Medical Surgical Nursing Concepts & Practice, 2nd Edition by Susan C. – Test Bank

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Medical Surgical Nursing Concepts & Practice, 2nd Edition by Susan C. – Test Bank

Chapter 02: Critical Thinking and Nursing Process

 

MULTIPLE CHOICE

 

  1. Basic to the ability to apply critical thinking, the nurse must have:
a. unshakable beliefs and values.
b. an open attitude.
c. the ability to disregard evidence inconsistent with set goals.
d. the ability to recognize the perfect solution.

 

 

ANS:  B

An open attitude not clouded by unshakable beliefs and values or preset goals allows the application of critical thinking. Acceptance that there may not be a perfect solution leaves the field open to new ideas.

 

DIF:    Cognitive Level: Comprehension   REF:   14-15             OBJ:   2 (theory)

TOP:   Factors Influencing Critical Thinking                              KEY:  Nursing Process Step: NA

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse explains that a fundamental basis for the nursing process is:
a. that basic needs must be met by the individual without assistance.
b. that patients and families appreciate an efficient health care system that functions without their input.
c. a focus on disease control.
d. that all persons have worth and dignity.

 

 

ANS:  D

The nursing process is based on the belief that all people have worth and dignity. Patient-centered care that is applied to all aspects of the patient’s health, and is not just disease oriented, is appreciated by the family and patient. Holistic care approach can support the patient to meet basic needs.

 

DIF:    Cognitive Level: Application          REF:   16                  OBJ:   5 (theory)

TOP:   Basic Beliefs Pertinent to the Nursing Process

KEY:  Nursing Process Step: Implementation

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

 

  1. Upon a patient’s admission to the facility, the nurse collects the following data: patient’s temperature is 100° F, oxygen saturation is 89%, frothy mucus is expectorated, and the patient’s chest feels tight. The nurse correctly identifies tightness in the chest as:
a. judgmental.
b. objective data.
c. subjective data.
d. drawing a conclusion.

 

 

ANS:  C

Subjective data is information given by the patient that cannot be measured otherwise. The other data are considered objective data. Objective data are pieces of information that can be measured by the examiner. The nurse should avoid making judgments or conclusions when obtaining data.

 

DIF:    Cognitive Level: Application          REF:   18                  OBJ:   2 (clinical)

TOP:   Assessment Data                            KEY:  Nursing Process Step: Planning

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

 

  1. The newly admitted patient is describing his recent symptoms to the nurse. The nurse is aware that the source of this information is considered:
a. primary.
b. objective.
c. secondary.
d. complete.

 

 

ANS:  A

The patient is the primary source of information. Objective refers to a type of data obtained by the nurse that is measured or can be verified through assessment techniques, secondary information is obtained from relatives or significant others, and information is not necessarily complete when the patient is the source.

 

DIF:    Cognitive Level: Application          REF:   19                  OBJ:   2 (clinical)

TOP:   Sources of Information                  KEY:  Nursing Process Step: Assessment

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

 

  1. The nurse performing an intake interview on a new resident to the long-term care facility detects the odor of acetone from the patient’s breath. The assessment is done by:
a. inspection.
b. observation.
c. auscultation.
d. olfaction.

 

 

ANS:  D

Olfaction is an assessment method of smells. Inspection and observation use the sense of vision. Auscultation refers to use of the sense of hearing.

 

DIF:    Cognitive Level: Comprehension   REF:   20                  OBJ:   3 (clinical)

TOP:   Olfaction        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse’s assessment reveals edema of both feet and ankles. The best documentation of these findings is:
a. pitting edema present in both feet and ankles.
b. edema in both feet and ankles approximately 4 mm deep.
c. 4 mm pitting edema quickly resolving.
d. bilateral pitting edema in feet and ankles: 4 mm deep resolving in 3 seconds.

 

 

ANS:  D

Edema should be recorded as to location, depth of pitting, and time for resolution.

 

DIF:    Cognitive Level: Application          REF:   20                  OBJ:   3 (theory)

TOP:   Palpation        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. To assess skin turgor, the nurse would:
a. examine mucous membranes of the mouth.
b. compare limbs for similar color.
c. pinch skinfold on chest for tenting.
d. palpate ankles for evidence of pitting edema.

 

 

ANS:  C

Skin turgor can be assessed by tenting the skin on the chest and recording the speed at which the “tent” subsides.

 

DIF:    Cognitive Level: Comprehension   REF:   21                  OBJ:   3 (clinical)

TOP:   Practical Assessment                                 KEY:              Nursing Process Step: Assessment

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

 

  1. The nursing student demonstrates an understanding of the Health Insurance Portability and Accountability Act (HIPAA) by:
a. using the patient’s full name only on clinical assignments submitted to the instructor.
b. using the facility printer to copy lab reports on an assigned patient.
c. shredding any documents that the student has been using that contain identifying patient information before leaving the clinical facility.
d. asking the patient for permission to copy lab and diagnostic reports for educational purposes.

 

 

ANS:  C

HIPAA forbids any information used for educational purposes to have any identifying information; therefore, shredding documents would be appropriate. Full names on documents, printing copies of chart forms, and asking the patient for permission to copy forms would be violations of HIPAA regulations.

 

DIF:    Cognitive Level: Application          REF:   22                  OBJ:   1 (clinical)

TOP:   HIPAA           KEY:  Nursing Process Step: Implementation

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

 

  1. The diabetic patient who had blood drawn for an HbA1c level says, “I don’t know why they want to look at my hemoglobin.” The most helpful reply by the nurse would be:
a. “The test is to evaluate your present level of blood sugar.”
b. “The HbA1c provides information relative to blood sugar levels from the past 2 to 3 months.”
c. “Hemoglobin levels and blood sugar levels are closely related.”
d. “The HbA1c tells if you have type 1 or type 2 diabetes.”

 

 

ANS:  B

HbA1c evaluates the average blood glucose level for the last 2 to 3 months.

 

DIF:    Cognitive Level: Comprehension   REF:   24                  OBJ:   2 (clinical)

TOP:   Diagnostic Studies                          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The RN has chosen the nursing diagnosis of Risk for impaired skin integrity related to immobility. The correct goal/outcome statement for the diagnosis would be:
a. patient will sit in chair at bedside for 15 minutes after each meal.
b. nurse will assist patient to chair every shift.
c. nurse will assess skin and record condition every shift.
d. patient will change position frequently.

 

 

ANS:  A

The goal/outcome statement is directed at the etiology and should be patient oriented. The statement should be realistic and measurable and reflect what the patient will do.

 

DIF:    Cognitive Level: Application          REF:   26                  OBJ:   5 (clinical)

TOP:   Goals             KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse who has recently moved from Louisiana to Texas is uncertain about the LPN/LVN’s role in applying the nursing process. The most appropriate source for the nurse to consult is:
a. hospital policies.
b. the Texas State Board of Nursing.
c. rules and regulations of the Louisiana Nurse Practice Act.
d. the National Association of Practical Nurse Education and Service.

 

 

ANS:  B

Each state has different guidelines for areas of care planning, intravenous therapy, teaching, and delegation. The Texas State Board of Nursing is the most reliable source.

 

DIF:    Cognitive Level: Application          REF:   16                  OBJ:   6 (theory)

TOP:   Nursing Process                              KEY:  Nursing Process Step: NA

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

 

  1. The nurse adds a nursing order to the care plan related to a patient with a nursing diagnosis of Nutrition: less than body requirement related to nausea and vomiting. The statement that is a nursing order is:
a. medicate with an antiemetic before each meal.
b. offer crackers and iced drink before each meal.
c. change diet to clear liquids.
d. give nothing by mouth until nausea subsides.

 

 

ANS:  B

Offering crackers and iced drinks are within the scope of nursing; the other options would require a medical order to complete.

 

DIF:    Cognitive Level: Analysis               REF:   26                  OBJ:   6 (clinical)

TOP:   Nursing Orders                               KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. Because the evaluation of the nursing care plan reflects lack of progress toward the goal, the nurse will confer with the patient to plan a:
a. more accessible goal.
b. revision of interventions.
c. different nursing diagnosis.
d. new evaluation.

 

 

ANS:  B

When lack of progress to reach the goal is seen on evaluation, the interventions are reviewed and/or revised.

 

DIF:    Cognitive Level: Application          REF:   27                  OBJ:   2 (clinical)

TOP:   Evaluation      KEY:  Nursing Process Step: Planning

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

 

  1. During the intake interview, the nurse notices that, although the patient denies pain, he is grimacing and holding his hand over his stomach. The nurse’s best approach would be to:
a. examine the history closely for etiology of pain.
b. question the patient about having feelings of pain.
c. record that patient denies pain but seems to be having abdominal discomfort.
d. physically examine the patient’s abdomen.

 

 

ANS:  B

The nurse should try to resolve any incongruence between body language and verbal responses.

 

DIF:    Cognitive Level: Application          REF:   17-20             OBJ:   1 (clinical)

TOP:   Patient Interview                             KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. During the admission interview, when asked about pain, the patient responds, “No. I’m pretty wobbly.” Which action by the nurse would be most appropriate?
a. Ask, “Did you hear me? I asked you about pain.”
b. Say, “What do you mean ‘wobbly’?”
c. Record the patient denied pain.
d. Record the patient stated he was wobbly.

 

 

ANS:  B

The nurse should ask for clarification if unsure of what is meant by one of the patient’s responses.

 

DIF:    Cognitive Level: Application          REF:   17-20             OBJ:   1 (clinical)

TOP:   Patient Interview                             KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse writes an intervention for the goal: Patient will sleep for 5 hours uninterrupted each night. The best nursing intervention is:
a. medicate with sedative each night.
b. offer warm fluids frequently.
c. arrange for a large meal at supper.
d. discourage daytime napping.

 

 

ANS:  D

Discouraging daytime napping increases the probability of sleep. Giving medication is a collaborative intervention as it requires an order. Large meal and large fluid intakes may interrupt sleep.

 

DIF:    Cognitive Level: Analysis               REF:   26-27             OBJ:   2 (clinical)

TOP:   Nursing Intervention                       KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nursing team prioritizing the nursing diagnoses of an overweight hospital patient will select as the highest priority the nursing diagnosis of:
a. Risk for dehydration related to vomiting.
b. Activity intolerance related to shortness of breath.
c. Knowledge deficit related to weight reduction diet.
d. Altered self-image related to excessive weight.

 

 

ANS:  B

Activity intolerance is the highest priority as it has to do with activities that are essential to life. The second is Knowledge deficit related to weight reduction diet, followed by Altered self-image related to excessive weight, and the last is Risk for dehydration related to vomiting.

 

DIF:    Cognitive Level: Analysis               REF:   24-27             OBJ:   2 (clinical)

TOP:   Setting Priorities                              KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse explains that, in addition to the NANDA stem and etiology, the complete nursing diagnosis should include:
a. a time reference for meeting the need.
b. a designation of what the patient should do.
c. signs and symptoms of the problem assessed.
d. a specifically worded medical diagnosis.

 

 

ANS:  C

A complete nursing diagnosis must have a NANDA stem, etiology, and signs and symptoms (etiology) of the problem.

 

DIF:    Cognitive Level: Comprehension   REF:   24-25             OBJ:   7 (clinical)

TOP:   Nursing Diagnosis                          KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse explains to a patient that inclusion of potential problems in the nursing care plan:
a. alerts nursing staff to prevent potential complications.
b. reminds the family of potential problems.
c. broadens the assessment of the caregiver.
d. educates the patient to aspects of her health.

 

 

ANS:  A

Addressing potential problems prevents complications by early action rather than waiting for a problem to materialize.

 

DIF:    Cognitive Level: Application          REF:   24-25             OBJ:   7 (clinical)

TOP:   Potential Health Problems               KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. During the admission process, the nurse receives orders for the patient to have arterial blood gases (ABGs) drawn. Which finding from the patient’s history may cause concern?
a. Taking ginkgo biloba for the last 6 months
b. Having an increased hematocrit (Hct) level during the last physical exam
c. Being diabetic for 10 years
d. Having a decreased white blood cell (WBC) count

 

 

ANS:  A

Ginkgo biloba may lower the platelet count and cause bleeding. Therefore, the nurse would be concerned about arterial bleeding occurring following ABGs being drawn. Increased Hct, a history of diabetes, and a decreased WBC count would not pose any problems with drawing a sample for ABGs.

 

DIF:    Cognitive Level: Application          REF:   23                  OBJ:   2 (clinical)

TOP:   Alternative Medicine                                 KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. The LPN/LVN adheres to facility policy regarding core measures by performing which interventions during patient care?
a. Administering the ordered amount of insulin to a patient with type 1 diabetes
b. Performing a thorough patient assessment upon admission to the health care facility
c. Documenting accurately and at appropriate intervals in the patient’s record
d. Providing patient teaching regarding proper diet for the patient diagnosed with renal failure

 

 

ANS:  A

Core measures are interventions that are based on scientifically researched, evidenced-based standards of care and are used to treat the majority of patients with a specific illness which often develops complications. Insulin administration for diabetics is evidence-based researched practice. The remaining options are good practice but are not considered core measures.

 

DIF:    Cognitive Level: Analysis               REF:   17                  OBJ:   10 (clinical)

TOP:   Core Measures                                KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. The nurse is caring for a patient diagnosed with pneumonia. The patient has a BP 160/94, P 102, R 28, crackles in posterior lower lobes bilaterally, oxygen saturation 89%, and complains of shortness of breath upon exertion. The highest priority nursing diagnosis for this patient is:
a. Activity intolerance
b. Impaired gas exchange
c. Ineffective cardiopulmonary tissue perfusion
d. Self-care deficit: Bathing and hygiene

 

 

ANS:  B

While all nursing diagnoses may apply to this patient, Impaired gas exchange is the highest priority because this is the underlying problem for the other nursing diagnoses, as well as physiologically the highest priority.

 

DIF:    Cognitive Level: Application          REF:   24-27             OBJ:   2 (clinical)

TOP:   Nursing Diagnosis                          KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

MULTIPLE RESPONSE

 

  1. The nurse explains to the nursing student that the application of critical thinking to patient care involves: (Select all that apply.)
a. identification of a patient problem.
b. setting priorities.
c. concentrating on the patient rather than family needs.
d. use of logic and intuition.
e. expansion of thought beyond the obvious.

 

 

ANS:  A, B, D, E

Critical thinking as applied to nursing care requires setting priorities of patient problems and needs by using logic and intuition. Inclusion of the family in the care makes the approach family oriented. Critical thinking should go beyond the obvious.

 

DIF:    Cognitive Level: Comprehension   REF:   14-16             OBJ:   2 (theory)

TOP:   Critical Thinking                             KEY:  Nursing Process Step: Implementation

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

 

  1. The nurse demonstrates application of the nursing process by: (Select all that apply.)
a. performing a head-to-toe assessment.
b. updating the patient care plan on a weekly basis.
c. evaluating if patient goals have been met.
d. determining if nursing interventions need to be changed based on lack of patient progress toward meeting goals.
e. ensuring that all personnel caring for the patient are implementing the care plan and working toward the same goals.

 

 

ANS:  A, C, D, E

The nursing care plan should be updated as necessary, not just on a weekly basis. Concepts of the nursing process are demonstrated by performing orderly, logical head-to-toe assessments, as well as ongoing evaluation of patient goals and interventions to meet those goals.

 

DIF:    Cognitive Level: Comprehension   REF:   16                  OBJ:   1 (clinical)

TOP:   Nursing Process                              KEY:  Nursing Process Step: Implementation

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

 

  1. The nurse demonstrates knowledge of the National Patient Safety Goals by performing patient care that includes: (Select all that apply.)
a. identifying the patient prior to medication administration by asking the patient to state his or her name.
b. reporting any sentinel event to the facility’s quality assurance team.
c. assessing the patient’s heart rate prior to administration of digoxin.
d. performing hand hygiene prior to performing a patient assessment.
e. documenting the appropriate time of medication administration.

 

 

ANS:  C, D, E

Assessing the patient’s heart rate prior to administration of digoxin demonstrates knowledge of medication actions and prevention of adverse effects; hand hygiene is required before any patient care, including assessment; and documentation of the time of medication administration is necessary to prevent medication errors. To meet National Patient Safety Goals, the nurse must use at least two methods of patient identification prior to medication administration. Reporting a sentinel event is required but demonstrates that National Patient Safety Goals were not met.

 

DIF:    Cognitive Level: Application          REF:   17 | Box 2-3   OBJ:   9 (clinical)

TOP:   National Patient Safety Goals         KEY:  Nursing Process Step: Implementation

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

 

COMPLETION

 

  1. The nursing student demonstrates knowledge of the proper use of the ___________ when determining that it is safe to administer meperidine (Demerol) and promethazine (Phenergan) together.

 

ANS:

Medication Reconciliation Form

The Medication Reconciliation Form tracks all medications the patient is taking as prescribed by different physicians and can identify overdoses or drugs that are not compatible.

 

DIF:    Cognitive Level: Application          REF:   19-20             OBJ:   2 (clinical)

TOP:   Medication Reconciliation Form     KEY:  Nursing Process Step: Implementation

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

 

  1. Shortness of breath due to emphysema would be a major component of the _________ care plan.

 

ANS:

interdisciplinary

An interdisciplinary care plan involves all members of the health care team and is based on the medical diagnosis rather than a nursing diagnosis.

 

DIF:    Cognitive Level: Application          REF:   27                  OBJ:   2 (clinical)

TOP:   Interdisciplinary Care Plan             KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

MATCHING

 

Place the steps of the nursing process in their proper sequence.

a. Evaluation
b. Assessment
c. Implementation
d. Planning
e. Nursing diagnosis

 

 

  1. Step 1

 

  1. Step 2

 

  1. Step 3

 

  1. Step 4

 

  1. Step 5

 

  1. ANS:  B                    DIF:    Cognitive Level: Comprehension   REF:   17

OBJ:   7 (clinical)      TOP:   Applying the Nursing Process

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

 

  1. ANS:  E                    DIF:    Cognitive Level: Comprehension   REF:   17

OBJ:   7 (clinical)      TOP:   Applying the Nursing Process

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

 

  1. ANS:  D                    DIF:    Cognitive Level: Comprehension   REF:   17

OBJ:   7 (clinical)      TOP:   Applying the Nursing Process

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

 

  1. ANS:  C                    DIF:    Cognitive Level: Comprehension   REF:   17

OBJ:   7 (clinical)      TOP:   Applying the Nursing Process

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

 

  1. ANS:  A                    DIF:    Cognitive Level: Comprehension   REF:   17

OBJ:   7 (clinical)      TOP:   Applying the Nursing Process

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

 

Chapter 16: The Hematologic System

 

MULTIPLE CHOICE

 

  1. The stem cells in the marrow are stimulated to make blood cells by the erythropoietin- stimulating factor in the:
a. brain.
b. lung.
c. kidney.
d. liver.

 

 

ANS:  C

The kidney secrets the erythropoietin-stimulating factor to stimulate the stem cells to make blood cells.

 

DIF:    Cognitive Level: Comprehension   REF:   332                OBJ:   2 (theory)

TOP:   Erythropoiesis                                           KEY:              Nursing Process Step: NA

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. Red blood cells only live about _____ days.
a. 30
b. 90
c. 100
d. 120

 

 

ANS:  D

Red blood cells live approximately 120 days.

 

DIF:    Cognitive Level: Knowledge          REF:   332                OBJ:   1 (theory)

TOP:   Life of RBCs                                  KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse explains that, in the event of a massive hemorrhagic episode, the _____ contracts and adds blood to the circulating volume.
a. spleen
b. liver
c. pancreas
d. bone marrow

 

 

ANS:  A

The spleen has the ability to contract and add blood to the circulating volume in the event of massive hemorrhage.

 

DIF:    Cognitive Level: Comprehension   REF:   332                OBJ:   1 (clinical)

TOP:   Spleen            KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse evaluates the lab reports for the patients on the unit, and recognizes the report requiring the most immediate attention is for the patient with RBCs, _____ mil/mm3; WBCs, _____ mil/mm3; and Hb, _____ g/dL.
a. 4.2; 4500; 9.1
b. 5.9; 4500; 12.7
c. 6.0; 6000; 13.2
d. 7.6; 8000; 18.0

 

 

ANS:  A

The low RBCs and low hemoglobin suggests possible anemia or blood loss. The normal range for adults is red blood cell (RBC) count 4.2 to 6.2 mil/mm3 ; white blood cell (WBC) count: 4500 to 11,000/mm3; and hemoglobin (Hb): females, 12.0 to 16.7 g/dL; males, 13.0 to 18.0 g/dL.

 

DIF:    Cognitive Level: Analysis               REF:   337 | Table 16-1

OBJ:   5 (theory)       TOP:   Blood Counts

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

 

  1. The nurse notes a rise in the eosinophil count and suspects the patient has a(n):
a. bacterial infection.
b. allergy.
c. viral infection.
d. blood dyscrasia.

 

 

ANS:  B

In the event of an allergy or the infestation of pinworms, the eosinophil count will rise. Bacterial infection stimulates the production of neutrophils and segmented neutrophils; lymphocytes are increased with viral infections. Blood dyscrasia refers to an imbalance in numbers of types of cells or other pathologic conditions of the blood.

 

DIF:    Cognitive Level: Application          REF:   333                OBJ:   5 (theory)

TOP:   Eosinophil Count                            KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse uses a visual aid to depict the several kinds of hemoglobin. The hemoglobin that changes the shape of the red blood cell (RBC) on which it resides is hemoglobin:
a. A.
b. A1c.
c. F.
d. S.

 

 

ANS:  D

Hemoglobin S is the abnormal hemoglobin seen in people with sickle cell anemia. The hemoglobin changes the shape of the RBC to a sickle shape.

 

DIF:    Cognitive Level: Comprehension   REF:   336                OBJ:   1 (theory)

TOP:   Hemoglobin S                                           KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is assessing an 82-year-old African American male with sickle cell anemia and notes the sclera of his eyes to be yellow. The nurse correctly interprets this finding as:
a. sickle cell crisis.
b. anemia.
c. jaundice.
d. a normal occurrence.

 

 

ANS:  C

Because of the dark complexion of the African American, the sclera is the best place to assess for jaundice. Jaundice is a yellow discoloration of the skin and/or sclera of the eyes and is usually the result of excessive destruction of red blood cells (hemolysis). Jaundice may occur as a symptom of sickle cell disease or sickle cell crisis. Jaundice is not a normal finding.

 

DIF:    Cognitive Level: Application          REF:   332                OBJ:   7 (theory)

TOP:   Assessing Jaundice                         KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse explains that jaundice is present as a result of the release of excessive _____ into the bloodstream.
a. histamine
b. bilirubin
c. plasma
d. platelets

 

 

ANS:  B

Excessive levels of bilirubin in the blood (hyperbilirubinemia) from the increased hemolysis of red blood cells are responsible for jaundice.

 

DIF:    Cognitive Level: Comprehension   REF:   339                OBJ:   7 (theory)

TOP:   Jaundice: Hyperbilirubinemia         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. When the patient with pernicious anemia says, “I don’t know why I am so tired,” the nurse can clarify by saying that the fatigue is related to:
a. lack of oxygen being carried to cells of the body.
b. enlarged spleen, which makes breathing difficult.
c. proliferation of white cells.
d. excessive red cells that have decreased the blood pressure.

 

 

ANS:  A

The fatigue experienced by people with anemia is related to the lack of oxygenation due to the lack of RBCs to carry the oxygen.

 

DIF:    Cognitive Level: Application          REF:   340                OBJ:   3 (clinical)

TOP:   Fatigue Associated With Anemia    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. When the nurse observes melena, she is aware that a minimum of _____ to _____ mL of blood has been deposited into the GI tract.
a. 25; 50
b. 50; 75
c. 75; 100
d. 100; 120

 

 

ANS:  B

For the symptom of melena (dark, tarry stools) to appear, a minimum of 50 to 75 mL of blood must have entered the GI tract.

 

DIF:    Cognitive Level: Application          REF:   343 | Clinical Cues

OBJ:   2 (clinical)      TOP:   Melena           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse reading a complete blood count notes there is an abnormal amount of “bands,” or immature granulocytes. From this assessment, the nurse suspects:
a. an ongoing bacterial infection.
b. an allergic reaction.
c. impending anemia.
d. an overwhelming viral infection.

 

 

ANS:  A

Immature white blood cells are released when the more mature circulating cells have not been able to combat an ongoing bacterial infection. Eosinophils increase in response to allergic reactions, and red blood cells are associated with anemia. An increase in lymphocytes is seen with a viral infection.

 

DIF:    Cognitive Level: Application          REF:   336 | Clinical Cues

OBJ:   5 (theory)       TOP:   Significance of Bands: Bacterial Infection

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse cautions that often confused and irritable older adults are thought to have dementia when the real underlying problem is a blood-related:
a. deficiency of WBCs resulting in infection.
b. excess of WBCs resulting in joint pain.
c. deficiency in RBCs resulting in hypoxia.
d. massive RBC destruction resulting in hyperbilirubinemia.

 

 

ANS:  C

Confusion and irritability caused by hypoxia is often mistaken for Alzheimer’s dementia.

 

DIF:    Cognitive Level: Comprehension   REF:   340 | Elder Care Points

OBJ:   5 (theory)       TOP:   Hypoxia vs. Dementia

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is reviewing a patient’s assessment data upon admission to the acute care facility and observes signs of iron deficiency anemia that include:
a. RBCs 5.0 mil/mm3.
b. WBCs 5.0 mill/mm3.
c. hemoglobin 14.0 g/dL.
d. pale conjunctivae.

 

 

ANS:  D

Pale conjunctivae are an indication of anemia.

 

DIF:    Cognitive Level: Comprehension   REF:   339 | Focused Assessment

OBJ:   7 (theory)       TOP:   Signs of Anemia

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

 

  1. Which nursing intervention is most appropriate following a bone marrow aspiration on the left posterior iliac crest from a patient with pernicious anemia?
a. Assist the patient to walk for 10 minutes to stimulate circulation.
b. Check the pulses in the leg and foot distal to the puncture.
c. Turn the patient on the back and remove the pillow.
d. Apply pressure to the site for 5 minutes with an ice pack.

 

 

ANS:  D

Pressure is applied to the site for 5 minutes to prevent a hematoma since this patient is prone to bleeding. Additionally, the use of ice reduces swelling and increases vasoconstriction. Activity may increase the chance for bleeding. Checking the pulses would be appropriate if the procedure involved an arterial stick.

 

DIF:    Cognitive Level: Application          REF:   342                OBJ:   7 (clinical)

TOP:   Post–Marrow Aspiration Care         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The patient who is taking radiation treatments has a platelet count of 100,000/mm3. The nurse should be alert for:
a. significantly decreased blood pressure.
b. hematuria.
c. constipation.
d. confusion and disorientation.

 

 

ANS:  B

Abnormal bleeding is associated with a low platelet count since platelets are involved in the clotting process. Hematuria may result from bleeding within the urinary system. Blood pressure, constipation, and confusion or disorientation is not directly related to a low platelet count.

 

DIF:    Cognitive Level: Application          REF:   341 | Table 16-2

OBJ:   2 (theory)       TOP:   Low Platelet Count

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

 

  1. The nurse reminds the patient with a bleeding disorder that the life span of the platelet is the shortest of all blood cells, approximately _____ days.
a. 10
b. 14
c. 30
d. 45

 

 

ANS:  A

Platelets only live about 10 days.

 

DIF:    Cognitive Level: Comprehension   REF:   334                OBJ:   2 (theory)

TOP:   Platelets: Life Span                         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The elderly patient’s daughter asks why her father seems to be catching so many colds. Which response by the nurse is the best?
a. “After the age of 60, the plasma volume decreases so there is less infection fighting ability.”
b. “Bone marrow activity decreases by about 50% with aging, which lowers the immune response to infection.”
c. “The elderly person’s blood is more prone to clotting, so infection-fighting cells don’t get to the source of infection quickly.”
d. “His antibody response to vaccines is overactive.”

 

 

ANS:  B

The elderly patient is more prone to infection due to the decrease in bone marrow activity, which in turn reduces the immune response. Plasma volume does decrease after age 60, but the concern is decreased blood reserve volume in case of blood loss, not infection. The older adult’s blood is more prone to clotting due to platelet aggregation and alterations in clotting activity; this increases the risk for problems related to thrombosis, not infection. Lastly, the older adult’s antibody response to vaccines is decreased.

 

DIF:    Cognitive Level: Analysis               REF:   334                OBJ:   3 (theory)

TOP:   Effects of Aging                             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. When reviewing the hematologic system, the student nurse is correct when making which statement?
a. “African Americans have the highest incidence of sickle cell disease.”
b. “Iatrogenic blood disorders are congenital in origin.”
c. “Folic acid is directly related to synthesis of hemoglobin.”
d. “Bruising in the elderly patient is of great concern.”

 

 

ANS:  A

African Americans do have the highest incidence of sickle cell disease. Iatrogenic blood disorders are brought on by medical treatment, such as bone marrow suppression. Iron, rather than folic acid, is directly related to hemoglobin synthesis; folic acid is related to RBC maturation. The elderly adult tends to bruise more due to the thinning of the skin and the increased fragility of the vessels; therefore, it is expected to see some bruising with these patients. Excessive bruising, however, in the elderly patient should be investigated.

 

DIF:    Cognitive Level: Application          REF:   334 | Cultural Considerations

OBJ:   3 (theory)       TOP:   Hematologic System Characteristics

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. The nurse explains that the function of blood includes: (Select all that apply.)
a. absorbing nutrients.
b. moving blood gases.
c. regulating pH by buffering.
d. regulating fluid distribution.
e. regulating body temperature.

 

 

ANS:  B, C, D, E

Blood transports, not absorbs, nutrients.

 

DIF:    Cognitive Level: Comprehension   REF:   331                OBJ:   1 (theory)

TOP:   Blood: Function                              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The lymphatic system is composed of: (Select all that apply.)
a. thymus.
b. lymph glands.
c. lymph channels.
d. spleen.
e. tonsils.

 

 

ANS:  A, B, C, D

The tonsils are not considered a part of the lymphatic system.

 

DIF:    Cognitive Level: Knowledge          REF:   334                OBJ:   2 (theory)

TOP:   Lymphatic System                          KEY:  Nursing Process Step: NA

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse explains that age-related changes that occur in the hematologic system include: (Select all that apply.)
a. decrease in blood volume.
b. decrease in bone marrow production.
c. decreased rate of blood cell production.
d. increased immune response.
e. increased clotting time.

 

 

ANS:  A, B, C, E

The immune response is slower in the older adult.

 

DIF:    Cognitive Level: Application          REF:   334                OBJ:   3 (theory)

TOP:   Blood: Age-Related Changes          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. To assure accuracy of a daily measurement of abdominal girth in a patient with ascites, the nurse will: (Select all that apply.)
a. place marks on the lateral sides of the abdomen where the tape is placed.
b. use the same tape every day.
c. measure girth with the tape placed 1 inch above the umbilicus.
d. measure the same area every day.
e. measure girth at the same time every day.

 

 

ANS:  A, B, D, E

Girth is measured at the level of the umbilicus.

 

DIF:    Cognitive Level: Comprehension   REF:   340 | Clinical Cues

OBJ:   2 (clinical)      TOP:   Measurement of Girth

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. To assess cyanosis in a patient with a dark complexion, the nurse should inspect the: (Select all that apply.)
a. conjunctiva.
b. gums.
c. roof of the mouth.
d. nail beds.
e. palms of the hands.

 

 

ANS:  B, C

A person with a dark complexion can be assessed for cyanosis by examining the gums and the roof of the mouth. Cyanosis is not usually apparent in the conjunctiva or palms of the hands. The nail beds tend to be darker in dark-skinned individuals so this would not render an accurate assessment of cyanosis.

 

DIF:    Cognitive Level: Application          REF:   339 | Focused Assessment

OBJ:   2 (clinical)      TOP:   Assessment: Cyanosis

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

 

  1. To help conserve energy for the severely anemic patient, the nurse will: (Select all that apply.)
a. manage care so that the patient can have frequent rest periods.
b. assist with activities of daily living.
c. place personal care items close at hand.
d. arrange for small meals with between-meal snacks.
e. ensure that exercise sessions are planned during the morning.

 

 

ANS:  A, B, C, D

Exercise sessions are not going to be planned for the severely anemic patient. By planning care using all the other options, the patient can be spared fatigue.

 

DIF:    Cognitive Level: Comprehension   REF:   343                OBJ:   3 (clinical)

TOP:   Fatigue           KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

COMPLETION

 

  1. The normal range of hemoglobin is from _____ g/dL to _____ g/dL.

 

ANS:

12.0; 18.0

The normal range for hemoglobin is from 12.0 to 18.0 g/dL.

 

DIF:    Cognitive Level: Knowledge          REF:   332                OBJ:   2 (theory)

TOP:   Hemoglobin: Normal Range           KEY:  Nursing Process Step: NA

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. In making an assessment of a patient with a bleeding disorder who has a dark complexion, the nurse should check the palms of the hands and the soles of the feet for _____________.

 

ANS:

petechiae

The small hemorrhages, petechiae, can be better assessed on people with a dark complexion by examining the palms of the hands and the soles of the feet.

 

DIF:    Cognitive Level: Comprehension   REF:   339                OBJ:   7 (theory)

TOP:   Assessment for Petechiae               KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A female patient being seen in an outpatient clinic states she is having excessive menstruation and reports saturating four peri-pads per day. The nurse estimates the blood loss for this patient as ______ mL per day.

 

ANS:

200

The average amount of blood loss via menstruation is less than 80 mL. Each saturated pad or tampon is equal to about 50 mL of blood loss. Therefore, this patient is losing approximately 200 mL of blood per day.

 

DIF:    Cognitive Level: Application          REF:   335 | Clinical Cues

OBJ:   4 (theory)       TOP:   Menstruation Blood Loss

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

MATCHING

 

The student nurse is drawing a diagram of the phases of the monocyte cell to present to the nursing class. The student correctly diagrams the phases in which order of occurrence?

a. Becomes a phagocyte
b. Becomes a macrophage
c. Engulfs bacteria
d. Migrates into tissues
e. Becomes a monocyte
f. Becomes a leukocyte

 

 

  1. Step 1

 

  1. Step 2

 

  1. Step 3

 

  1. Step 4

 

  1. Step 5

 

  1. Step 6

 

  1. ANS:  F                    DIF:    Cognitive Level: Analysis               REF:   333

OBJ:   1 (theory)       TOP:   Monocyte Phases

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. ANS:  E                    DIF:    Cognitive Level: Analysis               REF:   333

OBJ:   1 (theory)       TOP:   Monocyte Phases

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. ANS:  B                    DIF:    Cognitive Level: Analysis               REF:   333

OBJ:   1 (theory)       TOP:   Monocyte Phases

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. ANS:  D                    DIF:    Cognitive Level: Analysis               REF:   333

OBJ:   1 (theory)       TOP:   Monocyte Phases

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. ANS:  A                    DIF:    Cognitive Level: Analysis               REF:   333

OBJ:   1 (theory)       TOP:   Monocyte Phases

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. ANS:  C                    DIF:    Cognitive Level: Analysis               REF:   333

OBJ:   1 (theory)       TOP:   Monocyte Phases

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

Chapter 32: The Musculoskeletal System

 

MULTIPLE CHOICE

 

  1. The nurse is discussing actions that can be taken to best prevent osteoporosis with a patient. The nurse’s teaching should include:
a. taking an extra calcium supplement.
b. eating a balanced diet.
c. exercising throughout life.
d. eating daily amounts of milk products.

 

 

ANS:  C

A lifetime of even mild daily exercise will delay or prevent osteoporosis.

 

DIF:    Cognitive Level: Comprehension   REF:   718-719         OBJ:   4 (theory)

TOP:   Osteoporosis: Supplement              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. When the patient asks what the purpose of goniometry is, the nurse replies that goniometry measures:
a. bone strength.
b. muscle density.
c. muscle strength.
d. range of motion.

 

 

ANS:  D

Goniometry measures joint mobility, described as the number of degrees that the joint can move from the 0-degree mark.

 

DIF:    Cognitive Level: Comprehension   REF:   719                OBJ:   2 (clinical)

TOP:   Goniometry: Joint Mobility            KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse is aware that positioning and range-of-motion (ROM) exercises most help the immobilized patient to prevent:
a. increased pain.
b. contractures.
c. pressure ulcers.
d. compromised circulation.

 

 

ANS:  B

Although positioning may help decrease pain and increase circulation, anatomical alignment and ROM exercises are most helpful in preventing contractures in the immobilized patient. Pressure ulcers are prevented by frequent position changes.

 

DIF:    Cognitive Level: Analysis               REF:   719                OBJ:   2 (clinical)

TOP:   Contractures: Prevention                KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse adds interventions for range-of-motion (ROM) and isometric exercises for the new patient with a stroke because the nurse is aware that contracture formation begins as early as _____ day(s) of immobilization.
a. 1
b. 2
c. 3
d. 10

 

 

ANS:  C

Contracture-related muscle changes occur as early as 3 days of immobilization.

 

DIF:    Cognitive Level: Comprehension   REF:   727                OBJ:   2 (clinical)

TOP:   Process of Contracture Formation: Time Frame

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

 

  1. The nurse explains that, if muscles are not regularly stretched and contracted, the muscles will become:
a. longer and flexed.
b. fibrosed and spastic.
c. shorter and less elastic.
d. shorter and painful.

 

 

ANS:  C

The formation of contractures (shortening of skeletal muscle tissue causing deformity), loss of muscle tone, and fixation of joints can be prevented in most cases by consistent nursing intervention. The major components of the intervention are gradual mobilization, an exercise program, proper positioning, and instruction of the patient and family. Within a matter of a few days, the structures of immobilized muscles and joints begin to undergo changes. If no effort is made to prevent these changes, the patient will become permanently disabled.

 

DIF:    Cognitive Level: Comprehension   REF:   727                OBJ:   2 (clinical)

TOP:   Immobility: Effect on Muscles       KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse uses a visual aid to show the pathologic muscle tone changes that result in footdrop. Those changes are:
a. calf muscles are stretched.
b. flexor muscles are stretched.
c. toes curl downward.
d. thigh muscles contract.

 

 

ANS:  B

The most frequent contractures occurring in patients immobilized for long periods are “footdrop,” knee and hip flexion contractures, “wrist drop,” and contractures of the fingers and arms. Calf muscles contract and flexor muscles are stretched, allowing the unbraced foot to drop toward the surface of the bed.

 

DIF:    Cognitive Level: Comprehension   REF:   728                OBJ:   2 (clinical)

TOP:   Contractures: Pathophysiology       KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse informs the patient that the frequency of range-of-motion (ROM) exercises should be:
a. once a day.
b. once in the morning and once in the afternoon.
c. 3 to 4 times a day.
d. 4 to 6 times a day.

 

 

ANS:  C

ROM exercises, both passive and active, are planned and carried out as soon as feasible after immobilization occurs as a result of disease, injury, or surgery. The exercises are done to maintain functional connective tissue within the joint and thereby ensure that every joint retains its function and mobility. ROM exercises should be done three to four times a day.

 

DIF:    Cognitive Level: Comprehension   REF:   728                OBJ:   2 (clinical)

TOP:   ROM Exercises: Frequency            KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The physician has prescribed isometric exercises for a patient. The patient asks the nurse how these exercises work. The nurse uses an example to explain the physiology of isometric exercises, which is:
a. flexing the lower arm while trying to straighten it with the other hand.
b. pulling the knees up to chest with the arms.
c. forcefully flexing the neck to make the chin touch the chest.
d. flexing the toes up toward the head while lying flat.

 

 

ANS:  A

Isometric exercises are based on the energy of opposing muscles working against each other.

 

DIF:    Cognitive Level: Analysis               REF:   728-729         OBJ:   2 (clinical)

TOP:   Isometric Exercises: Concept          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. When the patient returns to the unit from having had an arthrogram, which intervention will the nurse perform first?
a. Ambulate the patient in the room.
b. Apply ice packs to the knee.
c. Perform passive range-of-motion exercises.
d. Wrap the knee in an elastic bandage.

 

 

ANS:  B

Ice packs applied to the knee will reduce swelling. The patient will ambulate at some point but not before the application of ice. There is not going to be a significant loss of mobility for the patient so range-of-motion exercises will not likely be included in the plan of care. There is no indication that an elastic bandage is needed.

 

DIF:    Cognitive Level: Application          REF:   721                OBJ:   4 (clinical)

TOP:   Arthroscopy: Aftercare                   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse encourages the patient to use the four-point crutch gait technique. This technique is most likely indicated because it:
a. allows non–weight bearing on one leg.
b. is the most stable gait.
c. mimics normal walking pattern.
d. allows the most rapid pace.

 

 

ANS:  B

The four-point crutch gait is the most stable, requires that there be partial weight bearing on both legs, and does not mimic normal walking pattern.

 

DIF:    Cognitive Level: Application          REF:   730                OBJ:   5 (clinical)

TOP:   Four-Point Crutch Gait: Characteristics

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. The nurse is assessing the patient’s cane for appropriate length. The nurse affirms that the appropriate cane has been selected when the:
a. hand grip is at the level of the hip.
b. elbow is flexed at 45 degrees when weight is placed on the cane.
c. cane tip is placed touching outside the good foot.
d. rubber tip has been removed when measuring cane length.

 

 

ANS:  A

The hand grip should be at hip level to allow for proper flexion of the arm to bear weight. The cane tip should be placed 6 inches from the good foot. The elbow angle should be 30 degrees.

 

DIF:    Cognitive Level: Application          REF:   731                OBJ:   5 (clinical)

TOP:   Cane: Measurement                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is instructing the patient on quadriceps and gluteal muscle exercises. The instructions will include:
a. while lying down, straightening the leg and tensing leg muscles while raising heel.
b. flexing the leg and holding it with the hands while pulling the leg back toward the hip.
c. straightening the legs and raising the head.
d. flexing both legs and doing an abdominal crunch up toward the knees.

 

 

ANS:  A

The quad setting exercise is to straighten the leg and tense the leg muscles while raising the heel.

 

DIF:    Cognitive Level: Application          REF:   729                OBJ:   2 (clinical)

TOP:   Quadriceps and Gluteal Muscle Exercises

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The anatomical structure that joins the bones of a joint together is referred to as:
a. a ligament.
b. a tendon.
c. a muscle.
d. cartilage.

 

 

ANS:  A

Ligaments hold the bones of a joint together. Tendons are connective tissues that provide joint movement. Cartilage is a type of connective tissue in which fibers and cells are embedded in a semisolid gel material.

 

DIF:    Cognitive Level: Knowledge          REF:   716                OBJ:   1 (theory)

TOP:   Ligament: Function                         KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. When a 90-year-old patient says, “My old bones are just about done in,” the nurse reminds him that his bones are being constantly renewed through the action of:
a. osteoblasts.
b. stem cells.
c. free circulating calcium ions.
d. combination of phosphorus and vitamin D.

 

 

ANS:  A

Osteoblasts build bone as the old bone is reabsorbed into the body.

 

DIF:    Cognitive Level: Comprehension   REF:   717                OBJ:   1 (theory)

TOP:   Bone Regeneration                         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The patient’s plan of care includes using the continuous passive motion (CPM) machine. Which statement by the patient indicates the need for further teaching?
a. “I marched in the Marines for 20 years, and now I’m marching flat on my back!”
b. “My new knee will be glad to rest at night.”
c. “I can make my new knee stronger if I reset this thing to go faster and flex my knee more.”
d. “I almost wish this CPM ran at night. The motor noise is soothing.”

 

 

ANS:  C

The continuous passive motion machine is used to provide movement to a joint in recovery. The apparatus is driven by a motor and requires no effort on the part of the patient or nurse to move the limb. It usually is left on all day and is discontinued at night while the patient sleeps. CPM is preset as to speed and the degree of flexion that is determined by the physician and should not be adjusted by the patient.

 

DIF:    Cognitive Level: Application          REF:   729                OBJ:   3 (clinical)

TOP:   CPM Machine                                           KEY:              Nursing Process Step: Evaluation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. When preparing a patient for electromyography (EMG), the nurse will instruct the patient to:
a. cease smoking for 12 hours before the test.
b. refrain from caffeine drinks for 3 hours before the test.
c. take muscle relaxants before the test.
d. prepare for a lengthy testing time (usually about 2 hours).

 

 

ANS:  B

Electromyography (EMG) is used to detect abnormal nerve transmission to the muscle and abnormal muscle function, and to assess the rehabilitation progress. Before the test, smoking and use of caffeine should be ceased for 3 hours. The test usually takes 1 hour.

 

DIF:    Cognitive Level: Application          REF:   723                OBJ:   5 (theory)

TOP:   EMG: Preprocedure Instructions     KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. When an 88-year-old patient enters the room for her health assessment, she walks with tiny steps, her shoulders are rounded and hunched, and her arms are crossed in front of her with her hands tucked in her armpits. Which response by the nurse is most appropriate?
a. “Are you cold?”
b. “Does your stomach hurt?”
c. “Are your shoes too small?”
d. “Do you always walk like that?”

 

 

ANS:  A

The patient in the scenario appears to be feeling chilled. Age-related changes may cause the older adult to feel cold more easily than a younger person. Older adults often walk with shoulders rounded and limbs close to the body.

 

DIF:    Cognitive Level: Application          REF:   724                OBJ:   4 (theory)

TOP:   Older Adult: Sense of Cold            KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is changing the position of a person with flaccid paralysis. The priority action will be:
a. to change joint position.
b. not to use a footboard.
c. to move only from side to side, not supine.
d. to refrain from using pillows to keep the patient in place.

 

 

ANS:  A

Frequent changes in joint position reduces the incidence of ankylosis.

 

DIF:    Cognitive Level: Comprehension   REF:   729                OBJ:   2 (clinical)

TOP:   Positioning: Flaccid Paralysis          KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is caring for a patient who has had an arthrocentesis. The nurse has completed discharge instructions. Which statement by the patient indicates the need for further instruction?
a. “I will need to avoid moving my knee for at least 1 to 2 weeks.”
b. “The steroids prescribed by my physician will reduce the inflammation in my knee.”
c. “Some pain is anticipated.”
d. “My elastic bandage will be worn for 2 to 3 days.”

 

 

ANS:  A

The patient with the arthrocentesis will be instructed to avoid overuse of the joint; however, it may be moved in moderation. Steroids will be prescribed to limit inflammation. Pain is anticipated and analgesics will likely be prescribed. Elastic bandages are frequently worn for 2 to 3 days.

 

DIF:    Cognitive Level: Application          REF:   722                OBJ:   5 (theory)

TOP:   Diagnostic Tests for the Musculoskeletal System

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

 

  1. A patient is learning to use crutches on the stairs. When evaluating this patient, which action indicates that the patient needs further instruction?
a. The patient places the good leg on the step to be climbed first.
b. The patient places the affected leg on the step to be climbed first.
c. The patient places the crutches on the floor and uses a swing-through method to get to the next step.
d. The patient places the crutch on the affected side on the next step first.

 

 

ANS:  A

When climbing stairs with crutches, the patient should first stand at the foot of the stairs with weight on the good leg and crutches, put weight on the crutch handles, and then lift the good leg up onto the first step of the stairs. Weight should be placed on the good leg to lift the injured leg and crutches up to that step.

 

DIF:    Cognitive Level: Application          REF:   731                OBJ:   5 (clinical)

TOP:   Patient Teaching: Special Maneuvers on Crutches

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

 

  1. The nurse is assessing the patient’s crutches. The nurse recognizes that correctly sized crutches are:
a. the same height as the patient’s shoulders.
b. approximately 12 inches shorter than the patient’s shoulders.
c. approximately 16 inches shorter than the patient’s height.
d. tall enough to allow the patient’s arms to be fully extended when walking.

 

 

ANS:  C

Crutches should be about 16 inches (40 cm) shorter than the patient’s height. When in the standing position with axillary crutches, the axillary bar should be two finger breadths below the axilla. The elbow should be flexed at a 30-degree angle when the palms of the hands rest on the hand grip. It is important that the patient not rest the body at the axilla on the top of the crutch; body weight should be borne by the arms on the hand rests of the crutches. If crutches are too long, pressure on the axilla will occur and can cause nerve and circulatory impairment.

 

DIF:    Cognitive Level: Application          REF:   731                OBJ:   5 (clinical)

TOP:   Patient Teaching: Special Maneuvers on Crutches

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

 

  1. A patient at risk for the development of osteoporosis has reported plans to increase calcium intake. When making menu choices, which selection demonstrates an understanding of calcium-rich foods?
a. Grilled salmon, green beans, and milk
b. Hamburger patty on a wheat bun, baked chips, and milk
c. Grilled chicken breast, tossed salad, and fruit punch
d. Bacon, lettuce, and tomato sandwich on whole grain bread, orange slices, and milk

 

 

ANS:  A

In addition to dairy products, sources of calcium include canned sardines or salmon, tofu, figs, and green vegetables.

 

DIF:    Cognitive Level: Application          REF:   719                OBJ:   4 (theory)

TOP:   Nutrition for Bone Growth and Density

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

 

MULTIPLE RESPONSE

 

  1. The functions of the musculoskeletal system are: (Select all that apply.)
a. motion.
b. fighting of infections.
c. support.
d. protection of organs.
e. body shape.

 

 

ANS:  A, C, D, E

All options listed except for the fighting of infections are functions of the musculoskeletal system.

 

DIF:    Cognitive Level: Knowledge          REF:   718                OBJ:   1 (theory)

TOP:   Bone Function                                          KEY:              Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse points out the age-related changes that occur in the musculoskeletal system, which are: (Select all that apply.)
a. increase of bone density.
b. bones are brittle and break easily.
c. bones heal slowly.
d. decrease in muscle mass.
e. tendon sclerosis.

 

 

ANS:  B, C, D, E

All options listed are age-related changes in the musculoskeletal system except increase in bone density. Bone density is usually decreased with aging.

 

DIF:    Cognitive Level: Comprehension   REF:   718                OBJ:   1 (theory)

TOP:   Age-Related Changes in Musculoskeletal System

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. When the nurse plans for the progressive mobilization of a hemiplegic, the nurse will consider the patient’s ability to: (Select all that apply.)
a. move limbs.
b. change position in bed independently.
c. transfer self from bed to chair.
d. perform all activities of daily living independently.
e. walk.

 

 

ANS:  A, B, C, E

All options listed are abilities that must be assessed before an effective progressive mobilization plan can be designed.

 

DIF:    Cognitive Level: Comprehension   REF:   727-728         OBJ:   2 (clinical)

TOP:   Planning Progressive Mobilization: Considerations

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

 

COMPLETION

 

  1. When a joint is obliterated by bony overgrowth, the joint is said to be _________.

 

ANS:

ankylosed

Ankylosis occurs when the joint is overgrown with bony overgrowth.

 

DIF:    Cognitive Level: Knowledge          REF:   728                OBJ:   4 (theory)

TOP:   Ankylosis: Process                         KEY:  Nursing Process Step: NA

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The canal system that runs through the bone and contains the blood and lymph vessels is called the ____________.

 

ANS:

haversian system

The haversian system is the canal system that runs through the bone to carry blood and lymph vessels.

 

DIF:    Cognitive Level: Knowledge          REF:   716                OBJ:   1 (theory)

TOP:   Haversian System                           KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

MATCHING

 

Arrange the instructions for a person on crutches to sit down.

a. Transfer both crutches to the side of injury.
b. With weight on good leg, reach back and grasp chair arm.
c. Sit back in chair.
d. Turn slowly and touch backs of legs to seat of chair.
e. Using crutch and chair arm for support, slowly sit on chair.

 

 

  1. Step 1

 

  1. Step 2

 

  1. Step 3

 

  1. Step 4

 

  1. Step 5

 

  1. ANS:  D                    DIF:    Cognitive Level: Application          REF:   731

OBJ:   5 (clinical)      TOP:   Crutch Walker: Instructions to Sit in Chair

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. ANS:  A                    DIF:    Cognitive Level: Application          REF:   731

OBJ:   5 (clinical)      TOP:   Crutch Walker: Instructions to Sit in Chair

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. ANS:  B                    DIF:    Cognitive Level: Application          REF:   731

OBJ:   5 (clinical)      TOP:   Crutch Walker: Instructions to Sit in Chair

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. ANS:  E                    DIF:    Cognitive Level: Application          REF:   731

OBJ:   5 (clinical)      TOP:   Crutch Walker: Instructions to Sit in Chair

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. ANS:  C                    DIF:    Cognitive Level: Application          REF:   731

OBJ:   5 (clinical)      TOP:   Crutch Walker: Instructions to Sit in Chair

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

 

 

Chapter 48: Care of Patients with Cognitive Disorders

 

MULTIPLE CHOICE

 

  1. The percentage of the population that is 85 years of age and older who have some stage of Alzheimer’s disease is _____%.
a. 10
b. 20
c. 35
d. 50

 

 

ANS:  D

Alzheimer’s disease (AD) is the most common degenerative disease of the brain. Approximately 5.3 million Americans have AD (Alzheimer’s Association, 2010), and there is no known cause or cure. AD typically affects people over 65 years of age, but can also strike younger people. The 85-year-old-and-over age group is currently the fastest-growing age group in the United States. It is estimated that 50% of this age group have AD.

 

DIF:    Cognitive Level: Knowledge          REF:   1087              OBJ:   1 (theory)

TOP:   Alzheimer’s Disease: Incidence      KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. An 85-year-old man is admitted to the hospital with gastroenteritis and dehydration after a hiking trip to Mexico. He is given a dose of meclizine hydrochloride, an anticholinergic, for vomiting. He begins to hallucinate and talk to his wife, who has been dead for 10 years. The nurse assesses this behavior to be:
a. dementia related to advanced age.
b. delirium related to dehydration.
c. dementia related to early Alzheimer’s disease (AD).
d. delirium related to side effect of anticholinergic.

 

 

ANS:  D

Anticholinergic drugs can cause sudden confusion in the elderly. There is nothing in the history that suggests that the behavior would be related to AD or any other dementia as dementias progress slowly. Dehydration would increase the effect of the anticholinergic.

 

DIF:    Cognitive Level: Analysis               REF:   1086              OBJ:   2 (theory)

TOP:   Delirium: Etiology                          KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is aware the older adult is at risk for drug-induced delirium because of:
a. slower bowel motility.
b. reduced fluid intake.
c. overall reduced metabolism.
d. sedentary lifestyle.

 

 

ANS:  C

Slower renal and liver clearance of drugs allows the drugs to accumulate in the system of the older adult.

 

DIF:    Cognitive Level: Comprehension   REF:   1086              OBJ:   2 (theory)

TOP:   Drug-Induced Delirium: Older Adult

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is aware that the memory lapses seen in early stages of Alzheimer’s disease (AD) are related to the pathophysiology of:
a. frontal lobe atrophy.
b. overproduction of neurotransmitters.
c. pituitary disorders.
d. inadequate clearance of metabolic toxins.

 

 

ANS:  A

Loss of neurons in the frontal and temporal lobes results in atrophy and the many signs of AD, memory deficits being one of the earliest.

 

DIF:    Cognitive Level: Comprehension   REF:   1087              OBJ:   3 (theory)

TOP:   Alzheimer’s Disease: Pathophysiology

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse notes that the newly admitted patient with Alzheimer’s disease has significant anomia. An appropriate intervention for this problem would be to:
a. frequently reorient him to his room location.
b. remind him what a particular item is and what its use is.
c. help him feed himself.
d. wait for the patient to find the word he wants.

 

 

ANS:  D

Anomia is the inability to recall a word. Waiting for the patient to remember the word or be able to substitute another is more supportive than supplying the word for him.

 

DIF:    Cognitive Level: Analysis               REF:   1088              OBJ:   3 (theory)

TOP:   Anomia: Intervention                                KEY:              Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. When assisting the patient with middle-stage Alzheimer’s disease (AD) to dress, the nurse should:
a. select clothes and dress him.
b. lay out clothing and coach patient to dress self.
c. ask patient what he wants to wear.
d. open closet and say, “Get a shirt.”

 

 

ANS:  B

Coaching to dress self will preserve dignity and function. Asking the patient what he wants to wear and telling him to “get a shirt” would increase confusion and the patient would be hampered by indecisiveness.

 

DIF:    Cognitive Level: Application          REF:   1090-1093     OBJ:   3 (theory)

TOP:   Alzheimer’s Disease: Activities of Daily Living

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse differentiates vascular dementia from Alzheimer’s dementia in that vascular dementia is related to:
a. cerebral atrophy.
b. global reduction of cognition.
c. hypertension.
d. emboli in cerebral vessels.

 

 

ANS:  D

Vascular dementia occurs from brain tissue becoming hypoxic and necrotic in local areas due to small emboli. The deficits may be intellectual or loss of sensory function.

 

DIF:    Cognitive Level: Comprehension   REF:   1093              OBJ:   2 (theory)

TOP:   Vascular Dementia vs. Alzheimer’s Dementia

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse will record that the patient with Alzheimer’s disease exhibited agnosia when the patient:
a. attempted to comb her hair with a spoon.
b. had difficulty expressing herself verbally.
c. was unable to understand written language.
d. could not feed herself, although she had adequate motor function to do so.

 

 

ANS:  A

Agnosia is the inability to recognize an object and use it as intended. Expressive aphasia is difficulty in expressing oneself. Alexia is the inability to recognize the written language. Apraxia is the inability to do an activity despite having the motor function to accomplish it.

 

DIF:    Cognitive Level: Application          REF:   1088              OBJ:   3 (theory)

TOP:   Agnosia: Behavior                          KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The patient with Alzheimer’s disease has been on donepezil (Aricept) for several weeks. The nurse suspects an overdose when the patient:
a. eats hungrily at each meal and looks for snacks between meals.
b. exhibits a consistent heart rate of 80 beats/min.
c. has an elevation in blood pressure after each exercise period.
d. is unable to grasp a glass tightly enough to prevent dropping it.

 

 

ANS:  D

Inability to grasp the glass indicates muscle weakness, a cardinal indicator of overdose of Aricept. Other overdose signs are hypotension, nausea and vomiting, and bradycardia. Appetite changes are not consistent with the use of this medication.

 

DIF:    Cognitive Level: Analysis               REF:   1089              OBJ:   4 (theory)

TOP:   Donepezil (Aricept): Overdose       KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. When communicating with a patient with moderate Alzheimer’s dementia, the nurse should speak:
a. slowly.
b. clearly.
c. loudly.
d. softly.

 

 

ANS:  B

Clarity is essential when communicating with a patient with Alzheimer’s dementia. Placing self directly in front of the patient and using pictures or symbols is helpful.

 

DIF:    Cognitive Level: Application          REF:   1090-1093     OBJ:   1 (clinical)

TOP:   Communication: Technique           KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse takes into consideration that the patient with AIDS dementia complex (ADC) is at risk for injury due to:
a. manic behavior.
b. numbness and muscle weakness.
c. suicidal ideation.
d. difficulty concentrating.

 

 

ANS:  B

Peripheral neuropathy results in numbness and muscle weakness that may contribute to falls and thermal skin injuries.

 

DIF:    Cognitive Level: Comprehension   REF:   1093              OBJ:   1 (theory)

TOP:   ADC: Characteristics                                 KEY:              Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse takes into consideration that the patient with moderate Alzheimer’s disease in a long-term care facility who “sundowns” would benefit from:
a. social interaction activities in the morning.
b. darkened bedroom to encourage sleep.
c. sedative to enhance initiating sleep.
d. exercise program after supper.

 

 

ANS:  A

Sundowning refers to the patient who is completely oriented during the day but becomes disoriented and confused during the evening and night hours. Planning interactive activities when the resident is not confused is beneficial. Exercise programs at night would add to agitation and confusion. Sedatives also frequently cause confusion. Lights should be left on to assist with reorientation should the resident wake up at night.

 

DIF:    Cognitive Level: Application          REF:   1087              OBJ:   3 (theory)

TOP:   Sundowning: Interventions             KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Psychosocial Integrity

 

  1. The patient with Alzheimer’s wakes up at 2:00 AM moaning and frightened and begs that her husband’s coffin be removed from her room. The nurse should:
a. turn light on and say, “There is no coffin here, Mrs. Smith. This is the dresser.”
b. leave the light off and shine a flashlight on the dresser and say, “See! No coffin!”
c. turn the light on, assist patient to the bathroom, and say, “This is your dresser.”
d. leave the light off and say, “You are in your room, Mrs. Smith.”

 

 

ANS:  C

Turning the light on helps reorient the patient. Distraction of going to the bathroom and identifying the dresser assist with reorientation after a frightening illusion. The other options would lead to greater confusion.

 

DIF:    Cognitive Level: Analysis               REF:   1094              OBJ:   3 (theory)

TOP:   Illusions: Interventions                   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. The CNA approaches the older adult in the long-term care facility and says, “Oh, look at your pretty dress. It is all icky with food spots! Come with me, sweetie, we’ll put on that special party dress so you will look cute.” The CNA is using:
a. instruction for personal hygiene.
b. encouragement for self-care.
c. simplistic “elderspeak.”
d. reorientation techniques.

 

 

ANS:  C

Elderspeak is a way of communicating with the elderly that is infantile, oversimplistic, oversolicitous, and demeaning. It serves no therapeutic purpose.

 

DIF:    Cognitive Level: Application          REF:   1090-1093     OBJ:   4 (theory)

TOP:   Communication: Elderspeak           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The home health nurse counseling a family who will be caring for a relative with moderate-stage Alzheimer’s disease will stress the need for:
a. a consistent routine to provide structured environment.
b. making each day different to enhance attention span.
c. using several caregivers to increase social skills.
d. placing bright scatter rugs, flower arrangements, and wall decorations to stimulate sensory perception.

 

 

ANS:  A

A consistent routine—eating, resting, medication, hygiene—are all beneficial to the demented patient. Different caregivers and distracting environmental objects increase confusion.

 

DIF:    Cognitive Level: Application          REF:   1098              OBJ:   3 (theory)

TOP:   Home Care: Preparations                KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. The exhausted caregiver to a patient with moderate Alzheimer’s disease asks what respite care entails. The nurse replies that respite care is:
a. placing the patient in a long-term care facility for a short period of time for the caregiver to rest.
b. bringing in home health aides to do housework to lighten duties of the caregiver.
c. accompanying patient to a long-term care facility and staying there while the facility staff do physical care.
d. attending a support group to ventilate feelings and communicate with other caregivers.

 

 

ANS:  A

Respite care is placing the patient temporarily in a long-term care facility (usually for no longer than a month) to give the family respite from the responsibility of 24/7 care.

 

DIF:    Cognitive Level: Comprehension   REF:   1098              OBJ:   7 (theory)

TOP:   Respite Care: Definition                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. Donepezil (Aricept) has been prescribed for a patient with Alzheimer’s disease. Which statement by the patient and spouse indicates an understanding of the medication?
a. “It is best for me to take the medication at bedtime.”
b. “The medication will be most effective if taken on an empty stomach.”
c. “Absorption of the medication will be improved if taken with a citrus beverage.”
d. “The medication should be taken with meals.”

 

 

ANS:  D

Donepezil (Aricept) is used in the management of Alzheimer’s disease. It has been shown to elevate acetylcholine levels in the brain and will slow the progression of the condition. The medication should be taken with meals to reduce gastrointestinal distress.

 

DIF:    Cognitive Level: Application          REF:   1098              OBJ:   4 (theory)

TOP:   Drugs Used to Treat Cognitive Disorders

KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. A recently licensed nurse is orienting to the Alzheimer’s disease care unit. The nurse is caring for a patient who is transitioning from oral rivastigmine (Exelon) to the medication patch. Which action observed by the nurse’s preceptor indicates an understanding of the medication?
a. The patient is instructed to put on the patch 12 hours after the last oral medication dosage.
b. The nurse reports that the patient will need to replace the patch every 36 hours.
c. The nurse explains to the patient and family that the sites of application will need to be rotated.
d. The nurse explains to the patient that the patch should not be placed on the trunk region of the body.

 

 

ANS:  C

Rivastigmine (Exelon) is used to manage Alzheimer’s disease by elevating acetylcholine. The medication is available orally and transdermally. The patch should be applied 24 hours after the last oral dosage is given. The sites for application of the drug patches should be rotated.

 

DIF:    Cognitive Level: Application          REF:   1089              OBJ:   4 (theory)

TOP:   Drugs Used to Treat Cognitive Disorders

KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. The nurse is caring for a patient who has dementia and has been getting up out of bed at night. What action by the nurse will be most therapeutic?
a. The nurse places all of the side rails in the up position.
b. The nurse raises the bed to a tall position to reduce the patient’s ability to get out of bed.
c. The nurse obtains orders from the physician to apply restraints at night.
d. The nurse places the mattress on the floor.

 

 

ANS:  D

The patient who is attempting to get out of bed and is at risk for falls will need provisions made to increase safety. The most appropriate and safest action will be to place the mattress on the floor. The use of side rails can be considered a restraint and it can present an additional safety hazard. Placing the bed in a tall position is a safety hazard and should not be done. Restraints are to be the last option when caring for patients.

 

DIF:    Cognitive Level: Application          REF:   1089              OBJ:   1 (theory)

TOP:   Alternatives to Restraints                KEY:  Nursing Process Step: Implementation

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

 

MULTIPLE RESPONSE

 

  1. The nurse explains that postmortem brain examinations of people with Alzheimer’s disease have revealed that there are: (Select all that apply.)
a. tangled nerve cells.
b. abnormal buildup of proteins.
c. hemorrhagic areas.
d. occluded cerebral vessels.
e. reduced white matter.

 

 

ANS:  A, B

Tangled nerve cells and abnormal buildup of protein in the brain have been found on postmortem brain examinations of people who have Alzheimer’s disease.

 

DIF:    Cognitive Level: Knowledge          REF:   1093              OBJ:   3 (theory)

TOP:   Alzheimer’s Disease: Cerebral Changes

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Criteria established for the diagnosis of dementia include: (Select all that apply.)
a. evidence of cognitive deficits.
b. evidence of aphasia, apraxia, or agnosia.
c. impairment in social function.
d. impairments of occupational function.
e. neurologic signs and symptoms, such as ataxic gait.

 

 

ANS:  A, B, C, D, E

Dementia is characterized by several cognitive deficits, memory in particular, and tends to be chronic in nature. It is classified according to etiology (cause or origin of disease). All options are criteria for the diagnosis of dementia.

 

DIF:    Cognitive Level: Comprehension   REF:   1087              OBJ:   3 (theory)

TOP:   Diagnostic Criteria: Dementia         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse uses the Mini-Mental Status Exam (MMSE) frequently to assess: (Select all that apply.)
a. orientation.
b. judgment.
c. memory.
d. insight.
e. ability to follow directions.

 

 

ANS:  A, C, E

The Mini-Mental Status Exam (MMSE) is a popular shortened version of the mental status examination that was developed by Folstein and colleagues in 1975. It can be used for patients who have cognitive disorders or thought disorders to assess orientation, memory, and ability to follow commands. It consists of 11 easily scored items and should take about 5 to 10 minutes to administer. The MMSE does not measure insight or judgment.

 

DIF:    Cognitive Level: Comprehension   REF:   1088              OBJ:   4 (theory)

TOP:   MMSE: Purpose                              KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse is aware the resident with global amnesia in the late stage of Alzheimer’s disease will benefit from: (Select all that apply.)
a. reorientation sessions.
b. music therapy.
c. reminiscence therapy.
d. pet therapy.
e. looking at family scrapbooks.

 

 

ANS:  B, D

Global amnesia wipes out all memory. Orientation and family pictures will not be helpful. Activities that stimulate the senses, such as music, stroking an animal, or aroma therapy, can be pleasing.

 

DIF:    Cognitive Level: Application          REF:   1093              OBJ:   3 (theory)

TOP:   Global Amnesia: Interventions       KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Psychosocial Integrity

 

  1. The home health nurse assesses a family who is caring for a person with a cognitive deficit for responses that indicates exhaustion, which include: (Select all that apply.)
a. irritability with other family members and the patient.
b. report of sleep disturbances.
c. anger at patient and self.
d. depression.
e. fatigue.

 

 

ANS:  A, B, C, D, E

All options are characteristics of exhaustion in caregivers to the cognitively impaired.

 

DIF:    Cognitive Level: Comprehension   REF:   1096              OBJ:   7 (theory)

TOP:   Caregiver Fatigue: Signs and Symptoms

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

 

  1. A patient who has been experiencing memory deficits questions the nurse about foods that are associated with better memory. What selections are linked to enhanced memory? (Select all that apply.)
a. Salmon
b. Red meat
c. Pork loin
d. Leafy green vegetables
e. Fruits

 

 

ANS:  A, D, E

Studies show that fish and omega-3 polyunsaturated fats, fruits and vegetables, curcumin (curry spice), and the traditional Mediterranean diet may lower the risk for loss of cognitive function and/or Alzheimer’s disease.

 

DIF:    Cognitive Level: Comprehension   REF:   1098              OBJ:   1 (clinical)

TOP:   Health Promotion: Diet and Memory

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

MATCHING

 

The nurse clarifies terminology related to cognitive disorders. Match the options to the expected characteristics. (Options may be used more than once.)

a. Cognition
b. Dementia
c. Delirium

 

 

  1. An acute alteration in cognition

 

  1. Characterized by slow onset

 

  1. Experiences an illusion

 

  1. Uses confabulation to cover memory gaps

 

  1. Results from cerebrovascular accident

 

  1. Processes of perception, memory, and judgment

 

  1. ANS:  C                    DIF:    Cognitive Level: Knowledge          REF:   1085

OBJ:   1 (theory)       TOP:   Terms: Characteristics                    KEY:  Nursing Process Step: NA

MSC:  NCLEX: NA

 

  1. ANS:  B                    DIF:    Cognitive Level: Knowledge          REF:   1086

OBJ:   1 (theory)       TOP:   Terms: Characteristics                    KEY:  Nursing Process Step: NA

MSC:  NCLEX: NA

 

  1. ANS:  C                    DIF:    Cognitive Level: Knowledge          REF:   1085

OBJ:   1 (theory)       TOP:   Terms: Characteristics                    KEY:  Nursing Process Step: NA

MSC:  NCLEX: NA

 

  1. ANS:  B                    DIF:    Cognitive Level: Knowledge          REF:   1086

OBJ:   1 (theory)       TOP:   Terms: Characteristics                    KEY:  Nursing Process Step: NA

MSC:  NCLEX: NA

 

  1. ANS:  C                    DIF:    Cognitive Level: Knowledge          REF:   1085

OBJ:   1 (theory)       TOP:   Terms: Characteristics                    KEY:  Nursing Process Step: NA

MSC:  NCLEX: NA

 

  1. ANS:  A                    DIF:    Cognitive Level: Knowledge          REF:   1085

OBJ:   1 (theory)       TOP:   Terms: Characteristics                    KEY:  Nursing Process Step: NA

MSC:  NCLEX: NA

 

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