Adult Health Care 7th edition By Cooper-Test Bank

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Adult Health Care 7th edition By Cooper-Test Bank

Chapter 2: Care of the Surgical Patient

 

MULTIPLE CHOICE

 

  1. The patient who had a nephrectomy yesterday has not used the patient-controlled analgesia (PCA) delivery system but admits to being in pain but fearful of addiction. What is the nurse’s best response?
a. “Modern analgesic drugs do not cause addiction.”
b. “Pain relief is worth a short period of addiction.”
c. “Addiction rarely occurs in the brief time postsurgical analgesia is required.”
d. “Addiction could be a real concern.”

 

 

ANS:  C

Addiction rarely occurs in the short time that it is required after surgery. Postsurgical analgesia, because of its brief application, does not usually produce a physical or a psychological dependence.

 

DIF:    Cognitive Level: Application          REF:   Page 34          OBJ:   13

TOP:   Fear of addiction                            KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A 73-year-old patient with diabetes was admitted for below-the-knee amputation of his right leg. Removal of his right leg is an example of which type of surgery?
a. Palliative
b. Diagnostic
c. Reconstructive
d. Ablative

 

 

ANS:  D

Ablative is a type of surgery where an amputation, excision of any part of the body, or removal of a growth and harmful substance is performed.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 16, Table 2-1

OBJ:   2                    TOP:   Types of surgeries

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. In which situation might surgery be delayed?
a. The patient has taken Dilantin today.
b. An illegible signature is on the consent form..
c. The patient is still taking anticoagulants.
d. The admission office is unable to confirm insurance coverage.

 

 

ANS:  C

All medications should be cancelled before surgery, except for drugs such as phenytoin (Dilantin). Anticoagulant therapy increases the threat of hemorrhage and may be a cause for delay.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 34, Page 36 Table 2-6

OBJ:   7                    TOP:   Anticoagulant therapy

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. Which circumstance could prevent the patient from signing his informed consent for a cholecystectomy?
a. The patient complains of pain radiating to the scapula.
b. The patient received an injection of Demerol, 75 mg IM, 1 hour ago.
c. The patient is 85 years of age.
d. The patient is concerned over his lack of insurance coverage.

 

 

ANS:  B

Informed consent should not be obtained if the patient is disoriented and under the influence of sedatives. Age, illegibility, and lack of insurance coverage do not prevent signing the consent. Pain into the scapula is a symptom of colitis.

 

DIF:    Cognitive Level: Application          REF:   Page 23          OBJ:   7

TOP:   Informed consent                           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse anticipates that the patient will be given ______________anesthesia because of the extensive tissue manipulation involved in a hysterectomy.
a. general
b. regional
c. specific
d. preoperative

 

 

ANS:  A

An anesthesiologist gives general anesthetics by IV and inhalation routes through four stages of anesthesia when the procedure requires extensive tissue manipulation.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 34          OBJ:   9

TOP:   Anesthesia     KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse caring for a patient who had an epidural block for a vaginal repair should be alert for:
a. a flushing of the face and torso.
b. numbness of the perineum.
c. complaint of thirst.
d. a sudden drop in blood pressure.

 

 

ANS:  D

Epidural anesthesia may cause a sudden drop in blood pressure or respiratory difficulty as the anesthetic agent moves up in the spinal cord. Elevating the patient’s torso may prevent respiratory paralysis.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 37          OBJ:   9

TOP:   Epidural block                                          KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. Why might the older adult patient not respond to surgical treatment as well as a younger adult patient?
a. Poor skin turgor
b. Fear of the unknown
c. Response to physiological changes
d. Decreased peristalsis related to anesthesia

 

 

ANS:  C

Of specific concern in older adults is the body’s response to temperature changes, cardiovascular shifts, respiratory needs, and renal function. Fear of the unknown and decreased peristalsis are common to all ages.

 

DIF:    Cognitive Level: Application          REF:   Page 17          OBJ:   5

TOP:   Older adult patients                        KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The postoperative nursing intervention that would be contraindicated for a 45-year-old patient who has had a repair of a cerebral aneurysm and is presenting signs of increased intracranial pressure (ICP) would be:
a. coughing every 2 hours.
b. turning every 2 hours.
c. monitoring intravenous therapy at 50 ml/hr.
d. assessing vital signs every 2 hours.

 

 

ANS:  A

Coughing increases ICP.

 

DIF:    Cognitive Level: Analysis               REF:   Page 28, Box 2-6

OBJ:   12                  TOP:   Postoperative complications

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse acting as a circulating nurse has a responsibility for:
a. observing for breaks in sterile technique.
b. identifying and handling surgical specimens correctly.
c. assisting with surgical draping of the patient.
d. maintaining count of sponges, needles, and instruments during surgery.

 

 

ANS:  A

The circulating nurse is responsible for observing breaks in sterile technique. The scrub nurse handles the surgical specimens, drapes the patient, and maintains needle and sponge count during surgery, then does a final sponge and needle check with the circulating nurse before closing.

 

DIF:    Cognitive Level: Analysis               REF:   Page 43, Box 2-7

OBJ:   11                  TOP:   Duties of circulating nurse

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Safe, Effective Care Environment

 

  1. Which statement made by a patient during a preoperative assessment would be significant to report to the charge nurse and surgeon?
a. “I have been taking an herbal product of feverfew for my migraines.”
b. “I exercise for 3 hours a day.”
c. “I drink 2 glasses of wine a day.”
d. “I use atropine eyedrops every day.”

 

 

ANS:  A

The herbal remedy of feverfew acts as an anticoagulant and increases the possibility of hemorrhage. The drug should be stopped before surgery, and bleeding and clotting times should be evaluated.

 

DIF:    Cognitive Level: Application          REF:   Page 21, Table 2-3

OBJ:   14                  TOP:   Preoperative assessment

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. A patient is on postoperative day 2 after a nephrectomy. What is the most effective way to increase her peristalsis?
a. Ambulation
b. An enema
c. Encouraging hot liquids
d. Administering a laxative

 

 

ANS:  A

Encouraging activity (turning every 2 hours, early ambulation) assists GI activity.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 50          OBJ:   13

TOP:   Postoperative complications           KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. A patient is transferred from the operating room to the recovery room after undergoing an open reduction and internal fixation (ORIF) of his left ankle. Which is the first assessment to make?
a. Check ankle dressings for hemorrhage.
b. Check airway for patency.
c. Check intravenous site.
d. Check pedal pulse.

 

 

ANS:  B

Evaluation of the patient follows the ABCs of immediate postoperative observation: airway, breathing, consciousness, and circulation.

 

DIF:    Cognitive Level: Application          REF:   Pages 42-43, Table 2-7

OBJ:   12                  TOP:   Nursing assessment

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Frequent assessment of a postoperative patient is essential. What is one of the first signs and symptoms of hemorrhage?
a. Increasing blood pressure
b. Decreasing pulse
c. Restlessness
d. Weakness, apathy

 

 

ANS:  C

A pulse that increases and becomes thready combined with a declining blood pressure, cool and clammy skin, reduced urine output, and restlessness may signal hypovolemic shock.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 45, Box 2-8

OBJ:   12                  TOP:   Postoperative complications

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. The nurse instructing a postsurgical patient in the use of thrombolytic deterrent stockings would include which of the following instructions?
a. Disregard appearance of edema above the stocking
b. Massage legs to smooth wrinkles out of stockings
c. Wring stockings thoroughly before hanging to dry
d. Wash stockings in warm water and mild soap

 

 

ANS:  D

Stockings should be washed gently in warm water and mild soap and laid over a surface to dry. They should not be wrung out or hung. Massaging legs may dislodge a clot and the appearance of edema indicates the stockings are too restrictive.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 31, Patient Teaching Box

OBJ:   13                  TOP:   Thrombolytic deterrent stockings

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The patient is brought into PACU still unconscious. What should the nurse do when the nurse assesses an oral temperature of 94° F?
a. Notify the charge nurse immediately
b. Offer warm fluids through a straw
c. Do nothing, this is a normal reaction to anesthesia
d. Cover with a warm blanket

 

 

ANS:  D

Hypothermia is a frequent assessment postsurgery. A warm blanket or a ventilated cover would be applied to bring up the temperature. Vital signs are checked every 15 minutes until stable.

 

DIF:    Cognitive Level: Analysis               REF:   Page 43, Page 45 Table 2-8

OBJ:   13                  TOP:   Hypothermia

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Physiological Integrity

 

  1. In which location are guidelines for ensuring that all nursing interventions on the day of surgery completed and documented?
a. In the nurse’s notes
b. In the anesthesia record
c. In the preoperative checklist
d. In the progress notes

 

 

ANS:  C

When the nurse signs the preoperative checklist, that nurse assumes responsibility for all areas of care included on the list.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 40          OBJ:   6

TOP:   Preoperative checklist                     KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. While turning a patient who had a bowel resection yesterday, the wound eviscerated. What is the initial nursing intervention?
a. Place the patient in the high Fowler’s position.
b. Give the patient fluids to prevent shock.
c. Replace the dressing with sterile fluffy pads.
d. Apply a warm, moist normal saline sterile dressing.

 

 

ANS:  D

Cover the wound with a sterile towel moistened with sterile physiological saline (warm).

 

DIF:    Cognitive Level: Application          REF:   Pages 46-47, Figure 2-13

OBJ:   13                  TOP:   Evisceration   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. When should the nurse offer prescribed analgesics to a patient who is 24 hours postoperative?
a. Only when the patient asks.
b. When the onset of pain is assessed.
c. Sparingly to avoid drug dependence.
d. Only when severe pain is assessed.

 

 

ANS:  B

The nurse should assess for pain frequently to medicate at the onset of pain.

 

DIF:    Cognitive Level: Application          REF:   Page 48          OBJ:   14

TOP:   Medication administration              KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. What should the nurse do to minimize the potential for venous stasis?
a. Place pillows under the knee in a position of comfort
b. Assist patient to sit with feet flat on the floor
c. Assist with early ambulation
d. Perform gentle leg massage

 

 

ANS:  C

Early ambulation has been a significant factor in hastening postoperative recovery and preventing postoperative complications.

 

DIF:    Cognitive Level: Application          REF:   Page 49          OBJ:   13

TOP:   Venous stasis                                  KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse clarifies that serum potassium levels are determined before surgery to:
a. assess kidney function.
b. determine respiratory insufficiency.
c. prevent arrhythmias related to anesthesia.
d. measure functional liver capability.

 

 

ANS:  C

Serum electrolytes are evaluated if extensive surgery is planned or the patient has extenuating problems. One of the essential electrolytes examined is potassium; if potassium is not available in adequate amounts, arrhythmias can occur during anesthesia.

 

DIF:    Cognitive Level: Analysis               REF:   Page 23          OBJ:   4

TOP:   Preoperative assessment                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. In performing the preoperative assessment, the nurse discovers that the patient is allergic to latex. What should the nurse do initially?
a. Notify the diet kitchen to omit peaches from diet tray
b. Apply a medical alert band to patient’s wrist
c. Tag chart with allergy alert
d. Place patient in an isolation room

 

 

ANS:  B

The initial intervention would be to place a medical alert band on the patient, then tag the chart. The charge nurse and the surgeon should be notified in the event the surgeon wants to order a preoperative prophylactic treatment.

 

DIF:    Cognitive Level: Knowledge          REF:   Pages 25-26, Box 2-5

OBJ:   13                  TOP:   Latex allergy

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. Which of the following early postoperative observations should be reported immediately?
a. “Coffee ground” emesis
b. Shivering
c. Scanty urine output
d. Evidence of pain

 

 

ANS:  A

Any emesis that is red or coffee ground should be reported immediately as it indicates GI bleeding. Shivering, scanty urine output, and evidence of pain are within normal expectation of a postsurgical patient.

 

DIF:    Cognitive Level: Application          REF:   Page 45          OBJ:   10

TOP:   Postoperative assessment                KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. When the postoperative patient complains of sudden chest pain combined with dyspnea, cyanosis, and tachycardia, the nurse recognizes the signs of:
a. hypovolemic shock.
b. dehiscence.
c. atelectasis.
d. pulmonary embolus.

 

 

ANS:  D

Sudden chest pain combined with dyspnea, tachycardia, cyanosis, diaphoresis, and hypotension is a sign of pulmonary embolism.

 

DIF:    Cognitive Level: Analysis               REF:   Page 47          OBJ:   13

TOP:   Assessment and postoperative complications

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. The removal of a nondiseased appendix during a hysterectomy is classified as:
a. major, emergency, diagnostic
b. major, urgent, palliative
c. minor, elective, ablative
d. minor, urgent, reconstructive

 

 

ANS:  C

Surgery is classified as elective, urgent, or emergency. Surgery is performed for various purposes, which include diagnostic studies, ablation (an amputation or excision of any part of the body or removal of a growth or harmful substance), and palliative (therapy to relieve or reduce intensity of uncomfortable symptoms without cure), reconstructive, transplant, and constructive purposes.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 16, Table 2-1

OBJ:   2                    TOP:   Types of surgery

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Physiological Integrity

 

  1. Which medication would cause surgery to be delayed if it had not been discontinued several days before surgery?
a. Analgesic agent
b. Antihypertensive agent
c. Anticoagulant agent
d. Antibiotic agent

 

 

ANS:  C

Anticoagulants alter normal clotting factors and thus increase risk of hemorrhaging. They should be discontinued for 48 hours before surgery.

 

DIF:    Cognitive Level: Analysis               REF:   Page 36, Table 2-6

OBJ:   4                    TOP:   Individual’s ability to tolerate surgery

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Physiological Integrity

 

  1. The most appropriate intervention by the nurse to decrease the pain of an abdominal incision while coughing would be to:
a. Support the surgical site with a pillow
b. Position patient in a side-lying position
c. Medicate with prescribed narcotic before coughing
d. Ask the patient to cross arms over the chest to increase force of cough

 

 

ANS:  A

To ease the pressure on the incision, the nurse helps the patient support the surgical site with a pillow, rolled bath blanket, or the heel of the hand.

 

DIF:    Cognitive Level: Application          REF:   Page 47          OBJ:   8

TOP:   Postoperative nursing interventions

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Physiological Integrity

 

  1. The nurse would include the nursing diagnosis of deficient knowledge, postoperative, when the patient scheduled for a bowel resection tomorrow remarks:
a. “I am going to have adequate pain medication after surgery.”
b. “I know you all are going to make me cough and walk soon after surgery.”
c. ”I am glad I will get to go home tomorrow evening.”
d. “I will have to put up with dressing changes.”

 

 

ANS:  C

The patient’s lack of understanding about the length of time in the hospital following such a serious surgery indicates a knowledge deficit that needs to be addressed.

 

DIF:    Cognitive Level: Analysis               REF:   Page 52, Box 2-11

OBJ:   16                  TOP:   Nursing process/diagnosis

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Safe, Effective Care Environment

 

  1. What instruction should a nurse give when teaching the patient to cough effectively after surgery?
a. Breathe through the nose, hold breath, and exhale slowly.
b. Take three deep breaths and cough from the chest.
c. Inhale while contracting the abdominal muscles and exhale while contracting the diaphragm.
d. Take short, frequent panting breaths and cough from the throat to clear accumulated mucus.

 

 

ANS:  B

Because lung ventilation is vital, the nurse assists the patient to turn, cough, and breathe deeply every 1 to 2 hours until the chest is clear. Having practiced this combination preoperatively, the patient is usually adequately able to remove trapped mucus and surgical gases.

 

DIF:    Cognitive Level: Application          REF:   Page 29, Skill 2-3

OBJ:   8                    TOP:   Prevention of postoperative complications

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What is the responsibility of the nurse as a witness to informed consent?
a. Explain the surgical options
b. Explain the operative risks
c. Verify/obtain the patient’s signature
d. Verify the patient’s understanding of the procedure

 

 

ANS:  C

A witness is only verifying that this is the person who signed the consent and that it was a voluntary consent. The witness (often a nurse) is not verifying that the patient understands the procedure.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 23          OBJ:   7

TOP:   Informed consent                           KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. On the patient’s return to the medical-surgical unit, the nurse performing an abdominal assessment can affirm an absence of bowel sounds after listening in each quadrant for at least:
a. 30 seconds.
b. 1 minute.
c. 2 minutes.
d. 3 minutes.

 

 

ANS:  D

Normal peristalsis is gauged by hearing 5 to 30 gurgles per minute. Absence of bowel sounds may be recorded if the nurse has listened to each quadrant 3 to 5 minutes.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 50          OBJ:   12

TOP:   Bowel sounds                                           KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. When the patient asks the nurse to make sure no one sees her with her dentures out, the nurse recognizes the common preoperative fear of:
a. anesthesia.
b. loss of control.
c. fear of separation from family.
d. mutilation.

 

 

ANS:  B

Fear of loss of control may be partially related to concerns about anesthesia, but this patient’s concern is about self-image. Preoperative anxiety from any cause may affect the amount of anesthesia and postoperative analgesia needed.

 

DIF:    Cognitive Level: Assessment          REF:   Page 20, Box 2-4

OBJ:   4                    TOP:   Nursing diagnosis

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Health Promotion and Maintenance

 

  1. What is the ideal time for preoperative teaching?
a. Immediately before surgery to eliminate fear
b. 2 months in advance so the patient can prepare
c. 1 to 2 days before the surgery when anxiety is not as high
d. In the surgical holding area

 

 

ANS:  C

Preoperative teaching is provided 1 to 2 days prior to surgery when anxiety is low.

 

DIF:    Cognitive Level: Implementation    REF:   Page 22          OBJ:   4

TOP:   Preoperative teaching                                KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. In preparation for the return of the surgical patient, the patient’s bed and equipment should be in what position?
a. Lowest position with side rails elevated with oxygen and suction equipment available
b. Highest position with side rails elevated with IV pole and pump at bedside
c. Lowest position with side rails down on the receiving side
d. Highest position with the side rails down on receiving side and up on opposite side

 

 

ANS:  D

In preparation for the return of the surgical patient, the patient’s bed should be in the highest position to be level with the surgical gurney and should have the side rail down on the receiving side, with the opposite side rail up to prevent the patient from falling out of bed during transfer.

 

DIF:    Cognitive Level: Implementation    REF:   Page 40          OBJ:   12

TOP:   Postoperative preparation               KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. A postoperative patient who had a left inguinal hernia repair is ready for his discharge instructions. Which information should the nurse provide? (Select all that apply.)
a. Care of the wound site and any dressings
b. When he may operate a motor vehicle
c. Signs and symptoms to report to the physician
d. Call the physician’s office once he arrives home
e. Report bowel movements to the physician
f. Actions and side effects of any medications

 

 

ANS:  A, B, C, F

As the day of discharge approaches, the nurse should be certain that the patient has vital information.

 

DIF:    Cognitive Level: Analysis               REF:   Page 53, Box 2-13

OBJ:   15                  TOP:   Discharge instructions

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Safe, Effective Care Environment

 

  1. Which of the following are considerations for the older adult surgical patient? (Select all that apply.)
a. The need for specific clear preoperative and postoperative teaching
b. Awareness of lower morbidity and mortality rate
c. Presence of coexisting conditions
d. Increased risk of respiratory complications
e. Expectation of normal recovery time

 

 

ANS:  A, C, D

Surgery places greater stress on older than on younger patients. Teaching should be given at the older person’s level of understanding. Teaching should be specific and clear. Presence of coexisting conditions may delay recovery time and response to surgery.

 

DIF:    Cognitive Level: Application          REF:   Page 17, Life Span Considerations

OBJ:   7                    TOP:   Older adult considerations

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following are preoperative conditions that may affect the patient’s response to surgery? (Select all that apply.)
a. Age
b. Religion
c. Mental status
d. Occupation
e. Nutritional status

 

 

ANS:  A, C, E

Each system of the body is affected by the patient’s age, health, nutritional status, and mental state. Religion and occupation do not affect the physiological response to the surgery.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 17          OBJ:   4

TOP:   Factors influencing toleration to surgery

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Which interventions in preparing the patient for abdominal surgery may be delegated to  unlicensed assistive personnel (UAP)?
a. Vital signs
b. Insertion of N/G tube
c. Enema
d. Height and weight
e. Obtaining operative consent
f. Sterile gowning

 

 

ANS:  A, C, D

Vital signs, enema, and height and weight can be safely performed by UAP. Insertion of an N/G tube, obtaining an operative consent, and sterile gloving are interventions requiring critical thinking and knowledge unique to a nurse.

 

DIF:    Cognitive Level: Application          REF:   Page 18, Box 2-2

OBJ:   3                    TOP:   Delegation     KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

COMPLETION

 

  1. ______________ therapy is performed to alleviate or decrease uncomfortable symptoms without curing the problem.

 

ANS:

Palliative

 

Palliative therapy is designed to relieve or reduce intensity of uncomfortable symptoms without cure.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 16, Table 2-1

OBJ:   1                    TOP:   Palliative therapy

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Safe, Effective Care Environment

 

  1. Discharge planning for a surgical procedure begins in the ______________ period and continues through the _____________ period.

 

ANS:

preoperative, recuperative

 

When discharge planning is begun in the preoperative period and all through the postoperative period, the patient can assume greater responsibility for self-care and will experience less stress about going home.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 52          OBJ:   15

TOP:   Discharge planning                         KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The type of anesthesia that uses a combination of drugs to reduce the level of consciousness and provides amnesia is _________________  __________.

 

ANS:

conscious sedation

 

Conscious sedation uses a combination of drugs to produce a reduced level of consciousness and amnesia, as well as pain control, but allows the patient to control his or her own breathing. The recovery is more rapid than with general anesthesia.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 48          OBJ:   10

TOP:   Conscious sedation                         KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is aware that there is a loss of _________ during catabolism after severe tissue injury.

 

ANS:

potassium

 

The injured cells loose potassium as catabolism (tissue breakdown) occurs.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 51          OBJ:   13

TOP:   Catabolism     KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse explains that to promote deep breathing and improve lung expansion and oxygenation the patient should use the _____________ ______________ at regular intervals during the day.

 

ANS:

incentive spirometer

 

The incentive spirometer is a device to encourage deep breathing and lung expansion. The usual rate of usage is 8 to 10 breaths hourly during waking hours.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 26          OBJ:   13

TOP:   Incentive spirometer                       KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse caring for a postsurgical patient is aware that the patient should void ____ to _____ hours postsurgery.

 

ANS:

6 to 8

6, 8

 

Urinary output should be obvious 6 to 8 hours postsurgery. If urinary output has not begun, a catheter may be inserted.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 48          OBJ:   13

TOP:   Resumption of urinary flow           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

OTHER

 

  1. A patient is transferred from the operating room to the recovery room after undergoing an amputation of his left foot. Place the interventions in the correct order for immediate assessment once the patient enters the PACU. (Separate letters by a comma and space as follows: A, B, C, D)

 

  1. System review
  2. Breathing
  3. Circulation
  4. Airway
  5. Level of consciousness

 

ANS:

D, B, E, C, A

 

The assessment of an adequate airway is primary in the postanesthesia assessment, followed by breathing assessment, level of consciousness, circulation, and finally system review.

 

DIF:    Cognitive Level: Application          REF:   Page 44, Table 2-7

OBJ:   12                  TOP:   Nursing assessment

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Place the instructions for controlled coughing in the correct sequence. (Separate letters by a comma and space as follows: A, B, C, D)

 

  1. Inhale deeply and hold breath for a count of three
  2. Document exercise and patient reaction
  3. Cough 2 or 3 times without inhaling then relax
  4. Take several deep breaths
  5. Inhale through nose
  6. Exhale through pursed lips

 

ANS:

D, E, F, A, C, B

 

The patient should be instructed to take several deep breaths, inhale through the nose, exhale through pursed lips, inhale deeply and hold for a count of three, cough two or three times without exhaling, relax. The procedure may be repeated before documentation.

 

DIF:    Cognitive Level: Application          REF:   Pages 29-30, Skill 2-3

OBJ:   13                  TOP:   Controlled coughing

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

Chapter 8: Care of the Patient with a Cardiovascular or a Peripheral Vascular Disorder

 

MULTIPLE CHOICE

 

  1. The nurse is aware that the muscle layer of the heart, which is responsible for the heart’s contraction, is the:
a. endocardium.
b. pericardium.
c. mediastinum.
d. myocardium.

 

 

ANS:  D

The myocardium is the specialized muscle layer that allows the heart to contract.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 308        OBJ:   2

TOP:   Myocardium  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse clarifies that the master pacemaker of the heart is the:
a. left ventricle.
b. atrioventricular (AV) node.
c. sinoatrial (SA) node.
d. bundle of His.

 

 

ANS:  C

The SA node is the master pacemaker of the heart.

 

DIF:    Cognitive Level: Application          REF:   Page 308        OBJ:   10

TOP:   Acute myocardial infarction           KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is aware that the symptoms of an impending myocardial infarction (MI) differ in women because acute chest pain is not present. Women are frequently misdiagnosed as having:
a. hepatitis A.
b. indigestion.
c. urinary infection.
d. menopausal complications.

 

 

ANS:  B

Indigestion, gallbladder attack, anxiety attack, and depression are frequent misdiagnoses for women having an MI.

 

DIF:    Cognitive Level: Application          REF:   Page 334        OBJ:   16

TOP:   MIs in women                                           KEY:              Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse identifies the “LUBB” sound of the “LUBB/DUBB” of the cardiac cycle as the sound of the:
a. AV valves closing.
b. closure of the semilunar valves.
c. contraction of the papillary muscles.
d. contraction of the ventricles.

 

 

ANS:  A

The LUBB is the first sound of a low pitch heard when the AV valves close.

 

DIF:    Cognitive Level: Application          REF:   Page 310        OBJ:   4

TOP:   Lubb sound    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient is admitted from the emergency department. The emergency department physician notes the patient has a diagnosis of heart failure with a New York Heart Association (NYHA) classification of IV. This indicates the patient’s condition as:
a. moderate heart failure.
b. severe heart failure.
c. congestive heart failure.
d. negligible heart failure.

 

 

ANS:  B

Class IV: Severe; patient unable to perform any physical activity without discomfort. Angina or symptoms of cardiac inefficiency may develop at rest.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 340, Box 8-3

OBJ:   9                    TOP:   Classification of heart failure

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. The nurse assesses that the home health patient has no signs or symptoms of heart failure, but does have a history of rheumatic fever and has been recently diagnosed with diabetes mellitus. The nurse is aware that using the American College of Cardiology and the American Heart Association (ACC/AHA) staging, this patient would be a:
a. stage A.
b. stage B.
c. stage C.
d. stage D.

 

 

ANS:  A

The ACC/AHA staging describes stage A as a person without symptoms of heart failure, but with primary conditions associated with the development of the disease.

 

DIF:    Cognitive Level: Analysis               REF:   Page 340, Box 8-3

OBJ:   9                    TOP:   Heart failure  KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse caring for a patient recovering from a myocardial infarct who is on remote telemetry recognizes the need for added instruction when the patient says:
a. “I can ambulate in the hallway with this gadget on.”
b. “I always take off the telemetry device when I shower.”
c. “My EKG is being watched by one of the nurses in CCU on the home unit.”
d. “I am able to sleep just fine with this device on.”

 

 

ANS:  B

Remote telemetry allows the patient to be on a separate unit, but be monitored in a central location. The patients can be ambulatory and can sleep with the monitor on. They should not remove the monitor to shower.

 

DIF:    Cognitive Level: Application          REF:   Page 314        OBJ:   6

TOP:   Remote telemetry                           KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse assesses pitting edema that can be depressed approximately  inch and refills in 15 seconds. The nurse would document this assessment as:
a. +1 edema.
b. +2 edema.
c. +3 edema.
d. +4 edema.

 

 

ANS:  B

A +2 edema can be documented if the skin can be depressed  inch and respond within 15 seconds.

 

DIF:    Cognitive Level: Analysis               REF:   Page 340, Table 8-5

OBJ:   9                    TOP:   Pitting edema

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. What do dark or “cold” spots on a thallium scan indicate?
a. Tissue with adequate blood supply
b. Dilated vessels
c. Areas of neoplastic growth
d. Tissue that has inadequate perfusion

 

 

ANS:  D

Thallium scans show adequate perfused areas by the collection of thallium. Dark spots or “cold spots” indicate tissues that have inadequate perfusion.

 

DIF:    Cognitive Level: Application          REF:   Page 314        OBJ:   6

TOP:   Thallium scan                                           KEY:              Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse recognizes the echocardiogram report that shows an ejection factor of 42% as an indication of:
a. normal heart action.
b. mild heart failure.
c. moderate heart failure.
d. severe heart failure.

 

 

ANS:  C

An ejection factor (cardiac output) of 42% indicates moderate heart failure.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 315        OBJ:   6

TOP:   Heart failure   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse takes into consideration that age-related changes can affect the peripheral circulation because of:
a. sclerosed blood vessels.
b. hypotension.
c. inactivity.
d. poor nutrition.

 

 

ANS:  A

Aging causes sclerotic changes in the blood vessels that lead to decreased elasticity and narrowing of the vessel lumen.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 317, Life Span Considerations

OBJ:   16                  TOP:   Endocarditis   KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse assessing a cardiac monitor notes that the cardiac complexes each have a P wave followed by a QRS and a T. The rate is 120. The nurse recognizes this arrhythmia as:
a. sinus bradycardia.
b. atrial fibrillation.
c. sinus tachycardia.
d. ventricular tachycardia.

 

 

ANS:  C

Sinus tachycardia has a P wave followed by the QRS and the T. All the components of the complex are present and in the correct order, but the rate is over 100 beats a minute.

 

DIF:    Cognitive Level: Application          REF:   Page 320        OBJ:   8

TOP:   Arrhythmias   KEY:  Nursing Process Step: I Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. After an influenza-like illness, the patient complains of chills and small petechiae in his mouth and his legs. A heart murmur is detectable. These are characteristic signs of:
a. congestive heart failure.
b. heart block.
c. aortic stenosis.
d. infective endocarditis.

 

 

ANS:  D

Collection of subjective data includes noting patient complaints of influenza-like symptoms with recurrent fever, undue fatigue, chest pain, and chills. Objective data may reveal the significant signs of petechiae in the conjunctiva and mouth. Both subjective data and objective data are indicative of infective endocarditis.

 

DIF:    Cognitive Level: Analysis               REF:   Page 351        OBJ:   13

TOP:   Endocarditis   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse notes a run of three ventricular contractions (PVC) that are not preceded by a P wave. This particular arrhythmia can progress into:
a. atrial fibrillation and possible emboli.
b. sinus tachycardia and syncope.
c. ventricular tachycardia and death.
d. sinus bradycardia and fatigue.

 

 

ANS:  C

PVCs are capable of progressing into ventricular tachycardia and death.

 

DIF:    Cognitive Level: Application          REF:   Page 322        OBJ:   10

TOP:   PVCs              KEY:  Nursing Process Step: I Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse reminds the patient who is on Coumadin for the treatment of atrial fibrillation that the ideal is to maintain the international normalized ratio (INR) at between:
a. 1 and 2.
b. 2 and 3.
c. 3 and 4.
d. 4 and 5.

 

 

ANS:  B

The desired INR for the monitoring of anticoagulant therapy is between 2 and 3.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 321        OBJ:   8

TOP:   INR                KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What should a person with unstable angina avoid?
a. Walking outside
b. Eating red meat
c. Swimming in warm pool
d. Shoveling snow

 

 

ANS:  D

The person with angina should avoid exposure to cold, heavy exercise, eating heavy meals, and emotional stress.

 

DIF:    Cognitive Level: Application          REF:   Page 327        OBJ:   9

TOP:   Angina           KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The elderly patient with angina pectoris says she is unsure how she should take nitroglycerin when she has an attack. The nurse’s most helpful response would be:
a. “Continue to take nitroglycerin sublingually at 5-minute intervals until the pain is relieved.”
b. “If the pain is not relieved after three doses of nitroglycerin at 5-minute intervals, call your physician and come to the hospital.”
c. “When nitroglycerin is not relieving the pain, lie down and rest.”
d. “Use oxygen at home to relieve pain when nitroglycerin is not successful.”

 

 

ANS:  B

Administer prescribed nitroglycerin. Repeat every 5 minutes, three times. If pain is unrelieved, notify the physician. Nitroglycerin administered sublingually usually relieves angina symptoms but does not relieve the pain from an MI. Administering nitroglycerin more than three times will probably not relieve the pain.

 

DIF:    Cognitive Level: Application          REF:   Page 320        OBJ:   9

TOP:   Angina pectoris                              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The patient has been hospitalized for hypertensive episodes three times in the last months. While preparing the discharge teaching plan, the nurse assesses that he does not comply with his medication regimen. The nurse’s immediate course of action would be to:
a. reteach him about his medications.
b. have a serious talk with him and his family about compliance.
c. arrange for home visits after discharge.
d. collect more information to identify his reasons for noncompliance.

 

 

ANS:  D

Nursing interventions include measures to prevent disease progression and complications. Reteaching about medication will not identify the cause of noncompliance.

 

DIF:    Cognitive Level: Application          REF:   Page 331        OBJ:   18

TOP:   Noncompliance                              KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. What is the major cause of cardiac valve disease?
a. Rheumatic fever
b. Long history of malnutrition
c. Drug abuse
d. Obesity

 

 

ANS:  A

Rheumatic fever, a streptococcal infection, is the major cause of cardiac valve disease.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 347        OBJ:   10

TOP:   Valvular disease                             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The patient has a total cholesterol of 190 with a high-density lipid (HDL) of 110 and a low-density lipid (LDL) of 80. The nurse’s reaction is one of:
a. satisfaction. This is good cholesterol control.
b. determination. This is evidence that more instruction is necessary.
c. inquiry. This needs to clarified as to the cause of noncompliance with the drug protocol.
d. regret. This shows very poor cholesterol control.

 

 

ANS:  A

Total cholesterol of less than 200 is desirable. The higher the number of HDLs the better. A high number of LDLs puts the patient at risk for heart disease.

 

DIF:    Cognitive Level: Analysis               REF:   Page 316, Box 8-1

OBJ:   6                    TOP:   Lipid studies

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Physiological Integrity

 

  1. A patient, age 72, was admitted to the medical unit with a diagnosis of angina pectoris. Characteristic signs and symptoms of angina pectoris include:
a. substernal pain that radiates down the left arm.
b. epigastric pain that radiates to the jaw.
c. indigestion, nausea, and eructation.
d. fatigue, shortness of breath, and dyspnea.

 

 

ANS:  A

The pain often radiates down the left inner arm to the little finger and also upward to the shoulder and jaw.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 327, Figure 8-11

OBJ:   9                    TOP:   Angina pectoris

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. A patient admitted to the emergency room with a possible myocardial infarction (MI) has reports back from the laboratory. Which laboratory report is specific for myocardial damage?
a. CK-MB
b. Elevated white count
c. Elevated sedimentation rate
d. Low level of sodium

 

 

ANS:  A

The CK-MB is elevated when there is infarcted myocardial muscle. The elevated white count, low sodium, and ESR are nonspecific.

 

DIF:    Cognitive Level: Application          REF:   Page 334        OBJ:   6

TOP:   CK-MB          KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The patient, age 26, is hospitalized with cardiomyopathy. While obtaining a nursing history from her, the nurse recognizes that the increased incidence of cardiomyopathy in young

adults who have minimal risk factors for cardiovascular disease is related to which factor(s)?

a. Cocaine use
b. Viral infections
c. Vitamin B1 deficiencies
d. Pregnancy

 

 

ANS:  A

Cardiomyopathy caused by cocaine abuse is seen more frequently than ever before. Cocaine also causes high circulating levels of catecholamines, which may further damage myocardial cells, leading to ischemic or dilated cardiomyopathy. The cardiomyopathy produced is difficult to treat. Interventions deal mainly with the HF that ensues.

 

DIF:    Cognitive Level: Analysis               REF:   Page 353        OBJ:   14

TOP:   Cardiomyopathy                             KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The patient has become very dyspneic, respirations are 32, and the pulse is 100. The patient is coughing up frothy red sputum. What should be the initial nursing intervention?
a. Lay the patient flat to reduce hypotension and the symptoms of cardiogenic shock.
b. Place patient in side-lying position to reduce the symptoms of atrial fibrillation.
c. Place patient upright with legs in dependent position to reduce the symptoms of pulmonary edema.
d. Lay the patient flat and elevate the feet to increase venous return in cardiogenic shock.

 

 

ANS:  C

Signs and symptoms of pulmonary edema are restlessness; vague uneasiness; agitation; disorientation; diaphoresis; severe dyspnea; tachypnea; tachycardia; pallor or cyanosis; cough producing large quantities of blood-tinged, frothy sputum; audible wheezing and crackles; and cold extremities. The legs in a dependent position will decrease venous return and ease the pulmonary edema.

 

DIF:    Cognitive Level: Analysis               REF:   Page 347        OBJ:   12

TOP:   Pulmonary edema                           KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse caring for a patient recovering from a myocardial infarction (MI) teaches which method to avoid the Valsalva maneuver during a bowel movement?
a. Mouth breathing
b. Pursing the lips and whistling
c. Taking a deep breath and holding it
d. Breathing rapidly through the nose

 

 

ANS:  A

Mouth breathing will lessen the severity of straining and will decrease the effect of the Valsalva maneuver on intrathoracic pressure.

 

DIF:    Cognitive Level: Application          REF:   Page 337        OBJ:   9

TOP:   MI                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse reminds the patient that the National Heart, Lung, and Blood Institute recommends a lipid study every _________ years.
a. 2
b. 3
c. 4
d. 5

 

 

ANS:  D

The National Heart, Lung, and Blood Institute recommend a lipid study every 5 years for all Americans, but especially for the older adult.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 317        OBJ:   6

TOP:   Lipid studies                                   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. During a health interview by the home health nurse, which patient complaint suggests left-sided heart failure?
a. “I have to sleep in my recliner and I have this hacking cough.”
b. “I have no appetite and I have lost 3 lb in the last week.”
c. “I have to urinate every 2 hours, even during the night.”
d. “I go barefoot most of the time because my feet are so hot.”

 

 

ANS:  A

Left ventricular failure; the first is signs and symptoms of decreased cardiac output. The second is pulmonary congestion. Signs and symptoms of this condition include dyspnea, orthopnea, pulmonary crackles, hemoptysis, and cough.

 

DIF:    Cognitive Level: Analysis               REF:   Page 340, Box 8-3

OBJ:   9                    TOP:   Heart failure  KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The home health nurse caring for a patient with infective endocarditis overhears the patient making a dental appointment for an extraction next month. Which question is most important for the nurse to ask?
a. “Do you have a toothache?”
b. “Have you contacted your physician about your dental appointment?”
c. “Is your dentist board certified?”
d. “Do you think you should wait that long for your tooth extraction?’

 

 

ANS:  B

Patients with endocarditis are put on a protocol of prophylactic antibiotics for any invasive procedure. The dentist and physician should be contacted before the extraction.

 

DIF:    Cognitive Level: Application          REF:   Page 349        OBJ:   13

TOP:   Endocarditis   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The home health nurse warns the patient who is taking warfarin (Coumadin) for anticoagulant therapy for thrombophlebitis to stop taking the herbal remedy of ginkgo because ginkgo can:
a. cause severe episodes of diarrhea.
b. cause a severe skin eruption if taken with Coumadin.
c. increase the action of the Coumadin.
d. cause the Coumadin to be less effective.

 

 

ANS:  C

Herbal remedies such as ginkgo, garlic, angelica, and red clover can increase (potentiate) the action of the Coumadin.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 364        OBJ:   21

TOP:   Coumadin      KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What is the difference between primary and secondary hypertension?
a. Secondary hypertension is caused by another disorder like renal disease.
b. Secondary hypertension is related to hereditary factors.
c. Secondary hypertension cannot be treated effectively.
d. Secondary hypertension is no real threat to health.

 

 

ANS:  A

Secondary hypertension is a consistently elevated blood pressure that is caused by another disorder, such as renal disease, diabetes, or Cushing syndrome.

 

DIF:    Cognitive Level: Analysis               REF:   Page 359        OBJ:   18

TOP:   Secondary hypertension                 KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is treating a patient who has had a pacemaker inserted for the correction of atrial fibrillation. Which diagnostic test is no longer available to the patient because of the implanted device?
a. MRI
b. CT scan
c. Thallium scan
d. PET

 

 

ANS:  A

Because of the large magnets in the MRI cabinet, the pacemaker may be reset to a fixed mode and interfere with the functioning of the pacemaker.

 

DIF:    Cognitive Level: Application          REF:   Page 326        OBJ:   10

TOP:   Pacemaker     KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. Which assessment would lead the nurse to examine the leg closely for evidence of a stasis ulcer?
a. Cool dry lower limb
b. Edematous, red scaly skin on medial surface of the leg
c. Lack of hair and shiny appearance of the lower leg
d. Lack of a pedal pulse

 

 

ANS:  B

Suggestion of a stasis ulcer in the making is an edematous, dry scaly area on the medial surface of the lower leg that has a darker pigmentation (rubor). Cool hairless limbs with absent or weak pedal pulses are indicative of arterial insufficiency.

 

DIF:    Cognitive Level: Application          REF:   Page 357        OBJ:   21

TOP:   Medications   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What is the patient goal of the walking exercise program designed for the rehabilitation of a post-MI patient?
a. Walk 2 miles in less than 60 minutes after 12 weeks.
b. Jog  mile in less than 30 minutes after 12 weeks.
c. “Fast walk” 1 mile in less than 20 minutes after 12 weeks.
d. Walk 1 mile in 15 minutes without dyspnea after 12 weeks.

 

 

ANS:  A

The goal of the 12-week walking program is that the patient can walk 2 miles in less than 60 minutes.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 338, Home Care Considerations

OBJ:   11                  TOP:   Cardiac rehab

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The postsurgical patient has a painful and swollen right calf that appears to be larger than the calf of the left leg. What is the nurse assessing for when she flexes the patient’s right leg and dorsiflexes the foot?
a. Pain, which would be a positive Homans sign
b. Muscular spasm, which would be a sign of hypocalcemia
c. Rigidity, which would be a sign of ankylosis
d. Crepitus, which would be a sign of a joint disorder

 

 

ANS:  A

A positive Homans sign for deep vein thrombosis (DVT) is a report of pain when the affected leg is flexed and the foot is dorsiflexed.

 

DIF:    Cognitive Level: Application          REF:   Page 370        OBJ:   21

TOP:   DVT               KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. How should the nurse advise a patient with an international normalized ratio (INR) of 5.8?
a. Make arrangements to go to the emergency room immediately
b. Increase fluid intake to 2000 mL/day
c. Stop taking the anticoagulant and notify health care provider
d. Add more leafy green vegetables to patient diet

 

 

ANS:  C

The INR that is desired should be maintained between 2 and 3. A reading of 5.8 puts the patient at risk for hemorrhage. The patient should stop taking the anticoagulant and contact the physician for further instruction.

 

DIF:    Cognitive Level: Application          REF:   Page 321        OBJ:   6

TOP:   Myocardial infarction                               KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse making a teaching plan for a patient with Buerger disease (thromboangiitis obliterans) will focus on the need for:
a. reduction of alcohol intake.
b. avoiding cold remedies.
c. cessation of smoking.
d. weight reduction.

 

 

ANS:  C

The hazards of cigarette smoking and its relationship to Buerger disease are the primary focus of patient teaching. None of the palliative treatments are effective if the patient does not stop smoking. Nowhere are the cause and effect of smoking so dramatically seen as with Buerger disease.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 369        OBJ:   20

TOP:   Buerger disease                              KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. Which statement would lead the nurse to offer more instruction about taking warfarin (Coumadin)?
a. “I eat a banana every morning with breakfast.”
b. “I try to eat more green leafy vegetables, especially broccoli, spinach, and kale.”
c. “I try to eat a well-balanced, low-fat diet.”
d. “I don’t drink alcohol or caffeine.”

 

 

ANS:  B

Avoid marked changes in eating habits, such as dramatically increasing foods high in vitamin K (e.g., broccoli, spinach, kale, greens). Limit alcohol intake to small amounts.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 372        OBJ:   10

TOP:   Warfarin        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse caring for a 92-year-old patient with pneumonia who is receiving IV carefully monitors the flow rate of the IV infusion because rapid infusion can cause:
a. hypotension.
b. thrombophlebitis.
c. pulmonary emboli.
d. heart failure.

 

 

ANS:  D

Heart failure can result from rapid infusion of intravenous fluids in older adults.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 317, Lifespan Considerations

OBJ:   9                    TOP:   Heart failure  KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse making the schedule for the daily dose of furosemide (Lasix) would schedule the administration for which of the following times?
a. Late in the afternoon
b. At bedtime
c. With any meal
d. In the morning

 

 

ANS:  D

Diuretics should be scheduled for morning administration to avoid causing the patient nocturia.

 

DIF:    Cognitive Level: Analysis               REF:   Page 342, Table 8-6

OBJ:   12                  TOP:   Lasix              KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. The nurse would assess closely for signs of right-sided heart failure which include (select all that apply):
a. cough.
b. increasing abdominal girth.
c. shortness of breath.
d. edema of feet and ankles.
e. distended jugular veins.
f. orthopnea.

 

 

ANS:  B, D, E

Indicators of right-sided heart failure are distended jugular veins, anorexia, abdominal distention from ascites, liver enlargement with right upper quadrant pain, and edema of feet and ankles.

 

DIF:    Cognitive Level: Analysis               REF:   Page 341, Box 8-4

OBJ:   9                    TOP:   Right-sided heart failure

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. The nurse would design teaching for a patient with Raynaud disease to include which of the following? (Select all that apply.)
a. Warming hands and feet with a heating pad
b. Using mittens in cold weather
c. Practicing stress-reducing techniques
d. Complete smoking cessation
e. Using caution when cleaning the refrigerator or freezer

 

 

ANS:  B, C, D, E

Nursing interventions include patient teaching in techniques for stress reduction, avoiding exposure to cold, and techniques for smoking cessation.

 

DIF:    Cognitive Level: Analysis               REF:   Page 370, Nursing Care Plan

OBJ:   20                  TOP:   Raynaud disease

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Physiological Integrity

 

  1. Which information should be taught to patients starting on anticoagulant therapy for a valvular disorder? (Select all that apply.)
a. Increase the dose of aspirin for better therapy.
b. Take medication at the same time each day.
c. Report to physician cuts that do not stop bleeding with direct pressure.
d. No restrictions for food or drink.
e. Report for prescribed blood tests (PTT, INR, CBC, blood sugar).

 

 

ANS:  B, C

Aspirin should not be used with anticoagulant therapy because it will increase bleeding. Gums, nosebleeds, excessive bruising, and cuts that do not stop bleeding with direct pressure should be reported to the physician. Alcohol and dark green and yellow vegetables should be avoided because they contain vitamin K. Normal blood tests for anticoagulant therapy are PTT, INR, and PT.

 

DIF:    Cognitive Level: Analysis               REF:   Page 366, Nursing Care Plan

OBJ:   10                  TOP:   Anticoagulant therapy

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Physiological Integrity

 

  1. What is the transesophageal echocardiogram (TEE) used for? (Select all that apply.)
a. Detect thrombi before a cardioversion
b. Check for cardiac arrhythmias
c. Visualize vegetation on the heart valves
d. Measure effectiveness of diuretic therapy
e. Visualize abscesses on the heart valves

 

 

ANS:  A, C, E

The TEE is used to check for thrombi before cardioversion, and to visualize vegetation and abscesses on the valves of the heart.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 367        OBJ:   16

TOP:   TEE                KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

  1. Which patient teaching would help to prevent venous stasis? (Select all that apply.)
a. Dangle legs when sitting
b. Avoid crossing legs at the knee
c. Elevate legs when lying in bed or sitting
d. Massage extremities to help maintain blood flow
e. Wear elastic stockings when ambulating

 

 

ANS:  B, C, E

Avoid prolonged sitting or standing. Avoid crossing the legs at the knee.

Elevate legs when sitting. Wear elastic stockings when ambulatory. Do not massage extremities because of danger of embolization of clots (thrombus breaking off and becoming an embolus).

 

DIF:    Cognitive Level: Analysis               REF:   Page 372        OBJ:   16

TOP:   Thrombophlebitis                           KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse points out which of the following as modifiable risks for coronary artery disease (CAD)? (Select all that apply.)
a. Diabetes mellitus
b. Heredity
c. Smoking
d. Hypertension
e. Hyperlipidemia
f. Age

 

 

ANS:  A, C, D, E

Modifiable risks for the development of CAD include smoking, hyperlipidemia, hypertension, diabetes mellitus, obesity, sedentary lifestyle, and stress.

 

DIF:    Cognitive Level: Analysis               REF:   Pages 318-319

OBJ:   7                    TOP:   Modifiable risks for CAD

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse outlines which of the following as conditions that would disqualify a candidate for a heart transplant? (Select all that apply.)
a. Recent malignancy
b. Dilated cardiomyopathy
c. Peptic ulcer disease
d. Diabetes type 2
e. Severe obesity
f. Inoperable coronary artery disease

 

 

ANS:  A, C, E

Contraindications for candidacy for cardiac transplant include recent malignancy, active peptic ulcer disease, severe obesity, diabetes type 1 with end-organ damage. Dilated cardiomyopathy and inoperable coronary artery disease are indications for transplant.

 

DIF:    Cognitive Level: Application          REF:   Page 354, Box 8-7

OBJ:   15                  TOP:   Contraindications for cardiac transplant

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. When assessing a patient with a possible MI, what should the nurse assess for? (Select all that apply.)
a. Pain radiating to left arm and jaw
b. Hypertension
c. Pallor
d. Diaphoresis
e. Erratic behavior
f. Cardiac rhythm changes

 

 

ANS:  B, C, D, E, F

Hypertension, vomiting, diaphoresis, hypotension, pallor, and cardiac rhythm changes are objective data seen in patients with an MI.

 

DIF:    Cognitive Level: Analysis               REF:   Page 333, Table 8-2

OBJ:   10                  TOP:   Myocardial infarction

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Which of the following are signs of digoxin (Lanoxin) toxicity? (Select all that apply.)
a. Ringing in the ears
b. Bradycardia
c. Headache
d. Visual disturbance
e. Hematuria
f. Gastrointestinal complaints

 

 

ANS:  B, C, D, F

Major signs of digoxin toxicity are nausea, bradycardia (HR <60), headache, and visual disturbances, as well as fatigue and arrhythmias.

 

DIF:    Cognitive Level: Application          REF:   Page 323, Table 8-1

OBJ:   10                  TOP:   Digitoxin toxicity

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. The nurse encourages the patient who is recovering from a myocardial infarct (MI) to ask the health care provider to prescribe a cardiac rehabilitation series in order to learn to (select all that apply):
a. improve stamina.
b. strengthen muscles.
c. plan an appropriate diet.
d. select herbal remedies.
e. reduce risk of further problems.
f. understand heart condition.

 

 

ANS:  A, B, E, F

Cardiac rehabilitation offers exercise programs to increase strength and increase stamina. Educational opportunities are offered on reduction of risk and understanding the disease process.

 

DIF:    Cognitive Level: Application          REF:   Page 338        OBJ:   11

TOP:   Cardiac rehab                                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Following an angiogram with the insertion site of the left groin, the nurse will include in the plan of care provisions for (select all that apply):
a. checking pedal pulses.
b. ambulating with assistance 2 hours after recovery.
c. checking color and warmth of left leg frequently.
d. sandbagging over insertion site.
e. placing patient in semi-Fowler position.

 

 

ANS:  A, C, D

The pulses below the insertion site are checked to ensure patency of the vessels; the color and warmth of the left extremity is checked to ensure adequate circulation. A sandbag or other pressure device is placed over the insertion site. The patient is maintained in a supine position for several hours postprocedure.

 

DIF:    Cognitive Level: Application          REF:   Page 312        OBJ:   6

TOP:   Angiogram     KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

COMPLETION

 

  1. The cardiac marker ___________ rises 3 hours after a myocardial infarct and measures myocardial contractile protein.

 

ANS:

troponin I

 

Troponin I is a serum cardiac marker that rises 3 hours after an MI and can measure myocardial contractile tissue. Troponin I is not affected by skeletal muscle injury as is troponin T.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 316        OBJ:   6

TOP:   Troponin I      KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The life support system that uses special techniques, ventilation equipment, and therapies for emergency situations is ________.

 

ANS:

advanced cardiac life support (ACLS)

advanced cardiac life support

ACLS

 

ACLS is a life support system that uses special techniques, ventilation equipment, and therapies for emergency situations.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 325        OBJ:   9

TOP:   ACLS             KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse explains that the heart has the ability to contract in a rhythmic pattern that is called ____________.

 

ANS:

automaticity

 

Automaticity is the special ability of the myocardium to contract in a rhythmic pattern.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 309        OBJ:   2

TOP:   Automaticity                                   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The patient with congestive heart failure who is on a diuretic drug shows a weight loss of 6.6 lb. The nurse is aware that the patient has lost ______ L of fluid.

 

ANS:

3

 

A liter of fluid equals 2.2 lb. A loss of 6.6 lb would mean the loss of 3 L of fluid.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 339        OBJ:   9

TOP:   Fluid loss       KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The pain that a person with arterial insufficiency feels on exertion, which is relieved by rest, is ______________ _____________.

 

ANS:

intermittent claudication

 

Intermittent claudication is a pain caused by ischemia when a person with arterial insufficiency exerts to the point that the tissues have inadequate oxygen-rich blood. The pain is relieved by rest.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 356        OBJ:   9

TOP:   Intermittent claudication                 KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The process by which a heart is shocked from a persistent arrhythmia back into sinus rhythm is called a ____________.

 

ANS:

cardioversion

 

Cardioversion is the restoration of the heart’s normal sinus rhythm with the delivery of synchronized electric shock.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 315        OBJ:   10

TOP:   Cardioversion                                           KEY:              Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

OTHER

 

  1. Trace the impulse pattern of conduction in sequence through the heart. (Separate letters by a comma and space as follows: A, B, C, D)

 

  1. Atrial wall
  2. Atrial-ventricular (AV) node
  3. Purkinje fibers
  4. Sinoatrial (SA) node
  5. Bundle branches
  6. Bundle of His

 

ANS:

B, A, D, F, E, C

 

The conduction begins with the impulse from the SA node that travels down the atrial wall to the AV node, to the Bundle of His, to the bundle branches, and finally to the Purkinje fibers.

 

DIF:    Cognitive Level: Analysis               REF:   Pages 308-309

OBJ:   3                    TOP:   Conduction    KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

  1. Arrange in sequence the path of the blood through the coronary circulation. (Separate letters by a comma and space as follows: A, B, C, D)

 

  1. Right atrium
  2. Pulmonary artery
  3. Tricuspid valve
  4. Right ventricle
  5. Superior and inferior vena cava
  6. Pulmonary vein
  7. Left atrium
  8. Mitral valve
  9. Left ventricle
  10. Lungs

 

ANS:

E, A, C, D, B, J, F, G, H, I

 

The blood travels through the vena cava to the right atrium, through the tricuspid valve to the right ventricle, through the pulmonary artery to the lungs. The pulmonary veins deliver the blood to the left atrium, then through the mitral valve to the left ventricle and out the aorta to the body.

 

DIF:    Cognitive Level: Analysis               REF:   Page 310, Figure 8-4

OBJ:   5                    TOP:   Path of blood through heart            KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

Chapter 12: Care of the Patient with a Reproductive Disorder

 

MULTIPLE CHOICE

 

  1. Which condition would prevent the use of a vaginal hysterectomy?
a. A woman with more than four pregnancies
b. Large uterine fibroids
c. Menorrhagia for over 6 months
d. Women over the age of 50

 

 

ANS:  B

In the case of large uterine fibroids, a vaginal hysterectomy is not an option.

 

DIF:    Cognitive Level: Application          REF:   Page 588        OBJ:   14

TOP:   Hysterectomy                                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. On the second postoperative day, a patient who has had an abdominal hysterectomy complains of gas and abdominal distention. Which intervention would be most appropriate to stimulate a bowel movement?
a. Offering carbonated beverages
b. Encouraging ambulation at least four times per day
c. Administering a 1000-mL soapsuds enema
d. Applying an abdominal binder

 

 

ANS:  B

Early ambulation is very helpful to return the bowel to normal function.

 

DIF:    Cognitive Level: Analysis               REF:   Page 588        OBJ:   14

TOP:   Hysterectomy                                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The young husband of a patient who has been scheduled for a hysterectomy because of the discovery of ovarian cancer in both ovaries says to the nurse, “Please go talk to my wife. She is real upset and says she won’t be a ‘woman’ anymore.” What is the nurse’s most therapeutic response?
a. “Don’t be concerned. All young women get upset before this kind of surgery.”
b. “Certainly, I will be glad to tell her about hormone replacement.”
c. “She will get over this feeling soon.”
d. “No matter what I may say to her, it is you that needs to listen to her concerns and assure her.”

 

 

ANS:  D

Assisting patients with recognizing and clarifying fears and with developing coping strategies for those fears by listening is helpful.

 

DIF:    Cognitive Level: Application          REF:   Page 597, NCP

OBJ:   12                  TOP:   Ovarian cancer

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient, age 41, has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometriosis. She asks the nurse if she will have “hot flashes.” What knowledge will guide the nurse’s response?
a. Only the uterus was removed, and the ovaries are still producing estrogen and she will not have hot flashes.
b. The patient is too young to have hot flashes associated with menopause.
c. The uterus, ovaries, and fallopian tubes were removed, and she will have surgically induced menopause and may have hot flashes.
d. The uterus and fallopian tubes were removed, and she will not experience “hot flashes.”

 

 

ANS:  C

A total abdominal hysterectomy with bilateral salpingo-oophorectomy is the removal of the uterus, fallopian tubes, and ovaries. If the ovaries are removed in these surgeries, the surgery will induce menopause and hot flashes may occur.

 

DIF:    Cognitive Level: Analysis               REF:   Page 588        OBJ:   14

TOP:   Hysterectomy                                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. On the fourth postoperative day after a modified radical mastectomy, the nurse finds the patient with her back to the nurse. She is crying and tells the nurse she feels ugly and is worried that her husband will not be in love with her anymore. The nurse bases subsequent nursing interventions on what diagnosis?
a. Disturbed body image related to removal of her breast
b. Deficient knowledge related to inadequate education
c. Impaired social interaction related to depression
d. Fear related to the cancer diagnosis and surgical intervention

 

 

ANS:  A

After losing a breast, many patients experience grief over the loss of a body part. The process of grieving is essential for personal adaptation to the loss. The nurse can assist the patient to find helpful coping mechanisms.

 

DIF:    Cognitive Level: Analysis               REF:   Page 599        OBJ:   18

TOP:   Mastectomy   KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Psychosocial Integrity

 

  1. Why would the nurse encourage the patient who is recovering from a modified radical mastectomy to exercise the affected arm?
a. To reduce pain
b. To stimulate appetite
c. To reduce lymphedema
d. To increase muscle tension

 

 

ANS:  C

An exercise regimen, built up gradually, can help reduce lymphedema following a modified radical mastectomy.

 

DIF:    Cognitive Level: Application          REF:   Pages 598-599, Box 12-7

OBJ:   19                  TOP:   Postmastectomy exercises

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Physiological Integrity

 

  1. A 20-year-old patient presents in the emergency room with a temperature of 103° F, blood pressure of 92/58, headache, and desquamation of both palms. What should the nurse make sure to ask about during the interview?
a. Any recent traveling outside the country
b. Immunization against influenza
c. Method of birth control
d. Use of tampons

 

 

ANS:  D

These are signs of toxic shock frequently brought on by leaving a tampon in place too long. The nurse should inquire about tampon use, headache, muscle pain, and fatigue.

 

DIF:    Cognitive Level: Application          REF:   Page 577        OBJ:   6

TOP:   Toxic shock syndrome (TSS)         KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. At what age should a male be taught testicular self-examination (TSE)?
a. 10
b. 13
c. 15
d. 20

 

 

ANS:  C

Young men should be taught to perform TSE monthly beginning at 15 years of age.

 

DIF:    Cognitive Level: Application          REF:   Page 605        OBJ:   22

TOP:   Testicular self-examination            KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Which statement made by a patient who has been taught the technique of testicular self-examination indicates the need for further teaching?
a. “The testes feel smooth and egg-shaped.”
b. “The best time to perform TSE is after a shower.”
c. “I will examine my scrotum after every ejaculation.”
d. “The epididymis feels like a soft tube.”

 

 

ANS:  C

It is not recommended for a patient to perform a testicular self-examination after every ejaculation. Perform testicular self-examination after a bath or shower when the scrotum is warm and most relaxed. The testes should feel smooth and be firm to the touch. The epididymis feels like a soft tube.

 

DIF:    Cognitive Level: Analysis               REF:   Page 605, Figure 12-16

OBJ:   22                  TOP:   Testicular self-examination

KEY:  Nursing Process Step: Evaluation   MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Which patient is most at risk for the infection of epididymitis?
a. 17-year-old athlete who trains for several hours a day
b. 22-year-old who has been exposed to mumps
c. 45-year-old who was circumcised at the age of 10
d. 50-year-old who has smoked for 30 years

 

 

ANS:  A

Symptoms can occur after trauma to the genital area, after instrumentation of the urethra and cystoscopy, and after physical exertion or prolonged sexual activity.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 603        OBJ:   20

TOP:   Epididymitis   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient, age 26, has had a tubal insufflation (Rubin test) to ascertain whether her fallopian tubes are patent. She complains of pain in her right shoulder. Which response is most appropriate?
a. “Don’t worry, that is a normal reaction.”
b. “I’ll report the findings immediately to the head nurse.”
c. “That is a symptom that resulted from your position on the operating table.”
d. “That is from the carbon dioxide passing from the fallopian tubes into your abdomen.”

 

 

ANS:  D

The Rubin insufflation test determines tubal patency. Carbon dioxide escapes into the abdominal cavity through the patent left fallopian tube.

 

DIF:    Cognitive Level: Application          REF:   Page 561        OBJ:   4

TOP:   Diagnostic procedures                    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse provides discharge teaching for a patient regarding her activity level as she recovers from her modified radical mastectomy. Which statement by her indicates to the nurse that the teaching has been successful?
a. “I should sleep on the side opposite my mastectomy.”
b. “I should keep my right arm supported in a sling when I am up and around until my incision is healed.”
c. “I can do whatever exercises and activities I want as long as I don’t elevate my right hand above my head.”
d. “I should take aspirin before moving or exercising my arm to prevent pain during the exercises.”

 

 

ANS:  A

The patient should be instructed to avoid sleeping on the involved arm.

 

DIF:    Cognitive Level: Analysis               REF:   Page 599, Box-12-7

OBJ:   18                  TOP:   Mastectomy   KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. A female patient, age 48, is undergoing a routine physical examination for the first time in 5 years. Which procedure would be included in this examination?
a. Culdoscopy
b. Colposcopy
c. Cervical biopsy
d. Papanicolaou smear

 

 

ANS:  D

The American Cancer Society recommends that all women who are or have been sexually active or who are at least 18 years of age have an annual Pap smear for 3 consecutive years and then every 3 years until middle age.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 558        OBJ:   5

TOP:   Routine examination                                 KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. What is the recommended age range for a baseline mammogram?
a. 25 and 30 years
b. 31 and 34 years
c. 35 and 39 years
d. 40 and 45 years

 

 

ANS:  C

The American Cancer Society recommends that mammograms be performed on women between 35 and 39, and annually for women 40 years of age and older.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 591-592

OBJ:   5                    TOP:   Routine examination

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Health Promotion and Maintenance

 

  1. What does the diagnosis of secondary infertility refer to?
a. Has never conceived
b. Is infertile because of repeated infection
c. Has conceived but is now unable to do so
d. Is over the age of 38

 

 

ANS:  C

Secondary infertility refers to a woman who has conceived in the past and now is unable to do so.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 572        OBJ:   7

TOP:   Infertility        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What instruction should a nurse give a patient with congenital herpes who does not have lesions at the present?
a. “Continued use of acyclovir (Zovirax) will prevent reinfection by the virus.”
b. “Condoms should be used during all sexual activity to prevent transmission of the virus, even when lesions are not present.”
c. “Acyclovir ointment should be applied to the lesions to increase comfort and speed healing.”
d. “Recurrent genital herpes is promoted by any sexual stimulation.”

 

 

ANS:  B

Sexual transmission of HSV (genital herpes, a virus) has been documented even in the absence of clinical lesions, and the use of condoms should be encouraged. Acyclovir does not cure the disease but makes the attacks less virulent.

 

DIF:    Cognitive Level: Application          REF:   Page 606, Safety Alert

OBJ:   23                  TOP:   Genital herpes

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The 10-year-old clinic patient reports that she is free of gonorrhea and can now engage in sexual activity. Which response is most appropriate?
a. “If you have been free of symptoms for 2 weeks you are cured.”
b. “You should get a rapid plasma reagin (RPR) just to make sure.”
c. “No case is considered cured until you have had three consecutive negative cervical smears.”
d. “To confirm your cure, you should get a Venereal Disease Research Lab (VDRL).”

 

 

ANS:  C

No case of gonorrhea is considered cured until you have had three consecutive negative cervical smears. The RPR and the VDRL are tests for syphilis.

 

DIF:    Cognitive Level: Analysis               REF:   Page 610        OBJ:   8

TOP:   Pelvic inflammatory disease (PID) KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A Gram stain smear of the patient’s discharge reveals the presence of N. gonorrhoeae. He tells the nurse that he had sexual contact with a new girlfriend but does not think he was exposed to gonorrhea because she did not appear to have any disease. Which information should the nurse include in response to his comment?
a. “Women do not develop gonorrhea infections but can serve as carriers to spread the disease to males.”
b. “When gonorrhea infections occur in women, the disease affects only the ovaries and not the other genital organs.”
c. “Many women are not aware that they have gonorrhea because they often do not have symptoms of infection.”
d. “Women develop subclinical cases of gonorrhea that do not cause tissue damage or symptoms.”

 

 

ANS:  C

Most women remain asymptomatic but may show a greenish-yellow discharge from the cervix.

 

DIF:    Cognitive Level: Application          REF:   Page 609        OBJ:   23

TOP:   Infectious diseases                         KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The patient who had a colporrhaphy for the repair of a cystocele and rectocele asks that the catheter be removed as it is bothersome to her. How should the nurse explain the reason for the catheter?
a. It replaces uncomfortable gauze packing
b. It will prevent adhesions and will be in place for about 2 weeks
c. It allows for quick urine sample collection
d. It keeps the bladder empty, and prevents stress on the sutures

 

 

ANS:  D

A retention catheter is usually inserted into the bladder to keep it empty and prevent pressure on sutures.

 

DIF:    Cognitive Level: Analysis               REF:   Page 581        OBJ:   14

TOP:   Postoperative care                          KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. Why is a mammogram the most useful method of diagnosing breast cancer?
a. It is the most reliable method of detecting breast cancer before it becomes palpable.
b. It is inexpensive and covered by most medical insurance plans.
c. It involves no radiation and takes only a few minutes.
d. It involves no pain or discomfort and is readily available.

 

 

ANS:  A

Mammography is radiography of the soft tissue of the breast to allow identification of various benign and neoplastic processes, especially those not palpable on physical examination.

 

DIF:    Cognitive Level: Analysis               REF:   Page 592        OBJ:   5

TOP:   Diagnostic procedures                    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The patient, age 52, is recovering from a modified radical mastectomy. Why is postoperative elevation of the patient’s arm important after this procedure?
a. To prevent vascular and lymph stasis, thus lymphedema
b. To prevent drainage accumulation at the incisional site
c. To prevent wound infection and dehiscence
d. To prevent pleural effusion and respiratory distress

 

 

ANS:  A

If the arm is not restricted by dressings, it may be elevated on a pillow with the hand and wrist higher than the elbow and the elbow higher than the shoulder joint. This will facilitate the flow of fluids through the lymph and venous routes and prevent lymphedema.

 

DIF:    Cognitive Level: Application          REF:   Page 598        OBJ:   18

TOP:   Mastectomy   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A patient, age 46, is recovering from an abdominal hysterectomy. Postoperative nursing assessment findings include a urinary output of 100 mL in 4 hours. What should the nurse do?
a. Force fluids
b. Report urinary retention to the charge nurse
c. “Milk” the urinary catheter
d. Turn the patient onto her right side

 

 

ANS:  B

Postoperative nursing interventions for patients with abdominal hysterectomy focus on monitoring vital signs and preventing urinary retention. The patient should have an output of at least 30 mL/hr. Anything less than that should be reported.

 

DIF:    Cognitive Level: Application          REF:   Page 588        OBJ:   14

TOP:   Hysterectomy                                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. When should postmenopausal women be instructed to perform breast self-examination (BSE)?
a. On the same date of their choice each month
b. Every 3 months
c. Every day, because they are at high risk for breast cancer
d. Whenever they begin to take estrogen supplements

 

 

ANS:  A

More than 90% of breast cancers are detected by the patient. BSE for postmenopausal women should be done on the same day of the month each month.

 

DIF:    Cognitive Level: Analysis               REF:   Page 591        OBJ:   15

TOP:   Breast self-examination (BSE)        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Which statement indicates that the patient who has had an abdominal hysterectomy needs further home teaching?
a. “I understand I can lift as much as 20 lb.”
b. “I’m leaving today to stay with my daughter, who lives 20 miles away. My husband plans to drive the family car.”
c. “The doctor said I can’t have sexual intercourse for 4 to 6 weeks.”
d. “I’m going to miss wearing my girdle or knee-high hose.”

 

 

ANS:  A

If there has been an abdominal incision, there may be further restrictions on heavy lifting (nothing over 10 lb).

 

DIF:    Cognitive Level: Analysis               REF:   Page 589        OBJ:   14

TOP:   Hysterectomy                                 KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. The patient with a swollen scrotum is amazed that diagnosis of the condition of hydrocele is such a simple thing as:
a. placing the scrotum on a warm pad.
b. shining light through scrotum.
c. squatting and letting the scrotum hang dependently.
d. packing the scrotum in ice.

 

 

ANS:  B

Shining a flashlight from behind the scrotum and visualizing the testes surrounded by fluid is called transillumination. That process is the simple diagnostic test for hydrocele.

 

DIF:    Cognitive Level: Application          REF:   Page 604        OBJ:   11

TOP:   Hydrocele      KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient, age 36, is scheduled for a unilateral orchiectomy for treatment of testicular cancer. He is withdrawn and does not initiate interaction with the nurse. What is the most appropriate nursing action at this time?
a. Carefully explain the postoperative activity restrictions.
b. Show him a diagram of what the orchiectomy will accomplish.
c. Assure him that he will have adequate future sexual functioning.
d. Assess his concerns related to his diagnosis and treatment.

 

 

ANS:  D

An appropriate nursing diagnosis for a patient with a reproductive disorder is Disturbed body image and Ineffective coping. It is beneficial to listen to the concerns about this treatment.

 

DIF:    Cognitive Level: Analysis               REF:   Page 605        OBJ:   20

TOP:   Orchiectomy                                   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity

 

  1. The 69-year-old patient laughs at the nurse when the nurse suggests that she should have a Pap smear and says, “I had my uterus removed except for the cervix 30 years ago and I am almost 70. Why in the world would I want to get a Pap smear at my age?” What is the nurse’s most informative reply?
a. “All persons who have a cervix remaining should be screened up to the age of 75.”
b. “Well, you have one more year to go to get a Pap smear.”
c. “My goodness, you look so young I thought you were still in the age bracket for regular Pap screens.”
d. “You are right. If you had no trouble so far, there is no need to do the smear.”

 

 

ANS:  B

Persons who have a hysterectomy without the removal of the cervix should continue to be screened at least until the age of 70.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 584        OBJ:   12

TOP:   Anatomy        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A male patient, age 23, seeks care at the health clinic because he has developed a profuse, purulent urethral discharge, and urination is painful. During assessment of the patient, it is most important that the nurse gather information related to his history of:
a. recent urinary infections.
b. episodes of prostatitis.
c. contagious diseases like mumps.
d. present and past sexual partners, and notify them to get treatment.

 

 

ANS:  D

The nurse should encourage notification of present and past sexual partners of the diagnosis, and stress the need for them promptly to seek medical care.

 

DIF:    Cognitive Level: Analysis               REF:   Page 610        OBJ:   23

TOP:   Sexually transmitted diseases (STDs)

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. A 25-year-old woman comes to the clinic with a yellowish-green malodorous vaginal discharge. She says it makes her itch and makes it hard to urinate. After a microscopic examination that confirms trichomoniasis, the patient is placed on metronidazole (Flagyl) for 7 days. How should the nurse advise the patient?
a. Avoid alcohol while on Flagyl
b. Be aware that her urine may turn blue and will stain clothing
c. Wear snug underwear during treatment
d. Be aware that she need not notify her sexual partners as trichomoniasis is not contagious

 

 

ANS:  A

Alcohol should be avoided as it can cause disorientation, cramps, and possibly convulsions.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 610        OBJ:   23

TOP:   Trichomoniasis                               KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The young woman comes to the free clinic for the complaint of stomach cramps. During the examination, the nurse recommends that she be tested for chlamydia. The woman says “I don’t need any test…I don’t have any symptoms for a sexual infection…I just came for my stomach.” Which response is most informative?
a. “Well, if you get more symptoms come back for testing.”
b. “The doctor may have to order medicine for syphilis and chlamydia. You probably have that too. You need to be tested today!”
c. “Testing is not mandatory…I probably wouldn’t bother either since you have no symptoms.”
d. “That stomachache may be part of a chlamydia infection. Many women do not have a discharge, but are carriers.”

 

 

ANS:  D

Chlamydia frequently displays no signs or symptoms in women. The Centers for Disease Control and Prevention (CDC) recommends an annual screening for all women over 25 who are at risk for STDs.

 

DIF:    Cognitive Level: Analysis               REF:   Page 611        OBJ:   14

TOP:   Chlamydia     KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What factor influences older women’s reluctance to seek medical care for problems of the reproductive system?
a. Embarrassment and cultural factors
b. Denial
c. Religious convictions
d. Lack of free time

 

 

ANS:  A

Many older women are reluctant to seek medical care for problems of the reproductive system. This may be related to cultural factors, embarrassment, or lack of knowledge.

 

DIF:    Cognitive Level: Analysis               REF:   Page 555, Life Span Considerations

OBJ:   N/A                TOP:   Age                KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. Although menopause is a normal part of aging, why do many women enter menopause at an earlier age?
a. Having become sexually active at an early age
b. Living at high altitudes
c. Excessive use of alcohol
d. Morbid obesity

 

 

ANS:  B

Early menopause may be brought on at an earlier age because of living in high altitudes, smoking, cancer treatment, and family history.

 

DIF:    Cognitive Level: Application          REF:   Page 555        OBJ:   5

TOP:   Early menopause                            KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

  1. Why do false-negative results in mammography occur in specific age groups?
a. Older women have greater density of breast tissue.
b. Older women have less density of breast tissue.
c. Younger women have greater density of breast tissue.
d. Younger women have less density of breast tissue.

 

 

ANS:  C

Because of the greater density of breast tissue, mammography is less sensitive in younger women, which may result in more false-negative results.

 

DIF:    Cognitive Level: Application          REF:   Page 592        OBJ:   5

TOP:   Diagnostic tests                               KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. Vaginal fistulas are caused by an ulcerating process resulting from (select all that apply):
a. Cancer
b. Radiation
c. Poor hygiene
d. Multiple sexual partners
e. Weakening of tissue from pregnancies
f. Surgical interventions

 

 

ANS:  A, B, E, F

Vaginal fistulas are caused by an ulcerating process resulting from cancer, radiation, weakening of tissue by pregnancies, and surgical interventions.

 

DIF:    Cognitive Level: Analysis               REF:   Page 579        OBJ:   10

TOP:   Vaginal fistulas                               KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. Select the interventions that should be performed with caution, in the affected arm, on patients who have undergone a modified radical mastectomy. (Select all that apply.)
a. Vaccinations
b. Taking of blood pressure or samples
c. Insertion of IV line
d. Physical therapy on uninvolved arm
e. Wear watch and jewelry on involved arm
f. Carry purse on involved arm or shoulder

 

 

ANS:  A, B, C

Patients should be taught not to have any procedures involving the arm on the affected side—BP readings, injections, intravenous infusion of fluids, or the drawing of blood, which may cause edema or infection—and to guard against infections from burns, needle pricks (sewing), and gardening injuries.

 

DIF:    Cognitive Level: Application          REF:   Page 598, NCP

OBJ:   18                  TOP:   Radical mastectomy

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Physiological Integrity

 

  1. What are some advantages of a vaginal hysterectomy over the abdominal hysterectomy? (Select all that apply.)
a. Less postoperative discomfort
b. Reduced hospital stay
c. Less expensive
d. Better visualization of the intrapelvic area
e. Faster recovery

 

 

ANS:  A, B, C, E

The vaginal approach allows for less postoperative discomfort, a reduced hospital stay, is less expensive, and offers a faster recovery.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 588        OBJ:   7

TOP:   Vaginal hysterectomy                               KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse instructs a group of women who attend the health clinic that persons who are particularly at risk for cervical cancer are persons who (select all that apply):
a. Smoke
b. Wear tampons
c. Have been sexually active since their teens
d. Have multiple sexual partners
e. Had chickenpox as a child
f. Have a history of sexually transmitted diseases (STD)

 

 

ANS:  A, C, D, F

Women who have been sexually active since their teens, have multiple sexual partners, and have a history of STDs are more at risk for cancer of the cervix.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 583        OBJ:   7

TOP:   Cervical cancer                               KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Which of the following are true of the Gardasil vaccine? (Select all that apply.)
a. It requires two more immunizations at 6 months after the first dose
b. It reduces incidence of cervical cancer
c. It reduces the incidence of human papilloma virus (HPV)
d. It can be given only to females
e. It should be given before a person becomes sexually active
f. It is safe for people as young as 8 years of age

 

 

ANS:  A, B, C, E

Gardasil is a vaccine that is effective against HPV and also reduces the incidence of cervical cancer; it can be given to males and females before they become sexually active. It is not recommended for children under 11 years of age.

 

DIF:    Cognitive Level: Application          REF:   Page 584        OBJ:   7

TOP:   Gardasil         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

COMPLETION

 

  1. A ___________ is performed to evaluate living tissue to establish or confirm a diagnosis or to follow the course of a disease.

 

ANS:

biopsy

 

Biopsies are procedures in which samples of tissue are taken for evaluation to confirm or locate a lesion.

 

DIF:    Cognitive Level: Application          REF:   Page 593        OBJ:   14

TOP:   Biopsy           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is assisting the physician in removing a small sample of tissue from the patient’s cervix to have it evaluated. This procedure is called a cervical _______________.

 

ANS:

conization

 

Conization of the cervix is indicated when eroded or infected tissue is to be removed or when there is a need for confirmation of cervical cancer. A cone-shaped section is removed when the mass is confined to the epithelial tissue.

 

DIF:    Cognitive Level: Application          REF:   Page 584        OBJ:   6

TOP:   Conization     KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. _____________ are the most benign tumors of the uterus and arise from the uterine muscle tissue.

 

ANS:

Fibroids

 

Fibroids are benign tumors arising from the muscle tissue of the uterus.

 

DIF:    Cognitive Level: Application          REF:   Page 581        OBJ:   N/A

TOP:   Fibroids          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. ________are produced in the seminiferous tubules and stored in the epididymis.

 

ANS:

Sperm

 

The two oval testes (gonads) are enclosed in the scrotum, a saclike structure that lies suspended from the exterior abdominal wall. This position keeps the temperature in the testes below normal body temperature, which is necessary for viable sperm production and storage. Each testis contains one to three coiled seminiferous tubules that produce the sperm cells.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 550        OBJ:   1

TOP:   Male reproductive tract                   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. An alternative remedy, ____________ , is used by men for the treatment of impotence.

 

ANS:

yohimbine, Pausinystalia yohimbe

 

Yohimbine is an alternative remedy for the treatment of male impotence.

 

DIF:    Cognitive Level: Knowledge

REF:   Page 616, Complementary and Alternative Therapies     OBJ:   21

TOP:   Alternative remedy                         KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

  1. When the veins in the scrotum become dilated, and the scrotum becomes enlarged and dilated, the condition is called a __________.

 

ANS:

varicocele

 

A varicocele is a condition in which the scrotum becomes enlarged and dilated, from obstructed vessels.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 604        OBJ:   21

TOP:   Varicocele      KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

OTHER

 

  1. Arrange the process of the menstrual cycle in order of their function to produce menses. (Separate letters by a comma and space as follows: A, B, C, D)

 

  1. Egg matures in the graafian follicle
  2. Corpus luteum is formed from old follicle
  3. Estrogen from the maturing follicle causes vascularization of the uterine lining
  4. Anterior pituitary releases luteinizing hormone (LH), releasing the ovum
  5. Anterior pituitary releases follicle-stimulating hormone (FSH)
  6. Corpus luteum releases estrogen and progesterone
  7. Corpus luteum disintegrates causing a decrease in progesterone
  8. Lining of uterus is shed as menses

 

ANS:

E, A, C, D, B, F, G, H

 

The anterior pituitary releases FHS, which allows the egg to mature in the graafian follicle; estrogen from the maturing follicle causes vascularization of the uterine lining; the anterior pituitary releases LS to release the ovum into the fallopian tubes and into the uterus; corpus luteum (made up of the old graafian follicle) releases estrogen and progesterone. The corpus luteum disintegrates, causing a decrease in progesterone and the lining of the uterus is shed as menses.

 

DIF:    Cognitive Level: Analysis               REF:   Page 554        OBJ:   2

TOP:   Menstrual cycle                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse gives discharge instructions to a person who has had a modified radical mastectomy of the right side to perform the “elbow pull-in.” Place the steps of the exercise in appropriate order. (Separate letters by a comma and space as follows: A, B, C, D)

 

  1. Pull elbows forward until they touch
  2. Lower and straighten the arms
  3. Extend arms sideways to shoulder level
  4. Bring elbows back and extend arms
  5. Clasp hands behind neck

 

ANS:

C, E, A, D, B

 

The exercise requires that you bring the arms out at shoulder level, clasp hands behind head and bring elbows to touch, then bring elbows back and extend arms lower and straighten arms.

 

DIF:    Cognitive Level: Application          REF:   Page 599, Box 12-7

OBJ:   19                  TOP:   Post-mastectomy exercise               KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Health Promotion and Maintenance

Chapter 16: Care of the Patient with HIV/AIDS

 

MULTIPLE CHOICE

 

  1. When assigned to a newly admitted patient with AIDS, the nurse says, “I’m pregnant. It is not safe for me or my baby if I am assigned to his case.” Which is the most appropriate response by the charge nurse?
a. “This patient would not be a risk for your baby if you use standard precautions and avoid direct contact with blood or body fluids.”
b. “You should ask for a transfer to another unit because contact with this patient would put you and your baby at risk for AIDS.”
c. “Wear a mask, gown, and gloves every time you go into his room and use disposable trays, plates, and utensils to serve his meals.”
d. “We should recommend that this patient be transferred to an isolation unit.”

 

 

ANS:  A

HIV is transmitted from human to human through infected blood, semen, cervicovaginal secretions, and breast milk. The use of Standard Precautions by all staff members for all patients all the time simplifies this issue.

 

DIF:    Cognitive Level: Application          REF:   Pages 769-770,Box 16–6

OBJ:   6                    TOP:   Transmission of AIDS

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The anxious male patient is fearful that he has been exposed to a person with an HIV infection. He states he does not want to go to a laboratory for the ELISA tests because he does not want to be identified. What would be the nurse’s most helpful response?
a. “There really is not an option, you will need to get the Western blot test first.”
b. “There is an FDA-approved home test called OraQuick.”
c. “The rapid test Reveal can identify all the HIV strains.”
d. “You can be tested anonymously for ELISA. If you are seronegative, your concerns are over.”

 

 

ANS:  B

The OraQuick is a home OTC test approved by the FDA. One seronegative on the ELISA is not evidence because seroconversion may not have taken place. The Western blot test follows if the ELISA is positive.

 

DIF:    Cognitive Level: Application          REF:   Page 783        OBJ:   6

TOP:   HIV testing     KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The patient, age 21, has been treated for chlamydia and has a history of recurrent herpes. What should the nurse counsel this patient about?
a. Sexual history, risk reduction measures, and testing for HIV
b. Getting an appointment at a family planning clinic
c. Testing for HIV and what the test results mean
d. Abstinence and a monogamous relationship

 

 

ANS:  A

Chlamydia is considered a sexually transmitted disease (STD). As such it requires further testing and a sexual history to advise the sexual partners.

 

DIF:    Cognitive Level: Analysis               REF:   Page 783        OBJ:   6

TOP:   Risk for infection                           KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A patient has just been diagnosed as HIV-positive. He asks the nurse, “Does this mean I have AIDS?” Which response would be most informative?
a. “Most people get AIDS within 3 to 12 weeks after they are infected with HIV.”
b. “Don’t worry. You may never get AIDS if you eat properly, exercise, and get plenty of rest.”
c. “It varies with every individual, but the average time is 8 to 10 years from the time a person is infected, and some go much longer.”
d. “You can expect to develop signs and symptoms of AIDS within 6 months.”

 

 

ANS:  C

Typical progress of HIV includes a period of relative clinical latency, occurring immediately after the primary infection, which can last for several years. Long-term nonprogressors remain symptom-free for 8 to10 years.

 

DIF:    Cognitive Level: Analysis               REF:   Page 763        OBJ:   4

TOP:   Progression of disease                    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following is a CDC criterion for the progression of HIV infection to AIDS?
a. Increase in viral load
b. Decreased ratio of CD8 to CD4
c. Increase in white blood cells
d. Increased reactivity to skin tests

 

 

ANS:  A

AIDS is the end stage of an HIV infection. The CDC has developed criteria for the diagnosis of AIDS, which are: increase in viral load even with pharmacologic interventions, increase in the ratio of CD8 to CD4, decline in the WBCs, and a decreased reactivity to skin tests.

 

DIF:    Cognitive Level: Analysis               REF:   Page 764        OBJ:   7

TOP:   AIDS diagnostic criteria                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What should the nurse look for when reviewing a patient’s chart to determine whether she has progressed from HIV disease to AIDS?
a. CD4+ count below 500, chronic fatigue, night sweats
b. HIV-positive test result, CD4+ count below 200, history of opportunistic disease
c. Weight loss, persistent generalized lymphadenopathy, chronic diarrhea
d. Fever, chills, CD4+ count below 200

 

 

ANS:  B

Patients who have progressed from HIV disease to AIDS will have the condition in which the CD4+ cell count drops to less than 200 cells/mm3 and have a history of opportunistic diseases.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 760-761, Table 16-1

OBJ:   9                    TOP:   Progression of disease

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. A male patient is advised to receive HIV antibody testing because of his multiple sexual partners and injectable drug use. What should the nurse inform the patient to ensure understanding?
a. The blood is tested with the highly sensitive test called the Western blot.
b. The blood is tested with an ELISA; if positive, it is tested again with an ELISA, followed by a Western blot if the second ELISA is positive.
c. A series of HIV tests is performed to confirm if the patient has AIDS.
d. If the HIV tests are seronegative, the patient can be assured that he is not infected.

 

 

ANS:  B

The individual’s blood is tested with ELISA or enzyme immunoassay (ELA), antibody tests that detect the presence of HIV antibodies. If the ELA is positive for HIV, then the same blood is tested a second time. If the second ELA is positive, a more specific confirming test such as the Western blot is done. Blood that is reactive or positive in all three steps is reported to be HIV-positive. A seronegative is not an assurance that the individual is free of infection since seroconversion may not have yet occurred.

 

DIF:    Cognitive Level: Application          REF:   Page 764, Box 16-2

OBJ:   9                    TOP:   Diagnostic procedures

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A 28-year-old married attorney with one child is in the first trimester of her second pregnancy. The patient states that she is at no risk for HIV, so she would not need to be counseled about testing for HIV. Which is the most appropriate response?
a. “She’s a professional woman in a monogamous relationship. She obviously is not at risk.”
b. “Women are not at great risk. The greatest risk is with gay men.”
c. “The fastest-growing segment of the population with AIDS is women and children. We need to assess her risks.”
d. “We need to review her chart to determine if her first child was infected.”

 

 

ANS:  C

Increases in AIDS cases in women and heterosexuals and a slowing of cases in the men who have sex with men (MSM) category are a direct reflection of early educational efforts directed at the MSM population, who were believed to be the only population at risk. Women need to be assessed for different manifestations of HIV infection. It is the current recommendation for voluntary HIV testing for all pregnant women.

 

DIF:    Cognitive Level: Application          REF:   Page 783        OBJ:   6

TOP:   Risk for infection                           KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A young gay patient being treated for his third sexually transmitted disease does not see why he should use condoms, because “they don’t work.” Which is the most appropriate response?
a. “Condoms may not provide 100% protection, but when used correctly and consistently with every act of sexual intercourse they reduce your risk of getting infected with HIV or other sexually transmitted diseases.”
b. “You are correct. Condoms don’t always work, so your best protection is to limit your number of partners.”
c. “Condoms do not provide 100% protection, so you should always discuss with your sexual partners their HIV status or ask if they have any STD.”
d. “Condoms do not provide 100% protection, but when used with a spermicide you can be assured of complete protection against HIV and other STDs.”

 

 

ANS:  A

Risk-reducing sexual activities decrease the risk of contact with HIV through the use of barriers. The most commonly used barrier is the male condom. Although not 100% effective, when used correctly and consistently, male condoms are very effective in the prevention of HIV transmission.

 

DIF:    Cognitive Level: Analysis               REF:   Page 785        OBJ:   5

TOP:   Transmission of disease                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A 21-year-old male who has been an IV heroin user has been experiencing fever, weight loss, and diarrhea and has been diagnosed as having AIDS. At this time, he has a low-grade fever, severe diarrhea, and a productive cough. He is admitted with Pneumocystis jiroveci. What should the nurse do when caring for the patient?
a. Use a gown, mask, and gloves when assisting the patient with his bath
b. Wear a gown when assisting the patient to use the bedpan
c. Use a gown, mask, and gloves to administer oral medications
d. Use a mask when taking the patient’s temperature

 

 

ANS:  A

The use of Standard Precautions and body substance isolation has been shown not only to reduce the risk of blood-borne pathogens, but also to reduce the risk of transmission of other disease between the patient and the health care worker.

 

DIF:    Cognitive Level: Application          REF:   Page 786        OBJ:   16

TOP:   Transmission of disease                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The nurse should instruct the patient who is diagnosed with AIDS to report signs of Kaposi sarcoma, which include:
a. Reddish-purple skin lesions
b. Open, bleeding skin lesions
c. Blood-tinged sputum
d. Watery diarrhea

 

 

ANS:  A

Kaposi sarcoma is a rare cancer of the skin and mucous membranes characterized by blue, red, or purple raised lesions seen mainly in Mediterranean men. Kaposi sarcoma: firm, flat, raised or nodular, hyperpigmented, multicentric lesions on the skin and mucous membranes.

 

DIF:    Cognitive Level: Application          REF:   Page 752        OBJ:   8

TOP:   Kaposi sarcoma                              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A patient states that he feels terrific, but a blood test shows that he is HIV-positive. It is important for the nurse to discuss with him that HIV may remain dormant for several years. What is true of the patient during this time?
a. He is not dangerous to anyone.
b. He experiences minor symptoms only.
c. He experiences decreased immunity.
d. He is contagious.

 

 

ANS:  D

A prolonged period in which HIV is not readily detectable in the blood follows within a few weeks or months of the initial infection. This titer, or viral load, falls dramatically as the immune system responds and controls the HIV infection, and it may last 10 to 12 years. During this period, there are few clinical symptoms of HIV infection, although an individual is still capable of transmitting HIV to others.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 763        OBJ:   15

TOP:   Progression of disease                    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. To be diagnosed as having AIDS, the patient must be HIV-positive, have a compromised immune system without known immune system disease or recent organ transplant, and present with which of the following?
a. Opportunistic infection
b. A positive ELISA or Western blot test
c. Weight loss, fever, and generalized lymphedema
d. CD4+ lymphocyte count less than 200 mm3

 

 

ANS:  D

The 1993 expanded case definition of AIDS includes all HIV-infected people who have CD4+, T-lymphocyte counts of less than 200 cells/mm3; this includes all people who have one or more of these three clinical conditions: pulmonary tuberculosis, recurrent pneumonia, or invasive cervical cancer, and it retains the 23 clinical conditions listed in the 1987 AIDS case definition.

 

DIF:    Cognitive Level: Analysis               REF:   Page 761, Table 16-1

OBJ:   2                    TOP:   Definition of AIDS disease

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. Why should interventions such as promotion of nutrition, exercise, and stress reduction be undertaken by the nurse for patients who have HIV infection?
a. They will promote a feeling of well-being in the patient.
b. They will improve immune function.
c. They will prevent transmission of the virus to others.
d. They will increase the patient’s strength and ability to care for himself or herself.

 

 

ANS:  B

HIV disease progression may be delayed by promoting a healthy immune system. Useful interventions for HIV-infected patients include the following: nutritional changes that maintain lean body mass, regular exercise, and stress reduction.

 

DIF:    Cognitive Level: Analysis               REF:   Page 776        OBJ:   15

TOP:   Immune function improvement      KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A male patient is concerned about telling others he has HIV infection. What should the nurse stress when discussing his concerns?
a. Care providers and sexual partners should be told about his diagnosis.
b. There is no reason to hide his disease.
c. Secrecy is a poor idea because it will lower his self-esteem.
d. His diagnosis will be obvious to most people with whom he will come into contact.

 

 

ANS:  A

Nurses have a responsibility to assess each patient’s risk for HIV infection and counsel those at risk about HIV testing and the behaviors that put them at risk, and about how to reduce or eliminate those risks. The diagnosis needs to be carefully protected and shared only with caregivers who need to know for the purpose of assessment and treatment.

 

DIF:    Cognitive Level: Application          REF:   Page 775        OBJ:   13

TOP:   Coping           KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The HIV patient asks the nurse about what to expect in terms of disease progression. The nurse tells this patient that although the disease can vary greatly among individuals, the usual pattern of progression includes:
a. viremia, clinical latency, opportunistic diseases, and death.
b. asymptomatic phase, clinical latency, ARC, and AIDS.
c. acute retroviral syndrome, early infection, early symptomatic disease, and AIDS.
d. transitional viral syndrome, inactive disease, early symptomatic infection, and opportunistic diseases.

 

 

ANS:  C

The progression from HIV to AIDS includes initial exposure, primary HIV infection, asymptomatic HIV infection, early HIV disease, and AIDS.

 

DIF:    Cognitive Level: Analysis               REF:   Page 763, Figure 16-3

OBJ:   4                    TOP:   Progression of disease

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. While teaching community groups about AIDS, what should the nurse indicate as the most common method of transmission of the HIV virus?
a. Sexual contact with an HIV-infected partner
b. Perinatal transmission
c. Exposure to contaminated blood
d. Nonsexual exposure to saliva and tears

 

 

ANS:  A

Modes of transmission have remained constant throughout the course of the HIV pandemic. It is also important for health care providers to remember that transmission of HIV occurs through sexual practices, not sexual preferences. Worldwide, sexual intercourse is by far the most common mode of HIV transmission.

 

DIF:    Cognitive Level: Application          REF:   Page 774, Box 16-11

OBJ:   7                    TOP:   Transmission of disease

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. What do the activated monocytes and macrophages produce in the presence of an inflammatory process?
a. Reduction of red cells
b. Increase in WBCs
c. Neopterin
d. Increase in T-helper cells increase natural killer (NK) cells

 

 

ANS:  C

Neopterin is produced in the presence of an inflammatory reaction and is increased in HIV disease.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 764, Box 16-2

OBJ:   5                    TOP:   Neopterin       KEY:  Nursing Process Step: Intervention

MSC:  NCLEX: Physiological Integrity

 

  1. For most people who are HIV-positive, marker antibodies are usually present 10 to 12 weeks after exposure. What is the development of these antibodies called?
a. Immunocompetence
b. Seroconversion
c. Opportunistic infection
d. Immunodeficiency

 

 

ANS:  B

Seroconversion is the development of antibodies from HIV, which takes place approximately 5 days to 3 months after exposure, generally within 1 to 3 weeks. Although the conversion has taken place, the patient is not yet immunodeficient.

 

DIF:    Cognitive Level: Analysis               REF:   Page 762        OBJ:   10

TOP:   Progression of disease                    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. What should the nurse emphasize when counseling an anxious HIV-positive mother about the care of her HIV-positive infant?
a. The baby will develop AIDS and refer her to a local AIDS support group. The baby will remain HIV-positive for the rest of its life.
b. Although infants of HIV-infected mothers may test positive for HIV antibodies, not all infants are infected with the virus.
c. She has not yet developed AIDS, and that it is possible the baby will not develop AIDS for many years.
d. If the infant is started on zidovudine (AZT) within the first month after delivery, AIDS can be prevented.

 

 

ANS:  B

The decline in pediatric AIDS incidence is associated with the increased compliance with universal counseling and testing of pregnant women and the use of zidovudine by HIV-infected pregnant women and their newborn infants. Infants born to HIV-infected mothers will have positive HIV antibody results as long as 15 to 18 months after birth. This is caused by maternal antibodies that cross the placenta during gestation and remain in the infant’s circulatory system.

 

DIF:    Cognitive Level: Analysis               REF:   Pages 758-759

OBJ:   5                    TOP:   Transmission of disease

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Psychosocial Integrity

 

  1. Why are snacks high in potassium, such as bananas and apricot nectar, recommended?
a. Electrolytes are lost through diaphoresis.
b. Sodium is lost through frequent diarrhea.
c. Potassium will support weight gain.
d. Potassium helps fight infection.

 

 

ANS:  C

HIV disease progression may be delayed by promoting a healthy immune system. Nutritional changes that maintain lean body mass, increase weight, and ensure appropriate levels of vitamins and micronutrients are helpful. Eat potassium-rich foods, such as bananas and apricot nectar.

 

DIF:    Cognitive Level: Analysis               REF:   Page 779, Box 16-6

OBJ:   15                  TOP:   Nutrition        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The depressed patient with AIDS says, “I don’t understand why I am going to be getting doses of testosterone. What good will that do me now?” What should the nurse keep in mind about testosterone when responding?
a. It can lower viral load
b. It can lighten depression
c. It can increase lean body mass
d. It can increase appetite

 

 

ANS:  C

Testosterone can increase body mass and lean weight.

 

DIF:    Cognitive Level: Application          REF:   Page 780        OBJ:   16

TOP:   Transmission of disease                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. After what period of time would the home health nurse make a mental health appointment for a patient with an HIV infection after assessing a diminished ability to attend to daily functioning?
a. 1 week
b. 2 weeks
c. 3 weeks
d. 1 month

 

 

ANS:  B

Patients with HIV infection have a great deal of anxiety and guilt, which may interfere with the daily functions of maintaining relationships and making decisions. When this apathy is assessed for a period of 2 weeks, the nurse should refer the patient for a mental health consult.

 

DIF:    Cognitive Level: Analysis               REF:   Page 775        OBJ:   13

TOP:   Coping           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity

 

  1. The HIV-infected patient who has just seroconverted says he just cannot take all those confusing, expensive antiretroviral (ART) medications. He says he still feels fine, anyway. What should the nurse keep in mind when counseling this patient?
a. Resumption of the ART later in the disease is just as effective
b. Adherence to the ART protocol is essential to the success of the treatment
c. Cessation of the ART may prevent the emergence of a resistant strain of HIV
d. Once ART is initiated it cannot be restarted in the same patient

 

 

ANS:  B

Compliance and adherence to the ART protocol is essential to its success. Cessation of the medication may stimulate the emergence of a resistant strain of HIV virus. ART can be restarted, but the optimum time to start is soon after seroconversion.

 

DIF:    Cognitive Level: Application          REF:   Page 776        OBJ:   5

TOP:   Adherence to ART                         KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What medication times should the nurse use in writing out a schedule for taking antiretroviral medication three times a day?
a. 8 AM – 2 PM – 8 PM
b. 8AM – 4PM – 12 AM
c. 8AM – 5PM – 1 AM
d. Be given with meals

 

 

ANS:  C

Antivirals should be given around the clock to keep the therapeutic level of the ART at a constant level.

 

DIF:    Cognitive Level: Analysis               REF:   Page 768        OBJ:   15

TOP:   Antiretroviral therapy (ART)          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. Which of the following are early signs and symptoms of an HIV infection? (Select all that apply.)
a. Dry mouth
b. Weight loss
c. Sore throat
d. Vaginal dryness
e. Nausea
f. Dyspnea

 

 

ANS:  B, C, F

Signs and symptoms of HIV infection include weight loss, sore throat, and dyspnea.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 762, Box 16-1

OBJ:   8                    TOP:   HIV infection

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following are methods in which children with AIDS could have contracted their disease? (Select all that apply.)
a. During intrauterine life with an HIV-positive mother
b. During the birth process of an HIV-positive mother
c. From other children who are HIV positive
d. From receiving a transfusion contaminated with the HIV virus
e. From breastfeeding by an HIV-positive mother

 

 

ANS:  A, B, D, E

In the United States, transfusion of infected blood and blood products and transplantation of infected tissues account for 1% of the total adult and adolescent AIDS cases and 2% of the total pediatric AIDS cases. HIV infection can be transmitted from a mother to her infant during pregnancy, at the time of delivery, or after birth, through breastfeeding. In the United States, it is estimated that approximately 30% of infected mothers will transmit HIV to their infants, with approximately 50% to 70% of the transmissions occurring late in utero or intrapartum. In the United States, among children who are less than 13 years old and have AIDS, 93% were infected at birth.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 758        OBJ:   5

TOP:   Transmission of disease                 KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The home health nurse designing a teaching plan for a person with HIV disease that would support weight gain would include information pertaining to (Select all that apply.)
a. Limit fluid intake
b. Eating high-protein/high-calorie diet
c. Drinking nutritional supplements (Boost, Sustacal, etc.)
d. Eating several small meals during the day
e. Providing referrals to dietitians
f. Resistance weight training

 

 

ANS:  B, C, D, E, F

Increase protein, calorie, and fat intake. Offer nutritional supplements. Eat several small meals per day instead of three large meals. Provide for referrals. Weigh the patient daily. Weight training maintains muscle tone and improves appetite.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 786        OBJ:   15

TOP:   Weight loss    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which foods would a nurse recommend for a person with debilitating diarrhea as a result of HIV infection? (Select all that apply.)
a. Bananas
b. Ensure
c. Fresh broccoli
d. Cooked fruits and vegetables
e. Red meat
f. Apricot nectar

 

 

ANS:  A, D, F

Avoid dairy products, red meat, margarine, butter, eggs, dried beans, peas, and raw fruits and vegetables. Cooked or canned fruits and vegetables will provide needed vitamins. Eat potassium-rich foods, such as bananas and apricot nectar. Discontinue foods, nutritional supplements, and medications that may make diarrhea worse (Ensure, antacids, stool softeners). Avoid gas-producing foods. Serve warm, not hot, foods. Plan small, frequent meals. Drink plenty of fluids between meals.

 

DIF:    Cognitive Level: Analysis               REF:   Page 779, Table 16-6

OBJ:   15                  TOP:   Weight loss    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. How does the HIV-2 virus compare to the HIV-1 virus? (Select all that apply.)
a. It has lower mortality risks in the older adult
b. It is less virulent
c. It is less infectious in the initial stage of infection
d. It predisposes the HIV-infected person to a normal life span
e. It develops high viral loads

 

 

ANS:  A, B, C, D

Persons who are infected with the HIV-2 are less infectious during the initial stage because the virus is less virulent than HIV-1. These persons tend to live a normal life span and the mortality in the later years is less.

 

DIF:    Cognitive Level: Application          REF:   Page 753        OBJ:   7

TOP:   HIV-2            KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Which of the following are examples of the AIDS wasting syndrome in a patient with an HIV infection? (Select all that apply.)
a. Episodes of vomiting for 20 days
b. Appearance of Kaposi sarcoma
c. Loss of 10% of body mass
d. Marked hair loss
e. Episodes of diarrhea for 30 days
f. Episodes of hypotension

 

 

ANS:  C, E

The AIDS wasting syndrome is due to disturbances in metabolism involving lean body mass. The wasting syndrome is signaled by 10% loss of body weight, 30 days of diarrhea, weakness, and fever. The person who has the wasting syndrome is considered to have AIDS.

 

DIF:    Cognitive Level: Analysis               REF:   Page 776        OBJ:   4

TOP:   Wasting syndrome                          KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

COMPLETION

 

  1. ______________ is a type of sexual option classified as “no risk” for a person to become infected with the HIV virus.

 

ANS:

Abstinence

 

Abstinence is refraining from sexual contact in which there is exchange of semen, vaginal secretions, or blood.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 782, Box 16-10

OBJ:   5                    TOP:   HIV infection prevention

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Health Promotion and Maintenance

 

  1. An organism that can cross from an animal species to humans is a(n) ____________organism.

 

ANS:

zoonotic

 

A zoonotic organism is an organism that can cross from an animal species to humans.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 753        OBJ:   1

TOP:   Zoonotic        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse explains that an enzyme ____________ ____________ allows the RNA of the retrovirus to be changed to DNA and incorporated into the host’s genetic material.

 

ANS:

reverse transcriptase

 

Reverse transcriptase allows the RNA of the retrovirus to be changed to DNA and incorporated into the host’s genetic material.

 

DIF:    Cognitive Level: Application          REF:   Page 759        OBJ:   7

TOP:   Reverse transcriptase                                KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The term that describes an immunosuppressed patient’s inability to react to a skin test is __________________.

 

ANS:

anergic

 

Anergic is the term that describes an immunosuppressed patient’s ability to react to a skin test.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 674        OBJ:   2

TOP:   Anergia          KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

  1. The combination of efforts of the medical team, nutritionist, social workers, and clergy is the necessary ______________ approach to the complex needs of the patients with HIV infection.

 

ANS:

multidisciplinary

 

The use of many disciplines in a combined approach to a complex medical problem is multidisciplinary.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 774        OBJ:   11

TOP:   Multidisciplinary                            KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Safe and Effective Care Environment

 

OTHER

 

  1. The historical progress of the HIV infection began to be tracked in 1979. Arrange the historical events in sequence of their discovery. (Separate letters by a comma and space as follows: A, B, C, D)

 

  1. Infection in heterosexual men and women
  2. Infection in hemophiliacs
  3. Infection in injection drug users
  4. Increased incidence of Kaposi carcinoma in young homosexual men
  5. Increased incidence of Pneumocystis jiroveci (previously PCP)

 

ANS:

E, D, C, B, A

 

The history of the incidence of HIV infection was slow in being recognized. The first observation was an increase in incidence of Pneumocystis jiroveci, followed by increasing incidence of Kaposi carcinoma in the homosexual population. The infection began to be seen in injection drug users, hemophiliacs, then into the heterosexual population.

 

DIF:    Cognitive Level: Application          REF:   Page 752        OBJ:   1| 12

TOP:   History of incidence of HIV infection                            KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Health Promotion and Maintenance

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