Medical-Surgical Nursing- Concepts & Practice, 3rd Edition by Susan C. deWit, Candice K. Kumagai Test Bank

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Medical-Surgical Nursing- Concepts & Practice, 3rd Edition by Susan C. deWit, Candice K. Kumagai Test Bank

Chapter 02: Critical Thinking and the Nursing Process

deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition

 

MULTIPLE CHOICE

 

  1. Which foundational behavior is necessary for effective critical thinking?
a. Unshakable beliefs and values
b. An open attitude
c. An ability to disregard evidence inconsistent with set goals
d. An 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.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   16, Box 2-1

OBJ:   2 (theory)       TOP:   Factors Influencing Critical Thinking

KEY:  Nursing Process Step: N/A              MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Which fundamental belief underscores the basis of the nursing process?
a. Recognition that basic needs must be met by the individual without assistance.
b. Acknowledgment that patients and families appreciate an efficient health care system that functions without their input.
c. A focus on disease control as the most important aspect of patient care.
d. Recognition that all people 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.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   17

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. The nurse is assessing a new patient who complains of his chest feeling tight. The patient displays a temperature of 100° F and an oxygen saturation of 89%, and expectorates frothy mucus. Which finding is an example of subjective data?
a. Temperature
b. Oxygen saturation
c. Frothy mucus
d. Chest tightness

 

 

ANS:  D

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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   18

OBJ:   8 (clinical)      TOP:   Assessment Data

KEY:  Nursing Process Step: Planning

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

 

  1. The nurse is caring for a newly admitted patient who is describing his recent symptoms to the nurse. This scenario is an example of which type of source?
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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   19

OBJ:   8 (clinical)      TOP:   Sources of Information

KEY:  Nursing Process Step: Assessment

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

 

  1. The nurse is performing an intake interview on a new resident to the long-term care facility. The nurse detects the odor of acetone from the patient’s breath. Which term accurately describes this assessment?
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.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   20

OBJ:   9 (clinical)      TOP:   Olfaction       KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. During a morning assessment, the nurse observes that the patient displays significant edema of both feet and ankles. Which statement best documents these findings?
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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   20

OBJ:   9 (theory)       TOP:   Palpation        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. Which technique should the nurse employ to best assess skin turgor?
a. Examine mucous membranes of the mouth.
b. Compare limbs for similar color.
c. Pinch a skinfold on chest to assess for tenting.
d. Palpate the 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.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   22

OBJ:   9 (clinical)      TOP:   Practical Assessment

KEY:  Nursing Process Step: Assessment

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

 

  1. Which example shows that the nursing student demonstrates compliance with the Health Insurance Portability and Accountability Act (HIPAA)?
a. The student uses the patient’s full name only on clinical assignments submitted to the instructor.
b. The student uses the facility printer to copy laboratory reports on an assigned patient.
c. The student shreds any documents that contain identifying patient information before leaving the clinical facility.
d. The student asks the patient for permission to copy laboratory 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.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   26

OBJ:   4 (theory)       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.” Which response is most appropriate for the nurse to make?
a. “Diabetes increases your risk of bleeding.”
b. “The HbA1c provides information relative to blood sugar levels for the last 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. By explaining the purpose of the common laboratory test (HgbA1c) and its relationship to diabetes, the nurse answers the patient’s question and clearly communicates relevant data.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   25, 27

OBJ:   8 (clinical)      TOP:   Diagnostic Studies

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is caring for a patient with the problem statement/nursing diagnosis of Risk for Impaired Skin Integrity Related to Immobility. Which goal/outcome statement best correlates with this diagnosis?
a. The patient will sit in chair at bedside for 15 minutes after each meal.
b. The nurse will assist the patient to chair every shift.
c. The nurse will assess skin and record condition every shift.
d. The patient will change positions 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.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   24

OBJ:   11 (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. Which source is most appropriate source for the nurse to consult?
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.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   17

OBJ:   4 (theory)       TOP:   Nursing Process                              KEY:  Nursing Process Step: N/A

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 problem statement/nursing diagnosis of altered nutrition/Nutrition: Less Than Body Requirements Related to Nausea and Vomiting. Which nursing order should the nurse include in the plan of care?
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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   18

OBJ:   11 (clinical)    TOP:   Nursing Orders

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. After evaluating the nursing care plan, the nurse finds lack of progress toward the goal. What action should the nurse take next?
a. Create a more accessible goal.
b. Revise the nursing interventions.
c. Change the problem statement/nursing diagnosis.
d. Use a new evaluation plan.

 

 

ANS:  B

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

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   26

OBJ:   10 (clinical)    TOP:   Evaluation     KEY:  Nursing Process Step: Planning

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

 

  1. During an intake interview, the nurse observes the patient grimacing and holding his hand over his stomach. The patient previously denied having any pain. What action should the nurse take next?
a. Examine the history closely for etiology of pain.
b. Ask the patient if he is experiencing abdominal pain.
c. Record that patient 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   20, Box 2-5

OBJ:   7 (clinical)      TOP:   Patient Interview

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

 

  1. While conducting an admission interview, the nurse questions the patient about pain. The patient responds, “No. I’m pretty wobbly.” Which action should the nurse take next?
a. Repeat the question about pain.
b. Ask the patient to clarify his meaning.
c. Record that the patient denied pain.
d. Record that 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   20, Box 2-5

OBJ:   7 (clinical)      TOP:   Patient Interview

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

 

  1. The nurse is caring for a patient with a goal/outcome statement of Patient will sleep for 5 hours uninterrupted each night. Which nursing intervention should the nurse include?
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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   25

OBJ:   11 (clinical)    TOP:   Nursing Intervention

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nursing team is prioritizing the problem statement/nursing diagnoses of an overweight hospital patient. Which problem statement/nursing diagnosis would be most important for this patient?
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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   23

OBJ:   11 (clinical)    TOP:   Setting Priorities

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse is explaining the components of a complete problem statement/nursing diagnosis. In addition to the NANDA stem and etiology, which other component should the diagnosis 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 problem statement/nursing diagnosis must have a NANDA stem, etiology, and signs and symptoms (etiology) of the problem.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   23

OBJ:   4 (theory)       TOP:   Nursing Diagnosis

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

 

  1. Which statement explains the reason for inclusion of potential problems in the nursing care plan?
a. To alert nursing staff to prevent potential complications.
b. To remind the family of potential problems.
c. To broaden the assessment of the caregiver.
d. To educate 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.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   23

OBJ:   7 (clinical)      TOP:   Potential Health Problems

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

 

  1. The nurse is completing the medication reconciliation form for a patient. Which information is most important for the nurse to include?
a. The patient reports taking Ginkgo biloba daily for the last 6 months.
b. The patient reports having high hematocrit levels during his last hospital stay.
c. The patient reports he has been diabetic for 10 years.
d. The patient reports having a recent infection.

 

 

ANS:  A

As part of the medication reconciliation form, all home medications (including herbal preparations like Gingko biloba) are listed and reviewed by the provider, pharmacist, and nurses. The information gathered during the completion of this form may impact care that the patient will receive. Abnormal lab work and history of chronic or acute illnesses are important components of the patient’s history but should not be part of the medication reconciliation form.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   20

OBJ:   7 (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, evidence-based standards of care, and are used to treat the majority of patients with a specific illness that often develops complications. Insulin administration for diabetics is evidence-based researched practice. The remaining options are good practice but are not considered core measures.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   25

OBJ:   4 (theory)       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 with pneumonia who complains of shortness of breath. Further assessment reveals an oxygen saturation of 89% on room air, 28 respirations/min with bilateral crackles in lung bases, blood pressure of 160/94, and a pulse rate of 102 beats/min. Which nursing diagnosis is priority for this patient?
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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   23

OBJ:   11 (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 which factor(s)? (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.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   15

OBJ:   7 (clinical)      TOP:   Critical Thinking

KEY:  Nursing Process Step: Implementation

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

 

  1. Which statement(s) demonstrates application of the nursing process? (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 goal.

 

 

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.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   17

OBJ:   8 (clinical)      TOP:   Nursing Process

KEY:  Nursing Process Step: Implementation

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

 

  1. Which example(s) demonstrate patient care that reflects knowledge of the National Patient Safety Goals? (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 heartrate 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   4, 23

OBJ:   4 (theory)       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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   20

OBJ:   8 (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 problem statement/nursing diagnosis.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   26

OBJ:   8 (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. Problem statement/nursing diagnosis

 

 

  1. Step 1

 

  1. Step 2

 

  1. Step 3

 

  1. Step 4

 

  1. Step 5

 

  1. ANS:  B                    PTS:   1                    DIF:    Cognitive Level: Comprehension

REF:   17                  OBJ:   4 (theory)       TOP:   Applying the Nursing Process

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

 

  1. ANS:  E                    PTS:   1                    DIF:    Cognitive Level: Comprehension

REF:   17                  OBJ:   4 (theory)       TOP:   Applying the Nursing Process

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

 

  1. ANS:  D                    PTS:   1                    DIF:    Cognitive Level: Comprehension

REF:   17                  OBJ:   4 (theory)       TOP:   Applying the Nursing Process

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

 

  1. ANS:  C                    PTS:   1                    DIF:    Cognitive Level: Comprehension

REF:   17                  OBJ:   4 (theory)       TOP:   Applying the Nursing Process

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

 

  1. ANS:  A                    PTS:   1                    DIF:    Cognitive Level: Comprehension

REF:   17                  OBJ:   4 (theory)       TOP:   Applying the Nursing Process

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

 

 

 

Chapter 16: Care of Patients with Hematologic Disorders

deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition

 

MULTIPLE CHOICE

 

  1. The nurse is caring for a 79-year-old male who underwent a gastrectomy 1 month ago. The nurse recognizes that this patient is at the greatest risk for which type of anemia?
a. Aplastic anemia
b. Pernicious anemia
c. Iron deficiency anemia
d. Nutritional anemia

 

 

ANS:  B

Pernicious anemia may result from the lack of the intrinsic factor found in the stomach lining. Without the intrinsic factor, the body is unable to absorb vitamin B12. Aplastic anemia is related to bone marrow suppression. Iron deficiency anemia is often related to a deficiency of iron in the diet.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   345, Clinical Cues

OBJ:   1 (theory)       TOP:   Pernicious Anemia: Etiology

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. Iron deficiency anemia impacts adequate production of which component?
a. Plasma
b. White blood cells (WBCs)
c. Hemoglobin
d. Antibodies

 

 

ANS:  C

Deficiency of iron causes reduced production of hemoglobin.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   345

OBJ:   1 (theory)       TOP:   Iron Deficiency Anemia

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is caring for a patient with anemia who has a past medical history of diabetes, hypertension, chronic kidney disease, and acid reflux. The nurse is aware the patient’s anemia is likely related to which condition?
a. Diabetes
b. Hypertension
c. Chronic kidney disease
d. Acid reflux

 

 

ANS:  C

The kidney makes most of the body’s erythropoietin stimulating factor, which then prompts the liver to release erythropoietin for erythrocyte production. Damaged kidneys produce decreased amounts of erythropoietin, which ultimately leads to decreased red blood cell production and anemia. Diabetes, hypertension, and acid reflux do not cause anemia.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   344

OBJ:   1 (theory)       TOP:   Causes of Anemia

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. Which descriptions accurately characterize the appearance of red blood cells (RBCs) in iron deficiency anemia?
a. Normochromic and normocytic
b. Hypochromic and microcytic
c. Hyperchromic and macrocytic
d. Normochromic and microcytic

 

 

ANS:  B

Iron deficiency anemia causes the RBCs to be smaller (microcytic) and have less color (hypochromic).

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   345

OBJ:   1 (theory)       TOP:   Characteristics of RBCs

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The home health nurse is caring for a patient who is taking ferrous sulfate (Feosol). Which statement indicates that the patient requires additional teaching about this medication?
a. “It tastes better when I take my medicine with milk.”
b. “My wife says I should take my medicine with orange juice.”
c. “I am always careful not to break open the capsule.”
d. “I usually take my iron with my whole-grain toast during breakfast.”

 

 

ANS:  A

Milk products inhibit the absorption of iron. Iron is better absorbed if vitamin C is in the gastrointestinal tract at the same time, so drinking orange juice with the ferrous sulfate is beneficial. Capsules and enteric-coated iron preparations should not be opened or crushed. Whole grains are not known as inhibitors of iron absorption.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   347, Table 16-3

OBJ:   2 (clinical)      TOP:   Anemia Treatment: Feosol

KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. The student nurse is preparing to administer an iron preparation via the intramuscular (IM) route. Which action indicates the need for further instruction?
a. The student changes needles after drawing up the medication.
b. The student administers 3 mL at the ventrogluteal site.
c. The student chooses a 20-gauge needle.
d. The student uses the Z-track technique when administering the injection.

 

 

ANS:  B

Such intramuscular (IM) injections must not exceed 2 mL at each site, and the sites of injection should be rotated to allow for proper absorption and to minimize the hazards of local inflammation. When administering an IM iron preparation, it is important to change the needle after drawing up the medication and use a 19- to 20-gauge, 3-inch needle for injection since iron is irritating to the tissues. The Z-track technique for IM injection is recommended.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   347, Table 16-3

OBJ:   2 (clinical)      TOP:   Absorption of Iron

KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. The nurse is caring for a patient with aplastic anemia. Which actions are most important for the nurse to take?
a. Alternate activity with periods of rest and provide magazines.
b. Provide a soft toothbrush and decrease clutter in the room.
c. Request an order for telemetry and limit intake of potassium-rich foods.
d. Encourage the patient to reposition regularly and float heels on pillows.

 

 

ANS:  B

Aplastic anemia can cause bleeding episodes. Priority nursing actions are directed toward preventing the episodes. Providing a soft toothbrush and decreasing clutter in the room are interventions to reduce risk of bleeding. While aplastic anemia can cause fatigue, and limiting activity and providing nontaxing entertainment can help, fatigue is a lesser priority than decreasing risk for bleeding. Requesting an order for telemetry and limiting intake of potassium-rich foods are indicated when monitoring high-potassium levels (which are not typical of aplastic anemia). Repositioning and floating heels are interventions helpful in preventing skin breakdown.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   349

OBJ:   1 (theory)       TOP:   Aplastic Anemia: Infection

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. The nurse is caring for a 20-year-old female patient with sickle cell trait. Which statement accurately reflects this patient’s condition?
a. The condition will evolve into sickle cell anemia as she ages.
b. All of her children will have sickle cell anemia.
c. The trait will be transmitted to male children only.
d. The trait can be passed on to all children.

 

 

ANS:  D

A person who has the trait can pass it on to male or female children, even if there are no symptoms. Fifty percent of the patient’s total hemoglobin may be affected. Age does not increase the chance of the trait evolving into the disease.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   350

OBJ:   3 (theory)       TOP:   Sickle Cell Trait

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is caring for a patient with sickle cell anemia. Which intervention may best help prevent sickle cell crisis?
a. Taking iron supplements daily
b. Maintaining adequate fluid intake
c. Engaging in daily exercise
d. Eating leafy green vegetables

 

 

ANS:  B

The maintenance of an adequate fluid intake keeps the circulating blood volume hydrated, which discourages clumping of the sickle cells.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   351

OBJ:   3 (theory)       TOP:   Sickle Cell Crisis: Prevention

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is caring for a patient with sickle cell anemia. Based on the underlying pathophysiology of this disorder, the nurse should carefully perform which detailed assessment?
a. Examination for skin breakdown
b. Auscultation of lungs
c. Abdominal girth measurement
d. Palpation of radial pulses

 

 

ANS:  A

Sickle cell anemia results in sluggish blood flow which increases the threat of stasis ulcers and makes it harder for existing wounds to heal. Careful assessment for skin breakdown is of priority importance in this patient. Lung auscultation, assessment of abdominal girth, and palpation of radial pulses do not directly correlate to sickle cell anemia.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   352, Figure 16-3

OBJ:   3 (theory)       TOP:   Sickle Cell Anemia: Stasis Ulcers

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

 

  1. The nurse is caring for a patient with sickle cell anemia. Which statement indicates that the patient requires further instruction?
a. “I should not drink iced drinks.”
b. “I miss drinking beer in the afternoon.”
c. “I walk every day rather than doing other strenuous exercise.”
d. “I am planning a trip to Colorado next month.”

 

 

ANS:  D

People with sickle cell anemia should avoid cold temperatures and high altitudes, which can bring on a crisis due to thickening of the blood. Avoidance of iced drinks, alcohol, and strenuous exercise is beneficial.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   351

OBJ:   3 (theory)       TOP:   Sickle Cell Anemia: Lifestyle Changes

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

 

  1. The nurse is assessing a patient with polycythemia vera. Which finding is consistent with this disorder?
a. Pallor
b. Blood pressure (BP) of 100/60
c. Hemoglobin of 17 mg/dL
d. Agitation

 

 

ANS:  C

A patient with polycythemia vera will have high hemoglobin and hematocrit related to the large number of RBCs. The complexion is ruddy with blue lips; there is fatigue and weakness and high BP.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   351

OBJ:   4 (theory)       TOP:   Polycythemia Vera: Signs

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. How often should a patient with polycythemia vera have phlebotomy to thin the blood?
a. Every 2 to 3 weeks
b. Monthly
c. Every 2 to 3 months
d. Semiannually

 

 

ANS:  C

The phlebotomies are scheduled about every 2 to 3 months in order to thin the blood to reduce hypertension and threat of stroke.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   352

OBJ:   4 (theory)       TOP:   Polycythemia Vera: Treatment

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

 

  1. The home health nurse is caring for a patient with polycythemia vera. Which focus is most important for the nurse to emphasize?
a. Maintenance of high fluid intake
b. Daily exercise to reduce weight
c. Daily dose of anticoagulants
d. Adequate intake of vitamin C

 

 

ANS:  A

The major focus is maintaining a high fluid intake to keep the circulating fluid well hydrated.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   352

OBJ:   4 (theory)       TOP:   Polycythemia Vera: Home Care

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

 

  1. The patient with acute myelogenous leukemia (AML) asks why he is making more WBCs when he already has so many. Which statement clarifies the underlying pathophysiology related to the patient’s white blood cells (WBCs)?
a. “The large number of leukemic white cells that you already have are not as effective as normal white cells.”
b. “The large number of leukemic white cells that you already have protect against infection.”
c. “The large number of leukemic white cells that you already have attempt to take over the functions of RBCs.
d. “The large number of leukemic white cells that you already have are produced by the lymphatic system.”

 

 

ANS:  A

The many leukemic white cells cannot function as normal WBCs do. The bone marrow “rushes” production of immature white cells (blasts) to try to create adequate protection. These cells do not protect against infection, nor do they take over the functions of the RBCs. AML originates in the bone marrow.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   353, Table 16-5

OBJ:   5 (theory)       TOP:   AML: WBC Production

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. Which statement accurately describes induction therapy for acute lymphocytic leukemia (ALL)?
a. Induction therapy is an intensive protocol of chemotherapy in high doses to achieve remission.
b. Induction therapy is a long-term protocol with smaller doses of chemotherapy to achieve a cure.
c. Induction therapy is a 2- to 5-year low-dose chemotherapy regimen to reduce painful symptoms.
d. Induction therapy is a combination of chemotherapy and radiation to achieve remission.

 

 

ANS:  A

A combination of several antileukemic drugs in high doses has been found to induce a remission.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   353

OBJ:   5 (theory)       TOP:   ALL: Treatment

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. When caring for a patient with advanced multiple myeloma, the nursing staff must exercise extreme care to prevent which complication?
a. Pain
b. Hematomas
c. Muscle spasms
d. Pathologic fractures

 

 

ANS:  D

Pathologic fractures of osteoporotic bones are an ongoing concern in the patient with multiple myeloma.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   357

OBJ:   1 (clinical)      TOP:   Multiple Myeloma: Safety

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. Blood infusions must be started within how many minutes of its arrival on the unit?
a. 10 minutes
b. 15 minutes
c. 30 minutes
d. 60 minutes

 

 

ANS:  C

To reduce the risk of infection, the blood must be started within 30 minutes of its arrival on the unit.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   361

OBJ:   2 (theory)       TOP:   Transfusion: Starting Blood

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

MULTIPLE RESPONSE

 

  1. A patient with a nutritional anemia may lack which nutrients? (Select all that apply.)
a. Proteins
b. Vitamin B1
c. Folic acid
d. Zinc
e. Iron

 

 

ANS:  A, C, E

Nutritional anemia occurs due to the lack of proteins, folic acid, and iron. Deficiencies in vitamin B1 and zinc do not result in anemia.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   344

OBJ:   1 (theory)       TOP:   Nutritional Anemia: Etiology

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse makes a visual aid differentiating between mild, moderate, and severe anemia. Which signs and symptoms are manifestations of mild anemia? (Select all that apply.)
a. Hemoglobin of 14.4 g/dL
b. Palpitations
c. Dyspnea on exertion
d. Pallor
e. Fatigue

 

 

ANS:  B, C

Palpitations and dyspnea on exertion are manifestations of mild anemia. Mild anemia is characterized by hemoglobin below 14 g/dL and does not result in pallor or abnormal levels of fatigue.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   345

OBJ:   1 (theory)       TOP:   Mild Anemia: Signs and Symptoms

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is caring for patient with iron deficiency anemia. The nurse should encourage intake of which food(s)? (Select all that apply.)
a. Liver
b. Lima beans
c. Prune juice
d. Cabbage
e. Dried apricots

 

 

ANS:  A, B, C, E

Iron-rich foods that can boost dietary iron intake include liver, lima beans, prune juice, and dried apricots. Cabbage is not high in iron.

 

PTS:   1                    DIF:    Cognitive Level: Application

REF:   364, Nutrition Considerations         OBJ:   2 (theory)

TOP:   Iron Deficiency Anemia: Diet        KEY:  Nursing Process Step: Implementation

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

 

  1. Which medication(s) may cause aplastic anemia? (Select all that apply.)
a. Antimetabolite cancer drugs
b. Phenylbutazone (Butazolidin)
c. Oral contraception drugs
d. Chloramphenicol (Chloromycetin)
e. Sulfonamides

 

 

ANS:  A, B, D, E

Antimetabolite cancer drugs, phenylbutazone (Butazolidin), chloramphenicol (Chloromycetin), and sulfonamides may cause aplastic anemia. Oral contraceptives are not known to cause aplastic anemia.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   349

OBJ:   1 (theory)       TOP:   Aplastic Anemia: Etiology

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

 

  1. Which factor(s) may be causative for leukemia? (Select all that apply.)
a. Radiation exposure
b. Pesticides exposure
c. Benzene exposure
d. Frequent bacterial infections
e. Virulent viral infections

 

 

ANS:  A, B, C

Exposure to radiation, pesticides, and benzenes has been linked to potential causes of leukemia. Bacterial and viral infections are not considered to be causes of leukemia.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   352

OBJ:   5 (theory)       TOP:   Leukemia: Etiology

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

 

  1. The patient with AML has a platelet count of 95,000. What interventions should the nurse include in the patient’s care plan? (Select all that apply.)
a. Observe for melena and hematuria.
b. Instruct the patient to brush and floss at least twice daily.
c. Measure abdominal girth daily.
d. Apply ice and pressure to puncture sites.
e. Instruct the patient to use an electric razor.

 

 

ANS:  A, C, D, E

A low platelet makes the patient prone to excessive bleeding. The nurse should monitor for bleeding into the stool and urine. An increase in the abdominal girth will alert the nurse to the possibility of internal bleeding. Ice and pressure on puncture sites aid in stopping bleeding. An electric razor reduces the chance of the patient being cut during shaving. Soft toothbrushes will decrease the likelihood of the gums bleeding, and the patient should not floss too frequently or brush teeth aggressively.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   355, Nursing Care Plan 16-1

OBJ:   5 (theory)       TOP:   Thrombocytopenic Precautions

KEY:  Nursing Process Step: Planning

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

 

  1. The nurse is monitoring a patient who is receiving a blood transfusion. Which finding(s) would lead the nurse to stop the infusion? (Select all that apply.)
a. Report of chills
b. Headache
c. Back pain
d. Report of a rash
e. Fever

 

 

ANS:  B, C, D, E

Headache, back pain, rash, and fever are findings that indicate a reaction to the transfusion; the transfusion should be stopped. The nurse should then infuse saline solution into the line to keep the intravenous line patent. Report of chills correlates to the infusion of the chilled blood. The transfusion is not stopped; the patient is given a blanket.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   362, Table 16-7

OBJ:   7 (theory)       TOP:   Transfusion: Complications

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

COMPLETION

 

  1. The nurse is aware that bone marrow transplantation (BMT) is a treatment alternative for aplastic anemia for people under the age of ____________________.

 

ANS:

45

forty-five

 

People under the age of 45 are considered candidates for BMT.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   350

OBJ:   1 (clinical)      TOP:   Aplastic Anemia: Treatment

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

 

  1. When assessing a complete blood count (CBC) of a patient with acute lymphocytic leukemia (ALL), the nurse would anticipate large numbers of immature white cells, called ____________________.

 

ANS:

blasts

 

Immature white cells are released from the bone marrow in response to the body’s need for more effective WBCs. Immature WBCs are known as blasts.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   353

OBJ:   5 (theory)       TOP:   ALL: CBC     KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The patient with acute myelogenous leukemia (AML) has a volume of blood extracted by machine, white cells are extracted in the machine, and the blood is then returned to the patient. This process is called ____________________.

 

ANS:

leukapheresis

 

Leukapheresis is a process by which blood is withdrawn from the patient by an extractor machine, the excess diseased WBCs are extracted, and the blood is returned to the patient.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   354

OBJ:   5 (theory)       TOP:   Leukapheresis

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse explains to a person who has undergone bone marrow transplantation (BMT) that engraftment takes up to ____________________ weeks.

 

ANS:

5

five

 

Engraftment takes from 2 to 5 weeks to begin to make stem cells.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   363

OBJ:   2 (clinical)      TOP:   BMT: Engraftment

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

 

 

Chapter 32: Care of Patients with Musculoskeletal and Connective Tissue Disorders

deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition

 

MULTIPLE CHOICE

 

  1. A patient has come to the ambulatory care clinic with a sprain. The nurse correctly differentiates a grade 2 sprain from a grade 3 sprain with the assessment of which finding?
a. Pain
b. Swelling
c. Bleeding into the joint
d. Minor loss of function

 

 

ANS:  D

The minor loss of function is the differentiating factor. Pain, swelling, and bleeding into the joint are true of both grade 2 and grade 3 sprains. A grade 3 sprain has loss of function of the joint.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   735

OBJ:   1 (theory)       TOP:   Sprains: Grade 2

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. An older adult has fallen and sprained his ankle in a local park. Which action should the responder perform first?
a. Elevate the foot.
b. Apply ice.
c. Administer aspirin.
d. Assist the patient with ambulation.

 

 

ANS:  A

Elevation to reduce swelling is the most important initial intervention. Elevation may be done immediately. The responder will have to acquire the ice and pain medication, but should do so as quickly as possible. The responder should not attempt to ambulate the patient at this time.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   735

OBJ:   1 (theory)       TOP:   Sprain: First Aid

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. When the clinic nurse starts to take the “air cast” off the grade 2 sprain, the patient asks why it is being removed since he still has pain. Which explanation is best?
a. “Long-term immobilization can interfere with adequate circulation.”
b. “Long-term immobilization may increase long-term edema.”
c. “Long-term immobilization can cause permanent disability.”
d. “This cast will be replaced with a heavier cast.”

 

 

ANS:  C

Air casts, braces, or supports are used only until a joint has been strengthened. If a joint is immobilized too long and muscles are not exercised, muscle atrophy—which begins in a matter of days—can cause permanent disability

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   735

OBJ:   1 (theory)       TOP:   Splinted Sprain: Complications

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. Which statement indicates that the patient needs further instruction about application of ice to a sprain?
a. “I know this ice will reduce the swelling.”
b. “I will keep the ice on this knee for the rest of the day.”
c. “I will use the ice as you have directed for 24 hours.”
d. “I can elevate my leg and use ice to reduce swelling.”

 

 

ANS:  B

Ice should be applied for 20 minutes of each hour for the first 24 hours.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   735

OBJ:   1 (theory)       TOP:   Ice: Duration of Application

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

 

  1. The industrial nurse examines an employee who complains of right shoulder pain on abduction. He points with one finger to the exact location of the pain and mentions that he won a racquetball tournament yesterday. The nurse suspects the employee is suffering from which problem?
a. Rotator cuff tear
b. Bursitis
c. Dislocation
d. Subluxation

 

 

ANS:  B

Bursitis occurs after overuse, with pain in the joint on activity with no erythema and little, if any, swelling. Dislocations are very painful and the pain is spread all over the shoulder. The shoulder also looks misshapen in a dislocation. Rotator cuff tear would prevent the patient from abducting his shoulder.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   737

OBJ:   1 (theory)       TOP:   Bursitis: Signs and Symptoms

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

 

  1. The nurse is caring for a patient who works as a legal secretary. The patient asks the nurse about ways to avoid developing carpal tunnel syndrome (CTS). Which action should the nurse suggest?
a. “Exercise your wrists with repetitive flexion movements nightly.”
b. “Wrap your wrists with elastic bandages.”
c. “Acquire a pad to support your wrists while typing.”
d. “Apply warm compresses to wrists every evening.”

 

 

ANS:  C

Elevating the wrist with a firm support eliminates the need to keep the wrists flexed for long periods of time. This wrist support will help prevent CTS. Repetitive motion increases risk for carpal tunnel. Wrapping the wrists or applying warm compresses do not lessen risk of developing carpal tunnel.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   737

OBJ:   1 (theory)       TOP:   CTS: Prevention

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Carpal tunnel syndrome (CTS) is caused when the carpal tunnel compresses which location?
a. Radial artery
b. Brachial artery
c. Median nerve
d. Ulnar nerve

 

 

ANS:  C

When the median nerve is compressed by the carpal tunnel to the point that numbness, pain, and tingling occur, the result is CTS.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   737

OBJ:   1 (theory)       TOP:   Carpal Tunnel Syndrome: Pathophysiology

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. Which vitamin is essential in treating osteoporosis?
a. Vitamin A
b. Vitamin D
c. Vitamin B12
d. Vitamin C

 

 

ANS:  B

Standard treatments for osteoporosis include vitamin D and calcium supplementation, along with weight-bearing exercise. Vitamins A, B12, and C are not included in the standard treatment regimen for osteoporosis.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   757

OBJ:   7 (theory)       TOP:   Osteoporosis: Treatment

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

 

  1. The nurse is caring for a patient who just returned from surgical decompression of the carpal tunnel. Which finding requires the nurse’s immediate action?
a. The patient’s fingers swollen and warm.
b. The patient complains of generalized pain 5/10.
c. The capillary refill time is 8 seconds.
d. The patient’s fingers are pink and cool bilaterally.

 

 

ANS:  C

A capillary refill of over 5 seconds is an indication of diminished perfusion. Pain and swelling are to be expected, and pink but cool fingers bilaterally do not indicate circulatory compromise.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   737

OBJ:   1 (theory)       TOP:   Nerve Decompression: Aftercare

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. An 80-year-old man falls and suffers a compound fracture of the femur. Which immediate action is most appropriate?
a. Position him flat on his back.
b. Apply a tourniquet on the leg.
c. Carefully splint the leg as it is.
d. Carefully straighten the leg.

 

 

ANS:  C

Any fracture, even a compound one, should be immobilized in position to avoid further injury to the soft tissue attached to the bones. Any other initial action may cause further injury.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   738

OBJ:   2 (theory)       TOP:   Fracture: First Aid Splinting

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. Which major advantage is specific to external fixation devices?
a. Faster healing time
b. Allowance for immediate weight bearing
c. Greater freedom of movement
d. Pain reduction

 

 

ANS:  C

The external device for fracture reduction allows greater freedom of movement, decreasing the problems of immobility. Healing time and pain are the same as with any other fracture reduction method.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   740

OBJ:   3 (theory)       TOP:   External Fixation Device: Advantages

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The patient in a long arm cast (from below the shoulder to the wrist, with a 90-degree elbow flexion) complains of a burning sensation over the elbow. The nurse’s initial intervention should be:
a. Elevate the casted arm on pillows.
b. Check to see if the cast is properly supported.
c. Notify the charge nurse of developing pressure ulcer.
d. Cut a “window” in the cast.

 

 

ANS:  B

The initial intervention should be to assess for adequate support to the cast, then elevate the limb for 30 minutes. If the pain has not diminished, document the intervention and notify the charge nurse.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   744, Focused Assessment

OBJ:   2 (clinical)      TOP:   Cast Care: Pain

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is performing an assessment on the patient who is in bilateral Buck traction. Which finding indicates the need to reposition the patient?
a. The patient’s heels are not touching the surface of the mattress.
b. The elastic bandages need to be rewrapped.
c. The patient’s feet are against the footboard.
d. The weights are hanging free.

 

 

ANS:  C

When the patient’s feet are against the footboard, the traction is ineffective. The heels should be off the surface of the mattress to reduce the threat of pressure ulcer. The weights should be hanging free.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   741

OBJ:   5 (theory)       TOP:   Buck Traction

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A patient in Russell traction with a Pearson attachment for a fracture of the tibia complains of intense pain at the fracture site. The nurse assesses a temperature of 102° F and increased swelling at the fracture site. Which complication do these findings suggest?
a. Osteomyelitis
b. Fat embolism
c. Traction misalignment
d. Nonunion of the fracture

 

 

ANS:  A

Osteomyelitis is a bacterial infection of the bone. The causative organism is most often Staphylococcus aureus, which enters the bloodstream from a distant focus of infection, such as a boil or furuncle, or from an open wound, as in an open (compound) fracture. It is usually found in the tibia or fibula, in vertebrae, or at the site of a prosthesis. Osteomyelitis has a sudden onset with severe pain and marked tenderness at the site, high fever with chills, swelling of adjacent soft parts, headache, and malaise. These findings are not consistent with fat embolisms, traction misalignment, or nonunion of the fracture.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   742

OBJ:   5 (theory)       TOP:   Osteomyelitis: Complications

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

 

  1. The nurse is performing morning care for a patient who sustained a fractured pelvis and bilateral femur fractures yesterday in a motorcycle collision. The patient complains of shortness of breath. Assessment reveals audible wheezes and oxygen saturation of 76%. What action should the nurse take first?
a. Establish a peripheral intravenous (IV) line.
b. Inform the charge nurse.
c. Explain the patient’s change in status to his family.
d. Raise patient to high Fowler position.

 

 

ANS:  D

Fat embolism is a rare but serious complication of a fracture of a bone that has an abundance of marrow fat (e.g., the long bones, pelvis, and ribs). In the early postinjury period, patients with multiple fractures resulting from severe trauma are at risk for this complication. Signs and symptoms of fat embolism include a change in mental status, respiratory distress, tachypnea, crackles and wheezes on auscultating the lungs, rapid pulse, fever, and petechiae (a fine red rash over the chest, neck, upper arms, or abdomen). The nurse should stay with the patient; put him in a high Fowler position, use a nonre-breather mask to give high-flow oxygen, and establish a peripheral IV line. The nurse should also summon the provider immediately as there is about an 80% mortality rate from this complication. Raising the patient to high Fowler position is the best initial intervention as it can be done immediately. The nurse should then verify patent IV access, notify the charge nurse and provider, and update the family on the patient’s status change.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   742

OBJ:   2 (clinical)      TOP:   Fracture Complication: Fat Embolus

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is instructing a patient with rheumatoid arthritis about a prescribed exercise program. Which information should the nurse include?
a. Perform exercises every day, 3 to 10 times for every joint.
b. Perform exercises even if inflammation is present.
c. Perform exercises past the point of pain.
d. Perform twice the number of exercises the next day if one day is missed.

 

 

ANS:  A

Exercises are essential to preserve joint function and should be done every day 3 to 10 times per joint. Exercises should be omitted if there is inflammation present and should not be taken past the point of pain, or made up the next day.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   755

OBJ:   9 (theory)       TOP:   Rheumatoid Arthritis: Exercises

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The patient with osteoporosis calls the nurse in the doctor’s office to report that she should have taken but has forgotten to take her weekly bisphosphonate (alendronate [Fosamax]) that was due 2 days ago. How should the nurse advise the patient?
a. “Take the dose now with 8 ounces of water.”
b. “Take two doses 3 days apart.”
c. “Skip this week and pick up the schedule next week.”
d. “Take two tablets now with a snack.”

 

 

ANS:  C

If 2 or more days have passed since the regular dose time, this week’s dose should be skipped and the weekly schedule should be picked up next week.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   758, Box 32-2

OBJ:   8 (theory)       TOP:   Osteoporosis: Treatment

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. When caring for a patient who has an abductor wedge in place after a total hip replacement, for which finding should the nurse assess?
a. Muscle spasms
b. Alteration in peripheral circulation
c. Compression fracture
d. Appropriateness of the size of the wedge

 

 

ANS:  B

Pressure from the abductor wedge can interrupt arterial blood supply and compress the peroneal nerve.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   751, Safety Alert

OBJ:   7 (theory)       TOP:   Care of a Total Hip Replacement

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

MULTIPLE RESPONSE

 

  1. A patient presents to the emergency department immediately after an injury. An x-ray has been ordered for a suspected dislocation. Before confirmation by x-ray, which finding(s) support the potential diagnosis? (select all that apply.)
a. History of forceful injury
b. Purple-black hematoma over joint
c. Severe pain, aggravated by motion
d. Muscle spasm
e. Abnormal appearance of joint

 

 

ANS:  A, C, D, E

A dislocation will be evidenced by severe pain aggravated by motion, muscle spasm, and an abnormal-appearing joint after the history of a forceful injury. A hematoma, if it forms, will not be evident for a few hours.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   736

OBJ:   1 (theory)       TOP:   Dislocation: Signs and Symptoms

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

 

  1. Soft-tissue injuries require the nurse to assist with or instruct about the importance of which components of care? (select all that apply.)
a. Bed rest
b. Pain control
c. Immobilization
d. Activity restrictions
e. Prevention of recurrence

 

 

ANS:  B, C, D, E

Pain control, immobilization, activity restrictions, and prevention of recurrence are part of the care to a patient with a soft-tissue injury. Bed rest is not warranted with this type of injury.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   736

OBJ:   1 (theory)       TOP:   Soft Tissue Injury: General Care

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. Which statement(s) accurately describe the advantage(s) of fiberglass casts? (select all that apply.)
a. Lighter weight
b. Allowance of weight bearing after 30 minutes
c. Cheaper
d. Dries more quickly
e. Easily pliable
f. Smooth surface that is less abrasive to skin

 

 

ANS:  A, B, D

Fiberglass casts are lighter and dry quickly, allowing weight bearing in as little as 30 minutes. Fiberglass casts are very expensive and do not lend themselves to molding to body parts. The surface is very rough and often abrades the skin.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   740

OBJ:   3 (theory)       TOP:   Fiberglass Casts: Advantages

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The patient is returning to the unit with a wet long leg cast. To prevent damage to the wet cast, what action(s) should the nurse take? (select all that apply.)
a. Determine the cast material.
b. Prop the casted limb on a footboard and elevate it until the cast is dry.
c. Support the cast with the palms of the hands rather than holding it with the fingers.
d. Assess heat generated from the drying cast.
e. Explain that the cast has dried when it acquires a grayish color.

 

 

ANS:  A, C, D

Determining the cast material will inform the nurse of how quickly the cast can be expected to dry. The cast should be supported with the palms of the hands rather than holding it with the fingers. The heat of the drying cast should be evaluated to prevent skin irritation. A grayish color indicates that the cast is still wet.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   740

OBJ:   3 (theory)       TOP:   Cast Care: Wet Cast

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. The nurse is educating a patient going home with a short arm synthetic cast. Which instructions should the nurse include in the teaching plan? (select all that apply.)
a. Cover the cast with a plastic bag when taking a shower.
b. Blow warm air into the cast to relieve itching.
c. Observe skin at the edge of the cast for irritation or injury.
d. Check circulation and sensation in the fingers frequently.
e. Move and flex the fingers to stimulate circulation.

 

 

ANS:  A, C, D, E

All options listed are important teaching points for cast care except blowing warm air into the cast. If itching occurs, cool air will be most helpful.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   745

OBJ:   1 (clinical)      TOP:   Cast Care: Discharge Instruction

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse suspects compartment syndrome in a patient with a side arm cast and traction when observing which finding(s)? (select all that apply.)
a. Warm, rosy fingers
b. Intense pain in hand and fingers
c. Edema of fingers
d. Weak radial pulse
e. Tingling and numbness

 

 

ANS:  B, C, D, E

Compartment syndrome is a restriction of blood flow that occurs in one or more muscle compartments of the extremities. Compartment syndrome is caused by external or internal pressure. The main sign of compartment syndrome is severe, unrelenting pain that is out of proportion to the injury and unrelieved by narcotics. Decreased sensation, numbness and tingling, paleness of the skin, and weakness of the extremity are other signs. Warm, rosy fingers would be assessed as a sign of adequate perfusion.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   743

OBJ:   4 (theory)       TOP:   Cast Complication: Compartment Syndrome

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

COMPLETION

 

  1. The nurse explains that the “C” in the acronym RICE for sprain treatment stands for _______.

 

ANS:

compression

 

RICE stands for Rest, Ice, Compression, and Elevation.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   735

OBJ:   1 (theory)       TOP:   Sprain Treatment: Acronym

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse uses a visual aid to show the difference between a complete dislocation and a partial dislocation, which is also called a(n) __________.

 

ANS:

subluxation

 

A subluxation is a partial dislocation.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   736

OBJ:   1 (theory)       TOP:   Subluxation: Definition

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

MATCHING

 

Match the fracture type to the description that characterizes it.

a. Complete fracture
b. Comminuted fracture
c. Closed fracture
d. Compound fracture
e. Greenstick fracture

 

 

  1. Bone is partially broken and partially bent

 

  1. Fracture that has not broken through skin

 

  1. Fracture bone end protruding through skin

 

  1. Bone that is in two distinct pieces

 

  1. Bone shattered in more than two pieces

 

  1. ANS:  E                    PTS:   1                    DIF:    Cognitive Level: Knowledge

REF:   738, Box 32-1                                           OBJ:               2 (theory)       TOP:    Fractures: Types

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

 

  1. ANS:  C                    PTS:   1                    DIF:    Cognitive Level: Knowledge

REF:   738, Box 32-1                                           OBJ:               2 (theory)       TOP:    Fractures: Types

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

 

  1. ANS:  D                    PTS:   1                    DIF:    Cognitive Level: Knowledge

REF:   738, Box 32-1                                           OBJ:               2 (theory)       TOP:    Fractures: Types

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

 

  1. ANS:  A                    PTS:   1                    DIF:    Cognitive Level: Knowledge

REF:   738, Box 32-1                                           OBJ:               2 (theory)       TOP:    Fractures: Types

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

 

  1. ANS:  B                    PTS:   1                    DIF:    Cognitive Level: Knowledge

REF:   738, Box 32-1                                           OBJ:               2 (theory)       TOP:    Fractures: Types

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

 

Match the type of fracture stabilization with the characteristics that best describe it. (The options can be used once, more than once, or not at all.)

a. Closed reduction
b. Open reduction
c. Internal fixation
d. External fixation

 

 

  1. Reduction of fracture through surgical incision

 

  1. Metal appliances are used to stabilize pieces of fracture

 

  1. Reduction of fracture and fixation to device that maintains alignment

 

  1. Used with infected fractures that do not heal properly

 

  1. Manual reduction and manipulation of bones into alignment

 

  1. Used with older adults when brittle bones do not heal quickly

 

  1. ANS:  B                    PTS:   1                    DIF:    Cognitive Level: Comprehension

REF:   739-740         OBJ:   3 (theory)       TOP:   Fracture Reduction Methods: Characteristics

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

 

  1. ANS:  C                    PTS:   1                    DIF:    Cognitive Level: Comprehension

REF:   739-740         OBJ:   3 (theory)       TOP:   Fracture Reduction Methods: Characteristics

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

 

  1. ANS:  D                    PTS:   1                    DIF:    Cognitive Level: Comprehension

REF:   739-740         OBJ:   3 (theory)       TOP:   Fracture Reduction Methods: Characteristics

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

 

  1. ANS:  D                    PTS:   1                    DIF:    Cognitive Level: Comprehension

REF:   739-740         OBJ:   3 (theory)       TOP:   Fracture Reduction Methods: Characteristics

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

 

  1. ANS:  A                    PTS:   1                    DIF:    Cognitive Level: Comprehension

REF:   739-740         OBJ:   3 (theory)       TOP:   Fracture Reduction Methods: Characteristics

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

 

  1. ANS:  C                    PTS:   1                    DIF:    Cognitive Level: Comprehension

REF:   739-740         OBJ:   3 (theory)       TOP:   Fracture Reduction Methods: Characteristics

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

 

Place the steps of the process of fracture healing in proper order.

a. Medullary canal is reconstructed.
b. Mature bone cells form ossification.
c. Callus is formed.
d. Granulation tissue is formed.
e. Hematoma is formed between broken ends of bone.

 

 

  1. Step 1

 

  1. Step 2

 

  1. Step 3

 

  1. Step 4

 

  1. Step 5

 

  1. ANS:  E                    PTS:   1                    DIF:    Cognitive Level: Analysis

REF:   739                OBJ:   2 (theory)       TOP:   Fracture Healing: Process

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

 

  1. ANS:  D                    PTS:   1                    DIF:    Cognitive Level: Analysis

REF:   739                OBJ:   2 (theory)       TOP:   Fracture Healing: Process

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

 

  1. ANS:  C                    PTS:   1                    DIF:    Cognitive Level: Analysis

REF:   739                OBJ:   2 (theory)       TOP:   Fracture Healing: Process

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

 

  1. ANS:  B                    PTS:   1                    DIF:    Cognitive Level: Analysis

REF:   739                OBJ:   2 (theory)       TOP:   Fracture Healing: Process

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

 

  1. ANS:  A                    PTS:   1                    DIF:    Cognitive Level: Analysis

REF:   739                OBJ:   2 (theory)       TOP:   Fracture Healing: Process

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

 

 

Chapter 48: Care of Patients with Thought and Personality Disorders

deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition

 

MULTIPLE CHOICE

 

  1. Approximately what percentage of the U.S. population is affected with schizophrenia?
a. 1%
b. 2%
c. 3%
d. 4%

 

 

ANS:  A

Schizophrenia is the most common thought disorder. It is estimated that 1.1% of the general population is affected with schizophrenia, and in the United States this represents 2.4 million Americans.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   1109

OBJ:   1 (theory)       TOP:   Schizophrenia: Incidence

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

 

  1. The nurse explains that depression is thought to be the result of a deficit of which neurotransmitter?
a. Norepinephrine
b. Serotonin
c. Acetylcholine
d. Dopamine

 

 

ANS:  B

Serotonin is a neurotransmitter of the central nervous system. It is important in sleep, pain perception, and emotional states. Lack of serotonin can lead to depression. Norepinephrine and acetylcholine are neurotransmitters of the autonomic nervous system. Norepinephrine plays an important role in the fight-or-flight reaction (constriction of the blood vessels, dilation of the pupils, increased heart rate, increased awareness, and vigilance). Acetylcholine causes decreased heart rate and force of contraction and plays a role in the sleep-wake cycle. Dopamine is located mostly in the brainstem. It is thought to play a role in controlling complex movements, motivation, and cognition.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   1110

OBJ:   3 (theory)       TOP:   Depression: Etiology

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. Which statement causes the nurse to document a schizophrenic patient’s delusion of persecution?
a. “Did you know that I own this hospital and pay all these people to work for me?”
b. “My doctor talked to all the other patients, but not to me. He doesn’t want me to get well.”
c. “The president’s speech tonight is going to give me a coded message.”
d. “I am going to wait in front of the hospital this morning for my limousine to pick me up and take me to my private jet.”

 

 

ANS:  B

Delusions can be either grandiose or persecutory. An individual who believes he owns the hospital or is planning to be picked up by a limousine or has a private jet is having delusions of grandeur. Individuals with delusions of persecution believe that they are being persecuted by agencies, by other people, or by supernatural beings. The patient who believes the president’s speech is coded is having an idea of reference.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   1110

OBJ:   3 (theory)       TOP:   Delusions: Persecution

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

 

  1. The paranoid schizophrenic patient states that his whole family has conspired to have him put in the hospital and that the medical staff are part of the conspiracy. Which is the nurse’s most therapeutic response?
a. “I promise that I want to help you.”
b. “You know your family is concerned about you.”
c. “I’m sorry you feel that way. I’ll be around if you want to talk about your feelings.”
d. “The doctors are trying to help you feel better. They have your best interest in mind.”

 

 

ANS:  C

Arguing with the paranoid patient, or defending self or others, reinforces the paranoia. Passively offering self to the patient to approach you rather than the other way around is helpful to the nurse–patient relationship.

 

PTS:   1                    DIF:    Cognitive Level: Application

REF:   1117, Nursing Care Plan 48-1        OBJ:   3 (theory)       TOP:   Paranoia: Intervention

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. The delusional patient has become agitated and angry. The patient reports that the cook put tacks in his cereal. He is pacing back and forth in the crowded dining room and cursing the cook. How should the nurse respond?
a. Keep distance from the patient and ask, “Can we go to the dayroom and talk?”
b. Touch the patient’s arm and say, “Calm down. I’m sure we can straighten this out.”
c. Call experienced CNAs to restrain the patient.
d. Stand calmly and say, “This behavior is unacceptable. Sit down and eat, Carl.”

 

 

ANS:  A

Allowing the angry patient space is important. Encourage the patient to find a quieter place. Acknowledge the anger and demonstrate willingness to help. The agitated patient should not be touched without permission. Restraints are a last resort and will increase the patient’s anger and feelings of persecution.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   1120, Box 48-2

OBJ:   2 (clinical)      TOP:   Agitation and Anger: Intervention

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. The manipulative patient approaches the nurse and says, “I know it’s too early to give me my pain medication, but you are the only one who seems to care. Could you give me my pain medication now?” Which response is best?
a. “The charge nurse is very stringent about scheduled medications. She would be very angry with me if I gave you the medication now.”
b. “I know how it is when you are in pain. I’ll give you your medication early.”
c. “Your medication is due in 2 hours. I will be glad to give it to you on schedule.”
d. “It makes me feel good to know you are appreciative of our care. Here is your medication.”

 

 

ANS:  C

Setting clear limits is important when managing manipulative patients. Once limits are set, it is important to maintain them. Blaming the charge nurse provides incentive for further manipulative behaviors. The nurse telling the patient that they know what it is like when they are in pain is not accurate or therapeutic. Providing the medication early likely does not follow the prescribed plan.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   1120, Box 48-2

OBJ:   3 (clinical)      TOP:   Manipulation: Intervention

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse observes a withdrawn schizophrenic. The patient is sitting alone and moving her lips as if she is talking, but there is no audible sound. The nurse speaks to the patient by name, but the patient does not seem to hear. What should the nurse do first?
a. Hug the patient’s shoulders, refer to the patient by name, and ask if she’s praying.
b. Document the patient’s nonresponsiveness and continued detached behavior.
c. Sit down in the chair next to the patient, touch her arm, and speak softly.
d. Touch the patient’s shoulder and then join another group of patients.

 

 

ANS:  C

Sitting with the patient and touching her presents the reality of the nurse’s presence. Continued attention will make the patient feel safe. Feelings of safety are needed in the beginning of the nurse–patient relationship. Hugging the patient may invade the patient’s personal space. The nurse’s assessment will be documented but it is most appropriate to attempt an interaction with the patient.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   1111

OBJ:   2 (theory)       TOP:   Withdrawal: Intervention

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. After signing a contract that he will no longer smoke in his room, the patient violates the contract. The contract consequences include confiscation of smoking materials and mandatory supervision for future smoke breaks. How should the nurse appropriately address the patient’s behavior?
a. “Why are you smoking in your room when you know it is not allowed?”
b. “The contract states that if you smoke in your room, you must give me your smoking materials. Let me have them, please.”
c. “Okay, Larry, give me your cigarettes and lighter now.”
d. “I am going to give you one more chance, Larry. Let’s see if you can live up to the contract.”

 

 

ANS:  B

Reminding the patient of contract violation and the penalty attached should be done before taking the cigarettes. This approach is fair and puts the blame for the consequence on the offender. Providing the patient with the opportunity to “explain” the actions does not conform to the agreed-on contract. Providing additional opportunities for compliance does not support the contract and may encourage manipulative behavior.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   1120, Box 48-2

OBJ:   2 (theory)       TOP:   Manipulation: Intervention

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. When receiving report, the nurse learns that a schizophrenic patient has been displaying waxy flexibility. Which behavior is consistent with this report?
a. The patient sits and stares at the wall without speaking.
b. The patient arranges himself in several seated postures on the couch.
c. The patient marches stiffly up and down the center of the dayroom.
d. The patient holds his arm over his head with his fist clenched for an hour.

 

 

ANS:  D

Waxy flexibility refers to maintaining a limb in one position for a long time. The catatonic patient will exhibit a stuporous demeanor. It is associated with rigidity and unusual posturing.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   1112, Table 48-1

OBJ:   2 (theory)       TOP:   Catatonia: Waxy Flexibility

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. The nurse is caring for a schizophrenic patient who has been prescribed large doses of thioridazine (Mellaril). Which manifestation may signal an overdose of the medication?
a. The patient walks with a shuffling gait and drooling.
b. The patient is lethargic and takes frequent naps.
c. The patient exhibits disorganized thought processes.
d. The patient exhibits extreme excitability with periods of mania.

 

 

ANS:  A

Extrapyramidal side effects of pseudo-parkinsonism with a shuffling gait, tremors, and excessive salivation are cardinal signs of overdose of neuroleptics.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   1112, 1113, Figure 48-3

OBJ:   2 (theory)       TOP:   Extrapyramidal Side Effects: Pseudo-Parkinsonism

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. The nurse adds an intervention to the nursing care plan for a patient on neuroleptics. Which intervention is most appropriate?
a. Increase fluid intake to compensate for the side effect of diarrhea.
b. Encourage snacks to prevent weight loss.
c. Monitor vital signs for hypertension.
d. Assess urinary output for evidence of urinary retention.

 

 

ANS:  D

Neuroleptics cause urinary retention, weight gain, constipation, and hypotension. Diarrhea is not associated with the administration of neuroleptics. Weight gain, and not weight loss, is associated with this type of medication. Hypertension is not associated with this type of medication.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   1112

OBJ:   2 (theory)       TOP:   Neuroleptic Drugs: Side Effects

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. The nurse has asked a catatonic patient, “Where is your hat?” Which response should cause the nurse to document episodes of echolalia?
a. The patient excitedly says, “Hat, cat, rat, fat, scat, splat!”
b. The patient tearfully says, “I had a hat when my mother drove her yellow car.”
c. The patient repeatedly says, “Your hat, your hat, your hat.”
d. The patient places his hands on his head and says, “Where is your hat?”

 

 

ANS:  D

Echolalia is the repetition of words spoken to the patient by another person.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   1112, Table 48-1

OBJ:   2 (theory)       TOP:   Catatonia: Echolalia

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

 

  1. A student nurse questions the nurse about the frequency of administration of antipsychotics, such as risperidone (Risperdal). Which advantage is true of newer antipsychotics like risperidone (Risperdal)?
a. Decreased photosensitivity
b. Fewer serious side effects
c. Less expensive
d. Decreased incidence of headaches

 

 

ANS:  B

Risperidone (Risperdal) is a newer generation of “atypical” antipsychotic medications that is known for having fewer serious side effects, such as tardive dyskinesia, but they still have significant effects.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   1113

OBJ:   2 (theory)       TOP:   Atypical Antipsychotics

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. The nurse is aware that interventions for the negative symptoms of schizophrenia are based on which factor?
a. Establishment of trust
b. Acceptance of medication protocols
c. Support in interpersonal social activities
d. Promotion of conversation with the patient

 

 

ANS:  A

General nursing interventions for the negative symptoms include establishing trust and teaching the patient and family how to manage the signs and symptoms. An attitude of acceptance is necessary to promote trust.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   1116

OBJ:   2 (theory)       TOP:   Negative Symptoms: Establish Trust

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

 

  1. During report, the nurse is told that a patient has Cluster B group type of personality disorder. Which type of behavior can the nurse anticipate?
a. Paranoia
b. Avoidance
c. Antisocial behavior
d. Obsessive-compulsive behavior

 

 

ANS:  C

The antisocial personality disorder is included in Cluster B: dramatic and erratic.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   1120, 1121, Box 48-3

OBJ:   4 (theory)       TOP:   Cluster B: Dramatic and Erratic

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

 

  1. The nurse is aware the patient with borderline personality disorder did not have a family visit this week and adds an intervention to address the patient’s probable perception of abandonment. Which intervention is most appropriate?
a. Schedule the patient for pet therapy visit.
b. Arrange for remote activity during next visiting time.
c. Assess daily for evidence of self-mutilation.
d. Assign a young CNA to his care.

 

 

ANS:  C

Patients with borderline personality disorder have a deep fear of abandonment and react with intense, emotionally charge acts, such as suicide attempts or self-mutilation.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   1121

OBJ:   4 (theory)       TOP:   Borderline Personality Disorder: Self-Mutilation

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

 

  1. What effect does the nurse desire to achieve by using clear, direct communication with patients with borderline personality disorder?
a. Avoid generating an intense reaction from the patient.
b. Eliminate the possibility of manipulation.
c. Decrease the probability of the patient reacting emotionally.
d. Provide a role model for good communication.

 

 

ANS:  D

Clear communication can model a communication style that allows a person to verbalize feelings and make thoughts and expectations known.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   1116

OBJ:   4 (theory)       TOP:   Communication: Setting a Model

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse is changing the dressing on self-inflicted cigarette burns on a patient with borderline personality disorder. When providing the care, which action is most therapeutic?
a. Change the dressings while being nurturing and caring to keep patient from feeling abandoned.
b. Approach the dressing change with a matter-of-fact demeanor to decrease secondary gains of sympathy.
c. Present a stern attitude to underscore the seriousness of the act.
d. Interact in a professional and distant manner to diminish the opportunity for manipulation.

 

 

ANS:  B

The person with borderline personality disorder will seek additional secondary gains in terms of attention about the manipulative act of self-mutilation. Nurturing will reinforce the effectiveness of the mutilation to gain attention. Stern and distant demeanors may appear confrontational to the patient and reduce the therapeutic aspects of the intervention.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   1121

OBJ:   4 (theory)       TOP:   Borderline Personality Disorder: Use of Attitude

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse is talking with a patient who voices concerns about the incidence of schizophrenia in her family. The patient states that she is worried the condition will be inherited by her teenage daughter. What response by the nurse is most appropriate?
a. “Unfortunately, schizophrenia does run in families.”
b. “Although some familial factors exist, there is no exact known cause for schizophrenia.”
c. “Your daughter would show some evidence of the condition by this point in her life, so there is no real reason to worry.”
d. “As long as your home environment is warm and loving, she will be fine.”

 

 

ANS:  B

The exact cause of schizophrenia is unknown; however, current research favors the theory that there is a neurologic basis with a genetic component. As with most chronic conditions, an unfavorable social environment contributes to a poor prognosis. Schizophrenia usually develops in late adolescence or the early twenties.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   1109-1110

OBJ:   2 (theory)       TOP:   Schizophrenia: Etiology and Pathophysiology

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. The family of a patient being treated for a recent diagnosis of schizophrenia voices concerns to the nurse. They report the patient just told them that the pepper flakes on his potatoes were crawling bugs. What response by the nurse is most appropriate?
a. “At this stage it is most important to humor him and agree that you see them as well.”
b. “To reduce his stress, just throw out the food.”
c. “It is important to tell him that you do not see the bugs.”
d. “The best thing to do in this case is to confront him and let him know that he is mistaken.”

 

 

ANS:  C

The patient is experiencing an illusion. It is most important to offer support but to attempt to provide reality orientation. Confronting him may cause anger or increased anxiety and should be avoided.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   1110

OBJ:   2 (theory)       TOP:   Schizophrenia: Signs and Symptoms

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse is caring for a patient with a recent diagnosis of schizophrenia. His wife asks how long it will be until her husband is cured. What response by the nurse is most appropriate?
a. “Unfortunately, there is no cure, but the condition can be managed.”
b. “It will take approximately 1 to 2 months of medication therapy to alleviate your husband’s symptoms.”
c. “We cannot consider your husband cured until he has been symptom free for at least 1 year.”
d. “There is no way to predict his outcome during his initial episode.”

 

 

ANS:  A

Schizophrenia can be managed with therapy and medications. It cannot be permanently cured. Evidence suggests that early treatment for schizophrenia improves long-term prognosis. Patients who are treated for first episodes generally respond to the therapeutic effects and require lower doses of antipsychotic medications. After starting a medication, the patient should be monitored for 2 to 4 weeks for therapeutic response.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   1112

OBJ:   2 (theory)       TOP:   Schizophrenia: Treatment

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity: Mental Health Concepts

 

MULTIPLE RESPONSE

 

  1. Which psychotic feature(s) is/are characteristic of schizophrenia? (Select all that apply.)
a. Hallucinations
b. Sexual dysfunction
c. Delusions
d. Disorganized speech
e. Disorganized behavior

 

 

ANS:  A, C, D, E

Sexual dysfunction is not a characteristic of schizophrenia.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   1111

OBJ:   2 (theory)       TOP:   Schizophrenia: Characteristics

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

 

  1. Which characteristic(s) is/are an example of a negative symptom of schizophrenia? (Select all that apply.)
a. Avolition
b. Hallucination
c. Psychomotor retardation
d. Delusions
e. Anhedonia

 

 

ANS:  A, C, E

Negative symptoms are abilities or personal characteristics that are absent or lost to the patient.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   1111

OBJ:   2 (theory)       TOP:   Schizophrenia: Negative Symptoms

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse explains that neuroleptic drugs such as chlorpromazine (Thorazine) are very effective in treating specific symptoms of schizophrenia. Which effect(s) should chlorpromazine have? (Select all that apply.)
a. Eliminating hallucinations
b. Stimulating effective interpersonal relationships
c. Enabling organized thought
d. Increasing activity level
e. Eliminating delusional systems

 

 

ANS:  A, C, E

Hallucinations, disorganized thought, and delusional systems are the positive symptoms that respond to neuroleptics. Negative symptoms such as withdrawal and inactivity do not respond well to these drugs.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   1112

OBJ:   2 (theory)       TOP:   Neuroleptic Drugs: Advantages

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. Which characteristic(s) of personality disorders should the nurse consider? (Select all that apply.)
a. Impaired cognition
b. Maladaptive response to life’s events
c. Inability to maintain relationships
d. Poor impulse control
e. Inappropriate emotional responses

 

 

ANS:  B, C, D, E

There is no impaired cognition in the individual with a personality disorder.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   1120

OBJ:   4 (theory)       TOP:   Personality Disorders: Characteristics

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

 

  1. Milieu therapy is a therapeutic application for people with personality disorders. What principle(s) underscore(s) the basis of this method? (Select all that apply.)
a. Maintaining a structured environment
b. Participating as a member of the structured environment
c. Practicing appropriate social behavior
d. Actively attempting to modify behavior
e. Learning to modify feelings and emotional responses

 

 

ANS:  A, B, C, D, E

Milieu therapy provides all these options for treating people with personality disorders.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   1121

OBJ:   5 (theory)       TOP:   Milieu Therapy: Characteristics      KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

COMPLETION

 

  1. The delusional patient rushes up to the nurse and begins to brush her uniform with his hands, saying, “I must get the weegos off of you!” The nurse recognizes that the word “weegos” is a(n) ________.

 

ANS:

neologism

 

A neologism is a word that the patient makes up to express his or her disorganized thinking.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   1116

OBJ:   2 (theory)       TOP:   Schizophrenia: Use of Neologisms

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

 

  1. The paranoid schizophrenic who is taking a neuroleptic is brought to the emergency department with acute muscle spasm of the face and neck with eyes that are fixed in an upward stare. The nurse recognizes the condition of ________.

 

ANS:

dystonia

 

Overdoses of neuroleptics can cause muscle spasms of the face and neck called dystonia.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   1112

OBJ:   2 (theory)       TOP:   Neuroleptic Drugs: Dystonia

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

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