Monahan Phipps Medical Surgical 8th Edition By Monahan -Test Bank

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Monahan Phipps Medical Surgical 8th Edition By Monahan -Test Bank

Monahan: Phipps’ Medical-Surgical Nursing: Health and Illness

Perspectives, 8th Edition

 

Test Bank

Chapter 2: The Aging Population

 

MULTIPLE CHOICE

 

  1.   Which is the primary goal of gerontologic care today?
1. Enhancing functional ability
2. Controlling chronic illness
3. Preventing depression
4. Reducing stress

 

 

ANS: 1                    PTS:   1                    DIF:   Category: No applicable category

TOP:  Nursing Process: Planning             MSC: Client Needs: Health Promotion and Maintenance

 

  1.  The nurse recognizes which finding as a secondary change of aging?
1. Vertebral disk shrinkage
2. Calcium loss from bones
3. Weakened hip and knee joints
4. Decreased pulmonary capacity

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1.  The nurse suspects the presence of infection when which finding is noted in an older adult patient?
1. Change in appetite
2. Constipation
3. Bradycardia
4. Dyspnea

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Blood and immunity

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Safe Effective Care Environment

 

  1.      Sexual interest:
1. Diminishes after menopause for women
2. Ends by age 60 or 70 for most men
3. May continue into late adulthood
4. Wanes during middle adulthood

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Reproductive and genitourinary

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Psychosocial Integrity

 

  1.  The risk for abuse of an older adult family member is greatest when the:
1. Caregiver lives alone with the older adult
2. Caregiver is close in age to the older adult
3. Older adult has decreased functional abilities
4. Older adult has more than one chronic illness

 

 

ANS: 4                    PTS:   1                    DIF:   Category: No applicable category

TOP:  Nursing Process: Assessment        MSC: Client Needs: Safe Effective Care Environment

 

  1.  Which is the best combination of foods for the older adult who complains of bloating, abdominal discomfort, and chronic constipation?
1. Iced tea, fried chicken, and macaroni
2. Oatmeal, applesauce, and green beans
3. Custard, cheese slices, and pureed chicken
4. Hamburger, gelatin, and enriched white bread

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Planning             MSC: Client Needs: Physiological Integrity

 

  1. Which is the best question to ask an older adult when assessing short-term memory?
1. “Do you know what day it is today?”
2. “How are beds, tables, and chairs similar?”
3. “Who was president during World War II?”
4. “What news item did you hear about today?”

 

 

ANS: 4                    PTS:   1                    DIF:   Category: No applicable category

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1.  An older adult patient with diabetes mellitus is prone to forgetfulness and is occasionally confused. Which nursing activity may help reduce her confusion?
1. Placing family photos in her line of sight
2. Standing directly in front of her and speaking loudly
3. Providing thorough explanations about procedures
4. Ensuring that she wears her glasses and hearing aid

 

 

ANS: 4                    PTS:   1                    DIF:   Category: No applicable category

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. Which observation alerts the nurse to the possibility that an older adult is contemplating suicide? The older adult:
1. Seeks spiritual comfort on a regular basis
2. Frequently talks about death and deceased relatives
3. Verbalizes being tired of dealing with a chronic illness
4. Stops verbalizing feelings and exhibits reduced activity

 

 

ANS: 4                    PTS:   1

DIF:   Category: Emotional needs related to health problems

TOP:  Nursing Process: Assessment        MSC: Client Needs: Psychosocial Integrity

 

  1. Which statement about the use of prescription and over-the-counter drugs by older adults is true?
1. Decreased drug duration and increased drug intensity occur when older adults are given the same drug dosage as are younger adults.
2. Older adults consume disproportionately more drugs than younger adults because they suffer more chronic illnesses.
3. Drug dependency is rare among older adults because they do not metabolize drugs as efficiently as younger people.
4. Prescription drugs are better tolerated and produce fewer side effects than over-the-counter drugs.

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Planning             MSC: Client Needs: Safe Effective Care Environment

 

Monahan: Phipps’ Medical-Surgical Nursing: Health and Illness

Perspectives, 8th Edition

 

Test Bank

Chapter 16: Pain

MULTIPLE CHOICE

 

  1. A 4-year-old who has recently undergone tonsillectomy begins crying. Her mother tells the nurse that the child is in pain. The child received Tylenol oral suspension 4 hours ago. The nurse instructs the mother to rock the child to encourage sleep. The nurse’s action is based on:
1. Inadequate knowledge of pain management
2. Evidence-based practice
3. The gate control theory of pain
4. Experience with other patients with tonsillectomies

 

 

ANS: 1                    PTS:   1                    DIF:   Category: No applicable category

TOP:  Nursing Process: Implementation  MSC: Client Needs: Physiological Integrity

 

  1. The gate control theory of pain implies that effective pain management plans should:
1. Deal primarily with emotional aspects of the patient’s pain experience
2. Focus chiefly on altering pain perception through behavior modification
3. Restrict analgesic use to pure opioid drugs that act centrally to close the gate
4. Include a combination of pharmacologic agents and noninvasive interventions

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Implementation  MSC: Client Needs: Physiological Integrity

 

  1. A patient is seen in the health clinic with a complaint of low back pain of 5 months’ duration. Vital signs are stable. An accurate nursing diagnosis is:
1. Chronic pain: low back, unclear etiology
2. Deficient knowledge regarding pain management
3. Acute pain related to low back strain
4. Anxiety related to acute pain

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1. A patient complains of pain in the chest and left arm and a diagnosis of myocardial infarction is made. This type of pain is:
1. Psychogenic
2. Localized
3. Referred
4. Somatic

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Cardiovascular

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. A patient receiving an agonist opioid such as morphine sulfate IV is at risk for a state of withdrawal with concurrent administration of which drug?
1. Transdermal fentanyl (Duragesic)
2. Hydromorphone (Dilaudid)
3. Meperidine (Demerol)
4. Butorphanol (Stadol)

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1. The analgesic order for a patient with cancer pain is changed from oral morphine sulfate 30 mg/day to morphine sulfate IV 2 to 15 mg/dose. How many milligrams per dose of IV morphine does the nurse select to achieve the same analgesic effect provided by the oral route?
1. 2 mg
2. 5 mg
3. 10 mg
4. 15 mg

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Implementation  MSC: Client Needs: Physiological Integrity

 

  1. Which assessment is essential to evaluate whether a dose of IV naloxone (Narcan) has been excessive?
1. Pain
2. Sedation
3. Constipation
4. Respiratory depression

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Discharge teaching for the patient receiving an NSAID includes notifying the physician when which occurs?
1. Nausea
2. Anorexia
3. Restlessness
4. Abnormal bleeding

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Evaluation          MSC: Client Needs: Safe Effective Care Environment

 

  1. The nurse observing self-administered transcutaneous electrical nerve stimulation determines that more teaching is required if the patient:
1. Places the electrodes over the painful area
2. Applies the electrodes along trigger points
3. Cannot identify when to change the battery
4. Cleanses the area before electrode application

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Evaluation          MSC: Client Needs: Safe Effective Care Environment

 

  1. An appropriate goal following rhizotomy for pain management is that the patient will be able to explain:
1. The importance of avoiding extremes in temperature
2. Methods to protect against electrical shock
3. The need for a high-fiber diet
4. Infection control measures

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Planning             MSC: Client Needs: Safe Effective Care Environment

 

  1. The patient describes postoperative pain as a dull ache located in the upper right abdomen and rates it at 5 on a scale of 1 to 5. What information is still missing for the nurse’s assessment?
1. Provoking factors
2. Quality of the pain
3. Severity or intensity
4. Region or radiation

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. To minimize pain while changing a postoperative knee dressing, nursing interventions should include:
1. Administering an analgesic immediately following the procedure
2. Selecting Demerol IM as the preprocedural analgesic
3. Having the nursing assistant support the leg under the knee
4. Placing a pillow under the calf of the affected leg

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Implementation  MSC: Client Needs: Physiological Integrity

 

  1. Evidence-based practice shows that opioid addiction occurs:
1. Less frequently if opioids are discontinued after 3 days
2. In fewer than 1% of hospitalized patients
3. Primarily in patients with chronic pain
4. Chiefly in the young adult population

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. The standard of care for any patient experiencing severe pain includes:
1. Analgesic decisions based on continuing assessment
2. Selecting oral analgesics following major surgery
3. Using low starting doses to minimize tolerance
4. Use of prn administration schedules

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Implementation  MSC: Client Needs: Physiological Integrity

 

  1. Which statement regarding opioid use in the elderly is true?
1. Opioid analgesics are too dangerous.
2. Subjective pain reports are not reliable.
3. Administration may need to be decreased.
4. Body surface area should be used to calculate dosages accurately.

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Planning             MSC: Client Needs: Physiological Integrity

 

  1. Guidelines for application of ice to a painful body part include:
1. Avoiding direct application of ice over the painful site
2. Leaving the ice in place for a minimum of 20 minutes
3. Applying enough cold to create mild discomfort
4. Placing cold between the painful area and the brain

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

Monahan: Phipps’ Medical-Surgical Nursing: Health and Illness

Perspectives, 8th Edition

 

Test Bank

Chapter 32: Assessment of the Hematologic System

 

MULTIPLE CHOICE

 

  1.    Which function does hemoglobin serve in the body?
1. Stimulates release of red blood cells from the bone marrow
2. Transports oxygen and carbon dioxide to and from cells
3. Converts oxygen to methemoglobin
4. Carries oxygen to cells

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Blood and immunity

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1.    Patients are at increased risk for anemia if they cannot produce:
1. Renin
2. Aldosterone
3. Erythropoietin
4. Antidiuretic hormone

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Blood and immunity

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1.    Which cells are increased in a person who has an active infection?
1. Basophils
2. Eosinophils
3. Neutrophils
4. Plasma cells

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Blood and immunity

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1.    Which organ is most likely diseased when a patient experiences an overall decrease in white blood cell count?
1. Lymph nodes
2. Bone marrow
3. Spleen
4. Liver

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Blood and immunity

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Which is an abnormal finding that needs to be reported immediately?
1. WBC 9500/mm3
2. Hematocrit 43%
3. Hemoglobin 12 g/dl
4. Platelets 100,000/mm3

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Blood and immunity

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. Which statement regarding changes in white blood cell counts due to the aging process is true? There is (or are):
1. Variations in percentages allotted to each blood cell category
2. An accelerated response to infection by basophils
3. A decreased total number of white blood cells
4. No significant changes

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Blood and immunity

TOP:  Nursing Process: Assessment        MSC: Client Needs: Health Promotion and Maintenance

 

  1. Which objective data substantiates the presence of a hematologic condition?
1. Weakness and lethargy
2. History of exposure to chemicals
3. Pain on palpation of the abdomen
4. Enlarged cervical and inguinal lymph nodes

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Blood and immunity

TOP:  Nursing Process: Assessment        MSC: Client Needs: Health Promotion and Maintenance

 

  1. Which skin assessment finding is consistent with thrombocytopenia?
1. Petechiae, ecchymoses
2. Pallor, spider angiomas
3. Cyanosis, dullness
4. Jaundice, purpura

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Blood and immunity

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Which lymph node is normally palpable during a physical examination?
1. Supraclavicular
2. Thoracic
3. Inguinal
4. Cervical

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Blood and immunity

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Which instruction is given to the patient being prepared for a bone marrow aspiration?
1. “You will not feel any pain, since this is not an invasive procedure.”
2. “There will be a brief, sharp pain during aspiration of the bone marrow.”
3. “You will be given a general anesthetic before the performance of this procedure.”
4. “It is normal to bleed for a while following the procedure, so you will be monitored closely.”

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Blood and immunity

TOP:  Nursing Process: Implementation  MSC: Client Needs: Health Promotion and Maintenance

 

  1. Which is the correct sequence for coagulation following trauma or surgery?
1. Prothrombin, thrombin, fibrinogen, fibrin
2. Prothrombin, fibrinogen, thrombin, fibrin
3. Fibrin, prothrombin, thrombin, fibrinogen
4. Fibrinogen, fibrin, thrombin, prothrombin

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Blood and immunity

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

 

Monahan: Phipps’ Medical-Surgical Nursing: Health and Illness

Perspectives, 8th Edition

 

Test Bank

 

Chapter 48: Traumatic and Neoplastic Problems of the Brain

 

MULTIPLE CHOICE

 

  1.    An important principle for neurologic assessment of the patient with a head injury is:
1. Establish trends in signs and symptoms
2. Vigorously stimulate the patient before neurologic assessment
3. Limit the frequency of neurologic checks to prevent overstimulation
4. Sensory assessment should be consistently performed before motor assessment

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1.    Which entry in the nursing notes is most helpful to the oncoming shift? “The patient:
1. opened eyes after their name was called three times”
2. responds slowly to stimulation”
3. is obtunded”
4. appears confused”

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Evaluation          MSC: Client Needs: Safe Effective Care Environment

 

  1. Nursing assessment reveals that the patient moans in response to a painful stimulus. This level of consciousness (LOC) is called:
1. Deep coma
2. Obtunded
3. Stuporous
4. Confused

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1. Criteria used to determine brain death include:
1. Known cause of coma, absence of reflexes and respirations
2. Decerebrate posturing and flat-line electrocardiogram
3. One or more flat electroencephalograms
4. Absent heartbeat

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Evaluation          MSC: Client Needs: Physiological Integrity

 

  1. Which nursing notation provides the best assessment information regarding level of consciousness in the comatose patient?
1. “Attempts to push nurse’s hand away when fingernail pressure applied”
2. “Grimaces and makes nonpurposeful movements”
3. “Unresponsive to painful stimulus”
4. “Responds to painful stimulus”

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Evaluation          MSC: Client Needs: Safe Effective Care Environment

 

  1. Which finding is an early indicator of altered level of consciousness?
1. Difficulty pronouncing words
2. Localizes to painful stimulus
3. Inability to state the date
4. Dilation of pupils

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1. To achieve accuracy in the assessment of head-injured patients, the nurse realizes it is important that:
1. The same evaluation tool be used by all personnel to assess the patient
2. LOC be assessed at the same time every day
3. Each assessment be conducted by two nurses
4. The Glasgow Coma Scale be used

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Assessment        MSC: Client Needs: Safe Effective Care Environment

 

  1. A plan for safe care in a patient experiencing dysphagia includes:
1. Restricting intake to clear liquids
2. Stroking the throat to promote swallowing
3. Restricting liquids and encouraging soft foods
4. Assessing the mouth for pocketed food and medication

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Planning             MSC: Client Needs: Safe Effective Care Environment

 

  1. Which approach demonstrates an important principle of communication with confused patients?
1. Touch the patient’s hand and speak quietly
2. Sit in a chair beside the bed and speak loudly
3. Bend close to the patient’s face and talk in a whisper
4. Ask permission to hold the patient’s hand and speak slowly

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. Which finding, if exhibited by the patient, is an early indicator of increasing intracranial pressure (ICP)?
1. Papilledema
2. Decreased LOC
3. Projectile vomiting
4. Significant increase in temperature

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1. An appropriate nursing intervention designed to decrease risk of increased ICP in the patient with a head injury is to:
1. Keep neck in alignment
2. Administer enemas daily
3. Place in Trendelenburg’s position
4. Encourage deep breathing and coughing

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. A patient with increased ICP is on a ventilator and requires suctioning. To prevent a rise in ICP, the nurse must:
1. Preoxygenate the patient
2. Administer an analgesic
3. Sedate the patient
4. Suction quickly

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. Which pharmacologic intervention does the nurse expect the physician to order for the patient who is in a coma and has increased ICP?
1. Sedatives and narcotic analgesics
2. Barbiturates and phenothiazines
3. Osmotic diuretics and steroids
4. Antibiotics and vasodilators

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Implementation  MSC: Client Needs: Physiological Integrity

 

 

  1. The most significant observations to be reported when monitoring a patient with increased ICP are:
1. Decreasing pulse, respirations, and blood pressure
2. Decreasing pulse and increasing systolic pressure
3. Increasing pulse, respirations, and blood pressure
4. Narrowed pulse pressure and hypothermia

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. A patient with a head injury begins to complain of a headache and cannot remember the date. Vital signs are blood pressure of 174/58 mm Hg, pulse of 50 beats/min, and respirations of 12/min. These signs and symptoms are consistent with:
1. Meningococcal infection
2. Cushing’s response
3. Diabetes insipidus
4. Encephalitis

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1. Which statement regarding care of the patient with a subdural hematoma and elevated ICP is correct? The nurse should:
1. Lower the head of the bed to increase cerebral blood flow
2. Encourage Valsalva’s maneuver to promote venous outflow
3. Treat fever promptly because it increases the metabolic needs of the brain
4. Encourage hyperventilation because CO2 increases cerebral blood volume

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Safe Effective Care Environment

 

  1. A patient complaining of episodic headaches describes the pain as a 10 (on a scale of 1 to 10), located on the left side, accompanied by nausea, and lasting 2 to 3 days. These signs and symptoms are consistent with which type of headache?
1. Sinus
2. Cluster
3. Tension
4. Migraine

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1. The pain reliever of choice for patients experiencing mild, infrequent headaches is:
1. Meperidine hydrochloride
2. Morphine sulfate
3. Codeine sulfate
4. Ibuprofen

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. A teaching plan to assist the patient in reducing the incidence of headaches includes instructions to:
1. Avoid large, high-calorie meals
2. Eliminate daily aerobic exercise routine
3. Eliminate all milk products from the diet
4. Minimize alcohol, caffeine, and salt intake

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Implementation  MSC: Client Needs: Health Promotion and Maintenance

 

  1. A 15-year-old girl has been seizing for 40 minutes (status epilepticus). Her teeth are clenched. What does the nurse do first?
1. Administer diazepam (Valium)
2. Provide oxygen by mask
3. Establish an intravenous site
4. Insert an airway

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. To interrupt seizure activity in the patient with status epilepticus the patient must receive:
1. Carbamazepine (Tegretol)
2. Valproic acid (Depakene)
3. Phenytoin (Dilantin)
4. Diazepam (Valium)

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. A frequent side effect of most of the common anticonvulsants is:
1. Facial rash
2. Drowsiness
3. Hypotension
4. Discoloration of the gums

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Evaluation          MSC: Client Needs: Physiological Integrity

 

  1. A patient on continuous video monitoring is observed having a generalized tonic-clonic seizure. This means that the patient is exhibiting:
1. Brief loss of consciousness
2. Jerking movements throughout the body
3. Rigidity for several seconds, then flaccidity
4. Rigidity of muscles followed by muscle jerking

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1. During the postictal period of a seizure, an appropriate nursing action is to:
1. Give the patient a sedative
2. Assist the patient to the bathroom
3. Assess the duration of the postictal phase
4. Explain to the patient that a seizure has just occurred

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Implementation  MSC: Client Needs: Physiological Integrity

 

  1. A classic sign of an absence (petit mal) seizure is:
1. Tonic-clonic movement
2. Vacant facial expression
3. Urinary incontinence
4. Lip smacking

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. When a patient is experiencing seizure activity, the most appropriate time to clear the airway is:
1. Any time during the seizure
2. Throughout the ictal period
3. During the most intense period of the seizure
4. Immediately after tonic-clonic movements stop

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. The method most commonly used to measure compliance and monitor anticonvulsant drug toxicity is:
1. Electroencephalogram once a month
2. Daily seizure record
3. Evidence of side effects
4. Blood test for drug levels

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Evaluation          MSC: Client Needs: Safe Effective Care Environment

 

  1. A patient is admitted to the hospital with a brain tumor manifested by headache, visual disturbances, and seizures. The physician orders dexamethasone and Pepcid IV. The purpose of the H2 antagonist is to:
1. Prevent nausea and vomiting
2. Diminish gastrointestinal symptoms caused by the tumor
3. Block the secretion of acidlike substances by the tumor
4. Decrease gastric acid secretion associated with steroid therapy

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1. The most malignant and rapidly growing forms of brain tumors are:
1. Glioblastoma multiforme
2. Oligodendrogliomas
3. Meningiomas
4. Neuromas

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1. Which preoperative nursing action is important for the patient undergoing intracranial surgery?
1. Administering sedatives to diminish anxiety
2. Controlling severe headache pain with narcotics
3. Obtaining written consent from significant other
4. Obtaining an accurate baseline neurologic assessment

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. Care of patients with increased ICP may involve placing the patient in a barbiturate coma for several days. This is done to:
1. Diminish cerebral metabolism and oxygen requirements
2. Minimize activity and risk for injury
3. Help maintain blood pressure
4. Reduce the patient’s anxiety

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1. Postoperative nursing responsibilities for the craniotomy patient include:
1. Measuring urinary glucose levels
2. Actions to prevent vomiting and coughing
3. Keeping side rails down to promote activity and independence
4. Maintaining bed rest and minimal activity for the first 48 hours

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. During postoperative assessment of a craniotomy patient, the nurse notes yellowish drainage on the head dressing. The nurse should:
1. Remove the dressing and examine the incision
2. Mark the drainage area and assess in 2 hours
3. Report drainage immediately to physician
4. Document and continue to observe

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. Which nursing diagnosis is appropriate for the patient after placement of a ventriculoperitoneal shunt for hydrocephalus?
1. Risk for ineffective protection related to dural leak
2. Risk for deficient fluid volume related to insufficient antidiuretic hormone
3. Diarrhea related to osmotic pressure alterations in the intestine
4. Ineffective thermoregulation related to trauma to the hypothalamus

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Safe Effective Care Environment

 

  1. Two days after intracranial surgery to remove a tumor, a patient’s urine output drops to 150 ml/day. The patient’s urine specific gravity is 1.032, serum sodium level is 129 mEq/L, and osmolarity is low. These findings are consistent with:
1. Fluid volume deficit related to fluid shift into interstitial tissue
2. Hypovolemia secondary to surgical blood loss
3. Syndrome of inappropriate release of antidiuretic hormone
4. Diabetes insipidus

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1. The nurse anticipates which intervention in the patient with diabetes insipidus after cranial surgery?
1. Increase in dietary salt intake
2. Administration of intravenous glucose
3. Intravenous infusion of normal saline
4. Increase in oral fluid intake

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Planning             MSC: Client Needs: Physiological Integrity

 

  1. The nurse knows that aqueous vasopressin given to the patient with diabetes insipidus is effective when the:
1. Urine output increases
2. Serum sodium level rises
3. Serum osmolarity increases
4. Urine specific gravity increases

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Evaluation          MSC: Client Needs: Safe Effective Care Environment

 

  1. Signs and symptoms suggestive of a basilar skull fracture include:
1. Seizures
2. Battle’s sign
3. Neck stiffness
4. Circumoral cyanosis

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. After a concussion, a motorcycle accident victim is discharged. Which finding should prompt the family to call the physician?
1. Fatigue
2. Mild headache
3. Cold symptoms
4. Nasal discharge

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Evaluation          MSC: Client Needs: Safe Effective Care Environment

 

  1. A patient who sustains a head injury after a diving accident is unconscious with bleeding from the skull, ears, and mouth. Vital signs are pulse of 110 beats/min, blood pressure of 98/55 mm Hg, and respirations of 12/min. Nursing care during this period should include:
1. Cleansing the ear canals with normal saline
2. Monitoring serum potassium and chloride levels
3. Inserting a nasogastric tube to prevent aspiration
4. Collaborative measures to optimize cerebral perfusion

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. After acute head injury, assessment reveals disorientation in all spheres. Furthermore, the left pupil reacts slower and is 3 mm in diameter while the right is 2 mm in diameter. What does the nurse do first?
1. Attempt to reorient the patient
2. Immediately inform the physician
3. Test gastric pH for increased acid production
4. Raise the head of the bed and reassess in 1 hour

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. A 19-year-old is brought to the emergency department with sudden onset of high fever, nuchal rigidity, and vomiting. These signs and symptoms are consistent with:
1. Poliomyelitis
2. Brain abscess
3. Polyneuritis
4. Meningitis

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Neuromuscular

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

 

Monahan: Phipps’ Medical-Surgical Nursing: Health and Illness

Perspectives, 8th Edition

 

Test Bank

 

Chapter 66: Burns

 

MULTIPLE CHOICE

 

  1.    Partial-thickness burns involve destruction of:
1. Part of the epidermis
2. Both the epidermis and the dermis
3. All skin layers and underlying nerve endings
4. Varying depths from the epidermis to the dermis

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Integumentary

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1.    What major fluid shift occurs in the patient 72 hours after a burn?
1. Intracellular to extracellular
2. Intracellular to intravascular
3. Interstitial to intravascular
4. Intravascular to interstitial

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Fluid and electrolyte

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1.    Which is a correct etiology for the diagnosis of deficient fluid volume for a patient with second-degree burns?
1. Vasoconstriction forcing fluid into the interstitial tissues
2. Increased plasma osmotic pressure
3. Increased capillary permeability
4. Impaired aldosterone secretion

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Fluid and electrolyte

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1.    The majority of the fluid lost in the patient with burns is lost through:
1. Extravasation of fluid into deep tissues
2. Visible fluid loss through the wound
3. Lymphatic channels
4. Blister formation

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Fluid and electrolyte

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1.    Which assessment finding is consistent with the hypovolemic phase of burns?
1. Hematocrit 45%
2. Urine output 20 ml/hr
3. Serum sodium 150 mEq/L
4. pH 7.48, PCO2 50 mm Hg, HCO3 30 mEq/L

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Fluid and electrolyte

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1.          After full-thickness burns to the upper body, a patient is experiencing hematuria. The most reasonable explanation for this finding is that:
1. Fluid has shifted from the cell into the plasma
2. Bacteria have invaded the burn and caused sepsis
3. The direct insult to the kidney from hyperthermia has caused hemolysis
4. Damaged red blood cells trapped in the burn are passing through glomeruli

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Fluid and electrolyte

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1.    Two days after partial-thickness burns to 15% of the body, the patient’s potassium level is 6.0 mEq/L. Which assessment takes priority in the nursing care plan?
1. Apical rate and rhythm
2. Blood glucose level
3. Urine output
4. Gastric pH

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Fluid and electrolyte

TOP:  Nursing Process: Assessment        MSC: Client Needs: Safe Effective Care Environment

 

  1.    A patient’s arterial blood gases after severe burns are: pH 7.31, PCO2 30 mm Hg, and HCO3 18 mEq/L. Which acid-base disturbance is the patient exhibiting?
1. Metabolic alkalosis from diuresis
2. Metabolic acidosis from cell injury
3. Respiratory acidosis from hypoventilation
4. Respiratory alkalosis from hyperventilation

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Fluid and electrolyte

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1.    The stress response to severe burns can be manifested by:
1. Gastric ulcer
2. Hypoglycemia
3. Hypertension
4. Sleep disturbances

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1.   Which assessment finding would indicate to the nurse that the patient with burns is entering the diuretic stage?
1. Hemoglobin 12.4 g/dl, hematocrit 35%
2. Urine osmolality 300 mOsm/kg
3. Serum potassium 5.0 mEq/L
4. Serum sodium 140 mEq/L

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Fluid and electrolyte

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1.   When responding to a fire alarm, the nurse finds a patient in bed with the sheets in flames. The nurse’s first action is to:
1. Run for the fire extinguisher
2. Throw a blanket over the flames
3. Douse the bed and patient with water
4. Ensure that the patient is removed from the bed

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Integumentary

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1.   The first intervention the nurse initiates for any individual who is burned is to:
1. Secure the airway
2. Stop the burning process
3. Administer 100% oxygen
4. Insert an intravenous catheter

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Integumentary

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1.   Which medical management goal is the first priority for the burn patient during initial treatment?
1. Control temperature
2. Support circulation
3. Secure the airway
4. Control pain

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Respiratory

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1.   Entrance and exit points from an electrical burn appear as minor burns to less than 1% of the body. The nurse appropriately concludes that:
1. Internal tissue damage is minimal
2. Full-thickness injury has not occurred
3. The patient will be discharged after stabilization
4. The degree of internal damage cannot be determined by external burns

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Integumentary

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1.   A child is burned on the foot with scalding water. Appropriate treatment before admission to the emergency department includes telling the mother to:
1. Apply ice to the area
2. Cover the wound with a damp cloth
3. Immerse the child in a tub of cold water
4. Apply petroleum jelly and cover with a towel

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Integumentary

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1.   Which criteria define a major burn?
1. Partial- and full-thickness burns over 5% of the body
2. Partial-thickness burns over 15% to 20% of the body; any age
3. Younger than 10 years or older than 40 years with burns over 5% to 10% of the body
4. Greater than 10% of the body surface area covered with full-thickness burns

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Integumentary

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1.   After securing an adequate airway, which activity does the nurse initiate first in the severely burned patient?
1. Insert a large-bore intravenous catheter
2. Draw arterial blood for arterial blood gas analysis
3. Administer tetanus vaccine
4. Insert a nasogastric tube

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Fluid and electrolyte

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1.   The drug of choice for pain control in the patient with burns is:
1. Nubain by subcutaneous injection
2. Morphine by intravenous injection
3. Meperidine by nasogastric tube
4. Tylenol with codeine orally

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Integumentary

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1.  During fluid resuscitation of the patient with burns, which type of fluid is appropriate?
1. D5W
2. 0.45% Normal saline
3. 0.33% Normal saline
4. Lactated Ringer’s solution

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Fluid and electrolyte

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1.   A patient weighing 68 kg has a 50% total body surface area (BSA) burn. According to the Parkland formula for fluid replacement, the patient should receive 13,600 ml in the first 24 hours. How much should the patient receive per hour in the first 8 hours?
1. 488 ml/hr
2. 625 ml/hr
3. 850 ml/hr
4. 1950 ml/hr

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Fluid and electrolyte

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Safe Effective Care Environment

 

  1.   Which is the most reliable indicator that adequate fluid replacement has been achieved in the burn patient during the diuretic phase?
1. Weight
2. Urine output
3. Blood pressure
4. Serum sodium level

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Fluid and electrolyte

TOP:  Nursing Process: Evaluation          MSC: Client Needs: Physiological Integrity

 

  1.   Using the “rule of nines,” the patient with burns to the anterior and posterior legs has what percentage of BSA involved?
1. 9%
2. 18%
3. 36%
4. 48%

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Integumentary

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1.   Factors considered in determining the severity of a burn include:
1. Gender, race, age
2. Depth, preburn skin condition
3. Age, body part, causative agent
4. History of skin disease, nutritional status

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Integumentary

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1.   The severity of the burn is greatest in which case?
1. 4.5% Burn of the anterior thigh
2. 9% Burn of the posterior leg
3. 9% Burn of the head
4. 4.5% Burn of the arm

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Integumentary

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1.   During the emergent period, a priority nursing diagnosis for the patient with a 9% full-thickness burn to the left leg is:
1. Acute pain
2. Hyperthermia
3. Deficient fluid volume
4. Ineffective airway clearance

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Fluid and electrolyte

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Safe Effective Care Environment

 

  1.   Fluid resuscitation is given during the first 24 hours. On the third day the nurse notes an increase in urine output. She concludes that:
1. Too much fluid was given
2. The patient is in the diuretic phase
3. Fluid resuscitation was successful
4. The patient is in early renal failure

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Fluid and electrolyte

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Safe Effective Care Environment

 

  1.   Which clinical finding suggests an inhalation injury?
1. Arterial pH of 7.35
2. Facial burns, hoarseness
3. Reduced level of consciousness
4. Pulmonary artery end-diastolic pressure of 10 mm Hg

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Integumentary

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1.   The primary goal for a patient with an inhalation injury is to prevent:
1. Cardiac dysrhythmias
2. Tissue asphyxiation
3. Hypovolemia
4. Heat loss

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Respiratory

TOP:  Nursing Process: Planning             MSC: Client Needs: Physiological Integrity

 

  1.   Which assessment is a nursing priority for a patient in the acute phase of severe burns to the lower extremities?
1. History of substance abuse
2. Sputum characteristics
3. Peripheral pulses
4. PO2 levels

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Integumentary

TOP:  Nursing Process: Assessment        MSC: Client Needs: Safe Effective Care Environment

 

  1.   Which topical medication is most beneficial to the patient with a gram-negative infection in the burn wound?
1. Silvadene
2. Scarlet red
3. Bacitracin
4. Collagenase

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Safe Effective Care Environment

 

  1.   The first day after a split-thickness skin graft to the thigh, nursing care of the graft site includes:
1. Irrigating the graft site with normal saline
2. Removing the dressing to permit the wound to air dry
3. Assessing the dressing for purulent drainage or odor
4. Directly inspecting the wound for infection every 4 hours

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Integumentary

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1.   Which expected outcome is appropriate for the patient with a 40% BSA full-thickness burn? The patient will:
1. Demonstrate healing within 10 to 15 days
2. Experience no pain during hospitalization
3. Exhibit signs of a negative nitrogen balance
4. Verbalize understanding of grafting procedures

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Integumentary

TOP:  Nursing Process: Planning             MSC: Client Needs: Physiological Integrity

 

  1.   Which calorie distribution reflects appropriate nutritional principles for the patient with burns who requires 3500 calories?
1. Protein 1750, fats 1750
2. Protein 2100, carbohydrates 720, fats 720
3. Protein 1750, carbohydrates 875, fats 875
4. Protein 700, carbohydrates 1750, fats 1050

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Integumentary

TOP:  Nursing Process: Planning             MSC: Client Needs: Safe Effective Care Environment

 

  1.   Which statement reflects appropriate nutritional principles for the patient with burns?
1. A carbohydrate intake of 75% of total calories is required to prevent hypoglycemia
2. A high fat intake will help boost the immune system
3. Adequate carbohydrates and fats are essential for energy
4. Proteins should constitute the bulk of the diet

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Integumentary

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1.   Before any dressing change on the patient with burns, the nurse must:
1. Assess the patient’s neutrophil count
2. Adjust the room temperature to 70º F
3. Turn off any bedside humidification device
4. Administer an analgesic 30 minutes before the procedure

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Integumentary

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1.   Wound care for the patient with extensive burns consists of:
1. Hydrotherapy for 60 minutes three times per day
2. Weekly cleansing and mechanical debridement
3. Tubbing for management of infected wounds
4. Strict sterile technique

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Integumentary

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1.   After what circumstance is the patient with burns at risk for developing a fungal infection?
1. A chemical burn
2. Grafting procedures
3. Extensive electrical burns
4. Treatment with broad-spectrum antibiotics

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1.   A patient with extensive full-thickness burns to the face and neck is withdrawn and avoids interacting with family and staff. An appropriate nursing approach would be for the nurse to:
1. Reinforce wound teaching with every interaction
2. Encourage the patient to talk about the accident
3. Intermittently provide information about care
4. Respect the patient’s grief and remain silent

 

 

ANS: 3                    PTS:   1

DIF:   Category: Emotional needs related to health problems

TOP:  Nursing Process: Implementation  MSC: Client Needs: Psychosocial Integrity

 

  1.   A realistic goal of the rehabilitation process in a patient with 80% BSA involvement is that the patient will:
1. Verbalize absence of pain
2. Discuss realistic plans for the future
3. Be free of disfigurement and scarring
4. Return to his or her preinjury job and lifestyle

 

 

ANS: 2                    PTS:   1

DIF:   Category: Emotional needs related to health problems  TOP:  Nursing Process: Planning

MSC: Client Needs: Safe Effective Care Environment

 

  1.   Teaching the patient with burns how to apply Ace bandages and a Jobst garment is aimed at which of the following goals?
1. Controlling drainage
2. Preventing muscle strain
3. Reducing skin sensitivity
4. Minimizing scar formation

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Integumentary

TOP:  Nursing Process: Implementation  MSC: Client Needs: Health Promotion and Maintenance

 

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