Adult Health Nursing 7th Edition By Cooper Gosnell -Test Bank

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Adult Health Nursing 7th Edition By Cooper Gosnell -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 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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