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Test Bank For Medical Surgical Nursing 2nd Edition Hoffman
Test Bank For Medical Surgical Nursing 2nd Edition Hoffman
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The medical-surgical nurse identifies a clinical practice issue and wants to determine if there is sufficient
evidence to support a change in practice. Which type of study provides the strongest evidence to support a
practice change?
1) Randomized control study
2) Quasi-experimental study
3) Case-control study
4) Cohort study
____ 2. The medical-surgical unit recently implemented a patient-centered care model. Which action implemented by
the nurse supports this model? NURSINGTB.COM
1) Evaluating care
2) Assessing needs
3) Diagnosing problems
4) Providing compassion
____ 3. Which action should the nurse implement when providing patient care in order to support The Joint
Commission’s (TJC) National Patient Safety Goals (NPSG)?
1) Silencing a cardiorespiratory monitor
2) Identifying each patient using one source
3) Determining patient safety issues upon admission
4) Decreasing the amount of pain medication administered
____ 4. Which interprofessional role does the nurse often assume when providing patient care in an acute care
setting?
1) Social worker
2) Client advocate
3) Care coordinator
4) Massage therapist
____ 5. The medical-surgical nurse wants to determine if a policy change is needed for an identified clinical problem.
Which is the first action the nurse should implement?
1) Developing a question
2) Disseminating the findings
3) Conducting a review of the literature
4) Evaluating outcomes of practice change
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 6. The nurse is evaluating the level of evidence found during a recent review of the literature. Which evidence
carries the lowest level of support for a practice change?
1) Level IV
2) Level V
3) Level VI
4) Level VII
____ 7. The nurse is reviewing evidence from a quasi-experimental research study. Which level of evidence should
the nurse identify for this research study?
1) Level I
2) Level II
3) Level III
4) Level IV
____ 8. Which level of evidence should the nurse identify when reviewing evidence from a single descriptive research
study?
1) Level IV
2) Level V
3) Level VI
4) Level VII
____ 9. Which statement should the nurse make when communicating the “S” in the SBAR approach for effective
communication?
1) “The patient presented to the emergency department at 0200 with lower left abdominal
pain.”
2) “The patient rated the pain upon admission as a 9 on a 10-point numeric scale.”
3) “The patient has no significant issues
NURSinIthe
NGmedical
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OM
4) “The patient was given a prescribed opioid analgesic at 0300.”
____ 10. The staff nurse is communicating with the change nurse about the change of status of the patient. The nurse
would begin her communication with which statement if correctly using the SBAR format?
1) “The patient’s heartrate is 110.”
2) “I think this patient needs to be transferred to the critical care unit.”
3) “The patient is a 68-year-old male patient admitted last night.”
4) “The patient is complaining of chest pain.”
____ 11. Which nursing action exemplifies the Quality and Safety Education for Nursing (QSEN) competency of
safety?
1) Advocating for a patient who is experiencing pain
2) Considering the patient’s culture when planning care
3) Evaluating patient learning style prior to implementing discharge instructions
4) Assessing the right drug prior to administering a prescribed patient medication
____ 12. Which type of nursing is the root of all other nursing practice areas?
1) Pediatric nursing
2) Geriatric nursing
3) Medical-surgical nursing
4) Mental health-psychiatric nursing
____ 13. Which did the Nursing Executive Center of The Advisory Board identify as an academic-practice gap for new
graduate nurses?
1) Patient advocacy
2) Patient education
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3) Disease pathophysiology
4) Therapeutic communication
____ 14. Which statement regarding the use of the nursing process in clinical practice is accurate?
1) “The nursing process is closely related to clinical decision-making.”
2) “The nursing process is used by all members of the interprofessional team to plan care.”
3) “The nursing process has 4 basic steps: assessment, planning, implementation,
evaluation.”
4) “The nursing process is being replaced by the implementation of evidence-based practice.”
____ 15. Which is the basis of nursing care practices and protocols?
1) Assessment
2) Evaluation
3) Diagnosis
4) Research
____ 16. Which is a common theme regarding patient dissatisfaction related to care provided in the hospital setting?
1) Space in hospital rooms
2) Medications received to treat pain
3) Time spent with the health-care team
4) Poor quality food received from dietary
____ 17. The nurse manager is preparing a medical-surgical unit for The Joint Commission (TJC) visit With the nurse
manager presenting staff education focusing on TJC benchmarks, which of the following topics would be
most appropriate?
1) Implementation of evidence-based practice
2) Implementation of patient-centered
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SINGTB.COM
3) Implementation of medical asepsis practices
4) Implementation of interprofessional care
____ 18. Which aspect of patient-centered care should the nurse manager evaluate prior to The Joint Commission site
visit for accreditation?
1) Visitation rights
2) Education level of staff
3) Fall prevention protocol
4) Infection control practices
____ 19. The medical-surgical nurse is providing patient care. Which circumstance would necessitate the nurse
verifying the patient’s identification using at least two sources?
1) Prior to delivering a meal tray
2) Prior to passive range of motion
3) Prior to medication administration
4) Prior to documenting in the medical record
____ 20. The nurse is providing care to several patients on a medical-surgical unit. Which situation would necessitate
the nurse to use SBAR during the hand-off process?
1) Wound care
2) Discharge to home
3) Transfer to radiology
4) Medication education
Multiple Response
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Identify one or more choices that best complete the statement or answer the question.
____ 21. The staff nurse is teaching a group of student nurses the situations that necessitate hand-off communication.
Which student responses indicate the need for further education related to this procedure? Select all that
apply.
1) “A hand-off is required prior to administering a medication.”
2) “A hand-off is required during change of shift.”
3) “A hand-off is required for a patient is transferred to the surgical suite.”
4) “A hand-off is required whenever the nurse receives a new patient assignment.”
5) “A hand-off is required prior to family visitation.”
____ 22. Which actions by the nurse enhance patient safety during medication administration? Select all that apply.
1) Answering the call bell while transporting medications for a different patient
2) Identifying the patient using two sources prior to administering the medication
3) Holding a medication if the patient’s diagnosis does not support its use
4) Administering the medication two hours after the scheduled time
5) Having another nurse verify the prescribed dose of insulin the patient is to receive
____ 23. The medical-surgical nurse assumes care for a patient who is receiving continuous cardiopulmonary
monitoring. Which actions by the nurse enhance safety for this patient? Select all that apply.
1) Silencing the alarm during family visitation
2) Assessing the alarm parameters at the start of the shift
3) Responding to the alarm in a timely fashion
4) Decreasing the alarm volume to enhance restful sleep
5) Adjusting alarm parameters based on specified practitioner prescription
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____ 24. The nurse is planning an interprofessional INconference
care GTB.COfor M a patient who is approaching discharge from
the hospital. Which members of the interprofessional team should the nurse invite to attend? Select all that
apply.
1) Physician
2) Pharmacist
3) Unit secretary
4) Social worker
5) Home care aide
____ 25. The nurse manager wants to designate a member of the nursing team as the care coordinator for a patient who
will require significant care during the hospitalization. Which skills should this nurse possess in order to
assume this role? Select all that apply.
1) Effective clinical reasoning
2) Effective communication skills
3) Effective infection control procedures
4) Effective documentation
5) Effective intravenous skills
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 1, Foundations for Medical Surgical Practice
Chapter learning objective: Discussing the incorporation of evidence-based practices into medical-surgical
nursing
Chapter page reference: 003-004
Heading: Evidence-Based Nursing Care
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Evidence-Based Practice
Difficulty: Easy
Feedback
1 Systematic reviews of randomized control studies (Level I) are the highest level of
evidence because they include data from selected studies that randomly assigned
participants to control and experimental groups. The lower the numerical rating of the
level of evidence indicates the highest level of evidence; therefore, this type of study
provides the strongest evidence to support a practice change.
2 Quasi-experimental studies are considered Level III; therefore, this study does not
provide the strongest evidenceNtoUR SINGa Tpractice
support B.COchange.
M
3 Case-control studies are considered Level IV; therefore, this study does not provide the
strongest evidence to support a practice change.
4 Cohort studies are considered Level IV; therefore, this study does not provide the
strongest evidence to support a practice change.
Feedback
1 Evaluation is a step in the nursing process; however, this is not an action that supports
the patient-centered care model.
2 Assessment is a step in the nursing process; however, this is not an action that supports
the patient-centered care model.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3 Diagnosis is a step in the nursing process; however, this is not an action that supports
the patient-centered care model.
4 Compassion is a competency closely associated with patient-centered care; therefore,
this action supports the patient-centered model of care.
Feedback
1 Safely using alarms is a NPSG identified by TJC. Silencing a cardiorespiratory monitor
is not nursing action that supports this NPSG.
2 Patient identification using two separate resources is a NPSG identified by TJC.
Identifying a patient using only one source does not support this NPSG.
3 Identification of patient safety risks is a NPSG identified by the TJC. Determining
patient safety issues upon admission supports this NPSG.
4
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Safe use of medication is a NPSG identified by the TJC. Decreasing the amount of pain
medication administered does not support this NPSG.
Feedback
1 The nurse does not often assume the interprofessional role of social worker when
providing patient care in an acute care setting.
2 The nurse does not often assume the interprofessional role of client advocate role when
providing patient care in an acute care setting.
3 The nurse often assumes the interprofessional role of care coordinator when providing
patient care in an acute care setting.
4 The nurse does not often assume the interprofessional role of massage therapist when
providing patient care in an acute care setting.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 The first step of evidence-based practice is to develop a question based on the clinical
issue.
2 The last step of evidence-based practice is to disseminate findings.
3 The second step of evidence-based practice is to conduct a review of the literature, or
current evidence, available.
4 The fifth step of evidence-based practice is to evaluate the outcomes associated with the
practice change.
Feedback
1 The lower the numeric value of the evidence the greater the support for a change in
practice. Level IV evidence does not carry the lowest level of support for a practice
change.
2 The lower the numeric value of the evidence the greater the support for a change in
practice. Level V evidence does not carry the lowest level of support for a practice
change.
3 The lower the numeric value of the evidence the greater the support for a change in
practice. Level VI evidence does not carry the lowest level of support for a practice
change.
4 The lower the numeric value of the evidence the greater the support for a change in
practice. Level VII evidence carries the lowest level of support for a practice change.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 A systemic review of randomized controlled studies, not a quasi-experimental research
study, is identified as Level I.
2 Evidence from at least one study randomized control study, not a quasi-experimental
research study, is identified as Level II.
3 A quasi-experimental research study is identified as a Level III.
4 Evidence from case-control or cohort studies, not a quasi-experimental research study,
is identified as a Level IV.
Feedback
1 Evidence from case-control or cohort studies, not a single descriptive research study, is
identified as a Level IV.
2 Evidence from systemic reviews of descriptive or qualitative studies, not a single
descriptive research study, is identified as Level V.
3 Evidence from a single descriptive research study is identified as Level VI.
4 Evidence from expert individual authorities or committees, not a single descriptive
research study, is identified as Level VII.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 The “S” reflects the patient’s current situation which is communicated by providing a
brief statement of the issue. This statement by the nurse exemplifies the current
situation.
2 The “A” reflects the patient’s assessment data. This statement by the nurse exemplifies
the patent’s assessment data.
3 The “B” reflects the patient’s medical history. This statement by the nurse exemplifies
communicating the patient’s history related to the current problem.
4 The “R” reflects specific actions needed to address the situation. This statement by the
nurse exemplifies the actions implemented to address current level of pain.
Feedback
1 This statement is the “A” in the SBAR communication. This is an assessment finding
by the staff nurse.
2 This statement is the “R” in the SBAR communication. This is the recommendation by
the staff nurse.
3 This statement is the “B” in the SBAR communication. This is the background
information.
4 This statement is the “S” in the SBAR communication. This is the situation
information.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Advocating for a patient who is in pain exemplifies the QSEN competency of patient-
centered care, not safety.
2 Considering the patient’s cultural background exemplifies the QSEN competency of
patient-centered care, not safety.
3 Evaluating the patient’s learning style prior to implementing discharge instructions
exemplifies the QSEN competency of patient-centered care, not safety.
4 Assessing the right drug prior to administering a prescribed medication exemplifies the
QSEN competency of safety.
Feedback
1 Pediatric nursing is not the root of all nursing practice areas.
2 Geriatric nursing is not the root of all nursing practice areas.
3 Medical-surgical nursing is the root of all nursing practice as care provided here can be
implemented in all other areas of nursing practice.
4 Mental health-psychiatric nursing is not the root of all nursing practice areas.
Feedback
1 Patient advocacy is not identified as an academic-practice gap for new graduate nurses.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 Patient education is not identified as an academic-practice gap for new graduate nurses.
3 Knowledge of pathophysiology of patient conditions is identified as an academic-
practice gap for new graduate nurses.
4 Therapeutic communication is not identified as an academic-practice gap for new
graduate nurses.
Feedback
1 The nursing process is closely related to the nurse’s decision-making in the clinical
environment. This statement is accurate.
2 The nursing process is not used by all members of the interprofessional team to plan
care.
3 The nursing process has 5, not 4, basic steps: assessment, diagnosis, planning,
implementation, and evaluation.
4
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The nursing process is not being replaced by the implementation of evidence-based
practice.
Feedback
1 Assessment is a step in the nursing process; however, this is not the basis for nursing
care practices and protocols.
2 Evaluation is a step in the nursing process; however, this is not the basis for nursing
care practices and protocols.
3 Diagnosis is a step in the nursing process; however, this is not the basis for nursing care
practices and protocols.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4 Evidence that is obtained through research is the basis for nursing care practices and
protocols.
Feedback
1 Space in each hospital room is not a common theme of patient dissatisfaction.
2 Medications received for pain management is not a common theme of patient
dissatisfaction.
3 A lack of time with members of the health care team is a common theme of patient
dissatisfaction.
4 Poor food quality is not a common theme of patient dissatisfaction.
Feedback
1 Implementation of evidence-based practice is not the benchmark in which acute care
facilities are evaluated against.
2 Implementation of patient-centered care is the benchmark in which acute care facilities
are evaluated against.
3 Implementation of medical asepsis practices is not the benchmark in which acute care
facilities are evaluated against.
4 Implementation of interprofessional care is not the benchmark in which acute care
facilities are evaluated against.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Visitation rights should be evaluated prior to a TJC accreditation site visit as this aspect
of patient-centered care is incorporated into the site evaluation.
2 The education level of staff is not evaluated prior to a TJC accreditation visit. This
information should be evaluated for a hospital that is attempting to earn Magnet status.
3 While the fall prevention program will be reviewed during a TJC accreditation site visit
this is not an aspect of patient-centered care.
4 While infection control practices will be reviewed during a TJC accreditation site visit
this is not an aspect of patient-centered care.
Feedback
1 While the nurse should take care to deliver the meal tray to the correct patient this
circumstance does not require verification of patient identity through two sources.
2 While the nurse should take care to implement passive range of motion on the correct
patient this circumstance does not require verification of patient identity through two
sources.
3 The nurse should identify a patient using two sources prior to medication
administration.
4 While the nurse should take care to document patient care in the correct medical record
this circumstance does not require verification of patient identity through two sources.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Describing the role of interprofessional collaboration and teamwork in the
provision of safe, quality patient care
Chapter page reference: 005-006
Heading: Patient Safety Outcomes
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Application [Applying]
Concept: Communication, Safety
Difficulty: Moderate
Feedback
1 Effective staff communication is essential to safe patient care, especially during hand-
offs. Implementation of wound care is not an example of a hand-off situation.
2 Effective staff communication is essential to safe patient care, especially during hand-
offs. Discharge to home is not an example of a hand-off situation.
3 Effective staff communication is essential to safe patient care, especially during hand-
offs. Patient transfer to another unit of the hospital necessitate a change in who is
responsible for direct patient care; therefore, this situation would necessitate the need
for SBAR during the hand-off process.
4 Effective staff communication is essential to safe patient care, especially during hand-
offs. Medication education is not an example of a hand-off situation.
Feedback
1. This is incorrect. Hand-off communication is not required prior to the administration of
medication. The nurse would, however, verify the patient’s identity using two sources.
2. This is correct. Hand-off communication is required when patient care is transferred from one
provider to another, such as during the change of shift.
3. This is correct. Hand-off communication is required when patient care is transferred from one
provider to another, such as when a patient is transferred to the surgical suite.
4. This is correct. Hand-off communication is required when patient care is transferred from one
provider to another, such as anytime the nurse receives a new patient assignment.
5. This is incorrect. Hand-off communication is not required prior to family visitation.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1. This is incorrect. Interruptions should be minimized during the medication administration
process; therefore, the nurse should not answer the call bell for another patient while
transporting medications for administration.
2. This is correct. Verification of the right patient is one of the rights of medication
administration; therefore, the nurse would identify the patient using two sources prior to the
administration of medication.
3. This is correct. The nurse should ensure that the rationale for all medications are associated
with the patient condition; therefore, this action enhances patient safety during medication
administration.
4. This is incorrect. One of the rights of medication administration is the right time, which
correlates to 30 minutesNbefore
URSI orN30
GT B.COafter
minutes M the scheduled time. This nursing action
would not enhance patient safety during medication administration.
5. This is correct. Verifying the dose of a high-risk medication, such as insulin, enhances patient
safety during medication administration.
Feedback
1. This is incorrect. Monitor alarms should be audible even during family visitation. Inaudible
alarms may impede patient safety.
2. This is correct. The nurse should assess the alarm parameters, comparing to the prescribed
settings, at the start of each shift. This action enhanced patient safety.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3. This is correct. The nurse should respond to all alarms in a timely fashion, which enhances
patient safety.
4. This is incorrect. Monitor alarms should be audible at all times, even when the patient is
asleep to enhance patient safety.
5. This is correct. The nurse should adjust alarm parameters based on specific practitioner
prescriptions. This action enhances safety.
Feedback
1. This is correct. The physician is a member of the interprofessional team and should be invited
to participate in the care conference.
2. This is correct. The pharmacist is a member of the interprofessional team and should be
invited to participate in the care conference.
3.
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This is incorrect. The unit secretary is not a member of the interprofssional team; therefore,
would not require an invitation to attend the care conference.
4. This is correct. The social worker is a member of the interprofessional team; therefore, should
be invited to participate in the care conference.
5. This is incorrect. The home care aide, while a member of the interprofessional team, would
not benefit from attending a care conference while the patient is hospitalized.
Feedback
1. This is correct. Effective clinical reasoning is a skill required for the nurse to assume the role
of care coordinator.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2. This is correct. Effective communication is a skill required for the nurse to assume the role of
care coordinator.
3. This is incorrect. Effective infection control procedures are expected to meet the standard of
care; however, this skill is not required for the nurse to assume the role of care coordinator.
4. This is correct. Effective documentation, a form of communication, is a skill required for the
nurse to assume the role of care coordinator.
5. This is incorrect. Effective intravenous skills are not required for the nurse to assume the role
of care coordinator.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The home care nurse is planning care for a diabetic patient requiring an extensive dressing change twice a
day, assistance with activities of daily living (ADLs), and comprehensive education. Which role is the nurse
assuming by coordinating the care this patient requires?
1) Collaborator
2) Case manager NURSINGTB.COM
3) Health educator
4) Health promoter
____ 2. The nurse is discussing follow-up care with a patient who is being discharged. The patient and family cross
their arms and state angrily that the team's suggestions are not acceptable. Which response by the nurse is
appropriate?
1) “We only want what's best for you.”
2) “We will leave you alone to discuss your options.”
3) “Perhaps you did not understand the recommendations.”
4) “Let's discuss other options that might work well for you and your family.”
____ 3. The nurse is preparing a patient for discharge who will be requiring physical therapy (PT) to rehabilitate after
a total knee replacement. After reading the health-care provider’s order for PT, which would be the nurse's
initial action?
1) Teach the family the exercises needed for the patient.
2) Call home health and schedule a therapist to visit the home for therapy.
3) Set up appointments according to the order with the hospital PT department.
4) Discuss the various types of settings for therapy and have the patient choose the venue.
____ 4. The nurse is caring for a patient with rheumatoid arthritis who expresses the desire to remain active as long as
possible. In order for the patient to meet this goal, what should the nurse prepare to do?
1) Tell the patient there is no hope.
2) Ask the patient the reason for the decision.
3) Teach the patient nutrition and joint exercises.
4) Refer the patient to the appropriate professionals.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 5. A nurse is working as the designated leader of a group of health-care providers in a community clinic setting.
The team members are working to decrease the number of adolescent pregnancies in the community. They
have defined the problem and are now focusing on objectives and considering various viewpoints presented
by the group. The nurse is tasked with helping the team to stay focused in order to address the defined
problem. Which competency of collaboration does this describe?
1) Trust
2) Mutual respect
3) Communication
4) Decision making
____ 6. The nurse managers in a community hospital have been charged with reviewing job descriptions of unlicensed
assistive personnel (UAPs) and have questions about the delegation of certain patient care activities to UAPs
by nurses. To which group, organization, or individual would committee members direct their questions to
obtain definitive answers about the parameters of nurse delegation to UAPs?
1) The state board of nursing
2) The American Nurses Association
3) The hospital's Chief Nursing Officer
4) The hospital's Chief Executive Officer
____ 7. Which statement is a primary and historical barrier to effective nurse-physician collaboration that has
persisted over time?
1) The view among the general population that nurses’ contributions to patients’ care is less
important to their health and well-being compared to the contribution of physicians
2) The nurses’ and physicians’ perceptions of inequity in their roles, with nurses assuming a
subservient role and physicians assuming leadership and superior role in health-care
settings NURSINGTB.COM
3) A general lack of education provided in schools for health professionals about the benefits
on health-care quality linked
4) A lack of published evidence about the effectiveness of collaborative efforts among and
between nurses and physicians to nurse-physician collaboration
____ 8. A patient with Type 1 diabetes mellitus has developed an open sore on the shin and is having trouble meeting
daily goals for exercising. The patient is scheduled for discharge in a couple of days. When planning for this
patient’s continued care, who will the nurse notify regarding the patient’s needs after discharge?
1) The pharmacy
2) The case manager
3) The physical therapist
4) The occupational therapist
____ 9. A patient who is recovering from coronary bypass surgery is placed on a critical pathway for extended care.
Which patient statement indicates appropriate understanding of the plan of care?
1) “I cannot alter the critical pathway plan.”
2) “I must be able to meet goals that are set for me.”
3) “My insurance plan can deny payment if I do not meet goals.”
4) “The chosen critical pathway can be altered to meet my needs.”
____ 10. The case manager interviews an older adult patient hospitalized after hip replacement surgery. The patient
requires in-patient rehabilitation prior to being discharged home. The case manager works with the hospital
nursing staff, the rehabilitation center, the patient’s family members, and other care providers to assist with a
smooth transition. Which is the primary goal of the care management model described here?
1) To provide greater peace of mind for the patient and his or her family members
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2) To track a patient’s progress to ensure that appropriate care is provided until discharge
3) To manage concerns that are related to the patient’s medical care and treatment regimen
only
4) To provide a continuum of clinical services in order to help contain costs and improve
patient outcomes
____ 11. The patient’s case manager, diabetes educator, and dietician meet to discuss the patient’s needs in preparation
for discharge to home. The patient’s primary health-care provider arrives and states, “I will be making all
decisions regarding the patient’s discharge care.” With the primary health-care provider’s decision to lead the
team, the dynamic has shifted between which two types of teams?
1) Intradisciplinary to interdisciplinary team
2) Multidisciplinary to intradisciplinary team
3) Interprofessional to interdisciplinary team
4) Interdisciplinary to multidisciplinary team
____ 12. A school-age patient is admitted to the pediatric intensive care unit (PICU), unconscious and with multiple
traumatic injuries, after a skateboard accident that included a closed head injury. Many health professionals
are involved in the patient’s care and the scene is chaotic. The parents are extremely anxious and want to
know what is happening. The case manager asks for an interdisciplinary team meeting to speak with the
patient’s parents. Which is the rationale for this meeting?
1) To allow for each specialty to practice independently
2) To share and evaluate information for care planning and implementation, and prevent
priority conflicts, redundancy, and omissions in care
3) To all the primary health-care provider to make all the decision regarding the patient’s
care
4) To prevent the parents from trying to change the plan of care
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____ 13. The Chief Nursing Officer and Chief Medical Officer in an urban teaching hospital are leading a series of
meetings with nurses, physicians, hospital lawyers, and risk managers to review and update hospital
privileging procedures and requirements for advanced practice RNs and physicians new to the hospital. This
is an example of which type of collaborative team?
1) Intradisciplinary
2) Interdisciplinary
3) Multidisciplinary
4) Complementary
____ 14. A local hospital formed a neurotrauma (NT) team with the following members: acute care nurses, physicians,
other care partners (e.g., physical therapists, social workers, case managers, dieticians), and representatives
from the NT outpatient clinic. This team is led by a physician who makes treatment decisions based on the
treatment plans developed by individual team members who each communicate with the patients, asking the
same or similar questions to obtain data needed for their treatment plan. Which type of communication and
action is represented in the scenario described?
1) Parallel communication
2) Parallel functioning
3) Information exchange
4) Coordination and consultation
____ 15. The nurse is caring for a patient who is reporting pain of 8/10 on a 1 to 10 numeric pain scale. The nurse
administers the prescribed pain medication. When the nurse re-evaluates the patient one hour later, the patient
is still reporting pain of 8/10. Which action by the nurse is appropriate at this time?
1) Wait for the health-care provider to make rounds to report the problem.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. The hospital’s nurse case manager has been extensively involved with a shooting victim and members of the
patient’s family in coordinating care of providers from many disciplines as the patient progressed from the
emergency department (ED) to the intensive care unit (ICU), and then onto the medical-surgical unit. After
three weeks of hospitalization, the case manager is helping to prepare the patient for discharge to a
rehabilitation center where treatment will continue. Which outcomes have been documented in the literature
as benefits of such collaboration? Select all that apply.
1) Improved patient outcomes
2) Decreased duplication of health-care services
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MULTIPLE CHOICE
1. ANS: 2
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Exploring the role of the registered nurse in patient-centered transitional care
programs
Chapter page reference: 017
Heading: Case Manager
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Collaboration
Difficulty: Easy
Feedback
1 Collaboration means a collegial working relationship with other health-care providers
to supply patient care. Collaborative practice requires the discussion of diagnoses and
management in the delivery of care.
2 Case management involves one or more individuals overseeing the needs and
requirements of a particular individual's health.
3 Health promotion activities include disease prevention and healthy lifestyle
interventions. Health education would be included in this particular situation, but
NUdefinition
collaboration is a more inclusive RSINGTofBwhat .COisMoccurring with these individuals
and the care they require.
4 Health promotion activities include disease prevention and healthy lifestyle
interventions. Health education would be included in this particular situation, but
collaboration is a more inclusive definition of what is occurring with these individuals
and the care they require.
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3 The patient may not understand the recommendations, but pointing that out can be seen
as demeaning.
4 The patient is the center of the team, and the goal is to facilitate healing. There are
always other options to consider to reach that goal. The nurse would discuss other
options with the patient, which will most likely increase cooperation by the patient,
who will feel in control as the decision is made.
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4 The number of patients with chronic diseases with health-care needs is increasing
rapidly, and nurses and primary health-care providers cannot meet all of these patients’
needs. When a patient expresses the desire to live as normally as possible, the nurse
should refer the patient to professionals who can help the patient meet that goal.
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4 This individual does not provide definitive answers regarding tasks that nurses can
delegate to UAPs.
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4 The occupational therapist mainly deals with the upper body areas needing
rehabilitation.
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Feedback
1 Intradisciplinary teams include members of the same profession. Interdisciplinary teams
include professionals of varied backgrounds who share in decision making.
2 Multidisciplinary teams include members of varied backgrounds, but treatment
decisions are made by one member–usually the primary health-care provider.
Intradisciplinary teams include members of the same profession.
3 The term interprofessional team is synonymous with interdisciplinary team.
4 Interdisciplinary teams include professionals of varied backgrounds who share in
decision making. Multidisciplinary teams include members of varied backgrounds, but
treatment decisions are made by one member–usually the primary health-care provider.
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Feedback
1 Intradisciplinary teams comprise members of the same profession working to achieve a
common goal.
2 A team comprising members from different disciplines that is focused on achieving a
common goal is an interdisciplinary team. Their varying professional backgrounds
helps to ensure that other perspectives are represented as the issue is considered.
3 Multidisciplinary teams are more commonly teams whose members work more
autonomously toward the common goal.
4 NURSINGTB.COM
Complementary is not a type of team, although team members’ efforts can be
complementary and provide a broader perspective of issues.
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2 The next level up on the continuum of communication and collaboration, but not
described in this scenario, is parallel functioning. Here, communication is more
coordinated, but each professional still develops separate interventions and care plans.
In parallel functioning, the exchange of information among team members is more
structured and planned, but decision making is unilateral and does not involve much
collegiality.
3 While there is an information exchange occurring, this is not the best description of the
scenario.
4 The actions of this NT team do not demonstrate coordination and consultation or co-
management and referral, the two highest levels of communication and collaborative
action.
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Feedback
1 Increased, not decreased, access is a basic principle of the Patient Protection and
Affordable Care Act of 2010.
2 Decreased cost of care is a basic principle of the Patient Protection and Affordable Care
Act of 2010.
3 Increased, not decreased, quality of care is a basic principle of the Patient Protection
and Affordable Care Act of 2010.
4 Increased, not decreased, safety is a basic principle of the Patient Protection and
Affordable Care Act of 2010.
MULTIPLE RESPONSE
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21. ANS: 1, 2, 4
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Describing models of transitional care
Chapter page reference: 009-010
Heading: Overview of Transitional Care
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Management
Difficulty: Easy
Feedback
1. This is correct. Research findings suggest that collaboration in health care among patients,
family members, caregivers, and communities leads to improved patient outcomes, a reduction
in duplicated health-care services, and a decrease in patient morbidity and mortality.
2. This is correct. Research findings suggest that collaboration in health care among patients,
family members, caregivers, and communities leads to improved patient outcomes, a reduction
in duplicated health-care services, and a decrease in patient morbidity and mortality.
3. This is incorrect. Research findings suggest that collaboration in health care among patients,
family members, caregivers, and communities leads to a decreased, not increased, cost of care.
4. This is in correct. Research findings suggest that collaboration in health care among patients,
family members, caregivers, and communities leads to improved patient outcomes, a reduction
in duplicated health-care services, and a decrease in patient morbidity and mortality.
5. This is incorrect. Collaborative efforts have also been found to contribute to an enhanced
sense of autonomy. ThisNincrease
URSINinGsense
TB.ofCOautonomy
M has been linked to nurses’ greater job
satisfaction.
Feedback
1. This is incorrect. Management teams are executive-level teams that run the day-to-day
operations of a corporation.
2. This is incorrect. Intradisciplinary teams include members of the same profession.
3. This is correct. Interdisciplinary teams include professionals of varied backgrounds who share
decision making. The terms interprofessional team and interdisciplinary team are
synonymous.
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4. This is correct. Interdisciplinary teams include professionals of varied backgrounds who share
decision making. The terms interprofessional team and interdisciplinary team are
synonymous.
5. This is incorrect. A primary nursing care team includes a primary nurse and associate nurses
who will provide care to a patient during a hospital stay.
Feedback
1. This is incorrect. Antibiotics are reflected on the medication administration record (MAR).
2. This is incorrect. Taking a shower does not need to be reported, only documented.
3. This is incorrect. Visiting with the family need not be mentioned at change of shift but should
be documented.
4. This is correct. The nurse would also report any as-needed medications given and when they
were last given.
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5. This is correct. In order to provide for the patient’s safety, the nurse would pass on the
patient’s response to ambulation so that the oncoming staff can take fall precautions.
Feedback
1. This is correct. When receiving a telephone order from a provider, the nurse should ask the
prescriber to repeat or spell out the medication, to speak slowly, and read the order back to the
prescriber once the prescription is complete.
2. This is correct. When receiving a telephone order from a provider, the nurse should ask the
prescriber to repeat or spell out the medication, to speak slowly, and read the order back to the
prescriber once the prescription is complete.
3. This is correct. It is also important for the nurse to know the agency’s policy regarding
telephone orders.
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4. This is incorrect. The nurse does not sign the prescriber’s name and credentials; the nurse only
transcribed the prescription and the prescriber countersigns it within a time period prescribed
by the agency’s policy.
5. This is correct. When receiving a telephone order from a provider, the nurse should ask the
prescriber to repeat or spell out the medication, to speak slowly, and read the order back to the
prescriber once the prescription is complete.
Feedback
1. This is correct. Improved team member satisfaction is an advantage of interprofessional
collaboration.
2. This is incorrect. There is a decreased, not increased, division among team members with
interprofessional collaboration.
3. This is incorrect. There N
is U RSINGsafety
increased TB.with
COMthe discharge transition process, not
medication administration, with interprofessional collaboration.
4. This is correct. Enhanced communication among team members is an advantage of
interprofessional collaboration.
5. This is correct. Increased patient satisfaction with the discharge transition process is an
advantage of interprofessional collaboration.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is providing care to a Muslim patient who presents to the emergency department (ED) with
abdominal pain and vaginal bleeding. The patient’s spouse asks that only a female examines the patient.
Which is the most culturally appropriate statement by the nurse in response to this request?
1) “Your spouse will be covered so it will not matter what the gender of the examiner is.”
2) “The male and female providers here both respect privacy.”
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2) The client lives in a neighborhood that is populated predominantly with people from
Mexico.
3) The client speaks Spanish only.
4) The client attends a church service in the neighboring community to meet new people.
____ 9. A male nurse enters the room of a female patient to obtain the patient's vital signs. The patient’s spouse
appears uncomfortable with the nurse and moves closer to the patient. Which action by the nurse is most
appropriate?
1) Ask a female staff member to obtain the patient’s vital signs.
2) Ask the spouse to leave the patient’s room to obtain the vital signs.
3) Perform the intervention without discussion with the patient or spouse.
4) Explain the procedure to both the patient and the spouse.
____ 10. The nurse is providing care to an adult patient from another country and notices that the patient consults with
her mother on all health-care decisions. Which action by the nurse is the most appropriate?
1) Ask the patient why the parent is being consulted for every decision.
2) Accept the behavior of the patient and family member.
3) Ask the patient's mother to leave the room to provide the patient with more privacy.
4) Confront the patient’s mother to state the importance of the patient making her own
decisions.
____ 11. When preparing an in-service for staff nurses regarding health disparity, which definition should the nurse
include in the presentation?
1) Factors that help explain why some people experience poorer health than others.
2) Describes the health of a person or community along with the many measures that
contribute to this health.
3) Achieved when every person has NUtheRopportunity
SINGTB.toCattainOM his or her health potential and
no one is disadvantaged.
4) Differences in the incidence, prevalence, mortality rate, and burden of diseases that exist
among specific populations.
____ 12. Which of these should the nurse focus on to decrease health disparities among Hispanic patients?
1) Translation services
2) Nutritional education
3) Pediatric immunizations
4) Hypertension prevention
____ 13. Which traditional Chinese medical treatment includes the insertion of needles into precise points along the
channel system of flow of the qi?
1) Cupping
2) Moxibustion
3) Acupuncture
4) Skin pinching
____ 14. Which traditional Chinese medical treatment involves the use of a heated cup used to treat joint pain?
1) Cupping
2) Moxibustion
3) Acupuncture
4) Skin pinching
____ 15. Which traditional Chinese medical treatment includes the application of heat from different sources to various
points which allows medicine to be absorbed through the skin?
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1) Cupping
2) Moxibustion
3) Acupuncture
4) Skin pinching
____ 16. Which traditional Vietnamese medical treatment is used to treat a headache or sore throat?
1) Cupping
2) Moxibustion
3) Acupuncture
4) Skin pinching
____ 17. A Vietnamese patient with a history of joint and muscle pain presents with large ecchymosis on the hips and
legs. Which traditional Vietnamese medical treatment should the nurse inquire about when conducing the
assessment?
1) Cao gio
2) Be bao or bar gio
3) Giac
4) Xong
____ 18. Which patient population should the nurse plan care based on individualistic cultural attributes?
1) Canadian
2) Latino
3) Filipino
4) Hindu
____ 19. Which patient population should the nurse plan care based on collectivistic cultural attributes?
1) British NURSINGTB.COM
2) Swedish
3) Norwegian
4) Vietnamese
____ 20. When communicating with a patient who is of Vietnamese descent, which action by the nurse is appropriate?
1) Using the patient’s surname with a title
2) Being straightforward with the patient
3) Maintaining direct eye contact with the patient
4) Sharing intimate life details with the patient
____ 21. Which nursing action is appropriate when conducting a cultural assessment for a patient?
1) Stereotyping concepts related to the patient’s culture
2) Evaluating the concepts in isolation from one another
3) Determining how each aspect of the patient’s culture interacts
4) Assuming that the patient believes all aspects of information related to the identified
culture
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 22. Which should the nurse consider when assessing for health disparities within the community? Select all that
apply.
1) Age
2) Gender
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3) Ethnicity
4) Disability
5) Education
____ 23. The nurse is caring for several pediatric patients with numerous cultural backgrounds. Which patients would
the nurse anticipate will be encouraged to express themselves? Select all that apply.
1) An Appalachian adolescent
2) A British school-age child
3) An Arab school-age child
4) An Asian-Indian adolescent
5) A Japanese pre-adolescent
____ 24. The nurse is caring for several pediatric patients with numerous cultural backgrounds. Which patients would
the nurse anticipate will be discouraged to express themselves? Select all that apply.
1) An Appalachian adolescent
2) A British school-age child
3) An Arab school-age child
4) An Asian-Indian adolescent
5) A Japanese pre-adolescent
____ 25. Which health-care practices are anticipated when providing care to a patient of German descent? Select all
that apply.
1) Traditional practices as the first line of defense
2) Self-medicating with over-the-counter drugs
3) Use of liberal pain medication
4) Use of medications ordered from other countries
5) Mental health issues hold a stigmaNUandRSare
INhidden
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____ 26. Which health-care practices are anticipated when providing care to an Alaskan Native patient? Select all that
apply.
1) Traditional practices as the first line of defense
2) Self-medicating with over-the-counter drugs
3) Use of liberal pain medication
4) Use of medications ordered from other countries
5) Mental health issues hold a stigma and are hidden
____ 27. Which questions should the nurse ask when conducting an assessment to determine if the patient has any
high-risk cultural behaviors? Select all that apply.
1) “Do you smoke tobacco products?”
2) “How many alcoholic beverages do you drink each day?”
3) “Who makes the health-care decisions within your family?”
4) “Do you use any herbal medications that we should be aware of?”
5) “Are there any foods you would like to include in your diet during hospitalization?”
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MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures
Chapter page reference: 030-034
Heading: Individualism versus Collectivism
Integrated Processes: Communication and Documentation
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Diversity
Difficulty: Moderate
Feedback
1 The response of covering the client or stating the request is unreasonable shows
insensitivity to the patient’s cultural need.
2 Although both male and female staff have professional and ethical responsibilities to
respect a patient’s privacy, the nurse must still make efforts to meet the request of the
client.
3 The response of covering the patient or stating the request is unreasonable shows
insensitivity to the patient’s cultural need.
4 NURSthat
Many cultures have religious beliefs ING TB.Cexamination
prohibit OM by men of the
reproductive areas of a female. To provide culturally appropriate care, the nurse must
recognize this as a legitimate request and make every attempt to honor this request.
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3 Members of the Chinese culture will typically not complain of pain or physical
problems because they are taught self-restraint and the priority of the group over
individual needs. Many people of this culture will consider refusal of something offered
as a gesture of courtesy. The nurse should take these into account and offer the pain
medication to the client.
4 The nurse should make every effort to offer the patient pain medication but respect his
or her decision.
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7. ANS: 4
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Identifying domains, concepts, and terminology essential to cultural assessment
Chapter page reference: 025-026
Heading: Culture and Essential Terminology
Integrated Processes: Culture and Spirituality
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Diversity
Difficulty: Moderate
Feedback
1 Reading about culture and remaining nonjudgmental are strategies that can be
incorporated after engaging in a self-awareness inventory.
2 Reading about culture and remaining nonjudgmental are strategies that can be
incorporated after engaging in a self-awareness inventory.
3 Although experience working with diverse clients will help, it will be more meaningful
after engaging in a self-awareness inventory.
4 It is a priority for the nurse to develop an awareness of his or her own perceptions,
prejudices, and stereotypes regarding the client populations that are served.
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Feedback
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1 This action is inappropriate and do not consider the patient’s cultural or family values.
2 The nurse should accept this behavior as a cultural norm.
3 This action is inappropriate and do not consider the patient’s cultural or family values.
4 This action is inappropriate and do not consider the patient’s cultural or family values.
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Feedback
1 Health-care providers and policymakers need to target vulnerable subgroups of
Hispanic seniors and identify areas of linguistic isolation to minimize these disparities;
therefore, the nurse should focus on translation services to decrease noted health
disparities for Hispanic patients.
2 Nutritional education, pediatric immunizations, and hypertension prevention may all be
appropriate; however, this is not the nurse’s focus to decrease health disparities for this
population.
3 Nutritional education, pediatric immunizations, and hypertension prevention may all be
appropriate; however, this is not the nurse’s focus to decrease health disparities for this
population. NURSINGTB.COM
4 Nutritional education, pediatric immunizations, and hypertension prevention may all be
appropriate; however, this is not the nurse’s focus to decrease health disparities for this
population.
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3 Acupuncture includes the insertion of needles into precise points along the channel
system of flow of the qi.
4 Skin pinching is traditional Vietnamese, not Chinese, medicine.
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16. ANS: 4
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures
Chapter page reference: 030-034
Heading: Individualism versus Collectivism
Integrated Processes: Culture and Spirituality
Client Need: Psychosocial Integrity
Cognitive level: Knowledge [Remembering]
Concept: Diversity
Difficulty: Easy
Feedback
1 Cupping is a traditional Chinese, not Vietnamese, medical treatment where a heated cup
or glass jar is put on the skin creating a vacuum, which causes the skin to be drawn into
the cup. The heat that is generated is used to treat joint pain.
2 Moxibustion is the application of heat from different sources to various points. The
localized erythema occurs with the heat from the burning substance and the medicine is
absorbed through the skin. This is a traditional Chinese, not Vietnamese, medical
practice.
3 Acupuncture includes the insertion of needles into precise points along the channel
system of flow of the qi. This is a traditional Chinese, not Vietnamese, medical
practice.
4 Skin pinching is traditional Vietnamese medical practice used to treat headache or sore
throat.
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22. ANS: 1, 2, 3, 4
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Describing how health disparities impact the health and welfare of society
Chapter page reference: 023-025
Heading: Health Disparities and the Need for Cultural Competence
Integrated Processes: Nursing Process – Assessment
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Diversity
Difficulty: Moderate
Feedback
1. This is correct. Health disparities can affect population groups based on gender, age, ethnicity,
socioeconomic status, geography, sexual orientation, disability, or special needs health-care
needs.
2. This is correct. Health disparities can affect population groups based on gender, age, ethnicity,
socioeconomic status, geography, sexual orientation, disability, or special needs health-care
needs.
3. This is correct. Health disparities can affect population groups based on gender, age, ethnicity,
socioeconomic status, geography, sexual orientation, disability, or special needs health-care
needs.
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4. This is correct. Health disparities can affect population groups based on gender, age, ethnicity,
socioeconomic status, geography, sexual orientation, disability, or special needs health-care
needs.
5. This is incorrect. Education is not a specific consideration when assessing the RN to assess for
health disparities within the community.
Feedback
1. This is correct. The Appalachian culture is considered individualistic; therefore, the nurse
would anticipate that this patient will be encourage to express him- or herself.
2. This is correct. The British culture is considered individualistic; therefore, the nurse would
anticipate that this patient will be encourage to express him- or herself.
3. This is incorrect. The Arab culture is considered collectivistic; therefore, the nurse would not
anticipate this patient to be encourage to express him- or herself.
4.
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This is incorrect. The Asian-Indian culture is considered collectivistic; therefore, the nurse
would not anticipate this patient to be encourage to express him- or herself.
5. This is incorrect. The Japanese culture is considered collectivistic; therefore, the nurse would
not anticipate this patient to be encourage to express him- or herself.
Feedback
1. This is incorrect. The Appalachian culture is considered individualistic; therefore, the nurse
would anticipate that this patient will be encouraged to express him- or herself.
2. This is incorrect. The British culture is considered individualistic; therefore, the nurse would
anticipate that this patient will be encouraged to express him- or herself.
3. This is correct. The Arab culture is considered collectivistic; therefore, the nurse would
anticipate this patient to be discouraged from expressing him- or herself.
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4. This is correct. The Asian-Indian culture is considered collectivistic; therefore, the nurse
would anticipate this patient to be discouraged from expressing him- or herself.
5. This is correct. The Japanese culture is considered collectivistic; therefore, the nurse would
anticipate this patient to be discouraged from expressing him- or herself.
Feedback
1. This is correct. A patient of German descent is likely to have individualistic cultural attributes;
therefore, this practice is anticipated.
2. This is correct. A patient of German descent is likely to have individualistic cultural attributes;
therefore, this practice is anticipated.
3. This is correct. A patient of German descent is likely to have individualistic cultural attributes;
therefore, this practice is anticipated.
4. This is incorrect. This would be anticipated for a patient with collectivistic cultural attributes.
NURSINGTB.COM
5. This is incorrect. This would be anticipated for a patient with collectivistic cultural attributes.
Feedback
1. This is incorrect. This would be anticipated for a patient with individualistic cultural attributes.
2. This is incorrect. This would be anticipated for a patient with individualistic cultural attributes.
3. This is incorrect. This would be anticipated for a patient with individualistic cultural attributes.
4. This is correct. An Alaskan Native patient is likely to have collectivistic cultural attributes;
therefore, this practice should be anticipated by the nurse.
5. This is correct. An Alaskan Native patient is likely to have collectivistic cultural attributes;
therefore, this practice should be anticipated by the nurse.
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27. ANS: 1, 2
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Identifying domains, concepts, and terminology essential to cultural assessment
Chapter page reference: 026-028
Heading: Overview of Cultural Domains and Their Concepts
Integrated Processes: Nursing Process – Assessment
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Diversity; Assessment
Difficulty: Moderate
Feedback
1. This is correct. Use of tobacco is considered a high-risk behavior that is monitored during the
cultural assessment process.
2. This is correct. Use of alcoholic beverages may be a high-risk behavior; therefore, this
question is appropriate to include in the domain of the cultural assessment which monitors
high-risk behaviors.
3. This is incorrect. This question assesses family roles and organization, not high-risk
behaviors.
4. This is incorrect. This question assesses health-care practices, not high-risk behaviors.
5. This is incorrect. This question assesses nutrition, not high-risk behaviors.
NURSINGTB.COM
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is providing care to a client who is considered brain dead. The family has opted to end care and the
health-care provider asks the nurse to pull the endotracheal (ET) tube. The nurse is uncomfortable with this
request. Which is the reason the nurse is experiencing difficulty with this task?
1) An ethical conflict
2) Personal values
3) Legal issues
4) A cultural conflict
____ 2. The nurse is providing care to an older adult patient with terminal cancer who has opted to discontinue
treatment and go home. The patient’s family, however, wants to continue treatment. The nurse agrees to be
present while the patient tells the family. Which ethical patient principle is the nurse supporting?
1) Beneficence
2) Autonomy
3) Nonmaleficence
4) Justice
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____ 3. Which statement best describes the American Nurses Association (ANA) Code of Ethics for professional
nurses?
1) “It alleviates suffering for those cared for by professional nurses.”
2) “It provides standards for professional nursing practice.”
3) “It reflects legal judgments in professional nursing practice.”
4) “It serves as legal standards for professional nursing practice.”
____ 4. Which statement regarding the American Nurses Association (ANA) Code of Ethics for professional nurses is
accurate?
1) “It is used by all health-care professionals.”
2) “It guides nurses in their professional behavior and relationships.”
3) “It forms the basis for possible lawsuits.”
4) “It is the only code of ethics available for nurses."
____ 5. Which professional value is the nurse demonstrating by volunteering time to work in a local free clinic?
1) Human dignity
2) Integrity
3) Altruism
4) Social justice
____ 6. Which action is appropriate when dealing with an ethical dilemma in practice?
1) Relying on nursing judgment
2) Examining all conflicts in the situation
3) Investigating all aspects of the situation
4) Making a decision based on the policy of the agency
____ 7. The hospice nurse is providing care to NUa Rterminal
SINGpatient
TB.Cwho
OM has asked about guidance and support in ending
life. Which should the nurse recognize in regards to making an ethical and moral decision in this
circumstance?
1) Euthanasia has legal implications along with moral and ethical ones.
2) Passive euthanasia is an easy decision to arrive at.
3) Active euthanasia is supported in the Code for Nurses.
4) Assisted suicide is illegal in all states.
____ 8. The nurse is providing care to a 3-year-old child whose parents decide to decline further treatment for cancer,
which has metastasized. There is a conflict between the child’s parents and the rest of the family. Which
should the nurse consider when determining the appropriate action for this patient?
1) The age of the child
2) The beliefs of the child
3) The values of the parents
4) The values of the rest of the family
____ 9. A patient is diagnosed with a sexually transmitted infections (STI) and states to the nurse, “Promise you will
not tell anyone about my condition.” Which action should the nurse take, when considering the Health
Insurance Portability and Accountability Act (HIPAA) of 1996?
1) Honor the patient’s wishes
2) Respect the patient’s privacy and confidentiality.
3) Communicate only necessary information.
4) Not disclosing any information to anyone.
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____ 10. The nurse is providing care to an older adult patient who has decided to discontinue the prescribed
hemodialysis. The patient’s family, however, is not supportive of this decision. When using the theory of
principles-based reasoning, which statement from the nurse is appropriate?
1) “The patient understands the decision and the advanced stage of the disease. If the patient
quits treatment, the patient will die.”
2) “I need to try to help the family understand the patient’s decision so they can work
through this situation together.”
3) “This patient is of sound mind and is capable of making independent decisions regarding
health care. It really is the patient’s decision to make.”
4) “This patient’s health is so deteriorated that the treatment is not saving the patient's life. It
is prolonging the ultimate outcome, which is death.”
____ 11. The nurse is providing care to an older adult patient who is scheduled for surgery. During the preoperative
assessment, the nurse discovers that the patient does not have an adequate understanding of the procedure.
Which is the reason for the nurse to take action in this situation?
1) The patient is very old and has multiple health problems.
2) The family needs to agree to the surgery.
3) The nurse witnessed the consent.
4) The patient has a right to informed consent.
____ 12. The nurse is providing care to a patient who states, “My doctor is refusing to treat me because I am
noncompliant with his recommendations.” Which is the priority nursing action in this situation?
1) Have the patient contact a consumer agency.
2) Advise the patient to sue the health-care provider.
3) Take the patient’s issue to the hospital ethics committee.
4) Notify the health-care provider of the patient’s complaints.
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____ 13. A patient diagnosed with acquired immune deficiency syndrome (AIDS) is admitted to the acute care floor.
Which stance regarding the care for this patient is supported by the American Nurses Association (ANA)
Code of Ethics?
1) The nurse is morally obligated to care for the patient unless the risk exceeds responsibility.
2) The nurse has the responsibility to ensure the patient gets adequate medical care.
3) The patient has the right to choose not to disclose his or her condition to staff.
4) The patient is morally bound to disclose every aspect of his or her condition to staff.
____ 14. An adolescent patient diagnosed with leukemia decides to stop chemotherapy treatments. The patient’s
parents, however, want the health-care team to continue all treatments. Which action by the nurse is
appropriate when providing care to this patient and family?
1) Helping the family by providing information and allowing them to voice their concerns
2) Confronting the parents and telling them not to be “selfish” in their child’s time of need
3) Calling the authorities immediately
4) Obtaining a court order to determine the patient is legally able to make his or her own
decisions
____ 15. A patient tells the nurse, “I don’t really like the nurse on the first shift; she treats me bad.” Which action by
the nurse is appropriate in order to advocate for this patient?
1) Call the agency patient advocacy department.
2) Confront the nurse when she comes to work.
3) Tell the patient he or she has the right to switch nurses.
4) Call the local authorities.
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____ 16. The nurse is providing care for a postpartum patient who states, “I know my rights and you have to do what I
tell you!” Which response by the nurse is appropriate?
1) “I don't mind doing anything within reason, but you have a responsibility to be considerate
to the staff as well.”
2) “That statement is not included in your patient rights; don't yell at me.”
3) “Why do you feel angry … did I do something you did not like?”
4) “Do you want me to take the baby to the nursery so you can calm down?”
____ 17. Which is the priority nursing action for the ethical decision-making process?
1) Determine exactly what needs to be decided.
2) Formulate alternatives to solve the issue.
3) Implement an action to achieve the greatest benefit with the least amount of risk.
4) Ascertain if new information is available regarding the issue.
____ 18. Which number of alternative solutions should be included when conducting ethical decision-making?
1) One
2) Two
3) Three
4) Four
____ 19. Which ethical principle is the nurse assessing when asking who benefits from the actions of others?
1) Beneficence
2) Autonomy
3) Justice
4) Fidelity
____ 20. Which ethical principle requires the nurse
NURS toIbe
Naccountable
GTB.COMfor commitments made to self or others?
1) Beneficence
2) Autonomy
3) Justice
4) Fidelity
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. Which should the nurse be aware of when preparing to act as a patient advocate in the hospital setting? Select
all that apply.
1) The rights of a patient in a long-term care facility
2) The health department's patient rights statement
3) The hospital's patient rights statement
4) State and federal patient rights legislation
5) The unit policy manual
____ 22. According to Provision 2 of the American Nurses Association (ANA) Code of Ethics, which member of the
health-care team is the nurse’s primary commitment? Select all that apply.
1) Patient
2) Family
3) Physician
4) Community
5) Surgeon
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____ 23. Which are ethical issues for the nurse to consider prior to deciding whether or not to honor the picket line
during a strike situation? Select all that apply.
1) The need to support coworkers in their efforts to improve working conditions
2) The need to ensure that clients receive care and are not abandoned
3) The desire to take some time off
4) Loyalty to the nurse’s employer
5) The need for higher pay
____ 24. The nurse is providing care to a pregnant patient with a history of drug use. The patient refuses testing for
human immunodeficiency virus (HIV) despite the recommendation of her nurse-midwife. Which actions by
the nurse are appropriate in this situation? Select all that apply.
1) Refusing to treat the patient unless she is tested
2) Running the test without the patient’s knowledge
3) Emphasizing the importance of the test to the patient
4) Offering counseling regarding the testing
5) Encouraging the patient to reconsider the decision to be tested throughout the pregnancy
____ 25. A hospice nurse is providing care to a patient diagnosed with ovarian cancer. The patient is concerned that her
two daughters are at an increased risk for cancer and asks the nurse for help. Which actions by the nurse are
appropriate? Select all that apply.
1) Provide the family with information on hereditary cancer risks.
2) Assure the client that ovarian cancer is not hereditary.
3) Offer to refer the daughters to a genetic counselor.
4) Arrange for the client to have genetic testing.
5) Tell the client that her additional worrying is too stressful.
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MULTIPLE CHOICE
1. ANS: 2
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Addressing ethical dilemmas associated with the care of the acutely ill adult
Chapter page reference: 042
Heading: Experimental Therapies
Integrated Processes: Caring
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Ethics
Difficulty: Easy
Feedback
1 The decision is within ethical principles.
2 The nurse is distressed because of personal values, which are in conflict with causing
the client's death.
3 Extubating this patient would not be a legal decision.
4 Cultural values are not evidenced in this instance.
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Feedback
1 The patient’s age and health problems are not the reasons for the nurse to take action.
2 The family does not make the decision regarding surgery unless the patient has been
declared incompetent by the court.
3 The nurse would want to have the surgery explained for the client’s sake, not because
the nurse signed the form.
4 The nurse should notify the surgeon because the patient has the right to informed
consent.
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Feedback
1 A consumer agency is not appropriate because this is an ethical matter.
2 The nurse never advises a patient to sue but assists the patient to find help resolving the
issue.
3 Acting as a patient advocate and protecting the patient’s rights, the nurse should enlist
the help of the hospital ethics committee.
4 The nurse should act on behalf of the patient, and the best way to do that is by taking
the issue to the hospital ethics committee, not to the health-care provider.
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2 Confronting the parents is likely to do more harm than good especially in the context of
telling the parents they are being selfish in their child’s time of need.
3 There is no need to contact the authorities.
4 It is not appropriate to obtain a court order to determine if the patient is legally able to
make his or her own decision in this circumstance.
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MULTIPLE RESPONSE
21. ANS: 3, 4
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Identifying professional standards that guide ethical nursing practice
Chapter page reference: 039-043
Heading: Ethical Dilemmas
Integrated Processes: Nursing Process – Planning
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Ethics; Nursing Roles
Difficulty: Easy
Feedback
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1. This is incorrect. The rights of a patient in a long-term care facility are not applicable when
providing care in the hospital setting.
2. This is incorrect. The rights of a patient in the health department setting are not applicable
when providing care in the hospital setting.
3. This is correct. The hospital’s patient rights statement will assist the nurse to act as a patient
advocate in the hospital setting.
4. This is correct. The state and federal patient rights legislation is applicable to patients in the
hospital setting; therefore, the nurse should have knowledge of this information when acting
as a patient advocate.
5. This is incorrect. The unit’s policy manual will not have a separate policy statement from the
hospital regarding the patient’s rights.
Feedback
1.
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This is correct. The patient is the nurse’s primary commitment according to the ANA Code of
Ethics.
2. This is correct. The family is the nurse’s primary commitment according to the ANA Code of
Ethics.
3. This is incorrect. The physician is not the nurse’s primary commitment according to the ANA
Code of Ethics.
4. This is correct. The community is the nurse’s primary commitment according to the ANA
Code of Ethics.
5. This is incorrect. The surgeon is not the nurse’s primary commitment according to the ANA
Code of Ethics.
Feedback
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1. This is correct. Strikers may be concerned about patient care as it is related to adequate
staffing.
2. This is correct. Strikes may adversely affect patient care and outcomes.
3. This is incorrect. The desire to take time off and the need for higher pay are not ethical issues.
4. This is correct. Nurses may feel allegiance to a hospital where they have worked for years.
5. This is incorrect. The desire to take time off and the need for higher pay are not ethical issues.
Feedback
1. This is incorrect. Testing for HIV status is not mandatory; therefore, it is unethical to refuse to
treat the patient unless she is tested.
2. This is incorrect. It is unethical to test the patient for HIV without her knowledge; patients
have the right to refuse treatment.
3. This is correct. SuggestingNUcounseling
RSINGTand B.C consistently
OM encouraging testing are recommended.
4. This is correct. Suggesting counseling and consistently encouraging testing are recommended.
5. This is correct. Suggesting counseling and consistently encouraging testing are recommended.
Feedback
1. This is correct. A nurse’s role as educator is crucial to ethical practice.
2. This is incorrect. Inaccurate reassurance or avoidance does not respect the patient’s rights.
3. This is correct. Providing appropriate alternatives and options for the patient and the family
are correct responses to the patient's concerns.
4. This is correct. Providing appropriate alternatives and options for the patient and the family
are correct responses to the patient's concerns.
5. This is incorrect. Inaccurate reassurance or avoidance does not respect the patient’s rights.
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Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A competent older adult patient has a living will that expresses the patient’s desire to avoid resuscitation and
heroic life support measures. The patient’s family, however, is not supportive of this directive and plans to
contest the living will. Which nursing action is appropriate based on the current situation?
1) Notify the hospital attorney.
2) Contact the Social Services department.
3) Place the document on the patient’s medical record.
4) Explain to the patient that the conflict could invalidate the document.
____ 2. The nurse is providing care for a Catholic patient who has suffered a massive cerebral hemorrhage and is not
expected to survive. Which intervention by the nurse is most appropriate?
1) Contact a priest to deliver the Sacrament of the Sick.
2) Make plans for the family to wash the body after death.
3) Contact a rabbi so that the patient can participate in prayer.
4) Discuss the need to cremate the patient, as burial is not accepted in this faith.
____ 3. The nurse is caring for a terminally ill patient and family members. The family has been tearful and sad since
the terminal diagnosis was given. Which
NURshould
SINGbeTtheB.nurse’s
COM focus when planning care?
1) Hopelessness
2) Caregiver role strain
3) Anticipatory grieving
4) Complicated grieving
____ 4. The nurse is providing care to a patient who is diagnosed with terminal lung cancer. The patient is lying in the
supine position with noisy wet respirations noted and is not breathing well. The patient has a living will which
designates the implementation of comfort measures. Which action by the nurse is appropriate?
1) Withhold all care until the patient dies.
2) Provide the patient with pain medication as ordered.
3) Ask the family what they want to be done for the patient.
4) Reposition the patient to a lateral position, with the head elevated as tolerated.
____ 5. The nurse is caring for a dying child who is being treated with comfort measures only. Which nursing action
supports the primary goal for this patient?
1) Assess and medicate, as ordered, for any signs and symptoms of distress.
2) Maintain a busy schedule for child and family members.
3) Keep the child entertained so she does not think about dying.
4) Ensure that a good relationship is maintained with the family.
____ 6. The parents of a child with terminal cancer ask the nurse that the child not be told that he will not recover.
The child asks the nurse if he is dying. What should the nurse do at this time?
1) Ignore the child’s question and change the subject.
2) Tell the child he is dying and offer to stay with him.
3) Suggest a meeting with the health-care team and the parents.
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4) Offer to bring in the child life therapist to help explain the situation.
____ 7. An older school-age child is brought to the emergency department (ED) after a car accident. The parents
witness and stare at the resuscitation scene unfolding before them. The child is not responding to the
resuscitative efforts after 30 minutes. Which is the best communication strategy for the nurse to use in this
situation?
1) Ask the parents to leave until the child has stabilized.
2) Ask the parents to stand at the foot of the cart to watch.
3) Discuss with the parents whether they would like resuscitative efforts to be continued at
this point.
4) Inform the parents that resuscitative efforts have not been effective and are not beneficial
to the child.
____ 8. An adolescent patient with terminal cancer tells the nurse that she does not want to continue treatment, even
though her parents are planning for her to participate in a study trial that involves aggressive chemotherapy.
Which action by the nurse is the most appropriate?
1) Tell her not to worry, that she knows her parents want the best for her.
2) Tell the patient that the decision is her parents’ and she has to participate in the study.
3) Notify the adolescent that she can make her own decisions no matter what her parents
want.
4) Request that the parents and daughter meet together with the health-care team to discuss
options and the implications of various choices.
____ 9. The nurse is providing care for a patient receiving curative care who is experiencing chronic pain due to
cancer. Which type of care should the nurse plan for upon discharge for this patient?
1) Home health care
2) Palliative care NURSINGTB.COM
3) Hospice care
4) Rehabilitative care
____ 10. The nurse is assessing the patient for palliative care. When assessing the social domain, which should the
nurse include?
1) Financial concerns
2) Pain
3) Depression
4) Spiritual concerns
____ 11. The nurse is assessing the patient for palliative care. When assessing the physical domain, which should the
nurse include?
1) Financial concerns
2) Pain
3) Depression
4) Spiritual concerns
____ 12. The nurse is assessing the patient for palliative care. When assessing the psychosocial and psychiatric domain,
which should the nurse include?
1) Financial concerns
2) Pain
3) Depression
4) Spiritual concerns
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____ 13. The nurse is assessing the patient for palliative care. When assessing the cultural domain, which question
should the nurse include?
1) “Do you have any financial concerns regarding your care?”
2) “Are you currently experiencing pain?”
3) “Are you experiencing any depression or anxiety?”
4) “Do you have any specific dietary preferences that affect your care?”
____ 14. The nurse is educating the family of a patient who is receiving hospice care due to a terminal illness. Which
medication should the nurse tell the family to administer for this patient if delirium occurs?
1) Morphine
2) Haloperidol
3) Diphenhydramine
4) Docusate
____ 15. The nurse is educating the family of a patient who is receiving hospice care due to a terminal illness. Which
medication should the nurse tell the family to administer to treat the patient’s pain?
1) Morphine
2) Haloperidol
3) Diphenhydramine
4) Docusate
____ 16. The nurse is educating the family of a patient who is receiving hospice care due to a terminal illness. Which
benzodiazepine medication should the nurse tell the family to administer to treat the patient if hyperactive
delirium occurs?
1) Morphine
2) Haloperidol
3) Diphenhydramine NURSINGTB.COM
4) Lorazepam
____ 17. The nurse is providing care to a patient who is approaching death. Which family member statement regarding
the physical and psychological changes associated with death is reflective of the late stage?
1) “A loss of appetite often occurs during this stage.”
2) “Respirations may sound loud and wet during this stage.”
3) “I might notice that he will begin to sleep more during this stage.”
4) “Confusion or disorientation may begin to occur during this stage.”
____ 18. The nurse is providing care to a patient who is approaching death. Which family member statement regarding
the physical and psychological changes associated with death is reflective of the middle stage?
1) “A loss of appetite often occurs during this stage.”
2) “Respirations may sound loud and wet during this stage.”
3) “I might notice that he will begin to sleep more during this stage.”
4) “Confusion or disorientation may begin to occur during this stage.”
____ 19. Which response by the nurse indicates the use of reflective reasoning when communicating with the family of
a patient who is in the process of dying?
1) “I can see this is difficult for you.”
2) “Thank you for taking such good care of your mother.”
3) “Your mother is experiencing quite a bit of pain at the moment.”
4) “A social worker will be able to answer all the questions that you have.”
____ 20. Which concept exemplifies a well-managed death experience for a terminal patient and family members?
1) Allowing the patient to die alone
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 22. Which factors can create moral distress for nurses? Select all that apply.
1) Supportive management staff
2) Low stress patient environment
3) High technology patient care situations
4) Cultural differences with the patient population
5) Resource pressures when providing patient care
____ 23. The nurse is providing care to a patient who is diagnosed with terminal lung cancer. Which clinical
manifestations indicate imminent death? Select all that apply.
1) Diaphoresis
2) Increased cardiac output
3) Decreased blood pressure
4) Tachycardia followed by bradycardiaNURSINGTB.COM
5) An increase in the volume of Korotkoff's sounds
____ 24. The wife of a patient with end-stage chronic obstructive pulmonary disease (COPD) tells the nurse that she
wishes her husband were eligible for hospice care but she thinks that hospice is only available for cancer
patients and would require a change in health-care providers. Which responses by the nurse are appropriate?
Select all that apply.
1) Inform her that hospice care is very expensive.
2) Inform her that a diagnosis of cancer is not required for hospice care.
3) Inform her that all hospice programs provide care 24 hours per day, 7 days per week
4) Inform her that her husband can retain his provider when transitioning to hospice care.
5) Inform her that her husband is not eligible for hospice care with the current diagnosis of
COPD.
____ 25. The nurse is providing care to a terminal patient who is experiencing delirium. Which should the nurse assess
prior to administering haloperidol to this patient? Select all that apply.
1) Last stool
2) Blood pressure
3) Respiratory rate
4) Bladder distention
5) Medication regimen
____ 26. Which statement from the nurse to family members is appropriate to encourage the participation of providing
physical care to the patient during the dying process? Select all that apply.
1) “You can bring in pictures of the family to comfort your loved one.”
2) “Apply lip balm to your loves one’s mouth if you feel the lips are dry.”
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3) “You can massage your loved one’s arms and legs to provide comfort.”
4) “Bring in music that your loved one likes to listen to with headphones.”
5) “Your child can call your loved one if you don’t want to expose him to this process.”
____ 27. A terminal patient has opted to stop treatment. The family, however, believes the patient is no longer
competent to make this decision. Which data supports that the patient is capable of making this treatment
decision? Select all that apply.
1) The patient is aware of the current date and location.
2) The patient does not want to be a burden on the family.
3) The patient communicates the decision with the health-care team.
4) The patient understands the nature and consequences of treatment.
5) The patient states the benefits and risks associated with the treatment.
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MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Analyzing the nursing care priorities for patients near the end of life
Chapter page reference: 051
Heading: Domain 8: Ethical and Legal Aspects of Care
Integrated Processes: Nursing Process – Implementation
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Critical Thinking; Legal
Difficulty: Moderate
Feedback
1 There is no need to notify the hospital attorney at this time.
2 If there are concerns about the authenticity of the document, the Social Services
department or the unit supervisor will need to be contacted.
3 This patient is competent; therefore, the wishes of the client take priority. The
document should be placed on the patient’s medical record and the health-care provider
notified.
4 A lack of support by the family, or a plan to contest, does not invalidate the document
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Chapter learning objective: Developing communication and support strategies for family members
Chapter page reference: 050-051
Heading: Family Support
Integrated Processes: Nursing Process – Planning
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
Feedback
1 There are no assessment findings that indicate complicated grieving or hopelessness.
2 This reaction is typical of family members, so there is no indication that the family is
exhibiting caregiver role strain.
3 Grieving prior to the actual loss is termed anticipatory grieving.
4 There are no assessment findings that indicate complicated grieving or hopelessness.
Feedback
1 “Comfort measures only” indicates that the patient does not want extraordinary
measures to sustain life. This does not mean that nursing care ceases but that nursing
care to provide patient comfort is intensified and maintained through the end stages of
the patient’s life.
2 The nurse did not note the patient had any verbal or nonverbal signs or symptoms of
pain, so medicating the patient for pain is not appropriate.
3 Asking the family what they want to be done is inappropriate when a patient has written
a living will.
4 Repositioning the patient from the supine position to a lateral position with the head
elevated as tolerated would be the first step to address the patient’s symptoms. The
nurse may need to medicate the patient with an anticholinergic agent to dry the
secretions if ordered. If not ordered, the patient may need to contact the health-care
provider to get an order for this type of medication for comfort measures.
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Feedback
1 The major goal for the dying child is to promote comfort and keep the child symptom-
free.
2 A dying child does not have the energy to maintain a busy schedule.
3 Keeping the child entertained is good, but the pediatric patient needs to voice her
feelings about death and dying.
4 Maintaining a good relationship is important but not a major goal for the child’s care.
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4 Rehabilitative care provides rehab services for patients who require strengthening after
hospitalization.
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Feedback
1 Morphine is an opiate administered to treat the patient’s pain, not delirium.
2 Haloperidol is a drug that is administered to treat delirium that can occur at the end of
life.
3 Diphenhydramine is an anticholinergic agent administered to dry the patient’s
secretions, not to treat delirium.
4 Docusate is a stool softener used to treat constipation, not delirium.
Feedback
1 Morphine is an opiate administered to treat the pain that patients may experience at the
end of life.
2 Docusate is a stool softener used to treat constipation, not delirium.
3 Diphenhydramine is an anticholinergic agent administered to dry the patient’s
secretions, not to treat delirium.
4 Lorazepam, a benzodiazepine, is administered for a patient who is experiencing
hyperactive delirium at the end of life.
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4 Sending a bereavement card to the family of a patient who has recently passed is a team
action nurses can employ as a stress-reducing strategy.
MULTIPLE RESPONSE
22. ANS: 3, 4, 5
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Explaining moral distress in end-of-life issues
Chapter page reference: 052-053
Heading: Ethical Implications and Moral Distress
Integrated Processes: Caring
Client Need: Psychosocial Integrity
Cognitive level: Comprehension [Understanding]
Concept: Grief and Loss
Difficulty: Easy
Feedback
1. This is incorrect. An unsupportive, not supportive, management staff leads to moral distress
for nurses.
2. This is incorrect. A high, not low, stress environment leads to moral distress for nurses.
3. This is correct. High technology patient care situations often lead to moral distress for nurses.
4. This is correct. Cultural differences between the nurse and the patient population often lead to
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moral distress for nurses.
5. This is correct. Resource pressures when providing patient care often lead to moral distress for
nurses.
Feedback
1. This is correct. Peripheral circulation decreases, leading to diaphoresis; clammy, cool skin;
and changes in skin coloring.
2. This is incorrect. Decreased cardiac output results from bradycardia and hypotension.
3. This is correct. The heart rate and blood pressure decrease, resulting in decreased cardiac
output, which is a sign of imminent death.
4. This is correct. The heart rate might initially increase as hypoxia develops; then the heart rate
and blood pressure decrease, resulting in decreased cardiac output.
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5. This is incorrect. A change in pulse pressure and a decrease in the volume of Korotkoff's
sounds indicate imminent death.
Feedback
1. This is incorrect. Hospice care is often less expensive than conventional care in the last six
months of life.
2. This is correct. In addition to clients who are diagnosed with cancer, a variety of clients
qualify for hospice care.
3. This is incorrect. Hospice teams visit clients intermittently, although they are available 24/7
for support and care.
4. This is correct. Hospice reinforces the client-primary physician relationship by advocating
office or home visits.
5. This is incorrect. In addition to clients who are diagnosed with cancer, a variety of clients
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qualify for hospice care. A diagnosis of end-stage COPD is often a qualifier for hospice care.
Feedback
1. This is correct. The last noted stool should be assessed to determine if constipation may be
causing the delirium prior to medicating with the prescribed drug.
2. This is incorrect. The nurse would not assess the patient’s blood pressure to determine the
cause of delirium.
3. This is incorrect. The nurse would not assess the patient’s respiratory rate to determine the
cause of the delirium.
4. This is correct. Bladder distention is often a cause for delirium; therefore, the nurse should
assess for this prior to administering the prescribed drug.
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5. This is correct. Certain medications are known to cause delirium; therefore, the nurse should
assess the patient’s medication regimen prior to administering the prescribed drug.
Feedback
1. This is incorrect. While bringing pictures is an appropriate suggestion, this does not allow the
family to participate in the physical care of the patient during the dying process.
2. This is correct. The lips of a patient who is experiencing the process of dying often become
dry; therefore, the application of lip balm is an appropriate suggestion to allow the family to
participate in the physical care of this patient.
3. This is correct. A patient who is dying often experiences pain that can be remedied by
massage; therefore, suggesting this to the family allows them to participate in the physical care
of this patient.
4. This is incorrect. While bringing music for the patient to listen to is appropriate, this addresses
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the patient’s psychosocial, not physical, needs.
5. This is incorrect. Suggesting that a child call the dying patient is appropriate; however, this
addresses the psychosocial, and not physical, needs of the patient and family.
Feedback
1. This is incorrect. While this data supports that the patient is alert and oriented it does not
indicate the patient’s decisional capacity.
2. This is incorrect. The patient stating that he or she does not want to be a burden on the family
is not data that supports the patient’s decisional capacity.
3. This is correct. Being able to communicate a decision with the health-care team supports the
patient’s decisional capacity.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4. This is correct. Understanding the nature and the consequences of treatment supports the
patient’s decisional capacity.
5. This is correct. Stating the benefits and risks associated with the treatment supports the
patient’s decisional capacity.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is providing care to an older adult patient who is experiencing bradycardia. When educating the
patient about this disorder, which age-related cardiovascular change should the nurse include?
1) Stiffened artery walls
2) Increased size of the left atrium
3) Reduced number of pacemaker cells in the SA node
4) Decreased cardiac responsiveness to beta-adrenergic stimuli
____ 2. The nurse is providing care to an older
NUadult
RSIpatient
NGTBwho.CisOMdiagnosed with congestive heart failure (CHF).
When educating the patient about this disorder, which age-related cardiovascular change should the nurse
include?
1) Stiffened artery walls
2) Increased size of the left atrium
3) Reduced number of pacemaker cells in the SA node
4) Decreased cardiac responsiveness to beta-adrenergic stimuli
____ 3. The nurse is providing care to an older adult patient who is diagnosed with atrial fibrillation. When educating
the patient about this disorder, which age-related cardiovascular change should the nurse include?
1) Stiffened artery walls
2) Increased size of the left atrium
3) Reduced number of pacemaker cells in the SA node
4) Decreased cardiac responsiveness to beta-adrenergic stimuli
____ 4. Which statement should the nurse include when educating older adult patients about dementia?
1) “Dementia causes impaired judgment.”
2) “Dementia causes fluctuations in alertness.”
3) “Symptoms of dementia cause day-night reversal.”
4) “Symptoms of dementia do not last more than one month.”
____ 5. The nurse is providing care to an older adult patient who is diagnosed with an ulcer. Which age-related
gastrointestinal change is often the cause for this diagnosis?
1) Slowed gastric emptying
2) Atrophied gastric mucosa
3) Increased secretion of gastrin
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1) Atrophy
2) Stenosis
3) Sclerosis
4) Calcification
____ 14. Which data collected by the nurse during the health history of an older adult patient increases the risk for
heart disease?
1) Dependent edema
2) Diabetes insipidus
3) Cigarette smoking
4) Diminished hearing
____ 15. Which nursing action supports The Joint Commission (TJCs) safety goals for providing home care to an older
adult patient?
1) Verifying the patient’s first and last name during each visit
2) Administering all prescribed medications to the patient during scheduled visits
3) Recommending the use of throw rugs on hard wood floors to prevent patient falls
4) Asking family members to smoke in another room when oxygen is in use by the patient
____ 16. Which clinical manifestation should the nurse anticipate when providing care to an older adult patient who is
diagnosed with Parkinson disease?
1) Tremors
2) Paralysis
3) Vision impairment
4) Right-sided weakness
____ 17. Which electrolyte imbalance should NtheUnurse
RSIN monitor
GTB.anCO
older
M adult patient for due to impaired renal diluting
capacity and concentrating ability?
1) Hypokalemia
2) Hyponatremia
3) Hypocalcemia
4) Hypomagnesemia
____ 18. Which electrolyte imbalance should the nurse monitor an older adult patient for when a diuretic is prescribed?
1) Hypokalemia
2) Hyponatremia
3) Hypocalcemia
4) Hypomagnesemia
____ 19. The nurse is providing care to an older adult patient who is diagnosed with a vitamin B deficiency. The
patient tells the nurse, “I feel so tired all the time and my daughter says I look pale.” Based on this data, which
should the nurse suspect?
1) Anemia
2) Osteoporosis
3) Atrophic gastritis
4) Gastroesophageal reflux disease (GERD)
____ 20. The nurse educates the older adult patient to increase activity, lose weight, and limit dietary intake of fats and
calories. Which disease process is the patient at risk for based on the teaching?
1) Fecal impaction
2) Diabetes insipidus
3) Type 2 diabetes mellitus (DM)
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 22. Which older adult patient diagnoses should the nurse include information regarding cachexia into the plan of
care? Select all that apply.
1) Lung cancer
2) Osteoporosis
3) Gastroesophageal reflux disorder (GERD)
4) Acquired immune deficiency syndrome (AIDS)
5) Chronic obstructive pulmonary disease (COPD)
____ 23. Which priority safety concerns should the nurse assess when providing care to older adult patients? Select all
that apply.
1) Falls
2) Neglect
3) Depression
4) Polypharmacy NURSINGTB.COM
5) Poor dietary intake
____ 24. Which items found by a nurse during a home health visit increase the older adult patient’s risk for physical
safety issues? Select all that apply.
1) Rugs
2) Electrical cords
3) Nonskid appliance in bathtub
4) Medications stored in a weekly divider
5) Telephone with emergency numbers listed
____ 25. Which changes associated with aging should the nurse identify as possible inhibitors to medication adherence
and safety? Select all that apply.
1) Decreased memory
2) Decreased visual acuity
3) Decreased hearing acuity
4) Decreased sense of smell
5) Decreased physical strength
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MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Discussing age-related physiological changes
Chapter page reference: 057-058
Heading: Common Cardiovascular Health Issues
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perfusion
Difficulty: Moderate
Feedback
1 The stiffening of artery walls causes the systolic blood pressure to rise.
2 Left atrial enlargement causes a fourth heart sound to be auscultated and is also
responsible for an increased risk for hypertension and congestive heart failure (CHF).
3 A reduced number of pacemaker cells in the SA node causes the maximum heart rate to
decrease with age, leading to bradycardia.
4 Decreased cardiac responsiveness to beta-adrenergic stimuli increases the risk for
arrhythmias, atrial fibrillation, and reduced heart rate control when exposed to stressors.
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PTS: 1 CON: Perfusion
2. ANS: 2
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Discussing age-related physiological changes
Chapter page reference: 057-058
Heading: Common Cardiovascular Health Issues
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perfusion
Difficulty: Moderate
Feedback
1 The stiffening of artery walls causes the systolic blood pressure to rise.
2 Left atrial enlargement causes a fourth heart sound to be auscultated and is also
responsible for an increased risk for hypertension and congestive heart failure (CHF).
3 A reduced number of pacemaker cells in the SA node causes the maximum heart rate to
decrease with age, leading to bradycardia.
4 Decreased cardiac responsiveness to beta-adrenergic stimuli increases the risk for
arrhythmias, atrial fibrillation, and reduced heart rate control when exposed to stressors.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 The stiffening of artery walls causes the systolic blood pressure to rise.
2 Left atrial enlargement causes a fourth heart sound to be auscultated and is also
responsible for an increased risk for hypertension and congestive heart failure (CHF).
3 A reduced number of pacemaker cells in the SA node causes the maximum heart rate to
decrease with age, leading to bradycardia.
4 Decreased cardiac responsiveness to beta-adrenergic stimuli increases the risk for
arrhythmias, atrial fibrillation, and reduced heart rate control when exposed to stressors.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Slowed gastric emptying causes gastric distention and anorexia.
2 Atrophied gastric mucosa causes gastric distention and anorexia.
3 Increased secretion of gastrin causes an increase in gastric acid which often leads to
ulceration.
4 Reduced secretion of intrinsic factor causes impaired vitamin B12 absorption.
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PTS: 1 NURSIN
CON: Evidence-Based GTB.COM
Practice
9. ANS: 4
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Defining the demographics of the aging population
Chapter page reference: 056
Heading: Demographics
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Knowledge [Remembering]
Concept: Communication
Difficulty: Easy
Feedback
1 A patient age 75 to 85 is classified as old.
2 A patient 85 years of age and older is classified as oldest old or old-old.
3 A patient 85 years of age and older is classified as oldest old or old-old.
4 A patient age 65 to 75 is classified as young-old.
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Feedback
1 Correctly identifying the patient is a TJC safety goal when providing home care. The
nurse verifies the patient using the first and last name in order to meet this safety goal.
2 Using medications safety is a TJC safety goal when providing home care. The nurse
must use communication, teaching, and organizational skills to educate the patient
about his or her medications. This includes indications, side effects, and dosing
intervals. The nurse helps the patient develop a system for organizing the medications,
usually accomplished with a “mediplanner” pill container.
3 Throw rugs are discouraged as these increase the risk for patient falls, according to the
TJC safety goals when providing home care.
4 Smoking is prohibited in the home of any patient who is receiving oxygen per the TJC
safety goals when providing home care.
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3 Calcium imbalances are not associated with impaired renal diluting capacity and
concentrating ability.
4 Magnesium imbalances are not associated with impaired renal diluting capacity and
concentrating ability.
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MULTIPLE RESPONSE
22. ANS: 1, 4, 5
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Identifying common health-care issues of the elderly
Chapter page reference: 063-064
Heading: Nutritional Issues
Integrated Processes: Nursing Process – Planning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
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Feedback
1. This is correct. Cachexia is the loss of weight and muscle mass and cannot be reversed
nutritionally. It is associated with the diagnosis of cancer.
2. This is incorrect. A diagnosis of osteoporosis is not associated with cachexia.
3. This is incorrect. A diagnosis of GERD is not associated with cachexia.
4. This is correct. Cachexia is the loss of weight and muscle mass and cannot be reversed
nutritionally. It is associated with the diagnosis of AIDS.
5. This is correct. Cachexia is the loss of weight and muscle mass and cannot be reversed
nutritionally. It is associated with the diagnosis of COPD.
Feedback
1. This is correct. Falls areNaUpriority
RSINsafety
GTB. concern
COM the nurse should assess for when providing
care to any older adult patient.
2. This is correct. Neglect is a priority safety concern the nurse should assess for when providing
care to any older adult patient.
3. This is incorrect. Depression is not a priority safety concern for older adult patients.
4. This is correct. Polypharmacy is a priority safety concern the nurse should assess for when
providing care for any older adult patient.
5. This is incorrect. Poor dietary intake is not a priority safety concern for older adult patients.
Feedback
1. This is correct. Rugs increase the risk for falls for older adult patients; therefore, this is a
physical safety risk.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2. This is correct. Electrical cords increase the risk for falls for older adult patients; therefore,
this is a physical safety risk.
3. This is incorrect. A nonskid appliance in the bathtub decreases the older adult patient’s risk for
falls.
4. This is incorrect. Medications that are stored in a weekly divider decrease the patient’s risk for
physical injury.
5. This is incorrect. A telephone with emergency numbers listed decreases the patient’s risk for
physical injury.
Feedback
1. This is correct. Decreased memory often interferes with the patient’s ability to remember if a
medication has been taken, which is a safety risk.
2. This is correct. Decreased visual acuity can interfere with the patient’s ability to read the
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medication label for administration purposes, which is a safety risk.
3. This is incorrect. While older adult patients do experience a decrease in hearing, this is not a
factor in medication adherence and safety.
4. This is incorrect. While older adult patients do experience a decrease in the sense of smell, this
is not a factor in medication adherence and safety.
5. This is correct. Decreased physical strength impedes the patient’s ability to safety administer
prescribed medications.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is providing care to a patient who has a tracheostomy. The loss of which protective mechanism
does the nurse plan to monitor this patient for during the respiratory assessment process?
1) The ability to cough
2) The filtration and humidification of inspired air
3) A decrease in the oxygen-carrying capacity of the trachea
4) The sneeze reflex initiated by irritants in the nasal passages
____ 2. When conducting a respiratory assessment, the nurse notes a low-pitched sound that is continuous throughout
inspiration. Which does this lung sound indicate to the nurse?
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1) Narrow bronchi
2) Narrow trachea passages
3) Inflamed pleural surfaces
4) Blocked large airway passages
____ 3. The nurse is providing care to a patient admitted with a respiratory disorder. Which laboratory finding would
be most significant?
1) Blood pH 7.32
2) Oxygen saturation 96%
3) Serum sodium 140 mg/dL
4) Hemoglobin level 12 mg/dL
____ 4. The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD) who is
prescribed 24% oxygen at 2 L/min. Which is the best method for the nurse to use in order to administer
oxygen to this patient?
1) Face mask
2) Venturi mask
3) Nasal cannula
4) Nonrebreather mask
____ 5. The nurse is providing care for a patient admitted with smoke inhalation injury who is developing acute
respiratory distress syndrome (ARDS). Which course of action regarding oxygen therapy does the nurse
anticipate for this patient?
1) Oxygen via a facial mask
2) Oxygen via a Venturi mask
3) Oxygen via a nasal cannula
4) Oxygen via mechanical ventilationNURSINGTB.COM
____ 6. The nurse is providing care to a patient, diagnosed with asthma, with a respiratory rate of 28 at rest who is
experiencing audible wheezing during inspiration. Which nursing diagnosis should the nurse use when
planning care for this patient?
1) Activity Intolerance
2) Impaired Tissue Perfusion
3) Ineffective Airway Clearance
4) Ineffective Breathing Pattern
____ 7. The nurse is providing care to a patient who is diagnosed with chronic obstructive pulmonary disease
(COPD). The nurse assesses the patient’s breathing rate at 32 breaths per minute. The patient is also
experiencing hypertension and fatigue. Which nursing diagnosis is a priority when planning care for this
patient?
1) Anxiety
2) Ineffective Coping
3) Ineffective Breathing Pattern
4) Ineffective Airway Clearance
____ 8. The nurse is providing care to a patient who is diagnosed with chronic obstructive pulmonary disease
(COPD). The patient’s pulse oximetry is 93% on room air with a current respiratory rate of 35 breaths per
minute. The most recent chest x-ray indicates a flattened diaphragm with infiltrates. The patient is currently
febrile with an increased number of white blood cells (WBCs) noted on the latest complete blood count
(CBC). Which prescription does the nurse question for this patient based on the current data?
1) Antibiotic therapy
2) Nonsteroidal anti-inflammatory therapy
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. Which independent nursing actions are appropriate to include in the plan of care for a patient who is
experiencing an alteration in oxygenation? Select all that apply.
1) Providing suctioning
2) Assisting with positioning
3) Prescribing bronchodilators NURSINGTB.COM
4) Monitoring activity tolerance
5) Encouraging deep breathing exercises
____ 27. Which should the nurse include in the plan of care for a mechanically ventilated patient who is receiving care
based on a ventilator bundle? Select all that apply.
1) Elevating the head of the bed
2) Ensuring a sedation vacation each day
3) Conducting a readiness to wean assessment
4) Administering a prescribed peptic ulcer prophylactic regimen
5) Avoiding the use of compression stockings during immobility
____ 28. Which information should the nurse document when monitoring a patient’s oxygen saturation via oximetry?
Select all that apply.
1) The SpO2 result
2) The current vital signs
3) The presence of family or visitors at the patient’s bedside
4) The type and amount of oxygen therapy in use
5) The education provided to the patient and family
____ 29. The nurse suctions a mechanically ventilated patient using in-line suctioning. Which information should the
nurse document in the medical record after the procedure is completed? Select all that apply.
1) The amount of secretions
2) The color of the secretions
3) The consistency of the secretions
4) The patient’s response to the procedure
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MULTIPLE CHOICE
1. ANS: 2
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Explaining indications, management, and complications of artificial airways
Chapter page reference: 085-092
Heading: Tracheostomy
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1 The client can still cough and sneeze, and there is no decrease in the oxygen-carrying
capacity of the trachea.
2 When the nasal passages are bypassed, as they would be in the case of a client with a
tracheostomy, the filtration, humidification, and warming of the nasal passages are also
bypassed.
3 The client can still cough and sneeze, and there is no decrease in the oxygen-carrying
capacity of the trachea.
4 The client can still cough and sneeze, and there is no decrease in the oxygen-carrying
capacity of the trachea. NURSINGTB.COM
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2 With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen
therapy alone; therefore, oxygen via a Venturi mask is not anticipated.
3 With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen
therapy alone; therefore, oxygen via nasal cannula is not anticipated.
4 With mechanical ventilation, the FiO2 (fraction of inspired oxygen–the percentage of
oxygen administered) is set at the lowest possible level to maintain a PaO2 higher than
60 mmHg and oxygen saturation of approximately 90%. It is important to remember
that mechanical ventilation does not cure ARDS; it simply supports respiratory function
while the underlying problem is identified and treated.
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Feedback
1 While using a site with adequate perfusion is important, this action does not determine
the accuracy of the detected waveform when monitoring a patient’s oxygen saturation
via oximetry.
2 While ensuring that any nail polish is removed is important, this action does not
determine the accuracy of the detected waveform when monitoring a patient’s oxygen
saturation via oximetry.
3 While leaving the sensor in place for a minimum of ten seconds is important, this action
does not determine the accuracy of the detected waveform when monitoring a patient’s
oxygen saturation via oximetry.
4 Assessing the heart rate and comparing it with the displayed pulse is the nursing action
that determines the accuracy of the wave form when monitoring a patient’s oxygen
saturation via oximetry.
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4 Each suctioning event should not last 60 seconds as this can cause hypoxia,
cardiopulmonary compromise, and a vagal response.
Feedback
1 The nurse should not continue suctioning and administer 50% oxygen if in-lining
suctioning causes a drop in oxygen saturation and bradycardia.
2 While the nurse should discontinue suctioning, it is not necessary to prepare for
resuscitation.
3 When in-line suctioning causes a drop in oxygen saturation and bradycardia, the nurse
discontinues suctioning and administers 100% oxygen.
4 The nurse should not continue suctioning and administer prescribed epinephrine if in-
lining suctioning causes a drop in oxygen saturation and bradycardia.
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Difficulty: Moderate
Feedback
1 Emptying water in the ventilator tubing is an appropriate action if the high-pressure
alarm is caused by moisture collection.
2 A mucous plug often causes a high-pressure alarm when a patient is being mechanically
ventilated. The appropriate action by the nurse is to suction the ET tube in order to
remove the mucous plug.
3 An oral airway is inserted if the patient is biting on the ET tube, which can cause a
high-pressure alarm for a patient who is being mechanically ventilated.
4 Assessing for asymmetric chest rise is an appropriate action if the high-pressure alarm
is caused by a pneumothorax, not a collection of moisture in the ventilator tubing.
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2 The device should be used 5 to 10 times each hour while awake. This statement
indicates the need for further education.
3 The patient exhales completely prior to placing the mouth on the device. This statement
indicates correct understanding of the information presented.
4 The patient should hold the breath for three seconds and then exhale completely. This
statement indicates correct understanding of the information presented.
Feedback
1 An FIO2 less than or equal to 0.4–0.5 indicates the patient is able to be weaned from
mechanical ventilation.
2 A PEEP less than or equal to 5–8 cm H2O indicates the patient is able to be weaned
from mechanical ventilation.
3 A pH greater than 7.25 during spontaneous ventilation indicates the patient is able to be
weaned from mechanical ventilation.
4 Hemodynamic instability, such as a drop in blood pressure to a hypotensive state,
indicates the patient is not a candidate for being weaned from mechanical ventilation.
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Feedback
1 A face-tent is a high-flow delivery device of oxygen that is appropriate for the patient
who requires supplemental oxygen if facial trauma is experienced.
2 While a nasal cannula might be appropriate for a patient who needs a low-flow delivery
device, this is not appropriate for the patient who requires a high-flow delivery device.
3 A Venturi mask delivers a high-flow of oxygen; however, facial trauma makes this an
unrealistic choice.
4 A nonrebreather mask is not an appropriate for the high-flow delivery of oxygen.
Feedback
1 A low flow rate of 1-2 L/min via NC is anticipated for a patient with COPD. The
patient who retains CO2, such as the patient with COPD, will use the lower amount of
oxygen (1–2 L/min) so the patient does not lose his or her hypoxic drive to breathe.
2 This flow rate is higher than anticipated when providing care for a patient with COPD
who requires supplement oxygen via NC.
3 This flow rate is higher than anticipated when providing care for a patient with COPD
who requires supplement oxygen via NC.
4 This flow rate is higher than anticipated when providing care for a patient with COPD
who requires supplement oxygen via NC.
MULTIPLE RESPONSE
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26. ANS: 1, 2, 4, 5
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Reviewing concepts of oxygenation
Chapter page reference: 074-076
Heading: Overview of Oxygen Therapy
Integrated Processes: Nursing Process – Planning
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1. This is correct. Suctioning is an independent nursing action.
2. This is correct. Repositioning is an independent nursing action.
3. This is incorrect. Prescribing bronchodilators is outside the scope of nursing practice.
4. This is correct. Monitoring activity tolerance is an independent nursing action.
5. This is correct. Encouraging deep breathing exercises is an independent nursing action.
Feedback
1. This is correct. Elevation of the head of the bed is included in the plan of care for a patient
who is receiving care based on a ventilator bundle.
2. This is correct. A sedation vacation each day is included in the plan of care for a patient who
is receiving care based on a ventilator bundle.
3. This is correct. Assessing for readiness to be weaned is included in the plan of care for a
patient who is receiving care based on a ventilator bundle.
4. This is correct. Administering the prescribed peptic ulcer prophylactic regimen is included in
the plan of care for a patient who is receiving care based on a ventilator bundle.
5. This is incorrect. The patient is placed on deep vein thrombosis prophylaxis, which should
include the use of compression stockings during immobility.
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Feedback
1. This is correct. The SpO2 result is documented in the medical record when monitoring a
patient’s oxygen saturation via oximetry.
2. This is correct. The current vital signs are documented in the medical record when monitoring
a patient’s oxygen saturation via oximetry.
3. This is incorrect. The presence of family or visitors at the patient’s bedside is not information
that is documented in the medical record when monitoring oxygenation saturation via
oximetry.
4. This is correct. The type, and amount, of oxygen therapy in use is documented in the medical
record when monitoring a patient’s oxygen saturation via oximetry.
5. This is correct. The education provided to the patient and family is documented in the medical
record when monitoring a patient’s oxygen saturation via oximetry.
Feedback
1. This is correct. The amount of secretions collected during in-line suctioning is documented in
the patient’s medical record.
2. This is correct. The color of secretions collected during in-line suctioning is documented in the
patient’s medical record.
3. This is correct. The consistency of secretions collected during in-line suctioning is
documented in the patient’s medical record.
4. This is correct. The patient’s response to the procedure is documented in the medical record.
5. This is incorrect. The amount of oxygen the patient received during the suctioning procedure
is documented on a separate flow sheet, not the medical record.
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Feedback
1. This is incorrect. The family should be educated about the procedure but there is no need to
ask the family to leave the bedside.
2. This is incorrect. The tracheostomy should be suctioned at the start of the procedure and as
needed.
3. This is correct. Personal protective equipment is applied to decrease the risk for infection.
4. This is correct. The tracheostomy site is assessed for infection, irritation, and skin breakdown.
5. This is incorrect. A reusable, not disposable, inner cannula is rinsed with sterile water and
dried prior to reinsertion.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
NURSINGTB.COM
____ 1. The nurse is providing care to a patient who is diagnosed with multisystem fluid volume deficit. The patient is
currently experiencing tachycardia and decreased urine output along with skin that is pale and cool to the
touch. The patient has a decreased urine output. Which probable cause to the patient’s symptoms should the
nurse include when educating the family?
1) Congestive heart failure
2) Rapidly infused intravenous fluids
3) Natural compensatory mechanisms
4) Pharmacological effects of a diuretic
____ 2. The nurse is providing care to a patient whose serum calcium levels have increased since a surgical procedure
performed three days prior. Which intervention should the nurse implement to decrease the risk for the
development of hypercalcemia?
1) Monitor vital signs every eight hours
2) Encourage ambulation three times a day
3) Irrigate the Foley catheter one time a day
4) Recommend turning, coughing, and deep breathing every two hours
____ 3. Which intervention should the nurse implement for a patient whose serum phosphorus level is 2.0 mg/dL?
1) Enforce contact precautions
2) Strain all urine for kidney stones
3) Encourage consumption of milk and yogurt
4) Discourage the consumption of a high-calorie diet
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____ 4. The nurse is providing care to a patient who is prescribed furosemide as part of the treatment for congestive
heart failure (CHF). The patient’s serum potassium level is 3.4 mEq/L. Which food should the nurse
encourage the patient to eat based on this data?
1) Peas
2) Iced tea
3) Bananas
4) Baked fish
____ 5. A patient is admitted to the emergency department (ED) for dehydration. The patient is 154 lbs. Which urine
output indicate the rehydration efforts for this patient have been effective?
1) 20 mL/hr
2) 25 mL/hr
3) 30 mL/hr
4) 35 mL/hr
____ 6. An older adult patient, who appears intermittently confused, is admitted to the hospital after a fall. Based on
the current data, which is the patient at an increased risk for developing?
1) Brain attack
2) Dehydration
3) Hemorrhage
4) Kidney damage
____ 7. The nurse is providing care to an older adult patient who is receiving intravenous (IV) fluids at 150 mL/hr.
The patient is currently exhibiting crackles in the lungs, shortness of breath, and jugular vein distention.
Which complication of IV fluid therapy does the nurse suspect the patient is experiencing?
1) Speed shock
2) Fluid volume excess NURSINGTB.COM
3) Anaphylactic reaction
4) Pulmonary embolism
____ 8. A patient is prescribed 20 mEq of potassium chloride due to excessive vomiting. Which is the rationale for
this drug the nurse should provide to the patient?
1) It controls and regulates water balance in the body.
2) It is used in the body to synthesize ingested protein.
3) It is vital in regulating muscle contraction and relaxation.
4) It is needed to maintain skeletal, cardiac, and neuromuscular activity.
____ 9. Which data collected by the nurse during the assessment process places the older adult patient at risk for
dehydration?
1) Poor skin turgor
2) Body mass index of 20.5
3) Blood pressure of 140/98 mmHg
4) Water intake of 2 glasses per day
____ 10. The nurse is reviewing laboratory values for a female patient suspected of having a fluid imbalance. Which
laboratory value evaluated by the nurse supports the diagnosis of dehydration?
1) Hematocrit 30%
2) Hematocrit 53%
3) Serum potassium 3.8 mEq/L
4) Serum osmolality 230 mOsm/kg
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____ 11. The nurse is analyzing the intake and output record for a patient being treated for dehydration. The patient
weighs 176 lbs. and had a 24-hour intake of 2,000 mL and urine output of 1,200 mL. Based on this data,
which conclusion by the nurse is the most appropriate?
1) Treatment has not been effective.
2) Treatment needs to include a diuretic.
3) Treatment is effective and should continue.
4) Treatment has been effective and should end.
____ 12. The nurse is providing care to a patient who seeks emergency treatment for headache and nausea. The patient
works in a mill without air conditioning. The patient states, “I drink water several times each day but I seem
to sweat more than I am able to replace.” Which suggestions should the nurse provide to this patient?
1) Drink juices and carbonated sodas.
2) Eat something salty when drinking water.
3) Eat something sweet when drinking water.
4) Double the amount of water being ingested.
____ 13. An older adult patient, who lives in a long-term care facility, presents in the emergency department (ED) due
to fever, nausea, and vomiting over the past two days. The patient denies thirst. The urine dipstick indicates a
decreased urine specific gravity. Which medical diagnosis should the nurse anticipate when planning care for
this patient?
1) Dehydration
2) Hypertension
3) Fluid overload
4) Congestive heart failure
____ 14. The nurse receives shift report on a pediatric medical-surgical unit. The nurse has been assigned four patients
NURplan
for the shift. Which child does the nurse SItoNG TB.first
assess COM based on the increased risk for dehydration?
1) A 4-year-old child with a broken leg
2) A 15-month-old child with tachypnea
3) A 16-year-old child with migraine headaches
4) A 10-year-old child with cellulitis of the left leg
____ 15. The nurse is teaching a group of children and their parents about the prevention of heat-related illness during
exercise. Which statement by a parent indicates an appropriate understanding of the preventive techniques
taught during the teaching session?
1) “My child only needs to hydrate at the end of an exercise session.”
2) “Water is the drink of choice to replenish fluids that are lost during exercise.”
3) “I will have my child stop every 15-20 minutes during the activity for fluids.”
4) “It is important for my child to wear dark clothing while exercising in the heat.”
____ 16. The nurse is providing care to an adult patient admitted with dehydration and hyponatremia. Which medical
condition supports the current nursing diagnosis of Electrolyte Imbalance?
1) Osmotic pressure
2) Hydrostatic pressure
3) Isotonic dehydration
4) Hypotonic dehydration
____ 17. The nurse is caring for a patient who is receiving intravenous fluids postoperatively following cardiac
surgery. The nurse is aware that this patient is at risk for fluid volume excess. The family asks why the patient
is at risk for this condition. Which response by the nurse is the most appropriate?
1) “Fluid volume excess is caused by inactivity.”
2) “Fluid volume excess is caused by the intravenous fluids.”
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3) “Fluid volume excess is caused by new onset liver failure caused by the surgery.”
4) “Fluid volume excess is common due to increased levels of antidiuretic hormone in
response to the stress of surgery.”
____ 18. The nurse is providing care to a patient following hemodialysis. The patient is experiencing tachycardia and
decreased urine output along with skin that is pale and cool to the touch. Which goal of hemodialysis does the
nurse determine the patient has not met based on the current data?
1) Cardiac decompensation
2) A reduction of extracellular fluid
3) The effects of rapidly infused intravenous fluids
4) The pharmacological effects of a diuretic infused in the dialysate
____ 19. The nurse is caring for a patient with congestive heart failure who is admitted to the medical-surgical unit
with acute hypokalemia. Which prescribed medication may have contributed to the patient’s current
hypokalemic state?
1) Cortisol
2) Demerol
3) Skelaxin
4) Nonsteroidal anti-inflammatory drugs (NSAIDs)
____ 20. The nurse is caring for a patient with a potassium level of 5.9 mEq/L. The health-care provider prescribes
both glucose and insulin for the patient. The patient’s spouse asks, “Why is insulin needed?” Which response
by the nurse is the most appropriate?
1) “The insulin will help his kidneys excrete the extra potassium.”
2) “The insulin is safer than other medications that can lower potassium levels.”
3) “The insulin lowers his blood sugar levels and this is how the extra potassium is excreted.”
4) “The insulin will cause his extraNpotassium
URSINGtoTmoveB.Cinto
OM his cells, which will lower
potassium in the blood.”
____ 21. A patient is admitted to the emergency department (ED) for fluid volume deficit. Which body system should
the nurse focus to determine the cause of this imbalance when assessing this patient?
1) Genitourinary
2) Cardiovascular
3) Gastrointestinal
4) Musculoskeletal
____ 22. The nurse is instructing a patient with heart failure about a prescribed sodium-restricted diet. Which patient
statement indicates that additional teaching is required?
1) “I can use as much salt substitute as I want.”
2) “I have to read the labels on foods to find out the sodium content.”
3) “I have to limit the intake of food with baking soda or baking powder.”
4) “I can use spices and lemon juice to add flavor to food when cooking.”
____ 23. The nurse is planning care for the patient with acute renal failure. The nurse plans the patient’s care based on
the nursing diagnosis of Excess Fluid Volume. Which assessment data supports this nursing diagnosis?
1) Wheezing in the lungs
2) Generalized weakness
3) Bowel sounds positive in four quadrants
4) Pitting edema in the lower extremities
____ 24. A patient with acute renal failure has jugular vein distention, lower extremity edema, and elevated blood
pressure. Based on this data, which nursing diagnosis is the most appropriate?
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. The nurse is providing care to a patient who is exhibiting clinical manifestations of a fluid and electrolyte
deficit. Based on this data, which health-care provider prescriptions does the nurse prepare to implement?
Select all that apply.
1) Administer diuretics
2) Administer antibiotics
3) Initiate hypodermoclysis
4) Closely monitor patient’s I&O’s
5) Initiate intravenous therapy
____ 27. A patient's serum sodium level is 150Nmg/dL.
URSIBased
NGTBon.C OMdata, which interventions should the nurse plan
this
for this patient? Select all that apply.
1) Elevate the head of the bed.
2) Instruct on a low-sodium diet.
3) Monitor heart rate and rhythm.
4) Administer diuretics as prescribed.
5) Administer potassium supplement as prescribed.
____ 28. The school nurse is preparing a class session for high school students on ways to maintain fluid balance
during the summer months. Which interventions should the nurse recommend Select all that apply.
1) Drink diet soda.
2) Reduce the intake of coffee and tea.
3) Drink more fluids during hot weather.
4) Drink flat cola or ginger ale if vomiting.
5) Exercise during the hours of 10 am and 2 pm.
____ 29. The nurse is concerned that an older adult patient is at risk for developing acute renal failure. Which
information in the patient’s history support the nurse’s concern? Select all that apply.
1) Diagnosed with hypotension
2) Recent aortic valve replacement surgery
3) Total hip replacement surgery five years ago
4) Taking medication for type 2 diabetes mellitus
5) Prescribed high doses of intravenous antibiotics
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____ 30. The community nurse visits the home of a young child who is home from school because of sudden onset of
nausea, vomiting, and lethargy. The nurse suspects acute renal failure. Which clinical manifestations support
the nurse’s suspicions? Select all that apply.
1) Edema
2) Wheezing
3) Hematuria
4) Postural hypotension
5) Elevated blood pressure
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Reviewing basic concepts related to fluid and electrolyte balance
Chapter page reference: 104-105
Heading: Basic Concepts of Fluids
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Fluid and Electrolyte Balance
Difficulty: Easy
Feedback
1 The manifestations reported are not indicative of cardiac failure in this client.
2 Rapidly infused intravenous fluids would not cause a decrease in urine output.
3 The internal vasoconstrictive compensatory reactions within the body are responsible
for the symptoms exhibited. The body naturally attempts to conserve fluid internally
specifically for the brain and heart.
4 A diuretic would cause further fluid loss, and is contraindicated.
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2 Fluid volume excess may occur when older adult patients receive intravenous fluids
rapidly.
3 The data does not support this complication.
4 The data does not support this complication.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Describing the pathophysiology, clinical presentations, and management of
dehydration, hypovolemia, and hypervolemia
Chapter page reference: 110
Heading: Laboratory Values
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1 A normal hematocrit value for a female is 37% to 47%. The hematocrit level will
decrease in overhydration.
2 The hematocrit measures the volume of whole blood that is composed of RBCs.
Because the hematocrit is a measure of the volume of cells in relation to plasma, it is
affected by changes in plasma volume. The hematocrit increases with severe
dehydration.
3 Serum potassium is not an electrolyte used to determine an alteration in fluid balance.
Serum sodium values would be more appropriate.
4 Serum osmolality is a measure of the solute concentration of the blood and is used to
evaluate fluid balance. Normal values are 280-300 mOsm/kg. An increase in serum
osmolality indicates a fluid volume deficit; a decrease reflects fluid volume excess.
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Feedback
1 Older adult patients are less able to concentrate their urine, making them susceptible to
dehydration. In addition, there is a deficit of the thirst response. However, fever,
nausea, and vomiting resulting from these changes are not considered normal. The
patient's symptoms of nausea and vomiting suggest decreased intake and increased
output through vomiting, placing the client at risk for dehydration.
2 Hypertension does not manifest with the current clinical indicators.
3 Congestive heart failure and fluid overload would present with respiratory difficulty
and peripheral edema.
4 Congestive heart failure and fluid overload would present with respiratory difficulty
and peripheral edema.
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Chapter learning objective: Describing the pathophysiology, clinical presentations, and management of
dehydration, hypovolemia, and hypervolemia
Chapter page reference: 108
Heading: Insensible Losses
Integrated Processes: Nursing Process – Planning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Fluid and Electrolyte Balance
Difficulty: Difficult
Feedback
1 The pediatric patient with a chronic or acute condition that does not directly affect the
GI or electrolyte system (migraine headache, broken leg, or cellulitis) is at a lower risk
than is a toddler with a condition that increases insensible water loss.
2 The pediatric patient with the greatest risk for dehydration is the child who is under 2
years of age experiencing tachypnea which increases insensible fluid loss.
3 The pediatric patient with a chronic or acute condition that does not directly affect the
GI or electrolyte system (migraine headache, broken leg, or cellulitis) is at a lower risk
than is a toddler with a condition that increases insensible water loss.
4 The pediatric patient with a chronic or acute condition that does not directly affect the
GI or electrolyte system (migraine headache, broken leg, or cellulitis) is at a lower risk
than is a toddler with a condition that increases insensible water loss.
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Feedback
1 Excess potassium loss through the kidneys is often caused by such medications as
corticosteroids, potassium-wasting (loop) diuretics, amphotericin B, and large doses of
some antibiotics. Cortisol is a type of corticosteroid and can cause hypokalemia.
2 NSAIDs, narcotics, and muscle relaxers would not bring about potassium loss to cause
hypokalemia.
3
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NSAIDs, narcotics, and muscle relaxers would not bring about potassium loss to cause
hypokalemia.
4 NSAIDs, narcotics, and muscle relaxers would not bring about potassium loss to cause
hypokalemia.
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Heading: Potassium
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1 Many salt substitutes use potassium chloride. Potassium intake is carefully regulated in
patients with renal failure, and the use of salt substitutes will worsen hyperkalemia.
2 Increases in weight do need to be reported to the health-care provider as a possible
indication of fluid volume excess, but this is not the reason why salt substitute is to be
avoided.
3 An AV fistula does need to be protected from injury and infection could be caused by
constricting clothing, venipunctures, and other items.
4 The control of hypertension is essential in the management of a client with kidney
disease, but salt substitute is not known to interact with antihypertensive medications.
MULTIPLE RESPONSE
26. ANS: 3, 4, 5
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Describing the pathophysiology, clinical presentations, and management of
NURSINGTB.COM
dehydration, hypovolemia, and hypervolemia
Chapter page reference: 105-109
Heading: Fluid and Electrolyte Regulation
Integrated Processes: Nursing Process – Implementation
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1. This is incorrect. Diuretics may be ordered to reduce fluid volume excess.
2. This is incorrect. Antibiotics are not used for fluid and electrolyte imbalance.
3. This is correct. Hypodermoclysis, fluid administered subcutaneously, may be employed as a
fluid delivery method, especially among older adults.
4. This is correct. Monitoring patient’s intake and output is one of several ways to assess the
patient’s fluid status.
5. This is correct. Intravenous fluids may be ordered for the patient with a fluid volume deficit if
replacement oral fluids cannot be taken in sufficient quantity.
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Feedback
1. This is incorrect. Elevating the head of the bed would be appropriate if the patient were
demonstrating signs of fluid volume overload. This is not known at this time and would not be
a routine intervention with an elevated sodium level.
2. This is correct. For an elevated sodium level, the electrolyte will need to be restricted, in the
form of a low-sodium diet.
3. This is incorrect. Monitoring of heart rate and rhythm would be more appropriate with a
potassium imbalance.
4. This is correct. Diuretics will remove excess fluid being held in the body because of the extra
sodium.
5. This is incorrect. A potassium imbalance is not associated with a sodium imbalance. More
information is needed before this intervention would be planned or implemented.
Feedback
1. This is incorrect. Diet soda often contains caffeine.
2. This is correct. Actions to prevent fluid volume deficit during the summer months include
increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of
coffee and tea.
3. This is correct. Actions to prevent fluid volume deficit during the summer months include
increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of
coffee and tea.
4. This is correct. Actions to prevent fluid volume deficit during the summer months include
increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of
coffee and tea.
5. This is incorrect. Exercising between the hours of 10 am and 2 pm, considered the hottest time
of the day, should be avoided.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
29. ANS: 1, 2, 5
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Describing the role of endocrine, renal, and respiratory systems in the regulation
of fluid and electrolyte balance
Chapter page reference: 105-109
Heading: Fluid and Electrolyte Regulation
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Fluid and Electrolyte Balance
Difficulty: Easy
Feedback
1. This is correct. Older adults develop acute renal failure more frequently because of the higher
incidence of serious illnesses, hypotension, major surgeries, diagnostic procedures, and
treatment with nephrotoxic drugs. Decreased kidney function associated with aging also puts
the older patient at risk for kidney failure. Hypotension, scheduled for aortic valve
replacement surgery, and receiving high doses of intravenous antibiotics increase this patient’s
risk for developing acute renal failure.
2. This is correct. Older adults develop acute renal failure more frequently because of the higher
incidence of serious illnesses, hypotension, major surgeries, diagnostic procedures, and
treatment with nephrotoxic drugs. Decreased kidney function associated with aging also puts
the older patient at risk for kidney failure. Hypotension, scheduled for aortic valve
replacement surgery, and receiving high doses of intravenous antibiotics increase this patient’s
risk for developing acute renal failure.
3. NURhistory
This is incorrect. A previous SINGof TBmajor
.COsurgery
M and current treatment for type 2 diabetes
mellitus are not identified risk factors for the development of acute renal failure.
4. This is incorrect. A previous history of major surgery and current treatment for type 2 diabetes
mellitus are not identified risk factors for the development of acute renal failure.
5. This is correct. Older adults develop acute renal failure more frequently because of the higher
incidence of serious illnesses, hypotension, major surgeries, diagnostic procedures, and
treatment with nephrotoxic drugs. Decreased kidney function associated with aging also puts
the older patient at risk for kidney failure. Hypotension, scheduled for aortic valve
replacement surgery, and receiving high doses of intravenous antibiotics increase this patient’s
risk for developing acute renal failure.
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Feedback
1. This is correct. Pediatric manifestations of acute renal failure characteristically begin with a
healthy child who suddenly becomes ill with nonspecific symptoms that indicate a significant
illness or injury. These symptoms may include any combination of the following: nausea,
vomiting, lethargy, edema, gross hematuria, oliguria, and hypertension.
2. This is incorrect. Wheezing is not a manifestation of acute renal failure.
3. This is correct. Pediatric manifestations of acute renal failure characteristically begin with a
healthy child who suddenly becomes ill with nonspecific symptoms that indicate a significant
illness or injury. These symptoms may include any combination of the following: nausea,
vomiting, lethargy, edema, gross hematuria, oliguria, and hypertension.
4. This is incorrect. Postural hypotension is a manifestation of acute renal failure in an older
person.
5. This is correct. Pediatric manifestations of acute renal failure characteristically begin with a
healthy child who suddenly becomes ill with nonspecific symptoms that indicate a significant
illness or injury. These symptoms may include any combination of the following: nausea,
vomiting, lethargy, edema, gross hematuria, oliguria, and hypertension.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
NURSINGTB.COM
____ 1. The nurse is providing care for an adult patient who is admitted to the emergency department (ED) after
passing out. The patient has been fasting and currently has ketones in the urine. Which acid-based imbalance
should the nurse monitor the patient for based on the current data?
1) Metabolic acidosis
2) Metabolic alkalosis
3) Respiratory acidosis
4) Respiratory alkalosis
____ 2. The nurse is providing care to patient with the following laboratory values: pH – 7.31; PaCO2 – 48 mmHg;
and a normal HCO3. Which condition should the nurse plan care for based on the current data?
1) Metabolic acidosis
2) Metabolic alkalosis
3) Respiratory acidosis
4) Respiratory alkalosis
____ 3. The nurse is reviewing the latest arterial blood gas results for a patient with metabolic alkalosis. Which result
indicates that the metabolic alkalosis is compensated?
1) pH 7.32
2) HCO3 8 mEq/L
3) PaCO2 48 mmHg
4) PaCO2 18 mmHg
____ 4. Which diagnostic test should the nurse anticipate when providing care to a patient diagnosed with chronic
obstructive pulmonary disease (COPD) to monitor acid-base balance?
1) Pulse oximetry
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2) Bronchoscopy
3) Sputum studies
4) Arterial blood gases
____ 5. Which patient statement indicates the need for additional education regarding the use of sodium bicarbonate
to treat acidosis?
1) “I need to purchase antacids without salt.”
2) “I should use the antacid for at least 2 months.”
3) “I should contact the doctor if I have any gastric discomfort with chest pain.”
4) “I should call the doctor if I get short of breath or start to sweat with this medication.”
____ 6. The patient is receiving sodium bicarbonate intravenously (IV) for correction of acidosis secondary to
diabetic coma. The nurse assesses the patient to be lethargic, confused, and breathing rapidly. Which is the
nurse's priority response to the current situation?
1) Stop the infusion and notify the provider because the patient is in alkalosis.
2) Increase the rate of the infusion and continue to assess the patient for symptoms of
acidosis.
3) Decrease the rate of the infusion and continue to assess the patient for symptoms of
alkalosis.
4) Continue the infusion, because the patient is still in acidosis, and notify the provider.
____ 7. The nurse is planning care for an older adult patient with respiratory acidosis. Which intervention should the
nurse include in this patient’s plan of care?
1) Maintain adequate hydration.
2) Reduce environmental stimuli.
3) Administer intravenous sodium bicarbonate.
4) Administer prescribed intravenous NUfluids
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carefully.
____ 8. The results of a patient’s arterial blood gas sample indicate an oxygen level of 72 mmHg. Which should the
nurse closely assess when providing care to this patient?
1) Perfusion
2) Cognition
3) Communication
4) Fluid and electrolytes
____ 9. The nurse is caring for a comatose patient with respiratory acidosis. For which intervention will the nurse
need to collaborate when caring for this patient?
1) Monitoring vital signs
2) Measuring intake and output
3) Determining recent eating behaviors
4) Identifying current oxygen saturation level
____ 10. The nurse is analyzing the patient's arterial blood gas report, which reveals a pH of 7.15. The patient has just
suffered a cardiac arrest. Which consequences of this pH value does the nurse consider for this patient?
1) Decreased cardiac output
2) Decreased potassium levels
3) Increased magnesium levels
4) Decreased free calcium in the ECF
____ 11. The nurse is caring for a patient admitted with renal failure and metabolic acidosis. Which clinical
manifestation would indicate to the nurse that planned interventions to relieve the metabolic acidosis have
been effective?
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1) Tachypnea
2) Palpitations
3) Increased deep tendon reflexes
4) Decreased depth of respirations
____ 12. A patient with metabolic acidosis has been admitted to the unit from the emergency department (ED). The
patient is experiencing confusion and weakness. Which independent nursing intervention is the priority?
1) Protecting the patient from injury
2) Placing the patient in a high-Fowler's position
3) Administering sodium bicarbonate to the patient
4) Providing the patient with appropriate skin care
____ 13. The nurse is reviewing new orders provided by the health-care provider for a critical care patient with
metabolic acidosis. Which prescription should the nurse question?
1) Draw serum potassium levels every two hours.
2) Draw arterial blood gas samples every two hours.
3) Administer one ampule of sodium bicarbonate now.
4) Begin intravenous infusion of 0.9% normal saline.
____ 14. The nurse is providing care to a patient who has been vomiting for several days. The nurse knows that the
patient is at risk for metabolic alkalosis because gastric secretions have which characteristic?
1) Gastric secretions are acidic.
2) Gastric secretions are alkaline.
3) Gastric secretions have a foul smell.
4) Gastric secretions are green in color.
____ 15. Which is the priority nursing action when
NURproviding
SINGTBcare
.Cto
OMa patient who is admitted with metabolic
alkalosis?
1) Monitoring oxygen saturation
2) Setting goals for the plan of care
3) Administering prescribed medications
4) Teaching the family about risk factors
____ 16. The nurse is providing care to a patient who is admitted after a morphine overdose. Which acid-base
imbalance should the nurse plan this patient’s care to reflect?
1) Metabolic acidosis
2) Metabolic alkalosis
3) Respiratory acidosis
4) Respiratory alkalosis
____ 17. The nurse is providing care for a patient admitted to the unit with respiratory failure and respiratory acidosis.
Which data from the nursing history is the probable cause for the patient’s current diagnoses?
1) Aspiration pneumonia
2) A recent trip to South America
3) Recent recovery from a cold virus
4) Use of ibuprofen for the control of pain
____ 18. Which chronic lung condition noted in the patient’s health history supports the current diagnosis of
respiratory acidosis?
1) Aspiration
2) Pneumonia
3) Cystic fibrosis
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4) Hyperthyroidism
____ 19. A patient is admitted to the emergency department for the treatment of a drug overdose causing acute
respiratory acidosis. Which substance noted on the toxicology report is the most likely cause for the current
diagnosis?
1) PCP
2) Cocaine
3) Marijuana
4) Oxycodone
____ 20. Which clinical manifestation supports the nurse’s plan of care focusing on chronic respiratory acidosis?
1) Irritability
2) Blurred vision
3) Daytime sleepiness
4) Warm, flushed skin
____ 21. The nurse is providing care to a patient who is admitted to the hospital with sudden, severe abdominal pain.
Which arterial blood gas supports the patient’s current diagnosis of respiratory alkalosis?
1) pH is 7.35 and PaO2 is 88.
2) pH is 7.30 and HCO3 is 30.
3) pH is 7.47 and PaCO2 is 25.
4) pH is 7.33 and PaCO2 is 36.
____ 22. The client is admitted to the emergency department (ED) with symptoms of a panic attack. Based on this data,
the nurse plans care for which health problem?
1) Emesis
2) Memory loss NURSINGTB.COM
3) Hypoventilation
4) Respiratory alkalosis
____ 23. The nurse completes discharge teaching for a patient with an anxiety disorder. Which patient statement
indicates correct understanding of information related to respiratory alkalosis?
1) “I will eat more bananas at breakfast.”
2) “I will see my counselor on a regular basis.”
3) “I will not take antacids when I have heartburn.”
4) “I will breathe faster when I am feeling anxious.”
____ 24. The nurse is reviewing the health-care provider orders for a patient who is diagnosed with respiratory
alkalosis. Which prescription is appropriate for this patient’s care needs?
1) Draw arterial blood gas analysis.
2) Administer oxygen via face mask.
3) Restrict fluids to two liters per day.
4) Infuse one ampule of sodium bicarbonate.
____ 25. The nurse is providing care to a patient who is intubated and receiving mechanical ventilation after a motor
vehicle crash. The patient is fighting the ventilator and attempting to remove the endotracheal tube. Which
nursing action decreases the patient’s risk for developing respiratory alkalosis?
1) Apply wrist restraints.
2) Administer a prescribed sedative.
3) Teach the patient to take slow, deep breaths.
4) Discuss removing the endotracheal tube with the health-care provider.
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. Which risk factors exhibited by the patient presenting in the emergency department (ED) would place the
patient at risk for metabolic acidosis? Select all that apply.
1) Pneumonia
2) Abdominal fistulas
3) Acute renal failure
4) Hypovolemic shock
5) Chronic obstructive pulmonary disease
____ 27. A patient recently diagnosed with diabetes mellitus (DM) is hospitalized in diabetic ketoacidosis (DKA) after
a religious fast. The patient tells the nurse, “I have fasted during this season every year since I became an
adult. I am not going to stop now.” The nurse is not knowledgeable about this particular religion. Which
nursing actions would be appropriate? Select all that apply.
1) Request a consult from a diabetes educator.
2) Assess the meaning and context of fasting for this religion.
3) Tell the patient that things are different now because of the new diagnosis.
4) Ask family members of the same religion to discuss fasting with the patient.
5) Encourage the patient to seek medical care if signs of ketoacidosis occur in the future.
____ 28. The nurse is caring for the patient experiencing hypovolemic shock and metabolic acidosis. Which nursing
actions are appropriate for this patient? Select all that apply.
1) Limit the intake of fluids.
2) Administer sodium bicarbonate.NURSINGTB.COM
3) Monitor ECG for conduction problems.
4) Keep the bed in the locked and low position.
5) Monitor weight on admission and discharge.
____ 29. The nurse is providing care to a patient who is admitted with manifestations of metabolic alkalosis. Which
diagnostic test findings support the admitting diagnosis? Select all that apply.
1) Serum glucose level 142 mg/dL
2) Blood pH 7.47 and bicarbonate 34 mEq/L
3) Intravenous pyelogram shows kidney stones
4) Bilateral lower lobe infiltrates noted on chest x-ray
5) Electrocardiogram changes consistent with hypokalemia
____ 30. Which nursing actions are appropriate when conducting an Allen test? Select all that apply.
1) Rest the patient’s arm on the mattress.
2) Support the patient’s wrist with a rolled towel.
3) Tell the patient to relax the hand and then clench a fist.
4) Ensure that a second nurse is available to assist with the procedure.
5) Press the patient’s radial and ulnar arteries using the index and middle fingers.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Comparing and contrasting major acid-base disorders
Chapter page reference: 141-143
Heading: Metabolic Acidosis
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: pH Regulation
Difficulty: Easy
Feedback
1 The patient who is fasting is at risk for metabolic acidosis. The body recognized fasting
as starvation and begins to metabolize its own proteins into ketones, which are
metabolic acid.
2 The nurse would not monitor this patient for metabolic alkalosis.
3 The nurse would not monitor this patient for respiratory acidosis.
4 The nurse would not monitor this patient for respiratory alkalosis.
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Feedback
1 The patient should be instructed to use non-sodium antacids to prevent the absorption
of excess sodium.
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2 Bicarbonate antacid should not be used for longer than two weeks. This statement
indicates the need for additional teaching.
3 The patient should be instructed to immediately contact the primary health-care
provider if gastric discomfort occurs with chest pain or if dyspnea or diaphoresis
occurs.
4 The patient should be instructed to immediately contact the primary health-care
provider if gastric discomfort occurs with chest pain or if dyspnea or diaphoresis
occurs.
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Feedback
1 The nurse knows that severe acidosis depresses myocardial contractility, which leads to
decreased cardiac output.
2 Acid-base imbalances also affect electrolyte balance. In acidosis, potassium is retained
as the kidney excretes excess hydrogen ion. Excess hydrogen ions also enter the cells,
displacing potassium from the intracellular space to maintain the balance of cations and
anions within the cells. The effect of both processes is to increase serum potassium
levels.
3 Magnesium levels may fall in acidosis.
4 In acidosis, calcium is released from its bonds with plasma proteins, increasing the
amount of ionized (free) calcium in the blood.
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Feedback
1 The patient with metabolic acidosis may have symptoms of drowsiness, lethargy,
confusion, and weakness. A priority of care would be preventing injury.
2 The high-Fowler's position would not be the safest position for the confused patient.
3 Medication administration requires a practitioner prescription.
4 Skin care would not be a priority on admission.
Feedback
1 As metabolic acidosis is corrected, potassium shifts back into the intracellular space.
This shift can lead to hypokalemia and cardiac dysrhythmias. Serum potassium levels
should be carefully monitored during treatment
2 Arterial blood gases are used to evaluate treatment and guide additional therapies.
3 Administering bicarbonate to Ncorrect acidosis
URSI NGTBincreases
.COM the risk for hypernatremia,
hyperosmolality, and fluid volume excess. This is the order that the nurse should
question before providing.
4 Treatment of metabolic acidosis includes correction of fluid balance. An infusion of
normal saline would be appropriate.
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3 The color and odor of gastric secretions have no influence on the development of
metabolic acidosis.
4 The color and odor of gastric secretions have no influence on the development of
metabolic acidosis.
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2 Cocaine is a stimulant.
3 Marijuana is not considered as a drug that depresses the central nervous system or
respiratory center.
4 Oxycodone is an opiate narcotic. Excessive use or overdose of narcotic substances can
lead to respiratory depression and respiratory acidosis.
Feedback
1 This data does not support the current diagnosis.
2 This data does not support the current diagnosis.
3 Acute pain usually causes hyperventilation, which causes the CO2 to drop and the client
to experience respiratory alkalosis. The pH would denote alkalosis and would be higher
than 7.45. HCO3 would trend downward as the kidneys begin to compensate for the
alkalosis by excreting HCO3. The PaO2 is likely to be normal unless the client has been
hyperventilating for a long time and is beginning to tire.
4 This data does not support the current diagnosis.
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Concept: pH Regulation
Difficulty: Easy
Feedback
1 Management of respiratory alkalosis focuses on correcting the imbalance and treating
the underlying cause. Arterial blood gases must be ordered prior to beginning
medication or oxygen therapy.
2 Oxygen is not anticipated when providing care to a patient experiencing respiratory
alkalosis.
3 A fluid restriction is not required in the treatment of respiratory alkalosis.
4 Sodium bicarbonate is used in the treatment of respiratory and metabolic acidosis.
Feedback
1 Applying wrist restraints to a patient who is demonstrating anxiety with an endotracheal
NURSINGTB.COM
tube might exacerbate the patient’s condition.
2 For a patient being mechanically ventilated, the only way to reduce rapid respirations
might be to provide a sedative.
3 The patient is being mechanically ventilated, which means there is a problem with
maintaining the airway. The patient will not be able to take slow, deep breaths at this
time.
4 The reason for the endotracheal tube is to maintain the patient's airway after chest
trauma. Removing the tube could lead to a collapse of the airway and a life-threatening
situation.
MULTIPLE RESPONSE
26. ANS: 2, 3, 4
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Comparing and contrasting major acid-base disorders
Chapter page reference: 141-143
Heading: Metabolic Acidosis
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: pH Regulation
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Difficulty: Easy
Feedback
1. This is incorrect. Chronic obstructive pulmonary disease and pneumonia place the patient at
risk for respiratory acidosis with the increased retention of carbon dioxide in the blood.
2. This is correct. Metabolic acidosis is rarely a primary disorder. It usually develops during the
course of another disease; presence of abdominal fistulas; which can cause excess bicarbonate
loss; acute renal failure; and hypovolemic shock.
3. This is correct. Metabolic acidosis is rarely a primary disorder. It usually develops during the
course of another disease; presence of abdominal fistulas; which can cause excess bicarbonate
loss; acute renal failure; and hypovolemic shock.
4. This is correct. Metabolic acidosis is rarely a primary disorder. It usually develops during the
course of another disease; presence of abdominal fistulas; which can cause excess bicarbonate
loss; acute renal failure; and hypovolemic shock.
5. This is incorrect. Chronic obstructive pulmonary disease and pneumonia place the patient at
risk for respiratory acidosis with the increased retention of carbon dioxide in the blood.
Feedback
1. This is correct. The diabetes educator should be contacted to work with the patient on
strategies that might allow the fasting to occur in a safe manner.
2. This is correct. Assessing the meaning and context of fasting in the patient’s religion would be
educative for the nurse and an appropriate action.
3. This is incorrect. Telling the patient that life is different now does not support religious
beliefs.
4. This is incorrect. Asking the family to talk to the patient might help, but the diabetes educator
would be able to provide more direct and helpful information for the patient.
5. This is correct. Stressing the importance of promptly seeking care when signs of ketoacidosis
occur helps to promote the patient's health and is appropriate.
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Feedback
1. This is incorrect. The treatment for hypovolemic shock would include the administration of
fluids, not limiting fluids.
2. This is correct. Administering sodium bicarbonate and monitoring ECGs are appropriate for
the patient with shock.
3. This is correct. Administering sodium bicarbonate and monitoring ECGs are appropriate for
the patient with shock.
4. This is correct. The patient recovering from hypovolemic shock is at risk for injury, so the bed
should be kept in the locked and low position.
5. This is incorrect. Patients being treated for hypovolemia will require daily weights, not a
weight on admission and then discharge.
Feedback
1. This is incorrect. Serum glucose level is not used to confirm the diagnosis of metabolic
alkalosis.
2. This is correct. In metabolic alkalosis, the blood pH will be greater than 7.45 and the
bicarbonate level greater than 28 mEq/L.
3. This is incorrect. The presence of kidney stones is not associated with the development of
metabolic alkalosis.
4. This is incorrect. The presence of bilateral lower lobe infiltrates on chest x-ray would not
contribute to the development of metabolic alkalosis. This finding might be the result of
metabolic alkalosis if the client's respiratory status is compromised.
5. This is correct. The ECG pattern shows changes similar to those seen with hypokalemia.
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Concept: pH Regulation
Difficulty: Moderate
Feedback
1. This is correct. Rest the patient’s arm on the mattress or bedside stand and support his wrist
with a rolled towel.
2. This is correct. Rest the patient’s arm on the mattress or bedside stand and support his wrist
with a rolled towel.
3. This is incorrect. The nurse will tell the patient to first clench the fist, hold the position for a
few seconds and then hold the hand in a relaxed position.
4. This is incorrect. A second nurse is not required to perform this test.
5. This is correct. The nurse uses the index and middle fingers to press on the patient’s radial and
ulnar arteries.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
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____ 1. The nurse is providing care to a patient who is receiving a blood transfusion. Ten minutes after the infusion is
initiated, the patient reports a headache. Upon further assessment the nurse notes that the patient is
experiencing dyspnea and feels warm to the touch. Which is the priority nursing action by the nurse?
1) Stop the transfusion.
2) Prepare for a full resuscitation.
3) Notify the health-care provider.
4) Decrease the rate of the transfusion.
____ 2. Which intravenous (IV) fluid should the nurse prepare when a patient requires an isotonic solution?
1) 0.9% normal saline
2) 2.5% dextrose in water
3) 0.33% sodium chloride
4) 5% dextrose in Lactated ringers
____ 3. The nurse adds a medication to an intravenous (IV) fluid container to be hung on the patient’s existing IV
line. Which is the first action the nurse takes after adding the medication to the container?
1) Connect the bag to the tubing.
2) Rotate the bag to distribute the medication.
3) Place a completed medication-added label to the bag.
4) Connect the bag to new tubing and flush the air from the tubing.
____ 4. The nurse is initiating intravenous (IV) therapy for an adult patient who requires IV fluid infusion for 2–3
days and might require blood administration. Which would the nurse choose as the best option for IV
catheterization?
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1) Butterfly
2) Huber needle
3) Angiocatheter
4) Implantable venous access device
____ 5. The nurse is assessing an intravenous (IV) insertion site noting redness, warmth, and mild swelling. The
patient reports a burning pain along the course of the vein during medication administration. Which term
should the nurse use when documenting these findings in the medical record?
1) Phlebitis
2) Infiltration
3) Extravasation
4) Inflammation
____ 6. The nurse is caring for a patient with a medical diagnosis of increased intracranial pressure (ICP). Which
intravenous (IV) fluid order would the nurse accept without questioning?
1) Run normal saline at 125 mL/hour.
2) Run half-normal saline at 200 mL/hour.
3) Run 5% dextrose in water at 80 mL/hour.
4) Run 5% dextrose in 0.45% NaCl at 75 mL/hour.
____ 7. The nurse working in the emergency department (ED) is caring for a patient who experienced deep-thickness
burns over 40% of the body and is in shock. Which intravenous (IV) prescription does the nurse anticipate for
this patient?
1) Nutrient solutions
2) Volume expanders
3) Electrolyte solutions
4) Total parenteral nutrition NURSINGTB.COM
____ 8. Which aspect of intravenous (IV) therapy could the nurse safely delegate to the unlicensed assistive personnel
(UAP)?
1) Changing the IV site dressing on the patient's left hand
2) Watching the IV insertion site of the patient who complained of pain at the site
3) Reporting patient’s complaints of pain or leakage from the IV site when bathing the
patient
4) Replacing patient’s IV solution when bag runs dry if it is only D5W, without medications
added
____ 9. The nurse is setting up an intravenous (IV) infusion on an electronic infusion pump for a patient recently
admitted to the unit. After leaving the room, the pump alarms and reads high pressure. Which is the priority
action by the nurse?
1) Resetting the pump to resume infusion
2) Asking the patient if the pump has been tampered with in any way
3) Assessing the IV site and the tubing for kinks or closed roller clamps
4) Discontinuing the patient’s IV access and restarting in a different area
____ 10. The nurse is administering a blood transfusion to an adult patient. The patient reports feeling cold and is
shivering 15 minutes after the initiation of the transfusion. The patient’s blood pressure has decreased since
the last assessment. Which is the nurse's priority action?
1) Notify the health-care provider.
2) Monitor the blood pressure every five minutes.
3) Stop the blood infusion, and run the normal saline on the other side of the Y tubing.
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4) Stop the blood infusion, and remove the tubing from the IV catheter, replacing it with
normal saline.
____ 11. The nurse is caring for a patient with a central venous catheter used for intermittent medication
administration. When flushing the catheter prior to administering the next dose of medication, which initial
action by the nurse is the most appropriate?
1) Aspirating the patient’s catheter for blood
2) Positioning the patient in reverse Trendelenburg position
3) Flushing the catheter, using as much force as required in order to clear the line
4) Obtaining a 3 mL syringe and filling it with normal saline for flushing the line
____ 12. When removing a patient’s central line dressing, which action by the nurse is the priority?
1) Applying sterile gloves
2) Inspecting the insertion site for signs of infection
3) Pulling the tape off in the direction of the catheter
4) Pressing the catheter into the skin while removing the tape
____ 13. The nurse is caring for a patient who is to have a peripherally inserted central catheter (PICC) line inserted
tomorrow afternoon. The patient’s current peripheral access line is infiltrated, and needs to be restarted.
Which site would the nurse avoid using?
1) Radial vein
2) Cephalic vein
3) Median cubital vein
4) Dorsal metacarpal veins
____ 14. Which intravenous (IV) fluid should the nurse prepare when a patient requires a hypertonic solution?
1) 0.9% normal saline NURSINGTB.COM
2) 2.5% dextrose in water
3) 0.33% sodium chloride
4) 5% dextrose in Lactated ringers
____ 15. Which intravenous (IV) fluid should the nurse prepare when a patient requires a hypotonic solution?
1) 0.9% normal saline
2) 5% dextrose in water
3) 0.33% sodium chloride
4) 5% dextrose in Lactated ringers
____ 16. The nurse is providing care to a trauma patient who will require the rapid administration of large volumes of
fluid in addition to a blood transfusion. Which gauge should the nurse use when initiating intravenous (IV)
access for this patient?
1) 18
2) 20
3) 22
4) 24
____ 17. Which component should the nurse anticipate will be prescribed for a patient with acute blood loss?
1) Platelets
2) Albumin
3) Fresh frozen plasma
4) Packed red blood cells
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____ 18. Which component should the nurse anticipate will be prescribed for a patient with an elevated prothrombin
time (PT) and international normalized ratio (INR) who is at an increased risk for bleeding?
1) Platelets
2) Albumin
3) Fresh frozen plasma
4) Packed red blood cells
____ 19. Which component should the nurse anticipate will be prescribed for a patient is not responding to crystalloids
for volume expansion?
1) Platelets
2) Albumin
3) Fresh frozen plasma
4) Packed red blood cells
____ 20. Which component should the nurse anticipate will be prescribed for a patient with severe thrombocytopenia?
1) Platelets
2) Albumin
3) Fresh frozen plasma
4) Packed red blood cells
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. The nurse is caring for a patient receiving intravenous (IV) medications. After infusing an IV antibiotic, the
nurse assesses the IV site and finds it to be red and edematous, and the patient is reporting pain at the site.
Which would the nurse document in N UR
the SINGnotes
nursing TB.regarding
COM the infiltration? Select all that apply.
1) Incident report
2) Actions taken to correct the problem
3) Size and location of erythematous area
4) Health-care provider notification and any orders received
5) Amount of fluid infused per shift on the intake and output record
____ 22. Which patients may benefit from central intravenous (IV) access? Select all that apply.
1) The patient receiving caustic IV therapy.
2) The patient requiring long-term IV therapy.
3) The patient who is afraid of needles and does not want a catheter in the peripheral
extremity.
4) The patient requiring numerous IV infusions that are not compatible and cannot be infused
together.
5) The unstable patient requiring reliable IV access for administration of medications
required. immediately.
____ 23. The nurse is performing venipuncture to initiate intravenous (IV) therapy. Which indicators should the nurse
use when choosing the site for IV therapy? Select all that apply.
1) Choosing a straight vein
2) Avoiding a sclerotic vein
3) Looking for sites distal to joints
4) Using the dominant arm, whenever possible
5) Choosing a vein that is visible in addition to palpable
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____ 24. The nurse is providing care to patient who is receiving total parenteral nutrition (TPN). During the shift
assessment, the nurse notes that the patient is lethargic and has an elevated temperature and white blood cell
count. The nurse suspects the patient is septic. Which actions by the nurse are appropriate in this situation?
Select all that apply.
1) Changing the IV tubing
2) Saving the remaining TPN
3) Notifying the health-care provider
4) Recording the lot number of the TPN
5) Replacing the TPN with a normal saline solution
____ 25. The nurse is caring for a patient with a central venous catheter (CVC). Which nursing actions should the nurse
implement to prevent an air embolism? Select all that apply.
1) Using Luer-locked connections
2) Frequently checking connections
3) Wearing sterile gloves when accessing any connections
4) Clamping catheters and injection sites when not in use
5) Placing the patient in low-Fowler position to remove the CVC
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MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Explaining the procedure for safely administering blood products
Chapter page reference: 161
Heading: Types of Infusion Reactions
Integrated Processes: Nursing Process – Implementation
Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies
Cognitive level: Analysis [Analyzing]
Concept: Medication
Difficulty: Moderate
Feedback
1 The priority nursing action is to stop the transfusion. If the patient is experiencing a
transfusion reaction, this will limit the amount of blood administered.
2 There is no need for resuscitation based on the current data.
3 While the nurse would contact the health-care provider, this is not the priority.
4 Slowing the rate of the transfusion allows for the blood to continue to be administered;
therefore, this is not an appropriate nursing action.
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Feedback
1 Redness, warmth, edema, and pain that runs along the course of the vein characterize
phlebitis.
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8. ANS: 3
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Describing the potential complications of infusion therapy and strategies to
prevent these complications
Chapter page reference: 156-162
Heading: Nursing Management of Infusion Therapy
Integrated Processes: Nursing Process – Implementation
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Medication; Legal
Difficulty: Moderate
Feedback
1 The IV dressing should be changed using sterile technique, and should not be delegated
to the UAP.
2
The UAP is not responsible for assessing the site, because the nurse is responsible for
all assessments.
3 The UAP can safely be taught to report complaints of pain or leakage from an IV site if
it is noted during routine care.
4 Whether medications are added to the IV fluid or not, only the nurse can change the
bag, because sterile technique is required, and even a plain solution is considered a
medication.
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Chapter learning objective: Explaining the procedure for safely administering blood products
Chapter page reference: 159-161
Heading: Administration of Blood Products
Integrated Processes: Nursing Process – Implementation
Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Medication
Difficulty: Moderate
Feedback
1 Only after the blood infusion is discontinued would the nurse notify the health-care
provider and monitor the patient’s condition.
2 Only after the blood infusion is discontinued would the nurse notify the health-care
provider and monitor the patient’s condition.
3 Stopping the blood infusion and running saline through the blood tubing will administer
the blood found in the tubing, and could make the transfusion reaction worse.
4 The nurse should completely discontinue the blood infusion, disconnecting the tubing
from the IV catheter and placing normal saline or the ordered solution infusing prior to
beginning the blood infusion with new tubing.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
15. ANS: 3
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Describing the characteristics of common IV solutions
Chapter page reference: 147-149
Heading: Solutions Used in Infusion Therapy
Integrated Processes: Nursing Process – Implementation
Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Medication
Difficulty: Moderate
Feedback
1 An example of an isotonic solution is 0.9% normal saline.
2 An example of an isotonic solution is 5% dextrose in water.
3 An example of a hypotonic solution is 0.33% sodium chloride.
4 An example of a hypertonic solution is 5% dextrose in Lactated ringers.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 Albumin is administered for volume expansion when crystalloid solutions are not
adequate.
3 Fresh frozen plasma is anticipated for a patient with a deficiency of plasma coagulation
factors.
4 Packed red blood cells are anticipated for a patient with acute or chronic blood loss and
for patients diagnosed with anemia.
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MULTIPLE RESPONSE
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21. ANS: 2, 3
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Describing the potential complications of infusion therapy and strategies to
prevent these complications
Chapter page reference: 156-157
Heading: Phlebitis and Infiltration
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Communication; Medication
Difficulty: Moderate
Feedback
1. This is incorrect. The nurse would complete an incident report any time an IV infiltrates;
however, this should not be included in the nursing notes.
2. This is correct. Actions taken, such as discontinuation of the IV, should also be documented in
the nursing notes.
3. This is correct. The size of the erythematous area should be measured, marked, and
documented in the nursing notes for continuity of care.
4. This is incorrect. Although the health-care provider might be notified, orders received would
be written on the health-care provider order sheet and not documented in the nursing record.
5. This is incorrect. Intake from IV fluid would be documented on the intake and output record,
not in the nursing notes.
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Feedback
1. This is correct. Central venous access can be very useful for patients requiring long-term IV
therapy because the catheter can remain in place for extended periods, and IV sites do not
have to be changed every few days.
2. This is correct. Caustic medications are less likely to cause phlebitis when administered into
the large central veins as opposed to the smaller peripheral veins.
3. This is incorrect. Because of the potential complications from central venous access, it would
not be an option considered because of patient preference if short-term IV therapy is required.
4. This is correct. In the critical care areas where patients may receive numerous continuous IV
medication drips that might not all be compatible infusing through the same site, a multiple-
port central venous access device can provide the best option.
5. This is correct. Patients N
whoURare
SIunstable
NGTB.and COrequire
M rapid administration of medications
require reliable IV access that might not be available with peripheral IV lines, and central
venous access may be the best option.
Feedback
1. This is correct. Straight veins provide space for the catheter to be inserted easily.
2. This is correct. Sclerotic veins make it difficult to obtain and maintain IV therapy.
3. This is correct. The site should be sufficiently distal to the wrist or elbow joint to avoid
bending or kinking of the IV catheter.
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4. This is incorrect. It is best, when possible, to use the patient’s non-dominant arm, because
movement might be somewhat limited, so the patient should be allowed to use the dominant
arm.
5. This is incorrect. Some patients, especially dark-skinned people, might not have easily visible
veins, so the veins should be palpable even if not visible.
Feedback
1. This is correct. This is an appropriate action by the nurse.
2. This is correct. This is an appropriate action by the nurse.
3. This is correct. This is an appropriate action by the nurse.
4. This is correct. This is an appropriate action by the nurse.
5. This is incorrect. The fluid
NUshould
RSINbe GTreplaced
B.COwithM a 5% or 10% dextrose solution, not normal
saline, because the patient has adjusted to a high sugar intake via the TPN, and eliminating all
sugar infused could result in hypoglycemia.
Feedback
1. This is correct. The nurse should use Luer-lock connections to prevent an air embolism.
2. This is correct. The nurse should frequently check all connections.
3. This is incorrect. Wearing sterile gloves when accessing any connections will not prevent an
air embolism.
4. This is correct. Clamping catheters and injection sites when not in use will help to prevent an
air embolism.
5. This is incorrect. The patient should be placed in the supine position for removal of the CVC.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. Which action by the nurse is the most appropriate when initiating guided imagery with a patient as a method
to control pain?
1) Suggesting a place where the patient will find peace
2) Guiding the patient toward a most beautiful or peaceful place
3) Asking the patient to use progressive muscle relaxation exercises
4) Asking the patient to take slow, full diaphragmatic/abdominal breaths
____ 2. A patient, who rates abdominal pain as a 10 on a 1 to 10 numeric scale is experiencing nausea, vomiting, and
restlessness. Which conclusion is appropriate by the nurse based on the current data?
1) Acute pain
2) Chronic pain
3) End-of-life pain
4) Fibromyalgia pain
____ 3. The nurse is caring for a patient who is experiencing acute chest pain that is rated as a 9 on a 0 to 10 pain
scale. Based on this data, which medication does the nurse plan to administer?
1) Morphine NURSINGTB.COM
2) Ibuprofen
3) Naproxen
4) Acetaminophen
____ 4. The nurse is teaching a class on the perception of pain. What will the nurse teach as being the second step in
processing pain stimuli?
1) Thalamus
2) Limbic system
3) Cerebral cortex
4) Reticular system
____ 5. Which nursing action will provide the patient with the most pain relief after abdominal surgery?
1) Offer pain relief before the patient complains of pain.
2) Assess the pain level every 4 hours around the clock.
3) Wait until the patient can describe the pain specifically.
4) Allow the patient to “sleep off” the anesthesia, and then offer pain medication.
____ 6. The patient with a sprained ankle is complaining of pain in the injured area. Which term will the nurse use
when documenting this patient’s pain?
1) Somatic pain
2) Visceral pain
3) Neuropathic pain
4) Physiological pain
____ 7. Which term should the nurse use to document the maximum amount of pain is able to tolerate?
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1) Allodynia
2) Hyperalgesia
3) Pain tolerance
4) Pain threshold
____ 8. The nurse is using a nonpharmacologic method to manage a patient’s pain, and applies a unit that applies low-
voltage electrical stimulation directly over the pain area. When documenting this intervention, which term is
the most appropriate for the nurse to use?
1) TENS unit
2) Nerve block
3) Functional restoration
4) Cutaneous stimulation
____ 9. The patient has pain in the lower back that radiates down the leg as the result of a herniated disk compressing
the sciatic nerve that began 4 months ago. When documenting this patient’s pain, which term will the nurse
use?
1) Acute somatic pain
2) Acute visceral pain
3) Acute neuropathic pain
4) Chronic neuropathic pain
____ 10. Which type of pain syndrome should the nurse assess when providing care to a female patient?
1) Back pain
2) Interstitial cystitis
3) Cluster headaches
4) Visceral pain from the heart
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____ 11. The nurse is providing care to a postoperative patient who is getting out of bed for the first time since surgery.
When conducting the pain assessment, the patient states, “It hurts, but I do not want to take any more drugs. I
do not want to end up addicted.” Which response by the nurse is most appropriate?
1) “Don’t worry about getting addicted. I will make sure you don’t get addicted.”
2) “If you don’t take the pain medication on a regular schedule, you won’t get addicted.”
3) “People who have real pain are unlikely to become addicted to analgesics provided to treat
the pain.”
4) “You are wise to be concerned; it is probably time to stop taking narcotics if you can
manage the pain in other ways.”
____ 12. The nurse is providing care to a patient who had an abdominal nevus removed who is reporting intense pain.
Which action by the nurse is appropriate?
1) Administer the stronger analgesic ordered by the primary care provider.
2) Administer a nonnarcotic analgesic because the patient had minor surgery.
3) Notify the health-care provider that the patient's pain is excessive for the minor surgery
performed.
4) Attempt to divert the patient without administering an analgesic because the surgery was
so minor.
____ 13. A nurse overhears another nurse say, “That patient is asking for pain medication again. He is constantly on
the call bell, always reporting how severe his pain is, and I think he is just drug-seeking. I am going to make
him wait the full 4 hours before I give this medication again.” Which action by the nurse is the most
appropriate in this situation?
1) Informing the charge nurse of what was overheard
2) Reprimanding the nurse and completing an incident or variance report
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3) Ignoring the situation because the patient is not this nurse’s responsibility
4) Reminding the nurse, in private, that the sensation of pain is whatever the patient says it is
____ 14. The hospice nurse is making a home visit to a patient with terminal cancer. The patient reports poor pain
control when the spouse says, “I am giving such big doses of medication, I am afraid she is going to overdose
if I give her more.” Which response by the nurse is the most appropriate?
1) “You are not giving adequate pain relief, and she is in severe pain as a result.”
2) “You are wise to be concerned. These are very strong medications you’re administering.”
3) “Let's talk about the medication you’re giving and warning signs to be concerned about.”
4) “You are not giving enough pain medication, so she is in severe pain. You need to give
more.”
____ 15. The nurse finds a postoperative patient perspiring with fist clenched upon entering the room. The nurse
administers routine medication and provides care. The patient is pleasant and cooperative. Which action by
the nurse is appropriate?
1) Asking the patient if pain is being experienced
2) Instructing the patient to use the call bell if he experiences pain
3) Informing the patient that he looks uncomfortable and asking him to describe his pain
4) Documenting “no complaints of pain offered” and assessing that the patient is comfortable
____ 16. The nurse is caring for a patient who is experiencing acute pain. Which action by the patient, noted by the
nurse during the assessment, is considered an associated symptom of pain?
1) Crying
2) Vomiting
3) Grimacing
4) Changing position
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____ 17. The nurse is obtaining a pain history. The patient reports pain in the right ear. Which response by the nurse is
the most appropriate?
1) “Is the pain minor?”
2) “Do you have anything else that hurts?”
3) “I will note that in the record. Is there anything else I should know?”
4) “Tell me more about the pain and what you do for it when it hurts.”
____ 18. Which data collected by the nurse is nonessential when conducting a patient pain history?
1) Intensity, quality, and patterns
2) Significant other’s assessment of the pain
3) Precipitating factors, alleviating factors, and associated symptoms
4) Effects on activities of daily living, coping resources, and affective responses
____ 19. When caring for an older adult patient who does not speak English, which assessment tool is the most
appropriate for the nurse to use to assess this patient’s pain?
1) An interpreter.
2) The patient’s affect.
3) The patient’s vital signs.
4) The FACES rating scale.
____ 20. The pain management team individualizes the analgesic regimen by guiding the adjustment of medication,
dose, time intervals, and route of administration. When discussing this method of treating pain, which term is
the most appropriate for the nurse to use?
1) Analgesia
2) Equianalgesia
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3) Polypharmacy
4) Dose-reduction pharmacology
____ 21. Which is the reason for the nurse to administer ibuprofen, over acetaminophen, when providing patient pain
management?
1) Analgesic effects
2) Antipyretic effects
3) Anti-inflammatory effects
4) Antipyretic and anti-inflammatory effects
____ 22. The patient reports difficulty sleeping related to anxiety. Which nonpharmacologic pain management
intervention might the nurse consider performing in order to relax the patient?
1) Massage
2) Distraction
3) Acupressure
4) Acupuncture
____ 23. The nurse administered an oral analgesic to a patient complaining of a mild-to-moderate headache. Which
activity would the nurse consider to help relieve the patient’s discomfort until the analgesic takes effect?
1) Crossword puzzles
2) Slow rhythmic breathing
3) Reading or watching TV
4) Video or computer games
Multiple Response
Identify one or more choices that best complete the
NUstatement
RSINGor TBanswer
.COMthe question.
____ 24. The nurse is creating a pain management plan using the three-step approach for a patient with intractable pain.
Which interventions should the nurse include in this plan? Select all that apply.
1) Administer an opioid analgesic first.
2) Administer a nonopioid analgesic first.
3) Administer a mild opioid analgesic last.
4) Administer analgesics upon patient request.
5) Administer a combination nonopioid-opioid second.
____ 25. The nurse is working on the orthopedic unit, and is caring for a patient who reports back pain. Which
responses by the nurse would be appropriate when caring for this patient? Select all that apply.
1) “Does anything other than your back hurt?”
2) “I'm sorry you're hurting. I want to make you feel better.”
3) “Why don't you try another position until it's time for more pain medication?”
4) “You had medication for your pain at 4 p.m., so I can't give you any more until 8 p.m.”
5) “People with back pain experience very different symptoms. Tell me more about your
back pain.”
____ 26. According to the World Health Organization Three-Step Approach, if the nurse is caring for a patient
reporting mild pain that persists after using full doses of step 1 medications, which medications can the nurse
administer? Select all that apply.
1) Codeine
2) Fentanyl
3) Morphine
4) Hydrocodone with ibuprofen
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MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 11, Pain Management
Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based
interventions into a plan of care for patients with pain
Chapter page reference: 179-196
Heading: Pain Management Options
Integrated Processes: Nursing Process – Implementation
Client Need: Physiological Integrity – Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
Feedback
1 The nurse should never suggest a peaceful place, but should allow the patient to choose
the place where he finds peace.
2 The nurse should never suggest a peaceful place, but should allow the patient to choose
the place where he finds peace.
3 After deep breathing, the patient may be asked to use progressive muscle relaxation
exercises, and then the nurse will guide the patient toward a peaceful place.
4 The nurse begins by helping the patient to relax using slow breaths.
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PTS: 1 CON: Comfort
2. ANS: 1
Chapter number and title: 11, Pain Management
Chapter learning objective: Defining types of pain
Chapter page reference: 174-177
Heading: Comprehensive Assessment Strategies for Acute and Chronic Pain
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Basic Care and Comfort
Cognitive level: Comprehension [Understanding]
Concept: Comfort
Difficulty: Easy
Feedback
1 Acute pain is pain of varying severity, location, and etiology that lasts fewer than 6
months. Acute pain is often manifested by nausea, vomiting, and restlessness.
2 Chronic pain lasts longer than 6 months and persists beyond the expected period of
healing.
3 End-of-life pain is pain that is associated with the process of dying.
4 Fibromyalgia pain is widespread muscular and joint pain.
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Feedback
1 Anticipating a patient’s pain will ensure a more manageable pain experience than
waiting until the patient complains of pain.
2 If the patient is asleep, she should not be awakened simply to assess the pain every 4
hours unless there are other significant nonverbal signs during sleep that indicate that
the patient is in pain. These can include grimacing, moaning, thrashing, or guarding of a
surgical site.
3 Pain management needs to be implemented prior to the patient's describing specific
postoperative pain, or “sleeping off” anesthesia.
4 Pain management needs to be implemented prior to the patient's describing specific
postoperative pain, or “sleeping off” anesthesia.
Feedback
1
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Somatic pain originates in the skin, muscles, bone, or connective tissue, and would best
describe this client’s pain.
2 Visceral pain tends to be poorly located, resulting from activation of pain receptors in
the organs and/or hollow viscera.
3 Neuropathic pain results from damaged or malfunctioning nerves.
4 Somatic pain is a subclassification of physiological pain, so it would be less specific to
call it physiological as opposed to somatic.
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4 Pain threshold is the lowest amount of stimuli needed for a person to label a sensation
as pain.
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Feedback
1
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This statement is inappropriate.
2 This statement is inappropriate.
3 Many patients worry about becoming addicted to narcotic analgesics if they are
required for more than a few days. It is important for the nurse to reassure the patient by
providing truthful information.
4 This statement is inappropriate.
Feedback
1 Pain perception is what the patient says it is, and the nurse should medicate the patient
based on the patient’s description of the pain, not what the nurse anticipates. If the
patient reports severe pain, the nurse should administer strong analgesics.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 Patients who have minor surgery can still experience severe pain, and administering
weaker analgesics when the patient reports severe pain would not be responsible
practice.
3 There is no need to notify the health-care provider unless the nurse’s assessment
indicates there is something unusual occurring.
4 Diverting the patient most likely will not be effective alone, although diversion might
be possible after administering the analgesic.
Feedback
1 Informing the charge nurse would only be necessary if the nurse who was overheard did
not respond constructively to the nurse’s correction.
2 This is not an appropriate response by the nurse.
3
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It is every nurse’s responsibility to speak up and advocate for the client when situations
arise that place the client at risk of incorrect treatment.
4 The nurse would address the situation privately, and not in front of others at the nurses’
station.
Feedback
1 This response is likely to make the spouse feel guilty and does not provide information
to provide the best care possible.
2 Telling the patient’s spouse that his or her concern is warranted is untrue.
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3 It is not unusual for a family caregiver to withhold medication out of fear of overdosing
the cancer patient. It is important for the nurse to inform the caregiver that his feelings
are not unusual, and then provide him with the information he needs to make an
informed and appropriate decision that will make the client more comfortable.
4 This response is likely to make the spouse feel guilty and does not provide information
to provide the best care possible.
Feedback
1 Some patients might feel that admitting to pain is a sign of weakness, and might not
bring it up unless the nurse specifically refers to the patient’s apparent discomfort and
asks him to describe his pain and indicates the patient's apparent discomfort.
2 Instructing the patient to use the call bell puts the responsibility for pain assessment on
the patient instead of on the nurse.
3 NURSINGTB.COM
It is the nurse’s responsibility to assess for pain and not wait for the patient to mention
it.
4 The patient’s body language indicates the likelihood of pain.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Describing components that comprise a comprehensive pain assessment
Chapter page reference: 174-177
Heading: Comprehensive Assessment Strategies for Acute and Chronic Pain
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
Feedback
1 This is a closed question and will not allow the nurse to gather the information needed
regarding the patient’s pain.
2 This is a closed question and will not allow the nurse to gather the information needed
regarding the patient’s pain.
3 This is a closed question and will not allow the nurse to gather the information needed
regarding the patient’s pain.
4 When the patient reports pain, the nurse should seek more information. When assessing
pain, the nurse should assess all aspects of the pain, including character, onset, location,
duration, exacerbation, relief, and radiation.
Feedback
1 The nurse should determine all of the other factors in order to put a plan of care in place
that will help the patient address and treat the pain effectively.
2 During a pain history, it is the patient’s description of the pain that is most important,
not the significant other’s.
3 The nurse should determine all of the other factors in order to put a plan of care in place
that will help the patient address and treat the pain effectively.
4 The nurse should determine all of the other factors in order to put a plan of care in place
that will help the patient address and treat the pain effectively.
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Feedback
1 If an interpreter is available the nurse can ask the interpreter to discuss the pain in more
detail, but the FACES rating scale will help the nurse to respond to the patient’s pain
appropriately and quickly without waiting for an interpreter.
2 Affect and vital signs might not be accurate indicators of the patient’s discomfort.
3 Affect and vital signs might not be accurate indicators of the patient’s discomfort
4 An interpreter might not always be readily available, so the FACES rating scale can be
used because it is not necessary to use language.
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4 Reading, watching TV, video games, and crossword puzzles might exacerbate the
symptoms because the patient with a headache is often more comfortable in a dark,
low-stimuli environment.
MULTIPLE RESPONSE
24. ANS: 2, 3, 5
Chapter number and title: 11, Pain Management
Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based
interventions into a plan of care for patients with pain
Chapter page reference: 179-196
Heading: Pain Management Options
Integrated Processes: Nursing Process – Implementation
Client Need: Physiological Integrity – Pharmacological and Parental Therapies
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
Feedback
1. This is incorrect. An opioid analgesic is not the first choice when using the three-step
approach in pain management.
2. This is correct. The first step in the three-step approach to pain management involves
administering a nonopioid NUdrug
RSIfirst.
NGTB.COM
3. This is correct. If the patient is still experiencing pain, the mild opioid should be replaced with
a stronger opioid in step 3.
4. This is incorrect. Pain-relieving drugs should be given “by the clock” (every 3-6 hours) rather
than on demand to maintain freedom from pain.
5. This is correct. If pain is not adequately controlled with this mild intervention, patients should
advance to step 2 and receive a mild opioid in combination with the same or a new nonopioid
drugs.
Feedback
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1. This is correct. The nurse should inform the patient that it is the job of the nurse to work to
make the patient feel better, seek more information about the type of pain the patient is
experiencing, and question any other discomforts the patient may be experiencing.
2. This is correct. The nurse should inform the patient that it is the job of the nurse to work to
make the patient feel better, seek more information about the type of pain the patient is
experiencing, and question any other discomforts the patient may be experiencing.
3. This is incorrect. Allowing the patient to remain in pain would not be prudent practice, and
would be lacking in caring.
4. This is incorrect. Allowing the patient to remain in pain would not be prudent practice, and
would be lacking in caring.
5. This is correct. The nurse should inform the patient that it is the job of the nurse to work to
make the patient feel better, seek more information about the type of pain the patient is
experiencing, and question any other discomforts the patient may be experiencing.
Feedback
1. This is correct. If the pain persists or the pain is moderate, the second step is a weak opioid, or
a combination of opioid and nonopioid medicine can be used. Codeine is a weak opioid.
2. This is incorrect. Fentanyl is a strong opioid that is not administered until step 3.
3. This is incorrect. Morphine is a strong opioid that is not administered until step 3.
4. This is correct. If the pain persists or the pain is moderate, the second step is a weak opioid, or
a combination of opioid and nonopioid medicine can be used. Hydrocodone with ibuprofen is
an opioid/nonopioid medicine.
5. This is correct. If the pain persists or the pain is moderate, the second step is a weak opioid, or
a combination of opioid and nonopioid medicine can be used. Oxycodone with acetaminophen
is an opioid/nonopioid medicine.
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Concept: Comfort
Difficulty: Moderate
Feedback
1. This is incorrect. These medications do not have sedating or anesthetic effects in most
patients, although some patients might report being able to fall asleep more easily once pain is
reduced.
2. This is correct. Nonsteroidal anti-inflammatory drugs (NSAIDs) have anti-inflammatory,
analgesic, and antipyretic effects.
3. This is incorrect. These medications do not have sedating or anesthetic effects in most
patients, although some patients might report being able to fall asleep more easily once pain is
reduced.
4. This is correct. Nonsteroidal anti-inflammatory drugs (NSAIDs) have anti-inflammatory,
analgesic, and antipyretic effects.
5. This is correct. Nonsteroidal anti-inflammatory drugs (NSAIDs) have anti-inflammatory,
analgesic, and antipyretic effects.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ NURthe
1. Which is a guiding principle when using SIRecipient/Practitioner
NGTB.COM Partnership in the delivery of
complementary and alternative medicine to a patient?
1) Defining health as harmonious and balanced
2) Believing that qi permeates and bonds all living things
3) Establishing a relationship because building trust instills hope
4) Emphasizing a healthy lifestyle for a proactive approach to wellness
____ 2. Which is a guiding principle when using the Wellness Model of Care in the delivery of complementary and
alternative medicine to a patient?
1) Defining health as harmonious and balanced
2) Believing that qi permeates and bonds all living things
3) Establishing a relationship because building trust instills hope
4) Emphasizing a healthy lifestyle for a proactive approach to wellness
____ 3. Which is a guiding principle when using the Energy Paradigm in the delivery of complementary and
alternative medicine to a patient?
1) Defining health as harmonious and balanced
2) Encouraging self-awareness regarding body changes
3) Establishing a relationship because building trust instills hope
4) Emphasizing a healthy lifestyle for a proactive approach to wellness
____ 4. The nurse should offer the inclusion of the Whole Medical Systems/Alternative Medical Systems in the plan
of care for patients with which emotional or psychological disorder?
1) Neuropathy
2) Fibromyalgia
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3) Chronic fatigue
4) Carpal tunnel syndrome
____ 5. The nurse should offer the inclusion of the Whole Medical Systems/Alternative Medical Systems in the plan
of care for patients with which pain disorder?
1) Insomnia
2) Menopause
3) Fibromyalgia
4) Chronic fatigue
____ 6. Which patient statement indicates the need for further education regarding the benefits of using Energy
Healing Therapies in the plan of care?
1) “It promotes relaxation.”
2) “It helps to reduce stress.”
3) “It will decrease my stamina.”
4) “It will relieve musculoskeletal discomfort.”
____ 7. Which gastrointestinal (GI) issue might benefit from the nurse educating the patient about the use of herbal
medicine?
1) Reflux
2) Flatulence
3) Constipation
4) Hemorrhoids
____ 8. A patient is interested in exploring the use of a complementary and alternative medicine (CAM) health-care
provider. Which patient statement indicates the need for further education regarding questions that should be
asked of any CAM provider? NURSINGTB.COM
1) “I will ask the provider if he or she accepts my insurance plan.”
2) “None of these providers are licensed so I need to be very careful.”
3) “I will ask the provider to provide education regarding any side effects.”
4) “Sessions may be required several times per month, so I will ask about frequency of
visits.”
____ 9. A nurse is interested in implementing complementary and alternative medicine (CAM) into practice. Which
research barrier may inhibit this from occurring?
1) Detailed standardization for interpretation of systematic reviews
2) Large number of patients involved in clinical trials
3) Generic treatment plans
4) Reluctant funding
____ 10. A patient asks for reliable information from the Internet regarding complementary and alternative medicine
(CAM). Which URL should the nurse provide to this patient?
1) www.google.com
2) www.webmd.com
3) www.cdc.gov
4) www.fda.gov
____ 11. Which term should the nurse use when referring to the dominant health-care system within the United States
during a training session with other health-care providers regarding complementary and alternative medicine
(CAM)?
1) Eastern medicine
2) Conventional medicine
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1) Natural
2) Artificial
3) Alternative
4) Complementary
____ 20. The nurse is preparing to administer a prescribed herbal product with a traditional antibiotic. Which should
the nurse consult prior to administering these prescribed therapies?
1) The charge nurse for the shift.
2) The pharmacologist for the unit.
3) A physician’s desk reference (PDR).
4) A reputable Internet site regarding complementary and alternative medicine (CAM).
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. Which top ten diagnoses for adult patients should the nurse include complementary and alternative therapies
when planning care? Select all that apply.
1) Cancer
2) Anxiety
3) Arthritis
4) Insomnia
5) Dyspepsia
____ 22. Which are the benefits for a patient diagnosed with heart disease, when the nurse includes Mind/Body
therapies in the plan of care? Select all that apply.
1) Decreased fatigue NURSINGTB.COM
2) Decreased headache
3) Decreased heart rate
4) Decreased blood pressure
5) Decreased body temperature
____ 23. The nurse plans to include the use of Mind/Body therapies for patients with which diagnoses in order to
facilitate communication and social interaction? Select all that apply.
1) Autism
2) Anxiety
3) Depression
4) Sleep disorders
5) Alzheimer disease
____ 24. The nurse plans to include the use of Mind/Body therapies for patients with which diagnoses in order to
facilitate relaxation? Select all that apply.
1) Autism
2) Anxiety
3) Depression
4) Sleep disorders
5) Alzheimer disease
____ 25. Which are general benefits the nurse would include in a teaching session for a patient who is considering the
use of Manipulative and Body-Based therapies? Select all that apply.
1) Alleviates pain
2) Relieves insomnia
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MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Defining complementary and alternative medicine
Chapter page reference: 202-203
Heading: Introduction
Integrated Processes: Nursing Process – Planning
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Promoting Health
Difficulty: Easy
Feedback
1 This is a guiding principle when using the Energy Paradigm for the implementation of
complementary and alternative medicine.
2 This is a guiding principle when using the Energy Paradigm for the implementation of
complementary and alternative medicine.
3 This is a guiding principle when using the Recipient/Practitioner Partnership for the
implementation of complementary and alternative medicine.
4 This is the guiding principle when using the Wellness Model of Care for the
implementation of the complementary and alternative medicine.
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PTS: 1 CON: Promoting Health
2. ANS: 4
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Defining complementary and alternative medicine
Chapter page reference: 202-203
Heading: Introduction
Integrated Processes: Nursing Process – Planning
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Promoting Health
Difficulty: Easy
Feedback
1 This is a guiding principle when using the Energy Paradigm for the implementation of
complementary and alternative medicine.
2 This is a guiding principle when using the Energy Paradigm for the implementation of
complementary and alternative medicine.
3 This is a guiding principle when using the Recipient/Practitioner Partnership for the
implementation of complementary and alternative medicine.
4 This is the guiding principle when using the Wellness Model of Care for the
implementation of complementary and alternative medicine.
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3. ANS: 1
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Defining complementary and alternative medicine
Chapter page reference: 202-203
Heading: Introduction
Integrated Processes: Nursing Process – Planning
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Promoting Health
Difficulty: Easy
Feedback
1 This is a guiding principle when using the Energy Paradigm for the implementation of
complementary and alternative medicine.
2 This is the guiding principle when using the Wellness Model of Care for the
implementation of complementary and alternative medicine.
3 This is a guiding principle when using the Recipient/Practitioner Partnership for the
implementation of complementary and alternative medicine.
4 This is the guiding principle when using the Wellness Model of Care for the
implementation of complementary and alternative medicine.
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Chapter learning objective: Differentiating the classifications of complementary and alternative medicine
Chapter page reference: 203-209
Heading: Classification of CAM
Integrated Processes: Nursing Process – Planning
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Nursing
Difficulty: Moderate
Feedback
1 Insomnia is an emotional or psychological, not pain, disorder that might be treated with
the inclusion of the Whole Medical Systems/Alternative Medical Systems in the plan of
care.
2 Menopause is an emotional or psychological, not pain, disorder that might be treated
with the inclusion of the Whole Medical Systems/Alternative Medical Systems in the
plan of care.
3 Fibromyalgia is a pain disorder that might be treated with the inclusion of the Whole
Medical Systems/Alternative Medical Systems in the plan of care.
4 Chronic fatigue is an emotional or psychological, not pain, disorder that might be
treated with the inclusion of the Whole Medical Systems/Alternative Medical Systems
in the plan of care.
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2 A limited, not large, number of patients involved in clinical trials is a research barrier
for the implementation of CAM into practice.
3 Personalized, not generic, treatment plans is a research barrier for the implementation
of CAM into practice.
4 Funding for research is an issue for the implementation of CAM into practice.
Feedback
1 Western, not eastern, medicine is another term for the traditional health-care system
within the United States.
2 Conventional medicine is another term for the traditional health-care system within the
United States.
3 Folklore medicine practices refers to CAM, not the traditional health-care system
within the United States.
4 Old-world traditional medicine refers to CAM, not the traditional health-care system
within the United States.
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Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Defining complementary and alternative medicine
Chapter page reference: 202-203
Heading: Introduction
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Health Care System
Difficulty: Difficult
Feedback
1 The goals of care for CAM and conventional medicine are quite similar. This statement
indicates the need for further education.
2 The term alternative in CAM refers to treatment that is outside of the conventional
methods.
3 The term complementary in CAM refers to practices that are paired with conventional
medicine.
4 Pain, anxiety, depression, and headaches are included in the top 10 reasons adult
patients seeks CAM.
Feedback
1 Refusing a patient assignment due to differing religious beliefs does not indicate a
holistic approach to patient care.
2 Telling a patient’s family that their spiritual beliefs should be kept to themselves does
not indicates a holistic approach to patient care.
3 Asking the patient to limit responses to information that is pertinent to today’s visit
does not indicates a holistic approach to patient care.
4 Providing information to a family about housing, when they seek care for their child’s
ear infection indicates a holistic approach to patient care.
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Feedback
1 The use of energy healing therapies is supported by anecdotal evidence for patients
diagnosed with asthma.
2 This condition does not support the use of energy healing therapies by anecdotal
evidence.
3 This condition does not support the use of energy healing therapies by anecdotal
evidence.
4 This condition does not support the use of energy healing therapies by anecdotal
evidence.
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19. ANS: 1
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Differentiating the classifications of complementary and alternative medicine
Chapter page reference: 208-209
Heading: Herbal Medicine and Botanicals
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Communication
Difficulty: Easy
Feedback
1 Natural is a term that is often used to describe the healing properties associated with
botanicals.
2 This is not the term that is used to describe the healing properties associated with
botanicals.
3 This is not the term that is used to describe the healing properties associated with
botanicals.
4 This is not the term that is used to describe the healing properties associated with
botanicals.
MULTIPLE RESPONSE
21. ANS: 2, 3, 4, 5
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Defining complementary and alternative medicine
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Feedback
1. This is incorrect. Cancer is not a top ten diagnosis for adult patients regarding the use of
complementary and alternative therapies.
2. This is correct. Anxiety is a top ten diagnosis for adult patients for the use of complementary
and alternative medicine.
3. This is correct. Arthritis is a top ten diagnosis for adult patients for the use of complementary
and alternative medicine.
4. This is correct. Insomnia is a top ten diagnosis for adult patients for the use of complementary
and alternative medicine.
5. This is correct. Dyspepsia, or stomach upset, is a top ten diagnosis for adult patients for the
use of complementary and alternative medicine.
Feedback
1. This is incorrect. Decreased fatigue is a benefit when including Mind/Body therapies in the
plan of care for a patient diagnosed with an emotional or psychological disorder, not heart
disease.
2. This is incorrect. Decreased incidence of headache is a benefit when including Mind/Body
therapies in the plan of care for a patient diagnosed with an emotional or psychological
disorder, not heart disease.
3. This is correct. A decrease in the heart rate is a benefit of including Mind/Body therapies in
the plan of care for a patient who is diagnosed with heart disease.
4. This is correct. A decrease in the blood pressure is a benefit of including Mind/Body therapies
in the plan of care for a patient who is diagnosed with heart disease.
5. This is correct. A decrease in body temperature is a benefit of including Mind/Body therapies
in the plan of care for a patient who is diagnosed with heart disease.
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Chapter learning objective: Differentiating the classifications of complementary and alternative medicine
Chapter page reference: 203-209
Heading: Classifications of CAM
Integrated Processes: Nursing Process – Planning
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Communication
Difficulty: Moderate
Feedback
1. This is correct. Mind/Body therapies are helpful to facilitate communication and social
interaction for patients diagnosed with autism.
2. This is incorrect. While Mind/Body therapies are helpful to patients with anxiety, they do not
facilitate communication and social interaction for these patients.
3. This is incorrect. While Mind/Body therapies are helpful to patients with depression, they do
not facilitate communication and social interaction for these patients.
4. This is incorrect. While Mind/Body therapies are helpful to patients with sleep disorders, they
do not facilitate communication and social interaction for these patients.
5. This is correct. Mind/Body therapies are helpful to facilitate communication and social
interaction for patients diagnosed with Alzheimer disease.
Feedback
1. This is incorrect. Mind/Body therapies are helpful to facilitate communication and social
interaction, not relaxation, for patients diagnosed with autism.
2. This is correct. Mind/Body therapies are helpful to facilitate relaxation for patients diagnosed
with anxiety.
3. This is correct. Mind/Body therapies are helpful to facilitate relaxation for patients diagnosed
with depression.
4. This is correct. Mind/Body therapies are helpful to facilitate relaxation for patients diagnosed
with sleep disorders.
5. This is incorrect. Mind/Body therapies are helpful to facilitate communication and social
interaction, not relaxation, for patients diagnosed with Alzheimer disease.
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Feedback
1. This is incorrect. Pain reduction is not a general benefit for the use of Manipulative and Body-
Based therapies.
2. This is correct. Relief of insomnia is a general benefit for the use of Manipulative and Body-
Based therapies.
3. This is incorrect. A reduction in heart rate is not a general benefit for the use of Manipulative
and Body-Based therapies. This is a cardiovascular benefit.
4. This is correct. The facilitation of mental clarity is a general benefit for the use of
Manipulative and Body-Based therapies.
5. This is correct. An increase in range of motion is a general benefit for the use of Manipulative
and Body-Based therapies.
____ 1. The nurse is caring for a patient with leukemia. Which treatment should the nurse expect to be prescribed?
1) Chemotherapy
2) IV fluid therapy
3) Diuretic therapy
4) Electrolyte replacement therapy
____ 2. The nurse is caring for an adolescent Asian patient with a strong family history of breast cancer. What should
the nurse teach the patient regarding cancer prevention?
1) Perform monthly breast self-examination.
2) Teach the side effects of cancer treatment.
3) Talk to family members who have the disease.
4) Discuss cancer fears with the health-care provider.
____ 3. A patient with anemia caused by chemotherapy is prescribed synthetic erythropoietin. When teaching the
patient about the therapeutic effect of this treatment, which is appropriate for the nurse to include?
1) Increase in platelets
2) Decrease in lymph fluid
3) Increase in red blood cells
4) Decrease in white blood cells
____ 4. A nurse is caring for a patient with cancer. The nurse teaches the patient about which potentially undesirable
cellular alterations that can occur during the cell cycle?
1) Dysphagia
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2) Adaptation
3) Hyperplasia
4) Differentiation
____ 5. During a treatment meeting on an oncology unit, the nurse learns that a patient is scheduled for chemotherapy
before surgery. What are the purposes for this patient to receive chemotherapy at this specific time?
1) Shrink the tumor
2) Improve wound healing
3) Eradicate all cancer cells
4) Allow the immune system to kill cancer cells
____ 6. The nurse has completed a seminar teaching a group in the community about ways to reduce cancer risks. The
nurse returns a month later to evaluate the effectiveness of the seminar. Which statements made by members
of the group indicate retention and application of the material presented by the nurse to reduce the risk of
developing cancer?
1) “I stopped using tanning booths.”
2) “I have reduced my intake of fiber.”
3) “I have increased the amount of lean red meat in my diet.”
4) “I began drinking two glasses of red wine a day with dinner.”
____ 7. The nurse is preparing a seminar that discusses the risk and incidence of cancer and culture. What information
is considered culturally correct when teaching about the risk of developing cancer?
1) Hispanics have an increased risk of cervical, stomach, and liver cancer.
2) African-Americans are more likely to develop cancer than any other ethnic group.
3) The incidence and mortality rate of all type of cancers are lowest in the Caucasian
population.
4) African-Americans are less likelyNUtoRdevelop
SINGT B.Cthan
cancer OM any other ethnic or racial group
in the United States.
____ 8. A patient being treated with chemotherapy for cancer complains of fatigue, pallor, progressive weakness,
exertional dyspnea, headache, and tachycardia. Which diagnosis should the nurse use as the priority when
planning this patient’s care?
1) Powerlessness
2) Ineffective Coping
3) Activity Intolerance
4) Imbalanced Nutrition, Less than Body Requirements
____ 9. The nurse accompanies the health-care provider into the patient’s room and listens as the diagnosis of cancer
is shared with the patient and family. Once the health-care provider leaves the room, the nurse notes that the
patient and family are teary-eyed regarding the diagnosis. What is the nurse’s most appropriate intervention at
this time?
1) Provide emotional support in coping with the diagnosis.
2) Help the patient and family remain realistic about prognosis.
3) Provide teaching about the treatment options for this form of cancer.
4) Arrange for the patient to complete a medical power of attorney form.
____ 10. A patient being treated for cancer has a tumor designation of Stage IV, T4, N3, M1. What does this staging
indicate to the nurse?
1) The tumor is small in size.
2) There is one single tumor to treat.
3) The tumor will respond to chemotherapy.
4) The tumor has metastasized with lymph node involvement.
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____ 11. During an assessment, the nurse notes that a patient receiving radiation treatments for breast cancer has
excoriated skin. What is the priority nursing diagnosis?
1) Risk for Infection
2) Activity Intolerance
3) Excess Fluid Volume
4) Ineffective Breathing Pattern
____ 12. A patient has just been told that a colectomy and ileostomy are needed to treat a new diagnosis of colon
cancer. Which nursing diagnosis should the nurse use to plan this patient’s preoperative nursing care?
1) Knowledge Deficit
2) Anticipatory Grieving
3) Risk for Disuse Syndrome
4) Risk for Perioperative–Positioning Injury
____ 13. The nurse is teaching a patient scheduled for a colonoscopy on pre- and postprocedure care. Which statement
by the patient indicates the need for further teaching?
1) “It might be quite painful.”
2) “The procedure will only take about one hour.”
3) “The physician might take tissue samples for further analysis.”
4) “I will likely have medications that will make me drowsy during the test.”
____ 14. A patient receiving radiation therapy as treatment for colorectal cancer is experiencing nausea and vomiting.
What should the nurse encourage the patient to do?
1) Use a commercial mouthwash before eating a meal.
2) Eat spicy or well-seasoned foods instead of bland foods.
3) Delay the intake of a meal until Nthree
URS toIfour
NGT hours
B.Cafter
OMtreatment.
4) Avoid all food and liquid until nausea and vomiting stop.
____ 15. A patient with terminal colon cancer is refusing all food and fluids. The patient has a living will that states no
artificial nutrition is to be provided; however, the family is asking for a gastrostomy tube. What should the
nurse do?
1) Take the case to the hospital’s ethics committee.
2) Honor the family’s wishes and have them sign a consent form.
3) Honor the patient’s refusal and help the family come to terms with the situation.
4) Talk to the physician so he or she can move forward with the family’s wishes.
____ 16. A patient is receiving chemotherapy for the treatment of leukemia. While providing care for this patient,
which clinical manifestations would indicate tumor lysis syndrome?
1) Thrombocytopenia
2) Respiratory distress
3) Upper-extremity edema
4) Altered levels of consciousness
____ 17. The nurse is caring for a patient who had a bone marrow transplant for the treatment of leukemia several
weeks ago. The patient requires protective isolation. Which statement by the patient’s family indicates
understanding of this type of isolation?
1) “It will be important to restrict all visitors.”
2) “We will encourage oral hygiene twice a day.”
3) “You will have to administer all medications by IM injection.”
4) “We will encourage meticulous hand washing among all visitors.”
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____ 18. The nurse is assisting the health-care provider with a bone marrow aspiration and biopsy on a patient who has
leukemia. The patient also has thrombocytopenia. Upon completing of the test, which intervention is a
priority for the nurse?
1) Make certain the patient understands the purpose of the test.
2) Hold pressure on the wound for approximately five minutes.
3) Label and refrigerate the specimen obtained by the physician.
4) Dispose of the equipment used, and clean the area properly.
____ 19. The nurse is caring for a patient with leukemia who is experiencing neutropenia as a result of chemotherapy.
Which action should the nurse include in the plan of care for this patient?
1) Restrict fluid intake
2) Replace hand hygiene with gloves
3) Restrict visitors with communicable illnesses.
4) Insert an indwelling urinary catheter to prevent skin breakdown
____ 20. A nurse is caring for a patient with leukemia who is neutropenic. Which intervention will the nurse implement
to ensure this patient’s safety?
1) Place patient in reverse isolation
2) Place patient in standard precaution isolation
3) Administer a prophylactic gram-negative antibiotic
4) Administer neutrophil colony-stimulating factor (N-CSF) as ordered
____ 21. A nurse is planning care for a patient with leukemia. The nurse chooses “Risk for Bleeding” as the nursing
diagnosis. Which interventions support this nursing diagnosis?
1) Educate patient in use of soft toothbrush for oral care
2) Use non-electric razor when providing grooming for patient
NUsites
3) Apply pressure to arterial puncture RSIforNG5Tminutes
B.COM
4) Encourage patient to breathe deeply and huff cough frequently
____ 22. The nurse is caring for a patient who is undergoing diagnostic tests to rule out lung cancer. The patient asks
the nurse why a computed tomography (CT) scan was ordered. What is the best response by the nurse?
1) “The doctor prefers this test.”
2) “Why are you concerned about this test?”
3) “It is more specific in diagnosing your condition.”
4) “To rule out the possibility that your problems are caused by pneumonia.”
____ 23. A patient is scheduled to undergo a prostate biopsy. The patient asks the nurse what is expected immediately
following the procedure. Which response by the nurse is the most appropriate?
1) ‘Your sexual partners will need to be notified.”
2) “You will need to avoid strenuous activity for 24 hours.”
3) “You will not have any restrictions following the biopsy.”
4) “You will likely experience discomfort for 24-48 hours after the procedure.”
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 24. The nurse is caring for a thin, older adult patient who is diagnosed with cancer and is receiving aggressive
chemotherapy. The patient is experiencing severe side effects from the therapy and has lost 10 pounds in the
past week. What should the nurse teach the patient to do? Select all that apply.
1) Keep a food diary and record intake.
2) Purchase fast foods and prepared foods.
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MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Identifying treatment options for oncology patients
Chapter page reference: 231-239
Heading: Treatment
Integrated Processes: Nursing Process – Planning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Cellular Regulation
Difficulty: Easy
Feedback
1 The patient with an alteration in cell growth has cancer and will most likely be treated
with chemotherapy and antibiotics.
2 Diuretic therapy, IV fluids, and electrolyte replacement are not typically used to treat
cancer, although they may be used if complications develop.
3 Diuretic therapy, IV fluids, and electrolyte replacement are not typically used to treat
cancer, although they may be used if complications develop.
4 Diuretic therapy, IV fluids, and electrolyte replacement are not typically used to treat
cancer, although they may be used if complications develop.
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PTS: 1 CON: Cellular Regulation
2. ANS: 1
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Describing vital diagnostic and preventive measures for the oncology patient
Chapter page reference: 226-229
Heading: Prevention
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Promoting Health
Difficulty: Moderate
Feedback
1 In families with a disease, the nurse should inform patients about breast self-
examination.
2 Teaching the side effects of cancer treatment would be appropriate if the patient was
diagnosed with breast cancer.
3 Talking to family members who have the disease will not help with early detection or
prevention.
4 The patient can discuss cancer fears with the nurse; however, this action will not help
prevent the development of the disease.
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8. ANS: 3
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Analyzing nursing care for the oncology patient
Chapter page reference: 239-245
Heading: Nursing Management
Integrated Processes: Nursing Process – Diagnosis
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Cellular Regulation
Difficulty: Moderate
Feedback
1 Powerlessness is the lack of control over current situations, but this is not the patient’s
current problem. Her needs/symptoms are physical, and according to Maslow’s theory
must be met prior to emotional needs. Although the patient might be having coping
issues, the physical symptoms are her greatest complaints; therefore, coping is not the
top priority in planning her care. Again, physiological needs must be met prior to self-
actualization needs.
2 Powerlessness is the lack of control over current situations, but this is not the patient’s
current problem. Her needs/symptoms are physical, and according to Maslow’s theory
must be met prior to emotional needs. Although the patient might be having coping
issues, the physical symptoms are her greatest complaints; therefore, coping is not the
top priority in planning her care. Again, physiological needs must be met prior to self-
actualization needs.
3 The symptoms (fatigue, pallor, progressive weakness, exertional dyspnea, headache,
and tachycardia) are caused by aplastic anemia from bone marrow suppression, which
NURSdrugs.
is a side effect of the chemotherapy INGDecreased
TB.COMred blood cells cause less oxygen
to be delivered to body tissues, resulting in tissue hypoxia. Tachycardia is a
compensation mechanism to speed up the delivery of oxygen that is available in the
fewer number of cells that are present. Tissue hypoxia will result in muscle fatigue, and
the symptoms that are related to aplastic anemia will decrease endurance and ability to
perform activities.
4 Nutrition is not the cause of the symptoms, which are related to tissue hypoxia.
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2 This is not an opportune time to teach, set goals, or make decisions regarding power of
attorney.
3 This is not an opportune time to teach, set goals, or make decisions regarding power of
attorney.
4 This is not an opportune time to teach, set goals, or make decisions regarding power of
attorney.
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4 Avoiding all food and liquid could put the patient at risk for dehydration.
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Feedback
1 Fluid intake should be encouraged.
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Feedback
1 The patient at risk for bleeding has specific interventions to which the nurse should
adhere. The nurse should educate the patient in the use of a soft toothbrush.
2 An electric razor is preferred when providing grooming for a patient who is at risk for
bleeding.
3 The nurse should also limit the use of parenteral injections and apply 15–20 minutes of
pressure to any arterial puncture sites.
4 The nurse should discourage the patient to forcefully cough to prevent further bleeding.
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MULTIPLE RESPONSE
24. ANS: 1, 3, 4, 5
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Developing teaching and support strategies for the oncology patient and family
Chapter page reference: 239-245
Heading: Nursing Management
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
Feedback
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1. This is correct. The goal of nutritional teaching is to help the patient increase caloric and
nutrient intake through the use of liquid supplements, small frequent meals, and a food diary
that will help the nurse evaluate strengths and weaknesses of the current plan.
2. This is incorrect. Fast foods and prepared foods tend to be high in fat and sodium and are not
the best choice because they do not contain adequate healthy nutrients. Instead, involving the
family in preparing meals or in enrolling in Meals on Wheels may be better options for easy
ways of obtaining meals.
3. This is correct. The goal of nutritional teaching is to help the patient increase caloric and
nutrient intake through the use of liquid supplements, small frequent meals, and a food diary
that will help the nurse evaluate strengths and weaknesses of the current plan.
4. This is correct. The goal of nutritional teaching is to help the patient increase caloric and
nutrient intake through the use of liquid supplements, small frequent meals, and a food diary
that will help the nurse evaluate strengths and weaknesses of the current plan.
5. This is correct. The patient receiving chemotherapy may tolerate cold foods better than hot
foods.
Feedback
1. This is correct. Cancer cells grow faster than normal cells, so they use more nutrients for
growth, resulting in wasting, which can only be counteracted by increasing the caloric intake
of the patient.
2. This is incorrect. While patients should not be inactive, they should be taught to reduce
activity to reduce weight loss and provide more energy to the healthy cells.
3. This is correct. Increased rest and sleep give the patient’s body more energy to fight the cancer
cells.
4. This is correct. Because cancer cells can grow in any area of the body, it is important for the
nurse to assess normal functioning of all organ systems.
5. This is incorrect. Decreasing oxygen supply will retard cancer cell growth but it will also
retard normal cell health.
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Feedback
1. This is correct. Malignant tumors are more difficult to remove. They invade neighboring tissue
and can return once removed.
2. This is correct. Benign tumors are slow-growing and stay in one area.
3. This is correct. Benign tumors are slow-growing and stay in one area.
4. This is incorrect. Benign, not malignant, tumors are easy to remove.
5. This is incorrect. Benign, not malignant, tumors push other tissue out of the way.
Feedback
NURSINGTB.COM
1. This is incorrect. Changes in appetite or cough that is associated with seasonal allergies are
not associated with the early warning signs of cancer.
2. This is correct. Nurses should assess all patients, especially those with a history of cancer, for
early warning signs of cancer. The early warning signs include change in bowel or bladder
habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the
breast or elsewhere, indigestion or difficulty swallowing, obvious change in wart or mole, or a
nagging cough or hoarseness.
3. This is correct. Nurses should assess all patients, especially those with a history of cancer, for
early warning signs of cancer. The early warning signs include change in bowel or bladder
habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the
breast or elsewhere, indigestion or difficulty swallowing, obvious change in wart or mole, or a
nagging cough or hoarseness.
4. This is correct. Nurses should assess all patients, especially those with a history of cancer, for
early warning signs of cancer. The early warning signs include change in bowel or bladder
habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the
breast or elsewhere, indigestion or difficulty swallowing, obvious change in wart or mole, or a
nagging cough or hoarseness.
5. This is correct. Nurses should assess all patients, especially those with a history of cancer, for
early warning signs of cancer. The early warning signs include change in bowel or bladder
habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the
breast or elsewhere, indigestion or difficulty swallowing, obvious change in wart or mole, or a
nagging cough or hoarseness.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
28. ANS: 1, 2, 4
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Describing vital diagnostic and preventive measures for the oncology patient
Chapter page reference: 229-231
Heading: Diagnosing Cancer
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Cellular Regulation
Difficulty: Easy
Feedback
1. This is correct. Many diagnostic tests are helpful in determining treatment for cancer. An
MRI, urinalysis, and tumor markers are all diagnostic tests that may be used to determine
treatment for cancer.
2. This is correct. Many diagnostic tests are helpful in determining treatment for cancer. An
MRI, urinalysis, and tumor markers are all diagnostic tests that may be used to determine
treatment for cancer.
3. This is incorrect. A stool analysis is not a diagnostic test listed to determine treatment for
cancer.
4. This is correct. Many diagnostic tests are helpful in determining treatment for cancer. An
MRI, urinalysis, and tumor markers are all diagnostic tests that may be used to determine
treatment for cancer.
5. This is incorrect. A physical assessment may be useful to determine how a patient is
responding to treatment, but it is not considered a diagnostic test.
NURSINGTB.COM
PTS: 1 CON: Cellular Regulation
29. ANS: 2, 3, 4
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Describing vital diagnostic and preventive measures for the oncology patient
Chapter page reference: 226-229
Heading: Prevention
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Cellular Regulation
Difficulty: Difficult
Feedback
1. This is incorrect. All smoking should be discouraged.
2. This is correct. The home should be tested for radon, which is a known cancer-causing
substance.
3. This is correct. Children should be protected from exposure to tobacco smoke.
4. This is correct. Sunscreen should be used by those who spend time outside regularly for work
or recreation.
5. This is incorrect. Efforts to reduce the development of cancer include eating five servings of
fruits and vegetables each day.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
30. ANS: 1, 2, 3, 5
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Developing teaching and support strategies for the oncology patient and family
Chapter page reference: 239-245
Heading: Nursing Management
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Cellular Regulation
Difficulty: Moderate
Feedback
1. This is correct. The patient should be instructed to call for help with any difficulty breathing,
significant increase in vomiting, a desire to end life, or a new onset of bleeding.
2. This is correct. The patient should be instructed to call for help with any difficulty breathing,
significant increase in vomiting, a desire to end life, or a new onset of bleeding.
3. This is correct. The patient should be instructed to call for help with any difficulty breathing,
significant increase in vomiting, a desire to end life, or a new onset of bleeding.
4. This is incorrect. An increased sense of well-being would be a desired effect of treatment for
cancer.
5. This is correct. The patient should be instructed to call for help with any difficulty breathing,
significant increase in vomiting, a desire to end life, or a new onset of bleeding.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is preparing an educational session on sepsis. Which should the nurse include as a major risk factor
for the development of this health problem?
1) Immunosuppression
2) Elevated temperature
3) Pneumococcal bacteria
4) Leukocytosis on the complete blood count
____ 2. The nurse identifies the nursing diagnosis of Ineffective Peripheral Tissue Perfusion as being appropriate for a
patient with septicemia. Which intervention will address this patient’s health problem?
1) Monitor for cyanosis.
2) Monitor heart rate every hour.
3) Assess temperature every four hours.
4) Monitor pupil reactions every eight hours.
____ 3. An older adult patient is recovering in the intensive care unit (ICU) from septicemia. Which intervention will
help prevent further infection for this patient?
1) Provide oral and skin care
2) Implement sterile wound care
3) Encourage turn, cough, and deep breathe every shift.
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4) Obstructive
____ 11. A nurse working in the intensive care unit (ICU) is caring for a patient in refractory stage of shock. When
planning care, which does the nurse anticipate?
1) A subtle change in heart rate
2) A change from aerobic to anaerobic metabolism
3) The development of hyperglycemia
4) The development of cardiac dysrhythmias
____ 12. The nurse is preparing to administer diphenhydramine to a patient who is experiencing a severe allergic
reaction to peanuts. Which information about the drug should the nurse provide to the patient?
1) “This is the medication of choice to treat airway obstruction.”
2) “This medication will help relieve your itching and runny nose.”
3) “This medication will prevent you from going into anaphylactic shock.”
4) “This medication will take a while to be effective but will control your symptoms for
several hours.”
____ 13. The nurse is conducting medication teaching for a patient who is prescribed an epi-pen. Which statements
made by the patient indicates the need for additional instruction?
1) “I will carry an epi-pen with me at all times.”
2) “I will check the expiration date on my epi-pen regularly.”
3) “I should hold the epi-pen in place for 10 seconds after injection.”
4) “I should use the epi-pen to inject the drug into my abdominal wall.”
____ 14. The nurse is providing care to a patient who is admitted to the emergency department with symptoms of a
myocardial infarction (MI). Which is the primary purpose of the interventions administered to this patient?
1) Providing pain relief NURSINGTB.COM
2) Preventing extension of damage
3) Preventing cardiogenic shock
4) Reducing blood pressure
____ 15. The nurse is providing care for a patient receiving treatment for cardiogenic shock. Which assessment finding
indicates that the compensatory mechanism of vasoconstriction has occurred in this patient?
1) Increased heart rate
2) Increased injection fraction
3) Decreased urine output
4) Decreased temperature
____ 16. The nurse is providing care to a patient who is admitted with cardiogenic shock. The nurse administers the
prescribed atropine with no results. Which prescription does the nurse anticipate from the health-care provider
based on this data?
1) A beta blocker
2) Transcutaneous pacing
3) Cardiac defibrillation
4) A preload reducer
____ 17. The nurse is providing care to a patient diagnosed with hypovolemic shock. Which nursing action is
appropriate for this patient during the initial compensatory phase?
1) Placing a cool blanket over the patient
2) Raising the patient’s head to a 30-degree angle
3) Positioning the patient in the left-lateral recumbent position
4) Turning the patient’s head to one side if no neck injury is suspected
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 18. During the initial stage of shock, which clinical manifestation should the nurse monitor for when assessing
the patient?
1) Lethargy
2) Hypotension
3) Respiratory alkalosis
4) Subtle changes in heart rate
____ 19. The nurse is providing care to a patient admitted to the emergency department (ED) with a gunshot wound
and profound blood loss. Which order does the nurse anticipate for this patient?
1) Normal saline
2) Dextrose in water
3) Packed red blood cells
4) Albumin
____ 20. A patient develops hypovolemic shock secondary to pancreatitis. Which action by the nurse is most
appropriate?
1) Starting an 18-gauge intravenous catheter in the patient’s nondominant hand
2) Ordering a type and cross-match of packed red blood cells
3) Preparing to assist with central line placement
4) Inserting a nasogastric tube
____ 21. The nurse is providing care to a patient admitted with a spinal cord injury. The patient is bradycardic,
hypotensive, and has cold and clammy skin. Which is the priority nursing action for this patient?
1) Starting two large intravenous catheters
2) Notifying the Rapid Response Team
3) Calling the patient’s physician to report
NU RSIthe
NGchanges
TB.COM
4) Placing oxygen on the patient
____ 22. A patient in neurogenic shock is receiving rapid intravenous fluids. Which assessment finding indicates the
need for additional nursing interventions?
1) The patient’s mean arterial pressure (MAP) is 60 mmHg.
2) The patient is unconscious.
3) The patient has received two liters of infused fluid.
4) The patient is perspiring heavily.
____ 23. Which is the highest priority nursing action when providing care to a patient with shock?
1) Starting two large intravenous catheters
2) Recognizing early clinical manifestations
3) Administering high-flow oxygen
4) Calling for help immediately
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 24. Which will the nurse closely monitor due to the pathophysiology associated with early shock? Select all that
apply.
1) Bowel sounds
2) Level of consciousness
3) Urine output
4) Peripheral pulses
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5) Heart rate
____ 25. Which assessment findings would indicate to the nurse that a patient is exhibiting early symptoms of shock?
Select all that apply.
1) Pallor
2) Increased bowel sounds
3) Restlessness
4) Decreased blood glucose
5) Increased respiratory rate
____ 26. A nurse working in the intensive care unit (ICU) is receiving a patient diagnosed with early septic shock from
the emergency department (ED). The nurse will recognize which symptoms associated with this condition?
Select all that apply.
1) Shallow respirations
2) Normal blood pressure
3) Warm and flushed skin
4) Lethargic mental status
5) Decreased urine output
6) Rapid and deep respirations
____ 27. A patient is admitted to the intensive care unit with a systemic infection. Which manifestations will the nurse
most likely assess in this patient? Select all that apply.
1) Pain
2) Fever
3) Edema
4) Anorexia
5) Tachycardia NURSINGTB.COM
____ 28. A nurse working in the intensive care unit (ICU) is receiving a patient diagnosed with late septic shock from
the emergency department (ED). The nurse will recognize which symptoms associated with this condition?
Select all that apply.
1) Shallow respirations
2) Lethargic mental status
3) Decreased urine output
4) Normal blood pressure
5) Warm and flushed skin
6) Rapid and deep respirations
____ 29. The nurse is concerned that a patient is demonstrating early signs of hypovolemic shock. Which assessment
findings support the nurse’s concern? Select all that apply.
1) Rapid weak pulse
2) Normal respirations
3) Normal blood pressure
4) Slight increase in pulse
5) Prolonged capillary refill time
____ 30. A patient is receiving intravenous nitroprusside (Nipride) for shock. Which adverse reactions will the nurse
assess this patient for when administering the infusion? Select all that apply.
1) Confusion
2) Tachycardia
3) Disorientation
4) Muscle spasms
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5) Gastrointestinal bleeding
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MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Discussing the pathophysiology of shock
Chapter page reference: 266-271
Heading: Sepsis/Septic Shock
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1 Immunosuppression is a risk factor for the development of sepsis.
2 An elevated temperature is a manifestation of sepsis.
3 Sepsis is most often the result of gram-positive infections from Staphylococcus and
Streptococcus bacteria but may also follow gram-negative bacterial infections such as
Pseudomonas, Escherichia coli, and Klebsiella.
4 Leukocytosis occurs with sepsis if the patient is able to mount an immune response.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3. ANS: 1
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Analyzing the nursing management of selected shock states
Chapter page reference: 266-271
Heading: Sepsis/Septic Shock
Integrated Processes: Nursing Process – Implementation
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1 Good oral and skin care will prevent breakdown and prevent entry by bacteria.
2 There is no evidence that this patient has a wound.
3 In order to prevent skin breakdown and promote respiratory function, the patient is
turned at least every two hours.
4 The Foley drainage bag is always kept below the level of the patient’s bladder to
prevent reflux.
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Feedback
1 Assessing the cause of bleeding would also occur after establishing invasive cardiac
monitoring.
2 Replacement of volume would occur after invasive cardiac monitoring is established.
3 With aging, there is a decrease in cardiac sympathetic activity. Older patients can have
secondary volume depletion because of diuretics or malnutrition, and if prescribed a
beta blocker, tachycardia may not occur as an early sign of hypovolemic shock. The
older patient will require early invasive monitoring in order to avoid excessive or
inadequate volume restoration. This should be done early in the treatment phase.
4 Pain would be a consideration but would not be attended to as a first priority.
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3 Antihistamines do not prevent anaphylactic shock; they are used to relieve the
histamine-related symptoms associated with an allergic reaction.
4 This description is more applicable to the action of corticosteroids.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
15. ANS: 3
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Cardiogenic shock
Chapter page reference: 257-261
Heading: Cardiogenic Shock
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Perfusion
Difficulty: Easy
Feedback
1 Tachycardia is the result of compensation for decreased cardiac output due to decreased
stroke volume.
2 Vasoconstriction does not result in an increase of ejection fraction.
3 Vasoconstriction results in diminished renal blood flow and urine production.
4 Vasoconstriction does not affect the patient’s core temperature; however,
vasoconstriction results in shunting of blood away from the skin, causing the skin to be
cold and clammy.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Concept: Safety
Difficulty: Moderate
Feedback
1 The patient should be kept warm and comfortable.
2 The head should lie flat.
3 The patient should be supine.
4 Turing the patient’s head to one side protects the airway in case of vomiting.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Describing the medical management of selected shock states
Chapter page reference: 253-257
Heading: Hypovolemic Shock
Integrated Processes: Nursing Process – Implementation
Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Perfusion
Difficulty: Moderate
Feedback
1 A single medium-gauge IV catheter is not sufficient for volume expansion required for
a patient experiencing hypovolemic shock.
2 The hypovolemia associated with pancreatitis is not a blood loss hypovolemia. It is also
outside of the scope of nursing practice to order laboratory and diagnostic testing.
3 Rapid volume expansion requires the use of large veins, preferably a central line.
4 While a nasogastric tube may be indicated for this patient, it will not be used to increase
fluid intake.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 Unconsciousness may result from the mechanism of injury and is not indicative of the
need for further intervention.
3 Large amounts of fluid may be required.
4 The presence of perspiration is not related to the adequacy of fluid resuscitation.
MULTIPLE RESPONSE
24. ANS: 1, 3, 4
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Describing the stages of shock
Chapter page reference: 247-250
Heading: Overview of Shock
Integrated Processes: Nursing Process – Implementation
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Perfusion
Difficulty: Difficult
Feedback
1. This is correct. Compensatory changes in early shock can result in hypoperfusion of the gut;
therefore, the nurse must closely assess bowel sounds.
2. This is incorrect. While the nurse will assess mental status, the brain is usually protected by
compensatory mechanisms in early shock; therefore, this is not an area of priority assessment.
3. This is correct. The shunting that occurs in early shock may cause hypoperfusion of the
kidneys leading to decreased urine output; therefore, the nurse must closely monitor intake
versus output.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4. This is correct. The body shunts blood away from the peripheral tissues in an effort to keep
vital organs perfused; therefore, the nurse will monitor for decreased peripheral pulses when
assessing for early clinical manifestations of shock.
5. This is incorrect. The body tries to protect the heart and does so in early shock by shunting
blood to it; therefore, this is not an area of priority assessment.
Feedback
1. This is correct. Pallor of the skin, lips, oral mucosa, nail beds, and conjunctiva may occur in
early shock.
2. This is incorrect. Bowel motility decreases, resulting in a decrease in bowel sounds.
3. This is correct. Slight decreases in perfusion of the brain may result in restlessness.
4. This is incorrect. Blood glucose typically rises slightly as a response to the stress of shock.
5. This is correct. A compensatory
NURSImechanism
NGTB.Cfor OMdecreased tissue oxygenation is the attempt to
obtain additional oxygen through more rapid respirations.
Feedback
1. This is incorrect. Shallow respirations, a lethargic mental status, and decreased urine output
are late-phase manifestations of septic shock.
2. This is correct. Early-phase manifestations include normal blood pressure, rapid and deep
respirations, and warm or flushed skin.
3. This is correct. Early-phase manifestations include normal blood pressure, rapid and deep
respirations, and warm or flushed skin.
4. This is incorrect. Shallow respirations, a lethargic mental status, and decreased urine output
are late-phase manifestations of septic shock.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5. This is incorrect. Shallow respirations, a lethargic mental status, and decreased urine output
are late-phase manifestations of septic shock.
6. This is correct. Early-phase manifestations include normal blood pressure, rapid and deep
respirations, and warm or flushed skin.
Feedback
1. This is incorrect. Edema and pain are symptoms of a local infection.
2. This is correct. Fever, tachycardia, and anorexia are the most common symptoms of a
systemic infection.
3. This is incorrect. Edema and pain are symptoms of a local infection.
4. This is correct. Fever, tachycardia, and anorexia are the most common symptoms of a
systemic infection.
5. This is correct. Fever, tachycardia,
NURSINand GTBanorexia
.COMare the most common symptoms of a
systemic infection.
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Feedback
1. This is incorrect. A weak rapid pulse is a characteristic of the irreversible stage of
hypovolemic shock.
2. This is incorrect. Normal respirations are not anticipated for a patient demonstrating early
signs of hypovolemic shock.
3. This is correct. Manifestations of early hypovolemic shock include a slight increase in pulse,
normal respirations, prolonged capillary refill time, and normal blood pressure.
4. NURSof
This is correct. Manifestations INearly
GTB .COM shock include a slight increase in pulse,
hypovolemic
normal respirations, prolonged capillary refill time, and normal blood pressure.
5. This is correct. Manifestations of early hypovolemic shock include a slight increase in pulse,
normal respirations, prolonged capillary refill time, and normal blood pressure.
Feedback
1. This is correct. Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning,
which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia
are adverse reactions that the nurse should report immediately to the health-care provider.
2. This is correct. Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning,
which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia
are adverse reactions that the nurse should report immediately to the health-care provider.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3. This is correct. Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning,
which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia
are adverse reactions that the nurse should report immediately to the health-care provider.
4. This is correct. Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning,
which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia
are adverse reactions that the nurse should report immediately to the health-care provider.
5. This is incorrect. Gastrointestinal bleeding is not an adverse effect of this medication.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse administers the preoperative medication to the patient one hour before elective surgery, and then
discovers the preoperative consent is not signed. Which action by the nurse is the most appropriate?
1) Have the patient sign the consent quickly, before the medication begins taking effect.
2) Have a family member or medical power of attorney sign the consent.
3) Send the patient to the holding area without a signed consent.
4) Notify the health-care provider that surgery will need to be canceled.
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____ 2. The nurse is completing the preoperative checklist on the night shift in preparation for the patient’s surgery,
scheduled for 0800. Which tasks could the nurse complete at this time?
1) Documenting the time of last voiding
2) Checking the medical record for the history, physical, and signed informed consent
3) Administering preoperative medication
4) Removing the prosthesis
____ 3. The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is
appropriate for the patient who is prescribed amiodarone?
1) Obtaining a baseline ECG
2) Monitoring blood pressure
3) Assessing for hyperglycemia
4) Tapering the drug two days prior to surgery
____ 4. The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is
appropriate for the patient who is prescribed warfarin?
1) Obtaining a baseline ECG
2) Monitoring blood pressure
3) Assessing for hyperglycemia
4) Tapering the drug two days prior to surgery
____ 5. The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is
appropriate for the patient who is prescribed metoprolol?
1) Obtaining a baseline ECG
2) Monitoring blood pressure
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 20. Which should the nurse ask the patient to verify during the initial time-out, the “pause for cause”?
1) “What is the name of your surgeon?”
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MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Discussing the essentials of the surgical experience
Chapter page reference: 274-279
Heading: Informed Consent
Integrated Processes: Nursing Process – Implementation
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Legal; Perioperative
Difficulty: Moderate
Feedback
1
The nurse cannot have the patient sign the consent once the preoperative medication
has been administered, because it affects the patient’s ability to reason.
2 Emergency surgery, in some facilities, may be performed if a family member or
medical power of attorney signs the consent when the patient is unable to do so, but
elective surgery requires the patient’s signature if she is capable of making a reasoned
decision.
3 The nurse cannot send the patient to the holding area without a signed consent form.
4 NURSprovider,
The nurse will notify the health-care INGTBwho .COwill
M need to cancel surgery until the
preoperative medication is excreted and no longer affecting the patient’s ability to make
informed decisions, at which time the consent can be signed.
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Difficulty: Moderate
Feedback
1 This nursing action is appropriate for a patient who is prescribed an antiarrhythmic.
2 The prescribed drug is an antihypertensive; therefore, the most appropriate nursing
action is to monitor the patient’s blood pressure.
3 This nursing action is appropriate for a patient who is prescribed a corticosteroid drug.
4 The nursing action is appropriate for a patient who is prescribed an anticoagulant drug.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
8. ANS: 4
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Explaining the priority assessments for the surgical patient
Chapter page reference: 280-284
Heading: Patient Assessment
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1 This nursing action is appropriate for a patient who is prescribed an antiarrhythmic.
2 This nursing action is appropriate for a patient who is prescribed an antihypertensive
drug.
3 This nursing action is inappropriate as insulin should be administered throughout the
perioperative period.
4 The prescribed drug is administered to control the patient’s blood glucose level;
therefore, the nurse should monitor the patient’s blood glucose level closely during the
perioperative period.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Difficulty: Difficult
Feedback
1 While ensuring NPO status is important, this is not the priority nursing action.
2 While monitoring vital signs is important, this is not the priority nursing action.
3 The health-care provider, not the nurse, is responsible for obtaining informed consent.
4 The priority nursing action during the preoperative period is to complete the
preoperative checklist prior to the patient being transferred to the surgical suite.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 While it is important to determine the type of reaction the patient experiences, this is
not the priority nursing action.
2 While it is important to document the information in the patient’s medical record, this is
not the priority nursing action.
3 The nurse should immediately place an alert bracelet on the patient and communicate
this information with the surgical team.
4 It is not necessary to verify the information with the patient’s family members at the
bedside.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE RESPONSE
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
20. ANS: 1, 2, 3, 4
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Explaining the priority assessments for the surgical patient
Chapter page reference: 279-280
Heading: Time-Outs/Pause for Cause
Integrated Processes: Nursing Process – Assessment
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1. This is correct. This question is included in the initial time-out, the “pause for cause.”
2. This is correct. This question is included in the initial time-out, the “pause for cause.”
3. This is correct. This question is included in the initial time-out, the “pause for cause.”
4. This is correct. This question is included in the initial time-out, the “pause for cause.”
5. This is incorrect. This question is not included in the initial time-out. This information is
included in the preoperative checklist.
Feedback
1. This is incorrect. Maintaining a patent airway is a nursing action that is performed during the
postoperative phase of surgical care.
2. This is correct. In the preoperative phase, when the patient is alert and oriented, the nurse
should focus teaching on deep breathing and coughing exercises, care of the surgical incision,
managing constipation, and managing pain.
3. This is correct. In the preoperative phase, when the patient is alert and oriented, the nurse
should focus teaching on deep breathing and coughing exercises, care of the surgical incision,
managing constipation, and managing pain.
4. This is correct. In the preoperative phase, when the patient is alert and oriented, the nurse
should focus teaching on deep breathing and coughing exercises, care of the surgical incision,
managing constipation, and managing pain.
5. This is correct. In the preoperative phase, when the patient is alert and oriented, the nurse
should focus teaching on deep breathing and coughing exercises, care of the surgical incision,
managing constipation, and managing pain.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
22. ANS: 2, 3, 4, 5
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Developing teaching and support strategies for the surgical patient and his or her
family
Chapter page reference: 284-286
Heading: Patient Preparation for the Surgical Experience
Integrated Processes: Nursing Process – Planning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1. This is incorrect. The suffix -ectomy indicates removal of an organ. The patient is having
surgery to repair lacerations. No organ is identified for removal.
2. This is correct. Emergency surgery is performed when a condition is life-threatening.
3. This is correct. Surgery to control internal hemorrhage from lacerations is an example of
emergency surgery. An open procedure usually requires a longer hospital stay.
4. This is correct. Open procedures place the patient at a higher risk for blood loss.
5. This is correct. If there is a large surgical opening, the patient cannot be adequately covered
and will be exposed to cold surgical suite air, and can develop hypothermia.
Feedback
1. This is correct. For the older patient, make sure the patient can hear the information to be
presented or provide information through alternative means.
2. This is incorrect. Transportation needs of the patient after discharge would not be part of the
preoperative teaching plan.
3. This is correct. Older adults are at greater risk for pneumonia and other postoperative
complications and should have teaching related to deep breathing and coughing.
4. This is correct. The older patient is going to need assistance once discharged and should have
the necessary medical equipment such as walkers and raised toilet seats, assistance with
transportation, or extended care.
5. This is correct. The older patient is at risk for pressure ulcer formation because of poor
nutritional status, diabetes, cardiovascular illness, or history of steroid use.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
24. ANS: 1, 3, 4, 5
Feedback
1. This is correct. The location of incisions is included in the preoperative teaching session.
2. This is incorrect. Discharge information is not included in the preoperative teaching session.
3. This is correct. Drains to expect after the surgical procedure is information included in the
preoperative teaching session.
4. This is correct. Postoperative pain management is information included in the preoperative
teaching session.
5. This is correct. Coughing and deep breathing exercises is information included in the
preoperative teaching session.
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Developing teaching and support strategies for the surgical patient and his or her
family
Chapter page reference: 284-286
Heading: Patient Preparation for the Surgical Experience
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1. This is incorrect. The nurse evaluates the patient’s understanding through the questions asked
and the return demonstration of skills performed.
2. This is incorrect. Although preoperative teaching can help to reduce anxiety, it is unlikely to
completely eliminate fear.
3. This is correct. The nurse evaluates the patient’s understanding through the questions asked
and the return demonstration of skills performed.
4. This is correct. The nurse evaluates the patient’s understanding through the questions asked
and the return demonstration of skills performed.
5. This is correct. The nurse evaluates the patient’s understanding through the questions asked
and the return demonstration of skills performed.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The patient is transferred to the operating table. Which dimension of the operative period is the patient
currently experiencing?
1) Postoperative period
2) Preoperative period
3) Perioperative period
4) Intraoperative period
____ 2. The nurse is performing a surgical hand scrub, and holds the hands in which position when rinsing?
1) Straight out from the elbows
2) Lower than the elbows
3) Higher than the elbows
4) Irrelevant as long as the hands are well scrubbed
____ 3. Which personal protective equipment should the scrub nurse don to decrease the likelihood of a splash injury
during a surgical procedure?
1) Gloves
2) Gown NURSINGTB.COM
3) Mask
4) Eyewear
____ 4. Which classification should the nurse document, according to the American Society of Anesthesiologists, for
a patient who is diagnosed with a mild systemic disease?
1) 2
2) 3
3) 4
4) 5
____ 5. Which classification should the nurse document, according to the American Society of Anesthesiologists, for
a patient who is diagnosed with a severe systemic disease?
1) 2
2) 3
3) 4
4) 5
____ 6. Which classification should the nurse document, according to the American Society of Anesthesiologists, for
a patient who is diagnosed with a severe systemic disease that is a threat to life?
1) 2
2) 3
3) 4
4) 5
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 7. Which classification should the nurse document, according to the American Society of Anesthesiologists, for
a patient who is not expected to survive without the planned surgical procedure?
1) 2
2) 3
3) 4
4) 5
____ 8. Which American Society of Anesthesiologists’ classification should the circulating nurse document for a
patient who is brain-dead and having organs procured for donation?
1) 3
2) 4
3) 5
4) 6
____ 9. Which term should the nurse document for a patient who is having surgery for the removal of female
reproductive organs?
1) Episiotomy
2) Hysterectomy
3) Amniocentesis
4) Cholecystectomy
____ 10. Which term should the nurse document for a patient who is having surgery for the removal of the gallbladder?
1) Episiotomy
2) Hysterectomy
3) Amniocentesis
4) Cholecystectomy
NURSINGTB.COM
____ 11. The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure.
When documenting the administration of propofol, which terminology should the nurse use?
1) A narcotic analgesic
2) An intravenous anesthetic
3) A depolarizing muscle relaxant
4) A nondepolarizing muscle relaxant
____ 12. The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure.
When documenting the administration of morphine sulfate, which terminology should the nurse use?
1) A narcotic analgesic
2) An intravenous anesthetic
3) A depolarizing muscle relaxant
4) A nondepolarizing muscle relaxant
____ 13. The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure.
When documenting the administration of cisatracurium, which terminology should the nurse use?
1) A narcotic analgesic
2) An intravenous anesthetic
3) A depolarizing muscle relaxant
4) A nondepolarizing muscle relaxant
____ 14. The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure.
When documenting the administration of succinylcholine, which terminology should the nurse use?
1) A narcotic analgesic
2) An intravenous anesthetic
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Completion
Complete each statement.
20. Place the steps the nurse will take to don sterile gloves using the close procedure. (Enter the number of each
step in the proper sequence; do not use punctuation or spaces. Example: 1234)
1. With the dominant hand, pick up the opposite glove with the thumb and index finger, handling it through
the sleeve.
2. Open the sterile glove wrapper while the hands are still covered by the sleeves.
3. Use the nondominant hand to grasp the cuff of the glove through the gown cuff, and firmly anchor it.
4. Extend the fingers into the glove as you pull the glove up over the cuff.
5. Place the fingers of the gloved hand under the cuff of the remaining glove.
Multiple Response
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Identify one or more choices that best complete the statement or answer the question.
____ 21. Which individuals should the nurse emphasize when discussing providers who take part in providing patient
care during the intraoperative period of the surgical process? Select all that apply.
1) Surgeon
2) Postoperative nurse
3) Circulating nurse
4) Anesthesiologist
5) Social worker
____ 22. Which of these items would the perioperative nurse identify as part of the intraoperative documentation?
Select all that apply.
1) Pain assessment
2) Start and stop times of anesthesia
3) Medication review
4) Antibiotic infusion times
5) Start and stop times of the procedure
____ 23. Which is included in the scope of practice for the circulating registered nurse (RN)? Select all that apply.
1) Obtaining informed consent
2) Conducting the initial assessment
3) Assisting the CRNA with patient monitoring
4) Labeling patient samples and sending for analysis
5) Documenting information pertinent the surgical procedure
____ 24. The nurse works in a facility whose policy requires an antiseptic hand rub instead of a surgical scrub when
NURare
performing surgical hand asepsis. Which SIknown
NGTBadvantages
.COM of the hand rub over the scrub? Select all that
apply.
1) Less harmful to the skin
2) Does not require the use of a brush
3) Contains ingredients that help to protect the skin
4) Takes longer to perform
5) Contains alcohol, which could dry the skin
____ 25. Which members of the surgical team are considered sterile? Select all that apply.
1) Surgeon
2) Scrub nurse
3) Anesthesiologist
4) Circulating nurse
5) Surgical assistant
____ 26. Which actions by the nurse are appropriate when preparing a patient for a surgical procedure that requires
supine positioning? Select all that apply.
1) Placing the patient on his or her back
2) Supporting the patient’s head in a headrest
3) Placing the patient’s feet on a padded footboard
4) Placing the patient’s arms at the sides with palms down
5) Lowering the foot of the bed flexing the patient’s knees
____ 27. Which actions by the nurse are appropriate when preparing a patient for a surgical procedure that requires
Fowler’s positioning? Select all that apply.
1) Placing the patient in a lateral position
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
NURSINGTB.COM
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Explaining priority assessments and procedures in the OR
Chapter page reference: 290-291
Heading: Overview of the Surgical Experience
Integrated Processes: Nursing Process – Planning
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Knowledge [Remembering]
Concept: Perioperative
Difficulty: Easy
Feedback
1 The postoperative phase begins with the admission of the patient to the postanesthesia
care unit, and ends when healing is complete.
2 The preoperative phase begins when surgery is planned, and ends when the patient is
transferred to the operating table.
3 The perioperative period covers all three time periods, from planning surgery until
healing is complete.
4 The intraoperative phase begins when the patient is transferred to the operating table,
and ends when the patient is admitted to the recovery room.
NURSINGTB.COM
PTS: 1 CON: Perioperative
2. ANS: 3
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Explaining priority assessments and procedures in the OR
Chapter page reference: 293-295
Heading: Priority Assessments and Procedures
Integrated Processes: Nursing Process – Implementation
Client Need: Safe and Effective Care Environment – Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1 This is not an appropriate nursing action during the surgical scrub.
2 This is not an appropriate nursing action during the surgical scrub.
3 The hands should be held higher than the elbows so the water drains down to the
elbows and prevents contamination of the clean hands by water running from above the
scrubbed area.
4 This is not an appropriate nursing action during the surgical scrub.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3 This is the appropriate classification for a patient with severe systemic disease that is a
constant threat to life.
4 This is the appropriate classification for a moribund patient who is not expected to
survive without the operation.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 An episiotomy is an incision made to the vagina during childbirth; -otomy is the suffix
that indicates an incision.
2 A hysterectomy is the removal of the female reproductive organs; -ectomy is the suffix
that indicates the removal of organs.
3 An amniocentesis is the removal of amniotic fluid during pregnancy for analysis; -
centesis is the suffix that indicates puncture.
4 A cholecystectomy is the removal of the gallbladder; -ectomy is the suffix that indicates
the removal of organs.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Heading: Anesthesia
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Perioperative; Medication
Difficulty: Moderate
Feedback
1 Morphine sulfate is a narcotic analgesic.
2 Propofol is an intravenous anesthetic.
3 Succinylcholine is a depolarizing muscle relaxant.
4 Cisatracurium is a nondepolarizing muscle relaxant.
Feedback
1 Fentanyl is a narcotic analgesic administered for pain.
2 Atropine is an anticholinergic agent that reverses muscle relaxants, not depolarizing
neuromuscular agents.
3 Neostigmine is a cholinergic agent that reverses the effects of cisatracurium, a
depolarizing neuromuscular agent.
4 Glycopyrrolate is an anticholinergic agent that reverses muscle relaxants, not
depolarizing neuromuscular agents.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
COMPLETION
20. ANS:
21354
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Explaining priority assessments and procedures in the OR
Chapter page reference: 290-291
Heading: Overview of the Surgical Experience
Integrated Processes: Nursing Process – Implementation
Client Need: Safe and Effective Care Environment – Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback: The first step of the process is to open the sterile glove wrapper while the hands are covered by the
sleeves of the gown. Next, with the dominant hand, pick up the opposite glove with the thumb and index
finger, handling it through the sleeve. The third step is to use the nondominant hand to grasp the cuff of the
glove through the gown cuff, and firmly anchor it. The fourth step is to place the fingers of the gloved hand
under the cuff of the remaining glove. Finally, the nurse will extend the fingers into the glove and pull the
glove up over the cuff.
MULTIPLE RESPONSE
21. ANS: 1, 3, 4
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Identifying the roles and responsibilities of operating room (OR) team members
Chapter page reference: 291-293
Heading: Overview of the Surgical Team Members
Integrated Processes: Caring
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Knowledge [Remembering]
Concept: Perioperative
Difficulty: Easy
Feedback
1. This is correct. The surgeon
NURperforms
SINGTthe B.procedure.
COM
2. This is incorrect. The postoperative nurse will provide care to the patient after the surgery is
completed.
3. This is correct. The circulating nurse is a perioperative registered nurse who cares for the
patient during the surgical procedure.
4. This is correct. The anesthesiologist provides the anesthesia during the surgery and continually
monitors the patient’s physiologic status.
5. This is incorrect. The social worker will not be in attendance during the procedure but may
become involved in the patient’s care during the preoperative and postoperative phases.
Feedback
1. This is incorrect. The pain assessment and medication review are documented during both the
preoperative and postoperative assessments.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1.
NURSINGTB.COM
This is incorrect. The surgical provider obtained the informed consent during the preoperative
period.
2. This is correct. The circulating RN conducts the initial assessment when the patient is received
to the surgical suite.
3. This is correct. The circulating RN assists the anesthesia provider with patient monitoring.
4. This is correct. The circulating RN labels patient samples and sends them for analysis.
5. This is correct. The circulating RN documents information pertinent to the surgical procedure.
Feedback
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1. This is correct. The antiseptic rub was implemented because it is less harmful to the skin, does
not require the use of a brush, and contains ingredients that actually protect the skin. As a
result, the nurse is less likely to develop abrasions or dermatitis when using a hand rub instead
of the older method of scrubbing the hands using a brush and caustic soaps.
2. This is correct. The antiseptic rub was implemented because it is less harmful to the skin, does
not require the use of a brush, and contains ingredients that actually protect the skin. As a
result, the nurse is less likely to develop abrasions or dermatitis when using a hand rub instead
of the older method of scrubbing the hands using a brush and caustic soaps.
3. This is correct. The antiseptic rub was implemented because it is less harmful to the skin, does
not require the use of a brush, and contains ingredients that actually protect the skin. As a
result, the nurse is less likely to develop abrasions or dermatitis when using a hand rub instead
of the older method of scrubbing the hands using a brush and caustic soaps.
4. This is incorrect. The antiseptic hand rub is faster, not longer, to perform.
5. This is incorrect. The antiseptic hand rub does not contain any drying agents, such as alcohol.
Feedback
1. This is correct. The surgeon is considered sterile during a surgical procedure.
2. This is correct. The scrub nurse is considered sterile during a surgical procedure.
3. This is incorrect. The anesthesiologist is not considered sterile during the surgical procedure.
4. This is incorrect. The circulating nurse is not considered sterile during the surgical procedure.
5. This is correct. The surgical assistant is considered sterile during a surgical procedure.
Feedback
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1. This is correct. This is an appropriate nursing action when using the supine position during a
surgical procedure.
2. This is incorrect. This nursing action is appropriate for Fowler’s position during a surgical
procedure.
3. This is incorrect. This nursing action is appropriate for Fowler’s position during a surgical
procedure.
4. This is correct. This is an appropriate nursing action when using the supine position during a
surgical procedure.
5. This is incorrect. This nursing action is appropriate for Fowler’s position during a surgical
procedure.
Feedback
1. This is incorrect. The lateral position is side-lying and would not be used if the surgical
NURSINGTB.COM
procedure required the patient to be positioned in Fowler’s position.
2. This is correct. This nursing action is appropriate for Fowler’s position during a surgical
procedure.
3. This is correct. This nursing action is appropriate for Fowler’s position during a surgical
procedure.
4. This is incorrect. This is an appropriate nursing action when using the supine position during a
surgical procedure.
5. This is correct. This nursing action is appropriate for Fowler’s position during a surgical
procedure.
Feedback
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1. This is correct. Pediatric patients are at an increased risk for complications during surgical
procedures due to required positioning.
2. This is correct. Older adult patients are at an increased risk for complications during surgical
procedures due to required positioning.
3. This is incorrect. A young adult patient is not at risk for complications due to positioning
during surgical procedures.
4. This is incorrect. A patient diagnosed with bipolar disorder is not at risk for complications due
to positioning during surgical procedures.
5. This is correct. Any patient diagnosed with a disease process affecting circulation, such as
diabetes mellitus, is at an increased risk for complications during surgical procedures due to
required positioning.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. Which laboratory test should the postanesthesia care nurse monitor closely for a patient who is prescribed
warfarin in the treatment of atrial fibrillation?
1) Serum glucose NURSINGTB.COM
2) Serum potassium
3) Prothrombin (PT) time
4) Blood urea nitrogen (BUN)
____ 2. The nurse is assessing a patient’s postoperative wound and finds it has separated from the suture line with
extrusion of the bowel through the opening. When documenting this finding, which term will the nurse use?
1) Wound infection
2) Wound dehiscence
3) Wound evisceration
4) Wound tunneling
____ 3. The nurse is caring for a patient with a drain connected to a portable drainage suction device shaped like a
grenade made of plastic. Which term will the nurse use when describing this system during end-of-shift
report?
1) Closed wound drainage system
2) Hemovac
3) Jackson-Pratt
4) Reinfusion drain
____ 4. The patient arrives at the surgeon’s office one week after surgery to have the sutures removed. Which
classification would the nurse use when documenting care for this patient?
1) Preoperative
2) Postoperative
3) Perioperative
4) Intraoperative
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 5. Upon receiving the patient from the postanesthesia care unit, which nursing action is the priority?
1) Apply clean linens to the bed
2) Assemble required equipment, such as suction, IV pole, or oxygen equipment
3) Assess the patient
4) Notify the family of the patient’s return to the room
____ 6. In the ongoing postoperative period, the nurse independently determines, within the protocols of the hospital,
the need for which provision of care?
1) Type of diet
2) Activity level
3) Assessment intervals
4) Intravenous solutions
____ 7. The postoperative patient displays sudden chest pain, shortness of breath, cyanosis, tachycardia, and low
blood pressure. The nurse suspects which postoperative complication?
1) Pneumonia
2) Atelectasis
3) Hypovolemia
4) Pulmonary embolism
____ 8. Which laboratory test should the postanesthesia care nurse monitor for a patient who is having difficulty
regaining consciousness after a surgical procedure?
1) Serum glucose
2) Serum potassium
3) Prothrombin (PT) time
4) Blood urea nitrogen (BUN) NURSINGTB.COM
____ 9. Which is the priority laboratory test that the postanesthesia care nurse should monitor closely for an older
adult patient with renal disease who retained fluid during a surgical procedure?
1) Serum glucose
2) Serum potassium
3) Prothrombin (PT) time
4) Blood urea nitrogen (BUN)
____ 10. The postanesthesia care nurse is providing care to a patient with fluid volume overload who is experiencing
cardiac dysrhythmias. Which laboratory test should the nurse monitor for this patient?
1) Serum glucose
2) Serum potassium
3) Prothrombin (PT) time
4) Blood urea nitrogen (BUN)
____ 11. The medical-surgical nurse is providing care to a postoperative patient who is experiencing an elevated
temperature. Which laboratory value should the nurse monitor to gather more information?
1) Platelet count
2) Serum glucose
3) Red blood cell (RBC) count
4) White blood cell (WBC) count
____ 12. Which nursing action is appropriate when providing care to a patient who is difficult to arouse in the
postanesthesia care unit (PACU)?
1) Monitor breath sounds
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 20. The nurse is providing care to a patient in the postanesthesia care unit (PACU) who lost a large amount of
blood during a surgical procedure. Which assessment finding should the nurse monitor this patient for based
on the current data?
1) Bradypnea
2) Tachycardia
3) Hypothermia
4) Hypertension
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. The postoperative nurse is planning care for a patient recovering from major thoracic surgery. Which nursing
diagnoses should the nurse select to plan for this patient’s immediate care needs? Select all that apply.
1) Risk for Impaired Gas Exchange
2) Risk for Decreased Cardiac Output
3) Risk for Ineffective Airway Clearance
4) Risk for Imbalanced Nutrition: Less than Body Requirements
5) Risk for Imbalanced Fluid Volume
____ 22. Which tasks can the nurse assign to the unlicensed assistive personnel (UAP) who is assisting with providing
care to postoperative patients on a medical–surgical unit? Select all that apply.
1) Documenting the assessment completed by the nurse
2) Giving the patient pain medication as ordered by the health-care provider
3) Assisting with patient exercises
4) Reporting when a patient cannotNcomplete
URSINexercises
GTB.COM
5) Conducting discharge teaching
____ 23. Which information should the postanesthesia care unit (PACU) nurse include in the hand-off that occurs with
the medical-surgical nurse who will assume care? Select all that apply.
1) Fluid intake and blood loss
2) Placement of intravenous (IV) lines
3) Patient identification using one identifier
4) Information regarding the surgical procedure
5) Over-the-counter (OTC) medications taken at home
____ 24. Which nursing actions are appropriate during Phase I of the postoperative period? Select all that apply.
1) Providing discharge instructions
2) Assessing vital signs per protocol
3) Monitoring electrocardiogram continuously
4) Providing ongoing care until a bed is available
5) Preparing for transfer to the medical-surgical unit
____ 25. Which are appropriate nurse-to-patient ratios in the postanesthesia care unit (PACU)? Select all that apply.
1) 1:1
2) 1:2
3) 1:3
4) 1:4
5) 1:5
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MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Explaining the priority assessments for the postsurgical patient
Chapter page reference: 312-314
Heading: Patient Care in the Post-Anesthesia Care Unit (PACU)
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1 Serum glucose is monitored for a patient who is having difficulty regaining
consciousness in the postoperative period.
2 Serum potassium is monitored for patients who experienced abnormal fluid or blood
losses and for patients who may have been overhydrated.
3 A PT time is monitored closely for any patient who is prescribed warfarin. Warfarin is
often stopped for several days prior to a surgical procedure. However, this patient will
continue to be at an increased risk for bleeding.
4 A BUN is monitored for any patient who may have experienced abnormal fluid or
blood losses during surgery. ANBUN
URSshould
INGTalsoB.C beOmonitored
M for older adult patients
and for those with renal disease.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Explaining the priority assessments for the postsurgical patient
Chapter page reference: 312-314
Heading: Patient Care in the Post-Anesthesia Care Unit (PACU)
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Perioperative; Communication
Difficulty: Moderate
Feedback
1 All of these drains are nonspecifically known as closed wound drainage systems.
2 A Hemovac is a flat disk.
3 The drain described, shaped like a grenade, is a Jackson-Pratt.
4 A reinfusion drain allows collection of blood from the wound for readministration.
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Feedback
1 Clean linens should be applied to the bed as soon as the patient leaves for surgery or
upon notification that the patient will be coming to the unit.
2 Equipment should be gathered in advance and set up to be ready when the patient
returns.
3 The priority action for the nurse is to perform a thorough assessment of the patient’s
condition.
4 Only after assessing the patient would the nurse notify family members.
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4 The patient is displaying signs of pulmonary emboli, which will cause sudden chest
pain and difficulty breathing.
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Difficulty: Moderate
Feedback
1 The nurse would monitor breath sounds for a patient experiencing inadequate
oxygenation.
2 The nurse would administer a prescribed anticoagulant, such as heparin, for a patient
who is experiencing venous thromboembolism (VTE).
3 A patient who is difficult to arouse should have prescribed analgesics held until the
patient stabilizes.
4 The nurse would assess a patient for malignant hyperthermia for a patient who is
experiencing an increased temperature in the PACU.
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4 While blood pressure is an important parameter in the nursing assessment, this is not
the priority. The ABCs should guide priority during the initial nursing assessment for
the patient admitted to the PACU.
MULTIPLE RESPONSE
21. ANS: 1, 2, 5
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Applying the vital postoperative interventions for the patient in the immediate
postoperative period
Chapter page reference: 315-317
Heading: Nursing Interventions
Integrated Processes: Nursing Process – Diagnosis
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Perioperative
Difficulty: Difficult
Feedback
1. This is correct. Nursing diagnoses appropriate for the immediate postoperative phase include
the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the
Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid
Volume because of blood loss and nothing by mouth status.
2. This is correct. Nursing diagnoses appropriate for the immediate postoperative phase include
the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the
Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid
Volume because of blood loss and nothing by mouth status.
3. This is incorrect. The Risk for Ineffective Airway Clearance might be appropriate later as the
patient recovers from surgery.
4. This is incorrect. There is no Risk for Imbalanced Nutrition: Less than Body Requirements
during the immediate postoperative phase.
5. This is correct. Nursing diagnoses appropriate for the immediate postoperative phase include
the Risk for Impaired GasNUExchange
RSINGbecause
TB.COofManesthesia medications and hypothermia, the
Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid
Volume because of blood loss and nothing by mouth status.
Feedback
1. This is incorrect. The nurse performs and documents the patient assessment, not the UAP.
2. This is incorrect. The UAP cannot pass medications.
3. This is correct. The UAP can assist the patient with exercises and report any problems the
patient has when performing exercises.
4. This is correct. The UAP can assist the patient with exercises and report any problems the
patient has when performing exercises.
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Feedback
1. This is correct. Fluid intake and blood loss is included in the hand-off communication process
between the PACU and medical-surgical nurses.
2. This is correct. Information regarding the placement of IV lines is included in the hand-off
communication process between the PACU and medical-surgical nurses.
3. This is incorrect. Patient identification during the hand-off process should include two patient
identifiers, not one.
4. This is correct. Information regarding the surgical procedure is included in the hand-off
communication process between the PACU and medical-surgical nurses.
5. This is incorrect. Important medications taken by the patient at home, not OTC medications,
NURSINGTB.COM
should be included in the hand-off process.
Feedback
1. This is incorrect. This is not an appropriate nursing action during Phase I of the postoperative
period.
2. This is correct. Assessing vital signs per protocol is an appropriate nursing action during
Phase I of the postoperative period.
3. This is correct. Monitoring the electrocardiogram continuously is an appropriate nursing
action during Phase I of the postoperative period.
4. This is incorrect. Providing ongoing care until a bed is available is not an appropriate nursing
action during Phase I of the postoperative period.
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5. This is incorrect. Preparing for transfer to the medical-surgical unit is not an appropriate
nursing action during Phase I of the postoperative period.
Feedback
1. This is correct. This is an appropriate nurse to patient ratio in the PACU.
2. This is correct. This is an appropriate nurse to patient ratio in the PACU.
3. This is correct. This is an appropriate nurse to patient ratio in the PACU if one patient is
awaiting transfer to another unit or awaiting discharge home.
4. This is incorrect. This is not an appropriate nurse to patient ratio in the PACU.
5. This is incorrect. This is not an appropriate nurse to patient ratio in the PACU.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. Which physiological barriers protect the patient’s body against microorganisms?
1) A surgical incision
2) Occasional smoking
3) Alcoholic beverages
4) Adequate urinary output
____ 2. A nurse working in the emergency department (ED) is providing care for a group of patients. Which patient
demonstrates a decline in immune response that typically occurs with the aging process?
1) An 88-year-old with pneumonia who has a temperature of 99.5°F.
2) A 56-year-old who has 8 mm induration at the site of a PPD skin test 72 hours earlier.
3) A 58-year-old who reports redness and itching due to a rash from contact with poison ivy.
4) A 70-year-old who has swelling and redness at the incision from an open appendectomy.
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____ 3. The nurse is providing care to a patient who has an increased number of lymphocytes. Which explanation
should the nurse provide to the patient regarding this abnormality?
1) “An elevated neutrophil count indicates your body is battling a parasitic infection.”
2) “An elevated neutrophil count indicates your body is battling a bacterial infection.”
3) “An elevated neutrophil count indicates your body is experiencing an allergic reaction.”
4) “An elevated neutrophil count indicates your body is experiencing an adaptive immune
response.”
____ 4. Which scenario should the nurse provide as one in which active immunity is acquired when educating a group
within the community?
1) Having measles as a child
2) Receiving an injection of gamma globulin
3) Becoming ill with tetanus and receiving tetanus toxoid
4) Receiving a rabies shot after being bitten by a rabid dog
____ 5. The nurse is providing care to a patient with a compromised immune system. Which independent nursing
intervention is appropriate for the nurse to include in the patient’s plan of care?
1) Recommending gene transfer therapy
2) Administering corticosteroids, per order
3) Prescribing prophylactic antibiotic therapy
4) Educating on the importance of a nutritious diet
____ 6. A nurse is caring for a patient with who is experiencing leukocytosis. When providing care to this patient,
which action by the nurse is the most appropriate?
1) Assess for source of infection
2) Assess for bleeding and bruising
NURprecautions
3) Place the patient in reverse isolation SINGTB.COM
4) Instruct the patient on the use of an electric razor and soft toothbrush
____ 7. Which question should the nurse to ask during a health history with an adolescent patient, accompanied by a
parent, to determine immune status?
1) “Is your child sexually active?”
2) “Is your child planning to go to college?”
3) “Does your child smoke tobacco products?”
4) “Are your child’s immunizations up-to-date?”
____ 8. Which nursing action is appropriate when assessing a patient’s tonsils during a physical examination?
1) Asking the patient to cough several times
2) Asking the patient to open the mouth and say “ah”
3) Palpating the soft tissue of the face near the patient’s nose
4) Palpating the left upper quadrant of the patient’s abdomen
____ 9. Which type of immunoglobulin (Ig) is produced during an allergic reaction?
1) IgA
2) IgD
3) IgE
4) IgM
____ 10. Which nutritional deficiency often impacts a patient’s ability to mount an immune response?
1) Proteins
2) Calcium
3) Potassium
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4) Carbohydrates
____ 11. The nurse is providing care to a patient who experienced an allergic reaction. Which leukocyte does the nurse
anticipate will be elevated?
1) Basophils
2) Monocytes
3) Eosinophils
4) Neutrophils
____ 12. The nurse is teaching a new mother the immune benefits of breastfeeding her newborn. Which
immunoglobulin (Ig) should the nurse include as one that is passed from mother to newborn by breast milk?
1) IgA
2) IgD
3) IgE
4) IgG
____ 13. The nurse is providing care to a patient who has a decreased neutrophil count and elevated hepatic enzymes.
Which data in the patient’s health history supports this laboratory data indicating an increased risk for
infection?
1) Anorexia nervosa
2) Acute renal failure
3) Pulmonary disease
4) Cirrhosis of the liver
____ 14. The nurse is providing care to patient who is at an increased risk for infection due to poor dietary intake, a
decreased white blood cell count, and diminished neutrophil activity. Which information in the patient’s
health history supports the current data?
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1) Anorexia nervosa
2) Acute renal failure
3) Pulmonary disease
4) Cirrhosis of the liver
____ 15. The nurse is providing care to a patient who had the spleen removed after a car accident. Which type of
infection is this patient at an increased risk for experiencing?
1) Viral
2) Fungal
3) Parasitic
4) Bacterial
____ 16. Which laboratory test should the nurse anticipate for a patient who reports chronic inflammation?
1) Varicella titer
2) Type and crossmatch
3) Erythrocyte sedimentation rate (ESR)
4) Complete blood count (CBC), with differential
____ 17. The nurse is teaching a group of patients about first-line defense against infection. Which patient statement
indicates the need for further education?
1) “The skin is a first-line defense against infection.”
2) “A sneeze is a mechanical first-line defense against infection.”
3) “My saliva is a biochemical first-line defense against infection.”
4) “A cut with pus is a mechanical first-line defense against infection.”
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____ 18. The nurse is conducting a health history for a patient who is at risk for infection. Which question is
appropriate when collecting data related to the current problem?
1) “Do you smoke cigarettes?”
2) “Are your immunizations current and up-to-date?”
3) “What type of reaction do you have with an allergy flair?”
4) “Did you have your spleen removed after your car accident?”
____ 19. The nurse is conducting a health history for a patient who is at risk for infection. Which question is
appropriate when collecting data related to the patient’s social history?
1) “Do you smoke cigarettes?”
2) “Are your immunizations current and up-to-date?”
3) “What type of reaction do you have with an allergy flair?”
4) “Did you have your spleen removed after your car accident?”
____ 20. The nurse is conducting a health history for a patient who is at risk for infection. Which question is
appropriate when collecting data related to the patient’s past medical history?
1) “Do you smoke cigarettes?”
2) “Are your immunizations current and up-to-date?”
3) “What type of reaction do you have with an allergy flair?”
4) “Did you have your spleen removed after your car accident?”
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. A patient receives the yellow fever vaccine before traveling to the Amazon Basin and asks the nurse how the
NURSINbyGthe
vaccine provides protection. Which responses TBnurse
.COisM the most appropriate? Select all that apply.
1) “The body's immune system eats away at the protective sheath that covers the nerves.”
2) “A response from yellow fever-specific T cells is activated. B cells secrete yellow fever
antibodies.”
3) “In the lymph nodes, part of the lymphoid system, the macrophages present yellow fever
antigens to T cells and B cells.”
4) “The initial weak infection is eliminated and the patient is left with a supply of memory T
and B cells for future protection against yellow fever.”
5) “Human macrophages engulf the weakened vaccine virus as if it is dangerous and antigens
stimulate the immune system to attack it.”
____ 22. The nurse is conducting a physical assessment for a patient with a compromised immune system. Which
actions by the nurse are appropriate? Select all that apply.
1) Assessing general appearance
2) Recommending increased fluid intake
3) Checking joint range of motion (ROM), including that of the spine
4) Inspecting the mucous membranes of the nose and mouth for color and condition
5) Palpating the cervical lymph nodes for evidence of lymphadenopathy or tenderness
____ 23. Which locations should the nurse include when discussing the storage and production of lymphocytes during
an education session for novice nurses? Select all that apply.
1) Liver
2) Spleen
3) Thymus
4) Lymph nodes
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5) Bone marrow
____ 24. The nurse is assessing a patient’s immune system. Which findings increase the patient’s risk for infection due
to alterations in biochemical barriers? Select all that apply.
1) Dysphagia
2) Dry mouth
3) Nonintact skin
4) Urinary retention
5) Clogged tear duct
____ 25. The nurse is assessing a patient’s immune system. Which findings increase the patient’s risk for infection due
to alterations in mechanical barriers? Select all that apply.
1) Dysphagia
2) Dry mouth
3) Nonintact skin
4) Urinary retention
5) Clogged tear duct
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Identifying key anatomical components of the immune system
Chapter page reference: 321-330
Heading: Overview of Anatomy and Physiology
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Knowledge [Remembering]
Concept: Immunity
Difficulty: Easy
Feedback
1 A surgical incision can both allow microorganisms to enter the body.
2 The consumption of alcoholic beverages has been known to increase the risk for
infection.
3 Occasional smoking does not defend the body from microorganisms; it destroys the
cilia in the nose that helps to filter organisms.
4 A physiological barrier protecting patients against microorganism is adequate urinary
output. The act of voiding flushes organisms that might try to enter the body through
the urinary meatus.
NURSINGTB.COM
PTS: 1 CON: Immunity
2. ANS: 1
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Discussing changes in immune function associated with aging
Chapter page reference: 335-336
Heading: Age-Related Changes
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Easy
Feedback
1 The patient who has only a slight elevation in temperature in response to pneumonia is
an example of a decline in the expected immune response.
2 This patient is demonstrating an expected immune response as evidenced by redness,
swelling, and induration.
3 This patient is demonstrating an expected immune response as evidenced by redness,
swelling, and induration.
4 This patient is demonstrating an expected immune response as evidenced by redness,
swelling, and induration.
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Feedback
1 It is outside the scope of nursing practice to prescribe medication and to recommend
therapies. The nurse can administer antibiotics and educate the patient on gene transfer
therapy, if prescribed by the health-care provider.
2 Administering corticosteroids, per order, is a collaborative intervention.
3 It is outside the scope of nursing practice to prescribe medication and to recommend
therapies. The nurse can administer antibiotics and educate the patient on gene transfer
therapy, if prescribed by the health-care provider.
4 While these may be appropriate treatments for a patient who is experiencing a
compromised immune system, the only independent nursing intervention is educating
the patient on the importance of a nutritious diet.
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Difficulty: Moderate
Feedback
1 While sexual activity places the adolescent at risk for sexual transmitted infections, this
is not the most appropriate question for the nurse to ask to determine immune status.
2 This question is not applicable to the adolescent’s immune status.
3 While smoking can increase the risk for infection, this is not an appropriate question for
the nurse to ask an adolescent patient when a parent is in the room.
4 Inquiring about the child’s immunization status is appropriate during the health history
interview to determine immune status.
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10. ANS: 1
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Identifying key anatomical components of the immune system
Chapter page reference: 321-330
Heading: Overview of Anatomy and Physiology
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Easy
Feedback
1 Nutritional status is a critical component of immunocompetence. Cellular immunity,
phagocyte activity, and complement ability are greatly impacted by protein
deficiencies.
2 A calcium deficiency is more likely to impact bone health.
3 A potassium deficiency is more likely to impact cardiovascular health.
4 A carbohydrate deficiency does not impact a patient’s ability to mount an immune
response.
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1 IgA is passed from mother to newborn in breast milk and provides immunity to the
newborn.
2 IgD is not secreted in breast milk.
3 IgE is not secreted in breast milk.
4 IgG is passed through the placenta during pregnancy and provides the newborn with
some immunity during the first few months of life.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
20. ANS: 4
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of a
patient with impaired immune function
Chapter page reference: 330-334
Heading: Assessment of the Immune System
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1 This question is appropriate to assess the patient’s social history.
2 This question is appropriate to assess the patient’s immunization history.
3 This question is appropriate to assess the patient’s current problem.
4 This question is appropriate to assess the patient’s past medical or surgical history.
MULTIPLE RESPONSE
21. ANS: 2, 3, 4, 5
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to immune
function NURSINGTB.COM
Chapter page reference: 321-330
Heading: Overview of Anatomy and Physiology
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1. This is incorrect. The immune system damaging the myelin is the autoimmune response that
occurs with multiple sclerosis (MS).
2. This is correct. Antibodies directly attack and destroy antigens either before or after antigens
invade body cells.
3. This is correct. Lymph nodes filter foreign products or antigens from the lymph system and
house and support proliferation of lymphocytes and macrophages.
4. This is correct. Memory B cells and T cells remember how to identify the antigen and will
reactivate at a future time if the same type of antigen is present.
5. This is correct. Macrophages ingest antigens and signal helper T cells that antigens are
present.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Describing the procedure for completing a history and physical assessment of a
patient with impaired immune function
Chapter page reference: 330-334
Heading: Assessment of the Immune System
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1. This is correct. The techniques of inspection and palpation are especially important in
assessing a patient’s immune system: The nurse will assess the patient’s general appearance,
inspect the mucous membranes of the nose and mouth for color and condition, palpate the
cervical lymph nodes for swelling or tenderness, and check the patient’s ROM, including that
of the spine.
2. This is incorrect. While recommending that the patient increase fluid intake may be an
appropriate intervention, this is not an action that is conducted during the physical assessment
for this patient.
3. This is correct. The techniques of inspection and palpation are especially important in
assessing a patient’s immune system: The nurse will assess the patient’s general appearance,
inspect the mucous membranes of the nose and mouth for color and condition, palpate the
cervical lymph nodes for swelling or tenderness, and check the patient’s ROM, including that
of the spine.
4. This is correct. The techniques of inspection and palpation are especially important in
NURS
assessing a patient’s immune INGTThe
system: B.nurse
COMwill assess the patient’s general appearance,
inspect the mucous membranes of the nose and mouth for color and condition, palpate the
cervical lymph nodes for swelling or tenderness, and check the patient’s ROM, including that
of the spine.
5. This is correct. The techniques of inspection and palpation are especially important in
assessing a patient’s immune system: The nurse will assess the patient’s general appearance,
inspect the mucous membranes of the nose and mouth for color and condition, palpate the
cervical lymph nodes for swelling or tenderness, and check the patient’s ROM, including that
of the spine.
Feedback
1. This is incorrect. The liver does not store or produce lymphocytes.
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Feedback
1. This is incorrect. Swallowing is a mechanical, not biochemical, barrier to infection.
2. This is correct. Saliva is a biochemical barrier to infection. A dry mouth increases the patient’s
risk for infection.
3. This is incorrect. Intact skin is a physical, not biochemical, barrier to infection.
4. This is incorrect. Urination is a mechanical, not biochemical, barrier to infection.
5. This is correct. Tears are a biochemical barrier to infection. A clogged tear duct increases this
patient’s risk for infection.
NURSINGTB.COM
PTS: 1 CON: Immunity
25. ANS: 1, 4
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Identifying key anatomical components of the immune system
Chapter page reference: 321-330
Heading: Overview of Anatomy and Physiology
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1. This is incorrect. Swallowing is a mechanical barrier to infection. Dysphagia, or impaired
swallowing, increases the patient’s risk for infection.
2. This is correct. Saliva is a biochemical, not mechanical, barrier to infection. A dry mouth
increases the patient’s risk for infection.
3. This is incorrect. Intact skin is a physical, not mechanical, barrier to infection. Nonintact skin
increases the patient’s risk for infection.
4. This is incorrect. Urination is a mechanical barrier to infection. Urinary retention increases the
risk for bacterial growth and infection.
5. This is correct. Tears are a biochemical, not mechanical, barrier to infection. A clogged tear
duct increases this patient’s risk for infection.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 19: Coordinating Care for Patients With Connective Tissue Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A patient recently diagnosed with rheumatoid arthritis (RA) asks the nurse if the disease is caused by
ethnicity. Which response by the nurse is the most appropriate?
1) “RA affects all races at the same rate.”
2) “RA is most prevalent in Caucasian females.”
3) “RA affects those of German descent most often.”
4) “RA is most prevalent in men under the age of 20 years.”
____ 2. The nurse is collecting a health history for a patient in an outpatient clinic who reports joint pain and swelling
for the last two months. The patient is diagnosed with rheumatoid arthritis (RA). When planning care for this
patient, which statement supports the nursing diagnosis of Activity Intolerance?
1) “I seem to get tired early in the day and require a nap.”
2) “My joints are stiffest at night before I go to sleep.”
3) “I find it difficult to move when I first get up in the morning.”
4) “I take ibuprofen for the pain as needed.”
____ 3. The nurse is completing a health screening for a school-age child with rheumatoid arthritis (RA). The parents
ask the nurse to recommend activitiesNthat
URSwill
INpromote
GTB.Cexercise
OM for their child. Which recommendation by
the nurse is the most appropriate?
1) Running
2) Softball
3) Football
4) Swimming
____ 4. A patient with rheumatoid arthritis (RA) is being seen in the outpatient clinic for a progress check-up. The
nurse is reviewing the patient’s plan of care and determines that the patient has met a goal of treatment when
the patient makes which statement?
1) “I sleep for 10 hours at night.”
2) “I have increased pain in my joints all the time now.”
3) “I have delegated many household chores to my children and spouse.”
4) “I do not perform household chores at all anymore.”
____ 5. The nurse is caring for a patient who was diagnosed with rheumatoid arthritis (RA) last year. The patient has
recently been placed on prednisone for treatment. Which patient statement indicates that the medication
teaching was successful?
1) “I will not have to limit my consumption of canned vegetables.”
2) “I will take this medication on a full stomach to enhance absorption.”
3) “I will not need to monitor my blood sugar more frequently while on this medication.”
4) “I will take the ordered dose at the same time every day.”
____ 6. A nurse is caring for a pregnant patient who has rheumatoid arthritis (RA). Based on this data, which does the
nurse anticipate when providing care to this patient?
1) A higher risk for preterm delivery
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____ 13. A nurse is caring for a patient with systemic lupus erythematosus (SLE). The patient begins to cry stating, “I
am afraid I will be disfigured because of all of these lesions.” Which intervention does the nurse plan to teach
this patient to minimize skin infections associated with SLE?
1) Use sunscreen with an SPF of 15 or greater
2) Remain indoors on sunny days
3) Avoid swimming in a pool or the ocean
4) Decrease sun exposure between 3:00 p.m. and 5:00 p.m.
____ 14. The nurse is caring for a patient diagnosed with discoid lupus erythematosus. The nurse is collaborating with
the patient to set goals for the nursing plan of care. Which is an appropriate goal for this patient?
1) Work through the stages of death and dying
2) Compliance with a sun protection plan
3) Gain weight to within 10 pounds of normal for height
4) Report pain no higher than 4 on a scale of 1-10
____ 15. The nurse is planning care for an adolescent patient who has systemic lupus erythematosus (SLE). Which
action by the patient indicates the implemented plan of care is appropriate?
1) Refusing to attend school
2) Discussing skin changes with a good friend
3) Refraining from attending any social functions
4) Discussing skin changes with the health-care provider
____ 16. The nurse is providing care for a newly married woman with systemic lupus erythematosus (SLE). Which
patient statement indicates an appropriate understanding of the plan of care?
1) “I will take birth control pills while I am taking cytotoxic medications.”
2) “I do not need to contact the doctor if I develop a fever or rash.”
3) “I plan to go to the movies this weekend
NURSIso NGthat
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M of the house.”
4) “I can take aspirin as indicated for pain.”
____ 17. A nurse is caring for a patient with systemic lupus erythematous (SLE) who is taking hydroxychloroquine
(Plaquenil). When providing care for this patient, the nurse monitors for which adverse effect associated with
the prescribed medication?
1) Renal toxicity
2) Retinal toxicity
3) Cushingoid effects
4) Pulmonary fibrosis
____ 18. An Asian male accompanies his spouse to the clinic and states, “I want you to fix my wife and tell her that
there is nothing wrong with her.” The patient reports pain, sleep disorders, and stiffness. Which would be
most appropriate for the nurse to include in a plan of care for this family?
1) Medications used to treat fibromyalgia
2) An exercise program to increase energy
3) Information and literature on fibromyalgia
4) Suggested dietary changes to help with the pain
____ 19. The nurse identifies the nursing diagnosis of chronic pain as being appropriate for a patient with fibromyalgia.
Which manifestation did the patient most likely report that caused the nurse to select this diagnosis?
1) Acute chest pain
2) Pain from eyestrain
3) Tender points in the knees
4) Pain from a severe skin rash
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____ 20. An adult patient is diagnosed with fibromyalgia. The patient asks the nurse whether a recent of infection with
the Coxsackie B virus could have caused fibromyalgia. Which response by the nurse is the most appropriate?
1) “The Coxsackie B virus has nothing to do with fibromyalgia.”
2) “The Coxsackie B virus may have triggered the fibromyalgia.”
3) “The Coxsackie virus definitely caused the fibromyalgia.”
4) “Fibromyalgia is a psychiatric disorder.”
____ 21. The nurse is counseling an adult patient with fibromyalgia. What are some elements of counseling that can
help this patient develop effective coping skills?
1) Remind the patient that the patient has a progressive disease.
2) Suggest to the patient that some symptoms may be psychosomatic.
3) Inform the patient that the patient does not need to see a specialist.
4) Teach the patient strategies including distractions, relaxation techniques, or journaling.
____ 22. The mother of three teenagers is diagnosed with fibromyalgia and asks the nurse how to keep up with all of
the children's activities. Which suggestion by the nurse is the most appropriate?
1) Ask the children to limit their activities.
2) Attempt to attend the all the functions of the children.
3) Avoid attending any afterschool functions for the children.
4) Negotiate with the children to alternate attending their functions.
____ 23. The nurse is discussing goals to relieve pain and fatigue with a patient newly diagnosed with fibromyalgia.
Which goal statement would be realistic for this patient to achieve within 30 days?
1) Join an exercise group
2) Get a job outside the home
3) Walk her son to school daily
4) Cook dinner five nights a week NURSINGTB.COM
____ 24. During a home visit, the family of a patient with fibromyalgia asks the nurse what they can do to help the
patient with painful episodes. What should the nurse suggest to the patient and family?
1) Plan a family reunion
2) Keep the patient in bed
3) Protect the patient from injury
4) Divide household chores among each member of the family
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 25. The nurse is caring for a patient who has recently been diagnosed with fibromyalgia. Which medications does
the nurse anticipate will be prescribed as part of the patient’s treatment plan? Select all that apply.
1) Ibuprofen
2) Aerobic exercise
3) Pregabalin (Lyrica)
4) Zolpidem (Ambien)
5) Tenormin (Atenolol)
____ 26. The nurse is providing care to a patient who is receiving nonsteroidal anti-inflammatory drugs (NSAIDs) in
the treatment of rheumatoid arthritis. When providing care to this patient, which actions by the nurse are
appropriate? Select all that apply.
1) Assessing for an allergic reaction
2) Monitoring for signs of renal problems
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Chapter 19: Coordinating Care for Patients With Connective Tissue Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Describing the epidemiology of connective tissue disorders
Chapter page reference: 344-351
Heading: Rheumatoid Arthritis
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1 RA affects 12% of the total population across all races.
2 RA is not more prevalent in Caucasian females.
3 RA does not affect those of German descent most often.
4 It affects women three times more than men, and the onset is usually between the ages
of 20 and 40 years.
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Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with connective tissue disorders
Chapter page reference: 344-351
Heading: Rheumatoid Arthritis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1 Running, softball or football could exacerbate joint discomfort.
2 Running, softball or football could exacerbate joint discomfort.
3 Running, softball or football could exacerbate joint discomfort.
4 Swimming exercises all the extremities without putting undue stress on joints.
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2 Steroids are taken with food to minimize GI distress, not to enhance absorption.
3 Steroids also increase blood sugar, so blood sugar may need to be monitored more
frequently while on the medication regimen.
4 Steroid therapy is usually done as part of a tapered-dose treatment plan. It is important
to take the medication at the same time each day.
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Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Lupus
erythematosus
Chapter page reference: 354-359
Heading: Lupus
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Easy
Feedback
1 While fibromyalgia, Lyme's disease, and gout share some symptoms of SLE, they do
not cause a rash over the nose and cheeks.
2 While fibromyalgia, Lyme's disease, and gout share some symptoms of SLE, they do
not cause a rash over the nose and cheeks.
3 While fibromyalgia, Lyme's disease, and gout share some symptoms of SLE, they do
not cause a rash over the nose and cheeks.
4 The rash over the nose and cheeks is sometimes called a butterfly rash and is classic for
the diagnosis of systemic lupus erythematosus (SLE).
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Difficulty: Easy
Feedback
1 SLE affects individuals of child-bearing age.
2 There is no evidence that the audience asked for the information.
3 Among women who are of child-bearing age, SLE is seen in more African-Americans,
Hispanics, and Asian-Americans than Caucasians.
4 Among women who are of child-bearing age, SLE is seen in more African-Americans,
Hispanics, and Asian-Americans than Caucasians.
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Heading: Lupus
Integrated Processes: Nursing Process – Evaluation
Client Need: Psychosocial Integrity
Cognitive level: Analysis [Analyzing]
Concept: Immunity
Difficulty: Difficult
Feedback
1 Refusing to go to school or attend social functions indicates nonacceptance of the
changes to body image.
2 Peer interaction is important to teens. Being able to discuss the physical changes related
to SLE with a friend indicates acceptance of the change in body image.
3 Refusing to go to school or attend social functions indicates nonacceptance of the
changes to body image.
4 Discussing changes only with health-care personnel does not indicate the teen has
adjusted to the body image changes.
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Feedback
1 The physician orders medication and diets.
2 There is no proof that exercise, or lack thereof, causes fibromyalgia.
3 In many cultures, accepting a disease like fibromyalgia may be difficult due to the
vagueness of the disease. Information and written literature may help the family
understand that the disease is real.
4
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The physician orders medication and diets.
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Feedback
1 Walking her son to school daily is a bit ambitious to start, as are joining an exercise
group and getting a job outside the home.
2 Walking her son to school daily is a bit ambitious to start, as are joining an exercise
group and getting a job outside the home.
3 Walking her son to school daily is a bit ambitious to start, as are joining an exercise
group and getting a job outside the home.
4 Fibromyalgia saps the patient’s energy. The patient might set as an initial goal to be
able to perform daily tasks for the family such as cooking and doing the laundry.
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Difficulty: Moderate
Feedback
1 A family vacation might cause more stress to the patient, who would more than likely
be planning and packing.
2 Keeping the patient in bed would not be therapeutic.
3 There is no reason to believe that this patient is at higher risk for injury than another
member of the family.
4 Although the causes and treatments are not all known, there is general agreement that
reducing stress may help lessen the effects of fibromyalgia. The nurse could help the
family by suggesting ways to decrease stress on the patient by having the family pitch
in on responsibilities.
MULTIPLE RESPONSE
25. ANS: 1, 2, 3
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Discussing the medical management of: Fibromyalgia
Chapter page reference: 362-364
Heading: Fibromyalgia
Integrated Processes: Nursing Process – Planning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity NURSINGTB.COM
Difficulty: Moderate
Feedback
1. This is correct. Treatment for fibromyalgia may include NSAIDs such as ibuprofen for pain,
pregabalin (Lyrica), and aerobic exercise.
2. This is correct. Treatment for fibromyalgia may include NSAIDs such as ibuprofen for pain,
pregabalin (Lyrica), and aerobic exercise.
3. This is correct. Treatment for fibromyalgia may include NSAIDs such as ibuprofen for pain,
pregabalin (Lyrica), and aerobic exercise.
4. This is incorrect. Zolpidem (Ambien) is for producing sleep.
5. This is incorrect. Tenormin (Atenolol) is an antihypertensive drug.
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Feedback
1. This is correct. When providing care to a patient who is receiving any medication, it is
important to monitor the patient for signs of an allergic reaction.
2. This is correct. If you take NSAIDs in high doses, the reduced blood flow can permanently
damage the kidneys, and it can eventually lead to kidney failure and require dialysis.
3. This is correct. Abrupt discontinuation can have serious side effects.
4. This is incorrect. NSAIDs have been linked to heart failure; therefore, this action by the nurse
is not appropriate when providing care to this patient.
5. This is correct. Taking NSAIDs with food may help reduce irritation of the stomach and
prevent an ulcer.
Feedback
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1. This is correct. RA can affect the respiratory system with pleural effusion (collection of fluid
in the pleural space); the cardiovascular system with coronary heart disease; the exocrine
glands, resulting in dry eyes and mouth; and the hematologic system with a variety of
disorders, particularly anemia.
2. This is correct. RA can affect the respiratory system with pleural effusion (collection of fluid
in the pleural space); the cardiovascular system with coronary heart disease; the exocrine
glands, resulting in dry eyes and mouth; and the hematologic system with a variety of
disorders, particularly anemia.
3. This is correct. RA can affect the respiratory system with pleural effusion (collection of fluid
in the pleural space); the cardiovascular system with coronary heart disease; the exocrine
glands, resulting in dry eyes and mouth; and the hematologic system with a variety of
disorders, particularly anemia.
4. This is incorrect. If properly managed, RA is not considered to be a danger for pregnant
women or their babies.
5. This is correct. RA can affect the respiratory system with pleural effusion (collection of fluid
in the pleural space); the cardiovascular system with coronary heart disease; the exocrine
glands, resulting in dry eyes and mouth; and the hematologic system with a variety of
disorders, particularly anemia.
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Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with connective tissue disorders
Chapter page reference: 344-351
Heading: Rheumatoid Arthritis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1. This is incorrect. Pain is a warning signal, and the patient with RA should stop any activity
that causes pain.
2. This is correct. Using a stronger joint or part of the body, such as the palm, to carry items is
preferable to grasping.
3. This is correct. When performing a task, the patient should avoid stress in the area of the
deformity to help prevent further deformities.
4. This is correct. Writing requires using a strong grip, so typing is preferable.
5. This is correct. The patient with RA should never attempt to push a joint beyond its ability.
Feedback
1. This is incorrect. Diffuse, not limited, systemic scleroderma has rapid onset.
2. This is correct. Limited systemic scleroderma often has an insidious onset.
3. This is incorrect. Internal organ involvement is more likely with diffuse, not limited, systemic
scleroderma.
4. This is correct. Limited systemic scleroderma is often preceded by a diagnosis of Raynaud’s
phenomenon.
5. This is correct. These are clinical manifestations associated with limited systemic scleroderma.
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Feedback
1. This is incorrect. This is an objective, not subjective, assessment finding for a patient
diagnosed with gout.
2. This is incorrect. This is an objective, not subjective, assessment finding for a patient
diagnosed with gout.
3. This is correct. This is a subjective assessment finding for a patient diagnosed with gout.
4. This is correct. This is a subjective assessment finding for a patient diagnosed with gout.
5. This is incorrect. This is an objective, not subjective, assessment finding for a patient
diagnosed with gout.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
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____ 1. A nurse is caring for a pediatric patient who is receiving an infusion of intravenous antibiotic at the
ambulatory clinic. Which clinical manifestation indicates that the patient is experiencing a type I
hypersensitivity reaction?
1) Erythema
2) Fever
3) Joint pain
4) Hypotension
____ 2. The nurse is assessing a patient who is receiving intravenous (IV) antibiotics. Which item in the patient’s
health history increases the risk for experiencing a hypersensitivity reaction?
1) 26 years of age
2) Caucasian race
3) Previous antibiotic therapy
4) Concurrent chronic illness
____ 3. The nurse is admitting a pediatric patient to the hospital with a ventroperitoneal (VP) shunt malfunction. The
patient’s family speaks very little English. The interpreter has arrived and the nurse is obtaining a health
history from the parents and learns that the patient received the shunt at birth after a menigocele repair. Based
on this data, which product should be avoided when providing care to this patient?
1) Synthetic rubber gloves
2) Polyethylene gloves
3) Nonpowdered nitrile gloves
4) Latex gloves
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____ 4. The nurse is caring for a patient in an allergy clinic. After completing the patient history, the nurse selects the
nursing diagnosis of Risk for Shock. Which item in the patient’s history supports the need for this nursing
diagnosis?
1) A history of an anaphylactic reaction to shellfish.
2) A drug reaction to penicillin causing a rash.
3) A history of glomerulonephritis.
4) A history of dermatitis resulting from a response to changing laundry detergent.
____ 5. The nurse is preparing to assess a patient when one of the patient’s family members begins showing
symptoms of a latex sensitivity. Which action by the nurse is the most appropriate?
1) Ask the family member to leave the unit
2) Transfer the patient to a department that does not use latex products
3) Wait until Monday to report the problem to the supervisor of the unit
4) Obtain latex-free products for the patient’s room
____ 6. The nurse is caring for a patient who is experiencing anaphylactic shock following the administration of a
medication. Which position is the most appropriate for the nurse to place the patient based on this data?
1) Trendelenburg position
2) Flat, with legs slightly elevated
3) Supine position
4) High Fowler position
____ 7. The nurse is caring for a patient with a history of latex allergies. The patient develops audible wheezing,
pruritus, urticaria, and signs of angioedema. Which is the priority intervention for this patient?
1) Teach the patient regarding using a kit that contains treatment for allergic reactions.
2) Administer diphenhydramine (Benadryl) by mouth every four hours per the health-care
provider's orders. NURSINGTB.COM
3) Administer epinephrine 1:1,000 by subcutaneous injection per the health-care provider's
orders.
4) Collect a detailed history from the patient regarding the history of latex allergies.
____ 8. A nurse has been providing a young adult patient with a history of hypersensitivity reactions. The nurse is
preparing instructions on the correct methods for using an EpiPen. Which patient statement indicates
understanding of the proper technique?
1) “I make sure the EpiPen is always available.”
2) “It's fine to leave the EpiPen out in the sun.”
3) “No one else in my family knows how to use the EpiPen.”
4) “I don't need a medical alert tag.”
____ 9. A pediatric patient with a history of anaphylactic hypersensitivity reactions will be discharged with a
prescription for an EpiPen. Which statement is appropriate for the nurse to include in the discharge
instructions for this patient and family?
1) “This medication does not come prefilled and must be measured.”
2) “Keep the medication in the car at all times.”
3) “Frequently check the expiration date of the medication.”
4) “Keep the medication in one location that is easy to remember.”
____ 10. A nurse is caring for a patient with seasonal hypersensitivity reactions. What teaching would the nurse
provide to improve this patient’s comfort?
1) Keep doors and windows open on high-allergen days to circulate air.
2) Maintain a clean, dust-free environment.
3) Take antihistamine and leukotriene medication as ordered
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1) Wheezes
2) Rhonchi
3) Tachypnea
4) Eupnea
____ 19. Which is the priority nursing diagnosis for a patient diagnosed with X-linked agammaglobulinemia (XLA)?
1) Risk for infection
2) Decreased cardiac output
3) Anticipatory grieving
4) Fatigue
____ 20. Which general manifestation should the nurse anticipate when providing care to a patient diagnosed with
DiGeorge’s syndrome?
1) Poor muscle tone
2) Failure to thrive
3) Shortness of breath
4) Delayed development
____ 21. Which respiratory manifestation should the nurse anticipate when providing care to a patient diagnosed with
DiGeorge’s syndrome?
1) Poor muscle tone
2) Failure to thrive
3) Shortness of breath
4) Delayed development
____ 22. Which should the nurse plan to monitor when providing care to a patient who is diagnosed with DiGeorge’s
syndrome? NURSINGTB.COM
1) Sodium
2) Calcium
3) Potassium
4) Magnesium
____ 23. Which is the priority nursing action to decrease the risk for infection for a patient diagnosed with DiGeorge’s
syndrome?
1) Hand hygiene
2) Reverse isolation
3) Prokinetic agents
4) Droplet precautions
____ 24. Which should the nurse include in the plan of care for a patient diagnosed with DiGeorge’s syndrome to treat
gastrointestinal reflux disorder (GERD)?
1) Hand hygiene
2) Reverse isolation
3) Prokinetic agents
4) Droplet precautions
____ 25. Which immune disorder should the nurse include in the plan of care for a patient who is receiving
chemotherapeutic agents in the treatment of cancer?
1) B-cell deficiency
2) T-cell deficiency
3) Excessive immune response
4) Secondary immune deficiency
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. A nurse is working in a summer camp for children. One of the children comes to the clinic with several bee
stings. Which clinical manifestations would necessitate the need to inject the child with epinephrine (EpiPen)?
Select all that apply.
1) Skin that is cold and clammy to the touch
2) Skin that is warm and dry to the touch
3) The child is hyperactive and hyperverbal.
4) Complaints of thirst
5) Restlessness and confusion
____ 27. The nurse is providing care to a patient who is suspected of having an immune deficiency. Which information
in the patient’s health history supports this suspected diagnosis? Select all that apply.
1) Persistent oral thrush
2) Tinea infection of the feet
3) One occurrence of pneumonia last year
4) Four or more infections in a one-year period
5) Two serious sinus infections in a one-year period
____ 28. The nurse is providing care to a pediatric patient who is diagnosed with DiGeorge’s syndrome. Which data
indicates a cardiovascular abnormality? Select all that apply.
1) Murmur
2) Cyanosis
3) Polycythemia NURSINGTB.COM
4) Failure to thrive
5) Cleft lip and palate
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MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Excessive
immune response
Chapter page reference: 378-385
Heading: Type I Hypersensitivity Reaction
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Inflammation
Difficulty: Easy
Feedback
1 Erythema and fever are associated with type IV hypersensitivity reactions.
2 Fever and joint pain are associated with a type III hypersensitivity reactions.
3 Fever and joint pain are associated with a type III hypersensitivity reactions.
4 Clinical manifestations associated with a type I hypersensitivity reaction include
hypotension, wheezing, gastrointestinal or uterine spasm, stridor, and urticaria.
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3 For mild reactions with wheezing, pruritus, urticaria, and angioedema, a subcutaneous
injection of 0.3-0.5 mL of 1:1,000 epinephrine is generally sufficient. The nurse should
give the epinephrine first due to the symptoms.
4 The nurse does not have time to collect a detailed history, because of the severity of the
patient’s signs and symptoms.
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Chapter learning objective: Developing a teaching plan for a patient with immune dysfunction
Chapter page reference: 377-390
Heading: Excessive Immune Response
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Inflammation; Medication
Difficulty: Moderate
Feedback
1 The nurse should instruct the patient to keep doors and windows closed on high-
allergen days and to remain indoors if possible.
2 A patient with seasonal hypersensitivity should be educated regarding prevention and
comfort measures. The nurse should also include teaching on maintaining a clean, dust-
free environment.
3 Medication instruction should include instruction on taking antihistamine and anti-
leukotriene medication, not leukotriene.
4 The patient should also be instructed to taper oral corticosteroids as ordered, not to
immediately stop taking them.
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Difficulty: Moderate
Feedback
1 Epinephrine is not used in the treatment of psoriasis.
2 Azathioprine is used to treat autoimmune hepatitis and rheumatoid arthritis.
3 Cyclosporine is used to treat psoriasis, rheumatoid arthritis, multiple sclerosis,
myasthenia gravis, scleroderma, and is used to prevent organ transplant rejection.
4 Mycophenolate mofetil is used to treat scleroderma, lupus, and to prevent organ
transplant rejection.
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15. ANS: 4
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune
dysfunction
Chapter page reference: 377-390
Heading: Excessive Immune Response
Integrated Processes: Nursing Process – Implementation
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Nursing
Difficulty: Difficult
Feedback
1 While assessing the patient’s vital signs per policy is important, this is not the priority
nursing action to decrease the risk of a transfusion reaction.
2 While documenting the procedure in the medical record is important, this is not the
priority nursing action to decrease the risk of a transfusion reaction.
3 While verifying the patient’s identity using two identifiers is important, this is not the
priority nursing action to decrease the risk of a transfusion reaction.
4 The priority nursing action to decrease the risk of a transfusion reaction is to ensure the
bag contains the correct blood type for the patient.
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Difficulty: Moderate
Feedback
1 Patients diagnosed with XLA should be immunized with IPV versus oral polio vaccine
due to the risk of developing vaccine-acquired polio.
2 IVIG should be administered every three to four weeks, not every six months.
3 Education regarding low, not high, dose prophylactic antibiotics is required.
4 Periodic chest x-rays, not MRIs, to monitor for respiratory complications are included
in the plan of care.
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Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: B-cell
deficiencies
Chapter page reference: 368-371
Heading: Primary Immune Dysfunction
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1 Poor muscle tone is classified as an “other” manifestation of DiGeorge’s syndrome.
2 Failure to thrive is a general manifestation of DiGeorge’s syndrome.
3 Shortness of breath is a respiratory manifestation of DiGeorge’s syndrome.
4 Delayed development is classified as an “other” manifestation of DiGeorge’s
syndrome.
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1 Sodium is not an electrolyte the nurse should plan to monitor when providing care to
this patient.
2 A patient with DiGeorge’s syndrome often has hypoparathyroidism resulting in a
decreased serum calcium level; therefore, the nurse would plan to monitor the patient’s
calcium.
3 Potassium is not an electrolyte the nurse should plan to monitor when providing care to
this patient.
4 Magnesium is not anticipated to be affected by this diagnosis.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune
dysfunction
Chapter page reference: 375-377
Heading: Secondary Immune Dysfunction
Integrated Processes: Nursing Process – Planning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
1 Chemotherapy does not cause B-cell deficiency.
2 Chemotherapy does not cause T-cell deficiency.
3 Chemotherapy does not cause an excessive immune response.
4 Chemotherapy often results in a secondary immune deficiency.
MULTIPLE RESPONSE
26. ANS: 1, 4, 5
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Excessive
immune response
Chapter page reference: 383 NURSINGTB.COM
Heading: Excessive Immune Response
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Inflammation
Difficulty: Easy
Feedback
1. This is correct. General symptoms of shock that would necessitate an epinephrine injection
include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy.
The skin may feel cold and clammy in shock.
2. This is incorrect. The skin will not be warm and dry to the touch.
3. This is incorrect. In shock, the patient will not be hyperactive or hyperverbal.
4. This is correct. Thirst is a common complaint in shock.
5. This is correct. General symptoms of shock that would necessitate an epinephrine injection
include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy.
The skin may feel cold and clammy in shock.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1. This is correct. Persistent oral thrush is an indication of immune deficiency.
2. This is incorrect. A tinea infection of the feet does not support suspected immune deficiency.
3. This is incorrect. Two, not one, occurrence of pneumonia within in one-year period indicates
immune deficiency.
4. This is incorrect. Six, not four, or more infections in a one-year period supports the diagnosis
of immune deficiency.
5. This is correct. Two or more serious sinus infections in a one-year period supports the
diagnosis of immune deficiency.
Feedback
1. This is correct. A heart murmur indicates a cardiovascular abnormality.
2. This is correct. Cyanosis indicates a cardiovascular abnormality.
3. This is correct. Polycythemia indicates a cardiovascular abnormality.
4. This is correct. Failure to thrive indicates a cardiovascular abnormality.
5. This is incorrect. While cleft lip and palate often occurs with this syndrome, this data does not
indicate a cardiovascular abnormality.
Chapter 21 Coordinating Care for Patients With Multidrug-Resistant Organism Infectious Disorders
Chapter 21: Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is planning care for several patients in the hospital environment. Which is a risk factor for a patient
developing hospital-acquired MRSA?
1) Recent use of antibiotics
2) Recent surgical procedure
3) Current intensive care unit stay
4) Prolonged rehabilitation unit stay
____ 2. The nurse is planning care for several patients in the hospital environment. Which is a risk factor for a patient
developing Clostridium difficile?
1) Recent use of antibiotics
2) Recent surgical procedure
3) Current intensive care unit stay
4) Prolonged rehabilitation unit stay
____ 3. The nurse is planning care for several patients in the hospital environment. Which is a risk factor for a patient
developing Acinetobacter baumannii?
1) Recent use of antibiotics
2) Recent surgical procedure
3) Current intensive care unit stay
4) Prolonged rehabilitation unit stay
____ 4. The nurse is planning care for severalNpatients
URSINinGthe
TBhospital
.COMenvironment. Which is a risk factor for a patient
developing VRE?
1) Recent use of antibiotics
2) Recent surgical procedure
3) Current intensive care unit stay
4) Prolonged rehabilitation unit stay
____ 5. The nurse is planning care for several patients. Which is a risk factor for a patient developing community-
acquired MRSA?
1) Recent use of antibiotics
2) Recent surgical procedure
3) Being younger than 2 years of age
4) Being older than 65 years of age
____ 6. The nurse is providing care to a several patients in the hospital environment. Which patient should the nurse
include education regarding the need for increased fluid intake in the plan of care?
1) The patient diagnosed with VRE
2) The patient diagnosed with MRSA
3) The patient diagnosed with Acinetobacter
4) The patient diagnosed with Clostridium difficile
____ 7. The nurse is providing care to a several patients in the hospital environment. Which patient requires the nurse
to closely monitor respiratory status?
1) The patient diagnosed with VRE
2) The patient diagnosed with MRSA
3) The patient diagnosed with Acinetobacter
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 15. The nurse is teaching a patient about the different routes of transmission. Which patient statement indicates
correct understanding of vector-borne transmission?
1) “It occurs when I get bit by a tick or other insect.”
2) “It occurs when I come in direct contact with a pathogen.”
3) “It occurs when I come into contact with pathogens in the air.”
4) “It occurs when I ingest food containing a disease-carrying organism.”
____ 16. The nurse is teaching a patient about the different routes of transmission. Which patient statement indicates
correct understanding of airborne transmission?
1) “It occurs when I get bit by a tick or other insect.”
2) “It occurs when I come in direct contact with a pathogen.”
3) “It occurs when I come into contact with pathogens by breathing.”
4) “It occurs when I ingest food containing a disease-carrying organism.”
____ 17. The nurse is teaching a patient about the different routes of transmission. Which patient statement indicates
correct understanding of vehicle transmission?
1) “It occurs when I get bit by a tick or other insect.”
2) “It occurs when I come in direct contact with a pathogen.”
3) “It occurs when I come into contact with pathogens in the air.”
4) “It occurs when I ingest food containing a disease-carrying organism.”
____ 18. The nurse is conducting an in-service on the spread of infection in the hospital environment. Which statement
should the nurse include regarding the most common mode of pathogen transmission?
1) “Contact transmission is the most common mode.”
2) “Vehicle transmission is the most common mode.”
3) “Airborne transmission is the most common mode.”
4) “Vector-borne transmission is theNUmost
RSIcommon
NGTB. mode.”
COM
____ 19. The infection prevention and control nurse is providing an in-service regarding multi-drug resistant (MDR)
infection. Which is the most common site of MDR MRSA colonization the nurse should include in the
presentation?
1) Throat
2) Axillae
3) Perineum
4) Anterior nares
____ 20. Which nursing action is appropriate when providing care to a patient who is diagnosed with multi-drug
resistant (MDR) MRSA?
1) Implementing isolation precautions
2) Implementing standard precautions only
3) Washing hands with soap and water only
4) Wearing a gown that is tied at the neck but not at the waist
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. Which is being studied when a nurse participates in the BUGG (benefits of universal gown and gloving)
research initiative? Select all that apply.
1) Decreasing the length of the hospital stay
2) Decreasing the frequency of adverse events
3) Increasing the risk for antibiotic resistance
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 21: Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Describing the epidemiology of multidrug-resistant organism infectious disorders
Chapter page reference: 393-394
Heading: Multidrug-Resistant Organisms
Integrated Processes: Nursing Process – Planning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
1 Recent use of antibiotics is a risk factor for Clostridium difficile.
2 Recent surgical procedure is a risk factor for Acinetobacter baumannii.
3 Current or recent hospitalization increases the risk for hospital-acquired MRSA.
4 A prolonged rehabilitation stay increases the risk for VRE.
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Feedback
1 Recent use of antibiotics is a risk factor for Clostridium difficile.
2 Recent surgical procedure is a risk factor for Acinetobacter baumannii.
3 A patient who is younger than 2 years of age is at an increased risk for community-
acquired MRSA.
4 A patient who is older than 65 years of age is not at an increased risk for community-
acquired MRSA.
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Difficulty: Moderate
Feedback
1 Vancomycin is a drug that the nurse anticipates administering when providing care to a
patient who is diagnosed with MDR MRSA.
2 Metronidazole is a drug that the nurse anticipates administering when providing care to
a patient who is diagnosed with MDR Clostridium difficile.
3 Ampicillin-sulbactam is a drug that the nurse anticipates administering when providing
care to a patient who is diagnosed with MDR Acinetobacter.
4 Quinupristin-dalfopristin is a drug that the nurse anticipates administering when
providing care to a patient who is diagnosed with MDR VRE.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 Metronidazole is a drug that the nurse anticipates administering when providing care to
a patient who is diagnosed with MDR Clostridium difficile.
3 Ampicillin-sulbactam is a drug that the nurse anticipates administering when providing
care to a patient who is diagnosed with MDR Acinetobacter.
4 Quinupristin-dalfopristin is a drug that the nurse anticipates administering when
providing care to a patient who is diagnosed with MDR VRE.
Feedback
1 This statement does not indicate correct understanding regarding the cause of
inflammation for a patient diagnosed with Clostridium difficile.
2 The bacteria release toxins which are responsible for the inflammation that occurs with
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a Clostridium difficile infection. This patient statement indicates correct understanding.
3 This statement does not indicate correct understanding regarding the cause of
inflammation for a patient diagnosed with Clostridium difficile.
4 This statement does not indicate correct understanding regarding the cause of
inflammation for a patient diagnosed with Clostridium difficile.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Discussing the medical management of: Methicillin-resistant Staphylococcus
aureus
Chapter page reference: 401
Heading: Management of Multidrug-Resistant Organisms
Integrated Processes: Nursing Process – Implementation
Client Need: Safe and Effective Care Environment – Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1 A patient diagnosed with MDR MRSA requires isolation precautions, specifically
contact precautions.
2 This patient would require isolation, not standard, precautions.
3 The patient diagnosed with MDR MRSA does not require the implementation of hand
hygiene with soap and water only. This intervention is appropriate for the patient
diagnosed with Clostridium difficile.
4 Gowns should be tied at the neck and waist in order to decrease the risk for disease
transmission.
MULTIPLE RESPONSE
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21. ANS: 1, 2, 4, 5
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with multidrug-
resistant organism infectious disorders
Chapter page reference: 406
Heading: Nursing Management
Integrated Processes: Nursing Process – Implementation
Client Need: Safe and Effective Care Environment – Safety and Infection Control
Cognitive level: Comprehension [Understanding]
Concept: Evidence-Based Practice
Difficulty: Easy
Feedback
1. This is correct. The BUGG study will test if doctors, nurses, and others wearing gloves and a
gown while caring for all patients in an intensive care unit (ICU) will decrease the length of
the hospital stay.
2. This is correct. The BUGG study will test if doctors, nurses, and others wearing gloves and a
gown while caring for all patients in an intensive care unit (ICU) will decrease the frequency
of adverse events.
3. This is incorrect. The BUGG study does not test for an increase in the risk for antibiotic
resistance.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4. This is correct. The BUGG study will test if doctors, nurses, and others wearing gloves and a
gown while caring for all patients in an intensive care unit (ICU) will decrease the risk for
hospital-acquired infection.
5. This is correct. The BUGG study will test if doctors, nurses, and others wearing gloves and a
gown while caring for all patients in an intensive care unit (ICU) will decrease the risk for
hospital-acquired infection.
Feedback
1. This is correct. Pus is a clinical manifestation associated with a MRSA skin infection.
2. This is correct. Edema, or swelling, is a clinical manifestation associated with a MRSA skin
infection.
3.
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This is incorrect. Tachypnea may occur with a systemic, not localized, MRSA skin infection.
4. This is correct. Discomfort, or pain, is a clinical manifestation associated with a MRSA skin
infection.
5. This is incorrect. Bradycardia may occur with a systemic, not localized, MRSA skin infection.
Feedback
1. This is correct. Hyperthermia, or fever, is an anticipated clinical manifestation when providing
care to any patient diagnosed with a MDR infection.
2. This is correct. Tachypnea, or an increased rate of respirations, is an anticipated clinical
manifestation when providing care to any patient diagnosed with a MDR infection.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1. This is correct. Decreased skin turgor often occurs due to dehydration; therefore, this supports
the current nursing diagnosis.
2. This is incorrect. A decreased, not increased, urine output supports the current nursing
diagnosis.
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3. This is correct. Dry mucous membranes often occur due to dehydration; therefore, this
supports the current nursing diagnosis.
4. This is correct. An increased serum creatinine level often occurs due to dehydration; therefore,
this supports the current nursing diagnosis.
5. This is incorrect. Increased white blood cell count is anticipated due to infection; however,
this does not support the current nursing diagnosis.
Feedback
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1. This is correct. The nurse should include ambulation in the patient’s plan of care to decrease
the risk for atelectasis.
2. This is correct. The nurse should include administration of prescribed oxygen in the patient’s
plan of care to increase oxygen saturation.
3. This is correct. The nurse should include chest physiotherapy in the patient’s plan of care to
mobilize secretions and increase oxygen saturation.
4. This is incorrect. Wound care is included in the plan of care for a patient with an MDR MRSA
skin infection, not pneumonia.
5. This is incorrect. Alcohol-based hand gels are effective to decrease the risk for infection with
all MDR infections with the exception of Clostridium difficile, not pneumonia.
Feedback
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1. This is incorrect. The sample should be sent to the laboratory immediately as a false-negative
may occur if the sample is not tested within two hours of collection.
2. This is incorrect. The C diff toxins are unstable at room temperature, and false-negative results
may occur in samples that are not tested within two hours of collection.
3. This is correct. The sample is sent to the laboratory immediately as C diff toxins are unstable
at room temperature, and false-negative results may occur in samples that are not tested within
two hours of collection.
4. This is correct. A laboratory requisition for a culture and sensitivity is required when sending
a stool sample to the laboratory to determine the presence of C diff.
5. This is incorrect. Any patient who is suspected of having C diff will require hand hygiene with
soap and water as alcohol-based hand gel displaces this organism but does not kill it.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 1. The nurse is caring for a patient with acquired immunodeficiency syndrome (AIDS) who is in antiretroviral
therapy. The patient reports nausea, fever, severe diarrhea, and anorexia. Which prescribed medication does
the nurse anticipate in order to relieve the anorexia and to stimulate the patient’s appetite?
1) Dronabinol (Marinol)
2) Abacavir (Ziagen)
3) Ciprofloxacin (Cipro)
4) Zidovudine (Retrovir, AZT)
____ 2. A nurse is performing an admission assessment on a patient with symptoms that indicate human
immunodeficiency virus (HIV). Which question from the nurse addresses a major risk factor for contracting
HIV?
1) “Has your partner been experiencing these symptoms?”
2) “When was your first sexual experience?”
3) “Have you had any fever, diarrhea, or chills over the last 48 hours?”
4) “Have you ever experimented with intravenous drugs?”
____ 3. The nurse is discharging a pediatric patient who was recently diagnosed with acquired immunodeficiency
syndrome (AIDS). When discussing appropriate health promotion activities for this child, which
immunization is contraindicated?
1) Varicella vaccine
2) Haemophilus influenzae type B (HIB conjugate vaccine)
3) Hepatitis B vaccine (hep B)
4) Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP)
____ 4. A nurse is developing a plan of care for a patient diagnosed with human immunodeficiency virus (HIV). The
patient states, “I don’t plan on giving up sex just because I am HIV positive.” Based on this data, which is the
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priority nursing diagnosis for this patient?
1) Risk for Infection
2) Death Anxiety
3) Deficient Knowledge
4) Social Isolation
____ 5. The nurse is caring for a patient who is newly diagnosed with human immunodeficiency virus (HIV). The
patient asks the nurse if there are ways to protect the patient’s life partner from getting the HIV virus. After
educating the patient, which statement indicates the need for further education?
1) “I know to use an oil-based lubricant to prevent spread of the disease to my partner.”
2) “I can still kiss and hug my partner to show affection.”
3) “I will not share my razor with my partner.”
4) “I know I have to practice safer sex with my partner by using a latex condom.”
____ 6. A home health nurse is conducting home visits for several patients who are diagnosed with acquired
immunodeficiency syndrome (AIDS). Which patient would the nurse see first?
1) A patient who is receiving lamivudine (Epivir) because of a diagnosis of a low CD4 cell
count
2) A patient with Pneumocystis carinii pneumonia (PCP) who called the office this morning
to report a new onset of fever, cough, and shortness of breath
3) A patient with wasting syndrome who needs modifications and education regarding
dietary changes
4) A patient who is receiving IV antibiotics daily for toxoplasmosis
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____ 7. The nurse is providing care to a pediatric patient who is HIV-positive. The patient’s mother is describing the
child’s current condition and activities to the nurse. Which parental statement indicates that the child may
require further intervention?
1) “My child seems somewhat isolated and doesn't have any real friends.”
2) “My child has a good appetite and eats regular meals.”
3) “My child hasn't shown any sign of infection.”
4) “My child attends school and doing well in class.”
____ 8. A nurse working in an intensive care unit (ICU) is assigned a patient diagnosed with acquired
immunodeficiency syndrome (AIDS). Based on this data, which type of precaution does the nurse implement
when providing direct care?
1) Droplet
2) Reverse
3) Standard
4) Contact
____ 9. The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+
count of 500 cells/L. Which classification of HIV should the nurse document for this patient?
1) Stage 0
2) Stage 1
3) Stage 2
4) Stage 3
____ 10. The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+
count of 300 cells/L. Which classification of HIV should the nurse document for this patient?
1) Stage 0
2) Stage 1 NURSINGTB.COM
3) Stage 2
4) Stage 3
____ 11. The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+
count of less than 200 cells/L. Which classification of HIV should the nurse document for this patient?
1) Stage 0
2) Stage 1
3) Stage 2
4) Stage 3
____ 12. The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The
patient has lost 15% of body weight since the last appointment. Which reason should the nurse include in a
teaching session for this patient regarding this occurrence?
1) Infection
2) Disease progression
3) Mycobacterial infection
4) Pneumocystis carinii pneumonia
____ 13. The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The
patient presents with a fever without other notable symptoms. Which is the most likely cause of this data?
1) Infection
2) Disease progression
3) Mycobacterial infection
4) Pneumocystis carinii pneumonia
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 14. The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The
patient reports night sweats. Which is the most likely reason for this clinical manifestation?
1) Infection
2) Disease progression
3) Mycobacterial infection
4) Pneumocystis carinii pneumonia
____ 15. The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The
patient has shortness of breath when walking, but no problems breathing at rest. Which is the most likely
cause for this clinical manifestation?
1) Infection
2) Disease progression
3) Mycobacterial infection
4) Pneumocystis carinii pneumonia
____ 16. The nurse is assessing a patient who is diagnosed with human immunodeficiency virus (HIV) who presents
with a rash. Which assessment question is most appropriate?
1) “Are you taking Bactrim?”
2) “Have you recently used a new soap?”
3) “What have you eaten in the last few days?”
4) “Did you have unprotected sex within the last week?”
____ 17. Which immunization should the nurse encourage for a patient who is diagnosed with Stage 2 human
immunodeficiency virus?
1) Measles, mumps, and rubella (MMR) vaccine
2) Oral polio vaccine (OPV)
3) Influenza vaccine NURSINGTB.COM
4) Varicella vaccine
____ 18. Which is the priority action for a nurse who is exposed to a needle-stick injury while providing patient care?
1) Washing the injury under running water
2) Squeezing the site to remove the patient’s blood
3) Taking two or three drugs for 28 days
4) Consenting to a human immunodeficiency virus (HIV) test
____ 19. Which patient should the nurse offer the opportunity for human immunodeficiency virus (HIV) testing during
an annual physical examination?
1) A 66-year-old male patient
2) A 75-year-old female patient
3) An 8-year-old school-age child
4) An 18-year-old young adult patient
____ 20. The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient’s
CD4+ count is currently 480 cells/L. Which complication is this patient at risk for developing?
1) Toxoplasmosis
2) Herpes zoster virus
3) Vaginal candidiasis
4) Severe bacterial infection
____ 21. The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient’s
CD4+ count is less than 200 cells/L. Which complication is this patient at risk for developing?
1) Toxoplasmosis
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Completion
Complete each statement.
25. Place the progression of human immunodeficiency virus (HIV) in sequential order. (Enter the number of each
step in the proper sequence; do not use punctuation or spaces. Example: 1234)
1) AIDS
2) Death
3) Seroconversion
4) Viral transmission
5) Acute viral infection
6) Asymptomatic chronic infection
26. Human immunodeficiency virus (HIV) infects and destroys CD4 cells. List the following events in the order
in which they occur for a patient who is HIV-positive. (Enter the number of each step in the proper sequence;
do not use punctuation or spaces. Example: 1234)
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 27. The nurse is planning care for a pediatric patient diagnosed with human immunodeficiency virus (HIV). The
nurse selects Risk for Infection as a priority nursing diagnosis for this pediatric patient. Based on this nursing
diagnosis, which actions by the nurse are appropriate? Select all that apply.
1) Administering tuberculosis skin tests every six months
2) Teaching proper food-handling techniques to the family
3) Instructing on the importance of consuming ample fresh fruits and vegetables
4) Assessing the health status of all visitors
5) Monitoring hand-washing techniques used by the family
____ 28. The nurse is reviewing the laboratory values of a patient who is newly diagnosed with acquired
immunodeficiency syndrome (AIDS). Which values should be reported to the patient’s health-care provider?
Select all that apply.
1) CD4 cell count 1,100/mm3
2) T4 cell count 150
3) CD4 lymphocytes 12%
4) Viral load 11,500 copies/mL
5) WBC 6,500
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological,
dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 415
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process – Planning
Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Infection; Medication
Difficulty: Moderate
Feedback
1 Megestrol (Megace) and dronabinol (Marinol) are often ordered to increase patient
appetite and promote weight gain.
2 Abacavir (Ziagen) is a potent inhibitor of reverse transcriptase.
3 Ciprofloxacin (Cipro) is an anti-infective medication, and zidovudine (Retrovir, AZT)
is an antiretroviral agent.
4 Ciprofloxacin (Cipro) is an anti-infective medication, and zidovudine (Retrovir, AZT)
is an antiretroviral agent.
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PTS: 1 CON: Infection | Medication
2. ANS: 4
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Describing the etiology of HIV disorders
Chapter page reference: 409-410
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1 Assessing recent symptoms, and asking if the patient’s partner is experiencing the same
symptoms, does not assess the patient’s risk factors for HIV transmission.
2 The patient’s first sexual experience is not applicable to the patient’s current risk for
HIV.
3 Assessing recent symptoms, and asking if the patient’s partner is experiencing the same
symptoms, does not assess the patient’s risk factors for HIV transmission.
4 One risk factor for contracting HIV is the use of intravenous recreational drugs. This
question is appropriate to determine the patient’s risk for HIV.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological,
dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 415
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process – Planning
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1 A child with an immune disorder such as HIV/AIDS should not be immunized with a
live varicella vaccine, because of the risk of contracting the disease.
2 DTaP, HIB, and hepatitis B vaccinations are not live vaccines, and should be given on
schedule.
3 DTaP, HIB, and hepatitis B vaccinations are not live vaccines, and should be given on
schedule.
4 DTaP, HIB, and hepatitis B vaccinations are not live vaccines, and should be given on
schedule.
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7. ANS: 1
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological,
dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 417-419
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process – Assessment
Client Need: Psychosocial Integrity
Cognitive level: Analysis [Analyzing]
Concept: Infection
Difficulty: Difficult
Feedback
1 This statement indicates that the patient is not adequately coping with the current
situation and requires further assessment and/or intervention by the nurse.
2 Positive outcomes for an HIV patient would include remaining free from secondary
infection, displaying normal nutritional patterns, demonstrating adequate coping with
the stress of chronic disease, and attending school.
3 Positive outcomes for an HIV patient would include remaining free from secondary
infection, displaying normal nutritional patterns, demonstrating adequate coping with
the stress of chronic disease, and attending school.
4 Positive outcomes for an HIV patient would include remaining free from secondary
infection, displaying normal nutritional patterns, demonstrating adequate coping with
the stress of chronic disease, and attending school.
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Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV
Chapter page reference: 409
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity – Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Infection; Communication
Difficulty: Moderate
Feedback
1 This is not a stage for the classification of HIV.
2 Stage 1 is documented for a patient with a CD4+ count of at least 500 cells/L.
3 Stage 2 is documented for a patient with a CD4+ count of 200–499 cells/L.
4 Stage 3 is documented for a patient with a CD4+ count of less than 200 cells/L.
Feedback
1 This is not a stage for the classification of HIV.
2 Stage 1 is documented for a patient with a CD4+ count of at least 500 cells/L.
3 Stage 2 is documented for a patient with a CD4+ count of 200–499 cells/L.
4 Stage 3 is documented for a patient with a CD4+ count of less than 200 cells/L.
Feedback
1 This is not a stage for the classification of HIV.
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2 Stage 1 is documented for a patient with a CD4+ count of at least 500 cells/L.
3 Stage 2 is documented for a patient with a CD4+ count of 200–499 cells/L.
4 Stage 3 is documented for a patient with a CD4+ count of less than 200 cells/L.
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Difficulty: Easy
Feedback
1 A fever is caused by infection.
2 Weight loss is generally caused by worsening of the disease or disease progression.
3 Night sweats are caused by a mycobacterial infection.
4 Dyspnea on exertion, but not at rest, is caused by Pneumocystis carinii pneumonia.
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Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological,
dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 415
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process – Planning
Client Need: Heath Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Promoting Health
Difficulty: Moderate
Feedback
1 This is a live virus vaccine and is contraindicated for a patient diagnosed with HIV.
2 This is a live virus vaccine and is contraindicated for a patient diagnosed with HIV.
3 The influenza vaccine is not a live virus vaccine and is recommended annually, early in
the flu season, for patients with HIV.
4 This is a live virus vaccine and is contraindicated for a patient diagnosed with HIV.
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1 This patient is not within the suggested age range for HIV testing during an annual
physical examination.
2 This patient is not within the suggested age range for HIV testing during an annual
physical examination.
3 This patient is not within the suggested age range for HIV testing during an annual
physical examination.
4 The nurse offers HIV testing to all patients between the ages of 15 years and 65 years
of age.
Feedback
1 Toxoplasmosis is a complication that occurs when the patient’s CD4+ count drops
below 200 cells/L. This complication typically indicates the patient has progressed
from HIV to acquired immunodeficiency syndrome (AIDS).
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2 Herpes zoster virus is a complication that occurs when the patient’s CD4+ is between
500 and 350 cells/L.
3 Vaginal candidiasis is a complication that occurs when the patient’s CD4+ count is
greater than 500 cells/L.
4 Severe bacterial infection is a complication that occurs when the patient’s CD4+ is 350
and 200 cells/L.
Feedback
1 Toxoplasmosis is a complication that occurs when the patient’s CD4+ count drops
below 200 cells/L. This complication typically indicates the patient has progressed
from HIV to acquired immunodeficiency syndrome (AIDS).
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2 Herpes zoster virus is a complication that occurs when the patient’s CD4+ is between
500 and 350 cells/L.
3 Vaginal candidiasis is a complication that occurs when the patient’s CD4+ count is
greater than 500 cells/L.
4 Severe bacterial infection is a complication that occurs when the patient’s CD4+ is 350
and 200 cells/L.
Feedback
1 Toxoplasmosis is a complication that occurs when the patient’s CD4+ count drops
below 200 cells/L. This complication typically indicates the patient has progressed
from HIV to acquired immunodeficiency syndrome (AIDS).
2 Herpes zoster virus is a complication that occurs when the patient’s CD4+ is between
500 and 350 cells/L. NURSINGTB.COM
3 Vaginal candidiasis is a complication that occurs when the patient’s CD4+ count is
greater than 500 cells/L.
4 Severe bacterial infection is a complication that occurs when the patient’s CD4+ is 350
and 200 cells/L.
Feedback
1 Toxoplasmosis is a complication that occurs when the patient’s CD4+ count drops
below 200 cells/L. This complication typically indicates the patient has progressed
from HIV to acquired immunodeficiency syndrome (AIDS).
2 Herpes zoster virus is a complication that occurs when the patient’s CD4+ is between
500 and 350 cells/L.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3 Vaginal candidiasis is a complication that occurs when the patient’s CD4+ count is
greater than 500 cells/L.
4 Severe bacterial infection is a complication that occurs when the patient’s CD4+ is 350
and 200 cells/L.
COMPLETION
25. ANS:
435612
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV
Chapter page reference: 411
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback: The progression of HIV is as follows: first, viral transmission occurs; second, seroconversion
occurs; next, the patient has symptoms of an acute viral infection; fourth, the patient has an asymptomatic
chronic infection; fifth, the patient becomes symptomatic and is diagnosed with AIDS; lastly, the patient dies.
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13452
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Describing diagnostic results used to confirm the diagnosis of HIV
Chapter page reference: 411
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback: The HIV virus gains entry into helper T cells, uses the cell DNA to replicate, interferes with
normal function of the T cells, and destroys the normal cells.
MULTIPLE RESPONSE
27. ANS: 2, 4, 5
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological,
dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 417-419
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process – Implementation
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Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1. This is incorrect. Tuberculosis skin tests should be administered annually, not every six
months.
2. This is correct. A patient with HIV is at risk for a myriad of bacterial, viral, fungal, and
opportunistic infections because of the effect of the virus on the immune system. The nurse
teaches the family to keep those who have symptoms of illness away from the child and also
instructs them in proper hand-washing technique and proper food handling to prevent
infection.
3. This is incorrect. Fresh fruits and vegetables are not recommended for a patient with a
depressed immune system.
4. This is correct. A patient with HIV is at risk for a myriad of bacterial, viral, fungal, and
opportunistic infections because of the effect of the virus on the immune system. The nurse
teaches the family to keep those who have symptoms of illness away from the child and also
instructs them in proper hand-washing technique and proper food handling to prevent
infection.
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5. This is correct. A patient with HIV is at risk for a myriad of bacterial, viral, fungal, and
opportunistic infections because of the effect of the virus on the immune system. The nurse
teaches the family to keep those who have symptoms of illness away from the child and also
instructs them in proper hand-washing technique and proper food handling to prevent
infection.
Feedback
1. This is incorrect. The risk of opportunistic infection is the most common manifestation of
AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The
normal CD4 cell count is greater than 1,000/mm3. All of the labs are abnormal except for the
CD4 cell count and the WBC, which was within normal range.
2. This is correct. The risk of opportunistic infection is the most common manifestation of AIDS.
The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal
CD4 cell count is greaterNthan
URS1,000/mm
INGTB3.. AllCOofM the labs are abnormal except for the CD4 cell
count and the WBC, which was within normal range.
3. This is correct. The risk of opportunistic infection is the most common manifestation of AIDS.
The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal
CD4 cell count is greater than 1,000/mm3. All of the labs are abnormal except for the CD4 cell
count and the WBC, which was within normal range.
4. This is correct. The risk of opportunistic infection is the most common manifestation of AIDS.
The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal
CD4 cell count is greater than 1,000/mm3. All of the labs are abnormal except for the CD4 cell
count and the WBC, which was within normal range.
5. This is incorrect. The risk of opportunistic infection is the most common manifestation of
AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The
normal CD4 cell count is greater than 1,000/mm3. All of the labs are abnormal except for the
CD4 cell count and the WBC, which was within normal range.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse educator is teaching a student nurse how to auscultate the lungs. Which action by the student nurse
indicates the need for further education?
1) Listening to sound over the bony structures
2) Asking the client to sit in an upright position
3) Instructing the client to breathe slowly through mouth
4) Beginning auscultation from lung apices and moving toward intercostal spaces
____ 2. The nurse is providing care to a patient who will need a bronchoscopy. Which patient statement indicates
appropriate understanding of the information presented?
1) “I will be awake and aware during the procedure.”
2) “I will require mechanical ventilation after the procedure.”
3) “I will need to have my prothrombin time drawn after the test.”
4) “I will abstain from eating or drinking for eight hours prior to the procedure.”
____ 3. The nurse is conducting a respiratory assessment for a patient who is diagnosed with asthma. Which
assessment finding indicates the patient is experiencing airway irritation?
1) Hemoptysis
2) Dry, hacking cough
3) Harsh, barky cough
4) Loose-sounding cough
____ 4. The nurse is assessing a patient who is admitted with a persistent cough and is diagnosed with pulmonary
edema. Which assessment finding supports the patient’s diagnosis?
1) Foul smelling sputum NURSINGTB.COM
2) Clear, whitish, or yellow sputum
3) Large amounts of frothy, pink tinged sputum
4) Clear to gray with occasional specks of brown sputum
____ 5. The nurse is assessing a patient who is diagnosed with tuberculosis. Which assessment finding supports this
diagnosis?
1) Wheezing
2) Hemoptysis
3) Grey sputum
4) Slightly whitish sputum
____ 6. When percussing the patient’s lung fields, the nurse notes a moderately low-pitched sound over the chest.
Which term does the nurse use to describe these sounds?
1) Dull
2) Tympany
3) Resonance
4) Hyperresonance
____ 7. Which diagnostic procedure is used to remove pleural fluid for analysis?
1) Lung biopsy
2) Bronchoscopy
3) Thoracentesis
4) Sputum studies
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____ 8. The nurse is providing care to a patient who undergoes a sputum study. Which will the sputum study help to
diagnose?
1) Asthma
2) Lung cancer
3) Bacterial lung infection
4) Chronic obstructive pulmonary disease
____ 9. While auscultating a patient’s chest, the nurse notes wheezing. Based on this data, which diagnosis does the
nurse anticipate?
1) Bronchiectasis
2) Pleural effusion
3) Pulmonary edema
4) Chronic obstructive pulmonary disease
____ 10. The nurse is conducting a health history interview for a patient who is diagnosed with chronic obstructive
pulmonary disease (COPD). Which question is appropriate when assessing the patient’s nutrition-metabolic
pattern?
1) “Have you lost any weight recently?”
2) “Do you have trouble getting to the toilet?”
3) “Does your breathing wake you up in the night?”
4) “Do you have any pain associated with breathing?”
____ 11. The nurse assesses a patient who presents with tachypnea and clubbing of the fingers. Based on this data,
which diagnosis does the nurse anticipate for this patient?
1) Asthma
2) Chest trauma
3) Chronic hypoxemia NURSINGTB.COM
4) Chronic pulmonary obstructive disease
____ 12. A patient is admitted to the emergency department (ED) with dyspnea. Upon assessment, the nurse notes a
bluish discoloration of the patient’s lips, fine crackles on auscultation, and dullness upon percussion of the
lung fields. Based on this data, which diagnosis does the nurse anticipate?
1) Asthma
2) Pleural effusion
3) Pulmonary edema
4) Pulmonary fibrosis
____ 13. Which is the term used to describe abnormal breath sounds?
1) Vesicular
2) Bronchial
3) Adventitious
4) Bronchovesicular
____ 14. Which would the nurse assess when using palpation during the respiratory assessment?
1) Tracheal position
2) Bronchovesicular sounds
3) Lung density
4) Adventitious sounds
____ 15. The nurse is performing pulmonary function testing on a patient. Which nursing action is beneficial to the
patient?
1) Assessing for respiratory distress
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. The nurse is providing care to a patient who is diagnosed with chronic obstructive pulmonary disease
(COPD). Which laboratory values will the nurse monitor when planning care for this client? Select all that
apply.
1) Elevated eosinophils count
2) Decreased neutrophils count NURSINGTB.COM
3) Elevated red blood cells count
4) Decreased partial pressure of arterial oxygen
5) Decreased partial pressure of arterial carbon dioxide
____ 27. Which questions are appropriate when assessing the effects of the patient’s respiratory diagnosis on activity-
exercise patterns? Select all that apply.
1) “Are you ever incontinent of urine when you cough?”
2) “Do you have trouble walking due to shortness of breath?”
3) “Does your spouse wake you in the middle of the night due to snoring?”
4) “How many flights of stairs can you walk before you are short of breath?”
5) “Do you ever feel full very quickly when eating due to your breathing issues?”
____ 28. During the respiratory assessment, the nurse notes coarse crackles upon auscultation of the lung fields. Which
diagnoses presents with this assessment finding? Select all that apply.
1) Pneumonia
2) Heart failure
3) Cystic fibrosis
4) Bronchospasm
5) Interstitial edema
____ 29. Which are age-related changes to the respiratory system’s defense mechanisms? Select all that apply.
1) Decreased cilia function
2) Decreased chest wall compliance
3) Decreased response to hypoxemia
4) Decreased cell-mediated immunity
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MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of
respiratory function
Chapter page reference: 427-431
Heading: Assessment
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation; Assessment
Difficulty: Easy
Feedback
1 Auscultation is performed to identify fluid, mucus, or obstruction in the respiratory
system. The nurse should avoid auscultating sound over bony structures as it interferes
with the sound quality.
2 Upright position optimizes airflow and allows chest expansion which facilitates clear
respiratory sounds during auscultation.
3 Breathing slowly through an open mouth prevents transmission of turbulent sound and
helps to hear clear sound.
4 NURapices
Beginning auscultation from lung SINandGTB .COMtoward intercostal spaces to the
moving
lung bases helps to compare one lung with the other at the same level.
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Concept: Oxygenation
Difficulty: Easy
Feedback
1 Wheezing is the term used to describe the musical sounds auscultated during
assessment and indicate some degree of airway obstruction that occurs with asthma and
emphysema.
2 Tuberculosis is characterized by hemoptysis, which is the term for coughing up of
blood or blood-tinged sputum from the respiratory tract.
3 Grey sputum often occurs in patients who are cigarette smokers.
4 Clear, slightly whitish, and viscous sputum are often normal findings.
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Feedback
1 Rhonchi are observed in patients with bronchiectasis.
2 Diminished breath sounds are observed in pleural effusion.
3 Coarse crackles are observed in patients with pulmonary edema.
4 Wheezes are continuous high-pitched squeaking or rapid sounds caused by the rapid
vibration of the bronchial walls, which is caused by a blockage in airways which often
occurs with chronic obstructive pulmonary disease.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Heading: Assessment
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation; Assessment
Difficulty: Moderate
Feedback
1 When assessing the affect that COPD has on the patient’s nutrition-metabolic pattern
the appropriate question to ask is if the patient has experienced any weight loss.
2 Asking about trouble getting to the toilet assesses the effect that COPD has on the
patient’s elimination patterns.
3 Asking the patient about waking in the middle of the night with breathing issues
assesses the patient’s sleep-rest.
4 Asking the patient if pain is associated with breathing assesses the patient’s cognition
and perception.
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Feedback
1 The olfactory nerve endings in the roof of the nose are responsible for the sense of
smell.
2 The bronchi and the trachea act as a pathway to conduct gases to the alveoli.
3 The nose functions to protect the lower airway by warming and humidifying air and
filtering small particles before the air enters the lungs.
4 The epiglottis is a small flap located behind the tongue that closes over the larynx
during swallowing. The function of the epiglottis is to prevent solids and liquids from
entering the lungs.
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Difficulty: Easy
Feedback
1 The main stem bronchi subdivide to form lobar, segmental and subsegmental bronchi.
Further divisions form bronchioles, which cause bronchoconstriction and
bronchodilation.
2 The alveoli are interconnected by pores of Kohn which allow the passage of air from
alveolus to alveolus.
3 Lungs are lined by a membrane called visceral pleura.
4 The chest cavity is lined with a membrane called parietal pleura.
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Feedback
1 Mechanical receptors such as juxtacapillary and irritant receptors are located in the
lungs, chest wall, and diaphragm.
2 The alveoli are interconnected by Pores of Kohn which allow movement of air from
alveolus to alveolus.
3 Olfactory nerve endings are located in the roof of the nose that are responsible for the
sense of smell.
4 Central chemoreceptors are located in the medulla oblongata and respond to changes in
pH in the cerebrospinal fluid.
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Feedback
1 Alveoli are structures found in the lower respiratory tract.
2 The larynx, trachea and pharynx are structures located in the upper respiratory tract.
3 The larynx, trachea and pharynx are structures located in the upper respiratory tract.
4 The larynx, trachea and pharynx are structures located in the upper respiratory tract.
Feedback
1 Accessory muscle is a relatively rare anatomic duplication of muscle that may appear
anywhere in the muscular system.
2 The intercostal muscles are several groups of muscles that run between the ribs and
help form and move their chest wall.
3 Diaphragm is the major muscle of respiration. It is a sheet of internal skeletal muscle.
4 Abdominal muscle supports the trunk, allows movement and hold organs in place by
regulating internal abdominal pressure and assist in expelling air during labored
breathing.
MULTIPLE RESPONSE
26. ANS: 1, 3, 4
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Correlating relevant diagnostic examinations to respiratory function
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Feedback
1. This is correct. Eosinophilic airway inflammation occurs with COPD which results in elevated
levels of eosinophils.
2. This is incorrect. Viral disease like influenza decreases neutrophils count.
3. This is correct. COPD produces hypoxic stimulus which causes excessive production of
erythropoietin. It elevates the red blood cells count.
4. This is correct. COPD reduces level of oxygen in the blood and results in decreased partial
pressure of arterial oxygen.
5. This is incorrect. COPD elevates partial pressure of arterial carbon dioxide. Decreased partial
pressure of arterial carbon dioxide is observed in hyperventilation/respiratory alkalosis.
Feedback
1. This is incorrect. Asking the patient about urinary incontinence with coughing is appropriate
when assessing elimination patterns.
2. This is correct. When assessing the effects that a respiratory diagnosis has on activity-exercise
patterns the nurse will ask the patient if walking is impacted by dyspnea and how many flights
of steps can be walked before dyspnea occurs.
3. This is incorrect. Asking the patient if the spouse wakes him or her in the middle of the night
due to snoring assess sleep-rest patterns.
4. This is correct. When assessing the effects that a respiratory diagnosis has on activity-exercise
patterns the nurse will ask the patient if walking is impacted by dyspnea and how many flights
of steps can be walked before dyspnea occurs.
5. This is incorrect. Asking the patient if there is a feeling of fullness quickly upon eating is
assessing the patient’s nutritional-metabolic pattern.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Describing the procedure for completing a history and physical assessment of
respiratory function
Chapter page reference: 427-431
Heading: Assessment
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1. This is correct. Coarse crackles are often auscultated for patients diagnosed with pneumonia or
heart failure.
2. This is correct. Coarse crackles are often auscultated for patients diagnosed with pneumonia or
heart failure.
3. This is incorrect. Rhonchi is auscultated for patients diagnosed with cystic fibrosis.
4. This is incorrect. Wheezes are auscultated when the patient is experiencing bronchospasm.
5. This is incorrect. Discontinuous low pitched lung sounds are auscultated for patients
experiencing interstitial edema.
Feedback
1. This is correct. There are three categories of age-related changes that impact the respiratory
system, including changes in structure, defense mechanisms, and respiratory control. A
decrease in cilia function and cell-mediated immunity are both age-related defense mechanism
changes.
2. This is incorrect. Decreased chest wall compliance is a structural change.
3. This is incorrect. Decreased response to hypoxemia is a respiratory control change.
4. This is correct. There are three categories of age-related changes that impact the respiratory
system, including changes in structure, defense mechanisms, and respiratory control. A
decrease in cilia function and cell-mediated immunity are both age-related defense mechanism
changes
5. This is incorrect. Decreased respiratory muscle strength is an age-related structural change.
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Feedback
1. This is incorrect. A less forceful cough is an age-related change to respiratory defense
mechanisms.
2. This is incorrect. Calcification of the costal cartilage and a decrease in functional alveoli are
age-related structural changes to the respiratory system.
3. This is correct. Age-related changes to respiratory control include decreased responses to
hypoxemia and hypercapnia.
4. This is incorrect. Calcification of the costal cartilage and a decrease in functional alveoli are
age-related structural changes to the respiratory system.
5. This is correct. Age-related changes to respiratory control include decreased responses to
hypoxemia and hypercapnia.
NURSINGTB.COM
Chapter 24: Coordinating Care for Patients With Infectious Respiratory Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is assessing several patients at a community clinic. Which patient should not receive an annual
influenza vaccination?
1) A 65-year-old woman
2) A 3-year-old with cystic fibrosis
3) A 35-year-old man with a severe allergy to eggs
4) A 25-year-old pregnant woman at 20 weeks’ gestation
____ 2. A patient with the flu is experiencing tachypnea. What intervention is inappropriate to address in the nursing
diagnosis of Ineffective Breathing Pattern related to the flu?
1) Maintain adequate hydration
2) Keep the head of the bed elevated
3) Teach the patient coughing, deep breathing, and hydration
4) Prepare the patient for the possibility of a tracheostomy tube.
____ 3. The nurse makes a home visit to a patient recovering from complications related to influenza. Which patient
statement indicates the need for further intervention by the nurse?
1) “I went back to work.”
2) “I'm eating healthy foods now.”
3) “I continue to wake up coughing at night.”
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____ 10. The nurse is providing discharge teaching to a patient recovering from pneumonia. Which patient statement
indicates that additional teaching is needed?
1) “I can't get the influenza vaccine due to my allergy to eggs.”
2) “I will get the influenza vaccine every year.”
3) “I will get the pneumococcal vaccine every fall.”
4) “I will get the pneumococcal vaccine as soon as I recover from this pneumonia.”
____ 11. The nurse is providing care to a patient with pneumonia and has a fever. Which intervention should the nurse
implement to attain the goal of normal body temperature?
1) Increase the temperature of the room environment to prevent shivering
2) Administer antipyretic medications
3) Restrict fluids during periods of hyperthermia because of the risk of electrolyte imbalance
4) Use ice packs and a tepid bath every two hours
____ 12. The nurse is preparing to assess an older adult patient admitted with tuberculosis. Which manifestations does
the nurse anticipate for this patient?
1) Night sweats
2) Swollen lymph nodes
3) Cough
4) Hemoptysis
____ 13. An adolescent patient is brought to the emergency department (ED) with fatigue, weight loss, a dry cough,
and night sweats. The family just recently immigrated to the United States. Based on this data, for which
potential risk should the nurse include when planning care for this patient?
1) Pneumothorax
2) Pneumonia
3) Renal failure NURSINGTB.COM
4) Septicemia
____ 14. The nurse in an inner city clinic is providing a health screening for a homeless patient with a history of drug
abuse. The patient has a chronic nonproductive cough. For which should the nurse expect to screen this
patient?
1) Herpes zoster
2) Sickle cell disease
3) Sick sinus syndrome
4) Tuberculosis
____ 15. The nurse is planning care for an older adult patient recently diagnosed with tuberculosis (TB). The patient
lives alone in an apartment and will continue treatment at home. Which nursing diagnosis is a priority for this
patient?
1) Ineffective Therapeutic Regimen Management
2) Deficient Knowledge
3) Ineffective Breathing Pattern
4) Risk for Injury
____ 16. An occupational health nurse is screening a new employee in a long-term care facility for tuberculosis (TB).
The employee questions why purified protein derivative (PPD) testing is done twice. Which is the most
appropriate response by the nurse?
1) “Different medication is used in the second PPD.”
2) “The treatment for TB is six months of medication, and we want to make sure the first
results of the first PPD were accurate.”
3) “The first PPD was not interpreted in the correct time frame of 48-72 hours.”
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4) “There is an increased risk for a false-negative response for people who work in long-term
care facilities. The two-step is recommended to accurately screen for TB.”
____ 17. The nurse is caring for a patient who is receiving multiple drugs for treatment of tuberculosis. The nurse
teaches the patient the rationale for the multiple-drug treatment and evaluates learning as effective when the
patient makes which statement?
1) “Multiple drugs are necessary to develop immunity to tuberculosis.”
2) “Multiple drugs are necessary because I became infected from an immigrant.”
3) “Multiple drugs will be required as long as I am contagious.”
4) “Multiple drugs are necessary because of the risk of resistance.”
____ 18. The nurse is caring for a patient who is admitted to the unit with tuberculosis (TB). The patient is placed in
isolation. To protect the caregivers and other patients on the unit, which type of isolation room is most
appropriate?
1) Single-door room with positive air flow (air flows out of the room.)
2) Isolation room with an anteroom and negative air flow (air flows into the room.)
3) Isolation room with an anteroom and normal airflow
4) Single-door room with normal airflow
____ 19. The charge nurse for a medical-surgical unit is notified that a patient with tuberculosis (TB) is being
transported to the unit. Which nursing action for infection prevention is the most appropriate in this
circumstance?
1) Stock the patient’s supply cart at the beginning of each shift
2) Wear a respirator mask and gown when caring for the patient
3) Perform hand hygiene only after leaving the room
4) Test all staff members for TB immediately
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____ 20. A nurse is caring for a patient with tuberculosis (TB) who is taking Rifampin for treatment of the disease.
Which nursing intervention is most appropriate for this patient?
1) Administer the medication with meals to reduce gastrointestinal side effects
2) Record a baseline visual examination before initiating therapy
3) Administer the medication on an empty stomach
4) Administer the medication by deep intramuscular injection into a large muscle mass
____ 21. The nurse is assessing a patient who is diagnosed with tuberculosis. Which assessment finding supports this
diagnosis?
1) Wheezing
2) Hemoptysis
3) Grey sputum
4) Slightly whitish sputum
____ 22. During the respiratory assessment, the nurse notes coarse crackles upon auscultation of the lung fields. Which
diagnosis presents with this assessment finding?
1) Pneumonia
2) Cystic fibrosis
3) Bronchospasm
4) Interstitial edema
____ 23. The nurse is providing care to a patient who is diagnosed with pneumonia. The patient admits to smoking one
pack of cigarettes per day. Which respiratory defense mechanism may have failed to cause the patient’s
diagnosis?
1) Cough reflex
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2) Filtration of air
3) Alveolar macrophages
4) Mucociliary clearance system
____ 24. The nurse receives a phone call from the parent of a child who is prescribed rifampin (Rimactane) for
treatment of tuberculosis because she saw that the child’s urine was orange. Which response by the nurse is
accurate?
1) “Encourage your child to drink cranberry juice.”
2) “An orange discoloration of urine is expected while your child is on this medication.”
3) “Bring your child to the clinic for a urinalysis.”
4) “Bring your child to the clinic for a radiograph of the kidneys.”
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 25. The nurse caring for a homeless patient at risk for tuberculosis (TB) will include which symptoms of the
disease when educating the patient? Select all that apply.
1) Fatigue
2) Low-grade morning fever
3) Productive cough that later turns to a dry, hacking cough
4) Weight loss
5) Night sweats
____ 26. The nurse is assessing a patient with acute malaise and muscle aches. Which questions should the nurse ask to
determine whether the patient is experiencing influenza? Select all that apply.
1) “Have you had a flu shot this year?”
NURSINGTB.COM
2) “Is your cough productive?”
3) “Have you been exposed to anyone with the flu?”
4) “Are you having any trouble urinating?”
5) “Do you have dizziness?”
____ 27. The school nurse is planning a teaching session with the parents of students to reduce the spread of the
influenza virus throughout the school. What should the nurse include when teaching the parents of a diverse
population about infection-control techniques? Select all that apply.
1) “Cover your cough” education
2) Appropriate hand hygiene
3) Safe food preparation and storage
4) Sanitizing high-touch items to kill pathogens
5) Withholding immunizations for children with compromised immune systems
____ 28. The nurse is caring for a patient who develops a fever and productive cough after having an appendectomy.
Which prescriptions should the nurse expect from the health-care provider for this health problem? Select all
that apply.
1) Sputum cultures
2) Antibiotics
3) Chest physiotherapy
4) Bronchial washing for culture
5) Isolation precautions
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 24: Coordinating Care for Patients With Infectious Respiratory Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Describing the etiology of infectious airway disorders
Chapter page reference: 443-447
Heading: Influenza
Integrated Processes: Nursing Process – Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
1 People at increased risk of influenza or its complications include infants, young
children, and anyone age 50 or older; therefore, this patient should receive an annual
influenza vaccine.
2 Patients with chronic disorders, especially diabetes and cardiac, renal, or pulmonary
diseases, are more susceptible to complications from the flu; therefore, this patient
should receive an annual influenza vaccine.
3 A 35-year-old man with a severe allergy to eggs should not get a flu shot, because the
vaccine contains eggs and it is not recommended.
4 Pregnant women, particularly N URSthe
during INsecond
GTB.and COM third trimesters, are at increased
risk of complications from the flu; therefore, this patient should receive the annual
influenza vaccine.
NURSINGTB.COM
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3 Pneumonia vaccines can also be considered to decrease the risk of development in the
future.
4 There is not an established body of scientific evidence that supports the claim that L.
casei immunitas cultures can improve immune function.
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Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with infectious airway disorders
Chapter page reference: 447-451
Heading: Pneumonia
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
Feedback
1 Influenza vaccine is administered annually to healthy individuals and should not be
given to those with an allergy to eggs.
2 Influenza vaccine is administered annually to healthy individuals and should not be
given to those with an allergy to eggs.
3 The pneumococcal vaccine is administered once. Revaccination is only recommended
in persons with renal failure, those who have had splenectomies, those with
malignancies, and those with HIV/AIDS.
4 This statement indicates correct understanding of the information presented.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Heading: Tuberculosis
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation; Infection
Difficulty: Easy
Feedback
1 Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting
symptoms of tuberculosis in the older adult.
2 Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting
symptoms of tuberculosis in the older adult.
3 Presenting symptoms of tuberculosis in the older adult are often vague and include
coughing, weight loss, diminished appetite, and periodic fevers.
4 Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting
symptoms of tuberculosis in the older adult.
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1 There is no evidence to support the need to screen the patient for sickle cell disease,
herpes zoster, or sick sinus syndrome.
2 There is no evidence to support the need to screen the patient for sickle cell disease,
herpes zoster, or sick sinus syndrome.
3 There is no evidence to support the need to screen the patient for sickle cell disease,
herpes zoster, or sick sinus syndrome.
4 The homeless patient who abuses drugs is at risk for contracting tuberculosis (TB);
therefore, the nurse would expect to screen this patient for TB.
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1 Wheezing is the term used to describe the musical sounds auscultated during
assessment and indicate some degree of airway obstruction that occurs with asthma and
emphysema.
2 Tuberculosis is characterized by hemoptysis, which is the term for coughing up of
blood or blood-tinged sputum from the respiratory tract.
3 Grey sputum often occurs in patients who are cigarette smokers.
4 Clear, slightly whitish, and viscous sputum are often normal findings.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
24. ANS: 2
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Discussing the medical management of: Tuberculosis
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1 Orange urine does not mean the child has a urinary tract infection, and a urinalysis,
radiograph, and encouragement of cranberry juice would not be options.
2 Rifampin can color the urine orange, so the parents and child should be taught that this
is an expected side effect.
3 Orange urine does not mean the child has a urinary tract infection, and a urinalysis,
radiograph, and encouragement of cranberry juice would not be options.
4 Orange urine does not mean the child has a urinary tract infection, and a urinalysis,
radiograph, and encouragement of cranberry juice would not be options.
MULTIPLE RESPONSE
Feedback
1. This is correct. Manifestations of tuberculosis often develop insidiously and are initially
nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that
the patient first seeks medical attention.
2. This is incorrect. A low-grade afternoon, not morning, fever is anticipated.
3. This is incorrect. A dry cough develops, which later becomes productive of purulent and/or
blood-tinged sputum.
4. This is correct. Manifestations of tuberculosis often develop insidiously and are initially
nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that
the patient first seeks medical attention.
5. This is correct. Manifestations of tuberculosis often develop insidiously and are initially
nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that
the patient first seeks medical attention.
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Feedback
1. This is correct. Based on the presenting symptoms, the nurse would ask whether the patient
has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is
nonproductive. A productive cough may indicate a different diagnosis.
2. This is correct. Based on the presenting symptoms, the nurse would ask whether the patient
has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is
nonproductive. A productive cough may indicate a different diagnosis.
3. This is correct. Based on the presenting symptoms, the nurse would ask whether the patient
has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is
nonproductive. A productive cough may indicate a different diagnosis.
4. This is incorrect. Insufficient voiding and dizziness are not routine manifestations of
influenza.
5. NURS
This is incorrect. Insufficient INGTand
voiding B.dizziness
COM are not routine manifestations of
influenza.
Feedback
1. This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching
children to wash their hands, and appropriate respiratory etiquette such as “cover your cough”
education all control the growth and spread of microorganisms.
2. This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching
children to wash their hands, and appropriate respiratory etiquette such as “cover your cough”
education all control the growth and spread of microorganisms.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3. This is incorrect. Teaching parents’ safe food preparation and storage is another tool to
prevent the spread of microorganisms, but is not related to the flu virus.
4. This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching
children to wash their hands, and appropriate respiratory etiquette such as “cover your cough”
education all control the growth and spread of microorganisms. To prevent the spread of
communicable diseases, microorganisms must be killed or their growth controlled.
5. This is incorrect. Immunizations should not be withheld from immunocompromised children,
and this is not an infection-control strategy.
Feedback
1. This is correct. The nurse would expect to obtain sputum cultures, administer antibiotics, and
perform chest physiotherapy to help clear the respiratory secretions.
2. This is correct. The nurse would expect to obtain sputum cultures, administer antibiotics, and
NURSINGTB.COM
perform chest physiotherapy to help clear the respiratory secretions.
3. This is correct. The nurse would expect to obtain sputum cultures, administer antibiotics, and
perform chest physiotherapy to help clear the respiratory secretions.
4. This is incorrect. Bronchial washings are not routine testing for this scenario.
5. This is incorrect. The patient likely has a noninfectious disease and is not contagious. Isolation
precautions are usually not ordered for noncontagious infections.
Chapter 24: Coordinating Care for Patients With Infectious Respiratory Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is assessing several patients at a community clinic. Which patient should not receive an annual
influenza vaccination?
1) A 65-year-old woman
2) A 3-year-old with cystic fibrosis
3) A 35-year-old man with a severe allergy to eggs
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2) “As you grow older, there is a decrease in the immune response, which puts you at greater
risk for developing an infection.”
3) “As you grow older, there in an overall increase in the speed and strength of your immune
response.”
4) “As you grow older, there is an increase in the number of B cells in the circulation, which
hinders the immune response.”
____ 9. The nurse determines that the diagnosis of Ineffective Airway Clearance is appropriate for a patient with
pneumonia who is experiencing copious amounts of respiratory secretions. Which intervention should the
nurse include in this patient's plan of care?
1) Perform chest percussion every four hours and prn
2) Administer the pneumococcal vaccine prior to discharge
3) Limit fluid intake to 1,000 mL per day
4) Provide the patient with smoking cessation education
____ 10. The nurse is providing discharge teaching to a patient recovering from pneumonia. Which patient statement
indicates that additional teaching is needed?
1) “I can't get the influenza vaccine due to my allergy to eggs.”
2) “I will get the influenza vaccine every year.”
3) “I will get the pneumococcal vaccine every fall.”
4) “I will get the pneumococcal vaccine as soon as I recover from this pneumonia.”
____ 11. The nurse is providing care to a patient with pneumonia and has a fever. Which intervention should the nurse
implement to attain the goal of normal body temperature?
1) Increase the temperature of the room environment to prevent shivering
2) Administer antipyretic medications
3) Restrict fluids during periods ofNhyperthermia
URSINGTbecause
B.COMof the risk of electrolyte imbalance
4) Use ice packs and a tepid bath every two hours
____ 12. The nurse is preparing to assess an older adult patient admitted with tuberculosis. Which manifestations does
the nurse anticipate for this patient?
1) Night sweats
2) Swollen lymph nodes
3) Cough
4) Hemoptysis
____ 13. An adolescent patient is brought to the emergency department (ED) with fatigue, weight loss, a dry cough,
and night sweats. The family just recently immigrated to the United States. Based on this data, for which
potential risk should the nurse include when planning care for this patient?
1) Pneumothorax
2) Pneumonia
3) Renal failure
4) Septicemia
____ 14. The nurse in an inner city clinic is providing a health screening for a homeless patient with a history of drug
abuse. The patient has a chronic nonproductive cough. For which should the nurse expect to screen this
patient?
1) Herpes zoster
2) Sickle cell disease
3) Sick sinus syndrome
4) Tuberculosis
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 15. The nurse is planning care for an older adult patient recently diagnosed with tuberculosis (TB). The patient
lives alone in an apartment and will continue treatment at home. Which nursing diagnosis is a priority for this
patient?
1) Ineffective Therapeutic Regimen Management
2) Deficient Knowledge
3) Ineffective Breathing Pattern
4) Risk for Injury
____ 16. An occupational health nurse is screening a new employee in a long-term care facility for tuberculosis (TB).
The employee questions why purified protein derivative (PPD) testing is done twice. Which is the most
appropriate response by the nurse?
1) “Different medication is used in the second PPD.”
2) “The treatment for TB is six months of medication, and we want to make sure the first
results of the first PPD were accurate.”
3) “The first PPD was not interpreted in the correct time frame of 48-72 hours.”
4) “There is an increased risk for a false-negative response for people who work in long-term
care facilities. The two-step is recommended to accurately screen for TB.”
____ 17. The nurse is caring for a patient who is receiving multiple drugs for treatment of tuberculosis. The nurse
teaches the patient the rationale for the multiple-drug treatment and evaluates learning as effective when the
patient makes which statement?
1) “Multiple drugs are necessary to develop immunity to tuberculosis.”
2) “Multiple drugs are necessary because I became infected from an immigrant.”
3) “Multiple drugs will be required as long as I am contagious.”
4) “Multiple drugs are necessary because of the risk of resistance.”
____ 18. The nurse is caring for a patient whoNisUadmitted
RSINGtoTthe B.unit
COM with tuberculosis (TB). The patient is placed in
isolation. To protect the caregivers and other patients on the unit, which type of isolation room is most
appropriate?
1) Single-door room with positive air flow (air flows out of the room.)
2) Isolation room with an anteroom and negative air flow (air flows into the room.)
3) Isolation room with an anteroom and normal airflow
4) Single-door room with normal airflow
____ 19. The charge nurse for a medical-surgical unit is notified that a patient with tuberculosis (TB) is being
transported to the unit. Which nursing action for infection prevention is the most appropriate in this
circumstance?
1) Stock the patient’s supply cart at the beginning of each shift
2) Wear a respirator mask and gown when caring for the patient
3) Perform hand hygiene only after leaving the room
4) Test all staff members for TB immediately
____ 20. A nurse is caring for a patient with tuberculosis (TB) who is taking Rifampin for treatment of the disease.
Which nursing intervention is most appropriate for this patient?
1) Administer the medication with meals to reduce gastrointestinal side effects
2) Record a baseline visual examination before initiating therapy
3) Administer the medication on an empty stomach
4) Administer the medication by deep intramuscular injection into a large muscle mass
____ 21. The nurse is assessing a patient who is diagnosed with tuberculosis. Which assessment finding supports this
diagnosis?
1) Wheezing
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2) Hemoptysis
3) Grey sputum
4) Slightly whitish sputum
____ 22. During the respiratory assessment, the nurse notes coarse crackles upon auscultation of the lung fields. Which
diagnosis presents with this assessment finding?
1) Pneumonia
2) Cystic fibrosis
3) Bronchospasm
4) Interstitial edema
____ 23. The nurse is providing care to a patient who is diagnosed with pneumonia. The patient admits to smoking one
pack of cigarettes per day. Which respiratory defense mechanism may have failed to cause the patient’s
diagnosis?
1) Cough reflex
2) Filtration of air
3) Alveolar macrophages
4) Mucociliary clearance system
____ 24. The nurse receives a phone call from the parent of a child who is prescribed rifampin (Rimactane) for
treatment of tuberculosis because she saw that the child’s urine was orange. Which response by the nurse is
accurate?
1) “Encourage your child to drink cranberry juice.”
2) “An orange discoloration of urine is expected while your child is on this medication.”
3) “Bring your child to the clinic for a urinalysis.”
4) “Bring your child to the clinic for a radiograph of the kidneys.”
NURSINGTB.COM
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 25. The nurse caring for a homeless patient at risk for tuberculosis (TB) will include which symptoms of the
disease when educating the patient? Select all that apply.
1) Fatigue
2) Low-grade morning fever
3) Productive cough that later turns to a dry, hacking cough
4) Weight loss
5) Night sweats
____ 26. The nurse is assessing a patient with acute malaise and muscle aches. Which questions should the nurse ask to
determine whether the patient is experiencing influenza? Select all that apply.
1) “Have you had a flu shot this year?”
2) “Is your cough productive?”
3) “Have you been exposed to anyone with the flu?”
4) “Are you having any trouble urinating?”
5) “Do you have dizziness?”
____ 27. The school nurse is planning a teaching session with the parents of students to reduce the spread of the
influenza virus throughout the school. What should the nurse include when teaching the parents of a diverse
population about infection-control techniques? Select all that apply.
1) “Cover your cough” education
2) Appropriate hand hygiene
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Chapter 24: Coordinating Care for Patients With Infectious Respiratory Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Describing the etiology of infectious airway disorders
Chapter page reference: 443-447
Heading: Influenza
Integrated Processes: Nursing Process – Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
1 People at increased risk of influenza or its complications include infants, young
children, and anyone age 50 or older; therefore, this patient should receive an annual
influenza vaccine.
2 Patients with chronic disorders, especially diabetes and cardiac, renal, or pulmonary
diseases, are more susceptible to complications from the flu; therefore, this patient
should receive an annual influenza vaccine.
3 A 35-year-old man with a severe allergy to eggs should not get a flu shot, because the
vaccine contains eggs and it is not recommended.
4 Pregnant women, particularly N URSthe
during INsecond
GTB.and COM third trimesters, are at increased
risk of complications from the flu; therefore, this patient should receive the annual
influenza vaccine.
NURSINGTB.COM
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3 Pneumonia vaccines can also be considered to decrease the risk of development in the
future.
4 There is not an established body of scientific evidence that supports the claim that L.
casei immunitas cultures can improve immune function.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with infectious airway disorders
Chapter page reference: 447-451
Heading: Pneumonia
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
Feedback
1 Influenza vaccine is administered annually to healthy individuals and should not be
given to those with an allergy to eggs.
2 Influenza vaccine is administered annually to healthy individuals and should not be
given to those with an allergy to eggs.
3 The pneumococcal vaccine is administered once. Revaccination is only recommended
in persons with renal failure, those who have had splenectomies, those with
malignancies, and those with HIV/AIDS.
4 This statement indicates correct understanding of the information presented.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Heading: Tuberculosis
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation; Infection
Difficulty: Easy
Feedback
1 Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting
symptoms of tuberculosis in the older adult.
2 Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting
symptoms of tuberculosis in the older adult.
3 Presenting symptoms of tuberculosis in the older adult are often vague and include
coughing, weight loss, diminished appetite, and periodic fevers.
4 Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting
symptoms of tuberculosis in the older adult.
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1 There is no evidence to support the need to screen the patient for sickle cell disease,
herpes zoster, or sick sinus syndrome.
2 There is no evidence to support the need to screen the patient for sickle cell disease,
herpes zoster, or sick sinus syndrome.
3 There is no evidence to support the need to screen the patient for sickle cell disease,
herpes zoster, or sick sinus syndrome.
4 The homeless patient who abuses drugs is at risk for contracting tuberculosis (TB);
therefore, the nurse would expect to screen this patient for TB.
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1 Wheezing is the term used to describe the musical sounds auscultated during
assessment and indicate some degree of airway obstruction that occurs with asthma and
emphysema.
2 Tuberculosis is characterized by hemoptysis, which is the term for coughing up of
blood or blood-tinged sputum from the respiratory tract.
3 Grey sputum often occurs in patients who are cigarette smokers.
4 Clear, slightly whitish, and viscous sputum are often normal findings.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
24. ANS: 2
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Discussing the medical management of: Tuberculosis
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1 Orange urine does not mean the child has a urinary tract infection, and a urinalysis,
radiograph, and encouragement of cranberry juice would not be options.
2 Rifampin can color the urine orange, so the parents and child should be taught that this
is an expected side effect.
3 Orange urine does not mean the child has a urinary tract infection, and a urinalysis,
radiograph, and encouragement of cranberry juice would not be options.
4 Orange urine does not mean the child has a urinary tract infection, and a urinalysis,
radiograph, and encouragement of cranberry juice would not be options.
MULTIPLE RESPONSE
Feedback
1. This is correct. Manifestations of tuberculosis often develop insidiously and are initially
nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that
the patient first seeks medical attention.
2. This is incorrect. A low-grade afternoon, not morning, fever is anticipated.
3. This is incorrect. A dry cough develops, which later becomes productive of purulent and/or
blood-tinged sputum.
4. This is correct. Manifestations of tuberculosis often develop insidiously and are initially
nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that
the patient first seeks medical attention.
5. This is correct. Manifestations of tuberculosis often develop insidiously and are initially
nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that
the patient first seeks medical attention.
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Feedback
1. This is correct. Based on the presenting symptoms, the nurse would ask whether the patient
has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is
nonproductive. A productive cough may indicate a different diagnosis.
2. This is correct. Based on the presenting symptoms, the nurse would ask whether the patient
has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is
nonproductive. A productive cough may indicate a different diagnosis.
3. This is correct. Based on the presenting symptoms, the nurse would ask whether the patient
has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is
nonproductive. A productive cough may indicate a different diagnosis.
4. This is incorrect. Insufficient voiding and dizziness are not routine manifestations of
influenza.
5. NURS
This is incorrect. Insufficient INGTand
voiding B.dizziness
COM are not routine manifestations of
influenza.
Feedback
1. This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching
children to wash their hands, and appropriate respiratory etiquette such as “cover your cough”
education all control the growth and spread of microorganisms.
2. This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching
children to wash their hands, and appropriate respiratory etiquette such as “cover your cough”
education all control the growth and spread of microorganisms.
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3. This is incorrect. Teaching parents’ safe food preparation and storage is another tool to
prevent the spread of microorganisms, but is not related to the flu virus.
4. This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching
children to wash their hands, and appropriate respiratory etiquette such as “cover your cough”
education all control the growth and spread of microorganisms. To prevent the spread of
communicable diseases, microorganisms must be killed or their growth controlled.
5. This is incorrect. Immunizations should not be withheld from immunocompromised children,
and this is not an infection-control strategy.
Feedback
1. This is correct. The nurse would expect to obtain sputum cultures, administer antibiotics, and
perform chest physiotherapy to help clear the respiratory secretions.
2. This is correct. The nurse would expect to obtain sputum cultures, administer antibiotics, and
NURSINGTB.COM
perform chest physiotherapy to help clear the respiratory secretions.
3. This is correct. The nurse would expect to obtain sputum cultures, administer antibiotics, and
perform chest physiotherapy to help clear the respiratory secretions.
4. This is incorrect. Bronchial washings are not routine testing for this scenario.
5. This is incorrect. The patient likely has a noninfectious disease and is not contagious. Isolation
precautions are usually not ordered for noncontagious infections.
Chapter 25: Coordinating Care for Patients With Upper Airway Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. An adult patient diagnosed with sleep apnea has been prescribed a continuous positive airway pressure
(CPAP) machine as treatment. The nurse is instructing the patient on how to use the machine. Which
instruction should the nurse include?
1) Any size mask will work
2) Straps can be loose, if that feels more comfortable
3) Use relaxation exercises to reduce uncomfortable feelings from the mask
4) Do not use a humidifier at the same time
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____ 2. The nurse is caring for a patient being weaned from the ventilator, and wants to improve the patient’s ability
to communicate. Which item will the nurse request an order for from the health-care provider?
1) Cuffed tracheostomy tube
2) Uncuffed tracheostomy tube
3) Fenestrated tracheostomy tube
4) Obturator
____ 3. The nurse is performing tracheostomy care. Which portion of the trach will the nurse use when tying the new
trach ties?
1) Inner cannula
2) Outer cannula
3) Obturator
4) Flange
____ 4. The nurse is caring for a patient with a longstanding permanent tracheostomy that has been in place for
several years in order to provide mechanical ventilation. Which type of tracheostomy does the nurse
anticipate this patient may have based on the health history?
1) Uncuffed tracheostomy
2) Cuffed tracheostomy
3) Fenestrated tracheostomy
4) Uncuffed or fenestrated tracheostomy
____ 5. The nurse is caring for a patient with a tracheostomy tube in place connected to a mechanical ventilator.
When facilitating communication, which strategy is inappropriate?
1) Using a fenestrated tracheostomy tube
2) Using writing materials
3) Using a communication board NURSINGTB.COM
4) Using a Passy-Muir valve
____ 6. When preparing to cap the patient’s tracheostomy tube with a speaking valve, which nursing action is
inappropriate before placing the valve?
1) Suctioning the oropharynx if there are any secretions present
2) Asking the patient to cough
3) Suctioning the tracheostomy tube
4) Deflating the cuffed tracheostomy tube
____ 7. When capping the patient’s tracheostomy tube with a speaking valve, the nurse assesses the patient’s breath
sounds around the tube and hears no air leak. Which nursing action is the most appropriate based on this
assessment finding?
1) Allowing the cap to remain in place as long as the patient tolerates it
2) Documenting the placement of the cap and relevant data regarding patient assessment
3) Removing the valve and notifying the health-care provider
4) Assisting the patient out of bed
____ 8. The nurse is providing care to a patient who is diagnosed with rhinitis and prescribed a first generation
antihistamine. Which drug should the nurse educate the patient about based on this data?
1) Loratadine
2) Fluticasone
3) Guaifenesin
4) Diphenhydramine
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____ 9. The nurse is providing care to a patient who is diagnosed with rhinitis and prescribed a second generation
antihistamine. Which drug should the nurse educate the patient about based on this data?
1) Loratadine
2) Fluticasone
3) Guaifenesin
4) Diphenhydramine
____ 10. The nurse is providing care to a patient who is diagnosed with rhinitis and prescribed a decongestant. Which
drug should the nurse educate the patient about based on this data?
1) Loratadine
2) Fluticasone
3) Guaifenesin
4) Diphenhydramine
____ 11. The nurse is providing care to a patient who is diagnosed with rhinitis and prescribed a corticosteroid nasal
spray. Which drug should the nurse educate the patient about based on this data?
1) Loratadine
2) Fluticasone
3) Guaifenesin
4) Diphenhydramine
____ 12. The nurse is providing education to the patient regarding nasal sprays that can be used to treat congestion.
Which drug should the nurse include for a patient who requires a corticosteroid?
1) Saline
2) Azelastine
3) Fluticasone
4) Oxymetazonline NURSINGTB.COM
____ 13. The nurse is providing education to the patient regarding nasal sprays that can be used to treat congestion.
Which drug should the nurse include for a patient who requires an antihistamine?
1) Saline
2) Azelastine
3) Fluticasone
4) Oxymetazonline
____ 14. The nurse is providing education to the patient regarding nasal sprays that can be used to treat congestion.
Which drug should the nurse include for a patient who requires a decongestant?
1) Saline
2) Azelastine
3) Fluticasone
4) Oxymetazonline
____ 15. The nurse is providing education to the patient regarding nasal sprays that can be used to treat congestion.
Which should the nurse recommend when the patient wants a natural?
1) Saline
2) Azelastine
3) Fluticasone
4) Oxymetazonline
____ 16. The nurse is providing care to a patient receiving radiation in the treatment of laryngeal cancer. Which patient
statement indicates the need for further education regarding radiation treatments?
1) “My skin may become red, tender, and peel.”
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____ 24. Which assessment data collected by the nurse indicates a patient with laryngeal trauma is experiencing issues
with airway clearance?
1) Tachypnea
2) Bradycardia
3) Hypotension
4) Increased oxygen saturation
____ 25. Which intervention should the nurse implement for a patient who is at risk for aspiration as a result of
laryngeal trauma?
1) Encouraging voice rest
2) Maintaining NPO status
3) Placing in high-Fowler’s position
4) Providing humidified air via face mask
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. Which criteria is used to diagnosis acute bacterial rhinosinusitis (ABRS) in adult patients? Select all that
apply.
1) Facial pain that lasts for one day
2) Decrease in nasal discharge after six days
3) New onset of headache after five or six days
4) Symptoms that last more than 10 days without clinical improvement
5) Temperature greater than or equal to 102°F [39°C] with purulent nasal discharge for four
days NURSINGTB.COM
____ 27. Which first-line medications should the nurse include in a teaching session for a patient who wants to quit
smoking? Select all that apply.
1) Clonidine
2) Bupropion
3) Varenicline
4) Nortriptyline
5) Nicotine gum
____ 28. Which patient statements accurately reflect the benefits of physical activity during the smoking cessation
process? Select all that apply.
1) “Exercise decreases stress.”
2) “Exercise decreases anxiety.”
3) “Exercise decreases cravings.”
4) “Exercise increases weight loss.”
5) “Exercise increases my support network.”
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Chapter 25: Coordinating Care for Patients With Upper Airway Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Developing a teaching plan for patients with upper airway disorders
Chapter page reference: 462-265
Heading: Obstructive Sleep Apnea
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1 Proper fitting of the mask to the face, including wearing the right size mask and
keeping the straps tight, is important.
2 Proper fitting of the mask to the face, including wearing the right size mask and
keeping the straps tight, is important.
3 Relaxation exercises can reduce the claustrophobic feelings caused by wearing the
mask.
4 Using a humidifier can minimize dry mouth and nose.
PTS: 1 NURSINGTB.COM
CON: Oxygenation
2. ANS: 3
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with upper airway
disorders
Chapter page reference: 466-471
Heading: Laryngeal Cancer
Integrated Processes: Nursing Process – Implementation
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Oxygenation; Communication
Difficulty: Moderate
Feedback
1 The cuffed tracheostomy would need to be deflated in order for the fenestrated tube to
function.
2 An uncuffed tube does not improve communication.
3 The fenestrated tracheostomy tube allows patients to speak, and could be safely used on
the patient who is being weaned from the ventilator.
4 An obturator is used to make the tracheostomy tube more rigid during insertion, and
must be removed as soon as the tube is in place, because it occludes the airway.
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Chapter learning objective: Developing a comprehensive plan of nursing care for patients with upper airway
disorders
Chapter page reference: 466-471
Heading: Laryngeal Cancer
Integrated Processes: Nursing Process – Implementation
Client Need: Physiological Integrity – Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1 This is an inappropriate action by the nurse when tying the new trach ties.
2 This is an inappropriate action by the nurse when tying the new trach ties.
3 This is an inappropriate action by the nurse when tying the new trach ties.
4 The trach ties attach to the flange.
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Feedback
1 Fenestrated tracheostomy tubes require placement of the inner cannula when the patient
requires mechanical ventilation, which defeats the speaking ability of the tube.
Although a fenestrated tube allows a patient to speak when weaning from the ventilator,
it will not improve communication for the ventilated patient.
2 Use of writing materials is useful for improving communication if the patient is alert
and strong enough to be able to use them.
3 A communication board is indicated if the patient is not strong enough to use writing
materials.
4 A Passy-Muir valve can be used when the patient is on or off of the ventilator, allowing
the patient to speak.
Feedback
1 The valve should be removed and the health-care provider notified because lack of an
air leak indicates the patient will not be able to exhale and, as a result, will not tolerate
the valve.
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2 Only after calling the health-care provider would the nurse document the inability to
use the valve.
3 The valve should be removed and the health-care provider notified because lack of an
air leak indicates the patient will not be able to exhale and, as a result, will not tolerate
the valve.
4 There would be no need to assist the patient out of bed.
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Heading: Rhinitis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Inflammation; Medication
Difficulty: Moderate
Feedback
1 Saline is a nasal spray; however, saline is not an antihistamine.
2 Azelastine is an antihistamine nasal spray.
3 Fluticasone is a corticosteroid nasal spray.
4 Oxymetazoline is a decongestant nasal spray.
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Feedback
1 An antiemetic agent is often prescribed to treat the nausea and vomiting that can occur
with chemotherapy.
2 A decongestant is more appropriate for a patient diagnosed with rhinitis.
3 An antihistamine may be administered during a scheduled chemotherapy session.
However, this drug is not prescribed for use between sessions. It is more appropriate for
a patient diagnosed with rhinitis.
4 A corticosteroid is more appropriate for a patient diagnosed with rhinitis. A
corticosteroid can increase the patient’s risk of infection is prescribed and administered
with chemotherapy.
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3 Liquid supplements are easy to swallow and increase the patient’s caloric intake when
used in additional to solid foods.
4 The patient is encouraged to eat foods that taste good and are easy to eat and swallow in
order to ensure an adequate caloric intake.
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Feedback
1 Encouraging voice rest is important to decrease inflammation and edema, not
aspiration.
2 Due to the edema and inflammation from the injury, an NPO status decreases the
patient’s risk for aspiration. NPO status is also encouraged prior to surgery for the same
reason.
3 Maintaining a high-Fowler’s position will decrease edema and maintain a patent
airway.
4 Cool, humidified air will decrease airway edema.
MULTIPLE RESPONSE
26. ANS: 3, 4, 5
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Rhinosinusitis
Chapter page reference: 459-462
Heading: Rhinosinusitis
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Inflammation; Infection
Difficulty: Easy NURSINGTB.COM
Feedback
1. This is incorrect. Facial pain with fever that lasts longer than three to four days would indicate
ABRS.
2. This is incorrect. An increase, not decrease, in nasal discharge after six days would indicate
ABRS.
3. This is correct. A new onset of headache after this length of time with symptoms often
indicates ABRS.
4. This is correct. Symptoms that last more than 10 days without clinical improvement often
indicates ABRS.
5. This is correct. This data supports the diagnosis of ABRS.
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Feedback
1. This is incorrect. Clonidine is a second, not first, line drug for smoking cessation.
2. This is correct. Bupropion is a first-line drug for smoking cessation.
3. This is correct. Varenicline is a first-line drug for smoking cessation.
4. This is incorrect. Nortriptyline is a second, not first, line drug for smoking cessation.
5. This is correct. Nicotine gum is a first-line drug for smoking cessation.
Feedback
1. This is correct. Exercise decreases stress that is often experienced during smoking cessation.
2. This is correct. Exercise decreases anxiety that is often experienced during smoking cessation.
3. This is correct. Exercise decreases cravings that are often experienced during smoking
cessation. NURSINGTB.COM
4. This is incorrect. While exercise is known to reduce the weight gain postcessation it is not
known to increase weight loss.
5. This is incorrect. Support groups, not exercise, increase the patient’s support network.
Chapter 26: Coordinating Care for Patients With Lower Airway Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The student nurse is questioning the instructor about the different types of chemotherapeutic agents used to
treat cancer. Which statement by the instructor best explains why lung cancers are less sensitive to
antineoplastic agents than other types of cancers?
1) “Lung cancer cells have a low growth fraction, so they are less sensitive to antineoplastic
agents.”
2) “Lung cancer cells grow in a high-oxygen environment, so they are not very sensitive to
antineoplastic agents.”
3) “Lung cancer cells have been growing for a long time before detection, so they are less
sensitive to antineoplastic agents.”
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4) “Lung cancer cells have a very erratic cell cycle, so they are not very sensitive to
antineoplastic agents.”
____ 2. The nurse is caring for a patient in a community clinic who wishes to quit smoking. The patient asks the
nurse, “If I quit smoking, will my risk of lung cancer be the same as a nonsmoker?” Which is the best
response by the nurse?
1) “No one knows for sure what the risk is for someone who quits smoking.”
2) “Your risk of lung cancer will be equal to that of a nonsmoker.”
3) “Your risk of lung cancer will decline if you quit, but it will remain higher than a
nonsmoker’s.”
4) “Your risk of lung cancer will never drop because the damage has already been done.”
____ 3. A male Hispanic patient has had a lung biopsy. The results indicate a poor prognosis for the patient. The
family is at the patient’s bedside and begins to moan and cry loudly. The health-care provider has told the
nurse that he needs to have the consent form signed for surgery. The patient has asked the nurse to allow the
family private time. What should the nurse do at this time?
1) Ask the family to come back later
2) Have the doctor get the consent with the family present
3) Provide the patient and family privacy
4) Take the patient to another room
____ 4. The nurse is caring for an older adult patient who is very thin and emaciated. The patient reports new onset of
shortness of breath. A chest x-ray reveals a spot on the lungs that the physician believes is an inoperable lung
cancer. Due to the patient’s poor nutritional status, chemotherapy is not an option. The health-care provider
also believes that the location of the cancer would make radiation therapy unsuccessful. In advocating for this
patient, what should the nurse encourage the health-care team to do?
1) Provide palliative care to keep theNUpatient
RSINcomfortable
GTB.COM without diagnostic testing
2) Perform any procedure necessary to diagnose the patient properly
3) Promote the use of blood tests to diagnose the suspected cancer
4) Determine the patient’s and family’s wishes regarding diagnostic testing
____ 5. A nurse is caring for a patient recovering from a wedge resection of the left lung for a tumor. Which is an
appropriate goal for the nursing diagnosis of ineffective airway clearance?
1) Participation in care by the patient
2) Maintain a patent airway
3) Maintain current weight
4) Express feelings and concerns
____ 6. The nurse is caring for a patient who is undergoing diagnostic tests to rule out lung cancer. The patient asks
the nurse why a computed tomography (CT) scan was ordered. What is the best response by the nurse?
1) “The doctor prefers this test.”
2) “To rule out the possibility that your problems are caused by pneumonia.”
3) “It is more specific in diagnosing your condition.”
4) “Why are you concerned about this test?”
____ 7. The nurse is providing care to a patient admitted after experiencing an acute asthma attack. Which assessment
findings indicate the need for immediate intervention by the nurse?
1) Retractions and fatigue
2) Tachycardia and tachypnea
3) Inaudible breath sounds
4) Diffuse wheezing and the use of accessory muscles when inhaling
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____ 8. Friends of a patient hospitalized with asthma would like to bring the patient a gift. Which gift would the nurse
recommend for this patient?
1) A basket of flowers
2) A stuffed animal
3) Fruit and candy
4) A book
____ 9. A nurse is teaching environmental control to the parents of a child with asthma. Which statement by the
parents indicates effective teaching?
1) “We’ll be sure to use the fireplace often to keep the house warm in the winter.”
2) “We will replace the carpet in our child’s bedroom with tile.”
3) “We’ll keep the plants in our child’s room dusted.”
4) “We’re glad the dog can continue to sleep in our child’s room.”
____ 10. An older adult patient diagnosed with asthma has a respiratory rate of 28 at rest with audible wheezes upon
inspiration. Based on this data, which nursing diagnosis is the most appropriate?
1) Ineffective Airway Clearance
2) Impaired Tissue Perfusion
3) Ineffective Breathing Pattern
4) Activity Intolerance
____ 11. A patient asks why asthma medication is needed even though the patient’s last attack was several months ago.
Which response by the nurse is appropriate?
1) “The medication needs to be taken or your lungs will be severely damaged and we will not
be able to prevent an acute attack.”
2) “The medication needs to be taken indefinitely according to your doctor, so you should
discuss this with him.” NURSINGTB.COM
3) “The medication is still needed to decrease inflammation in your airways and help prevent
an attack.”
4) “The medication needs to be taken for at least a year; then, if you have not had an acute
attack, you can stop it.”
____ 12. The nurse is instructing a patient who is prescribed ipratropium bromide (Atrovent) for asthma. Which should
be included in this patient’s teaching?
1) Take no more than the prescribed number of doses each day.
2) Rinse the mouth after taking this medication.
3) Take on an empty stomach.
4) Take with meals or a full glass of water.
____ 13. The nurse instructs a patient with asthma on bronchodilator therapy. Which statement indicates patient
understanding?
1) “The medication widens the airways because it acts on the parasympathetic nervous
system.”
2) “The medication widens the airways because it stimulates the fight-or-flight response of
the nervous system.”
3) “The medication widens the airways because it decreases the production of histamine that
narrows the airways.”
4) “The medication widens the airways because it decreases the production of mucous that
narrows the airways.”
____ 14. The nurse working on a pediatric unit is caring for a patient newly diagnosed with asthma. Which assessment
data indicates exhaustion and the need for immediate intervention?
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____ 21. The nurse is providing care for a patient diagnosed with chronic obstructive pulmonary disease (COPD).
Which intervention is inappropriate to control the patient’s breathing pattern?
1) Instruct in pursed-lip breathing
2) Teach visualization and meditation
3) Deep breathing and coughing every hour
4) Instruct in abdominal breathing
____ 22. A patient diagnosed with chronic obstructive pulmonary disease (COPD) has a pulse oximetry reading of
93%, increased red blood and white blood cell count, temperature of 101°F, pulse 100 bpm, respirations 35
bpm, and a chest x-ray that showed a flattened diaphragm with infiltrates. Based on this data, which
prescription does the nurse question for this patient?
1) Antibiotic therapy
2) Nonsteroidal anti-inflammatory agents
3) Oxygen by nasal cannula at 3-4 liters/minute
4) Bronchodilators such as an adrenergic stimulating drugs or anticholinergic agents
____ 23. The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD). A
nursing diagnosis for this patient is Imbalanced Nutrition: Less than Body Requirements. Which intervention
is appropriate for this nursing diagnosis?
1) Encourage a diet high in protein and fats
2) Keep snacks to a minimum
3) Encourage carbohydrate-rich foods to provide needed calories for energy
4) Suggest the patient eat three meals per day to maintain energy needs
____ 24. The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD).
Which observation would indicate that care provided to this patient has been effective?
1) Patient conducts morning care and NUambulates
RSINGTinBroom
.COwhile
M maintaining an oxygen
saturation of 92% on room air per oximetry reading.
2) Patient needs assistance with morning care and meals due to shortness of breath.
3) Patient states family members are discussing admission to a nursing home for continuing
care.
4) Patient leaves hospital unit to smoke outside four times a day.
____ 25. The nurse is teaching a patient diagnosed with chronic obstructive pulmonary disease (COPD). Which patient
statement indicates a need for further teaching?
1) “I should inhale by sniffing.”
2) “I should avoid aerosol sprays.”
3) “I should limit my fluid intake to 1-1.5 quarts daily.”
4) “I should get a flu vaccine every year.”
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. The nurse is planning care to address ineffective airway clearance for a patient with lung cancer. Which
interventions should the nurse include in the patient’s plan of care? Select all that apply.
1) Increase fluid intake to 3000 mL per day
2) Turn, cough, and deep breathe every two hours
3) Chest percussion every eight hours
4) Smoking cessation education
5) Administer pneumococcal vaccine
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____ 27. The nurse is planning care for a young adolescent patient diagnosed with asthma. Which evidence-based age-
appropriate interventions will the nurse include in the plan of care? Select all that apply.
1) Referring to a peer-led support group
2) Teaching the parents how to administer maintenance medication prior to teaching the
patient
3) Assessing peer-support when planning care
4) Collaborating with teachers for support in the school setting
5) Telling the patient to avoid medication while at school
____ 28. The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD)?
Which factors in the patient’s history support the current diagnosis? Select all that apply.
1) Working in an industrial environment
2) Working in an office setting with air conditioning
3) History of asthma
4) Current cigarette smoking
5) Playing golf several times a week
____ 29. Which assessment data would cause the nurse to suspect that an infant requires further testing for cystic
fibrosis? Select all that apply.
1) Rectal prolapse
2) Constipation
3) Steatorrheic stools
4) Meconium ileus
5) Diarrhea
____ 30. Which systems should the nurse anticipate will be affected when planning care for a patient diagnosed with
cystic fibrosis? Select all that apply. NURSINGTB.COM
1) Respiratory
2) Neurological
3) Reproductive
4) Cardiovascular
5) Gastrointestinal
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Chapter 26: Coordinating Care for Patients With Lower Airway Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Describing the epidemiology of lower airway disorders
Chapter page reference: 489-491
Heading: Lung Cancer
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Cellular Regulation; Oxygenation
Difficulty: Moderate
Feedback
1 Growth fraction is a ratio of the number of replicating cells to the number of resting
cells. Antineoplastic drugs are much more toxic to tissues and tumors with high growth
fractions. Breast and lung cancers have low growth fractions.
2 A high-oxygen environment is not the reason why lung cancer cells are less sensitive to
antineoplastic agents.
3 Lung cancer cells may grow for a long time before detection, but this is not the primary
reason they are less susceptible to antineoplastic agents.
4 Lung cancer cells do not have a very erratic cell cycle.
NURSINGTB.COM
PTS: 1 CON: Cellular Regulation | Oxygenation
2. ANS: 3
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Describing the epidemiology of lower airway disorders
Chapter page reference: 489-491
Heading: Lung Cancer
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Cellular Regulation
Difficulty: Moderate
Feedback
1 The risk for someone who quits is known to be dramatically less than for someone who
continues to smoke.
2 While the patient’s risk for lung cancer will diminish sharply upon quitting smoking, it
will not drop to the level of someone who never smoked.
3 The risk for someone who quits is known to be dramatically less than for someone who
continues to smoke.
4 Although damage has been done, the patient’s risk will drop dramatically upon quitting
smoking.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3. ANS: 3
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway
disorders
Chapter page reference: 489-491
Heading: Lung Cancer
Integrated Processes: Nursing Process – Implementation
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Cellular Regulation; Diversity
Difficulty: Moderate
Feedback
1 Asking the family to leave may cause extreme stress to the patient and family.
2 It would not be appropriate for the doctor to try to explain the surgery while the family
is grieving.
3 As the patient advocate, the nurse would allow this family to bond according to their
customs.
4 Taking the patient to another room would deprive the patient from participating in his
family’s customs.
Feedback
1 An older adult emaciated patient may have few options for treatment of cancer, if
confirmed. The best course of treatment may be palliative care, but it is the choice of
the patient and family that should direct the plan of care and choices of diagnostic
testing.
2 An older adult emaciated patient may have few options for treatment of cancer, if
confirmed. The best course of treatment may be palliative care, but it is the choice of
the patient and family that should direct the plan of care and choices of diagnostic
testing.
3 An older adult emaciated patient may have few options for treatment of cancer, if
confirmed. The best course of treatment may be palliative care, but it is the choice of
the patient and family that should direct the plan of care and choices of diagnostic
testing.
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4 An older adult emaciated patient may have few options for treatment of cancer, if
confirmed. The best course of treatment may be palliative care, but it is the choice of
the patient and family that should direct the plan of care and choices of diagnostic
testing.
Feedback
1 All of the outcomes for this patient are viable, but appropriate outcomes for the
diagnosis of ineffective airway clearance are maintaining a patent airway and
minimizing the accumulation of fluid.
2 All of the outcomes for this patient are viable, but appropriate outcomes for the
diagnosis of ineffective airway clearance are maintaining a patent airway and
minimizing the accumulation of fluid.
3 NURS
All of the outcomes for this patient areIviable,
NGTBbut .Cappropriate
OM outcomes for the
diagnosis of ineffective airway clearance are maintaining a patent airway and
minimizing the accumulation of fluid.
4 All of the outcomes for this patient are viable, but appropriate outcomes for the
diagnosis of ineffective airway clearance are maintaining a patent airway and
minimizing the accumulation of fluid.
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3 Computed tomography (CT) is used to evaluate and localize tumors, particularly tumors
in the lung parenchyma and pleura. It also is done before needle biopsy to localize the
tumor. In addition, CT scanning can detect distant tumor metastasis and evaluate tumor
response to treatment.
4 The patient’s question is valid and should not be minimized by asking why the patient
is having concerns about the test.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 A patient with asthma must not be exposed to items that can exacerbate their disease
process. Specific allergens, chemicals, and foods must be avoided. Flowers, food, and
items that may contain dust, such as a stuffed animal, should be avoided.
3 A patient with asthma must not be exposed to items that can exacerbate their disease
process. Specific allergens, chemicals, and foods must be avoided. Flowers, food, and
items that may contain dust, such as a stuffed animal, should be avoided.
4 Objects void of irritants, such as a book, would be an appropriate gift.
Feedback
1 Smoke from fireplaces should be eliminated.
2 Control of dust in the child’s bedroom is an important aspect of environmental control
for asthma management, and replacing the carpeting in the child’s bedroom with tile
flooring will reduce dust.
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3 Plants are often an allergen that can induce symptoms of asthma; therefore, this is not
appropriate.
4 When possible, pets and plants should not be kept in the home.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4 Not enough information is provided to determine whether the patient has ineffective
airway clearance, activity intolerance, or impaired tissue perfusion.
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Difficulty: Moderate
Feedback
1 When a life-threatening total airway obstruction occurs, efforts to clear the obstruction
include back blows and chest thrusts in an infant; therefore, the appropriate action for
the nurse to take is to deliver back blows and chest thrusts. Abdominal thrusts are
appropriate in older children.
2 When a life-threatening total airway obstruction occurs, efforts to clear the obstruction
include back blows and chest thrusts in an infant; therefore, the appropriate action for
the nurse to take is to deliver back blows and chest thrusts. Abdominal thrusts are
appropriate in older children.
3 When a life-threatening total airway obstruction occurs, efforts to clear the obstruction
include back blows and chest thrusts in an infant; therefore, the appropriate action for
the nurse to take is to deliver back blows and chest thrusts. Abdominal thrusts are
appropriate in older children.
4 When a life-threatening total airway obstruction occurs, efforts to clear the obstruction
include back blows and chest thrusts in an infant; therefore, the appropriate action for
the nurse to take is to deliver back blows and chest thrusts. Abdominal thrusts are
appropriate in older children.
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Difficulty: Moderate
Feedback
1 This statement is accurate and requires no further education.
2 This statement is accurate and requires no further education.
3 Herbal preparations that include atropa belladonna (the natural form of atropine) or
ephedra (also called ma huang), an herb that contains ephedrine, should not be used, as
they can interact with prescribed medications, indicating a need for further teaching.
4 This statement is accurate and require no further education.
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Feedback
1 There is no information to support Ineffective Airway Clearance, as there is no mention
that the patient is coughing.
2 There is no information to support Anxiety or Ineffective Coping.
3 There is no information to support Anxiety or Ineffective Coping.
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4 The patient’s respiratory rate of 32 per minute is an indication of an ineffective
breathing pattern. The elevated blood pressure and fatigue are indications of a
compromised respiratory status. The diagnosis of Ineffective Breathing Pattern would
be the priority for the patient at this time.
Feedback
1 Techniques used to instruct a patient to control the breathing pattern include pursed-lip
breathing, abdominal breathing, and relaxation such as visualization and meditation.
2 Techniques used to instruct a patient to control the breathing pattern include pursed-lip
breathing, abdominal breathing, and relaxation such as visualization and meditation.
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3 Deep breathing and coughing should be done every two hours to help keep the airway
clear and prevent the pooling of secretions, not to control the breathing pattern.
4 Techniques used to instruct a patient to control the breathing pattern include pursed-lip
breathing, abdominal breathing, and relaxation such as visualization and meditation.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3 Carbohydrate-rich foods would increase the patient’s carbon dioxide production and
worsen the symptoms of the disease.
4 The patient should be encouraged to eat frequent small meals, not three meals a day.
Feedback
1 Evidence that care provided to a patient with COPD was successful would be the
patient conducting morning care and ambulating in the room while maintaining an
oxygen saturation of 92%. This outcome identifies the patient’s ability to maintain
adequate oxygenation and perform activities of daily living.
2 The patient who needs assistance with morning care and meals because of shortness of
breath needs additional interventions.
3 The patient who states that his family would prefer he go to a nursing home may or
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may not have been positively affected by the interventions; not enough information is
provided to know.
4 The patient’s leaving the unit to smoke suggests that care has not been effective.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE RESPONSE
26. ANS: 1, 2, 3
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway
disorders
Chapter page reference: 489-491
Heading: Lung Cancer
Integrated Processes: Nursing Process – Planning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
Feedback
1. This is correct. An adequate fluid intake is needed. Patients with pneumonia should increase
their fluid intake in order to decrease the viscosity of respiratory secretions.
2. This is correct. Turning, coughing, deep breathing, and chest percussion can help clear
secretions.
3. This is correct. Turning, coughing, deep breathing, and chest percussion can help clear
secretions.
4. This is incorrect. Administering the pneumococcal vaccine and educating the patient on
smoking cessation are important in treating a patient with pneumonia, but they would be
aligned with a different Nnursing
URSIdiagnosis.
NGTB.COM
5. This is incorrect. Administering the pneumococcal vaccine and educating the patient on
smoking cessation are important in treating a patient with pneumonia, but they would be
aligned with a different nursing diagnosis.
Feedback
1. This is correct. Age-appropriate, evidence-based interventions for a young adolescent patient
diagnosed with asthma include referral to a peer-led support group, assessing peer-support of
the patient, and collaborating with teachers to ensure the patient has the necessary support in
the school setting.
2. This is incorrect. While it is appropriate to include the parents in the educational process, the
patient should be taught how to administer medications prior to teaching the parents.
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Feedback
1. This is correct. Risk factors associated with the development of COPD include working in an
industrial environment, N URSIof
a history NGasthma,
TB.Cand OMcigarette smoking.
2. This is incorrect. Working in an office setting with air conditioning and playing golf several
times a week are not risk factors for the development of COPD.
3. This is correct. Risk factors associated with the development of COPD include working in an
industrial environment, a history of asthma, and cigarette smoking.
4. This is correct. Risk factors associated with the development of COPD include working in an
industrial environment, a history of asthma, and cigarette smoking.
5. This is incorrect. Working in an office setting with air conditioning and playing golf several
times a week are not risk factors for the development of COPD.
Feedback
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1. This is correct. Steatorrhea and rectal prolapse might be signs of cystic fibrosis in an older
infant or child.
2. This is incorrect. Constipation is not a symptom of cystic fibrosis.
3. This is correct. Steatorrhea and rectal prolapse might be signs of cystic fibrosis in an older
infant or child.
4. This is correct. Newborns with cystic fibrosis might present in the first 48 hours with
meconium ileus.
5. This is incorrect. Diarrhea is not a symptom of cystic fibrosis.
Feedback
1. This is correct. Cystic fibrosis is a multisystem disease that produces increased amounts of
thick mucus in the respiratory, gastrointestinal (GI), and reproductive systems. The disease is
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characterized by thick, viscous mucus that clogs the lungs and obstructs the pancreas. Other
organs that are affected include the liver, salivary glands, and testes.
2. This is incorrect. The neurological system is not directly affected by cystic fibrosis.
3. This is correct. Cystic fibrosis is a multisystem disease that produces increased amounts of
thick mucus in the respiratory, gastrointestinal (GI), and reproductive systems. The disease is
characterized by thick, viscous mucus that clogs the lungs and obstructs the pancreas. Other
organs that are affected include the liver, salivary glands, and testes.
4. This is incorrect. The cardiovascular system is not directly affected by cystic fibrosis.
5. This is correct. Cystic fibrosis is a multisystem disease that produces increased amounts of
thick mucus in the respiratory, gastrointestinal (GI), and reproductive systems. The disease is
characterized by thick, viscous mucus that clogs the lungs and obstructs the pancreas. Other
organs that are affected include the liver, salivary glands, and testes.
Chapter 27: Coordinating Care for Critically Ill Patients With Respiratory Dysfunction
Multiple Choice
Identify the choice that best completes the statement or answers the question.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 1. The nurse is providing care to a patient who is diagnosed with acute respiratory distress syndrome (ARDS).
Which clinical manifestation does the nurse anticipate for this patient who is experiencing hypoxia as a result
of the ARDS diagnosis?
1) Fluid imbalance
2) Hypertension
3) Bradycardia
4) Dyspnea
____ 2. The nurse is providing care to a patient with an infected leg wound. The patient is exhibiting symptoms of a
systemic infection and is receiving intravenous antibiotics. The patient states to the nurse, “I am having
trouble breathing.” Based on this data, which does the nurse suspect the patient is experiencing?
1) Allergic response from antibiotic therapy
2) Deep vein thrombosis
3) Acute respiratory distress syndrome
4) Anemia
____ 3. A patient with a respiratory rate of eight breaths per minute has an oxygen saturation of 82%. Which nursing
diagnosis is a priority for this patient?
1) Risk for Infection
2) Impaired Spontaneous Ventilation
3) Risk for Acute Confusion
4) Decreased Cardiac Output
____ 4. A patient with acute respiratory distress syndrome (ARDS) is being weaned from mechanical ventilation.
Which nursing action is appropriate for this patient?
1) Increase percentage of oxygen being provided through the ventilator
2) Place in the Fowler position NURSINGTB.COM
3) Provide morning care during the weaning procedures
4) Medicate with morphine for pain as needed
____ 5. A patient is brought into the emergency department (ED) after being in a motor vehicle accident. The patient
has suffered traumatic injury that may involve multiple body systems. Which is the priority nursing
assessment for this patient?
1) Breathing and ventilation
2) Circulation with hemorrhage control
3) Airway maintenance with cervical spine protection
4) Disability and neurological assessment
____ 6. The nurse caring for a newborn on a ventilator for acute respiratory distress syndrome (ARDS) informs the
parents that the newborn is improving. Which data supports the nurse’s assessment of the newborn’s
condition?
1) Increased PCO2
2) Oxygen saturation of 92%
3) Pulmonary vascular resistance increases
4) Less than 1 mL/kg/hour urine output
____ 7. The nurse caring for a patient admitted with septic shock is aware of the need to assess for the development of
acute respiratory distress syndrome (ARDS). Which early clinical manifestation would indicate the
development of ARDS?
1) Intercostal retractions
2) Cyanosis
3) Tachypnea
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4) Tachycardia
____ 8. A patient admitted with smoke inhalation injuries develops signs and symptoms of acute respiratory distress
syndrome (ARDS). Which health-care provider prescription does the nurse anticipate for this patient?
1) Mechanical ventilation
2) Oxygen via a nasal cannula
3) Face mask oxygen administration
4) Continuous positive airway pressure
____ 9. The nurse in the intensive care unit (ICU) is caring for a patient diagnosed with acute respiratory distress
syndrome (ARDS). Vital signs prior to endotracheal intubation: HR 108 bpm, RR 32 bpm, BP 88/58 mm Hg,
and oxygen saturation 82%. The patient is intubated and placed on mechanical ventilation with positive
pressure ventilation. Which assessment finding indicates a further decrease of cardiac output secondary to
positive pressure ventilation?
1) Blood pressure 90/60 mm Hg
2) Urine output 25mL/hr
3) Heart rate 110 bpm
4) Oxygen saturation 90%
____ 10. The nurse caring for a patient recovering from an abdominal hysterectomy suspects the patient is experiencing
a pulmonary embolism. Which clinical manifestation supports the nurse’s suspicion?
1) Nausea
2) Decreased urine output
3) Dyspnea and shortness of breath
4) Activity intolerance
____ 11. The nurse is concerned that a patientNadmitted
URSINforGT
aBtotal
.Chip
OMreplacement is at risk for thrombus formation and
pulmonary embolism. Which assessment finding supports the nurse’s concern?
1) Body mass index (BMI) 35.8
2) Former cigarette smoker
3) Blood pressure 132/88 mm Hg
4) Age 45 years
____ 12. The nurse is providing discharge instructions to an older adult patient who is going home after having a total
knee replacement. Which will the nurse include in the discharge teaching to decrease the patient’s risk for
developing a thrombosis or pulmonary embolism?
1) Place pillows under the knees when in bed
2) Use compression stockings
3) Limit ambulation
4) Limit fluids
____ 13. A patient diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and
dyspnea. Which is the priority nursing diagnosis for this patient?
1) Ineffective Tissue Perfusion
2) Anxiety
3) Impaired Gas Exchange
4) Impaired Physical Mobility
____ 14. The nurse is planning care for a patient with a pulmonary embolism. Which intervention would assist with the
patient’s decrease in cardiac output?
1) Provide oxygen
2) Keep protamine sulfate at the bedside
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3) “Assist control is used when weaning a patient from the ventilator because the patient
must exercise the muscles of respiration in order to get a full breath.”
4) “Assist control is often used when a patient is receiving a paralytic agent.”
____ 22. The nurse is providing care for the patient requiring mechanical ventilation. Which action by the nurse would
be inappropriate when providing care to this patient?
1) Confirming airway placement by auscultating the lungs and checking the length marking
of the tube at the lip
2) Assuring that tube cuff inflation is no greater than 15 cm H2O, and that there is no audible
air leak
3) Assuring ventilator tubing is secured and does not pull on the patient’s airway
4) Verifying correct ventilator settings
____ 23. The nurse working in the intensive care unit is assigned a patient requiring mechanical ventilation. When
responding to the ventilator alarm, the nurse sees a high-pressure alarm. Which nursing action is the priority?
1) Silencing the alarm
2) Removing the patient from the ventilator and using a bag-valve device to oxygenate the
patient until the respiratory therapist can be summoned
3) Emptying the collected water from the ventilator tubing
4) Assessing the patient
____ 24. The nurse is providing care for a patient requiring mechanical ventilation. When the nurse enters the room at
the beginning of the shift, the patient’s monitor displays a heart rate of 64 and oxygen saturation of 88%.
Which nursing action is the priority?
1) Increasing the oxygen concentration and quickly assessing the patient
2) Removing the patient from the ventilator and hyperoxygenating and hyperventilating the
patient NURSINGTB.COM
3) Assessing the patient for airway obstruction
4) Checking ventilator settings
Completion
Complete each statement.
25. The nurse is providing care to a patient admitted to the emergency department with the diagnosis of acute
respiratory distress syndrome (ARDS). When educating the patient’s family on the disease progress, in which
order will the nurse present the material? (Enter the number of each step in the proper sequence; do not use
punctuation or spaces. Example: 1234)
1) Initiation of ARDS
2) Onset of pulmonary edema
3) End-stage ARDS
4) Alveolar collapse
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. The nurse educator prepares to speak to a group of nursing students about direct and indirect insults to the
lungs that may lead to the development of acute respiratory distress syndrome (ARDS). Which conditions will
the nurse include in the teaching session? Select all that apply.
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1) Septic shock
2) Viral pneumonia
3) Aspirin overdose
4) Head injury
5) Angioplasty
____ 27. A patient receiving treatment for acute respiratory distress syndrome (ARDS) is demonstrating anxiety and
fear of having to stay on the ventilator indefinitely. Which interventions by the nurse are appropriate? Select
all that apply.
1) Explain about care areas specifically designed for long-term ventilatory support.
2) Dim the lights and reduce distracting noise, such as the television.
3) Instruct that intubation and ventilation are temporary measures.
4) Encourage family visits and participation in care.
5) Remain with the patient as much as possible.
____ 28. Which assessment data would cause the nurse to document the patient is experiencing early respiratory
distress? Select all that apply.
1) Dyspnea
2) Restlessness
3) Tachycardia
4) Confusion
5) Cyanosis
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 27: Coordinating Care for Critically Ill Patients With Respiratory Dysfunction
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Acute
respiratory distress syndrome
Chapter page reference: 503-508
Heading: Acute Respiratory Distress Syndrome (ARDS)
Integrated Processes: Nursing Process – Planning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1 Fluid and electrolyte imbalances occur due to the nutritional imbalances associated with
ARDS.
2 Hypertension is not an anticipated clinical manifestation for this patient.
3 The nurse would expect tachycardia, not bradycardia, as a result of hypoxia.
4 Dyspnea is a clinical manifestation that patients experiencing hypoxia secondary to
ARDS.
PTS: 1 NURSINGTB.COM
CON: Oxygenation
2. ANS: 3
Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Acute
respiratory distress syndrome
Chapter page reference: 503-508
Heading: Acute Respiratory Distress Syndrome (ARDS)
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1 Deep vein thrombosis, anemia, or allergic response from antibiotic therapy may or may
not be associated with a systemic infection from an infected leg wound and are not
associated with the development of ARDS.
2 Deep vein thrombosis, anemia, or allergic response from antibiotic therapy may or may
not be associated with a systemic infection from an infected leg wound and are not
associated with the development of ARDS.
3 Sepsis is the most common cause of acute respiratory distress syndrome (ARDS). The
patient has a systemic infection, which is sepsis, and is complaining that it is getting
hard to breathe. The nurse should suspect the patient is developing acute respiratory
distress.
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4 Deep vein thrombosis, anemia, or allergic response from antibiotic therapy may or may
not be associated with a systemic infection from an infected leg wound and are not
associated with the development of ARDS.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5. ANS: 3
Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction
Chapter learning objective: Developing a comprehensive plan of nursing care for critically ill patients with
respiratory dysfunction
Chapter page reference: 508-512
Heading: Chest Trauma
Integrated Processes: Nursing Process – Assessment
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
Feedback
1 Assessing breathing and ventilation are important; however, this is not the priority
assessment at this time.
2 Assessing breathing and ventilation are important; however, this is not the priority
assessment at this time.
3 When caring for the trauma victim the nurse must always prioritize assessments, with
the ABCDEs as the highest-priority concerns. It is imperative that the nurse’s first
concern is airway maintenance with cervical spine protection.
4 Assessing breathing and ventilation are important; however, this is not the priority
assessment at this time.
Feedback
1 An expected outcome for a patient being treated for ARDS is maintaining an oxygen
saturation of greater than 90%. The newborn diagnosed with ARDS with an oxygen
saturation of 92% is improving.
2 Increased PCO2 and pulmonary vascular resistance are indicative of continued distress.
3 Increased PCO2 and pulmonary vascular resistance are indicative of continued distress.
4 Urine output of less than 1 mL/kg/hour is an abnormal finding and does not support that
the newborn is improving.
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Feedback
1 With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen
therapy alone. With mechanical ventilation, the FiO2 (fraction of inspired oxygen–the
percentage of oxygen administered) is set at the lowest possible level to maintain a
PaO2 higher than 60 mm Hg and oxygen saturation of approximately 90%. It is
important to remember that mechanical ventilation does not cure ARDS; it simply
supports respiratory function while the underlying problem is identified and treated.
2 With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen
therapy alone.
3 With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen
therapy alone.
4 Continuous positive airway pressure will not provide the patient with the oxygenation
that is required.
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Feedback
1 Although hypotension and tachycardia are indicative of a decreased cardiac output, this
is not a change from the previous assessment and would not indicate a further decrease
in cardiac output due to mechanical ventilation.
2 Decreased cardiac output is supported by a decrease of urine output. Expected urine
output is at least 30 mL/hr. This patient’s urine output is decreased; therefore, this
finding supports the diagnosis of decreased cardiac output.
3 Although hypotension and tachycardia are indicative of a decreased cardiac output, this
is not a change from the previous assessment and would not indicate a further decrease
in cardiac output due to mechanical ventilation.
4 The oxygen saturation level is within normal limits for this patient and improving from
the previous assessment.
Feedback
1 Decreased urine output, activity intolerance, and nausea are not clinical manifestations
of a pulmonary embolism.
2 Decreased urine output, activity intolerance, and nausea are not clinical manifestations
of a pulmonary embolism.
3 Manifestations of a pulmonary embolism include dyspnea, shortness of breath, pleuritic
chest pain, anxiety, apprehension, cough, tachycardia, tachypnea, crackles, and a low-
grade fever.
4 Decreased urine output, activity intolerance, and nausea are not clinical manifestations
of a pulmonary embolism.
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Feedback
1 Risk factors for the development of thrombus formation that could lead to a pulmonary
embolism include obesity, orthopedic surgery, myocardial infarction, heart failure, and
advancing age. The BMI of 35.8 falls into the category of obese, which would increase
the patient’s risk of developing a thrombus and possible pulmonary embolism.
2 The patient’s age, status as a former smoker, and blood pressure would not have as
significant an impact on the development of a thrombus as the patient’s weight.
3 The patient’s age, status as a former smoker, and blood pressure would not have as
significant an impact on the development of a thrombus as the patient’s weight.
4 The patient’s age, status as a former smoker, and blood pressure would not have as
significant an impact on the development of a thrombus as the patient’s weight.
Feedback
1 The patient should be encouraged to ambulate, avoid placing pillows under the knees,
and be well hydrated unless another physiological condition exists that would
necessitate a fluid restriction.
2 A patient being discharged after having orthopedic surgery is at increased risk for
pulmonary embolism. The nurse should instruct the patient to continue with leg
exercises and use compression stockings to reduce the risk of deep vein thrombosis
formation.
3 The patient should be encouraged to ambulate, avoid placing pillows under the knees,
and be well hydrated unless another physiological condition exists that would
necessitate a fluid restriction.
4 The patient should be encouraged to ambulate, avoid placing pillows under the knees,
and be well hydrated unless another physiological condition exists that would
necessitate a fluid restriction.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Developing a comprehensive plan of nursing care for critically ill patients with
respiratory dysfunction
Chapter page reference: 494-499
Heading: Pulmonary Embolism (PE)
Integrated Processes: Nursing Process – Diagnosis
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
Feedback
1 The patient may have ineffective tissue perfusion; however, this is not the priority.
2 The patient may be experiencing anxiety; however, this is not the priority at this time
either.
3 A reduction in arterial oxygen saturation level and dyspnea indicate the patient is
experiencing impaired gas exchange. This would be the priority for the patient at this
time.
4 There is not enough information to determine whether the patient is at risk for impaired
mobility.
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Feedback
1 The patient being discharged after treatment for a pulmonary embolism needs to be
instructed in anticoagulant therapy, avoiding green leafy vegetables because of vitamin
K, adhering to the physician’s prescribed activity level, and avoiding all over-the-
counter medications.
2 The patient being discharged after treatment for a pulmonary embolism needs to be
instructed in anticoagulant therapy, avoiding green leafy vegetables because of vitamin
K, adhering to the physician’s prescribed activity level, and avoiding all over-the-
counter medications.
3 The nurse should instruct the patient in symptoms of bleeding or recurrence of a
pulmonary embolism and the schedule for anticoagulation administration.
4 The patient being discharged after treatment for a pulmonary embolism needs to be
instructed in anticoagulant therapy, avoiding green leafy vegetables because of vitamin
K, adhering to the physician’s prescribed activity level, and avoiding all over-the-
counter medications.
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Feedback
1 This is not an anticipated diagnostic finding for a patient with a pulmonary embolism.
2 The patient with a pulmonary embolism will likely have respiratory alkalosis from
rapid breathing, not metabolic alkalosis.
3 The end-tidal carbon dioxide monitor (EtCOB). will be decreased, not increased, due to
rapid breathing.
4 With pulmonary embolism, tachycardia and nonspecific T-wave changes occur on
EKG.
Feedback
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1 Anticoagulant therapy is the standard first-line treatment of pulmonary embolism.
2 While major hemorrhage is uncommon, bleeding may occur.
3 Heparin and warfarin are usually initiated at the same time for the treatment of
pulmonary embolus.
4 Warfarin, not heparin, alters the synthesis of vitamin K–dependent clotting factors.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3 Because the ventilator provides the breath begun by the patient, it does not improve
muscle function.
4 Assist control would not be used for the patient receiving a paralytic agent because he
would be unable to initiate a breath.
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COMPLETION
25. ANS:
1243
Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction
Chapter learning objective: Describing respiratory conditions that require management in the critical care
setting
Chapter page reference: 503-508
Heading: Acute Respiratory Distress Syndrome (ARDS)
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
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Feedback: ARDS begins with inflammatory cellular responses and biochemical mediators that damage the
alveolar-capillary membrane. Increased interstitial pressure and damage to the alveolar membrane allow fluid
to enter the alveoli. The inflammatory process damages surfactant-producing cells, leading to a deficit of
surfactant, increased alveolar surface tension, and alveolar collapse. Multiple-organ system dysfunction of the
kidneys, liver, gastrointestinal tract, central nervous system, and cardiovascular system are the leading causes
of death in ARDS.
MULTIPLE RESPONSE
26. ANS: 1, 2, 3, 4
Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction
Chapter learning objective: Describing respiratory conditions that require management in the critical care
setting
Chapter page reference: 503-508
Heading: Acute Respiratory Distress Syndrome (ARDS)
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1. This is correct. ARDS isNaUsevere
RSINformGTB of.acute
COMrespiratory failure that occurs in response to
pulmonary or systemic insults. Such insults include, but are not limited to, hemorrhagic or
septic shock, smoke inhalation, aspiration, viral pneumonias, propoxyphene or aspirin
overdose, burns, head injuries, pancreatitis, and multiple transfusions.
2. This is correct. ARDS is a severe form of acute respiratory failure that occurs in response to
pulmonary or systemic insults. Such insults include, but are not limited to, hemorrhagic or
septic shock, smoke inhalation, aspiration, viral pneumonias, propoxyphene or aspirin
overdose, burns, head injuries, pancreatitis, and multiple transfusions.
3. This is correct. ARDS is a severe form of acute respiratory failure that occurs in response to
pulmonary or systemic insults. Such insults include, but are not limited to, hemorrhagic or
septic shock, smoke inhalation, aspiration, viral pneumonias, propoxyphene or aspirin
overdose, burns, head injuries, pancreatitis, and multiple transfusions.
4. This is correct. ARDS is a severe form of acute respiratory failure that occurs in response to
pulmonary or systemic insults. Such insults include, but are not limited to, hemorrhagic or
septic shock, smoke inhalation, aspiration, viral pneumonias, propoxyphene or aspirin
overdose, burns, head injuries, pancreatitis, and multiple transfusions.
5. This is incorrect. Angioplasty, a percutaneous intervention, does not lead to the development
of ARDS. However, undergoing an open heart surgery with cardiopulmonary bypass could
lead to the development of ARDS.
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Feedback
1. This is incorrect. Explaining that there are care areas designed for long-term ventilatory
support could increase the patient’s anxiety.
2. This is incorrect. The nurse should provide distractions such as television or radio and not dim
the lights or turn off the television, which could also increase the patient’s anxiety.
3. This is correct. The nurse should also remain with the patient as much as possible and instruct
that intubation and ventilation are temporary measures to allow the lungs to rest and heal.
4. This is correct. To reduce this patient’s anxiety, the nurse should encourage the family to visit
and participate in care.
5. This is correct. The nurse should also remain with the patient as much as possible and instruct
that intubation and ventilation are temporary measures to allow the lungs to rest and heal.
Feedback
1. This is correct. Dyspnea, or shortness of breath, is an early sign of respiratory distress.
2. This is correct. Restlessness is an early sign of respiratory distress.
3. This is correct. Tachycardia is an early sign of respiratory distress.
4. This is incorrect. Confusion is an intermediate sign of respiratory distress.
5. This is incorrect. Cyanosis is a late sign of respiratory distress.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
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____ 1. A patient is prescribed to have capillary blood glucose readings every four hours. What should the nurse
include when explaining capillaries to the patient?
1) It is a low-pressure vascular circuit.
2) Capillaries are the largest vessel within the arterial system.
3) The real work of the vascular system occurs at the capillary level.
4) They are flexible to adapt to changes in volume without large changes in pressure.
____ 2. While auscultating a patient’s heart rate the nurse hears scratching sounds. What is most likely causing this
sound?
1) Epicardium adhering to the heart surface
2) Low level of fluid in the pericardial cavity
3) Parietal pericardium adhering to the sternum
4) Endocardium adhering to the heart chambers
____ 3. The nurse is reviewing the anatomy of the heart with a patient scheduled for cardiac surgery. Which patient
statement indicates additional teaching is required?
1) “Oxygenated blood returns to the left atrium through the pulmonary vein.”
2) “The right atrium receives blood from the superior and inferior vena cava.”
3) “Blood leaves the right ventricle and travels through the pulmonary vein to the lungs.”
4) “Blood leaves the right ventricle and travels through the pulmonary artery to the lungs.”
____ 4. The nurse is preparing teaching about the coronary arteries for a group of patients scheduled for heart surgery.
Which information should the nurse include in this teaching?
1) The coronary arteries originate in the cusps of the aortic valve.
2) The coronary arteries prevent the backflow of blood into the atria.
3) The coronary arteries respond to changes in pressure within the heart.
4) The coronary arteries prevent theNU RSINGofTblood
backflow B.CO M the ventricles.
into
____ 5. The nurse notes that a patient has a low serum potassium level. Which phase of the cardiac action potential
will be most affected by this blood level?
1) Phase 0
2) Phase 1
3) Phase 3
4) Phase 4
____ 6. A patient’s QRS complex is becoming increasingly wider. What is occurring within the heart muscle that is
reflected on this tracing?
1) The ventricles are repolarizing.
2) Atrial repolarization is occurring.
3) Ventricular depolarization is prolonged.
4) The atria depolarize and the impulse at the AV node is delayed.
____ 7. A patient with a blood pressure of 88/50 mm Hg has a heart rate of 112 beats per minute. Which mechanism
should the nurse realize is occurring in this patient?
1) Positive chronotropic effect
2) Negative chronotropic effect
3) Force of the mechanical contraction
4) Reaction to ventricular volume at the end of diastole
____ 8. The nurse suspects that a patient is experiencing a release of norepinephrine from the adrenal medulla. Which
assessment finding did the nurse use to make this clinical decision?
1) Blood pressure 94/48 mm Hg 3) Heart rate 120 beats per minute
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____ 19. The nurse notes that an older patient’s point of maximum impulse is displaced to the left. What age-related
change should the nurse suspect as causing this assessment finding?
1) Valvular stenosis 3) Arterial wall narrowing
2) Left ventricular atrophy 4) Fibrosis of heart chambers
____ 20. The nurse is reviewing data collected during the assessment of an older patient. Which finding should the
nurse consider as being an age-related change of the cardiovascular system?
1) First heart sound louder 3) Heart rate 64 and regular
2) Friction rub auscultated 4) Blood pressure 168/96 mm Hg
Completion
Complete each statement.
21. The nurse is preparing a teaching tool about the cardiac electrical conduction system. In which order should
the nurse explain the route of the action potential? (Enter the number of each step in the proper sequence; do
not use punctuation or spaces. Example: 1234)
1) Impulse travels to the bundle of His
2) Sinoatrial node fires in the right atrium
3) Impulse extends through Purkinje fibers
4) Impulse travels through bundle branches
5) Impulse travels to the atrioventricular node
6) Impulse spreads through atrial myocardium
22. The clinical trainer is reviewing the renin-angiotensin-aldosterone system with graduate nurses during
orientation to the telemetry unit. In which order should the trainer discuss this system? (Enter the number of
each step in the proper sequence; do N UR
not SIpunctuation
use NGTB.CorOM spaces. Example: 1234)
1) Sodium and water reabsorbed in the kidneys
2) Renin reacts with angiotensin to create angiotensin 1
3) Angiotensin I is converted to angiotensin II in the lungs
4) Kidneys release renin in response to a drop in blood pressure
5) Angiotensin II influences adrenal glands to release aldosterone
23. A patient is prescribed a 12-lead electrocardiogram. In which order should the nurse apply the V leads? (Enter
the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234)
1) Midaxillary line
2) Between V2 and V4
3) Midclavicular line 5th intercostal space
4) 4th intercostal space left of the sternum
5) 4th intercostal space right of the sternum
6) Between V4 and V6 anterior axillary line
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 24. The nurse is preparing content for a community health fair on risk factors for heart disease. What should the
nurse include as nonmodifiable risk factors? Select all that apply.
1) Age
2) Weight
3) Alcohol intake
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4) Ethnic background
5) Parents’ health history
____ 25. Which information should the nurse include when documenting the findings of a patient’s heart sounds?
Select all that apply.
1) Pitch
2) Clicks
3) Quality
4) Intensity
5) Location
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 28, Assessment of Cardiovascular Function
Chapter learning objective: Describing the major anatomical components of the heart and cardiovascular
system
Chapter page reference: 517
Heading: Overview of the Cardiovascular System > Capillary Bed
Integrated Processes: Nursing Process – Implementation
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Perfusion
Difficulty: Easy
Feedback
1 The veins are a low-pressure vascular circuit.
2 Capillaries are the smallest vessels within the arterial system.
3 The real work of the vascular system is done at the capillary bed.
4 Veins are flexible to adapt to changes in volume without large changes in pressure.
Feedback
1 The epicardium or visceral pericardium is supposed to cover the heart surface.
2 Between the two layers of the heart is a pericardial cavity containing serous fluid that
provides a lubricant that allows the heart to beat without friction.
3 The parietal pericardium is the outer layer of the heart. It is a tough fibrous layer that
does not adhere to the sternum.
4 The endocardium is supposed to adhere to the heart chambers.
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Chapter learning objective: Describing the major anatomical components of the heart and cardiovascular
system
Chapter page reference: 519
Heading: Overview of the Cardiovascular System > Chambers
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Analysis [Analyzing]
Concept: Perfusion
Difficulty: Moderate
Feedback
1 Oxygenated blood returns to the left atrium through the pulmonary vein.
2 The right atrium receives blood from the superior and inferior vena cava.
3 Blood leaves the right ventricle and travels through the pulmonary vein to the lungs.
4 Blood leaves the right ventricle and travels through the pulmonary vein to the lungs.
Deoxygenated blood is delivered to the pulmonary circuit through the pulmonary artery.
Feedback
1 The left and right coronary arteries are the first arteries branching off of the aorta as it
leaves the left ventricle and actually originate in the cusps of the aortic valve.
2 The atrioventricular valves prevent backflow of blood into the atria.
3 Valves respond to changes in pressure within the heart.
4 The semilunar valves prevent the backflow of blood into the ventricles.
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Feedback
1 In phase 0 there is rapid depolarization caused by the opening of sodium (Na+)
channels allowing rapid Na+ influx, moving the membrane potential to +30.
2 In phase 1 Na+ influx decreases causing a slight movement toward negative of the
membrane potential, producing an initial repolarization.
3 In phase 3 final repolarization occurs, which is caused by the closing of the Ca++
channels and the rapid outflow of K+.
4 In phase 4 there is a return to the resting membrane potential.
Feedback
1 The T wave corresponds to ventricular repolarization.
2 Atrial repolarization occurs during ventricular contraction. That waveform is not visible
but is buried in the QRS complex.
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3 The QRS complex corresponds to ventricular depolarization. If the complex is
widening, then ventricular depolarization is taking longer to complete.
4 The PR interval reflects the time required for atrial depolarization and the delay of the
impulse at the AV node.
Feedback
1 Stimulus from the sympathetic nervous system initiated by information from
baroreceptors in the aortic arch and the carotids that are sensitive to changes in BP
increase the HR through the release of norepinephrine. This is called a positive
chronotropic effect.
2 The parasympathetic nervous system slows the HR through the release of acetylcholine,
a negative chronotropic effect.
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Feedback
1 Norepinephrine would be released from the adrenal medulla in response to low blood
pressure.
2 Norepinephrine would not be released since this heart rate is within normal limits.
3 Chemicals that can increase HR include norepinephrine released from the adrenal
medulla.
4 Norepinephrine would not be released in response to an elevated blood pressure.
Feedback
1 The heart rate is not used to determine preload.
2 The blood pressure is not used to determine preload.
3 Oxygen saturation is not used to determine preload.
4 Preload is reflected by measurements obtained through a centrally located IV line. For
preload the central venous pressure is used.
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Feedback
1 Preload is the amount of blood in the ventricles at the end of diastole. Extreme
overfilling decreases the effectiveness of the contraction, decreasing CO.
2 With the blood pressure being this elevated, the heart rate should be lower due to a
negative chronotropic effect.
3 Afterload is the resistance to flow the ventricle must overcome to open the semilunar
valves and eject its contents. This is related to BP in that hypertension on the right or
left is implicated in the negative effects of increased afterload.
4 Contractility refers to the force of the mechanical contraction, which can be increased
with sympathetic stimulation or calcium release or decreased when hypoxia or acidosis
occurs.
Feedback
1 Distended jugular veins are associated with pericarditis.
2 Distended jugular veins are associated with cardiac tamponade.
3 Unilateral extremity edema can indicate a lymphatic obstruction.
4 Bilateral lower extremity edema generally indicates venous insufficiency.
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Feedback
1 Adequate CO produces warm skin temperatures.
2 Variations in temperature between different parts of the body may indicate
vasoconstriction or vascular disease in the affected extremities. A more extensive
examination includes femoral, popliteal, and posterior tibial pulses.
3 Edema of the left lower extremity would cause the nurse to assess the pulses on the left
leg and not necessarily the brachial and carotid pulses.
4 Respiratory rate does not influence pulse assessment.
Feedback
1 A friction rub is described as a scratching or grating sound heard both during systole
and diastole. The sound is produced by inflammation of the pericardium. It is
NURSINGTB.COM
diagnostic for pericarditis and is referred to as the pericardial friction rub.
2 A click is a high-pitched sound heard early in diastole typically caused by mitral valve
stenosis.
3 Murmurs are usually caused by turbulent flow through the valves. That turbulence can
be caused by regurgitation of blood through an incompetent valve.
4 An atrial gallop can indicate decreased ventricular compliance.
Feedback
1 A lipid panel requires the patient to fast for approximately 8 to 12 hours prior to the
test.
2 Fasting is not required prior to a homocysteine level.
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Feedback
1 Brain natriuretic peptide does not measure the amount of lipids in the blood. A low-fat
diet would not be applicable for this level.
2 Brain natriuretic peptide is released from overstretched ventricular tissue. Elevations
are an indicator of heart failure.
3 Brain natriuretic peptide does not determine amounts of cardiac tissue damage.
4 Brain natriuretic peptide does not discern between lung or heart problems.
Feedback
1 Cardiac catheterization is an invasive x-ray procedure during which a radiopaque
catheter is advanced through an artery or vein to the heart under fluoroscopy in order to
evaluate cardiac filling pressures.
2 Coronary angiography is the primary reason cardiac catheterization is performed. It is a
left-sided cardiac catheterization with the purpose of inspecting the coronary arteries for
blockage.
3 A cardiac stress test is done to evaluate heart functioning during times of increased
workload.
4 Information about the presence of clots in the atrium, a risk factor for stroke, is more
easily viewed through TEE.
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Feedback
1 The limb of the puncture site should be monitored. Warmth indicates adequate
perfusion of the extremity.
2 Urine output should be monitored post procedure. A urine output of 250 mL/2 hours
indicates adequate renal perfusion postprocedure.
3 The patient will need to remain flat for two to six hours postprocedure. This could
cause temporary discomfort; however, this does not need to be reported to the health-
care provider.
4 The puncture site should be monitored for hematoma formation. This could cause
occlusion of the femoral artery and should be reported to the health-care provider.
Feedback
1 A cardiac click is not associated with hypertension.
2 A cardiac click is associated with valve stenosis.
3 A cardiac click is not associated with atrial fibrillation.
4 A cardiac click is not associated with congestive heart failure.
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Concept: Perfusion
Difficulty: Moderate
Feedback
1 Stenosis of heart valves can lead to hypertension in an older patient.
2 Aging produces a number of physiological changes in the anatomy and physiology of
the cardiovascular system. Physical deconditioning can result in atrophy of the left
ventricle, which would displace the point of maximum impulse.
3 In the older patient narrowing of arterial walls can lead to an increased risk of
thrombosis and stroke.
4 In the aging patient increased fibrosis of heart chambers can lead to hypertension.
Feedback
1
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A louder first heart sound may be normal depending upon the area being auscultated.
2 A friction rub is associated with pericarditis, which is not an age-related change to the
cardiovascular system.
3 A heart rate of 64 and regular is within normal limits.
4 Hypertension is a common cardiovascular health issues related to aging.
COMPLETION
21. ANS:
265143
Chapter number and title: 28, Assessment of Cardiovascular Function
Chapter learning objective: Discussing the electrical and mechanical components of the cardiac cycle
Chapter page reference: 521
Heading: Cells of the Electrical Conduction System
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Perfusion
Difficulty: Moderate
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Feedback: The action potential begins in the sinoatrial node, which fires in the right atrium. Then the impulse
spreads through the atrial myocardium and travels to the atrioventricular node. It then travels to the bundle of
His, through the bundle branches, and extends through the Purkinje fibers.
Feedback: When the blood pressure drops, the kidneys respond by releasing the enzyme renin. Renin reacts
with angiotensin to create angiotensin I. Angiotensin I is then converted in the lungs to angiotensin II via
angiotensin-converting enzyme. Angiotensin II acts on the adrenal glands to release aldosterone. The release
of aldosterone promotes sodium and water reabsorption in the kidneys, which increases circulating fluid
volume.
Feedback: The chest positions for the V leads are: V1: 4th intercostal space, just to the right of the sternum;
V2: 4th intercostal space, just to the left of the sternum; V3: Between V4 and V2; V4: on the midclavicular
line and 5th intercostal space; V5: between V6 and V4 on the anterior axillary line; and V6: on the
midaxillary line, horizontal with V4.
MULTIPLE RESPONSE
24. ANS: 1, 4, 5
Chapter number and title: 28, Assessment of Cardiovascular Function
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Chapter learning objective: Explaining assessment parameters incorporated into the history and physical of a
cardiovascular examination
Chapter page reference: 526
Heading: History
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Perfusion; Promoting Health
Difficulty: Easy
Feedback
1. Age is a nonmodifiable risk factor.
2. Weight is a modifiable risk factor.
3. Alcohol intake is a modifiable risk factor.
4. Ethnic background is a nonmodifiable risk factor.
5. Family history is a nonmodifiable risk factor.
Feedback
1. When describing heart sounds it is important to note pitch.
2. Clicks would be an abnormal finding, necessitating more thorough documentation.
3. When describing heart sounds it is important to note quality
4. When describing heart sounds it is important to note intensity.
5. When describing heart sounds it is important to note location.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A patient’s heart rate is 48 beats per minute. Which structure is most likely generating this heart rate?
1) Purkinje fibers
2) Sinoatrial node
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3) Atrioventricular node
4) Ventricular pacer cells
____ 2. The nurse is concerned that a patient is at risk for pulseless electrical activity. What information from the
assessment did the nurse use to make this clinical decision?
1) Blood pH 7.30
2) Temperature 100.5°F
3) Serum glucose level 170 mg/dL
4) Serum potassium level 4.1 mEq/L
____ 3. A patient asks why cardiac leads are being placed on the chest. What should the nurse respond to this patient?
1) “It shows where the heart vessels are blocked.”
2) “It is used to evaluate the effectiveness of dietary changes.”
3) “It provides a graphic picture of the heart’s electrical activity.”
4) “It determines which medications are needed to improve heart function.”
____ 4. When analyzing a patient’s electrocardiogram, the nurse notes that the P wave is normal. What criteria did the
nurse use to make this decision?
1) Pointed and skinny in width
2) Small and rounded in lead II
3) Upright and rounded in lead II
4) Length 0.10 seconds and height 2.5 mm
____ 5. A patient is being evaluated for a blockage in the cardiac ventricles. On which part of the electrocardiogram
should the nurse focus as evidence of this blockage?
1) T wave
2) U wave NURSINGTB.COM
3) PR interval
4) QRS interval
____ 6. The nurse is observed marching out the rhythm on a patient’s cardiac monitor tracing. What is this nurse
assessing?
1) Rate
2) Polarity
3) Regularity
4) Amplitude
____ 7. A patient with shortness of breath has a heart rhythm of 46 beats per minute. Which medication should the
nurse anticipate being prescribed for this patient?
1) Atropine sulfate
2) Atenolol (Tenormin)
3) Diltiazem (Cardizem)
4) Adenosine (Adenocard)
____ 8. A patient with atrial fibrillation has a heart rate of 90 beats per minute. Which manifestation should the nurse
expect to assess in this patient?
1) Headache
2) Chest pain
3) Palpitations
4) Hypotension
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____ 9. A patient with atrial fibrillation is being considered for cardioversion. Which diagnostic test should the nurse
anticipate being prescribed prior to this procedure being completed?
1) Chest x-ray
2) CT scan of the chest
3) 12-lead electrocardiogram
4) Transesophageal echocardiogram (TEE)
____ 10. A patient is experiencing supraventricular tachycardia. What should be done before determining this patient’s
treatment?
1) Assess for thyroid disease
2) Identify the underlying rhythm
3) Evaluate serum electrolyte values
4) Study lifestyle and behavioral habits
____ 11. A patient is admitted for treatment for a low junctional rhythm. Where should the nurse expect to assess the P
wave on this patient’s electrocardiogram?
1) Prior to the QRS wave
2) Buried within the QRS wave
3) At the tail end of the QRS wave
4) Superimposed over the previous T wave
____ 12. A patient’s cardiac rhythm has no identifiable P or QRS waves. What action should the nurse take first?
1) Apply oxygen
2) Assess a radial pulse
3) Insert an intravenous line
4) Begin chest compressions
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____ 13. A patient is in normal sinus rhythm with prolonged PR intervals. What treatment should the nurse expect to
be prescribed for this patient?
1) Continue to monitor
2) Anticipate defibrillating
3) Prepare for cardioversion
4) Prepare for pacemaker insertion
____ 14. The nurse notes that PR intervals are getting progressively longer before a QRS complex is dropped on a
patient’s cardiac rhythm strip. Which health problem should the nurse realize this patient is experiencing?
1) Mobitz I
2) Mobitz II
3) First-degree AV block
4) Third-degree AV block
____ 15. A patient is being prepared for a transvenous pacemaker. What should the nurse include when explaining this
pacemaker to the family?
1) “It is inserted using an internal jugular vein.”
2) “It is done by placing defibrillator pads on the torso using an anterior/posterior position.”
3) “It is done by placing a pacer wire in the atrium or the ventricle and fed out through the
skin, where it is attached to an external pacemaker.”
4) “It is inserted by placing pacer wires in the atrium, ventricle, or both and attached to a
small pacemaker generator placed under the skin near the clavicle.”
____ 16. A patient is diagnosed with third-degree AV block. For which type of pacemaker should the nurse prepare
this patient?
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1) Transvenous
2) Biventricular
3) Transthoracic
4) Transcutaneous
____ 17. The nurse is preparing to defibrillate a patient. Which setting should the nurse use for this treatment?
1) 50 J
2) 100 J
3) 150 J
4) 200 J
____ 18. A patient is being cardioverted for symptomatic atrial fibrillation. At which point of the cardiac cycle will the
electric impulse occur?
1) At the end of the P wave
2) Before the QRS complex
3) At the peak of the R wave
4) After the QRS complex but before the T wave
____ 19. The nurse notes that a patient with a cardiac dysrhythmia is developing shortness of breath. What is the
pathophysiological reason for this manifestation?
1) Decreased oxygen in the brain
2) Stimulation of the sympathetic nervous system
3) Imbalance in myocardial oxygen demand and supply
4) Increase in oxygenation because of a drop in cardiac output
____ 20. A patient with a cardiac dysrhythmia is experiencing nausea and vomiting. What is the reason for this to
occur? NURSINGTB.COM
1) Poor contractile function
2) Altered electrolyte levels
3) Blood shunted away from nonessential organ systems
4) An imbalance in myocardial oxygen supply and demand
____ 21. A patient with a cardiac dysrhythmia asks why it is important to recognize the signs of a stroke. What should
the nurse respond to this patient?
1) “So you can respond quickly and prevent adverse effects.”
2) “To encourage you to take your medication as prescribed.”
3) “So that you can recognize the signs of stroke in a family member.”
4) “Most people with a heart arrhythmia develop strokes as a side effect.”
____ 22. During a home visit the nurse learns that a patient has been skipping doses of antiarrhythmic medication.
What should the nurse include when counseling this patient?
1) Taking the medication as prescribed reduces the occurrence of side effects
2) Skipping doses increases the risk of developing chest pain and diaphoresis.
3) Adequate medication level decreases the adverse effects of the dysrhythmia.
4) Insufficient amounts of medication in the blood stream affect pacemaker functioning.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 23. An older client is being evaluated for a new onset of a cardiac dysrhythmia. What should the nurse consider
as being the cause for this abnormal heart rhythm? Select all that apply.
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1) Advanced age
2) Protein malnutrition
3) Fat deposits around the SA node
4) Fewer pacemaker cells in the SA node
5) Calcification around the SA node and valves
____ 24. A patient becomes unresponsive without a palpable pulse despite showing bradycardia on the rhythm strip.
What action should the nurse take immediately? Select all that apply.
1) Auscultate heart sounds
2) Begin cardiac compressions
3) Adjust cardiac monitor leads
4) Prepare for chest tube insertion
5) Place epinephrine at the bedside
____ 25. A patient has a heart rate of 132 beats per minute. What should the nurse assess to help determine the reason
for this rate? Select all that apply.
1) Muscle tone
2) Temperature
3) Urine output
4) Bowel sounds
5) Blood pressure
____ 26. The nurse is caring for a patient with a potentially life-threatening cardiac dysrhythmia. What should be
included in this patient’s plan of care? Select all that apply.
1) Document frequency of dysrhythmia
2) Administer antiarrhythmic medications
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3) Maintain continuous cardiac monitoring
4) Prepare to administer advanced cardiac life support
5) Complete preoperative checklist for pacemaker insertion
Completion
Complete each statement.
27. The nurse reviews the cardiac electrical cycle with a patient scheduled for pacemaker insertion surgery. In
which order should the nurse explain this process? (Enter the number of each step in the proper sequence; do
not use punctuation or spaces. Example: 1234)
A. P wave
B. T wave
C. QRS complex
D. Firing of the SA node
E. Ventricular contraction
F. Ventricular repolarization
28. When calculating a patient’s heart rate using the cardiac rhythm strip, the nurse notes the presence of four
large boxes between the two R waves. What is this patient’s heart rate? Record your answer as a whole
number. ______
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MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia
Chapter learning objective: Defining the pathophysiology of rhythm disorders
Chapter page reference: 537
Heading: The Normal Conduction Pathway
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Perfusion
Difficulty: Easy
Feedback
1 The Purkinje fibers can generate a ventricular rate of 20 beats per minute (bpm) or less.
2 The sinoatrial (SA) node can generate impulses at a rate of 60 to 100 bpm.
3 The AV node can generate impulses at a rate of 40 to 60 bpm.
4 The ventricular pacer cells can generate impulses at a rate of 40 bpm or less.
Feedback
1 Causes of pulseless electrical activity include acidosis, which is reflected in a blood pH
less than 7.35.
2 Causes of pulseless electrical activity include hypothermia. A temperature over 100°F
would not be seen in hypothermia.
3 Causes of pulseless electrical activity include hypoglycemia. A blood glucose of 170
mg/dL would by hyperglycemia.
4 Causes of pulseless electrical activity include hyper- or hypokalemia. A serum
potassium level of 4.1 mEq/L is within normal limits.
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4 The QRS interval is the measure of time to depolarize the ventricles. The normal
interval is 0.04 to 0.10 sec in length. If the QRS is prolonged it may be a sign of a
disturbance within the ventricle itself such as a block in the ventricles delaying impulse
travel time through the ventricles.
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Feedback
1 A chest x-ray most likely will be done; however, this does not need to be completed
prior to cardioversion.
2
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A CT scan of the chest does not need to be done prior to cardioversion.
3 A 12-lead electrocardiogram most likely will be done; however, this does not need to
be completed prior to cardioversion.
4 Cardioversion should be considered for atrial fibrillation only after the atrium has been
evaluated for the presence of clots by transesophageal echocardiogram (TEE).
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1 First-degree AV block looks very similar to normal sinus rhythm except the PR interval
is prolonged. Treatment is not typically required for first-degree AV block unless the
patient is having symptoms, which is very rare.
2 Defibrillation is not indicated for first-degree AV block.
3 Cardioversion is not indicated for first-degree AV block.
4 A pacemaker is not indicated for first-degree AV block.
Feedback
1 Second-degree AV block type I, also known as Wenckebach or Mobitz I, occurs when
not all atrial impulses get through the AV node to the ventricles. There are more P
waves than QRS complexes and the PR interval gets progressively longer until a QRS
is dropped.
2 Second-degree AV block type II, also known as Mobitz II, drops QRS complexes, but
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the PR intervals are exactly the same length with each complex.
3 First-degree AV block looks similar to a normal sinus rhythm except the PR interval is
prolonged.
4 In third-degree AV block or complete heart block the AV node is completely blocked
and prevents any impulses from entering or exiting. There is no communication
between the atria and the ventricles. The ECG records more P waves than QRS
complexes.
Feedback
1 For a transvenous pacemaker a pacer wire is inserted into the right ventricle through
central venous access, usually via the internal jugular vein.
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2 Defibrillator pads are placed on the patient’s torso using an anterior/posterior position
for a transcutaneous pacemaker.
3 A pacer wire that is surgically placed in the atrium or the ventricle and fed out through
the skin and attached to an external pacemaker is the process for inserting a
transthoracic or epicardial pacer.
4 For all internal pacemakers, pacer wires are placed in the atrium, ventricle, or both and
attached to a small pacemaker generator placed under the skin near the clavicle.
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Feedback
1 Decreased oxygen in the brain alters the level of consciousness.
2
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Stimulation of the sympathetic nervous system causes diaphoresis.
3 Imbalanced myocardial oxygen demand and supply causes chest pain.
4 Because of the lack of efficient contractile function of a heart experiencing
dysrhythmias, cardiac output may fall, causing a decrease in blood pressure. In an
attempt to increase oxygenation in the face of decreased cardiac output, shortness of
breath and tachypnea may occur.
Feedback
1 Poor contractile function causes peripheral edema.
2 Altered electrolyte levels can indicate acute cardiac injury.
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3 Shunting of blood away from nonessential organ systems during low-flow states may
cause nausea and vomiting.
4 An imbalance in myocardial oxygen supply and demand causes chest pain.
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MULTIPLE RESPONSE
23. ANS: 1, 3, 4, 5
Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia
Chapter learning objective: Defining the pathophysiology of rhythm disorders
Chapter page reference: 537
Heading: Epidemiology
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Perfusion
Difficulty: Moderate
Feedback
1. Age is a primary risk factor for the development of dysrhythmias.
2. Protein malnutrition is not identified as being a risk factor for the development of
dysrhythmias.
3. Older adults may have fat deposits around the SA node causing a delay in the propagation of
the action potential.
4. Older adults have fewer pacemaker cells in the SA node causing a delay in the propagation of
the action potential.
5. Slowed impulse transmission may be related to calcification around the AV node and valves.
Feedback
1. Auscultating for heart sounds will waste time when pulseless electrical activity occurs.
2. If pulseless electrical activity occurs, the nurse should begin chest compressions.
3. Adjusting cardiac monitor leads will waste time when pulseless electrical activity occurs.
4. Although a pneumothorax can cause pulseless electrical activity, a chest tube is not the
treatment for all episodes of this disorder.
5. The treatment for pulseless electrical activity includes epinephrine.
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Feedback
1. Muscle tone is not used to determine the cause for sinus tachycardia.
2. Causes of sinus tachycardia include fever.
3. Urine output is not used to determine the cause for sinus tachycardia.
4. Bowel sounds are not used to determine the cause for sinus tachycardia.
5. Causes of sinus tachycardia include hypotension.
Feedback
1. For the patient with a potentially life-threatening dysrhythmia the nurse should document the
frequency of the dysrhythmia,
2. For the patient with a potentially life-threatening dysrhythmia the nurse should administer
antiarrhythmic medication.
3. For the patient with a potentially life-threatening dysrhythmia the nurse should maintain
continuous cardiac monitoring.
4. For the patient with a potentially life-threatening dysrhythmia the nurse should prepare to
administer advanced cardiac life support.
5. Not all patients with potentially life-threatening dysrhythmias will have a pacemaker
inserted.
COMPLETION
27. ANS:
413526
Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia
Chapter learning objective: Defining the pathophysiology of rhythm disorders
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Feedback: When the impulse travels along the normal conduction pathway, it generates waveforms that
indicate the firing of the SA node, the P wave, followed by a QRS complex indicating ventricular contraction
and a T wave indicating ventricular repolarization.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is concerned that a patient is at risk for developing infective endocarditis. What information in the
patient’s history caused the nurse to have this concern?
1) 70 years of age
2) Treatment for osteoarthritis
3) Sister being treated for chronic renal failure
4) Diagnosed with benign prostatic hyperplasia
____ 2. A patient is admitted for treatment of pericarditis. For which additional health problem should the nurse
expect the patient to be evaluated?
1) Asthma
2) Myocardial infarction
3) Infective endocarditis
4) Chronic obstructive pulmonary disease
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____ 3. A patient is demonstrating manifestations of valvular disease. Which valve should the nurse expect to be
affected with this disorder?
1) Aortic
2) Mitral
3) Pulmonic
4) Tricuspid
____ 4. The nurse is explaining the development of atherosclerosis to a patient. What should the nurse emphasize as
beginning this process?
1) Oxidation
2) Inflammatory process
3) Injury to the vessel wall
4) Trapping of low-density lipoproteins
____ 5. The nurse explains about the development of tissue clumps within the innermost layer of the heart to a patient
with infective endocarditis. What aspect of the disease process is the nurse describing?
1) Vegetation
2) Oxidation
3) Foam cells
4) Fatty streaks
____ 6. A patient with pericarditis asks the nurse to explain the health problem. Which phrase should the nurse use
when responding to this patient?
1) Heart cell dysfunction
2) Plaque buildup in vessels
3) Infection of the innermost layer of the heart
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4) Inflammation of the tissue surrounding NG
the TB.COM
heart
____ 7. After completing a physical assessment the nurse anticipates the health-care provider to prescribe diagnostic
testing for valvular disease. What did the nurse assess to come to this conclusion?
1) Heart murmur
2) Carotid artery bruit
3) Bounding peripheral pulses
4) Displaced point of maximum impulse
____ 8. During an assessment a patient describes experiencing chest pain with exercise that disappears with rest. For
which health problem should the nurse plan care for this client?
1) Stable angina
2) Variant angina
3) Unstable angina
4) Prinzmetal’s angina
____ 9. After an assessment the nurse concludes that a patient is experiencing infective endocarditis. What finding
caused the nurse to make this decision?
1) Friction rub
2) Chest pain at rest
3) Jugular vein distention
4) Painless spots on the palms and soles
____ 10. The nurse notes that a newly admitted patient has an elevated sedimentation rate. For which health problem
should the nurse plan care for this patient?
1) Pericarditis
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2) Heart failure
3) Pericardial effusion
4) Coronary artery disease
____ 11. A patient with heart failure is having a B-type natriuretic peptide (BNP) level drawn. What is the purpose of
this laboratory test?
1) Predict life expectancy
2) Rule out an ischemic event
3) Differentiate right from left heart failure
4) Evaluate effectiveness of medication therapy
____ 12. The nurse is preparing teaching for a patient being treated for coronary artery disease. What dietary
information should the nurse emphasize?
1) Restrict carbohydrate intake
2) Limit calorie intake to under 1000/day
3) Reduce saturated fat and sodium intake
4) Have the biggest meal of the day for lunch
____ 13. A patient with infective endocarditis is being started on intravenous antibiotics. What should the nurse include
when teaching about this medication?
1) “The medication may be changed every few days.”
2) “The typical course of this medication is 7 to 10 days.”
3) “Expect to continue this medication for four to six weeks at home.”
4) “Since this infection is resilient, you might be taking antibiotics for life.”
____ 14. A patient is recovering from mechanical valve replacement surgery for valvular disease. What medication
teaching should medication teachingN should
URSI the
NGnurse
TB.prepare
COM for this patient?
1) Long-term use of diuretics
2) Anticoagulant therapy for life
3) Antibiotic therapy for four to six weeks
4) Episodic use of antiarrhythmic medications
____ 15. A patient with heart failure is prescribed an angiotensin-converting enzyme inhibitor. What should the nurse
explain as being the purpose of this medication?
1) Reduce afterload
2) Decrease preload
3) Increase contractility
4) Control sympathetic nervous system response to decreased cardiac output
____ 16. The nurse applies oxygen two liters via nasal cannula on a patient with coronary artery disease. What should
the nurse explain as being the purpose of the oxygen?
1) Ensures vessel dilation
2) Ensures perfusion to cerebral tissues
3) Supports myocardial oxygen demand
4) Facilitates the metabolism of medications
____ 17. The nurse is caring for a patient with infective endocarditis. For which reason would a referral to social
services be needed?
1) Lives with parents
2) Uses intravenous drugs
3) Taking a leave of absence from work
4) Has two terms of college to complete
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____ 18. The nurse is caring for a patient with pericardial effusion. Which action should the nurse use to relieve
shortness of breath and pain?
1) Elevate the head of the bed
2) Encourage ambulation in the room
3) Place in the left side-lying position
4) Coach in deep breathing and coughing
____ 19. The nurse is concerned that a patient with heart failure is decompensating. What assessment finding supports
the nurse’s clinical decision?
1) Dyspnea on exertion
2) Dry persistent cough
3) Weak peripheral pulses
4) Increased urine output
____ 20. The nurse is evaluating teaching provided to a patient with coronary artery disease. Which patient statement
indicates that additional teaching is required?
1) “I will adhere to my smoking cessation plan.”
2) “I am to reduce my daily intake of saturated fat.”
3) “I can take up to three doses of nitroglycerin 15 minutes apart.”
4) “I am to follow the exercise plan for 30 minutes, five days a week.”
____ 21. During a home visit the nurse determines that teaching provided to a patient recovering from infective
endocarditis has been effective. What did the nurse observe to make this clinical determination?
1) Drinking skim milk
2) Measuring radial pulse
3) Using a soft toothbrush NURSINGTB.COM
4) Taking anticoagulant daily
____ 22. A patient with pericarditis is prescribed corticosteroids. What should the nurse emphasize when teaching
about this medication?
1) Take the medication as prescribed
2) Increase the dose if symptoms get worse
3) Reduce the frequency when symptoms subside
4) Consider taking a dose every other day to reduce side effects
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 23. The nurse is preparing a community program on the metrics to improve cardiovascular health. What should be
included in this program? Select all that apply.
1) Healthy diet
2) Alcohol intake
3) Physical activity
4) Smoking cessation
5) Lower blood pressure
____ 24. While planning care the nurse identified interventions to reduce a patient’s risk for developing heart failure.
Which assessment findings did the nurse use to make this clinical determination? Select all that apply.
1) Body mass index 31.3
2) Smokes 1/2 pack of cigarettes
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MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders
Chapter learning objective: Describing the epidemiology of cardiac disorders
Chapter page reference: 569
Heading: Infective Endocarditis > Epidemiology
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Analysis [Analyzing]
Concept: Perfusion; Promoting Health
Difficulty: Moderate
Feedback
1 Risk factors for infective endocarditis include age greater than 60.
2 Osteoarthritis is not a risk factor for infective endocarditis.
3 Family history of renal failure is not a risk factor for infective endocarditis.
4 Benign prostatic hyperplasia is not a risk factor for infective endocarditis.
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Concept: Perfusion
Difficulty: Moderate
Feedback
1 The most commonly affected valve is the aortic valve.
2 The mitral valve is not identified as being commonly affected by valvular disease.
3 The least commonly affected valves include the pulmonic valve because of the low
pressure system in the right heart.
4 The least commonly affected valves include the tricuspid valve because of the low
pressure system in the right heart.
Feedback
1 Infective endocarditis begins with damage to the endocardial lining of the heart, which
leads to the development of nonbacterial thrombotic endocardial lesion. If the patient is
exposed to microorganisms present in the bloodstream, they can become trapped under
the layers of platelet and fibrin deposits. These clumps of tissue are known as
vegetation.
2 Oxidation is a process associated with atherosclerosis.
3 Foam cells are created in the development of atherosclerosis.
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Feedback
1 Often the first clinical sign of valvular disease is the auscultation of a murmur.
2 A carotid artery bruit is not associated with valvular disease.
3 Bounding peripheral pulses are not associated with valvular disease.
4 A displaced point of maximum impulse is associated with cardiomyopathy and not
valvular disease.
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Concept: Perfusion
Difficulty: Moderate
Feedback
1 Stable angina is chest pain or discomfort that is associated with physical activity.
Symptoms of stable angina are often alleviated with rest.
2 Variant angina is caused by coronary artery spasm rather than plaque formation and
typically occurs at rest and in clusters.
3 Unstable angina refers to chest pain that can occur at rest.
4 Prinzmetal’s angina is the same as variant angina, which is caused by coronary artery
spasm rather than plaque formation and typically occurs at rest and in clusters.
Feedback
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1 The most common clinical manifestation of pericarditis is a friction rub.
2 Chest pain at rest or unstable angina is a manifestation of coronary artery disease.
3 Right-sided heart failure is characterized by jugular vein distention.
4 Clinical manifestations of infective endocarditis include red, painless spots on the
palms and soles, called Janeway’s lesions.
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2 Laboratory testing for heart failure includes cardiac enzymes, serum electrolytes, a
complete blood count, urinalysis, fasting lipid profile, liver function testing, and serum
electrolytes.
3 The finding of cardiomegaly and clear lung fields on chest x-ray is suggestive of
pericardial effusion.
4 Electrolyte imbalances along with increases in renal or hepatic laboratory values may
indicate damage caused by poor perfusion or may indicate the presence of risk factors
for heart disease.
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Chapter learning objective: Discussing the medical management of: Infectious heart disease
Chapter page reference: 577
Heading: Infective Endocarditis > Medications
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Perfusion; Infection
Difficulty: Moderate
Feedback
1 The medication will not be changed every few days.
2 The medication will be provided for 4 to 6 weeks.
3 The standard duration of treatment is 4 to 6 weeks. These patients are often discharged
to home on IV antimicrobial therapy.
4 The patient will not be on antibiotics for life.
Feedback
1 Long-term use of diuretics may be indicated in the patient with heart failure.
2 Patients who undergo valve replacement with a mechanical prosthetic valve will need
to be anticoagulated for life to prevent thrombotic events.
3 Antibiotic therapy for four to six weeks is indicated for the patient with infective
endocarditis.
4 Antiarrhythmic medication is not routinely prescribed for the patient with a mechanical
heart valve.
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Feedback
1 Angiotensin-converting enzyme inhibitors (ACE-Is) are usually the first line of
medications used to reduce afterload.
2 Aldosterone antagonist diuretics such as spironolactone (Aldactone) as well as loop
diuretics are used to decrease preload.
3 A mainstay of HF management in the past has been digoxin (Lanoxin), an oral positive
inotropic medication used to increase cardiac contractility.
4 Beta blockers are used to control the sympathetic nervous system response to decreased
cardiac output, such as tachycardia, in order to decrease cardiac workload.
Feedback
1 A social services consult would not be needed if the patient lives with parents.
2 If drug use caused the disease, a referral to addiction counseling services would be
indicated.
3 A social services consult would not be needed because the patient is taking a leave of
absence from work.
4 A social services consult would not be needed because the patient is still enrolled in
college.
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Feedback
1 The nurse should keep the head of the bed elevated. Pericardial effusion exerts pressure
on surrounding organs, resulting in orthopnea and dyspnea. Raising the head of bed
relieves shortness of breath. Pain is also relieved by sitting in the upright position.
2 The patient should be on bedrest.
3 The left side-lying position will not relieve shortness of breath or pain.
4 Deep breathing and coughing will not relieve shortness of breath or pain.
Feedback
1 Dyspnea on exertion indicates deceased cardiac output and worsening heart failure.
2 A dry persistent cough is a side effect of angiotensin-converting enzyme inhibitors.
3 Weak peripheral pulses are a consequence of inadequate cardiac output.
4 Increased urine output would be an indication of the effectiveness of diuretic therapy.
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Concept: Perfusion
Difficulty: Moderate
Feedback
1 Patients with coronary artery disease should engage in smoking cessation activities.
2 Patients with coronary artery disease should reduce the intake of saturated fat.
3 A nitroglycerin administration regimen includes not exceeding three doses five minutes
apart.
4 Patients with coronary artery disease should engage in regular exercise for 30 minutes
five days a week.
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MULTIPLE RESPONSE
23. ANS: 1, 3, 4, 5
Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders
Chapter learning objective: Describing the epidemiology of cardiac disorders
Chapter page reference: 569
Heading: Coronary Artery Disease > Epidemiology
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Perfusion; Promoting Health
Difficulty: Moderate
Feedback
1. The new concept “cardiovascular health” is geared to encouraging people to maintain seven
metrics in order to achieve optimal cardiovascular health. These metrics include having a
healthy diet.
2. Alcohol intake is not one of the seven metrics to achieve optimum cardiovascular health.
3. The new concept “cardiovascular health” is geared to encouraging people to maintain seven
NURoptimal
metrics in order to achieve SINGcardiovascular
TB.COM health. These metrics include engaging in
sufficient physical activity.
4. The new concept “cardiovascular health” is geared to encouraging people to maintain seven
metrics in order to achieve optimal cardiovascular health. These metrics include not smoking.
5. The new concept “cardiovascular health” is geared to encouraging people to maintain seven
metrics in order to achieve optimal cardiovascular health. These metrics include lower blood
pressure.
Feedback
1. A risk factor for heart failure is obesity.
2. Smoking is a risk factor for the development of heart failure.
3. Employment is not identified as a risk factor for heart failure.
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Feedback
1. There is growing evidence that diastolic dysfunction is becoming more common among
patients diagnosed with HF.
2. Diastolic dysfunction is associated with patients who tend to be older and obese.
3. Diastolic dysfunction is seen in patients with diabetes mellitus and atrial fibrillation.
4. Infective endocarditis is exacerbated with invasive procedures and dental examinations.
5. Diastolic dysfunction typically has a normal EF also known as HF with preserve EF
(HFpEF). This is due to the fact that there is less blood in the ventricle to eject because of the
impaired filling. NURSINGTB.COM
PTS: 1 CON: Perfusion
26. ANS: 1, 3, 4, 5
Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders
Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of cardiac
disorders
Chapter page reference: 577
Heading: Infective Endocarditis > Laboratory and Diagnostic Tests
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity/Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Perfusion; Infection
Difficulty: Moderate
Feedback
1. Tests used to confirm infective endocarditis include blood cultures.
2. Ejection fraction is used to diagnose the type and extent of heart failure.
3. Tests used to confirm infective endocarditis include an electrocardiogram.
4. Tests used to confirm infective endocarditis include a TTE.
5. Tests used to confirm infective endocarditis include a TEE.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders
Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of cardiac
disorders
Chapter page reference: 571, 582
Heading: Coronary Artery Disease > Radiographical Diagnostic Tests
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Analysis [Analyzing]
Concept: Perfusion
Difficulty: Moderate
Feedback
1. An exercise stress test is not used to diagnose pericarditis.
2. An exercise stress test is not used to diagnose heart failure.
3. Diagnostic tests used to diagnose valvular disease include stress testing to identify functional
capacity.
4. An exercise stress test is not used to diagnose infective endocarditis.
5. A patient with suspected coronary artery disease may undergo an exercise stress test. This is
done to assess the function of the heart during exercise.
Feedback
1. If the fluid causing a pericardial effusion is not addressed, it can increase and cause cardiac
tamponade, which is manifested by hypotension,
2. If the fluid causing a pericardial effusion is not addressed, it can increase and cause cardiac
tamponade. Pulsus paradoxus may occur.
3. If the fluid causing a pericardial effusion is not addressed, it can increase and cause cardiac
tamponade, which is manifested by muffled heart sounds.
4. If the fluid causing a pericardial effusion is not addressed, it can increase and cause cardiac
tamponade, which is manifested by jugular vein distention.
5. Lower extremity edema is a manifestation of right heart failure.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A patient with atherosclerosis asks why smoking cessation is important. What should the nurse respond to this
patient?
1) “Tobacco causes atherosclerosis.”
2) “Tobacco reduces the effects of cholesterol in the body.”
3) “Tobacco causes the blood pressure to drop and changes the cells within the arteries.”
4) “Tobacco smoke speeds the growth of atherosclerosis in coronary arteries, aorta, and the
legs.”
____ 2. A patient is diagnosed with carotid artery disease. For which potential health problem should the nurse
prepare teaching for this patient?
1) Stroke
2) Diabetes
3) Hypertension
4) Dyslipidemia
____ 3. A patient learns of having a 1 cm abdominal aortic aneurysm. What should the nurse emphasize when
discussing the health problem with this patient?
1) Stop smoking
2) Increase physical activity
3) Engage in stress management
4) Reduce the intake of saturated fat
____ 4. The nurse suspects that a patient has atherosclerosis. What finding did the nurse use to make this clinical
determination? NURSINGTB.COM
1) Dizziness
2) Headaches
3) Nosebleeds
4) Pain when walking
____ 5. A patient with hypertension has a low serum potassium level. Which mechanism should the nurse consider as
being the cause for the elevated blood pressure?
1) Aldosterone
2) Increased sodium intake
3) Sympathetic nervous system
4) Renin-angiotensin-aldosterone system (RAAS)
____ 6. A patient experiencing pain and burning in the legs at rest. Which stage of peripheral arterial disease should
the nurse suspect this patient is experiencing?
1) Stage I
2) Stage II
3) Stage III
4) Stage IV
____ 7. An older patient seeks emergency care for a sudden onset of severe abdominal pain. Which health problem
should the nurse suspect be occurring in this patient?
1) Rupture of the appendix
2) Small bowel obstruction
3) Passing of a kidney stone
4) Rupture of an abdominal aneurysm
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 8. During a physical assessment the nurse suspects that a client is experiencing a femoral thrombosis. What
finding did the nurse use to make this clinical determination?
1) Calf pain
2) Dilated superficial veins
3) Thigh swelling to the knee
4) Entire leg swollen and painful
____ 9. A patient’s blood pressure is 158/90 mm Hg; however, previous measurements have been within normal
limits. Which intervention would be appropriate for this patient?
1) Investigate for additional health problems
2) Prepare teaching on antihypertensive medications
3) Schedule an additional measurement in a few weeks
4) Instruct on the effects of hypertension on major body organs
____ 10. The nurse auscultates a bruit over a patient’s carotid artery. Which noninvasive diagnostic test should the
nurse expect to be prescribed for this patient?
1) Carotid angiography
2) Carotid duplex ultrasound
3) Magnetic resonance angiography
4) Computed tomography angiography
____ 11. A patient is suspected of having an abdominal aortic aneurysm. For which gold standard diagnostic test
should the nurse prepare teaching for this client?
1) Cardiac MRI
2) Abdominal ultrasound
3) CT scan with IV contrast NURSINGTB.COM
4) Transthoracic echocardiography (TTE)
____ 12. A patient is being evaluated for medication therapy to treat atherosclerosis. For which health problem would a
statin be contraindicated?
1) Diverticulitis
2) Celiac disease
3) Liver cirrhosis
4) Type 2 diabetes mellitus
____ 13. A patient with peripheral arterial disease is instructed on the medication pentoxifylline (Trental). Which
patient statement indicates that teaching has been effective?
1) “This pill will cure my arterial disease.”
2) “This medication will begin to work in a week or two.”
3) “I should take this medication every day with a baby aspirin.”
4) “I might not feel the effect of this medication for up to two months.”
____ 14. A patient recovering from a carotid endarterectomy (CEA) has a blood pressure of 90/48 mm Hg. What
should the nurse do first?
1) Raise the head of the bed
2) Lower the head of the bed
3) Assess cranial nerve function
4) Maintain head in neutral position
____ 15. A patient is diagnosed with an abdominal aneurysm measuring 5 cm. Which teaching material should the
nurse prepare for this patient?
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1) Dietary changes
2) Preoperative and postoperative care
3) Actions to reduce high blood pressure
4) Activities to prevent aneurysm rupture
____ 16. The nurse is planning care for a patient with peripheral arterial disease. Which nursing diagnosis would be
appropriate for this patient?
1) Anxiety
2) Chronic pain
3) Risk for injury
4) Risk for decreased cardiac output
____ 17. A client with type 2 diabetes mellitus is newly diagnosed with carotid artery disease. What should the nurse
emphasize when discussing blood glucose control with this patient?
1) “Maintain blood glucose levels within normal limits.”
2) “The issue with the carotid arteries is a priority at this time.”
3) “Blood glucose control will be difficult because of the additional medications for the
carotid arteries.”
4) “Once you have the carotid artery surgery you won’t need to keep blood glucose levels
within normal limits.”
____ 18. A patient is diagnosed with a 7 cm abdominal aortic aneurysm. What should the nurse include in this patient’s
plan of care?
1) Keep the bed flat
2) Elevate the lower extremities
3) Raise the head of the bed 30 degrees
4) Assist to sit out of bed in a chairNtwice
URSaIday
NGTB.COM
____ 19. The nurse is preparing teaching material to help a patient with atherosclerosis manage lifestyle changes. What
should the nurse emphasize in this teaching?
1) Limit cigarette smoking
2) Follow a low-fat, low-cholesterol diet
3) Consider adopting an active lifestyle
4) Take medications when symptoms occur
____ 20. The nurse is evaluating teaching provided to a patient with hypertension. Which observation indicates that
additional instruction would be required?
1) Asks that no one smoke in the house
2) Takes a 15-minute walk three times a day
3) Enjoys four ounces of red wine with dinner
4) Adds salt when cooking eggs in a frying pan
____ 21. The nurse is visiting the home of a patient with peripheral arterial disease. For which observation should the
nurse immediately intervene?
1) Sits with both feet on the floor
2) Walks around the house barefoot
3) Uses a mirror to examine the bottom of the feet
4) Eats grilled chicken on whole wheat bread for lunch
____ 22. The nurse is identifying actions to reduce a patient’s risk for developing another deep vein thrombosis (DVT).
What should the nurse include?
1) Restrict fluids
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 23. The nurse is preparing material about peripheral artery disease (PAD) for a community fair. What should the
nurse include about modifiable risk factors for the disease? Select all that apply.
1) Diabetes
2) Smoking
3) Hypertension
4) Family history
5) Sedentary lifestyle
____ 24. The nurse is preparing a tool to instruct patients on the manifestations of carotid artery disease. What should
the nurse include with this information? Select all that apply.
1) Dizziness
2) Difficulty talking
3) Sudden vision changes
4) Sudden onset of nausea and vomiting
5) Sudden weakness on one side of the body
____ 25. A patient with a blood pressure over 160/90 mm Hg for two office visits is being started on antihypertensive
medication for the first time. For which medication classifications should the nurse prepare teaching? Select
all that apply. NURSINGTB.COM
1) Diuretics
2) Vasodilators
3) ACE Inhibitors
4) Calcium channel blockers
5) Angiotensin II receptor blockers (ARBs)
____ 26. A patient with a deep vein thrombosis (DVT) is disappointed to learn that tissue plasminogen activator (tPA)
is not an option. What information was used to make this treatment decision? Select all that apply.
1) History of osteoarthritis
2) Being treated for hemophilia
3) Previous surgery for spinal stenosis
4) Symptoms of a DVT present for a week
5) Diagnosis of DVT made upon symptoms
____ 27. A patient who comes to the community clinic for a wellness visit has a blood pressure of 164/92 mm Hg.
What additional information should the nurse assess from this patient? Select all that apply.
1) Heart rate
2) Bowel sounds
3) Lower extremities
4) Neurological system
5) BMI and waist circumference
Numeric Response
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
28. A patient’s ankle systolic blood pressure is 148 mm Hg and brachial systolic pressure is 118 mm Hg. What is
this patient’s ankle-brachial index? Record your answer as a whole number. ______
NURSINGTB.COM
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders
Chapter learning objective: Describing the epidemiology of vascular disorders
Chapter page reference: 592
Heading: Atherosclerosis/Arteriosclerosis > Epidemiology
Integrated Processes: Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Perfusion; Promoting Health
Difficulty: Moderate
Feedback
1 Cigarette smoke does not directly cause atherosclerosis.
2 Tobacco increases circulating cholesterol.
3 Cigarette smoke causes hypertension and changes endothelial cells.
4 Tobacco smoke greatly worsens atherosclerosis and speeds its growth in the coronary
arteries, aorta, and arteries in the legs.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Smoking is the only risk factor that, when modified, can slow the growth of an
aneurysm.
2 Increasing physical activity is not identified as reducing the risk of abdominal aortic
aneurysm development.
3 Stress management is not identified as reducing the risk of abdominal aortic aneurysm
development.
4 Reducing the intake of saturated fat will help prevent the development of
atherosclerosis; however, this will not alter an abdominal aortic aneurysm which has
already developed.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 Excess aldosterone release results in sodium and water retention, which results in
increased stroke volume and blood pressure.
2 Increased sodium causes fluid retention, increasing stroke volume and blood pressure.
3 Increased sympathetic activity is a primary precursor to hypertension. It can cause
vasoconstriction, resulting in increased peripheral vascular resistance and increased
blood pressure. It may also increase heart rate.
4 Excess angiotensin II results in vasoconstriction and increased blood pressure. Excess
angiotensin also results in increased aldosterone release.
Feedback
1 In stage I the patient has no symptoms of the disease.
2 In stage II the patient has pain with walking or claudication.
3
NURSINGTB.COM
In stage III the patient has burning pain in the extremities at rest.
4 In stage IV the patient experiences ulcers and blackened tissue on the toes, the forefoot,
or the heel of the foot.
Feedback
1 It is unlikely that the older patient is experiencing a ruptured appendix.
2 Sudden severe abdominal pain is not necessarily associated with a small bowel
obstruction.
3 Groin and flank pain are manifestations of a kidney stone.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4 Pain can occur depending on the location of the aneurysm. The pain is typically not
related to any activity and occurs spontaneously. Pain reflects a change in the aneurysm
that needs immediate attention.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Cardiac MRI has shown improved sensitivity and specificity in detecting aortic
dilation; however, it is not the gold standard.
2 Abdominal ultrasound is a screening modality; however, it is not the gold standard.
3 Computed tomography scanning with IV contrast is considered the gold standard for
assessing the size and location of an abdominal aneurysm.
4 Transthoracic echocardiography (TTE) is a screening modality; however, it is not the
gold standard.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Pentoxifylline controls the symptoms of circulation problems but does not cure them.
2 Although patients may feel the effects of this medication in two to four weeks, they
may need to take it for up to eight weeks before they feel the full effect.
3 Aspirin is typically prescribed with clopidogrel (Plavix).
4 Although patients may feel theNeffects
URSIofNG this
TBmedication
.COM in two to four weeks, they
may need to take it for up to eight weeks before they feel the full effect.
Feedback
1 Raising the head of the bed would be appropriate if the patient’s blood pressure was
elevated.
2 Following a CEA, a new “normal” pressure may be sensed as a high pressure signaling
the vagus nerve to respond, resulting in vasodilation, bradycardia, and hypotension. The
head of the bed should be lowered and the patient placed in a flat position to ensure
cerebral perfusion.
3 Assessing cranial nerve function is appropriate if the patient were demonstrating signs
of deficits.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4 Maintaining the head in the neutral position would be appropriate if the patient’s blood
pressure is elevated,
Feedback
1 Dietary changes will not affect the stability of an abdominal aortic aneurysm.
2 Surgical intervention is shown to be the only treatment effective in preventing AAA
rupture and aneurysm-related death.
3 Patients with an aneurysm may be started on medication to ensure blood pressure
control; however, this is not the most effective treatment.
4 There are no specific activities to prevent aneurysm repair other than having surgery.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with vascular
disorders
Chapter page reference: 611
Heading: Carotid Artery Disease > Nursing Management > Actions
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Perfusion
Difficulty: Moderate
Feedback
1 Blood glucose levels should be maintained within normal limits. Poorly controlled
diabetes mellitus results in increased plaque formation in the vessels due to the
breakdown of fats from injury, increasing the risk for ischemic stroke.
2 Both type 2 diabetes mellitus and carotid artery disease are important health issues that
need to be addressed and managed.
3 Medications for carotid artery disease do not adversely affect blood glucose levels.
4 A person with type 2 diabetes mellitus should attempt to keep glucose levels within
normal limits regardless of any other health problem or disease process.
Feedback
1 The patient with an abdominal aortic aneurysm should be on bedrest with the legs flat.
The patient should be instructed to avoid elevating or crossing the legs because it
restricts peripheral blood flow and increases pressure in the aorta or iliac arteries.
2 The lower extremities should not be elevated because it increases pressure in the aorta
or iliac arteries.
3 The head of the bed would increase pressure in the aorta or iliac arteries.
4 The patient should be on bedrest to prevent increasing pressure in the aorta or iliac
arteries.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 The patient should be encouraged to stop smoking because the nicotine and carbon
monoxide in cigarette smoke damage the endothelium, which sets the stage for the
buildup of plaque.
2 A low-fat, low-cholesterol diet helps manage risk factors and slows the progression of
atherosclerosis.
3 The person with atherosclerosis should be encouraged to increase activity and not just
consider adding activity.
4 Medications should be taken as prescribed.
Feedback
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 The patient should not cross the legs at the knees or the ankles when sitting.
2 The patient is prone to injury and should not be walking without footwear. The nurse
should immediately intervene.
3 The bottom of the feet should be examined every day.
4 The patient should eat a heart-healthy diet that restricts additional sodium.
Feedback
1 Fluids should not be restricted. Dehydration can cause the blood to thicken and
encourage the development of deep vein thrombosis.
2 Tight or restrictive clothing should be avoided.
3 Leg exercises should be performed daily or as frequently as prescribed.
4 Standing in place should be limited
NURSsince
INGthis
TBcan.Cincrease
OM the development of deep
vein thrombosis.
MULTIPLE RESPONSE
23. ANS: 1, 2, 3, 5
Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders
Chapter learning objective: Describing the epidemiology of vascular disorders
Chapter page reference: 601
Heading: Peripheral Arterial Disease > Epidemiology
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Perfusion; Promoting Health
Difficulty: Moderate
Feedback
1. Diabetes is a modifiable risk factor for PAD.
2. Smoking is a modifiable risk factor for PAD.
3. Hypertension is a modifiable risk factor for PAD.
4. Family history is a nonmodifiable risk factor for PAD.
5. Sedentary lifestyle is a modifiable risk factor for PAD.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1. Carotid artery disease is asymptomatic until the lumen of the vessel is obstructed to the point
that cerebral perfusion is impaired. The clinical manifestations of complications resulting from
impaired cerebral perfusion include dizziness.
2. Carotid artery disease is asymptomatic until the lumen of the vessel is obstructed to the point
that cerebral perfusion is impaired. The clinical manifestations of complications resulting from
impaired cerebral perfusion include difficulty talking.
3. Carotid artery disease is asymptomatic until the lumen of the vessel is obstructed to the point
that cerebral perfusion is impaired. The clinical manifestations of complications resulting from
impaired cerebral perfusion include sudden vision problems.
4. Sudden onset of nausea and vomiting are not associated with carotid artery disease.
5. Carotid artery disease isNasymptomatic
URSINGTB .Cthe
until OMlumen of the vessel is obstructed to the point
that cerebral perfusion is impaired. The clinical manifestations of complications resulting from
impaired cerebral perfusion include sudden weakness sometimes noted more on one side than
the other.
Feedback
1. Diuretics are often the first but not the only choice in high blood pressure medications.
2. Vasodilators relax the muscle tissue in the blood vessel walls and, in turn, lower the blood
pressure.
3. ACE Inhibitors help relax/dilate blood vessels by blocking the formation of angiotensin II, a
vasoconstrictor, to reduce blood pressure.
4. Calcium channel blockers help relax/dilate the muscles of the blood vessels.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5. ARBs are sometimes used in patients intolerant of ACE inhibitors. If this patient is being
prescribed medication for the first time, it is unlikely that an ARB will be prescribed.
Feedback
1. A history of osteoarthritis is not a contraindication for tPA to treat DVT.
2. Being treated for an existing bleeding disorder such as hemophilia increases the risk of
bleeding and contraindicates the use of tPA to treat the DVT.
3. Previous spinal surgeries are not a contraindication for tPA to treat DVT.
4. The symptoms of a DVT must be present for less than 3 days to be considered for tPA
treatment.
5. A definite diagnosis of DVT must be made by a venography before tPA treatment will be
considered.
NURSINGTB.COM
PTS: 1 CON: Perfusion | Medication
27. ANS: 1, 3, 4, 5
Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with vascular
disorders
Chapter page reference: 601
Heading: Hypertension > Nursing Management > Assessment
Integrated Processes: Nursing Process; Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Perfusion; Assessment
Difficulty: Moderate
Feedback
1. Heart rate should be assessed because increased peripheral vascular resistance can lead to
increased heart rate or increased stroke volume to compensate for the increased peripheral
vascular resistance.
2. Abdominal arteries should be assessed for bruits; however, auscultating bowel sounds is not
essential.
3. The lower extremities should be assessed for pulses and edema.
4. The neurological system should be assessed for signs and symptoms that could indicate
cerebrovascular disease and possible complications such as stroke and aneurysm.
5. BMI and waist circumference should be assessed because obesity and diet are major risk
factors in hypertension.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
NUMERIC RESPONSE
28. ANS:
1.25
Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders
Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of vascular
disorders
Chapter page reference: 602
Heading: Peripheral Arterial Disease > Diagnosis
Integrated Processes: Nursing Process; Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Perfusion; Assessment
Difficulty: Moderate
Feedback: The ankle-brachial index (ABI) uses a Doppler probe to compare the BP obtained at the ankle with
the pressure obtained at the brachial artery. The value can be derived by dividing the ankle BP by the brachial
BP. For this patient, the value would be calculated by dividing 118 into or 148 or 148/118 = 1.25.
NURSINGTB.COM
Chapter 32: Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The health-care provider wants an SvO2 level on a patient with a pulmonary artery catheter. From where
should this sample be taken?
1) Distal lumen
2) Balloon inflation lumen
3) Proximal injectable port
4) Proximal infusion port
____ 2. The nurse is preparing to obtain a pulmonary artery wedge pressure (PAWP) on a patient. What action should
be taken to ensure for the patient’s safety?
1) Inflate the balloon 1.5 mL
2) Place the patient in the Trendelenburg position
3) Monitor the waveform after inflating the balloon
4) Deflate the balloon within five minutes of obtaining the pressure
____ 3. The nurse wants to evaluate a patient’s right heart preload. Which approach should be used to obtain this
measurement?
1) Zero the arterial line
2) Measure the central venous pressure
3) Measure the pulmonary artery wedge pressure
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 11. The nurse is reviewing medications prescribed for a patient with hypertrophic cardiomyopathy. Which
medication should the nurse question before administering?
1) ACE-I
2) Diuretic
3) Digoxin
4) Beta blocker
____ 12. The nurse is caring for a patient experiencing cardiogenic shock. Which medication should the nurse expect to
be prescribed to improve this patient’s cardiac output?
1) Nitroglycerin
2) Morphine sulfate
3) Norepinephrine (Levophed)
4) Dobutamine hydrochloride (Dobutamine)
____ 13. The nurse is caring for a patient experiencing an acute myocardial infarction. Which assessment finding
indicates a decrease in this patient’s cardiac output?
1) Chest pain
2) Restlessness
3) Low urine output
4) ST segment elevation
____ 14. The nurse is preparing medications for a patient experiencing an acute myocardial infarction. Which
medication will dilate the patient’s coronary blood vessels?
1) Heparin
2) Fibrinolytics
3) Nitroglycerin
4) Beta blockers NURSINGTB.COM
____ 15. The nurse hears crackles when auscultating the lung sounds of a patient with cardiomyopathy. What should
this finding indicate to the nurse?
1) Atelectasis
2) Pneumothorax
3) Stasis pneumonia
4) Pulmonary edema
____ 16. The nurse notes that a patient with cardiomyopathy has been prescribed an angiotensin-converting enzyme
inhibitor. What is the purpose of this medication?
1) Reduce afterload
2) Improve heart muscle contractions
3) Reduce fluid accumulation in the lungs
4) Decrease sympathetic response to decreased cardiac output
____ 17. A patient with cardiogenic shock has an intra-aortic balloon pump (IABP). What should the nurse include
when caring for this patient?
1) Elevated the affected leg on a pillow
2) Elevate the head of the bed 45 degrees
3) Keep the affected leg straight at all times
4) Keep the bed flat with a small pillow under the head
____ 18. A patient recovering from cardiogenic shock is observed walking to the patient lounge. What should the nurse
recommend to this patient?
1) Call for help when wanting to walk
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Completion
Complete each statement.
23. The nurse is preparing to measure a patient’s central venous pressure. In which order should the nurse
perform the steps to ensure an accurate reading? (Enter the number of each step in the proper sequence; do not
use punctuation or spaces. Example: 1234)
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 24. The nurse is assigned to a patient with a newly inserted central line. What actions should be taken to prevent
the patient from developing an infection? Select all that apply.
1) Perform line care
2) Use aseptic technique
3) Minimize handling the line
4) Use normal saline to flush the line
5) Ensure an occlusive dressing is applied
____ 25. The nurse suspects that a patient is experiencing a complication from a pulmonary artery catheter. What
findings did the nurse use to make this clinical determination? Select all that apply.
1) Bleeding
2) Increased urine output
3) Elevated body temperature
4) Acute onset of shortness of breath
5) Development of a cardiac dysrhythmia
____ 26. The nurse is preparing to determine a patient’s left heart afterload. What measurements are needed to make
this calculation? Select all that apply.
1) Cardiac output
2) Mean arterial pressure
3) Central venous pressure
4) Pulmonary artery pressure
5) Pulmonary artery wedge pressure
____ 27. A patient with atypical chest pain is prescribed a 12-lead electrocardiogram. What findings would support this
patient experiencing an acute myocardial infarction? Select all that apply.
1) Q waves NURSINGTB.COM
2) Junctional rhythm
3) ST segment elevation
4) Prolonged PR interval
5) Premature ventricular contractions
____ 28. A patient with cardiomyopathy is scheduled for a biventricular implantable cardioverter defibrillator. What
should the nurse include when teaching the patient about this device? Select all that apply.
1) Part of the thickened overgrown septum is removed
2) A pacer wire is placed in the right and left ventricles
3) A small part of the thickened heart muscle is destroyed
4) The automatic defibrillator will deliver a shock if necessary
5) The automatic defibrillator monitors the heart for dysrhythmias
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 32: Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction
Chapter learning objective: Describing the indications and nursing implications for hemodynamic monitoring
in the critically ill patient
Chapter page reference: 633
Heading: Hemodynamic Monitoring Systems > PA Catheter Monitoring > Oxygen Utilization
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Perfusion
Difficulty: Moderate
Feedback
1 Oxygen utilization at the tissue level can be indirectly measured by evaluating an SvO2
level; a blood sample obtained via the distal port of the PA line.
2 The proximal infusion port is used for medications and fluid administration.
3 The balloon inflation lumen is used to inflate the balloon.
4 The proximal injection port is used for cold thermodilution fluid and for central venous
pressure measurements.
PTS: 1 NURSINGTB.COM
CON: Perfusion
2. ANS: 1
Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction
Chapter learning objective: Describing the indications and nursing implications for hemodynamic monitoring
in the critically ill patient
Chapter page reference: 633
Heading: Hemodynamic Monitoring Systems > PA Catheter Monitoring > Nursing Implications for the PA
Catheter
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Perfusion; Safety
Difficulty: Moderate
Feedback
1 When a PAWP is obtained, the balloon must be inflated no more than 1.5 mL.
2 The patient needs to be placed in the Trendelenburg position when the line is inserted.
3 The waveform does not need to be monitored after inflating the balloon.
4 After the value is obtained, it is essential that the nurse ensure the balloon is
immediately deflated. A PA catheter should never be inflated and in the wedge position
for more than 10 to 15 seconds.
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Chapter learning objective: Explaining the physiological relationship of hemodynamic parameters (preload,
afterload, and contractility) to cardiac function
Chapter page reference: 631
Heading: Hemodynamic Monitoring Systems > PA Catheter Monitoring > Cardiac Output
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Perfusion
Difficulty: Moderate
Feedback
1 Zeroing the arterial line is not an approach to obtain measurements or pressure
readings.
2 Measuring the central venous pressure is a reflection of right heart preload.
3 The pulmonary artery wedge pressure reflects left heart preload.
4 Attaching the proximal infusion port to an intravenous solution provides the patient
with fluids. It is not done to evaluate pressures.
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Concept: Perfusion
Difficulty: Moderate
Feedback
1 Many patients with diabetes never get the typical symptoms but may present with
fatigue.
2 Signs of a left ventricle infarct include dyspnea.
3 Signs of a left ventricle infarct include tachycardia.
4 Signs of a left ventricle infarct include hypertension.
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Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction
Chapter learning objective: Correlating the clinical manifestations to the underlying pathophysiology of:
Cardiogenic shock
Chapter page reference: 645
Heading: Cardiogenic Shock > Clinical Manifestations
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Perfusion
Difficulty: Moderate
Feedback
1 Compensatory mechanisms eventually fail to maintain adequate CO, worsening
inadequate organ perfusion. At this time, clinical manifestations include hypotension.
2 Cardiogenic shock is frequently caused by MI. The initiation of compensatory
mechanisms leads to increased heart rate.
3 Compensatory mechanisms eventually fail to maintain adequate CO, worsening
inadequate organ perfusion. At this time, clinical manifestations include absent urine
output.
4 Compensatory mechanisms eventually fail to maintain adequate CO, worsening
inadequate organ perfusion. At this time, clinical manifestations include cold, cyanotic,
and mottled skin.
Feedback
1 Serum lactate levels would increase in oxygen deprivation.
2 Serum calcium level is not used to determine oxygenation.
3 Reduction in hemoglobin and hematocrit would occur with bleeding.
4 Oxygen deprivation leads to excessive production of lactic acid. Arterial blood gases
reveal a metabolic acidosis.
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Feedback
1 Angiotensin-converting enzyme medications are given to improve the heart’s pumping
capacity. They reduce afterload or SVR, making it easier for the heart to eject blood.
2 Diuretics reduce fluid accumulation in the lungs that occurs because of the ineffective
pumping action of the heart.
3 Digoxin’s inotropic effects can worsen outflow obstruction in hypertrophic
cardiomyopathy.
4 Beta blockers decrease the sympathetic nervous system response to decreased CO
decreasing workload and myocardial oxygen consumption. They have been shown to
prevent progression of the disease and improve outcomes.
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4 Beta blockers decrease the sympathetic response to an MI, decreasing cardiac workload
and oxygen consumption.
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Feedback
1 No smoking of cigarettes is one of the American Heart Association’s Life Simple 7
strategies.
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2 Eating a heart-healthy diet is one of the American Heart Association’s Life Simple 7
strategies.
3 Exercise for at least 150 minutes with moderate-intensity activity, or 75 minutes of
vigorous-intensity activity, or a combination of each per week is one of the American
Heart Association’s Life Simple 7 strategies.
4 Keeping fasting blood glucose less than 100 mg/dL is one of the American Heart
Association’s Life Simple 7 strategies.
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COMPLETION
23. ANS:
3214 NURSINGTB.COM
Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction
Chapter learning objective: Describing the indications and nursing implications for hemodynamic monitoring
in the critically ill patient
Chapter page reference: 627
Heading: Hemodynamic Monitoring Systems
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Perfusion
Difficulty: Moderate
Feedback: In order to obtain accurate readings, several conditions need to be present. First, the transducer
should be secured at the phlebostatic axis. Second, the tubing between the transducer and the cannula must be
stiff, nonpliant, and less than 120 cm in length. Third, the transducer must be routinely calibrated, commonly
referred to as “zeroing,” to offset the atmospheric and hydrostatic pressures that may alter the reading.
Finally, the transducer and tubing need to be free from blood and air to ensure accurate readings and
waveform.
MULTIPLE RESPONSE
24. ANS: 1, 2, 4, 5
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Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction
Chapter learning objective: Describing the indications and nursing implications for hemodynamic monitoring
in the critically ill patient
Chapter page reference: 630
Heading: Hemodynamic Monitoring Systems > Nursing Implications for Central Line Maintenance
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Application [Applying]
Concept: Perfusion; Infection; Safety
Difficulty: Moderate
Feedback
1. It is the nurse’s responsibility to perform line care to minimize risk of infection.
2. It is the nurse’s responsibility to use aseptic technique to minimize risk of infection.
3. It is the nurse’s responsibility to minimize line handling to minimize risk of infection.
4. Flushing the line ensures line patency and does not reduce the risk of infection.
5. It is the nurse’s responsibility to maintain an occlusive dressing to minimize risk of infection.
Feedback
1. A potential pulmonary artery catheter complication is bleeding.
2. Increased urine output is not a potential pulmonary artery catheter complication.
3. Evidence of an infection or sepsis would be an elevated body temperature. This could
indicate a potential pulmonary artery catheter complication.
4. Acute onset of shortness of breath could indicate an air embolism or pneumothorax, which
are both potential pulmonary artery catheter complications.
5. The development of a cardiac dysrhythmia especially when floating the catheter through the
right ventricle is a potential pulmonary artery catheter complication.
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Feedback
1. Left heart afterload is reflected in the systemic vascular resistance (SVR) and is
representative of the force that the left heart must pump against in order to deliver the SV
into the periphery. Cardiac output is used to calculate systemic vascular resistance.
2. Left heart afterload is reflected in the systemic vascular resistance (SVR) and is
representative of the force that the left heart must pump against in order to deliver the SV
into the periphery. Mean arterial pressure is used to calculate systemic vascular resistance.
3. Left heart afterload is reflected in the systemic vascular resistance (SVR) and is
representative of the force that the left heart must pump against in order to deliver the SV
into the periphery. Central venous pressure is used to calculate systemic vascular resistance.
4. Pulmonary artery pressure is used to calculate pulmonary vascular resistance.
5. Pulmonary artery wedge pressure is used to calculate pulmonary vascular resistance.
Feedback
1. Typical electrocardiogram changes diagnostic of AMI includes the presence of Q waves.
2. A junctional rhythm is not associated with an acute MI.
3. Typical electrocardiogram changes diagnostic of AMI includes ST-segment elevation.
4. Prolonged PR interval is not diagnostic for an acute MI.
5. Premature ventricular contractions are not diagnostic for an acute MI.
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Feedback
1. Septal myectomy is an open-heart surgery in which the surgeon removes part of the
thickened, overgrown heart muscle wall (septum) that separates the ventricles.
2. When inserting a biventricular implantable cardioverter defibrillator, a pacer wire is placed in
both the right and left ventricles.
3. Septal alcohol ablation is a treatment in which a small portion of the thickened heart muscle
is destroyed by injecting alcohol through a catheter into the heart muscle.
4. This device delivers a shock if needed.
5. This device monitors the heart for lethal ventricular dysrhythmias.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
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1) Anemia
2) Neutropenia
3) Polycythemia
4) Thrombocytopenia
____ 14. Which term should the nurse use when documenting a decreased platelet count?
1) Anemia
2) Neutropenia
3) Polycythemia
4) Thrombocytopenia
____ 15. The nurse is conducting a teaching session regarding clotting factors. Which clotting factor is converted to
fibrin and is responsible for clot formation?
1) Fibrinogen
2) Prothrombin
3) Calcium ions
4) Tissue thromboplastin
____ 16. Which food should the nurse recommend for a patient who is experiencing anemia caused by a deficiency in
folic acid?
1) Fish
2) Poultry
3) Citrus fruits
4) Green leafy vegetables
____ 17. Which food should the nurse recommended for a patient who is diagnosed with iron deficiency anemia?
1) Shellfish NURSINGTB.COM
2) Lima beans
3) Citrus fruits
4) Milk products
____ 18. Which drug prescription should the nurse anticipate to prevent the formation of clots for a patient diagnosed
with deep vein thrombosis (DVT)?
1) Warfarin
2) Vitamin K
3) Abciximab
4) Streptokinase
____ 19. Which drug prescription should the nurse anticipate for a patient who presents in the emergency department
with symptoms of a thrombotic stroke?
1) Warfarin
2) Vitamin K
3) Abciximab
4) Streptokinase
____ 20. Which is an age-related hematologic change the nurse anticipates when reviewing a complete blood count
(CBC) for an older adult patient?
1) Increased hematocrit
2) Increased hemoglobin
3) Increased B- and T-cells
4) Increased sedimentation rate
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. The nurse is conducting a hematologic assessment for a new patient. Which questions should the nurse
include in the general/past health history? Select all that apply.
1) “Have you had any recent changes in energy level?”
2) “Do you take any herbal supplements such as goldenseal?”
3) “Have you been prescribed blood thinners by your doctor?”
4) “Have you experienced any recent bleeding or bruising?”
5) “Do you ever experience any pain, burning, or tingling sensations?”
____ 22. The nurse suspects that a patient with severe shortness of breath in the absence of cyanosis is experiencing
anemia. Which laboratory tests should the nurse review to confirm anemia? Select all that apply.
1) Glucose
2) Hematocrit
3) Hemoglobin
4) Cardiac enzymes
5) Serum electrolytes
____ 23. The nurse is caring for an older adult patient with hemolytic anemia. When planning care for this patient,
which should the nurse take into consideration regarding this diagnosis? Select all that apply.
1) It causes the red blood cells to be microcytic.
2) It is associated with an increase in the reticulocyte count.
3) It is the result of blood loss.
NURSIof
4) It is a result of the premature destruction NGred
TBblood
.COcells.
M
5) It always requires treatment with folic acid
Completion
Complete each statement.
24. Arrange the events of the erythrocyte growth pathway in the correct order (1-7). (Enter the number of each
step in the proper sequence; do not use punctuation or spaces. Example: 1234)
1) Formation of reticulocyte
2) Formation of erythrocyte
3) Formation of proerythroblast
4) Formation of basophilic erythroblast
5) Formation of orthochromatic erythroblast
6) Formation of polychromatic erythroblast
7) Formation of committed myeloid stem cell
25. Place the stages of hemostasis in the correct order (1-5). (Enter the number of each step in the proper
sequence; do not use punctuation or spaces. Example: 1234)
1) Vasospasm
2) Clot formation
3) Clot retraction
4) Clot dissolution
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MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 33, Assessment of Hematological Function
Chapter learning objective: Discussing the oxygenation function of the hematological system
Chapter page reference: 660-664
Heading: Overview of Hematology Function
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Knowledge [Remembering]
Concept: Hematologic Regulation
Difficulty: Easy
Feedback
1 Oxygen is circulated by the hematologic system.
2 The hematologic system protects the body against pathogens.
3 Coagulation is maintained by the hematologic system.
4 Temperature, along with fluids, electrolytes, acids, and bases, is regulated by this
system.
PTS: 1 NURSRegulation
CON: Hematologic INGTB.COM
2. ANS: 1
Chapter number and title: 33, Assessment of Hematological Function
Chapter learning objective: Identifying key anatomical components of the hematological system
Chapter page reference: 660-664
Heading: Overview of Hematology Function
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Knowledge [Remembering]
Concept: Hematologic Regulation
Difficulty: Easy
Feedback
1 Oxygen is circulated by the hematologic system.
2 The hematologic system protects the body against pathogens.
3 Coagulation is maintained by the hematologic system.
4 Temperature, along with fluids, electrolytes, acids, and bases, is regulated by this
system.
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Feedback
1 The patient does not have decreased red blood cell count; therefore, does not have
anemia.
2 The patient does not have decreased white blood cell count; therefore, does not have
leukopenia.
3 The patient does not have decreased platelet count; therefore, does not have
thrombocytopenia.
4 Platelets of 150,000–400,000/mm3, Hemoglobin of 12–16 g/dL, red blood cell count of
4.2-5.4 1012 cells/L, and white blood cell count: 5000–10,000/mm3 indicates normal
levels in the body.
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Feedback
1 Vitamin K causes hemolysis, but it does not impair platelet aggregation.
2 Anti-inflammatory agents reduce the platelet aggregation.
3 The normal level of white blood cell (WBC) count is 5000–10,000 cells/microliter and
the normal red blood cell (RBC) count is 4.7–6.1 million cells/microliter. While the
patient has a slightly decreased WBC and RBC count, this would not cause impaired
platelet aggregation.
4 The normal level of white blood cell (WBC) count is 5000–10,000 cells/microliter and
the normal red blood cell (RBC) count is 4.7–6.1 million cells/microliter. While the
patient has a slightly decreased WBC and RBC count, this would not cause impaired
platelet aggregation.
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3 In the intrinsic pathway, calcium ions combine with factor IX to activate factor X.
4 Tissue thromboplastin activates factor VII.
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MULTIPLE RESPONSE
21. ANS: 1, 4, 5
Chapter number and title: 33, Assessment of Hematological Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of the
hematological system
Chapter page reference: 664-675
Heading: Hematological Assessment
Integrated Processes: Nursing Process – Assessment
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Hematologic Regulation
Difficulty: Moderate
Feedback
1. This is correct. This question is appropriate when conducting the general/past health history of
the patient’s hematologic system.
2. This is incorrect. This question is more appropriate for the medication history.
3. This is incorrect. This question is more appropriate for the medication history.
4. This is correct. This question is appropriate when conducting the general/past health history of
the patient’s hematologic system.
5. This is correct. This question
NURS is I
appropriate
NGTB.CwhenOM conducting the general/past health history of
the patient’s hematologic system.
Feedback
1. This is incorrect. Blood sugar, cardiac enzymes, and serum electrolytes are not implicated in
this phenomenon.
2. This is correct. In order to exhibit cyanosis, the patient’s blood must contain about 5 g or more
of unoxygenated hemoglobin per 100 mL of blood and the surface blood capillaries must be
dilated. Severe anemia will interfere with the development of cyanosis, so the nurse should
review the hemoglobin and hematocrit.
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3. This is correct. In order to exhibit cyanosis, the patient’s blood must contain about 5 g or more
of unoxygenated hemoglobin per 100 mL of blood and the surface blood capillaries must be
dilated. Severe anemia will interfere with the development of cyanosis, so the nurse should
review the hemoglobin and hematocrit.
4. This is incorrect. Blood sugar, cardiac enzymes, and serum electrolytes are not implicated in
this phenomenon.
5. This is incorrect. Blood sugar, cardiac enzymes, and serum electrolytes are not implicated in
this phenomenon.
Feedback
1. This is incorrect. Hemolytic anemias are normocytic (red blood cells are normal size), not
microcytic.
2. This is correct. Hemolytic anemia is more common with aging and is caused by the premature
NURSINGTB.COM
destruction of the red blood cells. The normal life span of a red blood cell is 120 days. There is
an increase in the reticulocyte (immature red blood cells) count because they are released early
from the bone marrow to compensate.
3. This is incorrect. It is not associated with blood loss.
4. This is correct. Hemolytic anemia is more common with aging and is caused by the premature
destruction of the red blood cells.
5. This is correct. Hemolytic anemia is more common with aging and is caused by the premature
destruction of the red blood cells. The normal life span of a red blood cell is 120 days. All
hemolytic anemias require treatment with folic acid because this vitamin is consumed by the
increased bone marrow production of red blood cells in response to the anemia.
COMPLETION
24. ANS:
7346512
Chapter number and title: 33, Assessment of Hematological Function
Chapter learning objective: Identifying key anatomical components of the hematological system
Chapter page reference: 652-660
Heading: Overview of Anatomy and Physiology
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
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Feedback: Erythrocyte growth pathway results in formation of erythrocytes through a series of events. The
committed myeloid stem cell formation from the pluripotent cell initiates the erythrocyte growth pathway.
The proerythroblast then forms from the committed myeloid stem cell which further results in development of
the basophilic erythroblast. The basophilic erythroblast then forms from the proerythroblast. The
proerythroblast can further result in the formation of polychromatic erythroblast. The orthochromatic
erythroblast then forms from the polychromatic erythroblast. The polychromatic erythroblast then results in
reticulocyte, which matures into erythrocytes in the body.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The home healthcare nurse is preparing a care plan for a patient with severe anemia. The patient currently
lives alone and states, “I can’t even walk to the kitchen without getting winded.” What would be the priority
nursing diagnosis for this patient?
1) Hopelessness
2) Activity Intolerance
3) Altered Nutrition, Less than Body Requirements
4) Anxiety
____ 2. A nurse is providing discharge teaching for a patient with iron-deficiency anemia. The patient has been
prescribed ferrous sulfate and has been told to increase the intake of foods that are naturally high in iron.
Which patient statement indicates correct understanding?
1) “I will decrease my intake of green leafy vegetables while taking my ferrous sulfate
tablet.”
2) “I will increase my fluid intake while I am taking my ferrous sulfate.”
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____ 17. A child diagnosed with aplastic anemia is admitted to the hospital. The parents ask the nurse what aplastic
anemia is. Which response by the nurse is accurate?
1) “Aplastic anemia causes a proliferation of white blood cells.”
2) “Aplastic anemia is characterized by abnormally shaped red blood cells.”
3) “Aplastic anemia is caused by the bone marrow producing inadequate cells.”
4) “Aplastic anemia is a disorder that occurs after a viral illness.”
____ 18. Which is the priority nursing diagnosis for the child diagnosed with idiopathic thrombocytopenic purpura
(ITP)?
1) Ineffective Breathing Pattern
2) Nausea
3) Fluid Volume Deficit
4) Risk for Injury
____ 19. Which is the priority teaching point for the nurse to include in the discharge instructions for the parents of a
child who was admitted to the hospital in a sickle cell crisis?
1) Rapid weaning of pain medications
2) A diet high in protein
3) Adequate hydration
4) Restriction of activities
____ 20. The health-care provider prescribes laboratory tests following the initiation of treatment for a child who is
diagnosed with iron-deficiency anemia. Which laboratory result should the nurse share with the child’s family
as an indication of improvement?
1) Low hemoglobin
2) Normal platelet count NURSINGTB.COM
3) High reticulocyte count
4) Low hematocrit
____ 21. A patient complaining of mouth soreness had gastric bypass surgery one year ago. During the assessment, the
nurse notes the patient’s tongue is beefy, red, and smooth and the patient’s skin appears yellowish. Which
additional information is most likely needed before diagnosing this patient?
1) Vitamin B6 levels
2) Vitamin B12 levels
3) Potassium levels
4) Iron levels
____ 22. A patient experiencing fatigue, pallor, and dyspnea on exertion has a complete blood count drawn. Which red
blood cell disorder should the nurse anticipate the patient is experiencing?
1) Polycythemia
2) Erythropoiesis
3) Herpes simplex
4) Anemia
____ 23. An older adult patient with renal failure is diagnosed with anemia. Based on this data, which cause of anemia
will the nurse plan for when providing care?
1) Loss of the kidney hormone erythropoietin
2) A loss of appetite related to elevated blood urea nitrogen (BUN) and creatinine levels
3) The renal dialysis used to treat the chronic renal failure
4) Loss of blood through the urine because the failing kidney does not function properly
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____ 24. A nurse is educating a patient with anemia about the pathophysiological mechanisms of anemia. Which
should be excluded in the nurse’s teaching plan for this patient?
1) Altered hemoglobin synthesis
2) Altered DNA synthesis
3) Decreased hemolysis
4) Bone marrow failure
____ 25. Parents of a newborn infant are concerned that their baby may have sickle cell disease. The nurse reviews the
medical record and finds that both parents have the sickle cell trait. Which is the best response for the nurse to
give the parents?
1) “Since neither of you actually has sickle cell disease, your baby is not at risk.”
2) “Your baby has the disease, as you both carry the trait.”
3) “As you both have the sickle cell trait, your baby will be tested for the disease.”
4) “Have you talked to a genetic counselor about your concerns?”
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. A patient with a history of anemia has started a vegan diet. Which addition to meals should the nurse
recommend to help ensure that this patient has adequate amounts of iron in the diet? Select all that apply.
1) Legumes
2) Orange juice
3) Brewer’s yeast
4) Okra
5) Peas
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____ 27. An adult patient reports to the nurse an inability to tolerate usual exercise and the feeling of fatigue. The
patient states that these symptoms have been gradual over time. Which physical assessment findings, along
with the patient’s verbal reports, would indicate chronic lymphocytic leukemia (CML)? Select all that apply.
1) Joint pain
2) Pallor
3) Splenomegaly
4) Abnormal bleeding
5) Edema
____ 28. The nurse is teaching a class at a local community center about decreasing risk factors for cancer. Which risk
factors should the nurse include in the teaching regarding leukemia? Select all that apply.
1) Alkylating agents
2) Diets low in fat
3) Exposure to infectious agents
4) Bloom syndrome
5) Decreased exercise
____ 29. A nurse educator is teaching a group of parents how to prevent a crisis in the child with sickle cell disease.
What should the nurse instruct about the precipitating factors that could contribute to a sickle cell crisis?
Select all that apply.
1) Increased fluid intake
2) Altitude
3) Fever
4) Vomiting
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5) Regular exercise
____ 30. Which parental statements regarding precipitating factors for sickle cell disease indicate correct understanding
of the discharge information presented by the nurse? Select all that apply.
1) “My child should avoid regular exercise.”
2) “We should provide acetaminophen or ibuprofen to treat fever.”
3) “Our child needs to drink lots of fluid to avoid dehydration when playing sports.”
4) “High altitudes can cause exacerbation and should be avoided.”
5) “Fluid restriction is necessary to avoid exacerbations from occurring.”
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MULTIPLE CHOICE
1. ANS: 2
Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hematological
disorders
Chapter page reference: 681
Heading: Red Blood Cell Disorders
Integrated Processes: Nursing Process – Diagnosis
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Hematologic Regulation
Difficulty: Difficult
Feedback
1 While anxiety, hopelessness, and altered nutrition may be appropriate nursing
diagnoses for this patient, they are not the priority.
2 Activity Intolerance would be a priority diagnosis for this patient. Maslow’s Hierarchy
of Needs indicates physiological needs take priority over psychosocial needs.
3 While anxiety, hopelessness, and altered nutrition may be appropriate nursing
diagnoses for this patient, they are not the priority. While altered nutrition is a
physiological need according N toUMaslow,
RSINGthere TB.isCnoOMindication that the patient is
underweight.
4 While anxiety, hopelessness, and altered nutrition may be appropriate nursing
diagnoses for this patient, they are not the priority.
Feedback
1 The patient should not decrease milk or green leafy vegetables from the diet as these
are natural sources of iron and should be encouraged.
2 Increasing fiber (oatmeal) and fluid intake can also help prevent constipation.
3 Ferrous sulfate can cause gastric irritation and constipation. Taking it with a meal can
help minimize gastrointestinal distress.
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4 The patient should not decrease milk or green leafy vegetables from the diet as these
are natural sources of iron and should be encouraged.
Feedback
1 The meal of tofu with mixed vegetables in curry, milk, and a whole-wheat bun is high
in calcium, but the patient has iron-deficiency anemia and requires a high-iron diet.
2 The meal of fish, lettuce, grapefruit, and carrot sticks is high in fiber, low in fat, and
moderately high in protein, but low in iron.
3 The meal with a pork chop, mashed potatoes and gravy, cauliflower, and tea has a
moderate amount of protein, but no vitamin C.
4 This patient is anemic and needs iron. This meal contains iron in the beef, folic acid in
the spinach, and vitamin C in the tomato soup and orange juice. Vitamin C helps
absorption of the iron; folic acid is needed for production of red cells.
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Feedback
1 Glossitis, inflammation of the tongue that may cause the tongue and lips to turn red,
and cheilosis (fissures or cracks at the corners of the mouth) may occur with nutritional
deficiencies of iron, folate, and vitamin B12. Patient education should include
monitoring the condition of lips and tongue daily.
2 The patient should not use an alcohol-based mouthwash, as this would worsen the
glossitis.
3 The patient should use a petroleum-based lubricating jelly or ointment to the lips after
oral care.
4 The patient should provide frequent oral hygiene with a soft-bristle toothbrush or
sponge.
PTS: 1 NURSRegulation
CON: Hematologic INGTB.| C OM
Comfort
6. ANS: 1
Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hematological
disorders
Chapter page reference: 698
Heading: White Blood Cell Disorders
Integrated Processes: Nursing Process – Diagnosis
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Hematologic Regulation; Cellular Regulation
Difficulty: Difficult
Feedback
1 AML results in neutropenia (decreased neutrophils = risk of infection) and
thrombocytopenia (decreased platelets, which leads to increased risk of bleeding).
Therefore, actions to minimize these risks include caution when moving or assisting the
patient to move, as well as strict hand hygiene to prevent possible cross-contamination.
2 Heat intolerance is a symptom of CML, not AML. CML has heat intolerance due to
hypermetabolism state present with the condition.
3 Weight loss is a symptom of chronic myeloid leukemia (CML), not AML. Therefore,
dietary needs are not increased with AML.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4 Restriction of fluids and salt are not needed. The patient with AML does not have a
problem with fluid shifts or edema that would require these restrictions. Fluids are
encouraged to remove wastes that occur with chemotherapy treatment and cellular
breakdown.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hematological
disorders
Chapter page reference: 698
Heading: White Blood Cell Disorders
Integrated Processes: Nursing Process – Implementation
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Hematologic Regulation; Cellular Regulation
Difficulty: Easy
Feedback
1 The patient at risk for bleeding has specific interventions to which the nurse should
adhere. The nurse should educate the patient in the use of soft toothbrush to avoid
bleeding.
2 The nurse should also limit the use of parenteral injections and apply 15-20 minutes of
pressure to any arterial puncture sites.
3 The nurse should also limit the use of parenteral injections and apply 15-20 minutes of
pressure to any arterial puncture sites.
4 The nurse should discourage the patient to forcefully cough to prevent further bleeding.
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Feedback
1 The patient with profound pallor and fatigue likely is in an aplastic crisis, not
thrombosis.
2 A thrombotic sickle cell crisis is manifested by extreme pain and fever.
3 The patient in profound hypotension and shock likely has splenic sequestration as the
etiology, not thrombosis.
4 The patient with a pulmonary infarct likely has Acute Chest Syndrome, not thrombosis.
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Feedback
1 The patient with sickle cell disease who is in a sickle cell crisis will likely have extreme
pain. To aid in caring for this patient, the nurse will administer ordered analgesic
medications around the clock, place the patient in position of comfort, and support the
patient’s joints and extremities with pillows.
2 The patient with sickle cell disease who is in a sickle cell crisis will likely have extreme
pain. To aid in caring for this patient, the nurse will administer ordered analgesic
medications around the clock, place the patient in position of comfort, and support the
patient’s joints and extremities with pillows.
3 The use of heat or cold packs is contraindicated in the sickle cell patient. Ischemic
tissue is fragile and has reduced sensation, increasing the risk of burn injury from hot
compresses, whereas cold compresses promote sickling.
4 The patient with sickle cell disease who is in a sickle cell crisis will likely have extreme
pain. To aid in caring for this patient, the nurse will administer ordered analgesic
medications around the clock, place the patient in position of comfort, and support the
patient’s joints and extremities with pillows.
Feedback
1 Radiation decreases, not increases, the production of red blood cells.
2 Radiation suppresses the bone marrow in an attempt to decrease the production of red
blood cells.
3 Radiation does not provide vitamin supplementation.
4 Radiation does not decrease the risk for a transfusion reaction.
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Feedback
1 All blood cells, not just white blood cells, are affected by aplastic anemia.
2 Aplastic anemia does not cause abnormally shaped red blood cells; this is a description
of sickle cell disease.
3 In aplastic anemia, the bone marrow does not produce sufficient numbers of circulating
blood cells.
4 There is no known association between aplastic anemia and viral illness.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
20. ANS: 3
Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders
Chapter learning objective: Describing the diagnostic results used to confirm disorders of the hematological
system
Chapter page reference: 681
Heading: Red Blood Cell Disorders
Integrated Processes: Nursing Process – Implementation
Client Need: Physiological Integrity – Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Hematologic Regulation
Difficulty: Easy
Feedback
1 Low hemoglobin is a typical finding in iron-deficiency anemia.
2 Platelet count is unrelated to iron-deficiency anemia.
3 Reticulocytes are immature red blood cells and indicate new cells are being produced.
4 This would be a typical finding in iron-deficiency anemia.
Feedback
1 Vitamin B6 deficiencies are not typically seen with gastric bypass surgeries and are not
manifested with a beefy, red, smooth tongue.
2 Vitamin B12 deficiency is associated with gastric bypass surgery. A deficiency of
vitamin B12 levels will result in pernicious anemia. This deficiency will manifest as
pallor, jaundice, and weakness, and a beefy, smooth red tongue.
3 The patient’s reports are not consistent with a potassium deficiency.
4 Iron-deficiency anemia will manifest with weakness and fatigue.
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Feedback
1 This is not an appropriate response by the nurse.
2 This is not an appropriate response by the nurse.
3 Sickle cell disease is an autosomal recessive disorder. Both parents must have the trait
in order for a child to have a 25% chance of having this disease. The most appropriate
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response by the nurse is to tell the parents the baby will be tested for the disease.
4 This is not an appropriate response by the nurse.
MULTIPLE RESPONSE
26. ANS: 1, 2, 5
Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders
Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle
considerations for patients with hematological disorders
Chapter page reference: 680
Heading: Red Blood Cell Disorders
Integrated Processes: Nursing Process – Planning
Client Need: Physiological Integrity – Basic Care and Comfort
Cognitive level: Comprehension [Understanding]
Concept: Hematologic Regulation; Nutrition
Difficulty: Easy
Feedback
1. This is correct. Legumes and peas are good sources of nonheme iron.
2. This is correct. Orange juice supports iron absorption from foods since it is high in vitamin C.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3. This is incorrect. Brewer’s yeast is a good source of vitamin B12, which is often low in vegan
diets.
4. This is incorrect. Okra is not a good source of iron.
5. This is correct. Legumes and peas are good sources of nonheme iron.
Feedback
1. This is incorrect. Bone and joint pain with abnormal bleeding are characteristics of AML,
which also occurs in older patients.
2. This is correct. The symptoms for CML are insidious and occur over time, affecting older
adults. The patient may exhibit splenomegaly, pallor, edema, and lymphadenopathy.
3. This is correct. The symptoms for CML are insidious and occur over time, affecting older
adults. The patient may exhibit splenomegaly, pallor, edema, and lymphadenopathy.
4. This is correct. The symptoms
NURSfor INCMLGTBare
.Cinsidious
OM and occur over time, affecting older
adults. The patient may exhibit splenomegaly, pallor, edema, and lymphadenopathy.
5. This is incorrect. Bone and joint pain with abnormal bleeding are characteristics of AML,
which also occurs in older patients.
Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders
Chapter learning objective: Describing the epidemiology of disorders of the hematological system
Chapter page reference: 695
Heading: White Blood Cell Disorders
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Hematologic Regulation; Cellular Regulation
Difficulty: Easy
Feedback
1. This is correct. A higher incidence of leukemia associated with chromosomal defects such as
Bloom syndrome, exposure to infectious agents, and chemical agents used to treat previous
cancer, such as alkylating agents.
2. This is incorrect. Low-fat diets are not a risk factor for leukemia, and neither is lack of
exercise.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3. This is correct. A higher incidence of leukemia associated with chromosomal defects such as
Bloom syndrome, exposure to infectious agents, and chemical agents used to treat previous
cancer, such as alkylating agents.
4. This is correct. A higher incidence of leukemia associated with chromosomal defects such as
Bloom syndrome, exposure to infectious agents, and chemical agents used to treat previous
cancer, such as alkylating agents.
5. This is incorrect. Low-fat diets are not a risk factor for leukemia, and neither is lack of
exercise.
Feedback
1. This is incorrect. Regular exercise and increased fluid intake are recommended activities for a
child with sickle cell disease and will not contribute to a sickle cell crisis.
2. This is correct. Fever, vomiting, and altitude are some of the precipitating factors that
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contribute to a sickle cell crisis.
3. This is correct. Fever, vomiting, and altitude are some of the precipitating factors that
contribute to a sickle cell crisis.
4. This is correct. Fever, vomiting, and altitude are some of the precipitating factors that
contribute to a sickle cell crisis.
5. This is incorrect. Regular exercise and increased fluid intake are recommended activities for a
child with sickle cell disease and will not contribute to a sickle cell crisis.
Feedback
1. This is incorrect. Regular exercise and increased fluid intake are recommended activities for a
child with sickle cell disease and will not contribute to a sickle cell crisis.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2. This is correct. Fever, dehydration, and altitude are all precipitating factors contributing to a
sickle cell crisis.
3. This is correct. Fever, dehydration, and altitude are all precipitating factors contributing to a
sickle cell crisis.
4. This is correct. Fever, dehydration, and altitude are all precipitating factors contributing to a
sickle cell crisis.
5. This is incorrect. Regular exercise and increased fluid intake are recommended activities for a
child with sickle cell disease and will not contribute to a sickle cell crisis.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A patient is diagnosed with a health problem that causes demyelization of the peripheral nerves. Which cell
structure is being affected?
1) Microglia
2) Astrocytes
3) Schwann cells
4) Oligodendrocytes NURSINGTB.COM
____ 2. A patient is experiencing changes in eye movements. Which part of the central nervous system is most likely
causing these changes?
1) Pons
2) Midbrain
3) Medulla oblongata
4) Reticular formation
____ 3. A patient experiences a cramp in the right thigh. Which spinal tract is responsible for communicating to the
thigh muscle to contract?
1) Somatic motor division
2) Visceral motor division
3) Somatic sensory division
4) Visceral sensory division
____ 4. A patient reports a change in the taste of food. Which cranial nerve should the nurse suspect as being
affected?
1) CN VII Facial
2) CN V Trigeminal
3) CN XI Accessory
4) CN XII Hypoglossal
____ 5. A patient’s blood pressure increases after hearing that diagnostic tests for a health problem have to be
repeated. Which receptor of the sympathetic nervous system is responsible for this blood pressure change?
1) Beta
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2) Alpha
3) Nicotinic
4) Muscarinic
____ 6. The nurse needs to provide a strong stimulus to illicit a response; however, the patient drifts back to
unresponsiveness. What term should the nurse use to document this patient’s level of responsiveness?
1) Coma
2) Stupor
3) Lethargic
4) Conscious
____ 7. The nurse is completing a Mini Mental Status Examination with a patient. What should the nurse ask to
evaluate remote memory?
1) “Where did you park your car?”
2) “Where did you work in the 1970s?”
3) “Remember the colors red, green, blue, and yellow.”
4) “What television show was on this morning during breakfast?”
____ 8. Which technique should the nurse use to assess a patient’s CN IX Glossopharyngeal?
1) Apply a tongue depressor to the back of the throat
2) Ask the patient to read from a book or a newspaper
3) Ask the patient to smile, frown, puff cheeks, and raise eyebrows
4) Ask the patient to follow the examiner’s finger as it is moved toward the patient’s nose
____ 9. A patient is unable to feel light touch down the anterior left leg and top of the left foot. How should the nurse
document this finding?
1) Anesthesia NURSINGTB.COM
2) Paresthesia
3) Hypoesthesia
4) Hyperesthesia
____ 10. A patient is scheduled for a positron emission tomography (PET) scan. For which health problem should the
nurse anticipate planning care for this patient?
1) Brain tumor
2) Cerebral bleed
3) Cranial fracture
4) Cerebral blood clot
____ 11. A patient has been experiencing numbness of the right hand. Which diagnostic test should the nurse anticipate
being prescribed for this patient?
1) Myelogram
2) Evoked potentials
3) Electroencephalography
4) Magnetic resonance imaging
____ 12. The nurse notes that a patient has ataxia. Which test should the nurse use to gain more information about this
patient’s gait?
1) Romberg
2) Patellar reflex
3) Plantar flexion
4) Achilles reflex
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 13. During a neurologic assessment the nurse asks a patient to close the eyes and asks the patient to identify a
paper clip placed in the hand. What is the nurse assessing?
1) Stereognosis
2) Hyperesthesia
3) Graphesthesia
4) Two-point discrimination
____ 14. A patient with type 2 diabetes mellitus is scheduled for a CT scan with contrast. What should the nurse
specifically instruct the patient to prepare for this test?
1) Restrict fluids for 12 hours prior to the scan
2) Drink two liters of fluid the day before the scan
3) Limit the intake of meat and dairy products prior to the scan
4) Do not take Metformin for 48 hours prior to and after the scan
____ 15. A patient is scheduled for an electroencephalogram. What preprocedure information should the nurse
emphasize with this patient?
1) Avoid washing hair for two days prior to the test
2) Avoid caffeine for 8 to 12 hours before the test
3) Restrict the intake of fluids for six hours after the test
4) Apply minimal products to the hair the morning of the test
____ 16. A patient recovering from a lumbar puncture rates a headache as being 8 on a pain scale of 0 to 10. What
should the nurse do while waiting for the health-care provider to prescribe pain medication?
1) Raise the head of the bed
2) Assist to sit out of bed in a chair
3) Encourage increasing oral fluid intake
4) Turn on the side and massage the NU RSIspine
lower NGTB.COM
____ 17. A patient is scheduled for a myelogram prior to having spinal fusion surgery. What should the nurse instruct
the patient to do prior to this test?
1) Shower with antiseptic soap
2) Take nothing by mouth for four hours before the test
3) Take an over-the-counter analgesic before arriving for the test
4) Restrict the intake of caffeine products for 24 hours before the test
____ 18. The nurse is preparing to assess an older patient’s neurologic status. What should the nurse keep in mind
during this assessment?
1) Reaction time is slower
2) Flexibility is maintained
3) Pain sensation is heightened
4) Body movements are quicker
____ 19. The nurse notes that an older patient sways when moving from a sitting to a standing position. What is this
patient at risk for experiencing?
1) Falls
2) Hypothermia
3) Altered pain sensation
4) Reduced oxygen to the brain
____ 20. Family members are concerned because a patient has been confused over the last few days. What should the
nurse respond to the family?
1) “Confusion is a normal sign of aging.”
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. The nurse is preparing a teaching tool about the nervous system. Which type of tissue should the nurse
identify as being a part of gray matter? Select all that apply.
1) Dendrites
2) Cell bodies
3) Myelin sheath
4) Axon terminals
5) Nodes of Ranvier
____ 22. A patient sustains an injury to the left temporal lobe. Which body functions should the nurse expect to be
affected by this injury? Select all that apply.
1) Body position
2) Long-term memory
3) Auditory perception
4) Receptive speech center
5) Expressive speech center
____ 23. The nurse is conducting a medical history with a patient experiencing headaches. Which information should
be included in this history? Select all that apply.
1) Date of last lipid screen NURSINGTB.COM
2) Past surgical procedures
3) Recent diagnostic studies
4) Treatment for chronic illnesses
5) Date of last influenza vaccination
____ 24. The nurse notes that a patient has a positive Babinski response. For what should the nurse assess this patient?
Select all that apply.
1) Alcohol abuse
2) Substance abuse
3) Multiple sclerosis
4) Parkinson’s disease
5) Traumatic brain injury
____ 25. A patient is recovering from a cerebral angiogram. What care should the nurse provide to this patient? Select
all that apply.
1) Monitor intravenous fluid infusion
2) Elevate the puncture site limb on a pillow
3) Maintain pressure on arterial puncture site
4) Enforce bedrest for 6 to 12 hours after the procedure
5) Monitor vital signs every 15 minutes for the first hour
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 35, Assessment of Neurological Function
Chapter learning objective: Identifying key anatomical components of the neurological system
Chapter page reference: 709
Heading: Overview of Anatomy and Physiology > Neuroglial Cells
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Neurologic Regulation; Sensory Perception
Difficulty: Easy
Feedback
1 Microglia are small cells that become phagocytic when they encounter inflammation or
debris. They are a means of defense.
2 Astrocytes provide structure and support.
3 Schwann cells form myelin sheaths that cover axons in the peripheral nervous system.
4 Oligodendrocytes are small cells that form myelin sheaths that cover the axons of the
neurons in the central nervous system.
Feedback
1 The pons rests above the medulla oblongata below and anterior to the midbrain, and
relays all impulses between the brain and the spinal cord. Four cranial nerves originate
in the pons: trigeminal (V), abducens (V), facial (VII), and acoustic (VIII).
2 The midbrain contains the nerve pathways between the cerebrum and the medulla
oblongata. Cranial nerves III and IV, which control eye movements, have their origins
here.
3 The medulla oblongata is continuous with the spinal cord and is located at the level of
and below the foramen magnum. Four cranial nerves originate here: glossopharyngeal
(IX), vagus (X), spinal accessory (XI), and hypoglossal (XII).
4 The reticular formation consists of networks of neural cells that impact motor control
and coordination, balance and posture during movement, respiratory and cardiac
functions, pain modulation, and alertness and sleep.
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Feedback
1 The somatic motor division transports signals back to the skeletal muscles to produce a
contraction.
2 The visceral motor division transports signals back to smooth muscle, cardiac muscle,
and glands at an unconscious level.
3 The somatic sensory division transmits signals from receptors in muscles, bones, joints,
and skin.
4 The visceral sensory division transmits signals from the heart, lungs, GI tract, and
bladder.
Feedback
1 CN VII Facial influences taste.
2 CN V Trigeminal controls touch, temperature, pain sensations from the upper and lower
face, and chewing.
3 CN XI Accessory controls swallowing and head, neck, and shoulder movements.
4 CN XII Hypoglossal controls tongue movement with speech, food manipulation, and
swallowing.
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Feedback
1 CN XI Glossopharyngeal is assessed by applying a tongue depressor to the back of the
throat to check for a gag reflex.
2 Reading assesses CN II Optic.
3 Smiling, frowning, puffing out the cheeks, and raising the eyebrows assesses CN VII
Facial.
4 Having the patient follow a finger
NURasSitIisNG
moved
TB.Ctoward
OM the nose assesses CN IV
Trochlear.
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Feedback
1 The Romberg test is performed to assess balance.
2 Reflexes are involuntary and automatic responses to stimuli that provide the body with
protection and help to adjust to the environment.
3 Reflexes are involuntary and automatic responses to stimuli that provide the body with
protection and help to adjust to the environment.
4 Reflexes are involuntary and automatic responses to stimuli that provide the body with
protection and help to adjust to the environment.
Feedback
1 Fluids do not need to be restricted prior to a CT scan with contrast.
2 Fluids do not need to be increased prior to a CT scan with contrast.
3 Meat and dairy products do not need to be restricted prior to a CT scan with contrast.
4 Metformin is cleared primarily through the kidneys, and if it is administered prior to the
examination and the administration of contrast results in renal impairment, metformin
levels will remain elevated, potentially resulting in a lactic acidosis. Because of this
metformin must be held 48 hours prior to and after the CT scan or until renal function is
determined to be normal via normal BUN and creatinine levels.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
20. ANS: 4
Chapter number and title: 35, Assessment of Neurological Function
Chapter learning objective: Discussing changes in neurological function associated with aging
Chapter page reference: 734
Heading: Age-Related Changes
Integrated Processes: Nursing Process; Implementation
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Neurologic Regulation; Nursing
Difficulty: Moderate
Feedback
1 Caution should be taken in assuming that confusion is a “normal” part of aging, as this
change can also occur as a result of disease or an infection.
2 There is no evidence to support that older people get confused at the end of the day.
3 Confusion should be investigated. The patient should not have to wait until a fall occurs
to be evaluated for confusion.
4 Cognitive impairment can occur as a result of the aging process, disease, medications,
poor nutrition, and changes in the nervous system.
MULTIPLE RESPONSE
Feedback
1. Gray matter contains dendrites.
2. Gray matter contains cell bodies.
3. White matter contains myelin sheaths.
4. Gray matter contains axon terminals.
5. White matter contains the Nodes of Ranvier.
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Feedback
1. Body position is a function of the parietal lobe.
2. Long-term memory is a function of the temporal lobe.
3. Auditory perception is a function of the temporal lobe.
4. Receptive speech is a function of the temporal lobe.
5. Expressive speech is a function of the frontal lobe.
Feedback
1. A positive Babinski’s can occur in patients with alcohol abuse.
2. A positive Babinski’s can occur in patients with substance abuse.
3. A positive Babinski’s can occur in patients with multiple sclerosis.
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Feedback
1. After a cerebral angiogram intravenous fluids are needed to clear contrast dye from the
circulation.
2. The limb used for the puncture site should be kept straight for 6 to 12 hours.
3. Pressure should be maintained on the puncture site.
4. The patient should be on bedrest for 6 to 12 hours after the procedure.
5. Vital signs should be monitored every 15 minutes for the first hour.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is preparing material for a community health fair. What should the nurse identify as being the most
common cause of headache pain in adults?
1) Mixed
2) Cluster
3) Tension
4) Migraine
____ 2. It is believed that a patient’s migraine headaches are caused by vascular constriction. Which medication
should the nurse expect to be prescribed for this patient?
1) Citalopram (Celexa)
2) Imipramine (Tofranil)
3) Amlodipine (Norvasc)
4) Lamotrigine (Lamictal)
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____ 3. A patient is diagnosed with a continuous headache syndrome. What treatment should the nurse expect to be
prescribed for this patient?
1) Antibiotics
2) Diuretic therapy
3) Intravenous fluids
4) Sodium restriction
____ 4. The health-care professional is identifying the best course of treatment for a patient with a brain tumor. What
should be considered when selecting chemotherapeutic agents for this patient?
1) Cause mild neutropenia
2) Cross the blood-brain barrier
3) Restrict weight loss and hair loss
4) Limit the development of mucositis
____ 5. The nurse is planning discharge instructions for a patient recovering from surgery to debulk a brain tumor.
Why should self-monitoring of capillary blood glucose level be a part of this teaching?
1) Taking steroid medication
2) Manipulation of cerebral tissue
3) Interruption of glucose regulation in the brain
4) Alteration in oral intake from chemotherapy
____ 6. During morning care a patient with a seizure disorder asks why the room has suddenly turned green. What
should the nurse do?
1) Ask the patient to explain
2) Prepare for a seizure to begin
3) Turn on the overhead room lights
4) Document visual hallucinationsN URSINGTB.COM
present
____ 7. A patient with a seizure disorder asks the purpose of staying awake all night prior to having an
electroencephalogram in the morning. What should the nurse explain to this patient?
1) “You will be expected to sleep during the test.”
2) “Most people with seizure disorders receive too much sleep.”
3) “This is the only way to prove that you really have a seizure disorder.”
4) “Sleep deprivation can cause a seizure, which will be helpful during the test.”
____ 8. A patient has been experiencing a tonic-clonic seizure for five minutes. What should the nurse do first?
1) Assess carotid pulse
2) Prepare to insert an airway
3) Provide rescue breathing
4) Insert an intravenous access line
____ 9. The nurse is admitting a patient experiencing photophobia and nuchal rigidity. For which diagnostic test
should the nurse prepare this patient?
1) Lumbar puncture
2) Evoked potentials
3) CT scan with contrast
4) Electroencephalogram
____ 10. The nurse is planning care for a patient with meningitis. What teaching material should be prepared to explain
the prescribed treatment for this disorder?
1) Fluid restriction
2) Low-fat, low-calorie diet
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3) Over-the-counter analgesics
4) Long-term antibiotic therapy
____ 11. A patient with meningitis is prescribed a cooling blanket. What should the nurse explain as being the purpose
of this device?
1) Relieves pain
2) Increases cerebral venous outflow
3) Decreases oxygen demand in the brain
4) Reduces the transmission of the infection
____ 12. The nurse suspects that a patient with photophobia is experiencing encephalitis. What observation of the
patient’s behavior caused the nurse to make this clinical decision?
1) Closed the eyes
2) Covered the ears with both hands
3) Placed both hands in coat pockets
4) Rubbed the thighs with both hands
____ 13. The nurse is reviewing medical orders written for a patient with encephalitis. Which medication should the
nurse expect to be prescribed as a priority for this patient?
1) Antiviral
2) Antibiotic
3) Antiemetic
4) Antiseizure
____ 14. The nurse is preparing medications for a client with encephalitis. Which medication should the nurse question
before administering?
1) Furosemide (Lasix) NURSINGTB.COM
2) Phenytoin (Dilantin)
3) Docusate sodium (Colace)
4) Prochlorperazine (Compazine)
____ 15. During a home visit the nurse considers physical therapy for a patient recovering from encephalitis. What
would be the best explanation for this referral?
1) Rehabilitation from hemiparesis
2) Deconditioning from extended bedrest
3) Improve use of limbs because of paresthesias
4) Improve balance because of cerebellum dysfunction
____ 16. The nurse suspects that a patient is experiencing Parkinson’s disease. What did the nurse assess to make this
clinical determination?
1) Photophobia
2) Nuchal rigidity
3) Slow movements
4) Elevated body temperature
____ 17. A patient returns to the community clinic after being diagnosed with Parkinson’s disease. What should the
nurse expect to see documented in the patient’s medical record to support this diagnosis?
1) Rigidity with ambulation
2) Unremarkable electroencephalogram
3) Results of serum potassium and calcium levels
4) Integrity of cerebral vessels after a cerebral angiogram
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 18. A patient with Parkinson’s disease is prescribed carbidopa/levodopa (Sinemet). Which clinical manifestation
should the nurse expect to be most affected with this medication?
1) Tremors
2) Mood instability
3) Impaired balance
4) Behavioral changes
____ 19. The nurse interrupts unlicensed assistive personnel who is assisting a patient with Parkinson’s disease with
breakfast. Which observation caused the nurse to immediately intervene?
1) Patient sitting out of bed in a chair
2) Head of the bed raised to 30 degrees
3) Thickener added to liquid menu items
4) Oral suction catheter equipment turned on
____ 20. The nurse is concerned that a patient’s Alzheimer’s disease is progressing. What finding did the nurse use to
confirm this suspicion?
1) Inability to recall the word for “car”
2) Misplacement of health insurance cards
3) Unable to find sweater in the waiting room
4) Leaving the practitioner’s office without taking prescriptions
____ 21. A patient is suspected of having Alzheimer’s disease. What diagnostic testing should the nurse expect to
provide a presumptive diagnosis of this disorder?
1) Echocardiogram
2) Cerebral angiogram
3) Serum medication levels
4) History and physical examination NURSINGTB.COM
____ 22. During a home visit the nurse is concerned that the patient with Alzheimer’s disease is deteriorating. What
patient observation caused the nurse to have this concern?
1) Sitting in a chair watching a television program
2) Staying away from the door leading to the back yard
3) No recognition of bowel incontinence during the visit
4) Eating cheese and crackers placed on a table near the living room chair
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 23. The staff development trainer is preparing orientation materials for new staff hired to care for patients with
seizure disorders. Which type of seizure can occur in any age group? Select all that apply.
1) Absence
2) Myoclonic
3) Tonic-clonic
4) Simple partial
5) Complex partial
____ 24. The nurse suspects that a patient is in the premonitory phase of a migraine headache. What findings did the
nurse use to make this clinical decision? Select all that apply.
1) Yawning
2) Confusion
3) Food cravings
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4) Flashing lights
5) Increased urine output
____ 25. The nurse suspects that a patient with a brain tumor is developing increased intracranial pressure (ICP). What
assessment findings caused the nurse to make this conclusion? Select all that apply.
1) Ataxia
2) Nausea
3) Diarrhea
4) Vomiting
5) Headache
____ 26. The nurse notifies the health-care provider while caring for a patient recovering from a craniotomy as
treatment for a brain tumor. What did the nurse assess to cause this alarm? Select all that apply.
1) Heart rate 52 bpm
2) Temperature 99.2°F
3) Respiratory rate 10 and irregular
4) Urine output 200 mL over 4 hours
5) Systolic blood pressure 198 mm Hg
____ 27. A patient comes to the community clinic complaining of having a fever. What findings should suggest to the
nurse that the patient is experiencing meningitis? Select all that apply.
1) Eye tearing
2) Photophobia
3) Opisthotonos
4) Nuchal rigidity
5) Auditory hallucinations
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Numeric Response
28. A patient with a seizure disorder is prescribed a 1900-calorie diet of which 80% should be consumed as fat.
How many calories should the patient consume as fat? Record your answer as a whole number. _____
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders
Chapter learning objective: Describing the epidemiology of disorders of the brain
Chapter page reference: 738
Heading: Headache > Epidemiology
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Comfort; Neurologic Regulation; Promoting Health
Difficulty: Easy
Feedback
1 Mixed is not identified as a type of headache.
2 Cluster headaches, found predominantly in males with an onset of 30 to 50 years, show
an overall prevalence of 0.4% of the population.
3 The prevalence of tension headaches is in excess of 42%.
4 Migraine headaches have been reported in 11% of the population.
Feedback
1 Citalopram (Celexa) is a selective serotonin reuptake inhibitor believed to balance
chemicals in the brain to prevent migraine headaches.
2 Imipramine (Tofranil) is a tricyclic antidepressant that does not affect vascular
structure.
3 Antihypertensive medications such as amlodipine (Norvasc), a calcium channel
blocker, prevents vasoconstriction or vasodilation in the cerebral blood vessels.
4 Anticonvulsant medications used to treat seizure disorders, such as lamotrigine
(Lamictal), increase the levels of many neurotransmitters and diminish pain impulses.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Explaining the clinical presentation and management of complications associated
with disorders of the brain
Chapter page reference: 742
Heading: Headache > Medical Management > Treatment > Complications > Status Migrainosus and
Hemicrania Continua
Integrated Processes: Nursing Process: Planning
Cognitive Level: Application [Applying]
Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies
Concept: Comfort; Neurologic Regulation; Medication
Difficulty: Moderate
Feedback
1 Antibiotics are not used to treat continuous headache syndromes.
2 Diuretics are not used to treat continuous headache syndromes.
3 Treatment for continuous headache syndromes includes IV hydration.
4 A sodium restriction is not used to treat continuous headache syndromes.
Feedback
1 Chemotherapeutic agents cause neutropenia.
2 The chemotherapeutic agents used to treat brain tumors must have the ability to cross
the blood-brain barrier.
3 There is no way to eliminate weight and hair loss since these are side effects of
chemotherapy.
4 There is no way to limit the development of mucositis since this is a side effect of
chemotherapy.
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Difficulty: Moderate
Feedback
1 Some patients treated for a brain tumor become hyperglycemic as a result of steroid
administration and require home testing of glucose levels while they are receiving
glucocorticoids.
2 Cerebral tissue manipulation does not affect blood glucose level.
3 Surgery for a brain tumor does not interrupt glucose regulation in the brain.
4 Capillary blood glucose monitoring is not required because of a change in oral intake
caused by chemotherapy.
Feedback
1 Asking the patient to explain will waste valuable time since the patient is going to have
a seizure.
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2 Seizures can be preceded by a preictal phase that may include an aura. An aura can be a
visual hallucination like the room color changing to green.
3 Turning on the overhead rooms lights indicates that the nurse is unaware of the patient
experiencing an aura, which is a precursor to a seizure in many patients.
4 The nurse should not stop to document at this time. The patient is going to seize.
Feedback
1 The patient will not be expected to sleep during a sleep-deprived EEG.
2 Saying that people with seizure disorders sleep too much is inappropriate and incorrect.
3 A sleep-deprived EEG is not the only way to prove that the patient really has a seizure
disorder.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4 A sleep-deprived EEG may be performed. Stress, such as that found when the
individual is deprived of sleep, causes an increase in cortical activity and is a key
trigger for seizures.
Feedback
1 Assessing circulation might be required but only after establishing an airway and
providing rescue breathing.
2 In the case of status epilepticus, which is a seizure lasting longer than five minutes,
emergency actions should be taken. The first is to establish an airway.
3 Providing rescue breathing might be required but only after establishing an airway.
4 Inserting an intravenous access line is essential but only after the ABCs of emergency
care are completed.
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PTS: 1 CON: Neurologic Regulation
9. ANS: 1
Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders
Chapter learning objective: Describing the diagnostic results used to confirm disorders of the brain
Chapter page reference: 756
Heading: Meningitis > Medical Management > Diagnosis
Integrated Processes: Nursing Process: Planning
Cognitive Level: Application [Applying]
Client Need: Physiological Integrity/Reduction of Risk Potential
Concept: Neurologic Regulation
Difficulty: Moderate
Feedback
1 Examination of CSF via lumbar puncture is the hallmark for the diagnosis of
meningitis.
2 Evoked potentials are used to assess peripheral nerve function.
3 Patients with suspicion for space-occupying lesions and new-onset seizures and those
with a moderate to severe altered level of consciousness require a CT of the head prior
to the procedure, as they are at higher risk for herniation. However, the patient is not
demonstrating any of these manifestations.
4 An electroencephalogram is used to diagnose a seizure disorder.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
10. ANS: 4
Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders
Chapter learning objective: Discussing the management of: Meningitis
Chapter page reference: 756
Heading: Meningitis > Medical Management > Medications
Integrated Processes: Teaching and Learning
Cognitive Level: Application [Applying]
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Concept: Neurologic Regulation; Medication
Difficulty: Moderate
Feedback
1 The treatment for meningitis does not include fluid restriction.
2 The treatment for meningitis does not include a low-fat, low-calorie diet.
3 The treatment for meningitis does not include over-the-counter analgesics.
4 Treatment for meningitis generally requires 14 to 21 days of antibiotic treatment. Long-
term IV access such as a peripherally inserted central line or other central venous access
is typically initiated because of the need for long-term antibiotic therapy.
Feedback
1 Pharmacological and nonpharmacological interventions relieve pain.
2 Raising the head of the bed increases cerebral venous outflow.
3 Controlling a fever with a cooling blanket decreases metabolic activity and decreases
CNS oxygen demand.
4 Standard and droplet precautions reduce the transmission of the infection.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 The eyes would be closed because of photophobia.
2 Common complaints of encephalitis include phonophobia or a fear of loud noises.
3 Cold hands is not a manifestation of encephalitis.
4 Rubbing the thighs with the hands is not an indication of encephalitis.
Feedback
1 Antivirals are used to treat encephalitis. Acyclovir is used to treat most forms of
encephalitis.
2 Antibiotics are used to treat bacterial infections.
3
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Antiemetics are used to treat nausea and vomiting, which can occur because of the
encephalitis; however, this medication class is not a priority.
4 Antiseizure medications are used to treat seizure disorders, which can occur because of
the encephalitis; however, this medication class is not a priority.
Feedback
1 Diuretics should be questioned because the patient is at risk for dehydration from a
fever, nausea and vomiting, and other insensible losses from the disease process.
2 Phenytoin (Dilantin) is an antiseizure medication, which would be appropriate to
prevent seizures from developing.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3 Docusate sodium (Colace) is a stool softener, which would be appropriate to reduce the
risk of increasing ICP with bowel movements.
4 Prochlorperazine (Compazine) is an antiemetic, which would be appropriate to treat
nausea and vomiting.
Feedback
1 Hemiparesis is not an effect of encephalitis.
2 Because the course of encephalitis may lead to an extended hospitalization and bedrest,
the patient is at risk for deconditioning.
3 Paresthesias is not a manifestation of encephalitis.
4 Cerebellar dysfunction does not occur with encephalitis.
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PTS: 1 CON: Neurologic Regulation | Mobility
16. ANS: 3
Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Parkinson’s disease
Chapter page reference: 760
Heading: Parkinson’s Disease > Clinical Manifestations
Integrated Processes: Nursing Process: Assessment
Cognitive Level: Analysis [Analyzing]
Client Need: Physiological Integrity/Physiological Adaptation
Concept: Neurologic Regulation; Mobility
Difficulty: Moderate
Feedback
1 Photophobia occurs with migraine headaches, meningitis, and encephalitis.
2 Nuchal rigidity occurs with meningitis and encephalitis.
3 One discernible symptom of Parkinson’s disease is slowness of movement or
bradykinesia.
4 Elevated body temperature can occur with meningitis and encephalitis.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 The diagnosis of Parkinson’s disease is made when two or more cardinal symptoms
with asymmetrical presentation—such as rigidity—are observed in the absence of other
causes. Progressive decline in motor function accompanied by rigidity is typically how
the diagnosis is made.
2 There are no specific diagnostic studies to confirm Parkinson’s disease. This would not
be documented in this patient’s medical record.
3 There are no specific diagnostic studies to confirm Parkinson’s disease. This would not
be documented in this patient’s medical record.
4 There are no specific diagnostic studies to confirm Parkinson’s disease. This would not
be documented in this patient’s medical record.
Feedback
1 Dopamine precursors such as carbidopa/levodopa (Sinemet) are later utilized and are
most effective in the treatment of tremors.
2 Dopamine precursors are not identified to target mood instability.
3 Dopamine precursors are not identified to target impaired balance.
4 Dopamine precursors are not identified to target behavioral changes.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Sitting out of bed for meals facilitates swallowing.
2 The patient’s head of the bed should be elevated when eating and drinking. Impaired
swallowing associated with Parkinson’s disease increases the risk of aspiration.
Elevating the head facilitates the swallow reflex.
3 Adding thickener to liquids improves swallowing and reduces the risk of aspiration.
4 Oral suction equipment is a safety precaution and would be appropriate.
Feedback
1
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Forgetfulness is the first symptom of Alzheimer’s disease, which slowly progresses to
difficulty with language (vocabulary and fluency).
2 Forgetfulness is the first symptom of Alzheimer’s disease. Since this patient is already
diagnosed, forgetfulness would be expected.
3 Forgetfulness is the first symptom of Alzheimer’s disease. Since this patient is already
diagnosed, forgetfulness would be expected.
4 Forgetfulness is the first symptom of Alzheimer’s disease. Since this patient is already
diagnosed, forgetfulness would be expected.
Feedback
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE RESPONSE
23. ANS: 2, 3, 4
Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders
Chapter learning objective: Describing the epidemiology of disorders of the brain
Chapter page reference: 749
Heading: Seizures > Epidemiology
Integrated Processes: Teaching and Learning
Cognitive Level: Comprehension [Understanding]
Client Need: Health Promotion and Maintenance
Concept: Neurologic Regulation; Promoting Health
Difficulty: Easy
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1. Absence seizures occur between the ages of 4 to 12.
2. Myoclonic seizures can occur in any age group.
3. Tonic-clonic seizures can occur in any age group.
4. Simple partial seizures can occur in any age group.
5. Complex partial seizures occur over the age of 3.
Feedback
1. Yawning is a symptom of the premonitory phase of a migraine headache.
2. Confusion is a symptom of the postdromal phase of a migraine headache.
3. Food craving is a symptom of the premonitory phase of a migraine headache.
4. Auras can occur just prior
NUtoRthe
SImigraine.
NGTB.COM
5. Increased urine output is a symptom of the premonitory phase of a migraine headache.
Feedback
1. Clinical manifestations of increased ICP include ataxia.
2. Clinical manifestations of increased ICP include nausea.
3. Diarrhea is not a clinical manifestation of increased ICP.
4. Clinical manifestations of increased ICP include vomiting.
5. Clinical manifestations of increased ICP include headache.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
26. ANS: 1, 3, 5
Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with disorders of
the brain
Chapter page reference: 747
Heading: Primary Brain Tumors > Nursing Interventions > Assessments
Integrated Processes: Nursing Process: Assessment
Cognitive Level: Analysis [Analyzing]
Client Need: Physiological Integrity/Reduction of Risk Potential
Concept: Neurologic Regulation; Assessment
Difficulty: Moderate
Feedback
1. For a patient with a brain tumor, decreased heart rate is a manifestation of Cushing’s triad,
which occurs late in increased ICP that signals herniation syndrome, a medical emergency.
2. A temperature of 99.2°F is not an indication of Cushing’s triad.
3. For a patient with a brain tumor, an irregular respiratory rate is a manifestation of Cushing’s
triad, which occurs late in increased ICP that signals herniation syndrome, a medical
emergency.
4. Urine output of 200 mL over four hours is within normal limits.
5. For a patient with a brain tumor, increased intracranial pressure is a manifestation of
Cushing’s triad, which occurs late in increased ICP that signals herniation syndrome, a
medical emergency.
Feedback
1. Eye tearing is a manifestation of a cluster headache.
2. The patient with meningitis may report photophobia.
3. The patient with meningitis may be experiencing opisthotonos.
4. The patient with meningitis will experience nuchal rigidity as a sign of meningeal irritation.
5. Auditory hallucinations may be associated with a seizure disorder.
NUMERIC RESPONSE
28. ANS:
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1520
Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders
Chapter learning objective: Discussing the management of: Seizures
Chapter page reference: 753
Heading: Seizures > Medical Management > Diagnosis > Medications
Integrated Processes: Nursing Process: Planning
Cognitive Level: Application [Applying]
Client Need: Physiological Integrity/Reduction of Risk Potential
Concept: Neurologic Regulation
Difficulty: Moderate
Feedback: To calculate the number of fat calories, the total number of calories per day should be multiplied
by 80%, or 1900 x 80% = 1520. The client should consume 1520 calories per day of fats.
Chapter 37: Coordinating Care for Patients With Spinal Cord Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A patient asks what smoking cigarettes has to do with low back pain. How should the nurse respond to this
patient?
1) “Smoking is a sedentary activity.”
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2) “Smoking is linked to nutritional disorders.”
3) “Nicotine in cigarettes interferes with nutrients that supply the disk spaces.”
4) “Nicotine hinders the mobility of the vertebral spaces and interferes with nerve function.”
____ 2. A patient with multiple sclerosis experiences exacerbations of new symptoms that last a few days and then
disappear. Which type of multiple sclerosis is this patient most likely experiencing?
1) Relapsing-remitting
2) Primary progressive
3) Progressive relapsing
4) Secondary progressive
____ 3. A patient is diagnosed with spinal stenosis. Which manifestation is caused by age-related loss of spinal
muscle strength?
1) Fatigue
2) Constipation
3) Muscle spasm
4) Decreased stamina
____ 4. A patient with low back pain asks why nerve conduction studies are prescribed. What explanation should the
nurse provide to the patient relative to this diagnostic test?
1) “It measures damage to nerves.”
2) “It shows pressure on nerves from herniated disks.”
3) “It measures electrical impulses within muscle tissue.”
4) “It shows the structure of the vertebrae and joint outlines.”
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 5. A patient with low back pain asks what aspirin is supposed to do help with the pain. How should the nurse
respond to this patient?
1) “It depresses the central nervous system.”
2) “It blocks sodium channels and stops the formation of nerve impulses.”
3) “It blocks enzymes and chemicals in the body to decrease pain and inflammation.”
4) “It blocks the production of substances that trigger allergic and inflammatory reactions.”
____ 6. The nurse is caring for a patient with unrelenting low back pain caused by a herniated disk. What instruction
should the nurse provide to this patient to help with the pain?
1) Sit with the legs elevated
2) Reduce the intake of fluids
3) Limit activity until the pain subsides
4) Bend at the knees with a straight back
____ 7. The nurse directs a patient with a herniated disk to notify the health-care provider immediately if the patient
experiences which presentation?
1) New onset urinary incontinence
2) Sleepiness after taking pain medication
3) Difficulty with having a bowel movement
4) Transient pain with walking and changing position
____ 8. A patient receives a definitive diagnosis of multiple sclerosis. What finding occurred to validate this
diagnosis?
1) Onset of double vision
2) Loss of bowel and bladder control
3) Numbness and tingling of one limb
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4) MRI changes in two separate locations
____ 9. A patient with multiple sclerosis is admitted for treatment of clinical manifestations. What should the nurse
expect to be prescribed for this patient?
1) Corticosteroids
2) Beta interferons
3) Muscle relaxants
4) Immunosuppressive agents
____ 10. A patient with multiple sclerosis is developing speech difficulties. What should the nurse realize as being the
reason for this new manifestation?
1) Depression
2) Medications
3) Nerve regeneration
4) Mental status changes
____ 11. The nurse is caring for a patient with multiple sclerosis. What should the nurse do to increase venous return,
prevent stiffness, and maintain muscle strength and endurance?
1) Administer interferon
2) Administer corticosteroids
3) Turn and reposition every two hours
4) Encourage range-of-motion exercises
____ 12. A patient is experiencing increasing flaccid upper arms while the lower extremities periodically cramp and
contract. On which health problem should the nurse focus when assessing this patient?
1) Brain tumor
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
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____ 23. The nurse is concerned that a patient is at risk for a lumbar disk herniation. What assessment information is
causing the nurse to have this concern? Select all that apply.
1) Fell off of a ladder
2) Body mass index 32.3
3) Smokes 1 pack of cigarettes per day
4) Works in an automotive factory
5) Lifts 50 lb. sack of cement at work
____ 24. A patient with low back pain asks what nonmedical treatments can be used to help with the discomfort.
Which complementary and alternative therapies should the nurse recommend to this patient? Select all that
apply.
1) Yoga
2) Qi gong
3) Acupuncture
4) Massage therapy
5) Chiropractic treatments
____ 25. The nurse notes that a patient with low back pain is experiencing radiculopathy. What should the nurse expect
when assessing this patient? Select all that apply.
1) Pain
2) Edema
3) Weakness
4) Numbness
5) Inability to control motor movement
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 26. A patient with a herniated disk is prescribed conservative treatment. For which anticipated treatments should
the nurse prepare to instruct this patient? Select all that apply.
1) Reducing body weight
2) Avoiding painful positions
3) Engaging in aerobic activities
4) Performing planned exercises
5) Taking pain medication as prescribed
____ 27. The nurse is assessing a patient with multiple sclerosis. What should the nurse expect to assess in this patient?
Select all that apply.
1) Anxiety
2) Dizziness
3) Double vision
4) Unsteady gait
5) Electric shocks with head movement
____ 28. A patient with amyotrophic lateral sclerosis (ALS) is being prepared for discharge. What teaching would be
essential for the family to receive prior to taking the patient home? Select all that apply.
1) Skin care
2) Aspiration precautions
3) Recognizing exacerbations
4) Lower extremity circulation
5) Reporting changes in continence
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 37: Coordinating Care for Patients With Spinal Cord Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders
Chapter learning objective: Describing the epidemiology of spinal cord disorders
Chapter page reference: 771
Heading: Low Back Pain > Epidemiology
Integrated Processes: Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Mobility; Promoting Health
Difficulty: Easy
Feedback
1 There is no evidence to link smoking with a sedentary lifestyle.
2 There is no evidence to link smoking with nutritional disorders.
3 Nicotine in cigarettes is thought to interfere with vital nutrients being absorbed by the
intervertebral disks.
4 There is no evidence to link nicotine to vertebral space mobility and nerve function.
Feedback
1 In relapsing-remitting multiple sclerosis, relapses or exacerbations occur during which
new symptoms appear and old ones worsen or reappear; these relapses can last days or
months.
2 Primary progressive multiple sclerosis has gradual progression with no remissions.
3 Progressive relapsing multiple sclerosis has a gradual worsening of symptoms from
onset, and the relapses may or may not have recovery.
4 Secondary progressive multiple sclerosis is when the patient initially had relapsing-
remitting but it gradually becomes worse.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Correlating clinical manifestations to the pathophysiological processes of: Low
back pain
Chapter page reference: 772
Heading: Low Back Pain > Clinical Manifestations
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Mobility
Difficulty: Moderate
Feedback
1 Fatigue could occur because of needing to be sedentary to prevent the onset of pain.
2 Constipation could occur because of decreased mobility.
3 Muscle spasm is the sudden, involuntary contraction of a single muscle or muscle
group. Most back muscle spasms are due to inflammation and soreness because of
sudden movement or bending, but they can also result from age-related loss of spinal
muscle strength as muscles spasm to protect the worn areas of the spine.
4 Decreased stamina is possible if pain decreases activity and the patient becomes more
sedentary.
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Feedback
1 Muscle relaxants depress the central nervous system.
2 Tricyclic antidepressants block the sodium channels and decrease formation of ectopic
neuronal pacemakers.
3 NSAIDs block enzymes and prostaglandins throughout the body, thereby decreasing
pain and inflammation.
4 Corticosteroids block the production of substances that trigger allergic and
inflammatory reactions.
Feedback
1 Sitting with the legs elevated puts pressure on the lower spine.
2
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Reducing the intake of fluids can cause constipation, which worsens back pain.
3 Activity should be performed as prescribed to build core muscle strength and stabilize
and support the spine.
4 Bending at the knees with the back straight uses the leg muscles to lift and decreases
strain on the back muscles.
Feedback
1 Common complications of a herniated disk include loss of bladder control. The
development of this complication may require surgical intervention to prevent
permanent loss of function.
2 Depending upon the pain medication, sleepiness may be expected.
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Feedback
1 Corticosteroids are used to treat attacks.
2 Beta interferons are used to modify the disease course.
3 Medications used to treat clinical manifestations include muscle relaxants.
4 Immunosuppressive agents are used to modify the disease course.
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Heading: Multiple Sclerosis > Medical Management > Treatment > Complications
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Mobility; Communication
Difficulty: Moderate
Feedback
1 Depression is an adverse effect of the disease. It does not cause speech deficits.
2 Speech defects due to muscle weakness may be due to medications.
3 Nerve regeneration would improve speech.
4 Mental status changes is an adverse effect of the disease. It does not cause speech
deficits.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 The manifestations of a spinal cord tumor will depend upon the location of the mass
within the cord.
3 Both spasticity and flaccidity do not need to be present to diagnose multiple sclerosis.
4 To be diagnosed with ALS, patients must have clinical manifestations of both upper
and lower motor neuron damage that cannot be attributed to other causes. Upper motor
neuron damage is associated with spasticity, while lower motor neuron damage is
characterized by flaccidity.
Feedback
1 Riluzole (Rilutek) does not repair damaged neurons but has been shown both to
increase survival and to extend the period without the need for ventilator support.
2 Analeptics improve wakefulness.
3 Antispasmodics improve bladder spasms.
4 Riluzole (Rilutek) is the first drug approved to slow disease progression.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders
Chapter learning objective: Correlating clinical manifestations to the pathophysiological processes of: Spinal
cord injury
Chapter page reference: 786
Heading: Spinal Cord Injury > Pathophysiology
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Mobility
Difficulty: Moderate
Feedback
1 A hyperextension injury causes central cord syndrome. A clinical manifestation of this
syndrome is bladder dysfunction.
2 Posterior cord syndrome is caused by acute compression. A manifestation of this
syndrome is a loss of proprioception.
3 Brown-Sequard syndrome is caused by a penetrating injury. A manifestation of this
syndrome is an ipsilateral loss of motor function.
4 Anterior cord syndrome is caused by acute compression from bony fragments or acute
disk herniation. A manifestation of this syndrome is pain below the level of the injury.
Feedback
1 A patient with a spinal cord injury is at risk for skin breakdown and pressure ulcers. An
air mattress would be appropriate.
2 A patient with a spinal cord injury is at risk for paralytic ileus, septic or necrotic bowel,
and a GI bleed. A nasogastric tube to suction would be appropriate.
3 A patient with a spinal cord injury is at risk for urinary incontinence, urinary tract
infection, neurogenic bladder, and chronic kidney disease. An indwelling urinary
catheter and strict intake and output measurement would be appropriate.
4 Current guidelines for the management of acute SCIs no longer recommend the use of
corticosteroids for acute SCI. Because there is no strong medical evidence supporting
benefits from the administration of corticosteroids, this therapy is avoided because of
stronger evidence that the administration of high-dose steroids is associated with
harmful side effects, including hyperglycemia and immunosuppression.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Explaining the clinical presentation and management of complications associated
with disorders of the spinal cord
Chapter page reference: 790
Heading: Spinal Cord Injury > Medical Management > Complications > Autonomic Dysreflexia
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Mobility
Difficulty: Moderate
Feedback
1 After the head of the bed is raised the nurse can begin to assess for the cause of
autonomic dysreflexia, which includes palpating the bladder.
2 After the head of the bed is raised the nurse can begin to assess for the cause of
autonomic dysreflexia, which includes assessing for a bowel impaction.
3 Re-measuring the blood pressure will take precious time that is better spent beginning
interventions.
4 The head of the bed should be raised first so that blood can pool in the lower
extremities and help reduce the blood pressure.
Feedback
1 If crusting is noted, wrap gauze soaked with normal saline around the pin site for 15
minutes. After removing the gauze, use a clean cotton-tipped applicator to gently
remove the crust from the pin site.
2 The crusting should not be picked off the pins.
3 Hydrogen peroxide is not used to remove crusting from the pins.
4 Solutions should not be syringed on the pins. Hydrogen peroxide is not used to remove
crusting from the pins.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 MRI is considered to be the gold standard for examining spinal structures.
2 A myelogram may be used if an MRI is not available; however, the myelogram is not
identified as being the gold standard for the examination of spinal structures.
3 A cerebral angiogram would not be indicated for a spinal cord tumor.
4 Nerve conduction studies would not be indicated for a spinal cord tumor. However, if a
tumor is ruled out, nerve conduction studies might be indicated to determine nerve
damage and function.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 Surgery is usually the first step in treating tumors that can be removed with an
acceptable risk of nerve damage.
2 Radiation therapy is used following an operation to eliminate the tumor remnants or to
treat inoperable tumors.
3 Chemotherapy has not been proven effective for most spinal cord tumors.
4 Stereotactic radiosurgery is currently being studied for spinal cord tumors.
MULTIPLE RESPONSE
23. ANS: 2, 3, 4, 5
Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders
Chapter learning objective: Describing the epidemiology of spinal cord disorders
Chapter page reference: 775
Heading: Herniated Nucleus Pulposus > Epidemiology
Integrated Processes: Nursing Process; Assessment
Client Need: Health Promotion and Maintenance
Cognitive Level: Analysis [Analyzing]
Concept: Mobility
Difficulty: Moderate
Feedback
1. A traumatic event such as a fall or a blow to the back rarely causes a herniated disk.
2. Factors that increase the risk of a herniated disk include obesity.
3. Factors that increase the risk of a herniated disk include smoking.
4. Factors that increase the risk of a herniated disk include occupation that includes repetitive
lifting, pulling, pushing, bending sideways, and twisting.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5. Factors that increase the risk of a herniated disk include occupation that includes repetitive
lifting, pulling, pushing, bending sideways, and twisting.
Feedback
1. Yoga can be used as part of a general health regimen, to cope with illness, to improve
physiological balance, or to increase relaxation; techniques include physical postures and
breathing techniques with either a focused attention or an open attitude toward distractions.
2. Qi gong is an ancient Chinese discipline involving physical and mental exercises that focus on
specific parts of the body.
3. Acupuncture is the insertion of small needles or exerting pressure on “energy” points in the
body; the patient is supposed to experience a feeling of fullness, numbness, tingling, and
warmth.
4. Massage therapy consists of alternating levels of concentrated pressure on the areas of spasm;
NURSINGTB.COM
once pressure is applied, it should not vary for 10 to 30 seconds. Massage also leads to
increased endorphin levels (chemicals associated with decreased pain and increased euphoria)
that are effective in chronic pain management.
5. Chiropractic treatments are not identified as a complementary or alternative therapy for low
back pain.
Feedback
1. Radiculopathy is nerve root compression and can result in pain in the affected extremity.
2. Edema is not a manifestation of radiculopathy.
3. Radiculopathy is nerve root compression and can result in weakness in the affected extremity.
4. Radiculopathy is nerve root compression and can result in numbness in the affected extremity.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5. Radiculopathy is nerve root compression and can result in the inability to control motor
movement in the affected area.
Feedback
1. If obesity is a contributing factor, weight-loss measures are also indicated.
2. Conservative treatment consists of avoiding painful positions.
3. Conservative treatment consists of avoiding painful positions, which might include aerobic
activities.
4. Conservative treatment consists of following a regimen of planned exercise.
5. Conservative treatment consists of following a regimen of pain medications.
Feedback
1. Anxiety is not an identified manifestation of multiple sclerosis.
2. Depending on the location of the affected nerve fibers, a manifestation of multiple sclerosis
includes dizziness.
3. Depending on the location of the affected nerve fibers, a manifestation of multiple sclerosis
includes double vision.
4. Depending on the location of the affected nerve fibers, a manifestation of multiple sclerosis
includes unsteady gait.
5. Depending on the location of the affected nerve fibers, a manifestation of multiple sclerosis
includes electric shocks with head movement.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders
Chapter learning objective: Explaining the clinical presentation and management of complications associated
with disorders of the spinal cord
Chapter page reference: 783
Heading: Amyotrophic Lateral Sclerosis > Medical Management > Complications
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Mobility; Promoting Health
Difficulty: Moderate
Feedback
1. Amyotrophic lateral sclerosis is a progressive disease that leads to the inability to move.
Complications include pressure ulcers.
2. Amyotrophic lateral sclerosis is a progressive disease that leads to the inability to move.
Complications include aspiration of food or fluid, respiratory failure, and pneumonia.
3. Exacerbations occur with multiple sclerosis and not ALS.
4. Amyotrophic lateral sclerosis is a progressive disease that leads to the inability to move.
Complications include deep vein thrombosis (DVT) and pulmonary embolism (PE).
5. Changes in continence would be a potential complication of a herniated disk.
Chapter 38: Coordinating Care for Patients With Peripheral Nervous System Disorders
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Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A client is diagnosed with myasthenia gravis. What should the nurse explain about this disease process?
1) “Your nerve endings are worn out.”
2) “Your body does not recognize the neurotransmitter needed for movement.”
3) “Your body does not make enough of the neurotransmitter needed for movement.”
4) “Your nerves have lost their protective covering and impulses cannot reach body areas.”
____ 2. The nurse is reading the results of a single-fiber electromyography completed on a patient suspected of having
myasthenia gravis. Which information would validate this patient’s diagnosis?
1) Increased jitter
2) Nerve compression
3) Increased antibodies
4) Decreased muscle response
____ 3. A patient is being prepared for a tensilon test. What should the nurse ensure is available prior to the beginning
of this test?
1) Oxygen
2) Atropine sulfate
3) Intravenous fluids
4) Nasogastric suction
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 4. A patient with myasthenia gravis is experiencing sweating and pallor. After administering edrophonium
(Tensilon), which finding suggests the patient is experiencing a cholinergic crisis?
1) Clear vision
2) Fasciculations
3) Strong hand grasps
4) Equal shoulder shrugs
____ 5. The nurse is caring for a patient with myasthenia gravis. Which assessment should the nurse complete to
determine respiratory functioning?
1) Vital capacity
2) Pulse oximetry
3) Auscultate lung sounds
4) Arterial blood gas analysis
____ 6. A patient with myasthenia gravis has lost 6 kg of weight over the last two months. What should the nurse
suggest to improve this patient’s nutritional status?
1) Eat three large meals per day
2) Plan medication doses to occur before meals
3) Restrict drinking fluids prior to and during meals
4) Increase the amount of fat and carbohydrates in meals
____ 7. The nurse is reviewing discharge instructions for a patient with myasthenia gravis. What should the nurse
emphasize regarding medications?
1) Keep extra doses of medication in the car
2) Store extra doses of medication in the refrigerator
3) Take an extra dose of medication before leaving the house
4) Pack prescribed medications in N URSINbefore
a suitcase GTB. COMon an airplane
flying
____ 8. A patient seeks treatment for progressively deteriorating motor and sensory function. What question is
essential for the nurse to ask when completing this patient’s health history?
1) “Have you been around any small children?”
2) “When was the last time you had anything to eat?”
3) “When was the last time you traveled out of the country?”
4) “Have you recently experienced any lung or stomach infections?”
____ 9. A patient with Guillain-Barré syndrome (GBS) asks how the illness develops. What should the nurse respond
about the pathophysiology of the disorder?
1) “An infection eats away at the nerve endings.”
2) “An infection enters the spinal cord and erodes the nerves at the roots.”
3) “The nerves are killed by infiltration of your body’s white blood cells used to fight an
infection.”
4) “After an infection your immune system created antibodies that affect the covering of the
nerves.”
____ 10. A patient is experiencing bilateral symmetrical muscle weakness and sensory changes of both feet and legs.
What should the nurse expect to assess that determines the presence of Guillain-Barré syndrome (GBS)?
1) Areflexia
2) Hyporeflexia
3) Hyperreflexia
4) Hyperanalgesia
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 11. A patient with Guillain-Barré syndrome (GBS) loses respiratory function three weeks into the acute phase.
When should the nurse expect respiratory function to return in this patient?
1) During the plateau phase
2) Early in the recovery stage
3) At the end of the plateau stage
4) At the end of the recovery stage
____ 12. A patient with progressively deteriorating lower extremity motor and sensory function is having a lumbar
puncture. What finding suggests that this patient has Guillain-Barré syndrome (GBS)?
1) Elevated protein level
2) Elevated glucose level
3) Reduction in white blood cell count
4) Increased number of red blood cells
____ 13. A patient with Guillain-Barré syndrome (GBS) is receiving plasmapheresis. What finding should the nurse
identify as being a complication of this treatment?
1) Septicemia
2) Flu-like symptoms
3) Aseptic meningitis
4) Acute renal failure
____ 14. The nurse notes that a patient with Guillain-Barré syndrome (GBS) sweats profusely. What should the nurse
do about this finding?
1) Place on a cooling blanket
2) Notify the health-care provider
3) Monitor body temperature every two hours
4) Change linen and gown and keep NU RSINGTB.COM
comfortable
____ 15. The nurse is planning care for a patient with Guillain-Barré syndrome (GBS). Which intervention will help
with neuropathic pain?
1) Administer gabapentin
2) Turn and reposition every two hours
3) Apply sequential compression devices
4) Perform passive range of motion several times a day
____ 16. The nurse notes that a patient has been diagnosed with trigeminal neuralgia. What should the nurse expect the
patient to be experiencing?
1) Pain
2) Nausea
3) Sensory deficit
4) Motor weakness
____ 17. The nurse is concerned that a patient is at risk for trigeminal neuralgia. What information in the patient’s
medical record did the nurse use to make this clinical decision?
1) Has a BMI of 34
2) Takes birth control pills
3) History of hypertension
4) Works as a computer operator
____ 18. The nurse notes that a patient’s primary complaint is burning pain on the right side of the face. What should
the nurse realize this patient is describing?
1) Referred pain
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2) Atypical pain
3) Vascular compression
4) Peripheral neuropathy
____ 19. The nurse is conducting a physical examination on a female patient experiencing trigeminal neuralgia. What
observation indicates that the pain is triggered by hygienic practices?
1) Limited talking
2) Hair not combed
3) Wearing tennis shoes
4) Not wearing makeup
____ 20. The nurse is reviewing orders written for a patient with trigeminal neuralgia. Which medication should the
nurse expect to be prescribed for this patient?
1) Cogentin
2) Compazine
3) Carbamazepine
4) Hydrochlorothiazide
____ 21. A patient is scheduled for surgery to treat trigeminal neuralgia. For which procedure should the nurse explain
that a complication resulting in permanent numbness of the facial area might occur?
1) Plasmapheresis
2) Percutaneous rhizotomy
3) Stereotactic radiosurgery
4) Microvascular decompression
____ 22. A patient with trigeminal neuralgia asks if there are any nonpharmacological strategies to treat the pain. What
should the nurse suggest to this patient?
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1) Massage
2) Apply heat
3) Apply cold
4) Acupuncture
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 23. During an assessment the nurse suspects that patient should be evaluated for myasthenia gravis. What did the
nurse assess to make this clinical determination? Select all that apply.
1) Ptosis
2) Diplopia
3) Abdominal pain
4) Left leg weakness
5) Epigastric burning
____ 24. The nurse notes that a patient with myasthenia gravis is experiencing bulbar manifestations. On what should
the nurse focus when assessing this patient? Select all that apply.
1) Swallowing
2) Eye opening
3) Blood pressure
4) Tongue movement
5) Head and neck movement
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 25. The nurse is reviewing orders written for a patient with myasthenia gravis. Which medication order should the
nurse question before administering? Select all that apply.
1) Verapamil
2) Furosemide
3) Erythromycin
4) Nicotine patch
5) Warfarin sodium
____ 26. A patient is admitted for diagnosis and treatment of Guillain-Barré syndrome (GBS). What should the nurse
expect to assess during the acute stage of this syndrome? Select all that apply.
1) Edema
2) Paralysis
3) Difficulty breathing
4) Urinary incontinence
5) Numbness and tingling
Numeric Response
27. A patient who takes pyridostigmine (Mestinon) 30 mg 4 times a day is scheduled for surgery. How many mg
of intravenous neostigmine (Prostigmin) should be prescribed for an entire day? Record your answer as a
whole number. ______
28. A patient who weighs 176 lbs. is prescribed intravenous immunoglobulin 2 g/kg to be infused over three days.
How many grams of the medication should the nurse have sent from the pharmacy? Record your answer as a
whole number. ______
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 38: Coordinating Care for Patients With Peripheral Nervous System Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 2
Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders
Chapter learning objective: Explaining the pathophysiological processes of peripheral nervous system
disorders
Chapter page reference: 801
Heading: Myasthenia Gravis > Pathophysiology
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Neurologic Regulation; Sensory Perception
Difficulty: Moderate
Feedback
1 The nerve endings are not worn out in myasthenia gravis.
2 In myasthenia gravis the postsynaptic receptor sites are unavailable.
3 The amount of neurotransmitter is not altered in myasthenia gravis.
4 The nerves in myasthenia gravis have not lost their protective covering or myelin
sheath.
PTS: 1 NURRegulation
CON: Neurologic SINGTB| . COM Perception
Sensory
2. ANS: 1
Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders
Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected
disorders of the peripheral nervous system
Chapter page reference: 803
Heading: Myasthenia Gravis > Medical Management > Repetitive Nerve Stimulation and Electromyography
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Neurologic Regulation; Sensory Perception
Difficulty: Moderate
Feedback
1 In myasthenia gravis, there is increased “jitter” in a single-fiber electromyography test.
2 Specific nerve function and status is not measured through a single-fiber
electromyography.
3 Antibodies would be measured through the use of serology testing.
4 In myasthenia gravis, decreased muscle response would be seen in a repetitive nerve
stimulation test.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected
disorders of the peripheral nervous system
Chapter page reference: 803
Heading: Myasthenia Gravis > Medical Management > Tensilon Test
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Neurologic Regulation; Sensory Perception; Medication
Difficulty: Moderate
Feedback
1 Oxygen is not required for a tensilon test.
2 Edrophonium (Tensilon) is a rapid-acting AChE inhibitor. This leads to increased levels
of ACh at the neuromuscular junction, leading to improved muscle strength in patients
with myasthenia. However, ACh accumulates in the parasympathetic autonomic
nervous system and can cause side effects such as bronchospasm, bradycardia, and
diarrhea. Atropine is a muscarinic blocker, and thus the side effects of edrophonium
and other AChE inhibitors can be reversed with this medication.
3 Intravenous fluids are not required for a tensilon test.
4 Nasogastric suction is not required for a tensilon test.
Feedback
1 When Tensilon is administered, if the patient demonstrates muscle strength
improvement, it is determined to be a myasthenic crisis.
2 If Tensilon is administered and the patient demonstrates fasciculations and muscle
weakness, including respiratory muscles, it is a cholinergic crisis.
3 When Tensilon is administered, if the patient demonstrates muscle strength
improvement, it is determined to be a myasthenic crisis.
4 When Tensilon is administered, if the patient demonstrates muscle strength
improvement, it is determined to be a myasthenic crisis.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Because of the potential for respiratory weakness, a bedside test known as the vital
capacity is performed.
2 Pulse oximetry is not helpful in determining respiratory deterioration in a patient with
myasthenia gravis because failure is due to weakness of the diaphragm and intercostal
muscles.
3 Auscultating lung sounds will not help determine oxygenation at the cellular and
capillary level.
4 An arterial blood gas is a prescribed and obtained by a health-care provider. It is
beyond the nurse’s scope of practice to draw this sample for analysis.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 There is no evidence to suggest that GBS is transmitted from small children.
NURSINGTB.COM
2 Recent ingestion of food most likely did not cause the patient’s symptoms.
3 Traveling out of the country is not directly linked to the development of GBS.
4 About two-thirds of patients who develop GBS demonstrate clinical manifestations of
an infection three weeks prior to onset. Respiratory or gastrointestinal infections are the
most common sources.
Feedback
1 An infection does not eat away at the nerve endings in GBS.
2 An infection does not enter the spinal cord and erode the nerves at the roots in GBS.
3 The nerves are not killed by the body’s white blood cells in GBS.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4 In GBS, the patient’s own immune system begins to destroy the myelin that surrounds
the peripheral nerves. Destruction occurs between the nodes of Ranvier that results in
slowing of impulses or conduction block. There is infiltration of lymphocytes into the
peripheral nervous system, which attracts macrophages; the macrophages penetrate the
Schwann cell and invade the myelin resulting in demyelination.
Feedback
1 Areflexia is recognized as a key finding in GBS.
2 The reflexes in a patient with GBS will be absent and not just diminished.
3 The reflexes in a patient with GBS will be absent and not exaggerated.
4 There is no evidence to suggest that the patient with GBS will have a heightened pain
response.
NURSINGTB.COM
PTS: 1 CON: Neurologic Regulation | Sensory Perception
11. ANS: 2
Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Guillain-
Barré Syndrome (GBS)
Chapter page reference: 809
Heading: Guillain-Barré syndrome (GBS) > Clinical Manifestations
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Neurologic Regulation; Sensory Perception; Oxygenation
Difficulty: Moderate
Feedback
1 No further damage or repair occurs during the plateau stage.
2 The pattern of recovery is the reverse of onset, and the nerves that were affected last are
the first to improve. The respiratory nerves will repair first.
3 No further damage or repair occurs during the plateau stage.
4 The pattern of recovery is the reverse of onset, and the nerves that were affected last are
the first to improve. The respiratory nerves will repair first.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders
Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected
disorders of the peripheral nervous system
Chapter page reference: 809
Heading: Guillain-Barré Syndrome (GBS) > Medical Management > Diagnostic Tests
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Neurologic Regulation; Sensory Perception
Difficulty: Moderate
Feedback
1 In GBS, cerebrospinal fluid findings include an elevated protein level.
2 In GBS, there is no evidence to suggest that glucose is elevated in the cerebrospinal
fluid.
3 In GBS, the cell count in the cerebrospinal fluid is normal.
4 In GBS, the cell count in the cerebrospinal fluid is normal.
Feedback
1 Plasmapheresis increases the risk for infection. Septicemia is a complication of
plasmapheresis.
2 Flu-like symptoms are associated with intravenous immunoglobulin therapy.
3 Aseptic meningitis is associated with intravenous immunoglobulin therapy.
4 Acute renal failure is associated with intravenous immunoglobulin therapy.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Difficulty: Moderate
Feedback
1 Autonomic dysfunction is causing the sweating. The patient does not have a
temperature.
2 The health-care provider does not need to be notified.
3 The patient does not have a fever. Autonomic dysfunction is causing the sweating.
4 Patients with GBS may perspire because of autonomic manifestations, and the patient’s
clothing and linens require frequent changes.
Feedback
1 Gabapentin may be used to relieve neuropathic pain.
2
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Frequent repositioning promotes comfort and prevents complications of immobility
including thromboembolism and impaired skin integrity.
3 Sequential compression devices prevent venous stasis.
4 Range-of-motion exercises promote joint mobility and function.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Talking can be a trigger for pain; however, this is not a hygienic practice.
2 Hygiene activities such as combing the hair may be neglected because it triggers pain.
3 Wearing tennis shoes is a personal choice and is not a hygienic practice.
4 Not all females wear makeup. Wearing makeup is not necessarily a hygienic practice.
Feedback
1 Cogentin is a medication used to treat Parkinson’s disease.
2 Compazine is a medication used
3
NUtoRtreat
SINnausea
GTB.and COvomiting.
M
Carbamazepine is the first line of drug therapy used in the treatment of trigeminal
neuralgia, and it works by reducing the excitability of neurons by inhibiting neuronal
sodium channels.
4 Hydrochlorothiazide is a medication used to treat hypertension.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE RESPONSE
23. ANS: 1, 2
NURSCare
Chapter number and title: 38, Coordinating INGfor
TBPatients
.COMWith Peripheral Nervous System Disorders
Chapter learning objective: Describing the epidemiology of peripheral nervous system disorders
Chapter page reference: 801
Heading: Myasthenia Gravis > Epidemiology
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Neurologic Regulation; Sensory Perception
Difficulty: Moderate
Feedback
1. Ptosis is an ocular manifestation of myasthenia gravis.
2. Diplopia is an ocular manifestation of myasthenia gravis.
3. Abdominal pain is not a manifestation of myasthenia gravis.
4. Left leg weakness is not a specific manifestation of myasthenia gravis.
5. Epigastric burning is not a manifestation of myasthenia gravis.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1. Bulbar manifestations affect CN IX, which controls swallowing.
2. Eye opening is an ocular manifestation of myasthenia gravis.
3. Bulbar manifestations affect CN IX, which has a role in blood pressure control.
4. Bulbar manifestations affect CN XII, which controls tongue movement.
5. Bulbar manifestations affect CN XI, which controls movement of the head and neck.
Feedback
1. Edema is seen in the acute stage of GBS.
2. Paralysis is seen in the acute stage of GBS.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
NUMERIC RESPONSE
27. ANS:
2
Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders
Chapter learning objective: Discussing the medical management of selected disorders of the peripheral
nervous system
Chapter page reference: 804
Heading: Myasthenia Gravis > Medical Management > Medications
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Neurologic Regulation; Sensory Perception; Medication
Difficulty: Moderate
Feedback: The patient should receive 1 mg intravenous neostigmine (Prostigmin) for every 60 mg of
pyridostigmine (Mestinon). This patient should receive 0.5 mg for every 30 mg. Since the patient takes 4
doses of oral pyridostigmine (Mestinon) 0.5 mg x 4 or 2 mg of pyridostigmine (Mestinon) should be
prescribed. NURSINGTB.COM
PTS: 1 CON: Neurologic Regulation | Sensory Perception | Medication
28. ANS:
160 grams
Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders
Chapter learning objective: Discussing the medical management of selected disorders of the peripheral
nervous system
Chapter page reference: 805
Heading: Myasthenia Gravis > Medical Management > Medications
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Neurologic Regulation; Sensory Perception; Medication
Difficulty: Moderate
Feedback: First determine the patient’s weight in kg by dividing the weight in pounds by 2.2 or 176/2.2 = 80
kg. Then multiply the ordered dose by the weight or 2 g x 80 = 160 g. The nurse needs to have 160 grams of
the medication available to be infused over three days.
Chapter 39: Coordinating Care for Critically Ill Patients With Neurological Dysfunction
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is preparing a patient for insertion of an intraventricular catheter intracranial pressure (ICP)
monitoring device. What is an advantage of this device?
1) Must be inserted in the operating room
2) Catheter tip located in the lateral ventricle
3) Less mechanical drift of the measurement over time
4) Lower rate of infection because of no fluid reservoir
____ 2. A patient with increased intracranial pressure (ICP) is sensitive to fluid-volume shifts. Which approach would
be the safest to reduce this patient’s cerebral edema?
1) Mannitol
2) 3% normal saline
3) Bacteriostatic saline
4) Preservative-free saline
____ 3. The nurse is caring for a patient in a barbiturate coma for increased intracranial pressure (ICP). What should
the nurse assess to determine this patient’s cerebral function?
1) Gag reflex
2) Glasgow coma scale
3) Pupillary size and reaction
4) Blood pressure and heart rate
°
____ 4. A patient with increased intracranial N
pressure
URSI(ICP)
NGTBhas
.Ca O
body
M temperature of 100 F. What action should the
nurse take to address this temperature elevation?
1) Place head in a neutral position
2) Administer antipyretic as prescribed
3) Auscultate lung sounds and increase fluids
4) Send a urine sample for culture and sensitivity
____ 5. A patient in a barbiturate coma for increased intracranial pressure (ICP) has audible gurgling through the
endotracheal tube. What should the nurse do first before suctioning this patient?
1) Administer 100% oxygen
2) Elevate the head of the bed
3) Interrupt sedative administration
4) Place the head in a neutral position
____ 6. The nurse is concerned that a patient is at high risk for having a stroke. What finding did the nurse use to
make this clinical decision?
1) BMI 24.8
2) Heart rate 90 bpm
3) Blood pressure 182/90 mm Hg
4) Pulse oximetry 98% on room air
____ 7. The nurse suspects that a patient is experiencing a hemorrhagic stroke from a ruptured cerebral aneurysm.
What assessment finding caused the nurse to make this conclusion?
1) Slurred speech
2) Visual field deficits
3) Sudden severe headache
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 15. The nurse is caring for a patient with a diffuse axonal injury. What treatment plan should the nurse expect to
be prescribed for this patient?
1) Craniotomy
2) Wound debridement
3) Monitor and observe
4) Evacuation of the hematoma
____ 16. A patient with a traumatic brain injury is leaking clear fluid from the nose. What action should the nurse take?
1) Collect the fluid with gauze
2) Check the fluid for red blood cells
3) Send a specimen for a protein level
4) Insert a nasal plug in the nostril leaking the fluid
____ 17. The family of a patient with a traumatic brain injury asks why the bed side rails are padded. What should the
nurse explain to the family?
1) “There is a risk for seizure activity after a head injury.”
2) “The padding prevents injury when turning the patient.”
3) “The padding prevents the patient from climbing out of bed.”
4) “The padding ensures the side rails are kept elevated at all times.”
____ 18. A patient recovering from a stroke has profound bradycardia. What should the nurse suspect as the cause of
this manifestation?
1) Parasympathetic nervous system disruption
2) Irritation of the sympathetic nervous system
3) Shunting of fluid from the cerebral vasculature
4) Alteration in the vasomotor center in the brainstem
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____ 19. The nurse is caring for a patient with neurogenic shock. What finding should the nurse expect to assess in this
patient?
1) Tachycardia
2) Hypertension
3) Warm dry skin
4) Rapid shallow respirations
____ 20. A patient with neurogenic shock is demonstrating vagal stimulation. What should the nurse expect to be
prescribed for this patient?
1) Atropine
2) Epinephrine
3) Phenylephrine
4) Norepinephrine
____ 21. A patient with neurogenic shock has a sustained heart rate of 38 beats per minute. Based on this observation,
for what should the nurse prepare the patient?
1) Intravenous fluids
2) Pacemaker insertion
3) Cardiac catheterization
4) Arterial blood gas analysis
____ 22. The nurse is caring for a patient with hypotension caused by neurogenic shock. What action should the nurse
take to reduce the risk of developing orthostatic hypotension?
1) Raise the head of the bed slowly
2) Elevate the foot of the bed 30 degrees
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 23. The nurse contacts the health-care provider with data collected from a patient recovering from a stroke.
Which information indicated the patient was experiencing central herniation? Select all that apply.
1) Coma
2) Bradycardia
3) Positive Babinski’s
4) Unilateral dilated pupil
5) Increased systolic blood pressure
____ 24. A patient is demonstrating signs of increasing intracranial pressure (ICP). What physical actions should the
nurse take to reduce this pressure? Select all that apply.
1) Placing the head in a neutral position
2) Turning into a left side-lying position
3) Raising the head of the bed 60 degrees
4) Elevating the foot of the bed 45 degrees
5) Placing supine with a pillow under the head
____ 25. The nurse suspects a patient is experiencing an ischemic stroke of the basilar artery. What manifestations did
the nurse most likely assess in this patient? Select all that apply.
1) Ataxia
2) Nausea NURSINGTB.COM
3) Dysphasia
4) Inability to swallow
5) Difficulty with speech
____ 26. A patient with an ischemic stroke is being considered for recombinant tissue plasminogen activator (rt-PA).
What would cause this procedure to be contraindicated in this patient? Select all that apply.
1) Age 83 years
2) Symptoms present for 45 minutes
3) CT scan demonstrates area of ischemia
4) 10-year history of type 2 diabetes mellitus
5) Takes warfarin sodium for atrial fibrillation
____ 27. A patient is being discharged after treatment for an ischemic stroke. Which medications should the nurse
expect to be prescribed for this patient? Select all that apply.
1) Antibiotics
2) Anticoagulant
3) Antihypertensive
4) Antiplatelet therapy
5) Lipid-lowering agent
Numeric Response
28. A patient has an intracranial pressure measurement of 22 mm Hg and blood pressure of 174/88 mm Hg. What
is the patient’s cerebral perfusion pressure?
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 39: Coordinating Care for Critically Ill Patients With Neurological Dysfunction
Answer Section
MULTIPLE CHOICE
1. ANS: 2
Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction
Chapter learning objective: Describing the indications and nursing implications for ICP monitoring in the
critically ill patient
Chapter page reference: 821
Heading: Increased Intracranial Pressure > Intracranial Pressure Monitoring
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Neurologic Regulation
Difficulty: Moderate
Feedback
1 The intraventricular catheter ICP monitoring device can be inserted at the bedside or
the operating room. This is not an advantage.
2 The intraventricular catheter ICP monitoring device is considered the gold standard for
ICP measurement because the catheter tip is located in the lateral ventricle.
3 The intraparenchymal sensor/probe has less mechanical drift of the measurement over
time.
4 The subarachnoid bolt (SAB) N URa S
has INGrate
lower TBof.C OM because of no fluid reservoir.
infection
Feedback
1 Mannitol pulls water from the interstitial spaces across the blood-brain barrier into the
vascular space for diuresis through the kidney. This medication can cause dramatic
fluid shifts and should be provided with intravenous fluids to prevent reactions to fluid
imbalances.
2 High-concentration sodium chloride solutions pull water from the interstitial spaces into
the vascular space without the dramatic fluid shifts caused when osmotic diuretics are
utilized
3 Bacteriostatic saline is used to flush the intracranial pressure monitoring device.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 The patient in a barbiturate coma will not have a gag reflex.
2 The Glasgow coma scale would be inconclusive since the patient is in a coma.
3 The ability to elicit a neurological assessment from a patient in a barbiturate coma is
limited because of the suppression caused by the medication; therefore, other
parameters such as pupillary size and reaction must be used.
4 Blood pressure and heart rate will not provide maximum information about the patient’s
cerebral functioning.
NURSINGTB.COM
PTS: 1 CON: Neurologic Regulation | Assessment
4. ANS: 2
Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction
Chapter learning objective: Discussing the nursing management of patients with increased ICP, stroke,
traumatic brain injury, and neurogenic shock
Chapter page reference: 830
Heading: Increased Intracranial Pressure > Nursing Management > Actions
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Neurologic Regulation
Difficulty: Moderate
Feedback
1 Placing the head in a neutral position will not affect body temperature.
2 Antipyretics should be administered for temperature elevations because it will prevent
an increase in cerebral metabolism.
3 Auscultating lung sounds and increasing fluids assumes the temperature is caused by a
lung infection or pooling of secretions. This is not an identified action for a temperature
elevation.
4 Sending a urine specimen for analysis assumes that the temperature elevation is caused
by a urinary tract infection. This is not an identified action for a temperature elevation.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5. ANS: 1
Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction
Chapter learning objective: Discussing the nursing management of patients with increased ICP, stroke,
traumatic brain injury, and neurogenic shock
Chapter page reference: 830
Heading: Increased Intracranial Pressure > Nursing Management > Actions
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Neurologic Regulation
Difficulty: Moderate
Feedback
1 Administering 100% oxygen just prior to suctioning is performed to prevent hypoxia,
which can occur during the interruption of mechanical ventilation.
2 The patient’s head of the bed should already be elevated.
3 Interrupting sedative administration would be appropriate if a complete neurologic
assessment is going to be conducted.
4 The head should already be in the neutral position.
Feedback
1 Overweight is not identified as a risk factor for stroke.
2 Heart rate of 90 bpm is within normal limits and is not a risk factor for stroke.
3 A significant risk factor for stroke is hypertension.
4 A pulse oximeter reading of 98% on room air indicates adequate oxygenation and is not
a risk factor for stroke.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Slurred speech is not identified as a manifestation of a ruptured cerebral aneurysm.
2 Visual field deficits are not identified as a manifestation of a ruptured cerebral
aneurysm.
3 Subarachnoid hemorrhage is characterized by a sudden severe headache, often termed a
“thunderclap” headache because of the intensity of the pain experienced at the onset.
4 Lower extremity weakness is not identified as a manifestation of a ruptured cerebral
aneurysm.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Difficulty: Moderate
Feedback
1 Increasing the head of the bed could further reduce blood flow to the brain.
2 A protective mechanism of the brain, cerebral autoregulation, is dysfunctional after
stroke, rendering the brain vulnerable to hypotension because the cerebral blood vessels
are not able to automatically dilate ensuring adequate oxygen delivery to brain tissue.
The health-care provider should be notified with the blood pressure measurement.
3 Placing the head in a neutral position will not impact the patient’s blood pressure.
4 The patient’s condition could deteriorate in 15 minutes. The blood pressure should be
reported immediately.
Feedback
NURSINGTB.COM
1 Minimum thresholds for hemoglobin hemodilution are typically maintained at
approximately 30 g/dL.
2 A blood pressure of 154/80 mm Hg would indicate adequacy of hypertension within the
triple H therapy.
3 Serum sodium is not an indicator of effectiveness of triple H therapy.
4 Serum potassium is not an indicator of effectiveness of triple H therapy.
Feedback
1 A heart-healthy diet might be appropriate if the stroke is caused by atherosclerosis.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 Smoking cessation is essential for the nurse to include. Exposure to nicotine due to
cigarette smoking causes a decrease in oxygen levels in the blood, which may
contribute to blood clot formation and vasoconstriction with each inhalation of smoke.
Additionally, nicotine may cause more rapid deposition and accumulation of
atherosclerotic plaque. Patients may be more willing to consider smoking cessation
after an illness such as stroke.
3 Stress management has not been identified as essential teaching to reduce the risk of
stroke.
4 Weight reduction has not been identified as essential teaching to reduce the risk of
stroke.
Feedback
1 Verapamil (Calan) is a calcium channel blocker and not a diuretic.
2 NURSINGTB.COM
Verapamil (Calan) is a calcium channel blocker and not a beta blocker.
3 Verapamil (Calan) is a calcium channel blocker and not a lipid-lowering agent.
4 Verapamil (Calan) is a calcium channel blocker.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction
Chapter learning objective: Correlating the clinical manifestations to pathological processes of: Traumatic
brain injury
Chapter page reference: 847
Heading: Traumatic Brain Injury > Pathophysiology > Skull Fractures
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Neurologic Regulation; Assessment
Difficulty: Easy
Feedback
1 Hyperthermia is a manifestation of a diffuse axonal injury.
2 Episodic tachycardia is a manifestation of a diffuse axonal injury.
3 A late sign of a basilar fracture is bruising around the eyes (raccoon’s eyes) or the ears,
termed Battle’s sign.
4 Rapid deterioration to comatose is a manifestation of an epidural hematoma.
Feedback
1 A craniotomy may be indicated in patients with hemorrhagic injuries and typically
involve opening of the skull and removal of blood accumulations.
2 With skull fractures, there is a need to débride and clean the wound area as well as to
remove any bone fragments that may be at the area of impact.
3 Surgery is not indicated in patients with diffuse axonal injuries because there is no
specific area of blood removal.
4 Both epidural and subdural hematomas are surgically evacuated to decrease ICP.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 If clear fluid is draining from the ear or nose, it should be collected using loosely
applied gauze.
2 Clear drainage would be checked for glucose and not red blood cells.
3 Clear drainage would be checked for glucose and not protein.
4 If clear fluid is draining from the ear or nose, it should not be stopped.
Feedback
1 After a head injury, the patient should be on seizure precautions because of the risk of
seizure activity.
NURSINGTB.COM
2 Padding is not placed on a bed to prevent injury when turning the patient.
3 Padding is not used to prevent the patient from climbing out of the bed.
4 Padding is not used to ensure that the side rails remain elevated at all times. This would
be a form of physical restraint necessitating a health-care provider’s order.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Intravenous fluids are not indicated to treat sustained bradycardia.
2 In neurogenic shock, transcutaneous and then transvenous pacing may be utilized to
treat repeated episodes of profound bradycardia.
3 Cardiac catheterization is not indicated for the patient in neurogenic shock experiencing
bradycardia.
4 Arterial blood gas analysis is not indicated for the patient in neurogenic shock
experiencing bradycardia.
Feedback
NURSINGTB.COM
1 The nurse should raise the head of bed slowly (10–15 degrees per hour) in a systematic
manner. Because of loss of systemic vasomotor tone, raising a patient’s head of bed
may cause orthostatic hypotension because of an inability of the peripheral blood
vessels to constrict upon position change.
2 Elevating the foot of the bed will not prevent the development of orthostatic
hypotension.
3 The supine position with the head flat will not prevent the development of orthostatic
hypotension.
4 Keeping the head of the bed elevated at 60 degrees may precipitate the development of
orthostatic hypotension.
MULTIPLE RESPONSE
23. ANS: 1, 2, 3, 5
Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction
Chapter learning objective: Correlating the clinical manifestations to pathological processes of: Increased
intracranial pressure (ICP)
Chapter page reference: 817
Heading: Increased Intracranial Pressure > Pathophysiology and Clinical Manifestations
Integrated Processes: Nursing Process: Assessment
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1. Clinical manifestations of central herniation include coma.
2. Clinical manifestations of central herniation include bradycardia.
3. Clinical manifestations of central herniation include positive Babinski’s.
4. Unilateral dilated pupil is a clinical manifestation of uncal herniation.
5. Clinical manifestations of central herniation include increased systolic blood pressure.
Feedback
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1. Positioning a patient so that the neck is in a neutral position assists in facilitating venous
drainage from the head.
2. Positioning a patient so that hip flexion is minimized assists in facilitating venous drainage
from the head. The side-lying position uses hip flexion to maintain the position.
3. Blood volume in the intracranial space may be decreased by raising the head of the bed to
greater than 45 degrees to facilitate drainage of venous blood through the jugular venous
system.
4. Elevating the foot of the bed would increase ICP.
5. The supine position with a pillow under the head would increase ICP.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1. Manifestations of basilar artery syndrome include ataxia.
2. Manifestations of basilar artery syndrome include nausea.
3. Dysphagia is a manifestation of left middle cerebral artery syndrome.
4. Manifestations of basilar artery syndrome include difficulty swallowing.
5. Manifestations of basilar artery syndrome include difficulty in the articulation of speech.
Feedback
1. Exclusion criteria for rt-PA include age greater than 80 years.
2. Include criteria for re-PA include symptoms present for at least 30 minutes.
3. Include criteria for re-PA include a CT scan consistent with an ischemic stroke.
4. Exclusion criteria for rt-PA
NURinclude
SINGaTprior
B.Chistory
OM of diabetes.
5. Exclusion criteria for re-PA include receiving anticoagulants.
Feedback
1. Antibiotics are not routinely prescribed in the treatment of an ischemic stroke.
2. According to primary stroke center accreditation guidelines, stroke patients should be
discharged with anticoagulation if indicated for atrial fibrillation.
3. According to primary stroke center accreditation guidelines, stroke patients should be
discharged with a blood pressure control strategy in patients with hypertension.
4. According to primary stroke center accreditation guidelines, stroke patients should be
discharged with antiplatelet therapy.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
NUMERIC RESPONSE
28. ANS:
95
Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction
Chapter learning objective: Describing the indications and nursing implications for ICP monitoring in the
critically ill patient
Chapter page reference: 820
Heading: Increased Intracranial Pressure > Intracranial Pressure Monitoring
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Neurologic Regulation; Assessment
Difficulty: Moderate
Feedback: The equation MAP – ICP = CPP is used to determine cerebral perfusion pressure. First determine
the patient’s mean arterial pressure: (2(88) + 174)/3 = (176 + 174)/3 = 350/3 = 117. Then use the equation
MAP – ICP = CPP or 117 – 22 = 95. The patient’s cerebral perfusion pressure is 95.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is preparing a teaching tool that focuses on the endocrine system. How should the nurse explain the
negative feedback system?
1) Hormone secretion increases when circulating levels drop.
2) Hormone secretion increases when target organs send signals.
3) Hormone secretion increases when circulating levels increase.
4) Hormone secretion increases when the target tissue does not recognize the level.
____ 2. A patient is diagnosed with a disorder of the hypothalamus. To which other gland is this structure attached?
1) Thyroid
2) Thalamus
3) Pituitary gland
4) Adrenal glands
____ 3. The nurse notes that a patient’s aldosterone level is elevated. Which structure is responsible for controlling
this hormone?
1) Thyroid
2) Hypothalamus
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3) Adrenal cortex
4) Adrenal medulla
____ 4. The nurse notes that a patient has a tumor on the thyroid gland. Where should the nurse expect to palpate this
tumor?
1) Anteriorly below the chin
2) At the level of the clavicle
3) Below the cricoid cartilage
4) Slightly above the angle of Louis
____ 5. The nurse is preparing a teaching tool on the major hormones of the body for a community program. Which
gland should the nurse identify as controlling calcium levels in the body?
1) Thyroid
2) Parathyroid
3) Hypothalamus
4) Posterior pituitary
____ 6. An adolescent is experiencing delayed puberty. Which gland function should be evaluated?
1) Pancreas
2) Adrenal cortex
3) Anterior pituitary
4) Posterior pituitary
____ 7. A patient has not eaten for 18 hours because of diagnostic testing. Which pancreatic hormone is maintaining
this patient’s blood glucose level?
1) Insulin
2) Cortisol NURSINGTB.COM
3) Glucagon
4) Epinephrine
____ 8. The nurse is planning to assess a patient’s endocrine system. What should be included in this assessment?
1) Lung sounds
2) Body weight
3) Bowel sounds
4) Peripheral pulses
____ 9. Upon inspection the nurse notes that a patient’s face is puffy. Which endocrine gland should the nurse assess
for function?
1) Thyroid
2) Pancreas
3) Parathyroid
4) Adrenal cortex
____ 10. The nurse is conducting a physical assessment of a patient’s endocrine system. What should the nurse include
with auscultation?
1) Lung sounds
2) Bowel sounds
3) Carotid arteries
4) Abdominal aorta
____ 11. The nurse is preparing to complete a physical assessment on a patient’s endocrine system. Which gland
should the nurse prepare to palpate?
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1) Testes
2) Ovaries
3) Pancreas
4) Parathyroid
____ 12. The nurse is preparing to palpate a patient’s thyroid gland. Which technique should be used for this
assessment?
1) Palpate the left lobe with the patient’s head turned to the right
2) Palpate the right lobe with the patient’s head turned to the left
3) Stand behind the patient and place fingers on both sides of the neck
4) Stand in front of the patient and palpate the lobes when the patient swallows
____ 13. A patient’s vitamin D level is below normal. Which endocrine gland will need additional investigation?
1) Thyroid
2) Parathyroid
3) Hypothalamus
4) Anterior pituitary
____ 14. A patient is having a test to suppress cortisol levels. Which response suggests that additional testing of the
adrenal cortex would be required?
1) Increase in urine output
2) Increase in cortisol level
3) Decrease in cortisol level
4) No change in cortisol level
____ 15. A patient with an endocrine disorder is being considered for diagnostic tests. What test should the nurse
expect to be prescribed for this patient?
NURSINGTB.COM
1) CT scan
2) Urinalysis
3) Sedimentation rate
4) Hemoglobin and hematocrit
____ 16. A 60-year-old patient asks why endocrine testing is being done. Which is the best response for the nurse to
make?
1) “Endocrine organs atrophy with aging.”
2) “Endocrine function can change through the lifespan.”
3) “Endocrine function remains the same through the lifespan.”
4) “Endocrine testing identifies which hormone replacement therapy you will need.”
____ 17. The nurse suspects that an older patient’s new diagnosis of hypothyroidism is caused by downregulation.
How should the nurse explain this to the patient?
1) “The organ making the hormones is degenerating.”
2) “The strength of the hormones being synthesized is weaker.”
3) “The body becomes confused about the purpose of the hormones.
4) “There are fewer receptors on the surface of target tissues.”
____ 18. An older patient with several chronic diseases asks why some of the health problems are being caused by
hormone imbalances. What explanation should the nurse provide to this patient?
1) “The hormone imbalance caused the chronic disease.”
2) “The chronic diseases exposed the underlying hormone imbalance.”
3) “Other health problems can affect the normal production and response of hormones.”
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4) “The treatment for the chronic diseases adversely affected the organs and hormone
production.”
____ 19. The nurse notes that an older patient is wearing a sweater and scarf on a warm summer day. What should this
observation indicate to the nurse?
1) The patient’s target organs are diseased.
2) The patient’s metabolism is slowing down.
3) The patient needs hormone replacement therapy.
4) The patient’s endocrine organs are malfunctioning.
____ 20. An older patient’s fluid balance record shows a significant increase in urine output over the last few weeks
with no other reported clinical symptoms. For which potential health problem should the nurse plan care for
this patient?
1) Diabetes
2) Dehydration
3) Hyponatremia
4) Urinary tract infection
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. A patient is experiencing dysfunction of the hypothalamus. Which hormones will be affected by this
dysfunction? Select all that apply.
1) Follicle-stimulating hormone (FSH)
2) Thyrotropin-releasing hormone (TRH)
3) Corticotropin-releasing hormoneN(CRH)
URSINGTB.COM
4) Gonadotropin-releasing hormone (Gn-RH)
5) Growth hormone-releasing hormone (GHRH)
____ 22. A patient is diagnosed with insufficient growth hormone. What effects will this have on the patient? Select all
that apply.
1) Change in hair color
2) Alteration in bone density
3) Sluggish protein synthesis
4) Increased use of fatty acids
5) Increase in circulating blood glucose
____ 23. A patient is being evaluated for elevated levels of antidiuretic hormone (ADH). What findings would cause
ADH to be secreted? Select all that apply.
1) Dehydration
2) Decreased heart rate
3) Decreased blood pressure
4) Increased serum osmolarity
5) Elevated blood glucose level
____ 24. A patient’s cortisol level is elevated. How will this elevation affect the patient? Select all that apply.
1) Alteration in fat metabolism
2) Enhance secretion of sodium
3) Alteration in protein metabolism
4) Alteration in carbohydrate metabolism
5) Suppression of the immune response
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 25. The nurse suspects that a patient’s beta 2 receptors are being stimulated. What did the nurse assess to make
this clinical determination? Select all that apply.
1) Diaphoresis
2) Dilated pupils
3) Warm dry skin
4) Urinary incontinence
5) Elevated blood pressure
NURSINGTB.COM
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 2
Chapter number and title: 40, Assessment of Endocrine Function
Chapter learning objective: Discussing the actions of hormones excreted by endocrine glands
Chapter page reference: 858
Heading: Overview of Anatomy and Physiology
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Metabolism; Promoting Health
Difficulty: Easy
Feedback
1 Hormonal release is controlled by a negative feedback system that increases hormone
secretion when circulating levels are decreased.
2 Increasing hormone secretion when the target organ send signals does not describe a
negative feedback system.
3 Increasing secretion when the circulating levels increase describes a positive feedback
system.
4 Increasing secretion when the target tissue does not recognize the level does not
describe a negative feedback system.
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PTS: 1 CON: Metabolism | Promoting Health
2. ANS: 3
Chapter number and title: 40, Assessment of Endocrine Function
Chapter learning objective: Describing the location and function of endocrine glands
Chapter page reference: 861
Heading: Overview of Anatomy and Physiology > Hypothalamus and Pituitary Gland
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Metabolism
Difficulty: Easy
Feedback
1 The thyroid gland is in the neck.
2 The hypothalamus is a small structure located beneath the thalamus.
3 The hypothalamus is connected to the pituitary gland by the infundibulum.
4 The adrenal glands sit atop the kidneys.
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Feedback
1 The thyroid gland does not control calcium levels.
2 Thyrocalcitonin (calcitonin) has a role in the regulation of calcium, along with
parathyroid hormone (PTH; parathormone secreted from the parathyroid glands).
3 The hypothalamus does not control calcium levels.
4 The posterior pituitary gland does not control calcium levels.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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Feedback
1 Urine output is not affected by suppression testing of the adrenal cortex.
2 An increase in cortisol level would be expected during a stimulation test.
3 A decrease in the cortisol levelNindicates
URSINthat GTBthe
.Cadrenal
OM cortex is functioning as
expected.
4 Suppression tests are indicated when there are excess levels of circulating hormone.
When levels of circulating hormone do not decrease with suppression testing,
hyperfunction of the gland is indicated.
Feedback
1 Computed tomography (CT) is used to confirm abnormalities of the endocrine glands.
2 Urinalysis is not used to confirm an abnormality of the endocrine glands.
3 Sedimentation rate is used to evaluate inflammation and not the integrity of the
endocrine glands.
4 Hemoglobin and hematocrit are not used to confirm and abnormality of the endocrine
glands.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Concept: Metabolism
Difficulty: Moderate
Feedback
1 It is unlikely that the hormone imbalance caused the chronic disease.
2 It is unlikely that the chronic disease exposed the underlying hormone imbalance.
3 Chronic disease may affect hormone production and tissue response.
4 It is possible that the treatment for the chronic disease may affect endocrine balance;
however, it is unlikely that the treatment targeted the endocrine organ and hormone
production directly.
Feedback
1 Although polyuria is a manifestation of diabetes, the patient is not demonstrating other
symptoms. It is unlikely that the patient has diabetes.
2 Decreased synthesis of antidiuretic hormone in the older adult is associated with
increased urine frequency and dilute urine, leading to an increased risk of dehydration.
3 Increased urination will not necessarily lead to hyponatremia.
4 Urinary frequency is a manifestation of urinary tract infection; however, the volume of
urine would not be affected.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE RESPONSE
21. ANS: 2, 3, 4, 5
Chapter number and title: 40, Assessment of Endocrine Function
Chapter learning objective: Discussing the actions of hormones excreted by endocrine glands
Chapter page reference: 861
Heading: Overview of Anatomy and Physiology > Hypothalamus and Pituitary Gland
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Metabolism
Difficulty: Moderate
Feedback
1. FSH is controlled by the anterior pituitary gland.
2. TRH is controlled by the hypothalamus.
3. CRH is controlled by the hypothalamus.
4. Gn-RH is controlled by the hypothalamus.
5. GHRH is controlled by the hypothalamus.
Feedback
1. Melanocyte-stimulating hormone from the anterior pituitary gland affects skin and hair color.
2. Growth hormone is necessary for maintaining bone density.
3. Growth hormone facilitates protein synthesis.
4. Growth hormone increases the use of fatty acids.
5. Growth hormone affects blood glucose levels by decreasing the use of glucose for energy.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1. Antidiuretic hormone is secreted in response to dehydration.
2. Antidiuretic hormone is not secreted in response to a decreased heart rate.
3. Antidiuretic hormone is secreted in response to decreased blood pressure.
4. Antidiuretic hormone is secreted in response to increased serum osmolarity.
5. Antidiuretic hormone is not secreted in response to an elevated blood glucose level.
Feedback
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1. Glucocorticoids affect fat metabolism.
2. Glucocorticoids cause reabsorption of sodium.
3. Glucocorticoids affect protein metabolism.
4. Glucocorticoids affect carbohydrate metabolism.
5. Glucocorticoids suppress immune function.
Feedback
1. Alpha receptors in the skin affect sweating.
2. Alpha receptors in the eyes cause pupil dilation.
3. Beta 2 receptors in the blood vessels promote vasodilation, causing warm dry skin.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4. Beta 2 receptors in the bladder cause relaxation of the detrusor muscle, causing incontinence.
5. Beta 2 receptors in the kidney affect renin, causing elevation in blood pressure.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A patient is diagnosed with hypopituitarism. Which additional body structure will most like be examined to
determine the root cause of this disorder?
1) Thyroid
2) Cerebrum
3) Hypothalamus
4) Parathyroid glands
____ 2. A patient is demonstrating signs of low pituitary gland function. Which diagnostic test should the nurse
expect to be prescribed for this patient?
1) MRI
2) Lumbar puncture
3) Cerebral angiogram
4) Carotid Doppler studies
____ 3. The nurse is reviewing orders writtenNfor
URaSpatient
INGTwith
B.C OM
hypopituitarism. What should the nurse expect to be
prescribed for this patient?
1) Diuretics
2) Antibiotics
3) Antihypertensives
4) Electrolyte supplements
____ 4. The bone density report for a patient with hypopituitarism shows areas of thinning and demineralization.
What teaching should the nurse prepare for this patient?
1) Importance of avoiding extremes in temperature
2) Need to reduce exposure to people with infections
3) Food sources containing high amounts of calcium
4) Strategies to increase rest periods throughout the day
____ 5. A patient with hypopituitarism is experiencing muscle weakness. Which referral should the nurse make to
help this patient?
1) Home care
2) Physical therapy
3) Recreational therapy
4) Occupational therapy
____ 6. A patient is being evaluated for possible hyperpituitarism. Which manifestation most likely caused this
patient to seek medical treatment?
1) Hair loss
2) Headaches
3) Sore throat
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4) Muscle cramps
____ 7. A patient is concerned because facial features are changing and the hands are becoming larger and painful.
Which hormone should the nurse suspect is causing this patient’s manifestations?
1) Testosterone
2) Growth hormone
3) Thyroid-stimulating hormone
4) Adrenocorticotropic hormone (ACTH)
____ 8. A patient is recovering from surgery to remove a pituitary tumor. Why should the nurse schedule frequent
mouth care for this patient?
1) Medications dry mucous membranes
2) Maintenance of nothing by mouth status
3) Mouth breathing because of nasal packing
4) Stomatitis caused by the hormone imbalance
____ 9. The patient is preparing discharge teaching for a patient recovering from surgery to treat hyperpituitarism.
Which interdisciplinary team member should be consulted to ensure medication teaching is appropriate?
1) Surgeon
2) Pharmacist
3) Charge nurse
4) Endocrinologist
____ 10. A patient is being discharged after surgery for hyperpituitarism. What should the nurse emphasize to reduce
the risk of postoperative infection?
1) Restrict fluids
2) Avoid straining the suture line NURSINGTB.COM
3) Maintain bedrest for several days
4) Expect clear nasal drainage to occur
____ 11. A patient is suspected of having a disorder of the posterior pituitary gland. For which additional health
problem should the nurse anticipate planning care for this patient?
1) Acromegaly
2) Osteoporosis
3) Diabetes insipidus
4) Type 1 diabetes mellitus
____ 12. A patient is being treated for diabetes insipidus (DI). Which medication should the nurse prepare to
administer?
1) Calcium
2) Synthroid
3) Vitamin D
4) Desmopressin (DDAVP)
____ 13. The nurse notes that patient with diabetes insipidus (DI) has a loss of free water. Which nursing diagnosis
should the nurse use to guide care for this patient?
1) Fluid Volume Deficit
2) Alteration in Comfort
3) Body Image Disturbance
4) Sensory Perceptual Alteration
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 14. A patient with diabetes insipidus (DI) is experiencing extreme dehydration. What should be used to guide
intravenous fluid replacement therapy for this patient?
1) Skin turgor
2) Urine output total
3) Hemoglobin level
4) Serum sodium level
____ 15. The nurse is reviewing discharge instructions with a patient being treated for diabetes insipidus (DI). What
should the nurse direct the patient to do regarding changes in body weight?
1) Restrict fluids for a day
2) Notify the health-care provider
3) Increase the intake of salty foods
4) Take an extra dose of medication
____ 16. A patient with osteoarthritis develops the syndrome of inappropriate antidiuretic hormone (SIADH). What
information in the patient’s history should the nurse identify as being the best reason for the development of
this disorder?
1) Male gender
2) Age 70 years
3) Use of NSAIDs
4) African American
____ 17. A patient with syndrome of inappropriate antidiuretic hormone (SIADH) is experiencing a headache and
confusion. Which laboratory test would best explain the reason for this patient’s symptoms?
1) Sodium
2) Calcium
3) Potassium NURSINGTB.COM
4) Hematocrit
____ 18. The nurse is reviewing laboratory values for a female patient who has had minimal urine output over the last
shift. Which finding suggests that this patient may be experiencing syndrome of inappropriate antidiuretic
hormone (SIADH)?
1) Hematocrit 40%
2) Serum sodium 136 mEq/L
3) Urine specific gravity 1.035
4) Serum potassium 3.9 mEq/L
____ 19. The nurse is reviewing orders written for a patient with syndrome of inappropriate antidiuretic hormone
(SIADH). Which order should the nurse clarify?
1) No added salt diet
2) Fluid restriction 1L/day
3) IV fluids 0.9% normal saline 125 mL/hr
4) Furosemide (Lasix) 20 mg by mouth every day
____ 20. A patient has a serum sodium level of 126 mEq/L. What action should the nurse take to ensure for this
patient’s safety?
1) Apply wrist restraints
2) Implement seizure precautions
3) Prepare for nasogastric tube insertion
4) Plan for intermittent urinary catheterization
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 21. The nurse is preparing medications for a patient with syndrome of inappropriate antidiuretic hormone
(SIADH). Which medication would most likely be prescribed for this patient?
1) Ampicillin
2) Tetracycline
3) Vancomycin
4) Demeclocycline
____ 22. A patient with a history of syndrome of inappropriate antidiuretic hormone (SIADH) reports a low urine
output for several days. What should the nurse respond to this patient?
1) “Drink more fluids.”
2) “Avoid eating salty foods.”
3) “Go to the emergency room now.”
4) “Take an over-the-counter NSAID.”
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 23. A patient’s thyroid-stimulating hormone (TSH) is below normal. What should the nurse expect to assess in
this patient? Select all that apply.
1) Weight gain
2) Thinning hair
3) Decreased bone density
4) Decreased muscle strength
5) Complaints of decreased libido
NUwith
____ 24. The nurse is planning care for a patient RSIhypopituitarism.
NGTB.COM What interventions would be a priority for this
patient? Select all that apply.
1) Fertility
2) Skin care
3) Vital signs
4) Bone density
5) Fluid balance
____ 25. A patient is being evaluated for hyperpituitarism. Which laboratory studies should the nurse expect to be
prescribed for this patient? Select all that apply.
1) Calcium level
2) Growth hormone
3) Cortrosyn stimulation test
4) Follicle-stimulating hormone level (FSH)
5) Thyroid-stimulating hormone level (TSH)
____ 26. The nurse is preparing discharge teaching for a patient recovering from a transsphenoidal hypophysectomy
for a pituitary tumor. What should the nurse emphasize in this teaching? Select all that apply.
1) No lifting
2) Avoid coughing
3) Do not bend over
4) Sneeze with an open mouth
5) Avoid driving for several weeks
____ 27. The nurse is preparing to assess a patient with diabetes insipidus (DI). Which manifestations should the nurse
expect? Select all that apply.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1) Fatigue
2) Extreme thirst
3) Extreme hunger
4) Large amounts of urine output
5) Waking up to urinate during the night
____ 28. Laboratory results have been posted for a male patient experiencing manifestations of diabetes insipidus (DI).
Which results would confirm the diagnosis? Select all that apply.
1) Hematocrit 52%
2) White blood cells 8000
3) Serum sodium 150 mEq/L
4) Urine specific gravity 1.002
5) Serum potassium 5.5 mEq/L
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders
Chapter learning objective: Describing the epidemiology of pituitary disorders
Chapter page reference: 873
Heading: Hypopituitarism > Epidemiology
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Metabolism
Difficulty: Easy
Feedback
1 Hypopituitarism is not caused by dysfunction of the thyroid gland.
2 Hypopituitarism is not caused by dysfunction of the cerebrum.
3 The etiology of anterior pituitary dysfunction is often secondary to damage to the
hypothalamus.
4 Hypopituitarism is not caused by dysfunction of the parathyroid glands.
Feedback
1 If a tumor of the brain or pituitary is suspected, a head MRI may be completed.
2 A lumbar puncture is not indicated for a disorder of the pituitary gland.
3 A cerebral angiogram is not indicated for a disorder of the pituitary gland.
4 Carotid Doppler studies are not indicated for a disorder of the pituitary gland.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Diuretics are not routinely prescribed for a patient with hypopituitarism.
2 Antibiotics are not required to treat hypopituitarism.
3 Antihypertensives are not routinely prescribed for a patient with hypopituitarism.
4 Supportive therapies such as electrolyte replacement are the key to managing the
patient with hypopituitarism.
Feedback
1 The patient does not have a need for skilled nursing care.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 The patient most likely would not seek medical treatment for hair loss.
2 Hyperpituitarism is usually related to a hypersecreting tumor. The patient presentation
is consistent with clinical manifestations associated to the over-secreted hormone, and
the tumor itself may lead to headaches.
3
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A sore throat is a common symptom of the common cold and other upper respiratory
disorders. Medical treatment is not often sought for a sore throat.
4 Muscle cramps are not a manifestation of hyperpituitarism.
Feedback
1 Testosterone is not a hormone controlled by the pituitary gland.
2 Increased levels of growth hormone in an adult can cause course facial features and
alter the bone structure of the hands and feet.
3 Manifestations of increased thyroid-stimulating hormone include weight loss and
exophthalmos.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 The patient is not on any medications that dry the mucous membranes.
2 The patient most likely is no longer on nothing by mouth status.
3 Because of the surgical procedure and postoperative packing, the patient breathes
primarily through the mouth, increasing the chance of dry mouth.
4 Hormone imbalances do not cause stomatitis.
Feedback
1 The surgeon would be consulted regarding the surgical procedure.
2 Because of the complexity of the disease process and possible side effects of
medications (that may decrease secretion of other anterior pituitary hormones), the
patient and family need to understand the specific changes to be reported to the health-
care provider. Collaborate with the pharmacist for mediation teaching.
3 The charge nurse would not have the specific information required about the
medications.
4 The endocrinologist would be consulted regarding the hormone imbalance and the
effects.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders
Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle
considerations for patients with pituitary disorders
Chapter page reference: 877
Heading: Hyperpituitarism > Medical Management > Complications
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Application [Applying]
Concept: Metabolism; Infection; Promoting Health
Difficulty: Moderate
Feedback
1 Restricting fluids would not reduce the risk of postoperative infection.
2 Strain on the suture line could introduce microorganisms into the surgical site and enter
the central nervous system. Cerebrospinal fluid leak could lead to meningitis.
3 The client does not need to be on bedrest for several days.
4 Clear nasal drainage could indicate a cerebrospinal fluid leak that should be reported
since this increases the patient’s risk of developing meningitis postoperatively.
Feedback
1 Acromegaly is caused by over-secretion of growth hormone.
2 Osteoporosis is an adverse effect of hypopituitarism.
3 Central diabetes insipidus is caused by a decreased secretion of antidiuretic hormone
(ADH) from the posterior pituitary gland.
4 Type 1 diabetes mellitus is caused by a malfunction of the cells within the pancreas.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Calcium supplements would be required for a patient with hypopituitarism.
2 Synthroid is a replacement for hypothyroidism.
3 Vitamin D would be appropriate for a patient with osteoporosis caused by low growth
hormone levels.
4 Desmopressin (DDAVP), a synthetic analog of ADH, is the drug of choice in patients
with DI.
Feedback
1 The diagnosis Fluid Volume Deficit related to loss of free water secondary to lack of
ADH would be appropriate for this patient.
2
NURSINGTB.COM
The patient might be uncomfortable because of dehydration; however, this is not an
ideal nursing diagnosis for this patient.
3 Body image disturbance would be appropriate for the patient with hyperpituitarism.
4 Sensory perception alteration would address vision changes and not fluid balance.
Feedback
1 Skin turgor would not be used to guide intravenous fluid replacement therapy.
2 The urine output total would not be used to guide intravenous fluid replacement
therapy.
3 Hemoglobin level is not used to guide intravenous fluid replacement therapy.
4 The solution ordered is based upon serum sodium level.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 It is beyond the nurse’s scope of practice to prescribe therapy for weight changes.
2 Weight is directly associated with water loss or gain, and changes of more than 2 lb per
day should be reported to the health-care provider.
3 Salty foods would cause more water weight gain.
4 It is beyond the nurse’s scope of practice to alter the prescribed medication dose for the
patient.
Feedback
1 There are no specific relationships between the development of SIADH and sex.
2 There are no specific relationships between the development of SIADH and age.
3 Causes of SIADH vary and include side effects of medications such as non-steroidal
anti-inflammatory drugs (NSAIDs).
4 There are no specific relationships between the development of SIADH and race.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 The clinical presentation of the patient with SIADH is primarily related to the resultant
hyponatremia. The neurological signs associated with the hyponatremia are related to
osmotic fluid shifts in the brain that lead to cerebral edema and increased intracranial
pressure.
2 The manifestations of SIADH are not caused by a calcium imbalance.
3 The manifestations of SIADH are not caused by a potassium imbalance.
4 The manifestations of SIADH are not caused by a change in hematocrit level.
Feedback
1 The hematocrit level is within normal limits for a female.
2 The serum sodium level is within normal limits.
3 The urine specific gravity is elevated, which is seen in patients with SIADH. In patients
with SIADH, due to excessive ADH secretion, they present with scant urine output and
elevated urine specific gravity.
4 The serum potassium level is within normal limits even though this electrolyte is not
used in the diagnosis of SIADH.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Medical management is primarily focused on treating the hyponatremia. The nurse
should question a no added salt diet.
2 The patient is placed on a fluid restriction, usually less than 1000 mL/day.
3 IV administration of a saline solution would be expected.
4 Diuretics may be administered to increase urine output.
Feedback
1 There is no indication that wrist restraints are needed for this patient.
2 If the serum sodium level goes below 125 mEq/L, the patient is at risk of seizures.
3 The patient does not need a nasogastric tube.
4 Intermittent urinary catheterization is I
not
NURS NGindicated
TB.COfor M this patient.
PTS: 1 CON: Metabolism | Safety
21. ANS: 4
Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders
Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle
considerations for patients with pituitary disorders
Chapter page reference: 882
Heading: Syndrome of Inappropriate Antidiuretic Hormone > Nursing Management > Actions
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Metabolism; Medication
Difficulty: Moderate
Feedback
1 Ampicillin is not used to treat SIADH.
2 Tetracycline is not used to treat SIADH.
3 Vancomycin is not used to treat SIADH.
4 Demeclocycline (Declomycin), a tetracycline derivative, may also be used because it
increases water excretion by the kidneys.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders
Chapter learning objective: Coordinating the interprofessional plan of care for the patient undergoing
treatment for pituitary disorders
Chapter page reference: 883
Heading: Syndrome of Inappropriate Antidiuretic Hormone > Nursing Management > Teaching
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Metabolism
Difficulty: Moderate
Feedback
1 Drinking fluids will exacerbate the low sodium level and make the condition worse.
2 The patient most likely has a low sodium level. Restricting salt would make the
condition worse.
3 The patient needs medical attention immediately.
4 NSAIDs can cause SIADH. This could make the condition worse.
MULTIPLE RESPONSE
23. ANS: 1, 2, 5
Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders
NUclinical
Chapter learning objective: Correlating RSINmanifestations
GTB.COM to pathophysiological processes of:
Hypopituitarism
Chapter page reference: 873
Heading: Hypopituitarism > Clinical Manifestations
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Metabolism; Assessment
Difficulty: Moderate
Feedback
1. Manifestations of low TSH levels include weight gain.
2. Manifestations of low TSH levels include thinning hair.
3. Manifestations of low growth hormone include decreased bone density.
4. Manifestations of low growth hormone include decreased muscle strength.
5. Manifestations of low TSH levels include decreased libido.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1. Changes in fertility can occur in hypopituitarism.
2. Skin care is not an identified issue in hypopituitarism.
3. Vital signs can be altered in hypopituitarism.
4. Bone density can decrease in hypopituitarism.
5. Fluid balance is not an identified issue in hypopituitarism.
Feedback
1. No lifting is not identified as important to teach this patient.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2. The patient should be instructed to avoid activities that increase pressure at the incision site
such as coughing.
3. The patient should be instructed to avoid activities that increase pressure at the incision site
such as bending over.
4. The patient should be instructed to avoid all sneezing.
5. There is no evidence that driving is restricted after this surgery.
Feedback
1. Fatigue is a sign of fluid volume deficit.
2. Polydipsia or extreme thirst is a primary clinical manifestation of DI.
3. Extreme hunger is a manifestation of diabetes mellitus.
4. Polyuria is a primary clinical
NURS manifestation
INGTB.CofODI. M
5. Nocturia or waking up during the night to void is a primary clinical manifestation of DI.
Feedback
1. Hematocrit is increased in DI.
2. White blood cells are not measured specifically for DI.
3. Serum sodium is elevated in DI.
4. Urine specific gravity is decreased in DI.
5. Serum potassium is not measured specifically for DI.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A patient asks for a definition of adrenal insufficiency. Which response should the nurse make?
1) Increased secretion of hormones from the adrenal cortex
2) Decreased secretion of hormones from the adrenal medulla
3) Increased secretion of hormones from the anterior pituitary gland
4) Decreased secretion of hormones from the anterior pituitary gland
____ 2. A patient with adrenal insufficiency asks why the skin looks so tan. What should the nurse respond to this
patient?
1) “The darker skin means the hormone from the hypothalamus is low.”
2) “The darker skin is caused by the destruction of the cells of the adrenal glands.”
3) “The darker skin means that you have too much of the hormones cortisol and aldosterone.”
4) “The hormone causing the darker skin shares the same hormone as the one helping to
overcome the insufficiency.”
____ 3. A patient is prescribed to have a cortisol blood level drawn. At which time should this sample be drawn?
1) Midnight
2) 0700 hours
3) 1200 hours
4) 2200 hours
____ 4. The results of a patient’s MRI show evidence
NURSIof NGenlarged
TB.COadrenal
M glands. Which health problem is most likely
causing this finding?
1) Cancer
2) Stenosis
3) Infection
4) Autoimmunity
____ 5. A patient being treated for adrenal insufficiency has a serum potassium level of 5.9 mEq/L. What should the
nurse expect to be prescribed for this patient?
1) Kayexalate
2) Hydrocortisone
3) Dexamethasone
4) Dextrose 5% and 0.45% normal saline
____ 6. A patient recovering from emergency surgery after a motor vehicle crash is demonstrating signs of adrenal
insufficiency. What medication should the nurse expect to be prescribed for this patient?
1) Regular insulin 10 units
2) Potassium chloride 20 mEq
3) Intravenous infusion 0.9% normal saline
4) Hydrocortisone sodium succinate (Solu-Cortef)
____ 7. The nurse notes that a patient with adrenal insufficiency has muscular weakness. To what should the nurse
attribute this finding?
1) Infection
2) Inflammation
3) Hyperkalemia
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4) Hypernatremia
____ 8. The nurse is reviewing data collected on a patient with adrenal insufficiency. Which finding suggests that the
patient is experiencing dehydration?
1) Hematocrit 52%
2) Serum cortisol 11 mcg/dL
3) Serum sodium 134 mEq/L
4) Serum potassium 4.8 mEq/L
____ 9. The nurse is providing discharge instructions to a patient with adrenal insufficiency. Which statement
indicates that additional teaching is required?
1) “I should obtain a MedicAlert bracelet.”
2) “I should report changes in urine output.”
3) “I should take my medication every day.”
4) “I should expect to gain weight every day.”
____ 10. A patient is admitted for treatment of Cushing’s syndrome. What is the primary reason for this disorder?
1) Elevated glucocorticoid level
2) Elevated aldosterone secretion
3) Decreased glucocorticoid level
4) Decreased aldosterone secretion
____ 11. The nurse suspects that a patient with Conn’s syndrome has a decreased potassium level. What finding did the
nurse use to make this clinical decision?
1) Muscle wasting
2) Elevated blood glucose
3) Abnormal fat distribution NURSINGTB.COM
4) Development of U waves on the cardiac monitor
____ 12. A patient is being evaluated for hypercortisolism. Which laboratory test should the nurse expect to be
prescribed initially for this patient?
1) Serum sodium level
2) Serum potassium level
3) 24-hour urine for cortisol
4) Fasting blood glucose level
____ 13. The nurse plans to evaluate a patient for hypoglycemia and hypernatremia. Which medication did this patient
most likely receive?
1) Dexamethasone
2) Potassium chloride
3) Aminoglutethimide
4) Spironolactone (Aldactone)
____ 14. A patient is being evaluated for hyperaldosteronism. What should the nurse expect to assess in this patient?
1) Headache
2) Thin, friable skin
3) Dependent edema
4) Fat maldistribution
____ 15. A patient with hypercortisolism has significant fluid retention. Which nursing action would be most
appropriate for this patient?
1) Monitor blood glucose level
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 23. A patient is admitted to determine the cause for adrenal insufficiency. What body structures should the nurse
expect to be examined in this patient? Select all that apply.
1) Ovaries
2) Thyroid
3) Hypothalamus
4) Adrenal glands
5) Anterior pituitary gland
____ 24. The nurse is reviewing the medical history of a patient with adrenal insufficiency. What should the nurse
identify as possible causes for the disorder in this patient? Select all that apply.
1) Cancer
2) Trauma
3) Infection
4) Medications
5) Autoimmune disorder
____ 25. The nurse is visiting the home of a patient with adrenal insufficiency. Which observation indicates that the
patient needs to be seen by the health-care provider immediately? Select all that apply.
1) Fatigue
2) Poor skin turgor
3) Skin hyperpigmentation
4) Dry mucous membranes NURSINGTB.COM
5) Blood pressure 90/50 mm Hg
____ 26. A patient is admitted with hypertension and low potassium level. What information in the medical record
indicates that this patient has Conn’s syndrome? Select all that apply.
1) Age 35
2) Caucasian
3) Male gender
4) Female gender
5) African American
____ 27. The nurse is caring for a female patient with Cushing’s syndrome. What should the nurse expect to assess in
this patient? Select all that apply.
1) Leg cramps
2) Amenorrhea
3) Breast atrophy
4) Menstrual pain
5) Deepening of the voice
____ 28. The nurse is reviewing patient data. Which information suggests this patient has pheochromocytoma? Select
all that apply.
1) Headache
2) Palpitations
3) Weight gain
4) Hypertension
5) Hyperglycemia
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Adrenal
cortex insufficiency
Chapter page reference: 886
Heading: Adrenal Cortical Insufficiency > Pathophysiology
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Metabolism
Difficulty: Moderate
Feedback
1 Adrenal insufficiency may be caused by decreased secretion of glucocorticoids and
mineralocorticoids from the adrenal cortex.
2 The hormones secreted by the adrenal medulla do not affect the development of adrenal
insufficiency.
3 Increased secretion of hormones from the anterior pituitary gland does not cause
adrenal insufficiency.
4 The pathophysiology of adrenalNUinsufficiency
RSINGTBmay .CO beMrelated to decreased secretion of
corticotropin-releasing hormone (CRH) and decreased secretion of ACTH, both from
the anterior pituitary gland.
Feedback
1 The darker skin does not mean that hormones from the hypothalamus are low.
2 The darker skin does not mean that the cells of the adrenal glands are being destroyed.
3 The darker skin does not mean that the patient has increased levels of cortisol and
aldosterone.
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4 As the circulating levels of cortisol and aldosterone fall, the hypothalamus and anterior
pituitary gland increase secretion of CRH and ACTH, respectively. Because
melanocyte-stimulating hormone (MSH) and ACTH share a progenitor (ancestor)
hormone, there is an associated increase in secretion of MSH, leading to a darkened,
bronzed hyperpigmentation that accompanies the increased secretion of ACTH.
Feedback
1 There is no description of what cancer of the adrenal glands would appear like on an
MRI.
2 Stenosis of the adrenal glands would not occur.
3 Adrenal gland enlargement is often observed with infectious processes.
4 Shrinking of the adrenal gland is associated with autoimmune destruction.
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Chapter learning objective: Discussing the medical management of: Adrenal cortex insufficiency
Chapter page reference: 888
Heading: Adrenal Cortical Insufficiency > Medical Management
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Metabolism; Medication
Difficulty: Moderate
Feedback
1 In patients presenting with hyperkalemia, treatment with potassium binding or
excreting agents such as Kayexalate are indicated.
2 Hydrocortisone is part of routine treatment for adrenal insufficiency.
3 Dexamethasone is part of routine treatment for adrenal insufficiency.
4 IV fluids and glucose are part of routine treatment for adrenal insufficiency.
Feedback
1 The patient is at risk for hypoglycemia because of the lack of mineralocorticoid and
glucocorticoid. Insulin would make the hypoglycemia worse.
2 The patient is at risk for hyperkalemia because of the lack of mineralocorticoid and
glucocorticoid. Potassium chloride would make the hyperkalemia worse.
3 The patient is at risk for hypoglycemia. An infusion of Dextrose 5% would be more
appropriate.
4 Risk factors for adrenal crisis are seen in patients who have underlying adrenal
hypofunction and who undergo stressful events such as trauma, surgery, and infections.
Patients with primary adrenal insufficiency require additional doses of glucocorticoid
during periods of stress such as surgery, trauma, or infection.
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Feedback
1 Wearing the medical alert bracelet reduces time to definitive treatment in an emergency
situation.
2 It is important that the patient (and family) is able to detect early signs of adrenal
insufficiency because it can deteriorate to adrenal crisis, which is a life-threatening
emergency.
3 Adrenal cortex replacement is required to maintain fluid balance and normal glucose
levels.
4 Over-replacement of glucocorticoids results in adverse effects including weight gain.
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Feedback
1 Dexamethasone is used to treat Cushing’s syndrome.
2 Potassium chloride is used to treat hyperaldosteronism.
3 Aminoglutethimide is an example of a medication that interferes with cortisol
production in the adrenal cortex. The nurse must monitor for signs of adrenal
suppression, including hypoglycemia and hypernatremia.
4 Spironolactone (Aldactone) isNused toItreat hyperaldosteronism.
URS NGT B.COM
PTS: 1 CON: Metabolism | Medication
14. ANS: 1
Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with adrenal
disorders
Chapter page reference: 891
Heading: Adrenal Cortical Hyperfunction > Nursing Management > Assessment and Analysis
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Metabolism; Assessment
Difficulty: Moderate
Feedback
1 Patients with hyperaldosteronism present with headache.
2 Common findings in patients with hypercortisolism include thin, friable skin.
3 Common findings in patients with hypercortisolism include dependent edema.
4 Common findings in patients with hypercortisolism include fat maldistribution.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with adrenal
disorders
Chapter page reference: 892
Heading: Adrenal Cortical Hyperfunction > Nursing Management > Actions
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity/Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Metabolism
Difficulty: Moderate
Feedback
1 Serum glucose levels rise secondary to increased secretion of glucocorticoid.
2 Turn patient frequently and protect skin from injury. Thinning of skin along with
increased friability of skin accompanied by fluid retention increase the chances of skin
injury due to pressure or friction.
3 Head of bed elevated 45 degrees. This decreases the work of breathing that may
develop secondary to fluid retention.
4 Administer medications that interfere with production/secretion of cortisol. This will
decrease the secretion of cortisol.
Feedback
1 Increasing fluids can increase hypertension.
2 There is no evidence that the patient should increase activity.
3 Excessive salt intake may further exacerbate fluid retention.
4 Increasing salt intake could exacerbate fluid retention.
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Difficulty: Moderate
Feedback
1 Life-threatening cardiac arrhythmias are not seen in hypercortisolism.
2 Because of excessive catecholamine (epinephrine and norepinephrine) secretion,
pheochromocytoma may precipitate life-threatening cardiac arrhythmias.
3 Life-threatening cardiac arrhythmias are not seen in hyperaldosteronism.
4 Life-threatening cardiac arrhythmias are not seen in Cushing’s syndrome.
Feedback
1 The release of the epinephrine and norepinephrine is typically paradoxical, rather than
continuous, and leads to increased heart rate.
2
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The release of the epinephrine and norepinephrine is typically paradoxical, rather than
continuous, and leads to a rise in systolic blood pressure.
3 Catecholamine release also stimulates gluconeogenesis resulting in hyperglycemia.
4 The release of the epinephrine and norepinephrine is typically paradoxical, rather than
continuous, and leads to widening pulse pressure.
Feedback
1 The patient does not need to avoid red meat before this test.
2 The patient should be instructed to avoid chocolate because it is high in amines and can
lead to a false elevation of VMA.
3 The patient does not need to avoid whole grains before this test.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4 The patient does not need to avoid green vegetables before this test.
Feedback
1 Adrenalectomy is the definitive treatment for pheochromocytoma.
2 Pharmacological management focuses on lowering the blood pressure using smooth
muscle relaxants.
3 Pharmacological management focuses on lowering the blood pressure using beta-
adrenergic blocking agents.
4 Pharmacological management focuses on lowering the blood pressure using alpha-
adrenergic blocking agents.
Feedback
1 Immediately after surgery the patient may experience hypoglycemia; however, because
of long-term cortisol replacement the patient will be at risk for hyperglycemia.
2 The patient is not at risk for developing hypercortisolism.
3 The patient is not at risk for developing hyperaldosteronism.
4 Patients who undergo bilateral adrenalectomy are at risk for adrenal insufficiency for
the remainder of their lives.
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Feedback
1 Bedrest decreases secretion of catecholamines.
2 Beta-adrenergic agents lead to increased chronotropic (rate) and inotropic (force)
effects on the heart.
3 Cardiac monitoring will help detect tachyarrhythmias.
4 Sodium nitroprusside (Nipride) quickly decreases blood pressure through direct action
of blood vessels leading to peripheral vasodilation.
MULTIPLE RESPONSE
23. ANS: 3, 4, 5
Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders
Chapter learning objective: Describing the epidemiology of adrenal disorders
Chapter page reference: 886
Heading: Adrenal Cortical Insufficiency > Epidemiology
NUAssessment
Integrated Processes: Nursing Process: RSINGTB.COM
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Metabolism
Difficulty: Easy
Feedback
1. The ovaries are not examined as a cause for adrenal insufficiency.
2. The thyroid gland does not impact adrenal insufficiency.
3. Adrenal insufficiency may result from dysfunction of the hypothalamus.
4. Adrenal insufficiency may result from destruction of the adrenal glands or Addison’s disease.
5. Adrenal insufficiency may result from decreased secretion of adrenocorticotropic hormone
(ACTH) from the anterior pituitary gland.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Difficulty: Moderate
Feedback
1. Causes of primary adrenal insufficiency include cancer.
2. Causes of primary adrenal insufficiency include traumatic processes that lead to direct insults
to the adrenal cortex.
3. Causes of primary adrenal insufficiency include infection.
4. Medications are not identified as causing adrenal insufficiency.
5. Causes of primary adrenal insufficiency include autoimmune disorders.
Feedback
1. Fatigue is a manifestation
NUofRSadrenal
INGTinsufficiency;
B.COM however, it is not life-threatening.
2. Poor skin turgor is an indication of dehydration, which could be life-threatening.
3. Skin hyperpigmentation is a manifestation of adrenal insufficiency; however, it is not life-
threatening.
4. Dry mucous membranes indicate dehydration, which could be life-threatening.
5. A low blood pressure is an indication of hypotension, which could be life-threatening.
Feedback
1. Age is not identified as a risk factor for Conn’s syndrome.
2. The incidence of hyperaldosteronism is significantly greater in African Americans than in
Caucasians.
3. There is an autosomal dominant pattern of inheritance for primary hyperaldosteronism, with
females more at risk than males.
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Feedback
1. Leg cramping is not a manifestation of Cushing’s syndrome.
2. In female patients, clinical manifestations include amenorrhea.
3. In female patients, clinical manifestations include breast atrophy.
4. Menstrual pain is not specifically linked to Cushing’s syndrome.
5. In female patients, clinical manifestations include vocal changes (deepening).
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28. ANS: 1, 2, 4, 5
Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Pheochromocytoma
Chapter page reference: 893
Heading: Pheochromocytoma > Clinical Manifestations
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Metabolism; Assessment
Difficulty: Moderate
Feedback
1. Clinical manifestations of pheochromocytoma include headache.
2. Clinical manifestations of pheochromocytoma include palpitations.
3. Clinical manifestations of pheochromocytoma do not include weight gain.
4. Clinical manifestations of pheochromocytoma include hypertension.
5. Clinical manifestations of pheochromocytoma include hyperglycemia.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse notes that a patient is diagnosed with Hashimoto’s thyroiditis. What is the most likely cause of this
patient’s health problem?
1) Congenital
2) Iodine deficiency
3) Tyrosine deficiency
4) Autoimmune response
____ 2. A patient with hypothyroidism asks why the neck has become so large. What should the nurse respond to this
patient?
1) “The growth is cancer.”
2) “The sluggish thyroid caused fat to be deposited around the neck.”
3) “The growth is the body’s attempt to wall off the infection in your thyroid.”
4) “The gland got larger because it was trying to make more thyroid hormone.”
____ 3. A patient with hypothyroidism is prescribed levothyroxine (Synthroid). At which time should the nurse
schedule this medication to be administered?
1) 0800 hours
2) 1200 hours
3) 1700 hours
4) 2300 hours
____ 4. The nurse notices that a patient with hypothyroidism has a husky voice. To what should the nurse attribute
this finding?
1) Chronic fatigue NURSINGTB.COM
2) Enlarged thyroid gland
3) Edema of the tongue and larynx
4) Dry mucous membranes from dehydration
____ 5. The nurse is evaluating care provided to a patient with hypothyroidism. Which finding indicates that
additional care is needed?
1) Skin warm and supple
2) Heart rate 72 and regular
3) Blood pressure 118/68 mm Hg
4) Weight increase 2 kg over a month
____ 6. A patient is being evaluated for hyperthyroidism. What is the most common cause for this disorder?
1) Cancer
2) Toxic medications
3) Radiation exposure
4) Autoimmune disorder
____ 7. The nurse is preparing to assess a patient with exophthalmos. On which body system should the nurse focus
during this assessment?
1) Sensory
2) Hematological
3) Gastrointestinal
4) Musculoskeletal
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____ 8. A patient with hyperthyroidism is prescribed propylthiouracil (PTU). What should the nurse include in the
teaching plan when explaining the mechanism of this medication?
1) Diverts iodine pathways
2) Causes formation of thyroid antibodies
3) Decreases the vascularity of the thyroid gland
4) Blocks iodine from binding with thyroglobulin
____ 9. A patient is recovering from a thyroidectomy. Which observation needs to be reported immediately to the
health-care provider?
1) Changes in voice tone
2) Hypoactive bowel sounds
3) Blood pressure 138/70 mm H
4) Complaints of postoperative pain
____ 10. A patient with hyperthyroidism is placed on seizure precautions as a result of which observation?
1) Hyponatremia
2) Exophthalmos
3) Rapid heart rate
4) Increased T3 and T4 levels
____ 11. The nurse is preparing discharge instructions for a patient being treated medically for hyperthyroidism. What
should the nurse emphasize to protect the patient’s eyes?
1) Use artificial tears
2) Wear sunglasses at all times
3) Wear eye shields at all times
4) Tape the eyes closed at bedtime
NURSINGTB.COM
____ 12. A patient recovering from surgery to treat thyroid cancer continues to lose weight. Which health-care
professional should be consulted to help with this patient’s problem?
1) Surgeon
2) Dietician
3) Pharmacist
4) Radiologist
____ 13. A patient spontaneously develops manifestations of hypoparathyroidism. What should be considered as the
reason for this health problem?
1) Diabetes mellitus
2) Thyroid hypertrophy
3) Low intake of calcium-rich foods
4) Congenital absence of parathyroid glands
____ 14. The nurse is explaining the mechanism of hypoparathyroidism. Which electrolyte should the nurse explain as
being the most significant with regard to this disorder?
1) Sodium
2) Calcium
3) Potassium
4) Cholesterol
____ 15. During an assessment the nurse suspects that a patient is experiencing hypoparathyroidism. What finding
caused the nurse to make this clinical determination?
1) Low heart rate
2) Muscle weakness
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 23. The nurse is preparing to assess a patient with hypothyroidism. What findings should the nurse expect? Select
all that apply.
1) Fatigue
2) Weight gain
3) Increased sleep
4) Decreased energy
5) Increased appetite
____ 24. The nurse suspects that patient with hypothyroidism is experiencing myxedema. What findings caused the
nurse to come to this conclusion? Select all that apply.
1) Constipation
2) Thick, silky hair
3) Dry, coarse skin
4) Decreased heart rate
5) Generalized nonpitting edema
____ 25. A patient is diagnosed with hypothyroidism. What laboratory levels were used to make this diagnosis? Select
all that apply.
1) T3
2) T4
3) GH
4) TSH NURSINGTB.COM
5) FSH
____ 26. A patient with hypothyroidism is recovering from orthopedic surgery. Which findings suggest that this patient
is developing myxedema coma? Select all that apply.
1) Hypoxia
2) Slow heart rate
3) Low body temperature
4) Elevated blood pressure
5) Retaining carbon dioxide
____ 27. After performing an assessment, the nurse suspects that a patient is experiencing hyperthyroidism. What
findings caused the nurse to come to this conclusion? Select all that apply.
1) Anorexia
2) Heart rate 112 bpm
3) Hyperactive bowel sounds
4) Thinning hair noted on the head
5) Weight loss 10 lbs. over the last month
____ 28. The nurse suspects that a patient is experiencing thyroid storm. What actions should the nurse take to support
this patient? Select all that apply.
1) Position on a cooling blanket
2) Monitor intravenous fluid infusion
3) Administer antiemetics as prescribed
4) Administer dexamethasone as prescribed
5) Administer beta-adrenergic blockers as prescribed
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 43: Coordinating Care for Patients With Thyroid and Parathyroid Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders
Chapter learning objective: Describing the epidemiology of thyroid and parathyroid disorders
Chapter page reference: 897
Heading: Hypothyroidism > Epidemiology
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Metabolism
Difficulty: Easy
Feedback
1 One cause of primary hypothyroidism is a congenital thyroid disorder; however, this
does not cause Hashimoto’s thyroiditis.
2 Hypothyroidism can be caused by an iodine deficiency; however, this is rare because of
iodized salt.
3 Hypothyroidism can be caused by a tyrosine deficiency; however, this is rare because
of iodized salt.
4 Hashimoto’s thyroiditis is the most common type of hypothyroidism and is caused by
an autoimmune response that leads to destruction of the thyroid gland by
immunological processes. NURSINGTB.COM
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Feedback
1 Because thyroid hormone affects metabolism, the medication is to be taken in the
morning.
2 This medication should be taken in the morning.
3 This medication should be taken in the morning.
4 This medication should be taken in the morning.
Feedback
1 The husky voice is not caused by chronic fatigue.
2 The husky voice is not caused by an enlarged thyroid gland.
3 Edema of the tongue and around the larynx results in changes in speech resulting in a
husky tone.
4 The husky voice is not caused by dry mucous membranes or dehydration.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 Normal skin turgor and texture are indicative of thyroid health in this patient
population.
2 Vital signs within normal limits indicates thyroid health.
3 Vital signs within normal limits indicates thyroid health.
4 Stable weight indicates thyroid health. A weight gain indicates a sluggish thyroid in this
patient population.
Feedback
1 Protrusion of the eyeball, exophthalmos is characteristic of hyperthyroidism and results
in visual changes. The patient’s vision, which is a part of the sensory system, should be
the focus of the assessment.
2 Exophthalmos is not associated with a hematological problem.
3 Exophthalmos is not associated with a gastrointestinal problem.
4 Exophthalmos is not associated with a musculoskeletal problem.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
8. ANS: 1
Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders
Chapter learning objective: Discussing the medical management of: Hyperthyroidism
Chapter page reference: 903
Heading: Hyperthyroidism > Medical Management
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Metabolism; Medication
Difficulty: Moderate
Feedback
1 Propylthiouracil (PTU) inhibits the synthesis of thyroid hormone by diverting iodine
pathways.
2 Lithium carbonate (Lithonate) can cause thyroid antibodies.
3 Iodine decreases the vascularity of the thyroid gland.
4 Methimazole (Tapazole) blocks the combination of iodine with a protein called
thyroglobulin.
Feedback
1 Assessing for damage to the laryngeal nerve is also a priority in the postoperative
period following thyroidectomy. Changes in voice quality, particularly hoarseness or a
husky tone, may be indicative of laryngeal nerve damage.
2 Hypoactive bowel sounds could be caused by general anesthesia.
3 Blood pressure of 138/70 mm Hg could be within normal limits for this patient.
4 Postoperative pain would be expected in the perioperative period.
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Difficulty: Moderate
Feedback
1 Increased risk for seizure activity related to hyponatremia.
2 Exophthalmos does not increase the risk for seizures.
3 A rapid heart rate is a manifestation of hypermetabolism but will not directly cause
seizures.
4 Increased T3 and T4 levels are diagnostic for hyperthyroidism; however, they do not
directly cause seizures.
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Feedback
1 Heart rate of 88 bpm is within normal limits.
2 A respiratory rate of 16 is within normal limits.
3 A temperature of 99.2°F does not indicate hypoparathyroidism.
4 Hypotension may occur secondary to decreased myocardial contractility and cardiac
dysrhythmias.
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Feedback
1 Hyperparathyroidism is not associated with diabetes insipidus.
2 Hyperparathyroidism is not associated with hyperaldosteronism.
3 Secondary disorders are most often observed in patients with chronic renal failure.
4 Parathyroid adenomas account for 85% of the cases of primary hyperparathyroidism.
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Feedback
1 The patient has chronic renal failure and will most likely have a fluid restriction.
2 Thiazide diuretics increase reabsorption of calcium in the kidney.
3 The patient has chronic renal failure and will most likely have a fluid restriction.
4 Patients with hyperparathyroidism are also taught to decrease consumption of calcium-
containing antacids and vitamin D. Calcium and vitamin D supplements will most
likely be discontinued.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE RESPONSE
23. ANS: 1, 2, 3, 4
Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Hypothyroidism
Chapter page reference: 899
Heading: Hypothyroidism > Clinical Manifestations
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Metabolism; Assessment
Difficulty: Moderate
Feedback
1. The hypometabolic state is characterized by fatigue.
2. The hypometabolic state is characterized by weight gain.
3. The hypometabolic state is characterized by increased sleep.
4. The hypometabolic state is characterized by decreased energy.
5. The hypometabolic state is characterized by decreased appetite.
Feedback
1. Decreased gastrointestinal activity results in constipation.
2. Hair becomes thin and fragile, and hair loss occurs.
3. Skin changes may result over time secondary to cold intolerance, and a lack of sweating may
leave the skin dry and coarse.
4. Cardiac alterations secondary to myxedematous changes include decreased pulse.
5. The increased deposition of glycosaminoglycans causes an osmotic edema and a fluid
collection that is associated with a generalized nonpitting edema.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1. The diagnosis of hypothyroidism is confirmed through analysis of laboratory data, including
T3.
2. The diagnosis of hypothyroidism is confirmed through analysis of laboratory data, including
T4.
3. Growth hormone is not used to diagnose hypothyroidism.
4. The diagnosis of hypothyroidism is confirmed through analysis of laboratory data, including
TSH.
5. Follicle-stimulating hormone is not used to diagnose hypothyroidism.
Feedback
1. The most severe type of hypothyroidism is myxedema coma and is characterized by hypoxia.
2. Because of significant decreases in cardiac function, the patient is bradycardic.
3. The most severe type of hypothyroidism is myxedema coma and is characterized by
hypothermia.
4. Because of significant decreases in cardiac function, the patient is hypotensive.
5. The most severe type of hypothyroidism is myxedema coma and is characterized by carbon
dioxide retention.
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Difficulty: Moderate
Feedback
1. Increased appetite and not anorexia is associated with hyperthyroidism.
2. Clinical manifestations of hyperthyroidism include elevated heart rate.
3. Clinical manifestations of hyperthyroidism include increased gastric activity.
4. Clinical manifestations of hyperthyroidism include hair loss.
5. Clinical manifestations of hyperthyroidism include weight loss.
Feedback
1. Cooling blankets may be used to treat hyperthermia.
2. Fluid resuscitation is a priority in a thyroid storm.
3. Antiemetics are not indicated
NURSinIaNthyroid
GTB.storm.
COM
4. Glucocorticoids, of which dexamethasone is one, may be administered to block the conversion
of T4 to T3 and decrease the release of TS from the anterior pituitary gland.
5. For management of tachycardia, beta-adrenergic blockers may be administered.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A middle-aged patient is surprised to learn of the diagnosis of type 1 diabetes mellitus. What should the nurse
respond?
1) “It is odd since it is usually a disease of childhood.”
2) “You probably developed it because of an infection.”
3) “Type 1 diabetes mellitus can occur at any stage of life.”
4) “It usually means that another disease process is present.”
____ 2. The nurse is reviewing type 1 diabetes mellitus with a group of patients newly diagnosed with the disorder.
What should the nurse explain as the major cause for the disorder?
1) Autoimmune process
2) Cancer of the pancreas
3) Alteration in lipid and protein utilization
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____ 10. A patient with type 1 diabetes mellitus develops symptoms of hypoglycemia only when the blood glucose
level drops to 40 mg/dL. What should be done to reverse this condition?
1) Raise glycemic targets
2) Cut insulin dose in half
3) Add an extra snack to the meal plan
4) Eliminate the evening dose of insulin
____ 11. A patient with type 1 diabetes mellitus is experiencing elevated blood glucose levels in the morning. Which
action should be taken to determine the reason for this elevation?
1) Check urine for glucose level
2) Restrict oral fluids after 1800 hours
3) Measure blood glucose at 0200 hours
4) Limit carbohydrate intake to 45 grams with evening meal
____ 12. An older patient with type 1 diabetes mellitus has poor oral intake. What should be considered to ensure
adequate blood glucose control?
1) Hold all prandial doses
2) Consider increasing longer-acting insulin
3) Increase the frequency of correctional doses
4) Administer prandial and correctional insulin together
____ 13. The nurse is evaluating teaching provided to a patient with type 1 diabetes mellitus. Which patient
observation indicates that medication teaching has been effective?
1) Uses a 1 mL syringe to measure insulin dose
2) Places a new injection an inch away from previous injection site
3) Inserts the needle at a 25-degree angle prior to injecting the medication
NU
4) Provides an injection in the thigh RSan
after INabdominal
GTB.COinjection
M in the morning
____ 14. Which statement best describes the pathophysiology of type 2 diabetes mellitus?
1) An absolute lack of insulin is present
2) The cells resist glucose from entering
3) Pancreatic cells stop producing insulin
4) An autoimmune disorder damages pancreatic cells
____ 15. A patient with type 2 diabetes mellitus is prescribed a glucagon-like peptide-1 agonist. What clinical
symptom should the nurse instruct the patient to expect when taking this medication?
1) Nausea
2) Diarrhea
3) Dry mouth
4) Decreased appetite
____ 16. A patient is newly diagnosed with type 2 diabetes mellitus. Which medication classification should the nurse
expect to be prescribed for this patient?
1) Biguanides
2) Meglitinides
3) Sulfonylureas
4) Thiazolidinediones
____ 17. A patient with type 1 diabetes mellitus is preparing to play tennis. What should be done first before engaging
in this physical activity?
1) Drink 1 liter of fluid
2) Measure blood glucose level
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 23. The nurse suspects that a patient has undiagnosed type 1 diabetes mellitus. What findings did the nurse use to
make this clinical decision? Select all that apply.
1) Weight gain
2) Blurred vision
3) Extreme hunger
4) Excessive thirst
5) Voluminous urine output
____ 24. A patient is having testing to diagnose type 1 diabetes mellitus. Which diagnostic tests might be prescribed
for this patient? Select all that apply.
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1) Hemoglobin A1c
2) 2-hr postprandial
3) Serum albumin level
4) Fasting blood glucose
5) Random blood glucose
____ 25. A medication regimen is being planned for a patient newly diagnosed with type 1 diabetes mellitus. For which
reasons should the nurse instruct the patient to self-administer doses of insulin? Select all that apply.
1) Basal
2) Prandial
3) Deficient
4) Excessive
5) Correctional
____ 26. The nurse is concerned that a patient is at risk for developing type 2 diabetes mellitus. What assessment
findings caused the nurse to have this concern? Select all that apply.
1) Central obesity
2) Sedentary lifestyle
3) Body mass index 29
4) Blood pressure 140/90 mm Hg
5) Fasting blood glucose 76 mg/dL
____ 27. The nurse is reviewing data collected on a patient demonstrating signs of type 2 diabetes mellitus. Which
additional findings strongly suggest that this patient has type 2 of this disorder? Select all that apply.
1) Fatigue
2) Muscle cramps
3) Visual disturbances NURSINGTB.COM
4) Poor wound healing
5) Recurrent infections
Numeric Response
28. A patient with type 2 diabetes mellitus is prescribed 45 grams of carbohydrates for breakfast and 60 grams of
carbohydrates for lunch and dinner. Additional 30 grams of carbohydrates are to be eaten as snacks. How
many servings of carbohydrates is this patient to eat every day? Record your answer as a whole number.
______
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MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus
Chapter learning objective: Discussing the epidemiology of diabetes mellitus
Chapter page reference: 914
Heading: Type 1 Diabetes Mellitus > Epidemiology
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Metabolism
Difficulty: Easy
Feedback
1 Type 1 diabetes can occur at any stage of life.
2 Type 1 diabetes can develop in response to a virus infection; however, the nurse has no
way of knowing why the patient developed the illness.
3 Type 1 diabetes can occur at any stage of life.
4 Type 1 diabetes does not mean that another disease process is present or occurring in
the patient.
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PTS: 1 CON: Metabolism
2. ANS: 1
Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus
Chapter learning objective: Describing the pathophysiology of type 1 and type 2 diabetes mellitus
Chapter page reference: 914
Heading: Type 1 Diabetes Mellitus > Pathophysiology
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Metabolism; Promoting Health
Difficulty: Easy
Feedback
1 Type 1 diabetes is typically triggered by an autoimmune process in which the insulin-
producing beta cells of the pancreas are destroyed, resulting in an absolute lack of
insulin.
2 If part of the pancreas is removed for cancer, the patient can develop type 1 diabetes
mellitus.
3 Type 1 diabetes is not caused by an alteration in lipid and protein utilization.
4 Type 1 diabetes is not caused by a malfunction in carbohydrate metabolism.
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Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus
Chapter learning objective: Correlating clinical manifestations of type 1 and type 2 diabetes mellitus to the
pathophysiology of each disorder
Chapter page reference: 915
Heading: Type 1 Diabetes Mellitus > Clinical Manifestations
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Analysis [Analyzing]
Concept: Metabolism; Assessment
Difficulty: Moderate
Feedback
1 Hypercortisolism does not cause thirst, hunger, and weight loss.
2 Hyperaldosteronism does not cause thirst, hunger, and weight loss.
3 Despite an increased appetite leading to consumption of large amounts of food, the
continual breakdown of fats and proteins leads to weight loss and fatigue.
4 Weight loss is not typically associated with type 2 diabetes mellitus. Extreme hunger
may not be present with type 2 diabetes mellitus.
Feedback
1 A hemoglobin A1c level greater than or equal to 8% indicates poor glycemic control.
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2 A hemoglobin A1c result less than or equal to 6.5% indicates good glycemic control.
3 Hemoglobin A1c is not reported in mg/dL. The value of being less than 110 mg/dL is
the ideal fasting blood glucose level.
4 Hemoglobin A1c is not reported in mg/dL. The value of less than 140 mg/dL would be
ideal for the 2-hour postprandial test.
Feedback
1 One measurement would not be sufficient to achieve tight glycemic control.
2 Three measurements would not provide a total picture of glycemic control.
3 Generally, patients with type 1 DM are advised to check their blood glucose a
minimum of before meals and at bedtime or 4 times a day.
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4 Eight measurements might be needed if another health problem affecting blood glucose
levels is occurring with the patient.
Feedback
1 The heart rate would be rapid because of dehydration.
2 The patient develops Kussmaul’s respirations, which are rapid, deep respirations that
occur as a compensatory mechanism for the acidosis.
3 The urine output would be increased because of osmotic diuresis.
4 The blood pressure would be low because of dehydration.
Feedback
1 The patient will not need a diuretic because of osmotic diuresis occurring with the
DKA.
2 A laxative will not be needed. The patient will have abdominal pain; however, a
laxative is not indicated.
3 Antibiotics are not routinely prescribed in the treatment of DKA.
4 Care must be taken to monitor potassium levels prior to treating the hyperglycemia with
insulin. As insulin is administered to decrease hyperglycemia, potassium will also move
back into the cell, worsening hypokalemia. If hypokalemia is present, potassium
replacement is a priority.
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Feedback
1
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Insulin syringes should be used to measure insulin doses.
2 Rotating sites within one area rather than moving from area to area helps decrease
absorption variability from day to day. This can be done by injecting a new shot at least
an inch away from the last injection site.
3 The needle should be injected at a 90-degree angle. A 45-degree angle can be used if
the patient is very thin.
4 Rotating sites does help reduce lipohypertrophy; however, absorption will be variable
between injections if another body part and not a similar area is used.
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2 Type 2 diabetes mellitus involves defects at the cell membrane that prevent the normal
action of insulin. Even though insulin is present, the cell “resists” its effect in
transporting glucose into the cell.
3 Pancreatic cells stop producing insulin in type 1 diabetes mellitus.
4 Type 1 diabetes mellitus is considered an autoimmune disorder that damages pancreatic
cells.
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Feedback
1 Although adequate hydration is important, it is not required for this patient.
2 In individuals taking insulin, physical activity can cause hypoglycemia if medication
dose or carbohydrate intake is not adjusted. Carbohydrate should be ingested if pre-
exercise blood glucose levels are less than 100 mg/dL. The blood glucose needs to be
measured before ingesting a carbohydrate.
3 A carbohydrate should be ingested only if the blood glucose level is less than 100
mg/dL.
4 An additional dose of medication could cause hypoglycemia and should not be done.
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3 Capillary refill will not estimate the patient’s current blood glucose level.
4 Decreased perfusion secondary to microvascular changes may manifest as delayed
capillary refill.
MULTIPLE RESPONSE
23. ANS: 3, 4, 5
Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus
Chapter learning objective: Correlating clinical manifestations of type 1 and type 2 diabetes mellitus to the
pathophysiology of each disorder
Chapter page reference: 915
Heading: Type 1 Diabetes Mellitus > Clinical Manifestations
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Analysis [Analyzing]
Concept: Metabolism; Assessment
Difficulty: Moderate
Feedback
1. Weight gain is not a manifestation of type 1 diabetes mellitus.
2. Blurred vision can occur when blood glucose levels are too low or too high; however, this is
not used to diagnose type 1 diabetes mellitus.
3. Extreme hunger or polyphagia is a manifestation of type 1 diabetes mellitus.
4. Excessive thirst or polydipsia is a manifestation of type 1 diabetes mellitus.
5. Voluminous urine output or polyuria is a manifestation of type 1 diabetes mellitus.
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Feedback
1. The hemoglobin A1c gives an accurate indication of long-term, time-averaged glucose levels
over the 6 to 8 weeks prior to the HgbA1c blood draw.
2. 2-hr postprandial (after meals) or the oral glucose tolerance test measures blood glucose levels
1 and 2 hours after consuming a high-glucose beverage. The diagnostic value is based on the
blood glucose level 2 hours after consumption.
3. Serum albumin level measures protein in the body. It is not used to help diagnose type 1
diabetes mellitus.
4. Fasting blood glucose measures the glucose level after no caloric intake for at least 8 hours.
Normally, insulin is released, moving that glucose into the cells, preventing hyperglycemia.
Without adequate insulin, hyperglycemia results.
5. A random blood glucose level of greater than or equal to 200 mg/dL in a patient with classic
symptoms of hyperglycemiaNURorSIhyperglycemic
NGTB.COMcrisis may be indicative of diabetes mellitus.
Feedback
1. An approach using a combination of long- or intermediate-acting insulin once or twice a day
to provide basal insulin is most effective in maintaining tight glycemic control.
2. Insulin at mealtimes to cover the intake of carbohydrates is considered prandial insulin.
3. Deficient is not a type of insulin coverage.
4. Excessive is not a type of insulin coverage.
5. Correctional insulin is used to compensate for blood glucose elevations.
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26. ANS: 1, 2, 3, 4
Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus
Chapter learning objective: Discussing the epidemiology of diabetes mellitus
Chapter page reference: 925
Heading: Type 2 Diabetes Mellitus > Epidemiology > Risk Factors
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Analysis [Analyzing]
Concept: Metabolism; Assessment
Difficulty: Moderate
Feedback
1. A manifestation of metabolic syndrome is central obesity, which increases the risk of
developing type 2 diabetes mellitus.
2. A sedentary lifestyle increases the risk of developing type 2 diabetes mellitus.
3. A body mass index over 26 increases the risk of developing type 2 diabetes mellitus.
4. Elevated blood pressure increases the risk of developing type 2 diabetes mellitus.
5. A fasting blood glucose below 100 mg/dL does not increase the risk of developing type 2
diabetes mellitus.
Feedback
1. In addition to the 3 “Ps” of type 1 diabetes, polyuria, polydipsia, polyphagia, other common
clinical manifestations include fatigue.
2. Muscle cramps are not identified as a manifestation of type 2 diabetes mellitus.
3. In addition to the 3 “Ps” of type 1 diabetes, polyuria, polydipsia, polyphagia, other common
clinical manifestations include visual disturbances.
4. In addition to the 3 “Ps” of type 1 diabetes, polyuria, polydipsia, polyphagia, other common
clinical manifestations include poor wound healing.
5. In addition to the 3 “Ps” of type 1 diabetes, polyuria, polydipsia, polyphagia, other common
clinical manifestations include recurrent infections.
NUMERIC RESPONSE
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
28. ANS:
13
Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus
Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle
considerations based upon the disease process
Chapter page reference: 928
Heading: Type 2 Diabetes Mellitus > Medical Management > Carbohydrate Guidelines
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity/Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Metabolism
Difficulty: Easy
Feedback: To determine the number of carbohydrate servings, first add up the total number of carbohydrate
grams to eat each day and then divide by 15. For this patient this calculation would be 45 + 60 + 60 + 30 =
195; 195/15 = 13. The patient should consume 13 servings of carbohydrates per day.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
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1. The school nurse is reviewing the structures of the eye with a group of middle school students. Which
structure should the nurse emphasize as the first line of defense against eye infections?
1) Iris
2) Fovea
3) Cornea
4) Conjunctivae
____ 2. A patient notices a change in the ability to focus the eyes. Which structure should the nurse suspect is causing
this change?
1) Lens
2) Macula
3) Optic disk
4) Optic nerve
____ 3. A patient is diagnosed with amblyopia. On which eye structure should the nurse focus when explaining this
health problem to the patient?
1) Pupil
2) Retina
3) Sclera
4) Orbital muscles
____ 4. An older patient reports a vision change of seeing dark spots. Which structure is causing this patient’s health
concern?
1) Sclera
2) Macula
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3) Vitreous humor
4) Retinal blood vessels
____ 5. During morning care the nurse cleanses a patient’s eyes. Which structure will cause the eyes to blink?
1) Eyelids
2) Eyelashes
3) Lacrimal sacs
4) Lacrimal glands
____ 6. The nurse determines that a patient’s rods are functioning as expected. What color did the patient see that
caused the nurse to come to this conclusion?
1) Red
2) Blue
3) Gray
4) Green
____ 7. The nurse notes that a patient has difficulty seeing objects that are near. Which term should the nurse use
when documenting this finding?
1) Myopia
2) Hyperopia
3) Emmetropia
4) Astigmatism
____ 8. A patient’s eyes are dilated. Which term should the nurse use to document this finding?
1) Miosis
2) Myopia
3) Mydriasis NURSINGTB.COM
4) Hyperopia
____ 9. The nurse is preparing to assess a patient’s near vision. Which tool should the nurse use for this assessment?
1) Jaegar card
2) Snellen chart
3) Ishihara chart
4) Confrontation test
____ 10. The nurse notes that a patient’s left pupil constricts when the right pupil is exposed to a bright light. What
response did the nurse observe?
1) Ocular movements
2) Corneal light reflex
3) Pupillary light reflex
4) Consensual light reflex
____ 11. During an ophthalmologic examination a patient’s red reflex was absent from the left eye. What risk is
increased in the patient because of this finding?
1) Injury
2) Impaired comfort
3) Ineffective coping
4) Ineffective protection
____ 12. A patient is demonstrating manifestations of a detached retina. For which diagnostic test should the nurse
prepare this patient?
1) MRI
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2) CT scan
3) Ultrasound
4) Radioisotope scan
____ 13. A patient with eye pain is scheduled for slit-lamp testing. What should the nurse instruct the patient to do
before this test?
1) Remove contact lenses before the test
2) Take nothing by mouth for four hours before the test
3) Take an over-the-counter analgesic before the test
4) Restrict intake to less than two cups of fluid before the test
____ 14. A patient is scheduled for intraocular pressure testing. What teaching should the nurse provide the patient
about this test?
1) Eye shields will need to be worn after the test
2) Avoid consuming alcohol for 12 hours before the test
3) Eye drops will be needed for several hours after the test
4) Take nothing by mouth after midnight the morning of the test
____ 15. A patient is being prepared for corneal staining. Which health problem is this patient most likely
experiencing?
1) Cataracts
2) Glaucoma
3) Detached retina
4) Corneal abrasions
____ 16. The nurse is preparing a patient for fluorescein angiography. What should the nurse emphasize about care at
home after the test? NURSINGTB.COM
1) Increase oral intake of water after the test
2) Avoid lifting and sneezing for three days after the test
3) Remind that the skin may be yellow for a week after the test
4) Teach to notify the health-care provider if the urine turns green after the test
____ 17. A patient asks why sunglasses need to be worn when out of doors. What health problem should the nurse say
is reduced when responding to this patient?
1) Cataracts
2) Glaucoma
3) Detached retina
4) Corneal abrasions
____ 18. A 57-year-old patient asks how frequent eye examinations should be completed. What should the nurse
respond to this patient?
1) “It depends upon your age and health status.”
2) “Everyone should have an eye exam every year.”
3) “Most people need an examination every five years.”
4) “If you have a chronic illness, an exam is needed every six months.”
____ 19. A middle-aged adult is concerned about needing reading glasses. On which eye structure should the nurse
focus when explaining this age-related change to the patient?
1) Lens
2) Pupil
3) Retina
4) Vitreous humor
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____ 20. An older patient is concerned because the eyes are dry and feel gritty. What should the nurse respond to this
patient’s concern?
1) “This is because the eyelids lose elasticity with aging.”
2) “This is because the arteries in the eyes narrow with aging.”
3) “This is an emergency and needs to be treated immediately.”
4) “This is because the tear glands and conjunctiva don’t lubricate the eye as well with
aging.”
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. A sharp object that was impaled into a patient’s right eye has punctured the uvea. Which eye structures are at
risk because of this injury? Select all that apply.
1) Iris
2) Sclera
3) Retina
4) Choroid
5) Ciliary body
____ 22. The nurse is preparing a tool to teach preoperative patients about the eye. What should the nurse include about
the functions of the ciliary body? Select all that apply.
1) Maintains lens zonules
2) Produces aqueous humor
3) Allows for accommodation
4) Supplies blood to the retina NURSINGTB.COM
5) Changes the shape of the lens
____ 23. The nurse is assessing a patient’s eye function. On which cranial nerves should the nurse focus during this
assessment? Select all that apply.
1) CN II
2) CN III
3) CN IV
4) CN V
5) CN VI
____ 24. The nurse is preparing to assess a patient’s eyes. Which eye functions are responsible for maintaining clear
images of objects? Select all that apply.
1) Myopia
2) Refraction
3) Convergence
4) Pupillary constriction
5) Accommodation
Completion
Complete each statement.
25. The nurse is reviewing the mechanism of vision with a group of patients planning to have LASIK surgery. In
which order should the nurse explain this process? (Enter the number of each step in the proper sequence; do
not use punctuation or spaces. Example: 1234)
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MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 45, Assessment of Visual Function
Chapter learning objective: Identifying key anatomical components of the visual system
Chapter page reference: 937
Heading: Overview of Anatomy and Physiology > Internal Structures
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Sensory Perception; Promoting Health
Difficulty: Moderate
Feedback
1 The iris, or the colored portion of the eye, is actually a ring of muscle fibers located
behind the cornea and in front of the lens. The iris contracts and expands, opening and
closing the pupil in response to the amount of light present, thus helping to protect the
sensitive retina.
2 The fovea is the central part of the macula that provides the sharpest vision.
3 The cornea is the transparent dome that sits on top of the iris. The fovea contains no
NUmost
blood vessels and is the first and RSIpowerful
NGTB.lens COM in the optical system of the eye.
4 Conjunctivae function to lubricate the front portion of the eye as well as the eyelids.
This clear thin membrane is the first line of protection for the eye against infection.
Feedback
1 The lens are responsible for keeping images in focus on the retina.
2 The macula is the most sensitive part of the retina and provides vision for fine work and
reading.
3 The optic disk is the spot on the retina where the optic nerve leaves the eye.
4 The optic nerve carries visual signals from the eye to the brain.
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3. ANS: 4
Chapter number and title: 45, Assessment of Visual Function
Chapter learning objective: Identifying key anatomical components of the visual system
Chapter page reference: 937
Heading: Overview of Anatomy and Physiology > Internal Structures
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Sensory Perception; Promoting Health
Difficulty: Easy
Feedback
1 The pupil is the hole in the center of the iris that allows light to pass. Muscles in the iris
control the size of the pupil.
2 The retina is the portion of the eye that converts light rays into electrical signals and
then sends them to the brain via the optic nerve.
3 The sclera is the white tough covering that functions as the outer layer of the eyeball.
4 The orbital muscles include the six muscles that control eye movements. Weakness or
dysfunction of these muscles can lead to amblyopia or a lazy eye.
Feedback
1 The sclera is the white tough covering that functions as the outer layer of the eyeball.
The sclera is also covered by a clear mucous membrane consisting of cells and an
underlying basement membrane of conjunctival tissue. Tiny red lines (blood vessels)
are often visible; these blood vessels transport blood to the sclera. Discoloration of the
sclera can provide clues to the patient’s current health status.
2 The center area of the retina is called the macula.
3 Vitreous humor is the clear, jellylike fluid found in the back portion of the eye that
helps maintain the shape of the eye. With age, the vitreous humor changes from a gel-
type substance to a liquid and gradually shrinks, separating from the retina. This normal
sign of aging can cause people to start seeing “floaters” and dark spots in their vision.
4 Retinal blood vessels provide nourishment and oxygen to the eye. Abnormalities in
these vessels can lead to vision loss in conditions such as diabetic neuropathy and
macular degeneration.
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Feedback
1 Eyelids function to protect and lubricate the eyes. Oil-producing glands line the inner
edge of the eyelid; these oils mix with tears upon blinking, keeping the eyes moist and
clean.
2 Touching the eyelashes triggers the eyelids to blink.
3 Lacrimal sacs are the channels that drain tears and other debris from the eye.
4 Lacrimal glands function to lubricate and prevent dehydration of the cornea.
Feedback
1 Myopia is difficulty seeing objects that are far away.
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Feedback
1 The Rosenbaum Pocket Vision Screener or Jaeger card assesses for near vision.
2 The Snellen Chart is used to evaluate distance vision.
3 An Ishihara Chart is used to assess color vision.
4 The confrontation test determines the degree of peripheral vision.
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Feedback
1 Assessment of the six ocular movements is done to check eye alignment and
coordination. The patient is asked to follow the movement of a penlight with the eyes
only.
2 The corneal light reflex provides information about the alignment of the eyes. When
there are no alignment problems with the eyes, the light reflex is in approximately the
same position in both pupils.
3 Pupillary light reflex is the normal, expected constriction of the pupil observed when
exposed to bright light.
4 A consensual light reflex is the simultaneous constriction of the other pupil when one is
exposed to bright light.
Feedback
1 Absence of the red reflex could indicate opacity of the lens or cloudiness of the
vitreous. This will affect the patient’s vision, which increases the risk for injury.
2 There is no evidence to support that the absence of the red reflex could increase the
patient’s risk for comfort.
3 There is no evidence to support that the absence of the red reflex could increase the
patient’s risk for impaired coping.
4 There is no evidence to support that the absence of the red reflex could increase the
patient’s risk for ineffective protection.
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Feedback
1 An MRI scan is used most frequently to discover tumors, infection, chronic disease,
fractures, changes in the optic nerve, and enlarged eye muscles.
2 Computerized Tomography (CT) scans may be ordered to help diagnose diseases of the
eye in the following areas: blood vessels, eye muscles, optic nerve, presence of abscess
in or around the eye, fractures of the eye socket, and presence of a foreign body in the
eye or the eye socket.
3 An ultrasound is commonly prescribed to diagnose a detached retina.
4 Radioisotope scanning is often done to identify tumors and ocular melanomas that are
difficult to visualize in some of the less-invasive testing modalities.
Feedback
1 Eye shields do not need to be worn after this test.
2 The patient should be instructed that the test is most accurate when no alcoholic
beverages are consumed for at least 12 hours prior to the test.
3 Eye drops will not be needed after this test.
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4 The test is most accurate when no more than two cups of liquid are consumed four
hours before the test. NPO after midnight is not necessary.
Feedback
1 Corneal staining is not used to diagnose cataracts.
2 Corneal staining is not used to diagnose glaucoma.
3 Corneal staining is not used to diagnose a detached retina.
4 Corneal staining is performed to detect scratches or abrasions on the cornea.
Feedback
1 Instructions to increase intake of water after the test is important to help flush the
infused dye out the body.
2 There are no restrictions on activity or sneezing after the test.
3 The patient may have slightly yellow skin for a few hours after the test.
4 The patient may have green-colored urine after the test caused by excretion of the dye.
The health-care provider does not need to be notified if this occurs.
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Feedback
1 Sunglasses are an important piece of equipment. It is now known that there is an
association between excessive exposure to UV-B light and early formation of cataracts.
2 Sunlight does not cause the development of glaucoma.
3 Sunlight does not cause the development of a detached retina.
4 Sunlight does not cause the development of corneal abrasions.
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3 Arteries and veins of the retina become narrower with age, thus reducing blood flow
yielding a less responsive light reflex. However, this has nothing to do with the need for
reading glasses.
4 Deposits in the vitreous humor, often referred to as “floaters,” may become evident in
advancing years; however, this has nothing to do with the need for reading glasses.
Feedback
1 The loss of eyelid elasticity causes ptosis, which may affect visual fields. It has nothing
to do with dry eyes.
2 Narrowing of the arteries in the eyes with aging affects the light reflex and has nothing
to do with eye dryness.
3 Dry eyes is not an emergency. There is no need for immediate treatment.
4 Tear glands and conjunctiva may lose the ability to efficiently lubricate the eye and
NURSINGTB.COM
therefore produce “dry eye” with aging.
MULTIPLE RESPONSE
21. ANS: 1, 4, 5
Chapter number and title: 45, Assessment of Visual Function
Chapter learning objective: Identifying key anatomical components of the visual system
Chapter page reference: 936
Heading: Overview of Anatomy and Physiology > Internal Structures
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Sensory Perception
Difficulty: Easy
Feedback
1. The middle layer of the eye is the uvea and contains the iris.
2. The sclera is the external layer of the eye.
3. The retina is the innermost layer of the eye.
4. The middle layer of the eye is the uvea and contains the choroid.
5. The middle layer of the eye is the uvea and contains the ciliary body.
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Feedback
1. Maintenance of lens zonules is a function of the ciliary body.
2. Production of aqueous humor is a function of the ciliary body.
3. Accommodation is a function of the ciliary body.
4. The choroid supplies blood to the retina.
5. The ciliary muscles change the shape of the lens.
Feedback
1. CN II Optic transports visual information from the retina to the brain and is responsible for
vision.
2. CN III Oculomotor controls pupil constriction as well as eyelid and eyeball movement.
3. CN IV Trochlear innervates the superior oblique muscles and allows eye movement in a
downward and lateral motion.
4. CN V Trigeminal does not play a role in eye function.
5. CN VI Abducens controls lateral movement of the eye.
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Feedback
1. Myopia results from an eyeball that is too long or when the cornea has too much curve
present.
2. Refraction is a function of the eye that allows for clear images of objects.
3. Convergence is a function of the eye that allows for clear images of objects.
4. Pupillary constriction is a function of the eye that allows for clear images of objects.
5. Accommodation is a function of the eye that allows for clear images of objects.
COMPLETION
25. ANS:
21345
Chapter number and title: 45, Assessment of Visual Function
Chapter learning objective: Discussing the function of the visual system
Chapter page reference: 938
Heading: Overview of Vision Function
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
NURSINGTB.COM
Cognitive level: Application [Applying]
Concept: Sensory Perception; Health Promotion
Difficulty: Moderate
Feedback: Vision is controlled by the interaction of light and nerve impulses transmitted to the nervous
system. As light enters the pupil, it hits the lens. The lens then focuses light rays on the back of the eyeball
that is known as the retina. The ciliary muscles attached to the lens change the shape of the lens depending on
whether the focus is near or far away. The presence of light on the retina causes it to change the light into
nerve signals for the brain to interpret.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. While reviewing collected data the nurse notes that a patient has been newly diagnosed with myopia. What
information in the patient’s history might have contributed to this refractive error?
1) Has 3 children
2) Smokes 1 PPD of cigarettes
3) Raises homegrown tomatoes
4) Worked for 30 years as a tailor
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____ 2. The nurse is planning care for a patient with an astigmatism. What action should the nurse take to reduce this
patient’s headaches and blurred vision?
1) Encourage to wear corrective lenses while awake
2) Apply cool compresses to the eyes every four to six hours
3) Recommend removing corrective lenses every few hours
4) Instruct to gently massage out eye canthus several times a day
____ 3. The nurse suspects that a patient has undiagnosed hyperopia. What did the nurse assess to come to this
conclusion?
1) Squints, has headaches, and blurred vision
2) Sees distance objects better than those near
3) Sees near objects better than those at a distance
4) Unable to focus on objects held close to the face
____ 4. A patient has watery eye discharge affecting both eyes. Which health problem should the nurse suspect this
patient is experiencing?
1) Cataracts
2) Eye trauma
3) Conjunctivitis
4) Corneal abrasions
____ 5. The nurse is evaluating teaching provided to a patient with bacterial conjunctivitis. Which patient statement
indicates that additional teaching is required?
1) “I should place my towel in the bathroom.”
2) “I should wash my hands frequently during the day.”
3) “I should complete all of my prescribed medications.”
4) “I should make a follow-up appointment
NURSIas NGdirected.”
TB.COM
____ 6. A patient is diagnosed with a corneal abrasion. Which diagnostic test was used to confirm this diagnosis?
1) MRI
2) CT scan
3) Ultrasound
4) Fluorescein stain
____ 7. A patient seeks treatment for a corneal abrasion that occurred the previous week. What should the nurse
expect to be prescribed to reduce this patient’s risk of developing a complication?
1) Tetanus vaccination
2) Topical steroid drops
3) Systemic pain medication
4) Topical antihistamine drops
____ 8. The nurse suspects that a patient is developing a cataract. What finding did the nurse use to make this clinical
decision?
1) Itching of both eyes
2) Tearing of both eyes
3) Redness of the sclera
4) Double vision in one eye
____ 9. A patient contemplating cataract surgery asks if there are any risk factors. How should the nurse respond?
1) Blindness
2) Detached retina
3) Corneal abrasion
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4) Macular degeneration
____ 10. The nurse is caring for a patient recovering from cataract removal surgery. Which action should the nurse take
to reduce intraocular pressure (IOP)?
1) Restrict fluids
2) Position on the operative side
3) Administer mydriatic eye drops
4) Elevate the head of the bed 45 degrees
____ 11. During a vision test, the nurse notes that a patient has decreased peripheral vision of both eyes. Which health
problem should the nurse suspect that this patient is experiencing?
1) Secondary glaucoma
2) Acute angle glaucoma
3) Normal-tension glaucoma
4) Primary open-angle glaucoma
____ 12. The nurse notes that a patient is diagnosed with primary open-angle glaucoma. What diagnostic test would
have been used to diagnose this health problem?
1) MRI
2) CT scan
3) Tonometry
4) Ultrasound
____ 13. The nurse is visiting the home of a patient recovering from laser trabeculoplasty. Which observation made by
the nurse increases this patient’s risk of developing a postoperative complication?
1) Takes a daily laxative
2) Picks up a 3-year-old grandchildNURSINGTB.COM
3) Washes hands before applying eye drops
4) Applies pressure to the lacrimal duct after applying eye drops
____ 14. The nurse is reviewing teaching provided to a patient with glaucoma. Which patient statement indicates that
teaching has been effective?
1) “I should consider surgery to cure this disorder.”
2) “I should use the eye drops when my vision blurs.”
3) “I should cut down on eating salty and high-fat foods.”
4) “I should call my doctor before taking any over-the-counter medications.”
____ 15. The nurse notes that a patient known to the community clinic was unable to recognize the health-care
provider. What health problem should the nurse suspect is occurring with this patient?
1) Cataracts
2) Glaucoma
3) Corneal abrasions
4) Macular degeneration
____ 16. A patient has been experiencing a gradual loss of central vision. Which tool should the nurse use when
assessing this patient?
1) Jaeger card
2) Amsler grid
3) Snellen chart
4) Ishihara chart
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____ 17. A patient with macular degeneration is being treated with verteporfin (Visudyne). What should the nurse
emphasize in the patient teaching in order to reduce the risk of complications from this treatment?
1) Apply lotion to the skin for two weeks after the treatment
2) Increase the intake of water for three days after the treatment
3) Avoid indoor and outdoor light for five days after treatment
4) Wear sunglasses when going out of doors for one week after treatment
____ 18. It is documented in the medical record that a patient has a rhegmatogenous detached retina. How should this
diagnosis be explained to the patient?
1) Eye trauma causes the retinal to detach from the retinal pigment epithelium (RPE).
2) Eye inflammation causes vitreous fluid leaks into the area under the retina.
3) Vitreous fluid moves under the retina and separates the retina from the pigmented cell
layer.
4) Scar tissue on the retina causes the retina to separate from the retinal pigment epithelium
(RPE).
____ 19. A patient is demonstrating signs of a detached retina. What is the reason this occurred?
1) Blood vessels in the eye spasm
2) Inner layers of the retina separate
3) Overgrowth of vessels damages vision
4) Drainage of vitreous humor is blocked
____ 20. A patient comes into the emergency department with manifestations of retinal detachment. What should the
nurse do to minimize this patient’s eye movements?
1) Provide a sedative
2) Loosely cover both eyes
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3) Elevate the head of the bed 45 degrees
4) Apply an eye patch over the affected eye
____ 21. During a softball game a child was hit in the eye with a bat. What common manifestation should the nurse
expect when assessing this patient?
1) Edema
2) Blood-tinged tears
3) Loss of central vision
4) Loss of peripheral vision
____ 22. The nurse is evaluating teaching provided to a patient recovering from eye trauma. Which statement indicates
that additional teaching is required?
1) “I have to wear the eye patch.”
2) “I can play ball again this weekend.”
3) “I need to see the doctor in a few days.”
4) “I should call the doctor if my sight changes.”
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 23. A patient with myopia asks what can be done to correct the disorder. Which procedures should the nurse
review with this patient? Select all that apply.
1) LASIK
2) Radical keratotomy
3) Thermal keratoplasty
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders
Chapter learning objective: Describing the epidemiology of visual disorders
Chapter page reference: 949
Heading: Visual Acuity Disorders > Epidemiology
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Analysis [Analyzing]
Concept: Sensory Perception; Assessment
Difficulty: Moderate
Feedback
1 The number of children does not impact the development of myopia.
2 Smoking is not a risk factor for the development of myopia.
3 Gardening is not a risk factor for the development of myopia.
4 A risk factor for the development of myopia is doing excessive amounts of close work
such as tailoring.
Feedback
1 Wearing corrective lenses while awake will prevent blurred vision and reduce the
frequency of headaches.
2 Cool compresses are not identified as treatment for astigmatism.
3 Removing corrective lenses will cause blurred vision and increase the chance of
headaches.
4 Massage of the outer canthus is not identified as a treatment for astigmatism.
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Feedback
1 Astigmatism results in visual changes where objects that are near and distant occur
blurry. Other clinical manifestations include squinting, headaches, and blurry vision.
2 Hyperopia occurs when a person can see distant objects more clearly than near objects.
Blurred vision of near objects is the symptom associated with this disorder.
3 Myopia causes a person to see near objects more clearly than objects at a distance. The
result of this distortion is blurred vision for distant objects.
4 Presbyopia, an expected change in vision around midlife, results in the inability to
focus on objects held close to the face
Feedback
1 Watery eye discharge is not a manifestation of cataracts.
2 More information is required before determining if the patient is experiencing eye
trauma.
3 Conjunctivitis is described as an inflammation of the conjunctivae of the eye. There are
many types of conjunctivitis, and most people in their lifetime will have the unpleasant
experience of at least one of them. Diagnosis of conjunctivitis is made on history,
clinical presentation, and physical findings.
4 Corneal abrasions may cause eye tearing, but more information is needed to make this
clinical determination.
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Feedback
1 Towels should be isolated from other family members to prevent possible transmission
to another person.
2 Clean hands are essential to prevent the transmission of conditions from one eye to
another or from one person to another; conjunctivitis is considered extremely
contagious.
3 Completion of all prescribed medication as ordered is needed to prevent reoccurrence
or incomplete healing. Incomplete treatments can lead to an even deeper infection in the
eye.
4 It is essential that patients keep follow-up appointments with their practitioner to verify
the healing process and to monitor for any possible visual loss.
Feedback
1 An MRI is not used to diagnose a corneal abrasion.
2 A CT scan is not used to diagnose a corneal abrasion.
3 Ultrasound is not used to diagnose a corneal abrasion.
4 Examination for a corneal abrasion includes corneal staining with fluorescein stain, and
visualization under a Wood lamp to confirm diagnosis of the abrasion.
Feedback
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1 Tetanus vaccination should be verified and administered if the patient is not considered
up-to-date because any open surface of the body can provide a port of entry for
Clostridium tetani to enter.
2 Topical steroid drops are not used to treat or prevent a complication from a corneal
abrasion.
3 Systemic pain medications may be used for pain caused by a corneal abrasion;
however, they will not prevent a complication from developing.
4 Topical antihistamine drops are not used to treat or prevent a complication from a
corneal abrasion.
Feedback
1 Itching eyes is not a manifestation of cataracts.
2 Eye tearing is not a manifestation of cataracts.
3
NURSINGTB.COM
Reddened sclera is not a manifestation of cataracts.
4 Double vision in one eye is a manifestation of cataracts.
Feedback
1 Cataract removal does not increase the risk of blindness.
2 Cataract removal increases the risk of retinal detachment.
3 Cataract removal is not associated with a corneal abrasion.
4 Cataract removal does not increase the risk of macular degeneration.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with eye disorders
Chapter page reference: 960
Heading: Cataracts > Nursing Management > Actions
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Sensory Perception; Perioperative
Difficulty: Easy
Feedback
1 Fluids do not need to be restricted after cataract surgery. This does not decrease
intraocular pressure.
2 Positioning on the operative side would increase IOP.
3 Mydriatic eye drops dilate the pupil and would be provided preoperatively. These drops
do not affect IOP.
4 Elevating the head of the bed 30 to 45 degrees promotes drainage and prevents any
increase in IOP.
Feedback
1 Secondary glaucoma usually results from an eye injury, inflammation, tumor, or
advanced cases of cataracts, or diabetes. Medications such as steroids, when used
chronically, are also noted to cause this type of glaucoma.
2 Acute angle glaucoma is characterized by severe eye pain, nausea and vomiting, sudden
onset of visual disturbance (often in low light), blurred vision, halo vision, and
reddening of the eye.
3 Normal-tension glaucoma (also referred to as low-tension glaucoma) is a condition
where optic nerve damage and vision loss occur despite having a normal IOP between
10 and 21 mm Hg.
4 In primary open-angle glaucoma, clinical manifestations include gradual loss of
peripheral vision, usually in both eyes.
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Feedback
1 An MRI would not detect glaucoma.
2 A CT scan would not detect glaucoma.
3 Tonometry measures the pressures within the eyes and is usually conducted during a
routine eye examination.
4 An ultrasound would not detect glaucoma.
Feedback
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Feedback
1 Cataracts will not cause the patient to be unable to recognize faces.
2 Glaucoma will not cause the patient to be unable to recognize faces.
3 Corneal abrasions will not cause the patient to be unable to recognize faces.
4 Dry macular degeneration causes a gradual blurring of the central vision, and the
patient may have difficulty recognizing
NURSINfaces. GTB.COM
PTS: 1 CON: Sensory Perception | Assessment
16. ANS: 2
Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders
Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected
disorders of the eye
Chapter page reference: 966
Heading: Macular Degeneration > Clinical Manifestations
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Sensory Perception; Assessment
Difficulty: Moderate
Feedback
1 The Jaeger card assesses near vision.
2 The Amsler grid is used to determine if a matrix of black lines appear straight or are
wavy, which could indicate macular degeneration.
3 The Snellen chart is used to assess for visual acuity.
4 The Ishihara chart is used to assess color vision.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders
Chapter learning objective: Describing complications associated with selected disorders of the eye
Chapter page reference: 967
Heading: Macular Degeneration > Medical Management > Photodynamic Therapy
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Sensory Perception
Difficulty: Moderate
Feedback
1 This treatment does not affect the skin.
2 Increased fluid intake is not required after this treatment.
3 It is important to instruct the patient that he or she must avoid exposing skin/eyes to
direct sunlight or bright indoor light for five days after treatment with verteporfin
(Visudyne) because the medication is activated by light.
4 The patient should avoid indoor and outdoor bright light for five days. Sunglasses
would not be needed since bright light is avoided.
Feedback
1 Exudative retinal detachment can occur with eye trauma.
2 Exudative retinal detachment can occur with eye inflammation.
3 Rhegmatogenous is the most common form of retinal detachment and occurs when a
tear or break in the retina allows vitreous fluid to move under the retina and separate it
from the pigmented cell layer that nourishes the retina.
4 Tractional is the least common type of detachment and occurs when scar tissue on the
retina’s surface contracts and causes the retina to separate from the RPE.
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Feedback
1 Retinal detachment is not caused by vessel spasms.
2 Retinal detachment occurs when there is a separation of the inner layers of the retina
from the underlying retinal pigment epithelium (RPE; choroid).
3 Retinal detachment is not caused by overgrowth of vessels.
4 Retinal detachment is not caused by blocking the drainage of vitreous humor.
Feedback
1 A sedative might help with anxiety; however, it will not minimize eye movements.
2
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Movement of either eye can exacerbate internal eye injury. Because eyes move
together, both eyes must be covered to minimize injury.
3 Elevating the head of the bed helps decrease intraocular pressure; however, this is not a
problem with retinal detachment.
4 A single eye patch is not recommended. Both eyes should be covered.
Feedback
1 Common manifestations of eye trauma include edema around the eye.
2 Blood-tinged tears are not a common manifestation of eye trauma.
3 Loss of central vision occurs with macular degeneration.
4 Loss of peripheral vision occurs with glaucoma.
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Feedback
1 The patient should be instructed about wearing an eye patch if indicated for the injury.
2 The patient’s activity will most likely be restricted until the injury heals and vision is
restored.
3 The patient will need to follow up with the health-care provider at regular intervals.
4 The patient should notify the health-care professional with any vision changes during
the recovery period.
MULTIPLE RESPONSE
NURSINGTB.COM
23. ANS: 1, 2, 4, 5
Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders
Chapter learning objective: Discussing the medical management of selected disorders of the eye
Chapter page reference: 951
Heading: Visual Acuity Disorders > Surgical Management
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Sensory Perception; Perioperative
Difficulty: Moderate
Feedback
1. LASIK is identified as a treatment for myopia.
2. Radical keratotomy is identified as a treatment for myopia.
3. Thermal keratoplasty is identified as a treatment for hyperopia.
4. Phakic intraocular lens is another form of treatment to correct myopia. This treatment is
usually reserved for patients who are unsuitable for LASIK or other vision corrective
surgeries.
5. Photorefractive keratotomy is identified as a treatment for myopia.
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Feedback
1. Tearing is associated with allergic conjunctivitis.
2. Red sclera is associated with allergic conjunctivitis.
3. Puffy eyelids are associated with allergic conjunctivitis.
4. Purulent eye discharge is associated with bacterial conjunctivitis.
5. Matting of the eyelashes is associated with bacterial conjunctivitis.
Feedback
1. The treatment for viral conjunctivitis includes eye lubricants.
2. The treatment for viral conjunctivitis includes cold compresses to the eye for pain relief and
decrease in swelling/irritation.
3. The treatment for allergic conjunctivitis includes topical steroid drops instilled directly to the
eye to decrease inflammation and block the release of histamine.
4. The treatment for viral conjunctivitis includes ocular decongestants to help reduce swelling
and inflammation.
5. The treatment for allergic conjunctivitis includes topically antihistamine drops to decrease
itching.
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Feedback
1. The most common clinical manifestations of corneal abrasions include tearing.
2. The most common clinical manifestations of corneal abrasions include eye pain.
3. The most common clinical manifestations of corneal abrasions include squinting.
4. The most common clinical manifestations of corneal abrasions include photophobia.
5. Purulent drainage is a manifestation of bacterial conjunctivitis.
Feedback
1. Obesity may predisposeNan Uindividual
RSINGTtoBdevelopment
.COM of cataracts.
2. Cataracts are more common after age 60 but can occur at any time.
3. Those with family members who had cataracts are more likely to develop them at some point
in their life.
4. Alcohol intake is not identified as a risk factor for cataracts.
5. Chronic medical conditions such as diabetes, autoimmune disorders, hypertension, and other
eye problems are considered to be at higher risk for cataract development.
Feedback
1. Nonmodifiable risk factors for macular degeneration include race.
2. Nonmodifiable risk factors for macular degeneration include gender.
3. Modifiable risk factors for macular degeneration include obesity.
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Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The school nurse is preparing a poster for students focusing on the structures of the ear. What information
should be included about the Eustachian tube?
1) It is the most visible part of the ear
2) It is lined with glands that secrete cerumen
3) It connects the middle ear with the nasopharynx
4) It holds the sensory organs for equilibrium and hearing
____ 2. A patient is being evaluated for a hearing disorder. How should the nurse explain the semicircular canals?
1) Contain glands that make cerumen
2) Is the smallest bone in the human body
3) Cartilage containing fluid and hair cells
4) Separates the external from the middle ear
____ 3. A patient is diagnosed with a bone conduction hearing disorder. Which bones are responsible for transmitting
sound for bone conduction? NURSINGTB.COM
1) Skull
2) Maxilla
3) Mastoid
4) Mandible
____ 4. A patient is experiencing extreme vertigo. Which part of the ear is malfunctioning?
1) Pinnae
2) Malleus
3) Labyrinth
4) Organs of Corti
____ 5. Which observation made by the nurse indicates that the patient might be experiencing a hearing disorder?
1) Answers most questions incorrectly
2) Sits with the hands folded in the lap
3) Looks at the nurse’s face when talking
4) Takes a few extra seconds before responding
____ 6. During an assessment the nurse determines that a patient is at risk for a perforated eardrum. What information
caused the nurse to have this concern?
1) Flushes the ears with warm water
2) Uses a hair pin to remove ear wax
3) Cleanses the outer ear areas with a wash cloth
4) Places cotton balls in the ears before swimming
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 7. The nurse is preparing to use an otoscope to examine an adult patient’s external ear structures. What should
the nurse do to ensure the ear canal is straight?
1) Pull the pinna down
2) Pull the pinna up and back
3) Hold the otoscope upright
4) Tilt the patient’s head toward the nurse
____ 8. During a hearing assessment the nurse has the patient cover one ear and asks the patient to repeat a few words
spoken near the uncovered ear. Which assessment technique is the nurse using?
1) Voice test
2) Watch test
3) Weber test
4) Tympanic test
____ 9. A patient is scheduled for an audiometry examination. What should the nurse explain as being the purpose of
this test?
1) Determines hearing acuity
2) Measures cranial nerve function
3) Identifies if the middle ear is inflamed
4) Analyzes brain interpretation of sound
____ 10. A patient is experiencing “fullness” in the ears. Which diagnostic test should be anticipated for this patient?
1) MRI
2) CT scan
3) Tympanometry
4) Electronystagmography
NURSINGTB.COM
____ 11. A patient with a hearing disorder just underwent a CT scan with contrast. What should the nurse emphasize to
the patient after the test?
1) Increase oral fluids
2) Avoid caffeinated beverages
3) Take nothing by mouth for three hours
4) Avoid over-the-counter analgesics
____ 12. A patient is directed to schedule an MRI to help diagnose a new onset of unilateral deafness. For which health
reason should this diagnostic procedure be delayed?
1) Patient has a pacemaker
2) Patient takes metformin
3) Patient has claustrophobia
4) Patient is allergic to iodine
____ 13. A patient is experiencing a new onset of reduced hearing. Which medication should the nurse suspect is
causing this patient’s disorder?
1) Prilosec
2) Gentamycin
3) Dexamethasone
4) Calcium supplement
____ 14. During an assessment the nurse becomes concerned that a patient is at risk for a hearing loss. What
information caused the nurse to have this concern?
1) Age 35 years
2) Lives with spouse and two children
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. A patient is diagnosed with a middle ear infection. What structures are affected by this infection? Select all
that apply.
1) Cochlea
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2) Bony labyrinth
3) Eustachian tube
4) Mastoid process
5) Tympanic membrane
____ 22. The nurse notes that a patient has Level III Usher’s syndrome. What should the nurse expect when assessing
this patient? Select all that apply.
1) Deafness
2) Unilateral hearing loss
3) Variable vestibular dysfunction
4) Profound sensorineural hearing loss
5) Progressive sensorineural hearing loss
____ 23. A patient is scheduled for an electronystagmography. What should the nurse instruct the patient to prepare for
this test? Select all that apply.
1) Bring eyeglasses to the test
2) Report an allergy to iodine or shellfish
3) Drinking fluids after the test will occur slowly
4) Take nothing by mouth for three hours before the test
5) Avoid caffeine products for 24 hours prior to the test
____ 24. The nurse is preparing a teaching tool on hearing for a community fair. Which medication classifications
should the nurse identify as potentially causing hearing problems? Select all that apply.
1) Diuretics
2) Antibiotics
3) Vasodilators
4) Chemotherapy agents NURSINGTB.COM
5) Nonsteroidal anti-inflammatory drugs (NSAIDs)
Completion
Complete each statement.
25. The nurse is explaining the mechanism of hearing through sound conduction to a group of high school
students. In which order should the nurse explain this process? Enter the number of each step in the proper
sequence; do not use punctuation or spaces. Example: 1234)
1) Sound enters the pinna
2) Vibrations enter the cochlea
3) Vibrations cause the ossicles to move
4) Vibrations travel through nerves to the brain
5) Sound travels to the tympanic membrane
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MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 47, Assessment of Auditory Function
Chapter learning objective: Identifying key anatomical components of the auditory system
Chapter page reference: 978
Heading: Overview of Anatomy and Physiology > Anatomy
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Sensory Perception; Promoting Health
Difficulty: Easy
Feedback
1 The pinnae are the most visible part of the ear.
2 External auditory canals are lined with glands that secrete cerumen.
3 The Eustachian tube connects the middle ear with the nasopharynx.
4 Bony labyrinth is the structure that holds the sensory organs for equilibrium and
hearing.
Feedback
1 The ear canal contains glands that make cerumen.
2 The stapes is located in the middle ear and are the smallest bones in the human body.
3 Semicircular canals are tubes composed of cartilage that contain both fluid and hair
cells.
4 The tympanic membrane separates the external ear from the middle ear.
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Feedback
1 Bone conduction transmission of sound occurs when the skull bones transport
vibrations directly to the inner ear and then to the auditory nerve.
2 The maxilla is not used to transmit sound.
3 The mastoid bones are commonly used to test bone conduction.
4 The mandible is not used to transmit sound.
Feedback
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Feedback
1 Flushing the ears with warm water will not encourage a perforated eardrum.
2 Inserting foreign objects can cause tissue injury to the sides of the canal and can also
cause cerumen to be moved. Movement of the cerumen by a foreign object places the
patient at risk for cerumen impaction, causing changes in hearing, as well as rupture of
the eardrum.
3 Cleansing the outer ears with a wash cloth will not harm the eardrum.
4 Placing cotton balls in the earsNbefore
URSIswimming
NGTB.Cprotects
OM the eardrum.
PTS: 1 CON: Sensory Perception
7. ANS: 2
Chapter number and title: 47, Assessment of Auditory Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of the
auditory system
Chapter page reference: 980
Heading: Assessment of the Auditory System > Examination With an Otoscope
Integrated Processes: Nursing Process–Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Sensory Perception; Assessment
Difficulty: Moderate
Feedback
1 The pinna is pulled down in an infant or child under 3 years of age.
2 The pinna is pulled up and back in the adult.
3 The otoscope should be held upside down.
4 The patient’s head should be tilted away from the examiner.
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Chapter learning objective: Describing the procedure for completing a history and physical assessment of the
auditory system
Chapter page reference: 981
Heading: Auditory Assessment
Integrated Processes: Nursing Process–Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Sensory Perception; Assessment
Difficulty: Easy
Feedback
1 For the voice test, the practitioner whispers a short statement of four words or fewer
into the patient’s uncovered ear and asks the patient to repeat the words.
2 For the watch test, the watch is held about five inches from each ear, and the
practitioner verifies whether a patient is able to hear the ticking.
3 For the Weber test, a tuning fork is used.
4 Tympanic is not a type of test.
Feedback
1 Hearing acuity is measured through audiometry.
2 Audiometry does not measure cranial nerve function.
3 Audiometry does not diagnose middle ear status.
4 Audiometry does not determine the brain’s ability to interpret sound.
Feedback
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Feedback
1 Patients with pacemakers should check with their practitioner before having any MRI
procedure.
2 Metformin would be an issue if the patient were having a CT scan.
3 Sedatives can be prescribed for patients with claustrophobia.
4 Dye is not used during an MRI. The patient’s allergy to iodine is not an issue.
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Feedback
1 Prilosec is a medication for gastroesophageal reflux disease and is not considered at
high risk for causing hearing loss.
2 Some antibiotics can affect hearing. This medication should be investigated as causing
hearing loss.
3 Dexamethasone is a glucocorticoid, which is not identified as possibly causing a
hearing loss.
4 Calcium supplements are not identified as possibly causing a hearing loss.
Feedback
1 Advancing age is a risk factor for a hearing loss.
2 Marital status and children are not risk factors for a hearing loss.
3 Occupations that place the patient in the presence of loud noises such as those used in a
lawn and garden service is a risk factor for a hearing loss.
4 Living in the country would not increase the patient’s risk for a hearing loss.
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Feedback
1 The frequent use of “earbuds” for listening to music and other sounds can pose a
serious risk to the ear structures if used well beyond recommended volume levels
because damage may be done to sensitive hair cells or other structures within the ear.
2 Time spent on the computer will not necessarily adversely affect hearing.
3 The number of followers on Twitter will not have any effect on hearing.
4 The frequency of posting on Facebook will not have any effect on hearing.
Feedback
1 Waterproof earplugs would helpNUprevent
RSINthe GTdevelopment
B.COM of future ear infections
caused by swimming.
2 Cotton in the ears would trap water and could encourage the development of an ear
infection.
3 There is no evidence that castor oil in the ears prevents an ear infection.
4 Hydrogen peroxide is caustic and could damage the ear canal. This should not be
recommended.
Feedback
1 Drier cerumen is not related to diet.
2 Atrophy of the apocrine glands that produce cerumen causes the cerumen to become
drier.
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Feedback
1 Antibiotics are not required because of a stiff tympanic membrane.
2 There is no evidence to suggest that progressive hearing loss will occur.
3 In the middle ear, membrane changes that include stiffening of the tympanic membrane
will affect hearing.
4 Special care to protect the ears should occur at all times and not just because the
patient’s tympanic membrane is stiffer.
Feedback
1 Presbycusis is a type of hearing loss that occurs with older adults. Localization of
sound, especially in the presence of background noises, is impaired
2 The patient is not describing mixed hearing loss.
3 The patient is not describing conductive hearing loss.
4 The patient is not describing sensorineural hearing loss.
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Feedback
1 Presbycusis is a type of hearing loss that occurs with older adults. This loss is gradual
and is caused by nerve degeneration in the inner ear or auditory nerve.
2 There is no evidence to support that the patient uses NSAIDs.
3 There is no information to support that the patient is taking ototoxic medications.
4 Patients aged 70 years or older may also have an increased auditory reaction time that
results in it taking longer for the elderly patient to process and respond to sensory input.
MULTIPLE RESPONSE
21. ANS: 3, 5
Chapter number and title: 47, Assessment of Auditory Function
Chapter learning objective: Identifying key anatomical components of the auditory system
Chapter page reference: 977
Heading: Overview of Anatomy and Physiology > Anatomy
Integrated Processes: Nursing Process–Assessment
Client Need: Safe and Effective CareNEnvironment/Safety
URSINGTB.COand M Infection Control
Cognitive level: Comprehension [Understanding]
Concept: Sensory Perception; Infection
Difficulty: Easy
Feedback
1. The cochlea is a structure of the inner ear.
2. The bony labyrinth is a structure of the inner ear.
3. The Eustachian tube is a structure of the middle ear.
4. The mastoid process is a structure of the external ear.
5. The tympanic membrane is a structure of the middle ear.
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Feedback
1. Deafness is associated with neurofibromatosis type 2.
2. Unilateral hearing loss is associated with Waardenburg syndrome.
3. Variable vestibular function is associated with Type III Usher’s syndrome.
4. Profound sensorineural hearing loss is associated with Type I Usher’s syndrome.
5. Progressive sensorineural loss is associated with Type III Usher’s syndrome.
Feedback
1. Patients who normally wear eyeglasses should bring them to the test with them. Eyeglasses
assist the patient in vision during the testing.
2. This test does not use contrast
NURSmedium
INGTBso.an COallergy
M to iodine or shellfish is not reported.
3. Patients should be informed that reintroduction of fluids after this test will be gradual to
prevent the occurrence of nausea and vomiting.
4. The patient should be NPO for at least three hours prior to the test. Patients may experience
nausea and vomiting with this test; NPO status may help to decrease this sensation.
5. The patient should refrain from ingestion of caffeine for at least 24 hours prior to the test.
Caffeine can cause stimulation of the central nervous system and therefore possibly influence
testing results.
Feedback
1. The most common categories of medications that pose ototoxic risks include diuretics.
2. The most common categories of medications that pose ototoxic risks include antibiotics.
3. Vasodilators are not identified as posing ototoxic risks.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4. The most common categories of medications that pose ototoxic risks include chemotherapy
agents.
5. The most common categories of medications that pose ototoxic risks include NSAIDs.
COMPLETION
25. ANS:
15324
Chapter number and title: 47, Assessment of Auditory Function
Chapter learning objective: Discussing the function of the auditory system
Chapter page reference: 978
Heading: Overview of Anatomy and Physiology > Auditory Function
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Sensory Perception; Promoting Health
Difficulty: Moderate
Feedback: Sound is gathered by the pinna, and the waves enter the ear traveling through the auditory canal
until they reach the tympanic membrane (eardrum). The sound waves set up vibrations in the eardrum. The
vibrations of the eardrum cause the auditory ossicles in the middle ear to move back and forth. The cochlea
receives the sound vibrations next. Finally, the sound stimulus travels to the vestibulocochlear nerve (acoustic
or auditory nerve), cranial nerve VIII,Nand
URSterminates
INGTBin .Cthe
OMcerebral cortex.
PTS: 1 CON: Sensory Perception | Promoting Health
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. During a home visit the nurse suspects that someone in the family has hearing loss. What did the nurse
observe to come to this conclusion?
1) Television volume on loud
2) Patient sitting in the kitchen
3) Music playing in the background
4) Family member cooking at the stove
____ 2. A patient with a hearing loss is wearing headphones as a part of a diagnostic test. What test is being
completed with this patient?
1) Tympanometry
2) Pure-tone threshold
3) MRI with gadolinium
4) Speech reception threshold
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____ 3. A patient is scheduled for a cochlear implant. Which patient statement indicates that teaching about this
surgery has been effective?
1) “This implant will not restore my hearing.”
2) “I will be able to hear perfectly after this surgery.”
3) “This surgery will drain fluid from my middle ear.”
4) “This surgery will rebuild my damaged tympanic membrane.”
____ 4. The nurse is planning care for a patient recovering from a tympanoplasty. Which action should the nurse
include to ensure the ear packing stays intact?
1) Increase fluid intake
2) Administer tobramycin
3) Maintain nothing by mouth status
4) Position flat with the operative side up
____ 5. A patient who swims several times a week asks why the ears are becoming frequently infected. What should
the nurse explain to this patient?
1) “The pool water is entering your Eustachian tubes.”
2) “The pool water has microorganisms that are entering your ears.”
3) “The pool water is drying out your ears causing skin breakdown.”
4) “The pool water has chlorine that is killing all of the good bacteria.”
____ 6. A patient with external otitis has a ruptured tympanic membrane. Which medication should the nurse expect
to be prescribed for this patient?
1) Tobramycin
2) Fluoroquinolone
3) 2.0% Acetic acid (Vosol)
4) 90% to 95% isopropyl alcohol NURSINGTB.COM
____ 7. A patient with external otitis rates pain as 8 on a scale of 0 to 10. What should the nurse do to improve this
patient’s comfort?
1) Apply warm, dry heat to the ear
2) Apply a cool compress to the ear
3) Position supine with the affected ear down
4) Obtain an order for an opioid pain medication
____ 8. During a well-child visit the nurse suspects that a two-year-old is experiencing otitis media. What finding did
the nurse use to make this clinical determination?
1) Drowsiness
2) Tugging at the ear
3) Tearing of the eyes
4) Clear mucous from the nose
____ 9. A patient with a low-grade fever is diagnosed with otitis media. Which medication should the nurse expect to
be prescribed as a priority for this patient?
1) Cefixime (Suprax)
2) Ibuprofen (Motrin)
3) Acetaminophen (Tylenol)
4) Normal saline nose drops
____ 10. A patient being treated for otitis media is experiencing reduced hearing and dizziness. Which complication
should the nurse suspect is occurring with this patient?
1) Petrositis
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2) Meningitis
3) Mastoiditis
4) Labyrinthitis
____ 11. A patient seeking medical attention for “buzzing in the ears” asks why the blood pressure is being measured.
How should the nurse respond to this patient?
1) “Blood pressure measurement is done on every patient.”
2) “The ear buzzing means your blood vessels are constricted.”
3) “Elevated blood pressure makes the buzzing more noticeable.”
4) “The blood pressure is used to determine what medication you will need.”
____ 12. A patient asks what can be done to stop the “noises” in the ears. What should the nurse ask to determine if the
patient is experiencing tinnitus?
1) “What does the noise sound like?”
2) “How often do the noises occur?”
3) “What are the noises saying to you?”
4) “Do the noises occur mostly at night?”
____ 13. A patient with tinnitus is prescribed diphenhydramine. What should the nurse explain to the patient about this
medication?
1) “This is an antibiotic that will cure the problem.”
2) “This is a decongestant to help reduce the symptoms.”
3) “This is an anticonvulsant that will stop the aura of the noises.”
4) “This is a vitamin supplement that will improve blood flow to the ears.”
____ 14. A middle-aged patient is experiencing tinnitus. What should the nurse suggest to help determine the reason
for this health problem? NURSINGTB.COM
1) Increase the intake of fresh fruit
2) Write down when the noises occur
3) Sleep a few extra hours each night
4) Reduce fluid intake after 1800 hours
____ 15. After an assessment the nurse suspects a patient is experiencing vertigo. Which data caused the nurse to come
to this conclusion?
1) Nasal congestion
2) Spinning sensation at rest
3) Feeling of fullness in the ears
4) Mucopurulent drainage from the nose
____ 16. During a home visit the nurse notes that a patient continues to experience vertigo. On what should the nurse
focus care during this visit?
1) Safety
2) Nutrition
3) Perfusion
4) Fluid balance
____ 17. The nurse is evaluating teaching provided to a patient with vertigo. Which observation indicates that teaching
has been effective?
1) Sips a cup of coffee
2) Changes positions slowly
3) Prepares canned soup for lunch
4) Drinks diet soda during the day
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____ 18. The nurse is reviewing data in a patient’s medical record. Which information increases the patient’s risk for
developing Ménière’s disease?
1) Follows a gluten-free diet
2) Allergic to house dust and pet dander
3) Works as a computer science technician
4) Treated for a pinched nerve in the lower back
____ 19. A patient with Ménière’s disease is admitted for intravenous fluid administration. What additional
manifestation is seen in this disease process?
1) Muscle cramps
2) Drop in blood pressure
3) Capillary glucose 90 mg/dL
4) Uncontrollable eye movements
____ 20. A patient with Ménière’s disease is experiencing severe nausea and vomiting. Which medication should the
nurse expect to be prescribed for this patient?
1) Diazepam (Valium)
2) Meclizine (Antivert)
3) Promethazine (Phenergan)
4) Dimenhydrinate (Dramamine)
____ 21. A patient with severe Ménière’s disease is considering a labyrinthectomy. What should the nurse emphasize
as a complication of this procedure?
1) Long-term tinnitus
2) Chronic otitis media
3) Rupture of the tympanic membrane NURSINGTB.COM
4) Complete hearing loss of the affected ear
____ 22. The nurse suspects that patient is experiencing undiagnosed Ménière’s disease. Which assessment finding
supports the nurse’s clinical decision?
1) Facial pain
2) Nasal drainage
3) Positive Romberg test
4) Decreased deep tendon reflexes
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 23. The nurse is preparing teaching materials for a group of senior citizens. What information should the nurse
include as risk factors for hearing loss? Select all that apply.
1) Diet
2) Heredity
3) Medications
4) Recreational noise
5) Occupational noise
____ 24. A patient seeks medical attention for ear pain. What findings indicate that this patient is experiencing external
otitis? Select all that apply.
1) Edema of the ear canal
2) External ear tender to touch
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Numeric Response
28. A patient with vertigo is prescribed prochlorperazine (Compro) 10 mg intramuscularly four times a day. A
vial containing 250 mg/10 mL of the medication is delivered by the pharmacy. How many mL of the
medication should the nurse provide for each dose? Record your answer to the nearest tenth decimal point.
______
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MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Hearing
loss
Chapter page reference: 988
Heading: Hearing Loss > Clinical Manifestations
Integrated Processes: Nursing Process–Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Sensory Perception
Difficulty: Easy
Feedback
1 Manifestations of increasing difficulty in hearing include turning up the volume on
electronics such as televisions and radios.
2 The patient sitting in the kitchen does not indicate a hearing loss.
3 More information is needed about music playing in the background because the volume
of the music is not addressed.
4 A family member’s actions doNnot URindicate
SINGT aB .COMloss.
hearing
Feedback
1 Tympanometry is a test that measures the impedance of the middle ear to the acoustic
energy.
2 Pure-tone threshold is an audiological test conducted with air and bone conduction
assessment to quantify hearing loss. To complete this test, the patient wears
headphones.
3 Standard MRI with gadolinium enhancement is usually performed with patients who
present with an abnormal neurological examination and/or when a cerebellopontine-
angle lesion is suspected.
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Feedback
1 The cochlear implant does not restore normal hearing.
2 The cochlear implant does not restore normal hearing.
3 A myringotomy drains fluid from the middle ear.
4 A myringoplasty reconstructs the eardrum.
Feedback
1 Increasing the fluid intake may decrease the thickening of the earwax.
2 Tobramycin is an identified ototoxic medication and should be questioned.
3 There is no need to keep the patient NPO.
4 The patient should be positioned flat, turned on the side with the operative side facing
up after tympanoplasty. This decreases the chance of packing being displaced.
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Feedback
1 The pool water is not entering the patient’s Eustachian tubes.
2 The pool water is not causing the patient’s ear infections.
3 External otitis develops in swimmers as a result of excessive water exposure yielding a
decrease in cerumen. The decrease in cerumen can lead to drying of the external
auditory canal resulting in potential skin breakdown, providing an excellent entry port
for bacterial or fungal infections.
4 The pool water is not killing off the patient’s good bacteria.
Feedback
1 Dry, warm heat may provide some comfort when applied to the ear directly.
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Feedback
1 Drowsiness is not a clinical manifestation of otitis media.
2 Tugging or pulling at the ear is a clinical manifestation of otitis media seen in children.
3 Eye tearing is not a clinical manifestation of otitis media.
4 Clear mucous draining from the nose is not a clinical manifestation of otitis media.
NURSINGTB.COM
PTS: 1 CON: Sensory Perception | Infection | Assessment
9. ANS: 1
Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders
Chapter learning objective: Discussing the medical management of selected disorders of the ear
Chapter page reference: 996
Heading: Otitis Media > Medical Management
Integrated Processes: Nursing Process–Planning
Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Sensory Perception; Infection; Medication
Difficulty: Moderate
Feedback
1 Cefixime (Suprax) is an antibiotic. Oral antimicrobial therapy is the most effective
treatment for acute otitis media.
2 Ibuprofen (Motrin) can be used as an antipyretic and analgesic; however, this would not
be the priority.
3 Acetaminophen (Tylenol) can be used as an antipyretic and analgesic; however, this
would not be the priority.
4 Normal saline nose drops would be used for nasal congestion; however, there is no
information to support that the patient is experiencing nasal congestion.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
10. ANS: 4
Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders
Chapter learning objective: Describing complications associated with selected disorders of the ear
Chapter page reference: 996
Heading: Otitis Media > Medical Management > Complications
Integrated Processes: Nursing Process–Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Sensory Perception; Infection
Difficulty: Moderate
Feedback
1 Petrositis develops when there is inflammation of the temporal bone that penetrates
deep into the ear.
2 Meningitis is an inflammation of the meninges, which is the outer covering of the brain.
3 Mastoiditis is the spread of infection to the mastoid bone that causes an inflammation of
the mastoid air cells of the temporal bone.
4 Labyrinthitis is an inflammatory disorder of the inner ear labyrinth that occurs as a
complication of otitis media, which results in a disturbance in balance and hearing. This
complication may be unilateral or bilateral.
Feedback
1 Blood pressure measurement might be done on every patient; however, this does
address the patient’s problem.
2 Ear buzzing does not necessarily mean that the patient’s blood vessels are constricted.
3 Elevated blood pressure and factors contributing to elevated blood pressure, such as
stress, alcohol consumption, and caffeine, make tinnitus more noticeable.
4 The blood pressure measurement for tinnitus is not used to determine the medications
that should be prescribed.
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Feedback
1 The nurse should ask the patient to describe the noises. The most common bothersome
sensations of sound described by patients, when no sound is actually present, include
ringing, buzzing, roaring, clicking, whistling, and hissing sounds in the ear. These
sounds may be present consistently or intermittently.
2 Asking how often the noises occur will not help determine if the patient is experiencing
tinnitus.
3 Asking what the noises are saying to the patient would help determine if the patient is
experiencing a mental health disorder.
4 Asking if the noises occur at night is a closed-ended question and would not provide the
best information to determine if the patient is experiencing tinnitus.
Feedback
1 Antibiotics are not prescribed for tinnitus. Antibiotics will not cure the disorder.
2 Decongestants might be prescribed for tinnitus to reduce the symptoms.
3 Anticonvulsants have been used to reduce the symptoms. Tinnitus is not identified as
being an aura before a seizure.
4 Vitamin supplements have been shown to reduce the symptoms; however, there is no
information to support that the supplement will improve the blood flow to the ears.
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Feedback
1 Lack of fresh fruit is not identified as a risk factor for tinnitus.
2 Instructing patients to keep a diary of clinical manifestations may help to identify a
causative agent. This diary should include date/time/symptoms experienced to see if an
identifiable trend is present.
3 Lack of sleep is not identified as a risk factor for tinnitus.
4 Excess fluid is not identified as a risk factor for tinnitus.
Feedback
1 Nasal congestion is not a clinical manifestation of vertigo.
2 Clinical manifestations of vertigo include a spinning sensation at rest.
3 Feeling of fullness in the ears N
isUnot
RSa Iclinical
NGTBmanifestation
.COM of vertigo.
4 Mucopurulent drainage from the nose is not a clinical manifestation of vertigo.
Feedback
1 Injuries from falls in the patient with vertigo are not uncommon and may be of
particular concern to elderly patients, who can suffer catastrophic effects from a fall.
2 Nutrition is not an issue with vertigo.
3 Perfusion is not an issue with vertigo.
4 Fluid balance is not an issue with vertigo.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders
Chapter learning objective: Developing a teaching plan for a patient with an ear disorder
Chapter page reference: 1003
Heading: Vertigo > Nursing Management > Teaching
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Analysis [Analyzing]
Concept: Sensory Perception; Safety; Promoting Health
Difficulty: Moderate
Feedback
1 Avoiding caffeine is most likely associated to the stimulant effects of caffeine. The
patient would need more teaching for this observation.
2 Instructions to plan slow, methodical position changes help to decrease vertigo in
patients. Decreasing vertigo symptoms with changes of position may also decrease the
patient’s risk of falling.
3 Decreasing salt intake probably decreases tinnitus based upon its impact on fluid
retention and blood pressure. Limiting salt intake is particularly important in the patient
with hypertension who experiences tinnitus. The patient would need more teaching
about the sodium content of canned foods.
4 Aspartame may have a toxic effect on the inner ear and brain. The patient would need
more teaching about the intake of diet soda.
Feedback
1 A gluten-free diet is not a risk factor for Ménière’s disease.
2 Risk factors for Ménière’s disease include allergies.
3 Vocation is not identified as a risk factor for Ménière’s disease.
4 Lower spinal cord disorders are not identified as risk factors for Ménière’s disease.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Muscle cramps are not associated with Ménière’s disease.
2 Hypotension is not a manifestation of Ménière’s disease.
3 Blood glucose level is not typically assessed in Ménière’s disease.
4 Uncontrollable eye movements are manifestations of Ménière’s disease.
Feedback
1 Diazepam (Valium) depressesNall levels
UR SINofGthe
TBcentral
.COMnervous system and thereby
decreases symptoms.
2 Meclizine (Antivert) decreases excitability of the inner ear labyrinth and blocks
conduction of the inner ear vestibular cerebellar pathways.
3 Promethazine (Phenergan) blocks histamine at the site to decrease symptoms of nausea
and vomiting.
4 Dimenhydrinate (Dramamine) decreases the exaggerated sense of motion.
Feedback
1 Tinnitus is not a complication after a labyrinthectomy.
2 Chronic otitis media is not a complication after a labyrinthectomy.
3 Tympanic membrane rupture is not a complication after a labyrinthectomy.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4 A more radical surgery reserved for very severe cases includes removal of part of the
inner ear called a labyrinthectomy. Although this surgery also improves the vertigo
symptoms, complete hearing loss in the ear on the affected side is a result of the
procedure.
Feedback
1 Facial pain is not associated with Ménière’s disease.
2 Nasal drainage is not a primary symptom of Ménière’s disease.
3 In Ménière’s disease, patients may exhibit a positive Romberg test on examination
(meaning they have a disturbance in balance) and may also have nystagmus.
4 Changes in deep tendon reflexes do not occur in Ménière’s disease.
MULTIPLE RESPONSE
23. ANS: 2, 3, 4, 5
Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders
Chapter learning objective: Describing the epidemiology of hearing disorders
Chapter page reference: 988
Heading: Hearing Loss > Epidemiology
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Sensory Perception; Promoting Health
Difficulty: Easy
Feedback
1. Diet is not identified as placing a person at higher risk for developing hearing loss.
2. Heredity is identified as placing a person at higher risk for developing hearing loss.
3. Medications are identified as placing a person at higher risk for developing hearing loss.
4. Recreational noise is identified as placing a person at higher risk for developing hearing loss.
5. Occupational noise is identified as placing a person at higher risk for developing hearing loss.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: External
otitis
Chapter page reference: 993
Heading: External Otitis > Clinical Manifestations
Integrated Processes: Nursing Process–Assessment
Client Need: Safe and Effective Care Environment/Safety and Infection Control
Cognitive level: Comprehension [Understanding]
Concept: Sensory Perception; Infection; Assessment
Difficulty: Easy
Feedback
1. Common clinical manifestations of external otitis include edema of the ear canal.
2. Common clinical manifestations of external otitis include external ear is tender to touch.
3. Common clinical manifestations of external otitis include pain when moving the auricle of the
ear.
4. Common clinical manifestations of external otitis include scant drainage from the ear.
5. Common clinical manifestations of external otitis include swelling around the external ear.
Feedback
1. Chronic illnesses is not an identified risk factor for otitis media.
2. Smoking can cause chronic inflammation to the airways, increasing a person’s risk of
developing otitis media.
3. Patients with family members who have an identified genetic predisposition for otitis media
are at greater risk of developing this disorder.
4. The Eustachian tube is more flat in children or other congenital features can accentuate
infection. This flattening of the Eustachian tube prevents drainage and makes fluid in the ear
more likely to stagnate or to accumulate.
5. Inflammation from an upper respiratory infection can cause narrowing of passages in the ear,
predisposing the patient to fluid accumulation and infection.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1. Advanced age is a risk factor for the development of tinnitus.
2. Nutritional status is not identified as a risk factor for the development of tinnitus.
3. Earwax blockage is identified as a risk factor for tinnitus.
4. Certain medications such as salicylates, NSAIDs, and some antihypertensives, antidepressants,
and chemotherapeutic agents can increase the risk of developing tinnitus.
5. Exposure to loud noises can increase the patient’s risk of developing tinnitus.
NUMERIC RESPONSE
28. ANS:
0.4 mL
Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders
Chapter learning objective: Discussing the medical management of selected disorders of the ear
Chapter page reference: 1002
Heading: Vertigo > Medical Management > Treatment
Integrated Processes: Nursing Process–Implementation
Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Sensory Perception; Medication
Difficulty: Moderate
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback: First determine the amount of medication in each mL by dividing 250 mg/10 mL = 25 mg. Then
divide the dose prescribed by the dose available or 10 mg/25 mg x 1 mL = 0.4 mL. The patient should receive
0.4 mL of medication in each dose.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is preparing information on the integumentary system for a group of high school students. Which
layer of the skin should the nurse explain that plays an initial role in immunity?
1) Dermis
2) Hypodermis
3) Innermost layer of the epidermis
4) Outermost layer of the epidermis
____ 2. A patient is concerned about hair loss. What should the nurse explain about the relationship between hair and
the skin?
1) Hair follicles are anchored and protrude through the dermis.
2) Hair follicles are anchored and protrude through the epidermis.
3) Hair follicles are anchored in the dermis and protrude through the epidermis.
4) Hair follicles are anchored in theNhypodermis
URSINGTand B.protrude
COM through the dermis.
____ 3. The nurse notes that a male patient is bald. What is the status of the hair follicles on the head of this patient?
1) Dead
2) In the resting phase
3) Awaiting keratinization
4) Pausing in the growth cycle
____ 4. A patient asks why it takes so long for fingernails to grow. How should the nurse respond to this patient?
1) “Nail growth speeds up as a person ages.”
2) “Nails have a slow but continuous growth process.”
3) “Slow nail growth is associated with vitamin deficiencies.”
4) “This could mean you have an undiagnosed disease process.”
____ 5. The nurse is caring for a patient with a major burn on the right arm. Which function of the skin is most
affected by this injury?
1) Sensation
2) Excretion
3) Protection
4) Metabolism
____ 6. An older patient says that sunlight has always been avoided because of the risk for developing skin cancer.
Which function of the skin has been most affected by this patient’s practice?
1) Sensation
2) Protection
3) Vitamin D metabolism
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4) Temperature regulation
____ 7. The nurse notes that a patient’s skin and hair are dry. Which function of the skin is most likely
malfunctioning?
1) Sensation
2) Excretion
3) Protection
4) Metabolism
____ 8. The nurse notes that a patient’s fingertips are blue in color. What should this finding indicate to the nurse?
1) Anemia
2) Liver disease
3) Hemosiderin
4) Poor perfusion
____ 9. The nurse notes that a patient has irregularly shaped areas on the skin that are rough and thick. What health
problem should the nurse suspect is causing this patient’s skin condition?
1) Eczema
2) Drug rash
3) Open vesicles
4) Chronic dermatitis
____ 10. The nurse notes that a patient has longitudinal red lines in the finger nails. What health problem should the
nurse suspect is causing this problem?
1) Lymphedema
2) Respiratory failure
3) Bacterial endocarditis NURSINGTB.COM
4) Inflammatory bowel disease
____ 11. An older patient is experiencing dry skin that is itchy and burns. Which age-related change should the nurse
consider is causing this patient’s symptoms?
1) Xerosis
2) Eczema
3) Psoriasis
4) Herpes zoster
____ 12. An older patient asks why a wound is taking so long to heal. What explanation should the nurse provide to
this patient?
1) “There is less protein in the skin with aging.”
2) “The tissue between the skin cells is weaker.”
3) “The amount of blood flow to the skin is slower with aging.”
4) “The number of immune cells in the skin reduces with aging.”
____ 13. The nurse notes that an older patient complains of always feeling cold. Which age-related change to the skin
could be causing this in the patient?
1) Fewer protein stores
2) Decreased subcutaneous tissue
3) Reduced levels of immune cells
4) Slower blood flow to the skin layers
____ 14. An older patient has areas of psoriasis on the arms and legs. What should the nurse expect to be prescribed for
this patient?
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1) Topical steroids
2) Topical Benadryl
3) Lidocaine patches
4) Systemic antibiotics
____ 15. The nurse needs to send a specimen for a wound culture. What should the nurse do prior to obtaining the
specimen?
1) Apply clean gloves
2) Flush the wound bed with sterile saline
3) Cleanse the wound with antimicrobial solution
4) Keep the wound open to air for several minutes
____ 16. The nurse instructs a patient on care required after a punch biopsy. Which patient statement indicates that
teaching has been effective?
1) “I should avoid showering for several days.”
2) “I should change the bandage on the site once a day.”
3) “I should call the doctor if there is any blood on the dressing.”
4) “I should call the doctor if the site is not healed in a few days.”
____ 17. The results of a patient’s biopsy indicate a malignant growth. What should the nurse anticipate being
prescribed for this patient?
1) Systemic medication
2) Additional diagnostic testing
3) Topical antibiotic medication
4) Surgical removal of the lesion
____ 18. The nurse notes that a patient with a N
skin
URrash
SIN has
GTanBelevated
.COM white blood cell count. What should this
information suggest to the nurse?
1) An infection is present.
2) Protein status is questionable.
3) Infection is altering blood flow.
4) Infection has reached the blood stream.
____ 19. A patient is suspected as having a fungal infection. What should the nurse have available during the
evaluation of this skin area?
1) Sterile water
2) Potassium chloride
3) Sterile normal saline
4) Potassium hydroxide
____ 20. A patient recovering from a punch biopsy calls the community clinic because the site is red, warm, and
painful. What should the nurse direct this patient to do?
1) Take an over-the-counter analgesic
2) Clean the site with hydrogen peroxide
3) Go immediately to the emergency department
4) Remove the dressing and flush with sterile saline
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 21. The nurse is preparing information for high school students about the skin. What should the nurse include
about the function of the glands in the skin? Select all that apply.
1) Eccrine sweat glands serve to cool the body.
2) Apocrine sweat glands contribute to body odor.
3) The glands create strength and elastic recoil to the skin.
4) They support temperature regulation through dilation and constriction.
5) Sebaceous glands produce a substance that moisturizes the hair and skin.
____ 22. The nurse notes that a patient’s skin is dry, discolored, and easily torn. Which medications should the nurse
consider as causing this patient’s skin condition? Select all that apply.
1) Steroids
2) Furosemide
3) Amiodarone
4) Warfarin sodium
5) Nonsteroidal anti-inflammatory drugs (NSAIDs)
____ 23. The nurse suspects that a patient’s disrupted skin integrity has a chemical basis. What could have caused this
patient’s health problem? Select all that apply.
1) Urine
2) Stool
3) Adhesives
4) Immobility
5) Gastric fluids
____ 24. “Possible viral skin infection” is documented in a patient’s medical record. Which infections should the nurse
consider as causing the patient’s skin problem? Select all that apply.
1) Rubella NURSINGTB.COM
2) Measles
3) Cellulitis
4) Folliculitis
5) Herpes simplex
____ 25. A patient is to undergo a punch biopsy of a lesion. What should the nurse anticipate when assisting in the
collection of this specimen? Select all that apply.
1) A sterile blade will be used.
2) The site may need stitches.
3) Local anesthesia will be provided.
4) The entire lesion may be removed.
5) The sample includes epidermis, dermis, and subcutaneous tissue.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 49, Assessment of Integumentary Function
Chapter learning objective: Identifying key anatomical components of the integumentary system
Chapter page reference: 1011
Heading: Overview of Anatomy, Physiology, and Function > Epidermis
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Skin Integrity; Health Promotion
Difficulty: Moderate
Feedback
1 The dermis is beneath the epidermis and contains blood vessels, nerves, immune system
cells including macrophages and mast cells, dermal proteins including collagen and
elastin, hair follicles, and sweat and sebaceous glands.
2 The hypodermis contains adipose tissue, connective tissue, nerves, and blood supply.
3 The innermost level of the epidermis contains dendritic structures called Langerhans
cells, which are the outermost cells of the immune system.
4 The outermost skin layer is called the epidermis and protects the body by forming a
NURSINGTB.COM
barrier that resists pathogen invasion
Feedback
1 Hair follicles are anchored in the dermis, then protrude into the epidermis.
2 Hair follicles are anchored in the dermis, then protrude into the epidermis.
3 Hair follicles are anchored in the dermis, then protrude into the epidermis.
4 Hair follicles are anchored in the dermis, then protrude into the epidermis.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Complete death of a hair follicle results in baldness.
2 In the resting phase the hair follicle holds onto the hair shaft which minimizes hair loss.
3 Keratinization occurs during the hair growth cycle, which is absent when the hair
follicles are dead.
4 A pause in the growth cycle is the resting phase; however, this is not occurring because
the patient’s hair follicles are dead.
Feedback
1 Nail growth does not speed up as a person ages.
2 Nails have a slow but continuous growth process.
3 Slow nail growth is normal. This does not mean the patient has a vitamin deficiency.
4 Slow nail growth is normal. This does not mean the patient has an undiagnosed disease
process.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 The role of the skin in excretion relates to losses of fluid through the sweat glands, the
evaporation of water through the skin.
3 Providing protection from the external environment as well as to underlying structures
and organs, the skin is essential to homeostasis.
4 Vitamin D metabolism is another major function of the skin, as the epidermis is the
major source of vitamin D for the body. Activated in the epidermis by ultraviolet light,
vitamin D enters the circulation and works in the gastrointestinal system to facilitate
calcium absorption.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 Eccrine sweat glands cover most of the body’s surface and apocrine sweat glands are
present in hair follicles of the armpits and genitalia. Sebaceous glands produce sebum,
which exits from the hair follicle. Sebum is a lipid-rich substance that moisturizes hair
and skin.
3 Providing protection from the external environment as well as to underlying structures
and organs, the skin is essential to homeostasis.
4 Vitamin D metabolism is another major function of the skin, as the epidermis is the
major source of vitamin D for the body. Activated in the epidermis by ultraviolet light,
vitamin D enters the circulation and works in the gastrointestinal system to facilitate
calcium absorption.
Feedback
1 NURanemia.
Generalized pallor would indicate SINGTB.COM
2 Yellow skin and mucous membranes are seen in liver disease.
3 Hemosiderin discolors the skin brown and is caused by RBC trapped in dermal layers.
4 Cyanosis indicates poor perfusion.
Feedback
1 Eczema could cause dried exudate from a wound bed.
2 A drug rash would cause the skin to flake.
3 An open vesicle would be red and moist.
4 Lichenification is an irregular shape that causes the epidermis to become rough and
thick. This can be caused by chronic dermatitis.
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Feedback
1 Yellow nails are associated with lymphedema.
2 Cyanotic nails are associated with respiratory failure.
3 Longitudinal red lines are associated with bacterial endocarditis,
4 White or opaque nails are associated with inflammatory bowel disease.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 With aging, less collagen and elastin weakens the tensile strength of the skin.
2 With aging, flattening of the rete ridges weakens the strength of the epidermal-dermal
junction.
3 With aging, the vascularity of the dermis decreases, which causes slower healing rates.
4 With aging, fewer immune cells impacts the ability to recognize and respond to
invading organisms. This will not impact wound healing.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4 Systemic antibiotics would not be indicated for psoriasis but may be used for a bacterial
skin infection.
Feedback
1 A wound culture is obtained using sterile technique.
2 The wound should be flushed with normal saline to remove surface residue.
3 The wound should be cleansed with a non-antiseptic solution.
4 Keeping the wound open to air could dry the wound bed and affect the amount of
specimen obtained.
Feedback
1 Showering is permitted the day after the biopsy.
2 The bandage should be changed daily.
3 A small amount of red drainage is normal and does not need to be reported to the
health-care provider.
4 It may take one to two weeks for the site to heal. The health-care provider does not
need to be notified if the site has not healed in a few days.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Systemic medication may be prescribed for a fungal infection.
2 Additional diagnostic testing may be prescribed for an inflammatory lesion.
3 Topical antibiotic medication may be prescribed for a bacterial infection.
4 For a malignant growth treatment involves surgical removal of the lesion as well as
removal of 5–6 mm of healthy tissue surrounding the lesion to ensure safe margins.
Feedback
1 A complete blood count is used to evaluate for an infection.
2 Protein status is evaluated through a serum albumin level.
3 Doppler ultrasound will determine if the infection is altering the blood flow.
4 Blood cultures are used to determine if an infection has entered the circulatory system.
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Feedback
1 Sterile water is not used during the diagnostic evaluation of a fungal specimen.
2 Potassium chloride is not used during the diagnostic evaluation of a fungal specimen.
3 Sterile normal saline is not used during the diagnostic evaluation of a fungal specimen.
4 During diagnostic evaluation of a fungal specimen, a potassium hydroxide (KOH)
preparation is most frequently used because it partially dissolves the keratin protein so
that the fungal cells become perceptible in the specimen.
Feedback
1 The site needs to be cleansed. An over-the-counter analgesic may not be sufficient.
2
NURSINGTB.COM
If erythema, edema, increased pain, or drainage develops, clean the site with hydrogen
peroxide.
3 The patient does not need emergency care at this time.
4 The site should be flushed with hydrogen peroxide. Sterile normal saline would not
help remove any pathogens in the biopsy site.
MULTIPLE RESPONSE
21. ANS: 1, 2, 5
Chapter number and title: 49, Assessment of Integumentary Function
Chapter learning objective: Discussing the function of the integumentary system
Chapter page reference: 1012
Heading: Overview of Anatomy, Physiology, and Function > Dermis
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Knowledge [Remembering]
Concept: Skin Integrity; Health Promotion
Difficulty: Easy
Feedback
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1. Eccrine sweat glands cover most of the body’s surface. They produce a water-and-salt mixture
that evaporates to cool the body.
2. Apocrine sweat glands are present in hair follicles of the armpits and genitalia. Secretions
from these glands contribute to body odor.
3. Dermal proteins create tensile strength elastic recoil in the skin.
4. Blood vessels support temperature regulation via dilation and constriction.
5. Sebaceous glands produce sebum, which exits from the hair follicle. Sebum is a lipid-rich
substance that moisturizes hair and skin.
Feedback
1. Medications that may disrupt skin integrity include steroids.
2. Furosemide is not identified
NURasSaImedication
NGTB.CO that
M may disrupt skin integrity.
3. Medications that may disrupt skin integrity include amiodarone.
4. Medications that may disrupt skin integrity include warfarin sodium.
5. Medications that may disrupt skin integrity include NSAIDs.
Feedback
1. Urine is a chemical factor that disrupts the skin integrity.
2. Stool is a chemical factor that disrupts the skin integrity.
3. Adhesives are mechanical factors that disrupt the skin integrity.
4. Immobility is a mechanical factor that disrupts the skin integrity.
5. Gastric fluids are a chemical factor that disrupts the skin integrity.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1. Rubella is a viral infection.
2. Measles is a viral infection.
3. Cellulitis is a bacterial infection.
4. Folliculitis is a bacterial infection.
5. Herpes simplex is a viral infection.
Feedback
1. A sterile blade is used for a shave biopsy.
2. Minimal stitching may be required for a punch biopsy.
3. Local anesthesia will be provided for a punch biopsy.
4. The entire lesion may be removed for an excisional biopsy.
5. The sample includes the epidermis, dermis, and subcutaneous tissue in a punch biopsy.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 1. A patient seeks medical care for a carbuncle. What treatment should the nurse expect to be prescribed as a
priority for this patient?
1) Moist heat
2) Incision and drainage
3) Topical mupirocin ointment
4) Clindamycin and peroxide wash
____ 2. A patient has a leg wound that has beige exudate and a fishy odor. For which microorganism should the nurse
plan care for this patient?
1) Proteus
2) Pseudomonas
3) Streptococcus
4) Staphylococcus
____ 3. A patient is demonstrating signs of a herpes simplex virus infection. Which diagnostic test should be
prescribed to confirm this diagnosis?
1) Pap smear
2) Tzanck’s smear
3) Sedimentation rate
4) HSV-1 antibody testing
____ 4. A patient is diagnosed with herpes simplex viral encephalitis. Which medication should the nurse prepare to
administer to this patient?
1) Acyclovir
2) Famciclovir
3) Valacyclovir
4) Parenteral acyclovir NURSINGTB.COM
____ 5. A patient is experiencing scaly, patchy skin changes on the upper back, chest, and arms. In some areas the
skin is either red, dark in color, or lighter in color. Which type of fungal infection is this patient most likely
experiencing?
1) Intertrigo
2) Tinea corporis
3) Tinea unguium
4) Tinea versicolor
____ 6. A patient is diagnosed with tinea corporis. Which medication should the nurse expect to be prescribed to treat
this infection?
1) Topical miconazole
2) Topical terbinafine (Lamisil)
3) Topical butenafine (Lotrimin)
4) Topical selenium sulfide 1% (Selsun Blue)
____ 7. During an assessment the nurse notes skin changes on the patient’s elbows and knees. Which findings support
that these changes are plaque psoriasis?
1) Red raised areas with inconsistent borders
2) Thick red plaques covered with silvery scales
3) Large reddened areas of weeping and maceration
4) Small raised and reddened areas with fluid-filled pustules
____ 8. A patient with psoriasis is prescribed salicylic acid. What should the nurse explain to the patient about this
treatment?
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NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 16. A patient with a sacral stage III pressure ulcer has an elevated temperature. What diagnostic test would help
determine if this patient is developing osteomyelitis?
1) CT scan
2) Bone biopsy
3) Venous Doppler
4) Serum electrolytes
____ 17. The nurse is preparing an educational tool to teach high school students about skin cancer. What should the
nurse highlight as being the most common precancerous lesion?
1) Basal cell
2) Melanoma
3) Squamous cell
4) Actinic keratoses
____ 18. A patient is diagnosed with basal cell carcinoma. What should the nurse expect to assess in this patient?
1) Translucent papule
2) Reddish brown plaque
3) Crusted ulcerated plaque
4) Asymmetric black lesion
____ 19. The nurse is caring for a patient with a squamous cell lesion. For which treatment should the nurse prepare
this patient?
1) Radiotherapy
2) Mohs’ surgery
3) Photodynamic therapy
4) Curettage and electrodessication
NURSINGTB.COM
____ 20. The nurse is teaching at a community fair about ways to reduce the risk of skin cancer. What should the nurse
emphasize in this presentation?
1) Wear clothing with UV protection
2) Use sunscreen with an SPF of at least 15
3) Examine the body every six months for lesions
4) Spend time in the sun between the hours of 1000 and 1600
____ 21. A patient is admitted for reconstructive surgery. For which reason should the nurse consider that this surgery
is needed?
1) Cancer
2) Face lift
3) Rhinoplasty
4) Breast augmentation
____ 22. A patient recovering from reconstructive surgery is experiencing unrelenting postoperative pain. What should
the nurse consider is occurring with this patient?
1) Infection
2) Fluid imbalance
3) Electrolyte imbalance
4) Attention-seeking behavior
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 23. After reviewing the visit schedule, the home-care nurse prepares for patients who might have a community
acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infection. What skin conditions caused the
nurse to take this action? Select all that apply.
1) Abscess
2) Eczema
3) Cellulitis
4) Impetigo
5) Folliculitis
____ 24. The nurse is concerned that a patient is developing a complicated soft tissue bacterial infection. What
assessment findings caused the nurse to come to this conclusion? Select all that apply.
1) Pain
2) Fever
3) Tachycardia
4) Muscle atrophy
5) Low blood pressure
____ 25. The nurse suspects that a patient is experiencing a recurrent herpes simplex virus infection. What assessment
findings were used to make this decision? Select all that apply.
1) Fever
2) Anorexia
3) Areas of redness
4) Tingling sensation
5) Fluid-filled vesicles
____ 26. The nurse determines that a patient’s abdominal wound is in the proliferative phase of healing. What is
NUthat
occurring during this phase? Select all RSapply.
INGTB.COM
1) Granulation
2) Angiogenesis
3) Epithelialization
4) Collagen synthesis
5) Reorganization of collagen
____ 27. A patient’s leg wound is not healing as quickly as expected. What should the nurse do to determine the reason
for the patient’s poor healing? Select all that apply.
1) Obtain a referral for a dietician
2) Elevate the extremity on a pillow
3) Increase the frequency of dressing changes
4) Encourage increased independent movement
5) Obtain an order for prealbumin and albumin levels
Numeric Response
28. The nurse sends 10 samples of body sites to assess an intensive care patient’s Candida colonization index.
Seven of the samples came back as being positive. What is this patient’s colonization index? Record your
answer to the nearest tenth decimal point. ______
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 2
Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders
Chapter learning objective: Discussing the medical management of: Bacterial skin infections
Chapter page reference: 1041
Heading: Bacterial Skin Infections > Medical Management
Integrated Processes: Nursing Process–Planning
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Skin Integrity
Difficulty: Moderate
Feedback
1 Moist heat is used to treat folliculitis or furuncles.
2 Treatment of a carbuncle includes incision and drainage.
3 Topical mupirocin ointment is used to treat impetigo and a furuncle.
4 Clindamycin and peroxide wash is used to treat folliculitis caused by MRSA.
Feedback
1 Beige pus and fishy odor is associated with a Proteus infection.
2 Greenish-blue drainage with a fruity odor is associated with a Pseudomonas infection.
3 No specific drainage is identified for a Streptococcus infection.
4 Creamy yellow pus is associated with a Staphylococcus infection.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Client Need: Safe and Effective Care Environment/Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Skin Integrity; Infection
Difficulty: Moderate
Feedback
1 Pap smear is a nonspecific method of diagnosing herpes simplex virus.
2 Tzanck’s smear is a nonspecific method of diagnosing herpes simplex virus.
3 Sedimentation rate is used to determine inflammation.
4 Serological type-specific glycoprotein G–based assays obtained from capillary or serum
blood samples accurately diagnose herpes simplex virus.
Feedback
1
NURSINGTB.COM
The bioavailability of acyclovir is less through the oral route.
2 Famciclovir is helpful in the treatment of herpes simplex virus; however, it not
recommended for encephalitis.
3 Valacyclovir is helpful in the treatment of herpes simplex virus; however, it is not
recommended for encephalitis.
4 Because the bioavailability of IV acyclovir is greater than the oral route, IV acyclovir is
utilized for patients with severe disease or those who encounter complications of HSV
such as encephalitis.
Feedback
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 Intertrigo is a fungal infection that is found in the skinfolds and is worsened by heat,
moisture, and lack of air. The infection causes maceration, skin erosion, erythema,
itching, and burning.
2 Tinea corporis is a fungal infection that causes annual patches or plaques on the body.
3 Tinea unguium is a fungal infection that affects the nails, causing yellow, brittle, thick
nails with subungual hyperkeratosis.
4 Tinea versicolor is a fungal infection that occurs on the upper chest, back, and upper
arms that creates scaly patches of different colors that are either red, dark in color, or
absent of color.
Feedback
1 Treatment for tinea corporis includes topical miconazole.
2
NURSINGTB.COM
Treatment for tinea cruris includes topical terbinafine (Lamisil).
3 Treatment for tinea faciei includes topical butenafine (Lotrimin).
4 Treatment for tinea versicolor includes topical selenium sulfide 1% (Selsun Blue).
Feedback
1 Red raised areas with inconsistent borders does not describe plaque psoriasis.
2 Patients with plaque psoriasis present with well-circumscribed, thick, reddened
papules or plaques often covered with silvery scaling flakes.
3 Large reddened areas of weeping and maceration does not describe plaque psoriasis.
4 Small raised and reddened areas with fluid filled pustules does not describe plaque
psoriasis.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Corticosteroids prevent the formation of new lesions.
2 Salicylic acid decreases scaling and softens plaques.
3 Coal tar suppresses cell division and decreases inflammation.
4 Retinoids (vitamin A) diminish proliferation of keratinocytes and decrease
inflammation.
Feedback
1 Medications may not cure psoriasis; however, they do minimize symptoms and may
minimize exacerbations.
2 Some topical medications cause staining of the skin, hair, nails, and clothing.
3 Retinoids can cause skin irritation.
4 The disease can worsen after discontinuing strong topical corticosteroids.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Phototherapy should be held if the skin becomes painful.
2 Phototherapy should be held if the skin becomes reddened.
3 Phototherapy should be held if the skin becomes red or blistered.
4 Phototherapy should be held if the skin develops blisters with drainage.
Feedback
1 Heat does not cause a laceration.
2 Pressure could cause an ulcer.
3 A laceration is a break in the skin
NURcaused
SING byThigh
B.Cshearing
OM forces that exert a diagonal
force on the skin causing damage.
4 Moisture would cause maceration.
Feedback
1 In the maturation phase there is less fluid within the wound and collagen fibers
reorganize.
2 In the hemostasis phase of healing platelets and clotting factors are activated.
3 In the proliferative phase of healing granulation tissue forms and the wound contracts.
4 In the inflammatory phase of healing fluid escapes into the wound and causes edema.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
13. ANS: 2
Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders
Chapter learning objective: Discussing the medical management of: Skin Trauma
Chapter page reference: 1068
Heading: Skin Trauma > Surgical Management
Integrated Processes: Nursing Process–Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Skin Integrity
Difficulty: Easy
Feedback
1 Tape is used to close a primary closure wound.
2 Grafts are used to close a secondary closure wound.
3 Staples are used to close a primary closure wound.
4 Sutures are used to close a primary closure wound.
Feedback
1 A stage III pressure ulcer has full thickness tissue loss. Subcutaneous fat may be
visible, but bone, tendon, or muscle are not exposed. Slough may be present but does
not obscure the depth of tissue loss. May include undermining and tunneling.
2 A stage IV pressure ulcer has full thickness loss with exposed bone, tendon, or muscle.
Slough or eschar may be present on some parts of the wound bed. It often includes
undermining and tunneling.
3 An unstageable wound has full thickness tissue loss where the base of the ulcer is
covered in slough or eschar in the wound bed.
4 A suspected deep tissue injury is a purple or maroon localized area of discolored, intact
skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or
shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer,
or cooler as compared to adjacent tissue.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Ascorbic acid (vitamin C) strengthens capillaries.
2 Ascorbic acid (vitamin C) improves immune function.
3 Zinc helps with collagen formation and protein synthesis.
4 Copper helps with red blood cell formation.
Feedback
NURSINGTB.COM
1 If osteomyelitis is suspected, evaluation with a CT scan is recommended.
2 A bone biopsy is not recommended to diagnose osteomyelitis.
3 A venous Doppler is not used to diagnose osteomyelitis.
4 Serum electrolytes are not used to diagnose osteomyelitis.
Feedback
1 Basal cell carcinomas are the most common form of cancer occurring in human beings.
2 Melanoma is currently the most common cancer affecting women aged 25 to 29 and the
second most common cancer diagnosed in women aged 30 to 34.
3 Squamous cell carcinoma is mostly attributed to cumulative exposure to UVB rays over
an extended period of time and is a cancer that arises from epidermal squamous cells.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4 Actinic keratoses are atypical keratinocytes found in the epidermis and represent the
most common form of precancerous lesions.
Feedback
1 Basal cell carcinoma can present as a translucent papule.
2 Actinic keratoses can present as a reddish brown plaque.
3 Squamous cell carcinoma can present as a crusted ulcerated plaque.
4 Melanoma can present as an asymmetric black lesion.
Feedback
1 Radiotherapy is appropriate for use in patients who are poor surgical candidates
because of their health or the site and extent of the tumor. In cases of aggressive
squamous cell carcinoma, radiotherapy is an additional treatment following surgical
excision
2 Mohs’ micrographic surgery is considered the “gold standard” for the treatment of
nonmelanoma skin cancers.
3 Photodynamic therapy is advantageous for patients who are poor surgical candidates
because of other comorbidities or for those who have large or multiple lesions that can
be treated at one time.
4 Curettage and electrodessication is appropriate for low-risk, smaller lesions.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle
considerations for patients with skin disorders
Chapter page reference: 1088
Heading: Skin Cancer > Nursing Management > Teaching
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Skin Integrity; Cellular Regulation; Promoting Health
Difficulty: Moderate
Feedback
1 Clothing with UV protection or dark clothing is recommended to protect as much of the
skin as possible.
2 A sunscreen with an SPF of at least 30 is recommended.
3 The body should be examined every month.
4 Time in the sun should be avoided between the hours of 10 am and 4 pm when UV rays
are strongest.
Feedback
1 The most common reconstructive surgeries performed by a plastic surgeon in 2014
were for cancer reconstruction.
2 Reconstructive surgery is not identified as being highly used for a face lift.
3 Reconstructive surgery is not identified as being highly used for a rhinoplasty.
4 Reconstructive surgery is not identified as being highly used for breast augmentation.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Uncontrollable pain may indicate complications, including infection.
2 Fluid imbalance does not cause uncontrollable pain.
3 Electrolyte imbalance does not cause uncontrollable pain.
4 Pain is whatever the patient says it is. It is highly unlikely that a postoperative patient is
stating the existence of pain because of attention-seeking behavior.
MULTIPLE RESPONSE
23. ANS: 1, 3, 4, 5
Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders
Chapter learning objective: Discussing the epidemiology of disorders of the skin
Chapter page reference: 1039
Heading: Bacterial Skin Infections > Epidemiology
Integrated Processes: Nursing Process–Planning
Client Need: Safe and Effective Care Environment/Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Skin Integrity
Difficulty: Moderate
Feedback
1. Approximately 80% of CA-MRSA cases are uncomplicated skin and soft tissue infections in
NURSINfolliculitis,
the form of an abscess, cellulitis, GTB.COM or impetigo.
2. Eczema is not associated with CA-MRSA.
3. Approximately 80% of CA-MRSA cases are uncomplicated skin and soft tissue infections in
the form of cellulitis, folliculitis, impetigo, or an abscess.
4. Approximately 80% of CA-MRSA cases are uncomplicated skin and soft tissue infections in
the form of impetigo, cellulitis, folliculitis, or an abscess.
5. Approximately 80% of CA-MRSA cases are uncomplicated skin and soft tissue infections in
the form of folliculitis, cellulitis, impetigo, or an abscess.
Feedback
1. Moderate pain is a manifestation of a complicated soft tissue bacterial infection.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1. Fever is a manifestation of a primary herpes simplex virus infection.
2. Anorexia is a manifestation of a primary herpes simplex virus infection.
3. Areas of redness are manifestations of a recurrent herpes simplex virus infection.
4. Tingling sensation is a manifestation of a recurrent herpes simplex virus infection.
5. Fluid-filled vesicles are manifestations of a recurrent herpes simplex virus infection.
NURSINGTB.COM
PTS: 1 CON: Skin Integrity | Infection
26. ANS: 1, 2, 3, 4
Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders
Chapter learning objective: Describing the process and stages of wound healing
Chapter page reference: 1062
Heading: Skin Trauma > Pathophysiology and Clinical Manifestations
Integrated Processes: Nursing Process–Assessment
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Skin Integrity
Difficulty: Easy
Feedback
1. As the capillary bed is laid down, the wound fills with granulation tissue and appears beefy
red, shiny, and granular.
2. Endothelial cells are activated to initiate angiogenesis, which increases blood supply to the
new tissue.
3. Keratinocytes help with epithelialization during this phase.
4. Macrophages synthesis collagen during this phase.
5. The reorganization of collagen occurs during the maturation phase.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders
Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle
considerations for patients with skin disorders
Chapter page reference: 1069
Heading: Skin Trauma > Nursing Implications > Assessment
Integrated Processes: Nursing Process–Implementation
Client Need: Physiological Integrity/Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Skin Integrity
Difficulty: Moderate
Feedback
1. Nutritional status affects wound healing. A referral to a dietician may be needed.
2. Elevating the limb on a pillow will not enhance wound healing.
3. Increasing the frequency of dressing changes could damage fragile granulation tissue.
4. Increased activity will not necessarily improve wound healing,
5. Nutritional status affects wound healing. Prealbumin and albumin levels provide data about
overall nutritional status.
NUMERIC RESPONSE
28. ANS:
0.7 NURSINGTB.COM
Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders
Chapter learning objective: Describing complications associated with skin disorders
Chapter page reference: 1055
Heading: Fungal Infections > Complications
Integrated Processes: Nursing Process–Assessment
Client Need: Safe and Effective Care Environment/Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Skin Integrity; Infection
Difficulty: Easy
Feedback: The Candida colonization index requires the acquisition of surveillance cultures from
multiple patient body sites a few times per week up to daily while the patient is in the ICU. The
Candida colonization index is the ratio of the number of body sites that grow the same species of
Candida divided by the number of body sites tested. For this patient the number of sites that were
positive were 7 divided by 10 samples = 0.7. The patient’s index is 0.7.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 1. A victim of a house fire is brought to the emergency department for burn treatment. What assessment finding
indicates that the patient may have an inhalation injury?
1) Coughing
2) Soot on the face
3) Singed facial hair
4) Heart rate 98 bpm
____ 2. The nurse is caring for a patient with 50% total body surface area burns. Which finding indicates that burn
shock is resolving?
1) Heart rate 112 bpm
2) Respirations 24 per minute
3) Blood pressure 90/60 mm Hg
4) Urine output 800 mL over 2 hours
____ 3. A victim of a car fire is confused, dizzy, and nauseated. What diagnostic test should be done to determine if
this patient is experiencing carbon monoxide poisoning?
1) Chest x-ray
2) Bronchoscopy
3) Pulse oximeter
4) Carboxyhemoglobin level
____ 4. A patient is admitted for a suspected inhalation injury. What should the nurse emphasize when caring for this
patient?
1) Increase oral fluids
2) Turn in bed every two hours
3) Monitor strict intake and outputNURSINGTB.COM
4) Deep breathing and coughing every hour
____ 5. The nurse is caring for a patient who sustained electrical burns. Why should the nurse monitor this patient for
compartment syndrome?
1) Potential for undiagnosed injuries
2) Injuries from being thrown bruise soft tissue
3) Electrical current alters integrity of blood vessels
4) Fluid seeps from intravascular spaces into the interstitium
____ 6. The nurse is preparing an educational tool to instruct community members on burn prevention. What should
the nurse include as the most common injury in children under age 5?
1) Scald
2) Flame
3) Chemical
4) Carbon monoxide poisoning
____ 7. A patient with 55% total body surface area burned received two-thirds of the required fluid resuscitation. For
which potential problem should the nurse prepare to provide care to this patient?
1) Increased zone of stasis
2) Increased zone of hyperemia
3) Increased zone of coagulation
4) Decreased zone of coagulation
____ 8. A patient comes into the emergency room seeking treatment for radiation burns. What should be considered
prior to providing care to this patient?
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 23. An 11-year-old child received burns over both upper and lower arms, both hands, anterior upper and lower
legs, anterior chest, and the neck. Using the following as a guide, what is this child’s total body surface area
burned?
NURSINGTB.COM
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 24. The nurse is caring for a patient who sustained chemical burns. What would have caused these injuries? Select
all that apply.
1) Lime
2) Gasoline
3) Bleach
4) Fabric softener
5) Hydrofluoric acid
____ 25. The school nurse is preparing material for National Fire Prevention week. What information should be added
to the classroom posters? Select all that apply.
1) Never leave a burning candle unattended.
2) Set heating pads on “low” when sleeping.
3) Keep a flashlight and telephone near the bed.
4) Check smoke alarm batteries every six months.
5) Never use the oven as a method to warm the home.
____ 26. A patient is diagnosed with several superficial partial-thickness burns. What treatment would be indicated for
this patient? Select all that apply.
1) Apply bacitracin ointment
2) Cover with a nonadherent bandage
3) Apply mafenide acetate 10% cream
4) Wash with antiseptic soap and warm water
5) Apply collagenase and cover with roll gauze
____ 27. A patient has been recovering for 18 months from burns that affected 60% total body surface area. For which
problems should the nurse anticipate providing continuing care to this patient? Select all that apply.
1) Anxiety NURSINGTB.COM
2) Depression
3) Spiritual distress
4) Body image disorder
5) Post-traumatic stress disorder (PTSD)
Numeric Response
28. A patient weighing 187 lbs. has 38% total body surface area burns. Using the Parkland formula, how much
fluid should this patient receive over the first eight hours after the burn occurred? Record your answer as a
whole number. ______
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 51, Coordinating Care for Patients With Burns
Chapter learning objective: Discussing the epidemiology of burn injuries
Chapter page reference: 1102
Heading: Systemic Effects of Major Burn Injuries>Respiratory
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Skin Integrity; Oxygenation
Difficulty: Moderate
Feedback
1 Coughing does not indicate an inhalation injury.
2 Soot on the face does not indicate an inhalation injury.
3 Patients with an inhalation injury may present with singed facial hair.
4 A heart rate of 98 bpm does not indicate that the patient has an inhalation injury
Feedback
1 Tachycardia is a manifestation of burn shock.
2 Tachypnea is a manifestation of burn shock.
3 Hypotension is a manifestation of burn shock.
4 In the postburn shock phase, which begins 24 to 48 hours after injury, the capillaries
begin to regain integrity. Burn shock slowly begins to resolve, and the fluid gradually
returns to the intravascular space. Urinary output continues to increase secondary to
patient diuresis.
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Feedback
1 A chest x-ray will not diagnose carbon monoxide poisoning.
2 A bronchoscopy will not diagnose carbon monoxide poisoning.
3 In cases of suspected carbon monoxide poisoning, oxygen measurement by pulse
oximeter is useless because the determination between the oxygen and carbon
monoxide molecules saturating the hemoglobin is not possible.
4 Because carbon monoxide binds to the hemoglobin molecule with an affinity 200 times
greater than that of oxygen, tissue hypoxia results when carbon monoxide levels are
above normal. Carboxyhemoglobin levels will detect the amount of carbon monoxide in
the patient.
Feedback
1 The intake of oral fluids will depend upon the integrity of the patient’s throat. The
patient might be nothing by mouth until the extent of the inhalation injury is known.
2 Turning in bed every two hours is essential to reduce the hazards of immobility;
however, it is not as important as deep breathing and coughing.
3 Monitoring strict intake and output would be more important for a patient with burns.
An inhalation injury will not necessarily impact cardiac output and fluid balance.
4 Deep breathing and coughing should be done every hour to assist with airway clearance
and mobilization of secretions.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Monitoring for compartment syndrome is not because of the potential for undiagnosed
injuries.
2 Monitoring for compartment syndrome is not because of soft tissue injuries from being
thrown.
3 Monitoring for compartment syndrome is not because the electrical current has altered
the integrity of blood vessels.
4 Pulses are closely monitored in all affected extremities for the first 48 hours postinjury
in order to assess for the potential development of compartment syndrome. As fluid
seeps from the intravascular spaces into the interstitium, pressure within the tissues
continues to rise and confines swelling inside muscle compartments.
Feedback
1 Scald injuries are most prevalent in children under the age of 5.
2 Flame injuries are common in all age groups.
3 Chemical injuries are not the most prevalent in children under the age of 5.
4 Carbon monoxide poisoning is not the most prevalent in children under the age of 5.
Feedback
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 Without sufficient fluid resuscitation, the zone of stasis would convert to another zone.
2 Inadequate fluid resuscitation would not impact the zone of hyperemia.
3 The zone of stasis immediately surrounds the zone of coagulation and is characterized
by damaged cells and impaired circulation. It is this area of the burn that is most at risk
for conversion if the patient does not receive adequate resuscitation. Improper
resuscitation or under-resuscitation may cause the burn to become deeper because of
limited blood flow, causing the zone of stasis to convert into the zone of coagulation.
4 Inadequate fluid resuscitation would make the zone of coagulation greater.
Feedback
1 Pathway of flow through the body would be essential for an electrical burn.
2 Duration of contact would be essential for a chemical burn.
3 The severity of a radiation burn
NUisRdependent
SINGTB upon
.CO the
Mtype, dose, and length of
exposure.
4 The temperature to which the skin is heated is applicable for a thermal burn.
Feedback
1 A superficial burn is dry with blisters.
2 Deep-partial thickness burns have a waxy appearance and are cherry red.
3 Full-thickness burns are dry, leathery, pale and white, brown, or black in color.
4 A superficial partial-thickness burn has blisters that may be closed or open and
weeping; pink or red; mild edema; and blanches easily.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
10. ANS: 2
Chapter number and title: 51, Coordinating Care for Patients With Burns
Chapter learning objective: Correlating the pathophysiological changes to clinical manifestations seen in
patients with superficial, partial-thickness, and full-thickness burns
Chapter page reference: 1098
Heading: Pathophysiology>Classifications>Burn Depth>Full-Thickness
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity – Basic Care and Comfort
Cognitive level: Analysis [Analyzing]
Concept: Skin Integrity
Difficulty: Moderate
Feedback
1 Elevating the injured extremity would provide comfort.
2 A full-thickness burn involves destruction of the epidermis, the dermis, and portions of
the subcutaneous tissue. All epidermal and dermal structures are destroyed including
hair follicles, sweat glands, and nerve endings. As a result of the extensive damage to
the nerve endings, full-thickness burns are insensate to palpation and often are not
painful. Pain medication would be least likely to provide comfort to this patient
initially.
3 Applying medicated ointment to the injuries would provide comfort.
4 Elevating the head of the bed would ease respiratory effort.
Feedback
1 The majority of deep partial-thickness burns take more than two weeks to heal.
2 Superficial partial-thickness burns usually heal in one to two weeks with minimal to no
scarring.
3 Superficial burns typically resolve in 24 to 72 hours.
4 Full-thickness burns do not heal spontaneously and require skin grafting.
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Feedback
1 A chest x-ray is a basic diagnostic test done on all burn victims; however, it is not
specific to a patient with electrical burns.
2 A bronchoscopy is not indicated for electrical burns.
3 A CT scan of the head is not indicated for electrical burns.
4 A 12-lead electrocardiogram is indicated for an electrical injury.
Feedback
NURSINGTB.COM
1 Acidosis or a decreased pH can occur because of a loss of bicarbonate ions.
2 Decreased sodium is expected because large amounts of sodium are lost to third
spacing, wound draining, and shifting into cells as potassium is released.
3 Hyperkalemia is expected because of massive cellular trauma causing the release of
potassium into extracellular fluid.
4 An elevated hematocrit is expected because plasma is lost to extravascular spaces,
leaving the remaining blood very viscous.
Feedback
1 Ranitidine (Zantac) decreases stomach acid and risk of gastric ulceration.
2 Esomeprazole (Nexium) decreases stomach acid and risk of ulceration.
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Feedback
1 Indications of adequate fluid resuscitation include a blood pH between 7.35-7.45.
2 Indications of adequate fluid resuscitation include a heart rate less than 120 bpm.
3 Indications of adequate fluid resuscitation include a blood pressure greater than 100
mm Hg.
4 Indications of adequate fluid resuscitation include a central venous pressure between 5-
10 mm Hg. A pressure of 2 mm Hg indicates fluid volume deficit. More fluid would be
indicated.
Feedback
1 A gray wound bed indicates inadequate blood flow and dead tissue.
2 Enzymatic debridement involves the application of a proteolytic ointment that hastens
eschar separation.
3 Eschar would develop at the time of the burn.
4 Purulent exudate indicates an infection.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 The burn patient is not likely to experience referred pain.
2 Procedural pain is associated with therapeutic activities such as wound care and
physical therapy.
3 Background pain is the underlying pain from the primary injury that is continuous and
ongoing.
4 Breakthrough pain is pain related to specific episodes associated with activities of daily
living (ADLs), such as walking.
Feedback
1 Total parenteral nutrition is not often utilized among burn patients because of its
complication rates, including an increased risk for infection and hyperglycemia.
2 In large burn injuries, longer nutritional support is required, and placement of a
duodenal feeding tube is often recommended to help prevent aspiration and allow for
feeding up to and during procedures.
3 Nutritional supplementation is most often achieved through the placement of a
nasogastric tube, where feedings can be given continuously or intermittently in the form
of a bolus. However, the patient has a large TBSA burned. Another approach would be
more appropriate.
4 Once a person has sustained a burn of approximately 20% or greater, it is difficult to
consume the amount of calories and protein needed for wound healing.
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Feedback
1 Cross-contamination among burn patients is common, and as a result, isolation
guidelines are widespread practices among burn centers. Contact precautions may be
used when entering all patient rooms.
2 Protective isolation is not required.
3 Wound care is a clean procedure.
4 Prophylactic antibiotics are not recommended because of the potential of breeding
antibiotic-resistant pathogens, and instead treatment is based on positive culture results.
Feedback
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 Splinting is the most common method used to help prevent the formation of
contractures.
2 Physical therapy two hours every day is not recommended as a method to prevent
contractures.
3 Passive range of motion is not recommended as a method to prevent contractures.
4 Occupational therapy is not recommended as a method to prevent contractures.
Feedback: Select the percentage burn column for 10-14-year-old. The neck is 2; the anterior trunk is 13; the
right upper arm is 4; the right lower arm is 3; the left upper arm is 4; the left lower arm is 3; the right hand is
2.5; the left hand is 2.5; the right thigh is 9; the left thigh is 9; the right lower leg is 6.5; and the left lower leg
is 6.5. The total body surface area burned is 65%. The other answer choices are miscalculations or incorrect
use of the graphic provided.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE RESPONSE
24. ANS: 1, 2, 3, 5
Chapter number and title: 51, Coordinating Care for Patients With Burns
Chapter learning objective: Explaining the pathophysiological processes associated with burn injuries
Chapter page reference: 1195
Heading: Pathophysiology>Chemical
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment/Safety and Infection Control
Cognitive level: Comprehension [Understanding]
Concept: Skin Integrity
Difficulty: Easy
Feedback
1. Lime can cause a chemical burn.
2. Gasoline can cause a chemical burn.
3. Bleach can cause a chemical burn.
4. Fabric softener is not identified as causing a chemical burn.
5. Hydrofluoric acid can cause a chemical burn.
Feedback
1. To prevent fires, never leave a burning candle unattended.
2. To prevent fires, never use a heating pad during sleep.
3. To respond to a fire, keep a flashlight and telephone near the bed.
4. To prevent fires, check smoke alarm batteries every 6 months.
5. To prevent fires, never use the oven as a method to warm the home.
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Feedback
1. Care of a superficial partial-thickness burn includes applying bacitracin ointment.
2. Care of a superficial partial-thickness burn includes covering with nonadherent bandage.
3. Mafenide acetate 10% cream is used to treat full-thickness burns.
4. A superficial partial-thickness burn is to be washed with antiseptic soap and warm water.
5. An enzymatic cream like collagenase is used for full-thickness burn wound care.
Feedback
1. The burn patient may endure
NURmany
SINGpsychological
TB.COM and emotional challenges throughout his or
her lengthy course of treatment and recovery. The patient may experience anxiety.
2. The burn patient may endure many psychological and emotional challenges throughout his or
her lengthy course of treatment and recovery. The patient may experience depression.
3. Spiritual distress is not specifically identified as a potential problem for a patient recovering
from burns.
4. The burn patient may endure many psychological and emotional challenges throughout his or
her lengthy course of treatment and recovery. The patient may experience body image
disorder.
5. The burn patient may endure many psychological and emotional challenges throughout his or
her lengthy course of treatment and recovery. The patient may experience post-traumatic
stress disorder (PTSD).
PTS: 1 CON: Skin Integrity | Grief and Loss | Mood | Self | Stress
NUMERIC RESPONSE
28. ANS:
6460 mL
Chapter number and title: 51, Coordinating Care for Patients With Burns
Chapter learning objective: Explaining the medical and surgical management of patients with burn injuries
Chapter page reference: 1110
Heading: Management of Burn Injuries>Fluid Resuscitation
Integrated Processes: Nursing Process: Planning
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Feedback: First calculate the patient’s weight in kg by dividing the weight in lbs. by 2.2 or 187/2.2 = 85 kg.
Next use the formula 4 mL x kg of body weight x TBSA % to calculate the total fluid amount needed. For this
patient that would be 4 mL x 85 x 38 = 12,920 mL. Since one-half of the total fluid amount should be
provided in the first 8 hours, divide the total amount of fluid by 2 or 12,920/2 = 6460 mL. The patient should
receive 6460 mL of fluid in the first 8 hours after the burn injury.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is preparing information about bone health for a community fair. What part of the bone should the
nurse identify as containing living bone cells?
1) Nerves
2) Collagen
3) Osteoblasts
4) Blood vessels
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____ 2. A patient has a muscle that has been torn from the bone. Which structure has been injured in this patient?
1) Fascia
2) Tendon
3) Cartilage
4) Ligament
____ 3. A patient is experiencing bursitis of the hip. What physical finding should the nurse expect to assess in this
patient?
1) Muscle edema
2) Shortened limb
3) Hip contracture
4) Pain with movement
____ 4. The nurse is preparing teaching material on the musculoskeletal system. What should the nurse include about
the function of short bones?
1) Produces blood cells
2) Controls movement of the body
3) Provides stability with little movement
4) Controls contraction of organs and blood vessels
____ 5. The nurse is assessing a patient’s vertebral column. What term best describes the function of the joints
between the vertebrae?
1) Meiosis
2) Diarthrosis
3) Synarthrosis
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4) Amphiarthrosis
____ 6. A patient has a low level of thyroid stimulating hormone (TSH). How will this affect the musculoskeletal
system?
1) Reduces bone growth
2) Initiates the growth of bone
3) Slows the rate of bone destruction
4) Promotes the number of osteoblasts
____ 7. The nurse notes that a patient has muscular and skeletal balance. What should this observation indicate to the
nurse?
1) Joints are stressed.
2) Muscles are damaged.
3) Body organs are aligned.
4) Bones are compensating.
____ 8. The nurse is assessing a patient’s musculoskeletal status. Which observation indicates that the gait is normal?
1) Base is as wide as the patient’s hips.
2) Symmetrical arm swing occurs with each step.
3) Foot is on the ground for 40% of the stance phase.
4) Foot is off of the ground for 60% of the swing phase.
____ 9. The nurse is evaluating a patient’s musculoskeletal system. Which approach should be used to determine joint
mobility?
1) Gait
2) Posture
3) Range of motion NURSINGTB.COM
4) Palpation of muscle tone
____ 10. The nurse notes that a patient has full range of motion against gravity but not resistance. How should the
nurse document this finding?
1) Fair
2) Poor
3) Good
4) Normal
____ 11. A patient is scheduled for a CT scan of the left femur. What should the nurse expect the findings of this
diagnostic test to reveal?
1) Fractures
2) Disk disease
3) Osteomyelitis
4) Ligamentous tears
____ 12. The nurse notes that patient is scheduled for an arthrogram. What is the purpose of this test?
1) Evaluate healing of a bone fracture
2) Visualize joint soft tissue structures
3) Identify the location of a bone tumor
4) Determine the cause for muscle weakness
____ 13. A patient’s bone density results are -2.7. For which potential health problem should the nurse instruct this
patient?
1) Pain
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2) Fractures
3) Contractures
4) Muscle atrophy
____ 14. A patient’s bone scan results showed a 3 cm cold spot area on the right fibula. What does this finding
indicate?
1) Cancer
2) Bone infection
3) Healing fracture
4) Bone metabolism disease
____ 15. A patient has loose bone fragments within the knee. Which diagnostic test should be considered to remove
these fragments?
1) Bone scan
2) Arthroscopy
3) Arthrocentesis
4) Electromyography
____ 16. A patient is recovering from an arthrocentesis of the right knee. What should the nurse instruct the patient
regarding care at home?
1) Elevate the extremity
2) Ambulate with crutches
3) Avoid all weight bearing for three to five days
4) Apply ice to the wound for the first 24 hours
____ 17. The nurse notes that a 55-year-old female patient’s bone density test has changed from -1.2 to a current level
of -2.5. What could be the reason forNthis
URchange?
SINGTB.COM
1) Immobility
2) Loss of estrogen
3) Chronic diseases
4) Poor nutritional status
____ 18. An older patient is diagnosed with a fractured hip joint. What should the nurse consider as the reason for this
fracture?
1) Mineral deposits
2) Decreased joint fluid
3) Thinner joint cartilage
4) Loss of fluid in tendons
____ 19. An older patient is experiencing arthritis in major joints. What could be the reason for the development of this
disorder?
1) Decreased cartilage
2) Decline in muscle mass
3) Less fluid in joint spaces
4) Loss of fluid in ligaments
____ 20. An older patient asks what can be done to prevent bone fractures. What should the nurse suggest to this
patient?
1) Limit exposure to the sun
2) Increase the intake of water
3) Increase frequency of rest periods
4) Engage in weight-bearing exercise
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. The nurse is preparing educational material for the parents of children recovering from fractures. What should
the nurse include as the parts of long bones? Select all that apply.
1) Diaphysis
2) Epiphysis
3) Ligaments
4) Periosteum
5) Endosteum
____ 22. The nurse is assessing a patient’s musculoskeletal system. Which observation indicates that the muscles are
functioning appropriately? Select all that apply.
1) Limb bends at a joint.
2) A body part is raised.
3) Action occurs automatically.
4) Arm moves in a circle around the shoulder.
5) Limb moves away from the midline of the body.
____ 23. The nurse is preparing to conduct a physical assessment of a patient’s musculoskeletal system. Which
techniques should the nurse use for this assessment? Select all that apply.
1) Palpation
2) Inspection
3) Evaluation
4) Percussion NURSINGTB.COM
5) Auscultation
____ 24. A patient is scheduled for an MRI of the pelvis. What should the nurse include when preparing this patient for
the test? Select all that apply.
1) Insert a urinary catheter
2) Assess for metal implants
3) Remove all medication patches
4) Ensure all metal jewelry and hair items are removed
5) Maintain nothing by mouth status for eight hours before the test
____ 25. A patient is scheduled for electromyography. What teaching should the nurse provide to prepare the patient
for this test? Select all that apply.
1) Shower before the test.
2) Apply lotion for better electrode contact.
3) Slight pain might occur with needle insertion.
4) Slight bruising may occur at the site of electrodes.
5) Avoid caffeinated food items two to three hours before the test.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 52, Assessment of Musculoskeletal Function
Chapter learning objective: Identifying key anatomical components of the musculoskeletal system
Chapter page reference: 1128
Heading: Overview of Anatomy and Physiology>Bones
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Mobility; Nutrition; Promoting Health
Difficulty: Moderate
Feedback
1 The portion of the bone that contains living tissue includes the nerves.
2 The portion of the bone that contains living tissue includes collagen.
3 The living cells contain osteoblasts or the cells that help form bone.
4 The portion of the bone that contains living tissue includes the blood vessels.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4 Amphiarthrosis describes a joint that permits slight movement like between the
vertebrae.
Feedback
1 TSH inhibits the activity of osteoclasts and reduces bone growth.
2 Growth hormone initiates the growth of bone until adult size is achieved.
3 Estrogen induces a chemical in osteoclasts that causes them to self-destruct and slows
the rate of bone destruction.
4 Parathyroid hormone promotes the activity and number of osteoblasts.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
11. ANS: 1
Chapter number and title: 52, Assessment of Musculoskeletal Function
Chapter learning objective: Correlating relevant diagnostic examinations to musculoskeletal function
Chapter page reference: 1136
Heading: Diagnostic Studies>Imaging Studies>Computerized Tomography
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Mobility; Assessment
Difficulty: Easy
Feedback
1 Computed tomography scans are done to diagnose muscle and bone disorders including
fractures.
2 MRI is used to diagnose disk disease.
3 MRI is used to diagnose osteomyelitis.
4 MRI is used to diagnose ligamentous tears.
Feedback
1 An arthrogram is not used to evaluate healing of a bone fracture.
2 An arthrogram allows for visualization of soft tissue structures of a joint.
3 An arthrogram is not used to identify the location of a bone tumor.
4 An arthrogram is not used to determine the cause for muscle weakness.
NURSINGTB.COM
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Feedback
1 A bone density score of -2.5 does not increase the patient’s risk of pain.
2 A bone density score of -2.5 and below indicates the presence of osteoporosis and
increases the patient’s risk of fractures.
3 A bone density score of -2.5 does not increase the patient’s risk of contractures.
4 A bone density score of -2.5 does not increase the patient’s risk of muscle atrophy.
Feedback
1 Areas of “cold” spots define areas with a lack of blood supply to the bone and may
indicate the presence of cancer.
2 “Hot spots” are areas where the tracer accumulates in the bone. These spots are often
attributed to bone infection.
3 “Hot spots” are areas where the NUtracer
RSIaccumulates
NGTB.COinMthe bone. These spots are often
attributed to fractures that are healing.
4 “Hot spots” are areas where the tracer accumulates in the bone. These spots are often
attributed to diseases of bone metabolism.
Feedback
1 A bone scan is a diagnostic scan to find damage to bones, disease (such as cancer),
infection, or trauma.
2 Arthroscopy is used to diagnose, repair, and remove loose or foreign materials in the
joint.
3 Arthrocentesis is a clinical procedure where fluid is aspirated from a joint.
4 Electromyography (EMG) is a diagnostic test that assesses the health of motor neurons
and muscle.
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Feedback
1 After an arthrocentesis the extremity does not need to be elevated.
2 After an arthrocentesis the patient does not need to use crutches.
3 After an arthrocentesis the patient does not need to avoid weight bearing for three to
five days.
4 Postprocedure instructions after an arthrocentesis include applying ice to the wound for
the first 24 hours post procedure.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Sun exposure helps to synthesize vitamin D. This would not prevent bone fractures.
2 Water is not identified as a method to reduce bone fractures.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE RESPONSE
21. ANS: 1, 2, 4, 5
Chapter number and title: 52, Assessment of Musculoskeletal Function
Chapter learning objective: Identifying key anatomical components of the musculoskeletal system
Chapter page reference: 1129
Heading: Overview of Anatomy and Physiology>Bones
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Mobility; Promoting Health
Difficulty: Moderate
Feedback
1. Diaphysis is the shaft, which is made up of the long portion of the bone. It is constructed of a
thick compact bone that surrounds the medulla cavity in adults. The medulla cavity contains
fat known as the yellow marrow.
2. Epiphysis is known as theNUend
RSportion
INGTof B.theCO M A thin layer of compact bone forms the
bone.
exterior portion of the bone, and the interior of this portion of the bone contains spongy bone.
3. Ligaments are fibrous connective tissues present at joints to help provide stability to the joint.
4. Periosteum is the tough outer surface of the bone. It consists of connective tissue, primarily of
bone-forming cells known as osteoblasts. This portion of the bone also provides an insertion
or anchoring point for tendons and ligaments.
5. Endosteum is the internal bone surface that is covered with a delicate connective tissue
membrane.
Feedback
1. The main function of skeletal muscles is conscious or voluntary control of movement of the
body or its parts. These movements include flexion (bending a limb at a joint).
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2. The main function of skeletal muscles is conscious or voluntary control of movement of the
body or its parts. These movements include elevation or raising a body part.
3. Automaticity is a function of cardiac muscle.
4. The main function of skeletal muscles is conscious or voluntary control of movement of the
body or its parts. These movements include circumduction (moving the arm in a circle around
the shoulder).
5. The main function of skeletal muscles is conscious or voluntary control of movement of the
body or its parts. These movements include abduction (moving a limb away from the midline
of the body).
Feedback
1. Palpation is an important part of the physical examination to assess muscle tone and strength,
NURSINGTB.COM
range of motion, sensation, skin temperature, and quality of pulses.
2. A physical examination begins with a general inspection of the posture, gait, joint mobility,
and skin.
3. Evaluation is a step in the nursing process.
4. Percussion is not a technique used when assessing the musculoskeletal system.
5. Auscultation is not a technique used when assessing the musculoskeletal system.
Feedback
1. A urinary catheter is not required for an MRI.
2. Metal implants might contraindicate the use of an MRI as a diagnostic test. This needs to be
reported.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3. Medication patches can cause burns at the site and should be removed prior to the MRI.
4. Metal jewelry and hair items should be removed prior to the MRI. External metal items may
interfere with the magnetic imaging.
5. For an MRI of the pelvis the patient should be NPO for eight hours before the test.
Feedback
1. The patient should be instructed to shower before the test.
2. Lotion should not be applied to the skin. Lotion interferes with electrode contact.
3. The patient should be instructed that slight pain might occur when the needles are inserted.
4. The patient should be informed that slight bruising might occur where the electrodes were
placed.
5. The patient should be instructed
NURSItoNavoid
GTB.caffeinated
COM food items for two to three hours before
the test.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A patient with Duchenne muscular dystrophy has significant muscle damage. What is the primary reason for
this destruction?
1) High body fat
2) Lack of dystrophin
3) Breakdown of collagen
4) Decreased body protein
____ 2. The nurse is reviewing orders written for a patient with muscular dystrophy. Which medication should the
nurse expect to be prescribed for this patient?
1) Cortisol
2) Furosemide
3) Gabapentin
4) Acetaminophen
____ 3. A patient with osteoporosis asks why the health problem developed. What nursing response would be
appropriate for this patient?
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4) “Exercise helps with weight management, which is a major reason for the problem.”
____ 11. A patient with severe hip pain is diagnosed with osteoarthritis (OA). What information should the nurse
provide to the patient about this disease process?
1) “OA causes an overgrowth of cartilage in the joints.”
2) “OA causes joint fluid to become bluish-white in color.”
3) “OA causes a decrease in joint fluid that affects the cartilage.”
4) “OA causes a build of fluid in the joints, hindering movement.”
____ 12. The blood pressure of a patient recovering from total hip replacement surgery is dropping. What should the
nurse suspect is occurring with this patient?
1) Blood loss
2) Pain medication overdose
3) Development of a deep vein thrombosis
4) Development of a postoperative infection
____ 13. A patient recovering from total hip replacement surgery is having difficulty with position changes and
ambulation. Which member of the interdisciplinary team should be consulted to address this patient’s issues?
1) Orthopedic nurse
2) Physical therapist
3) Orthopedic surgeon
4) Occupational therapist
____ 14. The manager notes that several nurses have been seen in employee health for low back pain over the last
month. What type of education should the manager plan to help reduce the incidence of this health problem?
1) Safety
2) Body mechanics NURSINGTB.COM
3) Coordinating care
4) Stress management
____ 15. The nurse is preparing material about back pain for a community health fair. What should be included as a
reason why this pain occurs most frequently in the lumbar region of the spine?
1) It contains peripheral nerves.
2) It is the most rigid area of the spine.
3) It is the most flexible area of the spine.
4) It anchors the weight of the lower body.
____ 16. A patient is experiencing severe lower back pain that radiates down the leg causing weakness. Which
diagnostic test should be considered after an MRI?
1) CT scan
2) Bone scan
3) Spinal x-ray
4) Electromyography
____ 17. A patient is seeking medical treatment for chronic low back pain. Which approach will help speed this
patient’s recovery?
1) Regular exercise
2) Spinal injections
3) Nonsteroidal anti-inflammatory agents (NSAIDs)
4) Transcutaneous electrical nerve stimulation (TENS)
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 18. A patient with bone cancer is admitted for treatment. What finding should the nurse expect to observe when
assessing this patient?
1) Limp
2) Muscle atrophy
3) Skin discoloration
4) Dependent edema
____ 19. A patient is diagnosed with a primary bone tumor. Which treatment should the nurse expect to be prescribed
first for this patient?
1) Surgery
2) Amputation
3) Radiotherapy
4) Chemotherapy
____ 20. The nurse is planning care for a patient with osteosarcoma. What should be done before encouraging the
patient to increase activity?
1) Assess for pain
2) Assess heart rate
3) Measure blood pressure
4) Provide assistive devices
____ 21. A patient recovering from surgery for bone cancer is scheduled for postoperative radiation treatments. What
should the nurse emphasize when providing teaching before a treatment?
1) Apply lotion to the skin
2) Examine the condition of the skin
3) Coat the skin with protective cream
NU
4) Lightly dust the skin with talcum RSINGTB.COM
powder
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 22. The nurse is assigned to care for a patient with muscular dystrophy. What should the nurse expect to assess in
this patient? Select all that apply.
1) Nausea and vomiting
2) Alteration in cardiac rhythm
3) Progressive muscle weakening
4) Reduction in respiratory excursion
5) Wasting of voluntary muscle groups
____ 23. The nurse is reviewing orders written for a patient with Paget’s disease. Which medications should the nurse
expect to be prescribed? Select all that apply.
1) Etidronate (Didronel)
2) Ibandronate (Boniva)
3) Risedronate (Actonel)
4) Calcitonin (Miacalcin)
5) Zoledronic acid (Zoledronate)
____ 24. The nurse suspects that a home care patient recovering from hip replacement surgery is developing
osteomyelitis. What findings caused the nurse to come to this conclusion? Select all that apply.
1) Fever
2) Bone deformity
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 2
Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Muscular
dystrophies
Chapter page reference: 1144
Heading: Muscular Dystrophies>Clinical Manifestations
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Mobility
Difficulty: Moderate
Feedback
1 In Duchenne muscular dystrophy, muscle damage is not because of high body fat.
2 With progressive deterioration and weakness to the facial, limb, respiratory, and cardiac
muscles, the ultimate result is muscular damage. This is due primarily to the lack of the
key protein (dystrophin) to maintain the integrity of the muscle fibers as well as the
ability to repair muscle tissue as it breaks down and/or deteriorates.
3 In Duchenne muscular dystrophy, muscle damage is not because of the breakdown of
collagen. NURSINGTB.COM
4 In Duchenne muscular dystrophy, muscle damage is not because of decreased body
protein.
Feedback
1 There is no specific cure or pharmacological intervention. Glucocorticoid therapy is
frequently the medication of choice in conjunction with supportive and collaborative
care. Cortisol is a glucocorticoid.
2 Furosemide is a diuretic. This is not prescribed as treatment for muscular dystrophy.
3 Gabapentin is an anticonvulsant often prescribed for peripheral neuropathic pain. This
is not prescribed as treatment for muscular dystrophy.
4 Acetaminophen is a NSAID and is not prescribed as treatment for muscular dystrophy.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Osteoclasts breaking down bone with acids and enzymes is part of the process of
building new bone.
2 Bone loss osteopenia occurs when bone resorption or osteoclastic activity is greater
than bone rebuilding or osteoblastic activity, which ultimately results in a decreased
bone mineral density (BMD).
3 Osteoblastic activity is less than osteoclastic activity.
4 Osteoblasts rebuild bone by synthesis and mineralization of the new bony matrix within
the bone cavity.
Feedback
1 An MRI is not used to diagnose osteoporosis.
2 A CT scan is not used to diagnose osteoporosis.
3 A bone scan is not used to diagnose osteoporosis.
4 The gold standard assessment for osteoporosis is bone mineral density measurements.
They are obtained through a dual-energy x-ray absorptiometry (DEXA) scan.
NURSINGTB.COM
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Feedback
1 Alendronate (Fosamax) should not be taken at bedtime.
2 Alendronate (Fosamax) is not to be taken with a full meal.
3 Alendronate (Fosamax) should be taken on an empty stomach.
4 Alendronate (Fosamax) is not to be taken two hours after breakfast.
Feedback
1 Anticholinergic medications are not used in the treatment of Paget’s disease.
2 Thiazide diuretics are not used in the treatment of Paget’s disease.
3 Antihypertensives are not used in the treatment of Paget’s disease.
NURSINGTB.COM
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Feedback
1 Antibiotics will be prescribed; however, teaching about this medication can be
instructed at any time.
2 The patient will be experiencing pain; however, teaching about pain management
would not be a priority. With appropriate surgical and medical therapy, pain should be
managed and decrease.
3 Surgical intervention with débridement is required when a patient with osteomyelitis
demonstrates failure to respond to antibiotic therapy, evidence of soft tissue abscess or
subperiosteal collection, suspected or confirmed joint infection, and/or progressive
neurological deficits or spinal instability in the case of vertebral osteomyelitis. Since
NURorthopedic
this patient’s osteomyelitis is from SINGTBhardware,
.COM the hardware needs to be
removed.
4 In the event that a patient has known or suspected infected orthopedic hardware,
surgical removal is often warranted.
Feedback
1 Adequate ingestion of vitamin C, zinc, iron, thiamine, folic acid, and protein can help
with wound healing and eliminating infection. This meal choice would be adequate.
2 Adequate ingestion of vitamin C, zinc, iron, thiamine, folic acid, and protein can help
with wound healing and eliminating infection. This meal choice would be adequate.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3 This meal choice has no protein. It may have adequate zinc and folic acid; however,
protein is missing, which is required for wound healing.
4 Adequate ingestion of vitamin C, zinc, iron, thiamine, folic acid, and protein can help
with wound healing and eliminating infection. This meal choice would be adequate.
Feedback
1 Exercise is not used as complete pain control. Many people with scoliosis will have
some amount of pain.
2 Pain management is a medical strategy for people with scoliosis.
3 Exercise can reverse the signs and symptoms of spinal deformity and prevent further
progression within adolescents and adults.
4 Although obesity is a risk factor for the development of scoliosis, exercises are not
being prescribed for weight management but rather to prevent the progression of the
deformity.
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Feedback
1 OA causes a breakdown of the cartilage in the joints.
2 OA causes joint fluid to change to yellow-brown in color.
3 In OA, there is a decrease in the proteoglycans, which are responsible for the
management of the fluid within the joints. The result is a loss of cartilage strength and
functionality.
4 OA does not affect the volume of joint fluid.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
12. ANS: 1
Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with
musculoskeletal disorders
Chapter page reference: 1165
Heading: Joint Replacement>Nursing Management>Postoperative Assessment
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Mobility; Perfusion
Difficulty: Moderate
Feedback
1 Hypotension may signal blood loss.
2 A reduction in respiratory rate would be seen in the patient who is overmedicated for
pain.
3 Pain, redness, and edema would indicate a deep vein thrombosis.
4 Increased temperature and purulent drainage would indicate a postoperative infection.
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Feedback
1 Education about safety will not reduce the risk for low back pain.
2 Risk factors for low back pain include poor body mechanics, which would be helpful
for nurses.
3 Coordinating care is not a risk factor for low back pain.
4 Stress is not a risk factor for low back pain even though stress is a part of the diagnosis
for low back pain.
Feedback
1
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The lumbar region contains nerve roots that are susceptible to injury or disease.
2 The lumbar region is the most flexible area of the spine.
3 The lumbar region is the most flexible area of the spine.
4 The lumbar region supports the weight of the upper body.
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MULTIPLE RESPONSE
22. ANS: 3, 5
Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders
Chapter learning objective: Describing the epidemiology of musculoskeletal disorders
Chapter page reference: 1144
Heading: Muscular Dystrophies>Epidemiology
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Mobility
Difficulty: Moderate
Feedback
1. Nausea and vomiting are not primary symptoms of muscular dystrophies.
2. Alterations in cardiac rhythm are not primary symptoms of muscular dystrophies.
3. The primary symptoms of muscular dystrophies are progressive muscle weakening.
4. Reduction in respiratory excursion is not a primary symptom of muscular dystrophy.
5. The primary symptoms of muscular dystrophies are wasting of skeletal or voluntary muscle
groups.
Feedback
1. Etidronate (Didronel) was the first bisphosphonate used with a 50% reduction in disease
activity noted. Presently, it is used less, secondary to the fact that the therapeutic doses
required for effective management have been linked to side effects such as bone
demineralization.
2. Ibandronate (Boniva) is one of six nitrogen-containing bisphosphonates used for the initial
treatment of Paget’s disease.
3. Risedronate (Actonel) is one of six nitrogen-containing bisphosphonates used for the initial
treatment of Paget’s disease.
4. Calcitonin was the first therapeutic treatment used for Paget’s disease, but long-term
management is difficult because of side effects and the need for ongoing subcutaneous
injections. Patients also may develop resistance to this medication.
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5. Zoledronic acid (Zoledronate) is one of six nitrogen-containing bisphosphonates used for the
initial treatment of Paget’s disease.
Feedback
1. Clinical manifestations of acute osteomyelitis include fever.
2. Bone deformity is associated with Paget’s disease.
3. Clinical manifestations of acute osteomyelitis include pain relieved by rest.
4. Progressive muscle weakness is associated with muscular dystrophy.
5. Clinical manifestations of acute osteomyelitis include tenderness and warmth at the site.
Feedback
1. Obesity is a risk factor associated with scoliosis.
2. Sedentary lifestyle is a risk factor associated with scoliosis.
3. Smoking is a risk factor associated with scoliosis.
4. Psychologically strenuous work is a risk factor associated with scoliosis.
5. Occupations that require heavy, physical work are risk factors associated with scoliosis.
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Feedback
1. An uneven gait is identified as a symptom of scoliosis.
2. Uneven waist is a symptom of scoliosis.
3. Different arm lengths is a symptom of scoliosis.
4. Lateral curve of the spine is a symptom of scoliosis.
5. Uneven hemline at the knees could indicate one hip is higher than the other, which is a
symptom of scoliosis.
Feedback
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1. The initial medical management prior to joint replacement is focused on weight management.
2. The initial medical management prior to joint replacement is focused on nonsteroidal therapy.
3. The initial medical management prior to joint replacement is focused on activity modification.
4. The National Institute for Health and Care Excellence states that a total hip replacement
(THR) or a total knee replacement (TKR) can be considered once self-management, exercise,
and analgesia are no longer effective in relieving pain during activities of daily living.
5. The initial medical management prior to joint replacement is focused on the use of joint
supplements such as glucosamine and chondroitin.
Feedback
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1. With metastasis from the breast, kidney, or lung to the bone, elevated calcium levels are
frequently noted.
2. Serum alkaline phosphatase is frequently elevated with osteosarcomas due to the increased
enzyme activity at the level of the muscle, the deterioration of bone, and the inflammatory
response.
3. LD is frequently elevated with osteosarcomas due to the increased enzyme activity at the level
of the muscle, the deterioration of bone, and the inflammatory response.
4. ESR is frequently elevated with osteosarcomas due to the increased enzyme activity at the
level of the muscle, the deterioration of bone, and the inflammatory response.
5. AST is frequently elevated with muscular dystrophy (MD), not metastatic bone cancer. The
AST level is monitored to assess for muscle wasting and deterioration in MD.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A patient is recovering from surgery to repair a third-degree strain. What needs to be emphasized to the
patient about postoperative care?
1) Elevate the extremity
2) Rest the extremity for up to 72 hours
NUtimes
3) Apply ice to the area three to five RSIaNdayGTB.COM
4) Immobilize the extremity for four to six weeks
____ 2. A patient is treated for a second-degree sprain. Which patient statement indicates that teaching about care has
been ineffective?
1) “I should apply ice.”
2) “I should elevate my leg.”
3) “I should expect the leg to feel numb.”
4) “I should take pain medication as directed.”
____ 3. A 70-year-old patient is diagnosed with a low energy fracture. What most likely caused this injury to occur?
1) A fall
2) Contact sport
3) Bicycle accident
4) Motor vehicle collision
____ 4. A patient has an injury where one side of the bone is bent and the other is fractured. How should the nurse
document this fracture?
1) Spiral
2) Oblique
3) Greenstick
4) Comminuted
____ 5. A patient with Paget’s disease is demonstrating manifestations of a fracture. What diagnostic test should be
ordered to confirm if a fracture has occurred?
1) X-ray
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2) Bone scan
3) Myelogram
4) Angiogram
____ 6. While playing tennis a patient fell and fractured the right elbow. For which treatment should the nurse prepare
this patient?
1) Cast
2) Splint
3) External fixator
4) Pressure dressing
____ 7. A patient recovering from surgery to repair a fractured femur is experiencing extreme pain and pulselessness.
What should the nurse expect to be prescribed for this patient?
1) Fasciotomy
2) Limb CT scan
3) Intravenous fluids
4) Anticoagulant therapy
____ 8. A patient recovering from surgery to repair a fractured hip is placed on skin traction. Which finding indicates
that the traction is being effective?
1) Strong peripheral pulses
2) Reduction in muscle spasms
3) Improved mobility of the foot
4) Reduction of lower extremity edema
____ 9. A patient with peripheral vascular disease has a non-healing leg wound. Which observation indicates that the
patient is at risk for an elective amputation?
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1) Mutilation of soft tissue
2) Development of gangrene
3) Crushed lower extremity bone
4) Severed blood vessels and nerves
____ 10. A patient recovering from a traumatic amputation is experiencing phantom limb pain. What should the nurse
expect to be included in the treatment plan for this patient?
1) Gabapentin
2) Rigid splint
3) Ice compresses
4) Elevate stump on a pillow
____ 11. During a home visit the nurse suspects that a patient recovering from an amputation is not complying with
prescribed postoperative care. What observation caused the nurse to make this clinical determination?
1) Suture line pink and slightly edematous
2) Evidence of a developing hip contracture
3) Stump wrapped with a compression bandage
4) Taking opioid medication every 8 to 10 hours
____ 12. A patient seeks medical treatment for a meniscus injury. What assessment finding would suggest a reason this
injury occurred?
1) History of chronic joint disease
2) Participation in cycling or golf
3) Intake of sufficient water and protein
4) Use of nonsteroidal anti-inflammatory drugs (NSAIDs)
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____ 13. A patient sustained a meniscus injury several months ago and did not seek medical attention. What is this
patient at risk of developing?
1) Tendonitis
2) Fractured patella
3) Dependent edema
4) Permanent joint damage
____ 14. The nurse suspects that while playing basketball a patient sustained a meniscus tear. What information did the
nurse use to make this decision?
1) Knee pops when bent
2) Weak peripheral pulses
3) Reduced muscle tone of the thigh
4) Calf cramping with the knees bent
____ 15. The nurse notes that a patient recovering from surgery to repair a torn meniscus has a blood pressure of
158/90 mm Hg. This finding would suggest that the nurse also assess the patient for which condition?
1) Pain
2) Edema
3) Infection
4) Hemorrhage
____ 16. The nurse is preparing a teaching tool for a community health program. What should the nurse include as a
risk factor for the development of carpal tunnel syndrome (CTS)?
1) Male gender
2) Age less than 20
3) Plays musical instruments NURSINGTB.COM
4) Works as a marketing manager
____ 17. The nurse suspects that a patient is developing carpal tunnel syndrome (CTS). What finding caused the nurse
to make this clinical determination?
1) Reduced radial pulses
2) Fingers cool to touch
3) Capillary refill > 3 seconds
4) Hand tingling during the night
____ 18. A patient with bilateral carpal tunnel syndrome (CTS) does not want to have surgery. What is this patient at
risk for developing?
1) Infection
2) Chronic pain
3) Further nerve injury
4) Hematoma formation
____ 19. The nurse requests an occupational therapy consultation for a patient with bilateral carpal tunnel syndrome.
What is the reason for this consultation?
1) Evaluate the work area
2) Instruct on hand exercises
3) Instruct on the use of splints
4) Review the action of NSAIDs
____ 20. The nurse is reviewing postoperative instructions with a patient recovering from carpal tunnel syndrome
(CTS) surgery. Which statement indicates that additional teaching would be required?
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. The nurse is reviewing statistics about the frequency of anterior cruciate ligament (ACL) tears. What
increases the risk of experiencing this type of injury? Select all that apply.
1) Knee torque
2) Less knee flexibility
3) Practicing ice skating
4) Performing gymnastics
5) Less muscular strength
____ 22. A patient is diagnosed with a third-degree sprain. What should the nurse expect to assess in this patient?
Select all that apply.
1) Edema
2) Severe pain
3) Ecchymosis
4) Inability to ambulate
5) Altered ability to ambulate
____ 23. The nurse suspects that a patient with an injured ankle is experiencing neurovascular compromise. What did
NURSI
the nurse assess to come to this conclusion? NGTall
Select B.that
COapply.
M
1) Pain
2) Pressure
3) Paralysis
4) Peristalsis
5) Pulselessness
____ 24. A victim of a motor vehicle crash has a partially severed lowered extremity. What emergency care does this
patient need? Select all that apply.
1) Administer antibiotics
2) Prepare for blood transfusions
3) Prepare for emergency surgery
4) Assess for active hemorrhaging
5) Monitor effectiveness of tourniquet
____ 25. A patient is diagnosed with a small meniscus tear of the right knee. What should the nurse expect to be
prescribed for this patient? Select all that apply.
1) Ice
2) Limited rest
3) Physical therapy for a month
4) Total immobility for several weeks
5) Use of nonsteroidal anti-inflammatory drugs (NSAIDs)
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MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma
Chapter learning objective: Explaining the effective medical management of: Sprains and strains
Chapter page reference: 1175
Heading: Strains and Sprains>Medical Management
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity – Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Mobility; Perioperative
Difficulty: Moderate
Feedback
1 Treatment of first- and second-degree strains and sprains includes elevating the
extremity.
2 Treatment of first- and second-degree strains and sprains includes resting the extremity.
3 Treatment of first- and second-degree strains and sprains includes applying ice to the
extremity.
4 Postoperative treatment for strains and sprains involves immobilization of the affected
extremity for four to six weeks.
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Feedback
1 Skin traction is not used to improve blood flow.
2 Skin traction is applied to relieve muscle spasms.
3 Skin traction is not used to improve mobility.
4 Skin traction is not used to reduce edema.
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Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma
Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle
considerations based on patients with musculoskeletal trauma
Chapter page reference: 1188
Heading: Amputations>Nursing Management>Teaching
Integrated Processes: Nursing Process: Evaluation
Client Need: Physiological Integrity – Reduction of Risk Potential
Cognitive level: Analysis [Analyzing]
Concept: Mobility
Difficulty: Moderate
Feedback
1 A pink and slightly edematous suture line would indicate healing.
2 A developing hip contracture indicates that the patient is not complying with
postoperative exercises and actions to prevent the development of a contracture.
3 Wrapping the stump with a pressure bandage decreases edema and aids in the correct
fitting of the prosthesis.
4 Taking pain medication as prescribed indicates adherence to postoperative teaching and
care.
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Feedback
1 Meniscus tears are not related to tendonitis.
2 Meniscus tears will not cause patellar fractures.
3 Meniscus tears will not cause dependent edema.
4 If left untreated, meniscus tears can lead to permanent joint damage.
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Chapter learning objective: Describing the epidemiology of various types of musculoskeletal trauma
Chapter page reference: 1191
Heading: Carpal Tunnel Syndrome>Epidemiology
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Mobility; Promoting Health
Difficulty: Moderate
Feedback
1 Women are four to five times more likely to get CTS than their male counterparts,
partially because of the smaller size of the carpal tunnel in women.
2 Risk factors for carpal tunnel syndrome include advancing age.
3 Higher occurrences are noted in patients who have jobs requiring repetitive motions of
the hands such as musicians.
4 There is an increased prevalence of CTS among those who work in industrial
occupations involving repetitive movement of the hands and wrists.
Feedback
1 CTS does not affect the radial pulse.
2 CTS does not affect temperature of the fingers.
3 CTS does not affect capillary refill.
4 In CTS inflammation compresses the median nerve causing sharp pain, numbness, and
tingling of the hand. Symptoms initially occur intermittently at night, then progress if
not treated.
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Difficulty: Easy
Feedback
1 Postoperative complications include infection.
2 Untreated CTS can lead to chronic pain.
3 Postoperative complications include further nerve injury.
4 Postoperative complications include hematoma formation.
Feedback
1 An occupational therapist can evaluate the work area and make recommendations for
modifications to eliminate causative factors.
2 A physical therapist would instruct onIhand
3
NURS NGTexercises.
B.COM
A physical therapist would instruct on the use of splints.
4 The nurse or pharmacist would review the action of NSAIDs.
Feedback
1 The patient should take postoperative pain medication as prescribed.
2 The patient should report any worsening symptoms to the health-care provider.
3 The patient should perform physical therapy to promote movement, muscle strength,
and return to pre-injury functioning.
4 The patient should stop any activity that causes hand numbness or pain and evaluate the
environment to reduce the pain from reoccurring.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE RESPONSE
21. ANS: 1, 2, 4, 5
Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma
Chapter learning objective: Describing the epidemiology of various types of musculoskeletal trauma
Chapter page reference: 1174
Heading: Strains and Sprains>Epidemiology
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Mobility
Difficulty: Easy
Feedback
1. A great degree of knee torque increases the risk of an ACL injury.
2. Less knee flexibility increases the risk of an ACL injury.
3. The frequency of ankle sprains can be ranked highest among the sport of ice skating.
4. An ACL injury occurs most frequently in sports that involve twisting and jumping like
gymnastics.
5. Less muscular strength increases the risk for an ACL injury.
Feedback
1. Symptoms of a third-degree sprain include edema.
2. Symptoms of a third-degree sprain include severe pain.
3. Symptoms of a third-degree sprain include ecchymosis.
4. Third-degree or severe sprains include the complete tearing of a ligament, which renders the
patient unable to ambulate because of joint instability.
5. Symptoms of a second-degree sprain include an altered ability to ambulate.
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Chapter learning objective: Developing a comprehensive plan of nursing care for patients with
musculoskeletal trauma
Chapter page reference: 1176
Heading: Strains and Sprains>Nursing Management>Assessment
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Mobility; Assessment
Difficulty: Moderate
Feedback
1. Symptoms of neurovascular compromise include pain.
2. Symptoms of neurovascular compromise include pressure.
3. Symptoms of neurovascular compromise include paralysis.
4. Peristalsis is not a symptom of neurovascular compromise.
5. Symptoms of neurovascular compromise include pulselessness.
Feedback
1. Antibiotics are not part of emergency care for a traumatic amputation.
2. To prevent hemorrhagic shock after a traumatic amputation, the patient should be prepared for
blood transfusions.
3. The patient with a traumatic amputation should be prepared for emergency surgery.
4. The patient with a traumatic amputation should be assessed for active hemorrhaging.
5. The tourniquet or pressure bandage placed over the site of a traumatic amputation should be
assessed for effectiveness.
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Feedback
1. Smaller tears often heal within a few months and are treated with ice.
2. Smaller tears often heal within a few months and are treated with limited rest.
3. Physical therapy would be indicated for a larger meniscus tear requiring surgery.
4. Total immobility and resting of the affected joint is not recommended because it may cause
muscle atrophy, stiffness, and further movement problems.
5. Smaller tears often heal within a few months and are treated with NSAIDs.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. Which structure of the gastrointestinal (GI) system is found in the right upper quadrant (RUQ) and is the
primary site of absorption?
1) Stomach
2) Duodenum
3) Sigmoid
4) Large intestine
____ 2. The patient reports left upper quadrant
NU(LUQ)
RSINpain.
GTB Based
.COonM this data, which does the nurse suspect?
1) Ruptured spleen
2) Pneumonia
3) Hepatitis
4) Duodenal ulcer
____ 3. Which organ functions as a main site for metabolizing drugs and may become impaired with the aging
process?
1) Stomach
2) Liver
3) Spleen
4) Large intestine
____ 4. The nurse is assessing a patient who is prescribed an anticholinergic agent. Which assessment finding
indicates the patient is experiencing an adverse reaction to the drug?
1) GI bleeding
2) Hepatic necrosis
3) Diarrhea
4) Hypoactive bowel sounds
____ 5. The nurse is providing care to a patient who reports diffuse abdominal pain. Upon assessment, the nurse notes
absent bowel sounds and abdominal distension. Based on this data, which medical diagnosis does the nurse
suspect?
1) Appendicitis
2) Bowel obstruction
3) Cirrhosis
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4) Cholelithiasis
____ 6. The nurse notes a positive shifting dullness during abdominal percussion. Which diagnosis does this
assessment data support?
1) Ascites
2) Liver enlargement
3) Pancreatitis
4) An abdominal mass
____ 7. Which action by the nurse is appropriate when determining if bowel sounds are absent during the patient
assessment?
1) Palpating the abdomen for two minutes
2) Inspecting the abdomen for 30 seconds
3) Percussing the abdomen for 60 seconds
4) Auscultating the abdomen for five minutes
____ 8. Which is the correct sequence for the abdominal exam?
1) Inspection, palpation, percussion, and auscultation
2) Inspection, percussion, palpation, and auscultation
3) Inspection, auscultation, percussion, and palpation
4) Inspection, auscultation, palpation, and percussion
____ 9. Which sound would the nurse expect to elicit when percussing the liver?
1) Resonance
2) Hyperresonance
3) Dullness
4) Tympany NURSINGTB.COM
____ 10. Which is the normal liver span at the midclavicular line the nurse anticipates when conducting a
gastrointestinal assessment?
1) 3 to 6 cm
2) 4 to 8 cm
3) 6 to 12 cm
4) 12 to 16 cm
____ 11. An older adult patient is admitted to the hospital with blunt trauma to the abdomen after an auto accident.
Which finding may indicate intra-abdominal bleeding?
1) Borborygmi
2) Everted umbilicus
3) Visible peristaltic waves
4) Bluish tint around the umbilicus
____ 12. Which bowel sound noted by the nurse during the gastrointestinal assessment indicates an early bowel
obstruction?
1) Hyperperistaltic
2) Hypoperistaltic
3) Absent
4) Epigastric
____ 13. Which action by the nurse is appropriate when attempting to locate the spleen during the abdominal
assessment?
1) Percussing over the 9th to the 11th ribs at the midaxillary line
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Multiple Response
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Identify one or more choices that best complete the statement or answer the question.
____ 21. When conducting an abdominal assessment, the nurse notes tender unmovable inguinal nodes that are greater
than 1 cm. Which conclusions by the nurse may be appropriate? Select all that apply.
1) Infection
2) Appendicitis
3) Cancer
4) Cholecystitis
5) Lymphoma
____ 22. The nurse is conducting a health history for a patient who presents with abdominal discomfort. Which
assessment questions are appropriate? Select all that apply.
1) “Where is the pain?”
2) “Was the onset gradual or sudden?”
3) “When was your last menstrual period?”
4) “How is your appetite?”
5) “What have you had to eat in the last 24 hours?”
____ 23. The nurse is conducting a health history for a patient who presents with weight change. Which assessment
questions are appropriate? Select all that apply.
1) “Where is the pain?”
2) “Was the onset gradual or sudden?”
3) “When was your last menstrual period?”
4) “How is your appetite?”
5) “What have you had to eat in the last 24 hours?”
NU
____ 24. The nurse is conducting an abdominal RSINGTWhich
assessment. B.COstructures
M can be assessed by palpation in the right
upper quadrant (RUQ)? Select all that apply.
1) Liver
2) Gallbladder
3) Duodenum
4) Spleen
5) Stomach
____ 25. The nurse is assessing a patient who experienced blunt force trauma to the umbilical region of the abdomen.
Which structures may be affected based on this information? Select all that apply.
1) Right kidney
2) Ascending colon
3) Ileum
4) Aorta
5) Spine
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 2
Chapter number and title: 55, Assessment of Gastrointestinal Function
Chapter learning objective: Discussing the function of the gastrointestinal system
Chapter page reference: 1196-1213
Heading: Overview of Anatomy and Physiology
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Assessment; Digestion; Bowel Elimination
Difficulty: Easy
Feedback
1 The stomach, found in the left upper quadrant, turns the food bolus into chyme.
2 The duodenum is the primary site for digestion, especially chemical digestion. It is
located in the RUQ.
3 The sigmoid colon is found in the left upper quadrant.
4 The large intestine primarily reabsorbs water.
Feedback
1 A ruptured spleen would manifest with pain in the LUQ.
2 Pneumonia would manifest with pain in the right upper quadrant (RUQ).
3 Hepatitis would manifest with pain in the right upper quadrant (RUQ).
4 A duodenal ulcer would manifest with pain in the right upper quadrant (RUQ).
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Feedback
1 The stomach turns food bolus into chyme.
2 The liver detoxifies a variety of substances such as drugs and alcohol. This function
may become impaired with the aging process.
3 The spleen produces and stores red (RBCs) and white (WBCs) blood cells.
4 The large intestine reabsorbs water.
Feedback
1 GI bleeding is an adverse reaction
2
NURassociated
SINGTBwith .Caspirin,
OM not an anticholinergic drug.
Hepatic necrosis is an adverse reaction associated with toxic levels of acetaminophen,
not an anticholinergic drug.
3 Diarrhea is an adverse reaction associated with many drugs, but this is not an adverse
reaction associated with an anticholinergic drug.
4 Hypoactive bowel sounds may indicate an adverse drug reaction.
Feedback
1 Appendicitis causes abdominal pain; bowel sounds are absent if the appendix perforates
and causes peritonitis.
2 Absent bowel sounds are caused by late bowel obstruction, peritonitis, or paralytic ileus
after surgery in which the bowel was manipulated.
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Feedback
1 Palpation is not the technique used to assess bowel sounds.
2 Inspection is not the technique used to assess bowel sounds.
3 Percussion is not the technique used to assess bowel sounds.
4 Bowel sounds occur every 5 to 15 seconds in an average adult patient. The nurse should
auscultate the abdomen for 5 minutes before determining that bowel sounds are absent.
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Feedback
1 The normal liver span at the midclavicular line is not 3 to 6 cm.
2 The normal liver span at the midclavicular line is not 4 to 8 cm.
3 The normal liver span at the midclavicular line is 6 to 12 cm.
4 The normal liver span at the midclavicular line is not 12 to 16 cm.
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Feedback
1 Borborygmi is the term used to describe hyperactive bowel sounds.
2 An everted umbilicus is often a normal finding for pregnant patients.
3 Visible peristaltic waves can be a normal finding for pediatric patients.
4 Bluish discoloration around the umbilicus (Cullen's sign) indicates hemorrhagic
pancreatitis or intraperitoneal bleeding.
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Feedback
1 Dullness of the normal spleen will be noted around the 9th to the 11th ribs.
2 The scratch test is used to locate the liver.
3 Venous hums indicate liver disease.
4 Palpating the apical pulse is not a procedure used to locate the spleen.
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Feedback
1 The older adult patient will experience decreased, not increased, saliva. This finding
does not contribute to constipation.
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2 The older adult patient will experience decreased, not increased, stomach acid. This
finding does not contribute to constipation.
3 The older adult patient will experience increased, not decreased, abdominal fat
accumulation. This finding does not contribute to constipation.
4 Decreased peristalsis may contribute to constipation for older adult patients.
Feedback
1 Pain in the RLQ does not indicate gallstones.
2 Appendicitis manifests with pain in the RLQ.
3 Pain in the RLQ does not indicate gallbladder inflammation.
4 Pneumonia does not manifest with pain in the RLQ.
Feedback
1 Asking the patient about appetite is appropriate when the patient presents with weight
loss.
2 This question is more appropriate for a patient who is experiencing alterations in bowel
elimination.
3 This question is more appropriate for a patient who is experiencing alterations in bowel
elimination.
4 This question is more appropriate for a patient who is experiencing alterations in bowel
elimination.
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MULTIPLE RESPONSE
21. ANS: 1, 3, 5
Chapter number and title: 55, Assessment of Gastrointestinal Function
Chapter learning objective: Correlating relevant diagnostic examinations to gastrointestinal function
Chapter page reference: 1196-1213
Heading: Assessment
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Easy
Feedback
1. This is correct. This finding could indicate infection.
2. This is incorrect. This finding is not indicative of appendicitis.
3. This is correct. This finding could indicate cancer.
4. This is incorrect. This finding is not indicative of cholecystitis.
5. This is correct. This finding could indicate lymphoma.
Feedback
1. This is correct. This question is appropriate for the patient who presents with abdominal
discomfort. It is essential for the nurse to determine the exact location of the pain.
2. This is correct. This question is appropriate for a patient who presents with abdominal pain.
The onset may determine the source of the pain.
3. This is correct. Abdominal pain in female patients may indicate reproductive issues; therefore,
the nurse should determine the last menstrual period.
4. This is incorrect. This question is more appropriate for a patient who has experienced a change
in weight.
5. This is incorrect. This question is more appropriate for a patient who has experienced a change
in weight.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1. This is incorrect. This question is more appropriate for a patient who presents with abdominal
pain.
2. This is incorrect. This question is more appropriate for a patient who presents with abdominal
pain.
3. This is incorrect. This question is more appropriate for a patient who presents with abdominal
pain.
4. This is correct. Weight change is assessed by determining the patient’s appetite.
5. This is correct. A 24-hour dietary log is appropriate to further assess a patient who presents
with a change in weight.
Feedback
1. This is correct. The liver is located in the RUQ and assessed by palpation.
2. This is correct. The gallbladder is located in the RUQ and assessed by palpation.
3. This is correct. The duodenum is located in the RUQ and assessed by palpation.
4. This is incorrect. The spleen is located in the left, not right, upper quadrant.
5. This is incorrect. The stomach is located in the left, not right, upper quadrant.
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Feedback
1. This is incorrect. The right kidney is located in the right lumbar region.
2. This is incorrect. The ascending colon is located in the right lumbar region.
3. This is correct. The ileum is located in the umbilical region.
4. This is correct. The aorta is located in the umbilical region.
5. This is correct. The spine is located in the umbilical region.
Chapter 56: Coordinating Care for Patients With Oral and Esophageal Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is explaining the alteration in normal function to a patient recently diagnosed with gastroesophageal
reflux disease (GERD). Which etiology contributing to GERD will the nurse include in the teaching session?
1) Transient constriction of the lower esophageal sphincter
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2) Decreased pressure within the stomach
3) Incompetent lower esophageal sphincter
4) Prolonged constriction of the upper esophageal sphincter
____ 2. The nurse is providing care to several patients in an outpatient clinic. Which patient is at high risk of
developing gastroesophageal reflux disorder (GERD)?
1) A patient who is six weeks pregnant
2) A patient who is morbidly obese
3) A patient who follows a strict vegetarian diet
4) A patient who drinks one glass of wine monthly
____ 3. A patient is admitted to the emergency department reporting a burning pain in the chest of a 7 on a 0 to 10
pain scale. Gastroesophageal reflux disorder (GERD) secondary to hiatal hernia is diagnosed. Based on this
data, which is the priority nursing diagnosis?
1) Anxiety
2) Acute Pain
3) Ineffective Health Maintenance
4) Dysfunctional Gastrointestinal Motility
____ 4. A patient is with a history of gastroesophageal reflux disorder (GERD) presents with metabolic alkalosis.
Based on the data reviewed in the patient’s history, which medication does the nurse suspect contributed to
the current diagnosis?
1) Aluminum hydroxide
2) Omeprazole
3) Ranitidine
4) Metoclopramide
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____ 5. An adult patient with a BMI of 39 who smokes 1 pack of cigarettes per day is diagnosed with erosive
esophagitis through upper GI endoscopy. The patient is now refusing all medications and states “I'm not
getting hooked on any pills.” What would the nurse recommend for the multidisciplinary collaborative plan?
1) Interview the patient and spouse for a 24-hour recall of usual food content, intake, and
meal times.
2) Enlist the patient’s son to elevate the foot of the patient’s bed at home six inches.
3) Offer the patient a surgical consult to reduce the necessity of medication.
4) Omit the pharmacist notification of the Multidisciplinary Team meeting about the patient.
____ 6. The nurse has implemented a care plan for an adult patient with gastroesophageal reflux disorder (GERD). On
the next clinic visit, which statement by the patient indicates adherence to the plan of care?
1) “Spandex camisoles are worth heartburn.”
2) “I have switched from margaritas to wine.”
3) “I've lost six pounds because I eat every three hours and never before bed.”
4) “I take a TUMS with the ranitidine to make it work better.”
A
____ 7. Which data collected by the nurse during the physical assessment indicates the patient is experiencing stage 1
stomatitis?
1) Redness of mucosa
2) Patchy oral ulceration
3) Oral ulcerations that bleed with minor trauma
4) Tissue necrosis with significant bleeding noted
____ 8. Which data collected by the nurse during the physical assessment indicates the patient is experiencing stage 2
stomatitis?
1) Redness of mucosa NURSINGTB.COM
2) Patchy oral ulceration
3) Oral ulcerations that bleed with minor trauma
4) Tissue necrosis with significant bleeding noted
____ 9. Which data collected by the nurse during the physical assessment indicates the patient is experiencing stage 3
stomatitis?
1) Redness of mucosa
2) Patchy oral ulceration
3) Oral ulcerations that bleed with minor trauma
4) Tissue necrosis with significant bleeding noted
____ 10. Which data collected by the nurse during the physical assessment indicates the patient is experiencing stage 4
stomatitis?
1) Redness of mucosa
2) Patchy oral ulceration
3) Oral ulcerations that bleed with minor trauma
4) Tissue necrosis with significant bleeding noted
____ 11. Which patient activity should the nurse discourage for a patient who is diagnosed with stomatitis?
1) Mouth care after each meal
2) Alcohol-based mouth rinses
3) Soft-bristle toothbrush
4) Regular dental checkups
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____ 12. Which diagnostic test should the nurse anticipate when providing care to a patient who is suspected of having
a hiatal hernia?
1) Complete blood count
2) Lower abdominal x-ray
3) Magnetic resonance imaging (MRI)
4) Esophagogastroduodenoscopy (ECG)
____ 13. Which common site of metastasis should the nurse anticipate when providing care to a patient diagnosed with
oral cancer?
1) Skin
2) Liver
3) Breast
4) Brain
____ 14. The nurse is providing education to a patient who is diagnosed with oral cancer who is being treated with
radiation therapy. Which should the nurse include as a rare but serious complication?
1) Weight loss
2) Hearing loss
3) Skin irritation
4) Laryngeal edema
____ 15. Which common cause for oral trauma should the nurse include in an educational seminar for individuals over
the age of 60 years?
1) Falls
2) Athletic activities
3) Physical altercations
4) Automobile accidents NURSINGTB.COM
____ 16. The nurse is providing care to a patient whose mouth is wired shut after oral trauma. Which is a priority when
providing this patient’s care?
1) Monitoring for pain
2) Ensuring oxygen is available
3) Having wire cutters available
4) Administering prescribed analgesics
____ 17. Which is the priority nursing diagnosis when providing care for a patient with oral trauma?
1) Risk for bleeding
2) Risk for infection
3) Risk for ineffective airway clearance
4) Risk for imbalanced nutrition, less than body requirements
____ 18. The nurse is providing care to a patient who is suspected of having esophageal cancer. Which diagnostic test
should the nurse anticipate for this patient first?
1) Barium swallow
2) Computed tomography
3) Endoscopic ultrasonography
4) Positron emission tomography
____ 19. Which complementary and alternative medicine (CAM) therapy should the nurse suggest for muscular
relaxation for a patient who is experiencing pain due to esophageal cancer?
1) Yoga
2) Vibration
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3) Meditation
4) Spirituality
____ 20. The nurse is providing care to a patient who is diagnosed with esophageal cancer. Which assessment finding
indicates metastasis to the liver?
1) Emesis
2) Rhonchi
3) Jaundice
4) Dysphagia
____ 21. The nurse is providing care to a patient who ingested bleach. Which diagnosis should the nurse anticipate
when planning care for this patient?
1) Oral cancer
2) Oral trauma
3) Esophageal cancer
4) Esophageal trauma
____ 22. Which clinical manifestation associated with the ingestion of bleach causing esophageal trauma does the
nurse anticipate for the patient 48 hours after the initial event?
1) Peritonitis
2) Glottic edema
3) Kidney damage
4) Excessive salivation
Multiple Response
Identify one or more choices that best complete the
NUstatement
RSINGor TBanswer
.COMthe question.
____ 23. Which should the nurse include in the discharge teaching for a patient who is being discharged after a
laparoscopic Nissen fundoplication? Select all that apply.
1) Follow a soft diet for two weeks
2) Avoid foods that are not easy to swallow
3) Take large bites and eat quickly
4) Avoid carbonated beverages
5) No heavy lifting until cleared by surgeon
____ 24. Which should the nurse include in the discharge instruction regarding physical assessment findings that
requires the patient to seek emergent care following a laparoscopic Nissen fundoplication? Select all that
apply.
1) Feeling full with the ability to burp
2) Thick drainage with a foul odor from incision site
3) Difficulty swallowing
4) Abdomen is soft and tender
5) Watery stool
____ 25. Which are risk factors for the development of hiatal hernia? Select all that apply.
1) Obesity
2) Pregnancy
3) Tobacco use
4) Oral sex
5) Alcohol abuse
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 56: Coordinating Care for Patients With Oral and Esophageal Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders
Chapter learning objective: Describing the epidemiology of disorders of the oral cavity and esophagus
Chapter page reference: 1226-1229
Heading: Oral and Esophageal Diseases
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Digestion
Difficulty: Moderate
Feedback
1 The lower esophageal sphincter is normally constricted except during swallowing.
2 Increased pressure in the stomach can cause acid to reflux into the esophagus.
3 An incompetent lower esophageal sphincter remains open, allowing gastric acid to
reflux into the esophagus.
4 The action of the upper esophageal sphincter is not a cause of GERD.
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Feedback
1 Weight loss and smoking cessation will improve the symptoms of GERD. Determining
food types, amounts, and times of consumption can help the patient avoid foods that
stimulate acid production and avoid eating prior to lying down.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 The head of the bed should be elevated, and the team should recommend this to the
patient rather than enlisting the patient’s son.
3 A surgical consult should come from the primary provider and will not necessarily
reduce the need for medication.
4 The pharmacist should be included in the Multidisciplinary Team meeting to give input
to strategies to improve the patient's receptivity to medication therapy.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
11. ANS: 2
Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with oral and
esophageal disorders
Chapter page reference: 1218-1221
Heading: Oral and Esophageal Diseases
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Digestion; Comfort
Difficulty: Moderate
Feedback
1 Mouth care is encouraged after each meal for a patient diagnosed with stomatitis.
2 Alcohol-based mouth rinses are likely to cause pain and inflammation for a patient
diagnosed with stomatitis; therefore, this is discouraged by the nurse.
3 The use of a soft-bristle toothbrush is encouraged for a patient diagnosed with
stomatitis.
4 Regular dental checkups are encouraged for a patient diagnosed with stomatitis.
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Feedback
1 Barium swallow identifies irregularities in the surface of the wall of the esophagus and
is one of the first tests done to diagnose esophageal cancer.
2 Computed tomography scans are used to determine how far the cancer has spread in the
esophagus and to assess for spread to the lymph nodes and nearby organs.
3 Endoscopic ultrasonography is performed by placing a small ultrasound probe in the
esophagus. The probe produces sound waves that penetrate into normal tissue and
abnormal tissue. These sound waves are converted into a picture that shows how much
the tissue and nearby lymph nodes are affected by the cancer.
4 Positron emission tomography scans detect areas of metastasis and can even detect
small collections of cancer cells that are not detectable with other diagnostic studies.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE RESPONSE
23. ANS: 2, 4, 5
Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders
Chapter learning objective: Discussing the medical management of: Gastroesophageal Reflux Disease
Chapter page reference: 1224
Heading: Oral and Esophageal Diseases
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Digestion
Difficulty: Moderate
Feedback
1. This is incorrect. A soft diet is followed for one, not two, week post procedure.
2. This is correct. Foods that are not easy to swallow should be avoided.
3. This is incorrect. The patient should take small bites and eat slowly.
4. This is correct. Carbonated beverages should be avoided as this activity causes air to be
swallowed.
5. This is correct. Heavy lifting should be avoided until cleared by the surgeon post procedure.
Feedback
1. This is incorrect. Feeling full with the inability to burp or vomit indicates the need for
emergent care.
2. This is correct. Thick drainage from the incision site that has a foul odor indicates the need for
emergent care.
3. This is correct. Difficulty swallowing indicates the need for emergent care.
4. This is incorrect. An abdomen that feels hard and painful indicates the need for emergent care.
5. This is incorrect. Stools that are black, bloody, or tarry indicate the need for emergent care.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Describing the epidemiology of disorders of the oral cavity and esophagus
Chapter page reference: 1221-1226
Heading: Oral and Esophageal Diseases
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Knowledge [Remembering]
Concept: Digestion
Difficulty: Easy
Feedback
1. This is correct. Obesity is a risk factor for developing hiatal hernia.
2. This is correct. Pregnancy is a risk factor for developing hiatal hernia.
3. This is correct. Tobacco use, specifically smoking, is a risk factor for hiatal hernia.
4. This is incorrect. Oral sex that causes the transmission of HPV is a risk factor for
oropharyngeal cancer, not hiatal hernia.
5. This is incorrect. Alcohol abuse is a risk factor for oropharyngeal cancer, not hiatal hernia.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
NURSINGTB.COM
____ 1. The nurse is providing care to a patient who is hospitalized for complications associated with peptic ulcer
disease. Which data supports the patient is experiencing a gastrointestinal bleed?
1) Tarry stools
2) Pain in the right arm
3) Absent bowel sounds
4) Emesis of undigested food
____ 2. The nurse is providing care to a patient who is hospitalized for complications associated with peptic ulcer
disease. Which data supports the patient is experiencing penetration to another organ?
1) Tarry stools
2) Pain in the right arm
3) Absent bowel sounds
4) Emesis of undigested food
____ 3. The nurse is providing care to a patient who is hospitalized for complications associated with peptic ulcer
disease. Which data supports the patient is experiencing a perforation?
1) Tarry stools
2) Pain in the right arm
3) Absent bowel sounds
4) Emesis of undigested food
____ 4. The nurse is providing care to a patient who is hospitalized for complications associated with peptic ulcer
disease. Which data supports the patient is experiencing an obstruction?
1) Tarry stools
2) Pain in the right arm
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 12. Which food should the nurse encourage for a patient, diagnosed with gastritis, when a heavier liquid diet is
prescribed?
1) Milk
2) Broth
3) Gelatin
4) Carbonated beverages
____ 13. Which medication, acting as a physical barrier, does the nurse anticipate for a patient diagnosed with
gastritis?
1) Maalox
2) Mylanta
3) Pepcid
4) Carafate
____ 14. The nurse is providing education for a patient who is diagnosed with gastritis. Which statement indicates the
need for further education?
1) “I will eat bland, nonspicy foods.”
2) “I will eat smaller, more frequent meals.”
3) “I will take aspirin for headaches from now on.”
4) “I will take an antacid if my symptoms continue.”
____ 15. Which is the priority nursing diagnosis when planning care for this patient who is diagnosed with acute
gastritis?
1) Anxiety
2) Acute pain
3) Deficient knowledge
4) Risk for deficient fluid volume NURSINGTB.COM
____ 16. Which principal risk factor should the nurse assess for during the health history in a patient who is suspected
of having peptic ulcer disease?
1) Stress
2) Anxiety
3) H. pylori infection
4) Use of acetaminophen
____ 17. Which diagnostic test should the nurse anticipate to rule out anemia when providing care to a patient
diagnosed with peptic ulcer disease?
1) Hematocrit
2) Stool antigen
3) White blood cell
4) Fecal occult blood
____ 18. Which diagnostic test should the nurse anticipate to rule out peritonitis when providing care to a patient
diagnosed with peptic ulcer disease?
1) Hematocrit
2) Stool antigen
3) White blood cell
4) Fecal occult blood
____ 19. The nurse is providing discharge instructions for a patient diagnosed with peptic ulcer disease. Which
statement indicates the need for additional education?
1) “I will avoid spicy foods.”
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
NURSINGTB.COM
____ 23. The nurse is providing care to a patient who is diagnosed with peptic ulcer disease. When planning care,
which should the nurse include as first-line triple dose therapy for a patient who is allergic to penicillin?
Select all that apply.
1) Amoxicillin
2) Metronidazole
3) Clarithromycin
4) Bismuth subsalicylate
5) Proton pump inhibitor
____ 24. The nurse is providing care to a patient who is diagnosed with peptic ulcer disease. When planning care,
which should the nurse include as first-line triple dose therapy? Select all that apply.
1) Amoxicillin
2) Metronidazole
3) Clarithromycin
4) Bismuth subsalicylate
5) Proton pump inhibitor
____ 25. The nurse is providing care to a patient who is diagnosed with peptic ulcer disease. When planning care,
which should the nurse include as first-line quadruple dose therapy? Select all that apply.
1) Amoxicillin
2) Metronidazole
3) Clarithromycin
4) Bismuth subsalicylate
5) Proton pump inhibitor
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders
Chapter learning objective: Describing complications associated with selected disorders of the stomach
Chapter page reference: 1255-1261
Heading: Peptic Ulcer Disease
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Digestion
Difficulty: Easy
Feedback
1 Tarry stools indicate gastrointestinal bleeding.
2 Referred pain, such as that in the arm, is indicative of penetration to another organ.
3 Absent bowel sounds is indicative of perforation.
4 Emesis of undigested food is indicative of obstruction.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Difficulty: Easy
Feedback
1 Tarry stools indicate gastrointestinal bleeding.
2 Referred pain, such as that in the arm, is indicative of penetration to another organ.
3 Absent bowel sounds is indicative of perforation.
4 Emesis of undigested food is indicative of obstruction.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
9. ANS: 2
Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Gastritis
Chapter page reference: 1249-1254
Heading: Gastritis
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Digestion
Difficulty: Easy
Feedback
1 Weight loss is a clinical manifestation associated with acute gastritis.
2 Epigastric pain is a clinical manifestation associated with acute gastritis.
3 A decreased, not increased, appetite is a clinical manifestation with acute gastritis.
4 A decreased, not increased, blood pressure is a clinical manifestation of acute gastritis
with acute fluid loss.
Feedback
1 Guaiac is anticipated to detect blood in the stool for a patient diagnosed with gastritis.
2 Hematest is anticipated to detect blood in the stool for a patient diagnosed with
gastritis.
3 Hemoccult is anticipated to detect blood in the stool for a patient diagnosed with
gastritis.
4 A urea breathing test is anticipated to detect active infection with H. pylori for a patient
who is diagnosed with gastritis.
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Difficulty: Moderate
Feedback
1 Milk is a heavier liquid.
2 Broth is a clear liquid.
3 Pudding is a heavier liquid.
4 Cream soup is a heavier liquid.
Feedback
1 Milk is a heavier liquid.
2 Broth is a clear liquid.
3 Gelatin is a clear liquid.
4 Carbonated beverages are clear liquids.
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PTS: 1 CON: Digestion
13. ANS: 4
Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders
Chapter learning objective: Discussing the medical management of: Gastritis
Chapter page reference: 1249-1254
Heading: Gastritis
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies
Cognitive level: Comprehension [Understanding]
Concept: Digestion
Difficulty: Easy
Feedback
1 This drug is used to neutralize acid.
2 This drug is used to neutralize acid.
3 This drug is used to decrease the production of gastric acid.
4 Carafate is a drug that acts as a physical barrier protecting the lining of the stomach
from gastric acid.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Heading: Gastritis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Digestion
Difficulty: Difficult
Feedback
1 This statement indicates correct understanding.
2 This statement indicates correct understanding.
3 Aspirin should be avoided for a patient who is diagnosed with gastritis. This statement
indicates the need for further education.
4 This statement indicates correct understanding.
Feedback
1 While anxiety is an important diagnosis, physiological diagnoses take priority over
psychosocial diagnoses.
2 Acute pain is a physiological diagnosis that take priority in this situation.
3 While knowledge deficit is an important diagnosis, physiological diagnoses take
priority.
4 Risk for diagnoses do not take priority over actual diagnoses.
Feedback
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1 Stress is no longer considered a principal risk factor in the development of peptic ulcer
disease.
2 Anxiety is no longer considered a principal risk factor in the development of peptic
ulcer disease.
3 H. pylori infection is a principal risk factor in the development of peptic ulcer disease.
4 Use of NSAIDs, not acetaminophen, is a principal risk factor in the development of
peptic ulcer disease.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
19. ANS: 2
Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders
Chapter learning objective: Developing a teaching plan for a patient with stomach disorders
Chapter page reference: 1255-1261
Heading: Peptic Ulcer Disease
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Digestion
Difficulty: Difficult
Feedback
1 Spicy foods should be avoided; therefore, this statement indicates correct
understanding.
2 The patient should avoid eating two hours prior to bedtime; therefore, this statement
indicates the need for further education.
3 Aspirin and NSAIDs should be avoided; therefore, this statement indicates correct
understanding.
4 Caffeine is known to exacerbate peptic ulcer disease; therefore, this statement indicates
correct understanding.
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Concept: Digestion
Difficulty: Easy
Feedback
1 Anorexia is a clinical manifestation with early gastric cancer.
2 Indigestion is a clinical manifestation with early gastric cancer.
3 Epigastric pain is a clinical manifestation with early gastric cancer.
4 A palpable epigastric mass is a clinical manifestation of advanced gastric cancer.
MULTIPLE RESPONSE
23. ANS: 2, 3, 5
Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders
Chapter learning objective: Discussing the medical management of: Peptic ulcer disease
Chapter page reference: 1255-1261
Heading: Peptic Ulcer Disease
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies
Cognitive level: Comprehension [Understanding]
Concept: Digestion
Difficulty: Easy
Feedback
1. This is incorrect. Amoxicillin is not included in the first-line triple dose therapy for a patient
who is allergic to penicillin.
2. This is correct. Metronidazole is included in the first-line triple dose therapy for a patient who
is allergic to penicillin.
3. This is correct. Clarithromycin is included in the first-line triple dose therapy for a patient who
is allergic to penicillin.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4. This is incorrect. Bismuth subsalicylate is included in the first-line quadruple, not triple, dose
therapy.
5. This is correct. A proton pump inhibitor is included in the first-line triple dose therapy for a
patient who is allergic to penicillin.
Feedback
1. This is incorrect. Amoxicillin is included in the first-line triple dose therapy for a patient
diagnosed with peptic ulcer disease.
2. This is correct. Metronidazole is included in the first-line triple dose therapy only for a patient
who is allergic to penicillin and diagnosed with peptic ulcer disease.
3. This is correct. Clarithromycin is included in the first-line triple dose therapy for a patient who
is diagnosed with peptic ulcer disease.
4. This is incorrect. Bismuth subsalicylate is included in the first-line quadruple, not triple, dose
NURSINGTB.COM
therapy for a patient diagnosed with peptic ulcer disease.
5. This is correct. A proton pump inhibitor is included in the first-line triple dose therapy for a
patient diagnosed with peptic ulcer disease.
Feedback
1. This is incorrect. Amoxicillin is included in the first-line triple dose therapy for a patient who
is diagnosed with peptic ulcer disease.
2. This is correct. Metronidazole is included in first-line quadruple dose therapy for a patient
who is diagnosed with peptic ulcer disease.
3. This is incorrect. Clarithromycin is included in the first-line triple dose therapy for a patient
who is diagnosed with peptic ulcer disease.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4. This is incorrect. Bismuth subsalicylate is included in the first-line quadruple dose therapy for
a patient diagnosed with peptic ulcer disease.
5. This is correct. A proton pump inhibitor is included in the first-line quadruple dose therapy for
a patient diagnosed with peptic ulcer disease.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. An older adult African-American patient with a history of celiac disease presents with abdominal cramps,
pain, and diarrhea. The patient denies the use of alcohol, but states, “my favorite foods are steak, cheese, and
ice cream.” Based on this data, which condition does the nurse suspect?
1) Acute pancreatitis
2) Appendicitis
3) Lactase deficiency
4) Food poisoning
____ 2. The nurse is speaking with a patient who wants information regarding colorectal cancer. Which statement
indicates the patient understood the information presented by the nurse?
1) “The risk of colorectal cancer decreases with age.”
2) “Colorectal cancer can be detected in early stages by measuring the level of the
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carcinogenic embryonic antigen (CEA).”
3) “Colorectal cancer occurs more frequently in patients who have a history of ulcerative
colitis.”
4) “Colorectal cancer has no symptoms in the early stage, and there are no definitive
diagnostic tests.”
____ 3. The nurse provides an educational session for community members about the risk factors for colorectal
cancer. Which participant statement indicates the need for further education?
1) “There is a genetic link in the development of colorectal cancer.”
2) “People with other bowel disease are at increased risk for developing this cancer.”
3) “Eating a diet high in red meat reduces the risk for developing this type of cancer.”
4) “Taking aspirin and a multivitamin each day reduces the risk of colorectal cancer.”
____ 4. A nurse discusses medications prescribed to a patient who is diagnosed with Crohn’s disease. Which is the
typical prescribed pharmacological option for treatment?
1) Ciprofloxacin (Cipro)
2) Diazepam (Valium)
3) Furosemide (Lasix)
4) Digoxin (Lanoxin)
____ 5. The nurse is interpreting laboratory values for a patient suspected of having ulcerative colitis. Which finding
does the nurse anticipate based on the diagnosis?
1) Protein in the urine
2) Increased sedimentation rate
3) Decreased white blood cell count
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 13. The nurse is providing care to a patient who is diagnosed with irritable bowel syndrome (IBS). Which drug
prescription should the nurse anticipate to provide pain relief?
1) Tegaserod
2) Loperamide
3) Dicyclomine
4) Amitriptyline
____ 14. The nurse is providing care to a patient who is experiencing five to six loose, nonbloody stools each day.
Which diagnosis does the nurse anticipate when planning care for this patient?
1) Diverticulitis
2) Crohn’s disease
3) Ulcerative colitis
4) Colorectal cancer
____ 15. The nurse is providing care to a patient who is experiencing 10 liquid, bloody stools each day. Which
diagnosis does the nurse anticipate when planning care for this patient?
1) Diverticulitis
2) Crohn’s disease
3) Ulcerative colitis
4) Colorectal cancer
____ 16. The nurse is providing education to a patient, diagnosed with colorectal cancer, who will be treated with
chemotherapy. Which drug action should the nurse include in the teaching session for a patient who is
prescribed 5-Fluorouracil?
1) “This drug is cell-cycle specific and interferes with the synthesis of DNA and RNA,
causing its death.”
2) “This drug is converted in the tissue
NURtoS5-FU,
INGTwhichB.Cinhibits
OM DNA and RNA synthesis by
preventing thymidine production, causing death of rapidly replicating cells.”
3) “This drug is a platinum-based antineoplastic agent that binds to DNA and RNA,
miscoding information and/or inhibiting DNA replication, causing cell death.”
4) “This drug is an antiangiogenesis medication that reduces blood flow to the tumor cells,
depriving them of nutrients needed for replication.”
____ 17. The nurse is providing education to a patient, diagnosed with colorectal cancer, who will be treated with
chemotherapy. Which drug action should the nurse include in the teaching session for a patient who is
prescribed capecitabine?
1) “This drug is cell-cycle specific and interferes with the synthesis of DNA and RNA,
causing its death.”
2) “This drug is converted in the tissue to 5-FU, which inhibits DNA and RNA synthesis by
preventing thymidine production, causing death of rapidly replicating cells.”
3) “This drug is a platinum-based antineoplastic agent that binds to DNA and RNA,
miscoding information and/or inhibiting DNA replication, causing cell death.”
4) “This drug is an antiangiogenesis medication that reduces blood flow to the tumor cells,
depriving them of nutrients needed for replication.”
____ 18. The nurse is providing education to a patient, diagnosed with colorectal cancer, who will be treated with
chemotherapy. Which drug action should the nurse include in the teaching session for a patient who is
prescribed oxaliplatin?
1) “This drug is cell-cycle specific and interferes with the synthesis of DNA and RNA,
causing its death.”
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2) “This drug is converted in the tissue to 5-FU, which inhibits DNA and RNA synthesis by
preventing thymidine production, causing death of rapidly replicating cells.”
3) “This drug is a platinum-based antineoplastic agent that binds to DNA and RNA,
miscoding information and/or inhibiting DNA replication, causing cell death.”
4) “This drug is an antiangiogenesis medication that reduces blood flow to the tumor cells,
depriving them of nutrients needed for replication.”
____ 19. The nurse is providing education to a patient, diagnosed with colorectal cancer, who will be treated with
chemotherapy. Which drug action should the nurse include in the teaching session for a patient who is
prescribed bevacizumab?
1) “This drug is cell-cycle specific and interferes with the synthesis of DNA and RNA,
causing its death.”
2) “This drug is converted in the tissue to 5-FU, which inhibits DNA and RNA synthesis by
preventing thymidine production, causing death of rapidly replicating cells.”
3) “This drug is a platinum-based antineoplastic agent that binds to DNA and RNA,
miscoding information and/or inhibiting DNA replication, causing cell death.”
4) “This drug is an antiangiogenesis medication that reduces blood flow to the tumor cells,
depriving them of nutrients needed for replication.”
____ 20. The nurse is providing education to a patient who will receive surgical intervention for the treatment of
ulcerative colitis. Which patient statement indicates correct understanding of a proctocolectomy with a
permanent ileostomy?
1) “My colon and rectum will be removed, and my anus will be closed.”
2) “My colon will be removed, and my ileum is sutured to the anal canal.”
3) “My colon will be removed while the distal portion of my ileum is used to create a
pouch.”
4) “My colon and rectal mucosa will NUbeRS INGTand
removed B.Ca O M
reservoir created using a portion of
my ileum.”
____ 21. The nurse is providing education to a patient who will receive surgical intervention for the treatment of
ulcerative colitis. Which patient statement indicates correct understanding of an abdominal colectomy with
ileoanal anastomosis?
1) “My colon and rectum will be removed, and my anus will be closed.”
2) “My colon will be removed, and my ileum is sutured to the anal canal.”
3) “My colon will be removed while the distal portion of my ileum is used to create a
pouch.”
4) “My colon and rectal mucosa will be removed and a reservoir created using a portion of
my ileum.”
____ 22. The nurse is providing education to a patient who will receive surgical intervention for the treatment of
ulcerative colitis. Which patient statement indicates correct understanding of a proctocolectomy with
continent ileostomy?
1) “My colon and rectum will be removed, and my anus will be closed.”
2) “My colon will be removed, and my ileum is sutured to the anal canal.”
3) “My colon will be removed while the distal portion of my ileum is used to create a
pouch.”
4) “My colon and rectal mucosa will be removed and a reservoir created using a portion of
my ileum.”
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 23. The nurse is providing education to a patient who will receive surgical intervention for the treatment of
ulcerative colitis. Which patient statement indicates correct understanding of an ileal pouch–anal anastomosis
(IPAA) procedure?
1) “My colon and rectum will be removed, and my anus will be closed.”
2) “My colon will be removed, and my ileum is sutured to the anal canal.”
3) “My colon will be removed while the distal portion of my ileum is used to create a
pouch.”
4) “My colon and rectal mucosa will be removed and a reservoir created using a portion of
my ileum.”
____ 24. The nurse is providing education to a patient who is will undergo diagnostic studies for colorectal cancer.
Which patient statement indicates correct understanding regarding a lower-GI series?
1) “A stool sample is collected by my doctor by digital rectal examination.”
2) “After I have expelled most of the contrast, my intestine is filled with air and x-rays are
taken.”
3) “Constipation may occur as a result of this procedure, so I will increase my water and fiber
intake.”
4) “A flexible tube with a light and camera is inserted into my rectum so that tissue can be
biopsied.”
____ 25. The nurse is providing education to a patient who will undergo diagnostic studies for colorectal cancer. Which
patient statement indicates correct understanding regarding a double contract barium enema?
1) “A stool sample is collected by my doctor by digital rectal examination.”
2) “After I have expelled most of the contrast, my intestine is filled with air and x-rays are
taken.”
3) “Constipation may occur as a result of this procedure, so I will increase my water and fiber
intake.” NURSINGTB.COM
4) “A flexible tube with a light and camera is inserted into my rectum so that tissue can be
biopsied.”
____ 26. The nurse is providing care to a patient who presents to the emergency department (ED) with blunt abdominal
trauma after an automobile accident. Which should the nurse assess for based on the current data?
1) Spleen injury
2) Liver laceration
3) Intestinal obstruction
4) Traumatic brain injury
____ 27. The nurse is providing care to a patient who presents to the emergency department (ED) with an abdominal
stab injury. Which should the nurse assess for based on the current data?
1) Spleen injury
2) Liver laceration
3) Intestinal obstruction
4) Traumatic brain injury
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 28. The nurse is providing care to a patient diagnosed with celiac disease who experiences frequent diarrhea.
Based on this data, the nurse anticipates the patient may also experience which associated problems? Select
all that apply.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1) Skin breakdown
2) Fluid and electrolyte imbalance
3) Hair loss
4) Lifestyle issues
5) Sexual dysfunction
____ 29. The nurse is preparing care for a patient recovering from surgery for colorectal cancer. Which interventions
should the nurse use when creating a pain management plan for this patient? Select all that apply.
1) Provide pain medication upon request
2) Assess surgical site for inflammation
3) Assess bowel sounds
4) Administer pain medication after painful procedures
5) Instruct to use a pillow to splint when deep breathing and coughing
____ 30. A nurse is caring for a patient who has had a double-barrel colostomy. Which statement is true regarding the
proximal stoma? Select all that apply.
1) Is also called the mucous fistula
2) Diverts feces to the abdominal wall
3) Expels mucus from the distal colon
4) It is a functional stoma
5) Expels mucus from the proximal colon
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders
Chapter learning objective: Describing the epidemiology of infectious and noninfectious intestinal disorders
Chapter page reference: 1274
Heading: Intestinal Disorders
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Digestion
Difficulty: Easy
Feedback
1 The most common risk factor for pancreatitis is alcohol abuse.
2 Appendicitis usually involves loss of appetite and nausea and/or vomiting soon after
abdominal pain begins.
3 Lactose intolerance is more common in Native Americans, Asians, Hispanics, and
African-Americans and in those with a history of celiac disease.
4 Food poisoning generally causes some nausea and vomiting.
Feedback
1 The risk of colorectal cancer rises with age, and it is the most common cancer after the
age of 65.
2 Carcinogenic embryonic antigen (CEA) is not considered a diagnostic test but is used
as a tumor marker to follow and manage the disease in patients diagnosed with the
disease.
3 The incidence of colorectal cancer is increased in patients with a history of ulcerative
colitis, and these patients need diligent screening.
4 Colorectal cancer is asymptomatic in the early stages. Screening tools such as annual
fecal occult blood testing and colonoscopy performed every 5-10 years can detect the
cancer when it is still in the curable stage.
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Feedback
1 Metronidazole (Flagyl) and ciprofloxacin (Cipro) have demonstrated effectiveness in
the treatment of perianal complications. Antibiotics, such as ampicillin (Marcillin),
gentamicin (Garamycin), clindamycin (Cleocin), and metronidazole (Flagyl), are
effective during acute exacerbations.
2 This medication is not appropriate for the treatment of Crohn’s disease.
3 This medication is not appropriate for the treatment of Crohn’s disease.
4 This medication is not appropriate for the treatment of Crohn’s disease.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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4 Although a referral may be needed for the patient at some point, this is not the most
appropriate response by the nurse.
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Feedback
1 This drug is a serotonergic agent that causes the release of other neurotransmitters and
results in increased peristalsis, increased intestinal secretion, and decreased visceral
sensitivity.
2 This drug is an antidiarrheal agent that slows bowel transit, enhances water absorption,
and strengthens anal sphincter tone, resulting in fewer stools, but does not relieve pain.
3 This drug is an antispasmodic agent that relaxes smooth muscle spasm and GI motility
while also inhibiting gastric secretion.
4 This drug is an antidepressant that blocks norepinephrine reuptake and is believed to
slow transit time and improve pain tolerance.
Feedback
1 This drug is a serotonergic agent that causes the release of other neurotransmitters and
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results in increased peristalsis, increased intestinal secretion, and decreased visceral
sensitivity.
2 This drug is an antidiarrheal agent that slows bowel transit, enhances water absorption,
and strengthens anal sphincter tone, resulting in fewer stools, but does not relieve pain.
3 This drug is an antispasmodic agent that relaxes smooth muscle spasm and GI motility
while also inhibiting gastric secretion.
4 This drug is an antidepressant that blocks norepinephrine reuptake and is believed to
slow transit time and improve pain tolerance.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3 The assessment data does not support planning care for ulcerative colitis.
4 The assessment data does not support planning care for colorectal cancer.
Feedback
1 This is the action of 5-Fluorouracil.
2 This is the action of capecitabine.
3 This is the action of oxaliplatin.
4 This is the action of bevacizumab.
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Difficulty: Moderate
Feedback
1 This is the action of 5-Fluorouracil.
2 This is the action of capecitabine.
3 This is the action of oxaliplatin.
4 This is the action of bevacizumab.
Feedback
1 This is the action of 5-Fluorouracil.
2 This is the action of capecitabine.
3 This is the action of oxaliplatin.
4 This is the action of bevacizumab.
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PTS: 1 CON: Cellular Regulation
19. ANS: 4
Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders
Chapter learning objective: Discussing the medical management of: Colorectal cancer
Chapter page reference: 1287-1296
Heading: Colorectal Cancer
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Cellular Regulation
Difficulty: Moderate
Feedback
1 This is the action of 5-Fluorouracil.
2 This is the action of capecitabine.
3 This is the action of oxaliplatin.
4 This is the action of bevacizumab.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 This statement indicates correct understanding of a proctocolectomy with a permanent
ileostomy.
2 This statement indicates correct understanding of an abdominal colectomy with ileoanal
anastomosis.
3 This statement indicates correct understanding of a proctocolectomy with continent
ileostomy, also referred to a Kock pouch.
4 This statement indicates correct understanding of a colectomy, mucosal proctectomy,
and ileal pouch-anal canal anastomosis (IPAA). This procedure is performed in two
steps.
Feedback
1 This statement indicates correct understanding of a proctocolectomy with a permanent
ileostomy.
2 This statement indicates correct understanding of an abdominal colectomy with ileoanal
anastomosis.
3 This statement indicates correct understanding of a proctocolectomy with continent
ileostomy, also referred to a Kock pouch.
4 This statement indicates correct understanding of a colectomy, mucosal proctectomy,
and ileal pouch-anal canal anastomosis (IPAA). This procedure is performed in two
steps.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 This statement indicates correct understanding of a proctocolectomy with a permanent
ileostomy.
2 This statement indicates correct understanding of an abdominal colectomy with ileoanal
anastomosis.
3 This statement indicates correct understanding of a proctocolectomy with continent
ileostomy, also referred to a Kock pouch.
4 This statement indicates correct understanding of a colectomy, mucosal proctectomy,
and ileal pouch-anal canal anastomosis (IPAA). This procedure is performed in two
steps.
Feedback
1 This statement indicates correct understanding of a proctocolectomy with a permanent
ileostomy.
2 This statement indicates correct understanding of an abdominal colectomy with ileoanal
anastomosis.
3 This statement indicates correct understanding of a proctocolectomy with continent
ileostomy, also referred to a Kock pouch.
4 This statement indicates correct understanding of a colectomy, mucosal proctectomy,
and ileal pouch-anal canal anastomosis (IPAA). This procedure is performed in two
steps.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 This statement indicates correct understanding of a fecal occult blood test collected by
DRE.
2 This statement indicates correct understanding of a double contrast barium enema.
3 This statement indicates correct understanding of a lower GI series.
4 This statement indicates correct understanding of a colonoscopy.
Feedback
1 This statement indicates correct understanding of a fecal occult blood test collected by
DRE.
NURSINGTB.COM
2 This statement indicates correct understanding of a double contrast barium enema.
3 This statement indicates correct understanding of a lower GI series.
4 This statement indicates correct understanding of a colonoscopy.
Feedback
1 Blunt abdominal trauma is likely to cause a spleen injury.
2 Abdominal stab injury is likely to cause a liver laceration.
3 Intestinal obstruction is not likely to occur based on the current data.
4 Traumatic brain injury is not likely to occur based on the current data.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Blunt abdominal trauma is likely to cause a spleen injury.
2 Abdominal stab injury is likely to cause a liver laceration.
3 Intestinal obstruction is not likely to occur based on the current data.
4 Traumatic brain injury is not likely to occur based on the current data.
MULTIPLE RESPONSE
28. ANS: 1, 2, 4
Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders
NUclinical
Chapter learning objective: Correlating RSINmanifestations
GTB.COM to pathophysiological processes of: Irritable
bowel syndrome
Chapter page reference: 1274-1276
Heading: Intestinal Disorders
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Digestion; Bowel Elimination
Difficulty: Easy
Feedback
1. This is correct. Patients with diarrhea may have perianal skin irritation and skin breakdown.
2. This is correct. Diarrhea disturbs the fluid and electrolyte balance and can disrupt normal life
activities.
3. This is incorrect. There is no known direct connection between diarrhea and hair loss or sexual
dysfunction.
4. This is correct. Diarrhea disturbs the fluid and electrolyte balance and can disrupt normal life
activities.
5. This is incorrect. There is no known direct connection between diarrhea and hair loss or sexual
dysfunction.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Developing a comprehensive plan of nursing care with intestinal disorders
Chapter page reference: 1287-1296
Heading: Colorectal Cancer
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Cellular Regulation; Comfort
Difficulty: Moderate
Feedback
1. This is incorrect. Pain level should be routinely assessed, and pain medication should be
provided based upon the assessment and not only when the patient requests medication for
pain.
2. This is correct. The surgical site should be routinely assessed for inflammation as a potential
source of pain.
3. This is correct. Bowel sounds should be assessed, as a paralytic ileus could cause an increase
in pain.
4. This is incorrect. Pain medication should be provided before painful procedures.
5. This is correct. The patient should be instructed to use a pillow to splint the incision when
deep breathing and coughing.
Feedback
1. This is incorrect. The distal, not proximal, stoma is synonymous with a mucous fistula.
2. This is correct. The proximal stoma diverts feces to the abdominal wall.
3. This is incorrect. The distal, not proximal, stoma expels mucus from the distal colon.
4. This is correct. The proximal stoma is a functional stoma.
5. This is incorrect. The distal stoma expels mucus from the distal colon. The proximal stoma
does not expel mucus from the proximal colon.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 1. A patient is diagnosed with viral hepatitis transmitted by the fecal-oral route. Which conditions may be
acquired by this mode of transmission?
1) Hepatitis A (HAV)
2) Hepatitis B (HBV)
3) Hepatitis C (HCV)
4) Hepatitis D (HDV)
____ 2. The nurse is providing information about hepatitis to a high school health occupations class. The students all
volunteer examples of how hepatitis is transmitted. Which student statement indicates the need for further
education?
1) “Body piercing or tattoo with infected equipment”
2) “Contaminated food or fluids”
3) “Alcoholism or drug overdose”
4) “Bite of an infected mosquito or tick”
____ 3. The nurse is planning education for an adolescent patient recently diagnosed with hepatitis. The patient
moved back to the parent’s home. Which recommendation to the patient’s parents will best prevent them from
acquiring hepatitis B (HBV)?
1) Refuse to donate blood
2) Avoid contaminated water
3) Obtain postexposure prophylaxis
4) Abstain from alcohol
____ 4. When planning care for a patient with chronic hepatitis, which collaborative discipline will be most helpful in
treating continued alcohol use?
1) Social worker NURSINGTB.COM
2) Primary provider
3) Pharmacist
4) Dietitian
____ 5. The multidisciplinary care team is meeting to discuss care for a patient who exhibits symptoms of the
prodromal phase of hepatitis. Lab results incluade a positive anti-HAV IgM. The nurse creates an action plan
to present to the team. Which intervention is appropriate?
1) Early treatment with lamivudine
2) Referral to the liver transplant team
3) Patient education on acceptable pain medication
4) High-fat, low-calorie, and no-alcohol diet teaching
____ 6. A young adult waiter has been treated for viral hepatitis at a health-care clinic. Which patient outcome
indicates the need for additional intervention?
1) Body mass index (BMI) changes from 24 to 21.
2) Return demonstration of hand washing is correctly performed.
3) Social Services notified the Health Department of the occurrence.
4) Patient denies abdominal or epigastric pain.
____ 7. Which medication noted in the patient’s health history interview is a risk factor for developing hepatitis?
1) Aspirin
2) Ibuprofen
3) Acetaminophen
4) Naproxen sodium
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____ 8. Which patient statement regarding toxins causing hepatitis indicates the need for further education by the
nurse?
1) “Exposure to industrial chemicals is a risk factor for hepatitis.”
2) “Exposure to carbon tetrachloride is a risk factor for hepatitis.”
3) “Exposure to phosphorus is a risk factor for hepatitis.”
4) “Exposure to valproic acid is a risk factor for hepatitis.”
____ 9. The nurse is providing care to a patient who is diagnosed with hepatic encephalopathy. Which clinical
manifestation supports the documentation of stage 1?
1) Coma
2) Tremors
3) Disorientation
4) Difficulty to awaken
____ 10. The nurse is providing care to a patient who is diagnosed with hepatic encephalopathy. Which clinical
manifestation supports the documentation of stage 2?
1) Coma
2) Tremors
3) Disorientation
4) Difficulty to awaken
____ 11. The nurse is providing care to a patient who is diagnosed with hepatic encephalopathy. Which clinical
manifestation supports the documentation of stage 3?
1) Coma
2) Tremors
3) Disorientation
4) Difficulty to awaken NURSINGTB.COM
____ 12. The nurse is providing care to a patient who is diagnosed with hepatic encephalopathy. Which clinical
manifestation supports the documentation of stage 4?
1) Coma
2) Tremors
3) Disorientation
4) Difficulty to awaken
____ 13. Which laboratory data supports the patient’s diagnosis of liver failure?
1) Decreased AST
2) Elevated albumin
3) Elevated ammonia
4) Decreased total bilirubin
____ 14. Which information should the nurse provide to a patient who will be receiving the hepatitis A vaccine?
1) “The vaccine is considered effective for 15 years or longer.”
2) “You will receive a series of three shots over 6 to 12 months.”
3) “You will receive one shot with a booster 6 to 12 months later.”
4) “The vaccine is recommended for everyone including newborns.”
____ 15. Which information should the nurse include in a teaching session for a patient who is to receive the hepatitis
B vaccine?
1) “You will receive three injections over a 6 to 12 month period.”
2) “This vaccine provides protection within two to four weeks of vaccine.”
3) “You will receive one shot followed by a booster 6 to 12 months later.”
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4) “This vaccine is recommended for those who engage in risky behavior, such as illegal
injected drug users.”
____ 16. The nurse is providing care to a patient who is diagnosed with hepatic encephalopathy. Which term should the
nurse use to document a sweet fecal smell of the breath?
1) Asterixis
2) Euphoria
3) Fetor hepaticus
4) Rigid extremities
____ 17. Which patient should the nurse plan symptomatic treatment for hepatitis in the plan of care?
1) Hepatitis A
2) Hepatitis B
3) Hepatitis C
4) Hepatitis D
____ 18. Which patient statement regarding the incubation period of hepatitis requires further education from the
nurse?
1) “Hepatitis A has an incubation period of 15 to 50 days.”
2) “Hepatitis B has an incubation period of 30 to 60 days.”
3) “Hepatitis C has an incubation period of 2 to 25 weeks.”
4) “Hepatitis D has an incubation period of 2 to 8 weeks.”
____ 19. Which information found in the patient’s health history supports the current diagnosis of cirrhosis?
1) Biliary disease
2) Social alcohol use
3) Hepatitis D infection NURSINGTB.COM
4) Chronic intravenous drug use
____ 20. Which data collected by the nurse after a liver biopsy indicates the need for immediate action by the nurse?
1) The patient is awake and alert.
2) The patient’s blood pressure is 90/60 mm Hg.
3) The patient’s heart rate is 80 beats per minute.
4) The patients respiratory rate is 16 breaths per minute.
____ 21. Which therapeutic prescription should the nurse question when providing care to a patient who is diagnosed
with ascites?
1) Furosemide
2) Spironolactone
3) Placement of a shunt
4) Three gram per day sodium diet
____ 22. Which assessment data indicates to the nurse that the patient may be experiencing decreased clotting factors
as a complication of cirrhosis?
1) Epistaxis
2) Yellow skin
3) Clay-colored stool
4) Personality changes
____ 23. Which assessment data indicates to the nurse that the patient may be experiencing an increased ammonia
level, a complication of cirrhosis?
1) Epistaxis
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2) Yellow skin
3) Clay-colored stool
4) Personality changes
____ 24. Which oral agent should the nurse include in the plan of care for a patient who is diagnosed with hepatitis B?
1) Ribavirin
2) Tenofovir
3) Interferon-alpha
4) Pegylated interferon
____ 25. Which clinical manifestation assessed by the nurse supports the patient’s diagnosis of liver cancer?
1) Increased appetite
2) Shortness of breath
3) Decreased liver enzymes
4) Pain in the left upper quadrant
____ 26. Which is a common cause of death for a patient who presents for care in the emergency department (ED) with
liver trauma suffered as a result of a motor vehicle accident?
1) Infection
2) Hemorrhage
3) Cardiac arrest
4) Respiratory arrest
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
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____ 27. The nurse is providing care to several patients who are diagnosed with hepatitis. Which diagnoses indicate an
acute infection? Select all that apply.
1) Hepatitis A
2) Hepatitis B
3) Hepatitis C
4) Hepatitis D
5) Hepatitis E
____ 28. The nurse is providing care to several patients who are diagnosed with hepatitis. Which patients could have
avoided infection with a vaccination? Select all that apply.
1) Hepatitis A
2) Hepatitis B
3) Hepatitis C
4) Hepatitis D
5) Hepatitis E
____ 29. For which hepatitis infections would the nurse include interferon and antivirals in the plan of care? Select all
that apply.
1) Hepatitis A
2) Hepatitis B
3) Hepatitis C
4) Hepatitis D
5) Hepatitis E
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Completion
Complete each statement.
30. During an interview with a patient diagnosed with hepatitis B, the nurse obtains the following data: 10 kg
weight loss is noted from the patient’s last visit four months ago; review of systems reveals 1) limiting
fatigue, 2) not well enough for sexual intercourse but doubts if her husband will be willing to use a condom,
3) drinks three to five mixed drinks weekly socially, 4) RUQ pain rated at 6/10, and 5) “constant” pruritus.
Prioritize the nursing diagnoses formulated for this patient. (Enter the number of each step in the proper
sequence; do not use punctuation or spaces. Example: 1234)
1) Acute Pain
2) Deficient Knowledge
3) Imbalanced Nutrition
4) Impaired Skin Integrity
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MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders
Chapter learning objective: Describing the epidemiology of the hepatic disorders
Chapter page reference: 1301-1307
Heading: Hepatitis
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
1 HAV and HEV are transmitted by the fecal-oral route.
2 HBV is transmitted by blood, body fluids, and perinatal routes.
3 HCV is transmitted by blood and body fluids.
4 HDV is transmitted by blood, body fluids, and perinatal routes.
Feedback
1 The students who said that infected needles, contaminated food or fluids, alcoholism, or
drug overdose can cause different types of hepatitis were correct and do not require
further education.
2 The students who said that infected needles, contaminated food or fluids, alcoholism, or
drug overdose can cause different types of hepatitis were correct and do not require
further education.
3 The students who said that infected needles, contaminated food or fluids, alcoholism, or
drug overdose can cause different types of hepatitis were correct and do not require
further education.
4 The student who believes the bite of a mosquito or tick will transmit hepatitis is
incorrect and needs further education.
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3. ANS: 3
Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders
Chapter learning objective: Discussing the medical management of: Hepatitis
Chapter page reference: 1301-1307
Heading: Hepatitis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
1 Donating blood will not increase the risk of acquiring HBV.
2 HBV is not spread in water.
3 Obtaining postexposure prophylaxis treatment will best help the patient’s parents from
acquiring HBV. The HBV vaccine is started concurrently.
4 Alcohol abuse is implicated in nonviral hepatitis.
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Feedback
1 Most patients recover from acute viral hepatitis without pharmacological treatment and
certainly without liver transplant.
2 Most patients recover from acute viral hepatitis without pharmacological treatment and
certainly without liver transplant.
3 Patient education on acceptable pain medication is necessary due to the toxic effect of
common over-the-counter pain medicine.
4 A low-fat, high-calorie diet is recommended.
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8. ANS: 4
Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders
Chapter learning objective: Describing the epidemiology of the hepatic disorders
Chapter page reference: 1301-1307
Heading: Hepatitis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Infection
Difficulty: Difficult
Feedback
1 This statement indicates correct understanding of toxins that cause hepatitis.
2 This statement indicates correct understanding of toxins that cause hepatitis.
3 This statement indicates correct understanding of toxins that cause hepatitis.
4 Valproic acid is a medication, not toxin, that causes hepatitis.
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2 A decreased, not elevated, albumin level supports the diagnosis of liver failure.
3 An elevated ammonia level supports the diagnosis of liver failure.
4 An elevated, not decreased, total bilirubin supports the diagnosis of liver failure.
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Feedback
1 This statement indicates correct understanding of the incubation period of hepatitis A.
2 This statement indicates the need for additional education regarding the incubation
period of hepatitis B.
3 This statement indicates correct understanding of the incubation period of hepatitis C.
4 This statement indicates correct understanding of the incubation period of hepatitis D.
Feedback
1 Biliary disease is a risk factor for cirrhosis.
2 Chronic alcoholism, not social alcohol use, is a risk factor for cirrhosis.
3 Hepatitis A, B, and C, not D, are risk factors for cirrhosis.
4 Chronic alcoholism, not intravenous drug use, is a risk factor for cirrhosis.
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PTS: 1 CON: Digestion
20. ANS: 2
Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders
Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of hepatic
disorders
Chapter page reference: 1314-1316
Heading: Liver Cancer
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Digestion
Difficulty: Difficult
Feedback
1 This assessment data does not require intervention by the nurse.
2 A decrease in blood pressure may indicate bleeding; therefore, this data requires
intervention by the nurse.
3 This assessment data does not require intervention by the nurse.
4 This assessment data does not require intervention by the nurse.
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Feedback
1 Ribavirin is pharmacological treatment for hepatitis C, not hepatitis B.
2 Tenofovir is an oral pharmacological agent used to treatment hepatitis B.
3 Interferon-alpha is a parenteral agent used to treat hepatitis B.
4 Pegylated interferon is a parenteral agent used to treat hepatitis B.
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Concept: Perfusion
Difficulty: Easy
Feedback
1 Infection is not a common cause of death for a patient who presents with liver trauma.
2 Hemorrhage is a common cause of death for a patient who presents with liver trauma.
3 Cardiac arrest is not a common cause of death for a patient who presents with liver
trauma.
4 Respiratory arrest is not a common cause of death for a patient who presents with liver
trauma.
MULTIPLE RESPONSE
27. ANS: 1, 4, 5
Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders
Chapter learning objective: Describing the epidemiology of the hepatic disorders
Chapter page reference: 1301-1307
Heading: Hepatitis
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
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Feedback
1. This is correct. Hepatitis A is an acute infection.
2. This is incorrect. Hepatitis B is a chronic infection.
3. This is incorrect. Hepatitis C is a chronic infection.
4. This is correct. Hepatitis D is an acute infection.
5. This is correct. Hepatitis E is an acute infection.
Feedback
1. This is correct. Hepatitis A can be prevented with a vaccination.
2. This is correct. Hepatitis B can be prevented with a vaccination.
3. This is incorrect. Hepatitis C cannot be prevented with a vaccination.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1. This is incorrect. Hepatitis A is treated symptomatically.
2. This is correct. Hepatitis B is treated with interferon and antiviral therapy.
3. This is correct. Hepatitis C is treated with interferon and antiviral therapy.
4. This is correct. Hepatitis D is treated with interferon and antiviral therapy.
5. This is incorrect. Hepatitis E is treated symptomatically.
COMPLETION NURSINGTB.COM
30. ANS:
1234
Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hepatic
disorders
Chapter page reference: 1301-1307
Heading: Hepatitis
Integrated Processes: Nursing Process: Diagnosis
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Infection
Difficulty: Hard
Feedback
1. Relieving the pain associated with hepatitis and preventing the spread of infection are
priorities of hepatitis management. Interventions related to knowledge deficit will address the
potential for spread of the infection to the patient’s husband, use of alcohol, imbalanced
nutrition, and impaired skin integrity.
2. Relieving the pain associated with hepatitis and preventing the spread of infection are
priorities of hepatitis management. Interventions related to knowledge deficit will address the
potential for spread of the infection to the patient's husband, use of alcohol, imbalanced
nutrition, and impaired skin integrity.
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3. Relieving the pain associated with hepatitis and preventing the spread of infection are
priorities of hepatitis management. Interventions related to knowledge deficit will address the
potential for spread of the infection to the patient's husband, use of alcohol, imbalanced
nutrition, and impaired skin integrity.
4. Relieving the pain associated with hepatitis and preventing the spread of infection are
priorities of hepatitis management. Interventions related to knowledge deficit will address the
potential for spread of the infection to the patient's husband, use of alcohol, imbalanced
nutrition, and impaired skin integrity.
Chapter 60: Coordinating Care for Patients With Biliary and Pancreatic Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is providing care to a patient who is being admitted to rule out acute pancreatitis. Which item found
in the patient’s history increases the patient’s risk for this disease process?
1) Systemic lupus
2) Alcoholism
3) Cystic fibrosis
4) Hypertriglyceridemia
____ 2. A patient diagnosed with chronic pancreatitis asks if there are any alternative therapies that might help with
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treating the condition. Which alternative and complementary therapy is inappropriate to include in the
teaching session with this patient?
1) Qigong
2) Herbal kava tea
3) Magnetic field therapy
4) Low-salt, low-fat vegetarian diet
____ 3. A patient was discharged after hospitalization for acute pancreatitis with instructions on the use of analgesics,
cautions on the importance of avoiding alcohol and smoking, and recommendations for a low-fat diet. Which
outcome would indicate the need for further intervention by the nurse?
1) The patient continues to experience nausea.
2) The patient is free from alterations in nutritional status.
3) The patient experiences reduction or elimination of pain.
4) The patient remains free from alterations in fluid balance.
____ 4. Which data collected during the health history places the patient at risk for acalculous cholecystitis?
1) Spider bite
2) Gallstones
3) Sickle cell disease
4) Diabetes insipidus
____ 5. The nurse is asked to explain the common laboratory values associated with acute pancreatitis. Which should
the nurse include as the cause of decreased albumin?
1) Poor nutrition
2) Bile flow obstruction
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3) Gallstone pancreatitis
4) Fat necrosis and malnutrition
____ 6. The nurse is asked to explain the common laboratory values associated with acute pancreatitis. Which should
the nurse include as the cause of an elevated AST?
1) Poor nutrition
2) Bile flow obstruction
3) Gallstone pancreatitis
4) Fat necrosis and malnutrition
____ 7. The nurse is asked to explain the common laboratory values associated with acute pancreatitis. Which should
the nurse include as the cause of hypocalcemia?
1) Poor nutrition
2) Bile flow obstruction
3) Gallstone pancreatitis
4) Fat necrosis and malnutrition
____ 8. The nurse is asked to explain the common laboratory values associated with acute pancreatitis. Which should
the nurse include as the cause of an elevated ALT?
1) Poor nutrition
2) Bile flow obstruction
3) Gallstone pancreatitis
4) Fat necrosis and malnutrition
____ 9. The nurse is asked to explain the common laboratory values associated with acute pancreatitis. Which should
the nurse include as the cause of an elevated WBC count?
1) Poor nutrition NURSINGTB.COM
2) Gallstone pancreatitis
3) Inflammatory process
4) Fat necrosis and malnutrition
____ 10. Which patient data supports Ranson’s criteria for acute pancreatitis at admission?
1) Patient age is 43 years
2) WBC less than 16,000/mL
3) BUN greater than 5 mg/dL
4) Glucose greater than 200 mg/dL
____ 11. The nurse is teaching a patient about the approved therapeutic agents for acute pancreatitis. Which patient
statement indicates the need for further education?
1) “Opioids are used to treat pain.”
2) “Spasmolytics are used to relax the sphincter of Oddi.”
3) “Proton pump inhibitors are used to increase gastric acid secretions.”
4) “Anticholinergics are used to decrease the release of pancreatic enzymes.”
____ 12. The nurse is conducting patient education regarding prescribed drugs for acute pancreatitis. Which agent
should the nurse include as one that is used for pain management?
1) Spasmolytics
2) H2 Antagonist
3) Opioid narcotics
4) Pancreatic enzymes
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____ 13. The nurse is conducting patient education regarding prescribed drugs for acute pancreatitis. Which agent
should the nurse include as one that is used to decrease gastric acid secretions?
1) Spasmolytics
2) H2 Antagonist
3) Opioid narcotics
4) Pancreatic enzymes
____ 14. The nurse is conducting patient education regarding prescribed drugs for acute pancreatitis. Which agent
should the nurse include as one that is used for digesting fats and proteins?
1) Spasmolytics
2) H2 Antagonist
3) Opioid narcotics
4) Pancreatic enzymes
____ 15. The nurse is conducting patient education regarding prescribed drugs for acute pancreatitis. Which agent
should the nurse include as one that is used to relax smooth muscle and the sphincter of Oddi?
1) Spasmolytics
2) H2 Antagonist
3) Opioid narcotics
4) Pancreatic enzymes
____ 16. The nurse is providing care to a patient who is diagnosed with acute necrotizing pancreatitis. Which agent
should the nurse anticipate to be prescribed for this patient?
1) Antibiotic
2) Octreotide
3) Histamine antagonist
4) Proton pump inhibitor NURSINGTB.COM
____ 17. The nurse is reviewing the health history for a patient who is diagnosed with chronic pancreatitis. Which data
supports the patient’s current diagnosis?
1) Trauma
2) Gallstones
3) Cystic fibrosis
4) Hypotriglyceridemia
____ 18. The nurse is reviewing the health history for a patient who is diagnosed with acute pancreatitis. Which data
supports the patient’s current diagnosis?
1) Trauma
2) Cystic fibrosis
3) Hypercalcemia
4) Hypertriglyceridemia
____ 19. The nurse is providing care to a patient who scores a 4 with the Ranson’s score. Which conclusion by the
nurse is most appropriate?
1) This patient has a 2% chance of mortality.
2) This patient has a 15% chance of mortality.
3) This patient has a 40% chance of mortality.
4) This patient has a 100% chance of mortality.
____ 20. Which is the priority nursing action when providing care to a patient with a nasogastric tube (NGT) in place
following a pancreaticoduodenectomy?
1) Irrigating the tube
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. The nurse is providing care to a patient admitted with acute pancreatitis. Which data support the patient’s
diagnosis? Select all that apply.
1) Steatorrhea
2) Hypotension
3) Nausea and vomiting
4) Elevated temperature
5) Severe epigastric pain
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____ 27. The nurse is providing care to an older adult patient admitted to the medical unit for acute gastric and left
upper abdominal pain radiating to the back. The health-care provider has diagnosed the patient with chronic
pancreatitis. Which items are appropriate to include in the discharge teaching for this patient? Select all that
apply.
1) Taking antacids
2) Encouraging a high-fat diet
3) Monitoring weight every week
4) Eliminating alcoholic beverages
5) Properly administering pancrelipase
____ 28. The nurse is providing care to an older adult patient with a history of alcohol abuse who is admitted to the
hospital with acute pancreatitis. Which treatment options should the nurse plan for when caring for this
patient? Select all that apply.
1) High-fat diet
2) Opioid analgesics
3) Total parenteral nutrition
4) Nasogastric tube to suction
5) Pancrelipase administration
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Chapter 60: Coordinating Care for Patients With Biliary and Pancreatic Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 2
Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders
Chapter learning objective: Describing the epidemiology of biliary and pancreatic disorders
Chapter page reference: 1326-1332
Heading: Acute Pancreatitis
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Inflammation
Difficulty: Easy
Feedback
1 Autoimmune disorders, such as systemic lupus, cystic fibrosis, and
hypertriglyceridemia are all risk factors for chronic pancreatitis.
2 Risk factors for acute pancreatitis include alcoholism and gallstones.
3 Autoimmune disorders, such as systemic lupus, cystic fibrosis, and
hypertriglyceridemia are all risk factors for chronic pancreatitis.
4 Autoimmune disorders, such as systemic lupus, cystic fibrosis, and
hypertriglyceridemia are all risk factors for chronic pancreatitis.
PTS: 1 NURSINGTB.COM
CON: Inflammation
2. ANS: 2
Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders
Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle
considerations for patients with biliary and pancreatic disorders
Chapter page reference: 1332-1334
Heading: Chronic Pancreatitis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Inflammation
Difficulty: Moderate
Feedback
1 The complementary and alternative therapies that have proven to be effective if used in
conjunction with traditional treatment while under the care of a health-care provider
include fasting or a low-salt, low-fat vegetarian diet; qigong, which is a system of
gentle exercise, meditation, and controlled breathing and is believed to balance the flow
of qi (a vital life force) through the body; and magnetic field therapy.
2 Herbal kava tea is not a complementary and alternative therapy that has been proven
effective in the treatment of chronic pancreatitis.
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3 The complementary and alternative therapies that have proven to be effective if used in
conjunction with traditional treatment while under the care of a health-care provider
include fasting or a low-salt, low-fat vegetarian diet; qigong, which is a system of
gentle exercise, meditation, and controlled breathing and is believed to balance the flow
of qi (a vital life force) through the body; and magnetic field therapy.
4 The complementary and alternative therapies that have proven to be effective if used in
conjunction with traditional treatment while under the care of a health-care provider
include fasting or a low-salt, low-fat vegetarian diet; qigong, which is a system of
gentle exercise, meditation, and controlled breathing and is believed to balance the flow
of qi (a vital life force) through the body; and magnetic field therapy.
Feedback
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Feedback
1 Trauma is a cause for acute pancreatitis.
2 Cystic fibrosis causes chronic pancreatitis.
3 Hypercalcemia causes chronic pancreatitis.
4 Hypertriglyceridemia causes chronic pancreatitis.
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1 These NGTs should not be repositioned or irrigated or checked for placement. They are
placed intraoperatively. Doing so can cause a breakdown of the anastomotic site.
2 These NGTs should not be repositioned or irrigated or checked for placement. They are
placed intraoperatively. Doing so can cause a breakdown of the anastomotic site.
3 If a patient removes his NGT, it is not to be replaced by the nursing staff. A member of
the surgical team should be notified.
4 After a Whipple’s or pancreaticoduodenectomy, NGTs are placed postoperatively to
decompress the stomach, prevent bloating, and remove gastric acid secretions. A DO
NOT MANIPULATE NGT sign should be placed on the wall above the patient’s head.
Feedback
1 There is no evidence to support that this patient will present with vague symptoms of
cholecystitis.
2 There is no evidence to support that this patient will present with vague symptoms of
cholecystitis.
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3 There is no evidence to support that this patient will present with vague symptoms of
cholecystitis.
4 Older adult patients, and those with a concurrent diagnosis of diabetes, are likely to
present with vague symptoms of cholecystitis.
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MULTIPLE RESPONSE
26. ANS: 2, 3, 4, 5
Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Acute
pancreatitis
Chapter page reference: 1326-1332
Heading: Acute Pancreatitis
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
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Cognitive level: Comprehension [Understanding]
Concept: Inflammation
Difficulty: Easy
Feedback
1. This is incorrect. Steatorrhea is a clinical manifestation that is associated with chronic
pancreatitis.
2. This is correct. Acute pancreatitis presents with severe epigastric pain, nausea, vomiting,
elevated temperature, and hypotension.
3. This is correct. Acute pancreatitis presents with severe epigastric pain, nausea, vomiting,
elevated temperature, and hypotension.
4. This is correct. Acute pancreatitis presents with severe epigastric pain, nausea, vomiting,
elevated temperature, and hypotension.
5. This is correct. Acute pancreatitis presents with severe epigastric pain, nausea, vomiting,
elevated temperature, and hypotension.
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Feedback
1. This is correct. Appropriate teaching for a patient diagnosed with chronic pancreatitis includes
eliminating alcoholic beverages, proper administration of pancrelipase, and the importance of
taking antacids to prevent the destruction of the enzymes by hydrochloric acid.
2. This is incorrect. The patient should be taught to follow a low-fat diet.
3. This is incorrect. The patient’s weight should be monitored every other day.
4. This is correct. Appropriate teaching for a patient diagnosed with chronic pancreatitis includes
eliminating alcoholic beverages, proper administration of pancrelipase, and the importance of
taking antacids to prevent the destruction of the enzymes by hydrochloric acid.
5. This is correct. Appropriate teaching for a patient diagnosed with chronic pancreatitis includes
eliminating alcoholic beverages, proper administration of pancrelipase, and the importance of
taking antacids to prevent the destruction of the enzymes by hydrochloric acid.
Feedback
1. This is incorrect. A low-fat, not a high-fat, diet will be implemented once the patient is able to
eat by mouth.
2. This is correct. Opioid analgesics are often necessary for the acute pain experienced by the
patient.
3. This is correct. Total parenteral nutrition is initiated and a nasogastric tube is inserted and
connected to suction.
4. This is correct. Total parenteral nutrition is initiated and a nasogastric tube is inserted and
connected to suction.
5. This is incorrect. Pancrelipase is prescribed for patients with chronic pancreatitis, not acute
pancreatitis.
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Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is preparing to conduct a male genitourinary assessment. Which approach is least likely to be used
during this process?
1) Percussion
2) Palpation
3) Inspection
4) Auscultation
____ 2. The nurse is conducting a genitourinary assessment for an older adult male patient. Which is an expected
finding based on the patient’s age?
1) Thick pubic hair on the external genitalia
2) Larger and harder testicles
3) Atrophy of the penis
4) Elastic scrotal sac
____ 3. The nurse is conducting a health history interview while assessing a male patient who presents with
genitourinary symptoms. Which assessment question is most appropriate?
1) “Have you noticed any unusual discharge from your penis?”
2) “Do you have blood in your urine?”
3) “What color is your penile discharge?”
4) “Is there any odor to the discharge?”
____ 4. The nurse is caring for an older adult patient on a medical-surgical unit. The patient tells the nurse, “I don't
get any sleep at night because I have to get up and use the bathroom every couple of hours!” When providing
NU
an explanation for the nocturia, which RSINGbyTB
statement .nurse
the COM is the most appropriate?
1) “As you get older, there is a decrease in number of nephrons.”
2) “As you get older, there is a decrease in the blood supply to your bladder.”
3) “As you get older, you may have a decrease in bladder capacity.”
4) “As you get older, there is a decrease in cardiac output, which can cause your symptoms.”
____ 5. A patient is diagnosed with high blood pressure that is not responding to medications. The nurse suspects
renal stenosis. When assessing for this condition, which location will the nurse use for auscultation?
1) Renal arteries
2) Bladder
3) Ureters
4) Internal urethral sphincter
____ 6. The nurse is caring for a group of patients on a medical-surgical unit. Which patient does the nurse anticipate
to be at the greatest risk for alterations in urinary elimination?
1) The patient with hypertension who takes a diuretic to manage blood pressure
2) An 80-year-old male reporting frequent urination at night
3) A 25-year-old female patient with low self-esteem
4) A patient who had bladder cancer and now has a newly created ileal conduit
____ 7. The nurse is caring for an older adult patient with a history of urinary tract infections (UTIs). Which action by
the nurse would decrease the risk of the patient experiencing future UTIs?
1) Instruct the patient to completely empty the bladder.
2) Tell the patient to increase sugar in the diet.
3) Encourage the patient to take bubble baths.
4) Remind the patient to wipe from back to front.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 8. The nurse is providing care to a patient at a local clinic. The nurse suspects that the patient is experiencing a
urinary tract infection. Which urinalysis result supports the nurse’s suspicions?
1) pH 5.2
2) Negative glucose
3) WBC 10-15
4) Specific gravity 1.012
____ 9. The nurse is providing care to an older adult patient who is experiencing urinary incontinence. Which
independent nursing intervention is the most appropriate for this patient?
1) Encouraging increased fluid intake
2) Providing catheter care
3) Instructing on self-catheterization
4) Implementing hygiene care
____ 10. The nurse is providing care to a patient who is experiencing urinary retention. Which diagnostic tool does the
nurse anticipate will be ordered for this patient?
1) Ultrasonic bladder scan
2) Urinalysis
3) Intravenous pyelography (IVP)
4) Cystoscopy
____ 11. The nurse is providing education information regarding urinary health at an assisted living facility. When
planning topics to include in the session, which is appropriate for the nurse to consider?
1) Full urinary control usually occurs at four or five years of age.
2) Because of neuromuscular immaturity, voluntary urinary control is absent.
3) The kidneys reach maximum size NUbetween
RSIN35 GTand
B.40COyears
M of age.
4) Renal blood flow decreases because of vascular changes and a decrease in cardiac output.
____ 12. The nurse is providing care to a patient who is burning upon urination. Which diagnostic tool does the nurse
anticipate will be ordered for this patient?
1) Ultrasonic bladder scan
2) Urinalysis
3) Intravenous pyelography (IVP)
4) Cystoscopy
____ 13. The nurse is providing care to a patient who is experiencing symptoms of a kidney stone. Which diagnostic
tool does the nurse anticipate will be ordered for this patient?
1) Ultrasonic bladder scan
2) Urinalysis
3) Intravenous pyelography (IVP)
4) Cystoscopy
____ 14. The nurse is providing care to a patient who requires the removal of a kidney stone. Which procedure does the
nurse anticipate will be ordered for this patient?
1) Ultrasonic bladder scan
2) Urinalysis
3) Intravenous pyelography (IVP)
4) Cystoscopy
____ 15. The nurse is providing care to a patient with less than 100 mL of urine output in a 24-hour period. Which term
should the nurse use when documenting this occurrence?
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1) Anuria
2) Dysuria
3) Enuresis
4) Hematuria
____ 16. The nurse is providing care to a patient who is experiencing painful urination. Which term should the nurse
use when documenting this occurrence?
1) Anuria
2) Dysuria
3) Enuresis
4) Hematuria
____ 17. The nurse is providing care to a patient who is experiencing involuntary urination at night. Which term should
the nurse use when documenting this occurrence?
1) Anuria
2) Dysuria
3) Enuresis
4) Hematuria
____ 18. The nurse is providing care to a patient with blood in the urine. Which term should the nurse use when
documenting this occurrence?
1) Anuria
2) Dysuria
3) Enuresis
4) Hematuria
____ 19. The nurse is providing care to a patient
NUwho
RSIstates,
NGT“MyB.Cdoctor
OM says I am experiencing nocturia. What does
that mean?” Which response by the nurse is most appropriate?
1) “It means you have pain radiating to your groin.”
2) “It means you have the sudden urge to void immediately.”
3) “It means you are getting up frequently at night to urinate.”
4) “It means you are unable to completely empty your bladder.”
____ 20. The nurse is providing care to a patient who states, “My doctor says I am experiencing renal colic. What does
that mean?” Which response by the nurse is most appropriate?
1) “It means you have pain radiating to your groin.”
2) “It means you have the sudden urge to void immediately.”
3) “It means you are getting up frequently at night to urinate.”
4) “It means you are unable to completely empty your bladder.”
____ 21. The nurse is providing care to a patient who states, “My doctor says I am experiencing urinary urgency. What
does that mean?” Which response by the nurse is most appropriate?
1) “It means you have pain radiating to your groin.”
2) “It means you have the sudden urge to void immediately.”
3) “It means you are getting up frequently at night to urinate.”
4) “It means you are unable to completely empty your bladder.”
____ 22. The nurse is providing care to a patient who states, “My doctor says I am experiencing urinary retention.
What does that mean?” Which response by the nurse is most appropriate?
1) “It means you have pain radiating to your groin.”
2) “It means you have the sudden urge to void immediately.”
3) “It means you are getting up frequently at night to urinate.”
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 23. The nurse is conducting a health history interview for a patient who presents with urinary symptoms. Which
questions are appropriate? Select all that apply.
1) “What is your menstrual history?”
2) “What is your pregnancy history?”
3) “What is your sexual history?”
4) “Do you have pain when voiding?”
5) “Do you take showers or tub baths?”
____ 24. The nurse is preparing to conduct a genitourinary physical assessment for a male patient. Which will the nurse
use during the assessment process? Select all that apply.
1) Stethoscope
2) Sterile gloves
3) Water-soluble lubricant
4) Speculum
5) Otoscope
____ 25. The nurse admits a patient to the medical unit for a urinary disorder. Which questions are appropriate for the
nurse to include when assessing the patient’s voiding pattern?
1) How many times do you urinate in a 24-hour period?
2) Has your pattern of urination changed recently?
3) How often do you get out of bedNat UR SIN
night toGurinate?
TB.COM
4) What color is your urine?
5) Does your urine have any type of odor?
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 61, Assessment of Renal and Urinary Function
Chapter/learning objective: Describing the procedure for completing a history and physical assessment of the
renal and urinary systems
Chapter page reference: 1352-1356
Heading: Assessment
Integrated Processes: Nursing Process - Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Urinary Elimination
Difficulty: Easy
Feedback
1 Percussion is not a physical assessment approach that is routinely used during the male
genitourinary assessment.
2 Palpation is a physical assessment approach that is routinely used during the male
genitourinary assessment.
3 Inspection is a physical assessment approach that is routinely used during the male
genitourinary assessment.
4 NURSIapproach
Auscultation is a physical assessment NGTB.that COisMroutinely used during the male
genitourinary assessment.
Feedback
1 Pubic hair tends to thin, not thicken, on the external genitalia with age.
2 Testicles tend to become smaller and softer with age.
3 Atrophy of the penis is an expected assessment finding for an older adult patient.
4 The scrotal sac for an older adult patient tends to lose elasticity.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter/learning objective: Describing the procedure for completing a history and physical assessment of the
renal and urinary systems
Chapter page reference: 1352-1356
Heading: Assessment
Integrated Processes: Nursing Process - Assessment
Client Need: Physiological Integrity - Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Urinary Elimination
Difficulty: Moderate
Feedback
1 Asking the patient about unusual discharge is more appropriate for a patient who
presents with penile discharge.
2 Asking the patient if there is blood in the urine is an appropriate question when the
patient presents with genitourinary symptoms.
3 Asking about the color of penile discharge is more appropriate when the patient
presents with discharge.
4 Asking about the odor of penile discharge is more appropriate when the patient presents
with discharge.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3 Irritating soaps and bubble baths can contribute to infections and should be avoided.
4 The patient should wipe from front to back because wiping from back to front would
contaminate the urinary meatus.
Feedback
1 A urinalysis typically consists of the pH, glucose, specific gravity, protein, and WBC
count. The pH, glucose, and specific gravity are all within normal limits.
2 A urinalysis typically consists of the pH, glucose, specific gravity, protein, and WBC
count. The pH, glucose, and specific gravity are all within normal limits.
3 A normal WBC is 0-4. The WBC count for this patient is high and indicates infection.
4 A urinalysis typically consists of the pH, glucose, specific gravity, protein, and WBC
count. The pH, glucose, and specific gravity are all within normal limits.
NURSINGTB.COM
PTS: 1 CON: Urinary Elimination
9. ANS: 4
Chapter number and title: 61, Assessment of Renal and Urinary Function
Chapter learning objective: Discussing changes in renal and urinary system function associated with aging
Chapter page reference: 1342-1352
Heading: Overview of Anatomy and Physiology
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Urinary Elimination
Difficulty: Moderate
Feedback
1 Encouraging increased fluid intake is appropriate for a patient who is dehydrated.
2 Instructing on self-catheterization and providing catheter care is appropriate for a
patient who is diagnosed with urinary retention.
3 Instructing on self-catheterization and providing catheter care is appropriate for a
patient who is diagnosed with urinary retention.
4 Patients with urinary incontinence require determination of the cause, appropriate
treatment, and hygiene care.
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Feedback
1 While this statement is true regarding urinary health, it is not appropriate for this
presentation to older adult patients.
2 While this statement is true regarding urinary health, it is not appropriate for this
presentation to older adult patients.
3 While this statement is true regarding urinary health, it is not appropriate for this
presentation to older adult patients.
4 When planning an education session regarding urinary health at an assisted living
facility, the nurse would include information that affects the urinary health of the older
adult patient. Information that is appropriate for the nurse to consider is the decrease in
renal blood flow due to vascular changes and that urinary incontinence may occur
because of issues with mobility and neurological impairment.
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Feedback
1 An ultrasonic bladder scan is the diagnostic test that is used to examine for residual
urine.
2 A urinalysis is often used to monitor the urine for infection.
3 An IVP is used to diagnose a kidney stone.
4 A cystoscopy allows direct visualization of the bladder wall and urethra. It is often used
to remove stones.
Feedback
1 An ultrasonic bladder scan is the diagnostic test that is used to examine for residual
urine.
NURSINGTB.COM
2 A urinalysis is often used to monitor the urine for infection.
3 An IVP is used to diagnose a kidney stone.
4 A cystoscopy allows direct visualization of the bladder wall and urethra. It is often used
to remove stones.
Feedback
1 An ultrasonic bladder scan is the diagnostic test that is used to examine for residual
urine.
2 A urinalysis is often used to monitor the urine for infection.
3 An IVP is used to diagnose a kidney stone.
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4 A cystoscopy allows direct visualization of the bladder wall and urethra. It is often used
to remove stones.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Heading: Assessment
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Urinary Elimination
Difficulty: Moderate
Feedback
1 Anuria is the term used for a patient who is experiencing less than 100 mL of urinary
output in a 24-hour period.
2 Dysuria is the term used for a patient who is experiencing painful urination.
3 Enuresis is the term used for a patient who is experiencing involuntary urination at
night.
4 Hematuria is the term used for a patient who has blood in the urine.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE RESPONSE
23. ANS: 4, 5
Chapter number and title: 61, Assessment of Renal and Urinary Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of the
renal and urinary systems
Chapter page reference: 1352-1356
Heading: Assessment
Integrated Processes: Nursing Process - Assessment
Client Need: Physiological Integrity - Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Urinary Elimination
Difficulty: Moderate
Feedback NURSINGTB.COM
1. This is incorrect. Questions about the patient’s menstrual history are more appropriate if the
patient is experiencing amenorrhea.
2. This is incorrect. Questions about the patient’s pregnancy history are more appropriate if the
patient is experiencing amenorrhea.
3. This is incorrect. Questions about the patient’s sexual history are more appropriate if the
patient is experiencing amenorrhea.
4. This is correct. It is appropriate to ask the patient about pain when voiding when the patient
presents with urinary symptoms.
5. This is correct. It is appropriate to ask the patient about the use of tub or shower baths when
the patient presents with urinary symptoms.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1. This is correct. A stethoscope is equipment that is used during the genitourinary physical
assessment for a male patient.
2. This is incorrect. Nonsterile gloves, not sterile gloves, are used during the genitourinary
physical assessment for a male patient.
3. This is correct. Water-soluble lubricant is used during the genitourinary physical assessment
for a male patient.
4. This is incorrect. A speculum is used for a female, not a male, genitourinary assessment.
5. This is incorrect. A penlight, not an otoscope, is needed when conducting a male genitourinary
assessment.
Feedback
NURSINGTB.COM
1. This is correct. When assessing the patient’s voiding pattern, it is appropriate for the nurse to
ask how many times the patient voids in a 24-hour period; if the pattern of urination has
changed frequently; and how often the patient gets out of bed at night to urinate.
2. This is correct. When assessing the patient’s voiding pattern, it is appropriate for the nurse to
ask how many times the patient voids in a 24-hour period; if the pattern of urination has
changed frequently; and how often the patient gets out of bed at night to urinate.
3. This is correct. When assessing the patient’s voiding pattern, it is appropriate for the nurse to
ask how many times the patient voids in a 24-hour period; if the pattern of urination has
changed frequently; and how often the patient gets out of bed at night to urinate.
4. This is incorrect. Questions regarding the color and odor associated with urine are appropriate
when assessing urine characteristics.
5. This is incorrect. Questions regarding the color and odor associated with urine are appropriate
when assessing urine characteristics.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
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____ 1. The nurse is caring for a patient admitted with a diagnosis of acute kidney injury. The patient asks the nurse,
“Are my kidneys failing? Will I need a kidney transplant?” Which response by the nurse is the most
appropriate?
1) “No, don't think that. You're going to be fine.”
2) “Your condition can be reversed with prompt treatment and usually will not destroy the
kidney.”
3) “Kidney transplantation is likely, and it would be a good idea to start talking to family
members.”
4) “When the doctor comes to see you, we can talk about whether you will need a
transplant.”
____ 2. A young school-age patient is in the hospital with acute kidney injury following a streptococcus infection.
The parents are Spanish-speaking and speak little English. The parents, through an interpreter, ask the nurse
what mistake they made that caused the child to be so sick. Which response by the nurse is the most
appropriate?
1) “Your child does not have enough dietary protein.”
2) “Your child has a congenital defect that led to renal failure.”
3) “Your child's renal failure has been caused by a low calcium level.”
4) “Your child's recent infection may have caused the renal failure.”
____ 3. The nurse is planning care for the patient with acute kidney injury. The nurse plans the patient’s care based on
the nursing diagnosis of Excess Fluid Volume. Which assessment data supports this nursing diagnosis?
1) Pitting edema in the lower extremities
2) Bowel sounds positive in four quadrants
3) Wheezing in the lungs
4) Generalized weakness
NURSINGTB.COM
____ 4. A patient with renal failure is receiving peritoneal dialysis. The nurse is explaining the process to the patient.
Which statement would the nurse include in a discussion with the patient?
1) “The peritoneum is more permeable because of the presence of excess metabolites.”
2) “The metabolites will diffuse from the interstitial space to the bloodstream mainly through
diffusion and ultrafiltration.”
3) “The peritoneum acts as a semipermeable membrane through which wastes move by
diffusion and osmosis.”
4) “The solutes in the dialysate will enter the bloodstream through the peritoneum.”
____ 5. The nurse is caring for a patient who is diagnosed with acute kidney injury. When reviewing the patient’s
laboratory data, which finding indicates that a patient has met the expected outcomes?
1) Decreasing serum creatinine
2) Decreasing neutrophil count
3) Decreasing lymphocyte count
4) Decreasing erythrocyte count
____ 6. The nurse is administering peritoneal dialysis to a patient with acute kidney injury. The nurse notes the
presence of a cloudy dialysate return. After notifying the health-care provider, which action by the nurse is the
most appropriate?
1) Measure abdominal girth
2) Document the cloudy dialysate
3) Culture the dialysate return
4) Increase dialysate instillation
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____ 7. The nurse is providing education to a patient who is diagnosed with renal carcinoma. The patient states, “My
doctor says I am a stage I. What does that mean?” Which response by the nurse is most appropriate?
1) “Your cancer is limited to the renal capsule.”
2) “Your cancer involves the perirenal fat but is confined to fascia with metastasis to the
adrenal gland.”
3) “Your cancer involves the regional lymph node, renal vein, and vena cava.”
4) “Your cancer involves metastases to other sites in the body.”
____ 8. The nurse is providing care to a patient who is diagnosed with renal trauma. The patient is experiencing
hematuria and contusions but has normal imaging studies. Which grade of renal trauma should the nurse
document?
1) Grade 1
2) Grade 2
3) Grade 3
4) Grade 4
____ 9. The nurse is providing care to a patient who is diagnosed with renal trauma. The patient has a renal laceration
that is greater than 1 cm in depth, but the laceration does not involve the collecting system. Which grade of
renal trauma should the nurse document?
1) Grade 1
2) Grade 2
3) Grade 3
4) Grade 4
____ 10. A patient agrees to receive long-term hemodialysis to treat chronic kidney disease. For which surgical
procedure should the nurse instruct this patient?
NURinto
1) Insertion of a double-lumen catheter SIN theGT B.COMartery
subclavian
2) Placement of a peritoneal catheter
3) Insertion of a subarachnoid-peritoneal shunt
4) Placement of an arteriovenous fistula
____ 11. A patient with acute kidney injury is complaining of a metallic taste in the mouth and has no appetite. Based
on this data, which intervention by the nurse is the most appropriate?
1) Provide mouth care before meals
2) Administer an antiemetic as prescribed
3) Restrict fluids
4) Encourage the intake of protein, salt, and potassium
____ 12. The nurse is caring for a patient with chronic kidney disease who is pale and experiencing fatigue. The nurse
attributes these symptoms to anemia secondary to chronic kidney disease. The patient’s spouse asks why the
patient is anemic. Which response by the nurse is the most appropriate?
1) “Your spouse has a genetic tendency for the development of anemia.”
2) “The increased metabolic waste products in the body depress the bone marrow and cause
anemia.”
3) “There is a decreased production by the kidneys of the hormone erythropoietin, which is
the cause of anemia.”
4) “The patient is not eating enough iron-rich foods, which is causing anemia.”
____ 13. The nurse is caring for a patient from another country who was admitted with hypertension and chronic
kidney disease. The patient is receiving hemodialysis three times a week. The nurse is assessing the client’s
diet, and the patient reports the use of salt substitutes. When teaching the patient to avoid salt substitute,
which rationale supports this teaching point?
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____ 20. During a home visit, the nurse is concerned that an older adult patient is developing chronic kidney disease.
The patient has no history of cardiovascular disease. Which data in the patient’s assessment caused the nurse
to have this concern?
1) Progressive edema
2) Complaints of hip joint pain
3) Recent increase in hunger and thirst
4) Warm moist skin
____ 21. While caring for a patient with chronic kidney disease, the nurse tracks the patient’s serum albumin level. For
which nursing diagnosis is the action most indicated?
1) Excess Fluid Volume
2) Imbalanced Nutrition: Less Than Body Requirements
3) Risk for Ineffective Perfusion
4) Risk for Infection
____ 22. The nurse instructs a patient with chronic kidney disease on the prescribed medication furosemide (Lasix).
Which patient statement indicates that teaching has been effective?
1) “I will take this medication to keep my calcium balance normal.”
2) “This medication will make sure I have enough red blood cells in my body.”
3) “I will take this pill to keep the protein level in my body stable.”
4) “This pill will reduce the swelling in my body and get rid of the extra potassium.”
____ 23. A patient with chronic kidney disease is experiencing manifestations of anemia. Based on this data, which
treatment does the nurse anticipate for this patient?
1) Begin fluid restriction.
2) Administer intravenous glucoseNand URinsulin.
SINGTB.COM
3) Begin a low-sodium diet.
4) Epoetin injections
____ 24. The nurse is providing care to a patient who may have polycystic kidney disease. Which is the first symptom
the nurse should assess this patient for?
1) Hypertension
2) Hematuria
3) Urinary frequency
4) Urinary calculi
____ 25. The nurse is providing care to a patient diagnosed with polycystic kidney disease. Which assessment finding
would indicate to the nurse that the patient is experiencing an infection?
1) Increased temperature
2) Increased blood pressure
3) Decreased white blood cell count
4) Decreased urine output
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. A patient with frequent urinary tract infections is seen in the urology clinic and is at risk for acute kidney
injury. The nurse reviews the patient’s medical history. Which item supports the patient’s being at risk for
acute kidney injury? Select all that apply.
1) Dehydration
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2) Renal calculi
3) Ineffective wound healing
4) Low serum albumin
5) Hypertension
____ 27. The nurse is concerned that an older adult patient is at risk for developing acute kidney injury. Which
information in the patient’s history supports the nurse’s concern? Select all that apply.
1) Diagnosed with hypotension
2) Recent aortic valve replacement surgery
3) Prescribed high doses of intravenous antibiotics
4) Total hip replacement surgery five years ago
5) Taking medication for type 2 diabetes mellitus
____ 28. The nurse is preparing to administer hemodialysis treatment for a patient with chronic kidney disease. Which
laboratory values does the nurse anticipate prior to the patient’s treatment? Select all that apply.
1) Increased blood urea nitrogen (BUN)
2) Decreased potassium
3) Decreased phosphorus
4) Increased urine osmolality
5) Increased creatinine
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 2
Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders
Chapter learning objective: Describing the indications, management, and complications associated with renal
transplantation
Chapter page reference: 1381-1385
Heading: Acute Kidney Injury
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Urinary Elimination
Difficulty: Moderate
Feedback
1 Telling the patient that everything will be fine is condescending, provides no
information, and is not within the nurse’s ability to know.
2 Acute kidney injury is often resolved without the need for transplant if treatment is
initiated quickly.
3 There is no need to start lining up donors or wait for the provider to arrive to explore
options.
4 There is no need to start lining up donors or wait for the provider to arrive to explore
options. NURSINGTB.COM
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Acute
kidney injury
Chapter page reference: 1381-1385
Heading: Acute Kidney Injury
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Urinary Elimination
Difficulty: Easy
Feedback
1 The patient in acute kidney injury will likely be edematous, as the kidneys are not
producing urine.
2 Bowel sounds in four quadrants is a normal assessment finding.
3 Wheezing in the lungs is an assessment consistent with asthma.
4 Generalized weakness may be due to whatever disease process precipitated the acute
kidney injury.
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Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of renal disorders
Chapter page reference: 1381-1385
Heading: Acute Kidney Injury
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Urinary Elimination
Difficulty: Easy
Feedback
1 Creatinine is the metabolic end product of creatinine phosphate and is excreted via the
kidneys in relatively constant amounts.
2 Neutrophils, lymphocytes, and erythrocytes are not used to monitor the return of renal
function.
3 Neutrophils, lymphocytes, and erythrocytes are not used to monitor the return of renal
function.
4 Neutrophils, lymphocytes, and erythrocytes are not used to monitor the return of renal
function.
Feedback
1 Measurement of abdominal girth is performed prior to the dialysis procedure, and
although increased girth could indicate peritonitis, culturing the return is more
important.
2 Documenting the cloudy dialysate and nursing actions taken would be necessary but is
not the next-priority action.
3 The return should be clear. The presence of cloudy drainage might indicate peritonitis,
and the nurse should culture the return in order to help identify the presence and type of
organism that could be causing the infection.
4 The instillation part of the procedure is completed prior to the collection of the dialysate
return, and the rate of the instillation has no relationship to the development of an
infection.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Grade 1 renal trauma presents with hematuria and contusions; however, the patient will
have normal imaging studies.
2 Grade 2 renal trauma will present with nonexpanding hematomas and superficial
lacerations.
3 Grade 3 renal trauma will present with renal lacerations greater than 1 cm in depth not
involving the collecting system.
4 Grade 4 renal trauma will present with renal laceration or fracture extending into the
collecting system. The patient will have injuries of the renal artery or vein but with
controlled hemorrhage. The expanding hematomas compress the kidney.
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Difficulty: Moderate
Feedback
1 Grade 1 renal trauma presents with hematuria and contusions; however, the patient will
have normal imaging studies.
2 Grade 2 renal trauma will present with nonexpanding hematomas and superficial
lacerations.
3 Grade 3 renal trauma will present with renal lacerations greater than 1 cm in depth not
involving the collecting system.
4 Grade 4 renal trauma will present with renal laceration or fracture extending into the
collecting system. The patient will have injuries of the renal artery or vein but with
controlled hemorrhage. The expanding hematomas compress the kidney.
Feedback
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 A metallic taste in the mouth is due to a build-up of uremia. The nurse should provide
mouth care before meals to reduce this taste sensation and improve the patient's oral
intake.
2 An antiemetic is prescribed for nausea.
3 Restricting fluids will not reduce the metallic taste in the mouth.
4 Encouraging the intake of protein, salt, and potassium will exacerbate the build-up of
uremia that is causing the metallic taste in the mouth.
Feedback
1 Diet and heredity do not factor into the production of erythropoietin.
2 Metabolic wastes do not suppress the bone marrow.
3 Anemia is common in patientsNwithURSrenal
INGdisease.
TB.CAmong
OM the factors causing the
anemia are decreased production of erythropoietin by the kidneys and shortened red
blood cell (RBC) life. Erythropoietin is involved in the stimulation of the bone marrow
to produce RBCs.
4 Diet and heredity do not factor into the production of erythropoietin.
Feedback
1 An AV fistula does need to be protected from injury, and infection could be caused by
constricting clothing, venipunctures, and other items.
2 Increases in weight do need to be reported to the health-care provider as a possible
indication of fluid volume excess, but this is not the reason why salt substitute is to be
avoided.
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Feedback
1 Anxiety is not related to osteoporosis.
2 The patient on hemodialysis may have a disturbed body image, but in this case, it is
specified that the patient has significant osteoporosis.
3 The patient with chronic kidney disease with osteoporosis is at high risk for fractures;
therefore, preventing injury is the priority nursing diagnosis.
4 The patient is at risk for anemia, but not bleeding.
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16. ANS: 1
Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders
Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle
considerations for patients with renal failure
Chapter page reference: 1385-1392
Heading: Chronic Kidney Disease
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Urinary Elimination
Difficulty: Moderate
Feedback
1 The patient with chronic kidney disease has elevated phosphate levels due to the
inability of the damaged kidney to excrete this electrolyte. Calcium acetate, when given
with meals, will bind serum phosphorus and therefore lower the serum level.
2 Although calcium acetate can act as an antacid and neutralize gastric acid when given
between meals, this is not the reason it is given to a patient with chronic kidney disease.
3 This medication has no effect on appetite stimulation.
4 Calcium acetate has no effect on serum creatinine.
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Feedback
1 Assessing for edema and monitoring heart rate and blood pressure would be
NURSINGTB.COM
interventions for the diagnosis of Excess Fluid Volume.
2 Interventions appropriate for the diagnosis of Imbalanced Nutrition: Less Than Body
Requirements include monitoring laboratory values such as serum albumin.
3 Monitoring for orthostatic blood pressure changes would be appropriate for the
diagnosis of Risk for Ineffective Perfusion.
4 Monitoring the white blood cell count would be an intervention appropriate for the
diagnosis of Risk for Infection.
Feedback
1 Oral phosphorus-binding agents, such as calcium carbonate or calcium acetate, are
given to lower serum phosphate levels and normalize serum calcium levels.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 Folic acid and iron supplements are given to combat anemia associated with chronic
kidney disease.
3 There is no medication provided to a patient with chronic kidney disease that is used to
stabilize protein levels in the body.
4 Furosemide (Lasix) is a loop diuretic that may be prescribed to reduce extracellular
fluid volume and edema. Diuretic therapy also can reduce hypertension and cause
potassium wasting, lowering serum potassium levels.
Feedback
1 Hypertension is the first symptom the nurse should assess for when a patient is
suspected of having polycystic kidney disease.
2 While hematuria is a symptom of polycystic kidney disease, this is not the first
symptom the nurse should assess this patient for.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3 While urinary frequency is a symptom of polycystic kidney disease, this is not the first
symptom the nurse should assess this patient for.
4 While urinary calculi is a symptom of polycystic kidney disease, this is not the first
symptom the nurse should assess this patient for.
26. ANS: 1, 2, 5
Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders
Chapter learning objective: Describing the epidemiology of renal disorders
Chapter page reference: 1381-1385
Heading: Acute Kidney Injury
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Urinary Elimination
Difficulty: Easy
Feedback
1. This is correct. Dehydration, renal calculi, and hypertension can all precipitate acute kidney
injury.
2. This is correct. Dehydration, renal calculi, and hypertension can all precipitate acute kidney
injury.
3. This is incorrect. Ineffective wound healing has not been shown to cause acute kidney injury
unless the infection becomes systemic.
4. This is incorrect. A low serum albumin does not cause acute kidney injury.
5. This is correct. Dehydration, renal calculi, and hypertension can all precipitate acute kidney
injury.
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Feedback
1. This is correct. Hypotension, scheduled for aortic valve replacement surgery, and receiving
high doses of intravenous antibiotics increase this client’s risk for developing acute kidney
injury.
2. This is correct. Hypotension, scheduled for aortic valve replacement surgery, and receiving
high doses of intravenous antibiotics increase this client’s risk for developing acute kidney
injury.
3. This is correct. Hypotension, scheduled for aortic valve replacement surgery, and receiving
high doses of intravenous antibiotics increase this client’s risk for developing acute kidney
injury.
4. This is incorrect. A previous history of major surgery and current treatment for type 2 diabetes
mellitus are not identified risk factors for the development of acute kidney injury.
5. NURhistory
This is incorrect. A previous SINGof TBmajor
.COsurgery
M and current treatment for type 2 diabetes
mellitus are not identified risk factors for the development of acute kidney injury.
Feedback
1. This is correct. The patient will also have an increased blood urea nitrogen (BUN) level due to
the damaged kidneys.
2. This is incorrect. Both phosphorus and potassium increase during renal failure due to the
inability of the kidney to excrete them.
3. This is incorrect. Both phosphorus and potassium increase during renal failure due to the
inability of the kidney to excrete them.
4. This is incorrect. The damaged kidney is unable to excrete solutes; therefore, the serum
osmolality will be increased and the urine osmolality will be decreased.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5. This is correct. The damaged kidney is unable to excrete waste products, including creatinine,
so it will be increased.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse provides education for a patient who is experiencing urinary incontinence. Which statement by the
patient indicates the need for further education?
1) “Relaxation of pelvic muscles may be a factor in incontinence.”
2) “Reduced urethral resistance can be a cause of incontinence.”
3) “Incontinence is normal with aging.”
4) “A disturbance of my bladder is a factor in the development of incontinence.”
____ 2. The nurse is attempting to place a urinary catheter for an older adult female patient. The nurse is unable to
visualize the patient’s urinary meatus. Which alternate position for catheterization may be appropriate for this
patient?
1) Side-lying, lifting up the buttock
2) Supine, with the HOB elevated at 30°
3) Supine, with the head of bed (HOB) elevated at 45°
4) Supine, with the bed flat, legs bent and apart in stirrups
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____ 3. The nurse is caring for a patient with a urinary catheter. Which nursing diagnosis is a priority for this patient?
1) Chronic Pain related to an obstruction
2) Risk for Impaired Skin Integrity related to incontinence
3) Risk for Infection related to catheter placement
4) Self-Care Deficit related to presence of urinary catheter
____ 4. The nurse is caring for a patient who will be discharged with an indwelling catheter. The nurse has provided
education to the patient and family about catheter care once the patient is discharged. Which patient or family
action indicates a correct understanding of the information presented?
1) Hanging the drainage bag on the towel rod
2) Taking a shower each day instead of taking a tub bath
3) Restricting the amounts of fluids per day
4) Emptying the drainage bag twice a day
____ 5. The nurse is working in a urology clinic and is providing care for a patient with urinary stress incontinence.
The nurse has chosen the diagnosis of Stress Urinary Incontinence related to sphincter incompetence. Which
is the desired outcome for a patient with this diagnosis?
1) The patient will stop the flow of urine when voiding.
2) The patient will improve her incontinence within one month.
3) The patient will empty her bladder every time she voids.
4) The patient will perform four to five squeezes (Kegel exercises) for 10-15 seconds.
____ 6. The nurse is caring for a patient with a history of chronic urinary tract infections. The nurse is planning care
for this patient based on the priority nursing diagnosis of urinary retention related to scarring. Based on this
data, which prescription does the nurse anticipate from the health-care provider?
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1) Antibiotic therapy
2) An anticholinergic medication
3) Intermittent straight catheterization
4) Removal of bladder stones
____ 7. The nurse is assessing an adult patient in a urology clinic. The patient reports that she has been having
“accidents” and expresses frustration about this normal part of aging. Which response by the nurse is the most
appropriate?
1) “Tell me more about what you are experiencing.”
2) “You may need to have surgery to manage this problem.”
3) “I understand you are frustrated about this occurrence.”
4) “Unfortunately, aging and incontinence go hand in hand.”
____ 8. The nurse is reviewing discharge instructions for a patient diagnosed with urinary incontinence resulting from
a urinary tract infection. Which statement made by the patient indicates the need for further education?
1) “I should drink plenty of water to prevent damage to my kidneys while I am on the
antibiotics for the infection.”
2) “Drinking cranberry juice will decrease the risk for developing urinary tract infections.”
3) “I will contact the health-care provider prior to taking over-the-counter medications while
on my antibiotic.”
4) “I will continue to hold my urine while in public so that I do not get another infection.”
____ 9. The nurse is triaging a patient who presents to the urgent care clinic with symptoms of severe flank pain with
spasms, nausea, vomiting, and oliguria. The patient states that the pain was initially intermittent and radiated
from the lower back to the lower quadrants of the abdomen. Which action by the nurse is the most
appropriate?
1) Complete the physical assessment NURSINGTB.COM
2) Refer the patient to a urologist
3) Instruct the patient to increase fluids
4) Obtain a urine specimen for culture
____ 10. A nurse is providing care to a group of patients on a urology unit. Which patient does the nurse identify as
being at the greatest risk for developing urinary stones?
1) A 35-year-old female with quadriplegia from an auto accident
2) A 65-year-old male with a recent history of myocardial infarction
3) A 50-year-old male with type II diabetes mellitus
4) A 25-year-old female with several episodes of urinary infection
____ 11. The nurse educator is speaking with a group of students about renal disorders. Which statement is appropriate
for the educator to include regarding renal stones?
1) “Older adult patients are particularly at risk for urolithiasis.”
2) “Young- or middle-age adult men are at an increased risk for stones.”
3) “Women have a greater risk overall than men.”
4) “Frequency is greater in the northern United States.”
____ 12. A patient is admitted to the emergency department and diagnosed with urinary calculi after experiencing
symptoms for one week. When planning care for this patient, which nursing diagnosis is the most
appropriate?
1) Risk for Constipation
2) Risk for Disuse Syndrome
3) Imbalanced Nutrition
4) Activity Intolerance
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____ 13. The nurse is caring for a patient with a history of kidney stones. The stones have been analyzed and are all
composed of calcium phosphate. Based on this data, which foods should the nurse teach the patient to avoid?
1) Chicken, beef, and ham products
2) Organ meats, sardines, and seafood
3) Tomatoes, fruits, and nuts
4) Flour, milk, and ice cream
____ 14. A patient with urinary calculi is admitted to the hospital. When planning care for this patient, which goal is
most appropriate?
1) The patient will lose 25 pounds in three months.
2) The patient will ambulate three times a day.
3) The patient will request pain medication at the onset of pain.
4) The patient will shower independently.
____ 15. The nurse providing care to a patient whose medication therapy for the treatment of renal calculi has failed.
Based on this data, which treatment option does the nurse anticipate for this patient?
1) Lithotripsy
2) Surgical removal
3) Dietary control
4) Initiation of IV fluids
____ 16. The nurse is preparing to discharge a patient who underwent lithotripsy in the treatment of a kidney stone.
What should the nurse teach the patient to prevent further complications of urinary calculi after discharge?
1) “You will need to increase your oral fluid intake to 1 L/day.”
2) “It will be important that you not drive while taking pain medications.”
3) “It will be important to maintainNaUdiet
RShigh
INGinTpurines.”
B.COM
4) “You will need to monitor for the signs and symptoms of a urinary tract infection (UTI).”
____ 17. A patient admitted to the hospital with a diagnosis of gout has also been diagnosed with uric acid renal
calculi. When planning meals for this patient, which diet will the nurse anticipate?
1) Low-purine diet
2) Low-sodium diet
3) A diet high in calcium
4) A diet low in calcium
____ 18. The nurse on the medical unit is admitting an older adult patient whose primary symptoms include fatigue,
pruritus, and pain in the right flank area. When conducting this patient’s assessment, which technique is the
most appropriate?
1) Palpation over the costovertebral angles and flanks
2) Blunt percussion over the costovertebral angles and flanks
3) Palpation of the lower pole of both kidneys
4) Capturing of both kidneys
____ 19. The nurse is providing care to a patient with a spinal cord injury. Which type of incontinence should the nurse
include in this patient’s plan of care?
1) Urge
2) Stress
3) Overflow
4) Functional
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 20. The nurse is providing care to a patient who is experiencing urine leakage when coughing or laughing. Which
type of incontinence should the nurse include in this patient’s plan of care?
1) Urge
2) Stress
3) Overflow
4) Functional
____ 21. The nurse is providing care to a patient with urge incontinence. Which drug classification should the nurse
include in the patient’s plan of care?
1) Anticholinergic
2) Topical estrogen
3) Alpha-adrenergic agonist
4) Calcium channel blocker
____ 22. The nurse is providing care to a patient with stress incontinence. Which drug classification should the nurse
include in the patient’s plan of care?
1) Anticholinergic
2) Topical estrogen
3) Alpha-adrenergic agonist
4) Calcium channel blocker
____ 23. The nurse is providing care to a patient with benign prostatic hyperplasia (BPH). Which drug classification
should the nurse include in the patient’s plan of care?
1) Diuretic
2) Anticholinergic
3) Topical estrogen
4) Alpha-adrenergic agonist NURSINGTB.COM
____ 24. Which intervention should the nurse include in the patient’s plan of care to decrease the risk for developing a
catheter-associated urinary tract infection?
1) Implementing intermittent catheterization
2) Administering the prescribed prophylactic antibiotic
3) Retaining the indwelling catheter throughout hospitalization
4) Encouraging the consumption of cranberry juice twice per day
____ 25. The nurse is providing care to a patient who is diagnosed with bladder cancer and receiving Bacille Calmette-
Guérin therapy. Which is the priority teaching point for this patient?
1) Straining all urine to assess for calculi
2) Flushing the toilet immediately after urination
3) Pouring two cups of bleach in the toilet and flushing 20 minutes later
4) Notifying the health-care provider if the patient does not void every two hours
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. The nurse is providing care to a patient who is diagnosed with stress incontinence. Which assessment data
would the nurse expect to collect while performing the patient’s health history and physical? Select all that
apply.
1) Urine leakage while talking
2) Urine leakage while coughing
3) Urine leakage while laughing
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Completion
Complete each statement.
28. A patient is complaining of dull flank pain. List the order of the steps the nurse should take in conducting the
physical assessment for this patient. (Enter the number of each step in the proper sequence; do not use
punctuation or spaces. Example: 1234)
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with urinary
disorders
Chapter page reference: 1408-1412
Heading: Incontinence
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Urinary Elimination
Difficulty: Difficult
Feedback
1 A disturbance of the bladder, relaxation of the pelvic muscles, and reduced urethral
resistance are all potential factors in the development of incontinence.
2 A disturbance of the bladder, relaxation of the pelvic muscles, and reduced urethral
resistance are all potential factors in the development of incontinence.
3 Incontinence is not a normal result of aging.
4 A disturbance of the bladder, relaxation of the pelvic muscles, and reduced urethral
NURinSthe
resistance are all potential factors INdevelopment
GTB.COMof incontinence.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4 The supine position, regardless of the leg position or height of the bed, would not
increase the visualization of the urinary meatus because it is more distal from the
changes in the perineal area.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with urinary
disorders
Chapter page reference: 1408-1412
Heading: Incontinence
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Urinary Elimination
Difficulty: Moderate
Feedback
1 Patients are not instructed to stop the flow of urine when voiding, because this could
lead to retention.
2 Improved continence takes three to six months, so one month is not a realistic goal.
3 Emptying the bladder completely every time she voids would not be realistic in the
beginning. This will take time.
4 Performing four to five squeezes for 10-15 seconds is the goal to start with when
teaching a patient Kegel exercises, which are used for stress and urge incontinence.
Feedback
1 Antibiotic therapy is not indicated, as the patient does not have an infection now.
2 Anticholinergic medications can cause urinary retention.
3 The health-care provider may order straight catheterization so the patient can be taught
to self-catheterize and manage the urinary retention at home.
4 Bladder stones are not the problem; scarring is.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Difficulty: Moderate
Feedback
1 It is appropriate for the nurse to gather more information regarding the patient’s
incontinence.
2 It is beyond the nurse’s scope of practice to recommend surgery to the patient.
3 Saying that the nurse understands does not help to determine the cause of the patient’s
incontinence.
4 As the body ages, there are anatomical changes can increase the risk for urinary
incontinence; however, this is not a normal part of aging.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 Hydroureter is a complication that occurs when a renal calculus moves into the ureter
and blocks and dilates the ureter. Symptoms include severe pain and spasms, nausea,
vomiting, and diminished volume of urine. Hydroureter is a medical emergency that
can lead to shock, infection, and subsequent impaired renal function; medical
collaboration should be initiated immediately.
3 While this action is important, it would not be appropriate in an emergency situation.
4 While this action is important, it would not be appropriate in an emergency situation.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 Men who are in young to middle age are affected two to three times more than women
of that age.
3 This statement is not accurate.
4 The frequency of the occurrence of renal stones in the United States is greatest in the
southern and midwestern states.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4 Flour, milk, and milk products such as ice cream have high calcium levels and,
therefore, are recommended to be reduced to decrease the risk of further episodes of
calcium-containing calculi.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with urinary disorders
Chapter page reference: 1405-1408
Heading: Urolithiasis
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Urinary Elimination
Difficulty: Moderate
Feedback
1 Fluid intake per day should be 2.5-3.0 L.
2 By discharge, the stones should have passed and there would be no need for pain
medication.
3 Foods high in purines, such as organ meats, are to be avoided.
4 The patient with stones may develop a UTI when formed stones obstruct urinary flow.
These symptoms should be reported as early as possible to the primary care provider.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
NURSINGTB.COM
1 Urge incontinence occurs when there is bladder exposure to irritants such as caffeine,
artificial sweeteners, or nicotine. The patient will experience a strong urge to urinate
followed by uncontrolled leakage.
2 Stress incontinence is more common in women and occurs when abdominal pressure
increases: laughing, coughing, lifting, exercising.
3 Overflow incontinence occurs with spinal cord injury. The bladder is flaccid/enlarged
due to obstruction, and the patient experiences frequent urination.
4 Functional incontinence occurs when the patient is unable to get to the toilet or
communicate the need to do so. The patient is continent, but environmental factors lead
to loss of urine in inappropriate area.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Urge incontinence occurs when there is bladder exposure to irritants such as caffeine,
artificial sweeteners, or nicotine. The patient will experience a strong urge to urinate
followed by uncontrolled leakage.
2 Stress incontinence is more common in women and occurs when abdominal pressure
increases: laughing, coughing, lifting, exercising.
3 Overflow incontinence occurs with spinal cord injury. The bladder is flaccid/enlarged
due to obstruction, and the patient experiences frequent urination.
4 Functional incontinence occurs when the patient is unable to get to the toilet or
communicate the need to do so. The patient is continent, but environmental factors lead
to loss of urine in inappropriate area.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 Anticholinergic drugs are used to treat stress incontinence and mixed incontinence.
They block nervous stimulation from the parasympathetic nervous system to help relax
and control bladder muscle contractions.
2 Topical estrogens are used in stress incontinence to help restore moisture and flexibility
of the urethra.
3 Alpha-adrenergic agonists, beta-adrenergic agonists, and calcium channel blockers all
promote urethral relaxation; aid in issues of urinary retention, for example, issues
associated with BPH.
4 Alpha-adrenergic agonists, beta-adrenergic agonists, and calcium channel blockers all
promote urethral relaxation; aid in issues of urinary retention, for example, issues
associated with BPH.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE RESPONSE
26. ANS: 2, 3, 4
Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Incontinence
Chapter page reference: 1408-1412
Heading: Incontinence
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Urinary Elimination
Difficulty: Easy
Feedback
1. This is incorrect. Stress incontinence does not involve urine leakage when talking.
2. This is correct. Stress incontinence involves a small leakage of urine when a patient laughs,
coughs, or lifts something heavy, not if a patient just carries on a conversation.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3. This is correct. Stress incontinence involves a small leakage of urine when a patient laughs,
coughs, or lifts something heavy, not if a patient just carries on a conversation.
4. This is correct. If the patient has been experiencing incontinence, the nurse might expect to see
the skin inflamed and irritated because urine is very irritating to the skin.
5. This is incorrect. A patient with incontinence would wear some kind of undergarment pad; a
urinary catheter is not an expected finding.
Feedback
1. This is correct. An immobilized patient may experience incontinence if a call light is not
within reach; a patient with Alzheimer disease, along with other forms of dementia, may
perceive the urge to void but be unable to interpret its meaning or respond by seeking a
bathroom. A patient with impaired vision may not be able to find the bathroom. Minimal
facilities can create problems in urinary control.
2.
NURSINGTB.COM
This is correct. An immobilized patient may experience incontinence if a call light is not
within reach; a patient with Alzheimer disease, along with other forms of dementia, may
perceive the urge to void but be unable to interpret its meaning or respond by seeking a
bathroom. A patient with impaired vision may not be able to find the bathroom. Minimal
facilities can create problems in urinary control.
3. This is correct. An immobilized patient may experience incontinence if a call light is not
within reach; a patient with Alzheimer disease, along with other forms of dementia, may
perceive the urge to void but be unable to interpret its meaning or respond by seeking a
bathroom. A patient with impaired vision may not be able to find the bathroom. Minimal
facilities can create problems in urinary control.
4. This is correct. An immobilized patient may experience incontinence if a call light is not
within reach; a patient with Alzheimer disease, along with other forms of dementia, may
perceive the urge to void but be unable to interpret its meaning or respond by seeking a
bathroom. A patient with impaired vision may not be able to find the bathroom. Minimal
facilities can create problems in urinary control.
5. This is incorrect. Depression is not usually related to incontinence.
COMPLETION
28. ANS:
1234
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with urinary
disorders
Chapter page reference: 1405-1408
Heading: Urolithiasis
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Urinary Elimination
Difficulty: Moderate
Feedback: A quick survey of the patient enables the nurse to identify any immediate problem as well as the
patient’s ability to participate in the assessment. Begin the examination with the patient in a supine position
with the abdomen exposed from the nipple line to the pubis. Assess general appearance and inspect the
patient’s skin for color, hydration status, scales, masses, indentations, or scars.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is assessing for vaginal bleeding during the health history. Which question is appropriate?
1) “How many pads or tampons are used in a 2-hour period?”
2) “How many pads or tampons areNused URSinIaN10-hour
GTB.Cperiod?”
OM
3) “How many pads or tampons are used in a 24-hour period?”
4) “How many pads or tampons are used in a 72-hour period?”
____ 2. During the health history focused on reproductive function, the nurse should begin with questions about
which topic?
1) Sexual satisfaction
2) Self-care
3) Sexual practices
4) Symptoms
____ 3. The nurse is assessing a patient who reports vaginal discharge for one week, itching, and mild dysuria. Which
question is appropriate to include in the assessment history for this patient?
1) “What is the color of the discharge?”
2) “Does your sexual partner have the same symptoms?”
3) “How often do you have vaginal bleeding?”
4) “How would you describe your normal flow?”
____ 4. A yearly Pap test is recommended to screen for which type of cancer?
1) Ovarian
2) Vaginal
3) Uterine
4) Cervical
____ 5. Before beginning to perform a gynecological assessment, the nurse would ask the patient to perform which
action?
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____ 13. Which is the recommended procedure for palpating the testicle?
1) Use the first two fingers of each hand to palpate firmly
2) Gently palpate using the fingers of both hands
3) Palpate firmly using the palmar surface of one hand
4) Gently palpate using the thumb and first two fingers of one hand
____ 14. The nurse is examining an adult patient who complains of left inguinal pain. Bowel sounds are auscultated in
the scrotum, and the nurse palpates a bulge at the external inguinal ring when the patient coughs. Based on
this data, which diagnosis does the nurse suspect?
1) Hydrocele
2) Spermatocele
3) Rectocele
4) Hernia
____ 15. The nurse is conducting a genitourinary assessment for an older adult male patient. Which is an expected
finding based on the patient’s age?
1) Thick pubic hair on the external genitalia
2) Larger and harder testicles
3) Atrophy of the penis
4) Elastic scrotal sac
____ 16. The nurse is conducting a sexual history interview. Which assessment question is appropriate?
1) “Have you ever had a kidney stone?”
2) “Have you had any changes in your voiding pattern?”
3) “How many times do you wake up during the night to void?”
4) “Are you using birth control?”
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____ 17. The nurse is conducting a health history for a patient who presents with erectile dysfunction. Which question
is most appropriate?
1) “Do you have sex with men, women, or both?”
2) “Which types of sexual activity do you participate in?”
3) “Do you have more than one partner?”
4) “Have you maintained an interest in sex?”
____ 18. The nurse is conducting a health history for a patient who seeks care for breast pain. Which question from the
nurse is most appropriate?
1) “Where is the lump or mass located?”
2) “Is there discomfort when you palpate your breast?”
3) “When did you notice the lump?”
4) “Have you had a recent injury to your breast?”
____ 19. Which is the first step when teaching a patient to perform a self-breast examination?
1) Using the pads of the fingers to palpate the breast symmetrically
2) Compressing the nipple looking for discharge
3) Inspecting the breasts in the mirror
4) Reporting any redness or inflammation
____ 20. The nurse is assessing a patient who presents with nipple discharge. Which question from the nurse is
appropriate?
1) “Have you ever had this problem before?”
2) “How would you rate your pain on a scale of 0 to 10?”
3) “Has there been a change in your bra size?”
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. Which are the primary functions of the female reproductive system? Select all that apply.
1) Protecting ova for fertilization
2) Transporting the fertilized ova for implantation
3) Nourishing the developing fetus
4) Producing sperm
5) Providing a drainage site for the excretion of urine
____ 27. The nurse is assessing the patient’s scrotum. Which are normal assessment findings? Select all that apply.
1) Darker skin color than rest of the body
2) Swelling
3) Left testicle slightly lower than right testicle
4) Erythema
5) Hydrocele
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____ 28. The nurse is using transillumination during a scrotal assessment. Which conditions will produce a red glow?
Select all that apply.
1) Orchitis
2) Atrophic testicle
3) Hydrocele
4) Spermatocele
5) Hernia
____ 29. The nurse is providing education to a patient who is scheduled for a mammogram. Which information should
the nurse include in the teachings session? Select all that apply.
1) “You should avoid using deodorant prior to testing.”
2) “You will need to remove all jewelry prior to this test.”
3) “You will remove all your clothing from the waist down.”
4) “Your health-care provider will contact you with the results.”
5) “You will need to have a full bladder for the test to be accurate.”
____ 30. The nurse is providing education to a patient who will use a diaphragm for birth control. Which patient
statements indicate the need for additional education regarding this method of birth control? Select all that
apply.
1) “This method is close to 99% effective when used properly.”
2) “This method does not increase my risk for blood clots.”
3) “I will need to insert it prior to sexual intercourse.”
4) “I will need to keep it in place for 12 hours after intercourse.”
5) “This method may not be effective when I am prescribed antibiotics.”
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MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 64, Assessment of Reproductive Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of
reproductive function
Chapter page reference: 1425-1431
Heading: Assessment of Male and Female Reproductive Systems
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Female Reproduction
Difficulty: Moderate
Feedback
1 When assessing vaginal bleeding, the nurse would not ask how many pads or tampons
are used in a 2-hour period.
2 When assessing vaginal bleeding, the nurse would not ask how many pads or tampons
are used in a 10-hour period.
3 The nurse will ask the patient how many pads or tampons are used in a 24-hour period
to assess how much bleeding occurs.
4 NURthe
When assessing vaginal bleeding, SInurse
NGTwould
B.CO M ask how many pads or tampons
not
are used in a 72-hour period.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3. ANS: 1
Chapter number and title: 64, Assessment of Reproductive Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of
reproductive function
Chapter page reference: 1425-1431
Heading: Assessment of Male and Female Reproductive Systems
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Female Reproduction
Difficulty: Moderate
Feedback
1 It is appropriate for the nurse to ask the patient to describe the color of the vaginal
discharge.
2 Asking if the patient’s sexual partner has the same symptoms is more appropriate for a
patient who presents with a lesion.
3 Asking the patient about vaginal bleeding is more appropriate if the patient presents
with abnormal vaginal bleeding.
4 Asking the patient about the normal menstrual flow is more appropriate for a patient
who presents with vaginal bleeding.
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Feedback
1 Just because a patient is in menopause does not mean the patient is no longer sexually
active.
NURSINGTB.COM
2 Just because a patient is in menopause does not mean the patient is childless.
3 Menopause is not a type of sexually transmitted infection.
4 Menopause indicates the patient has not had a menstrual period in one year.
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Feedback
1 Asking the patient about the frequency of intercourse is more appropriate when
assessing sexual functioning.
2 Asking the patient about the ability to achieve an orgasm is more appropriate when
assessing sexual functioning.
3 Bloating is a common clinical manifestation associated with premenstrual syndrome.
4 Asking the patient about the number of sexual partners is more appropriate when
assessing sexual functioning.
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13. ANS: 4
Chapter number and title: 64, Assessment of Reproductive Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of
reproductive function
Chapter page reference: 1425-1431
Heading: Assessment of Male and Female Reproductive Systems
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Male Reproduction
Difficulty: Moderate
Feedback
1 The thumb is used in addition to the first two fingers.
2 This is not the technique used for this assessment.
3 This is not the technique used for this assessment.
4 Gently palpate a testicle between your thumb and your first two fingers. Note the size,
shape, consistency, and presence or absence of masses.
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1 Pubic hair tends to thin, not thicken, on the external genitalia with age.
2 Testicles tend to become smaller and softer with age.
3 Atrophy of the penis is an expected assessment finding for an older adult patient.
4 The scrotal sac for an older adult patient tends to lose elasticity.
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Feedback
1 Asking the patient where a lump or mass is located is more appropriate if the patient
presents with a mass versus breast pain.
2 It is appropriate for the nurse to ask the patient if there is discomfort with palpation
when the patient presents with breast pain.
3 Asking the patient when a lump was first noticed is more appropriate if the patient
presents with a mass versus breast pain.
4 Asking the patient if there was a recent injury to the breast is more appropriate if the
patient presents with a mass versus breast pain.
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Feedback
1 An appropriate question to ask the patient with nipple discharge is asking the patient if
the problem has been experienced before.
2 Asking the patient to rate pain is more appropriate for a patient who presents with
breast discomfort.
3 Asking the patient if there is a change in breast size is more appropriate for a patient
who presents with breast pain or a breast mass.
4 Asking the patient if there is a history of nipple piercings is more appropriate for a
patient who presents with pain versus discharge.
Feedback
1 Breast cancer can cause bloody nipple discharge.
2 Intraductal papilloma can cause serous or serosanguineous nipple discharge.
3 Fibrocystic breast disease usually does not have nipple discharge but does have fluid-
filled cysts.
4 Certain medications can cause lactation.
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2 Dimpling is not a normal finding during a breast examination and can indicate cancer.
3 Puckering is not a normal finding during a breast examination and can indicate cancer.
4 Erythema is not a normal finding during a breast examination and can indicate
infection.
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Feedback
1 This diagnostic test may or may not be helpful in diagnosing this patient.
2 This diagnostic test may or may not be helpful in diagnosing this patient.
3 This diagnostic test may or may not be helpful in diagnosing this patient.
4 The patient is complaining of a strange discharge from her vagina. A Papanicolaou
smear would be the most helpful in diagnosing the cause of that symptom.
MULTIPLE RESPONSE
26. ANS: 1, 2, 3, 5
Chapter number and title: 64, Assessment of Reproductive Function
Chapter learning objective: Discussing the function of the reproductive system
Chapter page reference: 1418-1422
Heading: Female Reproductive System
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
NURSINGTB.COM
Cognitive level: Comprehension [Understanding]
Concept: Female Reproduction
Difficulty: Easy
Feedback
1. This is correct. One of the primary functions of the female reproductive system is protecting
the ova for fertilization.
2. This is correct. One of the primary functions of the female reproductive system is transporting
the fertilized ova for implantation.
3. This is correct. One of the primary functions of the female reproductive system is nourishing
the developing fetus.
4. This is incorrect. Producing sperm is a primary function of the male, not the female,
reproductive system.
5. This is correct. One of the primary functions of the female reproductive system is providing a
drainage site for the excretion of urine.
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Feedback
1. This is correct. The scrotum is darker in color than the rest of the body.
2. This is incorrect. Swelling is not a normal assessment finding.
3. This is correct. The left testicle is expected to hang slightly lower than the right testicle.
4. This is incorrect. Erythema is not a normal assessment finding.
5. This is incorrect. A hydrocele is not a normal assessment finding.
Feedback
1. This is incorrect. Orchitis
NUisRnot
SIaNcondition
GTB.Cthat OMproduces a red glow with transillumination.
2. This is incorrect. An atrophic testicle is not a condition that produces a red glow with a
transillumination.
3. This is correct. A hydrocele will produce a red glow with transillumination.
4. This is correct. A spermatocele will produce a red glow with transillumination.
5. This is incorrect. A hernia will not produce a red glow with transillumination.
Feedback
1. This is correct. Deodorant, lotions, and creams should be avoided the day of the test until the
mammogram has been completed.
2. This is incorrect. Jewelry removal is required for an MRI, not a mammogram.
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3. This is incorrect. The patient would remove clothing from the waist down for an ultrasound,
not a mammogram.
4. This is correct. Results can take a few days; therefore, the nurse should tell the patient the
health-care provider will contact her with the results in a few days.
5. This is incorrect. A full bladder is often required for an abdominal ultrasound, not a
mammogram.
Feedback
1. This is correct. This method of birth control is 85% to 95% effective.
2. This is incorrect. This method of birth control does not increase the risk of blood clots like
those that are hormone dependent.
3. This is incorrect. This method of birth control must be inserted prior to sexual intercourse.
NURSINGTB.COM
4. This is correct. The diaphragm must be left in place 6, not 12, hours after intercourse.
5. This is correct. Hormone-based contraceptives may be ineffective with antibiotics.
Chapter 65: Coordinating Care for Female Patients With Reproductive and Breast Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A patient recovering from a hysterectomy does not want to take the prescribed estrogen replacement therapy
because of the fear of developing breast cancer. Which response by the nurse is the most appropriate?
1) “The risk of breast cancer is slightly increased for women who opt to take estrogen
replacement therapy.”
2) “Perhaps you should consider an estrogen-progestin combination therapy.”
3) “The risk of breast cancer is not increased for women who have had a hysterectomy and
take estrogen replacement medications.”
4) “Taking estrogen replacement is required after a hysterectomy.”
____ 2. The nurse is instructing a group of women between the ages of 40 and 50 about early detection of breast
cancer. What should the nurse include in this teaching?
1) Perform monthly breast self-exams
2) See a health-care provider if there is a strong family history of breast cancer
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____ 10. A nurse is caring for a patient who is perimenopausal and states that she has recently had frequent bacterial
vaginal infections. Which reason for these infections will the nurse include in the response to the patient?
1) Decreased vaginal pH
2) Increased vaginal pH
3) Increased estrogen level
4) Decreased vasomotor stability
____ 11. A nurse working in an outpatient women’s health clinic is caring for a patient in menopause. When discussing
hormone replacement therapy (HRT) with the patient, the nurse should include which statement?
1) “Most healthy, recently menopausal women should not use HRT for relief of hot flashes
and vaginal dryness.”
2) “HRT is the least effective treatment for menopausal hot flashes and vaginal dryness.”
3) “If vaginal dryness and painful intercourse are the only symptoms, then low-dose vaginal
estrogen is preferred.”
4) “The risk of blood clots in the legs or lungs is further increased by using transdermal
patches, gels, or sprays.”
____ 12. A female patient asks what causes the symptoms of menopause. On which hormonal function should the
nurse focus when responding to this patient's question?
1) Increased estrogen levels
2) Increased progesterone levels
3) Estrone as the major hormone
4) Increased luteinizing hormone levels
____ 13. A patient with a history of breast cancer who is entering menopause is seeking information about how to
manage hot flashes. What information NUcan
RSbeIprovided
NGTB.to COtheM patient?
1) Soy and black cohosh can be used to manage the hot flashes associated with menopause.
2) The patient should be advised that she will have to wait until menopause has finished for
the hot flashes to cease.
3) Estrogen is the only reliable method of treatment for hot flashes.
4) Olive oil and black cohosh are effective in the management of hot flashes.
____ 14. A patient who is postmenopausal confides in the nurse about pain experienced during intercourse. What
should the nurse instruct the patient to do?
1) Use vaginal lubricants during intercourse
2) Avoid intercourse
3) Tolerate this problem because it is a normal part of aging
4) Decrease the frequency of intercourse to decrease the pain
____ 15. A nurse is caring for a patient who complains of pain with menstruation. What is true regarding the etiology
and pathophysiology of this condition?
1) Primary dysmenorrhea is caused by decreased levels of prostaglandins, causing the
contractions of the uterus to increase in strength.
2) Primary dysmenorrhea begins within the first three or four menstrual periods after
menarche and will occur with each ovulatory cycle during the teens and 20s of a woman’s
life.
3) Secondary dysmenorrhea is more common than primary dysmenorrhea.
4) Primary dysmenorrhea causes include endometriosis, tumors, cysts, pelvic adhesions,
pelvic inflammatory disease, infections, cervical stenosis, uterine leiomyomas, and
adenomyosis.
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____ 16. The nurse identifies that a patient is at risk for dysfunctional uterine bleeding. What did the nurse assess in
this patient to lead to this clinical diagnosis?
1) Low level of stress
2) Weight gain of 5 lbs in five years
3) Uses birth control pills for contraception
4) Limits intake of high-fat foods
____ 17. A young adolescent patient is concerned about experiencing severe cramps with menstruation. How should
the nurse respond to this patient?
1) “This is not normal but is something that can be treated.”
2) “You have cramps because you started your periods too early.”
3) “Cramps are seen in those who just start having periods and will become less severe as
you get older.”
4) “You need to see a gynecologist for a pelvic examination.”
____ 18. The nurse has identified the diagnosis of Ineffective Coping for a patient with severe premenstrual syndrome.
What should be included in this patient’s plan of care?
1) Encourage frequent rest periods
2) Suggest four ounces of wine each day
3) Encourage exercise and relaxation techniques
4) Instruct to avoid contraception during menstruation if engaging in sexual intercourse
____ 19. The nurse is developing strategies to be used for the relief of menstrual cramping in a teaching session to a
group of young women. What should be the focus of these strategies?
1) Minimization of menstrual flow
2) Avoidance of uterine contraction
NURmuscle
3) Increase of blood flow to the uterine SINGTB.COM
4) Decrease in estrogen production
____ 20. The nurse instructs a patient on ways to reduce premenstrual difficulty. Which patient statement indicates the
instruction was beneficial?
1) The patient states the need to increase dietary sugar intake to promote energy.
2) The patient states that guided imagery does not help with the symptoms.
3) The patient states the need to increase intake of simple carbohydrates.
4) The patient states that reducing caffeine intake will help.
____ 21. The nurse is caring for a patient recovering from a total hysterectomy. What should the nurse include when
instructing this patient prior to discharge?
1) The importance of douching after intercourse for at least 6 weeks
2) Why bed rest is indicated for at least a month after the surgery
3) The risks and benefits of hormone replacement therapy
4) The importance of returning to normal activities of daily living as soon as possible
____ 22. The nurse is conducting a health history interview for a female patient with a family history of ovarian cancer.
Which information noted by the nurse indicates this patient has an increased risk for developing this type of
cancer?
1) Two noted pregnancies
2) Long term oral contraceptive use
3) Currently breastfeeding an infant
4) Body mass index indicates obesity
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____ 23. The nurse is assessing a patient who is at risk for endometrial cancer. Which is the priority question for the
nurse to include in the health history?
1) “How many times have you been pregnant?”
2) “Do you experience irregular or heavy periods?”
3) “How often do you engage in sexual intercourse?”
4) “Have you ever been diagnosed with a sexually transmitted infection?”
____ 24. Which patient has an increased risk for being diagnosed with cervical cancer in the later stages of the disease
process?
1) 35-year-old Hispanic woman with a Pap smear one year ago
2) 45-year-old Caucasian woman with a Pap smear three years ago
3) 50-year-old Native American woman with a Pap smear four years ago
4) 55-year-old African American woman with a Pap smear six years ago
____ 25. The nurse is preparing education for a patient who is diagnosed with endometriosis. Which should the nurse
plan to include in the teaching session as a first-line treatment option?
1) Oral contraceptives
2) Aromatase inhibitors
3) Laparoscopy with biopsy
4) Gonadotropin-releasing hormone agonists
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. The nurse is reviewing data collected during a health history and physical assessment and determines that a
patient is at risk for developing breastNcancer.
URSIWhich
NGTBdata
.COsupports
M this patient’s risk for developing breast
cancer? Select all that apply.
1) Age 60
2) Breastfed both children
3) Sister had breast cancer
4) Body mass index 22
5) Menopause at age 58
____ 27. The nurse is teaching a 34-year-old patient who has a sister and mother with a history of breast cancer about
early screening for the health problem. Which should the nurse include in this teaching session? Select all that
apply.
1) Routine monthly breast self-examination
2) Annual screening mammography
3) Routine breast exams to begin after age 35
4) Clinical breast examination every three years
5) Reporting of any changes in breast tissue to the health provider at the next routine visit
____ 28. The nurse is providing care to a patient who was recently diagnosed with breast cancer. The nurse is
providing education regarding the possible treatment options. Which options will the nurse include in the
teaching session? Select all that apply.
1) Mastectomy
2) Hormone therapy
3) Lumpectomy
4) Palliative care
5) Radiation
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Chapter 65: Coordinating Care for Female Patients With Reproductive and Breast Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with reproductive disorders
Chapter page reference: 1435-1441
Heading: Breast Cancer
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Female Reproduction
Difficulty: Moderate
Feedback
1 The risk for the development of breast cancer is not greater for women who take
estrogen replacement therapy after undergoing a hysterectomy.
2 Progestin therapies are not used for women who are in surgical menopause. Further, it
is inappropriate for the nurse to make suggestions of a prescriptive nature, as it violates
the scope of practice.
3 Estrogen replacement therapy is not associated with breast cancer for women who have
undergone a hysterectomy. Taking estrogen after a hysterectomy is optional, not
required. NURSINGTB.COM
4 While it is not mandatory for the patient to take estrogen replacement therapy after
surgery, the nurse should clarify and correct misconceptions of the patient.
Feedback
1 Breast self-exam is no longer recommended for all women. The American Cancer
Society recommends that young women who choose to do breast self-exams have their
technique validated by a health-care practitioner at a yearly physical exam. The earlier a
lump is discovered, the greater the effectiveness of treatment.
2 Discussing a family history of breast cancer would be part of the annual breast exam
performed by a health-care provider.
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3 Yearly mammography for all women over the age of 40 is encouraged, as it decreases
the mortality from breast cancer.
4 It is inappropriate for women in this age group to have a clinical breast exam every five
years.
Feedback
1 This patient is in the earliest stages of cancer treatment, with removal of the primary
tumor about to take place. The nurse’s role is to support this patient’s optimism and
help in fighting the disease by teaching about nutrition and other supportive actions the
patient can take to minimize complications of treatment.
2 Emphasizing the low survival rate, encouraging the patient to prepare for death, and
talking with the family about the patient’s unrealistic expectations would not support
the patient's optimism.
3 While the prognosis may be poor, the outcome is not absolute, and the patient’s wish to
do whatever is necessary to survive should be supported.
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4 Emphasizing the low survival rate, encouraging the patient to prepare for death, and
talking with the family about the patient’s unrealistic expectations would not support
the patient's optimism.
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Feedback
1 Range-of-motion exercises in the affected arm help develop collateral drainage and
prevent the development of lymphedema.
2 The patient should be instructed to protect the affected limb by not permitting blood
pressure measurement and avoiding tight jewelry and clothing on the limb.
3 There is no reason for the patient to avoid cleansing the skin of the affected arm with
soap.
4 Consuming fresh fruits and vegetables will not prevent the development of
lymphedema.
Feedback
1 The patient’s concerns are not related to cervical mucus.
2 Older women remain capable of multiple orgasms and may, in fact, experience an
increase in sexual desire after menopause. Vaginal lubrication and elasticity decrease
with menopause along with decreased estrogen, and phases of the sexual response cycle
may take longer to occur.
3 Older women remain capable of multiple orgasms and may, in fact, experience an
increase in sexual desire after menopause. Vaginal lubrication and elasticity decrease
with menopause along with decreased estrogen, and phases of the sexual response cycle
may take longer to occur.
4 Older women remain capable of multiple orgasms and may, in fact, experience an
increase in sexual desire after menopause. Vaginal lubrication and elasticity decrease
with menopause along with decreased estrogen, and phases of the sexual response cycle
may take longer to occur.
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Feedback
1 Increased risk of multiple births is associated with female infertility medications.
2 Androgen hormone replacements may be used to treat estrogen-dependent cancers. The
nurse should instruct the patient of the risk of developing secondary male sex
characteristics when taking this medication. This medication also affects body weight,
so the nurse should instruct the patient to monitor body weight weekly.
3 Reporting calf pain or dyspnea is associated with estrogen hormone replacement
therapy.
4 This medication does not need to be taken with food.
Feedback
1 The vaginal pH does not decrease.
2 In the perimenopausal patient, the vaginal pH increases, predisposing the patient to
bacterial vaginal infections.
3 In perimenopause, estrogen levels decrease, not increase.
4 Decreased vasomotor stability leads to hot flashes, not vaginal bacterial infections.
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Feedback
1 Most healthy, recently menopausal women may use HRT for relief of hot flashes and
vaginal dryness.
2 Most healthy, recently menopausal women may use HRT for relief of hot flashes and
vaginal dryness.
3 If vaginal dryness and dyspareunia (painful intercourse) are the only symptoms, then
low-dose vaginal estrogen is preferred.
4 The risk is further lowered by using low-dose estrogen pills or transdermal patches,
gels, or sprays.
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Feedback
1 It is not uncommon for a postmenopausal female to report painful intercourse that is
related to a decrease in vaginal lubrication. Vaginal lubricants can be very effective in
reducing the pain experienced during intercourse. It is stereotypical to assume the
patient would have less of a desire for intercourse at an older age.
2 Avoidance and decreasing frequency of intercourse would not resolve the problem for
the patient.
3 While this is a normal part of aging, it is not therapeutic to tell the patient to tolerate the
pain.
4 Avoidance and decreasing frequency of intercourse would not resolve the problem for
the patient. NURSINGTB.COM
Feedback
1 Primary dysmenorrhea is caused by the release of prostaglandins that cause the
contractions of the uterus needed to expel menstrual fluid and tissue.
2 Pain associated with menses, called dysmenorrhea, is one of the most common
menstrual dysfunctions. Primary dysmenorrhea is very common among women with
normal menstrual function and is more common than secondary dysmenorrhea. Primary
dysmenorrhea begins within the first three or four menstrual periods after menarche and
will occur with each ovulatory cycle during the teens and 20s of a woman's life.
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3 Secondary dysmenorrhea is related to pathology or diseases that affect the uterus and
pelvic area. It is not more common than primary dysmenorrhea.
4 Causes of secondary dysmenorrhea include endometriosis, tumors, cysts, pelvic
adhesions, pelvic inflammatory disease, infections, cervical stenosis, uterine
leiomyomas, and adenomyosis.
Feedback
1 A high, not low, level of stress is a risk factor for dysfunctional uterine bleeding.
2 Extreme weight change is associated with dysfunctional uterine bleeding. Gaining 5 lbs
in 5 years is not considered extreme weight change.
3 A number of factors may predispose a woman to dysfunctional uterine bleeding. These
factors include stress, extreme weight changes, and use of oral contraceptive agents.
4 Dysfunctional uterine bleeding is usually related to hormonal imbalances and not
associated with low-fat diets.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
18. ANS: 3
Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with reproductive
disorders
Chapter page reference: 1441-1442
Heading: Dysmenorrhea
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Female Reproduction
Difficulty: Moderate
Feedback
1 Frequent rest periods would be beneficial for a patient with dysfunctional uterine
bleeding.
2 The patient should not be encouraged to have four ounces of wine each day.
3 Interventions to aid with ineffective coping for a patient with severe premenstrual
syndrome include encouraging exercise and relaxation techniques and avoiding alcohol
intake.
4 The patient should be instructed to use contraception if engaging in sexual intercourse
during menstruation because ovulation and pregnancy can occur.
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Heading: Dysmenorrhea
Integrated Processes: Nursing Process: Evaluation
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Female Reproduction
Difficulty: Difficult
Feedback
1 This patient statement indicates the need for additional instruction because guided
imagery can be used to reduce stress and promote relaxation, and simple carbohydrates
and sugars should be reduced.
2 This patient statement indicates the need for additional instruction because guided
imagery can be used to reduce stress and promote relaxation, and simple carbohydrates
and sugars should be reduced.
3 This patient statement indicates the need for additional instruction because guided
imagery can be used to reduce stress and promote relaxation, and simple carbohydrates
and sugars should be reduced.
4 The patient stating that a reduction in caffeine intake will help is evidence that
instruction was beneficial.
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Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with reproductive disorders
Chapter page reference: 1443-1444
Heading: Endometriosis
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Female Reproduction
Difficulty: Moderate
Feedback
1 Oral contraceptives are first-line treatment for endometriosis.
2 This drug, while appropriate for endometriosis, is not first-line treatment.
3 This is a diagnostic tool for endometriosis.
4 This drug, while appropriate for endometriosis, is not first-line treatment.
MULTIPLE RESPONSE
26. ANS: 1, 3, 5
Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders
Chapter learning objective: Describing the epidemiology of reproductive disorders
Chapter page reference: 1435-1441
Heading: Breast Cancer NURSINGTB.COM
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Cellular Regulation
Difficulty: Easy
Feedback
1. This is correct. The risk for developing breast cancer increases with age.
2. This is incorrect. Breastfeeding and maintaining a normal body weight lower a person's risk
for developing breast cancer.
3. This is correct. Having a first-degree relative with breast cancer increases the risk.
4. This is incorrect. Breastfeeding and maintaining a normal body weight lower a person’s risk
for developing breast cancer.
5. This is correct. Menopause after the age of 55 also increases the risk for developing breast
cancer.
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Feedback
1. This is incorrect. While the American Cancer Society recommends that woman be familiar
with what is normal regarding breast tissue, routine monthly breast self-examination is no
longer recommended.
2. This is correct. Since this patient’s mother and sister both have a history of breast cancer, she
would be eligible for annual mammography.
3. This is incorrect. Routine breast exams should begin at age 20, not age 35.
4. This is correct. The American Cancer Society recommends clinical breast examination every
three years from ages 20 to 39.
5. This is incorrect. Prompt reporting of any change in the breast tissue to a health-care provider
is recommended by the American Cancer Society.
Feedback
1. This is correct. Treatment options appropriate for a patient newly diagnosed with breast cancer
may include mastectomy, hormone therapy, lumpectomy, and radiation.
2. This is correct. Treatment options appropriate for a patient newly diagnosed with breast cancer
may include mastectomy, hormone therapy, lumpectomy, and radiation.
3. This is correct. Treatment options appropriate for a patient newly diagnosed with breast cancer
may include mastectomy, hormone therapy, lumpectomy, and radiation.
4. This is incorrect. Palliative care will only be implemented once the patient’s cancer is
considered to be terminal in nature.
5. This is correct. Treatment options appropriate for a patient newly diagnosed with breast cancer
may include mastectomy, hormone therapy, lumpectomy, and radiation.
Chapter 66: Coordinating Care for Male Patients With Reproductive and Breast Disorders
Multiple Choice
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is preparing an educational program on risk factors for the development of prostate cancer. Which
information will the nurse include as being the greatest risk factor for developing prostate cancer?
1) The patient’s age
2) A family history
3) A history of a vasectomy
4) A diet high in fat
____ 2. While receiving discharge teaching, an adult patient recovering from a prostatectomy is distressed to learn
that episodes of incontinence may occur. Which should the nurse teach the patient to help minimize
incontinence?
1) Proper administration of incontinence medication
2) Steps to change the Foley catheter bag every day
3) Fluid restriction
4) Kegel exercises
____ 3. A patient is scheduled to undergo a prostate biopsy. The patient asks the nurse what is expected immediately
following the procedure. Which response by the nurse is the most appropriate?
1) “You will need to avoid strenuous activity for 24 hours.”
2) “Your sexual partners will need to be notified.”
3) “You will likely experience discomfort for 24-48 hours after the procedure.”
4) “You will not have any restrictions following the biopsy.”
____ 4. The nurse is caring for a patient who has a continuous bladder irrigation running following a prostatectomy.
During the shift, a total of 1500 mL of irrigant is infused. The Foley bag is emptied twice for the shift with
totals of 850 mL and 950 mL. What is NUtheRSpatient’s
INGTactual
B.COurine
M output for the shift?
1) 300 mL
2) 250 mL
3) 100 mL
4) 950 mL
____ 5. The nurse is caring for a patient who returns to the unit following transurethral resection of the prostate due to
prostate cancer with a three-way Foley catheter in place. The patient states that he has the urge to urinate and
wants the catheter removed. Which response by the nurse is the most appropriate?
1) “This must be a complication, because the Foley catheter is supposed to evacuate clots that
cause the sensation you are describing.”
2) “The spasm is an unexpected finding because the procedure does not invade the urethra.”
3) “The sensation is caused by the silicone used in the catheter. I will speak to the doctor
about switching to a different catheter.”
4) “This is an expected sensation, but the Foley catheter must remain in place.”
____ 6. The nurse is preparing to discharge a patient recovering from prostate surgery for cancer. What should the
nurse emphasize when providing discharge instructions for this patient?
1) “You may drive yourself home.”
2) “Avoid strenuous activity and heavy lifting for two weeks.”
3) “It is quite common to notice blood in your urine following this type of surgery.”
4) “Reduce your fluid intake so you won't need to void as often.”
____ 7. A nursing instructor is teaching a group of student nurses about the cultural implications of prostate cancer.
Which statement will the nursing instructor include in the teaching session?
1) “African-American men are at lowest risk for prostate cancer.”
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2) “Asian- and Native American men have the highest risk for developing prostate cancer.”
3) “Approximately one in eight men ages 70 and older will be diagnosed with prostate
cancer.”
4) “A diet low in dairy increases a man’s risk for developing prostate cancer.”
____ 8. The nurse is assessing a patient for symptoms of prostate cancer. Which symptoms would indicate the patient
is experiencing an enlarged prostate?
1) Dysuria
2) Nerve pain
3) Bone pain
4) Bowel dysfunction
____ 9. A patient with prostate cancer is being discharged from the hospital. Which educational topic is inappropriate
for this patient?
1) Provide information on doses of complementary herbs
2) Teach the patient and his family noninvasive methods of pain control
3) Stress the importance of keeping patient appointments with health-care providers
4) Provide the patient and the patient’s family information on support groups
____ 10. During a health history, the nurse learns that a patient has a recent onset of impotence. Which question will
help identify a potential cause of this manifestation?
1) “Does this occur often?”
2) “For what diseases and disorders have you been treated?”
3) “Are you on any medications?”
4) “How does your partner feel about this problem?”
____ 11. The nurse is conducting a health history
NUR with
SIaNpatient
GTB.diagnosed
COM with erectile dysfunction. Which finding
could provide a possible cause for the patient’s problem?
1) Blood pressure of 118/68 mmHg
2) Body mass index (BMI) of 24.5
3) Alcohol intake of four to six beers each day
4) Plays golf twice a week
____ 12. A patient is concerned about becoming impotent because of the inability to sustain an erection and a history
of a sexually transmitted infection as a young adult. What is the nurse’s best response to this patient's
concerns?
1) “An occasional incident like this is normal and common, and there is no reason to be
concerned.”
2) “Sexually transmitted infections may result in sexual problems in adults.”
3) “Erectile dysfunction is the correct term for the inability to achieve or sustain an erection.”
4) “The medical diagnosis of erectile dysfunction is not made until the man has erection
difficulties in 25% or more of his interactions.”
____ 13. A male patient tells the nurse that he has no idea why his wife wants to stay married to him because he has
not been able to “perform” sexually since his prostate surgery. Which diagnosis would be appropriate for this
patient?
1) Ineffective Coping
2) Situational Low Self-Esteem
3) Hormonal Imbalance
4) Sexual Dysfunction
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____ 14. The nurse is planning care for a patient with erectile dysfunction. What should the nurse include in this
patient’s plan of care?
1) Names of psychologists with experience in treating the disorder
2) Types of devices and surgeries available to help with the disorder
3) Reason for disorder as being side effect of prescribed medication
4) Information on exact cause
____ 15. The nurse is instructing a patient about the medication sildenafil (Viagra). Which patient statement indicates
teaching has been effective?
1) “Viagra should be taken with food.”
2) “I can take Viagra anywhere from one to six hours before sex.”
3) “I can take only one pill in a 24-hour period.”
4) “Grapefruit juice will decrease the effects of Viagra.”
____ 16. A patient asks for a prescription for tadalafil (Cialis). What would be important for the nurse know prior to
planning interventions for this patient?
1) “Do you have diabetes mellitus?”
2) “Do you take blood pressure medication?”
3) “Do you have any sexually transmitted infections?”
4) “Do you use nitroglycerine?”
____ 17. A nurse is caring for a patient who is prescribed a selective phosphodiesterase type 5 inhibitor for the
treatment of erectile dysfunction. The nurse should include which statement when educating the patient
regarding this medication?
1) “You should take this medication about 30 minutes before sexual activity.”
2) “The action of this medication will last up to 36 hours.”
3) “This medication will enhance erections
NURSIwith NGTorBwithout
.COM sexual stimulation.”
4) “This medication should not be taken more than twice daily.”
____ 18. A nurse is treating a patient with diabetes mellitus who reports erectile dysfunction (ED). Which hormonal
cause contributes to ED?
1) Increased prolactin levels
2) Decreased aldosterone levels
3) Decreased circulating catecholamines
4) Decreased thyroid-stimulating hormone
____ 19. The nurse is caring for a patient diagnosed with benign prostatic hyperplasia (BPH) who is experiencing an
increase in symptoms. Which statement by the patient would best explain the source of the increased
symptoms?
1) “I have decreased oral intake at night.”
2) “I recently had a vasectomy.”
3) “I am using an over-the-counter cold medication for a cold.”
4) “I am taking over-the-counter saw palmetto.”
____ 20. The nurse is caring for a male patient of Japanese descent who is experiencing urinary retention. The patient
asks the nurse if it is possible that he is experiencing benign prostatic hyperplasia (BPH). Which response by
the nurse is the most appropriate?
1) “No, you are not old enough to have BPH.”
2) “Your symptoms are not consistent with BPH.”
3) “Your provider will run some tests; however, you are considered low-risk for BPH.”
4) “Where did you get an idea that you might have BPH?”
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____ 21. The nurse is providing follow-up care for a patient was recently diagnosed with benign prostatic hyperplasia
(BPH). Which nursing diagnosis is the priority for the nurse to include in the patient’s plan of care?
1) Chronic Pain
2) Impaired Urinary Elimination
3) Constipation
4) Diarrhea
____ 22. A patient is recovering from prostate surgery on a medical-surgical unit. The patient will be ready for
discharge within the next few days. Which teaching point is appropriate for this patient?
1) The patient should not drive for six weeks after surgery.
2) The patient should call the health-care provider immediately for any pain.
3) The patient should increase the fiber in his diet.
4) The patient should avoid heavy lifting for two weeks after surgery.
____ 23. A patient is recovering from minimally invasive surgery due to a diagnosis of benign prostatic hyperplasia
(BPH). After assessing the patient, the nurse expects which outcome for this patient?
1) Bowel continence
2) Absence of pain
3) No postoperative treatment
4) Urinary continence
____ 24. The nurse is providing care to a patient who is diagnosed with mild benign prostatic hyperplasia (BPH).
Which lifestyle change is appropriate for this patient?
1) Increasing caffeine intake
2) Decreasing alcohol intake
3) Urinating at first urge
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4) Using over-the-counter antihistamines
____ 25. A patient reports getting up to urinate several times a night and difficulty starting a stream of urine. After
medical testing is completed, a diagnosis of benign prostatic hyperplasia (BPH) is made. After conducting
teaching regarding BPH, which statement by the patient indicates the need for further education?
1) “Alpha blockers can be used to control my symptoms.”
2) “I know I will get cancer of the prostate because of this.”
3) “As my condition progresses, I may need to consider surgical management.”
4) “There are nonsurgical treatment options available.”
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. A nurse is screening a patient for prostate cancer. Which assessment findings would cause the nurse to
suspect that the patient has prostate cancer? Select all that apply.
1) Fatigue
2) Back pain
3) Hematuria
4) Scrotal edema
5) Upper extremity weakness
____ 27. The nurse is caring for a patient with erectile dysfunction (ED). Which medication should the nurse anticipate
being prescribed for this patient? Select all that apply.
1) Tadalafil (Cialis)
2) Sildenafil (Viagra)
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3) Buspirone (BuSpar)
4) Vardenafil (Levitra)
5) Methylphenidate (Ritalin)
____ 28. The nurse is providing care to a patient who is diagnosed with benign prostatic hyperplasia (BPH). Which
items in the patient’s health history may have contributed to this diagnosis? Select all that apply.
1) 70 years of age
2) Diet high in milk
3) Excessive exercise
4) Diet high in meat and fats
5) African-American ethnicity
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Chapter 66: Coordinating Care for Male Patients With Reproductive and Breast Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders
Chapter learning objective: Describing the epidemiology of male reproductive disorders
Chapter page reference: 1466-1470
Heading: Prostate Cancer
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Cellular Regulation
Difficulty: Difficult
Feedback
1 The greatest risk for developing prostate cancer is age. Prostate cancer affects one out
of every eight men over the age of 60.
2 Genetics, vasectomy, and a diet high in fat are also risk factors.
3 Genetics, vasectomy, and a diet high in fat are also risk factors.
4 Genetics, vasectomy, and a diet high in fat are also risk factors.
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Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of male
reproductive disorders
Chapter page reference: 1466-1470
Heading: Prostate Cancer
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity – Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Urinary Elimination
Difficulty: Moderate
Feedback
1 Strenuous activity is avoided only for about four hours.
2 There is no need to notify sexual partners following the procedure.
3 The patient may experience discomfort for one to two days after the procedure.
4 The patient must restrict activity for only a short period after the procedure.
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3 The substance that the catheter is made of does not affect spasms.
4 Patients with a three-way Foley catheter usually complain of sensations of having to
void despite the presence of the catheter. This urge to void is caused by the pressure
exerted by the balloon in the internal sphincter of the bladder and the wide diameter of
the catheter that is used for the purpose of irrigation.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Prostate
Cancer
Chapter page reference: 1466-1470
Heading: Prostate Cancer
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Cellular Regulation; Urinary Elimination
Difficulty: Easy
Feedback
1 Symptoms of an enlarged prostate include hematuria, dysuria, reduction in urinary
stream, nocturia, frequency of urination, and abnormal size of prostate on digital exam.
2 This choice indicates nerve impingement.
3 This choice indicates metastatic symptoms.
4 This choice indicates metastatic symptoms.
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Chapter learning objective: Developing a comprehensive plan of nursing care for patients with male
reproductive disorders
Chapter page reference: 1464-1466
Heading: Erectile Dysfunction
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Male Reproduction
Difficulty: Difficult
Feedback
1 Asking the patient if the impotence occurs often will not help identify the cause of the
problem.
2 A patient's health history can provide clues to the underlying cause of impotence. The
question “for what diseases and disorders have you been treated” would provide the
nurse with information as to possible causes for the recent onset of the disorder.
3 The question “are you on any medication?” would be beneficial to ask; however, it
should be an open-ended question and not a closed-ended question as identified. The
nurse should ask the patient to “list any medications” instead of asking “are you on any
medication?” which could be answered with a yes or no.
4 Asking the patient how the partner feels about the problem also will not help identify a
possible cause.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with male
reproductive disorders
Chapter page reference: 1464-1466
Heading: Erectile Dysfunction
Integrated Processes: Communication and Documentation
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Male Reproduction
Difficulty: Moderate
Feedback
1 This patient is concerned about his masculinity and sexual abilities. The correct answer
at this point is to tell him that it is common and normal for men to experience
occasional erectile difficulties.
2 This is true; however, this does not serve to alleviate the patient’s concerns. If the
patient continues to have difficulties achieving or sustaining an erection, further
investigation should take place. Simply correcting the patient’s use of medical
terminology does not address his concerns.
3 This is true; however, this does not serve to alleviate the patient’s concerns. If the
patient continues to have difficulties achieving or sustaining an erection, further
investigation should take place. Simply correcting the patient’s use of medical
terminology does not address his concerns.
4 This is true; however, this does not serve to alleviate the patient’s concerns. If the
patient continues to have difficulties achieving or sustaining an erection, further
investigation should take place. Simply correcting the patient’s use of medical
terminology does not address N hisUconcerns.
RSINGTB.COM
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
14. ANS: 2
Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders
Chapter learning objective: Discussing the medical management of: Erectile dysfunction
Chapter page reference: 1464-1466
Heading: Erectile Dysfunction
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Male Reproduction
Difficulty: Moderate
Feedback
1 The nurse should not provide the names of psychologists who treat the disorder.
2 When planning the care of a patient with erectile dysfunction, the nurse should include
information on medications for treatment and types of devices and surgeries available
to help with the disorder.
3 Explaining the reason for the disorder as being a side effect of prescribed medication
could cause the patient to discontinue medication necessary to treat other health
disorders and should not be done.
4 Because an exact cause may be difficult to determine for the patient, this would not be
appropriate for the nurse to include in the patient's plan of care.
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Feedback
1 While age does increase the risk of BPH, it is not the only factor to consider.
2 The patient is experiencing urinary retention, which is consistent with BPH.
3 The nurse must always provide honest responses to patient questions. Telling the
patient that the provider will run tests but due to his ethnicity, he is considered low-risk
for developing BPH is the most appropriate response.
4 Asking a patient where he got that idea is demeaning.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with male
reproductive disorders
Chapter page reference: 1460-1464
Heading: Benign Prostatic Hyperplasia (BPH)
Integrated Processes: Nursing Process: Diagnosis
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Urinary Elimination
Difficulty: Difficult
Feedback
1 Acute pain, not chronic pain, is also an appropriate diagnosis.
2 The priority diagnosis for a patient diagnosed with BPH is Impaired Urinary
Elimination.
3 Patients with BPH have problems associated with urinary elimination, not bowel
elimination. Constipation and Diarrhea are not appropriate nursing diagnoses for this
patient.
4 Patients with BPH have problems associated with urinary elimination, not bowel
elimination. Constipation and Diarrhea are not appropriate nursing diagnoses for this
patient.
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2 BPH is benign condition that does not necessarily progress to cancer. It is caused by an
increase in size of the prostate gland and is seen in older males.
3 There are nonsurgical treatments available, such as medication to shrink the gland
along with surgical management, such as resection.
4 There are nonsurgical treatments available, such as medication to shrink the gland
along with surgical management, such as resection.
MULTIPLE RESPONSE
26. ANS: 1, 2, 3
Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Prostate
cancer
Chapter page reference: 1466-1470
Heading: Prostate Cancer
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Cellular Regulation
Difficulty: Easy
Feedback
1. NURSmany
This is correct. Unfortunately, INGpatients
TB.COwith M prostate cancer remain undiagnosed until
the cancer is well established. Hematuria, back pain, bilateral lower extremity weakness, and
fatigue are symptoms associated with prostate cancer.
2. This is correct. Unfortunately, many patients with prostate cancer remain undiagnosed until
the cancer is well established. Hematuria, back pain, bilateral lower extremity weakness, and
fatigue are symptoms associated with prostate cancer.
3. This is correct. Unfortunately, many patients with prostate cancer remain undiagnosed until
the cancer is well established. Hematuria, back pain, bilateral lower extremity weakness, and
fatigue are symptoms associated with prostate cancer.
4. This is incorrect. Scrotal edema is not a clinical manifestation associated with prostate cancer.
5. This is incorrect. Upper extremity weakness is not a clinical manifestation associated with
prostate cancer.
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Feedback
1. This is correct. Tadalafil (Cialis) works to relax the smooth muscles in the penis, allowing
increased blood flow to the penis resulting in an erection.
2. This is correct. Sildenafil (Viagra) works to relax the smooth muscles in the penis, allowing
increased blood flow to the penis resulting in an erection.
3. This is incorrect. Buspirone (Buspar) is an antianxiety agent and is not effective for erectile
dysfunction (ED).
4. This is correct. Vardenafil (Levitra) works to relax the smooth muscles in the penis, allowing
increased blood flow to the penis resulting in an erection.
5. This is incorrect. Methylphenidate (Ritalin) is a mild central nervous system stimulant and is
not effective for ED.
Feedback
NURSINGTB.COM
1. This is correct. Although the exact cause is unknown, risk factors associated with BPH are
increasing age, men of African-American descent, and a diet high in meat and fat.
2. This is incorrect. No link has been made to milk or exercise.
3. This is incorrect. No link has been made to milk or exercise.
4. This is correct. Although the exact cause is unknown, risk factors associated with BPH are
increasing age, men of African-American descent, and a diet high in meat and fat.
5. This is correct. Although the exact cause is unknown, risk factors associated with BPH are
increasing age, men of African-American descent, and a diet high in meat and fat.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A patient reports an open area on the penis. Which question will help the nurse with data collection?
1) “Do you think you have a disease?”
2) “Have you had sexual intercourse recently?”
3) “Are you promiscuous?”
4) “When did you initially notice this open area?”
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____ 2. A patient is experiencing dysuria, urinary frequency, and vaginal discharge. For which sexually transmitted
infection should the nurse prepare the patient for testing?
1) Syphilis
2) Vaginitis
3) Chlamydia
4) Trichomoniasis
____ 3. A patient diagnosed with a sexually transmitted infection reports having “no idea” how the illness was
contracted. Which nursing diagnosis would be appropriate for the patient at this time?
1) Anxiety
2) Knowledge Deficit
3) Ineffective Coping
4) Sexual Dysfunction
____ 4. The nurse is planning care for a patient with a history of sexually transmitted infections. What should be
included in this plan of care?
1) Instruction to limit sexual contact until recovered from illness
2) Plan for the patient to contact sexual partners regarding the diagnosis
3) Need to increase fluids and rest
4) Importance of adequate nutrition
____ 5. A patient with syphilis is allergic to penicillin. Based on this data, which medication does the nurse anticipate
as appropriate for this patient?
1) Doxycycline
2) Amoxicillin
3) Gentamicin
4) Erythromycin NURSINGTB.COM
____ 6. The nurse is planning care to address pain in the patient with genital herpes. Which intervention would be
appropriate for this patient?
1) Increase the intake of cranberry juice
2) Clean lesions two or three times a day with warm water and soap
3) Dry lesions with a hair dryer turned to the hot setting
4) Wear tight cotton clothing
____ 7. A public health nurse is educating a group of adults regarding sexually transmitted infections. Which is an
appropriate statement by the nurse?
1) “Males have higher rates of gonorrhea and chlamydia, whereas women have higher rates
of syphilis.”
2) “Men are disproportionately affected by STIs compared to women and infants.”
3) “Women often experience few early manifestations of the infection, delaying diagnosis
and treatment.”
4) “The incidence of STIs is highest among young Caucasian females.”
____ 8. A gray vaginal discharge with an unpleasant fishy or musty odor is likely to be a symptom of which
infection?
1) Candidiasis
2) Trichomonas
3) Gonorrhea
4) Chlamydia
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____ 9. An adolescent patient worriedly shows the nurse a wart located on her vulva. Based on this data which
diagnosis does the nurse suspect?
1) Condyloma
2) Genital herpes
3) Chancre
4) Secondary syphilis
____ 10. After a 5% acetic acid wash is applied to the cervix, the cervix blanches white. Based on this data, which
conclusion by the nurse is appropriate?
1) Bacterial vaginosis
2) Monilial vaginitis
3) HPV
4) Cervical cancer
____ 11. During a physical assessment, the nurse notes vesicles. Which disease process is associated with this clinical
manifestation?
1) Secondary syphilis
2) Herpes simplex virus
3) Hyperthyroidism
4) Gonorrhea
____ 12. A young adult patient reports penile discharge and dysuria for three days. Which is the most likely cause of
the patient’s clinical manifestations?
1) Sexually transmitted infection
2) Orchitis
3) Spermatocele
4) All of the above NURSINGTB.COM
____ 13. Which is not a warning sign of a sexually transmitted infection (STI)?
1) Penile discharge
2) Penile lesion
3) Testicular mass
4) Dysuria
____ 14. Which is not considered a risk factor for male patients in terms of contracting a sexually transmitted infection
(STI)?
1) Multiple sexual partners
2) Smoking
3) Intravenous (IV) drug use
4) Unprotected sex
____ 15. When conducting a physical examination, the nurse notes that the patient has a systemic rash. Which sexually
transmitted infection may be the cause for this clinical manifestation?
1) Herpes simplex virus
2) Gonorrhea
3) Secondary syphilis
4) Chlamydia
____ 16. Which is a clinical manifestation associated with neurosyphilis?
1) Systemic rash
2) Vesicles
3) Penile discharge
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4) Psychosis
____ 17. Which patient is at greatest risk for developing chlamydia trachomatis infection?
1) 16-year-old, sexually active, using no contraceptive
2) 22-year-old mother of two, developed dyspareunia
3) 35-year-old woman on oral contraceptives
4) 48-year-old woman with hot flashes and night sweats
____ 18. The health-care provider prescribes metronidazole (Flagyl) for a woman diagnosed with trichomoniasis.
Which statement should the nurse include in the discharge instructions for this patient?
1) “Both partners must be treated with the medication.”
2) “Alcohol does not need to be avoided while taking this medication.”
3) “It will turn your urine orange.”
4) “This medication could produce drowsiness.”
____ 19. Which patient should the nurse anticipate a prescription for ceftriaxone (Rocephin) IM and doxycycline
(Vibramycin) orally?
1) A pregnant patient with gonorrhea and a yeast infection
2) A nonpregnant patient with gonorrhea and chlamydia
3) A pregnant patient with syphilis
4) A nonpregnant patient with chlamydia and trichomoniasis
____ 20. Which diagnostic test should the nurse question when prescribed for a patient diagnosed with pelvic
inflammatory disease (PID)?
1) CBC (complete blood count) with differential
2) Vaginal culture for Neisseria gonorrhoeae
3) Throat culture for StreptococcusNAURSINGTB.COM
4) Nucleic acid amplification test (NAAT)
____ 21. The nurse is providing care to a patient who will have abnormal cervical tissue removed via cryosurgery.
Which term should the nurse use when educating the patient about this procedure?
1) Ablation
2) Excision
3) Hysterectomy
4) Chemotherapy
____ 22. The nurse is providing care to a patient who will have the uterus removed due to uterine cancer. Which term
should the nurse use when educating the patient about this procedure?
1) Ablation
2) Excision
3) Hysterectomy
4) Chemotherapy
____ 23. The nurse is providing care to a patient who will have advanced cervical lesions removed via cold knife
conization. Which term should the nurse use when educating the patient about this procedure?
1) Ablation
2) Excision
3) Hysterectomy
4) Chemotherapy
____ 24. Which clinical manifestation noted during the physical examination is a prodromal sign for genital herpes?
1) Dysuria
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2) Muscle pain
3) Abnormal sensation
4) Swollen lymph nodes
____ 25. The nurse is providing care to a patient who will receive toxic medication via intravenous infusion to treat
cancer. Which term should the nurse use when educating the patient about this procedure?
1) Ablation
2) Excision
3) Hysterectomy
4) Chemotherapy
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. During an assessment, the nurse suspects a patient is experiencing genital herpes. Which clinical
manifestations cause the nurse to come to this conclusion? Select all that apply.
1) Low blood pressure
2) Headache
3) Fever
4) Back pain
5) Vaginal discharge
____ 27. The nurse instructs a married couple on the importance of treatment for a chlamydia infection. Which
statements indicate that teaching was effective? Select all that apply.
1) “He could get an infection in the tube that carries the urine out.”
2) “She could have severe vaginal N itching.”
URSINGTB.COM
3) “It could cause us to develop rashes.”
4) “She could develop a worse infection of the uterus and tubes.”
5) “She could become pregnant.”
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 67: Coordinating Care for Patients With Sexually Transmitted Infection
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with sexually
transmitted infections
Chapter page reference: 1486-1489
Heading: Genital Herpes
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1 This a close-ended question and won’t yield the information required.
2 Determining the date of the last episode of sexual intercourse might be indicated later if
a disease is diagnosed.
3 Asking the patient about promiscuity is judgmental.
4 It will be important to record the onset of the open area.
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Feedback
1 The nurse should instruct the patient to avoid, not just limit, sexual contact until
recovered from the illness.
2 The patient has a history of sexually transmitted infections. The nurse should discuss
with the patient a plan for sexual partners to be contacted regarding the diagnosis.
3 The need to increase fluids, rest, and nutrition is important, but not as important as the
patient contacting sexual partners regarding the diagnosis.
4 The need to increase fluids, rest, and nutrition is important, but not as important as the
patient contacting sexual partners regarding the diagnosis
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Feedback
1 Vesicles are not clinical manifestations associated with secondary syphilis.
2
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Vesicles are a clinical manifestation associated with herpes simplex virus.
3 Vesicles are not clinical manifestations associated with hyperthyroidism.
4 Vesicles are not clinical manifestations associated with gonorrhea.
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Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Primary,
secondary, and tertiary syphilis
Chapter page reference: 1484-1486
Heading: Syphilis
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
1 Herpes simplex virus presents with vesicles, not a systemic rash.
2 Gonorrhea does not cause a systemic rash.
3 Secondary syphilis often manifests with a systemic rash.
4 Chlamydia does not cause a systemic rash.
Feedback
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Feedback
1 Doxycycline is contraindicated during pregnancy.
2 This combined treatment provides dual treatment for gonorrhea and chlamydia because
the two infections frequently occur together.
3 Syphilis is treated with penicillin.
4 Trichomoniasis is treated with metronidazole.
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Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection
Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of sexually
transmitted infections
Chapter page reference: 1493-1494
Heading: Pelvic Inflammatory Disease (PID)
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1 CBC with differential will give an indication of the severity of the infection.
2 Gonorrhea is a common cause of PID, and the patient should be tested for this.
3 Streptococcus of the throat is not associated with PID.
4 NAAT is a test for chlamydia, another cause of PID.
Feedback
1 Ablation is the process of burning or freezing in order to remove abnormal cervical
tissue. Most common procedures are cryosurgery and laser ablation.
2 Excision is the process of resecting or removing tissue. Most commonly done
procedure with advanced cervical lesions is cold knife conization (CKC).
3 Hysterectomy is the removal of the uterus.
4 Chemotherapy includes chemicals that have toxic effects used to kill cancer cells.
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Feedback
1 Ablation is the process of burning or freezing in order to remove abnormal cervical
tissue. Most common procedures are cryosurgery and laser ablation.
2 Excision is the process of resecting or removing tissue. Most commonly done
procedure with advanced cervical lesions is cold knife conization (CKC).
3 Hysterectomy is the removal of the uterus.
4 Chemotherapy includes chemicals that have toxic effects used to kill cancer cells.
Feedback
1 Ablation is the process of burning or freezing in order to remove abnormal cervical
tissue. Most common procedures are cryosurgery and laser ablation.
2
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Excision is the process of resecting or removing tissue. Most commonly done
procedure with advanced cervical lesions is cold knife conization (CKC).
3 Hysterectomy is the removal of the uterus.
4 Chemotherapy includes chemicals that have toxic effects used to kill cancer cells.
Feedback
1 Dysuria is a symptom of genital herpes but not a prodromal sign.
2 Muscle pain is a symptom of genital herpes but not prodromal sign.
3 Tingling or an abnormal sensation prior to presence of the vesicle or ulcer is a
prodromal sign for genital herpes.
4 Swollen lymph nodes is a symptom of genital herpes but not a prodromal sign.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 Ablation is the process of burning or freezing in order to remove abnormal cervical
tissue. Most common procedures are cryosurgery and laser ablation.
2 Excision is the process of resecting or removing tissue. Most commonly done
procedure with advanced cervical lesions is cold knife conization (CKC).
3 Hysterectomy is the removal of the uterus.
4 Chemotherapy includes chemicals that have toxic effects used to kill cancer cells.
Feedback
1. This is incorrect. Low blood pressure is not a manifestation of genital herpes.
2. This is correct. Manifestations of genital herpes include headache, fever, vaginal discharge,
and back pain.
3. This is correct. Manifestations of genital herpes include headache, fever, vaginal discharge,
and back pain.
4. This is correct. Manifestations of genital herpes include headache, fever, vaginal discharge,
and back pain.
5. This is correct. Manifestations of genital herpes include headache, fever, vaginal discharge,
and back pain.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1. This is correct. Chlamydia is a major cause of nongonococcal urethritis (NGU) in men.
2. This is incorrect. Treatment for chlamydia does not cause vaginal itching.
3. This is incorrect. Untreated syphilis, not chlamydia, can cause a rash.
4. This is correct. Chlamydia cervicitis can ascend and become pelvic inflammatory disease or
infection of the uterus, fallopian tubes, and sometimes ovaries.
5. This is incorrect. Chlamydia can contribute to infertility.
____ 1. The nurse is providing care to a patient who is eight hours postoperative for bariatric surgery. Which is the
priority safety intervention when providing care for this patient?
1) Monitoring for flatus
2) Repositioning for comfort
3) Advancing to a clear liquid diet
4) Assessing the nasogastric tube for patency
____ 2. The nurse is assessing an adult patient who is postoperative for bariatric surgery. Which assessment finding
requires immediate intervention by the nurse?
1) Increased flatus
2) Increased back pain
3) Increased urine output
4) Increased bowel sounds
____ 3. The nurse is providing medication teaching to an adult patient who is prescribed an anorectic drug for weight
loss. Which finding in the patient’s medical record would cause the nurse to question this drug prescription?
1) History of hypertension
2) History of hyponatremia
3) History of hyperglycemia
4) History of hypothyroidism
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____ 4. The nurse is planning care for a patient based on the National Institute of Health (NIH) classification of body
weight. Which body mass index (BMI) calculated by the nurse indicates the patient is overweight?
1) 20.3
2) 24.5
3) 27.7
4) 30.9
____ 5. The nurse is planning care for a patient based on the National Institute of Health (NIH) classification of body
weight. Which body mass index (BMI) calculated by the nurse indicates the patient is diagnosed with class 1
obesity?
1) 20.3
2) 24.5
3) 27.7
4) 30.9
____ 6. The nurse is planning care for a patient based on the National Institute of Health (NIH) classification of body
weight. Which body mass index (BMI) calculated by the nurse indicates the patient is diagnosed with class 2
obesity?
1) 27.7
2) 30.9
3) 35.3
4) 40.1
____ 7. The nurse is planning care for a patient based on the National Institute of Health (NIH) classification of body
weight. Which body mass index (BMI) calculated by the nurse indicates the patient is diagnosed with class 3
extreme obesity?
1) 27.7 NURSINGTB.COM
2) 30.9
3) 35.3
4) 40.1
____ 8. Which medication for diabetes is also considered an obesogenic drug?
1) Insulin
2) Prazosin
3) Propranolol
4) Dexamethasone
____ 9. Which is a goal of Healthy People 2020 that affects nutrition education that the nurse provides to the patient?
1) An increase in bariatric surgery
2) An overall increase in body mass index
3) The maintenance of healthy body weight
4) The promotion of carbohydrate restricting diets
____ 10. The nurse is assessing several patients at a local health fair. Which patient is at the greatest risk for obesity?
1) A young adult Caucasian female who lives in the city
2) An older adult African-American male who lives in the suburbs
3) A middle-aged unemployed Hispanic female who lives in a rural area
4) A middle-aged Native American male who has accepted a teaching job in the inner city
____ 11. Which is an evidence-based benefit to bariatric surgery that the nurse should include in a teaching session for
an obese patient who is considering this intervention?
1) “This surgery will assist in the management of your hypothyroidism.”
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2) “Research shows that you will live longer if you consent to this procedure.”
3) “You will lose weight at a slower pace; however, the weight loss is longer lasting.”
4) “Many people experience an improved quality of life and better management of diabetes
mellitus.”
____ 12. Which chronic health condition should the nurse include in the teaching session for a group of patients who
are obese?
1) Osteoporosis
2) Acute kidney injury
3) Coronary artery disease
4) Type 1 diabetes mellitus
____ 13. Which hormone should the nurse include in a teaching session regarding satiety?
1) Leptin
2) Estrogen
3) Testosterone
4) Progesterone
____ 14. Which is an environmental factor that increases an individual’s risk for obesity?
1) Automation
2) Hypertension
3) Leptin mutation
4) Genetic polymorphisms
____ 15. The nurse is planning care for an obese patient who will use calorie reduction diet therapy. Which patient
statement indicates the need for further education?
1) “I should reduce my calorie intakeNU500
RSIcalories
NGTBper.Cweek.”
OM
2) “I will reduce my calorie intake with the goal of a one to two lb loss each week.”
3) “If a very-low-calorie diet is recommended, I will be supervised by my doctor.”
4) “My goal is to engage in 30 minutes of moderate-intensity exercise most days of the
week.”
____ 16. Which behavioral therapy should the nurse include in a teaching session for an obese patient who is
attempting weight loss?
1) Food logs
2) Phentermine
3) Aerobic exercise
4) Calorie reduction
____ 17. Which physical activity should the nurse include in a teaching session for an obese patient who is attempting
weight loss?
1) Food logs
2) Phentermine
3) Aerobic exercise
4) Calorie reduction
____ 18. Which pharmacological therapy should the nurse include in a teaching session for an obese patient who is
attempting weight loss?
1) Food logs
2) Phentermine
3) Aerobic exercise
4) Calorie reduction
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____ 19. Which diet therapy should the nurse include in a teaching session for an obese patient who is attempting
weight loss?
1) Food logs
2) Phentermine
3) Aerobic exercise
4) Calorie reduction
____ 20. Which pharmacological therapy for weight loss can only be administered for 12 weeks when prescribed to a
patient for weight loss?
1) Orlistat
2) Lorcaserin
3) Metformin
4) Phentermine
____ 21. Which drug, prescribed for weight loss, should include information regarding loose and oily stools in the
patient teaching session initiated by the nurse?
1) Orlistat
2) Lorcaserin
3) Metformin
4) Phentermine
____ 22. Which prescription weight loss drug requires the nurse to administer pregnancy tests to the patient on a
monthly basis?
1) Orlistat
2) Lorcaserin
3) Metformin NURSINGTB.COM
4) Phentermine
____ 23. Which body mass index (BMI) calculated during the patient’s physical assessment indicates that bariatric
surgery is an option for weight loss?
1) 37
2) 38
3) 39
4) 40
____ 24. Which long-term complication of bariatric surgery should the nurse include in the teaching session for a
patient who is considering this procedure for weight loss?
1) Anemia
2) Infection
3) Anastomosis leak
4) Pulmonary embolism
Completion
Complete each statement.
25. The nurse teaches a patient who weighs 185 lb and is 5 feet, 3 inches tall on an eating plan to reduce the total
intake of calories per day. The body mass index that the nurse calculated to identify the type of eating plan to
use for this patient is ________.
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. During a health assessment, a patient says, “I only eat carbohydrates and low-fat foods. I don’t understand
why I am still gaining weight!” What should the nurse consider before responding to this patient? Select all
that apply.
1) Carbohydrates should only be eaten at breakfast.
2) Excess carbohydrates are converted to fat.
3) Excess carbohydrates can lead to obesity.
4) A carbohydrate limited diet is the only way to not gain weight.
5) Carbohydrates should be high in fiber and low in sugar.
____ 27. The nurse is planning care for a patient whose waist circumference is 48 inches and height is 5 feet, 2 inches.
Based on this data, which topics are appropriate for the nurse to include in the patient teaching? Select all that
apply.
1) Chronic lung disease
2) Osteoarthritis
3) Type 2 diabetes mellitus
4) Heart disease
5) High blood pressure
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 68: Managing Care for the Adult Patient With Obesity
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 68, Managing Care for the Adult Patient With Obesity
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with obesity
Chapter page reference: 1500-1506
Heading: Management
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment
Cognitive level: Analysis [Analyzing]
Concept: Nutrition
Difficulty: Difficult
Feedback
1 Monitoring for flatus, repositioning for comfort, and advancing to a clear liquid diet
may all be appropriate interventions for this patient; however, the safety priority is NG
tube patency.
2 Monitoring for flatus, repositioning for comfort, and advancing to a clear liquid diet
may all be appropriate interventions for this patient; however, the safety priority is NG
tube patency.
3 Monitoring for flatus, repositioning for comfort, and advancing to a clear liquid diet
may all be appropriate interventions for this patient; however, the safety priority is NG
tube patency. NURSINGTB.COM
4 The priority nursing action during the first 24-hours postoperative period following
bariatric surgery is assessing the nasogastric (NG) tube for patency. In gastroplasty
procedures, the NG tube drains both the proximal pouch and the distal stomach.
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Feedback
1 According to the NIH classification of body weight, this patient is underweight. The
range for an underweight individual is a BMI of less than 18.5.
2 According to the NIH classification of body weight, this patient is a normal weight. The
range for a normal weight individual is a BMI of 18.5 to 24.9.
3 According to the NIH classification of body weight, this patient is overweight. The
range for an overweight individual is a BMI of 25.0 to 29.9.
4 According to the NIH classification of body weight, this patient has class 1 obesity. The
range for class 1 obesity is a BMI of 30.0 to 34.9.
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Feedback
1 According to the NIH classification of body weight, this patient is underweight. The
range for an underweight individual is a BMI of less than 18.5.
2 According to the NIH classification of body weight, this patient is a normal weight. The
range for a normal weight individual is a BMI of 18.5 to 24.9.
3 According to the NIH classification of body weight, this patient is overweight. The
range for an overweight individual is a BMI of 25.0 to 29.9.
4 According to the NIH classification of body weight, this patient has class 1 obesity. The
range for class 1 obesity is a BMI of 30.0 to 34.9.
Feedback
1 According to the NIH classification of body weight, this patient is overweight. The
range for an overweight individual is a BMI of 25.0 to 29.9.
2 According to the NIH classification of body weight, this patient has class 1 obesity. The
range for class 1 obesity is a BMI of 30.0 to 34.9.
3 According to the NIH classification of body weight, this patient has class 2 obesity. The
range for class 2 obesity is a BMI of 35.0 to 39.9.
4 According to the NIH classification of body weight, this patient has class 3 extreme
obesity. The range for class 3 extreme obesity is a BMI greater than 40.0.
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Feedback
1 According to the NIH classification of body weight, this patient is overweight. The
range for an overweight individual is a BMI of 25.0 to 29.9.
2 According to the NIH classification of body weight, this patient has class 1 obesity. The
range for class 1 obesity is a BMI of 30.0 to 34.9.
3 According to the NIH classification of body weight, this patient has class 2 obesity. The
range for class 2 obesity is a BMI of 35.0 to 39.9.
4 According to the NIH classification of body weight, this patient has class 3 extreme
obesity. The range for class 3 extreme obesity is a BMI greater than 40.0.
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3 The maintenance of healthy body weight, through the consumption of healthful diets, is
a Healthy People 2020 goal.
4 Healthful diets with the balanced intake of nutrients is a Healthy People 2020 goal.
Feedback
1 This patient does not have risk factors associated with obesity.
2 This patient is a member of a minority population, a risk factor for obesity; however,
there is another patient with a higher risk.
3 This patient is a member of a minority population, middle-aged, economically
disadvantaged, and lives in rural setting. This patient is at the highest risk for obesity.
4 This patient is a member of a minority population and is middle-aged, both risk factors
for obesity; however, there is another patient with a higher risk.
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PTS: 1 CON: Nutrition
11. ANS: 4
Chapter number and title: 68, Managing Care for the Adult Patient With Obesity
Chapter learning objective: Developing a teaching plan for a patient with obesity
Chapter page reference: 1500-1506
Heading: Management
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
Feedback
1 Evidence does not support this statement.
2 Evidence does not support this statement.
3 Evidence suggests that the patient who has bariatric surgery experiences a greater
weight loss than a patient who has conventional treatment.
4 Evidence suggests that patients who have bariatric surgery have improvements in
quality of life and the management of diabetes mellitus.
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Feedback
1 Automation is an environmental factor that leads to a decrease in energy expenditure;
therefore, this increases the risk for obesity.
2 Hypertension is a consequence of, not a risk factor for, obesity.
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3 Leptin mutation is a risk factor for obesity; however, this is not an environmental
factor.
4 Genetic polymorphism is a risk factor for obesity; however, this is not an environmental
factor.
Feedback
1 A calorie reduction of 500 to 1000 calories per day is required for weight loss. This
statement indicates the need for further education.
2 A calorie reduction of 500 to 1000 calories per day to yield a one to two lb weight loss
each week indicates correct understanding.
3 A very-low-calorie diet is only used in limited circumstances, and the patient would be
supervised by a health-care professional. This statement indicates correct
understanding.
4
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Engaging in 30 minutes of moderate-intensity exercise most days of the week is
appropriate and indicates correct understanding.
Feedback
1 Food logs are considered a behavioral weight loss therapy.
2 Phentermine is a pharmacological, not behavioral, weight loss therapy.
3 Aerobic exercise is a physical activity for weight loss, not a behavioral therapy.
4 Calorie reduction is a diet, not behavioral, weight loss therapy.
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Chapter learning objective: Developing a teaching plan for a patient with obesity
Chapter page reference: 1500-1506
Heading: Management
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
Feedback
1 Food logs are considered a behavioral weight loss therapy and not a physical activity.
2 Phentermine is a pharmacological weight loss therapy and not a physical activity.
3 Aerobic exercise is a physical activity for weight loss.
4 Calorie reduction is a diet weight loss therapy and not a physical activity.
Feedback
1 Food logs are considered a behavioral, not pharmacological, weight loss therapy.
2 Phentermine is a pharmacological weight loss therapy.
3 Aerobic exercise is a physical activity for weight loss, not a pharmacological therapy.
4 Calorie reduction is a diet, not pharmacological, weight loss therapy.
Feedback
1 Food logs are considered a behavioral, not diet, weight loss therapy.
2 Phentermine is a pharmacological, not diet, weight loss therapy.
3 Aerobic exercise is a physical activity for weight loss, not a diet therapy.
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Feedback
1 Orlistat can be administered for more than 12 weeks when prescribed for weight loss.
2 Lorcaserin can be administered for more than 12 weeks when prescribed for weight
loss.
3 Metformin is not typically prescribed for weight loss.
4 Phentermine is administered for 12 weeks only when prescribed for weight loss.
Feedback
1 Orlistat is a pharmacological therapy for weight loss that can cause loose and oily
stools; therefore, this information should be included in the teaching session for this
patient.
2 Lorcaserin does not cause loose and oily stools.
3 Metformin does not cause loose and oily stools.
4 Phentermine does not cause loose and oily stools.
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COMPLETION
25. ANS:
32.77
Chapter number and title: 68, Managing Care for the Adult Patient With Obesity
Chapter learning objective: Identifying classifications of body weight
Chapter page reference: 1498-1499
Heading: Classification of Body Weight
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
Feedback: The nurse should use the formula: weight (lb) / [height (in)] 2 703 for this calculation. The BMI
is calculated by dividing weight in pounds (lb) by height in inches (in) squared and multiplying by a
conversion factor of 703. The calculation would be
185 / 63 63 = 185 / 3969 = 0.0466112 703 = 32.77.
MULTIPLE RESPONSE
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26. ANS: 2, 3, 5
Chapter number and title: 68, Managing Care for the Adult Patient With Obesity
Chapter learning objective: Describing the pathophysiology of obesity
Chapter page reference: 1499-1500
Heading: Pathophysiology
Integrated Processes: Nursing Process: Planning
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Nutrition
Difficulty: Easy
Feedback
1. This is incorrect. Carbohydrates should be eaten throughout the day.
2. This is correct. When carbohydrates are consumed in excess, they are converted to fat and
stored in adipose tissue, which can lead to weight gain and an increased risk for obesity.
3. This is correct. When carbohydrates are consumed in excess, they are converted to fat and
stored in adipose tissue, which can lead to weight gain and an increased risk for obesity.
4. This is incorrect. Carbohydrate deficiencies lead to protein tissue wasting.
5. This is correct. Carbohydrates should come from the consumption of foods high in fiber and
low in added sugars.
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Chapter number and title: 68, Managing Care for the Adult Patient With Obesity
Chapter learning objective: Developing a teaching plan for a patient with obesity
Chapter page reference: 1500-1506
Heading: Management
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
Feedback
1. This is incorrect. The risk for chronic lung disease and osteoarthritis is not determined by the
waist-to-height ratio.
2. This is incorrect. The risk for chronic lung disease and osteoarthritis is not determined by the
waist-to-height ratio.
3. This is correct. The waist-to-height ratio is calculated by dividing the circumference of the
waist in inches by the height in inches. For this patient, the waist-to-height ratio is 0.86, which
places the patient in the category of high risk for chronic diseases such as type 2 diabetes
mellitus, heart disease, and high blood pressure.
4. This is correct. The waist-to-height ratio is calculated by dividing the circumference of the
waist in inches by the height in inches. For this patient, the waist-to-height ratio is 0.86, which
places the patient in the category of high risk for chronic diseases such as type 2 diabetes
mellitus, heart disease, and high blood pressure.
5. This is correct. The waist-to-height ratio is calculated by dividing the circumference of the
waist in inches by the height in inches. For this patient, the waist-to-height ratio is 0.86, which
places the patient in the N URSIN
category ofGhigh
TB. COfor
risk M chronic diseases such as type 2 diabetes
mellitus, heart disease, and high blood pressure.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is conducting a class in the community regarding alcohol use to a group of college seniors. During
the class a participant admits to frequently using alcohol. Which is the priority action of the nurse?
1) Initiate a community assessment of the campus
2) Contact the campus nurse and refer the student
3) Notify campus security to watch for driving under the influence
4) Complete a crisis assessment
____ 2. A patient is admitted to the emergency department with signs of drug use. The patient reports having ingested
Percocet and is experiencing respiratory depression. Based on this data, which prescription does the nurse
anticipate for this patient?
1) Diazepam
2) Haldol
3) Vitamin B12
4) Naloxone
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____ 3. The nurse is planning to implement addiction treatment groups at the inner city clinic. Which knowledge
regarding addictions and its related therapies will facilitate implementation of the groups?
1) Relapse is a common feature of substance abuse.
2) Hereditary, as well as complex environmental influences, predisposes one to substance
dependence.
3) Patients with a substance dependence cannot be held accountable for their actions.
4) Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) are accepted treatment
approaches.
____ 4. The employee health nurse is providing care to an employee who was injured on the job. The patient has a
history of drug addiction and is currently enrolled in a 12-step recovery program. In order to determine
whether the employee was impaired at the time of the accident, which diagnostic tool will the nurse use?
1) Liver enzymes
2) Stool guaiac
3) Urine toxicology testing
4) Hair testing
____ 5. The patient with a history of alcohol abuse is being discharged to a treatment facility. Which prescription does
the nurse anticipate for this patient?
1) Disulfiram
2) Naloxone
3) Bupropion hydrochloride
4) Varenicline
____ 6. The nurse is providing care to a patient diagnosed with alcoholism. The patient’s physical examination
reveals a BMI of 18. Which prescription does the nurse anticipate to manage the patient’s nutritional status?
1) Sertraline NURSINGTB.COM
2) Methadone
3) Naloxone
4) Multivitamin with folic acid
____ 7. The nurse assesses a patient with a history of alcoholism who is hospitalized with anorexia, dysphagia,
odynophagia, and chest pressure after eating. Which nursing diagnosis is a priority for this patient?
1) Ineffective Coping
2) Imbalanced Nutrition: Less Than Body Requirements
3) Disturbed Sensory Perception
4) Disturbed Thought Processes
____ 8. The nurse is evaluating outcome goals written by a student for a patient diagnosed with alcoholism who is
being discharged from a detoxification program. Which outcome is appropriate for this patient?
1) Follow a 2000-calorie high-carbohydrate diet
2) Sponsor a participant in Alcoholics Anonymous (AA) meetings
3) Obtain at least six to eight hours of sleep per night
4) Acknowledge the blame that family members must take for codependent behavior
____ 9. The nurse is conducting a health history for a patient and wants to determine the patient’s alcohol use. What
question from the nurse will provide the greatest amount of information?
1) “Are you a heavy drinker?”
2) “How many alcoholic beverages do you drink each day?”
3) “Is alcohol use a concern for you?”
4) “Drinking doesn't cause any problems for you, does it?”
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____ 10. The nurse is caring for a patient who is diagnosed with cocaine addiction. For which additional disorder
should the nurse assess this patient?
1) Anxiety
2) Diabetes
3) Weight gain
4) Kidney stones
____ 11. A nursing instructor is teaching a class about the role of dopamine in substance abuse. Which student
statement indicates appropriate understanding?
1) “The dopamine D1 and dopamine D2 receptors are responsible for co-occurring disorders.”
2) “Dopamine increases opioid transmission, and this reinforces the cycle of substance
abuse.”
3) “Dopamine causes changes in brain neurotransmission that enhance the cycle of substance
abuse.”
4) “The dopamine D3 receptor is involved in drug-seeking behaviors.”
____ 12. A college student is incoherent after taking “downers with beer.” For which health problem should the nurse
also observe for in this patient?
1) Hallucinations
2) Respiratory depression
3) Seizure activity
4) Signs of withdrawal
____ 13. The nurse is completing a health history and determines the patient would benefit from teaching about
substance abuse. Which patient statement does not support the need for this teaching?
1) “I drink alcohol with my friends on the weekends.”
2) “I smoke cigarettes on a daily basis.”
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3) “I get good grades in school.”
4) “I became sexually active at the age of 13.”
____ 14. The nurse is providing care to a patient with alcohol and opioid dependency. A family member states, “I don't
understand why Naltrexone treatment is prescribed because it causes a high too, right?” Which response by
the nurse is appropriate?
1) “Naltrexone will cause your daughter to become violently ill if she drinks alcohol or
abuses drugs.”
2) “Naltrexone is less potent than the street drugs your daughter is currently taking and
therefore safer.”
3) “Naltrexone diminishes the cravings your daughter will feel for alcohol and opioids.”
4) “Naltrexone will prevent your daughter from getting drunk when she drinks.”
____ 15. A patient who is attending a Narcotics Anonymous (NA) program asks the nurse what the most important
initial goal of attending the meetings is. When responding to the patient, which indication will the nurse take
into account?
1) To admit to having a problem
2) To learn problem-solving skills
3) To take a moral inventory of self
4) To make amends to people they have hurt
____ 16. After an assessment of a patient, a nursing student expresses a belief that drug addiction is not a real illness,
as these patients “did it to themselves.” Which response by the staff nurse is appropriate?
1) “Sometimes a patient doesn't show much effort.”
2) “We are legally obligated to provide care.”
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3) “It is important to remain nonjudgmental when caring for any patient, even a drug addict.”
4) “You are right. I don't know why we bother.”
____ 17. A patient being treated for an alcohol use disorder asks the nurse, “Can my children inherit this?” Which
response by the nurse is most appropriate?
1) “The role of genetics is minor in comparison to the role of the environment.”
2) “Genetics does not seem to play a role in the development of substance use disorders.”
3) “The role of genetics in substance use disorders has not been determined.”
4) “Genetics plays a major role in the development of substance use disorders.”
____ 18. The nurse is caring for a patient who requires an opiate medication for chronic pain associated with a previous
injury. The patient tells the nurse, “Even though I don’t feel like I’m addicted to the medication, I get tremors
in my hands if I miss a dose.” What is the nurse’s best response?
1) “You may be addicted to the medication, but not necessarily physically dependent.”
2) “You may be physically dependent on the medication, but not necessarily addicted.”
3) “The symptoms you describe are indicative of addiction, whether you feel you are or not.”
4) “The symptoms you describe relate to your disease state and are not normal.”
____ 19. The nurse is caring for a patient who is an intravenous drug user. The nurse anticipates the need for
assessment for which complication?
1) Cardiac tamponade
2) Myocardial infarction
3) Congestive heart failure
4) Infective endocarditis
____ 20. A patient is brought to the emergency department by a parent. The nursing assessment reveals that the patient
has been acting strangely for the pastNthree
URShours
INGand
TBis
.Chypervigilant,
OM grandiose, and irritable. Vital signs
reveal hypertension, tachycardia, and some arrhythmias. Which substance does the nurse suspect that the
patient has been using?
1) Alcohol
2) Marijuana
3) Heroin
4) Amphetamines
____ 21. Ten hours after admission to the ICU following an auto accident, a patient begins to exhibit mild tachycardia,
irritability, and tremors. Three hours later the patient has a grand mal seizure. Which condition does the nurse
suspect?
1) Wernicke encephalopathy
2) Korsakoff syndrome
3) Undetected internal bleeding
4) Alcohol withdrawal syndrome
____ 22. A patient addicted to heroin is prescribed methadone as part of the treatment process. The patient’s spouse
asks, “I don’t understand the reason for the methadone treatment. Why replace heroin with methadone?”
Which response by the nurse is accurate?
1) “Methadone is safe even in large doses.”
2) “Methadone replaces a more potent drug.”
3) “Methadone is a deterrent to using other drugs.”
4) “Methadone blocks the craving for and the action of opiates.”
____ 23. The nurse is caring for a patient who is experiencing alcohol withdrawal. Which is the priority nursing
diagnosis for this patient?
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. The nurse is conducting a crisis assessment for a patient who admits to cocaine use. Which questions are
appropriate for the nurse to ask the patient during this process? Select all that apply.
1) “Are recreational centers available?”
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2) “What is the most significant stress/problem occurring in your life right now?”
3) “How long has this been a problem?”
4) “What are the living conditions of the neighborhood?”
5) “What other stresses do you have in your life?”
____ 27. A patient is admitted to the emergency department after overdosing on phencyclidine piperidine (PCP). Based
on this actions, which actions are appropriate by the nurse? Select all that apply.
1) Obtain materials to assist with lavage
2) Start an IV
3) Initiate seizure precautions
4) Induce vomiting
5) Administer ammonium chloride
____ 28. A nurse working in the emergency department is caring for a patient who has overdosed on cocaine. The
nurse receives a prescription to administer an antipsychotic medication from the health-care provider. Which
symptom would this medication help to manage? Select all that apply.
1) Alkaline urine
2) Decreased deep tendon reflexes
3) Hyperpyrexia
4) Respiratory distress
5) CNS depression
____ 29. Which are the priority nursing interventions when providing care to patients at various stages of the
detoxification process? Select all that apply.
1) Vital signs
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2) Medication administration
3) Motivational interviewing
4) Intake and output
5) Neurological assessment
____ 30. Which symptoms common to substance abuse will the nurse include in the assessment process for a patient
who is suspected of having a substance use disorder? Select all that apply.
1) Disregard for religious beliefs while abusing the substance
2) Lack of desire to quit using the substance
3) Need for greater amounts of the substance to achieve the same effect
4) Neglect of normal activities due to focus on obtaining or using more of the substance
5) Persistent craving for the substance
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MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 69, Substance Use Disorders in the Adult Population
Chapter learning objective: Analyzing the nursing care priorities for the hospitalized patient with a history of
one or more substance use disorders
Chapter page reference: 1527-1533
Heading: Screening and Interventions
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive level: Analysis [Analyzing]
Concept: Addiction
Difficulty: Difficult
Feedback
1 A community assessment is not an appropriate action at this time.
2 Contacting the campus nurse is not advised without the student's permission.
3 There is no evidence that the student is driving under the influence.
4 In a trusting relationship, the nurse will complete a crisis assessment to determine the
appropriate action.
Feedback
1 Diazepam can be prescribed to manage signs of an overdose.
2 Haldol can be administered to manage an overdose of phencyclidine piperidine (PCP).
3 Vitamin B12 is used to manage the neurological symptoms that might accompany a
nitrate overdose.
4 Percocet is a type of opiate. Naloxone is used to treat an overdose of opiates.
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1 Disulfiram (Antabuse) causes the patient to become immediately and violently ill when
consuming alcohol.
2 Naloxone is administered to patients who overdose on opiates.
3 Bupropion hydrochloride and varenicline are both medications to assist with smoking
cessation.
4 Bupropion hydrochloride and varenicline are both medications to assist with smoking
cessation.
Feedback
1 Ineffective Coping is a potential diagnosis used in substance abuse; however, there is
another diagnosis that takes priority.
2 An alcoholic patient with anorexia is at risk for Imbalanced Nutrition: Less Than Body
Requirements. This is a physiological diagnosis; therefore, this is the priority.
3 Disturbed Thought Processes and Disturbed Sensory Perceptions are diagnoses used for
delusions, hallucinations, and illusions that may occur during delirium tremens.
4 Disturbed Thought Processes and Disturbed Sensory Perceptions are diagnoses used for
delusions, hallucinations, and illusions that may occur during delirium tremens.
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1 Seizure activity, signs of withdrawal, and signs of hallucinations do not pose as great a
risk for this patient as respiratory depression.
2 Downers are central nervous system depressants. Barbiturates and alcohol are a lethal
combination. The patient who has ingested both items is at risk for varying degrees of
sedation, up to coma and death.
3 Seizure activity, signs of withdrawal, and signs of hallucinations do not pose as great a
risk for this patient as respiratory depression.
4 Seizure activity, signs of withdrawal, and signs of hallucinations do not pose as great a
risk for this patient as respiratory depression.
Feedback
1 Early sexual activity, smoking cigarettes, and drinking alcohol are all risk factors for
teenage substance abuse.
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2 Early sexual activity, smoking cigarettes, and drinking alcohol are all risk factors for
teenage substance abuse.
3 Getting good grades is not a risk factor for substance abuse.
4 Early sexual activity, smoking cigarettes, and drinking alcohol are all risk factors for
teenage substance abuse.
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4 Nurses must provide a nonjudgmental attitude with their patients in order to promote
trust and respect. Even if a patient is not currently making much effort toward
management of addiction disorders, the development of a trusting relationship with the
nurse helps to set the stage for movement toward recovery in the future.
Feedback
1 Research has not yet determined the relationship between genetics and substance use
disorders, particularly regarding why some people are more prone to addiction than
others.
2 Research has not yet determined the relationship between genetics and substance use
disorders, particularly regarding why some people are more prone to addiction than
others.
3 Research has not yet determined the relationship between genetics and substance use
NUwhy
disorders, particularly regarding RSI NGTpeople
some B.CO areMmore prone to addiction than
others.
4 Research has not yet determined the relationship between genetics and substance use
disorders, particularly regarding why some people are more prone to addiction than
others.
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2 The patient may be physically dependent on the substance, but not necessarily addicted.
Increasing frequency and amount of use creates physical dependence, in which the
body becomes so dependent on the substance that without it, withdrawal symptoms will
begin. Continued use leads to a breakdown in patterns of daily living, part of the
addictive process. Addiction, not physical dependence, is considered a disease state.
3 The patient may be physically dependent on the substance, but not necessarily addicted.
Increasing frequency and amount of use creates physical dependence, in which the
body becomes so dependent on the substance that without it, withdrawal symptoms will
begin. Continued use leads to a breakdown in patterns of daily living, part of the
addictive process. Addiction, not physical dependence, is considered a disease state.
4 The patient may be physically dependent on the substance, but not necessarily addicted.
Increasing frequency and amount of use creates physical dependence, in which the
body becomes so dependent on the substance that without it, withdrawal symptoms will
begin. Continued use leads to a breakdown in patterns of daily living, part of the
addictive process. Addiction, not physical dependence, is considered a disease state.
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Chapter learning objective: Describing the clinical manifestations of specific substances commonly used by
persons with a substance use disorder
Chapter page reference: 1516-1527
Heading: Substances and Clinical Manifestations
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Addiction
Difficulty: Moderate
Feedback
1 Alcohol intoxication may manifest in relaxed euphoria, lack of concentration, and
decreased inhibitions.
2 Marijuana intoxication manifests in euphoria and relaxation and does not typically
cause hypertension, tachycardia, or arrhythmias.
3 Heroin intoxication causes decreased respiratory rate and depth and bradycardia, not
tachycardia.
4 Amphetamine intoxication includes symptoms of hypervigilance, grandiosity, and
irritability.
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Concept: Addiction
Difficulty: Moderate
Feedback
1 Methadone does not replace more potent drugs or act as a deterrent to other drug use.
The doses of methadone are strictly regulated and administered by health professionals.
2 Methadone does not replace more potent drugs or act as a deterrent to other drug use.
The doses of methadone are strictly regulated and administered by health professionals.
3 Methadone does not replace more potent drugs or act as a deterrent to other drug use.
The doses of methadone are strictly regulated and administered by health professionals.
4 Methadone blocks the craving for and the action of opiates such as heroin.
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1 While this action may help to develop the nurse–patient relationship, this is not its
primary purpose.
2 The primary purpose of collaboration is not to allow the nurse to self-reflect, nor is it to
provide evaluation of outcomes.
3 The primary purpose of collaboration with the patient to establish and redefine mutual
goals of treatment is to encourage patient responsibility.
4 The primary purpose of collaboration is not to allow the nurse to self-reflect, nor is it to
provide evaluation of outcomes.
MULTIPLE RESPONSE
26. ANS: 2, 3, 5
Chapter number and title: 69, Substance Use Disorders in the Adult Population
Chapter learning objective: Analyzing the nursing care priorities for the hospitalized patient with a history of
one or more substance use disorders
Chapter page reference: 1533-1536
Heading: Nursing Management
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Addiction
Difficulty: Moderate
Feedback
1. This is incorrect. Asking about recreational centers and the living conditions of the
neighborhood are more appropriate when conducting a community crisis assessment.
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2. This is correct. When conducting a crisis assessment for a patient who admits to using an
illegal substance that is associated with addiction, the nurse will ask the patient about the most
significant stress occurring in life right now, how long the problem has been occurring, and
the other stresses in the patient’s life.
3. This is correct. When conducting a crisis assessment for a patient who admits to using an
illegal substance that is associated with addiction, the nurse will ask the patient about the most
significant stress occurring in life right now, how long the problem has been occurring, and
the other stresses in the patient’s life.
4. This is incorrect. Asking about recreational centers and the living conditions of the
neighborhood are more appropriate when conducting a community crisis assessment.
5. This is correct. When conducting a crisis assessment for a patient who admits to using an
illegal substance that is associated with addiction, the nurse will ask the patient about the most
significant stress occurring in life right now, how long the problem has been occurring, and
the other stresses in the patient’s life.
Feedback
1. This is incorrect. Lavage would be an inappropriate treatment for inhalation of any substance.
Narcan is a narcotic antagonist administered for opiate overdose.
2. This is correct. The patient has taken an overdose of phencyclidine piperidine (PCP), which
can produce an adrenaline-like response, or “speed” reaction. PCP overdose is associated with
possible hypertensive crisis, respiratory arrest, hyperthermia, and seizures. The patient will
require an IV line. The patient will need to have seizure precautions such as padded side rails
initiated. The patient may also be given ammonium chloride to acidify the urine to help
excrete the drug.
3. This is correct. The patient has taken an overdose of phencyclidine piperidine (PCP), which
can produce an adrenaline-like response, or “speed” reaction. PCP overdose is associated with
possible hypertensive crisis, respiratory arrest, hyperthermia, and seizures. The patient will
require an IV line. The patient will need to have seizure precautions such as padded side rails
initiated. The patient may also be given ammonium chloride to acidify the urine to help
excrete the drug.
4. This is incorrect. Vomiting is induced for overdoses of alcohol, barbiturates, and
benzodiazepines.
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5. This is correct. The patient has taken an overdose of phencyclidine piperidine (PCP), which
can produce an adrenaline-like response, or “speed” reaction. PCP overdose is associated with
possible hypertensive crisis, respiratory arrest, hyperthermia, and seizures. The patient will
require an IV line. The patient will need to have seizure precautions such as padded side rails
initiated. The patient may also be given ammonium chloride to acidify the urine to help
excrete the drug.
Feedback
1. This is incorrect. Antipsychotic medications are used in the treatment of patients who have
overdosed on crack or cocaine. These medications help to manage the hyperpyrexia,
respiratory distress, acidic urine, and convulsions associated with the overdose. CNS
depression and decreased deep tendon reflexes do not occur in acute cocaine overdose.
2. This is incorrect.
3. This is correct. NURSINGTB.COM
4. This is correct.
5. This is incorrect.
Feedback
1. This is correct. Priority nursing interventions for patients in the detoxification process are
those that relate to patient safety and will include careful monitoring of vital signs, monitoring
fluid volume and electrolyte levels, monitoring neurological status, and safe administration of
medications to ensure patient medical conditions do not place patients at further risk for
injury.
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2. This is correct. Priority nursing interventions for patients in the detoxification process are
those that relate to patient safety and will include careful monitoring of vital signs, monitoring
fluid volume and electrolyte levels, monitoring neurological status, and safe administration of
medications to ensure patient medical conditions do not place patients at further risk for
injury.
3. This is incorrect. Motivational interviewing, including assessing patients’ readiness to change,
does not take priority over patient safety during the detoxification process.
4. This is correct. Priority nursing interventions for patients in the detoxification process are
those that relate to patient safety and will include careful monitoring of vital signs, monitoring
fluid volume and electrolyte levels, monitoring neurological status, and safe administration of
medications to ensure patient medical conditions do not place patients at further risk for
injury.
5. This is correct. Priority nursing interventions for patients in the detoxification process are
those that relate to patient safety and will include careful monitoring of vital signs, monitoring
fluid volume and electrolyte levels, monitoring neurological status, and safe administration of
medications to ensure patient medical conditions do not place patients at further risk for
injury.
Feedback
1. This is incorrect. Patients who have a substance use disorder experience some universal
symptoms: a need for greater amounts of the substance to achieve the same effect, neglect of
normal activities due to focus on obtaining or using more of the substance, and a persistent
craving for the substance. The patient with a substance use disorder does not necessarily
disregard his or her religious beliefs or lack the desire to quit. Some patients have a desire to
reduce their use of the substance but have difficulty doing so.
2. This is incorrect.
3. This is correct.
4. This is correct.
5. This is correct.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. What should the nurse do to assist a patient brought to the emergency department as a victim of a gunshot
wound?
1) Ask the patient who shot him
2) Bathe the patient and provide a clean gown
3) Ask the patient where the weapon is
4) Preserve the chain of evidence
____ 2. A patient is brought into the emergency department after being assaulted. It is suspected that the patient has a
spinal cord injury. Which diagnostic test does the nurse anticipate based on the data collected?
1) Computed tomography (CT) scan
2) X-ray
3) Ultrasound
4) Magnetic resonance imaging (MRI)
____ 3. A patient recovering from a motor vehicle crash develops hypotension and jugular distension with a tracheal
deviation. Based on this data, which should the nurse suspect occurred?
1) Hemorrhage
2) Compensatory shock
3) Hypovolemic shock
4) Tension pneumothorax
____ 4. Which observation indicates that interventions provided to a patient with neck injuries from a motor vehicle
crash have been successful?
1) Urine is clear and odorless fromNindwelling
URSINGcatheter
TB.COM
2) Moves all four extremities independently, feeds self, and participates in partial bath
3) Unable to move independently in bed
4) Rests in bed with lights and television turned off
____ 5. Which intervention would be a priority when providing care to a patient recovering from thoracic injuries
sustained from a motor vehicle crash?
1) Monitor urine output
2) Assess vital signs
3) Perform passive range of motion to all extremities
4) Assist to deep breathe and cough every two hours
____ 6. A nurse is developing a plan of care for a patient with traumatic injuries from a motor vehicle crash. Which
nursing intervention does the nurse include in the plan of care to reduce the risk of integumentary
complications?
1) Provide active or passive exercises at least once every eight hours
2) Encourage coughing, deep breathing, and incentive spirometry
3) Assist the patient in turning at least every two hours
4) Assist the patient in turning at least every eight hours
____ 7. Which assessment data indicates the patient is experiencing a late symptom associated with chronic aspirin
overdose?
1) Emesis
2) Nausea
3) Tinnitus
4) Ecchymosis
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____ 8. The emergency department nurse is triaging patients. Which patient should be prioritized?
1) An adult patient experiencing mild chest pain
2) An adolescent patient with a possible fractured wrist
3) An older adult patient with a hip fracture who is in pain
4) A school-age patient with asthma presenting with dyspnea
____ 9. The registered nurse (RN) is the team leader for a group of patients using the functional model of nursing.
The team of nurses includes two licensed practical nurses (LPNs) and an unlicensed assistive personnel
(UAP). Which task will the RN delegate to the UAP?
1) Taking vital signs
2) Providing wound care
3) Conducting discharge teaching
4) Administering oral medications
____ 10. A medical-surgical unit is expecting a large volume of patient admissions after a train derailment. Which
member of the nursing care team will prioritize care for the unit?
1) Charge nurse
2) Nurse supervisor
3) Licensed practical nurse
4) Unlicensed assistive personnel
____ 11. Which is a potentially life-threatening condition found during the primary triage survey that would necessitate
priority nursing care?
1) Cystitis
2) Concussion
3) Lacerated arm NURSINGTB.COM
4) Fractured femur
____ 12. Which nursing action is appropriate when conducting a secondary survey during the emergency assessment?
1) Maintaining privacy
2) Having suction available
3) Giving supplemental oxygen
4) Assigning a nurse to support family members
____ 13. Which member of the health-care team, when using the team nursing approach, is responsible for prioritizing
patient care?
1) Team leader
2) Charge nurse
3) Licensed practical nurse
4) Unlicensed assistive personnel
____ 14. The nurse is conducting a primary survey during the emergency assessment. Which nursing action is
appropriate during the breathing assessment?
1) Assessing for edema
2) Counting respiratory rate
3) Checking for foreign bodies
4) Monitoring for respiratory distress
____ 15. The nurse is conducting a primary survey during an emergency assessment. Which is the priority nursing
action related to breathing in response to this assessment?
1) Having suction available
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____ 23. Which assessment data related to the patient’s airway would indicate the need for priority intervention by the
nurse?
1) Eupnea
2) Tachycardia
3) Hypotension
4) Agonal breaths
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 24. Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select
all that apply.
1) Inserting a nasogastric tube
2) Immobilizing the cervical spine
3) Arranging for diagnostic studies
4) Preparing for chest tube insertion
5) Applying direct pressure to a wound
____ 25. What would the nurse working in the emergency department identify as clinical priorities for the treatment of
a patient with a gunshot wound? Select all that apply.
1) Airway maintenance
2) Obtaining medical history
3) Ventilation assistance
4) Hemorrhage control
5) Hypothermia prevention
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____ 26. Which are the top priorities when conducting a primary patient survey during the emergency assessment?
Select all that apply.
1) Airway
2) Disability
3) Breathing
4) Circulation
5) Cervical spine
Completion
Complete each statement.
27. The nurse is providing care to several patients in the emergency department. In which order should the nurse
assess and provide care to the patients? (Enter the number of each step in the proper sequence; do not use
punctuation or spaces. Example: 1234)
28. The nurse is providing care to a trauma patient. What is the correct order of steps the nurse will implement
when providing care to this patient? Select all that apply. (Enter the number of each step in the proper
sequence; do not use punctuation or spaces. Example: 1234)
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MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: Emergency, Trauma, and Environmental Injuries
Chapter learning objective: Examining in hospital emergency/trauma care priorities
Chapter page reference: 1540-1553
Heading: Emergency Nursing
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Nursing
Difficulty: Moderate
Feedback
1 Because the majority of gunshot wounds require an investigation by law enforcement,
nurses working in emergency departments and trauma centers should be familiar with
their agency’s protocols for maintaining evidence required by law enforcement. Often,
law enforcement does not want the victim’s hands or the area around the victim’s
wounds cleansed. Clothes and personal items are often wanted as evidence. The nurse
should not bathe the patient and provide a clean gown. The nurse should not ask the
patient who shot him or whereNthe
URweapon
SINGis. TBThe
.Cnurse
OM should preserve the chain of
evidence.
2 Because the majority of gunshot wounds require an investigation by law enforcement,
nurses working in emergency departments and trauma centers should be familiar with
their agency’s protocols for maintaining evidence required by law enforcement. Often,
law enforcement does not want the victim’s hands or the area around the victim’s
wounds cleansed. Clothes and personal items are often wanted as evidence. The nurse
should not bathe the patient and provide a clean gown. The nurse should not ask the
patient who shot him or where the weapon is. The nurse should preserve the chain of
evidence.
3 Because the majority of gunshot wounds require an investigation by law enforcement,
nurses working in emergency departments and trauma centers should be familiar with
their agency’s protocols for maintaining evidence required by law enforcement. Often,
law enforcement does not want the victim’s hands or the area around the victim’s
wounds cleansed. Clothes and personal items are often wanted as evidence. The nurse
should not bathe the patient and provide a clean gown. The nurse should not ask the
patient who shot him or where the weapon is. The nurse should preserve the chain of
evidence.
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Feedback
1 Monitoring urine output and assessing vital signs are important but not the priority at
this time.
2 Monitoring urine output and assessing vital signs are important but not the priority at
this time.
3 The patient may be able to perform active range of motion for all extremities, so this
intervention may or may not be indicated.
4 The patient has thoracic injuries and might be reluctant to deep breathe and cough
because of pain. The nurse needs to ensure that the patient breathes deeply and coughs
every two hours to mobilize secretions and prevent respiratory complications.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 Emesis, tinnitus, and nausea are all early clinical manifestations of acute aspirin
poisoning.
2 Emesis, tinnitus, and nausea are all early clinical manifestations of acute aspirin
poisoning.
3 Emesis, tinnitus, and nausea are all early clinical manifestations of acute aspirin
poisoning.
4 Ecchymosis is a late symptom associated with a chronic aspirin overdose.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 A charge nurse coordinates care and assignments and may ultimately be the only person
familiar with all the needs of any individual patient; therefore, it is this member of the
team that will prioritize care for the patients who are being admitted.
2 The nurse supervisor may be in charge of assigning the trauma patients to individual
units.
3 The licensed practical nurse will receive a patient assignment on the unit but will not
prioritize care for the unit.
4 The unlicensed assistive personnel will be delegated tasks by other members of the
nursing team.
Feedback
1 Cystitis, a lacerated arm, and a fractured femur would not necessitate priority nursing
care.
2 A concussion, which is a type of head injury, is a potentially life-threatening condition
found during the primary triage survey that would necessitate priority nursing care.
3 Cystitis, a lacerated arm, and a fractured femur would not necessitate priority nursing
care.
4 Cystitis, a lacerated arm, and a fractured femur would not necessitate priority nursing
care.
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1 Nursing actions that are appropriate when conducting a primary survey during the
airway assessment include assessing for edema, checking for foreign bodies, and
monitoring for respiratory distress.
2 Counting the respiratory rate is a nursing action appropriate during the breathing
assessment.
3 Nursing actions that are appropriate when conducting a primary survey during the
airway assessment include assessing for edema, checking for foreign bodies, and
monitoring for respiratory distress.
4 Nursing actions that are appropriate when conducting a primary survey during the
airway assessment include assessing for edema, checking for foreign bodies, and
monitoring for respiratory distress.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 Noting the general appearance, examining the neck for stiffness, and auscultating for
heart and lung sounds are actions that occur during the head-to-toe physical assessment,
not the health history.
3 Noting the general appearance, examining the neck for stiffness, and auscultating for
heart and lung sounds are actions that occur during the head-to-toe physical assessment,
not the health history.
4 Noting the general appearance, examining the neck for stiffness, and auscultating for
heart and lung sounds are actions that occur during the head-to-toe physical assessment,
not the health history.
Feedback
1 An adult patient with an ankle sprain and an infant with a rash of unknown origin are
both classified as nonurgent.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 An adult patient with an ankle sprain and an infant with a rash of unknown origin are
both classified as nonurgent.
3 An adult patient with unstable vital signs would receive priority care based on the three-
tiered triage system due to emergent, or life-threatening, injury.
4 A pediatric patient with multiple fractures following a motor vehicle accident is
classified as an urgent patient.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1 While assessing bowel sounds, administering pain medication, and scheduling a CT
scan to determine retroperitoneal bleeding are important interventions, these are not the
priorities in this situation.
2 The priority nursing action when providing care to a patient with a penetrating
abdominal wound is to stabilize the impaled object to prevent further injury.
3 While assessing bowel sounds, administering pain medication, and scheduling a CT
scan to determine retroperitoneal bleeding are important interventions, these are not the
priorities in this situation.
4 While assessing bowel sounds, administering pain medication, and scheduling a CT
scan to determine retroperitoneal bleeding are important interventions, these are not the
priorities in this situation.
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PTS: 1 CON: Nursing
22. ANS: 2
Chapter number and title: Emergency, Trauma, and Environmental Injuries
Chapter learning objective: Discussing the medical management of selected emergencies
Chapter page reference: 1553-1562
Heading: Poisoning
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Nursing
Difficulty: Easy
Feedback
1 Gastric lavage will not remove concentrations of aspirin.
2 The nurse would prepare to administer activated charcoal to the client and repeat every
four hours, if needed, for a client with active bowel sounds.
3 Hemodialysis, not peritoneal dialysis, is a treatment that may be prescribed for a client
who presents with an overdose of aspirin.
4 Vitamin K, not D, is administered to assist with clotting.
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MULTIPLE RESPONSE
24. ANS: 2, 4, 5
Chapter number and title: Emergency, Trauma, and Environmental Injuries
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with selected
emergencies NURSINGTB.COM
Chapter page reference: 1540-1553
Heading: Emergency Nursing
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Nursing
Difficulty: Moderate
Feedback
1. This is incorrect. The secondary survey begins after addressing each step of the primary
survey and starting any lifesaving interventions. The secondary survey is a brief, systematic
process that aims to identify all injuries. Nursing actions appropriate during the secondary, not
primary, survey include inserting a nasogastric tube and arranging for diagnostic studies.
2. This is correct. The primary survey focuses on airway, breathing, circulation (ABC),
disability, and exposure or environmental control. It aims to identify life-threatening
conditions so that appropriate interventions can be started. Nursing actions that are appropriate
during the primary survey include immobilizing the cervical spine, preparing for chest tube
insertion, and applying direct pressure to a wound.
3. This is incorrect. The secondary survey begins after addressing each step of the primary
survey and starting any lifesaving interventions. The secondary survey is a brief, systematic
process that aims to identify all injuries. Nursing actions appropriate during the secondary, not
primary, survey include inserting a nasogastric tube and arranging for diagnostic studies.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4. This is correct. The primary survey focuses on airway, breathing, circulation (ABC),
disability, and exposure or environmental control. It aims to identify life-threatening
conditions so that appropriate interventions can be started. Nursing actions that are appropriate
during the primary survey include immobilizing the cervical spine, preparing for chest tube
insertion, and applying direct pressure to a wound.
5. This is correct. The primary survey focuses on airway, breathing, circulation (ABC),
disability, and exposure or environmental control. It aims to identify life-threatening
conditions so that appropriate interventions can be started. Nursing actions that are appropriate
during the primary survey include immobilizing the cervical spine, preparing for chest tube
insertion, and applying direct pressure to a wound.
Feedback
1. This is correct. Clinical priorities for the treatment of gunshot wound are the following:
maintain airway and assistNUventilation
RSINGTasB. COM control hemorrhage, prevent hypothermia.
necessary,
Also necessary is a rapid, recurrent assessment of the patient’s neurological status, as well as
prevention of infection.
2. This is incorrect. While obtaining the patient’s medical history is important, this action would
not be priority and would take place after the priority assessment and treatment. Once the
safety of the patient is assured, then the nurse will manage the patient’s emotional state and
obtain the medical history.
3. This is correct. Clinical priorities for the treatment of gunshot wound are the following:
maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia.
Also necessary is a rapid, recurrent assessment of the patient’s neurological status, as well as
prevention of infection.
4. This is correct. Clinical priorities for the treatment of gunshot wound are the following:
maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia.
Also necessary is a rapid, recurrent assessment of the patient’s neurological status, as well as
prevention of infection.
5. This is correct. Clinical priorities for the treatment of gunshot wound are the following:
maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia.
Also necessary is a rapid, recurrent assessment of the patient’s neurological status, as well as
prevention of infection.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1. This is correct. Airway and stabilization of the cervical spine are the top priorities when
conducting a primary patient survey during the emergency assessment.
2. This is incorrect. The nurse will then focus on breathing, circulation, and disability.
3. This is incorrect. The nurse will then focus on breathing, circulation, and disability.
4. This is incorrect. The nurse will then focus on breathing, circulation, and disability.
5. This is correct. Airway and stabilization of the cervical spine are the top priorities when
conducting a primary patient survey during the emergency assessment.
COMPLETION
27. ANS:
4321
Chapter number and title: Emergency, Trauma, and Environmental Injuries
NUinRhospital
Chapter learning objective: Examining SINGTemergency/trauma
B.COM care priorities
Chapter page reference: 1540-1553
Heading: Emergency Nursing
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Nursing
Difficulty: Difficult
Feedback: When using the Five-Level Emergency Severity Index (ESI), an ESI-1 is the highest priority while
an ESI-5 is the lowest priority. The patient who took an overdose of opioids and is experiencing bradypnea
(respiratory rate of less than 10 breaths per minute) is the priority at ESI-1. The patient who has multiple
trauma due to a motor vehicle accident is an ESI-2. The patient with abdominal pain rated as a 7 using the
numeric pain scale is an ESI-3. A patient with a leg laceration requiring sutures is an ESI-4.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Concept: Nursing
Difficulty: Difficult
Feedback: The first step the nurse takes when providing care to a trauma patient is to clear the airway. The
second step is to protect the cervical spine. The third step is to provide supplemental oxygen. The fourth step
is to perform chest compressions.
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. Which is the critical factor among health-care professionals, state agencies, and federal agencies to determine
when and how to evacuate safely during a natural disaster?
1) Cooperation
2) Classification
3) Collaboration
4) Communication
____ 2. A workplace violence prevention plan is often one component of a hospital disaster plan. Which unit assumes
priority for implementation and evaluation of this component to the plan?
1) Medical unit
2) Surgical unit
3) Radiology department
4) Emergency department NURSINGTB.COM
____ 3. Which is the priority in the preparedness of health-care professionals in any type of disaster plan?
1) Identification of hazards
2) Cooperation with state authorities
3) Collaboration with local authorities
4) Implementation of federal mandates
____ 4. Which treatment for anthrax should be included in the biological agent portion of a disaster plan for terrorist
attacks?
1) Antivirals
2) Antitoxins
3) Antibiotics
4) Vaccinations
____ 5. Which medication should be listed as the antidote to a nerve agent in the disaster plan for a terrorist attack?
1) Atropine
2) Dopamine
3) Epinephrine
4) Norepinephrine
____ 6. Which is the priority nursing action to include in a disaster plan for the radioactive dust and smoke that can
cause illness from a radiologic dispersal device (RDD)?
1) Covering the nose
2) Protecting the eyes
3) Decontaminating the skin
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____ 22. A green-tagged patient arrives at the emergency department after a mass casualty incident (MCI) involving
radiation. Which is the priority nursing action for this patient?
1) Implementing decontamination measures
2) Performing a head-to-toe physical examination
3) Placing a special bracelet with a disaster number
4) Taking a digital photo and placing it on the medical record
____ 23. Which entity is responsible for activating the disaster plan during a mass casualty incident (MCI)?
1) Local emergency management system
2) State emergency management system
3) Federal emergency management agency
4) Hospital-level emergency management system
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 24. Which threats, included in the term “NBC,” lead to the implementation of improved emergency medical
services (EMS) and hospital safety programs? Select all that apply.
1) Nuclear
2) Biological
3) Botulism
4) Chemical
5) Nipah virus
____ 25. A nurse is working an evening shift when a fire breaks out at the hospital. Which actions by the nurse are
appropriate? Select all that apply. NURSINGTB.COM
1) Removing patients from immediate danger
2) Discontinuing the use of oxygen for all patients
3) Using a wheelchair to move a bedridden patient
4) Directing ambulatory patients to walk to a safe location
5) Containing the fire immediately to avoid patient evacuation
____ 26. Which nursing actions are necessary when initiating care for patients who have been injured in a natural
disaster? Select all that apply.
1) Taking risks
2) Using principles
3) Stepping into the unknown
4) Showing a commanding presence
5) Formulating individualized plans of care
____ 27. Which psychosocial nursing actions are appropriate when providing patient care after a community disaster?
Select all that apply.
1) Performing triage of injuries
2) Administering first aid to wounds
3) Offering choices whenever possible
4) Establishing rapport through active listening
5) Requesting assistance from crisis counselors
____ 28. The nurse is contributing to a disaster plan for a possible terrorist attack. Which biological agents should be
included in the plan? Select all that apply.
1) Rubella
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2) Anthrax
3) Measles
4) Botulism
5) Tularemia
____ 29. Which are the most common types of injuries that should be identified along with treatment options in an
organizational disaster plan for the use of explosive devices as agents of terrorism? Select all that apply.
1) Burn
2) Blast
3) Crush
4) Penetration
5) Psychological
____ 30. Which nursing actions during a mass casualty incident should be included in the triage portion of an
organizational disaster plan? Select all that apply.
1) Treatment
2) Stabilization
3) Evaluation of interventions
4) Formulation of nursing diagnosis
5) Decontamination for suspected contamination
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 71, Mass Casualty and Disaster Preparedness
Chapter learning objective: Identifying current concepts in disaster response
Chapter page reference: 1590-1592
Heading: Current Concepts in Disaster Preparedness and Response
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Safety
Difficulty: Easy
Feedback
1 Cooperation, classification, and collaboration, while important, are not the critical
factors to determine when and how to safely evacuate during a natural disaster.
2 Cooperation, classification, and collaboration, while important, are not the critical
factors to determine when and how to safely evacuate during a natural disaster.
3 Cooperation, classification, and collaboration, while important, are not the critical
factors to determine when and how to safely evacuate during a natural disaster.
4 Communication is the critical factor among health-care professionals, state agencies,
and federal agencies to determine when and how to evacuate safety during a natural
disaster. NURSINGTB.COM
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3 Anthrax is treated effectively with antibiotics if sufficient supplies are available and the
organisms are not resistant.
4 Smallpox can be prevented or the incidence reduced by vaccination, even when first
given after exposure.
Feedback
1 Atropine should be listed as the antidote for nerve agent poisoning in the disaster plan
for a terrorist attack.
2 Dopamine, epinephrine, and norepinephrine are not medications used to treat nerve
agent poisoning.
3 Dopamine, epinephrine, and norepinephrine are not medications used to treat nerve
agent poisoning.
4
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Dopamine, epinephrine, and norepinephrine are not medications used to treat nerve
agent poisoning.
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Feedback
1 When terrorist acts occur, nurses are often required to go to an assigned site to offer aid.
When this occurs, the nurse is not covered from malpractice or negligent lawsuits.
2 Nurses who respond to injuries that occur in a neighborhood fire, roadside car accident,
or a high school sporting event are covered under the Good Samaritan Act.
3 Nurses who respond to injuries that occur in a neighborhood fire, roadside car accident,
or a high school sporting event are covered under the Good Samaritan Act.
4 Nurses who respond to injuries that occur in a neighborhood fire, roadside car accident,
or a high school sporting event are covered under the Good Samaritan Act.
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Feedback
1 An ankle sprain is a minor injury that would be tagged as green.
2 Hypovolemic shock is a life-threatening injury that requires immediate intervention and
would be tagged as red.
3 When using a triage tag system, an open femur fracture is an urgent but not life-
threatening injury that would be tagged as yellow.
4 A massive head injury is tagged black as the patient is expected to die.
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Concept: Safety
Difficulty: Easy
Feedback
1 Hospital disaster drills are priority training measures to familiarize health-care
providers with emergency response procedure.
2 Other methods that can also be used include tabletop exercises and computer
simulations; however, these methods will not provide immersive practice comparable to
well-planned drills.
3 Access to the policy is important but will not provide real world experience for
emergency response procedures.
4 Other methods that can also be used include tabletop exercises and computer
simulations; however, these methods will not provide immersive practice comparable to
well-planned drills.
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Feedback
1 A multi-casualty event, such as a motor vehicle accident involving five cars, is an event
that can often be handled with the implementation of an individual hospital disaster
plan without collaboration with other systems.
2 Any mass casualty event, such as a tornado, an act of terrorism, or a hurricane, often
requires not only the implementation of the hospital disaster plan but collaboration with
other systems.
3 Any mass casualty event, such as a tornado, an act of terrorism, or a hurricane, often
requires not only the implementation of the hospital disaster plan but collaboration with
other systems.
4 Any mass casualty event, such as a tornado, an act of terrorism, or a hurricane, often
requires not only the implementation of the hospital disaster plan but collaboration with
other systems.
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Feedback
1 There is not a significant risk for tornados, hurricanes, or earthquakes in this region of
the country.
2 There is not a significant risk for tornados, hurricanes, or earthquakes in this region of
the country.
3 Disaster drills are ideally planned based on a risk assessment or vulnerability analysis
that identifies the events most likely to occur in a particular community. For a hospital
in the Rocky Mountains, there is a significant risk for an avalanche. The nurse manager
will, therefore, recommend that avalanche planning be included in the hospital disaster
plan.
4 There is not a significant risk for tornados, hurricanes, or earthquakes in this region of
the country.
Feedback
1 While it is appropriate to have more than the minimum number of disaster drills each
year, the minimum that must be implemented per The Joint Commission (TJC)
requirements is twice per calendar year.
2 While it is appropriate to have more than the minimum number of disaster drills each
year, the minimum that must be implemented per The Joint Commission (TJC)
requirements is twice per calendar year.
3 While it is appropriate to have more than the minimum number of disaster drills each
year, the minimum that must be implemented per The Joint Commission (TJC)
requirements is twice per calendar year.
4 While it is appropriate to have more than the minimum number of disaster drills each
year, the minimum that must be implemented per The Joint Commission (TJC)
requirements is twice per calendar year.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 The nurse would use a red tag for a patient who has injuries that are an immediate
threat to life, such as hypovolemic shock, during mass casualty conditions.
2 A black tag is used for a patient who is expected and allowed to die.
3 A green tag is used for a patient with minor injuries that do not require immediate
treatment.
4 A yellow tag is used for a patient who has major injuries requiring treatment.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4 A black tag indicates the patient has suffered an extensive injury and is expected, or
allowed, to die. Typical examples of black-tagged patients are those with massive head
trauma, extensive full-thickness body burns, and high cervical spinal cord injury
requiring mechanical ventilation.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 State and federal emergency management systems may contact hospitals for
notification purposes of a mass casualty incident.
3 State and federal emergency management systems may contact hospitals for
notification purposes of a mass casualty incident.
4 Each hospital has its own policy that specifies who has the authority to activate and how
to activate the disaster or emergency preparedness plan.
MULTIPLE RESPONSE
24. ANS: 1, 2, 4
Chapter number and title: 71, Mass Casualty and Disaster Preparedness
Chapter learning objective: Identifying current concepts in disaster response
Chapter page reference: 1590-1592
Heading: Current Concepts in Disaster Preparedness and Response
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Health Care System
Difficulty: Easy
Feedback
1. This is correct. The term “NBC” was coined to describe nuclear, biological, and chemical
NUR
threats. In response, emergency SINGservices
medical TB.CO M agencies and hospitals improved
(EMS)
safety by upgrading their decontamination facilities, equipment, and all levels of personal
protective equipment to better protect staff.
2. This is correct. The term “NBC” was coined to describe nuclear, biological, and chemical
threats. In response, emergency medical services (EMS) agencies and hospitals improved
safety by upgrading their decontamination facilities, equipment, and all levels of personal
protective equipment to better protect staff.
3. This is incorrect. Botulism and nipah virus are two specific examples of biological threats.
4. This is correct. The term “NBC” was coined to describe nuclear, biological, and chemical
threats. In response, emergency medical services (EMS) agencies and hospitals improved
safety by upgrading their decontamination facilities, equipment, and all levels of personal
protective equipment to better protect staff.
5. This is incorrect. Botulism and nipah virus are two specific examples of biological threats.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Difficulty: Moderate
Feedback
1. This is correct. According to the fire safety portion of the emergency response for internal
disasters, the nurse should remove patients from immediate danger, use a wheelchair to
move bedridden patients, and direct ambulatory patients to walk to a safe location.
2. This is incorrect. The nurse should discontinue oxygen for patients who can breathe without
it but not for all patients.
3. This is correct. According to the fire safety portion of the emergency response for internal
disasters, the nurse should remove patients from immediate danger, use a wheelchair to
move bedridden patients, and direct ambulatory patients to walk to a safe location.
4. This is correct. According to the fire safety portion of the emergency response for internal
disasters, the nurse should remove patients from immediate danger, use a wheelchair to
move bedridden patients, and direct ambulatory patients to walk to a safe location.
5. This is incorrect. The nurse should seek to contain the fire only after everyone is out of
danger and there is no risk of injury for self or others.
Feedback
1. This is correct. Nursing actions that are required when initiating care for patients who have
been injured in a natural disaster include taking risks, using principles, stepping into the
unknown, and showing a commanding presence.
2. This is correct. Nursing actions that are required when initiating care for patients who have
been injured in a natural disaster include taking risks, using principles, stepping into the
unknown, and showing a commanding presence.
3. This is correct. Nursing actions that are required when initiating care for patients who have
been injured in a natural disaster include taking risks, using principles, stepping into the
unknown, and showing a commanding presence.
4. This is correct. Nursing actions that are required when initiating care for patients who have
been injured in a natural disaster include taking risks, using principles, stepping into the
unknown, and showing a commanding presence.
5. This is incorrect. Formulating individualized plans of care is not a nursing action that is
appropriate when providing care to patients who have been injured in a natural disaster.
This step is implemented later in the patient’s care.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback
1. This is incorrect. Performing triage of injuries and administering first aid to wounds are not
psychosocial nursing actions.
2. This is incorrect. Performing triage of injuries and administering first aid to wounds are not
psychosocial nursing actions.
3. This is correct. Psychosocial nursing actions appropriate when providing care after a
community disaster include offering choices whenever possible, establishing rapport
through active listening, and requesting assistance from crisis counselors.
4. This is correct. Psychosocial nursing actions appropriate when providing care after a
community disaster include offering choices whenever possible, establishing rapport
through active listening, and requesting assistance from crisis counselors.
5. This is correct. Psychosocial nursing actions appropriate when providing care after a
community disaster include offering choices whenever possible, establishing rapport
through active listening, and requesting assistance from crisis counselors.
Feedback
1. This is incorrect. Measles and rubella are not biological agents commonly used in terrorist
attacks; therefore, these would not be included in a disaster plan for terrorist attacks.
2. This is correct. Biological agents most commonly used in terrorist attacks include anthrax,
smallpox, botulism, plague, tularemia, and hemorrhagic fever.
3. This is incorrect. Measles and rubella are not biological agents commonly used in terrorist
attacks; therefore, these would not be included in a disaster plan for terrorist attacks.
4. This is correct. Biological agents most commonly used in terrorist attacks include anthrax,
smallpox, botulism, plague, tularemia, and hemorrhagic fever.
5. This is correct. Biological agents most commonly used in terrorist attacks include anthrax,
smallpox, botulism, plague, tularemia, and hemorrhagic fever.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
29. ANS: 2, 3, 4
Chapter number and title: 71, Mass Casualty and Disaster Preparedness
Chapter learning objective: Describing the many types of disasters and their impact
Chapter page reference: 1579-1590
Heading: Overview of Disasters
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Safety
Difficulty: Moderate
Feedback
1. This is incorrect. Burn injury and psychological injuries are possible; however, these are not
the most common injuries that result when explosive devices are used as agents of
terrorism.
2. This is correct. Blast, crush, and penetration injuries are most common when explosive
devices are used as an agent of terrorism. These injuries should be identified in the
organizational disaster plan along with appropriate treatment options for each.
3. This is correct. Blast, crush, and penetration injuries are most common when explosive
devices are used as an agent of terrorism. These injuries should be identified in the
organizational disaster plan along with appropriate treatment options for each.
4. This is correct. Blast, crush, and penetration injuries are most common when explosive
devices are used as an agent of terrorism. These injuries should be identified in the
organizational disaster plan along with appropriate treatment options for each.
5. This is incorrect. Burn injury and psychological injuries are possible; however, these are not
the most common injuries that NUresult
RSIwhen
NGTexplosive
B.COM devices are used as agents of
terrorism.
Feedback
1. This is correct. Victims need to be treated and stabilized and, if there is known or suspected
contamination, decontaminated at the scene.
2. This is correct. Victims need to be treated and stabilized and, if there is known or suspected
contamination, decontaminated at the scene.
3. This is incorrect. Evaluation of interventions and formulation of nursing diagnoses is not
implemented until the patient is admitted to the hospital.
4. This is incorrect. Evaluation of interventions and formulation of nursing diagnoses is not
implemented until the patient is admitted to the hospital.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5. This is correct. Victims need to be treated and stabilized and, if there is known or suspected
contamination, decontaminated at the scene.
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