practitioner is providing care for a hospital patient before a myelography
for diagnosis of a spinal column condition. Which statement regarding nursing care related
to this procedure is correct?
1. “I will check your vital signs throughout the procedure.”
2. “I will stay close during the magnetic resonance imaging (MRI) portion of the
testing.”
3. “You will be head down in bed so the medium flows to the neck.”
4. “You will receive medication for nausea before the testing starts.”
RIGHT ANSWER> 3
Chapter: Chapter 45. Musculoskeletal Function and Assessment
Objective: Describe the nursing care provided for hospital patients undergoing diagnostic tests of
the musculoskeletal system.
Source: pp. 944
Heading: Myelography
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Teaching/Learning
CL: Application (Applying) Concept:
Mobility
Difficulty: Moderate
CLARIFICATION
1 There is no reason for the nursing practitioner to be monitoring vital signs
throughout a myelogram.
2 A myelogram involves x-rays after the administration of a contrast medium.
The test is usually performed on hospital patients who are not good candidates
for computerized tomography (CT) or MRI tests.
3 The hospital patient will be placed head down for a short period of time so that
the
contrast medium will flow upward into the area of the neck.
4 There is no indication that the contrast medium used for myelography will
cause nausea; the hospital patient should not need medication.
PTS: 1 CON: Mobility
15. A hospital patient is receiving care for a torn ligament at the insertion site of an upper
arm muscle. The hospital patient asks the nursing practitioner how this condition will
affect movement. Which information will the nursing practitioner correctly share?
1. The lower arm can no longer be flexed.
2. The upper arm will become disabled.
3. The movement of the arm will seem normal.
4. The lower arm will tend to hyperextend.
RIGHT ANSWER> 3
Chapter: Chapter 45. Musculoskeletal Function and Assessment
Objective: Explain the anatomy and function of the musculoskeletal system.
Source: pp. 935
Heading: Muscle Structure and Arrangements
Integrated Process: Clinical Problem-Solving Process (Nursing Process) CL:
Analysis (Analyzing)
Concept: Mobility
Difficulty: Difficult
CLARIFICATION
1 The body extremities have groups of muscles to provide movement. If the
insertion site of an upper arm muscle is interrupted, movement is still possible
via other group muscles.
2 The upper arm is not disabled by interruption of the insertion site of an upper
arm muscle.
3 When a muscle of the upper arm is torn away from the insertion site, the arm
will seem to function normally after a period of healing.
4 The lower arm will not hyperextend if the tendon at the insertion site of an
upper arm is interrupted.
PTS: 1 CON: Mobility
16. A female hospital patient arrives at the HCP’s office for a routine checkup. The nursing
practitioner notes that the hospital patient is thin, of Asian descent, and experienced a surgery-
induced menopause. Which test does the nursing practitioner expect the HCP to prescribe?
1. An anterior x-ray of the thoracic area
2. A bone scan of the ankle and wrist
3. A test to determine blood calcium levels
4. A dual-energy x-ray absorptiometry (DEXA)
RIGHT ANSWER> 4
Chapter: Chapter 45. Musculoskeletal Function and Assessment
Objective: Identify diagnostic tests for musculoskeletal disorders.
Source: pp. 935
Heading: Bone Density Scan
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 An anterior x-ray of the thoracic area is not done to measure bone density; the
x-ray will provide visualization of thoracic bones, and to some extent the heart
and lungs.
2 A bone scan of the wrist and ankle will provide some information regarding
bone density, but the DEXA is more accurate for a high-risk hospital patient.
3 A blood test for blood calcium levels is not an effective way to diagnose
osteoporosis.
4 The test is a DEXA scan, which measures the spine, hip, and total body bone
density. This is the test the HCP is most likely to order for this high-risk
hospital patient.
PTS: 1 CON: Mobility
17. A hospital patient is prepared for a nuclear medicine scan of the skeleton, using gallium and
thallium as the radioisotopes. Which nursing care will the nursing practitioner provide if the scan
reveals high thallium concentrations?
1. Encourage fluid intake to neutralize radioisotopes.
2. Extend a willingness to sit and talk with the hospital patient.
3. Medicate the hospital patient as needed for pain from testing.
4. Support hospital patient during episodes of vomiting and nausea.
RIGHT ANSWER> 2
Chapter: Chapter 45. Musculoskeletal Function and Assessment
Objective: Describe the nursing care provided for hospital patients undergoing diagnostic tests of
the musculoskeletal system.
Source: pp. 944
Heading: Nuclear Medicine Scans
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Psychosocial Integrity
CL: Analysis (Analyzing) Concept:
Mobility
Difficulty: Difficult
CLARIFICATION
1 Fluid intake is encouraged regardless of the diagnostic outcome.
2 When a bone scan is performed using gallium and thallium, the radioisotopes
are drawn to the bone. High concentrations of gallium are indicative of tumors,
inflammation, and infection. High concentrations of thallium are indicative of
bone cancer, especially osteosarcoma. The best nursing care will involve
emotional and psychological support.
3 It is not likely the hospital patient will have pain related to the bone scan;
however, pain
from bone cancer will be managed.
4 It is not likely that the hospital patient will experience nausea or vomiting after
the bone scan.
PTS: 1 CON: Mobility
18. A hospital patient just had an arthrogram performed for pain in a synovial joint. Which
nursing care is inappropriate following this procedure?
1. Elevate the limb that was tested.
2. Apply ice to the affected area.
3. Discuss the need for 12 to 24 hours of rest.
4. Apply an elastic wrap for swelling.
RIGHT ANSWER> 1
Chapter: Chapter 45. Musculoskeletal Function and Assessment
Objective: Describe the nursing care provided for hospital patients undergoing diagnostic tests of
the musculoskeletal system.
Source: pp. 962
Heading: Arthrogram
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 After arthrogram, the involved limb needs to be elevated to decrease edema.
2 Ice is applied to the affected limb after an arthrogram to decrease edema and
pain.
3 After an arthrogram, the hospital patient is encouraged to rest for 12 to 24
hours to reduce discomfort and/or for safety.
4 Swelling is expected following an arthrogram. Applying an elastic wrap after a
procedure is not within the scope of practice for the nurse.
PTS: 1 CON: Mobility
MULTIPLE RESPONSE
1. A hospital patient is recovering from a biopsy of the right femur and was given pain
medication 1 hour ago. Which symptom does the nursing practitioner report and closely
monitor in this hospital patient? (Select all that apply.)
1. Temperature 98.4°F
2. Hematoma formation
3. Capillary refill of 3 seconds
4. Pain reported as 7 on a 0-to-10 scale
5. ROM of the ankle and knee present
RIGHT ANSWER> 2, 4
Chapter: Chapter 45. Musculoskeletal Function and Assessment
Objective: Describe the nursing care provided for hospital patients undergoing diagnostic tests of
the musculoskeletal system.
Source: pp. 942
Heading: Bone or Muscle Biopsy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Mobility
Difficulty: Difficult
CLARIFICATION
1. This is a normal body temperature.
2. The nursing practitioner inspects the biopsy site for bleeding, swelling, and
hematoma formation. Increased pain that is unresponsive to analgesic
medication may indicate bleeding in the soft tissue.
3. This is a normal capillary refill.
4. The nursing practitioner inspects the biopsy site for bleeding, swelling, and
hematoma formation. Increased pain that is unresponsive to analgesic
medication may indicate bleeding in the soft tissue.
5. Full ROM is an expected finding.
PTS: 1 CON: Mobility
2. A hospital patient was an unrestrained passenger in a motor vehicle accident and hit the
windshield. In addition, the hospital patient’s leg was fractured. Which areas should be included
in this hospital patient’s neurovascular checks? (Select all that apply.)
1. Pulses
2. Sensation
3. Movement
4. Orientation
5. Pupil reaction
RIGHT ANSWER> 1, 2, 3
Chapter: Chapter 45. Musculoskeletal Function and Assessment
Objective: Describe the nursing care provided for hospital patients undergoing diagnostic tests of
the musculoskeletal system.
Source: pp. 940
Heading: Role of the Nervous System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Mobility
Difficulty: Difficult
CLARIFICATION
1. Neurovascular checks for an extremity include movement, sensation
(numbness/tingling), presence of pulses, skin temperature, color, and
capillary refill.
2. Neurovascular checks for an extremity include movement, sensation
(numbness/tingling), presence of pulses, skin temperature, color, and
capillary refill.
3. Neurovascular checks for an extremity include movement, sensation
(numbness/tingling), presence of pulses, skin temperature, color, and
capillary refill.
4. Orientation and pupil reaction are neurologic checks that are done to monitor
the central nervous system.
5. Orientation and pupil reaction are neurologic checks that are done to monitor
the central nervous system.
PTS: 1 CON: Mobility
Chapter 46. Nursing Care of Hospital patients With Musculoskeletal and
Connective Tissue Disorders
MULTIPLE CHOICE
1. The nursing practitioner is preparing for a home visit to a hospital patient after surgery for
a compound fracture. Which specific care does the nursing practitioner anticipate for this
hospital patient?
1. Monitoring circulatory status
2. Changing wound dressings
3. Checking skin integrity
4. Validating immobilization
RIGHT ANSWER> 2
Chapter: Chapter 46. Nursing Care of Hospital patients With Musculoskeletal and Connective
Tissue Disorders
Objective: Plan nursing care for a hospital patient in a splint, cast, traction, or external
fixation. Source: pp. 950
Heading: Splints
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 Routine care for any hospital patient following a fracture is to perform
circulatory status.
2 Specific care for a hospital patient following a compound fracture is to perform
wound care. The hospital patient with an open wound is likely to be in a splint
and have an elastic bandage around the fracture location. This type of
immobilization
makes it possible to monitor and care for a wound.
3 Routine care for any hospital patient following a fracture is to check for skin
integrity.
4 Routine care for any hospital patient following a fracture is to validate
immobilization
regardless of the type used.
PTS: 1 CON: Tissue Integrity
2. A hospital patient experiences a fracture of the lower leg and undergoes a closed reduction
and placement of a fiberglass cast. The hospital patient is 65 years old and has a medical 30-year
history of diabetes mellitus. Which condition does the nursing practitioner recognize as a
possible complication for this hospital patient?
1. Delay or absence of healing
2. Malalignment of healed bones
3. Development of bone infection
4. Impaired mobility function
RIGHT ANSWER> 1
Chapter: Chapter 46. Nursing Care of Hospital patients With Musculoskeletal and Connective
Tissue Disorders
Objective: Explain the pathophysiology, signs and symptoms, and complications of
fractures.
Source: pp. 951
Heading: Non-Union Modalities
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 The possibility of non-union (delayed or absence of healing) is a higher risk for
some hospital patients. Contributing factors are age and diseases that alter the
healing process, such as diabetes mellitus.
2 Malunion (malalignment of healed bones) is a non-union modality, which is
most common in fractures that require internal fixation because of multiple
bone pieces and fragments.
3 With a closed reduction and placement of a cast, the risk for bone infection is
low.
4 Impaired mobility function is not an expected outcome for most bone fractures.
PTS: 1 CON: Mobility
3. An older adult hospital patient is postoperative for a total hip joint replacement. Which
nursing care is inappropriate for this hospital patient on the day of surgery?
1. Assisted out of bed the evening of surgery
2. Provided with an elevated toilet seat
3. Medicated with oral pain medications
4. Prescribed weight-bearing is maintained
RIGHT ANSWER> 3
Chapter: Chapter 46. Nursing Care of Hospital patients With Musculoskeletal and Connective
Tissue Disorders
Objective: Plan nursing care for a hospital patient having a total joint
replacement. Source: pp. 971
Heading: Total Hip Replacement
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 Hospital patients with a total hip replacement will get out of bed either the
evening of
the surgery or in the morning after surgery.
2 An elevated toilet seat is needed to prevent the hospital patient from hyper-
flexing the new joint.
3 Initially, pain is managed by epidural analgesia, hospital patient-controlled
analgesia, or IV analgesia. Oral analgesics are most likely introduced after the
first postoperative day.
4 The health care provider (HCP) will prescribe the amount of weight-bearing
that is acceptable for the hospital patient receiving a total hip replacement.
PTS: 1 CON: Mobility
4. The nursing practitioner is providing care for a hospital patient who is scheduled for joint
replacement the next day. Which hospital patient care goals are appropriate at this time?
1. Teach postoperative exercises.
2. Ask if a consent form was signed.
3. Explain the use of assistive devices.
4. Manage preoperative pain.
RIGHT ANSWER> 4
Chapter: Chapter 46. Nursing Care of Hospital patients With Musculoskeletal and Connective
Tissue Disorders
Objective: Plan nursing care for a hospital patient having a total joint
replacement. Source: pp. 971
Heading: Total Joint Replacement
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Comfort
Difficulty: Moderate
CLARIFICATION
1 The day before surgery is not the best time to be teaching postoperative
exercises. This activity should occur earlier along with some preoperative
strengthening exercises.
2 The nursing practitioner can check the hospital patient’s medical record and
confirm the presence of a signed surgery consent form.
3 Explanation of the use of assistive devices will most likely be provided as each
device is introduced to the hospital patient during recovery. The day before is
not
appropriate.
4 Hospital patients requiring total joint replacement are likely to be in severe
preoperative pain. Management of pain is an important hospital patient goal.
PTS: 1 CON: Comfort
5. The nursing practitioner is providing care for a hospital patient following an open
reduction of a compound fracture. Which neurologic finding does the nursing
practitioner report immediately to the HCP or registered nursing practitioner (RN)?
1. The foot on the surgical limb is cool to touch.
2. Surgical pain is reported at 8 on a 0-to-10 scale.
3. There exists numbness and tingling sensations.
4. There are decreased pulses and a dusky color on the surgical limb.
RIGHT ANSWER> 951
Chapter: Chapter 46. Nursing Care of Hospital patients With Musculoskeletal and Connective
Tissue Disorders
Objective: Explain the pathophysiology, signs and symptoms, and complications of
fractures.
Source: pp. 951
Heading: Neurovascular Status
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Mobility
Difficulty: Difficult
CLARIFICATION
1 The foot on the surgical limb should be warm to touch. However, this is a
circulatory issue and not a neurologic finding.
2 After any surgical procedure, it is expected for the hospital patient to report a
high level
of pain; however, this is not a neurologic finding.
3 When a hospital patient reports the presence of numbness and tingling
sensations, it is indicative of a neurologic manifestation. This finding needs to
be reported immediately to the HCP or RN.
4 Decreased pulses and dusky color of the surgical limb are indications of
circulatory problems. The question specifically asks for neurologic findings.
PTS: 1 CON: Mobility
6. A hospital patient with gout has been instructed on the prescribed medication allopurinol
(Zyloprim). Which hospital patient statement indicates understanding of the action of this
medication?
1. “It excretes proteins.”
2. “It blocks formation of uric acid.”
3. “It increases formation of purines.”
4. “It increases metabolism of purines.”
RIGHT ANSWER> 2
Chapter: Chapter 46. Nursing Care of Hospital patients With Musculoskeletal and Connective
Tissue Disorders
Objective: Describe the pathophysiology, treatment, and nursing care for gout.
Source: pp. 963
Heading: Gout
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Pharmacological
Integrity CL: Application (Applying)
Concept: Safety
Difficulty: Moderate
CLARIFICATION
1 Allopurinol (Zyloprim) does not excrete proteins or increase the formation or
metabolism of purines.
2 Allopurinol (Zyloprim) decreases uric acid production.
3 Allopurinol (Zyloprim) does not excrete proteins or increase the formation or
metabolism of purines.
4 Allopurinol (Zyloprim) does not excrete proteins or increase the formation or
metabolism of purines.
PTS: 1 CON: Safety
7. The nursing practitioner is contributing to the plan of care for a hospital patient who has an
upper extremity amputation. Which factor does the nursing practitioner keep in mind about this
type of amputation being more debilitating than a lower extremity amputation?
1. The upper extremity is more visible.
2. Prosthetic fitting is easier for the leg.
3. The upper extremity is more specialized.
4. There is greater blood supply to the upper extremity.
RIGHT ANSWER> 3
Chapter: Chapter 46. Nursing Care of Hospital patients With Musculoskeletal and Connective
Tissue Disorders
Objective: Explain hospital patient teaching for a hospital patient with a lower extremity
amputation and prosthesis.
Source: pp. 974
Heading: Surgical Amputation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 Upper extremity amputations are not more debilitating because the upper
extremity is more visible.
2 Upper extremity amputations are not more debilitating because the prosthetic
fitting is easier for the leg.
3 Upper extremity amputations are usually more significant than are lower
extremity amputations as the arms and hands are necessary for performing
activities of daily living.
4 Upper extremity amputations are not more debilitating because of a greater
blood supply to the upper extremities.
PTS: 1 CON: Mobility
8. A hospital patient who has a displaced midshaft fracture of the left femur is in balanced
suspension skeletal traction with 35 pounds of weight. The hospital patient reports calf pain
with right foot dorsiflexion. Which action does the nursing practitioner take?
1. Notify the RN.
2. Check the traction setup.
3. Reduce by 5 pounds of weight.
4. Encourage dorsiflexion more frequently.
RIGHT ANSWER> 1
Chapter: Chapter 46. Nursing Care of Hospital patients With Musculoskeletal and Connective
Tissue Disorders
Objective: Explain the pathophysiology, signs and symptoms, and complications of
fractures.
Source: pp. 952
Heading: Venous Thromboembolitic Complications
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Perfusion
Difficulty: Moderate
CLARIFICATION
1 Calf pain on dorsiflexion can indicate a thrombophlebitis (Homan’s sign) and is
indicative of a deep vein thrombosis (DVT). The RN should be informed.
2 The nursing practitioner should not take the time now to check the traction
setup.
3 Traction weight cannot be reduced without a physician’s order.
4 The hospital patient should not be encouraged to exercise the limb now since a
venous
thromboembolitic complication might be present.
PTS: 1 CON: Perfusion
9. The home-care nursing practitioner is attending to a hospital patient with osteomyelitis in a
lower extremity from a traumatic bone fracture. The hospital patient has an open wound that is
infected. Which observation prompts the nursing practitioner to provide additional information
to the hospital patient and family?
1. Clean technique is used when the dressing is changed.
2. Hand hygiene is performed correctly and appropriately.
3. Possible side effects of antibiotics are understood.
4. Children and pets are kept away from the wound.
RIGHT ANSWER> 1
Chapter: Chapter 46. Nursing Care of Hospital patients With Musculoskeletal and Connective
Tissue Disorders
Objective: Plan nursing care for osteomyelitis.
Source: pp. 958
Heading: Osteomyelitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Infection
Difficulty: Difficult
CLARIFICATION
1 When a hospital patient has osteomyelitis, sterile dressing changes are always
used, even in the home environment. Osteomyelitis is difficult to treat and
preventing
additional infections is important. Additional teaching is required.
2 Additional teaching is not required when the nursing practitioner validates that
hand hygiene is performed correctly and at the appropriate times (before and
after providing
care).
3 Additional teaching is not required if the hospital patient and family understand
the side
effects of antibiotics.
4 Because of the virulence of the infection, the difficulty of resolving the
infection, and the possibility of transmitting the infection to others, pets and
children are kept away from the wound. No additional teaching is required.
PTS: 1 CON: Infection
10. The nursing practitioner is providing care for a hospital patient being treated after a
complicated femur fracture. The nursing practitioner has noticed drowsiness, tachycardia,
and a low-grade fever. Which additional manifestation alerts the nursing practitioner to the
possibility of a fat emboli?
1. Respiratory rate of 20 breaths/min
2. Presence of a petechial rash on chest and neck
3. An oxygen saturation level of 92 percent on room air
4. Verbal complaints of nausea with vomiting
RIGHT ANSWER> 2
Chapter: Chapter 46. Nursing Care of Hospital patients With Musculoskeletal and Connective
Tissue Disorders
Objective: Explain the pathophysiology, signs and symptoms, and complications of
fractures.
Source: pp. 952
Heading: Fat Embolism Syndrome
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 A respiratory rate of 20 breaths/min is within normal range.
2 The presence of petechial rash is one of the classic manifestations of a fat
emboli; the rash can appear on the chest, neck, axilla, and conjunctiva.
3 An oxygen saturation level of 92 percent on room air is not necessarily an
indication of a fat emboli.
4 Verbal complaints of nausea with vomiting can be caused by multiple
problems; however, it is not alone indicative of a fat emboli.
PTS: 1 CON: Mobility
11. The nursing practitioner is assisting with the preparation of materials for a health fair
aimed at promoting health in women. Which reason does the nursing practitioner recognize as a
probable cause of an increase in the incidence of osteoporosis?
1. More adults are lactose intolerant.
2. Adults tend to be more sedentary.
3. The ages of adults have increased.
4. There is an increased number of smokers.
RIGHT ANSWER> 3
Chapter: Chapter 46. Nursing Care of Hospital patients With Musculoskeletal and Connective
Tissue Disorders
Objective: Describe risk factors, pathophysiology, treatment, and nursing care for
osteoporosis.
Source: pp. 958
Heading: Osteoporosis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
CLARIFICATION
1 Increased incidence of osteoporosis is not related to an increase of adults who
are lactose intolerant.
2 The most likely cause of an increase in the incidence of osteoporosis may or
may not be related to sedentary lifestyle.
3 The population in the United State is increasing in age due to longevity related
to better health care and disease management. Osteoporosis is a disease
connected to aging.
4 The number of smokers may or may not have increased. Hospital patient
education is
readily available about the health risks related to smoking.
PTS: 1 CON: Fluid and Electrolyte Balance
12. The nursing practitioner is providing care for a hospital patient who experienced a closed
reduction to a fracture of the ulna. Which manifestation does the nursing practitioner recognize
as an early symptom of acute compartment syndrome?
1. Paralysis of the affected limb
2. Lack of a distal pulse
3. Pallor with extremity warmth
4. Poikilothermia of the arm
RIGHT ANSWER> 3
Chapter: Chapter 46. Nursing Care of Hospital patients With Musculoskeletal and Connective
Tissue Disorders
Objective: Explain the pathophysiology, signs and symptoms, and complications of
fractures.
Source: pp. 954
Heading: Acute Compartment Syndrome
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 With compartment syndrome, paralysis is a late manifestation.
2 With compartment syndrome, the absence of a pulse is a late and ominous
manifestation.
3 Pallor is an early manifestation of compartment syndrome; however, there may,
at this time, be warmth or redness over the area.
4 Poikilothermia is indicative of suppressed circulation. The manifestation is
coolness of the extremity. The term indicates that the limb is the same
temperature as the environment.
PTS: 1 CON: Mobility
13. The nursing practitioner is providing care for a hospital patient after an above-the-knee
amputation because of ischemia related to diabetes mellitus complications. Which
nursing care is essential for promoting ambulation?
1. Building upper body strength
2. Promoting coordination exercises
3. Maintaining residual limb elevation
4. Lying on the abdomen as prescribed
RIGHT ANSWER> 4
Chapter: Chapter 46. Nursing Care of Hospital patients With Musculoskeletal and Connective
Tissue Disorders
Objective: Explain hospital patient teaching for a hospital patient with a lower extremity
amputation and prosthesis.
Source: pp. 974
Heading: Amputation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 The hospital patient may need upper body strength for moving about or for
using crutches when a prosthesis is not worn. However, this action does not
involve essential nursing care to promote ambulation.
2 Coordination may be helpful, but it is not part of the essential nursing care for
promoting ambulation.
3 It is important to avoid the formation of hip contractures from flexing the hip
for long periods of time. Sitting and the elevation of the residual limb are the
most common offenders. Once contractures develop, ambulating with a
prosthesis is impossible.
4 The hospital patient will need to lie supine for 30 minutes at least four times a
day. This activity will likely be prescribed by the HCP or physical therapist. Hip
contractures must be avoided if ambulation is to be accomplished.
PTS: 1 CON: Mobility
14. A hospital patient is being prepared for a prosthesis following surgery for an
amputation. Which information will the nursing practitioner provide to the hospital patient
regarding the use of a prosthesis?
1. Manual massage will help shape the end of the residual limb.
2. A prosthesis will not be fitted until the surgery site is healed.
3. A shrinker sock is worn with the prosthesis to prevent sores.
4. Skin inspection is performed each time the sock is removed.
RIGHT ANSWER> 4
Chapter: Chapter 46. Nursing Care of Hospital patients With Musculoskeletal and Connective
Tissue Disorders
Objective: Explain hospital patient teaching for a hospital patient with a lower extremity
amputation and prosthesis.
Source: pp. 975
Heading: Prosthesis Care
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 Manual massage is not specific enough to assure the correct preparation of the
residual limb for a prosthesis.
2 A temporary prosthesis is often worn until swelling subsides.
3 A shrinker sock is commonly worn to reduce swelling and help shape the limb
for the prosthesis. The sock is worn with and without the prosthesis.
4 It is essential that the residual limb be checked for infections and skin integrity
each time the shrinker sock is removed. Neurovascular checks are performed at
the same time.
PTS: 1 CON: Mobility
15. The nursing practitioner is providing care for a hospital patient with external fixation for
a fracture involving severe bone damage. Which is the most important focus for the nursing
practitioner during care of this hospital patient?
1. Monitoring pin and wound sites for signs of infection
2. Helping the hospital patient achieve a desired level of mobility
3. Being aware that the hospital patient may experience issues with body image
4. Providing a caring and supportive attitude during a challenging time
RIGHT ANSWER> 1
Chapter: Chapter 46. Nursing Care of Hospital patients With Musculoskeletal and Connective
Tissue Disorders
Objective: Plan nursing care for a hospital patient in a splint, cast, traction, or external
fixation. Source: pp. 952
Heading: External Fixation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 External fixation allows visualization and care for soft tissue injuries and holds
bone pieces in place with the insertion of a pin through the skin and into the
bone. Both conditions need to be monitored regularly for signs of infection.
This is the most important care performed by the nurse.
2 The nursing practitioner is aware of the hospital patient’s desired level of
mobility and can assist with meeting this goal. However, this is not the most
important nursing care for this
hospital patient.
3 The external fixation device is intimidating in appearance and may result in
issues related to body image. The nursing practitioner can assist with this issue;
however, it is not the most important nursing care for this hospital patient.
4 Providing a caring and supportive attitude is always an important nursing
intervention. It especially important with a hospital patient who has a
challenging, and
possibly prolonged, healing process. However, this is not the most important
nursing care for this hospital patient.
PTS: 1 CON: Mobility
16. The nursing practitioner is assisting with the care of a hospital patient with rheumatoid
arthritis (RA). The nursing practitioner must remember in which way RA care is different from
osteoarthritis care. Which nursing care does the nursing practitioner specifically provide for the
hospital patient with RA?
1. Exercise is poorly tolerated and frequent rest is needed.
2. Acutely inflamed joints will respond best to heat therapy.
3. It is essential to monitor all body systems for effects of the disease.
4. Injury and age are the greatest contributors to disease development.
RIGHT ANSWER> 3
Chapter: Chapter 46. Nursing Care of Hospital patients With Musculoskeletal and Connective
Tissue Disorders
Objective: Compare the care for osteoarthritis and rheumatoid arthritis.
Source: pp. 968
Heading: Rheumatoid Arthritis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Immunity
Difficulty: Moderate
CLARIFICATION
1 The hospital patient with RA will maintain a higher level of functioning with
exercise
and physical activity, which is balanced with rest periods.
2 With RA, inflamed joints will respond best to ice therapy. Heat applications
and hot showers will alleviate stiffness.
3 When a hospital patient has RA, all body systems can be affected. The nursing
practitioner needs to
carefully watch for changes to blood vessels, nerves, kidneys, pericardium,
lungs, and subcutaneous tissue. RA is a disease of the connective tissue.
4 Injury and age are actually the greatest contributors to osteoarthritis.
PTS: 1 CON: Immunity
17. The nursing practitioner is assisting with hospital patients on an orthopedic unit. Which
is an important factor to remember when caring for hospital patients after a total hip
replacement?
1. Side-lying position is permitted with a pillow between the legs.
2. A triangular pillow is used between the legs to avoid adduction.
3. Sitting in a bedside chair is permitted if the legs are elevated.
4. Place three pillows between the legs, one distal and three proximal.
RIGHT ANSWER> 2
Chapter: Chapter 46. Nursing Care of Hospital patients With Musculoskeletal and Connective
Tissue Disorders
Objective: Plan nursing care for a hospital patient having a total joint
replacement. Source: pp. 971
Heading: Hip Dislocation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 If a hospital patient is permitted to be in a side-lying position, the legs must be
abducted by more than one pillow, which is inadequate to prevent hip
dislocation.
2 After a total hip replacement, a triangular pillow is used between the legs to
avoid adduction.
3 When sitting in a bedside chair, overflexion of the hips is prevented by using a
higher chair; the lower legs are not elevated.
4 Three pillows can be used to maintain abduction; however, one pillow is placed
proximal and two are placed distal.
PTS: 1 CON: Mobility
18. The nursing practitioner is assisting with the care of hospital patients who have had
joint replacement surgery. Which action is unnecessary for the hospital patient after a total
knee replacement (TKR)?
1. Monitor for excessive bleeding.
2. Check for indications of a DVT.
3. Ambulate as prescribed by HCP.
4. Maintain proper joint alignment.
RIGHT ANSWER> 4
Chapter: Chapter 46. Nursing Care of Hospital patients With Musculoskeletal and Connective
Tissue Disorders
Objective: Plan nursing care for a hospital patient having a total joint
replacement. Source: pp. 972
Heading: Total Knee Replacement
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Mobility
Difficulty: Moderate
CLARIFICATION
1 As with any surgery, the hospital patient with a TKR is monitored for
excessive bleeding.
2 Hospital patients with total joint replacements need to be monitored for the
formation of
DVTs.
3 Hospital patients with a TKR are frequently gotten out of bed and/or
ambulated for a short distance the evening of surgery or the next morning.
4 Unlike the hospital patient with a total hip replacement, the TKR does not
require
maintenance of specific joint alignment.
PTS: 1 CON: Mobility
MULTIPLE RESPONSE
1. A hospital patient asks the difference between osteoarthritis and RA. Which manifestations
does the nursing practitioner explain are characteristic of RA? (Select all that apply.)
1. Low-grade fever
2. Heberden’s nodes
3. Autoimmune disease
4. Pain increasing by activity
5. Early morning stiffness
RIGHT ANSWER> 1, 3, 5
Chapter: Chapter 46. Nursing Care of Hospital patients With Musculoskeletal and Connective
Tissue Disorders
Objective: Compare the care for osteoarthritis and rheumatoid arthritis.
Source: pp. 962
Heading: Rheumatoid Arthritis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Immunity
Difficulty: Difficult
CLARIFICATION
1. RA is a systemic autoimmune disease with morning stiffness and low-grade
fever.
2. Heberden’s nodes are seen in osteoarthritis.
3. RA is a systemic autoimmune disease with morning stiffness and low-grade
fever.
4. Pain increases with activity in osteoarthritis.
5. RA is a systemic autoimmune disease with morning stiffness and low-grade
fever.
PTS: 1 CON: Immunity
2. The nursing practitioner is collecting data from a hospital patient suspected of developing
a fat embolus from a fracture of the right femur. Which manifestations does the nursing
practitioner expect? (Select all that apply.)
1. Petechiae
2. Migraine
3. Tachycardia
4. Mental confusion
5. Numbness in the right leg
RIGHT ANSWER> 1, 3, 4
Chapter: Chapter 46. Nursing Care of Hospital patients With Musculoskeletal and Connective
Tissue Disorders
Objective: Explain the pathophysiology, signs and symptoms, and complications of
fractures.
Source: pp. 956
Heading: Fat Emboli Syndrome
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Perfusion
Difficulty: Difficult
CLARIFICATION
1. The earliest manifestation of fat emboli syndrome (FES) is altered mental
status from a low arterial oxygen level. The hospital patient then experiences
tachycardia, tachypnea, fever, high blood pressure, severe respiratory distress,
and petechiae.
2. A migraine is not indicative of FES.
3. The earliest manifestation of FES is altered mental status from a low arterial
oxygen level. The hospital patient then experiences tachycardia, tachypnea,
fever, high blood pressure, severe respiratory distress, and petechiae.
4. The earliest manifestation of FES is altered mental status from a low arterial
oxygen level. The hospital patient then experiences tachycardia, tachypnea,
fever,
high blood pressure, severe respiratory distress, and petechiae.
5. Numbness in the right leg is not indicative of FES.
PTS: 1 CON: Perfusion
Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
MULTIPLE CHOICE
1. The nursing practitioner asks an older adult hospital patient to count backward from 100 in
increments of three; the hospital patient counts correctly until the nursing practitioner stops the
process. Which reason does the nursing practitioner identify as a likely cause of long periods of
hesitation during the process?
1. Normal loss of neurons related to aging
2. Early manifestation of dementia
3. Normal delay in problem solving
4. Result of malnutrition and depression
RIGHT ANSWER> 3
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: Identify the effects of aging on the nervous system.
Source: pp. 990
Heading: Aging and the Nervous System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 With age, the brain loses neurons. However, it loses only a small percentage of
the total, so this is not the usual cause of mental impairment in older adults.
2 Some forgetfulness and decreased ability to problem solve is expected with
aging, but these manifestations are not indicative of dementia.
3 The hospital patient’s long periods of hesitation are indicative of a normal delay
in problem solving.
4 The long delays during the testing are not indicative of malnutrition and
depression. However, some causes of mental changes include depression,
malnutrition, infections, hypotension, and medication side effects. There is not
enough information in this scenario to identify any of these causes.
PTS: 1 CON: Neurologic Regulation
2. The nursing practitioner is providing care for multiple hospital patients. Which hospital
patient does the nursing practitioner decide to report immediately to the health care provider
(HCP) or the registered nursing practitioner (RN)?
1. The hospital patient admitted with dysphagia who choked on a thickened liquid
2. The hospital patient who begins to exhibit lack of coordination and aphasia
3. The hospital patient whose neurologic checks show slight variations over 8 hours
4. The hospital patient who reports tingling in the fingers 1 hour after surgery on the hand
RIGHT ANSWER> 2
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: List data to collect when caring for a hospital patient with a disorder of the
nervous system.
Source: pp. 990
Heading: Nursing Assessment of the Neurologic System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1 After a stroke, a hospital patient with dysphasia is placed on a diet that
contains thickened liquids. It is possible for the hospital patient to
occasionally choke; the nursing practitioner will monitor the hospital patient
for complications and suggest that the dietitian reevaluate the hospital
patient’s diet.
2 Any sudden change in a hospital patient’s neurologic functioning should be
reported immediately to the HCP or the RN. Rapid intervention may make the
difference between chronic dysfunction and recovery, or even between life and
death for the hospital patient.
3 When a hospital patient is receiving neurologic checks over a period of time,
some slight variations are normal and expected.
4 One hour after surgery on a hospital patient’s hand, it may be expected to
experience tingling in the fingers as the anesthesia wears off. However, the
nursing practitioner should
perform additional neurologic checks to validate well-being.
PTS: 1 CON: Neurologic Regulation
3. The nursing practitioner is assisting with a hospital patient who was injured in an
accident and experienced head injury. The RN records the hospital patient as exhibiting
decerebrate posturing. Which condition does the nursing practitioner associate with the RN’s
finding?
1. Damage to the area of the brainstem
2. Injury to the spinal cord and ascending nerves
3. Significant impairment of cerebral functioning
4. Likelihood of coma preceding brain death
RIGHT ANSWER> 1
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: Identify tests used to diagnose disorders of the nervous system.
Source: pp. 991
Heading: Glasgow Coma Scale
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1 The hospital patient’s posturing is indicative of damage in the area of the
brainstem; the
arms and legs are extended and the arms are internally rotated.
2 Decerebrate posturing does not indicate injury to the spinal cord and ascending
nerves. Damage to the spinal cord is most likely to cause paralysis and/or
dysfunction of the descending nerves.
3 Significant damage to the cerebral area of the brain is noted by the presence of
decorticate posturing. This manifestation exhibits as flexion of the arms at the
elbows, hands are raised toward the chest, and legs are extended.
4 Neither posturing indicates the likelihood of a coma preceding brain death.
PTS: 1 CON: Neurologic Regulation
4. The nursing practitioner is preparing a hospital patient for neurologic testing. Which testing
does the nursing practitioner expect if the hospital patient expresses severe pain in the lower
back aggravated by movement?
1. Electroencephalogram
2. Angiogram
3. Myelogram
4. Spinal x-rays
RIGHT ANSWER> 3
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: Identify tests used to diagnose disorders of the nervous system.
Source: pp. 996
Heading: Diagnostic Tests for the Neurologic System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 An electroencephalogram is performed to record brain activity; analysis of the
tracings can identify areas of abnormality.
2 An angiogram consists of an x-ray following the injection of dye to examine
the structure of specific vessels as well as overall circulation to the area.
3 A myelogram is an x-ray performed after the injection of a contrast medium to
identify compressed nerve roots, herniated intravertebral disks, and blockage of
cerebrospinal fluid circulation.
4 Spinal x-rays are performed to determine the status of individual vertebrae and
their relationship to each other. This testing does not help determine the
involvement of nerves.
PTS: 1 CON: Neurologic Regulation
5. The nursing practitioner will be accompanying a hospital patient to the radiology
department for the performance of a computerized axial tomography (CAT) scan with
contrast. The hospital patient is an older adult who has pain and exhibits signs of mild
agitation. Which nursing care for the hospital patient related to the examination is
inappropriate?
1. Administer prescribed sedation prior to testing.
2. Reassure sensations are not caused by incontinence.
3. Monitor closely for symptoms of allergic reactions.
4. Provide pain medication as soon as the test is done.
RIGHT ANSWER> 4
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: Plan nursing care for hospital patients undergoing diagnostic tests for disorders
of the nervous system.
Source: pp. 996
Heading: Computed Tomography
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 Because the hospital patient is mildly agitated, the nursing practitioner will
administer the prescribed sedation prior to testing.
2 Hospital patients receiving dye may experience feelings of warmth; when the
sensation is in the groin area, the hospital patients may think they are
incontinent. The nursing practitioner can
reassure the hospital patient of the sensation either before or during the
procedure.
3 The dye may cause allergic reactions, such as nausea, diaphoresis, itching, or
trouble breathing. The hospital patient is monitored closely and symptoms are
reported immediately to the HCP.
4 If the hospital patient has pain, he or she can be given prescribed pain
medication prior to the testing. However, the nursing practitioner needs to be
aware of the side effects and take
care not to overmedicate the hospital patient with both a sedative and pain
medication.
PTS: 1 CON: Neurologic Regulation
6. The nursing practitioner is providing care for a female hospital patient who is paralyzed
from a C-4 spinal cord injury. The hospital patient is turned and repositioned every 2 hours.
Which action does the nursing practitioner take when repositioning the hospital patient in a
side-lying position?
1. Place the hospital patient’s call light within reach.
2. Ask the hospital patient if the new position is comfortable.
3. Check that her breast is not compressed under her body.
4. Massage reddened or blanched areas on her back.
RIGHT ANSWER> 3
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: Describe common therapeutic measures used for hospital patients with disorders
of the nervous system.
Source: pp. 997
Heading: Moving and Positioning
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application
(Applying) Concept: Neurologic
Regulation Difficulty: Moderate
CLARIFICATION
1 With a C-4 spinal cord injury, the hospital patient is unable to use a call light.
Other
methods of calling for assistance will be utilized.
2 With a C-4 spinal cord injury, the hospital patient is unable to determine if his
or her body is comfortable; the nurse’s responsibility to check for potentially
harmful
stress and pressure is crucial.
3 When a female with a C-4 spinal cord injury is positioned in a side-lying
position, it is important to make sure that her breast is not compressed beneath
her body and interrupting circulation. For the male hospital patient, the position
of the scrotum is evaluated.
4 Reddened or blanched areas are indicative of pressure injury or an increased
risk; this finding needs to be reported to the HCP or RN. Massage may cause
additional injury.
PTS: 1 CON: Neurologic Regulation
7. An older adult hospital patient is hospitalized for a respiratory infection. The nurses have
been placing the hospital patient’s feet into high-top tennis shoes even while in bed. Which
answer does the nursing practitioner make to a family member who asks about the purpose of
the shoes?
1. Instruct the family that the same practice should be continued at home.
2. Share that the practice keeps the hospital patient ready for ambulating to the bathroom.
3. Explain that this practice keeps the sheets from placing pressure on the feet.
4. Explain that without the proper foot position, it is impossible to stand.
RIGHT ANSWER> 4
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: Describe common therapeutic measures used for hospital patients with disorders
of the nervous system.
Source: pp. 996
Heading: Contractures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 The hospital patient may be perfectly able to stand and ambulate at home; there
is not
enough information to determine if the practice needs to be continued after
discharge.
2 The use of high-top tennis shoes while in bed is for proper foot alignment, not
for readiness to ambulate to the bathroom.
3 If a hospital patient is not able to get out of bed, or the sheets hold the hospital
patient’s feet in a
plantar flexed position, the sheets need to be loosened.
4 It does not take long for contractures of the feet to occur if the hospital patient is
unable to ambulate or stand on a regular basis. The high-top tennis shoes will
hold the feet in normal alignment to prevent those contractures.
Contractures of the feet and ankles will make standing and ambulation
impossible.
PTS: 1 CON: Neurologic Regulation
8. The nursing practitioner is collecting data from a hospital patient in the HCP’s office.
Which statement by the hospital patient indicates that the hospital patient is likely to be
having problems with some activities of daily living (ADLs)?
1. “I am more comfortable in slip-on shoes.”
2. “I am no longer able to carry heavy objects.”
3. “I can barely lift my arms above my shoulders.”
4. “I try to only go up and down the stairs once a day.”
RIGHT ANSWER> 3
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: List data to collect when caring for a hospital patient with a disorder of the
nervous system.
Source: pp. 997
Heading: Activities of Daily Living
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1 The preference for slip-on shoes is not alone a statement addressing the ability
to perform ADLs. This statement needs to be explored.
2 The inability to carry heavy objects may or may not interfere with the hospital
patient’s
ability to perform ADLs. This statement needs to be explored.
3 The inability to lift the arms above the shoulders causes serious concern about
the hospital patient’s ability to perform ADLs. This limitation can interfere
with personal hygiene care, and even the ability to eat and drink.
4 Attempting to limit trips up and down the stairs may or may not interfere with
the hospital patient’s ability to perform ADLs. This statement needs to be
explored.
PTS: 1 CON: Neurologic Regulation
9. A hospital patient is being admitted to a long-term care facility. Medical history includes a
recent stroke with dysarthria. Which factor does the nursing practitioner consider when
providing care for this hospital patient?
1. The hospital patient is likely to also have a cognitive deficit.
2. The hospital patient will be able to answer yes-or-no questions.
3. A picture board will help the hospital patient with word searching.
4. Profanity is expected due to hospital patient frustration.
RIGHT ANSWER> 3
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: Describe common therapeutic measures used for hospital patients with disorders
of the nervous system.
Source: pp. 997
Heading: Communication
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis
(Analyzing) Concept: Neurologic
Regulation Difficulty: Difficult
CLARIFICATION
1 When a hospital patient experiences dysarthria, it does not indicate that the
hospital patient has cognitive deficits. Treating the hospital patient as such only
increases the hospital patient’s frustration with the inability to communicate.
2 The nursing practitioner does not make the assumption that the hospital patient
can answer yes-or-no questions correctly. Hospital patients with dysarthria may
answer all questions with
either a yes or no.
3 For the hospital patient with unintelligible speech or with serious word
searching, a picture board with commonly used items can be useful and reduce
frustration.
4 Profanity is not necessarily a response to frustration. Some hospital patients will
use a single word as the response to all questions or communication. For some
hospital patients, that single word may be a profanity.
PTS: 1 CON: Neurologic Regulation
10. A hospital patient comes to the emergency room exhibiting confusion and manifestations
related to dementia. Records from previous visits indicate a history of drug and alcohol abuse
along with frequent treatment for sexually transmitted infections (STIs). Which laboratory test
does the nursing practitioner consider to be unnecessary?
1. Venereal disease research laboratory test (VDRL)
2. Anticholinesterase testing with antibody titers
3. Liver function and renal function tests
4. Erythrocyte sedimentation rate (ESR) and white blood cell (WBC) count
RIGHT ANSWER> 2
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: Identify tests used to diagnose disorders of the nervous system.
Source: pp. 995
Heading: Laboratory Tests
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 With a medical history of frequent treatment for STIs, a VDRL test for syphilis
is expected. The manifestations of confusion and those related to dementia
support this test.
2 Anticholinesterase testing with antibody titers is testing that is performed to
diagnose myasthenia gravis. This test is unnecessary given the hospital patient’s
symptoms.
3 The hospital patient’s history of alcohol and drug abuse may account for the
hospital patient’s
behavior; liver function and renal function tests are appropriate.
4 Without knowing the cause of the hospital patient’s symptoms, an ESR and
WBC count are appropriate to rule out infection.
PTS: 1 CON: Neurologic Regulation
11. The nursing practitioner is preparing to perform a Romberg test on a hospital patient. The
nursing practitioner instructs the hospital patient to stand with the feet together and eyes closed.
After 20 seconds, the hospital patient leans to one side and exhibits a swaying motion.
Which conclusion does the nursing practitioner draw from these test results?
1. The test is positive and indicates an inner ear infection.
2. The test is negative and indicates a benign cerebral tumor.
3. The test is positive and indicates cerebellar dysfunction.
4. The test is negative and indicates cochlear dysfunction.
RIGHT ANSWER> 3
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: Identify tests used to diagnose disorders of the nervous system.
Source: pp. 994
Heading: Nursing Assessment of the Neurologic System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1 A positive Romberg test does not indicate an inner ear infection.
2 A negative Romberg does not indicate a benign cerebral tumor.
3 A positive Romberg test, when the hospital patient sways or leans to one side
during the
test, can be indicative of cerebellar dysfunction.
4 A negative Romberg test is not indicative of cochlear dysfunction.
PTS: 1 CON: Neurologic Regulation
12. The nursing practitioner is assisting with the care of a hospital patient admitted following a
fall resulting in a head injury. Which finding prompts the nursing practitioner to inform the RN
that the hospital patient is experiencing a negative change in the level of
consciousness?
1. Verbal commands are completed as stated.
2. The hospital patient arouses quickly from a state of drowsiness.
3. The hospital patient falls asleep in the middle of a sentence.
4. The hospital patient withdraws from mild pain stimulation.
RIGHT ANSWER> 3
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: Identify tests used to diagnose disorders of the nervous system.
Source: pp. 989
Heading: Level of Consciousness
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction in Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 A hospital patient is exhibiting a normal level of consciousness when he or
she is able to complete a verbal command as stated.
2 A quick arousal from a state of drowsiness is not indicative of a negative
change in the hospital patient’s level of consciousness.
3 The inability to remain awake or alert can be a negative change in the hospital
patient’s level of consciousness. Falling asleep in the middle of a sentence is a
behavior that needs to be reported to the RN.
4 Withdrawal from mild pain stimulus is a normal response.
PTS: 1 CON: Neurologic Regulation
13. The nursing practitioner is monitoring a hospital patient who is 4 years of age who fell
down a flight of steps. A Babinski response was not present during the initial assessment. The
RN asks the nursing practitioner to recheck for a Babinski reflex and report abnormal responses.
Which response will the nursing practitioner report to the RN?
1. The great toe extends and the other toes fan out.
2. All the toes curl toward the sole of the foot.
3. The great toe flexes when sole is stroked.
4. The foot is jerked away when the sole is stroked.
RIGHT ANSWER> 1
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: Identify tests used to diagnose disorders of the nervous system.
Source: pp. 994
Heading: Nursing Assessment of the Neurologic System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 After the age of 6 months, the Babinski reflex is no longer present. At 4 years of
age, a positive reflex (extension of the great toe and fanning of the other toes) is
indicative of neurologic dysfunction. This finding is reported to the RN.
2 All toes curling toward the sole of the foot is not a positive Babinski reflex.
3 After the age of 6 months, the flexion of the great toe when the sole of the foot
is stroked is normal.
4 The hospital patient may or may not jerk the foot away when the sole of the foot
is stroked; this action is not a positive Babinski reflex.
PTS: 1 CON: Neurologic Regulation
14. The nursing practitioner is preparing to collect data during the reassessment of a
hospital patient’s neurologic status. Which equipment is unnecessary for this
procedure?
1. Clean gloves
2. Reflex hammer
3. Cotton ball
4. Pointed object
RIGHT ANSWER> 3
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: Identify tests used to diagnose disorders of the nervous system.
Source: pp. 994
Heading: Physical Examination
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 Clean gloves will be needed as the nursing practitioner performs the palpation
actions related to a neurologic reassessment.
2 A reflex hammer is used to assess the presence and characteristics of body
reflexes; however, this procedure is not performed by the licensed practical
nurse/licensed vocational nurse.
3 A cotton ball is used to reassess if the hospital patient can distinguish a soft-
touch sensation.
4 A pointed object is used to reassess if the hospital patient can distinguish a sharp
sensation.
PTS: 1 CON: Neurologic Regulation
15. The nursing practitioner is providing care for a hospital patient who is experiencing
difficulty eating due to a neurologic dysfunction. Which action by the nursing practitioner
will be least helpful in promoting adequate nutritional intake for this hospital patient?
1. Provide high-protein, high-caloric foods and supplements.
2. Position the hospital patient to sit upright as much as possible.
3. Plan for small frequent meals to improve toleration.
4. Allow the hospital patient adequate time and privacy to self-feed.
RIGHT ANSWER> 4
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: Describe common therapeutic measures used for hospital patients with disorders
of the nervous system.
Source: pp. 998
Heading: Nutrition
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 When a hospital patient is diagnosed with a neurologic dysfunction, it is often
difficult
for the hospital patient to achieve an adequate nutritional intake, a condition
often compounded by the increased metabolic rate that occurs with neurologic
dysfunction or illness. Nutrition should consist of high-protein, high-caloric
foods and supplements.
2 Choking and/or swallowing difficulties are often seen in hospital patients with
neurologic dysfunctions. The nursing practitioner will assist the hospital patient
to the most upright
position possible.
3 When a hospital patient has any condition that interferes with the ability or
desire to eat, small, frequent meals should be provided.
4 When a hospital patient has a neurologic dysfunction, the nursing practitioner
needs to remain close
by to be of assistance or to react to problems or complications.
PTS: 1 CON: Neurologic Regulation
MULTIPLE RESPONSE
1. The nursing practitioner suspects a hospital patient is experiencing a sympathetic response.
Which manifestations does the nursing practitioner expect the hospital patient to exhibit? (Select
all that apply.)
1. Relaxation of bladder
2. Decrease in peristalsis
3. Dilation of bronchioles
4. Decrease in heart rate to normal
5. Increase in salivary gland secretion
RIGHT ANSWER> 1, 2, 3
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: Describe the normal structures and functions of the nervous system.
Pages: 985–986
Heading: Sympathetic Division
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1. The bladder muscle relaxes and the sphincter constricts to prevent urination.
2. Relatively less important activities such as digestion (and salivation) are
slowed.
3. Vasodilation in skeletal muscles supplies them with more oxygen; the
bronchioles dilate to take in more air.
4. When the sympathetic nervous system is activated, the heart rate increases.
5. Relatively less important activities such as digestion (and salivation) are
slowed, and vasoconstriction in the skin and viscera permits greater blood
flow to more vital organs such as the brain, heart, and muscles.
PTS: 1 CON: Neurologic Regulation
2. The nursing practitioner is caring for a hospital patient scheduled for a computed
tomography (CT) scan with contrast. Which actions does the nursing practitioner include in
the preprocedure preparation? (Select all that apply.)
1. Check blood urea nitrogen (BUN) and creatinine levels.
2. Question the hospital patient about allergies to dye, shellfish, or iodine.
3. Determine if the hospital patient has aneurysm clips or metal pins in the body.
4. Explain to the hospital patient that a sensation of warmth may be felt when
the dye is injected.
5. Tell the hospital patient to report any nausea, itchiness, or difficulty breathing
during the scan.
RIGHT ANSWER> 1, 2, 4, 5
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: Plan nursing care for hospital patients undergoing diagnostic tests for disorders
of the nervous system.
Source: pp. 996
Heading: Computed Tomography
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1. The BUN and creatinine levels should be checked before administration of
contrast material because it is excreted through the kidneys. Hospital patients
with elevated BUN and creatinine or known renal disease may be unable to
tolerate the contrast material.
2. The hospital patient should be questioned about any allergies to contrast
material, iodine, or shellfish.
3. Clips or metal pins in the body would be assessed if the hospital patient were
scheduled for an MRI.
4. Hospital patients who are receiving dye should be warned that they may feel
a sensation of warmth following the injection; warmth in the groin area may
make them feel as though they have been incontinent of urine.
5. Nausea, diaphoresis, itching, or difficulty breathing may indicate allergy to
the dye and should be reported immediately to the physician or nurse
practitioner.
PTS: 1 CON: Neurologic Regulation
3. The nursing practitioner is preparing a review of the neurologic system as part of a
community health presentation. Which structures does the nursing practitioner identify as
being part of the diencephalon? (Select all that apply.)
1. Pons
2. Medulla
3. Thalamus
4. Brainstem
5. Hypothalamus
RIGHT ANSWER> 3, 5
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: Describe the normal structures and functions of the nervous system.
Source: pp.
985 Heading:
Brain
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Teaching/Learning
CL: Analysis (Analyzing) Concept:
Neurologic Regulation Difficulty:
Difficult
CLARIFICATION
1. The medulla and pons are structures within the brainstem.
2. The medulla and pons are structures within the brainstem.
3. The diencephalon consists primarily of the thalamus and hypothalamus.
4. The diencephalon is superior in structure to the brainstem.
5. The diencephalon consists primarily of the thalamus and hypothalamus.
PTS: 1 CON: Neurologic Regulation
4. While observing the neurologist complete a neurologic examination, the nursing
practitioner notes that a hospital patient has an absent left patellar reflex. Which possible areas
of dysfunction does the nursing practitioner consider? (Select all that apply.)
1. Spinal cord
2. Femoral nerve
3. Anterior fibula muscle
4. Posterior tibial muscle
5. Quadriceps femoris muscle
RIGHT ANSWER> 1, 2, 5
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: Describe the normal structures and functions of the nervous system.
Source: pp. 994
Heading: Normal Neurologic System Anatomy and Physiology
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1. If the patellar reflex is absent, the problem might be in the quadriceps
femoris muscle, the femoral nerve, or the spinal cord itself.
2. If the patellar reflex is absent, the problem might be in the quadriceps
femoris muscle, the femoral nerve, or the spinal cord itself.
3. The absence of a patellar reflex does not suggest that a problem exists within
the anterior fibula or posterior tibial muscles.
4. The absence of a patellar reflex does not suggest that a problem exists within
the anterior fibula or posterior tibial muscles.
5. If the patellar reflex is absent, the problem might be in the quadriceps
femoris muscle, the femoral nerve, or the spinal cord itself.
PTS: 1 CON: Neurologic Regulation
5. The nursing practitioner is using the FOUR tool to assess a hospital patient’s neurologic
functioning. In which areas does the nursing practitioner collect data when using this tool?
(Select all that apply.)
1. Reflexes
2. Eye response
3. Verbal response
4. Motor movement
5. Breathing pattern
RIGHT ANSWER> 1, 2, 4, 5
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: List data to collect when caring for a hospital patient with a disorder of the
nervous system.
Source: pp. 991
Heading: FOUR SCALE
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1. The FOUR tool measures data from four categories: eye response, motor
movement, reflexes, and breathing pattern.
2. The FOUR tool measures data from four categories: eye response, motor
movement, reflexes, and breathing pattern.
3. A major benefit of using the FOUR tool is that no evaluation of verbal
response is necessary.
4. The FOUR tool measures data from four categories: eye response, motor
movement, reflexes, and breathing pattern.
5. The FOUR tool measures data from four categories: eye response, motor
movement, reflexes, and breathing pattern.
PTS: 1 CON: Neurologic Regulation
Chapter 48. Nursing Care of Hospital patients With Central Nervous System
Disorders
MULTIPLE CHOICE
1. The nursing practitioner is working in a college infirmary when a student comes in and
states, “I think I have a migraine. My head hurts, I cannot stand the light, and I feel sick to
my stomach.” Which additional data collected by the nursing practitioner causes concern for
a different diagnosis?
1. A subnormal temperature
2. Ill college roommate
3. Positive Brudzinski’s sign
4. Positive Romberg test
RIGHT ANSWER> 3
Chapter: Chapter 48. Nursing Care of Hospital patients With Central Nervous System
Disorders Objective: Explain causes, risk factors, and pathophysiology of central
nervous system infections, including meningitis and encephalitis.
Source: pp. 1001
Heading: Meningitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1 A subnormal temperature can be caused by a variety of conditions; this alone
does not cause the nursing practitioner concern about the diagnosis.
2 The fact that the student’s college roommate is ill can be a concern. However,
this data alone does not cause the nursing practitioner concern. Additional data
are needed.
3 A positive Brudzinski’s sign is indicative of inflammation in the meninges and
spinal nerve roots. This information indicates a presence of meningitis.
4 A Romberg test is performed to diagnose the presence of a brain lesion.
PTS: 1 CON: Neurologic Regulation
2. A hospital patient is brought to the health care provider’s office with a headache, lethargy,
nausea, vomiting, and a fever, which has developed over the past few days. The nursing
practitioner begins collecting data about the possible causes of the symptoms. Which
information indicates a possible cause for encephalitis?
1. The hospital patient has recently exhibited flu-like manifestations.
2. The hospital patient lives in a home where a child has chickenpox.
3. The hospital patient has been camping within the last few weeks.
4. The hospital patient has experienced a stiff neck for 3 days.
RIGHT ANSWER> 3
Chapter: Chapter 48. Nursing Care of Hospital patients With Central Nervous System
Disorders Objective: Explain causes, risk factors, and pathophysiology of central
nervous system infections, including meningitis and encephalitis.
Source: pp. 1003
Heading: Encephalitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 Having the flu may or may not initiate encephalitis; the nursing practitioner
needs to look at a more specific cause.
2 Herpes simplex virus (HSV) is the most common non-insect cause of
encephalitis, and most individuals harbor HSV type 1 in a dormant state in the
body. However, the hospital patient’s exposure to chickenpox (varicella zoster
virus) is not an obvious cause of the symptoms.
3 Mosquitos and ticks are carriers of West Nile virus, a precursor to encephalitis.
This information will cause the nursing practitioner to suspect the development
of encephalitis.
4 The development of a stiff neck can be a symptom of encephalitis and not a
cause.
PTS: 1 CON: Neurologic Regulation
3. The licensed practical nursing practitioner (LPN) is assigned to assist the registered
nursing practitioner (RN) in providing care for a hospital patient admitted for an
inflammatory neurologic disorder. Which reassessment finding does the LPN report
immediately to the RN?
1. The hospital patient has a consistent temperature of 101.4°F rectally.
2. The hospital patient attempts to get out of bed to go to work.
3. A pain level of 5 on a scale of 0 to 10 is verbally reported.
4. The hospital patient is noticed to be changing position without assistance.
RIGHT ANSWER> 2
Chapter: Chapter 48. Nursing Care of Hospital patients With Central Nervous System
Disorders Objective: Plan nursing interventions for a hospital patient with a central nervous
system infection. Source: pp. 1005
Heading: Nursing Care Plan for a Hospital patient With a Brain Infection or
Injury. Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 The hospital patient with an inflammatory neurologic disorder is expected to
have an
elevated temperature. The LPN will record the existing temperature and the RN
will determine if additional nursing care is necessary.
2 If the hospital patient is attempting to get out of bed to go to work, the LPN
recognizes
the development of confusion, which can be related to cerebral edema and
increased intracranial pressure (ICP); the RN needs to be notified immediately.
3 The LPN will report the hospital patient’s pain level of 5 on a scale of 0 to 10.
The RN will determine if additional nursing or medical care is necessary.
4 The hospital patient’s ability to change positions independently is not a finding
that
needs reported to the RN immediately.
PTS: 1 CON: Neurologic Regulation
4. The nursing practitioner is providing information to a hospital patient with migraine
headaches. Which information from the hospital patient is least likely to be useful to the HCP
when prescribing treatment?
1. The effectiveness of resting in a dark, quiet environment
2. Keeping a diary about episodes including pre- and postinformation
3. Determining if there may be a genetic connection to the headaches
4. Making note of preheadache visual, speech, or sensation disturbances
RIGHT ANSWER> 1
Chapter: Chapter 48. Nursing Care of Hospital patients With Central Nervous System
Disorders Objective: Provide teaching for a hospital patient experiencing headaches.
Source: pp. 1010
Heading: Migraine Headaches
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 Ascertaining the effectiveness of a dark, quiet environment is the least useful
information to the HCP when prescribing treatment. Most hospital patients will
respond
positively to this intervention.
2 Keeping a diary about the episodes of migraines is likely to be helpful to the
HCP when making decisions about prescribing treatment.
3 Knowing about a possible genetic connection will be helpful to the HCP when
prescribing treatment. It is useful to know which treatments were successful or
unsuccessful with family members.
4 Knowledge about whether hospital patient has an aura assists the HCP to
prescribe actions and behaviors that will help the hospital patient to manage
migraine headaches. Some medications are effective if taken prior to or
immediately at the onset of a migraine.
PTS: 1 CON: Neurologic Regulation
5. The nursing practitioner is assisting with the care of a hospital patient after a traumatic brain
injury. The hospital patient experiences a seizure and exhibits bilateral jerking of the
extremities. Which type of seizure activity does the nursing practitioner recognize?
1. Partial
2. Chronic
3. Generalized
4. Traumatic
RIGHT ANSWER> 3
Chapter: Chapter 48. Nursing Care of Hospital patients With Central Nervous System
Disorders Objective: List the causes and types of seizures.
Source: pp. 1015
Heading: Seizure Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 A partial seizure usually involves one side of the body due to the involvement
of one side of the cerebral cortex.
2 Chronic seizures are usually classified as epilepsy. This hospital patient is at
risk for acquiring epilepsy due to a traumatic brain injury. Another cause is an
anoxic
event.
3 Generalized seizure involves both sides of the brain and results in the hospital
patient experiencing involvement of both sides of the body.
4 There is no specific description or classification for traumatic seizures.
PTS: 1 CON: Neurologic Regulation
6. The nursing practitioner is providing care for a hospital patient on a medical unit with a
history of seizure activity. The hospital patient exhibits the manifestations of a generalized
seizure, which does not respond to prescribed treatment. Seizure activity has been continuous
for over 30 minutes. Which prescription does the nursing practitioner prepare for the HCP?
1. Gathering equipment needed for mechanical ventilation
2. Administering IV lorazepam or diazepam for seizure control
3. Setting up for administration of IV phenobarbital to induce coma
4. Making immediate arrangements to transfer the hospital patient to the intensive
care unit (ICU)
RIGHT ANSWER> 4
Chapter: Chapter 48. Nursing Care of Hospital patients With Central Nervous System
Disorders Objective: Describe appropriate interventions for an individual experiencing a
seizure. Source: pp. 1014
Heading: Status Epilepticus
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 The need for mechanical ventilation is usually part of an emergency response
situation. The nursing practitioner does not need to gather the equipment for
mechanical
ventilation. It will be brought by the emergency response team.
2 It is unlikely that the HCP will prescribe additional medication for seizure
control if status epilepticus is occurring; the condition is defined as seizure
activity for longer than 30 minutes, which does not respond to treatment.
3 The hospital patient may need to have a phenobarbital coma induced to stop
seizure
activity; however, this treatment is not performed on a medical unit.
4 The nursing practitioner expects the HCP to prescribe moving the hospital
patient to ICU where aggressive treatment and close monitoring can occur.
PTS: 1 CON: Neurologic Regulation
7. An older adult hospital patient is experiencing the manifestation related to a neurocognitive
disorder and is being transferred to a long-term care facility. Which condition will involve the
nursing practitioner in reaching long-term goals related to this hospital patient?
1. Suggesting the family attend a support group
2. Considering the hospital patient’s input regarding care
3. Accepting the hospital patient’s attempts at independence
4. Requesting hospitalization when symptoms worsen
RIGHT ANSWER> 1
Chapter: Chapter 48. Nursing Care of Hospital patients With Central Nervous System
Disorders Objective: Plan nursing care for a hospital patient with a neurodegenerative
disorder.
Source: pp. 1012
Heading: Neurodegenerative and Neurocognitive Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 A long-term goal is for the family to understand and accept the disease process
related to neurocognitive disorders. The nursing practitioner can assist by
suggesting the family attend a support group.
2 When a hospital patient is placed into a long-term care facility for
neurocognitive
decline, the hospital patient may not be capable of providing input regarding
care. However, the hospital patient’s likes and dislikes are always considered.
3 A long-term goal is to allow whatever independence the hospital patient can
maintain, providing safety for the hospital patient is not compromised.
Maintaining independence
is not a long-term goal for the diagnosis.
4 Hospitalization for a hospital patient with a neurocognitive disorder is only
prescribed if
the hospital patient has a physiological condition requiring acute care.
PTS: 1 CON: Neurologic Regulation
8. A hospital patient is distressed to learn that a sibling is diagnosed with both neurologic and
cognitive manifestations of Huntington disease. When the hospital patient asks the nursing
practitioner how to determine the incidence of the disease, which answer is most
appropriate?
1. “All family members are now at risk for the disease.”
2. “You definitely need to have genetic testing for the disease.”
3. “Your children need to be tested for a genetic connection.”
4. “If you are not diagnosed by age 20, you are considered safe.”
RIGHT ANSWER> 2
Chapter: Chapter 48. Nursing Care of Hospital patients With Central Nervous System
Disorders Objective: Explain causes, risk factors, and pathophysiology associated with
neurodegenerative disorders such as Parkinson, Huntington, and Alzheimer diseases.
Source: pp. 1046
Heading: Huntington Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1 Huntington disease is caused by an autosomal dominant gene. All persons who
carry the gene will contract the disease; however, each offspring has a 50-50
chance of inheriting the gene.
2 It is imperative for the offspring of a parent who contracts Huntington disease
to be tested. If the gene is present, the individual will contract the disease, and
all offspring of that individual will have a 50-50 chance of also inheriting the
gene and the disease.
3 The hospital patient’s children do not need to be tested unless the parent tests
positive for the gene. If the parent is negative, all offspring are not at risk.
4 The unfortunate fact about Huntington disease is that it is not symptomatic until
the hospital patient is in his or her 30s or 40s, oftentimes after children are born.
PTS: 1 CON: Neurologic Regulation
9. The nursing practitioner is providing care for a hospital patient who was diagnosed with
Parkinson disease 12 years prior. Which manifestation of the disease presents the nursing
practitioner with the most likely risk for safety of this hospital patient?
1. Bradykinesia
2. Muscle rigidity
3. Shuffling gait
4. Resting tremors
RIGHT ANSWER> 3
Chapter: Chapter 48. Nursing Care of Hospital patients With Central Nervous System
Disorders Objective: Explain causes, risk factors, and pathophysiology associated with
neurodegenerative disorders such as Parkinson, Huntington, and Alzheimer diseases.
Source: pp. 1044
Heading: Parkinson Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1 Bradykinesia is slow movement, which can be a safety issue if the hospital
patient is trying to rebalance or prevent a fall. However, on its own, this is not
the manifestation most likely to be the greatest safety risk.
2 Muscle rigidity makes it difficult for the hospital patient to move; however, this
alone is
not the manifestation most likely to be a safety risk.
3 A shuffling gait is common in a hospital patient with Parkinson disease, and is
also the greatest risk for safety. The hospital patient may start off slowly, but
the speed of the gait increases until it is difficult for the hospital patient to stop
moving. Also, the inability to pick up one’s feet proposes an increased danger
of tripping and falling.
4 Resting tremors make it difficult to hold objects such as foods or liquids.
However, this is a manifestation least likely to pose a safety issue.
PTS: 1 CON: Neurologic Regulation
10. The nursing practitioner is hired by a family to provide care for a family member
diagnosed with stage 2 Alzheimer disease. Which action related to safety is most
important for the nursing practitioner to implement?
1. Help the hospital patient make lists for tasks to be completed.
2. Make sure that all doors are locked where potential risk exists.
3. Monitor for signs or behaviors related to the hospital patient’s physical needs.
4. Regenerate interest in activities, acquaintances, or surroundings.
RIGHT ANSWER> 2
Chapter: Chapter 48. Nursing Care of Hospital patients With Central Nervous System
Disorders Objective: Plan nursing care for a hospital patient with a neurodegenerative
disorder.
Source: pp. 1048
Heading: Alzheimer Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 The hospital patient who is most likely to benefit from lists and reminders
regarding
tasks is the hospital patient with stage 1 Alzheimer disease.
2 The hospital patient with stage 2 Alzheimer disease is likely to wander,
especially at night, because of disturbed sleep patterns. The danger is related to
the hospital patient getting into dangerous situations either in or out of the
home. All doors to areas of danger must be locked.
3 The loss of the ability to move independently, swallow, and express needs
occurs during stage 3 Alzheimer disease.
4 Diminished interest in activities, acquaintances, and surroundings occurs in
stage 2 Alzheimer disease. However, these manifestations are not likely to be
reversed or pose a safety risk.
PTS: 1 CON: Neurologic Regulation
11. A hospital patient is brought to the emergency department after being hit by a baseball bat
during a game. Which nursing intervention is immediately reported to the HCP or RN?
1. The presence of amnesia about details before and after the injury
2. Changes in heart and respiratory rate, fever, and diaphoresis
3. Presence of head and scalp contusions with a single lesion
4. One-sided paralysis, extreme weakness, or pupil dilation
RIGHT ANSWER> 2
Chapter: Chapter 48. Nursing Care of Hospital patients With Central Nervous System
Disorders Objective: Plan nursing care for a hospital patient with an injury to the brain or
spinal cord.
Source: pp. 1038
Heading: Traumatic Brain Injury
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurological Regulation
Difficulty: Difficult
CLARIFICATION
1 The nursing practitioner does report the presence of amnesia to the HCP and
RN. Because this is a common manifestation related to a concussion, it does
not warrant immediate reporting.
2 Rapid heart and respiratory rates, fever, and diaphoresis are indicative of
autonomic nervous symptoms caused by edema or hypothalamic injury. Of the
given manifestations, this is the finding that the nursing practitioner reports
immediately to
the HCP and RN.
3 Head and scalp contusions and a single lesion are reported to the HCP and RN;
however, they do not require immediate reporting.
4 The hospital patient’s symptoms are indicative of an acute subdural
hematoma, which generally occurs within 24 hours of injury. While the
possibility of this condition warrants monitoring, it is not necessarily the
symptom to report
immediately.
PTS: 1 CON: Neurologic Regulation
12. The nursing practitioner is assisting with care for a hospital patient in the ICU with an
extreme head injury. The HCP reports that the hospital patient has brain herniation. Which action
does the nursing practitioner expect from the HCP?
1. Insertion of a shunt to reduce fluid volume in the skull
2. Emergency surgery to relieve pressure in the intracranial space
3. Medication to promote movement of fluid into the circulation system
4. Arranging for the family to be approached about possible organ donation
RIGHT ANSWER> 4
Chapter: Chapter 48. Nursing Care of Hospital patients With Central Nervous System
Disorders Objective: Recognize symptoms in a hospital patient who is developing increased
intracranial pressure.
Source: pp. 1038
Heading: Brain Herniation
Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: Physiological Integrity—
Physiological Adaptation CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 Brain herniation is a condition that is not compatible with life.
2 Brain herniation is a condition that is not compatible with life.
3 Brain herniation is a condition that is not compatible with life.
4 Brain herniation is a condition that is not compatible with life; however, the
hospital patient is still a viable organ donor. The nursing practitioner should
expect the HCP to
arrange for the family to be approached about organ donation.
PTS: 1 CON: Neurologic Regulation
13. A hospital patient is diagnosed with bacterial encephalopathy. Which symptoms
exhibited by the hospital patient indicate late signs of the hospital patient’s diagnosis?
1. Short attention span and poor memory
2. Disorientation and difficulty following commands
3. Lack of involvement and lip smacking or chewing
4. Expressed fear about loud noises in the hallway
RIGHT ANSWER> 3
Chapter: Chapter 48. Nursing Care of Hospital patients With Central Nervous System
Disorders Objective: Explain causes, risk factors, and pathophysiology of central
nervous system infections, including meningitis and encephalitis.
Source: pp. 1003
Heading: Central Nervous System Infections
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Neurological Regulation
Difficulty: Moderate
CLARIFICATION
1 Short attention span and a poor memory are common mental status changes
commonly seen in hospital patients with meningitis.
2 Disorientation and difficulty following commands are common mental status
changes commonly seen in hospital patients with meningitis.
3 Lack of involvement can be related to lethargy, and lip smacking or chewing is
a sign of partial seizures. Both manifestations are late signs of encephalopathy
related to meningitis.
4 Misinterpretation of environmental stimuli is a common mental status change
in hospital patients with meningitis.
PTS: 1 CON: Neurologic Regulation
14. The nursing practitioner is assisting with the care of a hospital patient with a brain tumor
who is exhibiting ICP. Which nursing intervention is specifically initiated to provide safety for
this hospital patient?
1. Make sure the call light is always within the hospital patient’s reach.
2. Perform active or passive range of motion (ROM) at least twice each shift.
3. Relocate environmental objects and pad the bedside rails.
4. Follow HCP’s prescribed therapy for treatment of headache.
RIGHT ANSWER> 3
Chapter: Chapter 48. Nursing Care of Hospital patients With Central Nervous System
Disorders Objective: Identify nursing interventions that can help prevent increased
intracranial pressure.
Source: pp. 1003
Heading: Increased Intracranial Pressure
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Medium
CLARIFICATION
1 It is important for the nursing practitioner to make sure the call light is
available for all hospital patients regardless of their diagnosis.
2 Performing active or passive ROM at least twice each shift is important to
maintain the potential for mobility; however, this is not specifically related to
safety or to the hospital patient with ICP.
3 A hospital patient with ICP is at high risk for experiencing seizures; to
promote safety, the nursing practitioner will clear the environment of objects
that can cause injury and pad the side rails of the bed.
4 Following prescribed therapy for the treatment of headaches in a hospital patient
with
ICP is an important comfort measure.
PTS: 1 CON: Neurologic Regulation
15. The nursing practitioner is assisting the RN in providing care for a hospital patient with a
potential for ICP. Which manifestation does the nursing practitioner recognize as needing to be
reported to the RN?
1. Rapid apical pulse
2. Increased systolic blood pressure (BP)
3. Shallow, even respirations
4. Narrowing pulse pressure
RIGHT ANSWER> 2
Chapter: Chapter 48. Nursing Care of Hospital patients With Central Nervous System
Disorders Objective: Recognize symptoms in a hospital patient who is developing increased
intracranial pressure.
Source: pp. 1003
Heading: Increased Intracranial Pressure
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 Bradycardia is expected with increased ICP.
2 Increased systolic BP while the diastolic BP remains unchanged results in a
widening pulse pressure, which is a cardinal sign of ICP.
3 Uneven respiration is expected with increased ICP.
4 The pulse pressure widens with an increase in ICP. The systolic BP increases
while the diastolic BP remains unchanged.
PTS: 1 CON: Neurologic Regulation
MULTIPLE RESPONSE
1. The nursing practitioner is planning care for a hospital patient with a migraine headache.
Which actions does the nursing practitioner include in this plan of care? (Select all that apply.)
1. Rest
2. White noise
3. A dark, quiet room
4. Sumatriptan (Imitrex)
5. Acetaminophen (Tylenol)
RIGHT ANSWER> 1, 3, 4
Chapter: Chapter 48. Nursing Care of Hospital patients With Central Nervous System
Disorders Objective: Identify teaching to be provided for a hospital patient experiencing
headaches.
Source: pp. 1009
Heading: Migraine Headache
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1. A dark room and rest help reduce stimulation during a migraine headache.
2. Stimulation (noise and light) may worsen a migraine.
3. A dark room and rest help reduce stimulation during a migraine headache.
4. Sumatriptan is a medication available to be used for migraine relief.
5. Acetaminophen may be helpful for sinus headaches.
PTS: 1 CON: Neurologic Regulation
2. The nursing practitioner is caring for a hospital patient with an acute brain injury. Which
interventions does the nursing practitioner use to prevent increased intracranial pressure in this
hospital patient? (Select all that apply.)
1. Avoid hip flexion.
2. Administer stool softeners.
3. Keep head of bed elevated 30 degrees.
4. Encourage deep breathing and coughing.
5. Administer opioid analgesics for headache.
RIGHT ANSWER> 1, 2, 3
Chapter: Chapter 48. Nursing Care of Hospital patients With Central Nervous System
Disorders Objective: Identify nursing interventions that can help prevent increased
intracranial pressure.
Pages: 1005–1006
Heading: Increased Intracranial Pressure
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1. Elevation of the head of the bed may help reduce intracranial pressure (ICP).
2. Stool softeners prevent straining, which can increase ICP. Hip flexion may
also increase ICP.
3. Hip flexion may also increase ICP.
4. Coughing can increase ICP.
5. Opioid analgesics make neurological assessment difficult.
PTS: 1 CON: Neurologic Regulation
3. The nursing practitioner suspects that a hospital patient is experiencing increasing ICP.
What observations cause the nursing practitioner to come to this conclusion? (Select all that
apply.)
1. Headache
2. Rising temperature
3. Decreasing systolic pressure
4. Dilated pupil on affected side
5. Decreasing level of consciousness (LOC)
RIGHT ANSWER> 1, 2, 4, 5
Chapter: Chapter 48. Nursing Care of Hospital patients With Central Nervous System
Disorders Objective: Recognize symptoms in a hospital patient who is developing increased
intracranial pressure.
Source: pp. 1005
Heading: Increased Intracranial Pressure
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1. Headache, increasing systolic pressure, decreasing LOC, dilated pupil on
affected side, and rising temperature are all signs of increased ICP.
2. Headache, increasing systolic pressure, decreasing LOC, dilated pupil on
affected side, and rising temperature are all signs of increased ICP.
3. Decreasing systolic blood pressure is not associated with increased
intracranial pressure.
4. Headache, increasing systolic pressure, decreasing LOC, dilated pupil on
affected side, and rising temperature are all signs of increased ICP.
5. Headache, increasing systolic pressure, decreasing LOC, dilated pupil on
affected side, and rising temperature are all signs of increased ICP.
PTS: 1 CON: Neurologic Regulation
4. A hospital patient is prescribed the dopamine agonist pramipexole (Mirapex) for Parkinson
disease. Which instructions are important for the nursing practitioner to include when teaching
about this medication? (Select all that apply.)
1. “Take it at noon each day.”
2. “Increase fluids and fiber in your diet.”
3. “Taking the medication with food may reduce nausea.”
4. “You may experience sudden bouts of excessive sleepiness.”
5. “Do not drive until the effects of this drug on you are fully known.”
RIGHT ANSWER> 3, 4, 5
Chapter: Chapter 48. Nursing Care of Hospital patients With Central Nervous System
Disorders Objective: Plan nursing care for a hospital patient with a neurodegenerative
disorder.
Source: pp. 1043
Heading: Parkinson Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Pharmacological
Integrity CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1. Selegiline, not pramipexole, should be given at noon.
2. It is unknown if this medication causes constipation.
3. Giving with meals may reduce nausea.
4. Hospital patients may fall asleep suddenly when taking this medication. The
hospital patient
should be cautioned to avoid driving until effects are known.
5. Hospital patients may fall asleep suddenly when taking this medication. The
hospital patient should be cautioned to avoid driving until effects are known.
PTS: 1 CON: Neurologic Regulation
5. A hospital patient with a spinal cord injury at T3–T4 experiences a sudden increase in BP
and has cool, pale, gooseflesh skin on the lower extremities. Which action does the
nursing practitioner perform while awaiting physician orders? (Select all that apply.)
1. Monitor BP every 5 minutes.
2. Place the hospital patient in supine position.
3. Place elastic stockings on the hospital patient’s legs.
4. Check to see if the indwelling catheter is patent.
5. Perform a rectal examination to determine if impaction is present.
RIGHT ANSWER> 1, 4, 5
Chapter: Chapter 48. Nursing Care of Hospital patients With Central Nervous System
Disorders Objective: Plan nursing care for a hospital patient with an injury to the brain or
spinal cord.
Source: pp. 1035
Heading: Spinal Cord Injuries
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1. The hospital patient is experiencing autonomic dysreflexia, which can cause
hypertension and bradycardia. The nursing practitioner should monitor BP
and then check
for catheter patency and impaction, both of which can cause dysreflexia.
2. The hospital patient should be placed in high Fowler’s position, and elastic
stockings should be removed to allow blood to pool and reduce BP.
3. The hospital patient should be placed in high Fowler’s position, and elastic
stockings
should be removed to allow blood to pool and reduce BP.
4. The hospital patient is experiencing autonomic dysreflexia, which can cause
hypertension and bradycardia. The nursing practitioner should monitor BP
and then check for catheter patency and impaction, both of which can cause
dysreflexia.
5. The hospital patient is experiencing autonomic dysreflexia, which can cause
hypertension and bradycardia. The nursing practitioner should monitor BP
and then check for catheter patency and impaction, both of which can cause
dysreflexia.
PTS: 1 CON: Neurologic Regulation
Chapter 49. Nursing Care of Hospital patients With Cerebrovascular Disorders
MULTIPLE CHOICE
1. The nursing practitioner is providing care for a hospital patient diagnosed with a stroke
resulting in language disorder. Which type of disorder does the nursing practitioner
recognize if the hospital patient raises an arm in response to the nurse’s direction to stick out
his tongue?
1. Dysarthria
2. Expressive aphasia
3. Dysphasia
4. Receptive aphasia
RIGHT ANSWER> 4
Chapter: Chapter 49. Nursing Care of Hospital patients With Cerebrovascular Disorders
Objective: Describe causes, risk factors, and pathophysiology of transient ischemic attack,
ischemic stroke, and hemorrhagic stroke.
Source: pp. 1057
Heading: Language Disturbances
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 Slurred or indistinct speech (dysarthria) is caused when the stroke has caused a
motor problem.
2 Expressive aphasia is when the hospital patient knows what he wants to say but
cannot
speak or make sense.
3 Dysphasia is when the hospital patient experiences trouble selecting the
correct words, uses incomprehensible or nonsense speech, has trouble
understanding other’s speech, and has trouble writing or reading. Even with
this description, it is not as serious as aphasia.
4 The hospital patient has receptive aphasia, which is the inability to understand
spoken
and/or written words.
PTS: 1 CON: Neurologic Regulation
2. A hospital patient arrives at the emergency department and states, “Something is wrong. I
just don’t feel right.” Which objective data causes the nursing practitioner to suspect the
hospital patient is experiencing some type of stroke?
1. Symptoms have been increasing in severity for several days.
2. Ataxia is present when the hospital patient attempts to ambulate.
3. The hospital patient was diagnosed with hypertension managed with medication.
4. The hospital patient appears upset and cries easily throughout assessment.
RIGHT ANSWER> 2
Chapter: Chapter 49. Nursing Care of Hospital patients With Cerebrovascular Disorders
Objective: Identify emergency interventions for transient ischemic attack, ischemic stroke,
and hemorrhagic stroke.
Source: pp. 1056
Heading: Motor Disturbances
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1 The symptoms of a stroke usually have a rapid onset. However, the information
that symptoms have been increasing in severity for several days is subjective
data.
2 Ataxia may occur with a stroke and includes poor balance or stumbling, and a
staggering gate. This data is objective and strongly related to a stroke.
3 Diagnosis of hypertension and treatment with medication is subjective data.
However, hypertension is a major contributor to stroke.
4 The hospital patient appearing upset and crying easily is objective data;
however,
neither manifestation is unique to a stroke.
PTS: 1 CON: Neurologic Regulation
3. The nursing practitioner is providing care for a hospital patient diagnosed with an ischemic
stroke on the left side of the brain. The nursing practitioner notices that the hospital patient
does not easily locate items placed at the bedside. In which area does the nursing practitioner
place items for easy location?
1. On the left side
2. Directly in front
3. One the right side
4. As the hospital patient wants
RIGHT ANSWER> 3
Chapter: Chapter 49. Nursing Care of Hospital patients With Cerebrovascular Disorders
Objective: Describe causes, risk factors, and pathophysiology of transient ischemic attack,
ischemic stroke, and hemorrhagic stroke.
Source: pp. 1067
Heading: Visual Disturbances
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 The left side is not where the nursing practitioner places items for the hospital
patient. When a stroke is diagnosed on the left side, the eye that is affected is
on the same side as the
affected artery.
2 Placing items directly in front of the hospital patient may not be convenient at
all times.
3 The hospital patient with a stroke on the left side will have vision in the right
eye. Items
should be place on the right side.
4 The hospital patient may not be able to designate where items should be placed
because of the effects of the stroke. The nursing practitioner knows that the best
vision is on the right
side.
PTS: 1 CON: Neurologic Regulation
4. A hospital patient comes into the emergency department with symptoms of a stroke. Which
medication does the nursing practitioner expect to be given to the hospital patient if diagnostic
testing confirms an ischemic stroke?
1. Heparin
2. Clopidogrel
3. Warfarin
4. Tissue-type plasminogen activator (tPA)
RIGHT ANSWER> 4
Chapter: Chapter 49. Nursing Care of Hospital patients With Cerebrovascular Disorders
Objective: Identify emergency interventions for transient ischemic attack, ischemic stroke,
and hemorrhagic stroke.
Source: pp. 1060
Heading: Ischemic Stroke
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Pharmacological
Therapies CL: Application (Applying)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 Heparin can help prevent clots but is not effective in breaking up an existing
clot.
2 Clopidogrel can help prevent clots but is not effective in breaking up an
existing clot.
3 Warfarin can help prevent clots but is not effective in breaking up an existing
clot.
4 tPA is a thrombolytic agent that can break down the thrombus causing the
occlusion, which can potentially prevent or completely reverse the symptoms
of an ischemic stroke.
PTS: 1 CON: Neurologic Regulation
5. A hospital patient comes into the emergency department with unilateral paralysis,
aphasia, and inability to follow directions. Which emergency management by the health
care provider (HCP) is unexpected by the nurse?
1. Maintenance of oxygen therapy to a saturation of at least 94 percent
2. Careful monitoring of changes in the hospital patient’s level of consciousness
3. Scheduling laboratory tests, electrocardiogram (ECG), and computerized
tomography (CT) scan to be performed within 45 minutes
4. Immediate treatment for temperature greater than 99.6°F
RIGHT ANSWER> 3
Chapter: Chapter 49. Nursing Care of Hospital patients With Cerebrovascular Disorders
Objective: Plan therapeutic measures for transient ischemic attack, ischemic stroke, and
hemorrhagic stroke.
Source: pp. 1059
Heading: Therapeutic Measures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 Emergency care for a hospital patient suspected of a stroke is supportive while
test results are pending. ABCs (Airway, Breathing, and Circulation) are
monitored and oxygen therapy is ordered to maintain an oxygen saturation
rate of at least 94 percent.
2 The hospital patient’s level of consciousness is carefully monitored to determine
if the
hospital patient’s condition or the severity of the possible stroke is changing.
3 Laboratory tests, ECG, and CT scan are ordered with the expectation that
results will be available within 45 minutes of arrival. The HCP will want to
make a decision for thrombolytic therapy within an hour of arrival.
4 Any elevated temperature will be managed immediately because hyperthermia
is associated with poorer hospital patient outcomes.
PTS: 1 CON: Neurologic Regulation
6. A hospital patient arrives in the emergency department at 0200 exhibiting the
manifestations of a stroke. The hospital patient reports going to bed at 2100 and being
negative for symptoms. If the CT reveals an ischemic stroke related to a blood clot, for
which reason is tPA therapy withheld?
1. The therapy is based on the time the hospital patient went to bed.
2. The hospital patient’s symptoms have progressed too quickly.
3. The total effects of ischemia are not currently known.
4. The hospital patient is negative for any symptoms related to intracranial pressure (ICP).
RIGHT ANSWER> 1
Chapter: Chapter 49. Nursing Care of Hospital patients With Cerebrovascular Disorders
Objective: Plan therapeutic measures for transient ischemic attack, ischemic stroke, and
hemorrhagic stroke.
Source: pp. 1059
Heading: Thrombolytic Therapy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 When a hospital patient awakens during the night with symptoms of a stroke,
the time
of the stroke is set at the time the hospital patient went to bed. Thrombolytic
therapy must be started within 3 to 4.5 hours of symptom onset to be most
effective.
2 Thrombolytic therapy is not withheld because of the rate symptoms develop.
3 The total effects of ischemia is not a determining factor for tPA therapy; if the
CT scan reveals that a blockage exists in the brain, the therapy is started if all
other parameters are met.
4 The presence or absence of ICP is not a determining factor for tPA therapy.
PTS: 1 CON: Neurologic Regulation
7. The hospital patient is diagnosed with a cerebral vascular accident that has the slowest
rate of recovery and the highest probability of causing extensive neurologic deficits. For
which type of stroke does the nursing practitioner plan care for this hospital patient?
1. Thrombotic stroke
2. Cerebral aneurysm
3. Subarachnoid hemorrhage (SAH)
4. Reversible ischemic neurologic deficit (RIND)
RIGHT ANSWER> 3
Chapter: Chapter 49. Nursing Care of Hospital patients With Cerebrovascular Disorders
Objective: Describe causes, risk factors, and pathophysiology of transient ischemic attack,
ischemic stroke, and hemorrhagic stroke.
Source: pp. 1054
Heading: Subarachnoid Hemorrhage
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 A thrombotic stroke does not have the slowest rate of recovery.
2 Aneurysms are often asymptomatic if they do not bleed.
3 SAH is caused by rupture of blood vessels on the surface of the brain. This type
of infarct has the slowest rate of recovery and the highest probability of leaving
the hospital patient with extensive neurologic deficits.
4 RIND is reversible.
PTS: 1 CON: Neurologic Regulation
8. A hospital patient is recovering from a stroke. The family reports to the nursing
practitioner that the hospital patient alternates between periods of crying for no given
reason to periods of laughing inappropriately. Which condition does the nursing
practitioner suspect the hospital patient is exhibiting?
1. Pseudobulbar effect
2. Psychotic events
3. Bipolar disorder
4. Mood swings
RIGHT ANSWER> 1
Chapter: Chapter 49. Nursing Care of Hospital patients With Cerebrovascular
Disorders Objective: Identify outcomes that can be expected for a stroke victim.
Source: pp. 1061
Heading: Pseudobulbar Effect
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 A common consequence of a stroke is pseudobulbar effect in which the hospital
patient exhibits emotional lability or instability. Hospital patients move between
periods of profound sadness to euphoria and back again. Treatment is with the
medication dextromethorphan quinidine.
2 The hospital patient is not exhibiting psychotic events.
3 The symptoms are related to the stroke; there is no information supporting
bipolar disorder.
4 The hospital patient is not experiencing mood swings.
PTS: 1 CON: Neurologic Regulation
9. A hospital patient began experiencing manifestations of a stroke at 0800 hours. By
which time should thrombolytic medications be provided to reverse stroke symptoms?
1. 0900 hours
2. 1250 hours
3. 1400 hours
4. 1660 hours
RIGHT ANSWER> 2
Chapter: Chapter 49. Nursing Care of Hospital patients With Cerebrovascular Disorders
Objective: Identify emergency interventions for transient ischemic attack, ischemic stroke,
and hemorrhagic stroke.
Source: pp. 1059
Heading: Thrombolytic Therapy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1 A hospital patient needs to be treated within 4.5 hours and not 1 hour.
2 If a hospital patient experiencing ischemic stroke symptoms receives treatment
within
4.5 hours of symptom onset, medication can be provided to resolve the deficits.
3 This is too long to wait to provide medication to treat the symptoms of a stroke.
4 This is too long to wait to provide medication to treat the symptoms of a stroke.
PTS: 1 CON: Neurologic Regulation
10. The nursing practitioner is providing care for a hospital patient recovering from a right
hemisphere infarct who now exhibits unilateral neglect. Which nursing intervention is most
important at promoting safety for this hospital patient?
1. Encourage the hospital patient to turn her plate for ease in self-feeding.
2. Place the call light and phone on the hospital patient’s left side.
3. Teach the hospital patient to purposefully check the location of the left limbs.
4. Provide stimuli of all senses on the hospital patient’s affected side.
RIGHT ANSWER> 3
Chapter: Chapter 49. Nursing Care of Hospital patients With Cerebrovascular
Disorders Objective: Plan nursing care for a hospital patient with a cerebrovascular
disorder.
Source: pp. 1062
Heading: Unilateral Neglect
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1 Because a right hemisphere infarct causes neglect on the left side of the body,
the hospital patient is unaware of the left side of her environment and possibly
of the left side of her body. Turning the plate will assist with self-feeding, but it
is not a safety intervention.
2 The hospital patient’s call light and phone are placed so that they can be
easily found and used by the hospital patient. There is another option that is
more important for the
hospital patient’s safety.
3 Because the hospital patient can be totally unaware of the left side of the body,
injury can easily occur from unsafe positioning. The hospital patient needs to
check the location of the left limbs. This intervention is most important for
promoting safety.
4 It is important to provide stimuli of all senses on the hospital patient’s affected
side. This intervention will help improve the hospital patient’s condition, but is
not
necessarily related to safety.
PTS: 1 CON: Neurologic Regulation
11. The nursing practitioner is assisting the registered nursing practitioner (RN) in providing
care for a hospital patient who is recovering from a stroke. Which assigned intervention by the
RN will the nursing practitioner question?
1. Observe the hospital patient performing active range of motion (ROM) on the
affected side.
2. Assist with maintaining correct body alignment for comfort.
3. Support affected extremities with pillows to prevent dislocation.
4. Follow the physical therapist’s (PT’s) recommendations for being up in a bedside
chair.
RIGHT ANSWER> 1
Chapter: Chapter 49. Nursing Care of Hospital patients With Cerebrovascular
Disorders Objective: Plan nursing care for a hospital patient with cerebrovascular
disorder.
Source: pp. 1063
Heading: Impaired Physical Mobility related to decreased motor function
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Application (Applying)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 The hospital patient is not likely to be able to perform active ROM on the
affected side following a stroke. The nursing practitioner will seek clarification
from the RN.
2 The nursing practitioner will assist in maintaining correct body alignment for
the comfort of
the hospital patient and to prevent contractures.
3 The nursing practitioner will support affected extremities to promote comfort
and prevent dislocations.
4 The nursing practitioner will follow the PT’s instructions for being up in a
bedside chair or
for ambulation.
PTS: 1 CON: Neurologic Regulation
12. The nursing practitioner is preparing to assist a hospital patient with eating who is
recovering from a stroke. Which intervention is appropriate?
1. Have the hospital patient sip liquids in small amounts with a straw.
2. Place the hospital patient in a semi-Fowler’s position to promote swallowing.
3. Check the hospital patient’s mouth periodically for presence of pocketed food.
4. Instruct the hospital patient to swallow numerous times to clear food from the mouth.
RIGHT ANSWER> 3
Chapter: Chapter 49. Nursing Care of Hospital patients With Cerebrovascular
Disorders Objective: Plan nursing care for a hospital patient with cerebrovascular
disorder.
Source: pp. 1065
Heading: Imbalanced Nutrition
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 When a hospital patient is having trouble swallowing for any reason, the use
of straws is avoided. The amount of food and the rate of swallowing are not
easily
accomplished using a straw.
2 The hospital patient with swallowing issues should be placed in a high
Fowler’s position or sitting upright in a chair to prevent choking.
3 The nursing practitioner checks the hospital patient’s mouth periodically for
pocketed food, which
commonly occurs in hospital patients with swallowing issues.
4 The nursing practitioner teaches the hospital patient to swallow twice with each
bite to make sure the food is gone from the mouth. Swallowing numerous times
is not necessary.
PTS: 1 CON: Neurologic Regulation
13. The nursing practitioner is providing care for a hospital patient diagnosed with a
cerebral aneurysm and subarachnoid hemorrhage. Which statement by the hospital
patient indicates a need for additional information?
1. “The doctors are going to do studies to see if I can have surgery.”
2. “I know that I will be on some restrictions to prevent a rebleed.”
3. “No strenuous activity until this condition is cured by surgery.”
4. “It is very important to take my blood pressure medicine.”
RIGHT ANSWER> 3
Chapter: Chapter 49. Nursing Care of Hospital patients With Cerebrovascular Disorders
Objective: Plan therapeutic measures for transient ischemic attack, ischemic stroke, and
hemorrhagic stroke.
Source: pp. 1054
Heading: Cerebral Aneurysm, Subarachnoid Hemorrhage, and Intracranial Hemorrhage
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 The hospital patient has understanding about the need to perform studies to
see if surgery is possible.
2 The danger of an aneurysm is the risk for a rebleed. The hospital patient will
have
restrictions about strenuous activity with or without surgical treatment.
3 As stated above, restrictions are expected; however, the hospital patient needs
additional information about the prospect of curing the condition.
Subarachnoid hemorrhage is not curable; treatment consists of stabilizing the
cause if possible and preventing or managing complications.
4 With the diagnosis of an aneurysm and a resulting subarachnoid hemorrhage, it
is very important that systolic blood pressure remain between 120 and 160 mm
Hg.
PTS: 1 CON: Neurologic Regulation
14. A hospital patient is admitted from the emergency department to the hospital unit
following the diagnosis of an ischemic stroke. The hospital patient did not qualify for tPA
therapy. The nursing practitioner is aware that which poststroke condition places the
hospital patient at greatest risk for deep vein thrombosis (DVT)?
1. The inability to be mobile and move independently
2. Hypercoagulability related to the admitting diagnosis
3. Testing that identified the cause of the stroke as ischemic
4. Laboratory tests indicating hyperlipidemia with high-density lipoprotein (HDL) at
200
RIGHT ANSWER> 2
Chapter: Chapter 49. Nursing Care of Hospital patients With Cerebrovascular Disorders
Heading: Postemergent Care
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 Inability to move about and/or being restricted to bed can increase the risk of
DVT; however, there is no information regarding this restriction.
2 When an ischemic stroke occurs, it is commonly from a blood clot, a condition
complicated by the inability for tPA therapy. Therefore, the hospital patient is at
greatest
risk for DVT due to the hypercoagulability of the blood.
3 Testing that identifies the cause of an ischemic stroke may or may not place the
hospital patient at risk for DVT. Ischemic strokes are caused from any condition
that decreases blood flow in the brain.
4 Hyperlipidemia with a high low-density lipoprotein (LDL) and a low HDL, can
be a cause of a stroke. However, an HDL of 200 is a good test result.
PTS: 1 CON: Neurologic Regulation
15. The nursing practitioner is aware that children can be at risk for an embolic stroke.
Which condition is least likely to cause a child to have a stroke?
1. Contact sport trauma
2. Sickle cell disease
3. Hyperlipidemia
4. Congenital heart defect
RIGHT ANSWER> 1
Chapter: Chapter 49. Nursing Care of Hospital patients With Cerebrovascular Disorders
Objective: Describe causes, risk factors, and pathophysiology of transient ischemic attack,
ischemic stroke, and hemorrhagic stroke.
Source: pp. 1054
Heading: Embolic Stroke
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1 Contact sport trauma is the least likely cause of an embolic stroke, given the
other more likely causes.
2 Sickle cell disease causes the clumping of sickle-shaped red blood cells; the
clumped cells can create a clot and cause occlusions of blood vessels anywhere
in the body.
3 Hyperlipidemia, even in children, can cause an occlusion of a blood vessel,
which can create a clot if plaque deposits become dislodged.
4 A congenital heart defect may result in inadequate pump function allowing a
clot to form in the heart and travel to the brain.
PTS: 1 CON: Neurologic Regulation
16. The HCP is preparing to discharge a hospital patient from the hospital after a stroke. The
hospital patient is insistent on being sent to a rehabilitation center. The nursing practitioner is
aware that the hospital patient must meet which qualification to go to rehabilitation?
1. The determination to live alone and independently
2. The willingness to commit to long-term therapy
3. The ability to participate in intensive therapy
4. The acceptance of financial responsibility
RIGHT ANSWER> 3
Chapter: Chapter 49. Nursing Care of Hospital patients With Cerebrovascular Disorders
Objective: Plan therapeutic measures for transient ischemic attack, ischemic stroke, and
hemorrhagic stroke.
Source: pp. 1064
Heading: Rehabilitation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
CLARIFICATION
1 Determination alone is not a qualification to go to rehabilitation after a stroke.
2 Rehabilitation may or may not involve long-term therapy.
3 For a hospital patient to qualify for rehabilitation after a stroke, the hospital
patient must have
the ability to participate in intensive therapy.
4 Some insurance programs will pay for all or part of rehabilitation. The
willingness to accept financial responsibility is not a determining factor.
PTS: 1 CON: Neurologic Regulation
17. The nursing practitioner is reviewing the medical records of hospital patients in an HCP’s
practice. Which hospital patient does the nursing practitioner recognize as the greatest risk for a
stroke?
1. A postmenopausal hospital patient who has type 2 diabetes mellitus (DM)
controlled by diet
2. An overweight male with a 15-year smoking history, who is treated for
hypertension
3. A young adult born with a heart defect causing ventricle fibrillation
4. An older female hospital patient who has osteoporosis, a femur
fracture, and hyperlipidemia
RIGHT ANSWER> 4
Chapter: Chapter 49. Nursing Care of Hospital patients With Cerebrovascular Disorders
Objective: Describe causes, risk factors, and pathophysiology of transient ischemic attack,
ischemic stroke, and hemorrhagic stroke.
Source: pp. 1052
Heading: Prevention of Stroke
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficulty
CLARIFICATION
1 The postmenopausal hospital patient with type 2 DM controlled by diet has
three risk factors: gender, hormone change, and DM (even though controlled).
2 The male hospital patient has three risk factors: being overweight, smoking, and
hypertension.
3 The young hospital patient with a serious heart defect is a high risk for a
stroke. However, it is the only risk factor, which can be medically managed.
4 The older female hospital patient has five risks for a stroke: gender, age, fracture
of a
large bone, high cholesterol, and decreased activity related to a fractured femur.
PTS: 1 CON: Neurologic Regulation
18. The nursing practitioner is assisting with the care of a hospital patient following an
ischemic stroke who does not qualify for tPA therapy. The hospital patient’s current blood
pressure is 190/110 mm Hg. For which reason will the hospital patient’s hypertension remain
untreated?
1. The elevated blood pressure will create collateral circulation in the brain.
2. Therapeutic blood pressure needs to exceed 220/120 mm Hg to be effective.
3. Permissive hypertension is being therapeutically used to salvage brain tissue.
4. Hypertension will move the clot to an area of the brain treatable by tPA.
RIGHT ANSWER> 3
Chapter: Chapter 49. Nursing Care of Hospital patients With Cerebrovascular Disorders
Objective: Plan therapeutic measures for transient ischemic attack, ischemic stroke, and
hemorrhagic stroke.
Source: pp. 1055
Heading: Pharmacological Management
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Pharmacological
Therapies CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1 The high blood pressure does not create collateral circulation in the brain;
however, it does help blood to travel to the existing collateral vessels and
improve blood flow to the affected area.
2 When permissive hypertension is used, antihypertensive drugs are given if the
blood pressure exceeds 220/120 mm Hg.
3 Permissive hypertension is used when the hospital patient does not qualify for
tPA
therapy to improve cerebral circulation.
4 Moving the clot causing a stroke will only cause additional areas of damage.
Once a hospital patient is ruled out for tPA therapy, the decision is not reversed.
PTS: 1 CON: Neurologic Regulation
MULTIPLE RESPONSE
1. The nursing practitioner is providing care for a hospital patient with expressive aphasia.
Which intervention does the nursing practitioner expect to find in the hospital patient’s plan
of care? (Select all that apply.)
1. Speak loudly.
2. Use a picture board.
3. Obtain an interpreter.
4. Provide pencil and paper.
5. Speak slowly and clearly.
RIGHT ANSWER> 2, 4
Chapter: Chapter 49. Nursing Care of Hospital patients With Cerebrovascular
Disorders Objective: Plan nursing care for a hospital patient with a cerebrovascular
disorder.
Source: pp. 1056
Heading: Aphasia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1. Speaking loudly is not helpful unless the hospital patient has a hearing deficit
also.
2. For expressive aphasia, pencil and paper or a picture board can help with
communication.
3. Interpreters are used for language barriers, not for aphasia.
4. For expressive aphasia, pencil and paper or a picture board can help with
communication.
5. Speaking slowly and pantomiming may be helpful for receptive aphasia, not
expressive.
PTS: 1 CON: Neurologic Regulation
2. The nursing practitioner is involved in a blood pressure clinic in the community, and an
individual with possible stroke symptoms is brought for evaluation. Which findings in the
FAST (Face, Arms, Speech, and Time) assessment indicate the need to call emergency
personnel? (Select all that apply.)
1. The hospital patient sways when asked to stand still with eyes closed.
2. The hospital patient is unable to follow directions during the assessment.
3. The hospital patient is unable to repeat a stated phrase exactly as it was stated.
4. The hospital patient’s face shows signs of uneven symmetry when asked to smile.
5. When asked to close the eyes and hold arms straight in front, one arm drifts
downward.
RIGHT ANSWER> 3, 4, 5
Chapter: Chapter 49. Nursing Care of Hospital patients With Cerebrovascular Disorders
Objective: Describe causes, risk factors, and pathophysiology of transient ischemic attack,
ischemic stroke, and hemorrhagic stroke.
Source: pp. 1055
Heading: Warning Signs of Any Type of Stroke
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
CLARIFICATION
1. Swaying when asked to stand still with the eyes closed are indicators of a
possible stroke. Brain cells may be dying but is not part of the FAST
assessment.
2. Inability to follow instructions is a concern but is not part of the FAST
assessment.
3. The acronym FAST can help identify a stroke. Ask the person to say, “It is a
bright and sunny day.” Any difficulty understanding or speaking is abnormal.
Call 911 immediately for any abnormal findings.
4. The acronym FAST can help identify a stroke. Ask the person to smile. If the
face droops or is uneven on one side, it is abnormal. Call 911 immediately
for any abnormal findings.
5. The acronym FAST can help identify a stroke. Ask the person to close his or
her eyes and hold the arms out in front of him or her. If an arm cannot be
raised or drifts downward, it is abnormal. Call 911 immediately for any
abnormal findings.
PTS: 1 CON: Neurologic Regulation
Chapter 50. Nursing Care of Hospital patients With Peripheral Nervous System
Disorders
MULTIPLE CHOICE
1. The nursing practitioner is caring for a hospital patient experiencing an acute
exacerbation of multiple sclerosis (MS). Which pathophysiological change does the
nursing practitioner recognize as causing the manifestations of MS?
1. Myelin buildup in the central nervous system
2. Demyelination and destruction of nerve fibers
3. Gamma aminobutyric acid (GABA) deficiency
4. Reduced acetylcholine receptors with impaired nerve impulse transmission
RIGHT ANSWER> 2
Chapter: Chapter 50. Nursing Care of Hospital patients With Peripheral Nervous System
Disorders Objective: Explain the pathophysiology, major signs and symptoms, and
complications of selected peripheral nervous system disorders.
Pages: 1073–1075
Heading: Multiple Sclerosis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Immunity
Difficulty: Moderate
CLARIFICATION
1 Myelin does not build up with a diagnosis of MS.
2 In MS, the myelin sheath begins to break down or degenerates as a result of the
activation of the body’s immune system. The nerve becomes inflamed and
edematous. Nerve impulses to the muscles slow down. As the disease
progresses, sclerosis or scar tissue damages the nerve.
3 GABA is an inhibitory neurotransmitter and does not play a role in MS.
4 Acetylcholine receptors are damaged in myasthenia gravis (MG).
PTS: 1 CON: Immunity
2. The nursing practitioner is assisting with care of hospital patients diagnosed with
neuromuscular disorders. Which complication does the nursing practitioner recognize as a
medical emergency?
1. Evidence of severe muscle wasting
2. Indications of the development of pneumonia
3. Interruption of skin integrity over bony prominences
4. Difficulty maintaining weight due to difficulty swallowing
RIGHT ANSWER> 2
Chapter: Chapter 50. Nursing Care of Hospital patients With Peripheral Nervous System
Disorders Objective: List common nursing diagnoses associated with peripheral nervous
system disorders.
Source: pp. 1077
Heading: Neuromuscular Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Immunity
Difficulty: Moderate
CLARIFICATION
1 Neuromuscular disorders involve a disruption of impulse transmission between
neurons and the muscles they stimulate, resulting in muscle weakness. This
process occurs over time and is not likely to be considered as a medical
emergency.
2 When the respiratory muscles are affected by a neuromuscular disorder, the
hospital patient is at high risk for respiratory infections and/or respiratory
failure.
Indications of the development of pneumonia is a medical emergency.
3 An interruption of skin integrity over bony prominences is a concern; however,
the condition will occur over a period of time and is not considered a medical
emergency.
4 When a hospital patient has difficulty swallowing, there is a risk for choking,
aspiration,
or nutritional deficit. However, weight loss will occur over a period of time and
is not considered to be a medical emergency.
PTS: 1 CON: Immunity
3. A hospital patient who is prescribed neostigmine for newly diagnosed MG asks how the
medication works. Which response does the nursing practitioner provide to the hospital
patient?
1. “It is a muscle relaxant to prevent the cramping in your muscles.”
2. “It provides potassium to your muscles so that they will contract better.”
3. “It makes more neurotransmitters available so that your muscles can contract.”
4. “It reduces the inflammation in your nerves so that they transmit signals better.”
RIGHT ANSWER> 3
Chapter: Chapter 50. Nursing Care of Hospital patients With Peripheral Nervous System
Disorders Objective: Identify therapeutic measures used for selected peripheral nervous
system disorders.
Source: pp. 1080
Heading: Myasthenia Gravis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Pharmacological
Therapies CL: Application (Applying)
Concept: Immunity
Difficulty: Difficult
CLARIFICATION
1 This medication does not provide potassium or relax the muscles.
2 This medication does not provide potassium or relax the muscles.
3 Medications used to treat MG include the anticholinesterase (ACh) drugs
neostigmine and pyridostigmine. These drugs improve symptoms of MG by
destroying the acetylcholinesterase that breaks down ACh.
4 Steroids reduce inflammation.
PTS: 1 CON: Immunity
4. The nursing practitioner is collecting data from a hospital patient who is diagnosed with
MG. Which data is most important for the nursing practitioner to obtain?
1. Ascertain if the hospital patient’s needs are being met by an adequate support system.
2. Ask what amount of activity causes fatigue and muscle weakness to occur.
3. Determine baseline muscle strength through the use of appropriate techniques.
4. Monitor the hospital patient’s respiratory function and the ability to swallow effectively.
RIGHT ANSWER> 4
Chapter: Chapter 50. Nursing Care of Hospital patients With Peripheral Nervous System
Disorders Objective: Plan prioritized nursing interventions for hospital patients with peripheral
nervous system disorders.
Source: pp. 1080
Heading: Nursing Process for the Hospital patient with Myasthenia
Gravis Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: Physiological Integrity—Reduction of
Risk Potential CL: Analysis (Analyzing)
Concept: Immunity
Difficulty: Moderate
CLARIFICATION
1 It is important for the nursing practitioner to ascertain if a hospital patient with
MG has an adequate
support system and that needs are being met. However, this is not the most
important data for the nursing practitioner to collect.
2 The nursing practitioner will have a better understanding about the hospital
patient’s condition with information about how much activity causes fatigue and
muscle weakness to
occur. However, this is not the most important data for the nursing practitioner
to collect.
3 The nursing practitioner needs to determine baseline muscle strength through
the use of appropriate evaluation techniques. The information is useful for
tracking changes in the hospital patient’s condition; however, it is not the most
important data
for the nursing practitioner to collect.
4 The hospital patient with MG experiences muscle weakness. When the
respiratory muscles are involved, there is a high risk for complications. The
most important data for the nursing practitioner to collect is about the hospital
patient’s respiratory function and ability to swallow.
PTS: 1 CON: Immunity
5. A mother of three young children has a 3-year history of MG and recently stopped helping
in the children’s classrooms because of fatigue. Which advice does the nursing practitioner
give to help the hospital patient best cope with the problem?
1. “You need to realize that you may not be able to do the things you used to do.”
2. “Time your medication so its action peaks during the time you need the most
energy.”
3. “Get plenty of sleep the night before you help to give you the stamina you need.”
4. “Take your medication after you finish helping, and you may have a better energy
level.”
RIGHT ANSWER> 2
Chapter: Chapter 50. Nursing Care of Hospital patients With Peripheral Nervous System
Disorders Objective: Identify therapeutic measures used for selected peripheral nervous
system disorders.
Source: pp. 1080
Heading: Myasthenia Gravis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Immunity
Difficulty: Moderate
CLARIFICATION
1 This statement may also be true, but medication is needed to get through an
activity.
2 The hospital patient should be instructed to schedule activities at times when
medication is at peak action so that muscle strength is increased.
3 This statement may also be true, but medication is needed to get through an
activity.
4 Taking the medication after the activity will help with strength after, not
during, the activity.
PTS: 1 CON: Immunity
6. A hospital patient diagnosed with Guillain-Barré syndrome (GBS) asks how the disease
developed since the hospital patient rarely has an illness. Which nursing response is the most
accurate?
1. “No one knows an exact cause.”
2. “It may be an autoimmune reaction to a virus.”
3. “It most often occurs as a result of a bacterial infection.”
4. “It is usually hereditary. Does anyone in your family have it?”
RIGHT ANSWER> 2
Chapter: Chapter 50. Nursing Care of Hospital patients With Peripheral Nervous System
Disorders Objective: Explain the pathophysiology, major signs and symptoms, and
complications of selected peripheral nervous system disorders.
Source: pp. 1083
Heading: Guillain-Barre Syndrome
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Immunity
Difficulty: Moderate
CLARIFICATION
1 No one does know an exact cause; however, this statement is not the most
accurate.
2 GBS is believed to be caused by an autoimmune response to some type of viral
infection or vaccination.
3 It is believed to occur after a viral infection.
4 It is not hereditary.
PTS: 1 CON: Immunity
7. The nursing practitioner reviews information with a hospital patient and family members
about the hospital patient’s recent diagnosis of amyotrophic lateral sclerosis (ALS). Which
comment by a family member indicates a need for clarification?
1. “When the heart muscle is affected, death will occur shortly.”
2. “We need to remember that mental functioning is intact.”
3. “A feeding tube and ventilator may need to be considered later.”
4. “We need to do some research to see if this is a familial risk.”
RIGHT ANSWER> 1
Chapter: Chapter 50. Nursing Care of Hospital patients With Peripheral Nervous System
Disorders Objective: Evaluate the effectiveness of nursing care.
Source: pp. 1081
Heading: Amyotrophic Lateral Sclerosis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Immunity
Difficulty: Moderate
CLARIFICATION
1 ALS affects the voluntary muscles of the body; the heart and gastrointestinal
tract are controlled involuntarily and are not affected. Additional information is
needed.
2 The hospital patient with ALS retains mental functioning.
3 The hospital patient and family will need to consider whether a feeding tube
and ventilator is desired. Some hospital patients decide on comfort care
instead. However, this statement does not indicate a need for additional
information.
4 While the exact cause of ALS is unknown, it is believed to have a genetic
component. The family may benefit from knowing if there appears to be a
genetic risk.
PTS: 1 CON: Immunity
8. A hospital patient with trigeminal neuralgia is admitted to the hospital for diagnostic
testing and possible surgery. Which intervention is appropriate for this hospital patient?
1. Provide tissues for the hospital patient to deal with drooling.
2. Provide frequent mouth care with a firm toothbrush.
3. Provide soft foods at body temperature at mealtimes.
4. Provide a fan in the room to keep the room well ventilated.
RIGHT ANSWER> 3
Chapter: Chapter 50. Nursing Care of Hospital patients With Peripheral Nervous System
Disorders Objective: Plan prioritized nursing interventions for hospital patients with peripheral
nervous system disorders.
Source: pp. 1086
Heading: Trigeminal Neuralgia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Application (Applying)
Concept: Immunity
Difficulty: Moderate
CLARIFICATION
1 Hospital patients with Bell palsy may drool but not hospital patients with
trigeminal neuralgia.
2 Gentle mouth care is provided with a soft bristle toothbrush or mouth swabs.
3 Activities such as talking, face washing, teeth brushing, shaving, and eating can
cause pain in hospital patients with trigeminal neuralgia. Soft foods at room
temperature may be better tolerated than hot or cold foods.
4 Moving air from a fan can cause an exacerbation of pain.
PTS: 1 CON: Immunity
9. The nursing practitioner is assisting with the care of a hospital patient diagnosed with
postpolio syndrome. The nursing practitioner asks the registered nursing practitioner (RN) to
explain the source of the disease. Which answer by the RN is correct?
1. The syndrome begins with the contraction of polio.
2. The disease is common among third-world travelers.
3. The hospital patient must first have had a poliovirus infection.
4. The syndrome leads to development of great debilitation.
RIGHT ANSWER> 3
Chapter: Chapter 50. Nursing Care of Hospital patients With Peripheral Nervous System
Disorders Objective: Identify disorders that are caused by disruption of the peripheral
nervous system. Source: pp. 1084
Heading: Postpolio Syndrome
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Immunity
Difficulty: Moderate
CLARIFICATION
1 Postpolio syndrome affects survivors of polio 20 to 40 years after they have
recovered from infection caused by the poliomyelitis virus. Up to 40 percent of
hospital patients who previously had polio develop postpolio syndrome.
2 The original infection from the poliomyelitis virus does not occur commonly
among third-world travelers; there is no postpolio syndrome without a previous
infection from the virus.
3 The hospital patient must first have had a poliovirus infection; the syndrome
involves
further weakening of the muscles that were affected by the initial infection.
4 The postpolio syndrome may or may not cause great debilitation; some hospital
patients will develop lesser debilitation and fewer problems.
PTS: 1 CON: Immunity
10. A hospital patient reports to the nursing practitioner an inability to rest or sleep due to a
long-term condition causing a constant urge to move the legs called restless legs
syndrome (RLS). The hospital patient expresses a need for some type of relief. Which
suggestion by the nursing practitioner is most likely to help the hospital patient?
1. Elimination of alcohol, tobacco, and caffeine
2. Pramipexole or ropinrole medication therapy
3. Using a vibrating pad (Relaxis) approved by the Food and Drug Administration
(FDA)
4. Routine sleep habits and regular exercise program
RIGHT ANSWER> 2
Chapter: Chapter 50. Nursing Care of Hospital patients With Peripheral Nervous System
Disorders Objective: Identify therapeutic measures used for selected peripheral nervous
system disorders.
Source: pp. 1085
Heading: Restless Leg Syndrome
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Immunity
Difficulty: Difficult
CLARIFICATION
1 Elimination of alcohol, tobacco, and caffeine may or may not relieve RLS
symptoms.
2 Pramipexole or ropinrole are two medications ordered to treat moderate-to-
severe RLS by increasing serum dopamine levels. RLS is believed to be caused
by an imbalance of dopamine and serotonin in the brain; this is the suggestion
most likely to help the hospital patient.
3 In 2014, the FDA approved a vibrating pad (Relaxis) to aid in the relief of
RLS; some RLS sufferers have been helped.
4 Establishing routine sleep habits and a regular exercise program may or may
not help alleviate the symptoms of RLS.
PTS: 1 CON: Immunity
11. The nursing practitioner is providing care for a hospital patient after surgery for
treatment of trigeminal neuropathy. Which nursing intervention will the nursing
practitioner initiate for this hospital patient?
1. Protect the hospital patient’s face from any movement of air.
2. Place eye patches bilaterally while the hospital patient sleeps.
3. Check the eye on the surgery side for corneal sensation.
4. Provide a soft diet with food served at room temperature.
RIGHT ANSWER> 3
Chapter: Chapter 50. Nursing Care of Hospital patients With Peripheral Nervous System
Disorders Objective: Plan prioritized nursing interventions for hospital patients with peripheral
nervous system disorders.
Source: pp. 1086
Heading: Trigeminal Neuralgia
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Immunity
Difficulty: Moderate
CLARIFICATION
1 Trigeminal neuralgia can be triggered by air blowing across the effected side of
the hospital patient’s face; this should not be a concern after the corrective
surgery.
2 If the hospital patient has no feeling or cannot completely close the eye on the
side of surgery, a patch may be placed to protect the eye from injury during
sleep.
Bilateral patches are not necessary.
3 It is important to check for corneal sensation after surgery for trigeminal
neuralgia. If corneal sensation is lost, it is important for the hospital patient to
wear goggles and sunglasses to prevent injury to the cornea.
4 Extreme temperatures can trigger pain with trigeminal neuralgia, and food is
best served at room temperature. This will not be necessary following surgery.
PTS: 1 CON: Immunity
12. The nursing practitioner is preparing a hospital patient with MG to undergo plasmapheresis.
Which laboratory tests does the nursing practitioner verify and place on the medical record before
the procedure?
1. Urine analysis, urine protein, blood urea nitrogen (BUN), and creatinine
2. Complete blood count, platelets, and clotting studies
3. Creatinine phosphokinase, blood type, and electrolytes
4. Electrolytes, BUN, creatinine, and albumin
RIGHT ANSWER> 2
Chapter: Chapter 50. Nursing Care of Hospital patients With Peripheral Nervous System
Disorders Objective: Identify therapeutic measures used for selected peripheral nervous
system disorders.
Source: pp. 1080
Heading: Myasthenia Gravis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Immunity
Difficulty: Moderate
CLARIFICATION
1 Laboratory tests such as urinalysis, urine protein, BUN, creatinine, blood type,
electrolytes, and albumin are not necessary before having a plasmapheresis.
2 Plasmapheresis is used to remove the hospital patient’s plasma and replace it
with fresh plasma. Complete blood cell count, platelet count, and clotting
studies are assessed prior to the procedure.
3 Laboratory tests such as urinalysis, urine protein, BUN, creatinine, blood type,
electrolytes, and albumin are not necessary before having a plasmapheresis.
4 Laboratory tests such as urinalysis, urine protein, BUN, creatinine, blood type,
electrolytes, and albumin are not necessary before having a plasmapheresis.
PTS: 1 CON: Immunity
13. A hospital patient is scheduled for a thymectomy. For which peripheral nervous system
disorder does the nursing practitioner plan care for this hospital patient?
1. MS
2. MG
3. GBS
4. ALS
RIGHT ANSWER> 2
Chapter: Chapter 50. Nursing Care of Hospital patients With Peripheral Nervous System
Disorders Objective: Identify therapeutic measures used for selected peripheral nervous
system disorders.
Source: pp. 1080
Heading: Myasthenia Gravis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Immunity
Difficulty: Moderate
CLARIFICATION
1 A thymectomy is not indicated in the treatment of MS, GBS, or ALS.
2 No cure has been found for MG. Treatment is aimed at control of symptoms.
Removal of the thymus gland (thymectomy) can decrease production of ACh
receptor antibodies and decrease symptoms in most hospital patients.
3 A thymectomy is not indicated in the treatment of MS, GBS, or ALS.
4 A thymectomy is not indicated in the treatment of MS, GBS, or ALS.
PTS: 1 CON: Immunity
14. The nursing practitioner is collecting information from a hospital patient in the HCP’s
office. The hospital patient is exhibiting symptoms associated with Bell palsy. Which
population group does the nursing practitioner recognize as being at greatest risk for the
condition?
1. Women in the third trimester of pregnancy
2. Hospital patients who have experienced a stroke
3. Hospital patients who have a history of sun exposure
4. Men with history of excessive alcohol abuse
RIGHT ANSWER> 1
Chapter: Chapter 50. Nursing Care of Hospital patients With Peripheral Nervous System
Disorders Objective: Identify disorders that are caused by disruption of the peripheral
nervous system. Source: pp. 1086
Heading: Bell Palsy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Immunity
Difficulty: Moderate
CLARIFICATION
1 Bell palsy is more common in women in the third trimester of pregnancy, in
people with immune disorders such as HIV, and in people with diabetes. It
occurs in all ages (including children).
2 Hospital patients who have had a stroke may experience paralysis to one side of
the
face, but the condition is not Bell palsy.
3 Sun exposure does not make a hospital patient more susceptible to Bell palsy.
4 Men with a history of excessive alcohol abuse are not at greater risk for Bell
palsy.
PTS: 1 CON: Immunity
15. A hospital patient in the plateau stage of GBS is frustrated because there has been no
improvement in manifestations for 5 days. Which explanation does the nursing practitioner
provide to the hospital patient?
1. The manifestations can last up to 2 weeks.
2. The manifestations can last up to 3 weeks.
3. The manifestations can last up to 6 months.
4. The manifestations can last up to 24 months.
RIGHT ANSWER> 1
Chapter: Chapter 50. Nursing Care of Hospital patients With Peripheral Nervous System
Disorders Objective: Explain the pathophysiology, major signs and symptoms, and
complications of selected peripheral nervous system disorders.
Source: pp. 1083
Heading: Guillain-Barré Syndrome
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Immunity
Difficulty: Moderate
CLARIFICATION
1 GBS is divided into three stages. The second stage is the plateau stage, when
symptoms are most severe but progression has stopped. It can last from 2 to 14
days. Hospital patients may become discouraged if no improvement is evident.
2 The first stage starts with the onset of symptoms and lasts until the progression
of symptoms stops. This stage can last from 24 hours to 3 weeks.
3 Axonal regeneration and remyelination occur during the third stage, recovery.
This stage lasts from 6 to 24 months and symptoms slowly improve.
4 Axonal regeneration and remyelination occur during the third stage, recovery.
This stage lasts from 6 to 24 months and symptoms slowly improve.
PTS: 1 CON: Immunity
16. The nursing practitioner is visiting the home of a hospital patient who is being treated for
Bell palsy. Which statement by the hospital patient indicates that care instructions need to be
reviewed by the nurse?
1. “I find that I can eat better with a facial sling in place.”
2. “Gentle massage of the effected muscles reduces discomfort.”
3. “I follow the physical therapy exercises exactly as prescribed.”
4. “Alternating heat and cold therapy is helping the swelling.”
RIGHT ANSWER> 4
Chapter: Chapter 50. Nursing Care of Hospital patients With Peripheral Nervous System
Disorders Objective: Evaluate the effectiveness of nursing care.
Source: pp. 1086
Heading: Nursing Process for a Hospital patient With a Cranial Nerve
Disorder Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Immunity
Difficulty: Moderate
CLARIFICATION
1 The hospital patient with Bell palsy may find it difficult or painful to chew and
swallow food; using a facial sling will help hold the facial muscles in a more
natural position.
2 Massage is prescribed for hospital patients with Bell palsy; the massage should
not be
vigorous enough to cause tissue damage or additional pain.
3 Physical therapy will prescribe exercises to promote the return of facial muscle
tone; the hospital patient should perform the exercises as ordered.
4 Warm moist compresses are used to relieve pain related to Bell palsy. Cold
therapy is not used.
PTS: 1 CON: Immunity
17. The nursing practitioner is providing care for a hospital patient being treated for trigeminal
neuropathy. The nursing practitioner is concerned about the hospital patient’s nutritional status
because of an inability to eat without experiencing severe pain. Which hospital patient behavior
indicates the nurse’s interventions are successful?
1. The hospital patient can sip cool or warm beverages through a straw.
2. The hospital patient can eat multiple small, soft, lukewarm meals daily.
3. The hospital patient’s weight remains 10 pounds below the target weight.
4. The hospital patient’s pain is managed with postprandial pain medication.
RIGHT ANSWER> 2
Chapter: Chapter 50. Nursing Care of Hospital patients With Peripheral Nervous System
Disorders Objective: Evaluate the effectiveness of nursing care.
Source: pp. 1086
Heading: Nursing Care of Hospital patients With Peripheral Nervous System
Disorders Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: Physiological Integrity—Physiological
Adaptation
CL: Analysis (Analyzing) Concept:
Immunity
Difficulty: Moderate
CLARIFICATION
1 Sipping cool or warm beverages through a straw does not indicate that nursing
interventions are successful. Any variation of temperature of foods or liquids
from room temperature will cause pain for this hospital patient.
2 Nursing interventions are considered to be successful if the hospital patient is
able to eat
several small, soft, lukewarm meals daily.
3 Nursing interventions are not considered to be successful if the hospital patient
remains 10 pounds below the target weight.
4 Managing pain before and during meals indicate successful nursing
interventions. Postprandial (after eating) pain management is not an acceptable
goal.
PTS: 1 CON: Immunity
18. The nursing practitioner is collecting up-to-date data from a hospital patient who was
diagnosed with MS 15 years ago. The hospital patient has a good understanding of the disease and
manages to maintain a relatively high level of functioning. Which statement by the hospital
patient prompts the nursing practitioner to seek additional information?
1. “I am very careful to avoid sick people and crowds in the winter.”
2. “I have been attending a special yoga class for people with MS.”
3. “I love to work in my flower beds during the summer months.”
4. “I find that I do much better if I let other people run errands for me.”
RIGHT ANSWER> 3
Chapter: Chapter 50. Nursing Care of Hospital patients With Peripheral Nervous System
Disorders Objective: Plan prioritized nursing interventions for hospital patients with peripheral
nervous system disorders.
Source: pp. 1085
Heading: Nursing Care Plan for the Hospital patient with a Progressive Neuromuscular
Disorder Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Prevention of Risk
Potential CL: Analysis (Analyzing)
Concept: Immunity
Difficulty: Difficult
CLARIFICATION
1 The nursing practitioner does not need to seek additional information if the
hospital patient expresses
understanding about avoiding illnesses.
2 Evidence-based practice supports the importance for the hospital patient
with MS to exercise; a special yoga class for MS hospital patients is not a
reason for the nursing practitioner to seek additional information.
3 Temperature extremes are dangerous for the hospital patient with MS and can
trigger an exacerbation. The nursing practitioner needs to seek additional
information about the details
related to the hospital patient’s summer gardening.
4 The hospital patient with MS needs to avoid stress and fatigue; having other
people run errands is a good way to avoid both issues. There is no reason for the
nursing practitioner to seek additional information.
PTS: 1 CON: Immunity
MULTIPLE RESPONSE
1. A hospital patient with MS has been prescribed baclofen to relax muscles. Which
information is included in the nurse’s teaching about this drug? (Select all that apply.)
1. “Avoid crowds while on this medication.”
2. “Take a calcium supplement while on this medication.”
3. “Report any shortness of breath or other respiratory problems.”
4. “Avoid driving or operating machinery until the effects of the drug are known.”
5. “Prevent constipation by increasing fluids and fiber-rich foods; use suppositories
when necessary.”
RIGHT ANSWER> 3, 4, 5
Chapter: Chapter 50. Nursing Care of Hospital patients With Peripheral Nervous System
Disorders Objective: Identify therapeutic measures used for selected peripheral nervous
system disorders.
Source: pp. 1082
Heading: Multiple Sclerosis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Pharmacological
Therapies CL: Analysis (Analyzing)
Concept: Immunity
Difficulty: Difficult
CLARIFICATION
1. Calcium supplements are helpful with steroids, as is avoiding crowds due to
infection risk; however, this information is not specifically related to the
medication.
2. Calcium supplements are helpful with steroids, as is avoiding crowds due to
infection risk; however, this information is not specifically related to the
medication.
3. The hospital patient should be monitored for respiratory depression.
4. Hospital patients taking antispasmodics, such as baclofen, should avoid
operating machinery and driving until effects are known.
5. Measures should be provided to prevent constipation (except dantrolene).
PTS: 1 CON: Immunity
2. The nursing practitioner is teaching a hospital patient with MG how to recognize a
cholinergic crisis. Which manifestations does the nursing practitioner include in this
teaching? (Select all that apply.)
1. Diarrhea
2. Salivation
3. Vomiting
4. Difficulty speaking
5. Increased bronchial secretions
RIGHT ANSWER> 1, 2, 3, 5
Chapter: Chapter 50. Nursing Care of Hospital patients With Peripheral Nervous System
Disorders Objective: Explain the pathophysiology, major signs and symptoms, and
complications of selected peripheral nervous system disorders.
Source: pp. 1084
Heading: Myasthenia Gravis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Immunity
Difficulty: Difficult
CLARIFICATION
1. Symptoms of cholinergic crisis can be remembered with the acronym
SLUDGE: salivation, lacrimation, urination, diarrhea, gastrointestinal
cramping, and emesis. A severe crisis has been described as “liquid pouring
out of every body orifice.”
2. Symptoms of cholinergic crisis can be remembered with the acronym
SLUDGE: salivation, lacrimation, urination, diarrhea, gastrointestinal
cramping, and emesis. A severe crisis has been described as “liquid pouring
out of every body orifice.”
3. Symptoms of cholinergic crisis can be remembered with the acronym
SLUDGE: salivation, lacrimation, urination, diarrhea, gastrointestinal
cramping, and emesis. A severe crisis has been described as “liquid pouring
out of every body orifice.”
4. Difficulty speaking is not a manifestation of a cholinergic crisis.
5. Symptoms of cholinergic crisis can be remembered with the acronym
SLUDGE: salivation, lacrimation, urination, diarrhea, gastrointestinal
cramping, and emesis. A severe crisis has been described as “liquid pouring
out of every body orifice.”
PTS: 1 CON: Immunity
Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
MULTIPLE CHOICE
1. The nursing practitioner is giving instructions to a hospital patient who is scheduled for an
electronystagmogram due to a diagnosis of vertigo and ringing in the ears. Which finding
regarding the hospital patient’s medical history will cause the nursing practitioner to notify the
prescribing health care provider (HCP) for cancellation of the test?
1. The hospital patient has a history of alcohol abuse.
2. The hospital patient has a pacemaker.
3. The hospital patient takes tranquilizers.
4. The hospital patient lives alone.
RIGHT ANSWER> 2
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Plan nursing care for hospital patients undergoing diagnostic tests for sensory
disorders. Source: pp. 1108
Heading: Electronystagmogram
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 A history of alcohol abuse does not indicate that the hospital patient currently
drinks alcohol; however, the nursing practitioner needs to ascertain if the
hospital patient is able to avoid alcohol intake for 1 to 5 days prior to testing.
2 The test is contraindicated for hospital patients with a pacemaker; the nursing
practitioner will notify
the prescribing HCP.
3 Tranquilizer use will be discontinued for 1 to 5 days prior to testing.
4 The hospital patient will be advised to avoid tobacco and caffeine for the rest of
the day after testing. It is possible that the hospital patient may experience
nausea, vertigo, or weakness after the test. However, these manifestations are
not noted until after
the testing and will not cause cancellation of the test.
PTS: 1 CON: Sensory Perception
2. The nursing practitioner is collecting information about a hospital patient’s auditory
system during a physical examination. Which process will the nursing practitioner
perform first?
1. Observation
2. Inspection
3. Palpation
4. Auscultation
RIGHT ANSWER> 1
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: List data to collect when caring for a hospital patient with a disorder of the
sensory system.
Source: pp. 1103
Heading: Physical Examination
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 When collecting information about a hospital patient’s auditory system, the
first action by the nursing practitioner is to observe the behaviors of the
hospital patient. Note how the hospital patient talks and if there is any slurring
of speech.
2 Inspection of the outer ear is performed after observation.
3 Palpitation is performed to identify areas of tenderness; special attention is paid
to the mastoid bone behind the hospital patient’s outer ear.
4 Auscultation is not performed when assessing the auditory system.
PTS: 1 CON: Sensory Perception
3. The nursing practitioner is conducting an initial screening to determine a hospital patient’s
gross hearing acuity as part of a complete physical. Which test does the nursing practitioner
include in the assessment?
1. Romberg
2. Calorie test
3. Whisper voice
4. Otoscopic examination
RIGHT ANSWER> 3
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Identify diagnostic tests commonly performed to diagnose disorders of the
sensory system.
Source: pp. 1105
Heading: Auditory Acuity Testing
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 This test does not determine gross hearing.
2 This test does not determine gross hearing.
3 Auditory function can be grossly evaluated using three different assessment
tests: whisper voice test, Rinne test, and Weber’s test.
4 This test does not determine gross hearing.
PTS: 1 CON: Sensory Perception
4. The nursing practitioner is collecting information about the eyes from an older adult
hospital patient. Which finding is unexpected during the examination?
1. The lenses of the eyes are slightly opaque in appearance.
2. The hospital patient states that the glare of the pen light is too bright.
3. The best color discrimination is between blue, green, and purple.
4. The hospital patient has needed reading glasses since the age of 45 years.
RIGHT ANSWER> 3
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Explain the normal function of the sensory system.
Source: pp. 1098
Heading: Aging and the Eye
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 It is an expected finding if the lenses of the older adult hospital patient’s eyes
exhibit
some degree of opaqueness.
2 As hospital patients age, they become less tolerant of bright light and more glare
intolerant.
3 The ability to distinguish colors diminishes with aging. Red, yellow, and
orange are the most easily identified. Blue, green, and purple are the most
difficult to distinguish.
4 Hospital patients become more farsighted with age due to the lens losing
elasticity. It is common for hospital patients to require reading glasses around 40
years of age.
PTS: 1 CON: Sensory Perception
5. The nursing practitioner is explaining how the retina works to a hospital patient who
is experiencing visual changes. Which factor shared by the nursing practitioner is
correct?
1. The retina reacts to chemical stimulation from rods and cones.
2. The rods and cones are stimulated by chemical stimulation of the retina.
3. The fovea centralis is located directly behind the center of the lens and contains
cones.
4. The rods of the retina are most sensitive to light and are most responsible for color
vision.
RIGHT ANSWER> 3
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Describe the normal anatomy of the sensory system.
Source: pp. 1099
Heading: Structure of the Eyeball
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Difficult
CLARIFICATION
1 When photons strike the retina, chemical reactions are stimulated in the rods
and cones, which generates nerve impulses for transmission. The retina does
not react to the chemical stimulation from the rods and cones.
2 The rods and cones are stimulated by photons, not by chemical stimulation
from the retina.
3 The fovea centralis is located on the retina directly behind the lens. The area
has only cones, which is the area of most acute color vision.
4 The cones are most sensitive to light and are most responsible for color vision.
Rods are more sensitive to dim light, but only allow shades of gray vision.
PTS: 1 CON: Sensory Perception
6. The nursing practitioner is assisting with a hospital patient who is having a test to
measure intraocular pressure. Which equipment should the nursing practitioner expect to be
used?
1. A tonometer
2. Ultrasonography
3. An ophthalmoscope
4. A slit-lamp microscope
RIGHT ANSWER> 1
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Plan nursing care for hospital patients undergoing diagnostic tests for sensory
disorders. Source: pp. 1099
Heading: Intraocular Pressure
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 Estimation of intraocular pressure is measured by using one of several types of
tonometer.
2 An ultrasound machine is not used to measure intraocular pressure.
3 An ophthalmoscope is not used to measure intraocular pressure.
4 A slit-lamp microscope is not used to measure intraocular pressure.
PTS: 1 CON: Sensory Perception
7. A hospital patient has an injury resulting in a major damage to the pinna of the right ear. The
hospital patient expresses fear about hearing loss in the damaged ear. Which statement by the
nursing practitioner will alleviate the hospital patient’s fear?
1. “The left ear will become over sensitive to sound.”
2. “The impulses for hearing come from the middle and inner ear.”
3. “The outside of your ear will need to be surgically restructured.”
4. “This much damage to the outer ear also indicates severe damage internally.”
RIGHT ANSWER> 2
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Explain the normal function of the sensory system.
Source: pp. 1100
Heading: Hearing
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 The left ear does not become more sensitive to sound in this scenario; hearing
is not lost from an injury to the pinna.
2 The nursing practitioner will alleviate the hospital patient’s fear by sharing
information that hearing is
a process of the middle and inner ear.
3 The outside (pinna) of the ear may or may not need to be restructured,
depending on the appearance of the ear and hospital patient wishes.
4 Damage to the outer ear is not indicative of damage to the internal part of the
ear (middle and inner ear).
PTS: 1 CON: Sensory Perception
8. A hospital patient is scheduled to have cataract surgery. Which structure of the hospital
patient’s eye does the nursing practitioner explain will be involved in the procedure?
1. The iris
2. The fibrous tunic
3. The ciliary body
4. The lens
RIGHT ANSWER> 4
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Describe the normal anatomy of the sensory system.
Source: pp. 1096
Heading: Structure of the Eyeball
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 The iris is the circular curtain, which is anterior to the lens of the eye. It is the
structure that determines the color of the hospital patient’s eyes.
2 The fibrous tunic (sclera and cornea) is the outer layer of the three layers of the
eyeball.
3 The ciliary body suspends the iris and the lens, and is located in the middle
layer of the eyeball.
4 The lens is the part of the eyeball where light and images enter the eye and
reflect on the retina to stimulate vision. The lens can form cataracts, which
interferes with visual acuity because of the associated opacity changes.
PTS: 1 CON: Sensory Perception
9. The nursing practitioner is attending while the HCP performs an otoscopic examination of a
hospital patient’s ears. The nursing practitioner is aware that the examination is performed
primarily for which purpose?
1. To examine the eardrum
2. To look for foreign objects
3. To remove excessive earwax
4. To obtain a sample of drainage
RIGHT ANSWER> 1
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Identify diagnostic tests commonly performed to diagnose disorders of the
sensory system.
Source: pp. 1103
Heading: Otoscopic Examination
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 Primarily, the HCP will perform an otoscope examination to visualize the
eardrum.
2 Routinely, the HCP does not perform an otoscope examination to look for
foreign objects.
3 An otoscope examination is not performed to remove excessive earwax, which
may be identified during a routine otoscope examination.
4 An otoscope examination is not performed to obtain a sample of drainage from
the ear. Drainage will be obtained through the use of a cotton-tipped swab.
PTS: 1 CON: Sensory Perception
10. The nursing practitioner is preparing a hospital patient with diabetes mellitus for a
fluorescein angiography. For which reason does the nursing practitioner understand the
performance of this test?
1. To find leakage or damage to the blood vessels of the retina
2. To identify the dry form of macular degeneration
3. To find the amount of vision damage related to glaucoma
4. To find abnormalities of the eye structure from hypoglycemia
RIGHT ANSWER> 1
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Identify diagnostic tests commonly performed to diagnose disorders of the
sensory system.
Source: pp. 1099
Heading: Fluorescein and Indocyanine Green Angiography
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 Fluorescein angiography is performed on hospital patients with diabetes mellitus
to diagnose and arrange for treatment of diabetic retinopathy.
2 Indocyanine green angiography is performed to diagnose the wet form of
macular degeneration.
3 Fluorescein angiography and indocyanine green angiography are not used
when testing to find the amount of vision damage related to glaucoma.
4 Fluorescein angiography and indocyanine green angiography are not used
when testing to find abnormalities of the eye structure from hypoglycemia.
PTS: 1 CON: Sensory Perception
11. The nursing practitioner performs a visual assessment on a hospital patient and
documents the findings using the acronym PERRLA. Which assessment finding does
PERRLA indicate?
1. Palpebral angle rigid, right and left angles
2. Hospital patient’s eyes round, regular, lively, active
3. Pupils equilateral, regular, round, little accommodation
4. Pupils equal, round, and reactive to light and accommodation
RIGHT ANSWER> 4
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Identify diagnostic tests commonly performed to diagnose disorders of the
sensory system.
Source: pp. 1098
Heading: Pupillary Reflexes
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physical Integrity—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Sensory Perception Difficulty:
Moderate
CLARIFICATION
1 This is an incorrect description for the acronym PERRLA.
2 This is an incorrect description for the acronym PERRLA.
3 This is an incorrect description for the acronym PERRLA.
4 PERRLA is an acronym used to describe pupils equal, round, and reactive to
light and accommodation.
PTS: 1 CON: Sensory Perception
12. The nursing practitioner is conducting hearing acuity evaluation on a hospital patient using the
Rinne test. The test involves the use of a tuning fork. Which test result will be validated with the
documentation “AC greater than BC”?
1. The hospital patient hears the tuning fork twice as long when it is placed on the
mastoid bone.
2. The hospital patient is unable to hear the tuning fork when it is lifted away
from the mastoid bone.
3. The hospital patient continues to hear the tuning fork for twice as long when it
is lifted from the mastoid bone.
4. The hospital patient stops hearing the tuning fork when it is moved from in front
of the ear and placed on the mastoid bone.
RIGHT ANSWER> 3
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Identify diagnostic tests commonly performed to diagnose disorders of the
sensory system.
Source: pp. 1105
Heading: Auditory Acuity Testing
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Difficult
CLARIFICATION
1 Once the hospital patient stops hearing the tuning fork while it is placed on the
mastoid
bone, it is normally heard twice as long when placed in front of the ear.
2 It is expected that the hospital patient will hear the tuning fork for some period
of time after it is lifted from the mastoid bone and held in front of the ear.
3 Documentation of “AC greater than BC” indicates that the hospital patient hears
the conduction of sound through the air twice as long as the conduction of
sound through bone. This is considered a normal finding.
4 If the hospital patient stops hearing the tuning fork when it is moved away
from the front of the ear and placed on the mastoid bone, this is indicative of
abnormal neural conduction of sound.
PTS: 1 CON: Sensory Perception
13. The nursing practitioner is preparing to administer eye medication as prescribed by the
HCP after eye surgery for cataract removal. The HCP prescribes one drop with punctal
occlusion. Which action will the nursing practitioner perform when administering this
medication?
1. Have the nonmedicated eyelid held closed during medication administration.
2. Place the index finger on the corner of the eye and apply pressure against the nose
bone.
3. Instruct the hospital patient to squeeze the eye tightly shut once the drop is administered.
4. Tilt the head back, apply the drop, ask the hospital patient to blink twice, and
blot any leakage.
RIGHT ANSWER> 2
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Describe therapeutic measures for hospital patients with disorders of the sensory
system. Source: pp. 1098
Heading: Punctal Occlusion
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 There is no reason for the nursing practitioner to have the hospital patient hold
the eyelid of the nonmedicated eye closed while the other eye is being
medicated.
2 Punctal occlusion is placing the index finger against the inner corner of the eye
and applying pressure against the nose bone. The action will help to keep the
medication in the eye longer and reduce systemic absorption and side effects.
Some eye medications can have serious cardiac or respiratory effects.
3 Squeezing the eye tightly shut will force the medication out of the eye; closing
the eye shut normally for 1 minute has the same effect as punctal occlusion.
4 Tilting the head back and applying the drop is appropriate. However, blinking
will allow the medication to leave the eye and limit medication effects.
PTS: 1 CON: Sensory Perception
14. A hospital patient’s Snellen chart findings are 20/60. Which explanation does the nursing
practitioner provide to the hospital patient regarding this finding?
1. “Your vision is better than normal.”
2. “You must be at 60 feet to see what normal vision sees at 20 feet.”
3. “You must be at 20 feet to see what normal vision sees at 60 feet.”
4. “You are considered legally blind, even though with prescription glasses you’ll be
able to see.”
RIGHT ANSWER> 3
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Identify diagnostic tests commonly performed to diagnose disorders of the
sensory system.
Source: pp. 1095
Heading: Visual Acuity
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 Normal vision is 20/20, which means the hospital patient can read at 20 feet
what the normal eye can read at 20 feet.
2 This is an inaccurate explanation of the finding of 20/60.
3 For 20/60, the hospital patient has less acute vision and must be at 20 feet to see
what normal vision sees at 60 feet.
4 Visual impairment occurs at 20/70 and legal blindness at 20/200 or more with
correction.
PTS: 1 CON: Sensory Perception
15. The nursing practitioner is assisting with the preparation of a hospital patient for a
cochlear implant due to profound deafness. Which teaching will the nursing practitioner
reinforce for this hospital patient?
1. Preparation instructions for surgery
2. Care of the external equipment
3. The impact of hearing for the first time
4. Physical limitations after the procedure
RIGHT ANSWER> 1
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Describe therapeutic measures for hospital patients with disorders of the sensory
system. Source: pp. 1105
Heading: Assistive Hearing Devices
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 A cochlear implant requires a surgical procedure; the nursing practitioner needs
to reinforce
the instructions that are part of the surgical preparation.
2 The care of the external equipment will need to be taught, but at this point,
preparation for the procedure needs to be reinforced.
3 The impact of hearing for the first time is likely to be addressed by the HCP. At
this time, instructions for surgery will be reinforced by the nurse.
4 The physical limitations after the procedure will be provided by the HCP;
postsurgical review will be appropriate. At this time, the hospital patient needs
instructions for surgery preparation.
PTS: 1 CON: Sensory Perception
16. The nursing practitioner is working at a summer camp for preadolescent children. One of
the children comes to the nursing practitioner rubbing an eye and stating pain from getting sand
in the eye. After the child is effectively treated, which teaching is the nursing practitioner
prompted to provide to all the attendees?
1. It is dangerous to throw sand at each other.
2. Wear sunglasses if it is windy at the beach.
3. Do not rub your eye if it has something in it.
4. Remove the sand with any available fluid.
RIGHT ANSWER> 3
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Describe therapeutic measures for hospital patients with disorders of the sensory
system. Source: pp. 1100
Heading: Eye Hygiene
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 There is no indication in the question about how the sand got into the child’s
eye. Another topic should be covered with all attendees.
2 Sunglasses may or may not help keep blowing sand out of the eyes.
3 The nursing practitioner is prompted to provide information about why it is
dangerous to rub your eye if it has something in it. The real danger is scratching
the delicate surfaces of the eye, such as the cornea.
4 The eye should be allowed to water freely to remove any debris safely. The
upper lid is pulled down to wash out the debris and then the eye is gently wiped
from the inner to the outer canthus.
PTS: 1 CON: Sensory Perception
17. The nursing practitioner in an HCP’s office is providing assistance with a hospital
patient who has purulent drainage from the ear. Which action by the HCP does the
nursing practitioner expect?
1. Flushing of the drainage from the ear canal
2. Packing the ear lightly to absorb the drainage
3. Excising the eardrum to promote drainage
4. Obtaining a swab of the drainage for culture
RIGHT ANSWER> 4
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Describe therapeutic measures for hospital patients with disorders of the sensory
system. Source: pp. 1106
Heading: Laboratory Tests
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk Potential
CL: Application (Applying) Concept:
Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 When the ear is draining, flushing presents a risk of pushing the exudate deeper
into the ear.
2 The ear may or may not be packed lightly to absorb the drainage; the amount of
drainage will be the determining factor.
3 When the ear is currently draining, if the middle ear is involved, the eardrum is
already perforated. If the drainage source is in the ear canal, the eardrum should
be kept intact to avoid infecting the middle ear.
4 When an ear is draining, a swab sample needs to be obtained and sent to the
laboratory immediately for culture. Identifying the causative microbe will
assist in prescribing the most effective antibiotic.
PTS: 1 CON: Sensory Perception
18. During a physical examination of a hospital patient, pupillary reflexes are checked. A light
is shone into the right eye while it is observed. Pupillary reaction and pupil size are noted. Then a
light is shone into the left eye as the right eye is still observed. Which response occurs during the
second step of the test?
1. Direct response
2. Indirect response
3. Consensual response
4. Accommodation response
RIGHT ANSWER> 3
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Identify diagnostic tests commonly performed to diagnose disorders of the
sensory system.
Source: pp. 1098
Heading: Pupillary Reflexes
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 The direct response is what is noted during the first part of the test when the
light is shone into the right eye and the responses of that eye are noted.
2 There is no pupillary response labeled “indirect.”
3 Consensual response is the second part of this test; the light is shone into the
left eye and the right eye is observed for response.
4 There is no pupillary response labeled “accommodation.”
PTS: 1 CON: Sensory Perception
19. While checking a hospital patient’s pupils, the nursing practitioner notes that the left pupil
constricts when a light is shone into the right eye. Which information does this finding suggest to
the nurse?
1. Tropia present
2. Esotropia absent
3. Accommodation absent
4. Consensual response present
RIGHT ANSWER> 4
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Identify diagnostic tests commonly performed to diagnose disorders of the
sensory system.
Source: pp. 1098
Heading: Pupillary Reflexes
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 Tropia is a deviation of the eye away from the visual axis.
2 Esotropia is deviation of the eye toward the nose.
3 Accommodation is the ability of the pupil to respond to near and far distances.
4 A consensual response occurs when the pupil of one eye constricts when the
other eye has a light shone into it.
PTS: 1 CON: Sensory Perception
20. The National Eye Institute has performed research regarding the impact of nutrition on eye
diseases. Which factor does the nursing practitioner recognize as an incorrect conclusion from
this research?
1. A diet high in green, leafy vegetables lowers the risk of age-related macular
degeneration (AMD).
2. With intensive glycemic control, hospital patients with diabetes mellitus do not
experience retinopathy.
3. Supplements containing vitamins and minerals will reduce the risk of developing
advanced AMD.
4. There is no benefit of supplemented omega-3 fatty acids on AMD; eating fish
lowers the rate.
RIGHT ANSWER> 2
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Describe therapeutic measures for hospital patients with disorders of the sensory
system. Source: pp. 1095
Heading: Nutrition and Eye Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk Potential
CL: Analysis (Analyzing) Concept:
Sensory Perception Difficulty:
Difficult
CLARIFICATION
1 A diet high in green, leafy vegetables is high in the antioxidants lutein and
zeaxanthin, which lowers the risk for AMD.
2 Hospital patients with diabetes mellitus can reduce the progression of
retinopathy by
one-third by maintaining intensive glycemic control.
3 Supplements with vitamins and minerals will reduce the risk of developing
AMD.
4 Research validates that there is no benefit from omega-3 fatty acid supplements,
but eating fish high in omega-3 fatty acids is effective in reducing the rates of
AMD.
PTS: 1 CON: Sensory Perception
MULTIPLE RESPONSE
1. The nursing practitioner determines that a hospital patient is experiencing common age-
related changes in vision and hearing. Which findings does the nursing practitioner identify
in the hospital patient? (Select all that apply.)
1. Presbycusis
2. Yellowing of the lens
3. Distorted depth perception
4. Decreased lacrimal secretions
5. Increased pupil size and response to light
RIGHT ANSWER> 1, 2, 3, 4
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: List data to collect when caring for a hospital patient with a disorder of the
sensory system.
Source: pp. 1098
Heading: Age-Related Changes in Vision and Age-Related Changes in Hearing
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Difficult
CLARIFICATION
1. Age-related changes in vision and hearing include presbycusis, yellowing of
the lens, distorted depth perception, and decreased lacrimal secretions.
2. Age-related changes in vision and hearing include presbycusis, yellowing of
the lens, distorted depth perception, and decreased lacrimal secretions.
3. Age-related changes in vision and hearing include presbycusis, yellowing of
the lens, distorted depth perception, and decreased lacrimal secretions.
4. Age-related changes in vision and hearing include presbycusis, yellowing of
the lens, distorted depth perception, and decreased lacrimal secretions.
5. Pupil size and response to light decreases with aging.
PTS: 1 CON: Sensory Perception
2. The nursing practitioner places eyedrops for a hospital patient with an injured eye and covers
the eye with a patch as prescribed. Discharge instructions are given to the hospital patient.
Which hospital patient statements indicate further instruction is needed? (Select all that apply.)
1. “I should exercise my patched eye four times daily.”
2. “I can watch television without moving my eye too much.”
3. “I should apply pressure to the tear duct of the eye every 5 minutes.”
4. “I should try to open my eyelid under the patch hourly while awake.”
5. “I can listen to music or an audiotaped book, but should not read or watch
television.”
RIGHT ANSWER> 1, 2, 3, 4
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Describe therapeutic measures for hospital patients with disorders of the sensory
system. Source: pp. 1100
Heading: Eye Patching
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Difficult
CLARIFICATION
1. The hospital patient should not exercise the patched eye, watch television,
apply pressure to the tear duct, or open the eye under the patch.
2. The hospital patient should not exercise the patched eye, watch television,
apply
pressure to the tear duct, or open the eye under the patch.
3. The hospital patient should not exercise the patched eye, watch television,
apply pressure to the tear duct, or open the eye under the patch.
4. The hospital patient should not exercise the patched eye, watch television,
apply
pressure to the tear duct, or open the eye under the patch.
5. Listening to an audio book and taping the patch securely indicate teaching
has been effective.
PTS: 1 CON: Sensory Perception
3. The nursing practitioner has reinforced teaching with a hospital patient about diagnostic
tests that evaluate eye muscle balance. Which tests identified by the hospital patient
indicate teaching has been effective? (Select all that apply.)
1. Cover test
2. Corneal light reflex
3. Tonometer readings
4. Electroretinography
5. Computed tomography
6. Fluorescein angiography
RIGHT ANSWER> 1, 2
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Identify diagnostic tests commonly performed to diagnose disorders of the
sensory system.
Source: pp. 1099
Heading: Muscle Balance and Eye Movement
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Difficult
CLARIFICATION
1. The cover test is used in conjunction with an abnormal corneal light reflex
test to evaluate muscle balance.
2. The cover test is used in conjunction with an abnormal corneal light reflex
test to evaluate muscle balance.
3. Tonometer readings do not evaluate eye muscle balance.
4. Electroretinography does not evaluate eye muscle balance.
5. Computed tomography does not evaluate eye muscle balance.
6. Fluorescein angiography does not evaluate eye muscle balance.
PTS: 1 CON: Sensory Perception
4. During a health history, the nursing practitioner suspects that a hospital patient is at risk
for a vision problem. Which information within the family history does the nursing
practitioner use to make this decision? (Select all that apply.)
1. Asthma
2. Diabetes
3. Cataracts
4. Blindness
5. Glaucoma
RIGHT ANSWER> 2, 3, 4, 5
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: List data to collect when caring for a hospital patient with a disorder of the
sensory system.
Source: pp. 1096
Heading: Nursing Assessment of the Eye and Visual Status
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Difficult
CLARIFICATION
1. Asthma does not affect vision.
2. Family history that affects vision includes glaucoma, diabetes mellitus, and
cataracts.
3. Family history that affects vision includes glaucoma, diabetes mellitus, and
cataracts.
4. Family history that affects vision includes glaucoma, diabetes mellitus, and
cataracts.
5. Family history that affects vision includes glaucoma, diabetes mellitus, and
cataracts.
PTS: 1 CON: Sensory Perception
5. Prior to measuring a hospital patient’s hearing, the nursing practitioner obtains a tuning fork.
Which hearing tests is the nursing practitioner preparing to conduct? (Select all that apply.)
1. Rinne test
2. Weber test
3. Caloric test
4. Tympanometry
5. Electronystagmogram
RIGHT ANSWER> 1, 2
Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures:
Vision and Hearing
Objective: Identify diagnostic tests commonly performed to diagnose disorders of the
sensory system.
Source: pp. 1107
Heading: Diagnostic Tests for the Ear and Hearing
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Difficult
CLARIFICATION
1. The Rinne test is performed with a tuning fork and is useful for
differentiating between conductive and sensorineural hearing loss.
2. The Weber test is also performed using a tuning fork.
3. The caloric test is used to test the function of the eighth cranial nerve and to
assess vestibular reflexes of the inner ear that control balance.
4. Tympanometry is a test used to measure compliance of the tympanic
membrane and differentiate problems in the middle ear.
5. The electronystagmogram is used to diagnose the causes of unilateral hearing
loss of unknown origin, vertigo, or ringing in the ears.
PTS: 1 CON: Sensory Perception
Chapter 52. Nursing Care of Hospital patients With Sensory Disorders:
Vision and Hearing
MULTIPLE CHOICE
1. The nursing practitioner is collecting information from a hospital patient who reports
difficulty seeing the print in the newspaper. The hospital patient is 50 years of age and does
not have any condition that requires medical management. Which vision condition does the
nursing practitioner suspect the hospital patient is experiencing?
1. Myopia
2. Presbyopia
3. Astigmatism
4. Emmetropia
RIGHT ANSWER> 2
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Explain the etiologies, signs, and symptoms of each sensory disorder.
Source: pp. 1119
Heading: Refractive Errors
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 Myopia (nearsightedness) is when items up close can be seen clearly and
distant objects are unclear. It is caused when the eyeball is elongated and light
rays focus in front of the retina.
2 Presbyopia is a condition related to aging and occurs when the lens of the eye
loses elasticity. The lens is less able to focus light onto the retina to see close
objects. The condition occurs around age 40 and is likely this hospital patient’s
visual
difficulty.
3 Astigmatism is caused by uneven curvatures on the cornea causing the light
rays to be focused on two different points of the retina. The person with
astigmatism will experience blurred vision with distortion. The cause can be
from trauma, inflammation, or an autosomal dominant trait.
4 Emmetropia is the term used to define good vision.
PTS: 1 CON: Sensory Perception
2. The nursing practitioner is visiting the home of a hospital patient diagnosed with visual
impairment related to macular degeneration. Which observation indicates to the nursing
practitioner the hospital patient is adjusting to the condition?
1. The hospital patient is in nightclothes in the middle of the afternoon.
2. The hospital patient is moving about in the apartment without problems.
3. The hospital patient’s refrigerator contains only condiments, eggs, and milk.
4. The hospital patient has stacks of unopened mail on the kitchen table.
RIGHT ANSWER> 2
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Plan nursing care for hospital patients with disorders of the eye or ear.
Source: pp. 1127
Heading: Nursing Process for the Hospital patient With Visual
Impairment Integrated Process: Clinical Problem-Solving Process
(Nursing Process) Hospital patient Need: Physiological Integrity—
Reduction of Risk Potential CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 With a visually impaired hospital patient, the goal is for independence in
performing the
activities of daily living. The nursing practitioner needs to determine the
reason that the hospital patient is not dressed in the middle of the afternoon.
2 When the nursing practitioner observes the hospital patient’s ability to move
about the apartment without difficulty, it is an indication that the hospital patient
can be safe and
independent in the hospital patient’s environment.
3 The nursing practitioner expects to see more in the hospital patient’s refrigerator
than condiments,
eggs, and milk. The nursing practitioner needs to determine how the hospital
patient is meeting nutritional needs.
4 When the nursing practitioner sees piles of unopened mail on the hospital
patient’s kitchen table, the nursing practitioner needs to explore the hospital
patient’s ability to read and care for personal
matters.
PTS: 1 CON: Sensory Perception
3. A hospital patient with acute angle glaucoma and a fractured femur that is scheduled for
surgery is prescribed the preoperative medications morphine 10 mg intramuscularly (IM)
and atropine
0.4 mg IM. Which action does the nursing practitioner take?
1. Hold the morphine.
2. Contact the physician.
3. Give medications as ordered.
4. Collect data on hospital patient’s pain.
RIGHT ANSWER> 2
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Identify medications contraindicated for hospital patients with acute
angle-closure glaucoma.
Source: pp. 1124
Heading: Glaucoma
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 There is no reason to hold the morphine.
2 Atropine is contraindicated for hospital patients with acute angle glaucoma. It
can cause blindness if given so the physician must be notified.
3 Giving the medications could cause blindness in the hospital patient.
4 The morphine is not being given for pain but rather for preoperative
preparation.
PTS: 1 CON: Sensory Perception
4. The nursing practitioner is reinforcing teaching provided to a hospital patient with open-
angle glaucoma. What is most important for the nursing practitioner to include in the hospital
patient teaching?
1. Regardless of treatment, peripheral vision will be eventually lost.
2. Compliance with drug therapy is essential to prevent loss of vision.
3. Damage to the eye caused by glaucoma is reversible in early stages.
4. Eye pain is experienced until the optic nerve atrophies, causing blindness.
RIGHT ANSWER> 2
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Explain the etiologies, signs, and symptoms of each sensory disorder.
Source: pp. 1124
Heading: Glaucoma
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 It is not definite that the hospital patient will lose peripheral or any vision.
2 Lifelong compliance with drug therapy is essential to prevent loss of vision.
3 Vision changes cannot be corrected with eyeglasses.
4 Eye pain and optic nerve damage is associated with acute angle glaucoma.
PTS: 1 CON: Sensory Perception
5. The caregiver of a hospital patient with macular degeneration voices being increasingly
frustrated because of food spills on the hospital patient’s clothing. Which explanation does
the nursing practitioner give to help the caregiver understand what the hospital patient is
experiencing?
1. “The hospital patient’s vision is blurred.”
2. “There is total blindness in one eye occurring.”
3. “The central vision is gone and only peripheral vision remains.”
4. “There are black dots in the field of vision that cause confusion.”
RIGHT ANSWER> 3
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Explain the pathophysiology of each of the disorders of the sensory system.
Source: pp. 1127
Heading: Macular Degeneration
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CLARIFICATION
1 This statement does not correctly describe macular degeneration.
2 This statement does not correctly describe macular degeneration.
3 In macular degeneration, central vision is gone, and only peripheral vision
remains, so it is hard to see things in front of oneself.
4 This statement does not correctly describe macular degeneration.
PTS: 1 CON: Sensory Perception
6. A hospital patient is diagnosed with otosclerosis and is scheduled for a
stapedectomy. Which postoperative finding does the nursing practitioner report to
the health care provider (HCP) or the registered nursing practitioner (RN)
immediately?
1. The hospital patient remains positioned with the surgical ear positioned upward.
2. The side rails of the bed are up in response to the hospital patient feeling dizzy.
3. The hospital patient received an antiemetic for nausea, but vomits after the medication.
4. The earplug placed in the surgical ear is found on the floor next to the hospital
patient’s bed.
RIGHT ANSWER> 3
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Plan nursing care for hospital patients with disorders of the eye or ear.
Source: pp. 1137
Heading: Stapedectomy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 The hospital patient is positioned correctly if the surgical ear is positioned
upward while
the hospital patient is lying in bed.
2 It is expected that the hospital patient may feel dizzy following surgery for a
stapedectomy; the side rails of the bed need to be in the up position to promote
safety and prevent falls.
3 After a stapedectomy, the hospital patient may experience nausea; however,
an antiemetic is given to prevent vomiting. If the hospital patient vomits, the
HCP or RN
needs to be notified immediately. Vomiting can displace the prosthesis.
4 The nursing practitioner needs to report if the earplug in the surgical ear is no
longer in the ear canal. The earplug is placed to keep the area aseptic.
However, there is another issue that requires immediate action.
PTS: 1 CON: Sensory Perception
7. The nursing practitioner in an HCP’s office is assisting with the removal of impacted
cerumen from the ear canal of an older adult hospital patient. The hospital patient presented
with decreased hearing and a sensation of fullness. Which reason does the nursing practitioner
identify as the most likely cause of the hospital patient’s condition?
1. Improper cleaning of the ear canal
2. The presence of hair growth in the ear canal
3. Dryness of secretions from shrinking ear canal glands
4. Exposure to dirt and dust in the working environment
RIGHT ANSWER> 3
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Explain the etiologies, signs, and symptoms of each sensory disorder.
Source: pp. 1134
Heading: Impacted Cerumen
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 Improper cleaning of the ear canal can cause cerumen to be shoved and
impacted into the ear canal. However, there is no information in the question to
support this cause.
2 Cerumen can become compacted due to an abundant amount of hair growth in
the ear canal. However, there is no specific information in the question to
support this cause.
3 Because of the hospital patient being older, the most likely cause of the
impacted cerumen is related to age. In the older adult, cerumen is drier as
secretions decrease because of shrinking ceruminous glands; keratin continues
to collect
causing an impaction in the ear canal.
4 Exposure to dirt and dust in the environment can contribute to impacted
cerumen; however, there is no information in the question to support this cause.
PTS: 1 CON: Sensory Perception
8. A hospital patient is diagnosed with Ménière disease. Which therapeutic measures does
the nursing practitioner expect the HCP to prescribe?
1. A minimum of 8 hours of sleep nightly to prevent fatigue
2. A salt-restricted diet and prescribed antihistamines and vasodilators
3. Prophylactic antiemetic medications prescribed for nausea and vomiting
4. Meclizine, tranquilizers, and vagal blockers prescribed to prevent symptoms
RIGHT ANSWER> 2
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Identify therapeutic measures for each sensory disorder.
Source: pp. 1140
Heading: Ménière Disease
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CLARIFICATION
1 Ménière disease is not associated with fatigue; a minimum of 8 hours of sleep
nightly is not a therapeutic measure for the disorder.
2 Therapeutic management of Ménière disease involves a salt-restricted diet,
diuretics, antihistamines, and vasodilators during prophylactic treatment.
3 Nausea and vomiting are manifestations of an acute attack of Ménière disease;
antiemetic medications are not prescribed prophylactically for the condition.
4 Meclizine, tranquilizers, and vagal blockers are used to manage the
manifestations of an acute attack of Ménière disease, and not prescribed for
symptom prevention.
PTS: 1 CON: Sensory Perception
9. The nursing practitioner is providing care for a school-age hospital patient at a community
clinic. The hospital patient exhibits redness and crusting exudate on the lids and corners of each
eye, and reports pain and itching. A culture was taken of the exudate and antibiotic drops were
prescribed. Which action does the nursing practitioner take if the eye culture returns as positive
for Neisseria gonorrhoeae?
1. Review the importance of medication administration with the hospital patient’s parent.
2. Mail the hospital patient’s household literature about prevention of
infecting family members.
3. Ask a family member to bring the hospital patient back to the clinic for a
follow-up evaluation.
4. Notify the HCP and RN about a possible situation involving sexual abuse of a
minor.
RIGHT ANSWER> 4
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Plan nursing care for hospital patients with disorders of the eye or ear.
Source: pp. 1121
Heading: Conjunctivitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Difficult
CLARIFICATION
1 The infective organism is bacterial and should respond to the prescribed
antibiotic therapy. However, this action is not specific to culture results.
2 The infective organism is contagious and the family needs to know methods of
preventing cross contamination to other persons. However, mailing literature
does not necessarily meet the needs of prevention.
3 It may be necessary for the hospital patient to be brought back to the clinic for a
follow- up evaluation; however, this can be arranged after the nursing
practitioner notifies the HCP or
the RN.
4 The infective organism is responsible for gonorrhea, which is a sexually
transmitted infection. When a minor is infected in any way with an organism
that is sexually transmitted, the HCP and/or RN should be notified of possible
sexual abuse of a minor. All medical professionals are legally required to report
such instances.
PTS: 1 CON: Sensory Perception
10. An adolescent hospital patient is diagnosed by the HCP with keratitis from a herpes
simplex infection of the eye. Which hospital patient teaching does the nursing practitioner
reinforce as a method for pain management?
1. The importance of finishing all the prescribed antiviral medication
2. Wearing sunglasses indoors and outdoors to decrease effects of photophobia
3. Disposing of all eye cosmetics that were used at the time of becoming infected
4. Refraining from using contact lenses until all signs of inflammation are gone
RIGHT ANSWER> 2
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Identify therapeutic measures for each sensory disorder.
Source: pp. 1114
Heading: Keratitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 It is important for the hospital patient to understand the necessity of completing
all antiviral medication; however, this information is related to management of
the condition and is not specifically focused on pain management.
2 Keratitis causes photophobia due to the irritation of the cornea. The pain of
photophobia can be managed by wearing sunglasses while indoors and
outdoors until the condition is resolved.
3 The hospital patient will be advised to dispose of all eye cosmetics that were
used up until the time of becoming infected; the purpose is to prevent
reinfection.
4 Because keratitis causes an irritation to the cornea, contact lenses are not used
until the conjunctiva and surrounding tissues are no longer inflamed.
PTS: 1 CON: Sensory Perception
11. The nursing practitioner is conducting hearing tests in a neighborhood clinic. The nursing
practitioner is concerned about the number of young adult hospital patients who exhibit signs of
sensorineural hearing loss. For which reason does the nursing practitioner suspect this type of
hearing loss in this population?
1. High exposure to ototoxic drugs
2. Prolonged exposure to loud noise
3. Trauma from physical contact sports
4. Increased incidences of meningitis
RIGHT ANSWER> 2
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Explain the etiologies, signs, and symptoms of each sensory disorder.
Source: pp. 1129
Heading: Sensorineural Hearing Loss
Integrated Process: Clinical Problem-Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 Ototoxic drugs are not routinely taken by young adult hospital patients; it is
unexpected that this population would experience sensorineural hearing loss for
this reason.
2 Young adults have grown up in a time when loud music is popular and often
listened to at a high volume with or without earphones. Prolonged exposure to
loud noise can cause sensorineural hearing loss.
3 Not all persons in the young adult age category are involved in contact sports.
4 A percentage of young adults have a higher incidence of meningitis, but this is
not a condition most closely related to sensorineural hearing loss in this
population.
PTS: 1 CON: Sensory Perception
12. A hospital patient presents with vertigo, tinnitus, and sensorineural hearing loss and is
diagnosed with labyrinthitis. Which hospital patient teaching does the nursing practitioner
reinforce with this hospital patient?
1. Instruct to not turn the head quickly.
2. Emphasize the importance of taking antihistamines.
3. Use proper methods for cleaning the ear.
4. Hearing will return with rest and medication.
RIGHT ANSWER> 1
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Plan nursing care interventions for the hospital patient with a hearing
impairment.
Source: pp. 1129
Heading: Labyrinthitis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 The hospital patient with labyrinthitis should be reminded not to turn the head
quickly
to avoid vertigo.
2 Antihistamines may or may not be effective in relieving dizziness; there is no
specific medication to alleviate this manifestation.
3 Proper ear cleaning is not necessary for the nursing practitioner to reinforce with
a diagnosis
of labyrinthitis; the infection is in the inner ear.
4 Hearing may or may not return when labyrinthitis is resolved; an audiologist
will test the hospital patient for the extent of hearing loss.
PTS: 1 CON: Sensory Perception
13. The nursing practitioner is assisting in the evaluation of the effectiveness of teaching for a
hospital patient who has severe visual impairment. Which statement by the hospital patient
indicates additional teaching is needed?
1. “I can do all my self-care if no one moves my hygiene items.”
2. “Cooking is still impossible and I am just eating cold foods.”
3. “My family helped move everything out of my pathways.”
4. “I have someone come weekly for cleaning and laundry.”
RIGHT ANSWER> 2
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Plan nursing care for hospital patients with disorders of the eye or ear.
Source: pp. 1123
Heading: Nursing Care Plan for the Hospital patient With Visual
Impairment Integrated Process: Clinical Problem-Solving Process
(Nursing Process) Hospital patient Need: Physiological Integrity—
Reduction of Risk Potential CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 When a hospital patient with severe vision impairment is able to perform self-
care independently, hospital patient teaching is effective.
2 The hospital patient needs additional teaching about methods and/or agencies
that can
be helpful in supplying adequate nutrition.
3 When the hospital patient enlists the help of family to make the environment
safer, teaching is effective.
4 When the hospital patient understands the need for help with chores that cannot
be
performed independently, teaching is effective.
PTS: 1 CON: Sensory Perception
14. The nursing practitioner is collecting data from a hospital patient with diabetes mellitus.
The hospital patient’s medical history reveals multiple episodes of hyperglycemia requiring
medical management. The hospital patient tells the nurse, “I just got new glasses, but I still do
not see very well.” Which condition does the nursing practitioner suspect?
1. Preproliferative retinopathy
2. Background retinopathy
3. Proliferative retinopathy
4. Incomplete retinal detachment
RIGHT ANSWER> 2
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Explain the etiologies, signs, and symptoms of each sensory disorder.
Source: pp. 1123
Heading: Diabetic Retinopathy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 Preproliferative retinopathy is the second stage of diabetic retinopathy, which is
characterized by swollen and irregularly dilated veins. There are no symptoms
related to this stage.
2 Background retinopathy is the first stage of diabetic retinopathy when
microaneurysms form in the retina capillary walls. The hospital patient may
notice decrease in color discrimination and visual acuity.
3 Proliferative retinopathy is the third state of diabetic retinopathy characterized
by the formation of new blood vessels, which are fragile and leak blood into
the vitreous and retina. During this stage, retinal detachment may occur.
4 The hospital patient’s statement does not support the presence of any type of
retinal
detachment.
PTS: 1 CON: Sensory Perception
15. The nursing practitioner is providing care for an older adult hospital patient. The nursing
practitioner notices the hospital patient appears to be having difficulty understanding her and
asks that questions and comments be repeated. If the nursing practitioner suspects presbycusis,
which action does the nursing practitioner take to promote better hearing for the hospital
patient?
1. Ask the hospital patient if he is having difficulty hearing.
2. Sit closer to and directly in front of the hospital patient.
3. Speak to the hospital patient in a lower tone of voice.
4. Use a slightly louder and slower talking rate.
RIGHT ANSWER> 3
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Plan nursing care interventions for the hospital patient with a hearing
impairment.
Source: pp. 1129
Heading: Sensorineural Hearing Loss
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Basic Care and
Comfort CL: Application (Applying)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 The nursing practitioner can ask the hospital patient to confirm problems with
hearing, but should
expect the answer to be positive given the hospital patient’s actions.
2 Sitting closer and directly in front of the hospital patient may or may not help
the hospital patient to hear better; depending on the hospital patient, it may be
culturally contraindicated to make this change.
3 Older hospital patients are inclined to develop presbycusis and have difficulty in
deciphering higher pitched sounds, like the female voice. The nursing
practitioner should lower the tone of her voice to promote better hearing.
4 Talking slightly louder and slower will not improve the hospital patient’s ability
to hear.
PTS: 1 CON: Sensory Perception
16. The nursing practitioner is reinforcing teaching provided to a hospital patient with primary
open-angle glaucoma (POAG) about symptoms to report. Which hospital patient statement
regarding symptoms indicates a correct understanding of the teaching?
1. “Hypotension and bradycardia”
2. “Fever and reddened conjunctiva”
3. “Loss of central vision and dizziness”
4. “Headache and seeing halos around lights”
RIGHT ANSWER> 4
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Explain the etiologies, signs, and symptoms of each sensory disorder.
Source: pp. 1125
Heading: Glaucoma
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 Hypotension and bradycardia are not symptoms of POAG.
2 Fever and reddened conjunctiva are not symptoms of POAG.
3 Loss of central vision and dizziness are not symptoms of POAG.
4 POAG develops bilaterally. The onset is usually gradual and painless, so the
hospital patient may not experience noticeable symptoms or, after time, may
experience mild aching in the eyes, headache, halos around lights, or frequent
visual changes that are not corrected with eyeglasses.
PTS: 1 CON: Sensory Perception
17. The nursing practitioner is reinforcing teaching provided to a hospital patient
recovering from a stapedectomy. Which hospital patient statement indicates teaching has
been effective?
1. “I will avoid airplane travel for 6 months.”
2. “I will cough or sneeze with my mouth open.”
3. “I will gently blow my nose with both sides open.”
4. “I will keep the ear moist by packing it with cotton balls.”
RIGHT ANSWER> 2
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Plan nursing care for hospital patients with disorders of the eye or ear.
Source: pp. 1137
Heading: Middle Ear, Tympanic Membrane, and Mastoid Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 There is no need for the hospital patient to avoid airplane travel for 6 months.
2 It is important to prevent increased pressure to protect the graft site, so the
mouth should be open when coughing or sneezing.
3 The nose should be gently blown one side at a time.
4 The ear does not need to be kept moist; there is no need to pack the ear with
cotton balls.
PTS: 1 CON: Sensory Perception
18. The nursing practitioner is assisting with the care of a hospital patient being prepared for
emergency intervention for a detached retina. If the nursing practitioner asks the hospital patient
about the ability to maintain a reclining position for 16 hours, which procedure is planned for
this hospital patient?
1. Laser surgery
2. Cryopexy
3. Pneumatic retinopexy
4. Scleral buckling
RIGHT ANSWER> 3
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Identify therapeutic measures for each sensory disorder.
Source: pp. 1124
Heading: Retinal Detachment
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 Laser surgery does not require the hospital patient to recline for 16 hours prior
to the
procedure.
2 Cryopexy does not require the hospital patient to recline for 16 hours prior to the
procedure.
3 Pneumatic retinopexy is a procedure that involves injecting air or gas into the
eyeball to hold the retina in place. Reclining for about 16 hours before the
procedure is required to allow the retina to fall back toward the choroid. Three
weeks of specific positioning is required to complete the process of healing.
4 Scleral buckling does not require the hospital patient to recline for 16 hours
prior to the procedure.
PTS: 1 CON: Sensory Perception
19. The nursing practitioner is preparing to assist the HCP with the incision of a carbuncle in the
ear canal of a hospital patient. Which specific manifestation does the nursing practitioner associate
with the hospital patient’s diagnosis?
1. Necrotic tissue spreading toward the auricle
2. An absence of protective earwax in the canal
3. Several hair follicles that have formed an abscess
4. Fungus in the ear canal causing an infection
RIGHT ANSWER> 3
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Explain the pathophysiology of each of the disorders of the sensory system.
Source: pp. 1133
Heading: External Ear
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 Perichondritis is an infection of the auricle that can result in necrosis of the ear
cartilage. Necrotic tissue spreading toward the auricle is not associated with a
carbuncle.
2 The absence of protective earwax in the ear canal is swimmer’s ear and is not
associated with a carbuncle in the ear canal.
3 When several hair follicles in the ear canal become infected and form an
abscess, it is a carbuncle. Many carbuncles will rupture on their own; some will
need to be incised and drained.
4 Otomycosis is an infection of the ear canal caused by a fungus growth.
PTS: 1 CON: Sensory Perception
20. The nursing practitioner in the emergency department is assisting with the care of a hospital
patient with a penetrating wound to the eye. The hospital patient keeps crying out and asking that
the uninjured eye be uncovered. Which answer by the nursing practitioner provides understanding?
1. “It is less stressful if you cannot see anything about the other eye.”
2. “Covering your uninjured eye will keep anything from getting into it.”
3. “Being able to see will allow you to look around and get more upset.”
4. “Covering the uninjured eye stops ocular movement in the injured one.”
RIGHT ANSWER> 4
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Identify therapeutic measures for each sensory disorder.
Source: pp. 1129
Heading: Trauma
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Sensory Perception
Difficulty: Moderate
CLARIFICATION
1 The nursing practitioner needs to help keep the hospital patient calm; however,
it is not the reason the uninjured eye is covered.
2 The uninjured eye is not necessarily covered to keep anything from getting into
it; the goal is to prevent ocular movement in the injured eye.
3 Telling the hospital patient that the ability to look around will just upset them
more and does not help to keep the hospital patient calm.
4 The primary reason for covering the uninjured eye when there is a penetrating
injury to the other eye is to stop ocular movement that can cause additional
damage.
PTS: 1 CON: Sensory Perception
MULTIPLE RESPONSE
1. The nursing practitioner is providing care for a hospital patient with a sensorineural hearing
loss. Which prescribed medications does the nursing practitioner question before administering
medications to this hospital patient? (Select all that apply.)
1. Gentamicin
2. Furosemide
3. Indomethacin
4. Acetaminophen
5. Warfarin sodium
RIGHT ANSWER> 1, 2, 3
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: List three ototoxic drugs.
Source: pp. 1129
Heading: Hearing Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Difficult
CLARIFICATION
1. Gentamicin, furosemide, and indomethacin are all ototoxic medications. For
the hospital patient with sensorineural hearing loss, the nursing practitioner
should question these medications before providing.
2. Gentamicin, furosemide, and indomethacin are all ototoxic medications. For
the hospital patient with sensorineural hearing loss, the nursing practitioner
should question these
medications before providing.
3. Gentamicin, furosemide, and indomethacin are all ototoxic medications. For
the hospital patient with sensorineural hearing loss, the nursing practitioner
should question these medications before providing.
4. This medication is not considered ototoxic.
5. This medication is not considered ototoxic.
PTS: 1 CON: Sensory Perception
2. The nursing practitioner is collecting data from a hospital patient with a detached retina.
Which findings does the nursing practitioner expect in this hospital patient? (Select all that
apply.)
1. Severe pain
2. Blurred vision
3. Flashing lights
4. Loss of peripheral vision
5. Loss of acuity in the affected eye
RIGHT ANSWER> 3, 4, 5
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Explain the etiologies, signs, and symptoms of each sensory disorder.
Source: pp. 1124
Heading: Retinal Detachment
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Difficult
CLARIFICATION
1. There is no pain because the retina does not contain sensory nerves.
2. Blurred vision does not occur with a detached retina.
3. Hospital patients experiencing a retinal detachment report a sudden change in
vision. Initially, as the retina is pulled, hospital patients report seeing flashing
lights and then floaters. The flashing lights are caused by vitreous traction on
the retina, and
the floaters are caused by hemorrhage of vitreous fluid or blood.
4. On visual examination, the hospital patient typically has a loss of peripheral
vision when the visual fields are tested and a loss of acuity in the affected eye.
5. On visual examination, the hospital patient typically has a loss of peripheral
vision
when the visual fields are tested and a loss of acuity in the affected eye.
PTS: 1 CON: Sensory Perception
3. A hospital patient with acute ear pain and drainage comes into the community clinic.
Which diagnostic tests does the nursing practitioner expect to be performed prior to
beginning treatment for this hospital patient? (Select all that apply.)
1. Biopsy
2. Audiometric testing
3. Complete blood count (CBC)
4. Rinne and Weber tests
5. Culture of ear discharge
RIGHT ANSWER> 3, 4, 5
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Plan nursing care for hospital patients with disorders of the eye or ear.
Source: pp. 1133
Heading: External Ear
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Difficult
CLARIFICATION
1. A biopsy would be indicated for an ear mass.
2. Audiometric testing would be appropriate for the hospital patient with
impacted cerumen.
3. For an external ear infection diagnostic tests include a CBC, specifically
white blood cell count, and cultures of discharge. This will help diagnose the
infection.
4. The Rinne and Weber tests can indicate conductive hearing impairment.
5. Culture and sensitivity tests isolate the specific infective organism and
determine which antibiotics would be most effective to treat the infection.
PTS: 1 CON: Sensory Perception
4. A hospital patient with otitis media is experiencing severe ear pain. Which
nonpharmacological measures does the nursing practitioner apply to help relieve this
hospital patient’s discomfort? (Select all that apply.)
1. Offer a massage.
2. Apply heat to the area.
3. Offer liquid or soft diet.
4. Apply an ice pack to the area.
5. Dim the lights and reduce environmental noise.
RIGHT ANSWER> 1, 2, 3
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Plan nursing care for hospital patients with disorders of the eye or ear.
Source: pp. 1133
Heading: Middle Ear, Tympanic Membrane, and Mastoid Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Basic Care and
Comfort CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Difficult
CLARIFICATION
1. Nonpharmacological methods, such as relaxation, massage, music, guided
imagery, or distraction techniques help to relieve ear pain.
2. Apply heat as ordered to the area to promote comfort.
3. Offer liquid or soft foods to relieve pain when chewing.
4. Ice to the area could cause additional pain.
5. Dimming the lights and reducing environmental noise would be helpful for a
hospital patient with an eye injury or condition.
PTS: 1 CON: Sensory Perception
COMPLETION
1. After surgery for a detached retina, a hospital patient is experiencing nausea and is
prescribed prochlorperazine (Compazine), 10 mg IM prn every 6 hours. Compazine is
available as 5 mg/mL. The nursing practitioner administers mL in each dose.
RIGHT ANSWER>
2, two
1 two
2, two
Chapter: Chapter 52. Nursing Care of Hospital patients With Sensory Disorders: Vision and
Hearing Objective: Plan nursing care for hospital patients with disorders of the eye or ear.
Source: pp. 1133
Heading: Retinal Detachment
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Pharmacological
Therapies CL: Analysis (Analyzing)
Concept: Sensory Perception
Difficulty: Difficult
CLARIFICATION: The solution is found by mathematical process.
= 2 mL
PTS: 1 CON: Sensory Perception
10 mg 1 mL
5 mg
Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
MULTIPLE CHOICE
1. The nursing practitioner is assisting with a skin examination for a hospital patient. The
hospital patient asks, “I love the sun, why is everyone so concerned about sun exposure?”
Which answer by the nursing practitioner is best?
1. “Sun exposure will cause the skin to age and wrinkle.”
2. “The sun gives off ultraviolet (UV) rays that destroy vitamin D.”
3. “Melanin pigment is a barrier against UV exposure.”
4. “UV rays are mutagenic and can cause skin cancers.”
RIGHT ANSWER> 4
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: Explain normal structures and functions of the integumentary system.
Source: pp. 1147
Heading: Epidermis, Dermis, and Hypodermis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 Sun exposure can contribute to skin aging and the development of wrinkles;
however, this is not the best answer regarding sun exposure.
2 The sun gives off UV rays, but UV rays are not involved in the destruction of
vitamin D.
3 When melanin cells are stimulated by exposure to the sun, more pigment is
produced to form a barrier against UV exposure to living cells in the stratum
germinativum. The visible result is a tan.
4 The best answer about concern related to sun exposure is that UV rays are
mutagenic and can damage the DNA in cells, create mutations, and cause skin
malignancies.
PTS: 1 CON: Tissue Integrity
2. The nursing practitioner in a health care provider’s (HCP’s) office is reassessing a
hospital patient’s skin and making a comparison with the information from the hospital
patient’s last visit. For which reason does the nursing practitioner focus on any changes
noted in the hospital patient’s skin?
1. Detection of skin cancer early can improve chances of a cure.
2. The skin is a good communicator regarding the hospital patient’s health.
3. Skin lesions are seen as solid predictors of general health state.
4. The hospital patient’s psychological health is best predicted by
the skin. RIGHT ANSWER> 2
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: List data to collect when caring for a hospital patient with an integumentary
system disorder.
Source: pp. 1148
Heading: Nursing Assessment of the Integumentary System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 Skin cancer can be detected early with regular skin inspections; however, the
nurse’s focus on changes is not just related to skin cancer.
2 The nursing practitioner knows the condition of the skin can be caused by
underlying systemic conditions or manifestations of issues just related to the
skin. Both situations make it important for the nursing practitioner to focus on
changes from the last
examination.
3 Skin lesions are not solid predictors of a hospital patient’s general health issues.
Some skin lesions are just indications of skin problems.
4 Psychological stress can contribute to a hospital patient’s skin condition;
however, this
connection varies among individuals.
PTS: 1 CON: Tissue Integrity
3. The nursing practitioner is preparing to reexamine the skin of a hospital patient who has a
history of malignant skin growths. Which preparation by the nursing practitioner is incorrect?
1. Allow the hospital patient to leave on underwear and socks.
2. Plan to use the techniques of inspection and palpation.
3. Include the hair, nails, scalp, and mucous membranes.
4. Explain the need for a penlight and magnifying glass.
RIGHT ANSWER> 1
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: List data to collect when caring for a hospital patient with an integumentary
system disorder.
Source: pp. 1149
Heading: Physical Examination
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 The hospital patient needs to completely undress for a thorough inspection,
especially
with a history of malignant skin growths. The feet and genitalia are not immune
to skin lesions or cancers.
2 When reassessing the hospital patient’s skin, the nursing practitioner will use the
techniques of
inspection and palpation.
3 The body skin is not the only area inspected during a skin examination; the
hair, nails, scalp, and mucous membranes are also inspected.
4 The nursing practitioner needs to explain the need for a penlight and
magnifying glass during a skin inspection; some areas of concern may be very
small or in areas hidden
by other parts of the body.
PTS: 1 CON: Tissue Integrity
4. The nursing practitioner is applying wet dressings as ordered to a hospital patient who
has a crusted skin lesion. Which assessment finding causes the nursing practitioner the most
concern?
1. Edema formation
2. Dry, macerated skin
3. Increased lesion oozing
4. Excessive skin oiliness
RIGHT ANSWER> 2
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: Describe therapeutic measures that are used for hospital patients with
integumentary disorders.
Source: pp. 1150
Heading: Open Wet Dressings
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 Edema is not a common reaction to wet dressings.
2 Wet dressings should not be prescribed for more than 72 hours, because the
skin may become too dry or macerated.
3 Oozing is not a common reaction to wet dressings.
4 Oiliness is not a common reaction to wet dressings.
PTS: 1 CON: Tissue Integrity
5. The nursing practitioner works in an extended-care facility and is assisting in the
development of a policy and procedure addressing foot care of the residents. Which
intervention does the nursing practitioner identify as needing to be reconsidered in
regard to routine foot care?
1. Soak the residents’ feet briefly in warm water and wash with gentle soap.
2. Use gauze or pads to reduce pressure where toes lie across each other.
3. Use a pumice stone to remove dry skin from heels or callused areas.
4. Apply an alcohol-free lotion to massage and perform range of motion (ROM) on
feet and ankles.
RIGHT ANSWER> 3
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: Identify the effects of aging on the integumentary system.
Source: pp. 1181
Heading: Care of Older Hospital patients’ Feet
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Difficult
CLARIFICATION
1 Soaking the feet of residents in warm water for a brief period of time before
washing the feet with a gentle soap is appropriate care.
2 Placing a gauze or commercial pad between toes that overlap each other is an
appropriate action to prevent skin breakdown in pressure areas.
3 The nursing practitioner needs to identify and question the suggestion to gently
remove dry skin from heels and callouses with a pumice stone. Many residents
will be older adults and the diagnosis of diabetes mellitus is common. A
pumice stone is used on the feet of a hospital patient with diabetes only under
the direction of a podiatrist.
4 Massage and ROM performed on the feet and ankles are relaxing and
therapeutic. Alcohol-free lotion is used, but the lotion is not applied or allowed
to remain between the toes.
PTS: 1 CON: Tissue Integrity
6. A hospital patient presents with skin lesions that appear reddened, with seeping areas
partially crusted over. The HCP orders a viral culture to be performed. Which action by the
nursing practitioner is inappropriate when collecting the culture specimen?
1. An intact vesicle is gently squeezed to obtain fluid.
2. A sterile cotton swab is used to acquire culture material.
3. The collected fluid is evenly distributed over a glass slide.
4. The specimen is immediately transported to the laboratory.
RIGHT ANSWER> 3
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: Identify laboratory and diagnostic tests commonly performed to diagnose
integumentary disorders.
Source: pp. 1152
Heading: Cultures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 If an intact vesicle is available, it is gently squeezed to obtain fluid. If the area
is crusted over, the crusts are removed or punctured to obtain culture fluid.
2 A sterile cotton swab is used to obtain the material for a culture; care is taken to
not contaminate the specimen.
3 When obtaining a specimen for a virus culture, the cotton swab is placed in a
special collection tube and placed on ice. The nursing practitioner does not
distribute the collected fluid over a glass slide.
4 For viral cultures, the collected specimen is placed inside a special tube, which
is placed on ice and transported to the laboratory immediately.
PTS: 1 CON: Tissue Integrity
7. The nursing practitioner is preparing to assist the HCP in obtaining a full-thickness skin
biopsy. Which information from the nursing practitioner is most appropriate?
1. Explain that the surface of the biopsy area will be shaved off.
2. Inform the hospital patient that a thick area of skin will be punched out.
3. Tell the hospital patient that the most pain will be in numbing the area.
4. Instruct the hospital patient to expect considerable bleeding to occur.
RIGHT ANSWER> 3
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: Identify laboratory and diagnostic tests commonly performed to diagnose
integumentary disorders.
Source: pp.
1152 Heading:
Biopsy
Integrated Process: Clinical Problem-Solving Process (Nursing Process) CL:
Application (Applying)
Concept: Tissue Integrity
Difficulty: Difficult
CLARIFICATION
1 If the HCP plans a full-thickness biopsy, the technique will not involve shaving
off the surface of the lesion.
2 It is true that a thick area of skin will be punched out; however, this description
may cause the hospital patient anxiety or fear.
3 The most important information for the nursing practitioner to give the hospital
patient is the most
pain associated with obtaining the biopsy involves numbing the area.
4 Bleeding or the amount of bleeding is expected, although it is unnecessary for
the nursing practitioner to convey this information prior to the procedure.
PTS: 1 CON: Tissue Integrity
8. The nursing practitioner is assisting with a hospital patient who has a suspected
diagnosis of tinea capitis (ringworm). For which diagnostic test does the nursing
practitioner prepare the hospital patient?
1. Patch test
2. Scratch test
3. Skin biopsy
4. Wood’s light examination
RIGHT ANSWER> 4
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: Identify laboratory and diagnostic tests commonly performed to diagnose
integumentary disorders.
Source: pp. 1177
Heading: Wood Light Examination
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 A patch test is performed when allergic contact dermatitis is suspected.
2 A scratch test is performed when allergic contact dermatitis is suspected.
3 A skin biopsy is indicated for deeper infections to establish an accurate
diagnosis or for the evaluation of current treatment. A biopsy is an excision of a
small piece of tissue for microscopic assessment.
4 Wood’s light examination is the use of UV rays to detect fluorescent materials
in the skin and hair present in certain diseases such as tinea capitis (ringworm).
PTS: 1 CON: Tissue Integrity
9. While changing the dressing on a burned arm, the hospital patient informs the nursing
practitioner of feeling cold and having extreme pain. However, the hospital patient asks the
nursing practitioner to not apply so much pressure when wrapping gauze around the limb. Which
conclusion does the nursing practitioner draw from the hospital patient’s statements?
1. All nerves in the limb are damaged.
2. Free nerve endings in the arm are injured.
3. Encapsulated nerve endings in the arm are intact.
4. Encapsulated nerve endings in the arm are injured.
RIGHT ANSWER> 3
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: Explain normal structures and functions of the integumentary system.
Source: pp. 1203
Heading: Receptors
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 This is an incorrect interpretation of the hospital patient’s response and extent of
injury
to the nerve endings in the burned arm.
2 This is an incorrect interpretation of the hospital patient’s response and extent of
injury
to the nerve endings in the burned arm.
3 Sensory receptors for the cutaneous senses reside in the dermis. Receptors for
heat, cold, and pain are free nerve endings; encapsulated nerve endings are
specific for touch and pressure. The sensitivity of an area of skin is determined
by the density of receptors present.
4 This is an incorrect interpretation of the hospital patient’s response and extent of
injury
to the nerve endings in the burned arm.
PTS: 1 CON: Tissue Integrity
10. The nursing practitioner works in an office with a dermatologist. When preparing to assist
with a patch test for a hospital patient with suspected allergic contact dermatitis, which nursing
action is unnecessary?
1. Cleanse the hospital patient’s upper back and arms with alcohol.
2. Instruct the hospital patient to keep areas dry and free from moisture.
3. Place resuscitation equipment in the vicinity of the testing.
4. Arrange for the final reading of the testing in 2 to 5 days.
RIGHT ANSWER> 3
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: Identify laboratory and diagnostic tests commonly performed to diagnose
integumentary disorders.
Source: pp. 1153
Heading: Skin Testing
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 With a patch test, the skin needs to be oil free to promote adhesion of the patch;
alcohol is an acceptable prep for the skin.
2 The hospital patient needs to keep the tested area(s) dry and free from moisture
for the prescribed length of time.
3 Resuscitation equipment is not needed for patch testing. However, due to the
risk for anaphylaxis, the equipment is kept in a close location for scratch
testing, which elicits an immediate reaction.
4 With a patch test, the patches remain in place for 2 days and final reading or
evaluation of the reactions take place within 2 to 5 days.
PTS: 1 CON: Tissue Integrity
11. A hospital patient is admitted for treatment for a severe ulcerated pressure injury exhibiting
signs of infection. The HCP prescribes open wet dressings to be applied every 6 hours for a period
of 30 minutes. For which part of the prescription does the nursing practitioner consult with the
registered nursing practitioner (RN)?
1. Treatment is to continue for 7 days.
2. The procedure is performed with clean technique.
3. Room temperature normal saline is prescribed.
4. The appearance of the area is to be documented.
RIGHT ANSWER> 1
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: Describe therapeutic measures that are used for hospital patients with
integumentary disorders.
Source: pp. 1165
Heading: Open Wet Dressings
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 Open wet dressings are not prescribed for longer than 72 hours; the skin may
become too dry or macerated if treatment is extended. The nursing
practitioner needs to consult with the RN about the prescribed period of 7
days.
2 The procedure can be ordered as sterile or clean, depending on the tendency for
an infection to develop. Because the hospital patient already has an infection at
the site,
there is no need to consult with the RN since sterile technique is not necessary.
3 Room temperature normal saline is an appropriate soaking solution to use on an
open wet dressing. Other solutions include cool tap water, aluminum acetate
solution, or magnesium sulfate. There is no need to consult with the RN.
4 Documentation is always considered a part of nursing care.
PTS: 1 CON: Tissue Integrity
12. A hospital patient with widely distributed chronic eczema is prescribed to receive
medicated tar baths. Which important detail does the nursing practitioner acknowledge during
this procedure?
1. The hospital patient will need to be kept in the bath for 1 hour.
2. Old medications will need to be removed prior to the bath.
3. The room needs to have good ventilation because of volatility.
4. Slow addition of hot water will keep the bath temperature stable.
RIGHT ANSWER> 3
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: Describe therapeutic measures that are used for hospital patients with
integumentary disorders.
Source: pp. 1153
Heading: Balneotherapy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 Balneotherapy is prescribed for 15 to 30 minutes.
2 Balneotherapy is prescribed to apply medications to large areas of the body, for
debridement and removing old crusts, to remove old medications, and to
alleviate inflammation and itching. Medication does not need to be removed
prior to the bath.
3 When a medicated tar bath is prescribed, the room must be well ventilated
because tars are volatile.
4 During balneotherapy, hot water is not added to the bath to prevent skin burns.
The temperature of the bath should be comfortable.
PTS: 1 CON: Tissue Integrity
13. The nursing practitioner is providing care for a hospital patient with a large skin abrasion to
the outer thigh. The HCP has ordered a daily dressing change without disturbance of the healing
crusts that have formed in the area. Which dressing material will the nursing practitioner select?
1. Gauze 4 × 4s with paper tape to seal the edges of the dressing.
2. A nonadherent dressing for cover and gauze for wrapping.
3. Thick abdominal pad for protection with an elastic wrap.
4. A thin dressing wrapped around the thigh and taped securely.
RIGHT ANSWER> 2
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: Describe therapeutic measures that are used for hospital patients with
integumentary disorders.
Source: pp. 1166
Heading: Dressings
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 Gauze of any size will stick to the wound and pull away the crusts when the
dressing is removed. Tape should be avoided.
2 This wound requires a nonadherent dressing (Xeroform) held in place with a
gauze wrapping; this selection will protect the healing crusts on the wound.
3 A thick abdominal pad is not necessary and the material of the pad is not
nonadherent. An elastic wrap has the potential of being too tight.
4 The wound needs to have a dressing and wrapping a dressing around the entire
thigh is not necessary. Tape should be avoided.
PTS: 1 CON: Tissue Integrity
14. A hospital patient has an open skin lesion and the HCP wants the area covered with a
dressing after application of an antibiotic ointment. The hospital patient asks the nursing
practitioner the purpose of covering the area. Which reason does the nursing practitioner
provide?
1. The dressing is solely for the purpose of retaining moisture.
2. The dressing will prevent the evaporation of the medication.
3. The dressing will reduce pain in the lesion and prevent itching.
4. The dressing will enhance the absorption of the topical medication.
RIGHT ANSWER> 4
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: Describe therapeutic measures that are used for hospital patients with
integumentary disorders.
Source: pp. 1166
Heading: Dressings
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 There is no information to validate the need for a dressing to retain moisture at
the site of the lesion.
2 Ointment is not likely to evaporate; this is not a valid reason for the dressing.
3 There is no information provided to indicate that the hospital patient has pain
or itching at the site of the wound.
4 When the lesion is open and an antibiotic ointment is applied, the purpose of
the dressing is to enhance the absorption of the topical medication.
PTS: 1 CON: Tissue Integrity
15. The nursing practitioner is assisting in the care of a hospital patient with second-degree burns
to the arm. The blisters are not intact. The HCP prescribes an antibiotic ointment to be applied to
the open areas twice daily. Which method will the nursing practitioner use for applying the
prescribed medication?
1. A soft bristle brush
2. A cotton tipped swab
3. A wooden tongue depressor
4. A small surgical sponge
RIGHT ANSWER> 3
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: Describe therapeutic measures that are used for hospital patients with
integumentary disorders.
Source: pp. 1196
Heading: Topical Medications
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Pharmacological
Therapies CL: Application (Applying)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 Sometimes a soft brush can be used to apply thin or watery medications.
2 A cotton swab is so small it may not be time effective to apply ointment in this
manner.
3 Ointment is thick and will spread well with the use of a wooden tongue
depressor.
4 A small surgical sponge may not be solid enough to spread an ointment.
PTS: 1 CON: Tissue Integrity
16. The nursing practitioner is providing care for a hospital patient diagnosed with a fungal
infection in the skinfolds beneath the breasts. The HCP has prescribed the application of an
antifungal powder to the affected areas. For which reason does the nursing practitioner contact
the RN for validation of the prescribed treatment?
1. The area of treatment has developed open sores.
2. The hospital patient has an allergy to cornstarch.
3. The breasts are heavy and pendulant.
4. The hospital patient has a chronic respiratory disease.
RIGHT ANSWER> 4
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: Describe therapeutic measures that are used for hospital patients with
integumentary disorders.
Source: pp. 1149
Heading: Topical Medications
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 With a fungal infection in skinfolds, open sores are not unusual or a reason to
validate the prescribed treatment.
2 Antifungal powders come in a variety of bases (cornstarch, zinc oxide, talc), so
if an allergy exists, a different product can be ordered. However, there is no
information in the question to indicate an allergy to cornstarch.
3 The hospital patient is likely to have the fungal infection because the breasts are
heavy and pendulant; fungus is most common in warm moist areas. After the
application of the powder, the area can be covered with gauze dressings.
4 Powder medications are contraindicated for hospital patients with respiratory
disorders or a tracheotomy. This is the reason the nursing practitioner needs
the RN to validate the medication.
PTS: 1 CON: Tissue Integrity
17. The nursing practitioner is assisting in the care of a hospital patient presenting with painful
psoriatic lesions. The HCP is preparing for intralesional therapy using a sterile suspension of
corticosteroid. Which side effect does the nursing practitioner recognize as a possibility with
this therapy?
1. Thinning of the skin at the site of the injection
2. Infection from invasive administration of medication
3. Local atrophy if the injection is in subcutaneous tissue
4. Interference with healing if an infection occurs
RIGHT ANSWER> 3
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: Describe therapeutic measures that are used for hospital patients with
integumentary disorders.
Source: pp. 1150
Heading: Topical Medications
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 Thinning of the skin can occur with prolonged use of topical corticosteroids.
2 It is uncommon for an infection to develop because of the injection of
medication; the procedure is performed using aseptic technique.
3 If the intralesional injection is not placed deeply beneath the lesion and is
injected into subcutaneous tissue, local atrophy can occur.
4 Intralesional injections of a corticosteroid will not interfere with healing if an
infection occurs. However, the infection at the site may be masked by the
medication.
PTS: 1 CON: Tissue Integrity
18. The nursing practitioner is collecting data on an older adult hospital patient with a
generalized rash. The hospital patient reports severe itching and the nursing practitioner notes
open lesions from scratching. Which additional finding causes the nursing practitioner
the least concern?
1. The hospital patient has uncut fingernails.
2. The hospital patient is wearing soft-soled slippers.
3. The hospital patient has thin hair with seborrhea.
4. The hospital patient has an odor of urine and feces.
RIGHT ANSWER> 2
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: List data to collect when caring for a hospital patient with an integumentary
system disorder.
Source: pp. 1150
Heading: General Integrity and Cleanliness
Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Hospital patient Need: Physiological Integrity—Reduction
of Risk Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 Because of the reported itching and open lesions, the nursing practitioner is
concerned that the hospital patient has uncut fingernails, which enables skin
damage with scratching. Longer nails also harbor pathogens that can cause
infections.
2 The nurse’s least concern is the hospital patient wearing soft-soled slippers.
3 It is not unusual for older adult hospital patients to have thin hair. Seborrhea can
cause itching and provide an environment on the scalp that promotes the growth
of bacteria.
4 When the hospital patient has the odor of urine and feces, general cleanliness is
in question. Unclean skin allows for the growth of bacteria that can cause
infections.
PTS: 1 CON: Tissue Integrity
MULTIPLE RESPONSE
1. The nursing practitioner is caring for a hospital patient in a wound clinic who is treated with
plastic wrap dressings. Which findings indicate complications related to prolonged application of
the dressings? (Select all that apply.)
1. Cyanosis
2. Folliculitis
3. Maceration
4. Skin atrophy
5. Lichenification
RIGHT ANSWER> 2, 3, 4
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: Describe therapeutic measures that are used for hospital patients with
integumentary disorders.
Source: pp. 1154
Heading: Dressings
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Difficult
CLARIFICATION
1. Properly applied occlusive dressings do not cause cyanosis or lichenification.
2. Continued use of occlusive dressings can cause skin atrophy, folliculitis,
maceration, erythema, and systemic absorption of the medication. To prevent
some of these complications, the dressing is removed for 12 out of every 24
hours.
3. Continued use of occlusive dressings can cause skin atrophy, folliculitis,
maceration, erythema, and systemic absorption of the medication. To prevent
some of these complications, the dressing is removed for 12 out of every 24
hours.
4. Continued use of occlusive dressings can cause skin atrophy, folliculitis,
maceration, erythema, and systemic absorption of the medication. To prevent
some of these complications, the dressing is removed for 12 out of every 24
hours.
5. Properly applied occlusive dressings do not cause cyanosis or lichenification.
PTS: 1 CON: Tissue Integrity
2. The nursing practitioner is assisting with the presentation about skin for a group of senior
citizens in a community center. Which normal changes associated with aging does the nursing
practitioner include? (Select all that apply.)
1. Fibroblasts in dermis die.
2. Subcutaneous fat increases.
3. Epidermal cell division slows.
4. Hair follicles become inactive.
5. Sweat glands become more active.
RIGHT ANSWER> 1, 3, 4
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: Identify the effects of aging on the integumentary system.
Source: pp. 1155
Heading: Gerontological Issues
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Difficult
CLARIFICATION
1. In normal aging, cell division slows, hair follicles become inactive, and
fibroblasts in the dermis die.
2. Subcutaneous fat decreases, not increases.
3. In normal aging, cell division slows, hair follicles become inactive, and
fibroblasts in the dermis die.
4. In normal aging, cell division slows, hair follicles become inactive, and
fibroblastsin the dermis die.
5. Sweat glands become less, not more, active.
PTS: 1 CON: Tissue Integrity
Chapter 54. Nursing Care of Hospital patients With Skin Disorders
MULTIPLE CHOICE
1. The nursing practitioner is participating in a unit program aimed at preventing pressure
injuries to residents in a long-term care facility. Which intervention does the nursing
practitioner anticipate will be least effective?
1. Thoroughly dry all skin-to-skin surfaces after bathing.
2. Position hospital patients at a 45-degree angle when on their side.
3. Place a pillow lengthwise under the calves of the legs.
4. Ensure an adequate intake of protein, calories, and fluid.
RIGHT ANSWER> 2
Chapter: Chapter 54. Nursing Care of Hospital patients With Skin Disorders
Objective: Recognize the role of the nursing practitioner in preventing
pressure injuries. Source: pp. 1160
Heading: Pressure Injuries
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 It is important to keep the skin clean and dry for a hospital patient who is at
risk for pressure injuries. Places like under the breasts, the groin, and between
the toes are suitable for the growth of bacteria.
2 When positioning a hospital patient on the side, the angle should not be more
than 30 degrees to prevent pressure on the trochanter, a bony prominence, which
is
particularly subject to ischemia and pressure injury. The suggestion of 45
degrees is least helpful.
3 The heels need to be elevated off any surface to prevent pressure injuries;
placing a pillow lengthwise under the calves is an effective intervention.
4 Good nutrition and hydration will promote healthy skin and assist in preventing
pressure injuries, along with many other problems.
PTS: 1 CON: Tissue Integrity
2. The nursing practitioner is monitoring a hospital patient’s stage 3 pressure injury for
healing during treatment. Which finding indicates the nursing interventions have been
effective?
1. There is a hard crust over the wound.
2. The hospital patient states that pain is minimal.
3. The wound drainage is serosanguinous.
4. The wound has a grainy, spongy texture.
RIGHT ANSWER> 4
Chapter: Chapter 54. Nursing Care of Hospital patients With Skin Disorders
Objective: Explain how you will know whether your nursing interventions have been
effective.
Source: pp. 1167
Heading: Pressure Injuries
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 A hard crust indicates eschar, which must be removed for healing to occur.
2 Minimal pain is a good outcome, but is not a measure of healing.
3 Serosanguinous drainage indicates absence of infection, not healing.
4 Granulation tissue is a sign of healing and has a budding appearance, from the
development of tiny new capillaries. If the granulations are healthy, they have a
slightly spongy texture.
PTS: 1 CON: Tissue Integrity
3. The nursing practitioner is providing care for a hospital patient with limited mobility. The
nursing practitioner notes that the head of the hospital patient’s bed is frequently at 45 degrees
of elevation and the hospital patient is slouched in the bed. Which area of the hospital patient
needs to be inspected carefully?
1. The coccyx and buttocks
2. The buttocks and the hips
3. The shoulder blades and coccyx
4. The heels and the back of the head
RIGHT ANSWER> 1
Chapter: Chapter 54. Nursing Care of Hospital patients With Skin Disorders
Objective: Recognize the role of the nursing practitioner in preventing
pressure injuries. Source: pp. 1153
Heading: Reduce Pressure, Friction, and Shear Damage
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 The shearing and friction forces that occur when the hospital patient slides down
in bed will increase the possibility of pressure injury to the coccyx and buttocks.
The nursing practitioner needs to check these areas carefully and lower the head
of the bed to 30
degrees.
2 The hips are prone to pressure injuries if the hospital patient is not positioned
correctly in a side-lying position.
3 The shoulder blades are not at risk for pressure injuries unless the hospital
patient is left
in a supine position.
4 The heels and the back of the hospital patient’s head are at risk for pressure
injury if the
hospital patient is left in a supine position.
PTS: 1 CON: Tissue Integrity
4. The nursing practitioner is providing care for a hospital patient who has a stage 4
pressure injury that is 2 cm in diameter and 2 cm deep. Bone is visible in the wound. Which
hospital patient assessment finding does the nursing practitioner communicate to the registered
nursing practitioner (RN) immediately?
1. Hospital patient report of pain
2. Yellow wound drainage
3. A reddened area adjacent to the injury
4. Pink grainy appearance at wound edges
RIGHT ANSWER> 3
Chapter: Chapter 54. Nursing Care of Hospital patients With Skin Disorders
Objective: List data to collect when caring for hospital patients with disorders of the
integumentary system.
Source: pp. 1153
Heading: Pressure Injuries
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 Pain is not unexpected and can be treated by the licensed practical nursing
practitioner (LPN).
2 Yellow drainage may indicate colonization and not true wound infection.
3 A reddened area adjacent to the injury can indicate extension of the injury or
infection and should be reported.
4 Pink grainy appearance is a sign of healing.
PTS: 1 CON: Tissue Integrity
5. The nursing practitioner is providing care for a hospital patient with an open pressure
injury on the right hip. The bed of the wound is covered with thick, black eschar and the
tissue around the wound is red and warm to the touch. Which action does the nursing
practitioner take in anticipation of the type of debridement used for this pressure injury?
1. Obtain sterile forceps and scissors for the health care provider (HCP) to use for
mechanical debridement.
2. Read the instructions about how to apply and manage the use of a proteolytic
enzyme.
3. Expect that the hospital patient will be taken to surgery to remove any nonviable tissues.
4. Bring gauze and normal saline to the bedside for application of wet-to-dry
dressings.
RIGHT ANSWER> 3
Chapter: Chapter 54. Nursing Care of Hospital patients With Skin Disorders
Objective: Describe current therapeutic measures that are used for each of the skin
disorders.
Source: pp. 1165
Heading: Debridement
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Difficult
CLARIFICATION
1 Mechanical debridement can be performed to selectively remove nonviable
tissue. However, the debridement of the described wound may be more
extensive than a bedside procedure.
2 Proteolytic enzymes will selectively digest necrotic tissue; however, the
described wound is covered with thick eschar and the borders may be
exhibiting manifestations of becoming infected. A more aggressive and timely
procedure may be needed.
3 The nursing practitioner needs to anticipate that the hospital patient will require
surgical debridement to remove the eschar and explore the border tissues and
the areas underneath for the possibility of infection. The procedure is likely to
be painful and the hospital patient will need some type of anesthesia and
monitoring.
4 Because of the presence of the eschar, and the possibility of a developing
infection, wet-to-dry dressings are not the appropriate initial treatment; the
method may be used as needed after surgical debridement.
PTS: 1 CON: Tissue Integrity
6. A hospital patient is admitted with a recent surgical wound that is infected and exhibits
an open suture line. The HCP prescribes negative pressure wound therapy (NPWT).
Which step in setting up the treatment does the nursing practitioner anticipate?
1. Moist gauze is placed into the open wound.
2. The wound is packed loosely with a sterile sponge.
3. Pressure is applied and increased until drainage appears.
4. The wound is covered completely with thick, absorbent pads.
RIGHT ANSWER> 2
Chapter: Chapter 54. Nursing Care of Hospital patients With Skin Disorders
Objective: Describe current therapeutic measures that are used for each of the skin
disorders.
Source: pp. 1166
Heading: Negative Pressure Wound Therapy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 Moist gauze is not placed into the open wound when NPWT is prescribed.
2 The nursing practitioner should anticipate loosely packing the wound with a
sterile sponge.
3 Gentle negative pressure is applied to allow excess drainage and infectious
material to be removed. The result is less pressure on delicate new tissue and
better circulation to promote healing.
4 The wound is covered with an occlusive dressing to maintain the negative
pressure required for the procedure.
PTS: 1 CON: Tissue Integrity
7. A hospital patient comes into the HCP’s office and reports a rash. The nursing practitioner
notices a red rash on the hospital patient’s chest, back, arms, and legs. The hospital patient
describes an intense itching. Which question does the nursing practitioner ask to determine the
type of dermatitis displayed by the hospital patient?
1. “Have you changed any of your laundry products?”
2. “Did you have any swelling of your lips or mouth?”
3. “Are you still using your usual grooming products?”
4. “Does anyone in your family have the same rash?”
RIGHT ANSWER> 1
Chapter: Chapter 54. Nursing Care of Hospital patients With Skin Disorders
Objective: List data to collect when caring for hospital patients with disorders of the
integumentary system.
Source: pp. 1170
Heading: Inflammatory Skin Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Difficult
CLARIFICATION
1 Because of the distribution of the rash, which is underneath clothing, the
nursing practitioner needs to ask about a change in laundry products. The
hospital patient probably has
contact dermatitis.
2 If the rash were more generalized or specifically on the hospital patient’s head
or face, the nursing practitioner needs to ask about swelling of the lips or
mouth.
3 The nursing practitioner would ask about grooming products if the rash were in
areas such as
the hands, face, or scalp.
4 The nursing practitioner will need to ascertain if other members of the hospital
patient’s family has the same rash after a probable cause can be identified.
PTS: 1 CON: Tissue Integrity
8. A hospital patient in the emergency department has bright red edematous plaques along an
uneven line that runs from under the right arm toward the chest. The hospital patient states that
the breakout was sudden and is very painful. Which information does the nursing practitioner
need to obtain first?
1. Ask if the hospital patient was around anyone with the chickenpox.
2. Attempt to discover where the hospital patient was during the last 3 weeks.
3. Inquire if the hospital patient has ever received a vaccine for herpes zoster.
4. Verify if the hospital patient is aware of ever having a case of chickenpox.
RIGHT ANSWER> 4
Chapter: Chapter 54. Nursing Care of Hospital patients With Skin Disorders
Objective: Explain the pathophysiology of each of the skin disorders listed in this chapter.
Source: pp. 1176
Heading: Herpes Zoster (Shingles)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 A person is unable to get herpes zoster (shingles) from someone who has
chickenpox or shingles.
2 The hospital patient is not likely to be able to recall specifically where he or she
was during the last three 3. Exposure to either chickenpox or shingles does not
cause shingles.
3 It may be good to know if the hospital patient has received a vaccine for herpes
zoster; however, it is still possible to get shingles after receiving the vaccine.
4 To have herpes zoster (shingles), the hospital patient must have had chickenpox.
The
virus will lay dormant in the hospital patient’s nerve tissue near the brain and
spinal cord. Herpes zoster (shingles) is a reactivation of the latent varicella
virus.
PTS: 1 CON: Tissue Integrity
9. The nursing practitioner works in a clinic that specializes in the care of hospital patients
diagnosed with psoriasis. Which hospital patient does the nursing practitioner identify as being
the greatest challenge for management of the disease?
1. An adult male with a family history of the skin disease
2. An adult female who is postmenopausal and smokes
3. A school-age hospital patient who frequently has strep throat
4. An adult hospital patient who has a stressful occupation
RIGHT ANSWER> 3
Chapter: Chapter 54. Nursing Care of Hospital patients With Skin Disorders Objective:
Describe the etiologies, signs, and symptoms of each of the skin disorders. Source: pp.
1172
Heading: Psoriasis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 The exact cause of psoriasis is unknown; however, it is autoimmune in nature.
Often there is a family history of the condition. The management is not
impacted by a familial connection.
2 Hormone changes and smoking can be aggravating factors for psoriasis. The
hospital patient needs to stop smoking to prevent exacerbations of the disease.
3 The average age for contracting psoriasis is 27 years; the condition can be
severe if it develops in childhood. If the hospital patient also has a tendency to
have streptococcal pharyngitis, the condition is worsened by this aggravating
factor. This hospital patient will present the greatest challenge for the
management of the disease.
4 Stress can be an aggravating factor for the hospital patient with psoriasis. The
nurse
needs to present the hospital patient with stress management techniques to avoid
exacerbations.
PTS: 1 CON: Tissue Integrity
10. The nursing practitioner in a high school clinic is aware of an unusually high incidences of
cold sores among the student population. Which information from the nursing practitioner will be
the most helpful in controlling the spread of the causative virus, HSV-1?
1. Infected students need to stay out of school until the lesion is crusted over.
2. Students with an active lesion need to eat at a specific isolation table.
3. All students need to sustain from sharing lip products, drinks, and foods.
4. Any student who has not been infected needs to get immunized immediately.
RIGHT ANSWER> 3
Chapter: Chapter 54. Nursing Care of Hospital patients With Skin Disorders
Objective: Explain the etiologies, signs, and symptoms of each of the skin disorders.
Source: pp. 1174
Heading: Herpes Simplex
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 It is true that the HSV-1 virus is contagious for 2 to 4 days before the crusts
form; however, there is no reason for the infected student to stay home from
school until crusting occurs. Students do need to avoid direct contact with a
known blistering lesion to prevent developing a primary lesion.
2 Isolating infected students is not necessary; students need to understand that the
condition is contagious and direct contact with a blistered lesion needs to be
avoided.
3 The most helpful information from the nursing practitioner is that the HSV-1
virus can be spread by sharing lip products, drinks, or foods. The students need
to avoid
direct contact with a blistering lesion (no kissing or touching).
4 There is no immunization for HSV-1. The best management is to avoid
contracting a primary lesion from another person.
PTS: 1 CON: Tissue Integrity
11. The community nursing practitioner is working with a family who has had multiple
infestations of pediculosis capitis over a period of several months. Which comment by the
parent indicates that nursing information is now likely to be effective?
1. “I have washed all hats and linens in hot soapy water.”
2. “We are all using a medicated bath soap to kill the lice.”
3. “I frequently check the scalps of the children for reinfection.”
4. “We are no longer attending school, I am home schooling now.”
RIGHT ANSWER> 1
Chapter: Chapter 54. Nursing Care of Hospital patients With Skin Disorders
Objective: Explain how you will know whether your nursing interventions have been
effective.
Source: pp. 1181
Heading: Pediculosis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 All clothing and linens need to be washed in hot soapy water to kill lice and
prevent reinfestation. Until this action is taken, the family will not be rid of the
problem.
2 Pediculosis capitis is head lice and will not be managed by bathing with a
special soap. A special shampoo or treatment must be used on the hair and
scalp.
3 Checking the scalp is a good way to monitor for reinfection; however, other
actions are needed to kill the lice that are currently present.
4 School children are most susceptible to infestations of pediculosis capitis.
However, the condition is not necessarily associated with cleanliness. The
parent can home school the children but must still manage the current
infestation.
PTS: 1 CON: Tissue Integrity
12. The nursing practitioner is assisting with preparation for cryosurgery for a hospital patient
diagnosed with a lentigo maligna melanoma lesion on the forehead. Which information will the
nursing practitioner provide regarding the events related to this surgery?
1. Explain that pain medication is given for expected severe pain.
2. A hemorrhagic blister will form immediately after the procedure.
3. The area will be cleaned as ordered and a prescribed ointment applied.
4. The lesion is likely to reappear and follow up treatment is expected.
RIGHT ANSWER> 3
Chapter: Chapter 54. Nursing Care of Hospital patients With Skin Disorders
Objective: Describe current therapeutic measures that are used for each of the skin
disorders.
Source: pp. 1182
Heading: Malignant Skin Lesions
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Application (Applying)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 With cryosurgery, minor discomfort is expected. After the procedure, the
hospital patient may experience some swelling and local tenderness. It is
unlikely that the hospital patient will require pain medication.
2 A hemorrhagic blister will appear at the site of cryosurgery within 1 to 2 days.
3 After cryosurgery, the area is to be cleansed as ordered and a prescribed
ointment is applied.
4 After cryosurgery, the lentigo maligna melanoma lesion is not expected to
return and require additional treatment.
PTS: 1 CON: Tissue Integrity
13. The nursing practitioner is preparing to begin a position in an extended-care facility. The
RN shares that the administration is interested in research that guides the skin care of the
residents. Which information does the nursing practitioner discover about best practices?
1. The importance of assessing for risk factors monthly
2. The practice of bathing residents with dry skin weekly
3. The cleaning of moist areas with gentle synthetic soaps
4. The need to use moisture wicking adult diapers at night
RIGHT ANSWER> 3
Chapter: Chapter 54. Nursing Care of Hospital patients With Skin Disorders
Objective: Plan nursing care for hospital patients with each of the skin
disorders. Source: pp. 1179
Heading: Evidence Based Practice
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 It is important that residents of long-term care be assessed for skin-related risk
factors; the timing is not designated, but monthly may not be frequently enough
for residents who are at high risk.
2 Research does report that residents with dry skin should not be bathed
frequently. However, a specific schedule is not indicated and weekly seems
inadequate.
3 Research supports that moist areas (between the toes, skinfolds, and under the
breasts) be cleansed daily with gentle synthetic detergent soaps.
4 Research supports protecting the residents’ skin from exposure to urine or
stool. It is not advised to place the residents in any kind of adult diaper at any
time.
PTS: 1 CON: Tissue Integrity
14. The nursing practitioner is providing care for a hospital patient with an open pressure injury,
which exhibits the manifestations of an infection. The HCP prescribes wound cleansing with
normal saline at a pressure of 4 to 15 pounds per square inch. Which method of cleansing does the
nursing practitioner use?
1. A 30-mL syringe with an 18-gauge needle attached
2. A whirlpool bath in warm water and antiseptic soap
3. A hand-held showerhead directed at the open area
4. A needleless 30- to 60-mL syringe and normal saline
RIGHT ANSWER> 1
Chapter: Chapter 54. Nursing Care of Hospital patients With Skin Disorders
Objective: Describe current therapeutic measures that are used for each of the skin
disorders.
Source: pp. 1164
Heading: Wound Cleansing
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Application (Applying)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 When an open pressure injury is infected, the area needs to be cleansed by a
method that removes bacteria and dead tissue. A pressure of 4 to 15 pounds per
square inch can be achieved using a 30-mL syringe with an 18-gauge needle.
The pressure is changed by the force exerted on the plunger of the syringe.
2 A whirlpool bath will not supply the prescribed pressure.
3 A hand-held showerhead directed at the open area may or may not provide the
prescribed pressure.
4 A needleless 30- to 60-mL syringe will provide gentle pressure for cleaning an
open pressure injury exhibiting signs of healing.
PTS: 1 CON: Tissue Integrity
15. The nursing practitioner is assisting at a community health fair by performing skin checks.
Which characteristic is unexpected by the nursing practitioner when screening participants who
are dark skinned?
1. Keloid formation
2. Multiple birthmarks
3. Mongolian spots
4. Nevi
RIGHT ANSWER> 4
Chapter: Chapter 54. Nursing Care of Hospital patients With Skin Disorders Objective:
Describe the etiologies, signs, and symptoms of each of the skin disorders. Source: pp.
1166
Heading: Cultural Considerations
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing) Concept:
Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 Persons with dark skin color are more likely to form an overgrowth of
connective tissue at the site of an injury or infection. The formation of a keloid
is an example.
2 Persons with dark skin color are more likely to have multiple birthmarks.
3 Persons with dark skin color are prone to Mongolian spots, which may be
mistaken for bruising. Mongolian spots will fade with the passage of time.
4 Nevi, which are freckles and skin discolorations, are seen in persons of lighter
skin color. Nevi are a result of sun exposure and can increase the incidence of
skin cancer.
PTS: 1 CON: Tissue Integrity
16. The nursing practitioner at an HCP’s office is interviewing a hospital patient
presenting with a skin infection. Which question by nursing practitioner will provide the
least important information?
1. “How long have you had the infection?”
2. “Do you think you are contagious?”
3. “What aggravates or alleviates symptoms?”
4. “What do you think caused your infection?”
RIGHT ANSWER> 2
Chapter: Chapter 54. Nursing Care of Hospital patients With Skin Disorders
Objective: List data to collect when caring for hospital patients with disorders of the
integumentary system.
Source: pp. 1165
Heading: Nursing Process for the Hospital patient With a Skin Infection
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 Asking how long the hospital patient has had the infection will provide
important
information; the infection may be either acute or chronic.
2 The question that provides the nursing practitioner with the least information
about the hospital patient’s condition is asking if the hospital patient thinks the
infection is contagious.
3 It is important for the nursing practitioner to know what aggravates or
alleviates the symptoms of the hospital patient’s infection. This information
can guide diagnosis and
treatment.
4 Sometimes the most information is obtained by just asking the hospital patient
what he or she thinks about his or her condition and any possible causes.
PTS: 1 CON: Tissue Integrity
17. A hospital patient with an infected skin lesion is prescribed oral antibiotics, daily dressing
changes with topical antibiotic ointment, and acetaminophen with codeine for pain. Which
hospital patient statement indicates to the nursing practitioner additional teaching is necessary?
1. “Once the swelling and redness are gone, I can stop taking the antibiotics.”
2. “I should wash the area gently with antibacterial soap before applying a new
dressing.”
3. “Covering my pillow with plastic and cleaning it every day will help prevent
additional infection.”
4. “I will need to increase my fluid and fiber intake to prevent constipation from the
pain medication.”
RIGHT ANSWER> 1
Chapter: Chapter 54. Nursing Care of Hospital patients With Skin Disorders
Objective: Plan nursing care for hospital patients with each of the skin
disorders. Source: pp. 1166
Heading: Infectious Skin Disorders
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 Antibiotics should be taken for the complete course as ordered.
2 It is important to cleanse surrounding skin with antibacterial soap, followed by
application of antibacterial ointment.
3 Cover mattress and pillows with plastic and wipe daily with a disinfectant to
prevent spread of infection.
4 Constipation is a potential complication of the prescribed pain medication and
preventive measures such as increased fluid and fiber intake are important.
PTS: 1 CON: Tissue Integrity
18. A hospital patient is diagnosed with dermatomycosis. Which statement by the hospital
patient gives the nursing practitioner an idea of where the infection was acquired?
1. “I wash my hair every day.”
2. “I work out and shower at a club.”
3. “I have never owned any pet.”
4. “I always buy the organic foods.”
RIGHT ANSWER> 2
Chapter: Chapter 54. Nursing Care of Hospital patients With Skin Disorders
Objective: Explain the pathophysiology of each of the skin disorders listed in this chapter.
Source: pp. 1168
Heading: Fungal Infections
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Difficult
CLARIFICATION
1 Dermatomycosis is a fungal infection of the skin occurring when there is an
impairment of skin integrity in a warm moist location. Washing the hair daily is
an unlikely contributor to the development of tinea capitis.
2 Working out and showering at a club puts the hospital patient at risk for picking
up the fungus that causes tinea pedis (athlete’s foot). The infection is acquired
with direct contact with infected humans, animals, or objects. Feet are prone to
small skin openings and are primarily located in warm moist environments.
3 Dermatomycosis can be acquired from infected animals, but the hospital
patient has never owned a pet.
4 Eating only organic food does not protect the hospital patient from
dermatomycosis.
PTS: 1 CON: Tissue Integrity
MULTIPLE RESPONSE
1. The nursing practitioner is providing care for a hospital patient who is immobile and
being treated for diabetes mellitus and a urinary tract infection. Which intervention is
included in a plan of care to prevent pressure injuries in this hospital patient? (Select all that
apply.)
1. Apply moisturizer to the skin after bathing.
2. Reposition the hospital patient at least every 2 hours.
3. Elevate the head of the bed no more than 30 degrees.
4. Place the hospital patient on a donut-shaped cushion when sitting.
5. Assure that skin is dried carefully and completely after washing.
RIGHT ANSWER> 1, 2, 3, 5
Chapter: Chapter 54. Nursing Care of Hospital patients With Skin Disorders
Objective: Recognize the role of the nursing practitioner in preventing
pressure injuries. Source: pp. 1160
Heading: Pressure Injuries
Integrated Process: Clinical Problem-Solving Process
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Difficult
CLARIFICATION
1. After bathing, lubricate the skin with moisturizers to prevent dryness.
2. If hospital patients are on bedrest, turn and reposition them at least every 2
hours, but preferably more often because ischemia development begins after
20 to 40
minutes of pressure.
3. The head of the bed should not be elevated more than 30 degrees to reduce
pressure on the coccyx and to reduce friction and shear damage from sliding
down in the bed.
4. Avoid massaging bony prominences or reddened skin areas; research has
shown that blood vessels are damaged by massage when ischemia is present
or when they lie over a bone.
5. Because the hospital patient is diabetic, good skin care is essential, especially
with a urinary infection. Drying the skin carefully will prevent maceration due
to moisture.
PTS: 1 CON: Tissue Integrity
2. The nursing practitioner is completing the Braden scale to predict risk for pressure ulcer
development with a hospital patient on bedrest. Which findings does the nursing
practitioner score as increasing this hospital patient’s risk? (Select all that apply.)
1. Hospital patient eats half of offered foods.
2. Hospital patient responds only to painful stimuli.
3. Linen must be changed at least once per shift.
4. Hospital patient makes body position changes with assistance only.
5. Hospital patient walks independently outside of the room twice a day.
RIGHT ANSWER> 1, 2, 3, 4
Chapter: Chapter 54. Nursing Care of Hospital patients With Skin Disorders
Objective: List data to collect when caring for hospital patients with disorders of the
integumentary system.
Source: pp. 1160
Heading: Pressure Injuries
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Difficult
CLARIFICATION
1. Limited nutritional intake by only eating half of offered foods put the hospital
patient
at risk for development of pressure injuries.
2. Responding only to painful stimuli indicates the hospital patient is at risk for
development of pressure injuries.
3. If moisture necessitates linens needing to be changed at least once per shift,
the hospital patient is at risk for development of pressure injuries.
4. The inability to change body positions without assistance places the hospital
patient at risk for development of pressure injuries.
5. Walking independently outside of the room twice a day would reduce the
hospital patient’s risk of developing a pressure injury.
PTS: 1 CON: Tissue Integrity
Chapter 55. Nursing Care of Hospital patients With Burns
MULTIPLE CHOICE
1. The nursing practitioner is assisting with the care of an older adult hospital patient who is
hospitalized for second- degree burns of the legs and feet acquired when a deep fryer tipped over.
Which factor has the least impact on the condition and recovery of the hospital patient?
1. The normal condition of the hospital patient’s skin
2. The nature of the substance causing the burns
3. The hospital patient history of having diabetes mellitus
4. The hospital patient wearing light-weight cotton pajamas
RIGHT ANSWER> 4
Chapter: Chapter 55. Nursing Care of Hospital patients With
Burns Objective: List data to collect when caring for hospital
patients with burns. Source: pp. 1192
Heading: Burn Injury and the Older Adult
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Difficult
CLARIFICATION
1 An older adult hospital patient normally has skin that is thinner, which is more
easily damaged and more difficult to heal.
2 The fact that a deep fryer tipped over is indicative that the burn was caused by
hot oil, which is likely to have adhered to the skin surface and caused deeper
burns.
3 With a medical history of diabetes mellitus, the hospital patient is at risk for
poor healing and the increased possibility of infection.
4 Of all the factors, the fact that the hospital patient was wearing light-weight
cotton pajamas is the condition of least concern. The hospital patient would
have been at greater risk if the clothing had been heavy and retained both heat
and the oil or made
of a synthetic material that would “melt” into the burn areas.
PTS: 1 CON: Tissue Integrity
2. The nursing practitioner is providing care for a hospital patient with burns covering the entire
surface of both arms and the anterior trunk. Approximately what percentage of the hospital
patient’s body surface area has been affected?
1. 18 percent
2. 27 percent
3. 36 percent
4. 45 percent
RIGHT ANSWER> 3
Chapter: Chapter 55. Nursing Care of Hospital patients With Burns
Objective: List data to collect when caring for hospital patients
with burns. Source: pp. 1193
Heading: Evaluation of Burn Injuries
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 This is an inaccurate calculation using the Rule of Nines.
2 This is an inaccurate calculation using the Rule of Nines.
3 According to the Rule of Nines, each arm is 9 percent and the anterior trunk is
18 percent for a total of 36 percent.
4 This is an inaccurate calculation using the Rule of Nines.
PTS: 1 CON: Tissue Integrity
3. The nursing practitioner is providing care for a hospital patient in the emergent stage of
treatment for a partial- thickness burn. The hospital patient has been stabilized, with blood
pressure 140/88 mm Hg, pulse 78 beats/min, respirations 22 breaths/min, and temperature
97.4°F (36.3°C) orally. Which new assessment finding does the nursing practitioner
immediately communicate to the health care provider (HCP)?
1. Report of increasing pain
2. Temperature 99°F (37.2°C)
3. Serum-filled blister formation
4. Blood pressure 122/74 mm Hg
RIGHT ANSWER> 4
Chapter: Chapter 55. Nursing Care of Hospital patients With Burns
Objective: Plan nursing care for hospital patients with burns.
Source: pp. 1190
Heading: Emergent Stage
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 Pain is a concern, but is not immediately life threatening.
2 Temperature is a concern, but is not immediately life threatening.
3 Blister formation is expected.
4 A hospital patient with a burn is at risk for fluid volume deficit, and a dropping
blood pressure, even though it is still within normal limits, could be an early
sign.
PTS: 1 CON: Tissue Integrity
4. A child is brought to the emergency department with burns from hot liquid pulled from the
stove. Which information is most important for the nursing practitioner to acquire from the
accompanying adult?
1. If the adult is a parent or legal guardian
2. Identification of the substance causing the injury
3. An estimation of the temperature of the burning liquid
4. If any measures were taken at the scene of the accident
RIGHT ANSWER> 2
Chapter: Chapter 55. Nursing Care of Hospital patients With
Burns Objective: List data to collect when caring for hospital
patients with burns. Source: pp. 1192
Heading: Pathophysiology and Signs and Symptoms
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Difficult
CLARIFICATION
1 Identifying the person bringing a minor to the emergency department is
needed; however, if the adult is not a parent or legal guardian, emergency care
will be provided for the hospital patient immediately.
2 The identification of the substance causing the injury is the most important
information for the nursing practitioner to acquire; the nature of the substance
can contribute
to the intensity of the burn and how initial care will be determined.
3 An estimation of the temperature of the burning liquid is important, but
knowing the substance is most important.
4 An awareness of any measures taken at the scene of the accident may be
helpful, but it is not the most important information.
PTS: 1 CON: Tissue Integrity
5. The nursing practitioner is providing care for a hospital patient who is receiving fluid
replacement after being burned on 37 percent of the body. Nursing assessment reveals a blood
pressure of 80/60 mm Hg, pulse of 120 beats/min, and urine output of 10 mL over the past
hour. After reporting these findings, which order does the nursing practitioner expect to be
prescribed for this hospital patient?
1. Discontinue the IV fluid infusion.
2. Change the IV fluid to dextrose and water.
3. Increase the amount of IV fluid administered per hour.
4. Decrease the amount of IV fluid administered per hour.
RIGHT ANSWER> 3
Chapter: Chapter 55. Nursing Care of Hospital patients With
Burns Objective: Describe current therapeutic measures used for
burns. Source: pp. 1190
Heading: Emergent Stage
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 Decreasing or discontinuing fluids is inappropriate.
2 Dextrose and water are hypotonic and will not maintain circulating volume.
3 In the first 48 hours after a burn, fluid shifts lead to hypovolemia and, if
untreated, hypovolemic shock. Low blood pressure, elevated pulse, and low
urine output indicate hypovolemia, so the nursing practitioner should anticipate
increasing IV fluids.
4 Decreasing or discontinuing fluids is inappropriate.
PTS: 1 CON: Tissue Integrity
6. The nursing practitioner is providing care for a hospital patient who received synthetic
dressings over partial- thickness burns. Which comment by the hospital patient indicates to
the nursing practitioner that additional information is needed about the procedure?
1. “This is just a temporary method of covering the burns.”
2. “This material is used until my own skin can be grafted.”
3. “If these grafts begin to grow, I won’t need more surgery.”
4. “The purpose of this process is to reduce the risk of infection.”
RIGHT ANSWER> 3
Chapter: Chapter 55. Nursing Care of Hospital patients With
Burns Objective: Describe current therapeutic measures used for
burns. Source: pp. 1192
Heading: Acute Stage
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 Synthetic dressings are used in the management of partial-thickness burns and
donor sites. They are used as temporary wound coverings.
2 Synthetic dressings are used to help maintain the wound surface until healing
occurs, a donor site becomes available, or the wound is ready for autografting.
3 Synthetic grafts do not grow; they can be used until healing occurs or until
other methods of grafting are performed. This statement indicates a need for
additional teaching.
4 A major purpose of using a synthetic dressing is to help prevent infection.
PTS: 1 CON: Tissue Integrity
7. The nursing practitioner is providing care for a hospital patient admitted to the burn unit
with burns to 45 percent of the body. After 3 days, the nursing practitioner notes that the
hospital patient’s temperature is newly elevated at 100.2°F (37.9°C), and the hospital patient
exhibits new-onset agitation and confusion. Which action does the nursing practitioner take
first?
1. Increase oral fluids to 3,000 mL/day.
2. Notify the registered nursing practitioner (RN) or HCP.
3. Monitor the hospital patient for further changes in mental status.
4. Administer a prn dose of acetaminophen (Tylenol) for the fever.
RIGHT ANSWER> 2
Chapter: Chapter 55. Nursing Care of Hospital patients With Burns
Objective: Explain the pathophysiology of burns.
Source: pp. 1191
Heading: Complications
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 Fluids may also be appropriate, but only after the HCP determines the cause of
the change and provides recommendations.
2 The nursing practitioner should continually assess for and report signs and
symptoms of sepsis: temperature elevation, change in sensorium, changes in
vital signs and bowel sounds, decreased output, and positive blood and wound
cultures. A rise
in temperature should be reported.
3 Further monitoring may also be appropriate, but only after the HCP determines
the cause of the change and provides recommendations.
4 Tylenol may also be appropriate, but only after the HCP determines the cause
of the change and provides recommendations.
PTS: 1 CON: Tissue Integrity
8. The nursing practitioner is assisting in the care of a hospital patient with a circumferential
burn to the leg. The health care provider determines that an escharotomy is necessary. Which
action does the nursing practitioner recognize as the most important nursing intervention?
1. Checking for the return of distal pulses
2. Padding the bed for copious amounts of drainage
3. Monitoring for unlabored respiratory function
4. Medicating as prescribed for pain management
RIGHT ANSWER> 1
Chapter: Chapter 55. Nursing Care of Hospital patients With Burns
Objective: Plan nursing care for hospital patients with burns.
Source: pp. 1195
Heading: Acute Stage
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 Burned tissue can act as a tourniquet with a circumferential burn and cut off
circulation. The most important intervention following an escharotomy on a leg
is to monitor for the return of distal pulses, which indicates adequate
circulation.
2 Prior to the performance of an escharotomy, the bed should be well padded due
to the expectation of copious amounts of drainage.
3 If the circumferential burn is on the trunk of the body, respiratory function can
be compromised. However, respiratory function is not affected by an
escharotomy performed on an extremity.
4 Pain management will be a part of the postprocedure care; however, it is not the
most important intervention.
PTS: 1 CON: Tissue Integrity
9. The nursing practitioner notes that a hospital patient with full thickness burns has an
increase in hematocrit level. What does the nursing practitioner realize is causing this
change in laboratory value?
1. Loss of intravascular fluid
2. Destruction of blood vessels
3. Increased function of platelets
4. Migration of white blood cells
RIGHT ANSWER> 1
Chapter: Chapter 55. Nursing Care of Hospital patients With Burns
Objective: Explain the pathophysiology of burns.
Source: pp. 1190
Heading: Diagnostic Tests
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 A burn is followed by an initial decrease in cardiac output, which is further
compromised by the loss of circulating plasma volume. In the first 48 hours
after a burn, fluid shifts lead to hypovolemia and, if untreated, hypovolemic
shock. Loss of intravascular fluid causes a relative increase in hematocrit.
2 The increase in hematocrit level is not caused by destruction of red blood cells.
3 The increase in hematocrit level is not caused by increased function of
platelets.
4 The increase in hematocrit level is not caused by migration of white blood
cells.
PTS: 1 CON: Tissue Integrity
10. The nursing practitioner is assisting with the care of a hospital patient with second-degree
burns to 35 percent of the body. Five hours after the burn occurs, the HCP prescribes
nasogastric (NG) enteral feedings. For which reason does the nursing practitioner
understand the value of the NG feedings and the importance of the time frame?
1. Metabolic demands are increased by injury, interventions, and stress.
2. Enteral feedings will help replace proteins lost from the burn.
3. Nutritional status is maintained until oral intake resumes.
4. Incidence of mortality and infectious morbidity are reduced.
RIGHT ANSWER> 4
Chapter: Chapter 55. Nursing Care of Hospital patients With
Burns Objective: Describe current therapeutic measures used for
burns. Source: pp. 1195
Heading: Nutrition Notes
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Difficult
CLARIFICATION
1 The increase in metabolic demands is caused by the burn injury, surgical
interventions, and stress. However, the demands are ongoing and do not
specifically relate to the time frame provided in the question.
2 A goal of nutritional support for the hospital patient with burns is to reduce the
protein lost from the injury. However, the need is ongoing and the time frame
is not
specifically important to meeting this need.
3 Enteral feedings may continue even after the hospital patient is able to resume
oral intake.
4 Early (within 4 to 6 hours of injury) use of NG enteral feeding has been shown
to reduce the incidence of mortality and infectious morbidity.
PTS: 1 CON: Tissue Integrity
11. The nursing practitioner is working on the rehabilitation unit in a burn facility. The
nursing practitioner has been reinforcing the importance of returning the hospital patient
to an optimal level of physical functioning. Which statement by the hospital patient
indicates a lack of understanding?
1. “I am trying to accept that this recovery is full of pain.”
2. “I just keep hoping that someday I will be able to be normal.”
3. “I can now feed myself and that makes me independent enough.”
4. “I am tired of the pain and time that it is taking to move past this.”
RIGHT ANSWER> 3
Chapter: Chapter 55. Nursing Care of Hospital patients With Burns
Objective: Explain how you will know whether your nursing interventions have been
effective.
Source: pp. 1197
Heading: Rehabilitation Stage
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological
Adaptation CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Difficult
CLARIFICATION
1 When the hospital patient acknowledges that rehabilitation is painful, it does not
show a lack of understanding, it indicates acceptance of the work that is
required.
2 When the hospital patient expresses a hope to return to a state of normalcy, it
indicates
that the hospital patient is motivated to achieve rehabilitation.
3 When the hospital patient expresses satisfaction about partial rehabilitation, it
indicates a lack of understanding. The goal or rehabilitation is to return the
hospital patient to an optimal level of physical functioning.
4 Expressing disappointment about the pain and time involved in rehabilitation
does not indicate that the hospital patient lacks understanding about the process.
PTS: 1 CON: Tissue Integrity
12. A hospital patient receives extensive burns to the face, chest, and hands from a
random act of violence. The hospital patient states, “I was doing so well, but I will never
fit in again with my family, friends, or coworkers.” The nursing practitioner identifies
which need for this hospital patient?
1. Reinforcement from people who are close to the hospital patient
2. Professional psychiatric counseling to regain self-esteem
3. Identification of a support group that focuses on victims of crime
4. Information from medical specialists about reconstructive surgery
RIGHT ANSWER> 2
Chapter: Chapter 55. Nursing Care of Hospital patients With Burns
Objective: Plan nursing care for hospital patients with burns.
Source: pp. 1198
Heading: Psychosocial Effects of Burn Injury
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Psychosocial Integrity
CL: Analysis (Analyzing) Concept:
Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 Reinforcement from people who are close to the hospital patient may be helpful,
but it
may not restore the self-esteem of the hospital patient.
2 The biggest need of this hospital patient is to regain self-esteem. Professional
psychiatric counseling will be best suited to assist the hospital patient to regain
an acceptable level of psychosocial functioning.
3 Due to the nature of the hospital patient’s injuries, a support group with other
victims of
crime may or may not be helpful.
4 The hospital patient may or may not be a candidate for plastic reconstruction
surgery. When burn injuries are extensive, the hospital patient is not always
pleased with the options or the results.
PTS: 1 CON: Tissue Integrity
13. The nursing practitioner on a burn rehabilitation unit presents information addressing the
incidence of postburn itching. Which information from researching the topic will the
nursing practitioner identify as incorrect?
1. Scratching the opposite part of the body will stop the itching.
2. Itching is a problem because it interferes with daily activities.
3. There are pharmacological and nonpharmacological interventions.
4. Some techniques may include massage with a soothing lotion.
RIGHT ANSWER> 1
Chapter: Chapter 55. Nursing Care of Hospital patients With Burns
Objective: Plan nursing care for hospital patients with burns.
Source: pp. 1198
Heading: Evidence-Based Practice
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Application (Applying)
Concept: Tissue Integrity
Difficulty: Moderate
CLARIFICATION
1 There is no support in the evidence-based practice information supplied in this
chapter for the use of counterpart scratching to stop the itching of a burn site.
2 The nursing practitioner in a postburn unit needs to understand that itching is a
problem
because of the interference with the activities of daily living.
3 There are both pharmacological and nonpharmacological interventions that can
be helpful with postburn itching.
4 Many nonpharmacological techniques can be done at home and can be very
soothing.
PTS: 1 CON: Tissue Integrity
MULTIPLE RESPONSE
1. The nursing practitioner is assisting with the care of a hospital patient admitted to the
emergency department with chemical burns across the chest and hands. Which actions are
included in the plan of care? (Select all that apply.)
1. Apply ice packs to burn sites.
2. Remove all contaminated clothing.
3. Cover the hospital patient with a clean sheet.
4. Obtain a history of the event and burning agent.
5. Provide copious tepid water lavage for 20 minutes.
RIGHT ANSWER> 2, 3, 4, 5
Chapter: Chapter 55. Nursing Care of Hospital patients With Burns
Objective: Plan nursing care for hospital patients with burns.
Source: pp. 1194
Heading: Therapeutic Measures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Reduction of Risk
Potential CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Difficult
CLARIFICATION
1. Ice is not applied when a hospital patient has a chemical burn.
2. Initiate immediate copious tepid water lavage for 20 minutes for all chemical
burns, along with simultaneous removal of contaminated clothing.
3. Cover the hospital patient with a clean sheet and obtain a history of the
burning agent.
4. Cover the hospital patient with a clean sheet and obtain a history of the
burning agent.
5. Initiate immediate copious tepid water lavage for 20 minutes for all chemical
burns, along with simultaneous removal of contaminated clothing.
PTS: 1 CON: Tissue Integrity
2. The nursing practitioner is preparing a hospital patient with 46 percent total body surface
area burned for graft placement. Which anatomical locations does the nursing practitioner
expect to have a lower rate of graft success than other areas of the body? (Select all that apply.)
1. Axillae
2. Buttocks
3. Perineum
4. Forearms
5. Joint areas
RIGHT ANSWER> 1, 2, 3, 5
Chapter: Chapter 55. Nursing Care of Hospital patients With
Burns Objective: Describe current therapeutic measures used for
burns. Source: pp. 1196
Heading: Skin Grafts
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Hospital patient Need: Physiological Integrity—Physiological Adaptation
CL: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Difficult
CLARIFICATION
1. The perineum, axillae, buttocks, and joints are generally poor areas for graft
success.
2. The perineum, axillae, buttocks, and joints are generally poor areas for graft
success.
3. The perineum, axillae, buttocks, and joints are generally poor areas for graft
success.
4. Factors promoting graft success are smooth contoured areas, adequate
hemostasis, and good nutritional status.
5. The perineum, axillae, buttocks, and joints are generally poor areas for graft
success.
PTS: 1 CON: Tissue Integrity
Chapter 56. Mental Health Function, Assessment, and Therapeutic Measures
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. The nursing practitioner is caring for a hospital patient with a suspected mental health disorder who is having
blood drawn to check electrolyte levels. The hospital patient says, “What does my blood work have to do with my
mental health?” Which response by the nursing practitioner is correct?
a. “Electrolyte imbalances are the cause of certain mental health disorders.”
b. “Some mental health disorders cause the electrolytes to be out of balance.”
c. “The doctor wants to make sure your symptoms are not caused by a physical problem.”
d. “People with mental illnesses frequently take illicit drugs that can cause electrolyte
imbalances.”
2. What is the best general definition of “coping”?
a. The way one adapts to a stressor
b. The use of specific mechanisms to reduce anxiety
c. The development of unconscious behaviors to reduce psychological distress
d. The adaptation to mental health problems
3. A student feels anxious about being unprepared for an upcoming test. Which of the following is a positive
response to this anxiety?
a. Choosing not to worry about studying because grades have been good so far
b. Staying up all night the night before the test to study
c. Canceling nonessential activities for 3 days to study
d. Borrowing notes from another student who has had the class in the past
4. A hospital patient who has been diagnosed with a mental illness tells the nursing practitioner about plans to find
a voodoo doctor.
How should the nursing practitioner respond?
a. “You know voodoo doctors can’t really help you. Don’t waste your money.”
b. “Be sure to mention your plan to your psychiatrist. It is important to follow up with that
treatment plan also.”
c. “Research has shown that voodoo can effectively treat many mental health disorders. That
decision is up to you.”
d. “I do not think using voodoo is safe. I would recommend you think about it carefully
before contacting a voodoo doctor.”
5. The nursing practitioner is caring for a hospital patient with a history of schizophrenia who is admitted to a
surgical unit for a cholecystectomy. The hospital patient becomes extremely agitated when other hospital
patients are around and says, “They are going to kill me. Get me out of here.” Which of the following
interventions should the nursing practitioner assist with implementing in order to provide a therapeutic milieu
for the hospital patient?
a. Help the hospital patient clarify the meaning of the feelings
b. Request an order for antipsychotic medications
c. Suggest the hospital patient be scheduled for a psychotherapy session
d. Place the hospital patient in a private room
6. The nursing practitioner is caring for a hospital patient who has had electroconvulsive therapy (ECT) for
severe depression. During the recovery period, the hospital patient says to the nurse, “Where am I? What have
you done to me?” What action by the nursing practitioner is best?
a. Encourage the hospital patient to go back to sleep until the preprocedure medication has worn off.
b. Administer a sedative to help calm the hospital patient.
Chapter 56. Mental Health Function, Assessment, and Therapeutic Measures
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parent.
c. Call the physician and report the hospital patient’s response.
d. Explain that the hospital patient is in the hospital and has just had ECT.
7. A student is angry about failing a test at school and accuses the teacher of trying to fail everyone. This is an
example of what type of response?
a. Anger
b. Repression
c. Projection
d. Denial
8. After talking with a hospital patient being evaluated for a mental health disorder, the nursing practitioner
says, “It sounds as if you are feeling angry.” Which therapeutic communication technique is the nursing
practitioner employing?
a. Offering a general lead
b. Reflecting
c. Restating
d. Giving recognition
9. During initial assessment of mental health status, the nursing practitioner asks a hospital patient to interpret a
familiar proverb and explain what it means. The nursing practitioner is assessing which area/aspect of the
hospital patient’s mental status?
a. Level of awareness and orientation
b. Judgment
c. Memory
d. Mood and affect
10. A young mother is angry with the mess her son has made in his room. She yells at him and tells him to stay in
his room until it is cleaned up. About 20 minutes later, the mother enters the boy’s room offering him milk and
cookies. The mother is using which ego defense mechanism?
a. Regression
b. Restitution
c. Reaction formation
d. Conversion reaction
11. A hospital patient with schizophrenia states, “I’m going to the fribity to see a megnat.” What term should the
nursing practitioner use to describe this language?
a. Neologisms
b. Conversions
c. Imagery
d. Soliloquy
12. The nursing practitioner is providing care for a teenage mother expressing ambivalence about her new role as a
Which of the following responses by the nursing practitioner is best?
a. “Parenthood is certainly not for everyone, you shouldn’t feel guilty about that.”
b. “I’ll call the social worker so you can discuss adoption.”
c. “Tell me more about how you feel when you hold the baby.”
d. “I’m sure your own parents felt the same way when you were small, you should talk to
your mom.”
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
13. Which of the following qualities are considered essential in any nurse–hospital patient relationship?
(Select all that apply.)
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a. Friendship
b. Sympathy
c. Empathy
d. Respect
e. Humor
f. Honesty
14. Which of the following beliefs or techniques are associated with person-centered/humanistic therapy? (Select
all that apply.)
a. It stresses rethinking situations.
b. It focuses on the whole person.
c. It focuses on insights and finding the cause of problems.
d. It works in the present.
e. It is the basis of many nursing principles.
15. The nursing practitioner is caring for a hospital patient who is verbalizing concerns related to a difficult
relationship. Which of the following responses by the nursing practitioner will block communication and
should therefore be avoided? (Select all that apply.)
a. Using silence
b. Asking “why”
c. Changing the subject
d. Agreeing or disagreeing
e. Verbalizing the implied
16. Which neurotransmitters may be decreased in a hospital patient experiencing depression? (Select all that
apply.)
a. Norepinephrine
b. Dopamine
c. Serotonin
d. Acetylcholine
e. Substance P
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Chapter 56. Mental Health Function, Assessment, and Therapeutic Measures
Answer Section
MULTIPLE CHOICE
1. RIGHT ANSWER> C
Some mental health symptoms can be caused by physical illness. Laboratory tests are done to rule out problems
such as electrolyte imbalances, hypothyroidism, infections, dehydration, drug toxicity, or pregnancy. Electrolyte
imbalances can cause symptoms but do not cause mental illness. There is no evidence in the question that the
hospital patient takes illicit drugs.
PTS: 1 COMPLEXITY- Medium SOURCE: Page 1359
KEY: Hospital patient Need: Psychosocial Integrity | CL: Comprehension | Integrated Processes:
Teaching and Learning | Question to Guide Your Learning: 3
2. RIGHT ANSWER> A
Coping is the way one adapts psychologically, physically, and behaviorally to a stressor. This may encompass
B, C, and D, but A is the best general definition.
PTS: 1 COMPLEXITY- Easy SOURCE: Page 1361
KEY: Hospital patient Need: Psychosocial Integrity | CL: Knowledge | Question to Guide Your Learning: 1
3. RIGHT ANSWER> C
Canceling nonessential activities to study helps the student reach the goal of knowing the information and
passing the test. Not worrying will not help the student pass the test. Staying up all night will cause the
student to be tired and not think clearly. Borrowing notes may help but is not as reliable as a book or other
good study habits.
PTS: 1 COMPLEXITY- Easy SOURCE: Page 1362
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application | Integrated Processes: Clinical
Problem-Solving Process | Question to Guide Your Learning: 7
4. RIGHT ANSWER> B
Giving advice is not the role of the nurse. The nursing practitioner can help the hospital patient to explore
options or focus thinking. In this instance, the nursing practitioner can refer the comment to the psychiatrist,
who is licensed to make treatment recommendations.
PTS: 1 COMPLEXITY- Medium SOURCE: Page 1364
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application | Integrated Processes: Clinical
Problem-Solving Process | Question to Guide Your Learning: 7
5. RIGHT ANSWER> D
A therapeutic milieu is an environment that provides containment, support, structure, involvement, and
validation during the hospital patient’s stay. In this case, it will help keep the hospital patient
psychologically safe while undergoing care for a physiological problem. The hospital patient is likely
already receiving antipsychotic agents; psychotherapy and exploring feelings are not the priority at this
time—keeping the hospital patient safe for surgery is the priority.
PTS: 1 COMPLEXITY- Hard SOURCE: Page 1363
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application | Integrated Processes: Clinical
Problem-Solving Process | Question to Guide Your Learning: 5
6. RIGHT ANSWER> D
Chapter 56. Mental Health Function, Assessment, and Therapeutic Measures
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The hospital patient may feel confused and forgetful immediately after ECT. This can be from a combination of
the ECT and the medication that was used before the treatment. The nursing practitioner should be truthful in
responding to the hospital patient’s questions. A, B, and C avoid, and do not answer, the hospital patient’s
question.
PTS: 1 COMPLEXITY- Medium SOURCE: Page 1366
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application | Integrated Processes: Caring | Question
to Guide Your Learning: 7
7. RIGHT ANSWER> C
Projection is blaming others. It is a mental or verbal “finger-pointing” at another for the hospital patient’s
own problem. Repression is an unconscious “burying” or “forgetting” mechanism. Denial is an
unconscious refusal to see reality. Anger is a response, usually to a perceived threat.
PTS: 1 COMPLEXITY- Easy SOURCE: Page 1363
KEY: Hospital patient Need: Psychosocial Integrity | CL: Comprehension | Integrated Processes: Clinical
Problem-Solving Process | Question to Guide Your Learning: 4
8. RIGHT ANSWER> C
Restating is a therapeutic communication technique that repeats the main idea of what the hospital patient has
verbalized. A general lead is a statement such as “I see . . .” or “Go on . . .” Reflecting refers a statement or
question back to the hospital patient. Giving recognition acknowledges something the hospital patient has done.
PTS: 1 COMPLEXITY- Easy SOURCE: Page 1364
KEY: Hospital patient Need: Psychosocial Integrity | CL: Comprehension | Integrated Processes:
Communication and Documentation | Question to Guide Your Learning: 7
9. RIGHT ANSWER> B
Judgment refers to a hospital patient’s ability to make appropriate decisions about his or her situation or to
understand concepts and is often tested by asking the meaning of a proverb. Awareness and orientation are
assessed by asking questions related to person, place, and time. Memory is tested by asking the hospital patient to
recall recent or remote events. Mood and affect are assessed by determining if the hospital patient’s expression,
body language, and emotional condition match the hospital patient’s circumstances.
PTS: 1 COMPLEXITY- Easy SOURCE: Page 1361
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application | Integrated Processes: Clinical
Problem-Solving Process | Question to Guide Your Learning: 2
10. RIGHT ANSWER> B
Restitution attempts to make amends for a behavior one thinks is unacceptable, to reduce feelings of guilt.
Regression is turning to an earlier, less stressful time in life. Reaction formation involves developing a trait or
belief that is opposite to something the hospital patient cannot have (overcompensation). A conversion reaction
channels psychological discomfort into physical symptoms.
PTS: 1 COMPLEXITY- Easy SOURCE: Page 1363
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application | Integrated Processes: Clinical
Problem-Solving Process | Question to Guide Your Learning: 4
11. RIGHT ANSWER> A
Words that the hospital patient makes up are called neologisms.
PTS: 1 COMPLEXITY- Easy SOURCE: Page 1360
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application | Integrated Processes: Clinical
Problem-Solving Process | Question to Guide Your Learning: 2
12. RIGHT ANSWER> C
/
Therapeutic communication is accomplished through the deliberate use of verbal and nonverbal techniques.
The technique of focusing involves concentrating on a single idea or event, in this instance, how the young
woman feels when she holds the infant. The other responses are not hospital patient focused, are closed-
ended, and do not exemplify therapeutic communication techniques.
PTS: 1 COMPLEXITY- Medium SOURCE: Page 1364
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application | Integrated Processes: Communication
and Documentation | Question to Guide Your Learning: 7
MULTIPLE RESPONSE
13. RIGHT ANSWER> C, D, F
Three qualities are essential for caregivers: empathy, which is the ability to identify with the hospital patient’s
feelings without actually experiencing them with the hospital patient; unconditional positive regard (respect);
and genuineness or honesty. Friendship and sympathy (feeling sorry for the hospital patient) are not necessarily
therapeutic. Humor may not be perceived as intended by hospital patients with mental health disorders and is
best used cautiously.
PTS: 1 COMPLEXITY- Easy SOURCE: Page 1366
KEY: Hospital patient Need: Psychosocial Integrity | CL: Knowledge | Integrated Processes: Caring | Question
to Guide Your Learning: 7
14. RIGHT ANSWER> B, D, E
Person-centered therapy focuses on the whole person and works in the “present.” It is not important in
humanistic treatment to understand the cause of the problem or what happened in the person’s past; what is
important is the here-and-now. With this therapy, the hospital patient learns to see himself or herself as a
person who has value and who is respected by others. Nursing is very strongly centered in person-centered
principles.
PTS: 1 COMPLEXITY- Medium SOURCE: Page 1366
KEY: Hospital patient Need: Psychosocial Integrity | CL: Comprehension | Integrated Processes: Caring |
Question to Guide Your Learning: 6
15. RIGHT ANSWER> B, C, D
Asking why, changing the subject, and agreeing or disagreeing can block communication. Appropriate use of
silence and verbalizing the implied are therapeutic.
PTS: 1 COMPLEXITY- Medium SOURCE: Page 1364
KEY: Hospital patient Need: Psychosocial Integrity | CL: Comprehension | Integrated Processes:
Communication and Documentation | Question to Guide Your Learning: 7
16. RIGHT ANSWER> A, B, C
Norepinephrine, dopamine, and serotonin may be decreased in depression. Acetylcholine and substance P may
be increased.
PTS: 1 COMPLEXITY- Medium SOURCE: Page 1366
KEY: Hospital patient Need: PHYS—Physiological Adaptation | CL: Comprehension | Integrated
Processes: Clinical Problem-Solving Process | Question to Guide Your Learning: 6
Chapter 57. Nursing Care of Hospital patients With Mental Health Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A hospital patient with schizophrenia has not bathed recently and a family member states that the hospital
patient has not been out of the house for 10 days. The hospital patient tells the nurse, “They are trying to hurt me;
don’t let them hurt me.” Which symptom is this hospital patient demonstrating?
a. Paranoid delusions
b. Grandiose delusions
c. Auditory hallucinations
d. Persecutory hallucinations
2. A hospital patient is diagnosed as having a phobia. Which fear should the nursing practitioner expect to observe in
this hospital patient?
a. Fear of poisonous spiders
b. Fear of leaving the house during the day
c. Fear of failing a test that one has not studied for
d. Fear that a child playing in the street might get hurt
3. A hospital patient who is a war veteran states, “It should have been me that died. I’ll never forgive myself for
leaving my buddy when he needed me.” The nursing practitioner recognizes this statement is most associated
with which diagnosis?
a. Bipolar depression
b. Generalized anxiety
c. Obsessive-compulsive disorder
d. Post-traumatic stress disorder (PTSD)
4. The spouse of an older male hospital patient is concerned because since retiring the hospital patient sits
around the house, avoids eating, naps, and refuses to participate in sporting activities. Which disorder
should the nursing practitioner recognize as being associated with these manifestations?
a. Depression
b. Bipolar disorder
c. Conversion disorder
d. Post-traumatic stress disorder (PTSD)
5. A hospital patient hospitalized for bipolar disorder is sitting in the corner of the room with the lights off,
staring into space. Three hours later, the hospital patient is in the same position. What should the nursing
practitioner say to the hospital patient?
a. “Cheer up! Come on out and join us in a game!”
b. “Come with me. I’d like you join our group for a while.”
c. “You won’t make any progress if you stay in your room all the time.”
d. “What’s the matter? Don’t you know you should be in your group right now?”
6. The nursing practitioner is assisting with medication teaching for a hospital patient who is prescribed
lithium carbonate (Eskalith) for bipolar disorder. Which instruction by the nursing practitioner is most
important?
a. Instruct the hospital patient to discontinue other antidepressant agents.
b. Teach the hospital patient that the lithium will help stabilize mood swings.
c. Teach the hospital patient side effects to report, such as nausea or weight gain.
d. Explain to the hospital patient and significant other the importance of regular blood tests.
7. The nursing practitioner is caring for an older adult hospital patient with a history of depression. Which
comment by the hospital patient indicates an immediate need for further assessment?
Chapter 57. Nursing Care of Hospital patients With Mental Health Disorders
a. “I am so old; all my friends have died.”
b. “I am useless now; there is no reason to be alive.”
c. “I retire in 6 months, and it will be all downhill from there.”
d. “I am looking forward to seeing my husband in heaven someday.”
8. A hospital patient who has schizophrenia has a dull facial expression and speaks in a monotone voice, even
though a visitor is making an effort to be jovial. What terminology should the nursing practitioner use to
document this observation?
a. Bored
b. Depressed
c. Flat affect
d. Ambivalent attitude
9. A hospital patient with schizophrenia calls the nursing practitioner into the room and says, “Help me! The
books are on fire!” Which response by the nursing practitioner is best?
a. “I’ll get some water and put it out.”
b. “That’s crazy; you know the books are not on fire!”
c. “You don’t have any books; how could they be on fire?”
d. “I do not see any fire. Here is your supper; it’s time to eat.”
10. A hospital patient with a mental illness says, “I have to go to the bank. The voices are telling me to go
there.” Which response by the nursing practitioner is best?
a. “Do you need money?”
b. “I will call you a cab later. Right now, it is time for therapy.”
c. “Why do you think the voices are telling you to go to the bank?”
d. “I want to help you focus away from the voices. I am real, they are not.”
11. A hospital patient who experienced injuries from a motor vehicle crash 6 months ago continues to request
prescriptions for an opioid analgesic. When assessing this hospital patient for opioid dependency which
finding is the nursing practitioner least likely to observe?
a. The hospital patient drops out of a Saturday night Bingo group.
b. The hospital patient continues to manage to get to work each day.
c. The hospital patient tried to quit using the opioid but couldn’t stop thinking about it.
d. The hospital patient has been to three or four physicians to obtain new prescriptions for the drug.
12. The nursing practitioner is cautiously avoiding the temptation to take unused or wasted doses of narcotic
medications when providing hospital patient care. What percentages of nurses in the United States are
chemically impaired?
a. 0% to 5%
b. 6% to 15%
c. 25% to 35%
d. 49% to 50%
13. The nursing practitioner notes that another nursing practitioner colleague has been acting differently lately. The
nursing practitioner often has red watery eyes and a runny nose. Today, the nursing practitioner was unhappy
with the hospital patient assignment and screamed, “Someone is going to pay for this!” What should the nursing
practitioner who has observed this behavior do?
a. Nothing; all nurses have stressful days sometimes.
b. Tell the clinical manager exactly what was observed.
c. Tell the clinical manager that the nursing practitioner is abusing drugs.
d. Confront the nursing practitioner with the behavior and provide information about counseling.
14. The nursing practitioner is providing care for a hospital patient with symptoms of tardive dyskinesia from
major tranquilizers. What treatment should the nursing practitioner anticipate?
a. Use of anticholinergic agents
b. Use of muscle relaxant agents
c. Discontinuance of the tranquilizers
d. Addition of rational emotive therapy to the treatment plan
15. The nursing practitioner is completing a mental status examination for a newly admitted hospital patient. In
which part of the nursing process is the nursing practitioner functioning?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
16. The nursing practitioner is assisting with teaching a hospital patient who has been started on fluphenazine
(Prolixin). About which side effect should the nursing practitioner focus this teaching?
a. Weight loss
b. Hypoglycemia
c. Photosensitivity
d. Elevated blood pressure
17. A hospital patient cannot leave home without checking the coffee pot numerous times. This behavior makes
the hospital patient late to many functions. Which anxiety disorder should the nursing practitioner suspect the
hospital patient is experiencing?
a. Phobia
b. Generalized anxiety disorder (GAD)
c. Post-traumatic stress disorder (PTSD)
d. Obsessive-compulsive disorder (OCD)
18. A hospital patient who is withdrawing from alcohol is restless and reports seeing snakes on the ceiling. Vital
signs are blood pressure 180/100 mm Hg, pulse 92 beats/min, and respirations 22 breaths/min. What should
the nursing practitioner do first?
a. Teach the hospital patient a relaxation technique.
b. Administer a dose of lorazepam (Ativan).
c. Search the hospital patient’s room for hidden alcohol.
d. Administer an antihypertensive agent as ordered.
19. The nursing practitioner assists with admission of a hospital patient to the hospital with pancreatitis and a
history of alcohol abuse.
Why should the nursing practitioner observe the hospital patient for agitation, tremors, and hallucinations?
a. These are symptoms of alcohol withdrawal.
b. These symptoms indicate possible cirrhosis of the liver.
c. The hospital patient may be using alcohol in the hospital setting.
d. Hospital patients with a history of alcohol abuse are at risk for mental illness.
20. A hospital patient is newly diagnosed with a trauma related disorder. Which medication should the nursing
practitioner expect to be prescribed for this hospital patient?
a. Paroxetine (Paxil)
b. Sertraline (Zoloft)
c. Buspirone (Buspar)
d. Alprazolam (Xanax)
21. A hospital patient with extreme anxiety is arriving for out-hospital patient chemotherapy. What should the
nursing practitioner do to help reduce the hospital patient’s anxiety during this current treatment?
a. Play a CD with nature sounds.
b. Select a television station with a sporting event.
c. Close the door to the room during the treatment.
d. Remind the hospital patient that anxiety is not going to make the treatment effective.
22. A hospital patient with depression is prescribed duloxetine (Cymbalta). What should the nursing
practitioner instruct the hospital patient about this medication?
a. Take with fruit juice.
b. Do not take with St. John’s wort.
c. Stop the medication if experiencing adverse effects.
d. Expect blood pressure to drop with this medication.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
23. The nursing practitioner is assisting with teaching a hospital patient who is to begin taking a monoamine
oxidase inhibitor (MAOI).
Which foods should the nursing practitioner teach the hospital patient to avoid? (Select all that apply.)
a. Fish
b. Wine
c. Bread
d. Pastas
e. Aged cheese
24. The nursing practitioner is assisting in the preparation of an educational seminar on anxiety disorders.
Which anxiety disorders should the nursing practitioner make sure are included in this presentation?
(Select all that apply.)
a. Phobia
b. Panic disorder
c. Schizophrenia
d. Unipolar depression
e. Post-traumatic stress disorder
f. Obsessive-compulsive disorder
25. The nursing practitioner is assisting with data collection on a hospital patient newly diagnosed with
schizophrenia. Which observations should the nursing practitioner consider as being positive symptoms of
schizophrenia? (Select all that apply.)
a. Alogia
b. Apathy
c. Delusions
d. Hallucinations
e. Social isolation
f. Disorganized behavior
26. A hospital patient has been prescribed fluoxetine (Prozac) to treat depression. What should be included in
the nurse’s teaching about the drug? (Select all that apply.)
a. “You need to take this drug only once a week.”
b. “Take the prescribed dose in the early evening.”
c. “A decreased interest in sexual activity may occur with this medication.”
d. “You should not consume red wine, aged cheese, or other tyramine-rich foods.”
e. “Do not expect immediate results; it usually takes 6 to 8 weeks for therapeutic effects to
be felt.”
f. “You may experience some nausea, vomiting, and anorexia, but these side effects will
subside in time.”
27. The nursing practitioner is reviewing the causes of anxiety with a hospital patient diagnosed with an
anxiety disorder. Which neurotransmitter abnormalities should the nursing practitioner include as
causing symptoms of anxiety? (Select all that apply.)
a. Increased substance P
b. Increased epinephrine
c. Increased somatostatin
d. Decreased norepinephrine
e. Decreased gamma-aminobutyric acid (GABA)
28. The nursing practitioner is reviewing potential hospital patient teaching needs. For which prescribed
medications should the nursing practitioner plan to instruct hospital patients to follow a tyramine-free diet?
(Select all that apply.)
a. Phenelzine (Nardil)
b. Buspirone (Buspar)
c. Isocarboxazid (Marplan)
d. Valproic acid (Depakote)
e. Lithium carbonate (Eskalith)
29. A hospital patient comes into the emergency department experiencing chest pain and feelings of
impending doom. Which assessment findings should the nursing practitioner use to determine if this
hospital patient is experiencing a panic attack? (Select all that apply.)
a. Shaking
b. Neck pain
c. Dissociation
d. Vomiting brown emesis
e. Occurs at 3 p.m. every day
30. A hospital patient with schizophrenia is returning from a CT scan of the brain followed by an
electroencephalogram. Which diagnostic test findings should the nursing practitioner identify as supporting
this hospital patient’s diagnosis? (Select all that apply.)
a. Enlarged ventricles
b. Reduced amount of gray matter
c. Areas of nerve de-myelinization
d. Aneurysms of the cerebral vessels
e. Diminished prefrontal cortex activity
31. The nursing practitioner is assisting in planning care for a hospital patient with extreme anxiety. Which
interventions should the nursing practitioner include in this hospital patient’s plan of care? (Select all that
apply.)
a. Maintain a calm environment.
b. Encourage verbalization of feelings.
c. Model and encourage positive self-talk.
d. Encourage participation in competitive activities.
e. Permit the hospital patient to have time alone during acute anxiety events.
Chapter 57. Nursing Care of Hospital patients With Mental Health
Disorders Answer Section
MULTIPLE CHOICE
1. RIGHT ANSWER> D
Hospital patients with paranoid schizophrenia tend to have delusions of persecution or grandeur. Hospital
patients experiencing persecutory delusions state that they feel tormented and followed by people. B. In
delusions of grandeur, hospital patients may state that they are God or the President of the United States. C.
Hallucinations often accompany delusions but are not the same as delusions. The hallucinations can affect any of
the five senses but are most commonly auditory followed by visual. A. Hospital patients with paranoid
schizophrenia talk about hearing “voices.”
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Psychosocial Integrity | CL: Analysis
2. RIGHT ANSWER> B
A phobia is an irrational fear of an object or situation—it is not normal to fear leaving the house. A. C. D. The
fear of poisonous snakes, failing a test when unprepared, and a child getting hurt when playing in the street are
reasonable things to fear.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application
3. RIGHT ANSWER> D
A behavior associated with PTSD is survivor guilt, which is the feeling of guilt expressed by those who have
survived a tragedy. A survivor of an airline crash may say, “Why me? Why did I make it? I should have died
too!” A. B. C. Survival guilt is not associated with bipolar depression, generalized anxiety, or obsessive-
compulsive disorder.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application
4. RIGHT ANSWER> A
According to the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V), symptoms of
major depression include either a depressed mood or anhedonia which is the loss of pleasure in things that are
usually pleasurable along with additional symptoms such as change in appetite and sleep patterns. B. Bipolar
disorder is also characterized by periods of mania as well as depression. C. Conversion disorder involves the
conversion of a mental health problem into physical symptoms. D. PTSD occurs after a major trauma.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application
5. RIGHT ANSWER> B
Saying “Come with me. I’d like you to join our group for a while,” removes the hospital patient from the
situation and does not give him or her a choice. A is inappropriate. If the hospital patient could cheer up, he or
she would not be in the hospital. D. Asking what is the matter is also inappropriate—the hospital patient does
not likely know. C. Telling the hospital patient he or she will not make any progress will cause feelings of guilt,
which is not helpful.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application
6. RIGHT ANSWER> C
Lithium is an antimanic medication with a very narrow therapeutic range so toxic drug levels can easily
develop. Lithium levels must be drawn regularly to assess that serum levels are in the therapeutic range. C.
Reporting of side effects is important, but nausea and weight gain are not life-threatening. A. The hospital
patient should not discontinue other antidepressants unless instructed to do so by the physician. B. Lithium will
stabilize mood swings, and it is important to tell the hospital patient this, but not as important as advising the
hospital patient to have regular levels checked to avoid toxicity.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Physiological Integrity—Pharmacological and Parenteral Therapies | CL:
Application
7. RIGHT ANSWER> B
Comments by any older adult referring to hopelessness or desire to die must be explored to assess suicide risk.
A. C. These comments may require further assessment however is not as hopeless sounding as the statements
about having no reason to be alive. C. Looking forward to seeing a spouse in heaven someday is a positive
comment.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Psychosocial Integrity | CL: Analysis
8. RIGHT ANSWER> C
Affect is the outward expression of mood—a hospital patient who speaks in a monotone voice and has a dull
expression has a flat affect. B. Depression is a medical diagnosis. A. D. Documenting boredom or ambivalent
attitude is subjective and should be verified with additional assessment.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application
9. RIGHT ANSWER> D
The nursing practitioner needs to validate that the hospital patient’s comment was heard but then needs to bring
the hospital patient back to reality by saying that it is time for a meal. A. Putting water on it is inappropriate—
there is no fire. B. Telling a mental health hospital patient he or she is crazy is inappropriate. C. The nursing
practitioner cannot use logic such as saying that the hospital patient does not have any books. A hospital patient
with schizophrenia may be unable to see logic.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application
10. RIGHT ANSWER> D
The nursing practitioner needs to validate the hospital patient’s concern without exploring and focusing on the
delusion. The hospital patient needs to know what is real and what is not. B. Calling a cab and focusing on
therapy does not validate the hospital patient’s concern. C. Asking the hospital patient about the voices
encourages the hospital patient to focus on the delusion. D. Asking about money might be appropriate for an
older person with dementia, but a hospital patient with schizophrenia needs to be brought back to reality.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application
11. RIGHT ANSWER> B
Being able to work each day is not an observation associated with opioid addiction. A. C. D. The hospital
patient with an addiction gives up important social or professional functions to use the substance, has tried at
least once to quit but still obsesses about the substance, spends significant time obtaining the substance, and is
unable to fulfill major role obligations at work, school, or home.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Psychosocial Integrity | CL: Analysis
12. RIGHT ANSWER> B
According to the National Council of State Boards of Nursing, between 6 and 15 percent of nurses in the
United States are chemically impaired. A. More than 5% of nurses are chemically impaired. C. D. The
percentage of nurses who are chemically impaired is not above 15%.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application
13. RIGHT ANSWER> B
The nursing practitioner should document the behavior and inform the supervisor. A. Doing nothing could lead
to harm to the nurse’s hospital patients. C. Telling the manager that the nursing practitioner is using drugs is
making an assumption. D. Confronting the nursing practitioner is not the role of a coworker. It is the job of the
manager to follow up and ensure that the nursing practitioner is safe to provide hospital patient care.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application
14. RIGHT ANSWER> A
Anticholinergic medications such as benztropine (Cogentin) or trihexyphenidyl (Artane) are used to combat the
extrapyramidal side effects of the typical antipsychotics by helping return balance between dopamine,
acetylcholine, and other neurotransmitters. B. D. Addition of rational emotive therapy or muscle relaxants will
not affect the cause of the symptoms. C. Discontinuing the tranquilizers may help but may not be realistic if the
hospital patient needs them to control symptoms.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Physiological Integrity—Pharmacological and Parenteral Therapies | CL:
Application
15. RIGHT ANSWER> A
A mental status examination is part of the assessment phase, though it may be done again during the
evaluation phase to determine progress toward goals. B. C. An examination is not completed during the
planning or implementation phases of the nursing process.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application
16. RIGHT ANSWER> C
Prolixin can cause photosensitivity, so the hospital patient should be cautioned about sun protection. D. It can
cause hypotension, not hypertension. A. B. It is not associated with weight loss or hypoglycemia.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Physiological Integrity—Pharmacological and Parenteral Therapies | CL:
Application
17. RIGHT ANSWER> D
Repeatedly checking the coffee pot is an example of a compulsion which is a part of obsessive compulsive
disorder (OCD). A. B. C. Compulsions are not manifestations associated with GAD, phobias, or PTSD.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Psychosocial Integrity | CL: Analysis
18. RIGHT ANSWER> D
According to Maslow’s hierarchy, physiological symptoms must be attended to first. The hospital patient’s
blood pressure is at an unsafe level. A. B. Once the hospital patient’s blood pressure is under control, then
Ativan and relaxation may be helpful. C. Searching the room for alcohol is occasionally necessary, but a
hospital patient who has withdrawal symptoms is not likely using alcohol.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Physiological Integrity—Reduction of Risk Potential | CL: Application
19. RIGHT ANSWER> A
Hospital patients who are actively using drugs or alcohol when admitted to an inhospital patient setting, or who
are cut off from their alcohol abruptly, can experience a condition called delirium tremens (DTs). In DTs,
hyper-excitability can cause visual hallucinations, tremors, and possibly tonic-clonic seizures. B. These are not
symptoms of cirrhosis. D. Hospital patients with alcohol histories are at risk for cognitive changes, but not
necessarily mental illness. C. If the hospital patient were using alcohol in the hospital, he or she would not be
experiencing DTs.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Psychosocial Integrity | CL: Analysis
20. RIGHT ANSWER> D
Psychopharmacology for trauma related disorders may involve benzodiazepines which are antianxiety
medications. Alprazolam (Xanax) is commonly used and is effective in most cases. Benzodiazepines are used
for short-term treatment because of the strong potential for chemical dependency. A. B. C. Individuals who
need longer term therapy for anxiety or who have chemical dependency tendencies may be treated with
buspirone (Buspar), selective serotonin reuptake inhibitors (SSRIs) paroxetine (Paxil) or sertraline (Zoloft).
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Physiological Integrity—Pharmacological and Parenteral Therapies | CL:
Application
21. RIGHT ANSWER> A
A study was done that looked at the effect of nature based sounds to reduce agitation, anxiety level and
physiological signs of stress in hospital patients. The experimental group had significantly lower systolic blood
pressure, diastolic blood pressure, anxiety and agitation levels than the control group. The use of music or nature
based sounds incorporated into nursing care may help reduce anxiety. B. Selecting a program televising a
sporting event might be too stressful for the hospital patient. C. Closing the door to the treatment room might
cause the hospital patient to feel abandoned. D. Reminding the hospital patient that anxiety is not going to make
the treatment effective is threatening and is a negative statement. The hospital patient should be counseled in
positive self-talk.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application
22. RIGHT ANSWER> B
Many people take St. John’s wort, an OTC herbal supplement, for depression. Although it may be effective
for some people with mild depression, it can interact with many prescribed medications that influence
serotonin levels. If combined with prescription serotonin-type antidepressants, it can cause serotonin
syndrome, an excess of serotonin resulting in agitation, confusion, diarrhea, muscle spasms, and even death.
A. This medication does not need to be taken with fruit juice. C. This medication should not be abruptly
stopped. D. This medication can cause systolic hypertension.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Physiological Integrity—Pharmacological and Parenteral Therapies | CL:
Application
MULTIPLE RESPONSE
23. RIGHT ANSWER> B, E
When a hospital patient taking a monoamine oxidase inhibitor (MAOI) consumes foods high in tyramine, the
drug prevents the normal breakdown of tyramine, leading to excessive epinephrine levels. Hypertension can
occur which can be severe enough to cause intracranial hemorrhage. Foods to be avoided include wine and
aged cheese. A. C. D. Breads, pastas, and fish do not need to be restricted because of tyramine content.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application
24. RIGHT ANSWER> A, B, E, F
Phobias are the most common of the anxiety disorders. Additional disorders are panic disorder, generalized
anxiety disorder, obsessive-compulsive disorder, and post-traumatic stress disorder. D. Depression is a mood
disorder. C. Schizophrenia is a brain disorder that is a group of illnesses, not one of the anxiety disorders.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application
25. RIGHT ANSWER> C, D, F
Positive symptoms of schizophrenia can be thought of as those symptoms that reflect an “excess” or distortion
of normal functioning. Positive symptoms include hallucinations, delusions, disorganized thinking, and
disorganized behavior. A. B. E. Negative symptoms include affective blunting or flattening, alogia, avolition,
apathy, anhedonia, and social isolation.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Psychosocial Integrity | CL: Analysis
26. RIGHT ANSWER> C, F
Teach hospital patient who is taking a selective serotonin reuptake inhibitor (SSRI) that it will take 6 to 8
weeks for therapeutic effects to occur, and possibly longer with Prozac. Possible side effects include
excitation, nausea and vomiting, decreased libido, anorexia, and weight loss. B. SSRIs should be administered
before 3 p.m. to prevent excitation from affecting sleep. A. They are taken daily. D. Aged foods are avoided
with monoamine oxidase inhibitors (MAOIs), not SSRIs.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Physiological Integrity—Pharmacological and Parenteral Therapies | CL:
Application
27. RIGHT ANSWER> B, E
Anxiety, as explained by biological theory, is associated with increased epinephrine and norepinephrine, and
decreased GABA. A. C. Increased substance P is associated with depression, and increased somatostatin is
associated with Huntington’s disease. D. Anxiety is associated with increased and not decreased
norepinephrine.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Physiological Integrity—Reduction of Risk Potential | CL: Application
28. RIGHT ANSWER> A, C
Tyramine-free diet is required for hospital patients taking monoamine oxidase inhibitor (MAOI) antidepressants
including phenelzine (Nardil), tranylcypromine (Parnate), and isocarboxazid (Marplan). B. D. E. A tyramine-
free diet is not required for hospital patients taking buspirone (Buspar), valproic acid (Depakote), or lithium
carbonate (Eskalith).
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Physiological Integrity—Pharmacological and Parenteral Therapies | CL:
Application
29. RIGHT ANSWER> A, C, E
Panic is a state of extreme fear that cannot be controlled; it may be referred to as a panic attack. Panic
episodes are recurrent and occur unpredictably. Hospital patients may present themselves at the emergency
room because they believe they are having a heart attack or other significant physical illness. Hospital
patients must exhibit several episodes within a specified time frame to be given the diagnosis of panic
disorder. Additional symptoms associated with panic disorder include dissociation and shaking. B. D. Neck
pain and vomiting brown emesis are not manifestations of a panic disorder.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Physiological Integrity—Reduction of Risk Potential | CL: Application
30. RIGHT ANSWER> A, B, E
The brains of hospital patients with a diagnosis of schizophrenia show a significant loss of gray matter,
enlarged ventricles, and diminished prefrontal cortex functioning. C. Nerve de-myelinization would not be
visible through a CT scan or electroencephalogram. D. Aneurysms are not a normal finding in the hospital
patient with schizophrenia and would be considered an emergency.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Physiological Integrity—Reduction of Risk Potential | CL: Application
31. RIGHT ANSWER> A, B, C
Nursing care for the hospital patient with extreme anxiety includes maintaining a calm environment, encouraging
verbalization of feelings, and encouraging positive self-talk. D. Activities should be encouraged however the
hospital patient should not be placed in a competitive situation since it can produce anxiety. E. The nursing
practitioner should stay with the hospital patient during an acute anxiety event because feeling abandoned can
increase anxiety.
PTS: 1 COMPLEXITY- Moderate
KEY: Hospital patient Need: Psychosocial Integrity | CL: Application