Adult Health Nursing 6th Edition By kockrow-Test Bank

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Adult Health Nursing 6th Edition By kockrow-Test Bank

Christensen: Adult Health Nursing, 6th Edition

 

Chapter 02: Care of the Surgical Patient

 

Test Bank

 

MULTIPLE CHOICE

 

  1. The patient is 38 years old and is in her second postoperative day after placement of an intramedullary rod in her left femur. She is receiving analgesia via a patient-controlled analgesia (PCA) device. The inappropriate intervention related to caring for a patient with a PCA is:
a. Maintaining the system.
b. Recording activations of the system.
c. Administering the analgesia to the patient.
d. Monitoring the patient’s pain.

 

 

ANS:   C

With the PCA system of medication administration, the patient can self-administer an analgesic by pressing a control button. The nurse should not give medication doses by pushing the control button.

 

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

TOP:    Medication administration                 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 18, Table 2-1

OBJ:    2                      TOP:    Types of surgery

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

 

  1. The Patient’s Bill of Rights states that a patient must give his or her permission for any specific test or procedure to be performed. What is the legal term for this permission?
a. Verbal consent
b. Medical documentation
c. Informed consent
d. Informed decision

 

 

ANS:   C

The Patient’s Bill of Rights affirms that the patients must give informed consent (permission obtained from the patient to perform a specific test or procedure) before the beginning of any procedure.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 24           OBJ:    6

TOP:    Informed consent                               KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. An informed consent was to be obtained from the patient for his scheduled open cholecystectomy. Which circumstance could prevent the patient from signing his informed consent?
a. Pain radiating to the scapula
b. An injection of Demerol, 75 mg IM, 1 hour ago
c. The presence of jaundice and scleral icterus
d. His concern over his insurance company not covering the procedure

 

 

ANS:   B

Informed consent should not be obtained if the patient is disoriented and under the influence of sedatives.

 

DIF:    Cognitive Level: Application             REF:    Page 25           OBJ:    6

TOP:    Informed consent                               KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. The anesthesiologist provides ____ anesthesia by inhalation and IV administration routes.
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.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 37           OBJ:    11

TOP:    Anesthesia      KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. A type of anesthesia that requires a depressed level of consciousness is
a. regional anesthesia.
b. specific anesthesia.
c. optional sedation.
d. conscious sedation.

 

 

ANS:   D

Conscious sedation is routinely used for procedures that do not require complete anesthesia but rather a depressed level of consciousness.

 

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

TOP:    Conscious sedation                            KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. The older adult patient may not respond to surgical treatment as well as a younger adult because of
a. poor skin turgor resulting in dehydration.
b. disturbed body image related to surgical incision.
c. his or her body’s response to physiological changes.
d. decreased peristalsis related to general anesthesia.

 

 

ANS:   C

Of specific concern in older adults is the body’s response to temperature changes, cardiovascular shifts, respiratory needs, and renal function.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 20           OBJ:    7

TOP:    Older adult patient                             KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. A 45-year-old patient has had a repair of a cerebral aneurysm and is presenting signs of increased intracranial pressure (ICP). Which postoperative nursing interventions would be contraindicated?
a. Coughing every 2 hours
b. Leg exercises 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 32, Box 2-6

OBJ:    5                      TOP:    Postoperative complications

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. A male patient, age 80, has had a total hip replacement. Anxiety, hypotension, and jarring during transfer from the recovery room to his room can cause a postoperative increase in which of his vital signs?
a. Pulse rate
b. Temperature
c. Blood pressure
d. Pain

 

 

ANS:   A

An increase in pulse rate is an objective, detectable sign that the body is responding to “pain.” Other objective changes include a decrease in blood pressure in the immediate postoperative period, restlessness, diaphoresis, and pallor.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 48, Box 2-8

OBJ:    10                    TOP:    Postoperative complications

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

 

  1. A patient, age 65, underwent a right hemicolectomy. On postoperative day 4, her surgical wound dehisced. This means that
a. there is partial or complete wound separation.
b. there has been inadequate wound closure.
c. abdominal viscera protrude through the walls.
d. the wound will not heal well when it is resutured.

 

 

ANS:   A

A surgical incision may separate; this action of dehiscence (the separation of a surgical incision or rupture of a wound closure) may occur within 3 days to over 2 weeks postoperatively.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 48, Figure 2-15

OBJ:    1                      TOP:    Postoperative complications

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

 

  1. A patient is on postoperative day 2 after a nephrectomy. The nurse is aware that the most effective way to increase her peristalsis is
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: Application             REF:    Page 52, Box 2-10

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.
b. Check airway for patency.
c. Check intravenous site.
d. Check vital signs.

 

 

ANS:   B

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

 

DIF:    Cognitive Level: Application             REF:    Page 45, Table 2-6

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. One of the first signs and symptoms of hemorrhage may be
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 48           OBJ:    10

TOP:    Postoperative complications               KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. Frequent monitoring of the postoperative patient’s vital signs assesses which body system?
a. Gastrointestinal
b. Endocrine
c. Neurological
d. Cardiovascular

 

 

ANS:   D

Hypotension and cardiac dysrhythmias are the most common cardiovascular complications of the surgical patient, and early recognition and management of these complications before they become serious enough to diminish cardiac output depend on frequent assessment of the patient’s vital signs.

 

DIF:    Cognitive Level: Comprehension       REF:    Pages 35, 51, Table 2-4

OBJ:    14                    TOP:    Postoperative patient

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. Decreased activity in an obese surgical patient predisposes the patient to which complication?
a. Cardiac arrest
b. Pneumonia
c. Incisional hernias
d. Hypoventilation

 

 

ANS:   D

Immediate postoperative hypoventilation can result from drugs (anesthetics, narcotics, tranquilizers, sedatives) incisional pain, obesity, chronic lung disease, or pressure on the diaphragm.

 

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

TOP:    Postoperative complications               KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse acknowledges that all preoperative nursing interventions have been performed by signing which document?
a. Nurse’s notes
b. Anesthesia record
c. Preoperative checklist
d. Physician’s order sheet

 

 

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 41, Figure 2-10

OBJ:    9                      TOP:    Preoperative checklist

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. Which nursing interventions would be appropriate after a wound evisceration?
a. Place the patient in 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:    Page 48, Figure 2-15

OBJ:    13                    TOP:    Postoperative interventions

KEY:   Nursing Process Step: Planning         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. Regularly every three to four hours before pain gets severe.
c. Only when the physician orders.
d. Only when the patient is in severe pain.

 

 

ANS:   B

The nurse should ask the patient every 3-4 hours if something is needed for pain because some patients will not ask for an analgesic.

 

DIF:    Cognitive Level: Application             REF:    Page 49           OBJ:    10

TOP:    Medication administration                 KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Physiological Integrity

 

  1. What nursing interventions will minimize the effects of venous stasis?
a. Pillows under the knee in a position of comfort
b. Sitting with the feet flat on the floor
c. Early ambulation
d. 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 52, Box 2-10

OBJ:    13                    TOP:    Interventions

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

 

  1. Serum potassium levels are usually determined before surgery to
a. assess kidney function.
b. determine respiratory insufficiency.
c. prevent dysrhythmias 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, dysrhythmias can occur during anesthesia.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 24           OBJ:    9

TOP:    Preoperative assessment                     KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse is assisting with the sponge and instrument count in the operating room. The operative phase in which the nurse is assisting is called the
a. perioperative phase.
b. preoperative phase.
c. intraoperative phase.
d. postoperative phase.

 

 

ANS:   C

Counting of sponges, needles, and instruments with the scrub nurse before surgery and before closing the wound is done during the intraoperative phase of the surgery.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 24, Box 2-7

OBJ:    8                      TOP:    Intraoperative responsibilities

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. Which early postoperative observation is abnormal and should be reported immediately?
a. Emesis that is red
b. Complaint of feeling cold
c. Nausea
d. Complaint of pain

 

 

ANS:   A

Any emesis that is red should be reported immediately.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 46, Box 2-7

OBJ:    10                    TOP:    Assessment     KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. Sudden chest pain combined with dyspnea, cyanosis, and tachycardia is an indication 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 49           OBJ:    13

TOP:    Assessment and postoperative complications

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

 

  1. An appendectomy during a hysterectomy would be 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 18, Table 2-1

OBJ:    2                      TOP:    Types of surgery

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

 

  1. Which patients would be at greatest risk during surgery?
a. 78-year-old taking an analgesic agent
b. 43-year-old taking an antihypertensive agent
c. 27-year-old taking an anticoagulant agent
d. 10-year-old taking an 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 21, Box 2-3, Table 2-5

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

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

 

  1. A patient will have an incision in the lower left abdomen. Which intervention by the nurse will help decrease discomfort in the incisional area when she coughs postoperatively?
a. Apply a splint directly over the lower abdomen.
b. Keep the patient flat with feet flexed.
c. Turn her on her right side.
d. Apply a splint above and below the incision.

 

 

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:    Pages 31-32, Skill 2-4 Step 10, NCP 2-1

OBJ:    14                    TOP:    Postoperative nursing interventions

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

 

  1. Although informed about the proposed surgical procedure, the patient has only vague responses about the postoperative period. A nursing diagnosis at this time would be
a. Impaired verbal communication.
b. Impaired gas exchange.
c. Deficient knowledge, postoperative.
d. Acute pain.

 

 

ANS:   C

Knowledge, deficient regarding implications of surgery related to information misinterpretation is a correct nursing diagnosis.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 20, Box 2-11

OBJ:    14                    TOP:    Nursing process/diagnosis

KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. A patient and a nurse develop a preoperative teaching plan. In teaching the patient to cough effectively after surgery, the nurse should tell her to practice
a. breathing through her nose, holding her breath, and exhaling slowly.
b. taking three deep breaths and coughing from the chest.
c. inhaling while contracting the abdominal muscles and exhaling while contracting the diaphragm.
d. taking short, frequent panting breaths and coughing 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 able to adequately remove trapped mucus and surgical gases.

 

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

OBJ:    13                    TOP:    Prevention of postoperative complications

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. What is the responsibility of the nurse regarding informed consent?
a. Explain the surgical options.
b. Explain the operative risks.
c. Obtain the patient’s signature.
d. Check form for appropriate signatures.

 

 

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 25           OBJ:    6

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 performs an abdominal assessment. To assess bowel sounds, the nurse auscultates the lower abdomen for
a. 1 minute.
b. 5 to 20 seconds.
c. as long as it takes to hear a bowel sound.
d. one full inspiration and expiration.

 

 

ANS:   A

Normal peristalsis is gauged by hearing 5 to 30 gurgles per minute.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 52, Box 2-10

OBJ:    10                    TOP:    Assessment     KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. Which preoperative fear is linked to postoperative behavior?
a. Fear of anesthesia and death
b. Fear of death and malnutrition
c. Fear of unknown and lack of respect
d. Fear of malnutrition and addiction to new medications

 

 

ANS:   A

The preoperative anxiety level influences the amount of anesthesia required, the amount of postoperative pain medication needed, and the speed of recovery from surgery.

 

DIF:    Cognitive Level: Assessment             REF:    Pages 20, 24, Box 2-4

OBJ:    4                      TOP:    Nursing diagnosis

KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. Ideally, preop teaching should be done
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

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

 

DIF:    Cognitive Level: Implementation      REF:    Page 24           OBJ:    8

TOP:    Nursing diagnosis                               KEY:   Nursing Process Step: Assessment

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 43           OBJ:    13

TOP:    Nursing diagnosis                               KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. Southeast Asian and Native American patients often do not make eye contact when preoperative teaching is being performed because
a. they aren’t educated.
b. they aren’t paying attention.
c. they believe eye contact is disrespectful.
d. they believe they are superior to the nurse.

 

 

ANS:   C

Southeast Asians and Native Americans may believe eye contact is disrespectful.

 

DIF:    Cognitive Level: Application             REF:    Page 22, Cultural Considerations box

OBJ:    N/A                 TOP:    Nursing diagnosis

KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. What are the high-risk conditions that may affect perioperative procedures? (Select all that apply):
a. Age, health, occupation, mental status
b. Financial income, health, nutritional status
c. Age, mental state, nutritional status, health
d. Occupation, age, nutritional status, health
e. Financial Income, occupation, age, health

 

 

ANS:   C

Each system of the body is affected by the patient’s age, health, nutritional status, and mental state.

 

DIF:    Cognitive Level: Assessment             REF:    Page 24           OBJ:    4

TOP:    Nursing diagnosis                               KEY:   Nursing Process Step: Assessment

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 56, Box 2-13

OBJ:    13                    TOP:    Discharge instructions

KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. Two considerations for the older adult surgical patient include (Select the two that apply.)
a. pre- and postoperative teaching.
b. lower morbidity and mortality.
c. quick assessment skills.
d. surgery causes much physiological stress.

 

 

ANS:   A, D

Surgery places greater stress on older than on younger patients. Teaching should be given at the older person’s level of understanding.

 

DIF:    Cognitive Level: Application             REF:    Page 20, Life Span Considerations box

OBJ:    7                      TOP:    Older adult considerations

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

 

  1. In preparing the patient for abdominal surgery, the Assistive Personnel (AP) can perform which interventions? (Select all that apply.)
a. Vital signs
b. Insertion of N/G tube
c. Enema
d. Height and weight
e. Obtain operative consent
f. Sterile gowning

 

 

ANS:   A, C, D

The AP can perform vital signs, enema, and height and weight.

 

DIF:    Cognitive Level: Application             REF:    Page 38           OBJ:    16

TOP:    Nursing diagnosis                               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 18, Table  2-1

OBJ:    1                      TOP:    Palliative therapy

KEY:   Nursing Process Step: Assessment     MSC:   NCLEX: Comprehension

 

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

 

ANS:

preoperative, recuperative

 

Discharge planning for a surgical procedure begins in the preoperative and continues through the recuperative period.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 55           OBJ:    15

TOP:    Nursing diagnosis                               KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Health Promotion and Maintenance

 

  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. Place a comma between each answer choice (a, b, c, d, etc.).

 

a. System review
b. Breathing
c. Circulation
d. Airway
e. Level of consciousness

 

 

ANS:   D, B, E, C, A

 

DIF:    Cognitive Level: Application             REF:    Page 45, Table 2-6

OBJ:    12                    TOP:    Nursing assessment

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance

Christensen: Adult Health Nursing, 6th Edition

 

Chapter 10: Care of the Patient with a Urinary Disorder

 

Test Bank

 

MULTIPLE CHOICE

 

  1. The amount of water that is eliminated with the urine is regulated by a complex mechanism within the nephron and influenced by a hormone from the posterior pituitary gland called
a. pitocin.
b. rennin hormone.
c. antidiuretic hormone.
d. ACTH.

 

 

ANS:   C

ADH causes the cells of the distal convoluted tubules to increase their rate of water reabsorption.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 438         OBJ:    4

TOP:    Urine production                                KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. As the body breaks down protein, nitrogen wastes are broken down into urea, ammonia, and
a. nitrogen.
b. uric acid.
c. nitrates.
d. creatinine.

 

 

ANS:   D

As proteins break down, nitrogenous wastes—urea, ammonia, and creatinine—are produced.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 434         OBJ:    4

TOP:    Physiology      KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. Because the kidneys are located in proximity to the vertebrae and are protected by the ribs, their location in documentation is referred to as
a. retroperitoneal.
b. diaphragm-vertebral.
c. costovertebral.
d. urachal-peritoneal.

 

 

ANS:   A

The kidneys lie behind the parietal peritoneum (retroperitoneal).

 

DIF:    Cognitive Level: Knowledge             REF:    Page 434         OBJ:    1

TOP:    Location of kidneys                           KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. A patient with chronic renal failure (CRF) has a nursing diagnosis of Disturbed sensory perceptions related to central nervous system changes induced by uremic toxins. Which nursing intervention is appropriate for this problem?
a. Ensure restricted protein intake to prevent nitrogenous product accumulation.
b. Provide an opportunity for the patient to discuss concerns about his condition.
c. Convey a caring attitude and foster the nurse-patient relationship.
d. Discourage eating fruits and vegetables as sources of high potassium in the diet.

 

 

ANS:   C

Listen to the patient. Restricted protein intake will benefit acute renal failure but may not help CRF.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 472, Health Promotion box

OBJ:    7                      TOP:    Chronic renal failure (CRF)

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

 

  1. Chronic renal failure (CRF) affects both patients and their families because of the financial predicament and facing the death of a loved one. Which would be an appropriate nursing intervention to address these concerns?
a. Encourage open discussion with social services.
b. Allow family privacy to resolve their issues.
c. Refer the family to a support group.
d. Have the physician speak to the family.

 

 

ANS:   A

Encourage verbalization of financial concerns and long term care options with representative from social services.  Support groups are not designed to assist with financial concerns.

 

DIF:    Cognitive Level: Application             REF:    Page 472, Health Promotion box

OBJ:    12                    TOP:    Coping            KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity

 

  1. A nursing intervention to assist the patient with chronic renal failure (CRF) in learning about available community resources would be a consultation with
a. a chaplain.
b. social services.
c. the physician’s office.
d. administrative services.

 

 

ANS:   B

Patient teaching—inform the patient of community resources.

 

DIF:    Cognitive Level: Application             REF:    Page 472, Box 10-4

OBJ:    12                    TOP:    Community resources

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

 

  1. When preparing to teach a patient about continuous bladder irrigation, the nurse notes that the most frequently used irrigant is
a. sterile isotonic saline.
b. an antibiotic solution.
c. sterile water.
d. heparinized normal saline.

 

 

ANS:   A

The irrigant is an isotonic solution.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 464         OBJ:    13

TOP:    Continuous bladder irrigation            KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The patient is receiving continuous bladder irrigation after a transurethral resection of the prostate (TURP). He complains of a “spasmlike” pain over his lower abdomen. Which of these actions should the nurse perform first in response to this complaint?
a. Inform the nurse in charge.
b. Decrease the continuous bladder irrigation flow.
c. Administer the prescribed analgesic.
d. Check the catheter and drainage system for obstruction.

 

 

ANS:   D

The patient who has a TURP may have continuous closed bladder irrigation or intermittent irrigation to prevent occlusion of the catheter with blood clots, which would cause bladder spasms.

 

DIF:    Cognitive Level: Application             REF:    Page 464         OBJ:    13

TOP:    Transurethral resection of prostate (TURP)

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. A 56-year-old patient with cancer of the bladder is recovering from a cystectomy with an ileal conduit. An important aspect in nursing interventions of the patient with an ileal conduit is
a. instructing the patient to void when the urge is felt.
b. maintenance of skin integrity.
c. prevention of tissue rejection.
d. limiting acid-ash foods.

 

 

ANS:   B

Care of the patient with an ileal conduit is a nursing challenge because of the continual drainage of urine through the stoma. Complication of this procedure is wound infection, dehiscence, and urinary leakage.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 479         OBJ:    8

TOP:    Cystectomy     KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. It is 2 days after a difficult patient’s urinary diversion surgery. He continues to be critical of the hospital and the nursing care, even though the staff has spent time explaining the care to him. The most likely explanation for his behavior is that he
a. is used to having things done his way.
b. has an obsessive-compulsive disorder.
c. has no other responsibilities to keep him occupied.
d. is having problems accepting the urinary diversion.

 

 

ANS:   D

Patient teaching centers on tasks of lifestyle adaptation: care of the stoma, nutrition, fluid intake, maintaining self-esteem in light of altered body image, modifying sexual activities, and early detection of complications.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 479         OBJ:    9

TOP:    Coping            KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Psychosocial Integrity

 

  1. In teaching a patient how to decrease the chance of further problems with urolithiasis, barring any other contraindication, the nurse would encourage him to
a. increase his fluid intake.
b. avoid contact sports.
c. restrict his protein intake.
d. take one baby aspirin daily.

 

 

ANS:   A

Fluid intake should be encouraged to at least 2,000 mL of fluid in 24 hours, unless contraindicated.

 

DIF:    Cognitive Level: Application             REF:    Pages 458-459

OBJ:    11                    TOP:    Urolithiasis     KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse notes the amount and color of the urine of the patient with urolithiasis. While using standard precautions, the nurse’s next action would be to
a. discard the urine.
b. add the urine to a 24-hour collector.
c. save the urine for physician assessment.
d. strain the urine.

 

 

ANS:   D

All urine should be strained. Because stones may be any size, even the smallest speck must be saved for assessment.

 

DIF:    Cognitive Level: Application             REF:    Page 458         OBJ:    8

TOP:    Urolithiasis      KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Physiological Integrity

 

  1. When a patient on Lasix, a loop diuretic, complains of weakness and irregular pulse, there may be an electrolyte deficiency of
a. magnesium.
b. sodium.
c. potassium.
d. calcium.

 

 

ANS:   C

The loop diuretic prototype, furosemide (Lasix), affects electrolytes to cause hypokalemia,

the deficiency of the electrolyte can cause arrhythmias and muscle weakness.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 443         OBJ:    7

TOP:    Medication      KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. The patient is scheduled for a cystogram via a cystoscope. Which is the best explanation of this procedure by the nurse?
a. “Your doctor will insert a lighted tube into the bladder through your urethra, inspect the bladder, and instill a dye that will outline your bladder on x-ray film.”
b. “Your doctor will inject a dye into a vein in your arm that is carried to the urinary system. Then a lighted tube in your bladder is used to see when the dye appears.”
c. “Your doctor will insert a lighted tube into the bladder and inject a dye into your kidneys through little catheters inserted into the ureters.”
d. “Your doctor will place a catheter into an artery in your groin and inject a dye that will visualize the blood supply to the kidneys.”

 

 

ANS:   A

Cystoscopy is a visual examination to inspect, treat, or diagnose disorders of the urinary bladder and proximal structures.

 

DIF:    Cognitive Level: Application             REF:    Page 441         OBJ:    11

TOP:    Diagnostic procedures                        KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The physician orders a urinalysis and urine culture. To obtain the urine specimen, the nurse would first instruct the patient about
a. collecting the urine for a 24 hour period.
b. obtaining a clean-catch specimen.
c. bringing in an early morning specimen.
d. limiting fluid intake to concentrate the urine.

 

 

ANS:   B

Urinalysis is completed on a clean-catch or catheterized specimen.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 439         OBJ:    11

TOP:    Diagnostic procedures                        KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The patient is scheduled for a transurethral resection of the prostate. During preoperative teaching, it is important to emphasize that after surgery he should expect
a. red drainage from the catheter.
b. limited intake of fluids.
c. a sodium-restricted diet.
d. incisional drainage.

 

 

ANS:   A

The patient and family need to know that hematuria is expected after prostatic surgery.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 464         OBJ:    11

TOP:    Transurethral resection of prostate (TURP)

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. A patient, age 71, has benign prostatic hypertrophy. He is recovering from a transurethral prostatic resection. The physician orders removal of the indwelling catheter 2 days after the TURP procedure. The patient should be instructed that at first he might experience
a. an intolerance to acidic fluids.
b. normal voiding patterns.
c. dribbling of urine.
d. no urine output for 6-8 hours.

 

 

ANS:   C

The patient is informed that initially he may experience frequency and voiding small amounts with some dribbling.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 464         OBJ:    11

TOP:    Transurethral resection of prostate (TURP)

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. A patient, age 69, is admitted to the hospital with gross hematuria and history of a 20-pound weight loss during the last 3 months. The physician suspects renal cancer. In obtaining a nursing history from this patient, the nurse recognizes which factor as a significant risk factor for renal cancer?
a. High caffeine intake
b. Cigarette smoking
c. Use of artificial sweeteners
d. Chronic cystitis

 

 

ANS:   B

Risk factors include smoking; familial incidence; and preexisting renal disorders such as adult polycystic kidney disease and renal cystic disease secondary to renal failure.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 461         OBJ:    6

TOP:    Renal cancer                                       KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. As the nurse and the dietitian review a patient’s diet plan with her, she becomes very angry, shouting that with her diabetes and now the kidney failure, there is just nothing she can eat. She says she might as well eat what she wants, because these diseases will kill her anyway. Based on the patient’s response, which nursing diagnosis does the nurse identify?
a. Noncompliance, risk for, related to feelings of anger
b. Risk for ineffective health maintenance, related to complexity of therapeutic regimen
c. Anticipatory grieving, related to actual and perceived losses
d. Ineffective coping, related to emotional liability

 

 

ANS:   A

Diabetes mellitus is the most common cause of kidney failure, accounting for more than 40% of new cases. Emphasis is placed on emotional support for the patient who faces role changes.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 472         OBJ:    9

TOP:    Coping            KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Psychosocial Integrity

 

  1. The patient is on postoperative day 1 after having undergone a TURP procedure. He has continuous bladder irrigation (CBI). Actual urine output during continuous bladder irrigation is calculated by
a. measuring and recording all fluid output in the drainage bag.
b. measuring the total output and deducting the total of the irrigating and intravenous solutions.
c. adding the total of the intravenous and irrigating solutions and then deducting the amount of output.
d. measuring total output and deducting the amount of irrigating solution used.

 

 

ANS:   D

To determine urine output, the nurse will subtract the amount of irrigation fluid used with the Foley catheter output to calculate urine output.

 

DIF:    Cognitive Level: Application             REF:    Page 464         OBJ:    8

TOP:    Transurethral resection of prostate (TURP)

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. A patient has nephrotic syndrome. Which of these statements made by the patient indicates that she understands the dietary modifications?
a. “I will need to increase protein and decrease sodium intake.”
b. “I will need to drink more milk to get my calcium.”
c. “Carbohydrate restriction will be difficult.”
d. “Potassium restriction won’t be hard since I don’t like fruit.”

 

 

ANS:   A

Medical management for nephrotic syndrome depends on the extent of tissue involvement and may include the use of corticosteroids and a low-sodium, high-protein diet.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 468         OBJ:    6

TOP:    Nephrotic syndrome                           KEY:   Nursing Process Step: Evaluation

MSC:   NCLEX: Physiological Integrity

 

  1. A 69-year-old patient is admitted with severe diarrhea. His urinalysis report indicates an increased level of ketone bodies. This occurs with
a. kidney disease.
b. starvation or carbohydrate-restricted diets.
c. infection.
d. urolithiasis.

 

 

ANS:   A

The presence of ketone bodies in the urine, ketoaciduria, occurs when excessive quantities for fatty acids are oxidized.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 438         OBJ:    6

TOP:    Diagnostic procedures                        KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

 

 

  1. The patient has end-stage renal disease (ESRD) and is admitted with a blood urea nitrogen (BUN) level of 93 mg/dL. An excessive elevation of BUN could result in
a. dehydration.
b. disorientation.
c. edema.
d. catabolism.

 

 

ANS:   B

If the BUN is elevated, preventive nursing measures should be instituted to protect the patient from possible disorientation or seizures.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 440         OBJ:    6

TOP:    Diagnostic procedures                        KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. The patient, age 30, has a history of renal calculi and is admitted to the hospital with gross hematuria and severe colicky left flank pain that radiates to his left testicle. An intravenous pyelogram confirms the presence of a 4-mm renal calculus in the proximal left ureter. Physician orders include meperidine (Demerol) 100 mg IM q4h prn, strain all urine, and encourage fluids to 4,000 mL/day. In planning care for this patient, the nurse gives the highest priority to which nursing diagnosis?
a. Pain related to irritation of a stone
b. Anxiety related to unclear outcome of condition
c. Ineffective health maintenance related to lack of knowledge about prevention of stones
d. Risk for injury related to disorientation

 

 

ANS:   A

Nursing diagnoses include, but are not limited to, patient pain related to mobility of renal calculus.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 456         OBJ:    7

TOP:    Renal calculi                                       KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Physiological Integrity

 

  1. A patient is receiving a thiazide diuretic for hypertension. For prevention of complications, it is particularly important that the nurse
a. measure output.
b. increase fluid intake.
c. monitor serum potassium levels.
d. encourage emptying of the bladder.

 

 

ANS:   C

The thiazide diuretic, chlorothiazide (Diuril), affects electrolytes to cause hypokalemia (extreme potassium depletion in blood).

 

DIF:    Cognitive Level: Analysis                  REF:    Pages 443, 471

OBJ:    13                    TOP:    Medication     KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Physiological Integrity

 

  1. The patient, age 43, has cystitis with dysuria. She is receiving Pyridium to decrease her pain. Her urine is reddish-orange. The nurse should
a. report this immediately.
b. explain to the patient that this is normal.
c. increase fluid intake.
d. send a specimen to the laboratory for analysis.

 

 

ANS:   B

Pyridium will turn the urine reddish-orange.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 443, Table 10-3

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

MSC:   NCLEX: Physiological Integrity

 

  1. The patient, age 43, has cancer of the urinary bladder. He has received a cystectomy with an ileal conduit. Which characteristics would be considered normal for his urine?
a. Hematuria
b. Clear amber with mucus shreds
c. Dark bile-colored
d. Dark amber

 

 

ANS:   B

There will be mucus present in the urine from the intestinal secretions.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 479         OBJ:    6

TOP:    Ileal conduit    KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. A patient, age 78, has been admitted to the hospital with dehydration and electrolyte imbalance. She is confused and incontinent of urine on admission. Which nursing intervention does the nurse include in developing a plan of care?
a. Restrict fluids after the evening meal.
b. Insert an indwelling catheter.
c. Assist the patient to the bathroom every 2 hours.
d. Apply absorbent incontinence pads.

 

 

ANS:   D

Use of protective undergarments may help to keep the patient and the patient’s clothing dry. Confused patients are high risk for falls. Restricting fluids will only decrease incontinence during the night and will exacerbate the dehydration and electrolyte imbalance.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 449         OBJ:    10

TOP:    Incontinence                                       KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. Which complementary and alternative therapies are used to prevent and/or treat urinary tract infections (UTIs)?
a. Grape juice
b. Caffeine
c. Tea
d. Cranberry juice

 

 

ANS:   D

Cranberry (Cranberry Plus, Ultra Cranberry) has been used to prevent urinary tract infections (UTIs), particularly in women prone to recurrent infection. It has also been used to treat acute UTI. Monitor patients for lack of therapeutic effect. Caffeine and tea will increase diuresis but not prevent UTI.

 

DIF:    Cognitive Level: Application

REF:    Page 452, Complementary & Alternative Therapies box       OBJ:    7

TOP:    Complementary and alternative therapy

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

 

  1. Which can reduce the risk of skin impairment secondary to urinary incontinence?
a. Decreasing fluid intake
b. Catheterization of the elderly patient
c. Limiting the use of medication (diuretics, etc.)
d. Frequent toileting and meticulous skin care

 

 

ANS:   D                     DIF:    Cognitive Level: Analysis

REF:    Page 439, Life Span Considerations box                               OBJ:    8

TOP:    Urinary frequency                              KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. Pediatric patients, especially girls, are susceptible to urinary tract infections because
a. genetically females have a weaker immune system.
b. females have a short and proximal urethra in relation to the vagina.
c. girls are more sexually active than males.
d. girls have a weakened musculature and sphincter tone.

 

 

ANS:   B

Pediatric patients, especially girls, are susceptible to urinary tract infections because of the short urethra.

 

DIF:    Cognitive Level: Analysis                  REF:    Pages 453, 480

OBJ:    10                    TOP:    Urinary dysfunction

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

 

  1. Patients on diuretics who become hypokalemic should make sure they include which foods in their daily diet?
a. Bananas, oranges, cantaloupe
b. Carrots, summer squash, green beans
c. Apples, pineapple, watermelon
d. Winter squash, cauliflower, lettuce

 

 

ANS:   A

The use of most diuretics, with the exception of the potassium-sparing diuretics, requires adding daily potassium sources (e.g., baked potatoes, raw bananas, apricots, or navel oranges, cantaloupe, winter squash).

 

DIF:    Cognitive Level: Analysis                  REF:    Page 444         OBJ:    7

TOP:    Hypokalemia                                      KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. One method of monitoring for signs and symptoms of fluid overload when administering diuretics is
a. record daily morning weights (same time, scale, clothes).
b. record random weights throughout the day (same scale, clothes, staff member).
c. assess abdomen every shift.
d. eat a diet high in sodium.

 

 

ANS:   A

Because patients receiving diuretics often have complicated disease conditions such as heart failure and pulmonary edema, record daily morning weights for the patient receiving diuretics. Diet should be low in sodium with no added salt in cooking.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 444         OBJ:    7

TOP:    Heart failure and pulmonary edema

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

 

  1. The following constituent of the urinalysis test indicates possible renal disease, muscle exertion, or dehydration
a. proteinuria
b. positive glucose
c. positive bilirubin
d. bacteriuria

 

 

ANS:   A

Protein in the urine usually indicates possible renal disease, muscle exertion, or dehydration. Positive glucose indicates diabetes. Positive bilirubin indicates liver disease with obstruction or damage. Positive bacteria indicates urinary infection.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 439, Box 10-2

OBJ:    9                      TOP:    Urinalysis        KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. For a patient who is recovering from acute glomerulonephritis, which symptoms may exist even when other symptoms have subsided? (Select all that apply.)
a. Proteinuria
b. Oliguria
c. Hematuria
d. Anasarca

 

 

ANS:   A, C

Proteinuria and hematuria may exist microscopically even when other symptoms subside.

 

DIF:    Cognitive Level: Application             REF:    Page 469         OBJ:    6

TOP:    Acute glomerulonephritis                   KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Physiological Integrity

 

  1. Urinary frequency, urgency, nocturia, retention, and incontinence are common with aging. These occur because of (Select all that apply.)
a. weakened musculature in the bladder and urethra.
b. 1,000 to 2,000 mL fluids per 24 hours.
c. diminished neurologic sensation combined with decreased bladder capacity.
d. increased hormonal changes and muscle strength.
e. the effects of medications such as diuretics.

 

 

ANS:   A, C, E

Urinary frequency, urgency, nocturia, retention, and incontinence are common with aging. These occur because of weakened musculature in the bladder and urethra, diminished neurologic sensation combined with decreased bladder capacity, and the effects of medications such as diuretics. Older women are at risk for stress incontinence because of hormonal changes and weakened pelvic musculature. Inadequate fluid intake (less than 1,000 to 2,000 mL per 24 hours) can lead to urinary stasis.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 439, Life Span Considerations box

OBJ:    5                      TOP:    Urinary frequency

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

 

  1. Which are signs and symptoms of fluid overload in a patient receiving diuretics? (Select all that apply)
a. Changes in cardiac and lung sounds
b. Increase in daily weight
c. Decrease in daily weight
d. Dry skin

 

 

ANS:   A, B

Signs and symptoms of fluid overload: changes in pulse rate, respirations, cardiac sounds, and lung fields. Increase in daily morning weights.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 444         OBJ:    9

TOP:    Fluid overload                                                KEY:              Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. The type and size of urinary catheter are determined by the (Select all that apply.)
a. location of the urinary tract problem.
b. urinary output.
c. cause of the urinary tract problem.
d. weight of the patient.

 

 

ANS:   A, C

The type and size of urinary catheter are determined by the location and cause of the urinary tract problem.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 445         OBJ:    9

TOP:    Urinary drainage                                KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

COMPLETION

 

  1. Exercises to increase muscle tone of the pelvic floor are known as ____________ exercises.

 

ANS:

Kegel

 

Women with weakened structures of the pelvic floor are prone to stress incontinence. For the female patient, Kegel exercises are helpful; 10 repetitions, 5 to 10 times a day, is suggested to improve muscle tone.

 

DIF:    Cognitive Level: Knowledge             REF:    Pages 447, 450

OBJ:    11                    TOP:    Kegel exercises

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

 

  1. _____________ is a term for severe generalized edema.

 

ANS:

Anasarca

The patient with nephritic syndrome has severe generalized edema (anasarca), anorexia, fatigue, and impaired renal function.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 467         OBJ:    5

TOP:    Key term         KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. Acute ______________ is commonly a result of a preexisting infection.

 

ANS:

glomerulonephritis

 

The health history commonly reveals that the onset of acute glomerulonephritis is preceded by an infection, such as a sore throat or skin infection.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 468         OBJ:    9

TOP:    Acute glomerulonephritis                   KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. Aldactone (spironolactone) is classified as a ______________-sparing diuretic.

 

ANS:

potassium

 

The aldosterone antagonist prototype spironolactone (Aldactone) acts to block aldosterone in the distal tubule to promote potassium uptake in exchange for sodium secretion.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 444         OBJ:    7

TOP:    Diuretics         KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. _________ training involves developing the muscles of the perineum to improve voluntary control over voiding; bladder training may be modified for different problems.

 

ANS:   Bladder

 

DIF:    Cognitive Level: Knowledge             REF:    Pages 447, 450

OBJ:    9                      TOP:    Bladder training

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

 

 

 

  1. Bladder distention may be assessed by palpating above the ___________ _________.

 

ANS:   symphysis pubis

 

DIF:    Cognitive Level: Knowledge             REF:    Page 448         OBJ:    9

TOP:    Urinary retention                                KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

Christensen: Adult Health Nursing, 6th Edition

 

Chapter 16: Care of the Patient with HIV/AIDS

 

Test Bank

 

MULTIPLE CHOICE

 

  1. A patient, age 25, has just been admitted to the unit with a diagnosis of AIDS. The nurse’s colleague says, “I’m pregnant. It is not safe for me or my baby if I am assigned to his case.” The nurse’s response should be
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 utilization of standard precautions by all staff members for all patients all the time simplifies this issue.

 

DIF:    Cognitive Level: Application             REF:    Pages 736, 737, 758, 763

OBJ:    6                      TOP:    Transmission of AIDS

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. Members of the local emergency medical service unit have just transported an accident victim to the emergency department. They tell the ED nurse that the victim has AIDS, and they have blood on their hands and clothing. The nurse advises them to wash their hands and to change any clothing that is wet with blood. The nurse talks to them about getting a baseline HIV test and about future testing. They ask the nurse how long it will take before they will know if they are infected. The nurse’s response should be
a. “You will need to be tested in 6 weeks and regularly for the next 10 years, because that is the average length of time it takes to detect the virus by testing.”
b. “You will need to be tested in 3 months and again in 6 months, because 95% of people seroconvert to antibody-positive in 3 months and 99% in 6 months.”
c. “Transmission by occupational exposure is rare. There is no need for you to be concerned.”
d. “You will need to be tested in 3 weeks, because most people seroconvert in that length of time.”

 

 

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.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 745         OBJ:    6

TOP:    Prevention of infection                      KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. The patient, age 21, has been treated for chlamydia and has a history of recurrent herpes. What should the nurse plan to do next?
a. Counsel this patient about her sexual history, risk reduction measures, and testing for HIV.
b. Refer this patient to a family planning clinic.
c. Counsel this patient about testing for HIV and what the test results mean.
d. Counsel this patient about abstinence and a monogamous relationship.

 

 

ANS:   A

Unfortunately, the risk of acquiring HIV and other sexually transmitted disease still exists.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 771, Table 16-9

OBJ:    8                      TOP:    Risk for infection

KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. A patient has just been told by his physician that he is HIV-positive. He asks the nurse, “When will I get AIDS?” The nurse’s response should be
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

A typical progressor of HIV has a period of relative clinical latency, occurring immediately after the primary infection, that can last for several years. Long-term nonprogressors remain symptom-free for 10 years or more.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 742         OBJ:    4

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

MSC:   NCLEX: Physiological Integrity

 

  1. A patient asks the nurse, “How does HIV cause AIDS?” The nurse’s response should be
a. “HIV attacks the immune system, a system that protects the body from foreign invaders, making it unable to protect the body from organisms that cause diseases.”
b. “HIV breaks down the circulatory system, making the body unable to assimilate oxygen and nutrients.”
c. “HIV attacks the respiratory system, making the lungs more susceptible to organisms that cause pneumonia.”
d. “HIV attacks the digestive system, decreasing the absorption of essential nutrients and causing weight loss and fatigue.”

 

 

ANS:   A

HIV disease results from the progressive deterioration of the immune system over time; a diagnosis of AIDS is made in a later stage of this progression.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 742, Table 16-2

OBJ:    7                      TOP:    Progression of disease

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Adaptation

 

  1. In reviewing a patient’s chart to determine whether she has progressed from HIV disease to AIDS, the nurse should look for
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 below 200 cells/mm3.

 

DIF:    Cognitive Level: Comprehension       REF:    Pages 736, 747, Box 16-2, Table 16-1

OBJ:    5                      TOP:    Progression of disease

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

 

  1. A patient is advised to be tested for HIV because of his multiple sexual partners and injectable drug use. The nurse should ensure that this patient understands the test by informing him that:
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, John 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.

 

DIF:    Cognitive Level: Application             REF:    Pages 736, 747, Box 16-2, Table 16-1

OBJ:    8                      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. A colleague states that she is at no risk for HIV, so she would not need to be counseled about testing for HIV. The nurse’s most appropriate response would be
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

Among the 43,171 new AIDS cases reported to the CDC in 2003, 49.9% were African Americans, 20.3% were Hispanics, and 26.6% were females. Increases in AIDS cases in women and heterosexuals and a slowing of cases in 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.

 

DIF:    Cognitive Level: Application             REF:    Page 741         OBJ:    10

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.” The nurse’s most appropriate response would be
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 772         OBJ:    10

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. When caring for the patient, the nurse should
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 773         OBJ:    18

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

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. Kaposi’s sarcoma is a common problem in patients with AIDS. The nurse should instruct the patient who is diagnosed with AIDS to report which sign of Kaposi’s sarcoma?
a. Reddish-purple skin lesions
b. Open, bleeding skin lesions
c. Blood-tinged sputum
d. Watery diarrhea

 

 

ANS:   A

Kaposi’s 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’s sarcoma: firm, flat, raised or nodular, hyperpigmented, multicentric lesions on the skin and mucous membranes.

 

DIF:    Cognitive Level: Application             REF:    Page 734, Table 16-5,  Box 16-6

OBJ:    17                    TOP:    Opportunistic infections

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. During this time, the patient
a. is not dangerous to anyone.
b. experiences minor symptoms only.
c. experiences decreased immunity.
d. 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:    Pages 739, 745

OBJ:    5                      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
a. opportunistic infection.
b. a positive ELISA or Western blot test.
c. weight loss, fever, and generalized lymphedema.
d. CD4+ lymphocyte count below 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:    Pages 735-736, Table 16-1

OBJ:    5                      TOP:    Definition of AIDS disease

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

 

  1. Interventions such as promotion of nutrition, exercise, and stress reduction should be undertaken by the nurse for patients who have HIV infection, primarily because these interventions will
a. promote a feeling of well-being in the patient.
b. improve immune function.
c. prevent transmission of the virus to others.
d. increase the patient’s strength and ability to care for him- 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 763         OBJ:    7

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

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. A patient is concerned about telling others he has HIV infection. In discussing his concerns, which response by the nurse is most appropriate?
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:    Pages 763, 769, Box 16-8

OBJ:    6                      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 744, Figure 16-2

OBJ:    5                      TOP:    Progression of disease

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. While teaching community groups about AIDS, the nurse informs people that the most common method of transmission of the HIV virus currently is
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:    Pages 738-739

OBJ:    6                      TOP:    Transmission of disease

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. The nurse clarifies that the least likely method for children to contract AIDS is
a. during intrauterine life with an HIV-positive mother.
b. during the birth process of an HIV-positive mother.
c. from other children who have AIDS.
d. from receiving transfusions contaminated with the HIV virus.

 

 

ANS:   C

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 741         OBJ:    6

TOP:    Transmission of disease                      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. The development of these antibodies is 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.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 745         OBJ:    5

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

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. A patient, age 28, has a history of IV drug use and has tested positive for HIV. About 2 weeks ago, she delivered a baby who has tested positive for HIV. This patient will not care for the baby because she believes the baby will die soon. In counseling her about the care of her infant, which approach by the nurse is most appropriate?
a. Agree with her that the baby will develop AIDS and refer her to a local AIDS support group.
b. Inform her that although infants of HIV-infected mothers may test positive for HIV antibodies, not all infants are infected with the virus.
c. Remind her that she has not yet developed AIDS and that it is possible the baby won’t develop AIDS for many years.
d. Inform her that 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 741-742

OBJ:    13                    TOP:    Transmission of disease

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

 

  1. Snacks such as bananas and apricot nectar, which are high in potassium, are recommended because
a. electrolytes are lost through fever.
b. diarrhea is a common problem.
c. snacks help fight fatigue.
d. potassium helps fight infection.

 

 

ANS:   B

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 766, 769, Health Promotion box, Box 16-5, Table 16-11

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

MSC:   NCLEX: Physiological Integrity

 

  1. In addition to handwashing, what important precaution must the nurse take when changing the dressing of an AIDS patient?
a. Wearing mask
b. Wearing gown and gloves
c. Wearing gloves
d. Strict isolation

 

 

ANS:   C

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 diseases between the patient and the health care worker.

 

DIF:    Cognitive Level: Application             REF:    Pages 758, 763

OBJ:    6                      TOP:    Transmission of disease

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. HIV patients who are suffering from depression should be frequently assessed for
a. physical decline.
b. fear of death.
c. support systems.
d. suicidal ideation.

 

 

ANS:   D

Patients with HIV disease and depression should be assessed regularly for suicidal ideation.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 762         OBJ:    13

TOP:    Coping            KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Psychosocial Integrity

 

  1. What is the best way to prevent transmission of HIV to a fetus or infant?
a. Use of condoms
b. Avoidance of pregnancy
c. Use of anti-HIV therapy given during pregnancy
d. Use of anti-HIV therapy to the infant for the first 6 weeks of life

 

 

ANS:   B

Avoidance of pregnancy is the only certain way to prevent transmission of HIV to a fetus or infant.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 770, Box 16-18

OBJ:    6                      TOP:    Coping            KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Psychosocial Integrity

 

  1. A nursing intervention to help infected HIV patients regain lost weight is
a. schedule procedures that are painful, stressful, or nauseating immediately before a meal.
b. eat small meals throughout the day.
c. eat three big meals a day to provide for proper rest.
d. weigh the patient weekly to prevent frustration.

 

 

ANS:   B

Schedule procedures that are painful, stressful, or nauseating so they do not interfere with mealtimes. Eat several small meals throughout the day as opposed to three large meals.

 

DIF:    Cognitive Level: Application             REF:    Page 768, NCP 16-1

OBJ:    14                    TOP:    Nutrition         KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity

 

COMPLETION

 

  1. ______________ is a type of sexual option classified as “no risk” for a person to become infected with 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 771, Box 16-8, Box 16-9

OBJ:    9                      TOP:    HIV infection prevention

KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. Which are signs and symptoms of 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 744, Box 16-1

OBJ:    16                    TOP:    HIV infection

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

 

  1. Most children with AIDS 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 breast feeding 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 breast-feeding. 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 741-742, 763

OBJ:    6                      TOP:    Transmission of disease

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

 

  1. Which nutritional intake will assist the patient in regaining lost weight? (Select all that apply.)
a. Increase fluid intake
b. Limit protein and fat intake
c. Offer nutritional supplements (Boost, Sustacal, etc.)
d. Eat several small meals during the day
e. Provide referrals to dietitians and social workers
f. Weigh patient monthly

 

 

ANS:   C, D, E

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.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 768, NCP 16-1

OBJ:    14                    TOP:    Weight loss     KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. Nutritional management can help control diarrhea. Which foods would be recommended on a diarrhea diet? (Select all that apply.)
a. Bananas and apricot nectar
b. Ensure
c. Broccoli
d. Cooked fruits and vegetables
e. Red meat
f. Raw fruits and vegetables

 

 

ANS:   A, D

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 758, 766, Nursing Diagnoses box, Table 16-11            OBJ:    14

TOP:    Weight loss     KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

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