Contemporary Medical Surgical Nursing 2nd Edition by Daniels, Rick -Test Bank

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Contemporary Medical Surgical Nursing 2nd Edition by Daniels, Rick -Test Bank

Chapter 2–Clinical Decision Making and Evidence-Based Practice

 

MULTIPLE CHOICE

 

  1. The nurse is implementing evidence-based practice. Which of the following is not a component of this process?
1. Patient preference
2. Clinical expertise
3. Research evidence
4. Leader practice

 

 

ANS:  4

Evidence-based practice is the combination of applying research findings, creating clinical guidelines, and the individualization of the plan of care to meet the patient’s needs and desired. Leader practice is not a component of the evidence-based process.

 

PTS:   1                    DIF:    Analyze         REF:   The Process of EBP

 

  1. The nurse is planning the care for a client using an unstructured approach. Which of the following approaches did the nurse most likely use?
1. Research
2. Trial and error
3. Nursing theory
4. Validated order

 

 

ANS:  2

Examples of unstructured approaches to plan client care include trial and error, tradition, and authority. The approaches of research, nursing theory, and validated order all represent a structured approach to planning client care.

 

PTS:   1                    DIF:    Analyze         REF:   Knowledge Bases for Clinical Decisions

 

  1. The nurse is participating in an activity that is the first step of the ACE Star Model of Knowledge Transformation. Which of the following is the nurse doing?
1. Creating evidence summaries
2. Evaluating outcomes
3. Integrating findings into practice
4. Participating in research

 

 

ANS:  4

The ACE Star Model of Knowledge Transformation depicts the transfer of knowledge according to five sequential steps. The first step is primary research. Subsequent steps are: 2) evidence summary, 3) translation, 4) integration, and 5) evaluation.

 

PTS:   1                    DIF:    Analyze         REF:   EBP in Nursing

 

  1. A committee has been developed to implement knowledge transformation when providing client care. The members realize that the purpose of knowledge transformation is to:
1. reduce length of stay.
2. convert research findings to impact health outcomes.
3. reduce the cost of care.
4. increase the number of patients with health insurance.

 

 

ANS:  2

The core concept of the ACE Star Model is knowledge transformation. Knowledge transformation is the conversion of research findings to have an impact on health outcomes by way of evidence-based care. Knowledge transformation is not a method to reduce length of stay, reduce the cost of care, or increase the number of patients with health insurance.

 

PTS:   1                    DIF:    Analyze         REF:   Definition of Knowledge Transformation

 

  1. An advance practice nurse is being consulted to participate during the translation phase of the ACE Star Model of Knowledge Transformation. During this phase, which of the following will the nurse create?
1. Standardized care plans
2. Critical pathways
3. Clinical practice guidelines
4. Checklists to streamline documentation

 

 

ANS:  3

In the third step of the ACE Star Model of Knowledge Transformation, experts are consulted to consider the evidence summaries, fill in gaps, and merge research knowledge with expertise to produce clinical practice guidelines. The nurse is not creating standardized care plans, critical pathways, or checklists to streamline documentation since these items are not a part of the ACE Star Model of Knowledge Transformation.

 

PTS:   1                    DIF:    Apply            REF:   Star Point 3: Translation

 

  1. The nurse leaders of a health care organization are creating plans to change clinical and organizational practices to support evidence-based practice. Which phase of the ACE Star Model of Knowledge Transformation are the leaders implementing?
1. Integration
2. Evaluation
3. Translation
4. Evidence summaries

 

 

ANS:  1

During the Integration phase of the ACE Star Model of Knowledge Transformation, implementation plans are put into action to change the individual clinician practices, organizational practices, and environmental policies. Implementation plans are not a part of the evidence summaries, translation, or evaluation of the ACE Star Model of Knowledge Transformation.

 

PTS:   1                    DIF:    Apply            REF:   Star Point 4: Integration

 

  1. The advance practice nurse is writing clinical practice guidelines. Prior to writing these guidelines which of the following will the nurse need?
1. Current client census
2. Evidence summaries
3. Nursing department budget
4. Staffing ratios

 

 

ANS:  2

The ideal base for writing clinical guidelines are evidence summaries because they increase the power and validity of the cause-and-effect relationship between interventions and outcomes. Current client census, nursing department budgets, and staffing ratios are not used to write clinical practice guidelines.

 

PTS:   1                    DIF:    Apply            REF:   Evidence Summaries

 

  1. The nurse is writing a systematic review. After the nurse formulates questions and locates relevant studies, the nurse thing the nurse will do is:
1. update the reviews.
2. interpret the findings.
3. summarize and synthesize results.
4. select and appraise the studies.

 

 

ANS:  4

The next step in the systematic review writing process is selecting and appraising the studies. Afterwards, the nurse will complete, in order, summarize and synthesize results, interpret the findings, and regularly update the reviews.

 

PTS:   1                    DIF:    Apply            REF:   Method for Producing Systematic Reviews

 

  1. The nurse is using the scale for rating the strength of research evidence for one research article for potential inclusion in a clinical practice guideline. Which of the following is considered the strongest evidence?
1. Individual cohort study
2. Meta-analysis of randomized clinical trials
3. Expert opinion
4. Case studies

 

 

ANS:  2

When utilizing the Scale for Rating the Strength of Research Evidence, the level with the strongest evidence is level I, meta-analysis of randomized clinical trials. Level III is individual cohort studies. Expert opinion is Level VII or the weakest evidence. Case studies are Level VI.

 

PTS:   1                    DIF:    Analyze

REF:   Table 2-1 Scale for Rating the Strength of Research Evidence

 

  1. The nurse is considering a research study for inclusion in a clinical practice guideline that has been identified as being sufficient to determine effects on health outcomes. This research study would be considered as being:
1. fair.
2. passable.
3. poor.
4. good.

 

 

ANS:  1

Research studies are rated according to the Scale for Rating the Quality of Research Evidence. According to this scale, a research study that is sufficient to determine the effects on health outcomes is considered fair. A good study has consistent results for well-designed, well-conducted studies that directly assess effects on health outcomes. A poor study has insufficient results to assess the affects on health outcomes. Passable is not a category of this rating scale.

 

PTS:   1                    DIF:    Analyze

REF:   Table 2-2 Scale for Rating the Quality of Research Evidence

 

  1. The nurse is reviewing evidence-based clinical practice guidelines to use when planning care for a client. One guideline has been graded by the U.S. Preventive Services Task Force as being an A. According to this grade, the nurse should do which of the following?
1. Do not use this guideline because the harm outweighs the benefits.
2. Do not use this guideline because the benefits and harms cannot be determined.
3. Use this guideline because the benefit is substantial.
4. Use this guideline but understand that the net benefit to the client is small.

 

 

ANS:  3

The U.S. Preventive Services Task Force grades clinical practice guidelines from A to D plus I. A grade A guideline is recommended for care since there is high certainty that the benefit to the client is substantial. A grade C guideline has a small net benefit to the client. A grade D guideline has harms that outweigh the benefits. A grade I guideline has benefits and harms that cannot be determined.

 

PTS:   1                    DIF:    Apply

REF:   Box 2-6 Strength of Recommendations from the U.S. Preventive Services Task Force

 

  1. The nurse identifies errors and hazards in a care environment and implements basic safety to reduce the likelihood of an adverse event. Which of the following core competencies is this nurse implementing?
1. Provide patient-centered care
2. Apply quality improvement
3. Employ evidence-based practice
4. Utilize informatics

 

 

ANS:  2

Of the five Core Competencies for Health Professions, the competency that focuses on the identification of errors and hazards with implementation of basic safety is apply quality improvement. Provide patient-centered care focuses on direct care activities. Employ evidence-based practice focuses on the integration of research with clinical expertise. Utilize informatics to focus on communication and the use of information technology to support decision making.

 

PTS:   1                    DIF:    Apply            REF:   Box 2-1 Core Competencies for Health Professions

 

  1. The nurse is participating on a committee to select evidence-based practice guidelines.Which of the following statements by the nurse indicate a clear understanding of the purpose of these guidelines?
1. “They provide the best evidence to make decisions about the care of individual clients.”
2. “They promote changes in client care according to a research study.
3. “They ensure cost-effective care to the client.”
4. “They identify safe staffing ratios for client care.”

 

 

ANS:  1

Evidence-based practice guidelines provide the best evidence to make decisions about the care of individual clients. The use of a single research study to make changes in client care is a concept within research utilization and not evidence-based practice. Evidence-based practice does impact the costs of client care but their intent is not to ensure cost-effective care but rather to improve the overall quality of care. Evidence-based guidelines do not provide staffing ratios for client care.

 

PTS:   1                    DIF:    Analyze         REF:   The Process of EBP

 

MULTIPLE RESPONSE

 

  1. The nurse is determining the best way to ensure adherence to the core competencies for health professions. Which of the following competencies will the nurse implement when providing client care? (Select all that apply.)
1. Work in interdisciplinary teams
2. Utilize informatics
3. Implement basic safety principles
4. Employ evidence-based practice
5. Apply quality improvement
6. Provide patient-centered care

 

 

ANS:  1, 2, 4, 5, 6

Core competencies for health professions include providing patient-centered care, working in interdisciplinary teams, employing evidence-based practice, applying quality improvement, and utilizing informatics. Implementing basic safety principles is only one part of a quality improvement program.

 

PTS:   1                    DIF:    Apply

REF:   Box 2-1 Core Competencies for Health Professions.

 

  1. There are impediments that make the practice of evidence-based practice difficult. Which of the following are impediments to evidence-based practice? (Select all that apply.)
1. Complexity of science and technology
2. Difficulty of nowledge transformation
3. Variety of knowledge forms
4. Number of patient diagnoses
5. Evidence summary
6. Application of quality improvement

 

 

ANS:  1, 3

Hurdles to evidence-based practice are the increasing complexity of science and technology and the variety of knowledge forms, many of which are not suitable for direct practice. Knowledge transformation, number of patient diagnoses, evidence summary, application of quality improvement are not considered impediments to the implementation of evidence-based practice.

 

PTS:   1                    DIF:    Apply            REF:   Applying Evidence-Based Concept

 

  1. The nurse identifyies evidence summaries for evidence-based practice. Which of the following are references to types of evidence summaries? (Select all that apply.)
1. Review of literature
2. Evidence synthesis
3. Authentication review
4. Systematic reviews
5. Integrative reviews
6. Substantiation evidence

 

 

ANS:  1, 2, 4, 5

Evidence summaries are also referred to as being review of literature, evidence synthesis, systematic reviews, and integrative reviews. These summaries are not referred to as being authentication review or substantiation evidence.

 

PTS:   1                    DIF:    Apply            REF:   Star Point 2: Evidence Summary

 

  1. A health care organization is determining which clinical practice guidelines to adopt when providing client care. The organization is using the AGREE Instrument for Assessing Guidelines because this checklist helps the organization determine which of the following? (Select all that apply.)
1. Scope and purpose
2. Stakeholder involvement
3. Rigor of development
4. Clarity and presentation
5. Author credentials
6. Application

 

 

ANS:  1, 2, 3, 4, 6

The AGREE Instrument for Assessing Guidelines outlines the primary facets of the clinical practice guideline being appraised for adoption. It includes the following criteria: scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, application, and editorial independence. Author credentials is not a criteria of this checklist.

 

PTS:   1                    DIF:    Analyze         REF:   Clinical Practice Guidelines

 

  1. The nurse is participating in a committee to address the Institute of Medicine’s priority areas for quality improvement. Which of the following are considered priority areas? (Select all that apply.)
1. Diabetes
2. End-of-life organ failures
3. Motor vehicle accidents
4. Scoliosis
5. Tobacco dependence
6. Major depression

 

 

ANS:  1, 2, 5, 6

The Institute of Medicine has identified 20 priority areas for quality improvement which include diabetes, end-of-life organ failures, tobacco dependence, and major depression. Motor vehicle accidents and scoliosis are not priority areas identified by the Institute of Medicine.

 

PTS:   1                    DIF:    Analyze         REF:   Box 2-7 IOM-Priority Areas for National Action

Chapter 14–Complementary and Alternative Therapies

 

MULTIPLE CHOICE

 

  1. A client from the Asian culture tells the nurse that he has blockages in his life force that are causing him to have a disease. The nurse realizes that within this culture, the life force is considered:
1. Ayurveda.
2. Chi.
3. Prana.
4. Qi.

 

 

ANS:  2

In Chinese culture, the life force is known as chi. Ayurveda is Indian medicine. In Indian culture the life force is known as prana. In the Japanese culture the life force is know as qi.

 

PTS:   1                    DIF:    Analyze

REF:   History of Complementary and Alternative Therapies

 

  1. The nurse is planning to learn Reiki to become a master practitioner. Which level of learning will the nurse need to achieve in order to become a Reiki master?
1. Level I
2. Level II
3. Level III
4. Level IV

 

 

ANS:  3

Level I Reiki practitioners are prepared to provide healing work at the physiological/physical level, and they work with the patient physically present. Level II Reiki practitioners are prepared to provide healing on the emotional and spiritual levels and in absentia. The masters or Reiki teachers are Level III practitioners. There is no Level IV Reiki practitioner.

 

PTS:   1                    DIF:    Analyze         REF:   Reiki

 

  1. A client tells the nurse that she utilizes biofeedback to combat chronic back pain. The nurse identifies this type of complementary alternative medicine as being:
1. biological therapy.
2. mind-body therapy.
3. body-based therapy.
4. energy therapy.

 

 

ANS:  2

Mind-body therapies are a variety of techniques to facilitate the mind’s capacity to affect the body and various symptoms. Biofeedback is one type of mind-body therapy. Biological therapies use naturally occurring substances such as herbal medicine. Body-based therapies are based on manipulation or movement of one or more body parts. Energy therapy use energy fields to increase the flow of energy throughout the body.

 

PTS:   1                    DIF:    Analyze

REF:   NCCAM Categories of Complementary and Alternative Therapies

 

  1. A client tells the nurse that his health has improved since he starting practicing tai chi. The nurse realizes this alternative medicine approach:
1. is a modern form of yoga.
2. uses breathing, movement, and posture.
3. enhances the flow of prana.
4. improves the flow of chi through the meridians of the body.

 

 

ANS:  4

Tai chi improves the flow of chi through the meridians of the body to enhance health and promote healing. Tai chi is an ancient ritual movement that involves concentration, strength, flexibility, breathing, and the use of symbolic movements. Tai chi originated in China. Yoga originated in the Hindu culture. Yoga uses breathing, movement, and postures to enhance the flow of prana.

 

PTS:   1                    DIF:    Analyze         REF:   Tai Chi

 

  1. After an assessment, the nurse believes a client would benefit form the care of a chiropractor. Which of the following health problems could be addressed with this form of alternative therapy?
1. Headache
2. Sinusitis
3. Anemia
4. Kidney stones

 

 

ANS:  1

Chiropractic therapy is useful to treat back pain, neck pain, joint pain of the arms or legs, headaches, and other neuromuscular complaints. Chiropractic therapy is not indicated for sinusitis, anemia, or kidney stones.

 

PTS:   1                    DIF:    Analyze         REF:   Chiropractic Therapy

 

  1. When asked about an armband that a pregnant client is wearing, the client tells the nurse that it helps reduce morning sickness. The nurse realizes this client is utilizing which form of alternative medicine?
1. Acupressure
2. Acupuncture
3. Reiki
4. Guided imager

 

 

ANS:  1

Acupressure is the stimulation of pressure points on the body to affect a body response. Antiemetic armbands are one example of an acupressure device. Acupuncture uses needles to stimulate identified points to affect a body response. Reiki is the manipulation of energy fields. Guided imagery is the use of relaxation and mental visualization to improve mood or physical well-being.

 

PTS:   1                    DIF:    Analyze         REF:   Acupressure

 

  1. A client tells the nurse that she is having a series of massages to break up scar tissue created from back surgery which have caused uneven hip and shoulder height. The nurse realizes the type of massages the client is receiving would be:
1. shiatsu.
2. rolfing.
3. therapeutic.
4. relaxation.

 

 

ANS:  2

Rolfing is a form of deep tissue massage and manipulation to correct body posture. Usually 10 sessions are required to completely restore the body’s alignment. Shiatsu is a combination of acupressure, massage, stretching, and joint manipulation to unblock the flow of chi. Therapeutic massage will not break up scar tissue. Relaxation is not a type of massage.

 

PTS:   1                    DIF:    Analyze         REF:   Rolfing

 

  1. A client tells the nurse that he believes watching old comedy movies has helped him achieve a quick recovery from orthopedic surgery. The nurse realizes this client has been using which of the following forms of complementary alternative medicine?
1. Meditation
2. Prayer
3. Humor
4. Music

 

 

ANS:  3

Humor is a frequently used complementary alternative medicine therapy and one of the therapies most often used to promote wellness. Humor increases the ability to cope with pain, enhance immune function, enhance respiratory function, and reduce preprocedural anxiety.

 

PTS:   1                    DIF:    Analyze         REF:   Humor

 

  1. A client tells the nurse that she is not concerned about recovering from an acute illness since she has several people from her church praying for her health. The nurse realizes this client is utilizing which form of complementary alternative medicine?
1. Denial
2. Wishful thinking
3. Intercessory prayer
4. Positive thinking

 

 

ANS:  3

Intercessory prayer is defined as a group that holds their focused thought for healing on behalf of someone else. Denial, wishful thinking, and positive thinking are not forms of complementary alternative medicine.

 

PTS:   1                    DIF:    Analyze         REF:   Intercessory Prayer

 

  1. A client tells the nurse that he ingests only herbal preparations and not medications prescribed from a physician. Which of the following should the nurse respond to this client?
1. “How long have you been using herbal preparations?”
2. “Are you aware of the side effects of using herbal preparations?”
3. “They must be working.”
4. “They are probably less expensive than other medications.”

 

 

ANS:  2

The nurse must assess the client for herbal use and participate in knowledgeable client education on the potential effects of herbal preparations. The length of time the client has been using herbal preparations may or may not be significant. The nurse should not comment on the effectiveness of the preparations or the cost.

 

PTS:   1                    DIF:    Apply            REF:   Herbal Therapies

 

  1. The nurse is providing a client with a massage in order to create which of the following benefits?
1. Reduce blood glucose level
2. Increase heart rate
3. Reduce blood pressure
4. Enhance appetite

 

 

ANS:  3

Massage reduces heart rate, reduces blood pressure, increases energy, and increases immune system activity. Massage does not reduce blood glucose level, increase heart rate, or enhance appetite.

 

PTS:   1                    DIF:    Apply            REF:   Massage Therapy

 

  1. A client tells the nurse that she is interested in learning yoga to help with chronic back and leg pain. Which of the following should the nurse respond to this client?
1. “Local organizations have yoga classes and training programs that you could attend.”
2. “Yoga is not as good acupuncture.”
3. “Tai chi is probably better for you.”
4. “Have you considered weight training?”

 

 

ANS:  1

Nurses can encourage clients to participate in yoga by finding a local organization that has yoga teachers and training programs. This is what the nurse should respond to the client. Yoga has other benefits that acupuncture may not have. The nurse should not encourage the client to utilize one type of mind-body therapy over another. The client did not express an interest in weight training so the nurse should not make that suggestion.

 

PTS:   1                    DIF:    Apply            REF:   Yoga

 

  1. The client tells the nurse that his practitioner recommended whirlpool baths to relieve chronic back spasms. The nurse realizes the client is participating in which type of complementary alternative medicine approach?
1. Naturopathy
2. Homeopathy
3. Osteopathy
4. Heroic

 

 

ANS:  1

Naturopathy is a medical system that focuses on supporting health rather than fighting diseases. An example of a naturopathic treatment is hydrotherapy. Homeopathy is a medical system that is used for wellness and prevention and utilizes natural substances such as herbs to treat health concerns. Heroic medicine is the use of aggressive medical practices or methods of treatment. Osteopathy uses a full spectrum of medical treatments to include medication, surgery, and manipulation.

 

PTS:   1                    DIF:    Analyze         REF:   Naturopathy

 

MULTIPLE RESPONSE

 

  1. A client tells the nurse that she uses alternative forms of health care to help with her chronic health problems. The nurse realizes that which of the following would be considered alternative forms of health care? (Select all that apply.)
1. Acupuncture
2. Chiropractic
3. Weight lifting
4. Cycling
5. Massage
6. Yoga

 

 

ANS:  1, 2, 5, 6

Complementary alternative medicine therapies are numerous and include acupuncture, chiropractic, massage, and yoga. Weight lifting and cycling are not complementary alternative medicine therapies.

 

PTS:   1                    DIF:    Analyze

REF:   Table 14-1 CAM Therapies Used in the United States

 

  1. A client tells the nurse that he rarely sees a physician and relies upon complementary alternative medicine therapies to address ailments. Which of the following should the nurse be aware of regarding these different types of therapies? (Select all that apply.)
1. Potential benefits of complementary alternative medicine therapies
2. Cost of complementary alternative medicine therapies
3. Frequency of use
4. Drug interactions
5. Location of providers
6. Length of time used

 

 

ANS:  1, 2, 4

Nurses need to be knowledgeable about the different potential benefits of complementary alternative medicine therapies including costs, client knowledge, and drug interactions. Frequency of use, location of providers, and length of time used are not necessarily important for the nurse to be aware.

 

PTS:   1                    DIF:    Analyze

REF:   Box 14-1 Healthy People 2010 and Complementary and Alternative Therapies

 

  1. A client tells the nurse that her primary care physician is an osteopath. The nurse realizes that this physician will utilize which of the following approaches when providing care to the client? (Select all that apply.)
1. Hypnosis
2. Manipulation
3. Tai chi
4. Surgery
5. Yoga
6. Medications

 

 

ANS:  2, 4, 6

Osteopathy originally used manipulative techniques for correcting physical abnormalities thought to cause disease. Osteopathy now uses the full spectrum of medicine, including the use of surgery and medications in addition to manipulation to treat illnesses.

 

PTS:   1                    DIF:    Analyze

REF:   History of Complementary and Alternative Therapies in the United States

 

  1. The nurse is using guided imagery to help reduce a client’s pain level. When using this alternative medicine approach, which of the following client senses can be used? (Select all that apply.)
1. Visual
2. Auditory
3. Kinesthetic
4. Cognitive
5. Gustatory
6. Olfactory

 

 

ANS:  1, 2, 3, 5, 6

When using guided imagery, all five senses can be used to include visual, auditory, kinesthetic, gustatory, and olfactory. Cognitive is not one of the five senses.

 

PTS:   1                    DIF:    Apply

REF:   Table 14-2 Incorporating All Five Senses into Guided Imagery

 

  1. The nurse has identified the diagnosis of Disturbed Energy Field as appropriate for a client. Which of the following are identified causes for the slowing or blocking of this client’s energy field? (Select all that apply.)
1. Pathological
2. Socioeconomic
3. Situational
4. Treatment-related
5. Environmental
6. Maturational

 

 

ANS:  1, 3, 4, 6

The nursing diagnosis of Disturbed Energy Field is defined as a disruption of the flow of energy which can be due to pathological, situational, treatment-related, or maturational factors. Socioeconomic and environmental factors do not disrupt the flow of energy.

 

PTS:   1                    DIF:    Analyze         REF:   Energy Therapies

Chapter 28–Hypertension: Nursing Management

 

MULTIPLE CHOICE

 

  1. Which of the following should the nurse instruct a client who is newly diagnosed with hypertension?
1. It is a lifelong process.
2. It can be managed easily.
3. It is a short-term problem.
4. It happens only in the very poor and treatment is expensive.

 

 

ANS:  1

Treatment of hypertension is a lifelong process. It requires lifestyle modification and occurs in all racial and economical groups. Hypertension can either be easy or difficult to manage.

 

PTS:   1                    DIF:    Apply            REF:   Introduction

 

  1. A client is diagnosed with isolated systolic hypertension. The nurse realizes that this diagnosis means the client is experiencing a systolic pressure:
1. greater than 140 mmHg and a diastolic pressure greater than 90 mmHg.
2. greater than 90 mmHg and a diastolic pressure greater than 60 mmHg.
3. greater than 140 mmHg and a diastolic pressure lower than 90 mmHg.
4. lower than 140 mmHg and a diastolic pressure greater than 90 mmHg.

 

 

ANS:  3

The likelihood of developing isolated systolic hypertension is greater with age and is confirmed with a systolic pressure greater than 140 mmHg while the diastolic pressure remains less than 90 mmHg.

 

PTS:   1                    DIF:    Analyze         REF:   Hypertension: Nonmodifiable Risk Factors

 

  1. The nurse is instructing a client on the impact of cigarette smoking and the development of hypertension. Which of the following would not be appropriate for the nurse to include in these instructions?
1. Tobacco damages the lining of the artery walls.
2. Tobacco temporarily constricts blood vessels, increasing pulse and blood pressure.
3. Tobacco thins the blood and makes the person at risk for bleeding.
4. Carbon monoxide in tobacco smoke replaces the oxygen in the blood, forcing the heart to work harder to supply oxygen.

 

 

ANS:  3

Tobacco and smoking have been shown to increase heart rate and blood pressure because of vasoconstriction and the accumulation of plaque on the artery walls. Because of the replacement of oxygen with carbon monoxide from tobacco smoke, the heart has to work harder to supply oxygen to the organs. There is no evidence that smoking thins the blood and causes bleeding.

 

PTS:   1                    DIF:    Apply            REF:   Hypertension: Modifiable Risk Factors

 

  1. The nurse is assessing a client’s pulse pressure. His blood pressure reading is 130/82 mmHg. Which of the following is the correct pulse pressure?
1. 40
2. 48
3. 130
4. 82

 

 

ANS:  2

The pulse pressure is the difference between the systolic and diastolic pressure: 130 – 82 = 48. The other choices represent miscalculations or not understanding the correct way to calculate pulse pressure.

 

PTS:   1                    DIF:    Apply            REF:   Hypertension: Pathophysiology

 

  1. A client is surprised to learn that she has high blood pressure. Which of the following should the nurse assess in this client? The presence or occurrence of:
1. nausea.
2. pain.
3. headache.
4. fear.

 

 

ANS:  3

With very elevated blood pressure, headache is the most commonly reported symptom. Although pain and nausea may be reported, they are not the most common. Fear is not commonly associated with hypertension though it may occur with an onset of pain or nausea.

 

PTS:   1                    DIF:    Apply

REF:   Hypertension: Assessment with Clinical Manifestations

 

  1. A client’s blood pressure has been measured at 130/86 mmHg on two separate occasions. The nurse realizes this client’s blood pressure reading would be categorized as being:
1. normal.
2. prehypertension.
3. stage 1 hypertension.
4. stage 2 hypertension.

 

 

ANS:  2

Prehypertension is a new designation used to identify individuals at high risk for the development of hypertension. Systolic blood pressure of 120 to 139 and diastolic blood pressure of 80 to 90 are values for prehypertension. A normal blood pressure is less than or equal to 120 mmHg systolic and less than or equal to 80 mmHg diastolic. Stage 1 hypertension is a systolic blood pressure between 140 to 159 and a diastolic pressure between 90 to 99. Stage 2 hypertension is a systolic reading greater than or equal to 160 and a diastolic pressure of greater than or equal to 100 mmHg.

 

PTS:   1                    DIF:    Analyze

REF:   Table 28-6 JNC VII Classification of Blood Pressure in Adults

 

  1. The nurse uses a blood pressure cuff that is too small for the circumference of the client’s arm. How will this size of blood pressure cuff affect the client’s blood pressure measurement?
1. Falsely low
2. Falsely high
3. Not clearly heard
4. More time consuming

 

 

ANS:  2

The blood pressure cuff must be the appropriate size to get an accurate reading. A cuff that is too small could result in a falsely high reading. A blood pressure cuff that is too large could result in a falsely low reading. The cuff size may not affect the nurse’s ability to hear the blood pressure sounds. An incorrect blood pressure cuff size will not be more time consuming to use.

 

PTS:   1                    DIF:    Analyze

REF:   Table 28-2 Factors Causing False Blood Pressure Readings

 

  1. A client diagnosed with hypertension should be instructed by the nurse to avoid which of the following foods?
1. Cold cuts
2. Bananas
3. Milk
4. Oatmeal

 

 

ANS:  1

Cold cuts are processed meats that are usually high in sodium and may cause water retention and an increase in blood pressure. The rest of the foods really have no effect on blood pressure.

 

PTS:   1                    DIF:    Apply

REF:   Hypertension: Planning and Implementation: Evidence-Based Care

 

  1. A client is instructed to reduce his intake of daily sodium intake so that the total amount is what his body needs. The nurse should instruct the client to reduce sodium intake to:
1. 500 mg a day.
2. 1000 mg a day.
3. 2500 mg a day.
4. 4500 mg a day.

 

 

ANS:  1

A human body needs about 500 mg of sodium each day. The average intake of sodium for individuals in the United States is between 4000 to 6000 mg a day.

 

PTS:   1                    DIF:    Apply

REF:   Hypertension: Planning and Implementation: Evidence-Based Care

 

  1. A client asks the nurse why she should be concerned about the amount of sodium in ice cream. Which of the following should the nurse respond to this client?
1. Sodium is used to enhance the flavor.
2. Sodium is used to emulsify the ice cream.
3. Sodium is used to prevent mold.
4. Sodium is used as a preservative.

 

 

ANS:  2

Sodium is used in ice cream as an emulsifier. Sodium in canned or processed foods is used to enhance flavor. Sodium is used to prevent mold in cheese, breads, and cakes. Sodium is used as a preservative in cured meats and sausages.

 

PTS:   1                    DIF:    Apply            REF:   Table 28-6 Sodium-Based Food Additives

 

  1. Which of the following should the nurse instruct a client who desires to reduce his blood pressure through increasing physical activity?
1. Regular exercise can lower the blood pressure by 5 to 10 mmHg.
2. Regular exercise must be done 7 days a week.
3. Regular exercise has to be done for at least 2 hours each day.
4. Regular exercise is the participation in aerobic activities.

 

 

ANS:  1

Regular exercise can lower blood pressure by 5 to 10 mmHg. Regular exercise should be done 5 days a week for 60 minutes or 20 minutes of vigorous exercise at least 3 times a week to be effective. Regular exercise includes aerobic activity, flexibility, and strengthening exercises.

 

PTS:   1                    DIF:    Apply

REF:   Hypertension: Planning and Implementation: Evidence-Based Care

 

  1. A client is prescribed Spironolactone (Aldactone) for blood pressure control. Which of the following should the nurse assess in this client as a potential side effect?
1. Hypokalemia
2. Hyperkalemia
3. Hyponatremia
4. Hypernatremia

 

 

ANS:  2

Spironolactone (Aldactone) is a potassium-sparing diuretic. Side effects include hyperkalemia. Hypokalemia and hyponatremia are side effects of the thiazide diuretics. Hypernatremia is not a known side effect of any antihypertensive medication.

 

PTS:   1                    DIF:    Apply

REF:   Table 28-9 Pharmacologic Management of Hypertension

 

  1. A client is prescribed an ACE inhibitor for management of hypertension. Which of the following side effects should the nurse instruct the client as being expected with this medication?
1. Tachycardia
2. Constipation
3. Bizarre dreams
4. Persistent dry cough

 

 

ANS:  4

One side effect of ACE inhibitors that is expected with this medication is a persistent dry cough. Tachycardia, constipation, and bizarre dreams are not side effects associated with ACE inhibitors.

 

PTS:   1                    DIF:    Apply

REF:   Table 28-9 Pharmacologic Management of Hypertension

 

MULTIPLE RESPONSE

 

  1. The nurse is considering the risk factors for a client’s development of primary hypertension. Which of the following would be considered nonmodifiable risk factors for the client? (Select all that apply.)
1. Age
2. Stress
3. Gender
4. Ethnicity
5. Regular exercise
6. Limits fat and salt in diet

 

 

ANS:  1, 3, 4

Nonmodifiable risk factors are those thing we cannot change or control, such as age, gender, and ethnicity. Stress, exercise, and diet are considered modifiable risk factors or those the client can control.

 

PTS:   1                    DIF:    Analyze         REF:   Hypertension: Risk Factors

 

  1. Which of the following should the nurse tell a client when instructing on ways to reduce the risk factors for hypertension? (Select all that apply.)
1. Smoking
2. Diet
3. Exercise
4. Family history
5. Race
6. Stress

 

 

ANS:  1, 2, 3, 6

Modifiable risk factors can be changed or modified to help control hypertension. Smoking, diet, stress, and exercise can be changed to affect blood pressure. Persons with more risk factors have a greater chance of having hypertension during their lives. Family history and race cannot be modified.

 

PTS:   1                    DIF:    Apply            REF:   Hypertension: Risk Factors

 

  1. Which of the following assessment questions would be appropriate for the nurse to use when assessing a client for hypertension? (Select all that apply.)
1. Do you consume alcohol products? How much? How long?
2. Do you use nicotine products? How much? How long?
3. Do you experience nosebleeds?
4. Do you get hungry at night?
5. Do you experience cold sweats?
6. Do you experience headaches?

 

 

ANS:  1, 2, 3, 6

The nurse will often ask the client questions about risks of hypertension. Asking about alcohol and nicotine product use will tell you about increased risk factors. Nosebleeds and headaches are often associated with hypertension. Although cold sweats and hunger are symptoms a patient may report, they are not indicative of hypertension.

 

PTS:   1                    DIF:    Apply            REF:   Box 28-2 Hypertension Assessment

 

  1. The blood pressure measurement for a client is very different from the one that was assessed a few hours previously. The nurse should suspect that the blood pressure measurement is false when which of the following is assessed in the client?
1. Client needs to void.
2. Client smoked a cigarette 10 minutes prior to the measurement.
3. The examination room is very warm.
4. Doors are slamming and children are crying in the environment.
5. Client just had lunch.
6. Client slept for 8 hours the previous night.

 

 

ANS:  1, 2, 3, 4

Factors that cause false blood pressure readings include anxiety, full urinary bladder, excessively warm room, recent tobacco use, and loud or repetitive noises. Eating a meal or having 8 hours of sleep are not known to cause a false blood pressure reading.

 

PTS:   1                    DIF:    Analyze

REF:   Table 28-2 Factors Causing False Blood Pressure Readings

 

  1. A client is planning to use nicotine gum to aid with cigarette cessation. Which of the following should the nurse instruct the client as adverse effects of using nicotine gum? (Select all that apply.)
1. Rapid heart rate may result.
2. Mild headaches can occur.
3. A sore mouth and throat are possible.
4. Abnormal dreams are common.
5. Pruritis is possible.
6. Nausea can occur.

 

 

ANS:  1, 2, 3, 6

Adverse effects associated with the use of nicotine chewing gum include tachycardia, mild headache, sore mouth and throat, and nausea. Abnormal dreams and pruritis are adverse effects of nicotine patches, nicotine nasal spray, and nicotine inhalers.

 

PTS:   1                    DIF:    Apply            REF:   Table 28-7 Medications for Smoking Cessation

Chapter 42–Immunodeficiency and HIV Infection/AIDS: Nursing Management

 

MULTIPLE CHOICE

 

  1. A pregnant client diagnosed with human immunodeficiency virus (HIV) is asking about her baby’s risk of infection. Which of the following does put the newborn at risk?
1. Bottle-feeding
2. Changing diapers
3. Kissing the baby
4. Vaginal birth

 

 

ANS:  4

Breastfeeding and vaginal birth put the newborn at risk for HIV. HIV cannot be transmitted by changing diapers (feces) or kissing the baby (saliva).

 

PTS:   1                    DIF:    Apply

REF:   Human Immunodeficiency Virus Infection: Etiology

 

  1. A health care provider has accidentally been stuck with a used needle. The health care provider is going to be tested for human immunodeficiency virus (HIV). Which of the following would be the testing schedule for the health care provider?
1. Tested at 2 months, 4 months, and then at 6 months
2. Tested immediately and then again at 2 months
3. Tested immediately and then again at 6 months
4. Tested in 6 months and then again in 1 year

 

 

ANS:  3

The health care provider should be tested immediately to show if any preexisting infection exists. Seroconversion usually occurs in 1 to 3 months but can take up to 6 months. Testing at 2 months is too late to discover a preexisting infection and can be too early to detect a new infection. Testing at 6 months or 1 year would not detect a preexisting infection.

 

PTS:   1                    DIF:    Apply

REF:   Human Immunodeficiency Virus Infection: Etiology

 

  1. Which of the following CD4+ count would be used to confirm the diagnosis of acquired immunodeficiency syndrome (AIDS)?
1. 155 cells/mcL
2. 255 cells/mcL
3. 455 cells/mcL
4. 755 cells/mcL

 

 

ANS:  1

A CD4+ count of less than 200 cells/mcL is used as a criterion to establish the diagnosis of AIDS. In cell counts less than 500 to 600 cells/mcL, antiviral therapy should be initiated. Cell counts greater than 600 cells/mcL are in the normal range.

 

PTS:   1                    DIF:    Analyze

REF:   Human Immunodeficiency Virus Infection: Pathophysiology

 

  1. The nurse, planning care for a client diagnosed with human immunodeficiency virus, realizes that the most common infection that occurs in clients with this health problem is:
1. cytomegalovirus infection.
2. Mycobacterium tuberculosis.
3. Pneumocystis carinii pneumonia.
4. Streptococcus pneumoniae.

 

 

ANS:  3

As the immune system becomes overpowered, opportunistic infections can occur. The most common infection is Pneumocystis carinii pneumonia. The other infections can also occur, but they occur less frequently.

 

PTS:   1                    DIF:    Analyze

REF:   Human Immunodeficiency Virus Infection: Assessment with Clinical Manifestations

 

  1. A client diagnosed with acquired immunodeficiency syndrome (AIDS) 6 years ago has a purple lesion located on the inner thigh. This lesion is most likely to be:
1. AIDS-related syndrome.
2. Burkitt’s lymphoma.
3. cachexia.
4. Kaposi’s sarcoma.

 

 

ANS:  4

Kaposi’s sarcoma presents as abnormal lesions that appear purple or blue-red in color. They can be found anywhere but are common on the feet, arms, thighs, perineal area, and face. Cachexia is tissue wasting. Burkitt’s lymphoma is characterized by enlarged lymph nodes. AIDS-related syndrome is a collection of symptoms and infections resulting from the specific damage to the immune system caused by the HIV virus.

 

PTS:   1                    DIF:    Analyze

REF:   Human Immunodeficiency Virus Infection: Assessment with Clinical Manifestations

 

  1. The nurse realizes that which of the following tests can be used to initially identify the presence of human immunodeficiency virus (HIV) antibodies in a client?
1. Enzyme-linked immunosorbent assay (ELISA)
2. Platelet count
3. Red blood cell count
4. Western blot

 

 

ANS:  1

The ELISA test detects HIV antibodies. The Western blot is used as a confirmatory test to a positive ELISA test. Red blood cell counts and platelet counts are part of standard blood studies.

 

PTS:   1                    DIF:    Analyze

REF:   Human Immunodeficiency Virus Infection: Diagnostic Tests

 

  1. A client diagnosed with acquired immunodeficiency syndrome (AIDS) is sitting alone crying. Which of the following is an appropriate response for the nurse to give?
1. “Everything will be okay.”
2. “Let me call your doctor about your depression.”
3. “What’s wrong now?”
4. “Would you like to talk?”

 

 

ANS:  4

Asking the client if he would like to talk allows the client an opportunity to express his feelings. The other responses give the client false reassurance or put off the client.

 

PTS:   1                    DIF:    Apply

REF:   Human Immunodeficiency Virus Infection: Planning and Implementation

 

  1. The nurse is instructing a client on ways to reduce the risk of exposure to the human immunodeficiency virus. Which of the following activities would present the least risk of exposure to this virus?
1. Exposure to used needles
2. Multiple sex partners
3. Perinatal exposure
4. Teeth cleaning

 

 

ANS:  4

Teeth cleaning is a procedure in a dental office that routinely sterilizes its equipment and is not considered to present an increased risk of exposure to HIV. Exposure to used needles, multiple sex partners, and perinatal exposure during pregnancy and childbirth all would increase the client’s risk of exposure to the virus.

 

PTS:   1                    DIF:    Apply

REF:   Human Immunodeficiency Virus Infection: Epidemiology

 

  1. The nurse is teaching a small group of clients about human immunodeficiency virus (HIV) at a health clinic. Which of the following statements by a group member will need further clarification?
1. “Condoms should be used during sexual contact.”
2. “Exposure can occur to a baby during pregnancy.”
3. “HIV-infected mothers can breastfeed their babies.”
4. “Needles should never be reused or shared.”

 

 

ANS:  3

Exposure to HIV can occur while breastfeeding an infant. This is the statement that would necessitate further clarification. The other statements are correct.

 

PTS:   1                    DIF:    Analyze

REF:   Human Immunodeficiency Virus Infection: Epidemiology

 

  1. The nurse is caring for a client diagnosed with human immunodeficiency virus (HIV). Which of the following precautions is best in the care of the client?
1. Gloves and an N-95 mask
2. Gown, gloves, and mask if splashing with body fluids is likely
3. Gown, gloves, mask, and placement into a negative-pressure room
4. Only handwashing is needed

 

 

ANS:  2

Standard precautions should be followed when handling any body fluids and blood. An N-95 mask and a negative-pressure room are not necessary. Handwashing is always recommended, but it should be accompanied by other precautions if contact with body fluids or blood is likely.

 

PTS:   1                    DIF:    Apply

REF:   Human Immunodeficiency Virus Infection: Planning and Implementation

 

  1. A client receiving treatment for human immunodeficiency virus infection is demonstrating signs of resistance to the medication. Which of the following does this suggest to the nurse?
1. The medication dosages need to be increased.
2. The client needs to be taken off all medication.
3. The client needs additional medication to treat side effects.
4. The client is not adhering to the prescribed medication schedule.

 

 

ANS:  4

Resistance to medication prescribed to treat human immunodeficiency virus infection can develop if the client does not adhere to the dose schedule for each drug. Resistance to the medication does not mean the dosages need to be increased. The client should not be taken off all medication. Signs of resistance to the medication are not the same as side effects.

 

PTS:   1                    DIF:    Analyze

REF:   Human Immunodeficiency Virus Infection: Pharmacology

 

  1. A client diagnosed with rheumatoid arthritis receives a prescription for indomethacin. Which of the following statements by the client would indicate the need for further instruction about this medication?
1. “I have to let my doctor know if I need to start blood pressure medications.”
2. “I have to make sure I get my kidneys tested as scheduled.”
3. “I need to get my eyes checked regularly.”
4. “This medication shouldn’t upset my stomach.”

 

 

ANS:  4

Indomethacin can cause nausea, dyspepsia, gastrointestinal pain, diarrhea, vomiting, constipation, and flatulence. This is the statement that would indicate the need for further instruction about this medication. The client should regularly have her eyes, kidneys, and liver checked for impairment.

 

PTS:   1                    DIF:    Analyze

REF:   Table 42-2 Examples of Drugs Used for RA Therapy

 

  1. The nurse is providing discharge instructions to a client diagnosed with systemic lupus erythematosus (SLE). Which of the following would not be including in these instructions?
1. “Activity will need to be decreased during an exacerbation.”
2. “Body temperature should be monitored.”
3. “Corticosteroid treatment must be slowly tapered off.”
4. “Sunbathing decreases symptoms.”

 

 

ANS:  4

Exposure to sunlight exacerbates the disease process. Body temperature should be monitored for increases and possible infection. Corticosteroid treatment cannot be abruptly stopped. Activity with rest periods should be encouraged.

 

PTS:   1                    DIF:    Apply

REF:   Systemic Lupus Erythematosus: Planning and Implementation

 

  1. A client is scheduled for a bone marrow transplant from cells that were donated by his identical twin. The nurse realizes that the type of transplant this client is planning would be:
1. syngeneic.
2. autologous.
3. allograft.
4. apheresis

 

 

ANS:  1

A syngeneic transplant uses bone marrow donated by an identical twin. An autologous transplant is the removal of bone marrow cells from the individual; the cells are treated and stored and then returned after the individual receives intensive chemotherapy or radiation. Allograft refers to cells and tissue obtained from the same species who has a similar type or cell compatibility. Apheresis is a procedure used to treat autoimmune disorders.

 

PTS:   1                    DIF:    Analyze         REF:   Graft-versus-Host Disease

 

MULTIPLE RESPONSE

 

  1. The nurse is instructing a client on the modes of transmitting the human immunodeficiency virus infection. Which of the following can transmit this infection? (Select all that apply.)
1. Blood
2. Breast milk
3. Emesis
4. Saliva
5. Semen
6. Sweat

 

 

ANS:  1, 2, 5

HIV can be transmitted only under specific conditions that permit contact with infected body fluids. Common high-risk sources are infected blood via contaminated needlestick or sharp object, contact with infected breast milk, mucous secretions (vaginal, semen), and exposure to blood in the laboratory. HIV is not transmitted through tears, saliva, urine, emesis, sputum, feces, or sweat.

 

PTS:   1                    DIF:    Apply

REF:   Human Immunodeficiency Virus Infection: Epidemiology

 

  1. A client diagnosed with human immunodeficiency virus infection is prescribed antiretroviral Group 1 medications. Which medications are included in Group 1? (Select all that apply.)
1. Enfuvirtide (Fuzeon)
2. Ziduvudine (AZT)
3. Didanosine (Videx)
4. Abacavir (Ziagen)
5. Ritonavir (Norvir)
6. Saquinavir (Fortovase)

 

 

ANS:  2, 3, 4

Ziduvudine (AZT), didanosine (Videx), and abacavir (Ziagen) are all Group 1 medications. Ritonavir (Norvir) and Saquinavir (Fortovase) are protease inhibitors or medications within Group 2. Enfuvirtide (Fuzeon) is a fusion inhibitor or a Group 3 medication.

 

PTS:   1                    DIF:    Analyze         REF:   Box 42-3 Antiretroviral Drug Classifications

 

  1. The nurse suspects a client is experiencing rheumatoid arthritis when which of the following are assessed? (Select all that apply.)
1. Morning stiffness lasting more than 1 hour
2. Arthritis of three or more joint areas
3. Arthritis of the hand joints
4. Symmetrical arthritis
5. Nodules over bony prominences
6. Bruising

 

 

ANS:  1, 2, 3, 4, 5

Findings consistent with rheumatoid arthritis include morning stiffness lasting more than 1 hour, arthritis of three or more joint areas, arthritis of the hand joints, symmetrical arthritis, nodules over bony prominences, presence of serum rheumatoid factions, and radiographic changes. Bruising is not a finding consistent with rheumatoid arthritis.

 

PTS:   1                    DIF:    Analyze

REF:   Box 42-4 The American College of Rheumatology Criteria for Diagnosis of RA

 

  1. The nurse is planning care for a client diagnosed with rheumatoid arthritis. Which of the following should be included in this plan of care? (Select all that apply.)
1. Muscle strengthening exercises
2. Range-of-motion exercises
3. Application of heat
4. Application of cold
5. Joint massage
6. Yoga

 

 

ANS:  1, 2, 3, 4, 6

Interventions proven to help clients diagnosed with rheumatoid arthritis include muscle strengthening exercises, range-of-motion exercises, application of heat, application of cold, and yoga. Actual massage of the joints can aggravate the inflammation.

 

PTS:   1                    DIF:    Apply

REF:   Rheumatoid Arthritis: Planning and Implementation

 

  1. A client is diagnosed with progressive systemic sclerosis. Which of the following will the nurse most likely assess in this client? (Select all that apply.)
1. Telangiectasia
2. Sclerodactyly
3. Difficulty swallowing
4. Painful cold hands and fingers
5. Small white calcium deposits under the skin
6. Hematuria

 

 

ANS:  1, 2, 3, 4, 5

In progressive systemic sclerosis, the skin, muscle, joints, lungs, esophagus, heart, digestive system, and kidneys are often affected in the diffuse subcutaneous form, often termed as CREST. Clinical manifestations include calcinosis, or small white calcium deposits under the skin; Raynaud’s syndrome, or painful cold hands and fingers; alteration in esophageal movement, or difficulty swallowing; sclerodactyly of the fingers and toes; and telangiectasia or permanent dilation of the capillaries, arterioles, and venules. Hematuria is not seen in this disorder.

 

PTS:   1                    DIF:    Apply

REF:   Progressive Systemic Sclerosis: Assessment with Clinical Manifestations

Chapter 56–Endocrine Dysfunction: Nursing Management

 

MULTIPLE CHOICE

 

  1. A male client is diagnosed with hyperprolactinemia. The nurse realizes that which of the following clinical manifestations occurs less frequently in men?
1. A decrease in testosterone
2. Erectile dysfunction
3. Gynecomastia
4. Infertility

 

 

ANS:  3

In men, hyperprolactinemia causes a decrease in testosterone secondary to an inhibition of gonadotropin secretion, leading to decreased facial and body hair, erectile dysfunction, decreased libido, small testicles, and infertility. Gynecomastia occurs less frequently in men.

 

PTS:   1                    DIF:    Analyze

REF:   Hyperprolactinemia: Assessment with Clinical Manifestations

 

  1. A female client is admitted with hyperprolactinemia. Which of the following would not be a clinical manifestation of the disorder in this client?
1. Excessive estrogen
2. Hirsutism
3. Osteoporosis
4. Weight gain

 

 

ANS:  1

Hyperprolactinemia is associated with a decrease in estrogen, resulting in symptoms of vaginal dryness, hot flashes, osteopenia, and osteoporosis. The patient may also experience weight gain, irritability, hirsutism, anxiety, and depression.

 

PTS:   1                    DIF:    Analyze

REF:   Hyperprolactinemia: Assessment with Clinical Manifestations

 

  1. A client has been instructed regarding a prolactin level to be drawn the next day. Which of the following statements indicate that the client will need further instruction?
1. “I will be on time, in the afternoon.”
2. “I will be relaxed.”
3. “I will make sure not to take my antihistamine.”
4. “I will practice another method of birth control rather than the pill.”

 

 

ANS:  1

Certain medications (e.g., antihistamines and oral contraceptives) and fear can increase the prolactin level. The prolactin level is drawn in the morning.

 

PTS:   1                    DIF:    Analyze         REF:   Box 56-1 Prolactin Levels

 

  1. An adult client is complaining of vision changes and difficulty speaking because the tongue is larger. The client also states that his shoes no longer fit. Based on these symptoms, the client is most likely to be diagnosed with:
1. acromegaly.
2. cretinism.
3. gigantism.
4. Graves’ disease.

 

 

ANS:  1

Acromegaly is caused by a hypersecretion of the pituitary growth hormone over a long period. This hypersecretion causes a coarsening of the features, including soft tissue overgrowth such as the tongue. Shoes and rings may no longer fit due to tissue and bone overgrowth. In children, hypersecretion of growth hormone causes gigantism. Cretinism and Graves’ disease are caused by a thyroid hormone imbalance.

 

PTS:   1                    DIF:    Analyze

REF:   Acromegaly (Gigantism): Assessment with Clinical Manifestations

 

  1. A client is prescribed medication after recovering from surgery to treat acromegaly. Which of the following medications would the nurse expect to see prescribed?
1. None
2. Cabergoline (Dostinex) 1 mg PO twice a week
3. Cortisone acetate (Cortone) 100 mg PO three times a day
4. Octreotide (Sandostatin) 20 mg IM every 4 weeks

 

 

ANS:  4

Sandostatin is used for residual growth hormone hypersecretion following surgery. Cortone is used to treat adrenocorticotropic dysfunction, and Dostinex is used to treat hyperprolactinemia.

 

PTS:   1                    DIF:    Analyze         REF:   Acromegaly (Gigantism): Pharmacology

 

  1. A client, complaining of weight gain, has thin extremities, a “buffalo hump,” and a protruding abdomen. The nurse realizes that this client is most likely to be diagnosed with which disease process?
1. Addison’s disease
2. Cretinism
3. Cushing’s syndrome
4. Obesity

 

 

ANS:  3

Even though the client has gained weight (obesity), the distribution of that weight is characteristic for the disease process of Cushing’s syndrome. Cretinism and Addison’s disease do not exhibit those symptoms.

 

PTS:   1                    DIF:    Analyze

REF:   Cushing’s Disease (Hypercortisolism): Assessment with Clinical Manifestations

 

  1. The nurse is providing instructions to a client receiving treatment for Cushing’s syndrome. Which of the following instructions would not be appropriate for this client?
1. Monitor glucose levels.
2. Implement safety precautions.
3. Wear medical identification.
4. Volunteer at the hospital to prevent depression.

 

 

ANS:  4

A client diagnosed with Cushing’s syndrome is predisposed to falls, injury, and increased glucose levels. The client should wear an identification bracelet indicating her disease process. The client should avoid crowds and persons with infections.

 

PTS:   1                    DIF:    Apply

REF:   Cushing’s Disease (Hypercortisolism): Planning and Implementation

 

  1. The nurse is assessing a client diagnosed with hyperaldosteronism. Which of the following would take the least priority during this period?
1. Assessment of breath sounds
2. Cardiac monitoring
3. Assistance with activities of daily living (ADLs)
4. Review of electrolyte levels

 

 

ANS:  3

The first priority for the nurse is to monitor cardiac and respiratory status. Cardiac status can be impaired because of changes in potassium levels, and fluid balance can be impaired because of sodium, affecting the respiratory status. After the client is stabilized, the nurse can assist the client with activities of daily living.

 

PTS:   1                    DIF:    Analyze

REF:   Hypersecretion of the Adrenal Gland (Hyperaldosteronism): Assessment with Clinical Manifestations

 

  1. A client is diagnosed with primary adrenal insufficiency. The nurse realizes that this disorder affects which of the following glands?
1. Adrenal cortex
2. Adrenal medulla
3. Thyroid
4. Pituitary

 

 

ANS:  1

Mineralocorticoids, glucocorticoids, and androgens are produced in the adrenal cortex. The principal mineralocorticoid is aldosterone. The adrenal medulla secretes the catecholamines. The thyroid and pituitary do not secrete aldosterone.

 

PTS:   1                    DIF:    Analyze

REF:   Hyposecretion of the Adrenal Gland: Pathophysiology

 

  1. A client tells the nurse that he is “so thirsty” that he has already consumed four pitchers of water. The client’s urine output is 3500 mL in an 8-hour period. The client is recovering from surgery on the pituitary gland. What endocrine disorder is the client most likely experiencing?
1. Diabetes insipidus
2. Diabetes mellitus
3. Myxedema
4. Syndrome of inappropriate antidiuretic hormone secretion

 

 

ANS:  1

Diabetes insipidus and diabetes mellitus both cause increased urine output, but diabetes insipidus is related to a problem with antidiuretic hormone; diabetes mellitus is a problem with glucose. Myxedema is caused by a thyroid hormone imbalance. Syndrome of inappropriate antidiuretic hormone secretion causes fluid retention.

 

PTS:   1                    DIF:    Analyze

REF:   Diabetes Insipidus: Assessment with Clinical Manifestations

 

  1. The nurse is planning care for a client diagnosed with Graves’ disease. Which of the following nursing interventions would be appropriate for this client’s care?
1. Administer a stool softener.
2. Provide extra blankets.
3. Provide frequent meals.
4. Restrict the caloric intake.

 

 

ANS:  3

Nursing interventions for Graves’ disease (hyperthyroidism) include offering frequent, high-calorie meals; medicating for diarrhea; providing a fan or decreasing the temperature on the air conditioner; and taking daily weight measurements. The client does not need a stool softener. The client does not need extra blankets. The client’s metabolic rate is increased, and she should not have a restriction on caloric intake.

 

PTS:   1                    DIF:    Apply

REF:   Hypersecretion of the Thyroid Gland: Planning and Implementation

 

  1. A client is hospitalized with an ongoing fever. The nurse learns that the client has had a recent infection. Currently the client is restless, diaphoretic, and agitated with the following vital signs: temperature 106°F, pulse 114, blood pressure 180/80 mmHg. Which of the following disorders is the client most likely experiencing?
1. Addisonian crisis
2. Goiter
3. Myxedema
4. Thyroid crisis

 

 

ANS:  4

Thyroid crisis is a serious form of hyperthyroidism that is life threatening. It is most likely to occur in persons who have been inadequately treated or undiagnosed. Infection, stress or emotional trauma, pregnancy, and medications may precipitate the event. Myxedema and addisonian crisis would not produce a severe increase in blood pressure. Goiter tends to interfere with swallowing and breathing.

 

PTS:   1                    DIF:    Analyze         REF:   Thyroid Crisis (Thyroid Storm)

 

  1. A pregnant client is receiving treatment for hyperthyroidism. Which of the following medications would the nurse expect to see?
1. Levothyroxine
2. Methimazole
3. Propylthiouracil
4. Radioactive iodine

 

 

ANS:  3

Propylthiouracil (PTU) is the drug of choice for treating hyperthyroidism in a pregnant or breastfeeding client. Radioactive iodine and methimazole are treatments for nonpregnant clients with hyperthyroidism. Levothyroxine is used to treat hypothyroidism.

 

PTS:   1                    DIF:    Analyze

REF:   Hypersecretion of the Thyroid Gland: Pharmacology

 

  1. A client is diagnosed with chronic lymphocytic thyroiditis. The nurse should instruct the client regarding signs and symptoms of which of the following?
1. Type 2 diabetes mellitus
2. Heart failure
3. Hypothyroidism
4. Renal failure

 

 

ANS:  3

The client diagnosed with chronic lymphocytic thyroiditis will most often progress to hypothyroidism, which is permanent 95% of the time. The nurse should instruct the client regarding signs and symptoms of hypothyroidism. Chronic lymphocytic thyroiditis will not cause type 2 diabetes mellitus, heart failure, or renal failure.

 

PTS:   1                    DIF:    Apply            REF:   Thyroiditis

 

MULTIPLE RESPONSE

 

  1. Which of the following symptoms would suggest to the nurse that a client is experiencing symptoms of pheochromocytoma? (Select all that apply.)
1. Severe headache
2. Decreased urine output
3. Palpitations
4. Diarrhea
5. Profuse sweating
6. Weight gain

 

 

ANS:  1, 3, 5

Severe headache, palpitations, and profuse sweating are the most common symptoms of pheochromocytoma. Decreased urine output, diarrhea, and weight gain are not associated with this disorder.

 

PTS:   1                    DIF:    Analyze

REF:   Pheochromocytoma: Assessment with Clinical Manifestations

 

  1. A client is receiving diagnostic tests to determine the presence of a malignant thyroid lesion. Which of the following are symptoms that are usually associated with a malignant thyroid? (Select all that apply.)
1. Hoarseness
2. Onset of dysphagia
3. Age 20; male gender
4. Thyroid scan revealing a cold nodule
5. Soft nodules
6. Presence of a single firm nodule

 

 

ANS:  1, 2, 3, 4, 6

Assessment findings consistent with a malignant thyroid lesion include hoarseness, dysphagia, young adult male; thyroid scan revealing a cold nodule; and the presence of a single firm nodule. Multiple soft nodules are indicative of benign thyroid lesions.

 

PTS:   1                    DIF:    Analyze

REF:   Table 56-5 Comparison of Benign and Malignant Thyroid Lesions

 

  1. The nurse suspects a client is experiencing the early signs of myxedema coma when which of the following is assessed? (Select all that apply.)
1. Reduced level of consciousness
2. Hypothermia
3. Hypoventilation
4. Hypotension
5. Bradycardia
6. Reduced urine output

 

 

ANS:  1, 2, 3, 4, 5

Myxedema is a medical emergency. The client will present with a diminished level of consciousness, hypothermia, hypoventilation, hypotension, and bradycardia. Prior to the coma, the client may be depressed, confused, paranoid, or even manic. Reduced urine output is not associated with this disorder.

 

PTS:   1                    DIF:    Analyze         REF:   Myxedema Coma

 

  1. The nurse is planning care for a client diagnosed with hypercalcemia caused by hyperparathyroidism. Which of the following should the nurse add as interventions to this client’s care plan? (Select all that apply.)
1. Administer high volume intravenous fluids as prescribed.
2. Monitor arterial blood gases.
3. Calculate sodium chloride intake to achieve 400 mEq each day.
4. Provide low rates of intravenous fluids.
5. Provide thyroid replacement medication orally.
6. Monitor body temperature.

 

 

ANS:  1, 3

Management of fluid and electrolytes is the priority for a client diagnosed with hypercalcemia caused by hyperparathyroidism. The client needs intensive hydration with intravenous normal saline. The nurse also needs to ensure that the client receives greater than 400 mEq of sodium chloride each day. The other answer choices are interventions appropriate for a client diagnosed with myxedema.

 

PTS:   1                    DIF:    Apply

REF:   Hyperparathyroidism: Planning and Implementation

Chapter 66–Mass Casualty Care

 

MULTIPLE CHOICE

 

  1. The nurse in the emergency department is using a triage system because this system ranks clients by:
1. severity of illness or injury.
2. body systems involved.
3. name.
4. age.

 

 

ANS:  1

No one can predict when the next patient will arrive or the severity of their injury or illness; this is why emergency departments utilize a triage system, which is a method to rank or classify patients’ illnesses and the severity of their injuries. The triage system does not rank clients by body systems involved, name, or age.

 

PTS:   1                    DIF:    Apply            REF:   Triage

 

  1. In the event of a mass casualty situation, the best triage nurse is:
1. the recently graduated registered nurse (RN).
2. the licensed vocational nurse (LVN) with 5 years’ experience.
3. the registered nurse (RN) with the most experience and best assessment skills.
4. the recently graduated licensed vocational nurse (LVN).

 

 

ANS:  3

Triage is usually performed by an RN who is experienced and can complete a rapid assessment. Triage nurses are challenged with assessing the order in which clients need to be evaluated by an emergency department doctor. The recently graduated registered nurse does not have the experience necessary to perform adequate triage. The recently graduated licensed vocational nurse and the licensed vocation nurse with 5 years experience do not have the appropriate education on client assessment to serve as a triage nurse.

 

PTS:   1                    DIF:    Analyze         REF:   Triage

 

  1. The nurse, triaging victims of a mass casualty incident, will focus attention on the victims who are color coded as:
1. green.
2. yellow.
3. red.
4. black.

 

 

ANS:  3

Victims coded green will do well with minimal care, and victims coded black will most likely die even with care. The focus is on the red-coded victims, then the yellow, using immediate resources and rapid intervention for those who will benefit the most.

 

PTS:   1                    DIF:    Apply            REF:   START Method of Triage

 

  1. The emergency room nurse is utilizing a triage approach for a mass casualty incident that is different from traditional triage. The difference between these two triage approaches is that:
1. mass casualty is first come, first served; traditional is most critical first.
2. mass casualty is most likely to survive first; traditional is first come, first served.
3. mass casualty is most critical first; traditional is most likely to survive first.
4. mass casualty is most likely to survive first; traditional is most critical first.

 

 

ANS:  4

In traditional triaging the most critical come first, but in mass casualties the number of people and limits of supplies have to be taken into consideration. This means the clients who are most likely to survive are treated first and the most critical are treated last.

 

PTS:   1                    DIF:    Apply            REF:   START Method of Triage

 

  1. The emergency department nurse is preparing to triage victims of an internal event. Which of the following would be considered an internal event?
1. Bus crash in front of the hospital
2. Train crash 5 miles away
3. Fire in the hospital
4. Explosion in a nearby oil station

 

 

ANS:  3

An internal event is an event inside the facility, such as a fire in the building or a water pipe breaking. All the other events are outside the facility and would be external.

 

PTS:   1                    DIF:    Analyze         REF:   HEICS Activator

 

  1. The Emergency Preparedness Committee in a health care organization is reviewing available supplies for a mass casualty event since supplies need to be able to support the organization’s functioning for:
1. 24 hours.
2. 48 hours.
3. 96 hours.
4. 1 week.

 

 

ANS:  3

The plan must incorporate strategies to care for a large influx of clients for up to 96 hours because it may be this long before assistance from the government can arrive. The other choices are incorrect lengths of time for the organization to prepare for supplies.

 

PTS:   1                    DIF:    Apply            REF:   Hospital Operations Plan

 

  1. When reviewing the potential for biological warfare, the nurse realizes that one of the greatest bioterrorism threats in the world today is:
1. chickenpox.
2. smallpox.
3. rabies.
4. influenza.

 

 

ANS:  2

Smallpox was considered eradicated worldwide, and much of the vaccine was destroyed. Much of the current population has not been vaccinated or received booster shots. As a result, the number of casualties would be great. The other communicable diseases listed would not cause a great number of casualties.

 

PTS:   1                    DIF:    Analyze         REF:   Smallpox

 

  1. The nurse is a member of the emergency preparedness committee, and she learns that anthrax is a bioterrorism threat that could infect and kill large numbers of people. Because of this, the organization should have which of the following on stock to treat anthrax?
1. No treatment available
2. Adrenaline injections
3. Intravenous or oral ciprofloxacin
4. Oral Benadryl

 

 

ANS:  3

If anthrax is suspected, ciprofloxacin IV is recommended. Oral ciprofloxacin is recommended for postexposure treatment. Adrenaline and oral Benadryl are not treatments for anthrax. There is a treatment for anthrax and the health care organization should be prepared for clients admitted with this disease.

 

PTS:   1                    DIF:    Apply            REF:   Anthrax: Pharmacology

 

  1. A client is diagnosed with West Nile virus. The nurse should instruct the client that the most common carriers of this virus are:
1. rats.
2. birds.
3. mosquitoes.
4. cows.

 

 

ANS:  3

The nurse can help provide education to clients about decreasing their risk of exposure to infected mosquitoes. Rats and cows do not carry the West Nile virus. Birds are the main reservoir for this virus.

 

PTS:   1                    DIF:    Apply            REF:   West Nile Virus: Etiology

 

  1. Victims of a chemical spill are brought to the hospital for treatment. The nurse learns that 50 victims will be arriving within the hour. When preparing for these victims, the nurse should ensure that which of the following is available?
1. A small designated area to decontaminate the victims
2. A medium-sized area to decontaminate the victims
3. A large area to decontaminate the victims
4. The entire emergency department is available to decontaminate the victims

 

 

ANS:  3

The nurse is preparing to provide care to 50 victims. This is a large number to decontaminate, so the nurse should ensure that a large area is available to decontaminate the victims. A small area would be sufficient for a few victims. A medium-sized area would be sufficient for a slightly larger number of victims. It would not be reasonable to expect that the entire emergency department would be available to decontaminate the victims.

 

PTS:   1                    DIF:    Apply            REF:   Decontamination

 

  1. The nurse is told to wear a Level B Hazmat suit when decontaminating victims of a mass casualty incident. The nurse realizes that this suit will provide:
1. the highest level of respiratory and skin protection.
2. resistance to chemicals, and it is impermeable to gases and vapors.
3. respiratory protection, but it will allow chemical vapors to permeate the suit.
4. splash protection and chemical resistance.

 

 

ANS:  3

There are three levels of personal protective equipment. With a Level A suit, the highest level of respiratory and chemical protection is provided. This suit provides resistance to chemicals and is impermeable to gases and vapors. In a Level B suit, there is respiratory protection but chemical vapors are able to permeate the suit. The Level C suit provides splash protection and chemical resistance.

 

PTS:   1                    DIF:    Analyze         REF:   Box 66-4 OSHA PPE Levels

 

MULTIPLE RESPONSE

 

  1. The nurse is preparing to assess a client who was a victim of a blast injury. Prior to assessing the client, which are the mechanisms of a blast injury that the nurse will review? (Select all that apply.)
1. Primary
2. Secondary
3. Acute
4. Tertiary
5. Quaternary
6. Chronic

 

 

ANS:  1, 2, 4, 5

The four mechanisms of a blast injury are primary, secondary, tertiary, and quaternary. Each of these mechanisms of injury have associated injuries. The nurse should review the mechanisms of injury prior to assessing the client. Acute and chronic are not mechanisms of a blast injury.

 

PTS:   1                    DIF:    Apply            REF:   Blast Injuries

 

  1. The nurse believes a client is experiencing a reaction to a traumatic event when which of the following is assessed? (Select all that apply.)
1. Client is not responding verbally to assessment questions.
2. Client complains of dizziness.
3. Client’s blood pressure is 120/80 mmHg.
4. Client complains of nausea.
5. Client asks for medication for a headache.
6. Client asks for something to drink.

 

 

ANS:  1, 2, 4, 5

Common responses to a traumatic event include silence or not responding to verbal stimuli, dizziness, nausea, and headache. A blood pressure of 120/80 mmHg is considered normal. The client requesting something to drink is not a reaction to a traumatic event.

 

PTS:   1                    DIF:    Analyze

REF:   Table 66-5 Common Responses to a Traumatic Event

 

  1. The nurse is concerned about developing post-traumatic stress disorder after working for several years in the emergency department. Which of the following should the nurse do to ensure this disorder does not manifest? (Select all that apply.)
1. Eat well-balanced meals.
2. Drink water.
3. Limit caffeine.
4. Limit sugar intake.
5. Exercise at least 4 times a week for 30 minutes.
6. Ingest at least one alcoholic drink every evening.

 

 

ANS:  1, 2, 3, 4, 5

The nurse must learn to handle stress to reduce the onset of post-traumatic stress disorder by eating well-balanced meals, drinking water, limiting caffeine, limiting sugar intake, and exercising at least 4 times a week for 30 minutes. A daily intake of alcohol could be a sign that post-traumatic stress disorder is developing.

 

PTS:   1                    DIF:    Apply

REF:   Post-traumatic Stress Disorder: Planning and Implementation

 

  1. The nurse is participating in a debriefing session after participating in the care of victims of a mass casualty incident. Which of the following will occur during this debriefing session? (Select all that apply.)
1. The process for the debriefing will be explained.
2. Individual reactions to the event will be discussed.
3. Symptoms that the nurse may experience will be reviewed.
4. Stress reduction techniques will be provided.
5. Prescriptions for antianxiety medications will be provided.
6. Physician follow-up appointments will be made.

 

 

ANS:  1, 2, 3, 4

There are eight (8) phases to a debriefing session. During the introduction phase, the process for the debriefing will be explained. During the reaction phase, individual reactions to the event will be discussed. During the symptom phase, symptoms that the nurse may experience will be reviewed. During the teaching phase, stress reduction techniques will be provided. Prescriptions for medication and physician appointments are not a part of the debriefing session.

 

PTS:   1                    DIF:    Analyze         REF:   Box 66-9 The Eight Phases of a Debriefing

 

  1. The nurse is a member of a committee designing the hospital’s emergency incident command system. Which of the following are the four components of the committee’s design? (Select all that apply.)
1. Relief support
2. Staffing
3. Planning
4. Operations
5. Logistics
6. Finance

 

 

ANS:  3, 4, 5, 6

The hospital emergency incident command system has four components: 1) finance, 2) logistics, 3) operations, and 4) planning. Relief support and staffing are not parts of the hospital emergency incident command system.

 

PTS:   1                    DIF:    Apply            REF:   Hospital Emergency Incident Command System

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