Introduction to Medical-Surgical Nursing, 6e 6th Edition by Linton – test Bank

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Introduction to Medical-Surgical Nursing, 6e 6th Edition by Linton – test Bank

Chapter 02: Nursing in Varied Patient Care Settings

Linton: Introduction to Medical-Surgical Nursing, 6th Edition

 

MULTIPLE CHOICE

 

  1. While a home health nurse is making the entry to a service assessment on a home-bound patient, the spouse of the patient asks whether Medicare will cover the patient’s ventilator therapy and insulin injections. What is the best response by the nurse?
a. “Yes, Medicare will cover both the ventilator therapy and the insulin injections.”
b. “No, Medicare will not cover either of these ongoing therapies.”
c. “Medicare will cover the ventilator therapy, but it does not cover the insulin injections.”
d. “Medicare will cover the ongoing insulin therapy, but it does not cover a highly technical skill such as ventilator therapy.”

 

 

ANS:  C

Medicare will cover skilled nursing tasks such as ventilator therapy, but common tasks that can be taught to the family or the patient are not covered.

 

DIF:    Cognitive Level: Application          REF:   p. 18              OBJ:   3

TOP:   Medicare Coverage for Home Health

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. The wife of a patient asks the nurse whether her husband would be considered for placement in a skilled nursing care facility when he is discharged from the general hospital. The patient is incontinent, has mild dementia but is able to ambulate with a walker, and must have help to eat and dress himself. What is the nurse’s most appropriate response?
a. “Yes, your husband would qualify for a skilled care facility because of his inability to feed and dress himself.”
b. “No, your husband’s disabilities would not qualify him for a skilled facility.”
c. “Yes, your husband qualifies for placement in a skilled care facility because of his dementia.”
d. “Yes, anyone who is willing to pay can be placed in a skilled nursing facility.”

 

 

ANS:  B

Placement in a skilled nursing facility must be authorized by a physician. A clear need for rehabilitation must be evident, or severe deficits in self-care that have a potential for improvement and require the services of a registered nurse, physical therapist, or speech therapist must exist.

 

DIF:    Cognitive Level: Analysis               REF:   p. 19              OBJ:   9

TOP:   Placement Qualifications for Skilled Nursing Facility

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. A nurse has noted that a newly admitted resident to an extended care facility stays in her room, does not take active part in activities, and leaves the meal table after having eaten very little. The nurse should analyze this relocation response as
a. regression.
b. social withdrawal.
c. depersonalization.
d. passive aggressive.

 

 

ANS:  B

Social withdrawal is a frequent response to relocation.

 

DIF:    Cognitive Level: Application          REF:   p. 27              OBJ:   10

TOP:   Relocation Response                                 KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. A nurse clarifies to a new patient in a rehabilitation center what rehabilitation means. What statement made by the patient indicates a correct understanding?
a. “I will return to my previous level of functioning.”
b. “I will be counseled into a new career.”
c. “I will develop better coping skills to accept his disability.”
d. “I will attain the greatest degree of independence possible.”

 

 

ANS:  D

The rehabilitation process works to promote independence at whatever level the patient is capable of achieving.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 21              OBJ:   4

TOP:   Rehabilitation Goals                       KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Coordinated Care

 

  1. A nurse assesses a patient who needs to be reminded to take premeasured oral medications, wash, go to meals, and undress and come to bed at night, but coming and going as he pleases is considered safe for him. What facility placement would be most appropriate for this patient?
a. Skilled care
b. Intermediate care
c. Sheltered housing
d. Domiciliary care

 

 

ANS:  D

Domiciliary care provides room, board, and supervision, and residents may come and go as they please. Sheltered housing does not provide 24-hour care.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 25              OBJ:   3

TOP:   “Levels of Care, Criteria for Domiciliary Residence”

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. A nurse is making a list of the members of the rehabilitation team so the different types of services available to patients may be taught to a group of families. Which lists should be used?
a. Physical therapist, nurse, family members, and personal physician
b. Occupational therapist, dietitian, nurse, and patient
c. Rehabilitation physician, laboratory technician, patient, and family
d. Vocational rehabilitation specialist, patient, and psychiatrist

 

 

ANS:  A

The rehabilitation team usually consists of all of the choices except the laboratory technician, dietitian, and psychiatrist. (The mental health role is represented by the psychologist.)

 

DIF:    Cognitive Level: Comprehension   REF:   p. 23              OBJ:   8

TOP:   Rehabilitation Team Members        KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. A nurse explains the level of disability to a patient who was injured in a construction accident that resulted in the loss of both his right arm and right leg. This loss has affected his quality of life and ability to return to previous employment. At what level should the client be classified as being disabled?
a. I
b. II
c. III
d. IV

 

 

ANS:  B

The patient is limited in the use of his right arm for feeding himself, dressing himself, and driving his car, which are three main activities of daily living. He may be able to work if workplace modifications are made.

 

DIF:    Cognitive Level: Application          REF:   p. 21              OBJ:   5

TOP:   Levels of Disability                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. A nurse explains that in 1990, the Americans with Disabilities Act (ADA) was passed. For which extended services for the disabled persons did this act provide?
a. Covering the costs for the rehabilitation of disabled World War I servicemen by providing job training
b. Extending protection to the disabled in the military sector, such as wheelchair ramps on military bases
c. Extending protection to the disabled in private areas, such as accessibility to public restaurant bathrooms and telephones
d. Affording disabled persons full access to all health care services

 

 

ANS:  C

The ADA of 1990 extended the previous legislative Acts of 1920, 1935, and 1973. The ADA now covers private sector individuals and public businesses in particular.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 22-23         OBJ:   7

TOP:   Americans with Disabilities Act (ADA) of 1990

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. A frail patient in a long-term care facility asks the nurse if a bath is to be given this morning. What is the best reply by the nurse to encourage independence and give the patient the most flexibility?
a. “Based on your room number, you get bathed on Monday, Wednesday, and Friday. Today is Tuesday.”
b. “If you want to eat breakfast in the dining room with the others, you may sponge yourself off in your bathroom.”
c. “When your daughter comes this evening, ask her if she can give you a bath.”
d. “I will bring a basin of water for a sponge off for right now. After breakfast, we will talk about a bath schedule.”

 

 

ANS:  D

The resident should be provided as much flexibility as possible and support for independence.

 

DIF:    Cognitive Level: Application          REF:   p. 28              OBJ:   11

TOP:   Maintenance of Autonomy in Extended Care Facility

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX Physiological Integrity: Basic Care and Comfort

 

  1. A computer programmer who lost both legs is being retained by his employer, who has made arrangements for a ramp and a special desk to accommodate the patient’s wheelchair. What is the disability level of the computer programmer?
a. I
b. II
c. III
d. IV

 

 

ANS:  B

Level II allows for workplace accommodation, which is the desk modification in this case.

 

DIF:    Cognitive Level: Analysis               REF:   p. 21              OBJ:   5

TOP:   Reasonable Accommodation          KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A partially paralyzed forklift operator is to be retrained by vocational rehabilitation services for less demanding office work. What law provides for this rehabilitation?
a. Vocational Rehabilitation Act of 1920
b. Social Security Act of 1935
c. Rehabilitation Act of 1973
d. Americans with Disabilities Act of 1990

 

 

ANS:  C

The Rehabilitation Act of 1973 provided a comprehensive approach and expanded resources for public vocational training.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 22              OBJ:   7

TOP:   Rehabilitation Legislation               KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. The home health care nurse performs all the following actions. Which is the only action that is reimbursable under Medicare payment rules?
a. Observing a spouse cleaning and changing a dressing
b. Taking a frail couple for a walk to provide exercise
c. Watching a patient measure out all medications
d. Teaching a patient to self-administer insulin

 

 

ANS:  D

Medicare reimburses skilled techniques that are clearly spelled out; these include teaching but not return demonstration–type actions by patient or family.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 19              OBJ:   3

TOP:   Medicare Reimbursable Actions     KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. A patient with multiple sclerosis must be fed, bathed, and dressed. How should the nurse assess this patient?
a. Disabled
b. Disadvantaged
c. Handicapped
d. Impaired

 

 

ANS:  D

Feeding oneself, dressing, and bathing are activities of daily living. The patient is impaired in this scenario.

 

DIF:    Cognitive Level: Analysis               REF:   p. 21              OBJ:   4

TOP:   Principles of Rehabilitation | Defining Levels of Loss of Functioning Independently

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which law initially provided for rehabilitation of disabled Americans?
a. Vocational Rehabilitation Act of 1920
b. Social Security Act of 1935
c. Rehabilitation Act of 1973
d. Americans with Disabilities Act of 1990

 

 

ANS:  A

The U.S. government has passed four pieces of legislation to identify and meet the needs of disabled individuals with each one being more inclusive. The first one was passed in 1920.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 22              OBJ:   7

TOP:   Rehabilitation Legislation               KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A client was admitted to a long-term residential care facility. On what should the admitting nurse tell the family the concepts of long-term care are based?
a. Amount of activities the resident can do for herself
b. Maintenance care with an emphasis on incontinence
c. Successful adaptation to the regulations of the home
d. Maintenance of as much function as possible

 

 

ANS:  D

Maintenance of function and encouraging autonomy and independence are some of the basic concepts of long-term care.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 27              OBJ:   11

TOP:   Principles of Nursing Home Care   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. A 58-year-old patient with diabetes is recuperating from a broken hip and is concerned about how to pay for rehabilitation. The nurse should inform this patient that funds for rehabilitation are available from which resource?
a. Vocational Rehabilitation Act of 1920
b. Rehabilitation Act of 1973
c. Disabled American Veterans Act of 1990
d. Title V, Health of Crippled Americans 1935

 

 

ANS:  B

The Rehabilitation Act of 1973 assists in paying for rehabilitation for those who are younger than 65 years of age and who will benefit from vocational rehabilitation through teaching.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 22              OBJ:   7

TOP:   Legislation for Funding Health Care

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. What is an example of a description of community health nursing?
a. Visiting patients in their homes after hospital discharge to assess their personal health status
b. Asking a nursing assistant (NA) to identify the health services most needed in the patient’s personal life
c. Meeting with residents of low-income housing to identify their health care needs
d. Developing a hospital-based home health care service

 

 

ANS:  C

Whereas community-based nursing looks at identified community needs and provides care at all levels of wellness and illness, community health nursing seeks to provide services to groups to modify or create systems of care.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 16              OBJ:   2

TOP:   Defining Community-Based Nursing versus Community Health Nursing

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Coordinated Care

 

  1. Home health nurses have some different nursing activities than those of community health nurses. Which statement best describes the home health nurse’s activities?
a. Conducting health education classes in a senior citizens’ common residence building
b. Conducting blood pressure screening on a regular basis at a local mall
c. Visiting and assessing the home care and further teaching needs of a patient who has been recently discharged from the hospital
d. Acting as a nurse consultant to a chronic psychiatric section in a state institution

 

 

ANS:  C

The home health nurse works with individuals in the home; the other descriptors are community nurse activities.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 16-17 | p. 19

OBJ:   1                    TOP:   Activities of the Home Health Nurse

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. Based on guidelines from the Americans with Disability Act (ADA), which question is an appropriate choice for the director of nurses to ask a nurse with an artificial leg who is applying for a staff position in an extended care facility?
a. “How long have you had your prosthesis?”
b. “How many flights of stairs are you able to climb without assistance?”
c. “Are you able to lift a load of 45 lb?”
d. “Has your disability caused you to miss work?”

 

 

ANS:  C

Queries to disabled job applicants can be made relative to specific job functions, but they cannot be asked relative to the severity of the disability or the degree of disability in general.

 

DIF:    Cognitive Level: Application          REF:   p. 22              OBJ:   7

TOP:   ADA              KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

MULTIPLE RESPONSE

 

  1. What care skills are safe and appropriate for the licensed practical nurse (LPN) to teach family members in the home health care setting? (Select all that apply.)
a. Insulin injection
b. Sterile dressing changes
c. Venipunctures
d. Periodic Foley catheter insertions
e. Instillation of eye drops
f. Changing dressings on small wounds

 

 

ANS:  A, E, F

Insulin injections, instillation of eye drops, and small wound dressing changes are safe to teach a nonprofessional caregiver. Sterile dressings, venipunctures, and inserting Foley catheters are considered skilled, and the costs for these are reimbursed by Medicare.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 19              OBJ:   3

TOP:   Skills Taught by Home Health Nurse

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The nursing care plan in a long-term care facility calls for the documentation of regressive behavior of a newly admitted 82-year-old resident who has had congestive heart failure and osteoarthritis. Of these behaviors observed by the nurse, which should be documented as regression? (Select all that apply.)
a. Talks nonstop to staff and other residents
b. Wets and soils self several times a day
c. Wakes in the middle of the night and is unable to return to sleep
d. Wears the same clothes day after day
e. Cries frequently for no apparent reason

 

 

ANS:  B, D, E

Behaviors that are infantile or immature in the absence of dementia are considered regressive. Frequent episodes of crying and inattention to personal hygiene are regressive in nature. Excessive talking and wakefulness may be related to relocation anxiety, but they are not considered regressive.

 

DIF:    Cognitive Level: Analysis               REF:   p. 26-27         OBJ:   10

TOP:   Impact of Relocation                                KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. From what do most quality-of-care problems in home health care result? (Select all that apply.)
a. Patient’s noncompliance
b. Family’s reluctance to participate in the care
c. Inadequate documentation
d. Limited funding
e. Defective communication among care team members

 

 

ANS:  C, E

Inadequate communication and incomplete documentation create most of the quality-of-care problems.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 20              OBJ:   2

TOP:   Communication in Home Health Setting

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. An 80-year-old man is newly admitted to a long-term care facility and suddenly becomes incontinent of urine at night. What nursing interventions should be used to help restore self-toileting? (Select all that apply.)
a. Waking the resident every 2 hours and escorting him to the bathroom
b. Leaving a night-light on
c. Discouraging the use of long-legged pajama bottoms
d. Placing a urinal at the bedside
e. Keeping the room uncluttered

 

 

ANS:  B, C, D, E

Providing light in an uncluttered room, encouraging clothing that does not impede self-toileting, and making the urinal available increase independence and alleviate situations that make self-toileting difficult. Waking a resident not only disturbs his or her rest, but doing so also increases dependency on the staff.

 

DIF:    Cognitive Level: Application          REF:   p. 27              OBJ:   1

TOP:   Independence in Long-Term Care Center

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

COMPLETION

 

  1. The nurse clarifies that an impairment that creates a measurable diminished capacity to work is a(n) _______.

 

ANS:

disability

When there is a measurable impairment that changes the individual’s lifestyle, it is referred to as a disability.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 21              OBJ:   5

TOP:   Rehabilitation Concepts                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Coordinated Care

 

OTHER

 

  1. A home health nurse, while in the home to change a decubitus dressing, notices that the wound has a musky odor and is weepier than the previous visit, 2 days earlier. Place the following nursing interventions in order of priority from most to least. (Separate the letters with a comma and space: A, B, C, D.)
  2. Contact the case manager.
  3. Assess the patient’s entire skin and vital signs and be prepared to describe the wound findings.
  4. Cleanse the decubitus area well and redress the wound.
  5. Chart the appearance of the decubitus completely.
  6. Assess the patient’s mobility.

 

ANS:

B, C, E, D, A

The decubitus finding is important to communicate to the case manager but not until the nurse at the bedside has fully assessed the patient, signs and symptoms, vital signs, and other areas of change that need to be promptly communicated. Then the case manager will be able to give directions for further care.

 

DIF:    Cognitive Level: Application          REF:   p. 20              OBJ:   1

TOP:   Communication among Home Health Staff

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. What should the home health nurse do when teaching a family member the skill of injecting insulin effectively? Prioritize these nursing interventions for this situation. (Separate the letters with a comma and space: A, B, C, D.)
  2. Offer instruction at an appropriate pace.
  3. Write down the steps of the procedure.
  4. Assess the level of knowledge of the family member.
  5. Inquire about the preferred learning style.
  6. Evaluate the family member’s performance.

 

ANS:

C, B, D, A, E

Effective teaching depends on assessing the level of knowledge, breaking down the skill in steps, offering instruction in the preferred style, pacing the instruction appropriately, and evaluating the performance.

 

DIF:    Cognitive Level: Application          REF:   p. 19              OBJ:   1

TOP:   Home Health Teaching                   KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

Chapter 12: The Nursing Process and Critical Thinking

Linton: Introduction to Medical-Surgical Nursing, 6th Edition

 

MULTIPLE CHOICE

 

  1. What is the primary purpose of incorporating the nursing process into the care of patients?
a. Establish a basis of communication with other nursing staff members.
b. Maintain compliance with existing national nursing standards.
c. Provide structure and organization to the delivery of medical care to the patient.
d. Address current health issues, as well as health maintenance and rehabilitation.

 

 

ANS:  D

The goal of the nursing process is to alleviate, minimize, or prevent actual or potential health problems and direct nursing care, not medical care.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 151            OBJ:   1

TOP:   Purpose of the Nursing Process      KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What is the correct order of the five steps of the nursing process?
a. Data collection, nursing diagnosis, planning, intervention, and evaluation
b. Assessment, planning, documentation, intervention, and evaluation
c. Data collection, diagnosis, assessment, planning, and evaluation
d. History, physical, diagnosis, intervention, and evaluation

 

 

ANS:  A

The nursing process is a systematic method of providing care to patients. Each phase is dependent on the other phases.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 151            OBJ:   1

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

MSC:  NCLEX: N/A

 

  1. What is the basis of the nursing process?
a. Medical diagnosis of the patient
b. Identified physiologic and psychologic needs of the patient
c. Standards of nursing care provided by the American Nurses Association
d. Orders of the primary care provider

 

 

ANS:  B

The nursing process assesses the needs of the patient to establish goals and to carry out nursing implementations.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 151 | p. 159-160

OBJ:   1                    TOP:   The Nursing Process                       KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Who is responsible for initiating the nursing care plan?
a. Primary care provider
b. Registered nurse (RN)
c. Licensed practical/vocational nurse (LPN/LVN)
d. Nurse manager

 

 

ANS:  B

The LPN/LVN may contribute to the nursing care plan, but the care plan itself must be initiated by an RN.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 152            OBJ:   2

TOP:   Initiation of the Nursing Care Plan KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What is the most accurate statement about the patient plan of care?
a. It is continually reviewed and evaluated.
b. It must be reviewed by the primary caregiver.
c. It remains in effect until the patient is discharged.
d. It can only be changed by the initiating nurse.

 

 

ANS:  A

The care plan should reflect the current needs of the patient.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 151 | p. 159

OBJ:   1 | 2                TOP:   Nursing Care Plan                           KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What is the purpose of palpation?
a. Determining areas of tenderness
b. Differentiating between fluid- and air-filled organs
c. Hearing sounds produced by the body
d. Systematically approaching a physical assessment

 

 

ANS:  A

Palpation is a method of touching the patient to obtain information about symptoms and signs such as skin temperature, condition, and pain.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 155            OBJ:   2

TOP:   Palpation        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A patient complains of a headache. What type of data is this information considered?
a. Subjective
b. Objective
c. Pain assessment
d. Undifferentiated

 

 

ANS:  A

Subjective data are reported by the patient or family and cannot be observed.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 152            OBJ:   3

TOP:   Subjective Data                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A nurse notes the previous 24-hour urine output was 950 mL, well below the normal of 1500 mL. What is an effective nursing order to remedy the impending dehydration?
a. Offer more fluids daily.
b. Offer 8 oz of juice or water at 0800 (8 AM), 1200 (12 noon), 1600 (4 PM), and 2000 (8 PM).
c. Request extra fluid on a diet tray from the kitchen.
d. Place a large water pitcher at the bedside during each shift.

 

 

ANS:  B

The statement is clear and measurable and relates directly to the potential of dehydration. The other options are vague and have no measurement criteria.

 

DIF:    Cognitive Level: Application          REF:   p. 160            OBJ:   2

TOP:   Nursing Implementation                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. What sound should a nurse anticipate when percussing a patient’s abdomen?
a. Flat
b. Dull
c. Tympanic
d. Resonant

 

 

ANS:  C

Tympanic notes are anticipated over an air-filled organ such as the stomach.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 155-156     OBJ:   1

TOP:   Percussion      KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. Which documentation entry reflects objective data?
a. An area of erythema is noted on the upper right extremity, measuring approximately 1 ´ 4 inches.
b. The patient complains of pain in the right left quadrant (RLQ) of the abdomen and rates it 5 on a pain scale of 1 to 10.
c. The family states that the patient does not sleep at night and wanders around the house.
d. The medical history reveals a history of drug abuse.

 

 

ANS:  A

Objective data are data that are observable and measurable.

 

DIF:    Cognitive Level: Application          REF:   p. 152            OBJ:   3

TOP:   Data Collection                               KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. What is a priority nursing action when a postsurgical patient complains of shortness of breath?
a. Raise the head of the bed to 30 degrees.
b. Take vital signs.
c. Perform a focused assessment.
d. Inform the charge nurse.

 

 

ANS:  A

Although all these options will be eventually performed, the initial implementation should be to raise the head of the bed to ease breathing, perform a focused assessment with vital signs and oxygen concentration, and then inform the charge nurse about the patient’s symptoms and your assessment findings.

 

DIF:    Cognitive Level: Application          REF:   p. 152            OBJ:   4

TOP:   Assessment    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. Which is an example of a complete nursing diagnosis?
a. Peripheral neurovascular dysfunction
b. Peripheral neurovascular dysfunction exhibited by patient complaint
c. Peripheral neurovascular dysfunction related to decreased sensation, exhibited by the statement “My feet are tingling”
d. Peripheral neurovascular dysfunction exhibited by patient statement

 

 

ANS:  C

A complete nursing diagnosis includes diagnosis, related to and exhibited by problem, cause, and signs and symptoms (PES).

 

DIF:    Cognitive Level: Application          REF:   p. 157-159     OBJ:   1

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

MSC:  NCLEX: N/A

 

  1. A nurse assisting with prioritizing nursing diagnoses should select which nursing diagnosis as the highest priority?
a. Impaired adjustment
b. Acute pain
c. Risk for imbalanced body temperature
d. Ineffective airway clearance

 

 

ANS:  D

Without a clear airway, no need exists for the other diagnoses.

 

DIF:    Cognitive Level: Application          REF:   p. 157-159     OBJ:   7

TOP:   Nursing Diagnosis                          KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. Which is the best example of a nursing order?
a. Perform deep breathing exercises twice daily at 1000 and 1400.
b. Administer Tylenol every 4 hours as needed for headache.
c. Assess skin integrity and risk for impairment.
d. Patient will frequently perform quadriceps-setting exercises.

 

 

ANS:  A

Nursing orders should include a specific description of what, where, when, how much, how long, and how the order should be carried out.

 

DIF:    Cognitive Level: Application          REF:   p. 160            OBJ:   1

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

MSC:  NCLEX: N/A

 

  1. Which statement best describes Nursing Interventions Classifications (NIC)?
a. They are mandated by the North American Nursing Diagnosis Association International (NANDA-I) as interventions that are to be used for all patients.
b. They are currently approved nursing goals.
c. They are instituted on the basis of individual patient needs.
d. They are guidelines for goal setting and documentation of nursing care given to patients.

 

 

ANS:  C

NIC is a standardized list of nursing implementations divided into seven domains. The nurse selects those that pertain to the patient and then implements them.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 160            OBJ:   1

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

MSC:  NCLEX: N/A

 

  1. A nurse is aware that a patient goal states, “The patient will eat at least 50% of all meals.” The nurse has observed the patient eating more than 50% of all meals for 2 days. What is the most accurate evaluation statement?
a. Ate well for all meals.
b. Problem is resolved; goal is met.
c. Goal is met; patient ate 50% of all meals on 7/12 and 7/13.
d. Ate 50% of meals.

 

 

ANS:  C

The evaluation statement should reflect the actual outcome compared with the expected outcome, with the qualifying statement of goal met, goal not met, or goal partially met.

 

DIF:    Cognitive Level: Application          REF:   p. 160            OBJ:   3

TOP:   Nursing Diagnosis: Evaluation        KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. What elements should be included in data collection?
a. Information supplied by patient and family
b. Health history, physical assessment, and documentation
c. Health history and physical assessment
d. Assessment, patient records, and diagnostic tests

 

 

ANS:  D

Diagnostic tests supply general information that can be helpful in identifying general areas in which a patient might have a health care problem. Patient records provide valuable information regarding the medical history and present illness. Physical assessment can provide information concerning the patient’s current needs.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 152            OBJ:   3

TOP:   Data Collection                               KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. When reviewing a patient care plan the nurse reads that “the patient will maintain an adequate nutritional state without nausea or vomiting.” What does this statement represent?
a. Intervention
b. Process
c. Diagnosis
d. Goal

 

 

ANS:  D

Goals should be stated in terms of observable patient outcomes.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 160            OBJ:   1

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

MSC:  NCLEX: N/A

 

  1. What is the Nursing Outcomes Classification (NOC) a method of classifying?
a. Nursing process
b. Nursing care plan
c. Nursing goal
d. Nursing intervention outcome

 

 

ANS:  D

The NOC is a new classification system for outcomes that are amenable to nursing implementations.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 160            OBJ:   1

TOP:   Nursing Outcomes Classification    KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What are standardized care plans considered?
a. Clinical pathways
b. Evaluation tools
c. Outcome criteria
d. Nursing intervention based

 

 

ANS:  A

Clinical pathways are standard care plans developed to set daily care priorities, schedule achievement outcomes, and reduce length of hospital stay.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 160            OBJ:   1

TOP:   Clinical Pathways                           KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What should documentation include?
a. Objective and subjective data
b. Observations made by other nursing staff
c. Information that is accurate and complete
d. Incidence reports

 

 

ANS:  C

Documentation should be clear, concise, complete, and accurate.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 161            OBJ:   3

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

MSC:  NCLEX: N/A

 

  1. Which is the most accurate example of documentation?
a. 7/27/14; 0945; pt. vomited; pt. looked better after episode—A. Nurse, LPN
b. 7/27/14; 0945; pt. vomited large amount; reduced nausea
c. 7/27/14; 0945; pt. reported less nausea after vomiting—A. Nurse, LPN
d. 7/27/14; 045; pt. vomited 200 ml of partially digested food; pt. states nausea has diminished—A. Nurse, LPN

 

 

ANS:  D

Documentation should be completed immediately after care is given, never before care. It should be timed and dated, ending with the signature of the nurse performing the care or making the observation. Charting should be objective and describe only what is seen, heard, felt, or smelled.

 

DIF:    Cognitive Level: Application          REF:   p. 161-163     OBJ:   3

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

MSC:  NCLEX: N/A

 

  1. What is true regarding problem-oriented medical records (POMRs)?
a. The focus is on patient response to treatment.
b. They are considered source-oriented charting.
c. They reflect the patient’s current problems.
d. They focus on medical diagnosis.

 

 

ANS:  C

POMR is a method of keeping records that focuses on patient problems rather than on the medical diagnosis. POMRs are an excellent form of communication among various disciplines that are providing care.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 161            OBJ:   3

TOP:   POMR            KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. What elements are included in the characteristics of critical thinking?
a. Interpretation, analysis, and evaluation
b. Patient-centered criteria and problem solving
c. Realistic outcomes and frequent evaluation
d. Data gathering and assessment

 

 

ANS:  A

Critical thinking is reflective, and reasonable thinking is focused on deciding what to do. Characteristics include interpretation, analysis, evaluation, inference, explanation, and self-regulation.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 163            OBJ:   5

TOP:   Critical Thinking                             KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Why is critical thinking an integral part of the nursing process?
a. It promotes flexibility and individualized care.
b. It incorporates decision making.
c. It includes the patient in part of the nursing process.
d. It provides guidelines of care.

 

 

ANS:  A

The nursing process is a sequence of steps that requires critical thinking to provide sound, individualized patient care. Critical thinking makes the nursing process accurate, scientifically sound, appropriate, flexible, and individualized.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 163            OBJ:   4

TOP:   Critical Thinking and the Nursing Process                       KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

MULTIPLE RESPONSE

 

  1. What actions should a nurse implement when auscultating a patient’s chest? (Select all that apply.)
a. Use the diaphragm for assessing breath sounds.
b. Use the bell for assessing murmurs.
c. Apply earpieces pointing toward the ears.
d. Wet the chest hair with a cloth.
e. Press the diaphragm very firmly against the chest wall.

 

 

ANS:  A, B, D

A diaphragm is used to hear high-pitched sounds, and a bell is used to hear low-pitched sounds. Chest hair is moistened to diminish cracking sounds that could be misleading. The earpieces should be pointing toward the nose. The use of the diaphragm requires light pressure.

 

DIF:    Cognitive Level: Application          REF:   p. 155            OBJ:   2

TOP:   Auscultation   KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. In what ways does evidence-based practice support effective nursing care? (Select all that apply.)
a. Research on nursing care topics
b. Directives from the boards of nursing
c. Summation of studies
d. Recommendations for nursing care
e. Funding research

 

 

ANS:  A, C, D

Evidence-based practice uses current information from independent nursing research entities that has been summarized and formed into recommendations for nursing practice.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 163            OBJ:   6

TOP:   Evidence-Based Practice                KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

COMPLETION

 

  1. In PIE documentation, a type of POMR, the acronym PIE stands for _____, _____, and _____.

 

ANS:

problem; intervention; evaluation

problem;evaluation; intervention

intervention; evaluation; problem

intervention; problem; evaluation

evaluation; problem; intervention

evaluation; intervention; problem

The acronym PIE stands for problem, intervention, and evaluation.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 162-163     OBJ:   3

TOP:   PIE Documentation                        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Examine this goal statement: Patient will walk in the hall unassisted. The two missing components for a correctly stated goal in this example are the descriptors for _____ and _____.

 

ANS:

frequency; time duration

time duration, frequency

The example lacks the criteria of frequency and time duration.

 

DIF:    Cognitive Level: Application          REF:   p. 160            OBJ:   1

TOP:   Goal Statements                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A nurse who exhibits an open minded, professionally curious, mature, and self-confident approach to care would be considered a(n) _____.

 

ANS:

critical thinker

Curiosity, systematic, analytic, open minded, self-confident, mature, and truth seeking are characteristics of a critical thinker.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 163            OBJ:   5

TOP:   Critical Thinking                             KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

Chapter 36: Cardiac Disorders

Linton: Introduction to Medical-Surgical Nursing, 6th Edition

 

MULTIPLE CHOICE

 

  1. A nurse performs an apical-radial pulse evaluation, with the result of 100/88. What is the pulse deficit?
a. 12
b. 24
c. 76
d. 88

 

 

ANS:  A

To detect an apical-radial pulse deficit, the rates should be counted simultaneously and compared for differences. If a difference exists between the apical rate and the radial rate, then a pulse deficit is present. For example, in atrial fibrillation, a pulse deficit exists.

 

DIF:    Cognitive Level: Analysis               REF:   p. 687            OBJ:   8

TOP:   Vital Sign Assessment: Pulse Deficit

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. What is increased in hypertension that in turn causes an increase in the work of the heart?
a. Preload
b. Stroke volume
c. Contractility
d. Afterload

 

 

ANS:  D

An increase blood pressure creates an increase in afterload because the heart must work harder to push the blood out of the left ventricle into the circulating volume.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 685-686     OBJ:   7

TOP:   Hypertension Effect on Afterload  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. Which heart sound should the nurse record as normal?
a. Ventricular gallop in a 20-year-old patient
b. Atrial gallop in a 25-year-old patient
c. Friction rub in a 45-year-old patient
d. Medium diastolic murmur in a 50-year-old patient

 

 

ANS:  A

Ventricular gallops are considered normal in individuals younger than 30 years of age. All other options are pathologic abnormalities.

 

DIF:    Cognitive Level: Application          REF:   p. 688            OBJ:   7

TOP:   Heart Sound Assessment                KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A 49-year-old patient has multiple risk factors for coronary artery disease. Which risk factor is considered modifiable?
a. Family history
b. Age
c. Smoking
d. Male gender

 

 

ANS:  C

Smoking, a high-fat diet, hypertension, sedentary lifestyle, and stress are considered modifiable risk factors.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 708            OBJ:   7

TOP:   Coronary Artery Disease Risk Factors

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A patient asks what a transesophageal echocardiogram (TEE) is and what it is expected to do? What is the best explanation by the nurse?
a. Measures conductivity
b. Records the force of contraction
c. Evaluates the efficiency of the valves
d. Checks the volume of the preload

 

 

ANS:  C

TEE evaluates the efficiency of the valves.

 

DIF:    Cognitive Level: Application          REF:   p. 689            OBJ:   6

TOP:   TEE                KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A nurse records the finding of a normal sinus rhythm (NSR) when the P, Q, R, S, and T are all present in the electrocardiographic complex. What additional information should the nurse document?
a. Rate of 82 seconds
b. PR interval of 0.36 second
c. QRS complex of 0.16 second
d. Inverted T

 

 

ANS:  A

NSR requires the presence of P, Q, R, S, and T waves, in that order, and all pointing in the same direction, with a rate of 60 to 100 seconds. Normal intervals are a PR interval of 0.12 to 0.20 seconds and a QRS complex less than 0.10 second.

 

DIF:    Cognitive Level: Application          REF:   p. 730-731     OBJ:   5

TOP:   Normal Sinus Rhythm                    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A nurse should anticipate that a patient taking Vasotec, an angiotensin-converting enzyme (ACE) inhibitor, should have which positive outcome to this drug?
a. Increased fluid retention
b. Decreased blood pressure
c. Decreased urine output
d. Increased appetite

 

 

ANS:  B

ACE inhibitors suppress the excretion of angiotensin, which lowers the blood pressure, reduces fluid retention, and leads to increased urine output.

 

DIF:    Cognitive Level: Application          REF:   p. 696            OBJ:   6

TOP:   ACE Inhibitors                               KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. A 29-year-old patient is to receive cardioversion for a dysrhythmia. What should the nurse instruct the patient to expect?
a. Administration of a short-acting sedative
b. Digoxin dose to be taken as scheduled
c. Procedure to be completely safe
d. Pacemaker spikes to be carefully monitored

 

 

ANS:  A

A cardioversion has risks, such as ventricular fibrillation. Emergency equipment should be available. The digoxin dose is held before a cardioversion, and the patient is given a short-acting sedative such as Versed or Valium, which will require recovery. The electrocardiogram R wave is synchronized via the computer, and no pacemaker is involved.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 705            OBJ:   6 | 7

TOP:   Cardioversion                                           KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A 68-year-old patient is scheduled for open heart surgery in the morning and is crying. What is the most appropriate response by the nurse?
a. “Everything will go great! Dr. C. is the best!”
b. “I know how you feel, so do not cry.”
c. “Tell me what concerns you the most.”
d. “I will call the physician for a sedative. You are too upset.”

 

 

ANS:  C

Therapeutic implementations identify and acknowledge feelings. Do not assume that you know how the patient feels and do not give false assurances.

 

DIF:    Cognitive Level: Application          REF:   p. 707            OBJ:   7 | 9

TOP:   Open Heart Surgery                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. What do fibrous plaques of atherosclerosis serve as when they are laid down in the vessels?
a. Stent to keep the vessel open
b. Trap to which other substances adhere
c. Threat to the integrity of the vessel wall
d. Embolus

 

 

ANS:  B

The plaque surface acts as a trap to which fibrous plaques can adhere, causing more narrowing of the vessel. The enlarging plaque can become a thrombus but not an embolus because emboli are usually considered to be traveling aggregations that lodge in a small arteriole.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 709            OBJ:   7

TOP:   Atherosclerosis                               KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A patient with an irregular sinoatrial (SA) node conduction has a permanent pacemaker with the code AAIOO and is now going home. The patient asks, “What happens when my real SA node fires on its own?” How should the nurse respond regarding what the pacemaker should do?
a. Not fire
b. Fire only the ventricles
c. Change the rate of firing
d. Fire both the atria and the ventricles.

 

 

ANS:  A

The code is A (chamber-paced) atria, A (sense impulse) atria only, I (inhibit) inhibit firing from the pacemaker, O (rate modification) no rate modification, and O (multichamber) no other chambers to be stimulated by the pacemaker. If the SA fires on its own, the pacemaker does nothing until it fails to sense an impulse.

 

DIF:    Cognitive Level: Application          REF:   p. 615            OBJ:   7 | 9

TOP:   Permanent Pacemaker Care            KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A patient with angina pectoris complains of chest pain at rest and needs to take three nitroglycerin (NTG) pills to relieve the pain. Of what should the nurse assess this as a major symptom?
a. Stable angina
b. Unstable angina
c. Full-blown acute myocardial infarction (MI)
d. Pulmonary embolus

 

 

ANS:  B

A patient with angina who has pain at rest that is not relieved with one NTG pill is considered to have unstable angina, a precursor to an acute MI.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 688            OBJ:   7

TOP:   Unstable Angina                             KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A nurse explains that cardiac rehabilitation lasts from the end of acute care to the return to home and beyond. What does this service include?
a. One-on-one individualized care
b. Focus on the patient rather than the family
c. Telemetry-monitored exercise
d. Rejection from the program for noncompliance

 

 

ANS:  C

Cardiac rehabilitation programs are supervised by a team of experts who arrange for telemetry-supervised exercise and other modalities, such as diet and medical protocol management. The focus is on the family, as well as the patient. Although some patients reject the program, they are rarely rejected by the rehabilitation center.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 727            OBJ:   7

TOP:   Cardiac Rehabilitation                    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. On auscultation, a nurse detects a heart murmur. What should the nurse know that a heart murmur indicates?
a. Valves that do not close correctly
b. Pericardium that is inflamed
c. Decrease in pacemaker cells
d. Loud ventricular gallop

 

 

ANS:  A

Heart murmurs indicate turbulent blood flow and can be caused by valves that are stiff and do not shut correctly; consequently, blood flows back into the chamber.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 688            OBJ:   7

TOP:   Heart Murmur                                           KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. What is an important teaching point for a patient with mitral stenosis?
a. Obtain a place on the heart transplant list.
b. Balance activity with oxygen supply.
c. Increase daily fluid intake to over 2000 mL.
d. Have an annual electrocardiogram.

 

 

ANS:  B

Patients with mitral stenosis need to balance their activity with their oxygen supply and avoid overhydration.

 

DIF:    Cognitive Level: Application          REF:   p. 727            OBJ:   7

TOP:   Mitral Stenosis                                KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A physician has ordered continuous pulse oximetry. What should the nurse explain to the patient about this procedure?
a. Involves a single prick
b. Measures the amount of oxygen in the blood
c. Is applied to the wrist
d. Identifies damaged cells in the myocardium

 

 

ANS:  B

Pulse oximetry measures arterial oxygen saturation noninvasively by attaching a clip to a digit, an ear, or a nose.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 694            OBJ:   6

TOP:   Pulse Oximetry                               KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A stress test is scheduled for a 41-year-old patient. What action should the nurse implement to prepare the patient for the examination?
a. Have the patient sign a consent form.
b. Give the patient a special heart diet.
c. Prepare the patient for sedation.
d. Remove all metal objects.

 

 

ANS:  A

A stress test is a noninvasive test that consists of a patient walking on a treadmill while an electrocardiogram records the activity. A consent form is required.

 

DIF:    Cognitive Level: Application          REF:   p. 692            OBJ:   6

TOP:   Stress Test      KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. What action should a nurse expect to implement when a patient returns from a cardiac catheterization?
a. Ambulate the patient in the hall.
b. Check the puncture site.
c. Monitor the gag reflex.
d. Remove the gel from all sites on the skin.

 

 

ANS:  B

Cardiac catheterizations are invasive procedures during which a catheter is threaded through an artery. Postprocedure care requires bedrest and monitoring the puncture site.

 

DIF:    Cognitive Level: Application          REF:   p. 690            OBJ:   6

TOP:   Cardiac Catheterization                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A nurse assesses an inverted T wave on the ECG of a patient who had an acute MI two days earlier. How should the nurse interpret this finding?
a. Normal recovery
b. New MI
c. Abnormal wave form
d. Congestive heart failure

 

 

ANS:  C

The abnormal wave form of the inverted T wave is an indicator that tissue death has occurred in part of the cardiac wall. The cardiac wall now has no ability to conduct or to contract and sends that message to the ECG via the inverted T. The tissue will take 6 weeks to regenerate.

 

DIF:    Cognitive Level: Analysis               REF:   p. 711            OBJ:   8

TOP:   Significance of Inverted T Wave    KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. Laboratory tests are performed to identify damage to the heart muscle. Which test is elevated the earliest with heart damage?
a. Creatine phosphokinase-MB (CPK-MB)
b. Lactate dehydrogenase (LDH)
c. Lipid profile
d. Troponin

 

 

ANS:  D

Troponin is elevated within 3 to 6 hours and is often measured in the emergency department. CPK-MB is elevated in 12 to 24 hours. Three serial samples are drawn. The LDH increases with heart damage within 3 to 6 days. The lipid profile is not elevated with heart damage.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 690 | p. 712

OBJ:   8                    TOP:   Cardiac Enzymes

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A patient is scheduled for a heart catheterization. What action should the nurse implement in preparation for this examination?
a. Ask the patient about allergies to seafood or iodine.
b. Remove all metal objects.
c. Give the patient a special heart diet.
d. Test arterial blood gases (ABGs).

 

 

ANS:  A

The dye injected during the cardiac catheterization is iodine based. An allergy to seafood is correlated with a reaction to this dye as well.

 

DIF:    Cognitive Level: Application          REF:   p. 693            OBJ:   5

TOP:   Cardiac Catheterization                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. A patient has had atropine sulfate that has been administered intravenously to treat a dysrhythmia. What should the nurse assess this patient for after administration?
a. Weight gain
b. Tachycardia
c. Muscle twitching
d. Incontinence of urine

 

 

ANS:  B

Atropine increases the heart rate. The nurse should watch for tachycardia, which increases the workload of the heart. This medication causes urinary retention.

 

DIF:    Cognitive Level: Application          REF:   p. 701            OBJ:   7

TOP:   Drugs for Dysrhythmias                 KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. A dopamine infusion is being administered to a patient with shock. For what should the nurse be alert?
a. Sharp spike in blood pressure
b. Tremor of the hands
c. Increasing urinary output
d. Hyperirritability of the patient

 

 

ANS:  A

Dopamine has a direct effect by elevating the blood pressure. The criterion is to titrate to the target blood pressure. Urinary output should also be monitored for a decreased amount because a heightened blood pressure may slow urine filtration and reduce urine output.

 

DIF:    Cognitive Level: Application          REF:   p. 701            OBJ:   7

TOP:   Dopamine      KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. A patient with atrial fibrillation is prescribed amiodarone for the dysrhythmia. Which potential adverse reaction should the nurse report?
a. Ataxia
b. Decreasing pulse rate
c. Decreasing blood pressure
d. Increase in cardiac output

 

 

ANS:  A

The drug amiodarone is meant to quiet atrial activity and modify rapid pulse rate, high blood pressure, and decreased cardiac output caused by the dysrhythmia. The drug interferes with the thyroid and causes an ataxic gait and trembling of hands as adverse effects.

 

DIF:    Cognitive Level: Application          REF:   p. 699            OBJ:   7

TOP:   Atrial Fibrillation with Amiodarone

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. A medication, simvastatin (Zocor), is administered to lower a patient’s cholesterol level. Follow-up lipid levels are reviewed by the nurse. Which level indicates the desired therapeutic range?
a. High-density lipoprotein (HDL), 29 mg/dL; low-density lipoprotein (LDL), 160 mg/dL
b. HDL, 38 mg/dL; LDL, 120 mg/dL
c. HDL, 56 mg/dL; LDL, 106 mg/dL
d. HDL, 42 mg/dL; LDL, 98 mg/dL

 

 

ANS:  D

The reading that has both an HDL level above 40 mg/dL and an LDL level below 100 mg/dL is in the therapeutic target range.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 695            OBJ:   7

TOP:   Drug Therapy                                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. What information should a nurse include in a patient’s discharge instruction after an acute myocardial infarction (MI)?
a. Cautions about the use of morphine
b. Detailed symptoms that indicate impending MI
c. Written instructions on diet and follow-up appointments
d. High-energy exercise program directions

 

 

ANS:  C

The patient needs written instructions for diet, follow-up appointments, and exercise protocols. Giving detailed information about symptoms is not necessary other than to remind the patient about reporting chest pain and shortness of breath. A high-energy exercise program is not appropriate. Morphine is not part of the home care after an MI.

 

DIF:    Cognitive Level: Application          REF:   p. 716            OBJ:   7

TOP:   Myocardial Infarction                               KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A patient with acute congestive heart failure has jugular vein distention, crackles bilaterally, and dyspnea. Which nursing diagnosis should have the highest priority?
a. Activity intolerance
b. Excess fluid volume
c. Anxiety
d. Ineffective coping

 

 

ANS:  B

Fluid volume excess increases the workload of the heart and interferes with breathing.

 

DIF:    Cognitive Level: Application          REF:   p. 687 | p. 720

OBJ:   7                    TOP:   Congestive Heart Failure

KEY:  Nursing Process Step: Nursing Diagnosis

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

A nurse is assessing the cardiac complex above. What pattern should the nurse recognize in this rhythm strip?

a. NSR
b. Premature ventricular contractions (PVCs)
c. Ventricular tachycardia (VT)
d. AF

 

 

ANS:  A

This pattern is NSR because it has one P wave for every QRS and one T wave.

 

DIF:    Cognitive Level: Analysis               REF:   p. 731            OBJ:   7

TOP:   Recognition of NSR                       KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A diuretic medication, furosemide (Lasix), is being administered for congestive heart failure. Which assessment is not an anticipated consequence of the therapy?
a. Increased urinary output
b. Weight loss
c. Thirst
d. Muscle weakness

 

 

ANS:  D

Increased urinary output, weight loss, and thirst are all anticipated consequences of the therapy. Muscle weakness is a sign of hypokalemia.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 696            OBJ:   7

TOP:   Diuretic Therapy                            KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. A patient is receiving digoxin 0.25 mg/day. What should the nurse do prior to administering this medication?
a. Count an apical pulse for 15 seconds.
b. Hold the dose if the apical rate is 57 beats/min.
c. Give the dose if the apical rate is 59 beats/min.
d. Double the dose if the rate is 62 beats/min.

 

 

ANS:  B

The dose should be held if the apical rate is less than 60 beats/min for 1 minute.

 

DIF:    Cognitive Level: Application          REF:   p. 679            OBJ:   7

TOP:   Drug Therapy                                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. A 46-year-old patient is receiving propranolol (Inderal), a nonselective beta-adrenergic blocker, for a heart condition. What patient teaching is most appropriate?
a. Sit or lie down when taking the drug.
b. Limit caffeine intake.
c. Double the dose if symptoms occur.
d. Never stop taking the drug abruptly.

 

 

ANS:  D

Beta-blockers should never be stopped abruptly because they can cause angina or MI. Patients are gradually weaned off these medications.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 698            OBJ:   7

TOP:   Drug Therapy                                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. Which assessment should be immediately addressed in a patient on lidocaine?
a. Slowed ventricular rate
b. Occasional PVCs
c. Increase in temperature to 102° F
d. Nausea and vomiting

 

 

ANS:  C

A temperature that goes up drastically indicates an adverse reaction to lidocaine, malignant hyperthermia. The slowed ventricular rate, even with occasional PVCs, is an expected outcome of lidocaine infusion. Nausea and vomiting are adverse effects.

 

DIF:    Cognitive Level: Application          REF:   p. 699            OBJ:   7

TOP:   Drug Therapy                                 KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

How should a nurse interpret the arrhythmia in the above strip?

a. NSR
b. PVC
c. VT
d. AF

 

 

ANS:  B

This is an arrhythmia of a PVC with an extra premature QRS complex (inverted) before the P wave.

 

DIF:    Cognitive Level: Analysis               REF:   p. 732            OBJ:   7

TOP:   Recognition of PVC                       KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A nurse records a “1” for the pulse quality of the pedal pulse. What interpretation is correct regarding the pulse?
a. Absent
b. Normal
c. Thready
d. Forceful

 

 

ANS:  C

A “1” in a pulse evaluation indicates a thready pulse that is easily obliterated by pressure.

 

DIF:    Cognitive Level: Application          REF:   p. 687            OBJ:   8

TOP:   Pulse Quality                                  KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

MULTIPLE RESPONSE

 

  1. Which factors affect stroke volume? (Select all that apply.)
a. Contractility
b. Climate
c. Age
d. Preload
e. Afterload

 

 

ANS:  A, D, E

Stroke volume is dependent on contractility, preload, and afterload. Age may affect all three, but the stroke volume, regardless of age, is dependent on these three factors.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 685            OBJ:   2

TOP:   Stroke Volume                               KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. Which age-related changes in the heart should a nurse take into consideration? (Select all that apply.)
a. Decrease in contractility
b. Thickened valves
c. Stiffened valves
d. Decreased SA node cells
e. Increased nerve fibers in ventricles

 

 

ANS:  A, B, C, D

Aging thickens and stiffens the valves and reduces the cells in the SA node. Age decreases the nerve fibers in the ventricles.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 686            OBJ:   9

TOP:   Age-Related Cardiac Changes        KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. What actions should a nurse implement to decrease the workload of the heart in a patient with acute congestive failure? (Select all that apply.)
a. Eliminate unnecessary activities.
b. Direct the patient in active range-of-motion exercises.
c. Help the patient change positions every 2 hours.
d. Assist the patient to ambulate to the bathroom.
e. Give a partial bed bath rather than full bed bath.

 

 

ANS:  A, C, E

To minimize the workload of the heart, the nurse would adjust nursing care to eliminate all unnecessary activities, assist in position changes, and give a minimal bath. Ambulation and active range-of-motion exercises are unnecessary activities at this time.

 

DIF:    Cognitive Level: Application          REF:   p. 720            OBJ:   7

TOP:   Nursing Care of Congestive Failure

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A nurse urges a 50-year-old overweight executive who had a myocardial infarction (MI) 3 months earlier to take up some conditioning exercises for 30 minutes a day. What rationale supports this suggestion? (Select all that apply.)
a. Lose weight.
b. Improve function of the left ventricle.
c. Decrease arterial stiffening.
d. Decrease cholesterol levels.
e. Improve cardiac dysrhythmia.

 

 

ANS:  A, B, C, D

Conditioning exercises performed daily for 30 minutes can reduce weight, improve the cardiac output of the left ventricle, decrease arterial stiffening, and decrease LDLs. Exercise does not affect dysrhythmias.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 715-716     OBJ:   7

TOP:   Effects of Conditioning Exercises  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

COMPLETION

 

  1. At rest, the cardiac cells in the myocardium are electrically polarized, with the inside of the cell being more _____ than the outside of the cell.

 

ANS:

negative

When the heart is at rest, the inside of the cell is negatively charged.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 685            OBJ:   3

TOP:   Polarization of Myocardium           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

OTHER

 

  1. A nurse uses a picture to demonstrate the conduction pathway through the chambers of the heart. (Arrange the following options in the correct sequence. Separate letters by a comma and space as follows: A, B, C, D.)
  2. The atria contract.
  3. Conduction occurs through the bundle branches.
  4. The AV node fires.
  5. The Purkinje fibers conduct.
  6. The SA node fires.
  7. The ventricles contract.

 

ANS:

E, A, C, B, D, F

The conduction pathway begins in the SA node, travels down the atrial wall, depolarizing the atria, to the AV node, bundle branches, and Purkinje fibers, contracting the ventricles.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 684-685     OBJ:   4

TOP:   Conduction Pathway for Cardiac Contraction

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

Chapter 56: Psychiatric Disorders

Linton: Introduction to Medical-Surgical Nursing, 6th Edition

 

MULTIPLE CHOICE

 

  1. A patient is given anxiolytic medications for a mental disorder. What type of approach is this considered?
a. Analytical
b. Interpersonal
c. Biologic
d. Psychoanalytic

 

 

ANS:  C

The biologic approach attempts to manage the physiologic effects of mental illness using medications.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 1283          OBJ:   2

TOP:   Psychiatric Disorders                                KEY:              Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A patient states that he feels angry at work for no reason and often yells at his coworkers. The therapist asks the patient to describe events and then tells the patient to try different strategies to cope with these angry outbursts. What type of approach is this considered?
a. Biologic
b. Analytical
c. Cognitive or behavioral
d. Interpersonal

 

 

ANS:  D

The interpersonal approach helps the patient develop new coping skills.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 1284          OBJ:   2

TOP:   Psychiatric Disorders                                KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity: Psychosocial Adaptation

 

  1. What is the best action for the nurse to implement to effectively listen therapeutically to a patient?
a. Concentrate on the patient and not think of responses to the patient while he or she is speaking.
b. Determine the cause of the patient’s problem while the patient is speaking.
c. Ask the patient why he thinks he feels the way he does.
d. Tell the patient that you have had similar experiences.

 

 

ANS:  A

To listen therapeutically, the nurse needs to concentrate on the patient and refrain from making up responses to the patient while he is speaking.

 

DIF:    Cognitive Level: Application          REF:   p. 1284          OBJ:   1

TOP:   Establishing Therapeutic Relationships

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A nurse speaking to a patient who is depressed says, “So what you are saying is that you are feeling very sad today.” What is this considered?
a. Listening
b. Sharing observations
c. Clarifying
d. Being available

 

 

ANS:  C

By reflecting the meaning of the patient’s statement, the nurse is using clarification. This technique validates that the therapist understands what the patient is saying, and it provides validation for the patient.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 1284          OBJ:   2

TOP:   Establishing Therapeutic Relationships

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity: Psychosocial Adaptation

 

  1. When performing a mental status examination, a nurse notes that the patient keeps repeating, “I didn’t do it. I didn’t do it. I didn’t do it.” This response would be an example of which one of the components of the mental status examination?
a. Appearance
b. Mood and affect
c. Thought content
d. Memory and attention

 

 

ANS:  C

Repetitive statements and thoughts are considered to be obsessive. This would be an element of the thought content component of the mental status examination.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 1285          OBJ:   3

TOP:   Mental Status Examination             KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity: Psychosocial Adaptation

 

  1. A patient says, “I just don’t think I can keep going on. I just want it all to end.” The nurse assesses that this patient has suicidal ideation. What is the nurse’s best response?
a. “Do you have any thoughts of harming yourself?”
b. “Have you felt like this before?”
c. “You are just depressed. When you feel better, you won’t think that way.”
d. “We will keep you safe here.”

 

 

ANS:  A

The best response to a patient who may have suicidal ideation is to ask a simple direct question to determine the patient’s true intent. Having done that, this should be reported at once. All suicidal threats, even mild ones, should be reported and taken seriously.

 

DIF:    Cognitive Level: Application          REF:   p. 1286          OBJ:   3

TOP:   Mental Status Examination             KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity: Psychosocial Adaptation

 

  1. What should a nurse suspect a patient diagnosis might be when the patient states, “I often feel restless, have a tight sensation in my chest, and have an increased heart rate at times”?
a. Anxiety disorder
b. Panic disorder
c. Agoraphobia
d. Obsessive-compulsive disorder

 

 

ANS:  A

The patient is reporting symptoms that reflect signs of an anxiety disorder.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 1287          OBJ:   6

TOP:   Anxiety Disorders                          KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. A group of nursing students are taking their first major examination. What should the nursing instructor expect the students might experience?
a. Posttraumatic stress disorder
b. Panic disorder
c. Mild anxiety
d. Moderate anxiety

 

 

ANS:  C

The students are usually experiencing mild anxiety, which can be beneficial as a motivator.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 1287          OBJ:   6

TOP:   Anxiety Disorders                          KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Psychosocial Integrity: Psychosocial Adaptation

 

  1. A patient is admitted with posttraumatic stress disorder (PTSD) says he had a very stressful experience when in high school and has never really recovered. What is the most appropriate nursing action?
a. Encourage the patient to talk about what caused the traumatic event.
b. Guide the patient in relaxation techniques to distract him when flashbacks occur.
c. Provide sleeping medication so that he can sleep at night.
d. Allow the patient to talk about his condition as often as he likes.

 

 

ANS:  B

Patients with PTSD should not be encouraged to talk about the traumatic event. The patient should learn relaxation techniques to distract themselves when anxiety symptoms begin. Sedation does not address the problem of anxiety.

 

DIF:    Cognitive Level: Application          REF:   p. 1289          OBJ:   6

TOP:   Posttraumatic Stress Disorder         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity: Psychosocial Adaptation

 

  1. A patient admitted with a conversion disorder after an automobile accident insists he is paralyzed, although no physical cause for his paraplegia can be found. What is the best nursing response when the patient asks the nurse to push him to his room?
a. “There is nothing wrong with your arms. Roll yourself to your room.”
b. “I will help you to walk to your room. I know you can walk.”
c. “Let me lift the foot rests so you can move your chair with your feet.”
d. “OK. I am going that way myself.”

 

 

ANS:  D

The patient is experiencing dysfunction without a discernible cause, but this dysfunction is very real to him. The less attention brought to his coping mechanism, the better.

 

DIF:    Cognitive Level: Application          REF:   p. 1289 | p. 1291

OBJ:   6                    TOP:   Somatoform Disorders

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity: Psychosocial Adaptation

 

  1. Which combination of medications could be used to treat an anxiety disorder?
a. Librium and Xanax
b. Effexor and Ativan
c. Effexor and Haldol
d. Klonopin and Valium

 

 

ANS:  B

A combination of an antidepressant and anxiolytic medication is recommended as the appropriate drug therapy for the patient with an anxiety disorder. Xanax, Librium, Ativan, Valium, and Klonopin are all anxiolytic medications. Haldol is a neuroleptic medication, and Effexor is an antidepressant.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 1290          OBJ:   4

TOP:   Drug-Related Responses                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. Which nursing diagnosis is appropriate for all patients with an anxiety, a somatoform, or a dissociative disorder?
a. Altered nutrition, less than body requirements
b. Disturbed body image
c. Ineffective denial
d. Ineffective coping

 

 

ANS:  D

Ineffective coping is appropriate for all three disorders. Ineffective coping is the underlying psychopathologic process of these anxiety disorders.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 1291          OBJ:   7

TOP:   Nursing Care of the Patient with an Anxiety Disorder

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. A patient who went away to college in September returns in October, thinking that he is a drummer in a popular rock band. What is this most likely a manifestation of?
a. Dissociative disorder
b. Conversion disorder
c. Schizophrenia
d. Amnesia

 

 

ANS:  C

Schizophrenia occurs in adolescence or early adulthood. The patient experiences delusions that are characteristic of schizophrenia in a classic stress situation, which may have been the precipitating event that caused the thought disorder.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 1291          OBJ:   6

TOP:   Schizophrenia                                           KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient is receiving large doses of chlorpromazine (Thorazine) and begins to exhibit extrapyramidal signs of involuntary muscle movement. Which classification of drugs should the nurse anticipate will be added to the patient’s protocol?
a. Antiparkinsonian
b. Antihypertensive
c. Anticonvulsant
d. Antiemetic

 

 

ANS:  A

Antiparkinsonian drugs will control the muscle movement and drooling that are the major signs of neuroleptic toxicity.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 1292          OBJ:   7

TOP:   Neuroleptic Medications                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. A long-time patient with schizophrenia in the inpatient unit has developed involuntary movements of his tongue. What has this patient developed?
a. Acute dystonic reaction
b. Tardive dyskinesia
c. Neuroleptic malignant syndrome
d. Laryngospasm

 

 

ANS:  B

Tardive dyskinesia is a side effect of continued use of neuroleptic medications to control schizophrenia.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 1292          OBJ:   4

TOP:   Schizophrenia                                           KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. Which is not considered as a probable cause of mood disorders?
a. Loss of significant others
b. Learned helplessness
c. Neurotransmitter dysregulation
d. Traumatic event in childhood

 

 

ANS:  D

A traumatic event in childhood could, most likely, cause PTSD. All other options are causes of mood disorders.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 1295          OBJ:   5

TOP:   Mood Disorders                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. A patient with bipolar disorder is being treated with tricyclic medications. What should the nurse inform the patient to expect when teaching information concerning side effects?
a. Orthostatic hypotension
b. Hypercholesterolemia
c. Fatigue
d. Blurred vision

 

 

ANS:  A

Orthostatic hypotension and urinary retention are side effects of tricyclic antidepressants. These drugs are commonly used to treat the depressant effects of bipolar disorders.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 1295          OBJ:   7

TOP:   Drug Treatment                              KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. A patient with schizophrenia has undergone eight electroconvulsive therapy treatments (ECTs) in the past 2 weeks. The daughter is upset that her parent is lethargic, confused, and does not recognize her. What knowledge should the nurse consider when preparing to respond?
a. The combination of ECTs and neuroleptic medications can make a patient drowsy.
b. These reactions indicate a drug overdose.
c. Many patients with schizophrenia punish their families by pretending not to know them.
d. A temporary memory loss is common after several ECTs.

 

 

ANS:  D

When a patient has had several ECTs, an expected brief period of confusion and temporary memory loss may result. This effect dissipates in a short period.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 1298          OBJ:   6

TOP:   Electroconvulsive Therapy             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A patient is hyperactive with mania and has a nursing diagnosis of “Nutrition, altered, less than body requirements, related to hyperactivity,” What implementation is most appropriate when considering this diagnosis?
a. Offer nutritious finger foods and high-protein milk shakes to eat on the go.
b. Spoon-feed the patient while the patient is seated at the table.
c. Arrange for one large meal at noon to be eaten in the company of others.
d. Limit fluid intake to make the patient hungry at mealtime.

 

 

ANS:  A

Patients with mania are on the go. Nutritious foods that can be eaten while the patient is moving around will meet their dietary needs. The patient’s short attention span prevents him or her from sitting long enough to eat or to be fed by spoon. Limiting fluids is contraindicated for the patient who is hyperactive.

 

DIF:    Cognitive Level: Application          REF:   p. 1300          OBJ:   6

TOP:   Manic Behavior                              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A patient is brought in from the emergency department after telling the physician that he is a relative of the president of the United States. He says that he should not be detained because he has important business to attend to that involves national security. He is dressed in a bright coat with plaid pants and gets very angry when you try to question him. What is this patient is experiencing?
a. Panic attack
b. Hyperactive episode
c. Extrapyramidal effect
d. Manic episode

 

 

ANS:  D

Inappropriate dress, self-aggrandizement, hyperactivity, and frustration are elements of a manic episode.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 1288          OBJ:   6

TOP:   Nursing Care of the Patient with Bipolar Disorder with Manic Episodes

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. While in the dayroom, one of the patients becomes very agitated and begins to threaten to harm the other patients and is directing violence at the other patients and staff. What is the most appropriate nursing implementation?
a. Decrease the stimuli and use restraints if all other measures fail.
b. Offer to call the physician and ask another staff member to call security.
c. Remove harmful objects and try to perform relaxation exercises with the patient.
d. Restrain the patient and do not allow him or her to eat or drink anything by mouth.

 

 

ANS:  A

Because the patient is threatening to harm others, decreasing stimuli will be helpful to decrease the behavior and, if everything else fails, restraints will be needed. Restraints should be applied according to current policy. Patients who are being restrained need to have frequent checks and their nutritional and elimination needs monitored.

 

DIF:    Cognitive Level: Application          REF:   p. 1300          OBJ:   7

TOP:   Nursing Implementations for Manic Episodes

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. Since the summer weather began, a patient taking lithium for manic episodes has been walking daily. What important instruction should the nurse provide to this patient?
a. Stay in the shade when walking.
b. Stop walking.
c. Maintain hydration.
d. Wear sunscreen.

 

 

ANS:  C

Lithium toxicity can occur if the patient becomes dehydrated. The therapeutic range of lithium is narrow; consequently, toxicity to this drug is common.

 

DIF:    Cognitive Level: Application          REF:   p. 1297          OBJ:   7

TOP:   Medications for Manic Episodes    KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. A patient who has a history of episodes of road rage thinks that she is a very good driver and does not understand why she keeps being told she is a poor driver. She is losing her license now, and she tells the nurse that she is feeling very unhappy and abandoned. She feels like she might hurt herself. The nurse realizes that the patient is exhibiting which personality disorder?
a. Narcissistic
b. Paranoid
c. Schizoid
d. Borderline

 

 

ANS:  D

Difficulty controlling anger and an unstable sense of self are elements of a borderline personality disorder.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 1301          OBJ:   6

TOP:   Personality Disorders                                KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity

 

  1. A coworker is noted to be very organized. However, you see that he is always making lists and citing the rules of the organization. He wants all his projects to be perfect and gets very upset when things happen that make him miss his deadlines. The coworker is exhibiting signs of which personality disorder?
a. Avoidant
b. Obsessive-compulsive
c. Histrionic
d. Dependent

 

 

ANS:  B

Patients who have a preoccupation with perfectionism, orderliness, and control have an obsessive-compulsive personality disorder. These patients may be anxious and attempt to maintain the perfectionism. The patient data in this question demonstrate the elements of obsessive-compulsive disorder.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 1286 | p. 1301

OBJ:   5                    TOP:   Personality Disorders

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. What is a common cause of delirium?
a. Overuse of steroids
b. Liver abnormalities
c. Parkinson disease
d. Neoplasms

 

 

ANS:  D

Neoplasms and Alzheimer disease are two causes of delirium. All of the other options are causes of dementia.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 1300          OBJ:   6

TOP:   Cognitive Disorders                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

MULTIPLE RESPONSE

 

  1. A nurse is assessing a patient with an acute stress disorder. What characteristics of this disorder should the nurse assess? (Select all that apply.)
a. Diminished awareness of surroundings
b. Derealization
c. Depersonalization
d. Amnesia
e. Irritability

 

 

ANS:  A, B, C, D

Individuals who have been overcome by an acute stress disorder exhibit diminished orientation, reality testing, and personal awareness, and they frequently experience amnesia. Irritability is not part of the syndrome.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 1289          OBJ:   4

TOP:   Acute Stress Disorder                                KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity: Psychosocial Adaptation

 

  1. A nursing instructor is explaining the difference between illusion and hallucination. Which examples provided by students in the class indicate an illusion? (Select all that apply.)
a. A car backfiring being perceived as gunfire
b. The television news being perceived as someone talking to you
c. Hearing God’s voice directing you to drive your car off the road
d. Seeing your dead spouse smile at you from a flower
e. A spot on the wall being perceived as a spider

 

 

ANS:  A, B, E

An illusion has an external stimulus that causes an erroneous translation. Anyone, even a person with intact sensorium, can have an illusion. An example of an illusion is seeing water on the highway, which is really only heat waves. A hallucination has no external stimulus. An example of a hallucination is a person with alcoholism seeing spiders crawling on the ceiling.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 1286          OBJ:   6

TOP:   Hallucinations versus Illusions       KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity: Psychosocial Adaptation

 

COMPLETION

 

  1. When a patient asks a nurse to touch him, the nurse asks why he needs this. The patient replies, “I just need to know that I am real.” The nurse assesses that response as a primary sign of _____.

 

ANS:

derealization

Derealization causes patients to feel that they have lost touch with themselves and feel that they are not real. Physical touch helps them reorient.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 1289          OBJ:   4

TOP:   Derealization                                  KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity: Psychosocial Adaptation

 

  1. When a nurse asks questions like, “What day is today?” or “What time is it now?” the nurse is testing the patient’s _____.

 

ANS:

sensorium orientation

The sensorium is also referred to as orientation. The sensorium orients the person to person, place, and time.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 1287          OBJ:   6

TOP:   Sensorium      KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity

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