Medical Surgical Nursing Patient Centered Collaborative Care, 7th Edition by Donna D. – Test Bank

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Medical Surgical Nursing Patient Centered Collaborative Care, 7th Edition by Donna D. – Test Bank

Chapter 2: Introduction to Complementary and Alternative Therapies

Test Bank

 

MULTIPLE CHOICE

 

  1. The nurse wishes to learn more about the client’s use of natural products and their effectiveness. The nurse consults the National Center for Complementary and Alternative Medicine because it is known that this center serves which function?
a. Educates health professionals about complementary therapies
b. Educates new mothers on the benefits of massage
c. Engages in fundraising to offset client expenses with medical care
d. Provides a scholarship for a student to study naturopathy

 

 

ANS:  A

The purposes of the National Center for Complementary and Alternative Medicine (NCCAM) are to fund studies examining the effectiveness of various complementary therapies, advance knowledge about complementary therapies of health professionals, and serve as a clearinghouse for information about these therapies. It does not fund scholarships, nor is it a nonprofit organization. It focuses on advancing knowledge for health professionals rather than the general public.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 9

TOP:   Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort Interventions)

MSC:  Integrated Process: Teaching/Learning

 

  1. A client is anxious about having a dressing change. Which statement indicates that the nurse is promoting appropriate complementary therapy?
a. “I’ll call the doctor and ask for a larger dose of pain medication before the dressing change.”
b. “As we begin the next dressing change, I want you to think of a beautiful, calm place where you feel happy and peaceful.”
c. “I’ll get another nurse to stay in the room with us during the dressing change so that you have a hand to hold during the procedure.”
d. “Are you familiar with acupuncture? It’s a very effective technique.”

 

 

ANS:  B

Because the client’s primary problem is anxiety rather than pain at this point, the use of guided visual imagery should be the most effective intervention. Calling the physician for more pain medication and having another nurse present to help comfort the client will not address the main problem of the client. Acupuncture is used for relief of pain; an experienced practitioner is required to implement this technique.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort Interventions)

MSC:  Integrated Process: Nursing Process (Planning)

 

  1. The nurse has designed a treatment plan that includes the use of massage. Which intervention will the nurse implement first?
a. Assess the client to determine the most effective type of massage technique to use.
b. Inspect the skin over the tissue to be massaged to ensure that it is not infected or bruised.
c. Determine whether a licensed therapist will be needed to carry out the massage technique
d. Obtain permission from the client to implement this type of technique.

 

 

ANS:  D

Permission to use the procedure must be obtained from the client before any of the other interventions can be implemented.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort Interventions)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. A client who has been using which therapy requires the most immediate intervention by the nurse?
a. Aromatherapy to treat depression
b. Herbal preparations to treat hypertension
c. Therapeutic touch to decrease level of pain
d. Tai Chi to improve joint flexibility

 

 

ANS:  B

The client who has been using herbal preparations to treat hypertension may have endangered his or her life by inadvertently ingesting a substance that interacts poorly with another drug or that can be toxic. Aromatherapy may be used as a complementary therapy to treat depression. Therapeutic touch has been shown to decrease pain, and Tai Chi may assist in mobility. These therapies are appropriate and are not life threatening.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. A client scheduled for surgery has been taking garlic supplements. Which action is most important for the nurse to take?
a. No action is necessary because the herbal agent is harmless.
b. Notify the charge nurse that the client has been taking garlic.
c. Note the information on the client’s record and place in the chart.
d. Notify the surgeon that the client has been taking garlic capsules.

 

 

ANS:  D

Because garlic acts as an antiplatelet agent and has the potential to decrease clotting, much in the same way as aspirin, the surgeon will have to decide whether the surgery will be postponed. The nurse should never assume that any herbal supplement is “harmless” because many can interact with medications and diet. The nurse will note the information on the client’s chart, but the most important action is to notify the surgeon. Informing the charge nurse about the garlic is not necessary if the surgeon is notified.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems)                   MSC:  Integrated Process: Nursing Process (Planning)

 

  1. For which client does the nurse arrange animal-assisted therapy?
a. Middle-aged adult in a psychiatric facility with a history of schizophrenia
b. Older adult client with end-stage lung cancer in hospice care
c. Older adult client in a nursing home who is unresponsive
d. Adolescent in a drug treatment facility with a history of violent outbursts

 

 

ANS:  B

A client in hospice care may benefit from animal-assisted therapy because this type of therapy may decrease stress. A client in a psychiatric facility who has schizophrenia may not yet be stable enough to experience this type of therapy. A client who is unresponsive and is not interacting with the environment is not likely to benefit from this therapy. A client who is prone to violent outbursts would not be able to benefit from this type of therapy.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Psychosocial Integrity (Therapeutic Environment)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. Which statement indicates that the nurse understands the risks associated with herbal preparations?
a. Herbs are guaranteed to be safe and effective but are not necessarily natural.
b. Herbs require a different type of prescription than is required for standard prescribed medications.
c. Herbs are not classified as drugs and are regulated less strictly by the U.S. Food and Drug Administration (FDA).
d. Herbs are guaranteed to be all natural and of high quality but are not necessarily effective.

 

 

ANS:  C

Herbal preparations are regulated as food and nutritional supplements by the FDA. They do not require a prescription because they are not medications. Unfortunately, herbs are not under regulation by the government as drugs, and are not guaranteed to be natural, safe, or effective. This is one of the major disadvantages of herbal therapy.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 9

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)   MSC:  Integrated Process: Teaching/Learning

 

  1. A client asks the nurse to pray with him. The nurse is an atheist. Which statement by the nurse is the correct response?
a. “Yes, let’s pray together.”
b. “No, I’m sorry, I can’t do that.”
c. “No, I don’t believe in prayer.”
d. “I’ll hold your hand while you pray.”

 

 

ANS:  D

By stating that he will hold the client’s hand, the nurse offers support for the client’s choice without compromising his beliefs. The nurse should not participate in any activity that goes against his or her beliefs. The nurse should not just state that he or she can’t do this or tell the client personal views or preferences.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. The client has been diagnosed with cancer and is experiencing depression and insomnia as side effects of chemotherapy. The client tells the nurse that she has been supplementing her antidepressant medication with lavender oil and sandalwood but they aren’t working. Which statement by the nurse is the best response?
a. “Tell me more about exactly what you are taking, how much you take, and when you take the antidepressants and use the oils.”
b. “Perhaps you’re not using enough of the oil or are using it incorrectly.”
c. I’ll speak with your doctor to get you some medication that you can take while continuing the aromatherapy.”
d. “You don’t want your doctor to put you on sleeping pills and antidepressants. Keep using them.”

 

 

ANS:  A

The nurse should continue the assessment of the client to determine exactly what medications the client is taking and the specific type of complementary therapy the client is using, to determine whether the regimen is dangerous.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. The client is undergoing treatment for cancer and is experiencing a high level of anxiety. The client expresses interest in complementary therapies that might decrease the level of anxiety. Which action is the best choice for the nurse to implement with this client?
a. Direct the client to an imaginative peaceful setting using imagery.
b. Provide assistance in finding an acupuncturist.
c. Suggest Tai Chi during chemotherapy treatments.
d. Encourage the use of acupressure over tumor sites.

 

 

ANS:  A

Nurses traditionally have used a number of mind-body therapies such as prayer, imagery, meditation, music, and pet therapy to decrease anxiety in clients. Acupuncture and acupressure are pain relief therapies that usually require special education. Tai Chi is a body-based therapy that requires energy that may not be appropriate during chemotherapy sessions.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort Interventions)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. Which clients would benefit most from relaxation therapy?
a. Middle-age client who is undergoing chemotherapy treatments
b. Young client who is diagnosed with schizophrenia
c. Older client who is comatose and unresponsive
d. Young client who is diagnosed with major depression

 

 

ANS:  A

By reducing physical, mental, and emotional tension, relaxation is believed to result in changes opposite those of the “fight-or-flight” mechanism. Relaxation is helpful during painful procedures but may not be helpful with certain mental health problems or unresponsive clients because relaxation requires action from the client to relieve the tension.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort Interventions)

MSC:  Integrated Process: Nursing Process (Evaluation)

 

  1. A nurse is assisting a client in preparing for surgery by using progressive muscle relaxation. Which rationale best supports the use of this therapy at this time?
a. It rebalances or repatterns a person’s energy field.
b. It improves flexibility and assists with positioning during surgery.
c. It applies pressure, releasing congestion and promoting energy flow.
d. It uses intentional tensing and releasing of successive muscle groups.

 

 

ANS:  D

Progressive muscle relaxation provides intentional tensing and releasing of successive muscle groups, thereby promoting relaxation and decreasing anxiety. Anxiety reduction would be the best rationale for a client preparing for surgery. The other statements are inaccurate descriptions of progressive muscle relaxation and its use.

 

DIF:    Cognitive Level: Knowledge/Remembering                               REF:    p. 11

TOP:   Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort Interventions)

MSC:  Integrated Process: Caring; Nursing Process (Implementation)

 

  1. A client tells the nurse that he or she is considering using herbal supplements. What is the nurse’s best response?
a. “Herbs are not classified as drugs in the United States, so there is no contraindication to using them.”
b. “Herbs have pharmacologic effects on the body and can interact with some prescription medications.”
c. “It is never permissible to use herbal supplements with prescription medications.”
d. “I will refer you to an herbalist, who can help you decide which medications you can take.”

 

 

ANS:  B

Although herbs are not classified as drugs, they do possess pharmacologic properties. In caring for a client, the nurse should inquire whether the client takes herbal preparations and, if so, for what purpose. Many herbal preparations have not been adequately studied, and some can interact with prescription medications, causing toxic effects. The nurse should not refer the client to an herbalist. The client should be instructed that there are contraindications to herbal usage, but that herbs can be used with prescription medications, depending on the medication, the herbal substance, and the condition of the client.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 9

TOP:   Client Needs Category: Health Promotion and Maintenance (Health and Wellness)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. A client who is status post aortic valve replacement takes sodium warfarin (Coumadin) daily and has started taking Ginkgo biloba. What is the priority action for the nurse to take?
a. Encourage the use of Ginkgo biloba to enhance the client’s systemic circulation.
b. Assess the client for any bruising or petechiae.
c. Explain that replacing Ginkgo biloba with garlic would be much safer.
d. Assess for any forgetfulness or inappropriate speech.

 

 

ANS:  B

Taking Ginkgo biloba with warfarin increases the client’s risk of bleeding. Therefore, the client should be monitored first for bruising or bleeding associated with use of this combination. Ginkgo biloba is purported to reduce memory problems and dementia and has vasodilator properties, but these uses cannot be supported if the client is on an anticoagulant for the heart valve replacement. Garlic would not be a safer choice because it can act as an antiplatelet agent and would increase the risk of bleeding with warfarin (Coumadin).

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention)    MSC:           Integrated Process: Nursing Process (Planning)

 

  1. Which statement indicates that the client needs further teaching about complementary therapy?
a. “I’ve decided to use herb therapy for cancer treatment, so I can cancel my radiation treatments.”
b. “I’m hoping that massage therapy will help reduce the amount of pain medication I use for my myalgia.”
c. “I think it helps me get better faster when I picture the drugs punching out the germs in my body.”
d. “I intend to pray about my cancer treatment several times a day. It makes me feel so much better.”

 

 

ANS:  A

Complementary therapies are intended to be used with, rather than to replace, traditional forms of therapy to integrate mind, body, and spirit into the healing process. The client must have this information clarified, so that he will follow his recommended regimen for cancer treatment. The other statements appropriately indicate that the client understands the purpose of complementary therapy.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. Which teaching strategy is appropriate for a client who wishes to use mind-body complementary therapy to supplement traditional treatment for cancer?
a. Instruct the client to make a follow-up appointment with the health care provider after using mind-body treatments to assess the client’s response to treatment.
b. Instruct the client never to use alternative or complementary treatments for serious illnesses.
c. Explain to the client that physicians and nurses are not prepared to recommend and monitor alternative treatments.
d. Explain to the client that physicians and nurses do not incorporate such treatments into their practice.

 

 

ANS:  A

Complementary or alternative treatments may be used in association with traditional therapy. The client who uses complementary or alternative therapy should be advised to make a follow-up visit to the health care provider to assess the client’s response to therapy and to detect any adverse effects.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

MSC:  Integrated Process: Teaching/Learning

 

  1. Which complementary or alternative therapy would the nurse recommend to a client with “stiff joints” to improve mobility?
a. Imagery
b. Animal-assisted therapy
c. Tai Chi
d. Aromatherapy

 

 

ANS:  C

Tai Chi is an active holistic therapy that integrates body movements, concentration, muscle relaxation, and breathing to improve body function, such as flexibility and posture. Imagery has been used successfully to reduce pain, nausea and vomiting, and anxiety. Animal-assisted therapy generally is used with clients who need to improve motor skills or the ability to concentrate. Aromatherapy uses essential oils to achieve relaxation, improve concentration, and ease depression.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort Interventions)

MSC:  Integrated Process: Teaching/Learning

 

  1. A client is experiencing nausea and vomiting from chemotherapy. Which alternative or complementary therapy would be best for the nurse to explore with the client?
a. Meditation
b. Imagery
c. Yoga
d. Music therapy

 

 

ANS:  B

Imagery has been used frequently to help clients reduce nausea and vomiting. Meditation, yoga, and music therapy are more useful for chronic pain, for hypertension, and in improving emotional health.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort Interventions)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. The nurse is working in the community and completes home visits with older adult clients. Which statement by a client demonstrates a need for further instruction about the use of complementary and alternative therapies?
a. “My doctor monitors my kidney function since I started taking calcium.”
b. “I always talk to my doctor first before starting an herbal preparation.”
c. “I heard that St. John’s wort is good for any type of depression.”
d. “I may start a Tai Chi program to help with my mobility and lift my spirits.”

 

 

ANS:  C

The client needs some education regarding the use of St. John’s wort for depression. It is advisable to seek the advice of a physician and to be evaluated for psychotherapy and/or drug therapy. Often older women consume too much calcium, and this can result in renal calculi. It is recommended that the older adult should have calcium levels monitored, as well as kidney function. All clients need to inform their health care team about any use of herbal preparations because of possible interactions with medications and possible side effects. Tai Chi is to be encouraged in the older adult to improve physical and mental health.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Health and Wellness)

MSC:  Integrated Process: Teaching/Learning

 

MULTIPLE RESPONSE

 

  1. During an initial health assessment interview, the nurse learns that the client is taking warfarin (Coumadin) for a history of deep vein thrombosis. Later, the client admits to taking several herbal preparations as well. Which herbal preparations would the nurse caution the client to avoid? (Select all that apply.)
a. Ginkgo biloba
b. Garlic
c. Ginseng
d. Zinc
e. St. John’s wort

 

 

ANS:  A, B, C

Ginkgo biloba may increase the anticoagulant effects of warfarin. Garlic and ginseng have been found to affect the international normalized ratio (INR).

 

DIF:    Cognitive Level: Knowledge/Remembering                               REF:    Table 2-2, p. 10

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. The nurse wishes to start music therapy with an older adult client who has high anxiety and hypertension. What essential elements should be considered when music is used with this client? (Select all that apply.)
a. Assess the client’s preferences in choice of music.
b. Use fast tempo music to energize and motivate the client.
c. Consider rap music to provide diversion.
d. Consider live or recorded music such as music performed on a harp.
e. Consider generation-specific music.

 

 

ANS:  A, D, E

In music therapy, the nurse is encouraged to provide generation-appropriate music and to evaluate the client’s preference. Live harp music may have a calming effect with anxious clients. Rap music is not generation-appropriate for older clients. Music with a fast tempo may escalate the client’s anxiety and increase blood pressure.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Psychosocial Integrity (Stress Management)

MSC:  Integrated Process: Nursing Process (Planning)

 

Chapter 16: Care of Preoperative Patients

Test Bank

 

MULTIPLE CHOICE

 

  1. A client voluntarily signed the operative consent form. What is the nurse’s next action?
a. Teach the client about the surgery.
b. Have family members witness the signature.
c. Sign under the client’s name as a witness.
d. Call for the physician to sign the form.

 

 

ANS:  C

The nurse’s signature as a witness indicates that the consent form was signed by the client voluntarily. None of the other steps are necessary.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Management of Care—Informed Consent)

MSC:  Integrated Process: Communication and Documentation

 

  1. The nurse is caring for an older adult client with a history of chronic lung disease who will be undergoing surgery the following day. When postoperative care is planned, which potential problem is the highest priority for this client?
a. Maintaining oxygenation
b. Tolerating activity
c. Anxiety and fear
d. Hypovolemia

 

 

ANS:  A

Breathing problems take priority over the other problems listed. This would be compounded in a client with any chronic lung disorder.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations)

MSC:  Integrated Process: Nursing Process (Analysis)

 

  1. The nurse is completing preoperative teaching for a client, and it becomes apparent that the client does not understand the surgery that will be performed. What is the priority action for the nurse?
a. Obtain informed consent from the client.
b. Continue teaching the client about the surgery.
c. Revise the teaching plan for the client.
d. Notify the surgeon and document the finding.

 

 

ANS:  D

The surgeon should be notified right away so that the client can be instructed about the surgery to be performed. The client cannot give informed consent unless he or she understands the procedure.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Management of Care—Informed Consent)                MSC:              Integrated Process: Teaching/Learning

 

  1. During the preoperative assessment, the client tells the nurse that he smokes three packs of cigarettes daily. Which action by the nurse is best?
a. Call the surgeon to cancel the surgery.
b. Have baseline laboratory studies drawn.
c. Perform a respiratory assessment.
d. Give a nebulizer treatment.

 

 

ANS:  C

Smoking increases the client’s risk for atelectasis and hypoxia. The nurse should assess the client for signs of respiratory disease. The physician will need to know this information but will not necessarily cancel the operation. Baseline laboratory studies need to be ordered by the physician. There is no indication for giving a nebulizer to this client.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations)

MSC:  Integrated Process: Nursing Process (Intervention)

 

  1. When the nurse brings a client’s preoperative medications, the client responds, “I don’t need that. I had a good night’s sleep last night.” What is the nurse’s best response?
a. “The doctor ordered this medication so you should take it.”
b. “I will make a note that you refused to take the medication.”
c. “I will ask your surgeon if you have to take the medication.”
d. “Let me teach you about your medications for surgery.”

 

 

ANS:  D

Preoperative medications can include sedatives but are often given to prevent laryngospasm and to help reduce pharyngeal and gastric secretions. The client must be fully aware of the rationale for all medications and the risks of not taking them.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

MSC:  Integrated Process: Communication and Documentation

 

  1. A client receiving preoperative medication tells the nurse that she took all the following vitamins and herbs last night before going to bed. Which one does the nurse report to the surgical team as a priority?
a. Valerian root
b. St. John’s wort
c. Garlic
d. Chamomile

 

 

ANS:  C

Garlic interferes with coagulation, increasing the client’s risk for bleeding during and after the surgical procedure. This would be a critical piece of information for the surgical team to know.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions)

MSC:  Integrated Process: Nursing Process (Intervention)

 

  1. The nurse reviews a client’s laboratory results before surgery and notes a fasting blood glucose of 120 mg/dL, a prothrombin time (PT) of 25 seconds, and potassium (K+) of 3.8 mEq/L. Which action by the nurse is best?
a. Ask the surgeon for additional laboratory studies.
b. Administer a potassium supplement of 20 mEq.
c. Increase the IV infusion of D5W to 100 mL/hr.
d. Record laboratory results on the preoperative assessment.

 

 

ANS:  A

The prothrombin time is elevated, which could lead to bleeding during or after surgery. The surgeon and the anesthesiologist should be notified of this laboratory test result right away, and additional coagulation studies will be needed. The potassium is within normal limits. The blood glucose level is elevated but not critically so. The surgeon should be notified of all laboratory work, and the client may need an IV solution without glucose. The results should be recorded, but the surgery will likely be cancelled owing to the coagulation problem, which is the priority concern with this client.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values)       MSC:           Integrated Process: Nursing Process (Analysis)

 

  1. A client is brought to the emergency department (ED) after a motorcycle accident. The client has suffered a ruptured spleen. What is the immediate priority?
a. Emergent surgery to control bleeding
b. Aggressive pain control
c. Calling the family members
d. Assessment of neurologic status

 

 

ANS:  A

Emergent surgery is indicated when the client may die without immediate intervention. Other interventions are appropriate but do not have the priority because controlling hemorrhage via surgery is the priority.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies)      MSC:           Integrated Process: Nursing Process (Implementation)

 

  1. The nurse has just completed preoperative teaching with a client who will be having surgery the following day. Which statement by the client indicates that additional teaching is needed?
a. “When I brush my teeth before surgery, I will be sure to spit out the water.”
b. “I will go to the bathroom as soon as I receive all my preoperative medications.”
c. “I will remember to wear my glasses tomorrow instead of my contact lenses.”
d. “I won’t have to worry about putting my makeup on tomorrow morning.”

 

 

ANS:  B

The client should void before receiving any preoperative medication. The medication could make the client sleepy and at risk for falling. The other statements are correct.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention)               MSC:  Integrated Process: Teaching/Learning

 

  1. The nurse is performing preoperative teaching with an older adult client who will be having colon resection surgery the following day. The surgeon has ordered bowel preparation the night before. Which action is a priority?
a. Administer antibiotics with a sip of water.
b. Encourage the client to drink plenty of juice.
c. Teach the client to eat only low-fat foods the night before surgery.
d. Tell the client not to get up and go to the bathroom alone.

 

 

ANS:  D

Safety is the priority, and the older adult client can become exhausted and may fall. Antibiotics, if ordered, would be administered with a sip of water, but this is not the priority. The client would not be encouraged to drink juice, because this is not a clear liquid.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. When examining an adult client’s preoperative laboratory results, the nurse notes that the potassium level is 2.9 mEq/mL. What is the nurse’s priority action?
a. Document the finding.
b. Alter the client’s diet to include fruit.
c. Increase the IV flow rate.
d. Notify the surgeon.

 

 

ANS:  D

The normal range for serum potassium is 3.5 to 5.0 mEq/L or mmol/L. A value of 2.9 represents hypokalemia, which must be corrected before surgery. The surgeon should be notified of this finding. The finding should be documented; however, notifying the surgeon is the priority.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values)       MSC:           Integrated Process: Nursing Process (Implementation)

 

  1. What recently learned information about a client who is scheduled to have surgery within the next 2 hours is the nurse certain to communicate to the surgical team?
a. An allergy to cats
b. Hearing problem
c. Consumption of a glass of wine 12 hours ago
d. Taking 2000 mg of vitamin C each day

 

 

ANS:  B

The team will need to communicate with the client in the surgical holding area, in the operating room, and in the postanesthesia recovery unit. Any problem with communication, such as a hearing impairment, should be stressed, so that team members can use alternative means to ensure accurate communication with the client.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. A client will be undergoing palliative surgery. The client’s daughter asks what this means. What is the nurse’s best response?
a. “The surgery will relieve the symptoms but will not cure your father.”
b. “There are fewer risks with this type of surgery.”
c. “There is no guarantee of the outcome of the surgery.”
d. “The surgery must be performed immediately to save your father’s life.”

 

 

ANS:  A

The purpose of palliative surgery is to improve the client’s quality of life by reducing or eliminating distressing symptoms. It does not cure a health problem and often does not prolong life.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   Table 16-1, p. 242

TOP:   Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort Measures)

MSC:  Integrated Process: Communication and Documentation

 

  1. Twenty minutes after a client has received a preoperative injection of atropine and midazolam (Versed), the client tells the nurse that he must be allergic to the medication because his mouth is dry and his heart seems to be beating faster than normal. What is the nurse’s priority action?
a. Document the findings.
b. Assess the client’s pulse and blood pressure.
c. Administer diphenhydramine (Benadryl).
d. Explain to the client that these symptoms are expected.

 

 

ANS:  B

Although these are expected physiologic responses to the preoperative medication, whenever the client states that he or she can feel a change in normal cardiac function, he should be assessed.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. A client undergoing preoperative assessment informs the nurse that he takes medication for high blood pressure and for asthma. What is the nurse’s best action?
a. Tell the client not to take the medication on the day of surgery.
b. Notify the surgeon and the anesthesiologist.
c. Document the information in the client’s record.
d. Tell the client to take medications preoperatively with a sip of water.

 

 

ANS:  B

Medications for cardiac and respiratory problems usually are given with sips of water before surgery. However, the nurse should notify the surgeon and the anesthesiologist before giving the client any advice. While some medications can be given with a sip of water, other medications must be held for a specified time before surgery. Documentation should occur, but only after the nurse has consulted with the physician and anesthesiologist and has spoken to the client.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. Which action is most appropriate during a preoperative chart review?
a. Ensure that the consent form is signed, dated, and witnessed.
b. Call the surgeon if the client has any food allergies.
c. Make sure all marks are washed off the surgical site.
d. Make sure the client understands the procedure.

 

 

ANS:  A

During the preoperative chart review, the nurse should make sure that the consent form is signed, dated, and witnessed. The nurse does not have to call the surgeon for food allergies, nor should the marks be washed off the surgical site. The client should be taught about the procedure before the preoperative chart review.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 259

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. The nurse is caring for a client who will be undergoing emergency surgery as soon as possible. Which information is most important for the nurse to teach the client at this time?
a. How the surgery will be performed
b. Importance of early ambulation after surgery
c. What to expect in the operating and recovery rooms
d. Complications that may occur after surgery

 

 

ANS:  C

With only a few minutes before surgery, the nurse should tell the client what to expect in the operating room and in the recovery room to minimize his or her anxiety. Although the other information is important, the nurse needs to start with what is vital for the client to know right now.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC:  Integrated Process: Teaching/Learning

 

  1. A client tells the nurse that he has an advance directive with durable power of attorney for health care. The client asks how the advance directive will affect the surgery. What is the nurse’s best response?
a. “You will not be intubated during general anesthesia for the surgery.”
b. “There will be no effect on your surgery.”
c. “The surgical staff will resuscitate only if your heart stops during the operation.”
d. “If you are unable to make a decision, your designee will be asked.”

 

 

ANS:  D

The advance directive with durable power of attorney indicates whom the client wishes to designate for medical decisions if he is unable to make decisions for himself. An advance directive with power of attorney does not eliminate the need for intubation during surgery. Although the document does not affect the procedure, simply acknowledging that fact does not help the client understand. If the client’s heart stops during the operation and the client has not made his or her wishes known about that situation, the power of attorney would be consulted.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 252

TOP:   Client Needs Category: Safe and Effective Care Environment (Management of Care—Advance Directives           MSC:              Integrated Process: Communication and Documentation

 

  1. A client is brought to the hospital unconscious and needs emergency surgery. The client’s only family member cannot come to the hospital before the surgery. Which is the best option for obtaining informed consent for the client’s emergent surgery?
a. Proceed with surgery and have the family member sign the consent as soon as possible.
b. Contact the family member by phone and obtain verbal consent with two witnesses.
c. Obtain written consultation with two surgeons that the surgery is needed.
d. Have the hospital administrator appoint a temporary legal guardian.

 

 

ANS:  B

In the event that a family member cannot come to the hospital before the surgery needs to begin, verbal consent should be obtained over the phone with two witnesses.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Management of Care—Informed Consent)

MSC:  Integrated Process: Communication and Documentation

 

  1. Four clients are scheduled for surgery. Which client does the nurse determine is at highest risk for postsurgical complications?
a. 89-year-old scheduled for a knee replacement
b. 40-year-old requiring gallbladder surgery
c. 19-year-old requiring a laparoscopy
d. 10-year-old admitted for a tonsillectomy

 

 

ANS:  A

The older client is at highest risk for postoperative complications. Older adults often have multiple medical conditions, take several medications, are slightly dehydrated, and may have cognitive or physical impairments that potentially could hinder their recovery from an operation.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. The nurse is conducting preoperative assessments. Which client does the nurse teach about the possibility of developing a venous thromboembolism (VTE)?
a. Client with a latex allergy
b. Client with body mass index (BMI) of 19
c. Client with an international normalized ratio (INR) of 2.2
d. Client undergoing hip replacement surgery

 

 

ANS:  D

The client will have limited mobility following hip replacement surgery, increasing the risk of postoperative venous thromboembolism (VTE). The other conditions will not increase the risk of VTE.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. The nurse applies antiembolism stockings to a client preoperatively. When the client says that they are uncomfortably tight, what is the nurse’s best action?
a. Remove the stockings for an hour to relieve the pressure.
b. Pull the stockings down so that they are not constricting.
c. Measure the client’s calf to ensure that they are the correct size.
d. Teach the client the purpose of wearing the stockings.

 

 

ANS:  D

Thromboembolic disease (TED) stockings should feel slightly tight on the legs to promote venous return and prevent the client from developing venous thromboembolism (VTE). The nurse should not remove the stockings nor pull them down. The calf would have been measured before the stockings were obtained.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

MSC:  Integrated Process: Teaching/Learning

 

MULTIPLE RESPONSE

 

  1. The nurse is assessing a client before surgery. Which assessments contraindicate the client having surgery as scheduled? (Select all that apply.)
a. Potassium level of 2.8 mEq/L
b. International normalized ratio (INR) of 4
c. Prothrombin time (PTT) of 30 seconds
d. Calcium level of 8.8 mEq/dL
e. Positive pregnancy test
f. Platelet count of 150,000

 

 

ANS:  A, B, E

Hypokalemia, elevated bleeding times, and a positive pregnancy test could all contradict the client having surgery as scheduled and could lead to complications. Normal PTT, normal calcium, and normal platelet count would not contradict surgery.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values)       MSC:           Integrated Process: Nursing Process (Assessment)

 

  1. Which medications does the nurse correctly administer preoperatively? (Select all that apply.)
a. Hydroxyzine (Atarax, Vistaril) for sedation
b. Lorazepam (Ativan) for anxiety
c. Hydromorphone (Dilaudid) to decrease postoperative secretions
d. Metoclopramide (Reglan) to increase stomach emptying
e. Aspirin to decrease blood clotting postoperatively
f. Cimetidine (Tagamet) to prevent infection

 

 

ANS:  A, B, D

The nurse will administer hydroxyzine (Atarax) for sedation, lorazepam (Ativan) for anxiety, and metoclopramide (Reglan) to increase stomach emptying. Hydromorphone is given for pain, and cimetidine (Tagamet) decreases histamine. Aspirin would not be administered preoperatively because it can increase bleeding.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)   MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. The nurse is conducting preoperative teaching with a client who will be undergoing pelvic surgery. What teaching is essential for this client? (Select all that apply.)
a. “Wearing elastic stockings and using pneumatic compression devices are essential after surgery.”
b. “Extended bedrest will help you heal after this type of surgery.”
c. “Coughing and deep breathing will help to decrease postoperative complications.”
d. “Turning and moving your legs after surgery will help prevent clots from forming.”
e. “You will need to have your abdomen shaved before surgery.”
f. “You cannot wear your hearing aid into the surgical suite.”

 

 

ANS:  A, C, D

A pneumatic compression device and elastic stockings will help prevent clots after pelvic surgery. Coughing and deep breathing will help to decrease postoperative respiratory complications. Turning and moving legs after surgery will also help prevent clots. Hearing aids can be worn into the surgical suite because this will help communication before surgery. Extended bedrest is not helpful, and shaving would not be necessary.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

MSC:  Integrated Process: Teaching/Learning

 

  1. What data are essential for the nurse to assess on a client who is scheduled for surgery? (Select all that apply.)
a. Use of tobacco
b. Current medications
c. Use of herbal or over-the-counter therapy
d. Mental status examination
e. Power of attorney
f. Allergies
g. Date of last tetanus shot

 

 

ANS:  A, B, C, D, F

The client should be screened for things that may increase the risk of complications during surgery. Smoking, certain medications and herbs, and allergies may increase a client’s risk. Mental status examination is essential to determine competency and ability to teach. The date of the client’s last tetanus shot is not required information from a preoperative chart review.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 242

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations)

MSC:  Integrated Process: Communication and Documentation

 

OTHER

 

  1. The nurse is preparing to transfer a client to the operating room for surgery. Put the interventions in order for the nurse to perform. (List in order of priority.)
  2. Take a full set of vital signs.
  3. Have the client go to the bathroom to void.
  4. Ask the client to state his or her name and check the ID band.
  5. Administer ordered preoperative sedation.

 

ANS:

c, b, a, d

First, the nurse should identify the client using two identifiers to ensure that the correct client is being prepped for surgery. Next, the nurse should assist the client to the bathroom, then take vital signs, then finally administer preoperative sedation once the client is in bed.

 

DIF:    Cognitive Level: Application/Applying or higher

TOP:   Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention)

MSC:  Integrated Process: Nursing Process (Implementation)

 

 

Chapter 32: Care of Patients with Noninfectious Lower Respiratory Problems

Test Bank

 

MULTIPLE CHOICE

 

  1. A client with asthma reports “not being able to take deep breaths.” The nurse auscultates decreased breath sounds in the bases, and no wheezes. What is the nurse’s best action?
a. Encourage the client to stay calm and take deep breaths.
b. Document the findings and continue to monitor.
c. Have the client cough forcefully.
d. Assess the client’s oxygen saturation.

 

 

ANS:  D

Decreased wheezing accompanied by decreased breath sounds can mean airway occlusion from mucus and from inflammation. The nurse should assess the client’s oxygenation and determine whether additional interventions are needed. Coughing forcefully may cause the smaller airways to collapse and may not help the client. Encouraging the client to remain calm and to try to take deep breaths is not helpful. Although providing documentation is important, the nurse needs to do more than that.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. A client with asthma has been having frequent asthma attacks. What is the nurse’s best action?
a. Teach the client to stay away from pets.
b. Assist the client in using an incentive spirometer.
c. Administer aspirin for its anti-inflammatory properties.
d. Administer montelukast (Singulair).

 

 

ANS:  D

A client who has been having increased attacks can have some chronic inflammation occurring. This inflammation is probably stimulated by mediators such as histamine and leukotriene and can be blocked by drugs like diphenhydramine (Benadryl) and montelukast (Singulair).

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. A client diagnosed with asthma has not responded well to medication. The client is concerned and asks the nurse, “What is wrong with me, and why am I not getting better?” What is the nurse’s best response?
a. “You just weren’t used to the medication yet.”
b. “The medication dose has to be increased.”
c. “It is possible that genetic testing may help.”
d. “You should try homeopathic medicine.”

 

 

ANS:  C

Some genetic variations may cause the activity of beta-adrenergic receptors to change, meaning that the client would not respond as expected to beta agonists. Genetic testing may help to determine why the drug therapy is not working and may help the clinician to identify new therapy that will work.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. The nurse is caring for four clients with asthma. Which client does the nurse assess first?
a. Client with a barrel chest and clubbed fingernails
b. Client with an SaO2 level of 92% at rest
c. Client whose expiratory phase is longer than the inspiratory phase
d. Client whose heart rate is 120 beats/min

 

 

ANS:  D

Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. A barrel chest is not an emergency finding. Likewise a pulse oximetry level of 92% is not considered an acute finding. The expiratory phase is expected to be longer than the inspiratory phase in someone with airflow limitation.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)           MSC:              Integrated Process: Nursing Process (Assessment)

 

  1. The nurse is caring for an older adult who reports experiencing frequent asthma attacks and severe arthritic pain. What action by the nurse is most appropriate?
a. Review pulmonary function test results.
b. Assess use of medication for arthritis.
c. Assess frequency of bronchodilator use.
d. Review arterial blood gas results.

 

 

ANS:  B

Aspirin and other NSAIDs can trigger asthma in some people. This results from increased production of leukotriene when aspirin or NSAIDs suppress other inflammatory pathways and is a high priority given the client’s history. Reviewing pulmonary function test results will not address the immediate problem of frequent asthma attacks. This is a good intervention for reviewing response to bronchodilators. Questioning the client about the use of bronchodilators will address interventions for the attacks but not their cause. Reviewing arterial blood gas results would not be of use in a client between attacks because many clients are asymptomatic when not having attacks.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. The nurse is evaluating a client’s response to medication therapy for asthma. The client has a peak flowmeter reading in the yellow zone. What does the nurse do next?
a. Nothing; this is an acceptable range.
b. Teach the client to take deeper breaths.
c. Assist the client to use a rescue inhaler.
d. Assess the client’s lungs.

 

 

ANS:  C

The client with a peak flow reading in the yellow zone needs to use a rescue inhaler, then have a reading taken again within a few minutes. The nurse has no reason to assess the client’s lungs at this point in time, nor would the nurse take the time to teach at this moment.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. Which statement indicates that the client understands teaching about the use of long-acting beta2 agonist medications?
a. “I will not have to take this medication every day.”
b. “I will take this medication when I have an asthma attack.”
c. “I will take this medication daily to prevent an acute attack.”
d. “I will eventually be able to stop using this medication.”

 

 

ANS:  C

This medication will help prevent an acute asthma attack because it is long acting. The client will take this medication every day for best effect. This is not the medication the client will use during an acute asthma attack because it does not have an immediate onset of action. The client will not be weaned off this medication because this is likely to be one of his or her daily medications.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)   MSC:  Integrated Process: Nursing Process (Evaluation)

 

  1. Which statement indicates that a client understands teaching about the correct use of a corticosteroid medication?
a. “This drug can reverse my symptoms during an asthma attack.”
b. “This drug is effective in decreasing the frequency of my asthma attacks.”
c. “This drug can be used most effectively as a rescue agent.”
d. “This drug can be used safely on a long-term basis for multiple applications daily.”

 

 

ANS:  B

Corticosteroids decrease inflammatory and immune responses in many ways, including preventing the synthesis of mediators. Both inhaled corticosteroids and those taken orally are preventive; they are not effective in reversing symptoms during an asthma attack and should not be used as rescue drugs. Systemic corticosteroids, because of severe side effects, are avoided for mild to moderate intermittent asthma and are used on a short-term basis for moderate asthma.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)   MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. A client is using omalizumab (Xolair) for the first time. What is the priority nursing action?
a. Make sure the client takes the medication with water.
b. Administer ibuprofen (Motrin) because Xolair often causes headaches.
c. Teach the client how to use a syringe.
d. Remain with the client and assess for anaphylaxis.

 

 

ANS:  D

Immune modulators are monoclonal antibodies that prevent allergens from binding to receptor sites on mast cells and basophils. The risk of anaphylaxis is high; the nurse should assess and stay with the client.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. A client is demonstrating diaphragmatic breathing for the nurse. Which action by the client shows adequate understanding of this breathing technique?
a. Lying on his or her side with knees bent
b. Having his or her hands on the abdomen
c. Having his or her hands over the head
d. Lying in the prone position

 

 

ANS:  B

To perform diaphragmatic breathing correctly, the client should put the hands on his or her abdomen to create resistance. This type of breathing cannot be performed effectively while lying on the side or with hands over the head. This type of breathing would not be as effective lying prone.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)           MSC:              Integrated Process: Teaching/Learning

 

  1. A client is undergoing lung reduction surgery. What is the nurse’s highest priority preoperatively?
a. Administer medications.
b. Discuss the possibility of ventilator dependency.
c. Teach how to cough and deep breathe.
d. Teach about preoperative testing.

 

 

ANS:  D

In addition to standard preoperative testing, the client who will undergo lung reduction surgery is tested to determine the location of greatest lung hyperinflation and poorest lung blood flow. These tests include pulmonary plethysmography, gas dilution, and perfusion scans. The other interventions are lower priorities.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. The nurse assesses a client receiving chemotherapy for lung cancer and notes red swollen mucous membranes and open sores in the mouth. The client reports mouth pain and difficulty swallowing. Which action does the nurse perform first?
a. Document the size of the sores.
b. Perform mouth hygiene.
c. Have the client rinse his or her mouth.
d. Call the health care provider and hold chemotherapy.

 

 

ANS:  D

Although the nurse should perform all interventions for mucositis, the priority is to call the health care provider and hold the chemotherapy. Mucositis may be a dose-limiting condition in chemotherapy. The nurse should call the provider, then should assist the client with mouth hygiene, rinsing the mouth, and obtaining pain relief. Documenting the size and location of ulcers is also important.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. A client is undergoing radiation therapy as treatment for lung cancer and has developed esophagitis. Which is the best diet selection for this client?
a. Spaghetti with meat sauce, ice cream
b. Scrambled eggs, bacon, toast
c. Omelet, whole wheat bread
d. Pasta salad, custard, orange juice

 

 

ANS:  C

Side effects of radiation therapy may include inflammation of the esophagus. Clients should be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements. Tomato sauce may prove too spicy for a client with esophagitis. Toast is too difficult to swallow with this condition, and orange juice and other foods with citric acid are too caustic.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 633

TOP:   Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration)           MSC:              Integrated Process: Nursing Process (Assessment)

 

  1. A client with lung cancer refuses pain medications because he or she is “afraid of addiction.” What is the nurse’s best response?
a. “I can ask the physician to change your medication to a drug that is less potent.”
b. “I can use other measures such as music therapy to distract you.”
c. “It is unlikely you will become addicted from taking medicine for pain.”
d. “I can just give you aspirin or acetaminophen (Tylenol) if you like.”

 

 

ANS:  C

Clients should be encouraged to take their pain medications; addiction usually is not an issue with a client in pain. The nurse would not request that the pain medication be changed unless it was not effective. Other methods to decrease pain can be used, in addition to pain medications.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Pharmacological Pain Management)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. What is the best instruction for a client who has step II (mild persistent) asthma?
a. “Avoid participating in aerobic exercise.”
b. “You will need daily inhaled low-dose steroids.”
c. “You need to evaluate your diet for asthma triggers.”
d. “Make sure you use a rescue inhaler three times per day.”

 

 

ANS:  B

The most important information for clients with step II (mild persistent) asthma is that they need daily preventive anti-inflammatory medication. Low-dose inhaled steroids are necessary. The client should exercise as tolerated; however, using a rescue inhaler frequently is not recommended and, if this is needed, it should be reported to the health care provider because a change in therapy is likely needed.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   Chart 32-2, p. 603

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)         MSC:           Integrated Process: Teaching/Learning

 

  1. The nurse assesses a client with asthma and finds wheezing throughout the lung fields and decreased pulse oxygen saturation. In addition, the nurse notes suprasternal retraction on inhalation. What is the nurse’s best action?
a. Perform peak expiratory flow readings.
b. Assess for a midline trachea.
c. Administer oxygen and a rescue inhaler.
d. Call a code.

 

 

ANS:  C

Suprasternal retraction caused by inhalation usually indicates that the client is using accessory muscles and is having difficulty moving air into the respiratory passages because of airway narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also supports this finding. The asthma is not responding to the medication, and intervention is needed. Administration of a rescue inhaler is indicated, probably along with administration of oxygen. The nurse would not do a peak flow reading at this time, nor would a code be called. Midline trachea is a normal and expected finding.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)         MSC:           Integrated Process: Nursing Process (Implementation)

 

  1. The nurse is teaching a client with asthma about self-management. Which statement by the nurse is best?
a. “Keep a daily symptom and intervention diary.”
b. “Measure your anterior/posterior diameter weekly.”
c. “Note your symptoms when you don’t take your medications.”
d. “Exercise before and after taking inhalers and compare tolerance.”

 

 

ANS:  A

The nurse should tell the client to keep a daily symptom diary. This will help identify triggers and responses to therapy in asthma. Chest circumference is not expected to change in clients with asthma. The client should not be instructed to discontinue medications. Comparing exercise tolerance before and after activity will not give the client the most complete information about his or her asthma.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 606

TOP:   Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC:  Integrated Process: Teaching/Learning

 

  1. Which statement indicates that a client needs additional teaching about using an inhaler?
a. “I will not exhale into the inhaler.”
b. “I will store the inhaler in a drawer in my bedroom.”
c. “I will soak my inhaler in water to clean it.”
d. “I will inhale and hold my breath.”

 

 

ANS:  C

Submerging an inhaler in water to wash it is not necessary and may cause the medication in the inhaler to clump together if it is a dry powder inhaler. The other statements are all correct—the client should not exhale into the inhaler, can store the inhaler in his or her bedroom, and will need to inhale and hold breath slightly when using the inhaler.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. The home care nurse observes white patches on the oral mucosa of a client with severe, chronic airflow limitation. What is the nurse’s best action?
a. Ask the client whether he or she uses a steroid inhaler.
b. Inquire about any recent viral illnesses.
c. Have the client rinse the mouth with salt water.
d. Have the client brush the patches with a soft-bristled brush.

 

 

ANS:  A

Excessive use of steroid inhalers reduces local immune function and increases the client’s risk for oral-pharyngeal infection, including candidiasis, which manifests as white patches on the oral mucosa. The client should not brush the lesions, and salt water will not help the sores. Recent illnesses would have no effect on these lesions.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. What statement indicates that a client needs further teaching regarding therapy with salmeterol (Serevent)?
a. “I will be certain to shake the inhaler well before I use it.”
b. “It may take a while before I notice a change in my asthma.”
c. “I will use the drug when I have an asthma attack.”
d. “I will be careful not to let the drug escape out of my nose and mouth.”

 

 

ANS:  C

Salmeterol is designed to prevent an asthma attack; it does not relieve or reverse symptoms. The client does not have to keep this inhaler with him or her always because it is not used as a rescue medication. Salmeterol (Serevent) has a slow onset of action; therefore it should not be used as a rescue drug. The drug must be shaken well because it has a tendency to separate easily. Poor technique on the client’s part allows the drug to escape through the nose and mouth.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC:  Integrated Process: Nursing Process (Evaluation)

 

  1. The nurse is teaching a client about different medications for asthma. Which medication does the nurse teach the client to administer to control the prolonged inflammatory response?
a. Diphenhydramine (Benadryl)
b. Montelukast (Singulair)
c. Aspirin
d. Bitolterol (Tornalate)

 

 

ANS:  B

Leukotriene and eotaxin cause later, prolonged inflammatory responses in asthma, which can be blocked by drugs like montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo). No evidence suggests that aspirin helps this inflammatory response. Histamine starts an immediate inflammatory response, which can be blocked by drugs like diphenhydramine (Benadryl). Bitolterol (Tornalate) is a short-acting beta agonist that will enhance bronchodilation during an asthma attack, but it will not assist in controlling late inflammation.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   Chart 32-6, p. 606

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)   MSC:  Integrated Process: Teaching/Learning

 

  1. A client with chronic obstructive pulmonary disease (COPD) reports social isolation. What does the nurse encourage the client to do?
a. Join a support group for people with COPD.
b. Ask the client’s physician for an antianxiety agent.
c. Verbalize his or her thoughts and feelings.
d. Participate in community activities.

 

 

ANS:  C

Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They also can experience fatigue, which limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be selected. Joining a support group would not decrease feelings of social isolation if the client does not verbalize feelings. Antianxiety agents will not help the client with social isolation. Encouraging a client to participate in activities without verbalizing concerns also would not be an effective strategy for decreasing social isolation.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Psychosocial Integrity (Coping Mechanisms)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. The nurse is teaching a client with cystic fibrosis. What activity does the nurse teach as the priority?
a. Taking daily antibiotics
b. Having genetic screening
c. Maintaining good nutrition
d. Exercising daily

 

 

ANS:  C

Clients with cystic fibrosis (CF) often are malnourished owing to vitamin deficiency and pancreatic malfunction. Maintaining nutrition is essential. Daily antibiotics and daily exercise are not essential actions. Genetic screening would not help the client manage CF better.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC:  Integrated Process: Teaching/Learning

 

  1. The nurse is assessing a client with lung disease. Which symptom does the nurse intervene for first?
a. The client’s anterior-posterior chest diameter is 2:2.
b. Clubbing of the finger tips is noted.
c. The client has bilateral dependent leg edema.
d. The client is pale.

 

 

ANS:  C

The client with bilateral dependent edema may be developing right-sided heart failure in response to respiratory disease. This symptom should be investigated right away and reported to the health care provider. Further assessment is needed. The client with chronic lung disease may develop increased anterior-posterior diameter and clubbing as responses to chronic hypoxia. These symptoms do not require immediate intervention. The client is often pale or has a dusky appearance; this also would not warrant immediate intervention.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. A client with lung cancer is lying flat in bed and reports shortness of breath. What action does the nurse take first?
a. Notify the health care provider.
b. Elevate the head of the bed.
c. Assess oxygen saturation.
d. Have the client take deep breaths.

 

 

ANS:  B

The nurse’s first action should be to elevate the head of the bed. Next, assessing oxygen saturation will help the nurse determine the client’s status. If the oxygen is low, the nurse would increase oxygen flow and have the client take deep breaths. The provider could be notified after the nurse performs the interventions.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)           MSC:              Integrated Process: Nursing Process (Implementation)

 

  1. The nurse observes hematuria in a client receiving IV cyclophosphamide (Cytoxan). After notifying the health care provider, what intervention is the nurse’s priority?
a. Obtain a urine specimen.
b. Assess laboratory studies.
c. Increase hydration.
d. Stop the medication.

 

 

ANS:  D

Hemorrhagic cystitis is a frequent side effect of cyclophosphamide therapy. The physician should be notified to prescribe co-administration of a bladder-protecting agent. The nurse then should stop the medication. Other actions would be to further assess the client and provide hydration to flush the medication.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. A client with pulmonary fibrosis is being discharged home. What is the highest priority teaching need?
a. Dietary modifications
b. Determining activity tolerance
c. Avoiding infection
d. Medication therapy

 

 

ANS:  C

It is extremely important to teach the client with pulmonary fibrosis to avoid infection because the disease will quickly become worse as a result of decreased lung function. The client may take longer to recover from an infection, and the ability to recover may be severely limited owing to the progression of the disease. Teaching the client about modifications in diet, how to determine response to activity, and treatment medications would be secondary.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC:  Integrated Process: Teaching/Learning

 

  1. The nurse is caring for a client with bronchiolitis obliterans organizing pneumonia (BOOP) and assesses decreased vital capacity during pulmonary function testing. What is the nurse’s best action?
a. Administer intermittent positive-pressure breathing treatments.
b. Administer a short-acting beta-adrenergic medication.
c. Prepare to administer IV antibiotics.
d. Document the finding in the client’s chart.

 

 

ANS:  D

Decreased vital capacity is a common finding with this disorder because the white blood cells clump and obliterate airways. The nurse should note the finding and should assist the client in activities that help him or her maintain quality of life.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. The nurse is teaching a client with bronchiolitis obliterans organizing pneumonia (BOOP) about corticosteroid therapy. What statement is accurate for the nurse to teach the client?
a. “You will be on this drug the rest of your life.”
b. “You will be prone to many long-term side effects of this drug.”
c. “A short course of therapy will help with acute episodes.”
d. “This medication cannot be taken with antibiotic therapy.”

 

 

ANS:  C

Corticosteroids are used for acute episodes and are very effective in decreasing manifestations. The client may never have another relapse after therapy. The client is not on the drug for “life,” and therefore is not prone to long-term side effects. Agents can be given with antibiotics.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 630

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)   MSC:  Integrated Process: Teaching/Learning

 

  1. A client recently diagnosed with lung cancer is being taught by the nurse. What information does the nurse teach the client?
a. “You will receive 6 weeks of daily radiation therapy.”
b. “Lung cancer has a very good prognosis.”
c. “Further testing is not needed because lung cancer rarely metastasizes.”
d. “It is very likely that surgery will be curative.”

 

 

ANS:  A

This is the only statement that is accurate. Small doses of radiation given over long periods are an effective routine treatment. Lung cancer does not have a good prognosis, and it often metastasizes. Surgery often is only palliative.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 633

TOP:   Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

MSC:  Integrated Process: Teaching/Learning

 

  1. Which nursing intervention is an example of primary prevention for lung cancer?
a. Teaching clients with lung cancer how to cough and deep breathe
b. Teaching clients with lung cancer to avoid infection
c. Teaching clients about prophylactic antibiotics
d. Teaching people about smoking and secondhand smoke

 

 

ANS:  D

Primary prevention for lung cancer focuses on reducing tobacco smoking. The other examples are examples of secondary prevention.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 631

TOP:   Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

MSC:  Integrated Process: Teaching/Learning

 

  1. A client’s chest tube is accidentally dislodged. What action by the nurse is best?
a. No action is necessary because the area will reseal itself.
b. Cover the insertion site with a sterile gauze and tape three sides.
c. Obtain a suture kit and prepare for the physician to suture the site.
d. Cover the area with an occlusive dressing.

 

 

ANS:  B

Immediately covering the insertion site helps prevent air from entering the pleural space and causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering the chest. The nurse should not leave the client to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies)      MSC:           Integrated Process: Nursing Process (Implementation)

 

  1. Which is the highest priority problem for a client with late-stage lung cancer?
a. Malnutrition
b. Constipation
c. Weakness and fatigue
d. Pain

 

 

ANS:  D

Although all of these problems are important issues, effective pain management is the most important issue for this client and family. The nurse must serve as a client advocate and must ensure that all appropriate measures for management of intractable, severe pain are implemented.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Management of Care—Illness Management)           MSC:              Integrated Process: Nursing Process (Diagnosis)

 

  1. The nurse assesses a client’s chest tube and finds continuous bubbling in the water seal chamber. When the nurse clamps the chest tube close to the client’s dressing, the bubbling stops. How does the nurse interpret this finding?
a. An air leak is present at the chest tube insertion site or in the thoracic cavity.
b. An air leak is present in the drainage system.
c. More water needs to be added to the water seal.
d. The system is functioning appropriately and no intervention is needed.

 

 

ANS:  A

Bubbling in the water seal chamber indicates air drainage from the client and usually is seen when the client’s intrathoracic pressure is greater than atmospheric pressure, such as during exhalation, coughing, or sneezing. When the air in the pleural space has been sufficiently removed, bubbling stops. Continuous bubbling indicates an air leak. If the air leak is in the thoracic cavity, air and air pressure increase in the thoracic cavity, forcing more air into the water seal chamber. This air movement is prevented when the chest tube is clamped close to the insertion site.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)         MSC:           Integrated Process: Nursing Process (Assessment)

 

  1. A client was diagnosed with lung cancer and appears distressed. The client states, “I am so afraid.” What is the best action for the nurse to take?
a. Provide comfort by holding the client’s hand.
b. Offer to give the client a back rub for relaxation.
c. Offer the client a PRN antianxiety medication.
d. Ask the client what is causing the most fear right now.

 

 

ANS:  D

A diagnosis of lung cancer often causes fear for many reasons, usually poor prognosis, fear of pain, and fear of dyspnea. The nurse should assess what is worrying the client most at the moment so appropriate interventions can be planned. Touch is often a powerful tool, but the nurse should assess whether this is acceptable to the client. The nurse should assess the client further and provide assistance with coping before offering to medicate him.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Psychosocial Integrity (Stress Management)

MSC:  Integrated Process: Caring

 

  1. The nurse is assessing a client who has a chest tube. Which assessment finding requires intervention by the nurse?
a. Pain at the insertion site
b. Bloody drainage in the collection chamber
c. Intermittent bubbling in the water seal chamber
d. Tidaling in the water seal chamber

 

 

ANS:  A

Pain is the priority for the client. Bloody drainage may be normal, depending on the client’s condition. Intermittent bubbling in the water seal indicates air escaping as the lung fully expands, and does not need to be addressed immediately. Tidaling often occurs with inspiration and expiration.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)         MSC:           Integrated Process: Nursing Process (Implementation)

 

  1. The nurse assesses a client who is on fluticasone (Flovent) and notes oral lesions. What is the nurse’s best action?
a. Teach the client to rinse the mouth after Flovent use.
b. Have the client use a mouthwash daily.
c. Start the client on a broad-spectrum antibiotic.
d. Document the finding as a known side effect.

 

 

ANS:  A

The drug reduces local immunity and increases the risk for local infection, especially Candida albicans. Rinsing the mouth after using the inhaler will decrease the risk for developing this infection. Use of mouthwash and broad-spectrum antibiotics is not warranted in this situation. The nurse should document the finding, but the best action to take is to have the client start rinsing his or her mouth after using Flovent.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. A client has recently been placed on prednisone (Deltasone). What is the highest priority instruction the nurse will provide?
a. “Expect to experience weight gain.”
b. “Watch your diet while on this medication.”
c. “Take the drug with food or milk.”
d. “Report any abdominal pain or dark-colored vomit.”

 

 

ANS:  D

All of these directions are appropriate to give the client; however, telling the client to report abdominal pain and dark-colored vomit is most important because these could signal gastric ulceration.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects)

MSC:  Integrated Process: Teaching/Learning

 

  1. A client infected with Burkholderia cepacia is admitted to the unit. What is the nurse’s priority action when caring for this client?
a. Instruct the client to wash his or her hands after contact with other people.
b. Place the client on strict isolation.
c. Keep the client isolated from other clients with cystic fibrosis.
d. Administer IV vancomycin daily.

 

 

ANS:  C

The infection is spread through casual contact between cystic fibrosis clients, thus the need for isolation of these clients from each other. Strict isolation measures will not be necessary. Although the client should wash his or her hands frequently, the most important measure that can be implemented on the unit is isolation of the client from other cystic fibrosis clients.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. The nurse assesses the following lung sounds in a client. What is the nurse’s best action? (Click the media button to hear the audio clip.)
a. Administer a rescue inhaler.
b. Administer oxygen.
c. Assess vital signs.
d. Elevate the client’s head.

 

 

ANS:  A

Stridor is the sound heard. This sound indicates severe airway constriction. The nurse must administer a bronchodilator to get air into the lungs. Administering oxygen will not help until the client’s airways are open.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation-Pathophysiology)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. The nurse assesses an older adult after an upper respiratory infection and notes the following lung sound on auscultation. What is the nurse’s best action? (Click the media button to hear the audio clip.)
a. Assess the client for the development of asthma.
b. Ask the client if he or she finished all the medication.
c. Administer oxygen immediately.
d. Assess arterial blood gas.

 

 

ANS:  A

Scattered wheezes is the sound heard. New-onset asthma can occur in older clients after they recover from an upper respiratory infection or severe cold. The nurse should assess the client for other symptoms such as sputum production and  response to activity. Finishing medication would not necessarily cause the client to have wheezing. The nurse should assess oxygen saturation before administering oxygen or assessing arterial blood gas.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment)      MSC:           Integrated Process: Nursing Process (Assessment)

 

MULTIPLE RESPONSE

 

  1. A client has a mediastinal chest tube. Which symptoms require the nurse’s immediate intervention? (Select all that apply.)
a. Production of pink sputum
b. Tracheal deviation
c. Oxygen saturation greater than 95%
d. Sudden onset of shortness of breath
e. Drainage greater than 70 mL/hr
f. Pain at insertion site
g. Disconnection at Y site

 

 

ANS:  B, D, E, G

Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension pneumothorax; sudden shortness of breath because this could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax; or drainage greater than 70 mL/hr because this could indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing. Production of pink sputum, oxygen saturation less than 95%, and pain at the insertion site are not signs/symptoms that would require immediate intervention.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)         MSC:           Integrated Process: Nursing Process (Assessment)

 

  1. What information about nutrition does the nurse teach a client with chronic obstructive pulmonary disease (COPD)? (Select all that apply.)
a. “Avoid drinking fluids just before and during meals.”
b. “Rest before meals if you have dyspnea.”
c. “Have about six small meals a day.”
d. “Practice diaphragmatic breathing against resistance four times daily.”
e. “Eat high-fiber foods to promote gastric emptying.”
f. “Eat dry foods rather than wet foods, which are heavier.”
g. “Increase carbohydrate intake for energy.”

 

 

ANS:  A, B, C

Fluids can make a client feel bloated and should be avoided with meals. Resting before the meal will help a client with dyspnea. Six small meals a day also will help to decrease bloating. Dry foods can cause coughing. Fibrous foods can produce gas, which can cause abdominal bloating and can increase shortness of breath. Diaphragmatic breathing will not necessarily help nutrition.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC:  Integrated Process: Teaching/Learning

 

  1. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) to determine activity tolerance. Which questions elicit the most important information? (Select all that apply.)
a. “What color is your sputum?”
b. “Do you have any difficulty sleeping?”
c. “How long does it take to perform your morning routine?”
d. “Do you walk upstairs every day?”
e. “Have you lost any weight lately?”

 

 

ANS:  B, C, E

Difficulty sleeping could indicate worsening breathlessness, as could taking longer to perform activities of daily living. Weight loss could mean increased dyspnea as the client becomes too fatigued to eat. The color of the client’s sputum would not assist in determining activity tolerance. Asking whether the client walks upstairs every day is not as pertinent as determining if the client becomes short of breath on walking upstairs, or if the client goes upstairs less often than previously.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. A client has a chest tube. What assessment findings require immediate intervention from the nurse? (Select all that apply.)
a. Intermittent bubbling in the water seal chamber in the client with a pneumothorax
b. “Silent chest” in the client with a pneumothorax
c. Tidaling in the water seal chamber in a client with a pneumothorax
d. Bloody drainage in the tubing of a client with a hemothorax
e. Tracheal deviation in a client after chest trauma
f. No drainage in the chest tube of a client with a pneumothorax
g. Constant bubbling in the water seal chamber in a client post chest surgery

 

 

ANS:  B, E, G

The client with a silent chest could have a mucous plug, the client with tracheal deviation could have a collapsed lung or tension pneumothorax, and the client with constant bubbling in the water seal could have an air leak. All of these assessments require intervention. The others are normal for the condition stated.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)         MSC:           Integrated Process: Nursing Process (Assessment)

 

  1. Which symptoms in chronic lung disease require nursing intervention? (Select all that apply.)
a. Clubbed fingers
b. Increased residual volume
c. Decreased peak flow
d. Increased anterior-posterior diameter
e. Elevated platelets
f. Expiratory wheezing
g. Stridor
h. Change in sputum color and amount

 

 

ANS:  C, F, G, H

Decreased peak flow could indicate worsening of symptoms of airflow occlusion. Likewise, expiratory wheezing and stridor can indicate inflammation and fluid accumulation leading to airway occlusion. A change in the amount and color of sputum can indicate infection. The other symptoms normally occur with chronic disease.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. The nurse is teaching a client with asthma how to avoid attacks. What information does the nurse give the client? (Select all that apply.)
a. “You should not dust your furniture.”
b. “Stay inside as much as possible.”
c. “Stay away from people who are sick.”
d. “Do not go out in the fall.”
e. “Stay out of the snow.”
f. “Do not take aspirin.”

 

 

ANS:  A, F

Dusting the furniture may increase dust in the air and cause an asthma attack. Aspirin may stimulate asthma. Staying inside probably will not help. Staying away from snow probably will not have an effect on the client’s attacks; neither will going outside during the fall.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)         MSC:           Integrated Process: Nursing Process (Planning)

 

  1. The nurse is assessing a client with asthma. Scattered wheezes are noted, and the client’s oxygen saturation is 88%. What other assessments are essential for the nurse to perform? (Select all that apply.)
a. Assess for accessory muscle use.
b. Assess anterior-posterior diameter.
c. Assess inspiration/expiration ratios.
d. Assess the suprasternal notch.
e. Perform a stress test.
f. Assess a chest x-ray.
g. Assess mucous membranes.

 

 

ANS:  A, C, D, G

Accessory muscle use may help the client breathe during an attack. Muscle retraction may be seen at the sternum and at the suprasternal notch. Mucous membranes can also tell the nurse about oxygenation. Inspiration versus expiration can tell the nurse how the client is breathing. The anterior-posterior diameter gives indication of a chronic condition; assessing this during an attack will not help the client. Likewise, performing a stress test and a chest x-ray during an attack would not be beneficial.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Assessment)

 

OTHER

 

  1. The nurse is teaching a client to cough productively. Put the actions in proper sequence.
  2. Have the client flex the head and hold a pillow to the stomach.
  3. Assist the client to a sitting position with feet on the floor.
  4. Instruct the client to bend forward and to cough two or three times.
  5. Have the client return to an upright position and take a deep breath.
  6. Encourage the client to take several deep breaths.

 

ANS:

b, a, e, c, d

When the client can tolerate it, the best position for effective coughing and secretion removal is sitting with the shoulders turned inward and the head bent slightly down while hugging a pillow. The client should take several deep breaths followed by holding the breath slightly before coughing two or three times in a row. Then the client should cough at the end of exhalation; this should be followed by taking several deep breaths.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC:  Integrated Process: Teaching/Learning

 

  1. Place the steps for obtaining a peak expiratory flow rate in the order in which they should occur.
  2. Take as deep a breath as possible.
  3. Stand up (unless you have a physical disability).
  4. Place the meter in your mouth, and close your lips around the mouthpiece.
  5. Make sure the device reads zero or is at base level.
  6. Blow out as hard and as fast as possible for 1 to 2 seconds.
  7. Write down the value obtained.
  8. Repeat the process two additional times, and record the highest number in your chart.

 

ANS:

d, b, a, c, e, f, g

The proper order for obtaining a peak expiratory flow rate is as follows: Make sure the device reads zero or is at base level. Stand up (unless you have a physical disability). Take as deep a breath as possible. Place the meter in your mouth, and close your lips around the mouthpiece. Blow out as hard and as fast as possible for 1 to 2 seconds. Write down the value obtained. Repeat the process two more times, and record the highest of the three numbers in your chart.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   Chart 32-4, p. 605

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration)        MSC:  Integrated Process: Nursing Process (Assessment)

 

 

Chapter 48: Assessment of the Eye and Vision

Test Bank

 

MULTIPLE CHOICE

 

  1. Why is the optic disc considered to be a blind spot?
a. This area does not contain photoreceptors.
b. Light rays are unable to focus on this location.
c. Blood vessels form a meshwork and interfere with vision.
d. This area is heavily pigmented and light rays are absorbed.

 

 

ANS:  A

The optic nerve enters the eyeball at this point and contains no photoreceptors. The other responses are incorrect.

 

DIF:    Cognitive Level: Knowledge/Remembering                               REF:    p. 1040

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. During assessment of an older adult, which finding does the nurse immediately report to the health care provider?
a. Yellowing or bluing of the sclera
b. Lack of discrimination between green and violet
c. An opaque, bluish-white ring within the outer edge of the cornea
d. Pupil constriction in response to light occurring in 2 seconds

 

 

ANS:  D

In an older client, it is normal for the sclera to turn yellow or blue with aging. It is also common for the older adult to have problems discriminating between the colors of green, blue, and violet. Arcus senilis, an opaque, bluish-white ring on the edge of the cornea, is a common occurrence in the older adult. This does not cause vision loss. Pupil constriction as a reaction to light should occur in less than 1 second. If pupil constriction takes longer, then the reaction is considered sluggish and should be reported to the provider.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)           MSC:              Integrated Process: Nursing Process (Assessment)

 

  1. Which teaching is essential for a client who is going to have intraocular pressure measurement with a slit lamp?
a. “The test causes temporary blindness.”
b. “The test is quick and a local anesthetic is used.”
c. “The test does cause a little pain, but it is over quickly.”
d. “The test causes some tearing, but no pain.”

 

 

ANS:  B

The IOP test done with a slit lamp must have direct eye contact, which could cause discomfort, so a local anesthetic is used. The test is quick but does not cause temporary blindness.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC:  Integrated Process: Teaching/Learning

 

  1. The nurse performs an assessment of a client’s extraocular movement and notes no difficulty. Which additional assessment data assist in confirming this finding?
a. No episodes of double vision
b. Synchronized blinking movements
c. No reports of headaches and dizziness
d. Both pupils constricting equally in response to light

 

 

ANS:  A

The voluntary muscles of the orbit rotate the eye and coordinate eye movements to ensure that the retina of each eye receives an image at the same time, so that only a single image is perceived. If the client has reported double vision, this would indicate a problem with this coordination. The other answers are not related to extraocular eye movements.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. A client has paralysis of the right medial rectus muscle of the right eye. Which assessment finding assists the nurse in validating this diagnosis?
a. Client is unable to turn the eye in toward the nose.
b. Client is unable to lift the upper eyelid.
c. Client cannot look downward.
d. Client cannot look upward.

 

 

ANS:  A

Contraction of the medial rectus muscle turns the eye toward the nose. The superior oblique muscle pulls the eye downward, and the inferior oblique muscle pulls the eye upward. The ocular muscles do not lift the upper eyelid.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   Table 48.1, p.1042

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. The nurse is assessing extraocular eye movements (EOMs) in an older adult client and finds that the client is unable to sustain an upward gaze for longer than 2 seconds. What does the nurse do next?
a. Repeat the test while holding the client’s head in a fixed position.
b. Perform a cover-uncover eye test.
c. Document the finding and continue assessing.
d. Assess for additional signs of impending brain attack.

 

 

ANS:  C

In the older adult, decreased muscle tone impairs the ability to maintain an upward gaze and to sustain convergence. Therefore, this finding is normal for an older adult client. The nurse would not repeat the test or hold the client’s head in a fixed position. The nurse would document the finding and continue to assess. This would not be a cause for concern, nor would it be a symptom of impending brain attack. The cover-uncover test is used for determining the degree of peripheral vision.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems)                   MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. The nurse is assessing an older adult client whose irises no longer fully dilate. What is the best intervention for the nurse to suggest?
a. “Wear dark glasses whenever you are outside.”
b. “Use eyedrops on a regular basis to prevent dryness.”
c. “Avoid rubbing your eyes to prevent corneal abrasions.”
d. “Turn up room lights when reading or doing close work.”

 

 

ANS:  D

With increasing age, the iris has less ability to dilate and clients have difficulty adapting to a darker environment. Older adult clients may need additional light for reading. Wearing dark glasses will not assist the client, and no indication suggests that the client’s eyes are dry. Rubbing the eyes should not cause corneal abrasions.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems)                   MSC:  Integrated Process: Teaching/Learning

 

  1. The nurse is performing vision screenings. Which client is at greatest risk for developing vision problems?
a. Postpartum woman with no complications
b. Young client who has diabetes mellitus
c. Middle-aged adult who takes aspirin daily
d. Older client with chronic dry eye syndrome

 

 

ANS:  B

The hyperglycemia that characterizes diabetes mellitus causes numerous vascular problems in the eye and damages the nerves. Although good control of blood glucose levels delays visual problems, it does not eliminate these problems in the diabetic population. Daily aspirin therapy does not place a client at risk for vision problems. Dry eyes are a common finding with older clients because tear production is decreased, but this does not necessarily interfere with the client’s vision. Postpartum women should not be at risk for vision problems.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. A client relates that the vision in the left eye is greatly decreased from the day before. What does the nurse do first?
a. Assess current medications.
b. Patch the left eye.
c. Notify the ophthalmologist.
d. Perform an in-depth interview.

 

 

ANS:  D

A client with a sudden or persistent loss of vision needs to undergo a complete history and assessment first to identify the possible cause. Information such as current medications must be available before the ophthalmologist is called. The nurse cannot patch the left eye without completing an interview first.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests)          MSC:           Integrated Process: Nursing Process (Assessment)

 

  1. During assessment, the nurse notes that a client’s right pupil is 2 mm larger than the left pupil. Which is the nurse’s first action?
a. Ask the client how long this condition has been present.
b. Attempt to elicit a red reflex in both eyes.
c. Document the finding as the only action.
d. Identify the medications that the client is taking.

 

 

ANS:  A

Although both pupils are normally the same size and a difference in size can indicate various pathologies, approximately 5% of people have a noticeable difference in the size of their pupils. The nurse should first determine whether this condition represents a change or has been present for a long time.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. The nurse is assessing the blink reflex in a client who is blind. Which is the best technique to use?
a. Ask the client to blink first with one eye and then with the other.
b. Expel a syringe of air toward the client’s eyes.
c. Shine a bright light at the client’s pupils one at a time.
d. Suddenly bring a finger toward the client’s face.

 

 

ANS:  B

A blind client cannot respond with a blink reflex to visually threatening movements such as bright light or bringing a finger toward the client. Air blowing suddenly at the eye should elicit the blink reflex as a protective response. Asking the client to blink first with one eye and then with the other will not elicit the blink reflex.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific Assessments)           MSC:              Integrated Process: Nursing Process (Assessment)

 

  1. The nurse is performing an eye assessment on a client. Which finding confirms normal accommodation during visual assessment?
a. Both pupils constrict when a light is shined at one eye.
b. The client blinks in response to a threatening movement.
c. Both pupils constrict when focusing on an object being moved in toward the nose.
d. The client is able to hold an upward gaze without moving the head for 15 seconds.

 

 

ANS:  C

Normal accommodation is seen when the client’s eyes converge. The pupils constrict when the client focuses on an object that is being moved from about 18 cm from the client’s nose in closer toward the nose. Consensual response occurs when both pupils constrict after a light is shined at one eye. The blink reflex occurs in response to a sudden movement. Extraocular muscle function is tested when the client is asked to hold an upward gaze while keeping the head still.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 1046

TOP:   Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. The nurse is assessing a client for the possibility of a lens opacity. Which assessment finding confirms this problem?
a. Increased intraocular pressure
b. Absence of a red reflex
c. Decreased central vision
d. Positive corneal staining

 

 

ANS:  B

The red reflex is elicited with an ophthalmoscope and represents reflection of the ophthalmoscopic light through the lens onto the vascular retina. The absence of a red reflex strongly indicates a lens opacity that does not allow light to penetrate through to the retina. The other answers are not related to a lens opacity. Increased intraocular pressure is measured by tonometry and could indicate glaucoma. Decreased central vision is measured by a Snellen chart and a Jaeger card and indicates decreased visual acuity. Positive corneal staining with topical dye could indicate corneal abrasion.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 1049

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. A client is scheduled for electroretinography. Which statement indicates that the client understands the teaching about this procedure?
a. “I will wear dark glasses in sunlight to prevent eye pain.”
b. “I am going to drink at least 3 liters of water to flush the dye out of my system.”
c. “I will avoid rubbing my eyes until the anesthetic drops have worn off.”
d. “I will not drive for the first 24 hours after the procedure.”

 

 

ANS:  C

A local anesthetic agent is used for this procedure because an electrode is placed on the cornea. The client could inadvertently scratch or harm the eye by touching or rubbing it while the anesthetic effect is present. No eye pain should be noted with this procedure, no dye is used, and restricting driving for 24 hours is not necessary.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests)          MSC:           Integrated Process: Teaching/Learning

 

  1. The nurse is evaluating a client’s technique for instilling eyedrops. Which behavior indicates that the client needs more teaching?
a. Closing they eye after the drops are in
b. Touching the eye with the tip of the dropper
c. Allowing the drops to spread across the eye surface
d. Getting the drops into the conjunctival pocket

 

 

ANS:  B

Touching the eye with the tip of the dropper contaminates the dropper and the medication. If the client has an infection in the eye that is touched, the dropper cannot even be used on the client’s other eye. The other answers indicate correct technique.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration)        MSC:  Integrated Process: Nursing Process (Evaluation)

 

  1. The nurse is educating a client about the instillation of eyedrops. Which client statement indicates the need for additional teaching?
a. “Squeezing my eye tightly after I put the drops in may force the drops out of my eye too quickly.”
b. “If the drops are kept in the refrigerator, I will be able to tell when they are in my eye because they will feel cold.”
c. “My sister has the same prescription, so we can use the same bottle of eyedrops.”
d. “I will wash my hands before I use these eyedrops.”

 

 

ANS:  C

Eyedrops or eye ointment should never be shared because of the risk of spreading infection. The other answers indicate correct technique.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration)        MSC:  Integrated Process: Nursing Process (Evaluation)

 

  1. A client with presbyopia asks her nurse about corrective lenses. Which is the nurse’s best response?
a. “This type of problem cannot be helped with corrective lenses.”
b. “Corrective lenses are needed for both near and distance vision.”
c. “Corrective lenses can be used for reading and close work.”
d. “Corrective lenses are needed for distance only.”

 

 

ANS:  C

Presbyopia is caused by stiffening of the lens as a result of water loss as the lens ages. Consequently, the lens does not refract as well and light waves converge behind the retina—a condition similar to farsightedness (hyperopia). The condition makes near vision blurry. Corrective lenses for presbyopia increase light wave refraction and are used for reading or close work. Therefore the other answers are incorrect. Presbyopia can be helped with corrective lenses but only for near vision, not for distance vision.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. A teenager is admitted to the emergency department with a possible fracture of the left orbit after getting hit in the face with a baseball. All tests are negative and the client is being discharged. Which is important for the nurse to teach the client?
a. “Keep an eye patch on the eye for 48 hours.”
b. “Always wear protective equipment to prevent eye damage.”
c. “Take aspirin if a headache should occur.”
d. “Do not do any heavy lifting for a week.”

 

 

ANS:  B

If all tests are negative, restrictions on heavy lifting are not needed. An eye patch does not have to be worn. Acetaminophen (Tylenol) would be a better choice for a headache because aspirin promotes bleeding. The client and the family should be taught about protective equipment while playing sports (helmet and goggles).

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

MSC:  Integrated Process: Teaching/Learning

 

  1. An anxious adult client asks why she needs to have intraocular pressure tested every year. What is the best response from the nurse?
a. “Many changes can occur because of aging.”
b. “If the pressure is too low, you will be blind.”
c. “If the pressure is too high, blood will not flow through the eye.”
d. “Loss of vision can occur if the pressure is too high or too low.”

 

 

ANS:  D

Although all responses are somewhat correct, explaining the outcome of abnormal pressure is to the point and is done at the client’s level of understanding, especially if she is anxious about the test.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests)          MSC:           Integrated Process: Teaching/Learning

 

  1. A client is told that he has 20/10 vision when tested on the Snellen chart. How does the nurse explain this finding to the client?
a. “You can read at 10 feet what others can read at 20 feet.”
b. “You can read at 20 feet what others can read at 10 feet.”
c. “This demonstrates normal vision.”
d. “You are considered legally blind.”

 

 

ANS:  B

The “20” is the point at which the client can see from the chart, and the “10” is the point at which a healthy eye can see from the chart. Normal vision is 20/20.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 1046

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests)          MSC:           Integrated Process: Nursing Process (Assessment)

 

  1. The nurse is assessing a client’s eyes. Which is the first step for the nurse in this procedure?
a. Explain the procedure.
b. Wash the hands.
c. Assess for infections.
d. Use the Snellen chart.

 

 

ANS:  B

Before examining a client’s eyes, the examiner should wash his or her hands. This is done to prevent contamination of the eye and structures. The nurse could then proceed to explain any procedure, assess infection, or assess visual acuity using the Snellen chart.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. The nurse is triaging clients in the emergency department. Which clients require immediate attention by an ophthalmologist?
a. Older client with an intraocular pressure (IOP) of 15
b. Confused client in need of an ophthalmoscopic examination
c. Young client with dry drainage from one eye
d. Middle-aged client with recent onset of eye pain

 

 

ANS:  D

A client with abrupt onset of eye pain should be the priority because of possible underlying pathology causing the symptom. An IOP of 15 is within the normal range (10 to 21); therefore the client does not need to be seen by an eye doctor. If a client is confused, the ophthalmoscopic examination must be rescheduled because it would not be safe to perform the examination at this time. Drainage from an eye indicates possible infection, but this would not be the first client to be seen.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

MSC:  Integrated Process: Nursing Process (Implementation)

 

MULTIPLE RESPONSE

 

  1. The nurse is assessing the eye changes in an older adult. Which changes lead the nurse to consult with the health care provider? (Select all that apply.)
a. Increasing difficulty perceiving greens, blues, and violets
b. Increasing redness in the eyes
c. Acute pain in the eyes
d. Sudden change in acuity
e. Need for additional lighting for reading
f. Need to hold newspaper farther away to read

 

 

ANS:  B, C, D

Increasing redness, acute pain, and sudden changes in acuity represent manifestations that might be indicative of a more serious complication and need the provider’s evaluation. Delay could cause harm. The other signs are associated with the aging process and do not require immediate evaluation.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC:  Integrated Process: Nursing Process (Implementation)

 

OTHER

 

  1. The nurse is administering ophthalmic drops to a client with an eye infection. Put the following nursing interventions in order, from first to last. (Separate letters by a comma and space as follows: a, b, c, d.)
  2. Recheck the five Rs and the expiration date of the drug.
  3. Put on gloves.
  4. Have the client tilt the head backward.
  5. Wash your hands.
  6. Pull the lower eyelid downward and instill the medication into the conjunctival sac.
  7. Instruct the client to close the eyes gently without squeezing the eyelids together.

 

ANS:

d, b, a, c, e, f

Medication checking of the five Rs the first time is always the first step, followed by handwashing and gloving because of the risk for secretions. Rechecking the five Rs right before giving the medication, which is actually the third time that the five Rs are checked, is critical for maintaining safety. The nurse has the client tilt the head back, prepare the eye, give the drug, and have the client gently close the eye.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. A client is scheduled for a fluorescein angiography. Place the nurse’s activities in order, from highest to lowest priority. (Separate letters by a comma and space as follows: a, b, c, d.)
  2. Start an intravenous access.
  3. Instill mydriatic eyedrops.
  4. Have the consent form signed.
  5. Have the client drink fluids.
  6. Inject fluorescein dye.
  7. Have the client wear dark glasses.

 

ANS:

c, b, a, e, d, f

Before the invasive procedure is started, an informed consent form must be signed. The mydriatic drops are then instilled 1 hour before the procedure. An IV is inserted and the fluorescein dye injected. A series of photographs are taken. After the procedure, the client is instructed to drink plenty of fluids to aid with excretion of the dye through the urine. The client is taught to wear dark glasses to prevent pain caused by the bright light until the mydriatic action of the drops has worn off.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 1050

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests)          MSC:           Integrated Process: Nursing Process (Implementation)

 

 

Chapter 64: Assessment of the Endocrine System

Test Bank

 

MULTIPLE CHOICE

 

  1. A client is taking a drug that blocks a hormone’s receptor site. What is the effect on the client’s hormone response?
a. Greater hormone metabolism
b. Decreased hormone activity
c. Increased hormone activity
d. Unchanged hormone response

 

 

ANS:  B

Hormones cause activity in the target tissues by binding with their specific cellular receptor sites, thereby changing the activity of the cell. When receptor sites are occupied by other substances that block hormone binding, the cell’s response is the same as when the level of the hormone is decreased.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 1359

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)   MSC:  Integrated Process: Nursing Process (Evaluation)

 

  1. How does a tropic hormone differ from other hormones?
a. Tropic hormones are given to clients who have a hormone deficiency.
b. Tropic hormones are exclusively involved in the production of sex hormones.
c. Tropic hormones stimulate other endocrine glands to secrete hormones.
d. Tropic hormones are not under negative feedback control.

 

 

ANS:  C

The target tissues for tropic hormones are other endocrine glands. The effect of these agents is to stimulate another endocrine gland to secrete its hormone. The other statements are inaccurate.

 

DIF:    Cognitive Level: Knowledge/Remembering                               REF:    p. 1361

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Evaluation)

 

  1. A client has a deficiency of aldosterone. Which assessment finding does the nurse correlate with this condition?
a. Increased urine output
b. Vasoconstriction
c. Blood glucose, 98 mg/dL
d. Serum sodium, 144 mEq/L

 

 

ANS:  A

Aldosterone, the major mineralocorticoid, maintains extracellular fluid volume. It promotes sodium and water reabsorption and potassium excretion in the kidney tubules. A client with an aldosterone deficiency will have increased urine output. Sodium and potassium levels are normal; in aldosterone deficiency, the client would have hyponatremia and hyperkalemia. Vasoconstriction is not related.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. A male client reports fluid secretion from his breasts. What does the nurse assess next in this client?
a. Posterior pituitary hormones
b. Adrenal medulla functioning
c. Anterior pituitary hormones
d. Parathyroid functioning

 

 

ANS:  C

Breast fluid and milk production are induced by the presence of prolactin, secreted from the anterior pituitary gland. The other hormones do not influence this process.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. A client has a condition of excessive catecholamine release. Which assessment finding does the nurse correlate with this condition?
a. Decreased blood pressure
b. Increased pulse
c. Decreased respiratory rate
d. No change in vital signs

 

 

ANS:  B

Catecholamines are responsible for the “fight-or-flight” stress response. Activation of the sympathetic nervous system can be correlated with tachycardia. The other options are not correlated with excessive catecholamine release.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Evaluation)

 

  1. A client is admitted to the hospital with exacerbation of heart failure, which had been stable for several years. Which finding does the nurse associate with the client’s current condition?
a. Recent prescription for thyroid hormone replacement medication
b. Recent onset of menopause
c. Patchy areas of depigmentation on the face
d. Absence of fish in the diet, but inclusion of the iodized form of table salt

 

 

ANS:  A

Thyroid hormones regulate metabolism. Starting on thyroid replacement therapy can lead to an increase in heart rate and tissue oxygen use, which can lead to an exacerbation of heart failure if the client’s heart is not able to meet these increased demands. Menopause and vitiligo (depigmentation of the skin) would not be related. Thyroid function is needed to produce thyroid hormones. The client who does not eat shellfish should use iodized table salt.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC:  Integrated Process: Nursing Process (Analysis)

 

  1. A client has abnormal calcium levels. Which hormone does the nurse anticipate testing for?
a. Thyroxine (T4)
b. Triiodothyronine (T3)
c. Thyrocalcitonin (calcitonin)
d. Propylthiouracil (PTU)

 

 

ANS:  C

Parafollicular cells produce thyrocalcitonin (calcitonin [TCT]), which helps regulate serum calcium levels. The other hormones are not related directly to calcium levels.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. Which is the expected clinical manifestation for a client who has excessive production of melanocyte-stimulating hormone?
a. Hypoglycemia and hyperkalemia
b. Irritability and insomnia
c. Increased urine output
d. Darkening of the skin

 

 

ANS:  D

Melanocyte-stimulating hormone increases the size of melanocytes in the skin and increases the amount of pigment (melanin) that they produce. The other actions do not occur as the result of excessive melanocyte-stimulating hormone function.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 1367

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. Which pulse rate finding in a client taking a drug that stimulates beta1 receptors requires immediate action by the nurse?
a. 50 beats/min
b. 95 beats/min
c. 85 beats/min
d. 100 beats/min

 

 

ANS:  A

Stimulation of beta1 receptor sites in the heart has positive chronotropic and inotropic actions. The nurse expects an increase in heart rate and increased cardiac output. The client with a heart rate of 50 beats/min would be cause for concern because this would indicate that the client was not responding to the medication. The other heart rates are within normal limits but on the higher end and would be considered a therapeutic response to the medication.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)   MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. Which situation or condition is likely to result in increased production of thyroid hormones?
a. Starvation
b. Dehydration
c. Adequate sleep
d. Cold environmental temperature

 

 

ANS:  D

Cold environmental temperatures stimulate the hypothalamus to secrete thyrotropin-releasing hormone, which in turn stimulates the anterior pituitary gland to secrete thyroid-stimulating hormone (TSH). TSH then stimulates the thyroid gland to secrete thyroid hormones, which, when bound to target tissues, increase the rate of metabolism to maintain body temperature near normal. The other situations would not lead to an increase in thyroid hormone production.

 

DIF:    Cognitive Level: Knowledge/Remembering                               REF:    p. 1363

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. A client has bilateral patchy areas of skin depigmentation on the arms and the face. Which action by the nurse is best?
a. Assess the client’s mucous membranes.
b. Draw a laboratory specimen for thyroid hormone levels.
c. Schedule the client for fasting blood glucose.
d. Question the client about sexual functioning.

 

 

ANS:  A

Vitiligo, patchy areas of depigmentation of the skin, is associated with primary hypofunction of the adrenal glands. Other assessment findings in this condition include uneven pigmentation on the mucous membranes. The other assessments are not related to vitiligo.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. A new nurse is palpating a client’s thyroid gland. Which action requires intervention from the nurse’s mentor?
a. The nurse stands behind, instead of in front of, the client.
b. The client is asked to swallow while the nurse finds the thyroid gland.
c. The nurse palpates the right lobe with his or her left hand.
d. The client is placed in a sitting position with the chin tucked down.

 

 

ANS:  C

The client should be in a sitting position with the chin tucked down as the examiner stands behind the client. The nurse feels for the thyroid isthmus while the client swallows and turns the head to the right, and the nurse palpates the right lobe with the right hand. The technique is repeated in the opposite fashion for the left lobe.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 1368

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific Assessments)           MSC:              Integrated Process: Nursing Process (Assessment)

 

  1. Which client statement indicates the need for clarification regarding the instructions for collecting a 24-hour urine specimen for assessment of endocrine function?
a. “I will continue to take all my prescribed medicine during the test.”
b. “I will add the preservative to the container at the beginning of the test.”
c. “I will start the collection by saving the first urine of the morning.”
d. “At the end of 24 hours, I will urinate and save that last specimen.”

 

 

ANS:  C

The 24-hour urine collection specimen is started when the client first arises and urinates. The first urine specimen is discarded because there is no way to know how long it has been in the bladder, but the time is noted. The client adds all urine voided after that first discarded specimen during the next 24 hours. When the 24-hour mark is reached, the client voids one last time and adds this specimen to the collection. The preservative, if used, must be added to the container at the beginning of the collection. Clients can continue to take all their normal medications during a timed urine collection. They should, however, avoid unnecessary medications.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests)          MSC:           Integrated Process: Teaching/Learning

 

  1. A female client with an endocrine problem has hirsutism. Which question or statement by the nurse is most appropriate?
a. “Do you have the money to pay for treatment?”
b. “I’m interested in knowing how you feel about yourself.”
c. “Many treatment options are available for this problem.”
d. “What can you do to prevent this from happening?”

 

 

ANS:  B

Hirsutism, excessive hair growth on the face and body, can result from endocrine disorders. This may cause a disruption in body image, especially for female clients. The nurse should gently inquire into the client’s body image and self-perception. Asking about the client’s financial status sounds judgmental. Simply stating that treatment options are available minimizes the client’s concerns. The client is not doing anything to herself to cause the problem, so the last question is inappropriate.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Psychosocial Integrity (Therapeutic Communications)

MSC:  Integrated Process: Caring

 

  1. A client asks why a 24-hour urine collection is necessary to measure excreted hormones instead of a random voided specimen. Which response by the nurse is most accurate?
a. “We are testing for a hormone secreted on a circadian rhythm.”
b. “The hormone is so dilute in urine, we need a large volume.”
c. “We want to see when the hormone is secreted in both large and small amounts.”
d. “You’d have to be here at a specific time of the day for a random urinalysis.”

 

 

ANS:  A

Some hormones are secreted in a pulsatile, or circadian, cycle. When testing for these substances, a collection that occurs over 24 hours will most accurately reflect hormone secretion. The other responses are not accurate.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests)          MSC:           Integrated Process: Nursing Process (Assessment)

 

  1. An older client is being admitted to the hospital for pneumonia. The client has no other health problems. Which action by the nurse is best?
a. Place the client on airborne precautions.
b. Offer the client fluids every hour or two.
c. Leave the bathroom light on at night.
d. Palpate the client’s thyroid gland on admission.

 

 

ANS:  B

A normal age-related endocrine change is decreased antidiuretic hormone (ADH) production. This results in a more dilute urine output, which can lead to dehydration. If no contraindications are known, the nurse should offer (or delegate) the client something to drink at least every 2 hours. A client with a simple pneumonia would not need Airborne Precautions. The client may or may not need/want the bathroom light left on at night. Palpating the client’s thyroid gland is a part of a comprehensive examination but is not specifically related to this client.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Aging Process)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. The nurse is teaching a client about self-care after menopause. Which teaching topic is the priority?
a. Weight-bearing exercise
b. Skin care
c. Intimacy needs
d. Body image changes

 

 

ANS:  A

After menopause, the ovaries produce less estrogen. This leads to decreased bone mass. The client should engage in regular weight-bearing exercise to prevent fractures. The other topics are appropriate but do not take priority over safety needs.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems)                   MSC:  Integrated Process: Teaching/Learning

 

  1. The nursing assistant reports that while pouring urine into a 24-hour urine container, some urine splashed the nursing assistant’s hand. Which action by the nurse is best?
a. Ask the assistant if he or she washed the hands afterward.
b. Call the laboratory to see if the container has preservative in it.
c. Have the assistant fill out an incident report.
d. Send the assistant to Employee Health right away.

 

 

ANS:  A

For safety, the nurse should find out if the assistant washed his or her hands. The nursing assistant should do this for two reasons. First, it is part of Standard Precautions to wash hands after client care. Second, if the container did have preservative in it, this would wash it away. The preservative may be caustic to the skin. The nurse can call the laboratory while the assistant is washing hands if needed. The nursing assistant would then need to fill out an incident or exposure report and may or may not need to go to Employee Health. The nursing assistant also needs further education on Standard Precautions, which include wearing gloves.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Handling Hazardous and Infectious Materials)

MSC:  Integrated Process: Teaching/Learning

 

MULTIPLE RESPONSE

 

  1. Which are common key features of hormones? (Select all that apply.)
a. Hormones may travel long distances to get to their target tissues.
b. Continued hormone activity requires continued production and secretion.
c. Control of hormone activity is caused by negative feedback mechanisms.
d. Most hormones are stored in the target tissue for use later.
e. Most hormones cause target tissues to change activities by changing gene activity.

 

 

ANS:  A, B, C

Hormones are secreted by endocrine glands and travel through the body to reach their target tissues. Hormone activity can increase or decrease according to the body’s needs, and continued hormone activity requires continued production and secretion. Control is maintained via negative feedback. Hormones are not stored for later use, and they do not alter genetic activity.

 

DIF:    Cognitive Level: Knowledge/Remembering                               REF:    pp. 1359-1360

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. A client has a hypofunctioning anterior pituitary gland. Which hormones does the nurse expect to be affected by this? (Select all that apply.)
a. Thyroid-stimulating hormone
b. Vasopressin
c. Follicle-stimulating hormone
d. Calcitonin
e. Growth hormone

 

 

ANS:  A, C, E

Thyroid-stimulating hormone, follicle-stimulating hormone, and growth hormone all are secreted by the anterior pituitary gland. Vasopressin is secreted from the posterior pituitary gland. Calcitonin is secreted from the thyroid gland.

 

DIF:    Cognitive Level: Knowledge/Remembering                               REF:    Table 64-1, p. 1359

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Assessment)

 

 

Chapter 76: Care of Patients with Sexually Transmitted Disease

Test Bank

 

MULTIPLE CHOICE

 

  1. The nurse is teaching a young woman about her risk of contracting a sexually transmitted disease (STD). Which statement by the client indicates that further instruction is needed?
a. “I am at decreased risk for an STD if I don’t rely on contraceptive sponges or foams to protect me.”
b. “I am at decreased risk for an STD because I am using an intrauterine device for contraception.”
c. “I am at increased risk for an STD because of the way that my body is designed as a woman.”
d. “I will be at increased risk for an STD if I rely on oral contraceptives to protect me from contracting a disease.”

 

 

ANS:  B

Using an intrauterine device provides no protection against contracting a sexually transmitted disease. Other risk factors that increase a young woman’s chances of contracting a sexually transmitted disease include the vascularity of the vagina and reliance on contraceptive sponges or foams or on oral contraceptives for protection against pregnancy and STDs.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC:  Integrated Process: Teaching/Learning

 

  1. Which statement by a middle-aged woman indicates that further instruction is needed for her and her partner regarding prevention of sexually transmitted diseases (STDs)?
a. “I’m glad we don’t have to use condoms anymore because I can’t get pregnant.”
b. “Changes in my vagina may make me more likely to be at risk for an STD.”
c. “I told my partner that we need to switch to condoms instead of the pill now.”
d. “I should report any evidence of infection, even if symptoms are minor.”

 

 

ANS:  A

The female who is probably postmenopausal should still use barrier protection to decrease the risk of contracting a sexually transmitted disease. Unfortunately, many women forget that they need barrier protection (i.e., condoms) once the need for contraception is gone. Any evidence of infection should be reported promptly because vaginal atrophy makes this client more vulnerable to develop an STD.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC:  Integrated Process: Teaching/Learning

 

  1. The nurse is conducting an assessment on a client and identifies a lesion that appears as a smooth indurated area. Which is the highest priority action on the part of the nurse?
a. Question the client further regarding sexual practices.
b. Ask the client about any associated symptoms.
c. Document the findings and obtain a specimen of fluid from the lesion.
d. Don gloves before continuing to assess the lesion any further.

 

 

ANS:  D

The lesion could be a chancre, which is highly contagious. The nurse should be wearing gloves. The nurse should finish assessment of the lesion before continuing to interview the client and documenting findings. The nurse does need to collect fluid for a culture, but the nurse’s safety is the priority.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. The nurse is counseling a client who has recently been diagnosed with syphilis. Which is the highest priority instruction that the nurse provides to the client regarding sexual partners?
a. “As long as both of you are being treated, abstinence is not necessary.”
b. “If you both have the same disease, you can continue to have sex.”
c. “Your partner must be treated with antibiotics within the next 90 days.”
d. “Once the health department gets your partner’s name, confidentiality is not considered to be important.”

 

 

ANS:  C

Once a client has been diagnosed with syphilis, his or her partner must be prophylactically treated as soon as possible, preferably within the next 90 days. Sexual abstinence is required of both partners until they complete treatment. Although the disease will be reported to the local health department, all information will be held in strictest confidence.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 1656

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)         MSC:           Integrated Process: Teaching/Learning

 

  1. A client has been diagnosed with genital herpes. Which statement by the client indicates an accurate understanding of the disease and treatment?
a. “Antiviral drugs can cure genital herpes and prevent a recurrence.”
b. “I can prevent outbreaks with suppressive antiviral therapy.”
c. “Suppressive therapy will prevent shedding of the virus.”
d. “Medication should be taken only when symptoms are present.”

 

 

ANS:  B

No cure for the disease is known, but it can be controlled with suppressive therapy with

antiviral drugs. The client can be shedding the virus with no symptoms present and despite the use of antiviral medications. Medications should be taken on a suppressive basis or as soon as the client has symptoms.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)   MSC:  Integrated Process: Teaching/Learning

 

  1. A client has recently been diagnosed with gonorrhea. The client comes from a deeply religious family. When the nurse finds the client weeping, the client tells the nurse, “I’m being punished for having an affair.” How does the nurse respond?
a. “Surely you don’t really believe that.”
b. “Why don’t we get you a sedative?”
c. “Tell me more about how you feel.”
d. “Which religion do you practice?”

 

 

ANS:  C

The priority for the nurse is to gain more information to have a clear understanding about how the client feels. The other answers discount the seriousness of the client’s feelings or are evasive.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. A client has just been diagnosed with a recurrence of genital herpes simplex. She asks how this is possible because she has not had sex since she was diagnosed and treated 1 year ago. Which is the nurse’s best response?
a. “Sometimes one course of therapy is not enough to eradicate the disease.”
b. “The disease can be controlled but is never cured, and outbreaks are common.”
c. “Did you take the medication exactly the way it was prescribed for you?”
d. “If you have more than one sex partner, you may have more than one strain.”

 

 

ANS:  B

Viral diseases cannot be cured. Antiviral drugs suppress viral replication but do not kill the organism. The causative virus remains in the body and can become active at any time. The other statements are not accurate.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 1656

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Teaching/Learning

 

  1. A client has secondary syphilis. What precautions are necessary for the nurse to take when caring for this client?
a. No precautions in addition to Standard Precautions are necessary.
b. Gloves should be worn whenever direct contact with the client’s skin is required.
c. Handwashing is required before and after contact with the client.
d. A mask should be worn by anyone entering the client’s room.

 

 

ANS:  B

The secondary stage of syphilis is a systemic disease, with microorganisms present in the client’s blood. Skin lesions and rashes are present. These lesions are considered highly contagious and should not be touched without gloves. Handwashing before and after contact is needed but is not sufficient to prevent spread of the disease. Masks are not needed.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. A client with primary syphilis was treated with an intramuscular injection of benzathine penicillin G. Later, the client reports a hard painful lump at the injection site and aching joints. Which is the nurse’s highest priority initial action?
a. Assess the client’s vital signs.
b. Give the client acetaminophen (Tylenol).
c. Document the finding in the chart.
d. Apply a warm compress to the site.

 

 

ANS:  A

A common reaction to penicillin injections for primary syphilis is the Jarisch-Herxheimer reaction, caused by rapid destruction of the causative microorganism and release of intracellular products. This is not usually serious, but it can cause fever and hypotension. The nurse should first assess the client’s blood pressure for stability and should take the temperature. Then if the client’s condition warrants, the nurse can administer acetaminophen or even fluids if needed. Documentation can be completed after the assessment is done. A warm compress to the site may or may not be helpful.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. Which statement made by a client about condom use indicates a need for clarification?
a. “I will use a new condom each time I have intercourse.”
b. “I will use an oil-based lubricant whenever I have intercourse.”
c. “I will always use a latex condom rather than a natural membrane condom.”
d. “I will keep the condom on until I have withdrawn from the vagina.”

 

 

ANS:  B

Oil-based lubricants can dissolve or damage the condom. Only water-soluble lubricants should be used with condoms. The other statements are accurate.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC:  Integrated Process: Nursing Process (Evaluation)

 

  1. A client has been diagnosed with Trichomonas vaginalis. Which statement by the client indicates an accurate understanding of this disease?
a. “I need to have a throat culture for Trichomonas.
b. “This will affect only my vagina and can cause itching.”
c. “My partner does not need to be treated.”
d. “My lymph nodes may stay swollen after treatment.”

 

 

ANS:  B

Trichomoniasis affects only the vagina in females, leading to itching and vaginal discharge. Men can get it too, so both partners need treatment. Lymph nodes are not affected.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Evaluation)

 

  1. A client with pelvic inflammatory disease (PID) from gonorrhea asks how this can cause sterility. Which is the nurse’s response?
a. “The infection damages the ovary so that less estrogen is secreted and ovulation is not possible.”
b. “The infection remains in your body and can infect your baby, so it is best if you don’t become pregnant.”
c. “If the infection is present in the fallopian tubes, it can cause enough scarring to block the tubes permanently.”
d. “The infection causes such damage to the cervix that it cannot contain a pregnancy inside the uterus for longer than 3 months.”

 

 

ANS:  C

The chronic inflammation sets up scar tissue formation in the fallopian tubes, thereby narrowing or completely blocking the lumens. This situation can prevent fertilization by not allowing sperm to reach the ovulated egg. Irreversible scarring or stricture, causing sterility, may occur even before the condition is diagnosed. The other statements are inaccurate.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 1663

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems)                   MSC:  Integrated Process: Teaching/Learning

 

  1. A client is brought to the emergency department by the family, who state that the client was diagnosed last week with gonorrhea but has not taken the medications yet. Today the family notes that the client is “not acting right” and seems confused. Which action by the nurse is most appropriate?
a. Start an IV and notify the health care provider about the client’s diagnosis.
b. Perform a thorough neurologic assessment and document the findings.
c. Administer acetaminophen (Tylenol) if the client has a fever.
d. Ask the client why he or she has not started the medication regimen yet.

 

 

ANS:  A

A rare but possible complication of gonorrhea is meningitis. Because the client has a change in mental status according to the family, the nurse must prepare the client for IV antibiotics to be given as soon as possible. The provider needs to know the diagnosis of untreated gonorrhea to help plan appropriate, rapid care. Conducting a neurologic examination and administering Tylenol are appropriate but do not take priority over initiating appropriate therapy. When the client is stable, the nurse can assess for reasons leading to noncompliance and offer appropriate assistance, such as referral to social services if the client cannot afford medications.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)           MSC:              Integrated Process: Nursing Process (Analysis)

 

  1. A client was diagnosed with chancroid. Which manifestation does the nurse associate with this condition?
a. Vaginal discharge
b. High fever
c. History of ectopic pregnancies
d. Genital ulcers

 

 

ANS:  D

Chancroid is characterized by genital ulcers and occasionally by enlarged lymph nodes. The other assessment findings are not related to chancroid.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Analysis)

 

  1. Which disease process places the client at greatest risk for development of an ectopic pregnancy?
a. Chlamydia infection
b. Genital herpes
c. Human papilloma virus infection
d. Pelvic inflammatory disease (PID)

 

 

ANS:  D

Pelvic inflammatory disease is a leading cause of infertility and ectopic pregnancies. The other diseases are not as likely to cause an ectopic pregnancy.

 

DIF:    Cognitive Level: Knowledge/Remembering                               REF:    p. 1663

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. Which should be the nursing focus for a female client during the initial outbreak of genital herpes simplex?
a. Instruction in condom use
b. Promotion of comfort
c. Prevention of pregnancy
d. Institution of isolation

 

 

ANS:  B

The initial outbreak of genital herpes simplex in a woman causes severe discomfort. Promotion of comfort is the first priority, because clients may not be receptive to instruction attempts until some degree of comfort has been achieved.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)         MSC:           Integrated Process: Nursing Process (Implementation)

 

  1. A female client is diagnosed with human papilloma virus (HPV) infection. Which intervention by the nurse takes priority?
a. Instruct the client on using podofilox (Condylox) cream.
b. Prepare the client for a Pap test and HPV DNA testing.
c. Teach the client to take all medications until they are gone.
d. Encourage the client to drink 8 to 10 glasses of water daily.

 

 

ANS:  B

Because certain strains of HPV cause cervical cancer, the client needs to have a Pap smear and HPV DNA testing done. The nurse should also teach her to use topical medications, such as Condylox, but this is not as high a priority as diagnostic testing. The other two options are not related to infection with HPV.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)           MSC:              Integrated Process: Nursing Process (Analysis)

 

  1. A 24-year-old woman has just been diagnosed with human papilloma virus (HPV) infection. She is very angry at her ex-boyfriend, who has been her only sexual contact. She is crying and says that she isn’t going to tell him that he is infected. Which is the nurse’s best response?
a. “You do not have to tell him because this is not a reportable disease in this state.”
b. “Because there is no cure for this disease, telling him would be of no benefit.”
c. “He should be told so he can take precautions to prevent the spread of infection.”
d. “You should tell him because he may not know that this can cause cancer.”

 

 

ANS:  C

Many clients are angry at the person who infected them with a sexually transmitted disease. Even though HPV is not a reportable disease in many states, all contacts should be told, so that they can take precautions to prevent infecting others. Although some strains of HPV do cause cancer, this is not the primary reason for telling a male sexual contact about the infection.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Psychosocial Integrity (Coping Mechanisms)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. A client has been diagnosed with anal cancer. Which test does the nurse prepare the client for?
a. Darkfield microscopy
b. Culture of discharge
c. Blood draw for the Venereal Disease Research Laboratory (VDRL) test
d. Human papilloma virus (HPV) DNA

 

 

ANS:  D

Human papilloma virus is known to cause cancers of the genitals, anus, and perianal areas. The client needs to undergo testing for HPV DNA. Darkfield microscopy is used to detect syphilis. Discharge is tested for gonorrhea, Chlamydia, and pelvic inflammatory disease. The VDRL is also used for syphilis.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests)          MSC:           Integrated Process: Nursing Process (Assessment)

 

  1. A female client admitted for cardiac problems also has condyloma acuminatum. Which type of precautions does the nursing staff implement with this client?
a. Standard
b. Airborne
c. Contact
d. Droplet

 

 

ANS:  A

Although it is considered highly contagious, condyloma acuminatum requires close intimate contact for transmission. Only Standard Precautions are needed for health care providers.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. Why are women more likely than men to have silent sexually transmitted disease (STD) infection?
a. Women are less susceptible to STDs and are not assessed often for them.
b. Lesions may not be visible, or the woman can be asymptomatic.
c. A man’s longer urethra provides increased opportunity for bacteria to multiply.
d. Symptoms of infection in women are likely to be systemic and vague, not local.

 

 

ANS:  B

Most clinical manifestations of an STD in a man are experienced in or around the penis. Most of a woman’s genital mucous membranes are inside the vagina and around the cervix, where direct observation of any lesions is unlikely. Also some women have no symptoms or only vague symptoms of STDs, and this leads to a delay in diagnosis.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 1660

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. The nurse manages a clinic in an area with a high rate of sexually transmitted diseases (STDs). Which strategy best helps decrease the rate of infection?
a. Start an expedited partner treatment program.
b. Use a single-dose drug given in the clinic.
c. Provide referrals to a low-cost pharmacy.
d. Plan occasional community educational programs.

 

 

ANS:  B

Although all options could decrease the occurrence rate of STDs, administering the medications needed to control two common STDs (gonorrhea and Chlamydia) right in the clinic improves compliance and will help decrease rates of infection in the fastest way. The manager would need to investigate the legal issues surrounding expedited partner treatment before starting a program.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. The nurse assesses a client and finds the manifestation shown in the photograph. Which drug does the nurse prepare to administer to the client?

 

 

a. Doxycycline (Vibramycin)
b. Ceftriaxone (Rocephin)
c. Acyclovir (Zovirax)
d. Podophyllin (Pododerm)

 

 

ANS:  D

The image is of a perianal HPV infection, which can be treated by provider-applied Pododerm. Doxycycline is used to treat chlamydia, ceftriaxone is for gonorrhea, and acyclovir is for herpes.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies-Expected Actions/Outcomes)   MSC:  Integrated Process: Nursing Process (Analysis)

 

COMPLETION

 

  1. A client weighing 110 lb is admitted with acute pelvic inflammatory disease. The client is ordered to receive an initial dose of gentamicin (Garamycin), 2 mg/kg. The client will receive an initial dose of gentamicin of ____ milligrams.

 

ANS:

100

1 kg = 2.2 lb

110 lb/(2.2 kg/lb) = 50 kg

2 mg/kg ´ 50 kg = 100 mg of gentamicin

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Dosage Calculation)

MSC:  Integrated Process: Nursing Process (Implementation)

 

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